bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP322: Small Vessel Disease Burden Alters the Clinical Phenotype of Acute Hypertensive Crises
Authors: Pektezel Mehmet Yasir , Topcuoglu Mehmet Akif , Gocmen Rahsan , Erbil Bulent , Kunt Mehmet Mahir , Metin Aksu Nalan , Oguz Kader K , Arsava Ethem Murat
Published: June 2021

Background:
Acute elevations in systemic blood pressure are associated with a wide array of manifestations involving the central nervous system, ranging from no overt neurologic symptoms or signs to catastrophic scenarios like intracerebral hemorrhage (ICH). Very little is known regarding the determinants of this clinical variability. In this study we determined clinical and imaging features of neurologically asymptomatic hypertensive crisis patients, patients with hypertensive ICH and hypertensive posterior reversible encephalopathy syndrome (PRES).

Methods:
Magnetic resonance imaging (MRI) data was prospectively collected from a consecutive series of patients admitted to the emergency department with a diagnosis of hypertensive urgency or emergency but no neurologic symptoms. Features of small vessel disease (lacunes, microbleeds, perivascular spaces, white matter hyperintensities) were rated and small vessel disease burden score was determined. These features, together with clinical characteristics, were compared to those of patients presenting with hypertensive ICH and PRES.

Results:
Patients with hypertensive ICH (n=58) comprised the group with the oldest age, longest duration of hypertension and highest burden of vascular risk factors, while the PRES group (n=9) signified the youngest group with short duration of hypertension and minimum number of vascular risk factors. The neurologically asymptomatic hypertensive crisis group (n=51) showed an intermediary phenotype not only with respect to these clinical characteristics, but also in terms of small vessel disease features. Multivariate analyses revealed advanced age (p=0.009), cerebral microbleeds (p<0.001) and small vessel disease burden (p=0.019) to be related with cerebral hemorrhage rather than asymptomatic hypertensive crisis or PRES.

Conclusion:
The clinical phenotype in the setting of an acute hypertensive episode depends on specific clinical and imaging features. PRES occurs in young brains not accustomed to chronic hypertension, while the episode results in ICH in old patients with a high small vessel disease burden and remains asymptomatic among patients devoid of such characteristics.
Abstract TP331: Right Insular Damage is Associated With New Onset Atrial Fibrillation in Patients With Acute Intracerebral Hemorrhage
Authors: Prats-Sánchez Luis , Pascual-Goñi Elba , Fayos Fernando , Painous Celia , Delgado-Mederos Raquel , Martínez-Domeño Alejandro , Camps-Renom Pol , Martí-Fàbregas Joan
Published: June 2021

Introduction:
The frequency and risk factors for new-onset atrial fibrillation (nAF) after acute intracerebral hemorrhage (ICH) are uncertain.

Hypothesis:
By analogy with ischemic stroke, we hypothesized that insular cortex damage may be a risk factor for nAF.

Methods:
This is an observational study of consecutive patients with spontaneous ICH. All patients underwent continuous bedside cardiac monitoring for at least 24 hours. We excluded patients with previous history of AF, recent myocardial infarction and ischemic stroke. We prospectively collected the following variables: Demographic data (age and sex), traditional vascular risk factors, neurological severity (assessed with the Glasgow scale coma score), vital signs, laboratory and radiological data (localization and volume of the hematoma, concomitant intraventricular or subarachnoid hemorrhage), and detection of nAF. A blind evaluator using an interactive brain atlas assessed the insular cortex damage. Bivariate and multivariate regression analyses were performed to describe nAF risk factors.

Results:
We included 167 patients who fulfilled the inclusion/exclusion criteria. Mean age was 70.5±14.7 years and 56.8% were men. Cardiac monitoring was initiated after a median of 240 minutes (interquartile range 67-720) of the onset of ICH symptoms. We detected nAF in 9 patients (5.3%). Patients with nAF were older (75.6±13.1 vs 70.5±14.7 years, p=0.30) and most of them were men (8/9 vs 87/158, p=0.07) but these differences did not reach the statistical significance. We observed that right insular cortex damage (3/9 vs 9/158, p=0.019) and any insular cortex damage (5/9 vs 25/158, p=0.010) were more frequent in nAF patients. In the logistic regression analysis right insular cortex damage (OR 8.2; 95% CI 1.7-38.4, p=0.007) was associated with nAF.

Conclusion:
The frequency of nAF in patients with spontaneous ICH is 5.3%. Insular cortex lesions, probably due to the central autonomous nervous system dysregulation, are associated with nAF. This finding may have important implications in the hemodynamic and antithrombotic management.
Abstract TP332: Intracerebral Hemorrhage Volume to Edema Volume Ratio Predicts Poor Functional Outcome in Young Patients with Non-Lobar Primary Intracerebral Hemorrhage
Authors: Hays Shapshak Angela , Sisson April , Singh Mini , Lyerly Michael J , Albright Karen
Published: June 2021

Background and Purpose:
Cerebral edema is known to contribute to clinical decline in patients with spontaneous ICH. We sought to evaluate the significance of cerebral edema on outcome in young patients with primary ICH.

Methods:
We performed a retrospective review of patients presenting to our CSC center from 2014-2015 with primary ICH, excluding patients with lobar ICH and age 55 and above. Patients were grouped according to functional outcome at discharge (mRS 0-3 vs. 4-6). Imaging characteristics of those with poor short-term functional outcome (mRS 4-6) were compared to those with mRS 0-3. Receiver Operating Characteristics curves were used to evaluate the discriminatory ability of imaging characteristics with regards to poor functional outcome.

