bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W MP87: Lack of Improvement in Incidence and Case-Fatality of First Time Hospital Admission With Intracerebral Hemorrhage in Denmark 2004-2012
Authors: Ottosen Tobias Pilgaard , Schmitz Marie Louise , Schmidt Morten , Jacobsen Jacob Bonde , Andersen Grethe , Johnsen Søren Paaske
Published: March 2022

Background:
The mortality from ischemic stroke and other ischemic cardiovascular events have declined substantially in the last decades. Less is known about the epidemiology of intracerebral hemorrhage (ICH). However, the distribution of major modifiable risk factors, particularly hypertension, smoking, and use of antithrombotic medications changes rapidly in most populations, which underlines the need for updated data.

Objectives:
To examine trends in incidence of first hospitalization due to ICH and subsequent 30-day case-fatality in Denmark 2004-2012.

Methods:
We performed a nationwide population-based cohort study. Patients with a first hospitalization due to ICH were identified in the Danish Stroke Registry and followed using the Danish Civil Registration System to determine 30-days case-fatality. We calculated the standardized incidence rates of hospitalization for ICH. Using 2004 as reference, we used multivariable logistic regression with 95% confidence interval to estimate the odds ratio (OR) of death according to year of admission adjusting for age, gender, diabetes, atrial fibrillation, hypertension, previous myocardial infarction, diabetes, smoking, alcohol intake, and quality of in-hospital stroke care.

Results:
We identified 7850 patients with incident ICH (51.7 % men, median age 74 years). The overall standardized incidence rate (SIR) was 20.9 per 100.000 person years (95% CI: 19.5-22.3) and slightly higher among men compared with women. The SIR remained stable throughout the study period (2004: 20.7 (95% CI: 19.3-22.1) vs. 2012: 18.2 (95% CI: 16.9-19.5)). The average 30-day case-fatality was 31.2%. The adjusted OR for 30-day case-fatality was 1.24 (95% CI: 0.94-1.64) when comparing 2012 with 2004.

Conclusions:
The incidence rate of first hospitalization due to ICH and subsequent case-fatality have remained stable in Denmark in recent years despite increased focus on modifiable risk factors and improved early in-hospital stroke care.
Abstract W MP98: Tracheostomy Timing Impacts Stroke Recovery
Authors: Villwock Jennifer A , Villwock Mark R , Deshaies Eric M
Published: March 2022

The timing of tracheostomy in stroke patients unable to protect their airway has become a topic of debate. Proponents for early tracheostomy cite benefits including less ventilation-associated pneumonia, less sedative drug use, shorter length of stay, and reduced mortality in comparison to late tracheostomy. We examined the timing of tracheostomy on stroke patient outcomes across the United States using the Nationwide Inpatient Sample (2008-2010). Our hypothesis was that patients receiving an early tracheostomy would fare better at discharge in comparison to their counterpart receiving a late tracheostomy. Independent samples t-tests and chi-squared tests were used to make comparisons between early (≤10 days) and late (11-25 days) tracheostomy. Multivariable models, adjusted for confounding factors, investigated outcome measures. There were 13,165 stroke cases included in the study (5,591 in the early tracheostomy group and 7,574 in the late tracheostomy group). Univariate comparisons between groups can be found in the included table. Patients receiving an early tracheostomy had a significant reduction in the odds of ventilator-associated pneumonia in comparison to the late tracheostomy group (OR: 0.688, 95% CI: 0.495 - 0.956, P=.026). The adjusted length of stay for patients receiving an early tracheostomy was significantly lower in comparison to the late tracheostomy group (P<.001) and was associated with a 17% reduction in total hospital costs (P<.001). In conclusion, early tracheostomy for stroke patients may reduce the incidence of ventilator-associated pneumonia, thereby shortening the hospital stay and lowering total hospital costs. These relationships warrant further investigation in a large prospective multicenter trial.
Abstract W P10: Endovascular Treatment for Anterior Circulation Stroke Leads to Similar Outcomes in Very Early (within 3 hours) versus Selected Late (Beyond 8 Hours) Presenting Patients
Authors: Streib Christopher , Aghaebrahim Amin , Rangarauju Srikant , Jankowitz Brian , Amorim Edilberto , Paolini Stephanie , Wintermark Max , Zhu Guangming , Leiva-Salinas Carlos , Jadhav Ashutosh , Jovin Tudor
Published: March 2022

Background and Purpose:
Endovascular therapy for acute ischemic stroke (AIS) is thought to have a higher chance of good outcome in patients presenting early than in those presenting late. However, a subgroup of late presenting patients, identifiable through advanced neuroimaging methods, has favorable physiology and can still experience good outcomes following reperfusion. We sought to compare outcomes in patients treated very early (within 3 hours) vs. late (beyond 8 hours) at our institution.

Methods:
Via retrospective analysis of a prospectively collected database of 961 consecutive patients treated at our center (2001-2013), we identified patients with anterior circulation stroke who underwent endovascular treatment < 3 hours from time last seen well (with or without prior IV thrombolysis), and patients who underwent endovascular treatment > 8 hours from time last seen well, selected with advanced neuroimaging. Baseline characteristics and outcomes including MRI derived final infarct volumes (FIV) for each group were analyzed. [Table]

Results:
We identified 108 patients treated < 3 hours and 177 patients treated > 8 hours from time last seen well. Baseline characteristics were not significantly different between the two groups except for differences in atrial fibrillation, baseline ASPECTS, and baseline NIHSS. All outcome measures were not significantly different between the two treatment groups. [Table]

Conclusion:
Despite larger baseline infarcts in the > 8 hour group compared to the < 3 hour group, rates of good outcomes, FIV, and mortality did not differ between the two groups. These findings may be explained by differences in the rate of infarct growth from presentation to reperfusion in the two patient populations.
Abstract W P118: Ocular Circulation and Chronic Ocular Ischemic Syndrome in Carotid Artery Stenosis Treated by CEA and CAS
Authors: Kawaguchi Shoichiro , Iida Jun-ichi , Uchiyama Yoshitomo , Kotani Yukiko
Published: March 2022

Background:
We evaluated the effect of carotid revascularization surgery for ocular circulation and chronic ocular ischemic syndrome (OIS).

