bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 2396: Barriers to Improve IV tPA Door to Needle Time-Comparing Small Rural Hospitals and Primary Stroke Centers
Authors: Pittenger Jeanne , Hansen Anne , Fuhrman Sue , Polum Kathy , Wilson Marjorie , Gardner Michelle
Published: March 2022

Background and Issues-
Stroke continues to be a significant cause of morbidity and mortality in Wisconsin. Research has shown improved outcomes when IV tPA is started as close as possible to the time the patient was last known well. Wisconsin has continued to work on the improvement of stroke systems of care through rural and urban initiatives and the awareness of time critical factors.

Purpose-
To evaluate the current state of compliance with factors known to increase the percentage of eligible patients receiving IV tPA within 60 minutes of arrival in both rural and urban settings.

Methods-
Two benchmarking groups were established in Wisconsin through the Get With The Guidelines online Patient Management tool. The Rural hospital benchmark includes an average of 21 hospitals and the Primary Stroke Center (PSC) group includes 24 hospitals. A total of 15,783 patient records between Q1 2008 and Q4 2010 were reviewed.

Results-
Both groups show similar barriers in getting IV tPA to the patient within 60 minutes of arrival. The measures that showed the greatest opportunity for improvement included pre-notification of an acute stroke from EMS to the receiving hospital allowing the hospital team to prepare and CT turnaround time. The rural group received pre-notification 64.8% between 2008 and 2010 and the PSC group at 66.1% during that same time frame. Another time critical factor is CT <= 25 minutes. The PSC group achieved that timeframe 21.9% of the time, doing slightly better than the rural group at 18.5%.

Conclusions-
Structured outreach activities utilizing national initiatives such as the American Heart Association’s
Target: Stroke
has highlighted the distance between the current situation and desired goal. This indicates the need to implement targeted QI programs, with follow up data collection to increase DTN <60. Specifically targeting small rural hospitals has increased awareness of the current barriers in administering IV tPA. Wisconsin hospitals in both benchmarks have committed to work on the identified measures, analyze progress and resolve specific barriers to timely IV tPA administration.
Abstract 2399: Protocol for Rapid Acquisition and Interpretation of Head CT in Acute Stroke Patients Eligible for Thrombolysis
Authors: Mazabob Janine M , Brown Gerard , Livesay Sarah , Nguyen Thuy , Hu BeeBee , Suarez Jose , Bershad Eric , Smirnakis Stelios
Published: March 2022

Introduction
The American Heart Association’s quality improvement initiative, Target Stroke, is designed to reduce door-to-needle (DTN) times for IV r-tPA to improve patient outcomes. One of the quality indicators is time-to-CT scan and interpretation. Although, we were already meeting the recommended target, we sought to further enhance efficiency of this process in our institution.

Method
We performed a retrospective chart review of patients with CT Brain Acute Stroke protocol orders from January to December 2010, which represents a one-year period after instituting changes to our CT protocol. Some of the changes included: improved emergency medical service communication, streamlined patient registration and emergency department (ED) training on time-sensitive stroke care elements. CT scan times were analyzed based on time ordered, time of completion, and radiology interpretation. Our review included DTN for IV r-tPA administration for acute stroke patients during the same time period.

Results
Of the 571 acute stroke patients admitted through the ED during the study period, 12% received IV r-tPA. Of these, 79% received IV r-tPA within 60 minutes, with a mean (±SD) DTN time of 52 (±27) minutes. The relative efficiency of thrombolysis was attributed in part due to our fast-track CT head protocol process. The mean time from CT order to completion was 12 minutes and CT completion to verbal reporting to the ordering physician was 6 minutes.

Conclusion
Using a multi-disciplinary approach for quality improvement in CT acquisition and interpretation times, we were able to enhance the efficiency of our overall DTN time. We believe that our protocol is easily adaptable in any Neurointensivist led stroke service, and would benefit patients on a national level to allow for more rapid administration of IV r-tPA by reducing delays in the CT head protocol. Developing a strong infrastructure that is hard-wired and part of the institutional culture resulted in decreased CT times along with 79% of stroke patients receiving r-tPA in less than 60 minutes. Are efforts have paid off; our hospital has been designated on the Target Stroke Honor Roll.
Abstract 2408: Relationship between Outcome and Polyunsaturated Fatty Acids level in Acute Ischemic Stroke
Authors: Mishina Masahiro , Kim Kyongsong , Kobayashi Shiro , Katayama Yasuo
Published: March 2022

Introduction:
Fish intake is greater in the Japanese than in the Europeans and Americans, and the Japanese have higher levels of n-3 polyunsaturated fatty acids (PUFA) such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) than the Europeans and Americans. Although n-3 PUFA have attracted much attention in stroke management, relationship between n-3 PUFA and subtypes of ischemic stroke remains largely uninvestigated. The primary objective of this study was to assess the difference of the serum PUFA level among the subtypes of ischemic stroke in acute phase. Key secondary objective included assessment of relationship between good outcome and some laboratory data included serum PUFA.

Methods:
We retrospectively evaluated 697 consecutive patients with acute cerebral infarction who were hospitalized in our hospital. We excluded the patients who were not examined serum fatty acid fractions during their hospitalization. In this study, we selected 221 patients with lacunar infarction (LI; n = 85), atherothrombotic infarction (AT; n = 78) and cardiogenic embolism (CE; n = 58). On the day two or day three of hospitalization, all patients in this study were performed blood examinations with fasting state; low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), triglyceride (TG), blood glucose (BG), hemoglobin A1c by National Glycohemoglobin Standardization Program (HbA1c) and uric acid (UA). We also examined serum fatty acid fractions: icosapentaenoic acid (EPA), docosahexaenoic acid (DHA), dihomo-γ-linolenic acid (DGLA) and arachidonic acid (AA). We calculated EPA/AA, DHA/AA and DGLA/AA ratio. We used modified Rankin scale (mRS) to assess clinical outcome at discharge, and defined good outcome as mRS score ≤2.