Results:
A total of 38 patients met inclusion criteria (mean age 47, 42% black, 55% male). On presentation, patients with poor functional outcome had larger mean ICH volume (26 vs 9cc; p=0.020), higher ICH volume to edema volume ratios (2.0 vs. 0.7, p=0.010), more evidence of midline shift (38% vs. 6%, p=0.026), and IVH (52% vs. 17%, p=0.043). Groups did not differ in terms of edema volume, amount of midline shift, evidence of hydrocephalus, or herniation. ICH volume to edema volume ratio was a better discriminator of poor outcome (AUC=0.813, p=0.006) than ICH volume (AUC=0.802, p=0.008, Figure 1a). Further, ICH volume to edema volume ratio was a better discriminator of poor outcome (AUC=0.801, p=0.009) than ICH score (AUC=0.724, p=0.051, Figure 1b).

Discussion:
Among young patients with non-lobar primary ICH we observed that the ICH to edema ratio was a better predictor of poor functional status at discharge than ICH volume or ICH score.
Abstract TP333: Transferred ICH Patients Are Less Frequently Screened For Illicit Drugs
Authors: Cline Brandie , Gazi Melissa , Lyerly Michael , Albright Karen , Gropen Toby
Published: June 2021

Introduction:
Despite the fact that illicit substance use has been associated with intracerebral hemorrhage (ICH), it is not standard care to perform a urine drug screen (UDS) on all patients presenting with stroke symptoms. We examined predictors of performing a UDS in ICH patients and possible predictors of a positive UDS of those screened.

Methods:
We conducted a retrospective analysis of 180 patients diagnosed with ICH between September 2014 and November 2015. We compared demographics, clinical features including reported substance abuse and discharge disposition in the patients who received toxicology screening against those who did not. Logistic regression was performed to assess predictive factors for toxicology screening and the likelihood of a positive toxicology.

Results:
We identified 180 ICH patients of whom 123 received toxicology screening on arrival. There was no significant difference in sex, age, or race between the groups. A UDS was less likely to be performed if the patient transferred from an outside institution (48% vs 68%, p=0.01). Direct presenters had higher odds of getting a UDS compared to transfer patients, (OR: 2.4, 95% CI 1.2-4.9, p=0.01). Of those screened, 38% had a positive UDS. Race and sex were not significant predictors of toxicology results while age< 65 had higher odds of a positive toxicology compared to older patients (OR:4.5, 95% CI: 1.85-10.86, p=0.0009). Although most neuroimaging parameters of the ICH did not differ based on UDS, those with hydrocephalus had greater odds of having a positive UDS (OR 3.0, 95% CI 1.3-6.8, p=0.007)

Conclusion:
In our sample, we found that only two-thirds of patients received a UDS. Although transferred patients were less likely to receive screening, we did not identify other significant predictors of physician UDS ordering behavior. We found a high rate of positive UDS, particularly among younger patients, suggesting that routine drug screening should be performed in all patients with ICH.
Abstract TP335: Hospital-Acquired Infection is Associated with Poor Outcome in Young Adults with Hemorrhagic Stroke
Authors: Sundheim Kathryn M , Miller Eliza C , Willey Joshua Z , Marshall Randolph S , Shao Yuefan , Boehme Amelia K
Published: June 2021

Background and Purpose:
Infections are associated with poor outcomes in young people with ischemic stroke, particularly if they are hospital-acquired. However, the influence of infection on hemorrhagic stroke outcomes in a young population is less well characterized.

Methods:
We conducted a single-center retrospective analysis of a prospectively collected stroke registry, for patients, aged 18-45, admitted with hemorrhagic stroke of any type from 01/2008 to 03/2015. We reviewed charts for study variables, including patient characteristics, risk factors, and hospital-acquired infections (HAI) or infections present on admission (POA). Poor outcome was defined as modified Rankin score of 3-6 at time of discharge. We compared patients with HAI and infection POA to those without an infection.

Results:
Of the 219 hemorrhage cases in young adults, 31 (14%) had an infection POA, and 65 (29.7%) had a HAI. As shown in the table, patients who had a HAI and a POA infection had higher baseline NIHSS than those without an infection. In the unadjusted analyses, POA infections (OR = 2. 96, 95%CI: 1.91-4.58) and HAI (OR= 6.51, 95%CI: 4.06 - 10.44) are associated with poor mRS on discharge for hemorrhagic stroke. Adjusting for NIHSS, the relationship between POA infections and poor outcome is no longer significant (OR = 1.45, 95%CI: 0.34- 6.27) while HAI remains associated with poor outcome (OR= 6.73, 95%CI: 2.22 - 20.41). In SAH only patients, after adjusting for NIHSS, HAI remains associated with poor outcome (OR = 21.61, 95%CI: 3.35 - 139) while POA infections are not associated (OR = 3.01, 95%CI: 0.294 - 30.8). In ICH only patients, after adjusting for NIHSS, neither HAI (OR = 3.18, 95%CI: 0.656 - 15.4) nor POA infections (OR = 2.19, 95%CI: 0.334- 14.3) are associated with poor outcomes.