Methods:
We examined ninety-2 patients with carotid artery stenosis (more than 50% stenosis) at its origin treated by carotid endarterectomy (N=58) or carotid artery stenting (N=34). Twenty-five patients (28%) complained of chronic OIS. Ocular circulation was examined before and after revascularization surgery using ophthalmic artery (OphAr) and central retinal artery (CRA) color Doppler flow imaging.

Results:
1) Ocular circulation: Preoperatively, the average OphAr peak systolic flow velocity (Vs) was 0.05 m/sec, and the average CRA Vs was 0.07 m/sec. At 1 week after surgery, the average OphAr Vs significantly increased to 0.32 (
p
< 0.05), and the average CRA Vs significantly increased to 0.11 m/sec (
p
< 0.05). These significant improvements were sustained throughout the three months of the follow up.2) OIS: During the follow-up period (mean: 3.6 years), 15 patients (60%) showed visual acuity improvement, and no patients complained of amaurosis fugax or worsening of the chronic OIS.

Conclusion:
Carotid revascularization surgery was effective in improving the ocular circulation, and it was also useful for the chronic OIS due to the carotid artery stenosis.
Abstract W P123: Associations of Temperature and Average Dew Point With Stroke Hospitalizations and Mortality
Authors: Lichtman Judith H , Leifheit-Limson Erica C , Wang Yun , Goldstein Larry B
Published: March 2022

Background:
Some studies suggest meteorological factors may affect stroke incidence and mortality, but results are inconsistent. We investigated the effects of average annual temperature, daily temperature fluctuation, and average dew point on ischemic stroke hospitalizations and mortality in a nationally representative sample from the United States.

Methods:
Ischemic stroke hospitalizations (ICD-9 433, 434, 436) were identified for those ≥18 years of age from the Nationwide Inpatient Sample 2009-2010. Temperature and dew point data were obtained from the National Climatic Data Center and linked to stroke discharges at the county level. Hierarchical logistic regression was used to assess the relationship between meteorological variables and stroke hospitalization and in-hospital mortality, adjusting for region, season, and patient demographics and comorbidities.

Results:
We identified 134,510 ischemic stroke hospitalizations (mean age 72 ± 14 years). In unadjusted analyses, each 1°F increase in average temperature was associated with a 0.86% decrease in the odds of stroke hospitalization and a 1.1% decrease in the odds of dying in-hospital after stroke. Increases in daily temperature fluctuation and average dew point were associated with an increased odds of stroke hospitalization (ORs 1.02 and 1.01, respectively), but were not associated with in-hospital mortality. These relationships persisted in risk-adjusted analyses (Figure).

Conclusions:
Larger daily temperature changes and higher average dew point were associated with higher stroke hospitalization, while lower average annual temperatures were associated with both hospitalization and mortality after stroke. Further research is needed to understand these effects to develop prevention strategies for vulnerable populations during periods of extreme weather conditions.
Abstract W P125: Glycemic Variability Should Be Associated with the Ischemic Volume Expansion and Neurological Deterioration in Acute Stroke
Authors: Uemura Junichi , Shimoyama Takashi , Shibazaki Kensaku , Saji Naoki , Kimura Kazumi
Published: March 2022

Background and Purpose:
Several studies suggested that hyperglycemia on admission worsen the prognosis of acute stroke patients. However, it is not clear that glycemic variability in acute stroke is associated with neurological deterioration and infarct volume expansion. The purpose of this study was to clarity above issue using continuous glucose monitoring device (CGMS).

Methods:
Consecutive acute stroke patients with the internal carotid artery(ICA) or middle cerebral artery(MCA) occlusion within 24 hours of stroke onset were prospectively studied. We evaluated glucose values during 72 hours after stroke onset using CGMS. All patients were classified into following three groups. Persisting hyperglycemia (PH) group had persisting hyperglycemia as glucose level above 180mg/dl, persisting normoglycemia (PN) group had persisting normoglycemia as glucose level 70mg/dl to 140mg/dl and the glucose variability (GV) group had glycemic variability as glucose level 70mg/dl to 400mg/dl during 72 hours monitoring. We compared clinical characteristics including infarct volume, and neurological change among three groups. Multivariate logistic regression analysis was performed to identify factors associated with neurological deterioration.

Results:
69 patients (male 28, median 82 years old, ICA occlusion in 11 patients) were enrolled into the present study. PH group had 10 patients, PN had 26, and GV had 33. GV group had highest baseline NIHSS score among three groups(PH;9.6, PN;12.8, GV;16.4, p=0.013).There were no differences in other factors and initial DWI volume among three groups. Follow-up infarct volume at 72 hours and infarct volume growth were largest in GV groups among three groups(PH; 53.5 and 21.5 ml, PN;69.8 and 28.8ml, and GV; 136.5 and 69.4ml, P=0.019 and P=0.015). GV group more frequently had neurological deterioration among three groups. (PH;10%, PN;0%, GV;30%, P=0.005). Multivariate logistic regression analysis demonstrated that glucose variability was an only independent factor associated with acute neurological deterioration (OR 4.671; 95%CI, 1.503-22.561, P=0.003).

