bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP237: Improved Thrombolysis Rates and Quality of Care for Stroke Patients Through a Provincial Emergency Department Quality Improvement Initiative
Authors: Harris Devin R , Stenstrom Robert , Grafstein Eric , Collison Mark , Innes Grant , Lindsay Patty , Singer Joel
Published: July 2021

Background:
The care of stroke patients in the emergency department (ED) is time sensitive and complex. We sought to improve quality of care for stroke patients in British Columbia (B.C.), Canada, emergency departments.

Objectives:
To measure the outcomes of a large-scale quality improvement initiative on thrombolysis rates and other ED performance measures.

Methods:
This was an evaluation of a large-scale stroke quality improvement initiative, within ED’s in B.C., Canada, in a before-after design. Baseline data was derived from a medical records review study performed between December 1, 2005 to January 31, 2007. Adherence to best practice was determined by measuring selected performance indicators. The quality improvement initiative was a collaboration between multidisciplinary clinical leaders within ED’s throughout B.C. in 2007, with a focus on implementing clinical practice guidelines and pre-printed order sets. The post data was derived through an identical methodology as baseline, from March to December 2008. The primary outcome was the thrombolysis rate; secondary outcomes consisted of other ED stroke performance measures.

Results:
48 / 81 (59%) eligible hospitals in B.C. were selected for audit in the baseline data; 1258 TIA and stroke charts were audited. For the post data, 46 / 81 (57%) acute care hospitals were selected: 1199 charts were audited. The primary outcome of the thrombolysis rate was 3.9% (23 / 564) before and 9.3% (63 / 676) after, an absolute difference of 5.4% (95% CI: 2.3% - 7.6%; p=0.0005). Other measures showed changes: administration of aspirin to stroke patients in the ED improved from 23.7% (127 / 535) to 77.1% (553 / 717), difference = 53.4% (95% CI: 48.3% - 58.1%; p=0.0005); and, door to imaging time improved from 2.25 hours (IQR = 3.81 hours) to 1.57 hours (IQR 3.0), difference = 0.68 hours (p=0.03). Differences were found in improvements between large and small institutions, and between health regions.

Conclusions:
Implementation of a provincial emergency department quality improvement initiative showed significant improvement in thrombolysis rates and adherence to other best practices for stroke patients. The specific factors that influenced improvement need to be further explored.
Abstract WP24: Improvement In Collateral Score And Level Of Occlusion Are Early Angiographic Indicators Of The Degree of Infarction In Acute Ischemic Stroke
Authors: Amans Matthew R , Vella Maya , Cooke Daniel L , Hetts Steven W
Published: July 2021

INTRODUCTION:
Brain parenchyma contrast staining on CT after recanalization therapy and digital subtraction angiography (DSA) in large vessel occlusion acute ischemic stroke (LVO-AIS) patients has been demonstrated to be a marker for significant brain injury, possibly indicating blood brain barrier breakdown or no-reflow phenomena at the capillary level. Most often stained parenchyma undergoes infarction. We evaluated several DSA parameters in order to determine if findings on DSA at the time of LVO-AIS intervention can predict postintervention parenchymal contrast staining on CT and, thus, serve as early prognostic factors for brain infarction.

HYPOTHESIS:
Point of cerebral arterial occlusion, TICI score, and degree of pial collateraliation correlate with presence of parenchymal contrast staining on post-intervention CT in LVO-AIS patients.

METHODS:
Our institution’s CHR approved this analysis of imaging and patient charts. We reviewed 17 years of LVO-AIS intervention at our institution, and 67 patients met inclusion criteria. Angiograms were evaluated for level of occlusion, TICI scores before and after intervention, and level of collateralization before and after intervention. Statistical analysis was performed using Fisher’s exact test and ANOVA.

RESULTS:
More proximal sites of cerebral arterial occlusion were more likely patients to have post-intervention staining (p=0.08). Preprocedure TICI, postprocedure TICI and improvement in TICI score did not predict contrast staining on post procedure CT (p=0.34, 0.54, and 0.52). Preprocedure collateral score, post procedure collateral score were similarly not predictive (p=0.28 and 0.93). Decreasing collateral score (i.e., increased antegrade flow with decreased need for collateral supply) was predictive of contrast staining (p=0.09).

CONCLUSION:
Improvement in pial collateral score was more predictive of postprocedure contrast staining than was change in TICI grade, and thus may serve as a complement to TICI in the assessment of revascularization efficacy at the time of stroke intervention.
Abstract WP248: Methods to Achieving a 9-minute Door to TPA Time
Authors: Nair Deepak S , Talkad Arun , McNeil Clayton , Jahnel Jan , Swanson-Devlin Teresa , Beck Judi , Wang David Z
Published: July 2021

Introduction
Despite guidelines recommending “door to needle times” (DTN) of ≤60 minutes and the Target: Stroke program, the national average for stroke treatment is 79 minutes. We present the factors that have reduced DTN in our Stroke Center.

Methods
We retrospectively identified all patients who received IV rt-PA using our acute stroke code database, from 2007 to 2012. The patients were organized by their DTN into four groups: <20min, 20-39min, 40-59min, and ≥60min. Median NIHSS scores were calculated, along with median DTN per group and annually. We also specified median lab times, the source of the stroke code (EMS or ED), and time of day for the code.