Conclusions:
In our single-center study, HAI, but not infections POA, were associated with poor outcomes in young adults with SAH. This relationship was not seen in patients with ICH.
Abstract TP336: Characteristics and Outcome of Patients With Acute Intracerebral Hemorrhage Who Overuse Alcohol
Authors: Avellaneda-Gómez Carla , Serra Martínez Maria , Gómez González Alejandra , Rodríguez-Campello Ana , Ois Angel , Cuadrado-Godia Elisa , Jiménez-Conde Jordi , Giralt-Steinhauer Eva , de Ceballos Cerrajería Pablo , Zabalza de Torres Ana , Roquer Jaume
Published: June 2021

Background:
Alcohol overuse (AO) is considered a cause of spontaneous intracerebral hemorrhage (ICH), but the clinical and outcome characteristics of these patients (AO+ICH) are not well known.

Methods:
All patients with ICH admitted from January 2005 to June 2015 to a single university tertiary stroke center were prospectively studied and followed up during 5 years. Demographic features, radiological characteristics, and clinical outcome of patients with acute ICH and previous heavy alcohol intake (>40 gr/day or >300 gr/week) were analyzed.

Results:
During the study period, 609 patients with ICH were admitted. Nineteen patients were excluded because data on alcohol intake was not available. At admission, 83 patients (13.6%) were identified with AO (22.7% of men vs 2.9% of women; p< 0.0001) and was more frequent in younger patients (mean age, 63.11 years, compared to 72.7 years overall; p< 0.0001). Smoking was associated with AO (63,9% vs 13,8% non-AO; p< 0.0001) but not significant differences were found according with cardiovascular risk factors (dyslipidemia, diabetes and hypertension). ICH score was lower in the AO group (1.3 vs 1.8, p= 0.009) and deep ICH were more frequent (p= 0.036), compared to non-AO. Adjusted by sex, age, and high blood pressure, a trend in favor of increased deep ICH in AO patients remained (HR: 1.68 [95% CI: 0.92-3.05], p= 0.086). Adjusted mortality at 3-month, 12-month, and 5-year follow-up was similar in both groups.

Conclusions:
AO was present in 13.6% of ICH patients. These patients were an average of 11.5 years younger, predominantly men, and smokers, compared to the non-AO group. Adjusted short-term and long-term mortality was similar in AO and non-AO groups.
Abstract TP338: Differences Between the Modified Rankin Scale and Barthel Index in Measuring Intracerebral Hemorrhage Recovery at 12 Months
Authors: Sreekrishnan Anirudh , Leasure Audrey , Zhou Sonya , Amin Hardik , Petersen Nils , Hwang David , Schindler Joseph , Gilmore Emily , Sansing Lauren , Greer David , Sheth Kevin
Published: June 2021

Background:
The modified Rankin Scale (mRS) and the Barthel Index (BI) are both commonly employed measures of recovery used in intracerebral hemorrhage (ICH) patients. While these measures have been utilized routinely between 3 to 6 months post-hemorrhage, few outcome studies have compared improvements in these measures in long-term outcome.out to one year. The aim of this study was to examine differences in improvement across these measures through up to 12 months post-ICH.

Methods:
139 patients diagnosed with primary ICH at Yale-New Haven Hospital were prospectively enrolled in this observational study between July 1, 2014, and July 1, 2016. Patient recovery was evaluated using the mRS and BI at discharge, 3 months, 6 months, and 12 months. Repeated-measures parametric and non-parametric testing was conducted to examine improvement in measures over time.

Results:
Using the BI, there was a significant improvement across time points (p = 0.005), with follow-up testing showing improvement between discharge and 3 months (p < 0.001), 6 months (p < 0.001), and 12 months (p = 0.036), and between 3 months and 12 months (p = 0.021). There was no significant trend in mRS scores across all time points in non-parametric testing (p > 0.05). Between individual time points, there was a significant improvement in mRS scores between discharge and 3 months (p = 0.004) as well as 6 months (p = 0.010).

Conclusions:
These results suggest improved recovery of ICH patients in activities of daily living up to 1 year post-hemorrhage. While the mRS has a plateau effect in measuring recovery for this patient population between 3 and 6 months, the BI may be a more sensitive measure for assessing recovery up to 12 months.
Abstract TP346: Pge2 Ep1-4 Temporospatial Expression Level Changes in the Brain After Intracerebral Hemorrhage in Young, Aged, and Ep1 Deficient Mice Suggests Cross-talk Interactions
Authors: Leclerc Jenna L , Fadool Andrew R , Bailes Julie C , Chambers Chase , Doré Sylvain
Published: June 2021

Intracerebral hemorrhage (ICH) is the most severe form of stroke with the highest mortality. Neuroinflammation contributes to ICH-induced brain injury and the upregulation of prostaglandin E
2
(PGE
2
) has been implicated in modulating these deleterious pathways. PGE
2
acts mainly on four G-protein-coupled E Prostanoid (EP) receptors, EP1-4, each having different downstream pathways, tissue distributions, and expression profiles. Our previous studies demonstrate that EP1 receptor deletion promotes injury following ICH; whereas, deletion of EP2 and EP3 is neuroprotective in an equivalent approach. Here, we aimed to investigate the time course, brain sub-region expression profile, and relative level of EP1-4 mRNA expression in young (5-7mo) and aged (12-13mo) wildtype (WT) and EP1-/- mice. Following ICH or sham surgery, EP1-4 mRNA levels were assessed by RT-qPCR whereby the relative fold change of the gene of interest were determined using the reference gene Tbp and the 2
-ΔΔCT
method relative to the control. Minimal EP1-4 expression changes are seen at 24h after ICH; although, EP2 (p=0.036) and EP4 (p=0.066) are 1.6X increased in the cortex of young WT mice. At 72h post-ICH, EP1 is 3.9x elevated in the cortex (p=0.0003) and 4.6x in the striatum (p=0.012). EP3 is also 1.6x elevated in the cortex (p=0.044). In the contralateral hemisphere, a mean 2.4x increase of EP1-4 (p<0.01) expression is seen. In contrast, at 72h after ICH, EP1-/- mice have 0.53x reduced EP3 in the cortex (p=0.030) and 0.68x and 0.71x decreased EP3 (p=0.016) and EP4 (p=0.049), respectively, in the contralateral. Aged EP1
-/-
mice show significantly decreased expression levels of EP2-4 in nearly all areas. Due to the contralateral differences, basal expression levels of EP2-4 were investigated in the EP1-/- mice, where EP2 is 2.6x, 3.4x, and 3.8x increased in the cortex, hippocampus, and cerebellum; whereas, EP3 trended oppositely. These data indicate a cross talk between EP1 and the other EP receptors pre- and post-ICH and an association between age and EP receptor expression levels. A better understanding of EP receptor localization and dynamic expression levels after ICH will spark the development of effective pharmacological treatments.

