bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP205: Left Atrial Size is Not a Predictor for Detection of Atrial Fibrillation in Cryptogenic Stroke
Authors: Ramaiah Guru , Salahuddin Hisham , Espinosa Aixa , Zaidi Syed , Jumaa Mouhammad , Tietjen Gretchen
Published: October 2018

Objective:
Left atrial dilation is considered to be an indirect marker of atrial fibrillation. The purpose of the study is to determine if an enlarged left atrium is a predictor of paroxysmal atrial fibrillation in patients with cryptogenic stroke.

Methods:
We performed a retrospective chart review of patients who were deemed to have cryptogenic strokes by vascular neurologists at a tertiary care center in Ohio. Patients had an implantable cardiac monitor (ICM) placed at hospital discharge and were monitored for atrial fibrillation. Age (mean: 65.8 years), Sex (male: 49.3%), initial NIHSS score (mean: 4.45), risk factors, CHADS2 score (mean: 3.54) and location were recorded.

Results:
829 stroke and 295 TIA patients were screened between September 2012 and July 2016. 79 patients were deemed to have cryptogenic stroke and had an ICM placed. Left atrial size was classified based on the left atrial volume index. Of the 79 patients, 61 (77.2%) patients were found to have a normal left atrium (22 +/- 6 ml/m
2
), 14 (17.7%) patients had mildly enlarged left atrium (29-33 ml/m
2
), and 4 (5.06%) patients had moderately enlarged left atrium (34-39 ml/m
2
). No patients from the cohort had severe enlargement of the left atrium (≥ 40 ml/m
2
). 21 patients (26.6%) have been detected to have atrial fibrillation on ICM. Of the 21 patients with atrial fibrillation, 6 (28.6%) had mildly enlarged left atrium and 15 (71.4%) were found to have a normal left atrium. A higher NIHSS was found to be a predictor of atrial fibrillation (p=0.037, CI 0.83-0.99), consistent with previous studies showing that patients with atrial fibrillation have more severe strokes. Multivariate analysis failed to reveal any other significant predictors.

Conclusion:
Left atrial size was not a significant predictor of paroxysmal atrial fibrillation in patients with cryptogenic stroke. A normal atrial size should not preclude placement of an ICM for detection of paroxysmal atrial fibrillation.
Abstract WP211: Mechanism of Simultaneous Cerebral Infarcts in Multiple Arterial Territories: A Literature-Based Pooled Analysis
Authors: Akhtar Tauseef , Shahjouei Shima , Zand Ramin
Published: October 2018

Introduction:
Acute multiple cerebral infarcts in multiple arterial territories are thought to suggest the presence of cardioembolic sources. However, several studies have shown other etiologies for simultaneous cerebral infarcts in multiple arterial territories.

Methods:
We conducted a systematic review of the literature through PubMed, Scopus, Embase, Clinicaltrial.gov, ICTRP and Cochrane library. Studies containing multiple acute strokes in more than one arterial territory based on diffusion weighted imaging (DWI) findings were screened. Articles were excluded if they had limited inclusion criteria, performed limited subgroup analysis, or did not use DWI.

Results:
Out of 16551 stroke patients from 25 studies included in this study, 1967 (12%) patients had simultaneous acute cerebral infarcts in multiple arterial territories. 199 patients were excluded as their workup and diagnosis were not reported. Out of 1768 patients, 491 (28%) patients had an undetermined etiology. Cardioembolism was the most common cause of stroke in multiple arterial territories (38%, 95%CI: 36-40%) followed by large artery atherosclerosis including aortic arch atheroma (23%, 95%CI: 21-25%). Hematological disorders were found to be the cause of cerebral infarcts in 52 (3%, 95%CI: 2-4%) patients. Out of 143 patients who were reported to have simultaneous brain infarcts in bilateral hemispheres or anterior and posterior circulations, 78 (54%, 95%CI: 46-62%) were found to have cardiacembolism. Other etiologies for stroke in multiple arterial territories were intracranial atherosclerosis, vasculitis and other inflammatory diseases, infection, and iatrogenic causes.

Conclusion:
Simultaneous cerebral infarcts in multiple arterial territories occur among 12% of stroke patients. Although cardioembolism is the most common cause, there are several other etiologies that require a different workup and secondary prevention strategy.
Abstract WP217: EMS Quarterback Role Improves Stroke Alert Time Targets
Authors: Fussner Julie M , Montgomery Kelly , Ellenberger Daniel , Beilman Colin , Sila Cathy
Published: October 2018

Background:
Process standardization is an effective tool to improve efficiency in acute stroke assessment and treatment. Pre-hospital providers use standardized assessment tools, stroke protocols, and communication guidelines but these can vary for squads directed by various Medical Controls. In May 2015, the University Hospitals- Cleveland Comprehensive Stroke Center initiated a Direct-to-CT policy for acute stroke patients but had difficultly adhering to the process because the staff and process of receiving the EMS calls and directing EMS on arrival varied.

Hypothesis:
A dedicated EMS liaison position in the ED could have a significant impact on improving communication and engagement with pre-hospital EMS providers to improve assessment and treatment times for transported acute stroke patients.

Methods:
In August 2016, a “Quarterback” (QB) position for an Advanced Stroke Life Support certified paramedic was developed to be stationed at the ED entrance, answer all incoming EMS calls, activate alerts for Stroke-Trauma-STEMI, direct incoming squads, expedite registration, and provide feedback on patient outcomes.

Results:
The implementation of the EMS Quarterback role was associated with improved Stroke Alert processes from 1q 2016- pre-implementation of the EMS Quarterback role and 1q 2017, post-implementation: The percentage of Stroke Alerts called by EMS prior to arrival increased from 50% to 86%. The percentage of patients that went direct to CT increased from 23% to 92%. The average Door-to-CT times decreased from 21 minutes to 9.7 minutes overall, with 8 minutes for these stroke alerts called prior to arrival by EMS. The average Door-to-Needle times for IV-tPA decreased from 44 minutes to 34 minutes.