Results
There were 180 patients that received IV rt-PA: 7 patients in <20min, 49 in 20-39min, 52 in 40-59min, and 72 in ≥60min. Median DTN was 14min, 30min, 46.5min, and 76min, respectively, with the overall fastest DTN being 9 minutes. Median NIHSS scores were 7, 12, 13, and 8, respectively. EMS initiated the code in 100% of the <20min cases, 45% in 20-39min, 44% in 40-59min, and 40% in ≥60min. Eighty-six percent of the <20min cases arrived during the day, as did 84% of the 20-39min, 65% of the 40-59min, and 42% of the ≥60min cases. When rt-PA was given before labs were resulted, the median DTN was 30min; otherwise, the median DTN was 54min. All cases with <20min DTN presented after May 2011, when the first such case occurred. The median DTN was 65.5min in 2007, 51min in 2008, 61min in 2009, 59.5min in 2010, 47min in 2011, and 35min in 2012.

Conclusions
Our experience suggests that the “Target: Stroke” strategies (EMS initiation of stroke codes, rapid triage, rt-PA before labs) can significantly reduce the time to thrombolysis. However, our significant improvement over the past two years followed a singular 13-minute DTN, which demonstrated that teamwork and passion for acute stroke care can catalyze the consistent delivery of efficient stroke treatment.
Abstract WP25: Concomitant IV tPA Does Not Increase Harm to Patients Who Receive Simultaneous Mechanical Thrombectomy and Emergent Carotid Artery Stent Treatment
Authors: Bozorgchami Hormozd , Fields Jeremy , Walker Gary , Jahans Cindy , Lutsep Helmi ,   Merci Registry Investigators
Published: July 2021

Background:
Stenting of the cervical internal carotid artery (ICA) may be performed acutely in patients undergoing endovascular intervention for stroke due to occlusion of the intracranial ICA or MCA. It is unclear if pre-intervention IV tPA increases complications of carotid artery stenting (CAS) in this group.

Hypothesis:
We assessed the hypothesis that pre-intervention IV tPA does not increase the risk of complications in acute ischemic stroke patients (AIS) who require concurrent mechanical thrombectomy and emergent CAS.

Methods:
Patients undergoing both mechanical thrombectomy and CAS within 24 hours of stroke onset were identified from the Merci Registry, a prospective database of AIS patients treated with the Merci Retriever. Those receiving IV tPA were compared with those that did not for associations with functional independence (mRS 0-2) and risk of symptomatic intracerebral hemorrhage (sICH). The primary endpoint for this study was the percentage of patients with mRS 0-2 at 90 days. Secondary endpoints included 90-day mortality and sICH. Outcomes were compared with Fisher’s exact test.

Results:
103 patients were included. Thirty received IV tPA (mean age 59.1, time to treatment 6.3 hrs, median NIHSS 18) and 74 did not (mean age 66.1, time to treatment 9.8 hrs, median NIHSS 16). Although numerically higher, there was no significant difference in sICH at 24 hours, occurring in 18.2% (4/22) of IV tPA patients and 7.3% (4/55) of patients without IV tPA (p=0.22) [sICH data was not available on 28 patients]. At 90 days, 40% of the IV tPA group (12/30) was functionally independent while 30.6% (22/73) was functionally independent in the non-IV tPA group (p=0.36). There was no difference in 90-day mortality between the two groups (26.7% vs. 34.7%, p=0.67).

Conclusions:
This study demonstrates that concomitant IV tPA use in acute stroke patients who had simultaneous mechanical thrombectomy and CAS did not significantly affect patient outcomes or increase complications. Although neither result was statistically significant, there was a trend toward improved functional outcomes at 90 days in the IV tPA treated group despite a trend toward increased rates of sICH.
Abstract WP256: Pretreatment of Rosuvastatin Ameliorates Early Brain Injury after Subarachnoid Hemorrhage through the Inhibition of Microglial Activation in Rats.
Authors: Uekawa Ken , Hasekawa Yu , Ma Mingjie , Nakagawa Takashi , Katayama Tetsuji , Sueta Daisuke , Toyama Kensuke , Keiichiro Kataoka , Koibuchi Nobutaka , Kuratsu Jun-ichi , Kim-Mitsuyama Shokei
Published: July 2021

BACKGROUND AND PURPOSE:
We investigated the protective effects of pretreatment of oral-administered rosuvastatin, a water soluble HMG-CoA reductase inhibitor, on early brain injury (EBI) after subarachnoid hemorrhage (SAH).

METHOD:
Male Sprague-Dawley rats were operated on with endovascular perforation model and randomly divided into 4 groups: sham-operated, SAH+vehicle, SAH+1mg/kg, or 10mg/kg rosuvastatin. The animals in treatment groups were administered with daily oral rosuvastatin from 7 days before to 1 day after operation. All rats were evaluated regarding neurofunction, brain edema, and blood-brain barrier (BBB) disruption at 24 hours after SAH. Anti-inflammatory responses were also conducted using Western blot and immunohistochemistry at 24 hours after SAH.

RESULTS:
Compared with the vehicle group, rosuvastatin significantly improved the neurofunction

score (modified Garcia score/ 22: 13.0±1.6 vs 17.0±1.0,
P
<0.05) , brain edema (brain water content: 79.11±0.15% vs 78.68±0.09%,
P
<0.05)

, and BBB disruption (IgG extravasation); data are showed as a mean±SEM. Rosuvastatin reduced number of activated microglial cells , activation of nuclear factor-kappa B(NF-kB), and expression of tumor necrosis factor-alpha (TNF-α) , which were considered as markers of inflammatory response from microglia, and downregulated the expression of neuronal cyclooxygenase-2 (COX-2) and endothelial matrix metalloproteinase-9 (MMP-9).