Funding: NIH F31NS086441 (JLL) and R01NS046400 (SD)
Abstract TP353: Implementing a Nurse Driven Patient Education Program to Improve Understanding of Stroke Signs and Symptoms and Personal Risk Factors Post-discharge
Authors: Coyle Jennifer , Szlachta Carolyn , Merkel Lori , Labella Giuliana , Casey Stephanie
Published: June 2021

Purpose:
Nurse led patient education programs to improve patient understanding of the signs and symptoms (s/s) of a stroke and their personal stroke risk factors can play a significant role in preventing secondary stroke. No such initiatives could be found for an urban academic medical center in the United States when conducting a literature search, despite a Healthy People 2020 edict to address stroke awareness in adults. The goal of this project was to improve patient understanding of s/s of stroke as well as personal risk factors, and to ensure smooth patient transitions to the community.

Method:
A tool was developed for charge nurses to use when providing education to patients. The tool included patient demographic information and patient specific stroke risk factors. The previously used script for phone calls included signs and symptoms but was modified to include personal risk factors and corresponding behavior modification. All patients, discharged to home with a diagnosis of stroke or transient ischemic attack (TIA), were called within two weeks of discharge per the Joint Commission Comprehensive Stroke Center recommendation. Two attempts were made to reach each patient and a detailed log was maintained to track patient’s response to questions.

Results:
In the two months prior to the project being initiated, there were 37 patients reached via phone who had been discharged home from the stroke unit with a diagnoses of stroke or TIA. Of the 37 called, there were 5 who were unaware of the s/s of a stroke. For the two months since beginning the intervention, 42 successful calls were made to patients discharged home. Of these 42, only 2 patients did not know the s/s of stroke or their personal risk factors (p value: 0.16).

Conclusions:
This project allowed for a new approach to patient focused, nurse led education to improve patient understanding of the s/s of a stroke and individual risk factors. There was a ten percent improvement in the number of patients with an understanding of the s/s of a stroke. An encouraging outcome from this project was an improvement in RN Communication scores on patient’s HCAHPS surveys in the two months since starting the intervention.
Abstract TP354: Decreasing Door to Needle Times in Acute Stroke: A Multidisciplinary Approach
Authors: Kupniewski Sonny , Duncan Rachael , van Vliet Rebecca
Published: June 2021

Background:
IV tPA is the only drug approved for the initial treatment of acute ischemic stroke, and can only be given within 3-4.5 hours from stroke symptom onset. Studies demonstrate that for every 15-minute reduction in door to needle time (DTN) there is a 5% lower odds of mortality. The faster tPA is administered, the better the patient’s chance for a meaningful recovery.

Purpose:
As part of an ongoing initiative to decrease DTN times, we applied the concept of “mobile mixing” to our stroke alert process. Typically, tPA is mixed in the main pharmacy and delivered to the CT scanner, which occasionally resulted in a delay in care. The mobile mixing process gives the pharmacist the resources necessary to compound tPA for immediate use while the patient is still in CT.

Methods:
We began work on this quality improvement project in August 2015. Our multidisciplinary team, consisting of advanced practice providers, pharmacists, nurses, and our stroke medical director, met monthly to design and evaluate our pilot process. Pharmacy created tackle boxes containing the medications and supplies required to mix and administer tPA. We addressed staffing challenges, held mock stroke alerts; collected data on response times for a six-week period, and evaluated the impact this intervention made on our times.

Results:
During the pilot period, we treated 10 patients with tPA with a median DTN of 23.5 minutes. Further, as of July 2016, we gave tPA 60 times with a pharmacist present with a median DTN of 23.5 minutes. This has translated into a 2016 year-to-date DTN of 23.5 minutes. Members of the stroke team acknowledge that this process has also contributed to an increased sense of patient safety and team collaboration.

Conclusions:
The mobile mixing project has had a direct positive impact on patient care. The faster we give tPA, the faster the patient is then ready for the angiography suite if he or she is candidate for mechanical thrombectomy. In stroke, every minute counts and the mobile mixing project is one piece of the well-oiled machine that achieves a positive outcome for patients every day.
Abstract TP357: Risk Factors of Stroke Among Community- residing Patients with Chronic Obstructive Pulmonary Disease (copd)
Authors: Song Hee-Young
Published: June 2021

Introduction:
Worldwide, chronic obstructive pulmonary disease (COPD) and stroke are leading causes of death. Increasing evidence suggests that COPD patients have a higher risk of stroke than the general population

Objectives:
This study was undertaken to investigate risk factors of stroke including concurrent cardiovascular disease(CVD); to explore differences of these variables and their relationships according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage among community-residing patients with COPD.