Results:
EPA/AA ratio was 0.460±0.263 in the LI group, was 0.425±0.251 in the AT group, and was 0.389±0.193 in the CE group (not significant, Kruskal-Wallis test). DHA/AA ratio was 0.981±0.317 in the LI group, was 0.910±0.261 in the AT group, and was 0.877±0.268 in the CE group (not significant, ANOVA). DGLA/AA ratio was significantly higher in the LI group (0.221±0.067) than in the AT group (0.197±0.060, p<0.05) and in the CE group (0.195±0.056, p<0.05, Tukey-Kramer
post hoc
test). The probability for good outcome and independence was positively affected by diagnosis of LI (OR, 95%CI; 2.32, 1.18 to 5.00) and higher EPA/AA ratio (2.92, 1.42 to 6.24, logistic regression analysis).

Conclusions:
There was no significant difference in the serum EPA/AA ratio among the three stroke subgroups. Considering the confounding factors, high EPA/AA ratio was related with good outcome in the ischemic stroke. Our paper suggested that dietary habits before the attack might affect their outcome in the patients with ischemic stroke.
Abstract 2427: Significance of Susceptibility Vessel Sign on T2 Star Weighted-images to Predict Clinical Outcome following Emergency Endovascular Treatment in Patients with Probable Acute Embolic Basilar Artery Occlusion
Authors: Tajiri Hiroyuki , Mori Takahisa , Iwata Tomonori , Miyazaki Yuichi , Nakazaki Masahito
Published: March 2022

Purpose
The purpose of our retrospective study is to investigate whether or not susceptibility vessel sign of the basilar artery (SVS-BA) on T2*-weighted gradient echo images at 1.5T can predict clinical outcome after emergency endovascular treatment (EET) in patients where MRA suggests the embolic acute BA occlusion.

Materials and Methods
Included for retrospective analysis were patients as follows, (1) study period was from November 2005 to December 2010, (2) who were admitted to our institution within 8 hours from stroke onset, (3) who underwent emergency MR imaging including DWI, T2*WI, MRA at 1.5T and symptomatic and embolic acute BAO was diagnosed by MRA, (4) whose NIHSS score on admission was 10 or more, and (5) who underwent EET. Excluded were patients (1) in whom DWIs showed extensive high signal intensity area in pons or cerebelli, (2) who had contraindications for EET. They were divided into two groups according to presence (group P) or absence (group A) of SVS-BA on T2*WI. The relationships between the presence of BA-SVS and patients’ baseline characteristics on admission (age, gender), onset to admission time (OTA time), onset to treatment time (OTT time), NIHSS on admission (NIHadm), NIHSS on the 7th day (NIH7th), modified Rankin Scale at 3 months (3M-mRS) and estimated lengths of BAO on emergency MRA (eMRA) were investigated. Estimated lengths of BAO were graded according to eMRA as follows: grade 4, no occlusion; grade 3, occluded distal AICA; grade 2, occluded distal union; grade 1: not visualized. TIMI grades 2 and 3 were defined as successful recanalization.

Results
During the study periods, 17 patients were included for analysis. Successful recanalization was achieved in 11 patients (65%). In P (n=8) and A (n=9) groups, there were no significant differences statistically in age (mean; 73.6±15.2 and 68.1±14.0 years), man (%) (88 and 89), OTA time (median; 0.8 and 1.7 hrs), OTT time (median; 4.2 and 3.5 hrs), and NIHadm (median; 27 and 16). There were significant differences between two groups in BAO grade (median; 1.5 and 3), successful recanalization rate (%) (38 and 89), NIH7th (median; 35 and 8), 3M-mRS (median; 5.5 and 3) (p<0.05), respectively.

Conclusion
Clinical outcome following emergency endovascular treatment for probable acute embolic basilar artery occlusion was better in patients without SVS-BA on T2*WI than with SVS-BA. The SVS-BA on T2*WI seems to be a significant predictor for achieving less recanalization immediately after EET.
Abstract 2428: Nutritional Predictors Of Long-term Clinical Outcome In Patients Fed Through A Gastro-intestinal Tube Following Serious Acute Stroke.
Authors: Tajiri Hiroyuki , Mori Takahisa , Iwata Tomonori , Miyazaki Yuichi , Nakazaki Masahito
Published: March 2022

Purpose
The purpose of our retrospective study was to find nutritional predictors of long-term clinical outcome in patients fed through a gastro-intestinal tube following serious acute stroke.

Methods
Included were acute stroke patients as follows, 1) who were admitted to our institution from January 2008 to December 2009, 2) who undertook gastro-intestinal tube feeding due to serious neurological deficits. Patients who were comatose condition, suffered from gastro-intestinal bleeding or severe aspiration pneumonia on admission were excluded. Evaluated were patient’s baseline characteristics (age, gender, stroke subtype), NIHSS (NIH), albumin (ALB), total cholesterol (T-CHO), total lymphocyte count (TLC) and CONUT (CONtrolling NUTritional status: CON) score on admission (adm) and on the 7th day (7th). Correlation between variables and 3M-mRS was analyzed univariately and multivariately.