Conclusion:
The innovative EMS Quarterback role in a busy, urban ED was associated with a significant improvement in assessment and treatment times for patients with acute stroke as well as improved communication and engagement with pre-hospital providers.
Abstract WP218: EMS Based Telestroke Suggests Reduced Door to Needle Time Compared to Hospital Based Telestroke (REACHOUT Project)
Authors: Hackett Christopher T , Protetch Jack , Rana Sandeep S , Wright David G , Fishman Robert , Schmidt Eric C , Pratt Rebekah A , Tayal Ashis H
Published: October 2018

Introduction:
Implementation of telestroke in community hospitals and primary stroke centers has resulted in reduced door to needle times. Mobile stroke units equipped with CT scanners, also utilizing telestroke have demonstrated a further reduction in door to needle times. Despite the benefits of mobile stroke units, the cost of producing and maintaining these units may be a limiting factor in system-wide adoption of the concept. There is little data examining continuous telestroke support provided by neurologists in the EMS setting. We tested this lower-cost alternative, by providing 24/7 telestroke access to two local EMS providers. We hypothesized that telestroke in the EMS setting would be safe, feasible and reduce door to needle times.

Methods:
Stroke-specialized neurologists provided continuous (24/7) video-based telestroke access to two local EMS agencies from December 2015 through May 2017 as part of the REACHOUT project. Data were prospectively collected and retrospectively analyzed. Intravenous (IV) tPA door to needle times were compared between patients who were assessed via EMS telestroke to patients assessed by hospital based telestroke in one of the nine hospitals within our telestroke network, during the same time period.

Results:
Fifty-eight telestroke requests were registered with 52 (89.7%) successful consultations during the study period. The initial telestroke impression in 42/52 (80.8%) cases was a possible acute stroke or TIA. There were 142 patients treated with IV tPA via hospital based telestroke encounters and 4 patients were treated with IV tPA after being evaluated via EMS telestroke. A comparison of door to needle times suggested shorter door to needle times in the EMS telestroke group (mean rank 12.8; median 39.5 min) compared to the hospital based telestroke group (mean rank 74.2; median 65.5 min),
U
= 41,
p
= .004,
r
= .24.

Conclusions:
Despite isolated connectivity issues, we found EMS based telestroke encounters to be safe and feasible. Pre-hospital evaluation of patients by a stroke-specialized neurologist provided a comprehensive clinical picture to emergency department physicians upon arrival to the hospital. Reduced door to needle times were reported in EMS based telestroke compared to hospital based telestroke.
Abstract WP221: A Pragmatic Computer Algorithm Successfully Matches De-identified Regional Quality Improvement Database Records and Emergency Medical Services Records
Authors: Richards Christopher T , Li Zhiyuan Mathew , Woodhouse Alexandra , Braciak Adriana , Smith Henry , White William , Xie Sarah , O’Neill Kathleen , Sednew Renee M , Stein-Spencer Leslee , Werwath Mark , Rosenman Marc B , Prabhakaran Shyam
Published: October 2018

Introduction:
Linking prehospital data from emergency medical services (EMS) patient care records with hospital-based data in quality improvement databases, such as the American Heart Association’s Get With the Guidelines (GWTG)-Stroke database, can help inform initiatives that aim to improve both prehospital and hospital-based acute stroke care. However, inconsistent data collection, discrete systems, and privacy concerns prevent simple data merging of prehospital and hospital-based databases.

Hypothesis:
A simple, pragmatic computer algorithm using probabilistic matching can successfully link EMS data with hospital-based quality improvement data.

Methods:
A retrospective pilot study was performed that matched hospital data from GWTG-Stroke, a regional quality improvement database, and prehospital data from a single municipal fire-based EMS provider agency that responds to all 9-1-1 calls in a large US city with 15 primary and comprehensive stroke centers participating in GWTG-Stroke data collection. Using data for patients with confirmed stroke arriving via EMS from July to December 2013, we implemented a rule-based probabilistic matching algorithm that incorporated patient age, sex, time of hospital arrival +/- 30 minutes, and destination hospital to match de-identified records between the GWTG-Stroke and EMS databases. A subset of records at one stroke center was audited to verify successful matches. Python (Python Software Foundation, Beaverton, Oregon) was used to facilitate analysis.

Results:
Among 328 patients with confirmed stroke arriving by EMS, a probabilistic matching algorithm successfully linked the prehospital and hospital records for 300 (91%). The 28 unmatched records were due to typographical errors or missingness of entered data. Of 40 algorithm-matched records audited at one stroke center for accuracy, 40 (100%) had been matched correctly.

Conclusions:
A simple algorithm using patient age, sex, time of hospital arrival, and destination hospital successfully matched greater than 90% of de-identified prehospital and hospital records. Leveraging high fidelity database matching can facilitate future work that links prehospital and hospital stroke interventions to patient outcomes.
Abstract WP222: Predictive Value of the Miami Emergency Neurologic Deficit (MEND) Exam for Detecting Large Vessel Occlusion Strokes
Authors: Motola Ivette , Brotons Angel A , Rodriguez Richard D , Marulanda-Londoño Erika , Carter Steven , Li Hua , Issenberg S. Barry
Published: October 2018

Introduction:
The Miami Emergency Neurologic Deficit (MEND) exam is a screening tool for identifying stroke patients in the field. It is rapid, and can detect both anterior and posterior circulation strokes. Recent developments in the care of ischemic stroke patients with large vessel occlusion (LVO) have highlighted the need to transport these patients to comprehensive stroke centers (CSC) with neurointerventional capabilities. This field triage requires a screening tool that can rapidly and accurately identify LVO patients.