Methods:
A total of 118 participants with mean aged 69.4 years old were recruited among those patients with COPD who have been treated at the outpatient department of pulmonology at a University hospital in an urban area of South Korea. Along with BP and anthropometric measurement, trained interviewers interviewed participants with a structured questionnaire including demographic characteristics, lifestyle risk factors, and comorbid CVD. Data were analyzed using SPSS statistics 20.0

Results:
Most of participants (89.8%) were men, almost half (50.4%) of them were categorized into GOLD stage II, and 39.3 % and 10.3 % of them were GOLD stage III and IV, respectively. Mean systolic BP of participants was 123.8 mmHg and mean diastolic BP, 80.3 mmHg. Seventy percent of them were currently non-smoker and 45% of them did not drink. Sixty eight percent of them had no CVD, while 32% of them had been diagnosed with and treated due to hypertension, atrial fibrillation, or coronary artery diseases. The duration of COPD diagnosis was significantly shorter among those who had comorbid CVD. There were no significant differences in histories of smoking or drinking according to the GOLD stages. However, those in GOLD stage II had more CVD than those in COLD stage III and IV. Also, age and BMI showed significant differences according to the GOLD stages.

Conclusions:
The findings demonstrated the presences of stroke risk factors and possible associations between some risk factors, such as comorbid CVD, and COPD severity among patients with COPD. Further research is needed to explore the precise relationships among stroke risk, concurrent CVD, and the severity, duration, treatment of exacerbations of COPD among this population.
Abstract TP367: Decreasing Decision to Transfer Times
Authors: Sorenson Denise , Cooke Jason , Loll Lisa
Published: June 2021

Novant Health Greater Charlotte market is comprised of three advanced primary stroke care centers; one providing 24/7 stroke interventional radiology coverage. To expedite the transfer of patients meeting criteria for mechanical thrombectomy, the stroke best practice teams in the two community primary stroke centers collaborated to develop a protocol to improve the decision to transfer time to meet a goal of 120 minutes from door to skin puncture time, regardless of original transport destination.

The Novant Health Charlotte market teams realize the benefit of cohesive physician coverage among the Emergency Department, Radiology and Inpatient Neurology physician providers. CTA scans performed in the non-interventional facilities are readily available to Neuro-Endovascular Radiologists, allowing for prompt interpretation and mobilization of the IR team to prepare for patient arrival.

Recognizing internal critical care transport resources are limited and may not be available, the process was facilitated by the development of an activase transport protocol implemented by Mecklenburg County EMS in June of 2016. Since actual transport time is affected by traffic patterns in urban areas, the controllable measure selected by the teams was decision to transfer time.

Prior to the initiation of the protocol, the median decision to transfer time for ischemic stroke patients requiring tertiary care was 66.5 minutes. Post protocol implementation the median time was reduced 32% to 44.5 minutes. Across the market, median door to skin puncture time in 2016 is 131.5 minutes.

Ongoing evaluation of the transfer process, and multidisciplinary IR case review with identification of process variation is key to the success of this initiative. The Emergency Department at the tertiary care facility has been an instrumental partner in identifying issues that are barriers to timely throughput of these patients.

A consistent feedback process informs all team members regarding patient outcomes. Individual case feedback is provided to all direct care givers, EMS crews and stroke team leaders, usually within 24 to 48 hours of the intervention. This data is shared monthly with the stroke best practice teams at the transferring facilities.
Abstract TP37: Negative Diffusion-Weighted Imaging in Mild Ischemic Stroke Patients: An Exploratory Analysis of a Single-Center Six-Year Cohort
Authors: Schmitz Marie Louise , Andersen Grethe , Mikkelsen Irene , Madsen Mette H , Vagal Achala , Simonsen Claus Z , Khatri Pooja
Published: June 2021

Background:
DWI-negativity was observed in nearly one third of patients with non-disabling ischemic stroke in a recent study and complete reversal of DWI-positivity was reported in 2% of mild-moderate strokes after IV rtPA treatment. We sought to identify acute DWI-negativity and DWI reversal rates in an independent cohort treated with IV rtPA because of mild stroke symptoms (defined as NIHSS 0-5).

Methods:
We reviewed a prospective single-center registry of consecutive, IV rtPA-treated patients at Aarhus University Hospital from 2004 to 2010 with a substantial number of strokes with low (0-5) NIHSS scores and reviewed their acute (<4.5 hours) and 24-hour MRI characteristics. Acute MRI is standard stroke work-up imaging at our center (except for patients with MRI contraindications). The local practice was to prefer IV rtPA treatment in mild stroke patients if clinical suspicion was supported by either MRI DWI positivity or other imaging data (MRI-perfusion lesions or visualized arterial occlusions on MRA). Only patients with final diagnoses of ischemic stroke upon hospital discharge were included in this analysis.

Results:
Among 694 patients treated with IV rtPA from 2004-2010, 266 (38.3%) had NIHSS 0-5. Among these mild stroke patients, 238 received acute MRI and 107 had 24-hour follow-up MRI. Acute DWI-negativity was observed in 32/238 (13.5%; 95% CI 9.4-18.4) patients prior to IV rtPA treatment. Among the cohort with both acute and 24-hour MRIs, acute DWI-negativity was present in 15/107 (14.0%) patients and persisted in 8/15 (53.3%; 95% CI 26.6-78.7). Of 92 DWI-positive patients, only 2/92 (2.1%) became DWI-negative at 24 hours. An association of acute DWI-negativity with younger age (OR 0.98; 95% CI 0.96-1.01) or lower NIHSS (OR 0.90; 95% CI 0.69-1.18) was not found in this cohort.