Results
During the study period, consecutive 805 acute stroke patients were admitted to our institution, 150 patients among them were included for analysis. The average age was 80.1±12.3 (±SD) years old, 68 were men (45.3%), and 103 were infarction(68.7%). There were statistically significant correlations between 3M-mRS and Age (ρ=0.309), NIH adm (ρ=0.357), CON adm (ρ=0.231), ALB adm (ρ=0.281), NIH 7th (ρ=0.498), CON 7th (ρ=0.496), ALB 7th (ρ=0.433), T-CHO 7th (ρ=0.309)(p<0.01) and TLC 7th (ρ=0.174) (p<0.05) in univariate analysis. Logistic regression analysis demonstrated that Age and CON 7th were independent nutritional predictors of 3M-mRS (p<0.01), and the cut-off value of CON 7th for good clinical outcome (3M-mRS: 0-2) was 3 by using ROC curve (AUC: 0.794, p=0.001, 74% of sensitivity, 73% of specificity).

Conclusions
In serious acute stroke patients who had to undertake gastrointestinal-tube feeding, the CONUT score on the 7th day was the independent nutritional predictor of 3-month clinical outcome. In order to achieve favorable clinical outcome at 3 month, nutrition management within 7 days of stroke onset is very important and CONUT score on the 7th day must be 3 or less.
Abstract 2437: Timing of Mobile Cardiac Outpatient Telemetry May Increase Diagnostic Yield of Atrial Fibrillation in Select Patients with Cryptogenic Strokes
Authors: Kandel Amit , Ching Marilou I , Covey Thomas J , Shucard David W
Published: March 2022

Introduction:
Cryptogenic stroke accounts for 30-40% of ischemic strokes. Routine Holter monitoring detects atrial fibrillation (AF) in only 5-7% of patients with ischemic strokes. However, prolonged cardiac monitoring increases the diagnostic yield of AF. Objective: In this study we used mobile cardiac outpatient telemetry (MCOT)and sought to determine 1)what percentage of our patients with cryptogenic stroke had underlying AF, 2) whether a period of highest diagnostic yield for AF could be derived and 3) whether there are clinical and electrocardiogram(EKG) parameters that predict AF in a select population.

Methodology:
Between March 2009 and December 2010, the data for 50 consecutive patients with MCOT at the stroke follow up clinic were analyzed. All had imaging, echocardiogram, EKG, hypercoagulable panel and at least 48 hours of in-patient cardiac telemetry monitoring. Of these, 16 were excluded because they either had no restricted diffusion on Diffusion Weighted Imaging (DWI) or had procedure-related strokes, hypercoagulable state or TEE detected mobile plaques in the ascending aorta.

Results:
The final 34 patients (19 males, 15 females, mean age of 62.8±12.9) had a diagnosis of cryptogenic stroke.Magnetic rasonance imaging( MRI) detected anterior circulation strokes in 67.6% (23/34) of the cases with the remaining being posterior circulation strokes or a combination of both. MCOT of 21 days duration was initiated up to a median of 8 weeks (2-24 weeks) post discharge. Overall, AF was detected in 29.4% (10/34) of the patients within a median of 8.5 days. Of these, the detection rates were 8.8% within the first 7 days and 26.5% within 14 days. Beyond 14 days, AF detection rate increased by only 3%. Regression analysis indicated that enlarged left atrial size (>4 cm) was not a significant predictor of AF in our patient population. The combination of stroke, dyslipidemia, coronary artery disease, atrio-ventricular block II type 1, supraventricular tachycardia and regional wall motion abnormality on echocardiogram however was correlated with a higher diagnostic yield of detecting AF on MCOT (r
2
=0.72).

Conclusion:
Occult AF is common in patients with cryptogenic stroke. We found increased detection of atrial fibrillation with monitoring between 7 to 14 days, especially in those with an underlying history of stroke, coronary artery disease and certain EKG rhythm abnormalities.
Abstract 2450: Assessing The Variability Of Ctp Post Processing Techniques To Define The Acute Infarct Core And Penumbra In A Large Dataset
Authors: Bivard Andrew , Levi Christopher , Parsons Mark
Published: March 2022

Aim:
In order to fully validate CTP for the selection of acute stroke patients for treatment, comparison of the accuracy of different deconvolution techniques to detect infarct core and penumbra is required.

Methods:
A cohort of 314 patients that presented with <6 hour hemispheric ischemia between 2004 and 2011 were studied retrospectively. Patients were imaged with multimodal CT at baseline and MRI at 24 hours. From the patient cohort, 133 had no significant reperfusion at 24 hours, so were suitable for the analyses to define the ischemic penumbra. Another 102 patients with major reperfusion at 24 hours, were suitable for the analyses to define the acute infarct core. Perfusion CT maps were generated using the Maximum slope (Peters) model, Partial Deconvolution (PD), Single Value Deconvolution (SVD), Single Value Deconvolution with Delay Correction (cSVD) and a Block Circulant Deconvolution (BCD). The perfusion CT maps were coregistered to the corresponding acute and 24 hour DWI. Receiver Operating Characteristic (ROC) Curve Analysis was used to test the predictive performance of CTP in relation to the DWI infarct core.

Results:
Using the Maximum slope model, a relative CBF 145% of normal (AUC 0.71) was demonstrated the best threshold to define the acute penumbra. Using the partial deconvolution approach CBF 155% of normal (AUC 0.73) and a TTP <4 seconds (AUC 0.74). The threshold to describe the acute infarct core with SVD was a CBF 6 seconds (AUC 0.77). Using SVD with delay correction a CBF 2 seconds +normal (AUC 0.81) accurately defined the acute penumbra. Using a block circulant method the infarct core was best defined by CBF <15 mL/100g/min (AUC 0.69) and a DT < 4 seconds (+baseline) is the most accurate when defining the acute penumbra (AUC 0.72).