Purpose:
Determine the predictive value of the MEND exam for detecting LVO stroke, when completed by prehospital providers in the field.

Methods:
We analyzed MEND exam findings conducted by paramedics on patients suspected of stroke, who were airlifted to our CSC. We sought to determine the MEND’s ability, when administered by paramedics, to identify LVO, based on imaging (CT/CTA or MRA) or findings on intervention. Large vessel occlusion was defined as a total occlusion of the ICA, MCA-M1, MCA-M2, ACA-A1, ACA-A2, BA, VA, PCA-P1, or PCA-P2. Statistical analysis was conducted using SAS, v.9.3. Receiver operating characteristic curves, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated.

Results:
From September 2008 to June 2017, 143 patients had MEND exams completed. Of these, 121 were airlifted to a CSC, where they had the NIHSS performed. The mean MEND score was 5 (0-14), and the mean NIHSS on arrival to the hospital was 10 (0-34). Of 101 strokes, 89 were ischemic (88%) and 12 hemorrhagic (12%). LVO was diagnosed in 43 stroke patients (42%). Area under the curve for MEND exam predictability for LVO was 0.65 (95% CI 0.49-0.75). The sensitivity, specificity, PPV and NPV for different cut-offs of the MEND exam are: MEND ≥3: 98%, 29%, 0.43, 0.96; MEND ≥4: 81%, 51%, 0.48, 0.83; MEND ≥5: 60%, 65%, 0.49, 0.74.

Conclusion:
The MEND is a simple and rapid evaluation that can be performed in the field by EMS personnel to screen for LVO strokes. In our study, a MEND score ≥3 identified 98% of LVOs, and a score ≥4 identified 81% of LVOs, with improved specificity. The MEND exam is an effective tool to identify patients with LVO for transport to a CSC.
Abstract WP223: Accelerating Growth in Medicare Beneficiary US Population Served by Mobile Stroke Units During Early Pilot Years (2014-2017)
Authors: Nour May , Grotta James C , Parker Stephanie A , Gausche-Hill Marianne , Bosson Nichole , Ghurabi Walid H , Eckstein Marc , Sanko Stephen , Starkman Sidney , Saver Jeffrey
Published: October 2018

Background:
Mobile Stroke Units (MSUs, mobile CT ambulances) are a new platform for accelerated delivery of proven, time-dependent therapies for acute ischemic and hemorrhagic stroke, undergoing systematic evaluation to determine cost-effectiveness. Formal analysis of the reach of MSU programs in the US during the early pilot period has not previously been undertaken.

Methods:
We identified all US MSU programs, active or expected to be active by the end of 2017, via the PRESTO consortium, program leader referrals, vehicle and scanner manufacturer informants, and press release search. MSU access was calculated using geospatial mapping of each vehicle and its surrounding 10 mile radius catchment area, for: 1) population aged ≥ 65, using US Census Bureau county-level values for land area, population density, and proportion of population ≥ 65; and 2) strokes in CMS beneficiaries, using CDC/CMS county-level values for annual stroke hospitalizations.

Results:
During the 4 year study period, the number of active MSUs grew from 1 in 2014, 2 in 2015, 6 in 2016, to 13 in 2017, all operating in distinct counties, including 7 (54%) in Census-defined large central metros with high population density, 3 (23%) in large fringe metros with moderately high population density, 3 (23%) in medium/small metros with moderate population density, and 0 (0%) in rural areas. The population over age 65 with MSU access increased from 153,860 in 2014, 315,884 in 2015, 671,960 in 2016, to 1,495,896 in 2017. The number of annual CMS stroke hospitalizations in MSU-covered regions increased from 1,831 in 2014, 3,775 in 2015, 7,031 in 2016, to 15,566 in 2017. By the end of 2017, MSUs were positioned to provide service to 2.9% of all Medicare beneficiaries experiencing stroke hospitalization in the US.

Conclusions:
In the short span of the first 4 years of MSU pilot programs in the United States, with only 13 vehicles in service, expanding MSU programs provide access to accelerated treatment for 3 of every 100 US Medicare beneficiaries. This early geomapping analysis indicates that, if demonstration projects confirm cost-effectiveness, supporting wider dissemination, MSU care could provide rapid therapy to a substantial proportion of older Americans with acute ischemic and hemorrhagic stroke.
Abstract WP227: Compliance and Real Life Performance of a FAST-ED Scale Based Pre-Hospital Stroke Initiative
Authors: De Los Rios La Rosa Felipe , Ramirez Maygret , Strauss Jayme , Gonzalez Ivis C , Tocre Carrion Camila , Ramos Virginia , Starosciak Amy K
Published: October 2018

Introduction:
In March 2017 Miami-Dade Fire Rescue (MDFR) started to use the FAST-ED score (FES) as the tool to triage those with possible large vessel occlusions (LVO). All suspected of having a stroke should have the score calculated. Those with a score ≥ 4 bypass for a comprehensive stroke center (CSC). Those with a score ≥ 6 have the interventional team activated from the field. We sought to describe basic compliance and performance measures of this initiative.

Methods:
All acute stroke patients brought to our CSC by MDFR during the months of March, April, and May were included. Patients were identified based on stroke ICD-10 codes. Study variables are obtained prospectively as part of our internal quality monitoring protocol. FES was obtained from 3 sources: run sheet, medical record, and retrospectively calculated from the first hospital NIHSS performed by trained stroke nurses. An LVO is present if there is an occlusion of the internal carotid artery, middle cerebral artery (M1 or M2 segments), or basilar artery on initial imaging.