Conclusions:
Acute DWI-negativity was observed in ~14% of ischemic strokes with NIHSS 0-5, and half remained negative at 24 hours following IV rtPA. DWI reversal from positive to negative, possibly representing an averted infarction, occurred in 2% of patients. These rates may be lower than the true rate of DWI-negativity and reversal in mild stroke, given limitations of this analysis, including DWI-positivity influencing the initial IV rtPA decision.
Abstract TP380: Improving Outcomes for Stroke Patients at Risk for Cognitive and Mood Impairments
Authors: Djoeva Sanny , Lara-Angulo Melissa N
Published: June 2021

Background:
Improved survival rates of stroke patients have resulted in a rise in disability within this population. Research demonstrates that stroke patients are at high risk for cognitive decline and depression. Neuropsychological intervention can improve outcomes for this population. At an academic medical center in the Midwest, the process in which stroke patients are screened for these impairments and subsequently referred to a neuropsychologist is ineffective.

Purpose:
The purpose of this quality improvement project was to critically appraise the process in which stroke patients are screened for cognitive decline and depression and to improve the process using a multi-disciplinary approach of nursing, medicine, rehabilitation and neuropsychology.

Methods:
A total of 231 patient charts were reviewed in this quality improvement project. The Plan-Do-Study-Act model was utilized. Process changes included: provider education on order placement of neuropsychology referrals, occupational therapist education on correct progress note use, and improvement of visibility of the stroke patient list to screening staff. Pre- and post-intervention data were examined to assess for changes in screening compliance and consultations.

Results:
Baseline data collected December 2016 showed 64% compliance with Montreal Cognitive Assessment (MoCA) screening, 50% compliance with Patient Health Questionnaire (PHQ-2) screening, and 50% compliance with neuropsychology referral. After new processes were implemented, April 2016 data showed 100% MoCA compliance, 95% PHQ-2 compliance, and 100% neuropsychology referral compliance. Although these numbers look promising, we will continue to gather and analyze data to ensure this positive compliance trend continues.

Conclusion:
Multidisciplinary education and increased visibility of stroke patients requiring a screening may increase compliance of cognitive decline and depression screening as well as subsequent referral to neuropsychology. The increase in screening compliance will ultimately lead to appropriate referrals and further resources for the stroke population.
Abstract TP386: From Zero to Stroke Elite Gold Plus in Three Years
Authors: Kester Margaret C , Monczewski Maureen , Groody Angela , Cummings Christopher , Holland Neil , Zand Ramin
Published: June 2021

Background and Purposes:
Geisinger Community Medical Center is located in Scranton, Pennsylvania. We serve six counties with a population of 700,000. Due to the Scranton aging population, the incidence of stroke is 1.3 x the national average. We began our stroke program in March 2011 and grew to one of the best stroke programs in this region. Here, we describe our strategies leading to our success.

Subjects and Methods:
To achieve our goal ,beside employing routine strategies such as ongoing hospital-wide education and monthly stroke meetings; we took the following intuitive steps: 1. Recruited a stroke program coordinator who was a RN with a post-graduate degree, certified in neurological nursing and rehab counseling with substantial experience in working in a trauma unit 2. Consistent presence of the stroke coordinator in the ER and an office on the stroke floor. 3. Developed a collegial relationship with all team members 4. Bottom-up approach to gain the trust and support of nursing staff and administration 5. Consistent real-time chart review of neurology / neurosurgery consults and scanning the emergency department patients’ list . 6. Develop an organized Feedback / Performance Improvement in stroke care. 7. Weekly Rehabilitation Collaboration Meeting. 8. Kept the ER medical service highly engaged in our stroke program by having regular meetings and offering on-site education and feedback 9. Recruited a Nurse Navigator and a Data Analyst.

Results:
Geisinger Community Medical Center became a Joint Commission designated Primary Stroke Center and obtained a Gold Plus status in 2013. Since then, the number of treated stroke patients has increased to greater than 550. We have met the American Heart and Stroke Association and Joint Commission criteria for over 90% (95%CI: 87.5-92.5) compliance for eight stroke core measures. Our intravenous thrombolysis rate significantly increased to 12.6% (95%CI: 9.8-15.4). We achieved Honor- Roll Elite award for decreasing Door to Needle time below 60 minutes in 2015.

Conclusions:
Our experience indicates a few simple strategies, can make a big difference in stroke care in community hospitals. A fledgling stroke center can rise from Zero to Gold Plus with Elite Status with careful planning, coordination and caring.
Abstract TP390: Continuous Quality Improvement Implementation Across a Large Stroke Network of Affiliated Rural Hospitals Demonstrates Improved Care
Authors: Bellamy Lisa M , Elkins Kelley L , Dobbs Michael R
Published: June 2021

Background and Purpose:
Currently, the stroke care network includes 28 affiliate hospitals. One of the network missions is to improve quality of care through an evidence-based, standardized approach. In 2014, a formalized continuous quality improvement process began.

Methods:
Each affiliate receives quality education and utilizes a data report to collect and submit monthly stroke data elements quarterly. Data were compared for system analysis.

