bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP279: Cardiac Biomarkers Predict Large Vessel Occlusion in Patients With Ischemic Stroke
Authors: Chang Andrew , Ricci Brittany , Mac Grory Brian , Cutting Shawna , Burton Tina , Dakay Katarina , Schomer Ashley , McTaggart Ryan , Jayaraman Mahesh , Merkler Alexander , Reznik Michael , Lerario Michael , Song Christopher , Kamel Hooman , Elkind Mitchell S , Furie Karen , Yaghi Shadi
Published: January 2019

Background and Purpose:
Cardiac biomarkers may help identify stroke mechanisms and may aid in improving stroke prevention strategies. There is limited data on the association between these biomarkers and large vessel occlusion (LVO) in patients with acute ischemic stroke (AIS). We aim to determine the association between cardiac biomarkers [cardiac troponin and left atrial diameter (LAD)] and the presence of large vessel occlusion.

Methods:
Data was abstracted from a single center prospective AIS database over 18 months and included all patients with AIS with intracranial vascular imaging (CT angiogram or MR angiography). The presence of large vessel occlusion was defined as proximal LVO of the internal carotid artery terminus, middle cerebral artery (M1 or proximal M2), or basilar artery. Univariate analyses and predefined multivariable models were performed to determine the association between cardiac biomarkers [positive troponin (troponin > 0.1) and LAD on transthoracic echocardiogram] and LVO adjusting for demographic factors (age and sex), risk factors (hypertension, diabetes, hyperlipidemia, history of stroke, congestive heart failure, coronary heart disease, and smoking), and atrial fibrillation (AF).

Results:
We identified 1234 patients admitted with AIS; 886 patients (71.8%) had intracranial MRA or CTA. Of those with imaging available, 398 patients (44.9%) had LVO and 232 patients (26.2%) underwent thrombectomy. There was an association between positive troponin and LVO after adjusting for age and sex and other risk factors [adjusted OR 1.97 (1.29-3.00), P=0.002)] and this association persisted after including AF in the model [adjusted OR 1.90 (1.24-2.93), p=0.003]. There was an association between LAD and LVO after adjusting for age, sex, and risk factors [adjusted OR per mm 1.04 (1.01-1.06), p = 0.002] but this association was not present when AF was added to the model [adjusted OR 1.01 (0.99-1.04), p = 0.323]. Sensitivity analyses using thrombectomy as an outcome yielded similar findings.

Conclusion:
Cardiac biomarkers predict acute LVO in patients with ischemic stroke. Prospective studies are ongoing to confirm this association and to test whether anticoagulation reduces the risk of recurrent embolism in this patient population.
Abstract WP284: Tpa for Patients Found to Have Stroke Mimics is Safe via Telemedicine
Authors: Kerro Ali , Cai Chunyan , Ankrom Christy M , Bambhroliya Arvind B , Malazarte Rene M , Trevino Alyssa D , Astudillo Cesar , Soomro Jazba , Cossey TC D , Savitz Sean , Wu Tzu-Ching , Jagolino-Cole Amanda
Published: January 2019

Introduction:
tPA use is safe over telemedicine (TM) in acute ischemic stroke (AIS). Risk of tPA for stroke mimics (SM) is low when administered in-person. Assessment of SM over TM may differ than in-person given physical barriers. We evaluated differences between patients with a final diagnosis of SM versus AIS, who were treated with tPA via TM.

Methods:
We identified patients in our TM stroke registry (9/2015-12/2017) who received tPA for suspected AIS. We compared baseline patient characteristics and comorbidities, along with outcomes after tPA, between AIS and SM patients.

Results:
693 patients received tPA via TM. Of these, 16.6% were found to have SM (13.2% were noted for in-person evaluations at our Comprehensive Stroke Center). SM patients were younger, less likely to have hypertension and atrial fibrillation, but more likely to have self-reported history of stroke, TIA, or seizure (Table 1). SM patients presented with milder stroke and less likely with face droop (Table 1). Adverse events from tPA in SM patients were minimal, with no observed symptomatic hemorrhages. mRS, discharge disposition, and length of stay were better for SM than AIS patients (Table 2). Door-to-needle time was six minutes longer for SM than AIS patients via TM (Table 2).