Results:
We identified 320 stroke alerts, 164 from EMS of which 139 were from MDFR and subject to our analysis. The average age was 72 years, 52% female, average NIHSS of 10.3. A total of 79% had an FES described in the run sheet. The field score varied by ≥ 2 points on 51% of patients when compared to the calculated score. Of all stroke alerts 60% were ultimately coded as stroke or TIA. If restricted to run sheet FES ≥ 4 or ≥ 6, the number of patients coded as stroke or TIA were 69% and 58%, respectively. The number of patients found to have a large vessel occlusion was 13 (29%) for FS ≥4 and 6 (32%) for ≥6. The number of patients undergoing endovascular treatment was 10 (22%) for a FS ≥4 and 5 (26%) for FS ≥6.

Discussion:
Protocol compliance was good. We found significant differences in the run sheet FES compared to the calculated score. Because these scores are calculated at two different time points the finding could be explained by changes in the patient’s symptoms or to inter-rater variability. In a real life scenario, 2 out of 5 patients with a FS ≥ 6 have an ischemic stroke mimic and only 1 out of 4 will undergo a thrombectomy. Further improvements are required to minimize unnecessary hospital bypass and interventionist field activations.
Abstract WP232: Prospective Validation of the Miami Emergency Neurologic Deficit (MEND) Exam for Detection of Stroke
Authors: Motola Ivette , Brotons Angel A , Rodriguez Richard D , Marulanda-Londoño Erika T , Li Hua , Hernandez Salma , Rivera Hector F , Schwemmer Sandra L , Issenberg S. Barry
Published: October 2018

Introduction:
Early detection and rapid transport to a stroke center are essential in the care of stroke patients. The Miami Emergency Neurologic Deficit (MEND) exam, developed in 1998, incorporates the posterior circulation elements missed by the Cincinnati Prehospital Stroke Scale (CPSS). It has a max score of 22, and includes all three components of the CPSS and six additional components from the National Institutes of Health Stroke Scale (NIHSS) (level of consciousness, orientation, commands, visual fields, gaze, leg motor, limb ataxia, and sensation). The MEND exam takes under two minutes to perform, and requires no tools, making it ideal as a screening tool, or for repeated examinations.

Purpose:
Determine the predictive value of the MEND exam completed by prehospital providers in the field for final diagnosis of stroke.

Methods:
We analyzed MEND exam findings conducted by paramedics on consecutive patients suspected of stroke, transferred directly from Monroe County, FL to our large urban academic hospital. We sought to determine the MEND’s ability, when administered by paramedics, to predict stroke or transient ischemic attack (TIA), based on the patient’s final diagnosis on hospital discharge. Statistical analysis was conducted using SAS, v.9.3. Receiver operating characteristic curves, sensitivity, specificity, positive predictive value and negative predictive value were determined.

Results:
From September 2008 to June 2017, 143 patients presenting to EMS had MEND exams completed. Eighty-one percent (n=57) were males. Mean age was 68 (21-98). The average MEND score was 5 (range 0-14). Of 101 strokes, 89 were ischemic (88%) and 12 hemorrhagic (12%). Area under the curve for MEND exam predictability for final diagnosis of stroke or TIA was 0.82 (95% CI 0.73-0.91). The sensitivity, specificity, PPV and NPV for different cut-offs of the MEND exam are: MEND ≥2: 94%, 59%, 0.84, 0.81; MEND ≥3: 84%, 69%, 0.87, 0.64; MEND ≥4: 64%, 78%, 0.87, 0.47.

Conclusion:
The MEND exam, completed in the prehospital setting by paramedics, is an effective screening tool for detecting stroke. Since the MEND includes components excluded in other commonly used screening exams, and can be completed quickly, it is a valuable tool for assessing stroke patients.
Abstract WP235: Should a Transthoracic Echocardiogram be a Routine Part of the Diagnostic Evaluation of Transient Ischemic Attack in an Emergency Department Observation Unit?
Authors: Siket Matthew S , Vozzo Paul T , Paolucci Gino A , Godbout Edmond E , Yaghi Shadi , Saad Ali , Cutting Shawna M , Madsen Tracy E , Jayaraman Mahesh V , Furie Karen L
Published: October 2018

Introduction:
ED observation units offer an alternative to hospitalization for the rapid diagnosis and etiologic evaluation of clinically suspected TIA. While cardiac embolism is thought to account for at least 25% of ischemic cerebrovascular events, the diagnostic yield and clinical impact of TTE in an ED observation unit has yet to be determined.

Methods:
We conducted a retrospective review of 676 patients with suspected TIA within prospectively collected registry data of an ED observation unit between 2013-2017. Patients were considered eligible regardless of clinical risk score and routinely underwent DW-MRI/MRA and TTE. New onset atrial fibrillation was considered an exclusion criterion. A multivariable logistic regression was used to identify clinical predictors of abnormal TTE findings of possible cardioembolic etiology. Fisher’s exact test was performed to compare 30-day outcomes of patients who did or did not receive a TTE.

Results:
Among 676 patients with clinically suspected TIA who underwent ED observation, a TTE was performed on 69% (n=465). After completion of the observation period, a final diagnosis of ischemic stroke, TIA, or mimic accounted for 14%, 44%, and 42% respectively. Of those diagnosed with stroke or TIA, abnormal TTE findings suggestive of a low or high-risk source occurred in 12% (n=35) and 2% (n=6) respectively. Age, gender, ECG abnormalities, heart murmur, history of diabetes, hypertension, hyperlipidemia, atrial fibrillation, anticoagulant use, cardiac surgery, coronary disease or stenting did not predict abnormal TTE findings (chi
2
p=.78 for low-risk, p=.31 for high-risk TTE findings). These findings led to initiation of anticoagulation in 2 patients (0.7%). There was no difference in 30-day clinical outcomes (recurrent TIA/stroke, ED recidivism or hospital admission) in patients that did or did not have a TTE (p=0.92).