CONCLUSION:
The current study showed that pretreatment of rosuvastatin induced anti-inflammatory processes through inhibition of microglial activation and thereby attenuated early brain injury. Rosuvastatin seems to be a promising agent for treatment of SAH.
Abstract WP261: In Vitro Characterization, Pharmacokinetics and Reversal of Supratherapeutic Doses of Dabigatran-Induced Bleeding in Rats by a Specific Antibody Fragment Antidote to Dabigatran
Authors: van Ryn Joanne , Litzenburger Tobias , Gan Guanfa , Coble Kelly , Schurer Johanna
Published: July 2021

One feature all new oral anticoagulants share is the lack of a specific antidote in cases of emergency. A fully humanized monoclonal antibody fragment (Fab) against dabigatran is currently in development for use in the clinic.

Fab binding to dabigatran was tested as dissociation constant (K
D
), on- and off-rate. Inhibition of glucuronidated dabigatran was tested using diluted thrombin time assay. Any prothrombotic activity of the Fab was tested for the ability to induce coagulation in endogenous thrombin potential (ETP, 5 pM tissue factor) and ecarin chromogenic assay (ECA). Pharmacokinetics (PK) was determined by measuring functional and total dabigatran and total Fab in the rat. Dabigatran etexilate (DE), 30 mg/kg, was given to rats every 8 hrs to induce bleeding. Increasing Fab doses were given to test for bleeding reversal in this rat tail bleeding model.

The Fab bound to dabigatran with a Kd of 2 pM, with a rapid k
on
(1.5x10
6
M
-1
s
-1
) and slow k
off
(3x10
-6
s
-1
). Dabigatran (7nM) inhibition by Fab was 3.5 nM (IC
50
) and metabolite inhibition was 2nM (IC50) in human plasma. There was no effect on thrombin generation with 3 mg/mL Fab added to plasma (ETP, 0.89-fold of control), in contrast, FEIBA (0.8 U/mL), resulted in 2.06 increase of ETP. ECA was also not elevated vs control. The PK of the Fab in rats showed a short initial phase t
1/2
(0.24 h) and longer terminal phase t
1/2
(5.8 h). Clearance was low (1.95 mL/min/kg) and steady-state volume of distribution small (0.0688 L/kg). PK of the Fab was not affected by dabigatran. DE (30 mg/kg p.o.) given in 8 hr intervals achieved steady state levels in the rat, plasma levels of 1500 nM (~750 ng/mL), and resulted in ~2-fold increase of tail cut bleeding time. There was a rapid, dose-dependent decrease in blood loss after i.v. injection of Fab. Anticoagulation (clotting ex vivo) was also reversed. Treating rats with warfarin (0.5 mg/kg p.o.) over 3 days resulted in a 2-fold elevation of blood loss. Similar doses of Fab had no effect on reversing warfarin induced blood loss.

Thus this Fab is specific and selective for dabigatran and reversed DE-induced blood loss, correlating with reversal of ex vivo clotting tests. This agent holds promise for reversing dabigatran-induced anticoagulation and bleeding effects and is currently under development.
Abstract WP263: Protective Role Of Microglial Alpha7 Nicotinic Receptor In Ischemia
Authors: Parada Esther , Egea Javier , Negredo Pilar , Buendia Izaskun , Ló Manuela G
Published: July 2021

Background and Purpose:
It is well known that activation of α7 nicotinic acetylcholine receptors (nAChR) protects neurons against neurotoxic and neuro-inflammatory stimuli. However, little is known about the importance of this receptor in microglia. This study was planned to evaluate the contribution of microglial α7 nAChRs in controlling inflammation and affording neuroprotection in brain ischemia models.

Methods:
Organotypic hippocampal cultures (OHCs) were conducted on 8-10 day-old Sprague Dawley rats. Oxygen-glucose deprivation (OGD) was used as an
in vitro
model of cerebral ischemia. Viability assays with PNU282987 (a selective α7 agonist) were performed 24 hours after the OGD period. Focal ischemia was induced in C57BL/6J mice by photothrombotic stroke; PNU 282987 was administered i.p. 1 h after the ischemia onset. We performed the beam walk test as a measured of motor activity. Infarct volume and beam walk assay were measured 24 hours after the ischemia
.

Results:
In OHCs, 15 minutes of OGD followed by 24 hours of reoxygenation increased cell death (180 ± 2.13, n=6, p<0.001) with respect to the basal slices (100%). Under these experimental conditions, 10μM-PNU282987 administered after the OGD period significantly reduced cell death (110.1 ± 10.41, n=6, p≤0.001). In microglia-depleted slices, we observed that the same period of OGD increased cell death compared to control slices (p<0.05). In addition, the protective effect of PNU282987 was significantly lower (p<0.001). In the phototrombotic stroke model, PNU282987 administered at 1 and 10 mg/kg, reduced the infarct volume in a dose-dependent manner (12.22 ± 0.52, n=8, p<0.05 and 9.28 ± 0.58, n=8, p<0.001, respectively) with respect to the saline animals (15.93 ± 1.2, n=7). In the beam walk test, 10 mg/kg-PNU282987 reduced the studied parameters compared with the saline-mice: freezing time (2.36±0.43 vs 7.29±0.87) time to cross (10.53 ± 0.85 vs 16.95 ± 1.65) and paw slips (5.41 ± 0.77 vs 10.83 ± 0.53).