Conclusion:
Glycemic variability should be associated with the ischemic volume expansion, and neurological deterioration in acute stroke.
Abstract W P128: Development and Validation of Clinical Prediction Model for Obstructive Sleep Apnea among Patients with Ischemic Stroke and TIA
Authors: Sico Jason J , Ofner Susan , Qin Li , Yaggi Henry K , Bravata Dawn M
Published: March 2022

Introduction:
Obstructive sleep apnea (OSA) screening instruments that perform well in the general population have demonstrated poor correlation with OSA diagnosis in stroke and TIA populations. Given that OSA is common post-stroke/TIA, has been associated with recurrent vascular events, and is treatable, we sought to develop and validate a cerebrovascular disease specific prediction model for OSA.

Methods:
We developed and validated a clinical prediction model using data from two separate multi-site randomized, controlled strategy trials: the development population included chronic stroke/TIA patients; the validation population included acute stroke/TIA patients. Data on patient demographics, vital signs, anthropomorphic measurements, past medical history, medications, NIHSS, sleep questionnaires, and polysomnography (PSG) were obtained. OSA was defined as present if the apnea-hypopnea index (AHI) was ≥5 events/hour. Variables considered clinically important and required to remain in the multivariable logistic regression model were gender, weight, neck circumference (women >16”, men >17”), history of CHF, DM and NIHSS. Variables associated with OSA in bivariate analyses (p≤0.25) were also included: age, history of chronic obstructive COPD, automatic implantable cardioverter defibrillator (AICD), Charlson comorbidity, Epworth Sleepiness Scale (ESS), Berlin Questionnaire ≥10, and patient health questionnaire (PHQ8) depression scale. Backward elimination was used to identify factors that were independently associated with OSA (p<0.05).

Results:
Sleep apnea occurred commonly in the development (119/194; 61%) and validation (75/96; 76%) cohorts. The final model included: gender, CHF, DM, large neck, and the quadratics of weight, NIHSS, and ESS. The model showed reasonable discrimination in the development (c-statistic 0.73) and validation (c-statistic 0.70) cohorts. This model correctly classified 68% of patients in the validation sample as having OSA.

Conclusions:
A model based on readily available clinical information predicted the presence of OSA reasonably well. Future work is required to determine the utility of this model in clinical practice for the identification of patients who should receive OSA management.
Abstract W P140: Neuroanatomical Correlates of Atrial Fibrillation: A Longitudinal MRI study
Authors: Saed Aveen , Tasneem Nudrat , Adil Malik M , Qureshi Mushtaq H , Qureshi Adnan I
Published: March 2022

Background:
We hypothesized that atrial fibrillation maybe associated with structural changes in particular regions of the brain.

Objectives:
To determine baseline volume and rate of volume change of whole brain, hippocampus, and entorhinal cortex.

Methods:
We analyzed clinical and neuroimaging data collected as part of Alzheimer’s Disease Neuroimaging Initiative from 200 normal controls and 400 individuals with mild cognitive impairment (MCI) recruited at approximately 50 sites in the United States and Canada. Patients with atrial fibrillation were identified based on baseline clinical/cognitive assessments and age and gender matched controls without atrial fibrillations were selected (1:1 ratio). All participants underwent 1.5 T structural MRI at specified intervals (6 or 12 month) for 2-3 years.

Results:
A total of 40 persons with atrial fibrillation were included [Age mean (±SD) 78±6, 23 (57.5) were men]. There were no patients with stroke and 10 controls who had a previous history of stroke. There was no difference in whole brain and ventricular volumes at baseline MRI between cases and controls. There was significantly lower entorhinal cortex volume on right (p=0.001) and left (p=0.002) sides in patients with atrial fibrillation. There was significantly lower volume for middle temporal lobes on right (p=0.001) and left (p=0.001) sides. The rate of progression of atrophy in entorhinal cortex and middle temporal lobes was not different between patients with atrial fibrillation and controls.

Conclusions:
The association of atrial fibrillation with volume loss in entorhinal cortex and middle temporal lobes may provide new insights into pathophysiology of atrial fibrillation.
Abstract W P143: Race-specific Effects of Inflammatory and Vascular Remodeling Biomarkers in Ischemic Stroke
Authors: Bushnell Cheryl , Snively Beverly M , Worrall Bradford B , Colton Carol , Hoogeveen Ronald , Mosley Thomas , Gottesman Rebecca , Folsom Aaron , Wagenknecht Lynne
Published: March 2022

Background:
Blacks have a higher risk of stroke than whites; inflammatory and vascular remodeling (VR) biomarkers may mediate this risk. We aimed to determine associations between inflammatory and VR biomarkers and ischemic stroke in a bi-racial sample of the Atherosclerosis Risk In Communities (ARIC) cohort.

Methods:
In a case-control pilot study, 133 participants from Forsyth and Jackson Field Centers were identified: 32 blacks and 33 whites with first ischemic stroke after visit 2, and 33 black and 35 white stroke-free controls. We assayed IL-8, IL-10, IL-1 receptor antagonist (IL-1ra), IL-1β, matrix metalloproteinase-9 (MMP-9), and tissue inhibitor of metalloproteinase-1 (TIMP-1) with Quantikine ELISA. We calculated IL-1β/IL-1ra ratio, representing the IL-1 pathway. Biomarkers were covariates in race-specific logistic regression models; if significant, biomarker-by-race interactions were explored.

Results:
Cases were older (mean age 60y vs 56y; p<0.0001); more had hypertension (52% vs 35%; p=0.043), and diabetes (35% vs 13%; p=0.0034). There were no differences in biomarkers between blacks and whites (cases and controls). In blacks, there was a trend toward a reduced risk of stroke with increasing levels of IL-1ra after adjustment (p=0.074). In whites, stroke was associated with higher levels of TIMP-1 (p=0.011; interaction p=0.079) and with higher levels of IL-8 (p=0.011; interaction p=0.11) in the unadjusted, but not adjusted model (Table).