Conclusions:
In our cohort of ED patients undergoing ED observation for clinically suspected TIA, a TTE informed of a possible cardioembolic source in 14% of patients with a final diagnosis of TIA or ischemic stroke. These abnormalities were not predicted by clinical variables alone and tended to not lead to a change in clinical management.
Abstract WP24: Angiographic Blush After Mechanical Thrombectomy is Associated With Hemorrhagic Conversion of Ischemic Stroke
Authors: Salehi Omran Setareh , Boddu Srikanth Reddy , Gusdon Aaron , Kummer Benjamin , Díaz Ivãn , Baradaran Hediyeh , Patel Praneil , Navi Babak , Gupta Ajay , Kamel Hooman , Patsalides Athos
Published: October 2018

Introduction:
Risk factors for hemorrhagic transformation of ischemic stroke after mechanical thrombectomy are not well established.

Hypothesis:
Prominent cerebral tissue vascularity on angiography after recanalization with thrombectomy (angiographic blush) is associated with hemorrhagic transformation.

Methods:
Among patients in the Cornell AcutE Stroke Academic Registry (CAESAR), we identified those who underwent stent-retriever-based thrombectomy for anterior circulation occlusion between 2012 and 2015. The presence of hemorrhagic transformation and angiographic blush were determined by neuroradiologists and neurointerventionalists. We identified angiographic blush as hypervascularity with or without early venous drainage. Hemorrhagic transformation was defined using CT or MRI studies performed within 7 days of thrombectomy. Our primary outcome was the volume of hemorrhagic transformation, determined using 3D-Slicer software. Our secondary outcome was the presence of any hemorrhagic transformation. Using a doubly robust estimator, we analyzed whether the presence of angiographic blush after recanalization was associated with an increased volume of hemorrhagic transformation after adjustment for demographics and previously published risk factors for hemorrhagic transformation.

Results:
Among 48 eligible patients (median age, 68 years; median NIHSS score, 18), 31 (64.6%) had angiographic blush and 26 (54.2%) had hemorrhagic transformation (mean volume, 7.6 cc). Patients with angiographic blush had lower TICI scores and had more often received alteplase. After adjustment for demographics and risk factors for hemorrhagic transformation, the presence of angiographic blush was significantly associated with an increased volume of hemorrhagic transformation: mean volume, 10.3 (95% CI, 3.7-16.9) cc with any blush versus 1.8 (95% CI, 0.1-3.4) cc without any blush (p=0.01). Angiographic blush was nonsignificantly associated with the presence of any hemorrhagic transformation (odds ratio, 1.5; 95% CI, 0.9-2.5).

Conclusions:
In a single-center study, we found that the presence of angiographic blush after mechanical thrombectomy was independently associated with an increased volume of hemorrhagic transformation.
Abstract WP240: Regional Disparities in Stroke Transfers for Endovascular Treatment- Outcomes from the Early Years of Neurointervention
Authors: Mehta Tapan , Desai Ninad , Mehta Kathan , Patel Smit , Hussain Mohammed , Nouh Amre , McCullough Louise
Published: October 2018

Introduction:
Acute stroke care has been revolutionized with the advent of intravenous alteplase and endovascular therapy. The number of centers in the United States equipped to offer endovascular therapy are limited, often necessitating inter-hospital transfer. We studied the outcomes of such patients in terms of mortality and disability, and attempted to determine the possible contributory factors in the early years of neurointervention for acute stroke management.

Methods:
We used the Nationwide Inpatient Sample data to identify the acute stroke patients requiring transfer for endovascular treatment, the National Center for Health Statistics data to determine their location, the United States Census Bureau website for determining the population demographics, the Joint Commission data on the distribution of Primary Advanced and Comprehensive Stroke Centers, and the Human Resources and Services Administration data on delivery of medical care. We compared the outcomes in the four major regions of the country in terms of mortality and disability at discharge.

Results:
Age above 80 years (p<0.05) and a high Charlson’s co-morbidity index (p<0.01) were consistent predictors for increased disability in transferred patients receiving endovascular therapy. Age greater than 80 years was also a predictor for higher mortality (p<0.001) in all regions. The prevalence of significant disability was higher in the Midwest compared to the national average (p=0.0147).

Conclusion:
Distribution of healthcare facilities capable of offering endovascular treatments affects time to treatment and consequently, outcomes. Strategic triage system and distribution of Primary Advanced and Comprehensive Stroke Centers could help reduce disparities of outcomes.
Abstract WP242: An International Survey of Progressive Stroke System Processes
Authors: Ehrlich Matthew E , Shah Shreyansh , Kolls Brad , Roettig Mayme , Graffagnino Carmelo
Published: October 2018

Introduction:
Understanding of high performing stroke systems can help development of regional stroke systems of care and bring meaningful system improvement. We sought to evaluate the current state of advanced systems worldwide to inform the development of a large-scale regional system of care improvement program.

Methods:
An 81 question, internet-based survey was developed to obtain information on current practices in large and progressive stroke systems. Data was collected from January 2017 - May 2017. Advanced stroke systems were identified by prior knowledge and colleague input. A total of 22 stroke centers from Europe and North America were invited to participate. The survey included questions encompassing center demographics, staffing, acute stroke code processes, Endovascular therapy (EVT) processes, EMS systems, stroke IT, telestroke use, transfer of patients, post-acute patient management and system feedback. Data analysis was conducted using REDCap internal analytic tools; simple counts and averages (mean) were calculated where appropriate.

Results:
Of the 22 invited centers, 9 (41%; 2 European, 1 Canadian, 6 US) completed the questionnaire, 7 of which were CSCs. Responding centers reported yearly average of 887 ischemic strokes (range 350-1444), and 202 (100-501) primary hemorrhagic strokes. Average annual IV tPA volume was 168 (60-440) and EVT volume was 68 (12-130). At all 9 systems, EMS agencies were trained in identifying potential strokes and reported utilizing an established prehosptial stroke scale. Six systems (66.7%) reported a destination protocol based on stroke severity involving bypass to an EVT-capable center. All 9 centers have developed processes for expedited transfer of stroke patients in need of neurointervention from their non-EVT-capable referral hospital network. For patients with confirmed large vessel occlusion being transferred to the hub hospital, 5 (55.6%) centers reported these patients bypass the ED to go directly to the neurointervention suite.