Conclusion:
Activation of microglial α7 nAChR contributes to neuroprotection against OGD in OHCs and to reduction of infarct volume and improvement of motor activity in mice subjected to photothrombotic stroke. Taken all together, α7 nicotinic modulation could be a good target for stroke.
Abstract WP288: High Non-HDL Cholesterol Is Associated With Acute Neurological Deterioration In Ischemic Stroke Patients: the Fukuoka Stroke Registry (FSR)
Authors: Matsuki Takayuki , Kuwashiro Takahiro , Fujimoto Shigeru , Mezuki Satomi , Jinnouchi Juro , Kamouchi Masahiro , Ishitsuka Takao , Kitazono Takanari
Published: July 2021

Background and Purpose:
Several studies have shown that non-HDL cholesterol, defined as total cholesterol minus HDL cholesterol, was one of the risk factors for coronary heart diseases. However, the relationship between non-HDL cholesterol and cerebrovascular diseases remains unclear. We assessed the hypothesis that high non-HDL cholesterol may affect the outcome in acute ischemic stroke patients.

Methods:
The FSR is a multicenter prospective registry of acute stroke patients admitted to seven stroke centers in Fukuoka, Japan. From June 2007 to March 2012, 5995 patients were enrolled. Among them, 1915 patients who fulfilled the following criteria were included in the present study: (1) first-ever, (2) ischemic stroke, (3) hospitalization within 24 hours after onset, (4) modified Rankin scale (mRS) of 0 or 1 before onset. Patients were divided into quartiles based on the value of non-HDL cholesterol (mg/dL); G1 (non-HDL <120), G2 (120 ≤non-HDL <140), G3 (140 ≤non-HDL <160), G4 (non-HDL ≥160). Neurological severity was evaluated by National Institute of Health Stroke Scale (NIHSS). A NIHSS increase of ≥1-point during the first 21 hospital days was defined as an acute neurological deterioration, and a mRS of 2 or more at discharge as a functional dependence.

Results:
The worse the non-HDL cholesterol grade became (from G1 to G4), the lower age (p<0.0001), the frequency of male (p=0.003) and initial NIHSS score (p<0.001) were, and the higher blood pressure (p<0.0001), body mass index (p<0.0001) on admission, and the frequency of dyslipidemia (p<0.0001) were. As non-HDL cholesterol grade was worse, the frequency of acute neurological deterioration (p=0.008) and functional dependence at discharge increased (p=0.036). Multivariate logistic regression analysis revealed that as non-HDL cholesterol grade was worse, acute neurological deterioration was more prevalent (p for trend = 0.016) and the worst grade (G4) was independently associated with acute neurological deterioration (Odds Ratio 1.66; 95% CI 1.06-2.61; p=0.026) compared to G1.

Conclusion:
The frequency of acute neurological deterioration is significantly higher in ischemic stroke patients with higher plasma non-HDL cholesterol on admission.
Left Ventricle Hypertrophy is Common in Patients with Cerebral Amyloid Angiopathy-Related Intracerebral Hemorrhage and Is Independently Associated with Long-Term Mortality.
Authors: Pontes-Neto Octavio M , Martinez-Ramirez Sergi , Viswanathan Anand , Auriel Eitan , Schwab Kristen M , Ayres Alison , Gurol M. Edip , Rosand Jonathan , Greenberg Steven M , Goldstein Joshua N
Published: July 2021

Background:
A post-hoc analysis of the PROGRESS trial suggested that long-term anti-hypertensive therapy prevents intracerebral hemorrhage (ICH) in patients with cerebral amyloid angiopathy (CAA). However, the burden of underlying hypertension in patients with CAA is unclear, and it is also unclear whether this hypertensive burden contributes to long-term outcome in survivors of CAA-related ICH. Left ventricle (LV) hypertrophy is a measure of the chronicity and severity of hypertension and could be used to assess hypertensive end-organ damage in patients with CAA.

Objective:
To test the hypothesis that LV hypertrophy is common in patients with CAA-related ICH and is associated with increased long-term mortality and shorter survival in those patients.

Methods:
This was a retrospective analysis of a prospectively collected cohort of consecutive patients with primary ICH presenting to a single academic center. We included patients presenting between January/2000 to December/2010, age > 55 years, who received a transthoracic echocardiogram (echo) during follow-up and were diagnosed with definitive, probable or possible CAA according to the Boston criteria. LV mass index (10g/m2) was calculated according to Penn convention. Ninety-day survivors were followed prospectively for long-term mortality or censoring at January/2012. Cox proportional hazards models were used to identify predictors of mortality as time-dependent variables adjusting for potential confounders.

Results:
Among 211 patients who met inclusion criteria, the mean time to follow-up was 4.28 ± 2.7 years; the median time to echocardiogram was 3 days (IQR:49). The mean age was 75.7 ± 9.1 years; 103 (49%) were male. LV hypertrophy was present in 55 (31.8%) patients and 152 (72%) patients survived more than 90 days. In multivariate analysis, after adjusting for baseline characteristics, LV mass index (10g/m2) was associated with higher long-term mortality (HR: 1.20; 95%CI: 1.01-1.4; p=0.039). On Cox-regression, LV hypertrophy was independently associated with shorter long-term survival (HR 1.91; 95%CI 1.05-3.47; p=0.034).

Conclusions:
LV hypertrophy is common in patients with CAA-related ICH and is associated with increased risk of subsequent mortality among 90-day survivors.
Abstract WP303: Disparities among Native Hawaiians and Pacific Islanders with Intracerebral Hemorrhage: Effect of Methamphetamine Abuse
Authors: Nakagawa Kazuma , Vento Megan A , Koenig Matthew A , Asai Susan M , Chang Cherylee W , Seto Todd B
Published: July 2021

Background and Purpose:
Native Hawaiians and other Pacific Islanders (NHPI) with intracerebral hemorrhage (ICH) are younger and have a higher burden of cardiovascular risk factors compared to other racial groups in Hawaii. Furthermore, NHPI in Hawaii have a higher prevalence of methamphetamine abuse compared to other major racial-ethnic groups. Therefore, it is unclear whether younger age of NHPI with ICH is due to methamphetamine abuse or untreated risk factors.