Conclusion:
In circumstances over TM where the diagnosis of AIS is unclear, tPA may take longer to consider but is safe to administer. Certain comorbidities and presenting symptoms may help differentiate SM from AIS via TM.
Abstract WP285: Comparison of Telestroke versus In-person Treatment of Acute Stroke by the Same Vascular Neurologists at a Comprehensive Stroke Center
Authors: Nguyen Claude , Jia Judy , Rasmussen-Winkler Jennifer , Allen Leigh , Leverton Sonya
Published: January 2019

Introduction:
Telemedicine (TM) has enabled rapid treatment of acute ischemic stroke with intravenous (IV) t-PA in remote centers where vascular neurologists are scarce. We are a Comprehensive Stroke Center (CSC) serving a large rural community in Central Texas. 24/7 stroke coverage is provided by three vascular neurologists, who evaluate patients at the CSC in-person from 8am to 4pm on weekdays and over telemedicine during all other times. This provides a unique opportunity to isolate and compare the effects of telemedicine to in-person treatment.

Objective:
Compare door-to-needle (DTN) times of the same vascular neurology group, over TM versus in-person evaluation

Methods:
We retrospectively reviewed time metrics of patients treated with IV t-PA between October 2017 and June 2017. Patients treated outside of the emergency department were excluded.

Results:
In the study timeframe, 107 patients received IV t-PA, 34 (31.8%) of whom were treated over TM. There was no statistically significant difference in median DTN time between patients treated with IV t-PA in-person versus over TM (50 min, IQR 19.25 versus 47 min, IQR 24, p=0.193; Table 1). There was also no significant difference in door-to-CT and door-to-lab results between the two groups (Table 1).

Conclusion:
Our study demonstrates that our vascular neurology group achieves similar DTN times for patients our CSC regardless of whether they are evaluated on-site versus through TM. This suggests that the application of TM itself does not affect DTN times. Limitations include the usual hospital variability seen during nights and weekends.
Abstract WP287: Emergency Medical Services Providers’ Knowledge of Prehospital Stroke Care and Recommendations for Feedback
Authors: Li Timmy , Munder Sneh Preet , Chaudhry Anisha , Madan Rima , Gribko Michele , Katz Jeffrey , Arora Rohan
Published: January 2019

Introduction:
It has been estimated that more than 30% of all stroke cases are still missed by prehospital stroke scales and 50% or more of cases identified as stroke have been false positives. There may exist opportunities to improve the quality of prehospital stroke care by providing one-on one EMS education. The objective of this project was to provide EMS providers with one-on-one education and survey their stroke care knowledge, identify barriers to providing prenotification, and ask them about the optimal method of providing feedback.

Methods:
Summer students staffed four hospital emergency departments in our health system and administered a quality improvement educational survey to EMS providers over a three-month period. The survey included questions related to knowledge of prehospital stroke care and barriers to providing prenotification. Descriptive statistics were used to describe results.

Results:
Surveys from 301 EMS providers were analyzed. Only 33% correctly identified the time window for IV tPA administration for AIS as within 4.5 hours from the last known well time. The majority of EMS providers (83%) correctly identified the comprehensive stroke center in our health system. EMS providers reported barriers to providing prenotification, including short transport time (41%), information being lost in dispatch (40%), and not having direct communication with hospital staff (30%). Most EMS providers reported wanting to receive feedback on the stroke patients they transported (94%), and 50% reported that the optimal method of providing feedback is via a mobile application.

Conclusions:
Addressing deficits in prehospital stroke care knowledge among EMS providers and their barriers to providing prehospital notification are key steps to improving prehospital stroke care, and ultimately, patient outcomes. Most EMS providers desire real-time feedback via a mobile application.
Abstract WP291: Utilization of Novel Imaging Algorithms for Patient Triage at Primary Stroke Centers in a Stroke System of Care
Authors: Tarasaria Karan , Topiwala Karan , Lima Jussie , Beland Dawn , Pervez Mubashir , Nouh Amre , Alberts Mark J
Published: January 2019

Background:
The 24 hour time window for endovascular therapy (EVT) in ischemic strokes due to large vessel occlusions (LVO) is a significant advance. Although many stroke systems of care have adopted a paradigm of transferring all potential EVT patients to the hub center for further evaluation, we developed an approach using advanced screening and imaging at spoke hospitals to improve transfer triage.

Hypothesis:
Utilizing a novel algorithm combining clinical and imaging (CTA plus CT Perfusion “RAPID”) criteria at the transferring facilities (spokes), more appropriate patient transfer decision to the CSC (hub) can be made.

Methods:
We developed and implemented a clinical and imaging screening algorithm for our 3 PSCs equipped with CTA and CTP-“RAPID capabilities”. Patients at these 3 hospitals with NIHSS> 6 or fulfilling Stroke VAN (Hemiparesis and Visual field cut, aphasia or neglect) criteria and presenting between 4.5 to 24 hours from last seen normal undergo CTA plus CTP, and a decision for transfer if LVO plus core ≤50cc is met. Data including diagnosis, clinical and radiographic features, transfer status and final diagnosis of 102 patients from January 2018 to June 2018 were analyzed.