Conclusions:
This international survey of progressive stroke systems reveals useful practice patterns and processes that can be adopted by other stroke systems to improve patient care. This information will be integrated into the IMPROVE Stroke program.
Abstract WP249: Speed of 911 Alarms and EMS Care in Hyperacute Intracranial Hemorrhage and Cerebral Ischemic Patients
Authors: Avila-Rinek Gilda , Brown Christa D , Sanossian Nerses , Young-Saver Dashiell F , Starkman Sidney , Hamilton Scott , Sharma Latisha , Liebeskind David S , Kim-Tenser May , Restrepo Lucas , Stratton Samuel , Eckstein Marc , Valdes-Sueiras Miguel , Pratt Frank , Conwit Robin , Saver Jeffrey L ,   on behalf of the FAST-MAG Trial Coordinators and Investigators
Published: October 2018

Introduction:
Among all stroke patients, intracranial hemorrhage (ICH) patients activate the 911 system sooner than cerebral ischemia (CI) patients. However, the temporal profiles of EMS alarm and response among hyperacute patients who may be enrolled in prehospital treatment trials has not been well delineated.

Methods:
We analyzed all final diagnosis acute cerebrovascular disease patients enrolled in the NIH Field Administration of Stroke Therapy-Magnesium (FAST-MAG) trial, in 315 ambulances transporting to 60 receiving stroke centers.

Results:
Among 1632 hyperacute cerebrovascular disease patients, final diagnosis was ICH in 23.7% and CI in 76.3%. Compared with CI patients, ICH patients were younger (65.3 vs 70.9, p < 0.001), less often female (33.3% vs 45.3%, p<0.001), and had greater deficits in the field (LAMS 4.1 vs 3.7, p<0.001), and upon ED arrival (NIHSS median 12 vs 7, p<0.001). Intervals from last known well to 911 call (LKW-to-alarm) did not differ between ICH and ACI patients (median 15 vs 16 mins, p=0.32); however, fewer ICH patients had prolonged LKW-to-alarm times ≥ 30 mins (25.1% vs 30.3%, p = .049). Intervals from symptoms first observed to 911 call (SFO-to-alarm) did not differ (11 vs 12 mins, p=0.40). Times from 911 call to paramedic arrival (alarm-to-on patient) were similar for ICH and CI patients (median 6 vs 6 mins, p=0.80), as were times from paramedic arrival on patient to ED arrival (scene-to-door) (median 32 vs 33 mins, p=0.46) and overall 911 call to ED arrival (alarm-to-door) (median 39 vs 39 mins, p=0.51). The nationally recommended alarm-to-on patient interval ≤ 8 minutes was achieved in 76% of ICH and 78% of CI patients.

Conclusion:
Speed of prehospital care is swift among hyperacute cerebrovascular disease patients, including 911 calls at 15 minutes after last known well, paramedic arrival on patient 6 minutes after 911 activation, and ED arrival 39 minutes after 911 activation. In the hyperacute window, ICH patients call 911 only slightly faster than ACI patients, and subsequent prehospital intervals of care are similar. In a busy metropolitan region, national alarm-to-on patient time targets were achieved in more than three-quarters of patients.
Abstract WP25: Calculate Probability in Each Pass of Stent-Retriever
Authors: Cardona Pedro , Lara Blanca , Quesada Helena , De Miquel Ma , Barranco Roger , Aja Lucia , Paipa Andres , Chirife Oscar , Rubio Francisco , Mora Paloma , Escrig Ana
Published: October 2018

Background:
Endovascular treatment with stent-retrievers has been approved and has demonstrated effective in treating strokes with large vessel occlusions. However number of passes through occluded artery and probability of recanalization in each artery could be an important technical and clinical topic.

Methods:
We performed an analysis of consecutives patients treated with stent-retriever from January 2011-May 2017. We analyze the number of passes to get recanalization (TICI 2b-3) according to occluded arteries. We assessed good functional outcome in Rankin scale (0-2) at 3 month, symptomatic intracranial hemorrhage (SICH) and mortality according to number of stent-retriever passes in each treated artery.

Results:
A total of 626 patients were analyzed, mean age 67+/-13, baseline NIH:17, OSTP (onset stroke time to groin puncture):268 min. Rankin 0-2 in 3month: 53%. Percentage of complete recanalization TICI 2-3 was 74% (43% after first pass of stent retriever, 65% in whom received a second pass, 76 % in third pass and 82% over four passes). Patients with few pass of stent retrievers (three passes) present a significant good functional outcome compared to patients treated with > 4 passes (61%vs19%), with same percentage SICH ( 7,4%vs8%). A variable associated to number of passes was OSTP. The percentage of successful recanalization (TICI 2b-3) with first-second pass of stent retriever were significantly different in TICA 54%, tandem 58%, basilar 56 % and 74% M1-M2 occlusions.

Conclusions:
Successful recanalization (TICI 2b-3) is highly probable till third pass of stent retriever. New devices could be tested in cases of failed recanalization after this third attempt.
Abstract WP26: The Effects of Blood Pressure Variation Within 24 Hours of Intracerebral Large Vessel Occlusion Mechanical Thrombectomy and Clinical Outcomes
Authors: Hussain Mohammed , Inoa Violiza , Rath Subhendu , Mehta Tapan , Modak Janhavi , Lima Jussie , Staff Ilene , Lee Daniel , Bruno Charles , Ollenschleger Martin
Published: October 2018

Introduction:
Mechanical thrombectomy (MT) is now the standard of care for acute intracranial large vessel occlusion (LVO). There are currently no established guidelines for post MT blood pressure parameters in LVO patients. Our study examines the influence of blood pressure fluctuation and variation within the first 24 hours on clinical outcomes in post MT LVO patients.