Conclusion:
We identified race-specific associations between biomarkers and incident stroke. VR biomarkers (TIMP-1) may be associated with stroke in whites, and there was a trend towards lower levels of IL-1ra (counter-inflammatory) and risk of stroke in blacks. Larger studies are warranted to confirm these findings and determine if these markers will explain differences in stroke risk in blacks vs whites.
Abstract W P157: Radiographic Markers of Small Vessel Disease in Young Stroke Patients.
Authors: Shoamanesh Ashkan , Catanese Luciana , Lau Helena , Wang Na , Romero Jose R , Babikian Viken L , Benavente Oscar R , Kase Carlos S , Pikula Aleksandra
Published: March 2022

Background:
White-matter hyperintensities (WMH) and cerebral microbleeds (CMBs) are considered radiographic markers of small vessel disease (SVD). Literature on CMB and WMH prevalence and associated risk factors in young patients presenting with stroke is limited. We have reported high prevalence of both WMH and CMBs in our cohort of young stroke patients. The aim of this report is to better characterize independent determinants of WMH and CMBs in the same cohort

Methods:
Charts of consecutive patients ≤49 years of age admitted with a diagnosis of ischemic stroke (IS) or spontaneous intraparenchymal hemorrhage (IPH) between 01/06-02/10 were reviewed (n=146). Patients with interpretable T2*-GRE (104) and/or T2/FLAIR (107) sequences on MRI were eligible. WMH was graded according to the Age-Related White Matter Changes Scale, and cerebral volume using the Global Cortical Atrophy Scale. Using multivariable regression analysis, we compared baseline demographics and vascular risk factors between patients with MRI markers of SVD and those without.

Results:
CMBs were present in 17% and moderate-severe WMH in 27% of individuals. Male gender (OR 4.93 [95%CI 1.01, 24.1]), hypertension (HTN) (OR 8.84 [95%CI 1.76, 40.5]), moderate-severe WMH (OR 5.25 [95%CI 1.54, 17.9]), and IPH (OR 6.97 [95%CI 1.81, 26.8]) were independently associated with the presence of CMBs. CMBs (OR 4.27 [95% CI 1.35, 13.5]), HTN (OR 4.14 [95% CI 1.42, 12.1]), serum creatinine on admission (OR per 1 mg/dl increment: 3.02 [95% CI 1.14, 7.99]) and moderate-severe cortical atrophy (OR 6.26 [95% CI 1.40, 27.94]) were significantly associated with moderate-severe WMH.

Conclusions:
Our data suggest male gender, HTN, IPH and moderate-severe WMH are associated with CMBs, while HTN, CMBs, elevated serum creatinine and moderate-severe cortical atrophy are associated with moderate-severe WMH. The association of CMBs with higher WMH severity and IPH supports the notion that CMBs are an indicator of an advanced stage of SVD that is prone to bleeding. Further studies are needed to examine if presence of CMBs and/or WMH may impact outcomes after ischemic stroke in young adults.
Abstract W P168: Intracranial Dolichoectasia in Patients with Recent Lacunar Strokes: The SPS3 Trial
Authors: Nakajima Makoto , Pearce Lesly A , Field Thalia S , Bazan Carlos , Heart Robert G , Benavente Oscar R
Published: March 2022

Background and Purpose:
Intracranial arterial dolichoectasia (IADE) is associated with atherothrombotic strokes, but its relationship with lacunar infarcts is less certain. We investigated the prevalence of IADE and associated risk of recurrent stroke and death in the Secondary Prevention of Small Subcortical Strokes (SPS3) trial.

Methods:
Maximum diameter of the intracranial internal carotid artery (ICA), middle cerebral artery (MCA), vertebral artery (VA), and basilar artery (BA) were measured on 2794 MRAs with IADE defined a priori as >7.0 mm for ICA, >4.0 mm for MCA, >4.0 mm for VA, and >4.5 mm for BA. Patient characteristics and outcomes were compared between patients with and without IADE.

Results:
IADE was present in ≥1 artery in 210 (7.1%) patients, none in ICA, 5 MCA, 163 BA, and 116 VA. Patients with IADE were more often older (65 vs. 63 years; p = 0.01) male (81% vs. 61 %; p <0.001) and had hypertension (82% vs. 74%; p = 0.008), while diabetes (29% vs. 37%; p = 0.01) was more frequent in patients without IADE. White matter hyperintensities (ARWMC score) were more frequent (severe) in patients with IADE (31% vs. 21%, p = 0.001). In multivariable logistic regression analyses, after adjusting for age, assigned treatments, and hypertension, IADE was not predictive of recurrent stroke (OR 1.2, 95% CI 0.8-1.8) or death (OR 1.5, CI 0.94-2.3). In similar analyses, neither BA nor VA diameter as a continuous measure was predictive of recurrent stroke, however, increased BA diameter was predictive of death (OR 1.2 per mm, CI 1.0-1.5, p = 0.04). VA diameter was not.

Conclusion:
In this large well characterized cohort of lacunar stroke patients, dilatation of BA was independently associated with death but not recurrent stroke, and IADE in other arteries did not predict stroke or death. IAED in lacunar stroke patients seems to be unrelated to the mechanism and severity of small vessel disease.
Abstract W P184: Comparison of Thrombolytic Treatment for Acute Ischemic Stroke Pre- and Post -Telemedicine Implementation in the Spoke Hospital Setting
Authors: Mountford William K , Chen Er , Krukas Michelle R , Tayama Darren , Ernst Frank R , Wagner Jeff
Published: March 2022

Background:
Stroke telemedicine enables “Hub” hospitals with stroke expertise to interact with smaller “Spoke” hospitals in an effort to improve capabilities of accurate diagnosis and treatment of patients suffering from an acute stroke event. Administration of recombinant tissue plasminogen activator (rtPA) for treatment for acute ischemic stroke (AIS) patients is time dependent, and telemedicine has the potential to increase AIS patient thrombolytic treatment rate.