Methods:
We conducted a retrospective study on consecutive patients hospitalized for acute ICH at a single tertiary center on Oahu between 2006 and 2010. To determine the factors associated with young ICH (age<45), we performed unadjusted and multivariable logistic regressions, adjusting for methamphetamine abuse, untreated hypertension and whether they were transferred from another hospital to account for a potential referral bias. Non-Hispanic whites were the reference group.

Results:
A total of 384 consecutive ICH patients (NHPI 19%, Asians 65% and non-Hispanic whites 16%) were studied. Compared to non-Hispanic whites, NHPI were younger (mean ages, NHPI 54±16 vs. whites 68±16, p < 0.0001), and had higher prevalence of diabetes (NHPI 36% vs. whites 19%, p = 0.03) and untreated hypertension (NHPI 32% vs. whites 15%, p = 0.02). Young ICH (age<45) was more common among NHPI (26%) than Asians (9%) and non-Hispanic whites (6%) (p <0.05). Methamphetamine abuse was slightly more common among NHPIs than whites and Asians (10% vs. 3% vs. 6%, p = NS for all comparison). After controlling for potential confounders, young ICH (age<45) was independently associated with NHPI race (OR 5.07, 95% CI 1.55 to 16.62), methamphetamine abuse (OR 4.17, 95% CI 1.56 to 11.20) and being transferred from another hospital (OR 3.37, 95% CI 1.66 to 6.84).

Conclusions:
Native Hawaiian and other Pacific Islander race and methamphetamine abuse are independently associated with young ICH in Hawaii. Further studies are needed to determine factors other than methamphetamine abuse that are contributing to the young age of ICH presentation in this unique racial group.
Abstract WP304: Prothrombin Complex Concentrate Rapidly Reverses Coagulopathy but does not Alter Mortality in Warfarin Intracerebral Hemorrhage
Authors: Cai Xuemei , Orzell Susannah , Suh Sarah , Bresette Linda , Sorond Farzaneh , Henderson Galen , Feske Steven , Chou Sherry H
Published: July 2021

INTRODUCTION:
Warfarin-associated intracerebral hemorrhage (wICH) remains the most lethal form of iatrogenic stroke. Conventional therapy with fresh frozen plasma (FFP) and intravenous vitamin K takes up to 30 hrs to normalize the international normalized ratio (INR). Prothrombin complex concentrate (PCC) does not require cross-match and is fast acting. We hypothesized that PCC can rapidly reverse coagulopathy and reduce mortality in wICH.

Methods:
We identified 130 consecutive adult wICH patients over five years from a prospectively collected database. 33 patients were excluded for death or withdrawal of care within 48 hours of admission and 8 patients were excluded for antecedent head trauma, leaving 89 patients for analysis. Forty patients received FFP and vitamin K (conventional therapy) and 49 received PCC in addition to conventional therapy. We compared 6-month mortality, time to INR normalization, quantity of FFP transfused, and thromboembolic complication rates between the two groups. We used logistic regression to adjust for important confounders.

Results:
PCC-treated and conventional therapy patients had similar distributions of age, sex, co-morbidities, ICH location, initial blood pressure and INR. PCC-treated patients had a higher incidence of intraventicular hemorrhage (IVH) (67% vs 33%). PCC-treated patients required less FFP (mean 6.8 units vs 3.3 units, p<0.0001) and had faster time to INR normalization (mean 3.8 hrs vs 9.8 hrs, p<0.0001). Incidence of ICH expansion was low in both groups. There was no difference in the incidence of deep venous thrombosis and pulmonary embolism (p=0.236) or troponin elevation (p=0.573). There was no significant difference in 6-month mortality (p=0.437) after adjusting for age, ICH location, ICH volume, and presence of IVH.

Conclusions:
PCC use in wICH was associated with shorter time to INR normalization and reduced FFP transfusion but was not associated with 6-month mortality in this cohort. There was no difference in thromboembolic complication rates between PCC-treated and FFP and vitamin K treated patients. Prospective trials of PCC are necessary to determine if its use can improve morbidity and mortality in wICH and to identify potential subgroups of wICH patients who may benefit from PCC.
Abstract WP308: Global Cerebral Edema Among Good Grade Patients with Intracerebral Hemorrhage. Results from the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) Study
Authors: Majidi Shahram , Gilani Waqas I , Tariq Nauman , Hussein Haitham M , Palesch Yuko Y , Qureshi Adnan I , ATACH I Investigators For
Published: July 2021

INTRODUCTION:
There is some evidence that injury and blood brain barrier disruption can be seen in regions distant from the hematoma in patients with intracerebral hemorrhage (ICH).

Objective:
To ascertain the occurrence of global brain edema in patients with ICH and to explore the relationship between patient characteristics and three month outcomes.

Design:
A post-hoc analysis of a traditional Phase I dose escalation multicenter prospective study recruited patients with ICH, elevated SBP≥170 mmHg, and Glasgow Coma Scale score ≥8, who presented within 6 hours of symptom onset. Computed tomographic (CT) scans at baseline, 24 hours, and any performed at later intervals were submitted to a core image laboratory. We were able to ascertain the presence and magnitude of global brain edema in 41 of 60 subjects with adequate CT scan resolution.

Settings:
Emergency departments and intensive care units.