Results:
The mean age was 69 (SD 1.7) years and mean NIHSS was 9 (SD 0.73). NIHSS> 6 or Stroke VAN criteria was met in 78% (n=80). Of all screened patients, 26% (n=27) were found to have LVO. The mean CTP core size for patients transferred (n=20) to the hub was lower than those who remained at the spoke (n=7) but not significant due to small sample size (8.6 cc SD 2.5 vs. 38 cc SD 22
p
=0.31). Five additional patients without LVO were transferred for higher level of care. Of all transferred LVO patients, 35% (n=7) were treated with EVT; 65% (n=13) did not meet treatment criteria. Overall, only 7 of 102 patients (7%) were treated with EVT. Of the 75% (n=77) non-transferred patients, 55% (n=41) were stroke mimics based on final diagnosis..

Conclusion:
Using our current algorithm, 60% of screened patients were ischemic strokes and 26% had LVO’s, but only 7% qualified for EVT. Using advanced clinical and imaging paradigms, 75% of screened patients did not require transfer. While challenges with implementation and patient selection remain, triage at the spoke facilities is feasible and effective.
Abstract WP295: Feasibility and Safety of a Large-Scale Teleneurology Network for the Treatment of Acute Stroke in a Heterogeneous Multihospital Patient Population
Authors: Morton Johanna L , Northington Diamond K , Jolly B. T
Published: January 2019

Background:
Administration of alteplase is the standard of care for eligible patients presenting with symptoms of acute ischemic stroke (AIS). Telemedicine is increasingly being used to deliver acute stroke care to patients without in-person access to stroke expertise. This study reviews the alteplase experience and outcomes of the largest known teleneurology network spanning 34 states and distributed across a heterogeneous multihospital population.

Methods:
Data was abstracted from internal medical records systems and relevant medical records obtained from partner hospitals. A retrospective analysis on the prospectively maintained database of patients who have received alteplase was performed. Data was collected from December 1, 2015 to June 30, 2018. Outcome analysis was restricted to those patients with available complete discharge data. Collected data included demographics, stroke severity, symptomatic intracranial hemorrhages (sICH), discharge disposition and mortality.

Results:
The analysis revealed 6199 patients as having received alteplase during the study period. Of these, 56.7% had discharge information available. The mean patient age was 69.7 years, with a mean age of 71.8 years for females and 67.4 for males. The median initial NIHSS was 7, with 30.3% of patients presenting with NIHSS ≤4 and 8.5% initially presenting with initial NIHSS ≥21. Only 19.7% of patients were transferred to another facility. Clinical outcomes data were available for 3327 patients (53.7%). There were 1536 home discharges (46.2%), 626 acute rehabilitation discharges (18.8%), and 283 skilled nursing facility discharges (8.5%). The sICH rate in this population was 0.9% (29) and there were 136 patient deaths (4.1%).

Conclusion:
Large-scale teleneurology for the treatment of patients presenting with symptoms of AIS is feasible, with clinical outcome data similar to other published studies. Further refinement of this data, to include subgroup analyses, transfer patterns, and more comprehensive clinical outcomes is warranted.
Abstract WP301: Clinical characteristics and Outcomes of Acute Ischemic Stroke by Hospital Arrival Time : CRCS-K (Clinical Research Collaboration for Stroke in Korea) registry
Authors: Cho Yong-Jin , Park Jong-Moo , Lee Kyung Bok , Lee Ji Sung , Park Tai Hwan , Hong Keun-Sik , Park Hong-Kyun , Kang Kyusik , Cha Jae Kwan , Lee Soo Joo , Lee Jun , Kim Joon-Tae , Kim Dong-Eog , Oh Mi Sun , Yu Kyung-Ho , Choi Jay Chol , Lee Juneyoung , Kim Beom Joon , Bae Hee-Joon
Published: January 2019

Background and Objectives:
The aim of this study was to evaluate the clinical characteristics and outcomes of acute ischemic stroke according to the patients’ arrival time at hospital.

Methods:
In this prospective stroke registry, all consecutive patients, who admitted via emergency room of 12 participating centers nationwide from 2009/12 to 2017/11, were identified. All patients were presented with first-ever stroke within 7 days from symptom onset, and had relevant ischemic lesions on brain imaging. We categorized hospital arrival time into 4 groups, such as early morning (EM, 0 to 6), late morning (LM, 6 to 12), afternoon (AF, 12 to 18), and evening (EV, 18 to 24 o’clock).