Discussion:
cSVD was the most accurate method of defining both the acute infarct core and penumbra in this study. The SVD, BCD and max slope methods all produced different thresholds to define the acute stroke pathophysiology. Of note is that a CBF was always the best method to define the acute infarct core, regardless of the method. However the threshold to define the acute infarct core did vary. This is the first study to ever directly compare the acute threshold for tissue pathophysiology in ischaemic stroke with different CTP post processing methods.
Abstract 2497: Achieving Door-to-Needle Times of 37 minutes using a Streamlined Resident-Based Acute Stroke Protocol
Authors: Ford Andria L , Williams Jennifer A , Khoury Naim , Sampson Tomoko , McCammon Craig , Panagos Peter , Lee Jin-Moo
Published: March 2022

Background:
While tPA efficacy is enhanced by shorter delivery times, a recent analysis of the National Get-With-the-Guidelines stroke data demonstrated that only 29% of patients receive tPA < 60 min from hospital arrival. To further improve door-to-needle (DTN) times (time from patient arrival to time of tPA administration) within our resident-driven stroke protocol, we carefully reviewed our process to identify inefficiencies, leading to a revised protocol. We tested the efficiency and safety of the new, streamlined protocol comparing protocol metrics, symptomatic hemorrhage rates, and discharge outcomes before and after the changes.

Methods:
In early 2011, a value stream analysis (VSA) was conducted, identifying several inefficiencies within our tPA protocol which included: (1) routing of patients to room, then CT, then back to room; (2) serial processing of work flow; and (3) delays in waiting for labs. On 3/1/11, a new resident-driven protocol was adopted incorporating changes to minimize delays: (1) routing patients directly to head CT prior to patient room, (2) utilizing a parallel approach to process work flow, and (3) implementing point-of-care (POC) labs. We directly compared the “Pre-VSA” epoch (1/1/09-2/28/11) to the “Post-VSA” epoch (3/1/11-7/31/11) with regard to baseline variables, protocol metrics, and discharge outcomes. Wilcoxon Rank Sum test was used for continuous data and Fisher’s Exact test was used for binary data with p<.05 required for significance.

Results:
In the Pre-VSA epoch, 132 patients were treated with IV tPA (0-4.5hr window). In the Post-VSA epoch, 37 patients were treated with IV tPA. Baseline variables such as age, NIH Stroke Scale, and past medical history were similar between the 2 epochs except for greater proportion of African-Americans and hypertension in the Post-VSA epoch (
Table
). Median DTN and onset-to-needle times were lower in the Post-VSA epoch: 60 min pre-VSA vs. 37 min post-VSA (p<0.0001) and 131 vs. 102 min. (p=0.056, strong trend), respectively. Of the remaining metrics, door-to-CT time differed between the 2 epochs (16 min vs. 1 min, p<0.0001). To ensure that efficiency was not gained at the cost of patient safety, “Favorable” discharge location (discharge to home or inpatient rehabilitation), symptomatic hemorrhage rate, and percentage of stroke mimics (patients with non-stroke diagnosis at discharge) were compared and did not differ between the two groups (
Table
).

Conclusions:
A resident-based stroke protocol using efficient choreography, parallel processing, and POC labs can accelerate tPA delivery without compromising patient safety.
Abstract 2531: Gene Pathway Analysis In Young- Vs. Old-onset Ischemic Stroke
Authors: Kim Young J , Cheng Yu-Ching , Cole John W , Meschia James F , Nalls Michael , Sharma Pankaj , Kittner Steven J , Mitchell Braxton D
Published: March 2022

BACKGROUND AND PURPOSE:
Ischemic stroke is a heterogeneous complex disease that results from the interaction between numerous genetic and environmental risk factors. Stroke heritability is approximately 40% in the overall population, similar to that of cancer, although there may be important differences in the etiologies of young (<49 years old) versus older onset ischemic stroke. The goal of this study was to conduct a mechanistic genome-wide association (GWA) analysis contrasting the gene pathways involved in young- and old-onset stroke.

METHODS:
Our analysis included 946 young subjects (448 ischemic stroke subjects and 498 age and sex matched controls, mean age of stroke onset 41 years) and 2558 older subjects (1070 ischemic stroke subjects and 1488 controls, mean age of stroke onset 66.5 years). All subjects were of European ancestry. The young onset cases and controls were genotyped by Illumina Omni1-Quad array with imputation up to 1.8 M SNPs and the old onset cases and controls by a combination of 550 v1 and v3 as well as 610 Illumina arrays with imputation up to 5.0 M SNPs. Single SNP association testing was performed within each contributing study by logistic regression adjusting for age, sex and population structure. Numbers of genes assigned with significant SNPs (P<=0.0001) were 18 and 25 with young- and old-onset groups, respectively, which were used as an input to pathway analysis by the Pathway Studio (Ariadne Genomics, Co.)

RESULTS:
SNP-level analyses did not reveal any significant associations with each group that met Bonferroni adjusted thresholds for statistical significance. In analyzing the ‘suggestively associated SNPs’, protein-protein interaction pathway analysis in the young-onset group revealed a strong segregation of significant hub proteins (CAT, RUNX1, and EIF4E) with more than 100 connections, while in the old-onset group the interaction networks were dispersed without much segregation. We observed that protein-protein interaction networks have a power-law connectivity distribution in both young- and old-onset groups. We identified 3 significant and focused pathways, ROS metabolism, melanogenesis, and IGF1R->CdEBPA/FOXO1A signaling, enriched for young-onset stroke (P<0.04). In the old-onset group, 10 pathways were identified involving broader signaling pathways.