Objective:
To compare treatment rates of AIS patients in the Spoke hospital setting before and after implementation of telemedicine.

Methods:
The study included patients (age≥18) hospitalized with a primary diagnosis of AIS (ICD-9 codes 433.x1, 434.x1, 436) admitted to the hospital between January 1, 2006 and December 30, 2012 from 13 pre-specified Spoke hospitals in the Premier research database with telemedicine implementation ranging from October 2009 through December 2011. Evidence of MRI or CT scan during the hospital stay was required for study inclusion. Treatment of rtPA was identified using ICD-9 procedure code 99.10 and/or charge master data indicating rtPA use.

Results:
A total of 9,629 and 5,228 patients were included in the study population pre- and post- telemedicine implementation respectively. Mean age and gender distribution were similar for pre- and post- implementation (72.0 vs. 71.3 years; 53.1% vs. 51.9% female, respectively). The percentage of patients treated with rtPA increased from 4.4% during pre- to 6.9% during post-implementation (p <0.0001) time period, a 56.8% increase. Increase in treatment percentages were seen in hospitals with <200 beds (1.1% vs. 7.3% p<0.0001) and hospitals with >= 200 beds (5.2% vs. 6.8% p=0.0003).

Conclusions:
Results from the study demonstrate that the percent of patients treated with rtPA with telemedicine increased more than 50% as compared to the pre-telemedicine time period. Smaller hospitals showed the most significant increase in rtPA treatment rate. This finding supports previous findings that telemedicine improves appropriate use of thrombolytic treatment for AIS patients and highlights the impact in smaller hospital settings.
Abstract W P190: Emergency Medical Services Protocols for Routing Stroke Patients to Designated Stroke Center Hospitals
Authors: Dimitrov Nikolay , Koenig William , Bosson Nichole , Song Sarah , Saver Jeffrey L , Sanossian Nerses
Published: March 2022

Background:
Stroke systems of care include routing patients to the nearest designated stroke center hospital, bypassing non-designated hospitals. Routing protocols are implemented at the state or county level and vary in qualification criteria and determination of destination hospital. We surveyed all counties in the state of California for presence and characteristics of their prehospital stroke routing protocols.

Methods:
Each county in California was queried for the presence of a stroke routing protocol. These protocols were obtained and reviewed for method of stroke identification and criteria for patient transport to a stroke center.

Results:
Thirty-three local EMS agencies (LEMSAs) serve 58 counties in California with populations ranging from 1175 to almost 10 million (mean 642,000), area ranging from 47 to 20,000 sq. mi (mean 2690) and population density 2 to 17,000 persons per sq. mi (mean 661). Fifteen LEMSAs (45%) had stroke routing protocols, covering 23 counties (40%) and 68% of the state population. Counties with protocols had higher population density (1500 vs. 140 persons per sq. mi). All protocols designated a time period from symptom onset to EMS evaluation to qualify for routing, median 3 hr (IQR 2.5-4, range 2 - 8). Twelve of 23 (52%) allowed a maximum transport time of 30 minutes to qualify for diversion. The number of LEMSA-designated stroke hospitals per county in jurisdictions with diversion was median 2 (IQR 0-7, range 0 - 29). In the six counties without designated stroke centers, patients meeting criteria were transported out of county. Stroke identification in the field among diverting LEMSAs was achieved using the CPSS/FAST in 23, the LAPSS in 2, county-specific protocol in 7, and not stated in 1.

Conclusion:
California EMS stroke routing protocols cover 68% of the state population and vary in characteristics including activation by symptom onset time and destination facility features, reflecting matching of system design to local geographic resources.
Abstract W P200: Human Albumin Improves Leptomeningeal Collateral Flow Following Experimental Stroke in Type 2 Diabetic Mice
Authors: Akamatsu Yosuke , Lee Chih Cheng , Liu Jialing
Published: March 2022

Introduction:
Type 2 diabetes mellitus (T2DM) is major risk factor of ischemic stroke and is associated with poor outcome after stroke. Previously we found that T2DM mice exhibited impaired leptomeningeal collateral flow recruitment after distal middle cerebral artery occlusion (MCAO). Human albumin has emerged as a potent neuroprotective agent in experimental stroke due to its multiple salutary actions. However, the effect of albumin on collateral flow in T2DM subjects is yet to be determined.

Methods:
Distal MCAO was induced in male db/db and db/+ mice (19-22 weeks of age). To evaluate the effect of albumin on collateral flow recruitment, mice were treated with 25% albumin or saline 2h after stroke. Doppler optical coherence tomography was used to quantify the MCA flow direction, flow velocity and vessel diameter before and after treatment. The chosen regions of interest of MCA network were classified according to branching order as segment 1 (seg1), seg2 and seg3, with seg1 most proximal to ACA while most distal to MCA. 5-10 points corresponding to the same location of each segment were selected for quantification. The infarction volume was assessed 7 days after stroke.

Results:
Albumin treatment significantly improved MCA flow velocity in db/db as well as db/+ mice (albumin effect: P<0.005/ P <0.05/ P <0.05 per seg1/seg2/seg3; genotype effect: NS in all segments; Two-way-ANOVA). The albumin effect on collateral flow velocity in seg 2 and seg 3 of db/+ mice is less pronounced compared to that in db/db mice, due to an already robust retrograde flow from ACA to MCA in the former after MCAO. In contrast, albumin did not have an effect on MCA diameter in all segments of either group. Further, albumin treatment reduced infarct size in both groups of mice (db/db: albumin: 2.2±0.5%, saline: 5.0±0.4%, P<0.01; db/+: albumin: 1.9±0.4%; saline: 3.3±0.5%, P<0.05).