Results:
Total of 31992 patients were included. In patients arriving in EM, the number was 2034 (6.4%) [vs. 9400 (29.4%), 13277 (41.5%), 7281 (22.8%)], age (mean) was 64.9 years (vs. 68.2, 67.4, and 67.0, p<0.001), subtype of cardioembolism was 26.7% (vs. 21.6%, 20.3%, and 24.4%, p<0.001), initial NIHSS (median) was 4 (vs. 4, 3 and 4, p<0.001), the rates of total thrombolysis (IV+IA) was 24.8% (vs. 17.9%, 14.8%, and 21.4%, p<0.001), and mRS (0-2) at 3 months was 53.6% (vs. 58.4%, 62.7%, 58.9%, p<0.001) compared to LM, AF, and EV, respectively.

Conclusion:
Though the number of patients arriving at hospital in EM was lowest, that group required highest rate of thrombolysis, showed younger age, higher cardioembolism, higher stroke severity, and poor functional outcome at 3 months. Adequate management needs to be considered for the patients arriving in EM.
Abstract WP310: On versus Off-hour Intravenous Thrombolysis in Acute Ischemic Stroke Patients Treated via Telestroke: Impact on Long-term Functional Outcome
Authors: Almallouhi Eyad , Girotra Tarun , Reddy Deepak , Al Kasab Sami , Debenham Ellen , Turner Nancy , Banerjee Chirantan , Holmstedt Christine
Published: January 2019

Introduction:
Telestroke has expanded access to acute stroke care. Time of presentation to the emergency department affects the door to needle time (DTN) and may subsequently affect long-term outcome in acute ischemic stroke (AIS) patients assessed via telestroke. In this study, we assess whether DTN times and long-term functional outcome differ among AIS patients treated with IV tPA via telestroke during on-hours versus off-hours.

Methods:
All patients who received IV tPA through the Medical University of South Carolina telestroke network between January 2016 and December 2017 were analyzed. Primary outcome was 90-day Modified Rankin Scale (mRS), with mRS ≤2 considered a good functional outcome. Independent variables included time of presentation, age, race, sex, admission NIHSS, symptom onset to needle, and door to needle time. On-hours were defined as 8am-5pm monday - friday, and off-hours were 5pm-8am Monday-Friday, weekends and holidays. Chi-square and t-tests were used to compare differences among categorical and continuous baseline variables, respectively. Multivariable logistic regression was used to examine the relationship between tPA delivery time and 90-day mRS, adjusting for patient baseline characteristics.

Results:
During the study period, 223 (39%) AIS patients received IV tPA during on-hours and 349 (61%) during off-hours in our telestroke network. Baseline characteristics were similar, except that the off-hours group had more white patients (P=0.04), and longer tPA decision to administration time (P=0.006). On-hours mean DTN time was 57.3 minutes, as compared to 63.2 minutes during off-hours (P=0.017). Primary outcome was similar between the 2 groups (OR 1.088, 0.687-1.722).

Conclusion:
AIS patients who presented during off-hours and received tPA had a longer DTN time, but comparable long-term outcome after IV thrombolysis in our telestroke network. The findings need validation in other telestroke cohorts, with the aim of providing consistent 24-hour telestroke care.
Abstract WP311: Impact of Physician Volume and Specialty on In-hospital Mortality of Ischemic and Hemorrhagic Stroke -j-aspect Study
Authors: Nishimura Kunihiro , Ogasawara Kuniaki , Kitazono Takanari , Yoneyama Kihei , Shiokawa Yoshiaki , Toyoda Kazunori Toyoda , Hashimoto Yoichiro Hashimoto , Suzuki Michiyasu , Hasegawa Yasuhiro , Kada Akiko , Onozuka Daisuke , Nishimura Ataru , Hagiwara Akihito , Iihara Koji
Published: January 2019

Background:
The association between physician volume and the death rate for patients who are hospitalized for ischemic and hemorrhagic stroke remains unclear. It is unknown whether a volume threshold for such an association exists. We aimed to analyze the correlation between in-hospital stroke mortality and physician volume considering board certification status.

Methods:
For this cross-sectional study, data on patients hospitalized for ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) between 2010 and 2016[MOU1] [KN2] were obtained from the Diagnosis Procedure Combination database in Japan using International Classification of Diseases-10 diagnosis codes. The numbers of stroke care physicians and relevant board-certified physicians were asked. Odd ratios (ORs) of 30 day in-hospital mortality were estimated after adjustment for institutional differences, age, sex, comorbidities, and level of consciousness using generalized mixed logistic regressions.