Primary Outcomes:
We determined the total brain, hematoma, and perihematoma edema volumes from baseline, 24 hour, and 48 hour (if available) CT scans using image analysis software. The global brain edema volume was determined by subtracting the hematoma and perihematomal edema volumes from the total brain volume.

Results:
A total of 18 (44%) of 41 patients had global cerebral edema that developed between initial CT scan and 24 hour CT scan. The median increase in brain volume among the 18 subjects was 35 cc ranging from 0.12 cc to 296 cc. The baseline GCS score (median 15 versus 15) and hematoma volume (mean±SD; 11.5±10.3 versus 13.9±17) were similar between subjects who experienced global cerebral edema and those who did not. The initial serum glucose was higher among subjects with global cerebral edema (150.5±74.3 mg/dl verus 119.7±34.6 mg/dl). Of the 18 patients who underwent a CT scan at 48 hours, 5 had either new or worsening global cerebral edema. Three of the 18 patients with global cerebral edema underwent neurological deterioration and 1 patient died during hospitalization.

Conclusions:
Global cerebral edema can occur even in subjects with mild ICH. The pathophysiological basis and prognostic significance needs to be studied in future trials.
Abstract WP314: Frequency and Characteristics of Hemiplegic Shoulder Pain - A Population-Based Assessment
Authors: Allen Zoe A ,   SEARCH Investigator Group
Published: July 2021

Background:
Shoulder pain is common complication of stroke with multiple aetiological mechanisms but there are few population-based studies of the clinical profile, frequency and impact of the disorder.

Objectives:
To determine the frequency and characteristics of hemiplegic shoulder pain in the first year after stroke.

Methods:
Data on any shoulder pain were obtained in patients registered in a population-based stroke incidence study undertaken in a defined area of the western suburbs of Adelaide, South Australia, over a 12-month period to July 2010. Subjective (any, onset, severity [visual analogue scale] and aggravating factors) and three objective (modified Neer test, passive hand-behind-neck, and passive external rotation) measures of pain were undertaken at baseline, and 4 and 12 months post-stroke.

Results:
Among 301 stroke patients, shoulder pain data were available for 198 (66%), as 62 had died prior to the 4 month assessment and 41 either refused or were unavailable for assessment. Information on shoulder pain was available from 198 stroke survivors at baseline, 156 at 4 months and 148 at 12 months. Overall, 10% reported shoulder pain at baseline, whilst 21% reported pain at both follow-up assessments, so that overall approximately one third (27%) of patients reported some shoulder pain during 12 months post-stroke. The median pain score (visual analogue scale = 40) was highest at 4 months, and the characteristics varied from mild and prominent at rest (including night) in the early weeks, to being more associated with limited range of movement and aggravated by active movement towards 12 months, suggesting increasing musculoskeletal contributions to pain over time. Objective passive range of motion tests were associated with higher frequencies of pain than were elicited by self-reports.

Conclusions:
The frequency of post-stroke shoulder pain was similar to other population-based studies, suggesting limited progress in prevention and management of this complication. As the disorder is most common and severe after hospital-discharge, targeted protocols may facilitate identification and management.
Abstract WP324: Stroke Recognition Among Inpatient Staff at an Academic Medical Center
Authors: Adelman Eric E , Meurer William J , Nance Dorinda K , Kocan Mary Jo , Maddox Kate E , Morgenstern Lewis B , Skolarus Lesli E
Published: July 2021

Background
About 10% of all strokes occur in hospitalized patients. The goal of this work was to evaluate the knowledge of stroke signs and to determine predictors of that knowledge among inpatient staff at an academic medical center.

Methods
Stroke education was the topic of a mandatory in-service for all adult inpatient medical, surgical, and ICU nursing unit clinical staff; including nurses, techs, and aides. The staff members anonymously completed an optional web-survey which included free text responses for stroke signs and symptoms, along with additional multiple choice questions regarding experience and training. The primary outcome was stroke knowledge which was defined as correct naming of 2 or more stroke warning signs or symptoms. Logistic regression was used to determine predictors of the primary outcome.

Results
The survey was offered to 1,593 staff members and 875 (55%) completed the survey. Eighty-seven percent of inpatient staff members correctly identified 2 or more stroke warning signs or symptoms while 31% identified 3 stroke warning signs or symptoms. Individual level predictors of stroke knowledge are shown in the Table. Greater self-reported confidence in identifying stroke symptoms and higher ratings for the importance of rapid identification of stroke symptoms were associated with stroke knowledge. Clinical experience, educational experience, work location, and personal knowledge of a stroke patient were not associated with stroke knowledge.

Conclusion
More than 80% of adult clinical inpatient staff members have knowledge of two or more stroke signs and symptoms. Future nursing education should emphasize the importance of rapid identification of stroke signs and symptoms and increasing confidence in knowledge of stroke symptoms.
Abstract WP328: A Nurse-Led Initiative Improves Adherence Rates for Stroke Follow-up and Blood Pressure Management
Authors: Larsen Darren T , Lutsep Helmi L
Published: July 2021

Background and Issues
Aggressive management of vascular risk factors reduces stroke rates. It is unknown whether structured nurse-led follow up increases adherence rates for stroke patients after hospital discharge.

Purpose
The purpose of this program is to improve secondary stroke risk factor management by instituting a nurse-led initiative called Stroke Therapy, Education, Prevention (STEP).

Methods
The pilot STEP program was based on protocols used for other stroke prevention trials. This nurse-led program includes inpatient initiation and outpatient maintenance of pharmacologic and lifestyle goals for stroke patients.

Eligible patients have a non-disabling ischemic stroke or TIA and are without insurance restrictions and live within a distance allowing return to clinic for follow up.