Conclusion:
Albumin enhances leptomeningeal collateral flow recruitment during the acute phase of stroke in both type 2 diabetic mice and normoglycemice control mice, coincided with a reduction in stroke size. Our data suggest that albumin is a viable option for the treatment of a diverse population of stroke patients including those with vascular risk factor.
Abstract W P21: Extent of Reperfusion and Clinical Outcomes After Endovascular Therapy: More is Better
Authors: Liang Conrad W , Saver Jeffrey L , Jahan Reza , Starkman Sidney , Ali Latisha K , Rao Neal , Hinman Jason D , Vespa Paul M , Blanco Manuel B , Modir Royya F , Tansy Aaron P , Calderon-Arnulphi Mateo , Ng Kwan L , Noorian Ali R , Sheth Sunil A , Viñuela Fernando , Duckwiler Gary R , Tateshima Satoshi , Gonzalez Nestor R , Liebeskind David S ,   UCLA Stroke Investigators
Published: March 2022

Background:
Revascularization is critical to the treatment of acute stroke, yet the association between degree of reperfusion and clinical outcome of endovascular therapy has been incompletely characterized.

Methods:
In a prospectively maintained registry, we analyzed acute ischemic stroke patients treated with endovascular therapy from 2004-2013. Final TICI scores were compared to non-disabled (mRS 0-2), independent (mRS 0-3), and poor (mRS 5-6) outcomes at discharge in a univariate analysis. Multiple regression analysis was performed to separate effects of baseline patient characteristics, stroke severity, complications, and technical aspects of endovascular treatment. To determine the maximal predictive value of the TICI score, the ROC curve for binned combinations of TICI were compared.

Results:
Of 183 patients, age was mean 68.4 ± 16.9 years, 58% were female, baseline NIHSS was 16.5 ± 6.9, and mean time from stroke onset to groin puncture was 395 ± 378 minutes. At discharge, the rate of freedom from disability (mRS 0-2) was 15%, freedom from dependency (mRS 0-3) 26%, and poor outcome (mRS 5-6) 54%. Any reperfusion (TICI 2a or higher) was achieved in 79% of patients. Substantial reperfusion (TICI 2b or higher) was associated with higher rates of non-disabled (26% vs 4%, p < 0.001) and independent outcome (37% vs 15%, p = 0.001), and reduced poor outcome (42% vs 66%, p = 0.001). In the multivariate analysis, independent predictors of non-disabled outcome included higher TICI (unmodified 5-level score, β = -0.260, p < 0.001), younger age (β = 0.289, p < 0.001), and lower initial NIHSS (β = 0.355, p < 0.001). Trichotomized TICI scores (0-1, 2a, 2b-3) showed substantial power in predicting discharge outcome: mRS 0-2, c-statistic = 0.72; mRS 0-3, c = 0.64; and mRS 5-6, c = 0.64.

Conclusions:
Clinical outcome is closely related to the degree of reperfusion achieved during endovascular stroke intervention. Age and initial stroke severity additionally help differentiate patients who are more likely to do well from those who will not. Trichotomized TICI scores are highly predictive of functional clinical outcome.
Abstract W P212: Combination Therapy With Amlodipine and Irbesartan Persists a Neuroprotective Effect Associated With Glial Deactivation on Paraventricular Nucleus in Hypertensive Rats
Authors: Hasegawa Yu , Nakagawa Takashi , Uekawa Ken , Ma Minglie , Lin Hakubun , Kusaka Hiroyuki , Katayama Tetsuji , Sueta Daisuke , Toyama Kensuke , Koibuchi Nobutaka , Kim-Mitsuyama Shokei
Published: March 2022

Although combination therapy with calcium channel antagonist and angiotensin II receptor blocker is sometimes more effective for hypertension than monotherapy, it is little known the significant roles against stroke onset. In this study, we investigated the beneficial effect of the combination therapy with amlodipine and irbesartan against stroke onset in stroke-prone spontaneously hypertensive rats (SHRSP). High-salt-loaded SHRSP were assigned to 1)vehicle, 2)amlodipine (AM; 2mg/kg/day), 3)irbesartan (IR; 20mg/kg/day), and 4)AM+IR. The drugs were given every day until 35 days. Incidences of neurological deficit and mortality were monitored every day and blood pressure was measured at 7 and 28 days. Cerebral blood flow (CBF), weight of brain and left ventricle (LV) and histological evaluations were conducted at 42 days. The blood pressure in AM and AM+IR groups were significantly reduced compared with that in vehicle groups. Although the incidence of neurological deficit and mortality until 28 days were 90% and 40% in vehicle group, the rats in treatment groups were almost healthy until 35 days. After the drugs discontinued, abnormal signs were frequently seen in monotherapy groups until 42 days (neurological deficit; AM 50%, IR 50%, AM+IR 0%, mortality; AM 30%, IR 10%, AM+IR 0%). Although there was no significant difference in CBF among the groups, the weight of brain and LV in AM+IR group were decreased compared with those in single treatment groups.