CONCLUSIONS:
Young-onset stroke may involve genetic predisposition characterized by a few distinct and finite pathways. Our data suggests that young onset stroke may involve a few pathways that relate to a small number of key hub proteins, including ROS metabolism, melanogenesis, and IGF1R->CEBPA/FOXO1A signaling. Our analysis is consistent with the hypothesis that different pathways may be involved in young versus old onset stroke.
Abstract 2543: Thrombolytic Efficacy of Encapsulated Plasminogen
Authors: Meunier Jason M , Huang Shao-Ling , Wenker Evan P , Shaw George J
Published: March 2022

Introduction:
Incidence of hemorrhage linked to treatment of ischemic stroke with tissue plasminogen activator (tPA) has led to interest in combination therapies such as plasminogen (Plg), with the goal of decreasing the administered volume of tPA. In-vitro studies using Plg have shown enhancement of lysis. However, due to rapid deactivation of Plg-derived plasmin in-vivo, local delivery of Plg via encapsulation by liposomes and release by ultrasound (US) may be necessary. This study examined the enhancement of tPA-induced lysis using encapsulated Plg (EPlg), in an in-vitro clot model.

Methods:
Blood was drawn from 26 subjects after local Institutional Review Board approval. Clots were made in 20-µL pipettes and placed in a water tank for microscopic visualization during treatment. Sample clots were exposed to tPA in human fresh-frozen plasma (hFFP) at a concentration of 3.15 µg/ml and EPlg at a concentration of 167 µg Plg/ml. Clots were exposed to no tPA (Control), tPA alone (+tPA), tPA and EPlg (+EPlg), tPA and 120-kHz US (+US), or tPA, EPlg, and 120-kHz US (+EPlg-US) for 30 minutes. The extent of thrombolysis was determined by assessing clot width as a function of time, using a time-lapse microscopic imaging technique; the fractional clot loss (FCL) at 30 minutes was used to determine thrombolytic efficacy.

Results:
Each treatment group had a minimum of 6 clots (range: 6-158) from 2 different donors (range: 2-24). FCL for +tPA was 38% (95% Confidence Interval: 36-40%); FCL for +EPlg was 39% (30-46%) (p=0.48 vs. +tPA). FCL for +EPlg-US was 49% (43-54%) (p<0.01 vs. +tPA). However, it did not exceed FCL for +US at at 70% (64-76%) (p<0.01 vs. +EPlg-US).

Conclusions:
Lysis with EPlg with tPA and US is more effective than tPA alone. This improvement of lytic efficacy using EPlg is dependent on concomitant use of US. Interaction between liposomes, Plg, and US is complex and merits further study.
Abstract 2549: Favorable Vascular Profile Is An Independent Predictor Of Outcome: A Post Hoc Analysis Of The Sentis Trial
Authors: Schellinger Peter D , Köhrmann Martin , Liu Songling , Dillon William P , Nogueira Raul G , Shuaib Ashfaq , Liebeskind David S
Published: March 2022

Background:
The Safety and Efficacy of NeuroFlo
TM
Technology in Acute Ischemic Stroke (SENTIS) trial was the first randomized interventional stroke study for hemodynamic augmentation by partial aortic occlusion to improve neurological outcome versus standard medical management. We hypothesized that a favourable vascular profile (FVP) defined as anatomical intactness of the Circle of Willis (CoW, including visualization of the communicators) combined with a stable cerebral perfusion pressure (CPP) is a prerequisite for collateral recruitment and maintenance. We performed post hoc analyses to identify whether a favorable vascular profile (FVP) is associated with independent outcome.

Methods:
We identified all patients from the primary dataset (n=515 patients) with available intracranial vascular imaging (MRA, CTA, or conventional angiography) at baseline. Two independent readers evaluated the vascular imaging blind to clinical and treatment data. CPP compromise was assumed in critical hypotension defined as mean arterial blood pressure (MAP) drop below 65mmHg. FVP was scored, when CoW was intact and MAP >65mmHg at all timepoints within the first 12h of the NeuroFlo procedure. We performed univariate and multivariate analyses to identify predictors of independent outcome (mRS 0-2) at 90 days.

Results:
192/515 SENTIS subjects had available baseline vascular imaging (91 treated / 101 controls). Baseline characteristics did not differ between groups (age, weight, infarct side, NIHSS, race, time from symptom onset, vital parameters, cardiovascular risk factors including atrial fibrillation (AF), medical history). Overall, FVP was seen in 89.6% of patients with a trend in favor of treated patients (94.5% vs 85.2%, p=0.0562). Nevertheless, presence of FVP predicted independent outcome in univariate (OR=7.46, 1.68-33.18, p=0.0082) and multiple logistic regression analyses after adjustment for all variables (OR=10.22, 1.78-58.57, p=0.0091). Aside from FVP, only baseline NIHSS (OR=0.74, 95% CI 0.67-0.82, p<0.0001) and presence of atrial fibrillation (OR=0.48, 95% CI 0.21-1.12, p=0.0909) entered the predictive model. There was no interaction with randomization to treatment or control.

Conclusion:
FVP and baseline NIHSS independently predicted outcome in this subset of the SENTIS population. FVP is a novel parameter to predict outcome of acute stroke patients and further studies will establish its potential role for selection of optimal candidates for hemodynamic augmentation.
Abstract 2583: Customizing the Electronic Medical Record to Achieve Excellence in Nursing Documentation of Stroke Care Indicators in the Emergency Department at Kenmore Mercy Hospital
Authors: Kramer Amanda , Mulawka Catherine
Published: March 2022

Background:
Chart review demonstrated inconsistencies in the documentation of specific areas of Emergency Department Nursing stroke care indicators. These inconsistencies included the Dysphagia Screen and the documentation of time of Code Stroke called. At the time of this discovery in 2008, the patient chart was a hybrid of a paper and an electronic record. This resulted in the potential for data being captured in multiple areas of the chart, and was identified as a patient safety risk.