Results:
18 of 24 (75%) affiliates submitted data in 2014, compared to 23 of 26 (88%) in 2015. For STK[PM]-7: dysphagia screening, 42% of the affiliates submitted data in 2014, compared to 73% in 2015. Out of the hospitals submitting inpatient data for both years, the average for all appropriate measures was 84% in 2014, compared to 88% in 2015. Of these, 27% (4/15) improved, 60% (9/15) remained the same and 13% (2/15) worsened on these inpatient measures. For CT interpretation time (
<
45 minutes), the average time was 50 minutes in 2014, and 52 minutes in 2015. 55% (6/11) improved on the CT interpretation time and 45% (5/11) worsened. For Door to Needle time (
<
60 minutes), the average time was 89 minutes in 2014, and 65 minutes in 2015. 70% (7/10) improved on the Door to Needle time and 30% (3/10) worsened.

Conclusions:
The network showed substantial improvement with the CQI program in: data submission rates, CT interpretation time, and Door to Needle time. Additionally, for inpatient measures, 87% of affiliates who submitted data for both years improved or remained the same. This is a great success overall. We believe this reflects focused improvement efforts at individual affiliates and network-wide. Areas for focus in the next year were determined: Door to Needle and CT interpretation times, STK-4, STK[PM]-7 and quality of abstraction.
Abstract TP398: Cognitive Performance Over Time in Children With Intracerebral Hemorrhage
Authors: Murphy Lexa K , Compas Bruce E , Gindville Melissa C , Reeslund Kristen L , Jordan Lori C
Published: June 2021

Introduction:
Spontaneous intracerebral hemorrhage (ICH) accounts for 40% of stroke in children. Few studies report cognitive outcomes and none have conducted serial testing over time. We hypothesized that children with ICH would continue to make cognitive improvements over a two-year period.

Methods:
Children with spontaneous ICH, including those with primary intraparenchymal hemorrhage (IPH) and/or intraventricular hemorrhage (IVH), were prospectively enrolled from 2011-2015 at a single institution. Two raters measured total brain volume, IPH, and IVH volumes. Outcome was assessed with the Pediatric Stroke Outcome Measure and a cognitive testing battery (Wechsler IQ) at 3 (T1), 12 (T2) and 24 months (T3) after ICH.

Results:
Sample included 7 children, 6-16 years (median=12.9); 2 had pure ICH, 1 had pure IVH, and 4 had both. Brain AVM was the cause of ICH in 6 of 7; 1 was idiopathic. Initial Glasgow coma scale ranged from 3-14 (median=9). Median hemorrhage volume as a percentage of brain volume was 1.96, interquartile range (IQR) 1.17-3.74. Total PSOMs improved over time from median of 3 (IQR=1.5-4.5) at T1 to 2 (IQR =0.5-3.0) at T3. PSOM worsened in 2 children, 1 with recurrent ICH (pt #2) and 1 with worsening expressive language and increased depression despite full surgical resection of AVM (pt #3). However, serial cognitive testing indicated greater heterogeneity over time, including general improvements in Verbal IQ and sustained low performance in working memory and processing speed in a subgroup (Figure).

Conclusion:
Children with spontaneous ICH may continue to improve cognitively over two years. However, cognitive performance is heterogeneous across participants and across domains of cognitive functioning with some worsening as cognitive demands increase developmentally with age. Clinical implications include the need for early and serial cognitive testing to assess for cognitive difficulties as children age.
Abstract TP399: Hemodynamic Imaging in Children with Transient Neurologic Symptoms
Authors: Lehman Laura L , Danehy Amy R , Bernson-Leung Miya E , Trenor Cameron C , Calahan Christopher F , Robertson Richard L , Rivkin Michael J
Published: June 2021

Children who present with transient neurologic symptoms raise concern for stroke as the underlying etiology. The rapid differentiation of stroke mimic from stroke in order to determine eligibility for hyperacute stroke treatment constitutes a unique and important diagnostic challenge in children. We used perfusion, diffusion, and magnetic resonance angiography (MRA) imaging to identify key imaging findings that together indicated a stroke mimic. We present a case series of 17 children who had transient neurologic symptoms and had MRA, perfusion, and diffusion weighted imaging in the acute period. The children ranged in age from 2 to 17 years of age. Among 17 children, 13 (76%) had headache at presentation. Thirteen (76%) children had focal MRA evidence of arterial pruning without occlusion, all had negative diffusion weighted imaging, and all showed evidence of hemispheric decreased perfusion by susceptibility-weighted imaging and/or arterial spin label perfusion imaging. Thirteen of 17 had left sided imaging findings. In all children who had repeat imaging (6/17;35%) these findings had reversed. No patient met clinical criteria for familial hemiplegic migraine. Only 6 (35%) had recurrence of transient neurologic symptoms since initial presentation; none had stroke. Use of combined MR imaging to include perfusion, diffusion and angiography can help to distinguish rapidly children who present with stroke mimics whose symptoms are likely to be transient and who do not require hyperacute stroke treatment.
Abstract TP40: Prediction of a Small DWI Lesion Using Single Phase Collateral Score and Noncontrast CT ASPECT Score
Authors: Hakimelahi Reza , Buch Karen A , Leslie-Mazwi Thabele M , Hirsch Joshua A , Rabinov James D , Gonzalez R. Gilberto , Schaefer Pamela
Published: June 2021

Introduction and Hypothesis:
Small initial DWI lesion volume (≤70 mL) is a strong predictor of favorable outcome post i IA thrombectomy and has been used for patient selection in multiple clinical trials. We sought to investigate if collateral and/or CT ASPECT scores could predict a small DWI lesion volume.