Findings:
In a total of 295,150, 98,657 and 36,1741 patients with ischemic stroke, ICH and SAH, 30 day in-hospital mortality rates were 4.4,16 and 26.6 %. For all types of stroke, the number of stroke care physicians was associated with reduced in-hospital mortality (all p for trend<0·001). The number of board-certified neurosurgeons, stroke physicians, and endovascular surgeons stroke physicians showed clear association with reduced in-hospital mortality of ischemic stroke (volume threshold, OR [95%CI] for three specialties: six, 0·86 [0·79-0·95]; p=0·002, one, 0·79 [0·71-0·87]; p<0·001, three, 0·90 [0·80-1·00]; p=0·046), ICH (six, 0·87 [0·78-0·98]; p=0·019, two, 0·76 [0·60-0·96]; p=0·02, three, 0·82 [0·73-0·93]; p=0·002), and SAH (four, 0·80 [0·71-0·91]; p=0·001, six, 0·72 [0·53-0·98]; p=0·04, two, 0·85 [0·75-0·96]; p=0·01). The number of board-certified neurologists did so only for ischemic stroke (two, 0·88 [0·80-0·97]; p=0·013).

Interpretation:
The number of stroke care physicians was associated with reduced in-hospital mortality for all types of stroke. The volume threshold of board-certified physicians depends on specialty and stroke types.
Abstract WP318: On Versus Off-Hour Intravenous Thrombolysis in Acute Ischemic Stroke Patients Treated via Telestroke- Impact on Long-Term Functional Outcome
Authors: Almallouhi Eyad , Girotra Tarun , Reddy Deepak , Al Kasab Sami , Turner Nancy , Debenham Ellen , Banerjee Chirantan , Holmstedt Christine
Published: January 2019

Introduction:
Time of presentation to the emergency department may affect the door to needle time (DTN) and could subsequently affect long-term outcome in acute ischemic stroke (AIS) patients assessed via telestroke. In this study, we evaluate whether DTN times and long-term functional outcome differ among AIS patients treated with IV tPA via telestroke during on-hours versus off-hours.

Methods:
All patients who received IV tPA through the Medical University of South Carolina telestroke network between January 2016 and December 2017 were analyzed. Primary outcome was 90-day Modified Rankin Scale (mRS), with mRS ≤2 considered a good functional outcome. Independent variables included time of presentation, age, race, sex, admission NIHSS, symptom onset to needle, and door to needle time. On-hours were defined as 8am-5pm Monday-Friday, and off-hours were 5pm-8am Monday-Friday, weekends and holidays. Chi-square and t-tests were used to compare differences among categorical and continuous baseline variables, respectively. Multivariable logistic regression was used to examine the relationship between tPA delivery time and 90-day mRS, adjusting for patient baseline characteristics.

Results:
During the study period, 223 (39%) AIS patients received IV tPA during on-hours and 349 (61%) during off-hours in our telestroke network. Baseline characteristics were similar, except that the off-hours group had more white patients (P=0.04), and longer tPA decision to administration time (P=0.006). On-hours mean DTN time was 57.3 minutes, as compared to 63.2 minutes during off-hours (P=0.017). Primary outcome was similar between the two groups (OR 1.088, 0.687-1.722).

Conclusions:
AIS patients who presented during off-hours and received tPA had a longer DTN time, but comparable long-term outcome after IV thrombolysis in our telestroke network. The findings need validation in other telestroke cohorts, with the aim of providing consistent 24-hour telestroke care.
Abstract WP32: Mechanical Thrombectomy for Mild Acute Ischemic Stroke with Large Vessel Occlusion: Results from the MISTWAVE Prospective Study
Authors: Toth Gabor , Samaniego Edgar , Ortega Santiago , Tsai Jenny , Al Kasab Sami , Bain Mark , Rasmussen Peter , Elgabaly Mohamed , Hussain Shazam
Published: January 2019

Introduction:
Endovascular therapy (EVT) for emergent large vessel occlusion (ELVO) is standard of care for disabling strokes. There is no sufficient prospective data evaluating EVT for mild ischemic stroke with ELVO. Retrospective data suggests that many patients may not have favorable outcomes without intervention. We present our initial data investigating safety and outcomes of EVT in patients with ELVO and initial NIHSS of < 6.