Purpose:

Increase compliance in Emergency Room nursing documentation

Create clear and consistent stroke patient record via universal format

Enhance the ease of use of patient record by eliminating the hybrid system in the ED

Ensure reliable communication among all clinicians caring for the patient

Methods:

Retrospective and concurrent review of charts to determine most common opportunities for improvement

Identify staff barriers to compliance, i.e. lack of standardized format to document care, and the reluctance to return to paper charting once the electronic record was efficiently utilized

Create a mandatory “Time Code Stroke Called” and “Dysphagia Screen” pathway in the electronic medical for triaged patients vs. free text/paper Code Stroke log documentation

Re-review charts after implementation and provide staff education of the standardized format

Results:

Increase in Dysphagia Screen compliance from
45.6%
in
2008
, to
69.9%
in
2009
, to
83%
in
2010

Reliable documentation of “Code Stroke Called” is found in every record

Lesson Learned: creating simple documentation for clinicians increases compliance in capturing the required elements of stroke care

Conclusions:
Customizing electronic medical records to eliminate hybrid charting has increased nursing documentation compliance of the Dysphagia Screen and the time of Code Stroke called in Emergency Department stroke patients at Kenmore Mercy Hospital.
Abstract 2590: Supratentorial Superficial Siderosis is a Warning Sign of Subsequent Intracerebral Hemorrhage
Authors: Opherk Christian , Wollenweber Frank , Lummel Nina , Bochmann Katja , Pfefferkorn Thomas , Dichgans Martin , Bruckmann Hartmut , Linn Jennifer
Published: March 2022

Background:
Non-traumatic supratentorial superficial siderosis (SupSid) is a putative MRI-marker for cerebral amyloid angiopathy (CAA). Case reports have suggested that SupSid might be a predictor for subsequent intracranial hemorrhage in these patients. However, systematic studies on its prognostic significance are missing.

Methods:
We retrospectively analysed patients with SupSid most probably due to CAA. Patients were identified by a systematic database search at our institution (years 2000-2010). Additional inclusion criteria were clinical or imaging follow-up (MRI or CT, minimum 6 months) and at least one angiographic modality to exclude intracranial vascular malformations. Exclusion criteria were infratentorial siderosis, poor image quality, presence of an aneurysm or history of aneurysmal subarachnoid haemorrhage (SAH), head trauma, head or spine surgery, and SupSid due to known other causes than CAA.

Results:
A total of 51 patients met the inclusion criteria (35 males, mean age at t0 = 72.8 ± 7.2 years, range: 50 to 86 years). The median clinical follow-up time was 88.2 months (range: 6 to 292.5 months). Additional imaging follow-up was available in 33 patients (median imaging follow-up time: 36.2 months; range: 0.3 to 283 months). A total of 18 (35.3 %) patients developed intracerebral hemorrhage (ICH) during follow up. Among those, the majority (13) was located at the site of initial siderosis and 5 were situated elsewhere (p<0.01). Six (11.7%) patients developed SAH during follow up. Demographic, clinical and medication characteristics did not differ between patient groups.

Conclusions:
Patients with SupSid are at high risk for subsequent ICH or SAH. SupSid can be considered a warning sign of subsequent ICH at its location. Prospective studies are needed to confirm and further evaluate these findings.
Abstract 2605: Comparison of Intra-Operative Indocyanine Green Angiography and Digital Subtraction Angiography for Clipping of Intracranial Aneurysms
Authors: Doss Vinodh T , Arthur Adam , Hoit Daniel , Elijovich Lucas
Published: March 2022

BACKGROUND:
The presence of residual aneurysm after microsurgical clipping carries a risk of aneurysm growth and rupture. Digital subtraction angiography (DSA) is the gold standard to determine the adequacy of clipping post-operatively. Intra-operative Indocyanine green (ICG) angiography is increasingly utilized to confirm optimal clip positioning across the neck and to evaluate adjacent vasculature. We evaluated the correlation between ICG and DSA in clipped intracranial aneurysms.

METHODS:
This is a retrospective study of patients who underwent craniotomy and microsurgical clipping of intracranial aneurysms with ICG between January 2010 and May 2011. A chart review was performed to abstract the baseline characteristics and details of presentation of patients, details of the operative reports of clipping were reviewed, and pre and post clipping angiographic images were reviewed to determine the adequacy of clipping. Post-clipping DSA was evaluated by two physicians not involved in the care of the patient for the presence of residual aneurysm and patency of branch vessels/parent artery.

RESULTS:
Twelve patients (58 % female, mean age 53.6) underwent clipping of intracranial aneurysms with ICG and had post-operative DSA. Operative reports indicated complete clipping of all aneurysms without compromise of branch vessels. Postoperative DSA was performed in follow-up ranging from 1 day to 6 months. Seventeen aneurysms were clipped, seven patients (58.3%) presented with subarachnoid hemorrhage. Thirteen aneurysms were located in the anterior circulation (avg. size 7.3mm) and four in the posterior circulation (avg. size 6.6mm). Four patients had two aneurysms clipped in the same setting. Of the 17 aneurysms treated 5 aneurysms demonstrated a residual on DSA not identified on ICG. The residual sizes ranged from 0.8-4.3 mm with an average size of 1.2mm. There was no apparent predilection to location; three were in the anterior and two in the posterior circulation. Post-operative DSA demonstrated no branch occlusions, two patients demonstrated slow flow in the posterior communicating artery, and there was no compromise of the parent vessel in any cases.

CONCLUSION:
Intra-operative ICG is useful in the microsurgical clipping of intracranial aneurysms to ensure patency of branch vessels. However, the presence of residual aneurysm and subtle changes in flow in branch vessels is best seen by DSA. This has important clinical implications in regards to immediate post-operative management, the need for delayed follow-up imaging, and decisions to re-treat incompletely clipped aneurysms.
Abstract 2620: Differential Effects of Cyclosporine Regimens on Rat Brain Responses to Human Neural Cell Grafts
Authors: Jensen Matthew B , Krishnaney-Davison Rajeev , Zhang Su-Chun
Published: March 2022

Background
Transplantation of neural cells is a promising stroke recovery therapy requiring animal model research, but rejection of human xenografts is an obstacle. While a variety of immunosupression strategies have been reported, few comparison data are available. We asked if different cyclosporine regimens would affect rat brain responses to human neural cell grafts.