Prior to discharge, the STEP nurse completes patient education, and reviews outpatient goals.

The STEP nurse makes phone contact with the patient 7-10 days after discharge to review medication compliance and reinforce education.

At 30 days post discharge patients are seen in clinic by the STEP nurse where a resting blood pressure (BP) is measured. If the patient does not meet targets (<140 SBP or <130 SBP for DM) medications are adjusted by a stroke neurologist.

We undertook a retrospective chart review of a consecutive cohort of patients matched to STEP eligibility criteria to determine whether the program improved retention rates and BP management. Chi-Square analysis was used to compare visit adherence and percentage achieving goal BPs at 30 days.

Results
In the STEP group 25/32(78%) patients completed the 30 day follow up compared to 14/32 (44%) patients in the historical matched cohort (p=0.0048). Target BP was achieved in 13/25(52%) STEP patients and 5/14 (36%) matched cohort patients (p=0.32) returning to clinic. Overall, target BP was achieved in 13/32 (41%) and 5/32 (16%) respectively (p=0.026).

Conclusions
In conclusion, follow up adherence and BP management in the group as a whole was better in the nurse-led model and is recommended for secondary stroke prevention. Long term follow up with this model may further increase in-target rates of BP control and other stroke risk factors.
Abstract WP335: Closing the Gap - Development of a Regional Stroke System
Authors: Sharp Johanna , Hunter-Alonzo Melissa , Blanchette Adam , Birnbaum Lee , Epley Eric , Lacson Eleanor , Leonard Anne , Love Preston , Motz Deb , Patterson Michele , Pruitt Justin , Wright Brandi , Huey Dicky
Published: July 2021

Background and Purpose:
In 2009, the 7
th
largest populated city in the United States, had no certified Primary Stroke Centers, or organized approach to care for stroke patients. The purpose is to describe how in one year, a large geographic region progressed from no system of stroke care to an organized system of 10 Certified Primary Stroke Centers and numerous EMS agencies.

Methods:
Hospital leaders were compelled to create stroke programs in their facilities in response to intense community pressure following a patient who had a poor outcome secondary to no access to a stroke center in San Antonio. The Southwest Texas Regional Advisory Council (STRAC) Stroke Committee, comprised of hospital, physician and EMS leaders developed a Stroke Letter of Attestation signed by participating hospitals and EMS agencies. This letter defined an interim process for performance and pre-hospital stroke alert criteria while hospitals developed programs and became certified as stroke centers. The agreement established a commitment to maintain rapid response teams, a central one-call transfer process, and process improvement. Transfer tracking sheets were developed to monitor hospital responses to transfer requests and patient acceptance. Despite a competitive environment, Stroke Coordinators met monthly to discuss data and develop regional reports for review in the Stroke Committee. In addition, stroke algorithms were distributed to rural facilities to assist with care prior to transfer to a stroke center.

Results:
By coordinating a system of care with first responders, no longer diverting patients out of the service area, and data sharing, a large region progressed from having no stroke system to an organized system of 10 Certified Primary Stroke Centers, which provide the region access to quality care. The STRAC Stroke/Performance Improvement Committee and Coordinator Committee continue monthly meetings.

Conclusions:
This process successfully closed the gap in stroke care. The STRAC Stroke Committee continues to improve data collection, provide feedback to EMS, set goals for public education, and engage hospitals and EMS agencies in the commitment to quality stroke care.

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st
paragraph in methods?
Abstract WP340: Is There a Ceiling Effect For EMS Stroke Diagnostic Accuracy?
Authors: Handler Diane , Kane Catherine , Wehr Michelle , Alexandrov Anne W
Published: July 2021

Background:
The accuracy of paramedic diagnosis of stroke is essential to the American Heart Association’s Stroke Chain of Survival. The highest rate of stroke diagnostic accuracy reported in the literature is 79% (Wojner-Alexandrov et al, 2005) and resulted from continuous feedback education. We aimed to see whether an EMS Report Card intervention could achieve similar results in a rural community hospital setting.

Methods:
Consecutive EMS-diagnosed stroke patients were evaluated by the Stroke Team. An EMS Report Card was developed to provide feedback on all suspected stroke patients and formal education was provided based on trends in EMS reports to support improved diagnostic accuracy.

Results:
A total of 198 EMS diagnosed Stroke Alerts were analyzed; 41 were admitted in 2009, 83 in 2010, 74 in 2011. The rate of stroke mimic transports for EMS was 29% in 2009 (sensitivity=71%), and improved to 26% in 2010 (sensitivity=73%), and improved to 23% by 2011 (sensitivity=77%). Specificity was not calculated. Table 1 shows the frequency of stroke mimic diagnoses for this 3 year period. The number of EMS admissions treated with intravenous tPA was 8 for 2009 (door to bolus time 55.6 minutes + 21.7, median 60.5 minutes, range 25-84 minutes), 22 for 2010 (door to bolus time 52.1 minutes + 14.5, median 50.5 minutes, range 20-90 minutes), and 17 for 2011 (door to bolus time 50.8 minutes + 18.3, median 51 minutes, range 28-68 minutes). The number of intravenous tPA treatments, and door to bolus time were not significantly different over the 3 year period. There was a trend towards increased tPA treated patients by EMS squad (Chi Square=23.3; p=0.078).