Methods:
Our single arm prospective study (Mild acute Ischemic Stroke With lArge Vessel occlusion - MISTWAVE) recruited patients in 2 large tertiary care centers. Inclusion criteria included anterior circulation or basilar artery ELVO within 24 hours of onset. We excluded patients with ASPECTS score ≤ 6 on pre-intervention imaging, prior intracranial hemorrhage, or current anticoagulant use. Our primary endpoints were symptomatic cerebral hemorrhage within 24 hours, and/or change in NIHSS by ≥ 4 points within 72 hours or during hospitalization. Secondary endpoints included angiographic recanalization grade, NIHSS and disability assessment at discharge, 30 days, or on last follow-up.

Results:
We screened over 50 patients, and enrolled 20 as of November 2018 (mean age 65.6 ± 12.3 years; 55% males; 12 M1 occlusions, 8 M2 occlusions). Main reasons for exclusion were: outside treatment window, worsening NIHSS to >5, tandem or extracranial carotid occlusion, and inability to obtain consent. TICI 2B/3 thrombectomy was achieved in 95% of patients. The median NIHSS on presentation was 3 (range 0-5), and at last available follow-up it was 0 (0-10). The majority of patients (85%) were discharged home with minimal or no residual deficits. The average follow-up was 60.9 days (range 9-210 days), and mRS 0-2 was achieved in 90%. None of the patients suffered symptomatic cerebral hemorrhage. One patient (5%) had neurologic worsening within 24 hours despite TICI 3 recanalization. There were no other periprocedural complications.

Conclusion:
This is one of the first truly prospective studies designed to assess the safety and feasibility of EVT in patients with low NIHSS and ELVO. Our results are preliminary, but suggest excellent radiographic and clinical outcomes, and no significant procedural complications.
Abstract WP323: Significant Reduction in Prehospital Evaluation and Door-to-Treatment Times With a Mobile Stroke Unit
Authors: Kowalski Robert G , Schimpf Brandi , Wilson Derek , Poisson Sharon N , Nyerg Eric M , Carrera Eduardo , Bernard Timothy J , Vela-Duarte Daniel , Simpson Jennifer R , Kluger Benzi M , Taylor Matthew R , Sillau Stefan H , Jones William J
Published: January 2019

Background:
The University of Colorado Mobile Stroke Unit (UC MSU) provides ambulance-mounted CT scanning and tele-stroke neurologic assessment in the Denver, CO, metropolitan area. As one of the first U.S. medical centers to utilize a mobile stroke protocol we sought to compare operational characteristics of the MSU during its first year with standard management (SM) of pre-hospital stroke alerts at a Comprehensive Stroke Center.

Methods:
The study compared patient and stroke characteristics, ambulance response, neurologic evaluation, and treatment between the MSU, and SM patients for the same ambulance service area. Variables included time from stroke alert (MSU or ambulance dispatch) to tPA administration, as well as time from arrival at the door of MSU or ED to first brain CT and to IV tPA administration. Patients were dichotomized into those with time from door to needle greater or less than the American Stroke Association “Target: Stroke” study goal of 45 minutes.

Results:
Between Jan. 15, 2016 and Jan. 9, 2017, 47 patients received prehospital management with the UC MSU, and 73 received standard management. Median age was 66 years (IQR 57-77), and 45% were female, with no difference between MSU and SM patients. Thirteen (28%) of patients were treated with IV tPA on the MSU, compared with 16 (22%) through SM. Median time was significantly shorter from door to first CT on the MSU than SM [4 minutes (IQR 4-5) MSU vs. 9 minutes (IQR 6-15) SM, p<0.001]. Median time from dispatch to IV tPA administration was shorter on the MSU [39 minutes (IQR 35-45) MSU vs. 65 minutes (IQR 49-96) SM, p<0.001], and for door to IV tPA [26 minutes (IQR 20-29) MSU vs. 37 minutes (IQR 24-65) SM, p=0.022]. MSU patients were more likely to have door-to-needle times meeting the ASA goal of <45 minutes [13 (100%) MSU vs. 11 (69%) SM, p=0.048].

Conclusions:
Patients treated via the MSU benefited from quicker time to CT, neurologic evaluation, and, critically, significantly shorter time from dispatch to tPA administration, compared with pre-hospital stroke alerts arriving from the same service area. These results suggest prehospital management with an MSU has potential to aid the goal of earlier thrombolysis after ischemic stroke symptom onset.
Abstract WP327: CT Angiogram Has High Yield in Code Stroke
Authors: Cutting Shawna M , Chang Andrew , Jindal Guarav , James Brandon , Burton Tina , Mac Grory Brian , Dakay Katarina , Siket Matt S , Sacchetti Dan , Mc Taggart Ryan , Saad Ali , Yaghi Shadi , Furie Karen , Jayaraman Mahesh , Murphy Brian
Published: January 2019

Introduction:
Although studies have examined emergent CTAs of the head and neck in patients seen by neurologists who are suspected of having a large vessel occlusion, the utility and accuracy of CTA for patients called as a ‘code stroke’ by any healthcare provider has not been evaluated.