Methods
Rats received intracerebral grafts of neural progenitors derived from human embryonic stem cells, and 6 rats each were randomized to 1 of 4 immunosupression groups: 1) SC (subcutaneous) group - cyclosporine 10 mg/kg/day SC starting 2 days prior to transplantation; 2) SC/PO (per os) group - the same injections for the first 7 days followed by 100 ug/ml in the drinking water; 3) PO group - only cyclosporine in the drinking water starting 2 days prior to transplantation; 4) Control - no immunosupression. Immunostaining, stereology, and optical densitometry were performed after 2 weeks for quantification of markers of human cells, neural cell types, and immune cells.

Results
More rats in the SC (6/6) and SC/PO (5/6) groups had surviving graft cells than the PO (1/6) and control (3/6) groups (p<0.05), with a trend toward more surviving graft cells as well. All rats with surviving graft cells showed co-labeling for the neural progenitor marker Nestin, and a minority of graft cells co-labeled for the cell division marker Ki67 and the neuronal marker MAP2. Optical densitometry showed more cellularity (p<0.05) and reactive astrocytosis (p<0.05) in grafted versus contralateral hemispheres, which was similar between groups. Areas of dead graft cell debris were seen in all groups; in these areas the human nuclear antigen was present in the cytoplasm of cells co-labeling for the microglia marker CD11b, suggesting that they had phagocytosed graft cells.

Conclusions
The survival of human neural cells in rat brains differed with immunosupression regimens, but immune cell infiltration, phagocytosis of graft cells, and reactive astrocytosis occurred in all groups. Frequent injections of laboratory animals is undesirable, and a compromise strategy of peri-transplant injections followed by mixing the drug in the drinking water showed good results to prevent graft cell rejection. Further research is needed to optimize the immunosupression approach for this application.
Abstract 2622: Human Placental Derived Adherent Cells (PDA001) Treatment Induces Angiogenesis, Synaptogenesis And Improves Functional Outcome After Stroke
Authors: Shehadah Amjad , Chen Jieli , Pal Ajai , He Shuyang , Zeitlin Andrew , Cui Xu , Zacharek Alex , Roberts Cynthia , Lu Mei , Hariri Robert , Chopp Michael
Published: March 2022

Background and purpose:
Mesenchymal stem cells (MSCs) show promising therapeutic potential in myocardial, limb, and brain ischemia. Human Placenta-derived Cells (PDA001) is a novel cell population derived from normal, full-term human placental tissue and a rich source of MSC like cells. In this study, we investigated the efficacy of PDA001 cells in a rat stroke model.

Methods:
Adult male Wistar rats were subjected to 2 h of middle cerebral artery occlusion (MCAo) and treated with or without different doses of PDA001 cells (1x10
6
, 4x10
6
and 8x10
6
) at 24 h after MCAo. A battery of functional outcome tests was performed prior to PDA001 cell therapy and at days 7, 14, 21, 28, 42, and 56 after MCAo. Rats were sacrificed at 56 days after MCAo and lesion volumes were measured. The optimal dose of PDA001 cell treatment of stroke was chosen for bromodeoxyuridine (BrdU),Von Willebrand Factor (vWF), and Synaptophysin immunostaining.

Results:
PDA001 cell treatment dose-dependently improves functional outcome compared to dermal fibroblast cells (FBC-control) and Dextran vehicle control. PDA001 cell treatment significantly increased the number of BrdU immunoreactive endothelial cells as well as the vascular density and perimeter in the ischemic brain compared with the FBC-control and Dextran control groups (p<0.05). PDA001 cell treatment significantly increased synaptic plasticity as measured by increased Synaptophysin expression in the ischemic border zone (IBZ) compared to FBC-control (p<0.05).

Conclusion:
PDA001 cell treatment of stroke dose-dependently improves functional outcome in stroke in rats. The neurorestorative effects induced by PDA001 cell treatment may relate to the increase of angiogenesis and synaptic plasticity.
Abstract 2633: Coated-Platelet Levels are Elevated in Symptomatic Carotid Stenosis Patients and Associated with Stroke Recurrence
Authors: Kirkpatrick Angelia , Stoner Julie , Dale George , Prodan Calin
Published: March 2022

Background:
Coated-platelets are a subset of platelets with high procoagulant potential observed upon dual agonist stimulation with collagen and thrombin. Coated-platelet levels, expressed as percentages of the total platelet population, are elevated in patients with non-lacunar ischemic stroke and decreased in patients with spontaneous intracerebral hemorrhage compared to controls. Because of these findings, we investigated whether coated-platelets are elevated in patients with symptomatic carotid stenosis compared to controls and if there is an association between coated-platelet levels and stroke recurrence among subjects with carotid stenosis.

Methods:
Coated-platelet levels were determined in 40 consecutive patients with acute stroke due to ipsilateral high-grade internal carotid artery stenosis and 60 gender-frequency-matched controls without history of stroke. The neurologist establishing the diagnosis was unaware of the patient's coated-platelet levels, and the individuals performing the coated-platelet assay were not aware of the clinical diagnosis. Stroke recurrence data were obtained through stroke clinic visits or telephone interviews performed at 1month following the initial infarct. The distribution of baseline characteristics was compared between patients and controls using either a t-test for continuous measures or a Chi-square test (or Fisher’s exact test) for categorical measures. Linear regression models were fit to explore the association between carotid stenosis status and coated-platelet levels with and without adjustment for confounding factors. Percentages of subjects who developed a recurrent stroke at one month were compared using Fisher’s exact test.