Conclusion:
Accuracy of stroke paramedic diagnosis is important. While our intervention did not demonstrate further improvement, this may indicate a ceiling effect for paramedic stroke diagnostic accuracy above 77-79% that should be considered acceptable.
Abstract WP345: Stroke Risk Factors Screening and Education: A Regional Strategy to Address Stroke Prevalence and Mortality in Eastern North Carolina
Authors: Congleton Terry M , Small Cristine W , Freeman Susan D
Published: July 2021

Background:
Eastern North Carolina (ENC) stroke mortality is 12 percent higher than the rest of the state. Often, geographical and sociological barriers prevent people residing in our rural communities from seeking routine health care. Stroke risk factors are known. The purpose of this initiative is to reduce the stroke prevalence and mortality in ENC through community risk factors screening and education.

Methods:
Medical center volunteers’ staff the screening and volunteer hours are recorded in a community benefit database. Each participant completes a standardized evidenced based assessment. Information collected at each screening includes demographic data, cardiovascular history, knowledge of stroke/transient ischemia signs and symptoms. Clinical metrics obtained are finger stick for random lipid panel and blood glucose, body mass index, hip to waist ratio and carotid bruit screen. Based on the screening results, education, recommendations and referrals are reviewed with every participant.

Results:
From 2007-2010 the screening volume doubled. In 2011, there was a reduction in screening volume as our system hospitals expanded their community stroke outreach efforts. Approximately 4900 community screenings have been conducted from 2007-2011. Elevated blood pressure and cholesterol respectively are most frequently occurring stroke risks factor found, which is consistent with national trends. Stroke mortality has decreased in the region while transient ischemia attack admissions volume has increased at our certified primary stroke center and regional referral center.

Conclusions:
In conclusion, primary and secondary prevention through community outreach education, risk factors screening and regional collaboration has made a difference. The region has seen a decrease in stroke prevalence and mortality in ENC. Further reduction is necessary to continue to make an even greater impact. Future directions for the stroke risk factor identification screening is to further integrate community efforts and seeks grant opportunities to establish stroke prevention and management clinics throughout the region.
Abstract WP363: Journey of a Five-Hospital System to Primary Stroke Center Certification
Authors: Motz Deb , Huey Dicky , Moore Tracy , Freemyer Byron , Austin Tommye
Published: July 2021

Background:
In 2008, a city with a population of over one million people had no organized stroke care or Certified Primary Stroke Centers. Patients presenting with stroke symptoms had inconsistent neurology coverage and little or no access to rtPA. The purpose is to describe steps taken for five acute-care hospitals (with one CMS provider number) to become Primary Stroke Certified.

Methods:
The journey began with administrative support and a commitment to provide the resources for a successful program. To oversee development, a Medical Director and Stroke Coordinator were appointed. To bridge the gap in available specialty physicians, partnerships were formed with a telemedicine group to provide emergency treatment and an academic medical center to augment the neurology and neuro-surgical coverage. Multidisciplinary teams met monthly in each facility. Representatives from each team formed a regional committee and an education council was created to share best practices and assure consistency across the system. Evidenced based order sets were developed using clinical practice guidelines. The Medical Executive Committee at each facility and ultimately the Medical Executive Board endorsed the order sets and mandated their use. Each facility chose the appropriate unit to cohort the stroke patients which encouraged expertise in care.

Results:
This journey resulted in a high functioning system of care. Baptist Health System became Joint Commission Certified in all five locations (May 2009). We were awarded the Get with the Guidelines Bronze Award (September 2010), the Silver Plus Award (July 2011) and the Gold Plus Award (July 2012). In addition, we were the first in Texas to achieve the Target Stroke Honor Roll (Q3 2011) and have maintained this status for eight consecutive quarters.

Conclusion:
In conclusion, administrative support is imperative to the success of a stroke program. Leadership, partnerships, committees, councils and staff involvement from the start drove the team to a successful certification process with outstanding outcomes. The stroke committees continue to meet monthly to analyze performance measures, identify opportunities for improvement and execute action plans.
Abstract WP365: STARS PLUS Patient Transition Pilot Program
Authors: Graves Alexandra , West Angie , Bretz Miranda N , Welch Marie , Toth Lynn , Kiesz Karen
Published: July 2021

Background:
As the leading cause of adult disability and the fourth leading cause of death in the United States, stroke prevention strategies are imperative. Arguably equal attention should be given towards both primary and secondary prevention of stroke. While much is known about medications and lifestyle changes to prevent recurrent stroke, additional research is needed to effectively ensure stroke survivors are following the recommended guidelines. Research shows that support after discharge from the hospital post-stroke is frequently inadequate.

Purpose:
The purpose of the Steps Against Recurrent Stroke (STARS) Plus Patient Transition Pilot Program was to design and deliver a program to facilitate optimal recovery for stroke survivors and prevent recurrent stroke. The program began at discharge from the hospital and continued through the first year of rehabilitation and recovery. Patients could opt in based on perceived benefits of support with medication management, timed educational mailings and calls about stroke recovery and recurrent stroke prevention.

Results:
Twelve hospitals participated; 261 patients enrolled and contact was established with 193. Outcomes were gathered based on patient self-report of health status using the Standard Form 12 (SF-12) Health Survey at 30, 90, 180 and 360 days. A total of 72 patients completed each follow-up in the full 12 months of the program. A dependent sample t-test was completed comparing participants’ 30 and 360 day follow-up scores. Results demonstrated an overall increase in subjective pain. A repeated MANOVA was conducted to compare 30 and 360 day SF-12 scores across age and subscales. Results revealed that those in the younger and older age groups reported poorer health outcomes.

Conclusion:
STARS Plus Program found no statistically significant change in perceived health benefits, although the majority found the program to be beneficial. Future programs should consider targeting pain management in all ages and education targeted at younger and older age groups, as they reported poorer health outcomes. The findings from this program should contribute to the guidance and insight for others developing transitional interventions for stroke survivors.