Methods:
At our institution, imaging for all Code Stroke patients includes non-contrast CT of the brain as well as CTA of the neck and brain, regardless of severity. This imaging is often performed prior to detailed neurology evaluation. We queried our radiology department report database for all studies labelled ‘CTA ELVO’, an imaging order code which is specific for Code Stroke. We then cross-referenced this list with our prospectively acquired ischemic stroke registry, which consists of all patients discharged with a diagnosis of acute ischemic stroke.

Results:
Between January and August 2017, 1265 CTA ELVOs were performed. Average age was 66.3 years, and 52.4% were female. Of all CTA ELVOs, 144 were performed on inpatients (11.3%) and neuroradiologists read 149 studies (11.8%). Critical findings on vessel imaging were present in 165 studies (13%); of these 118 patients were ultimately diagnosed with acute ischemic stroke. Studies with critical findings involved older patients (73.7 years, p<0.001) and were less likely to be performed on inpatients (29 studies, p=0.012) but were no different in number of females (55%, p=0.51) or whether read by a neuroradiologist (23 studies, p=0.36). Critical findings included acute intracranial large vessel occlusion involving the middle cerebral artery, intracranial internal carotid artery (ICA), or basilar artery (87 studies); critical cervical ICA stenosis, acute cervical ICA occlusion, or acute dissection (42 studies); M2 occlusion (32 studies); critical intracranial stenosis (7 studies) and vascular malformation such as aneurysm or arteriovenous malformation (6 studies).

Conclusion:
The yield of non-invasive vessel imaging in patients called as a code stroke in detecting critical findings is high, revealing abnormalities in approximately one in eight patients. Patients presenting with acute neurologic symptoms should receive vessel imaging as part of the initial workup for suspected stroke.
Abstract WP331: Choice of Antihypertensive Agent Prior to Thrombolysis Has No Affect on Door-to-Needle Time: A Single Center Experience
Authors: Sorace Brian , Ugochukwu Uzoamaka , Carrera Joseph
Published: January 2019

Introduction:
Treatment of acute ischemic stroke with intravenous thrombolysis (IVT) should be as rapid as possible. A subset of patients with acute ischemic stroke present with blood pressures above that considered safe for thrombolytic administration, and antihypertensive therapy is necessary. Guideline statements are ambivalent regarding which antihypertensive agent should be used to obtain a satisfactory blood pressure (BP < 185/110 mmHg) prior to IVT.

Hypothesis:
DTN time will not differ amongst the antihypertensive agent groups.

Methods:
We reviewed data from consecutive patients at our institution treated with IVT from 01/2014 to 07/2018 and collected door-to-needle (DTN) time, antihypertensive agent (if used), and antihypertensive-to-needle (ATN) time. Patients were grouped by initial agent administered. An independent samples t-test was used to compare the labetalol and nicardipine group DTN and ATN times, as well as DTN times for patients receiving any antihypertensive agent with DTN times for those who did not. We performed a one-way ANOVA to compare DTN times across all groups (no agent, labetalol, nicardipine, hydralazine). Significance was defined as p < 0.05 for all tests.

Results:
Analysis included 205 patients: 149 receiving no antihypertensive, 42 receiving labetalol, 12 receiving nicardipine, and 2 receiving hydralazine. Those not administered an antihypertensive prior to IVT had shorter DTN times (53.05 min versus 61.96 min, p = 0.039). Although not statistically significant, there was a trend towards longer DTN (64.76 min versus 51.33 min, p = 0.205) and ATN times (18.02 min versus 10.58 min, p = 0.171) in the labetalol group. There was not a difference in DTN time across all groups (F(3,205) = 2.213, p = 0.088), although labetalol trended towards higher times than those not administered any agent on post-hoc Tukey HSD test (p = 0.071).

Conclusions:
At our institution, patients requiring antihypertensive treatment did experience slower DTN times. Choice of antihypertensive agent did not affect DTN times, however there was a trend towards slower times with labetalol. This study is limited by relatively small sample size. Pooling data from multiple institutions could provide a more robust assessment and inform clinical practice.
Abstract WP347: Long Non-coding RNA TUG1 Contributes to Microglial Activation After Oxygen Glucose Deprivation
Authors: Wang Haoyue , Liao Songjie , Yu Jian
Published: January 2019

Introduction:
Microglial activation plays a critical role in inflammatory injury after ischemic stroke. Long non-coding RNA taurine up-regulated gene 1 (lncRNA TUG1) is widely expressed in adult brain and retina and has been reported to participate in multiple biological processes associated with nervous system diseases. However, the underlying function of TUG1 on inflammatory response and microglial activation after hypoxic insult remains unidentified.