Methods:
A hospital based stroke registry retrospectively identified 111 consecutive patients undergoing MT for LVO (2012-2015). Blood pressure recordings within the 1st 24 hours post MT were analyzed: Maximum (Max), minimum, median and standard deviation (SD) of the systolic (SBP), diastolic (DBP) and mean arterial pressures (MAP) were calculated individually and as composite aggregates. Good outcomes were defined as National Institute of Health Stroke Scale (NIHSS) improvement of >=10 at discharge and or discharge NIHSS<=2 Poor outcomes were defined as post-MT intracerebral hemorrhagic (ICH) and mortality. Univariate (UV). and multivariate logistic regression (MV) were used to identify effect of blood pressure variation on good and poor outcomes. IBM-SPSS version 21 was used for data analysis.

Results:
On UV analysis a lesser degree of 24 hour post MT SBP (median 16, IQR (Inter Quartile Range) 13, 23 mmHg, p=0.03) and DBP (Median 10, IQR 8, 12 mmHg p .04) SD were associated with good outcome. Maximum SBP was associated with higher rates of mortality (median 188, IQR 174-195 mmHg, p=0.03) and ICH (median 179, IQR 167-196 mmHg, p=0.05). There is no statistically significant association between Post MT 24 hours DBP or MAP maximum, minimum, median and SD values with associated poor outcomes. On MV, SBP variance and maximum SBP were found to be significantly associated with good outcomes (Odds Ratio (OR) 1.09, 95%CI (Confidence interval) 1 - 1.2, p=0.04) and mortality (OR 1.02, 95%CI 1 - 1.004, p=0.02) respectively.

Conclusion:
Importance of proper blood pressure regulation within the 1st 24 hours of an LVO MT cannot be understated. To maintain good outcomes after MT, minimizing SBP SD becomes important. With the underlying premise of post cerebral ischemia induced vasomotor dysregulation, controlling Max SBP also decreases ICH and mortality. A prospective study is warranted to reinforce our findings.
Abstract WP261: Dcr1 and Dcr2 Protect Neuron Against Ischemia and Hypoxia Damage via Differential Mechanisms on Ischemia Preconditioning-Induced Neuroprotection
Authors: Xu Wei , Jin Wei , Zhang Xiaoxiao , Chen Jing , Liu Mingli , Zhang Shufan , REN Chuancheng
Published: October 2018

Objective:
To investigate the neuroprotective roles and mechanisms of DcR1 and DcR2 under ischemia and hypoxia.

Methods:
SH-SY5Y cell were used to build to oxygen glucose deprivation model (OGD) and ischemic preconditioning model (IPC) in vitro. CCK-8 and LDH were performed to evaluate cellular survival and cytotoxicity. Overexpressing DcR1, DcR2 and DR5 were induced by lentivirus vectors, knocking down DcR2 was conducted by siRNA technique in SHSY5Y cells. TRAIL Recombiant Human Protein was employed to activate the TRAIL induced extrinsic apoptotic pathway. Western blot was performed to evaluate the protein level of DcR1, DcR2, DR5, DR4, cleaved caspase-8, cleaved caspase-3 and tBid. Co-immunoprecipitation was used to investigate the interaction of DcR1, DcR2, DR5, DR4, TRAIL and caspase-8. Western blot was performed to evaluate the protein level of pAkt, and LY294002 was used to inhibit the activation of PI3K-Akt pathway.

Results:
We found that IPC ameliorated the cellular apoptosis and cytotoxicity (
P
< 0.01), reduced the protein level of DR5 (
P
< 0.05) and DR4 (
P
< 0.01), and upregulated the protein level of DcR2 (
P
< 0.05) after OGD. Besides, overexpressing DcR1 enhanced the protective effect of IPC to cells (
P
= 0.045,
P
= 0.01), and knocking down DcR2 abated the protective effect of IPC (
P
= 0.012,
P
=0.011) against OGD. Additionally, overexpressing DcR1 or knocking down DcR2 regulated expression of extrinsic apoptosis pathway related proteins, including caspase-8, cleaved caspase-3 and tBid. We also found that overexpressing DcR1 competitively combined TRAIL, suppressed DISC from assembling, and subsequently reduced extrinsic cellular apoptosis. Moreover, we discovered that overexpressing DcR2 inhibited the extrinsic apoptotic pathway via interacting with the extracellular domains of DR5, and up-regulated pAkt (
P
= 0.0081).

Conclution:
(1) DcR1 competitively bound with TRAIL, inhibited DISC assembling, and subsequently reduced extrinsic cellular apoptosis. (2) DcR2 inhibited the extrinsic apoptotic pathway via interacting with extracellular domains of DR5. (3) Besides with inhibiting TRAIL, overexpressing DcR2 exerted neuron protection by activating PI3K/Akt pathway.
Abstract WP263: Early Brain Injury After Subarachnoid Hemorrhage and It’s Potential Role in Epileptogenesis
Authors: Geraghty Joseph , Xu Hao-Liang , Muhammad Abdullah , Loeb Jeffrey A , Testai Fernando D
Published: October 2018

Introduction:
Subarachnoid hemorrhage (SAH) accounts for up to 5% of strokes each year and has a mortality around 40%. Early brain injury (EBI) develops within the first 72 hours of the SAH and involves neuroinflammation, activation of platelets and clotting factors, blood-brain barrier dysfunction, and neuronal loss. These changes set the stage for the development of further delayed brain injury and long-term impairments such as the development of seizures which is common after SAH. In this study we investigate the association of EBI and epileptogenesis.