Results:
Coated-platelet levels (mean±SD) were significantly higher in patients with symptomatic carotid stenosis compared to controls (41.3±15.5% vs. 30.1±13.4%, p=0.0002). The estimated difference remained significant after adjustment for demographics, medication use and co-morbidities (p=0.0003). Among the 40 carotid stenosis patients, the cumulative incidence of recurrent stroke at 1 month was 18% (95% CI:9-34%, 7 recurrences). Patients were then analyzed according to quartiles of coated-platelet levels (split at ≤32%, 32.1-42.4%, 42.5-51%, >51%). The 1-month stroke recurrence percentages differed significantly between the coated-platelet quartiles (p=0.041), with 50% recurrence percentage (n=5) among patients in the highest quartile compared to 10% among those in the first (n=1) and third (n=1) quartiles and 0% among those in the second quartile.

Conclusions:
Coated-platelet levels are higher in patients with symptomatic high-grade carotid stenosis compared to controls and are associated with early stroke recurrence in this patient population. Additional study of coated-platelets in carotid stenosis is warranted.
Abstract 2645: Functional Outcome in Young Adults after First-Ever Ischemic Stroke: A Particular Impact of Lipoproteins
Authors: Putaala Jukka , Strbian Daniel , Mustanoja Satu , Haapaniemi Elena , Kaste Markku , Tatlisumak Turgut
Published: March 2022

Background and Purpose:
We aimed to determine functional outcome in a cohort of young adults with ischemic stroke, focusing on components of lipid profile.

Methods:
In our registry including consecutive patients with first-ever ischemic stroke aged 15 to 49 from 1994-2007, we analyzed predictors of 3-month functional outcome (modified Rankin Scale, mRS). Infarct size fell into small, medium, large posterior, or large anterior. Stroke severity was assessed with NIH Stroke Scale (NIHSS). Serum lipids were measured within 72 h after admission. Binary, multinomial ordinal, and Poisson regressions allowed revealing factors associated with size of infarct, stroke severity, and unfavorable outcome or death (mRS, 2-6) or mRS as an ordinal measure.

Results:
In the 968 patients included (mean age 41.3±7.6; 62.6% males; 49.5% with mRS 0-1), factors associated with unfavorable outcome after multivariable analysis were increasing age (odds ratio 1.03 per year, 95% confidence interval 1.01-1.05), higher NIHSS score (1.22 per point, 1.16-1.29), large anterior infarcts (4.51, 2.22-9.17), bilateral lesions (2.61, 1.43-4.77), internal carotid artery dissection (ICAD) (3.45, 1.29-9.19), large-artery atherosclerosis (2.30, 1.03-5.11), and inversely high-density lipoprotein (HDL) levels (0.59 per unit increase, 0.39-0.89). Increasing HDL associated with smaller infarct size (0.70, 0.49-0.98) and higher levels of HDL and low-density lipoprotein (LDL) were both associated with a lower NIHSS score (0.81, 0.75-0.88 for HDL; 0.96, 0.93-0.99 for LDL) and lower 3-month mRS (0.65, 0.47-0.90 for HDL; 0.86, 075-0.98 for LDL).

Conclusions:
In addition to known prognosticators, ICAD and lower HDL levels were independently associated with adverse clinical outcomes in our young adult stroke cohort.
Abstract 2672: Osmotic Therapy in the Management of Cerebral Edema after Stroke across the United States.
Authors: Ferioli Simona , Kleindorfer Dawn O , Shutter Lori A , Khatri Pooja , Meganathan Karthikeyan , Hornung Richard , Adeoye Opeolu
Published: March 2022

Introduction
Osmotically active substances like mannitol and hypertonic saline are widely accepted options in management of cerebral edema after ischemic stroke. However, use of these agents can be very heterogeneous in practice given the lack of randomized clinical trials to confirm and compare their effectiveness. We queried the PREMIER database to investigate the differences in the use of osmotic therapy in ischemic stroke patients across the United States.

Methods
First ever ischemic stroke-related hospitalizations (ICD-9 codes 433.x1, 434.x1 and 436) of patients aged 18+ years were reviewed for fiscal years of 2007-2010 from the Premier Perspective™ Database. Use of osmotic therapy and time of its administration were determined through pharmacy billing records for mannitol and hypertonic saline while presence of documented cerebral edema was identified using ICD-9 diagnosis code 348.5.Differences in osmotic treatment were tested by gender and race of the patient as well as hospital characteristics.

Results
We identified 244,482 patients with first ever ischemic stroke. Of these, 12,301 (5%) were treated with osmotic therapy, the majority of which occurred within 7 days of hospitalization. Of those receiving osmotic therapy, 64% received mannitol, 44% received hypertonic saline and 7% received both treatments. The ICD -9 code for cerebral edema was associated to 11% of these cases. Essentially no differences in race (63% whites) and sex distribution (49% females) were found. The majority of osmotic therapy use occurred in urban areas (93%). There was no difference in use between teaching vs non-teaching institutions (51% vs 49%).

Conclusions
Despite the lack of evidence to support its effectiveness, we found that osmotic therapy was given to 5% of stroke patients during fiscal years 2007-2010, primarily in urban centers. Only a minority of treated cases were associated with the ICD-9 code for cerebral edema, which is the principal indication for this treatment, likely reflecting a diffuse underutilization of this diagnostic code in practice. Mannitol was more frequently used than hypertonic saline in both teaching and non-teaching hospitals. Randomized control trials are warranted to demonstrate the efficacy of osmotic therapy using mannitol or hypertonic saline in ischemic stroke.