Histological findings showed that glial activation at paraventricular nucleus and atrophy of white matter were more seen in stroke group compared with non-stroke groups. These data suggest that the therapy with AM+IR persist a neuroprotective effect against hypertension-induced stroke onset and the effect might associate with glial deactivation on paraventricular nucleus.
Abstract W P219: Delivery of an Oral Formulation of Angiotensin-(1-7) After Stroke is Neuroprotective
Authors: Bennion Douglas M , Haltigan Emily , Irwin Alexander , De Sousa Frederico B , Sinisterra Ruben D , Santos Robson A , Sumners Colin
Published: March 2022

Background:
The renin angiotensin system has become the focus of recent interest in stroke research as accumulating evidence indicates that activation of the angiotensin converting enzyme 2/angiotensin-(1-7)/mas (ACE2-Ang-(1-7)-Mas) axis exerts neuroprotective benefit in animal stroke models. Pre- and post-stroke activation of this axis by intracerebroventricular infusion of Ang-(1-7) reduces infarct size and improves neurological function in rats. The recent development of an orally active formulation of Ang-(1-7) in hydroxypropylβ-cyclodextrin [HPβCD/Ang-(1-7)] provides a non-invasive avenue for testing the efficacy of systemic post-stroke administration of Ang-(1-7). We tested the hypothesis that post-stroke oral gavage of HPβCD/Ang-(1-7) exerts neuroprotection in a rat model of ischemic stroke.

Methods:
Male SD rats underwent ischemic stroke by endothelin-1-induced middle cerebral artery occlusion and were randomly divided into 2 groups of 12 each that received oral gavages of dH2O or HPβCD/Ang-(1-7) (50 ug/kg) at 4, 24, and 48h after stroke, as well as blinded neurological assessments at 4, 24, and 72h after stroke. Immediately after the 72h tests, animals were euthanized and cerebral infarct sizes were assessed by TTC staining. Data are expressed as mean ± SEM with significance inferred at p<0.05.

Results:
Mean infarct sizes (%) were significantly decreased by post-stroke oral gavage of HPβCD/Ang-(1-7) (32.57±2.74) vs. dH2O (43.65±5.27,
Fig 1
). As compared to deficits at 4h post-stroke, 72h neurologic deficits (Bederson Scale) were significantly improved in HPβCD/Ang-(1-7)-treated rats (4h: 1.67±0.22; 72h: 0.83±0.21) and not in dH2O-treated rats (4h: 1.25±0.22; 72h: 1.17±0.24).

Conclusions:
Our results suggest that activating the ACE2/Ang-(1-7)/Mas axis by post-stroke administration of an oral formulation of Ang-(1-7) is neuroprotective.
Abstract W P226: Delirium After Intracerebral Hemorrhage Is Common and Independently Predicts Reduced Domain-Specific Quality Of Life
Authors: Naidech Andrew M , Beaumont Jennifer L , Maas Matthew B , Ault Michael L , Cella David , Ely E W
Published: March 2022

Background:
Delirium sypmptoms are common after ischemic stroke and in the medical and surgical ICU, and predictive of increased length of stay and worse outcomes. There are few data in intracerebral hemorrhage (ICH). We tested the hypothesis that delirium symptoms were associated with increased length of stay, worse functional outcomes, and worse domain-specific quality of life (QOL) at follow-up.

Methods:
We prospectively identified 114 patients with ICH. Delirium symptoms were assessed by trained nursing staff twice daily with the Confusion Assessment Method for the ICU (CAM-ICU), a validated method. Arousal was measured with the Richmond Agitation Sedation Score. Functional outcomes were measured with the modified Rankin Scale at 1 and 3 months, with poor outcome defined at <=3 (moderately severe disability or worse). QOL was assessed at 1, 3 and 12 months with Neuro-QOL, instruments developed by NIH for neurologic disease and validated for proxy report.

Results:
Of 114 patients, 31(27%) patients had delirium symptoms, 67 (59%) were never delirious, and the remainder (14%) had persistent coma. Only 2 (2%) were ever very agitated (both of whom were delirious), so most delirium symptoms were hypoactive. Any benzodiazepine (BZD) use, age, pneumonia, seizure, hematoma volume and NIH Stroke Scale were not associated with delirium symptoms in patients who could be assessed. Delirium symptoms were detected mean 5.9 days after ICH symptom onset and were associated with longer ICU length of stay (mean 3.5 days longer in ever delirious patients, 95%CI 1.5 - 8.3, P=0.004) after correction for age, admit NIH Stroke Scale (NIHSS) and any BZD exposure. Delirium symptoms were associated with increased odds of poor outcome at 28 days (OR 8.7, 95%CI 1.4 - 52.5, P=0.018) after correction for admission NIHSS and age. After correction for NIHSS, age, any BZD use and time of follow-up, delirium symptoms were associated with worse QOL in the domains of applied cognition - executive function (0.6 SD, 95%CI 0.2 - 1.1 SD, P=0.045) and fatigue (0.7 SD, 95%CI 0.17-1.3 SD, P=0.01).

Conclusions:
Delirium symptoms (encephalopathy) were not predictable on admission, common after ICH, and independently predictive of longer length of stay, worse functional outcomes and reduced QOL.
Abstract W P233: Multi-Center Study of Adverse Events After Tissue-Type Plasminogen Activator Treatment for Ischemic Stroke
Authors: Fernandez-Gotico Hannah , Lightfoot Tiffany , Meighan Melissa
Published: March 2022

RESEARCH QUESTION:
When do adverse events occur within 24 hours after intravenous tissue-type plasminogen activator (IV tPA) treatment for acute stroke?

BACKGROUND AND PURPOSE:
The FDA approved medication for ischemic stroke is IV tPA. Patients are monitored for adverse events using a protocol that has been in use since 1995. There is limited evidence for the safest and most efficient monitoring protocol. The purpose of this study was to identify when adverse events occur within 24 hours post IV tPA.

METHODS:
This was a retrospective descriptive study. A convenience sample of medical records of 597 patients was examined using a pharmacy adverse event report, a computerized abnormal vital sign detection program, and a manual data collection tool. Detecting indicators of potential adverse events was used to identify high-risk patients for manual data collection. Indicators included heart rate above 120 bpm and systolic blood pressure (SBP) < 90 mm Hg and >180 mm Hg. The high-risk patient group (n=420) was randomly sampled. Then episodes of neurological decline, allergic reactions, and intracerebral hemorrhage (ICH) were manually collected on 220 patients. The time the event was detected was determined. A scoring system was used to identify the degree of risk in the ICH events. Statistical analysis was done using descriptive statistics.