Methods:
Using the endovascular perforation (EVP) model of SAH in rats, our lab has performed histological studies of EBI for markers including Iba-1 (inflammation), fibrinogen (microthrombosis), EBA (vascular integrity), and Flurojade B (FJB, neuronal degeneration). We coupled the EVP model with the implantation of subdural electrodes for long-term video electroencephalography (EEG) to characterize the development of interictal spikes and seizures following SAH. The EEG activity was continuously monitored for 4 months post-SAH.

Results:
Results of our study show a two- to three-fold increase in immunoreactivity of Iba-1, fibrinogen, EBA, and FJB following SAH compared to sham controls. EEG analysis demonstrated the presence of frequent interictal spikes during the first week post-SAH that often cluster and are periodic. By 3-4 weeks after SAH, clinical and subclinical seizures are observed that then increase in frequency and duration over time.

Conclusions:
This is the first study using long-term EEG monitoring to investigate the occurrence of seizures in the animal model of SAH. EBI after SAH is multifactorial and likely drives long-term deficits such as the development of a chronic epileptic condition. Neuroinflammation is a potential driver of epileptogenesis post-SAH. The use of immunomodulatory drugs in the late development of seizures in SAH may warrant further investigation.
Abstract WP265: Debunking the Myth of Regular Soda Beverages Use and the Risk of Incident Cardiovascular Events
Authors: Saeed Omar , Malik Ahmed A , Qureshi Adnan I
Published: October 2018

Objective:
The goal of this study was to determine the effect of soda beverage intake on occurrence of cardiovascular in diseases in a large prospective cohort of postmenopausal women.

Methods:
The data were analyzed for 93, 676 women 50-79 years of age who were enrolled in the observational arm of the Women’s Health Initiative Study. The effect of regular soda beverage intake (none or minimal, non-caffeinated, and caffeinated) on risk of ischemic stroke, hemorrhagic stroke, any stroke, myocardial infarction, and cardiovascular deaths was determined over a period of 12 ± 1 years (mean ± SD) using Cox proportional hazards analysis after adjusting for age, ethnicity, body mass index, systolic blood pressure, diabetes, cardiac catheterization, atrial fibrillation, and high cholesterol.

Results:
The rates of diabetes mellitus were higher among regular non-caffeinated and caffeinated soda beverage users compared with those with none or minimal use. Compared with women who were non-users or <1 /month, regular non-caffeinated soda beverage users (>1/wk) had a lower risk of myocardial infarction (hazards ratio [HR] 0.9, 95% confidence interval [CI] 0.8 - 1.0, p<0.02), and cardiovascular death (HR 0.8, 95% CI 0.7-1.0, p=0.02). Compared with women who were non-users or <1 /month, regular caffeinated soda beverage users (>1/wk) had a lower risk of any stroke (HR 0.89, 95% CI 0.80-1.0, p=0.05), hemorrhagic stroke (HR 0.69, 95% CI 0.0.47 - 0.97, p=0.034), and myocardial infarction (HR 0.90, 95% CI 0.81-1.0, p=0.056).

Conclusions:
There appeared to be no increase in risk of incident cardiovascular events in women using non caffeinated or caffeinated soda beverages despite higher rates of underlying diabetes mellitus.
Abstract WP267: Controlling Nutritional Status Score Predicts 3-Month Functional Outcome in Patients With Acute Ischemic Stroke
Authors: Naito Hiroyuki , Nezu Tomohisa , Hosomi Naohisa , Aoki Shiro , Kinoshita Naoto , Shimomura Ryo , Araki Mutsuko , Ueno Hiroki , Ochi Kazuhide , Maruyama Hirofumi
Published: October 2018

Background:
Malnutrition is an independent risk factor of poor outcome in acute ischemic stroke patients, but the indicator of malnutrition has not been well-established. The Controlling Nutritional Status (CONUT) score is reported to be a useful prognostic value of malnutrition in the cardiovascular diseases and malignant tumors. We investigated the relationship between the CONUT score and functional outcomes in acute ischemic stroke patients.

Method:
Acute ischemic stroke patients (n=264, 70±12 years old) within 7 days of stroke onset were consecutively studied. The CONUT score was calculated from the serum albumin, total peripheral lymphocyte count and total cholesterol and the CONUT score ≥5 was defined as malnutrition. In the present study, we obtained the blood samples for the CONUT score within 2 days after admission. The primary outcome was evaluated from the 3-month functional status: poor outcome as a modified Rankin Scale (mRS) score ≥ 3 and good outcome as a mRS score <3.

Results:
Of the total enrolled cohort, 230 patients (87.1%) were assessed for the functional outcomes. The patients with poor outcome (n=85) were older, lower body mass index (BMI), and more frequently had atrial fibrillation, chronic heart failure and anemia, and less frequently had dyslipidemia and current smoking. In addition, the CONUT score and National Institutes of Health Stroke Scale (NIHSS) score at admission were significantly higher in the patients with poor outcome. As the CONUT score was higher, the proportion of patients with poor functional outcome increased, and the poor functional outcome exceed 70% when the score was ≥ 5. Univariate logistic analyses showed that the CONUT score ≥5 was significantly associated with poor outcome at 3 months (odds ratio [OR] 6.05, 95% confidence interval [CI] 2.95-13.09, P<0.001). After multivariate analysis, the CONUT score ≥5, initial NIHSS score, and current smoking were independently associated with poor outcome (OR 4.15, 95% CI 1.52-11.67, P=0.005, OR 1.23, 95%CI 1.15-1.34, P<0.001, OR 0.14, 95%CI 0.03-0.53, P=0.002, respectively).

Conclusion:
The CONUT score at admission is expected to be a useful prognostic marker of a 3-month functional outcome in acute ischemic stroke patients.