Methods:
We included 130 consecutive patients with CTA showing ICA and/or proximal MCA occlusions who underwent DWI within 8 hours of stroke onset. DWI lesion volumes were dichotomized to small (≤70mL) and large (>70ml). Collateral vessels were categorized to 5 groups: 0=none, 1=minimal, 2=less than 50%, 3=more than 50%, 4=equal and 5=more than the contralateral side. Logistic regression, ROC curve analyses and weighted Kappa test were performed.

Results:
In 130 patients, 62 female (48%), the average values (mean±SD) were: age 70±17 years, NIHSS 16±6, DWI volume 59±65 mL, time after stroke onset 4.4±1.8 hours, CT ASPECT score 6±2 and collateral score 3±1. Time, age, gender, or occlusion site (ICA vs MCA) were not independent predictors of a small DWI volume with p values all >0.05. Collateral score (OR 6.32, P<0.0001), CT ASPECT score (OR 2.37, P<0.0001), and NIHSS (OR 0.87, P<0.0003) significantly contributed to prediction of a small DWI volume. ROC curve analysis with both ASPECT and collateral scores contributing to predicted probabilities showed an AUC of 0.93. The AUC was 0.88 and 0.85 for collateral and ASPECT scores alone respectively. Collateral score ≥3 with ASPECT ≥9 yields specificity of 97.4% and sensitivity of 48.9% while collateral score ≥4 alone provides specificity of 97.4% and sensitivity of 38.9%, missing approximately 16% and 43% of potential candidates for IA therapy based on a DWI lesion volume < 70 mL respectively. Inter-rater agreements between two neuroradiologists were k=0.53 (41.5% agreement) for collateral and k=0.53 (32.3% agreement) for ASPECT scores.

Conclusion:
Collateral score alone or combined with ASPECTS can predict a small DWI lesion volume with high specificity. However, sensitivity is relatively low and inter-rater agreement is fair. These findings should be considered when DWI is not available to select patients for IA therapy.
Abstract TP403: Sex-Dependent Differences in a Mouse Model of Acta2-Related Cerebrovascular Disease
Authors: Wright Jamie M , Chen Jiyuan , Milewicz Dianna M
Published: June 2021

Moyamoya Disease is two to four times more common in females than males. The underlying mechanisms behind this are currently unknown. Missense mutations in
Acta2
predispose affected individuals to a variety of vascular diseases, including Moyamoya-like cerebrovascular disease. In this study we examined vessel wall thickness on H&E stained brain sections from WT and
Acta2-/-
male and female mice at 12 weeks of age (n=3 per a group). We found that female
Acta2-/-
mice had significantly greater percent vessel wall thickness compared to male
Acta2-/-
mice across all vessel sizes. There was not a significant difference between male and female vessel wall thickness in the wild-type groups. These findings in
Acta2-/-
mice suggest important sex-dependent differences in the function of α-smooth muscle actin (SMA) in the cerebrovascular system, and likely the vascular system as a whole. This has important implications for the design of studies examining the role of SMA in cerebrovascular disease and the investigation of novel therapies.

Figure. Percent wall thickness (%TH) by sex. Two-tailed two-sample t-Test assuming unequal variances: * = p<0.05, ** = p<0.005, *** = p<0.0005 and # = one-tailed t-test significant but not two-tailed. SL=short vessel diameter.
Abstract TP405: Psychological Outcomes After Childhood Arterial Ischemic Stroke
Authors: Maxwell Emily C , Ballantyne Tonia , Carlson Kathleen E , Hollatz Amanda L , Clevenger KC , Armstrong-Wells Jennifer , Bernard Timothy J , Boada Richard
Published: June 2021

Introduction:
Previous research has broadly documented that emotional and behavioral difficulties are seen after pediatric stroke; however, global ratings are generally reported without comparison to age-based norms. Additionally, little is known about the discrete symptomatology exhibited by these children. Thus, the goal of the present study was to evaluate specific psychological symptoms following childhood arterial ischemic stroke (AIS).

Hypothesis:
Children with AIS were predicted to have increased difficulties in both internalizing and externalizing symptoms compared to the normative sample. Age at AIS was anticipated to influence the presence of psychological symptoms, with internalizing symptoms occurring at higher levels when the AIS occurred at a later age.

Methods:
Participants were children (
n
= 50, mean age = 12.1 years) who suffered an AIS during childhood (range = 1 month to 17.1 years). Parents completed the Child Behavior Checklist at least 10 months post-AIS (mean = 4.1 years). Children were divided into groups by age at AIS: early (<6 years), middle (6-10 years), or late (>10 years) childhood. Data were analyzed using one-sample
t
-tests and ANOVA.

Results:
Children with AIS had significantly greater problems on the following DSM-oriented scales compared to the normative sample (all
p
-values < 0.01): Affective Problems, Anxiety Problems, Somatic Problems, Oppositional Defiant Problems, and Conduct Problems. There was a significant age-at-AIS effect on the Anxiety Problems subscale,
F
(2, 49) = 3.31,
p
= 0.05, such that the early childhood group had significantly higher levels of anxiety compared to the late childhood group.

Conclusions:
Increased internalizing and externalizing symptoms were seen in children with AIS compared to the normative sample, and a higher percentage of children with AIS exceeded a clinically significant threshold in each domain. Contrary to expectations, children who had AIS at an earlier age showed greater number of anxiety symptoms relative to same-age peers. Possible mechanisms for the latter may include changes in family dynamics when young children suffer a neurological injury. These results support the need for careful psychological follow-up in this vulnerable population.