RESULTS:
A total of 597 patients received IV tPA for ischemic stroke, of which 420 patients (70.3%) were found to have an abnormal vital sign trigger. Eighty percent of vital sign abnormalities and episodes of neurological decline occurred within the first twelve hours of IV tPA administration. Ten (4.5%) adverse events were detected. They were allergic reaction (1.8%; n=4) and high-risk ICH (2.7%; n=6). All adverse events occurred within the first 12 hours of IV tPA administration.

CONCLUSION:
Close monitoring during the first 12 hours after IV tPA treatment may be essential for safety. However, ICU or step down monitoring after 12 hours may not significantly impact outcome. Larger studies may provide evidence for the safest monitoring for patients treated with IV tPA for ischemic stroke.
Abstract W P265: Improved Symptomatic ICH Rates for Ischemic Stroke Patients Receiving IV rtPA
Authors: Nystrom Karin V , Asuzu David T , Sheth Kevin N , Chi Nai Fang , Halliday Janet R , Wira Charles , Greer David M , Schindler Joseph L
Published: March 2022

Introduction:
Symptomatic intracranial hemorrhage (sICH) is a concerning complication after the administration of IV r-tPA for treatment of acute ischemic stroke. Results from the NINDS trial demonstrated a 6.2% sICH rate. As such, acute stroke teams have used this data as a benchmark to compare their program’s complication rate related to IV r-tPA treatment in acute ischemic stroke.

Hypothesis:
We examined the percent of acute ischemic stroke patients treated with IV r-tPA each year who developed sICH, and compared our sICH rate with the NINDS benchmark data for this adverse outcome. We anticipated that the sICH rate would decline with additional experience and expanded use of evaluation and treatment protocols at our institution.

Methods:
Clinical data was analyzed from consecutive patients (n = 187) receiving IV rt-PA therapy from January 2009 until December 2012 at the Yale-New Haven Hospital. Adverse outcome was assessed by presence of symptomatic intracerebral hemorrhage (sICH). According to the NINDS definition, a hemorrhage was considered symptomatic if it was not seen on a previous CT scan and there had subsequently been either a suspicion of hemorrhage or any decline in neurologic status. The proportion of patients with sICH was calculated for each year and pairwise comparisons were made using two-sample tests of proportions.

Results:
18 out of 187 patients (9.6%) who received IV r-tPA therapy between 2009 and 2012 developed sICH after IV r-tPA treatment. When analyzed by year, 17.74% of sICH cases occurred in 2009, and this proportion decreased to 11.76% in 2010 (p-value = 0.4424), to 8.89% in 2011 (p-value = 0.1952) and to 2.86% in 2012 (p-value = 0.0329).

Conclusions:
The proportion of ischemic stroke patients who were treated with IV rt-PA and subsequently developed sICH decreased each year from 2009 to 2012 at our center. This difference reached statistical significance by 2012. Our program’s expanded experience and focused approach using current guidelines and latest published practices likely explain the two-fold reduction in complication rates when compared to the NINDS benchmark. Further studies are warranted to compare our clinical decision-making protocol to proposed models for predicting adverse outcome after IV rt-PA therapy.
Abstract W P267: Utilizing a Team-Based Educational Approach to Increase IV rt-PA Treatment Rates at a Community-Based Target: Stroke Honor Roll Designated Primary Stroke Center (PSC) in Urban Los Angeles
Authors: Liu Antonio , Garland Jennifer
Published: March 2022

Background:
Intravenous recombinant tissue plasminogen activator (IV rt-PA) is the only FDA approved treatment for acute ischemic stroke offering at least a 30% chance of improvement over placebo, however, IV rt-PA treatment rates tend to remain low with the national average of ischemic stroke patients being treated with IV rt-PA near 2%.

Purpose:
To utilize a team-based educational approach in order to maintain Target: Stroke Honor Roll status and increase IV rt-PA treatment rates from 20.4% in 2011 at a community-based PSC in urban Los Angeles for patients presenting with acute ischemic stroke from Jan 1, 2012 to Dec 31, 2012.

Methods:
A team based educational approach was utilized to increase IV rt-PA treatment rates in the Emergency Department (ED) by addressing topics such as benefits of IV rt-PA , stroke mimics, IV rt-PA exclusion criteria and eligibility criteria, stroke code activation, the consent process, and neurological assessment. The education was provided throughout the year and reinforced during monthly meetings, on-going in services, an annual stroke symposium, and during annual skill competency days across departments. These educational opportunities and meetings included physicians, RNs, radiology technicians, lab technicians, rehabilitation therapists, social workers, pharmacists, and case managers. Baseline year end data in 2011 was compared to year end data in 2012. In-patient mortality rates were also compared.

Results:
For 2012, the proportion of patients who received IV rt-PA treatment increased to 25.8% (62/240 total acute non-tPA ischemic strokes), up from 20.4% (50/244 total acute non-tPA ischemic strokes) in 2011. For 2012, the in-patient mortality rate for IV rt-PA receiving patients decreased to 3.22% (2/62) from the 2011 in-patient mortality rate of 4% (2/50).

Conclusions:
Target: Stroke Honor Roll status was maintained and the strategic goal to increase IV rt-PA treatment rates for acute ischemic stroke from 20.4% in 2011 to 25.8% in 2012 was met. Our IV rt-PA treatment rates were significantly higher than the national average of 2%. In addition, the mortality rate decreased from 4% in 2011 to 3.22% in 2012 despite the increase in IV rt-PA treatment rates, demonstrating the safety of IV rt-PA treatment in this population.