Methods:
BV2 microglial cells were cultured in vitro and TUG1 siRNA was used to knockdown TUG1. Cells were subjected to oxygen-glucose deprivation (OGD) for 4 hours following TUG1 siRNA or scramble siRNA transient transfection. Then, the levels of TUG1 and inflammatory cytokines were assessed by quantitative real time PCR and ELISA. Microglial M1/M2 polarization was identified by western blot and immunofluorescence. Meanwhile, MiR-145a-5p was also detected to explore a potential interaction with TUG1.

Results:
OGD treatment led to downregulation of interleukin-10 and upregulation of tumor necrosis factor-α and interleukin-1β. The cellular level of TUG1 was significantly augmented while miR-145a-5p was significantly diminished in OGD-treated cells compared with normal control. By contrast, TUG1 knockdown increased the level of MiR-145a-5p, and further reversed OGD-induced changes of above inflammatory cytokines. Meanwhile, TUG1 knockdown blocked OGD-driven M1 microglial polarization, represented by decreased expression of CD68 (M1) and increased expression of Arg-1 (M2).

Conclusion:
Our study indicates that lncRNA TUG1, which could be as a miRNA sponge, is required for the release of inflammatory cytokines and microglial activation after OGD treatment, possibly providing a potential therapeutic target for inflammatory injury.
Abstract WP348: Astrocyte Reaction After Ischemic Stroke in Nonhuman Primate
Authors: Choudhury Gourav , Redmond Gene , Daadi Marcel
Published: January 2019

In the mammalian central nervous system, gliogenesis and neurogenesis constitutively occurs in the subventricular zone (SVZ) and the hippocampus albeit on a much lower scale in comparison to the other organs. In response to stroke and presumably as an endogenous mechanism of brain self repair, the neural precursors located in the SVZ and the hippocampus are induced to proliferate and migrate towards stroke-damaged tissue. This innate neural reaction in adult brain may represent a mechanism of neuroplasticity and structural remodeling that leads to functional recovery. The rodent animal model of ischemic stroke (IS) showed a clear and pronounced neurogenesis and gliogenesis. However, to date little is known about this innate response in human and nonhuman primates to IS. We have developed a nonhuman primate model of IS with well-defined anatomical infarct lesions and motor behavioral deficit. After a small craniotomy, the dura was opened and with microsurgical technique and the M3 segment of the middle cerebral artery was occluded for 90 minutes followed by reperfusion. Animals with IS showed significant (p<0.005) motor deficit in right hand. To label endogenous neural precursors undergoing cell proliferation in vivo we injected all animals with the S-phase marker 5-bromo-2-deoxyuridine (BrdU). Postmortem analysis demonstrated significant increase of GFAP+ astrocytes (P<0.0001) in the infarct area. These astrocytes exhibited unique re-organization around the infarct zone and expressed various types of morphologies and phenotypes. Less than 1% incorporated BrdU. Sixty-five % of astrocytes with elongated processes oriented toward the IS co-expressed vimentin while tissue from control animals expressed no vimentin. Approximately 35% of astrocytes co-expressed Sox-2, while control animals showed about 4% in the same area of the cortex. Both vimentin and Sox-2 are markers for neural stem cells. These data suggests that astrocytes may be more heterogeneous than previously thought and may undertake various roles in response to IS. A subpopulation of astrocytes may be reprogrammed to an early developmental stage under IS conditions to promote tissue repair and homeostasis.
Abstract WP352: Mitochondrial Electron Transport Support as a New Mechanism of Action of Carbon Nano-particles in the Treatment of Stroke
Authors: Derry Paul J , Mendoza Kimberly , Jalilov Almaz , Sikkema William K , Berka Vladimir , Tsai Ah-Lim , Tour James M , Kent Thomas A
Published: January 2019

Introduction:
Mitochondrial damage, including electron leakage and oxidative stress, likely contributes to stroke pathophysiology and is a potential therapeutic target. We recently reported robust protection when non-toxic graphene-derived PEGylated hydrophilic carbon clusters (PEG-HCCs) were administered at a realistic time point in severe reversible stroke rodent models (Front Neurol 2018). We attributed this efficacy to their high capacity, catalytic antioxidant features (PNAS 2015). Here we report a new action, the shuttling of electrons between mitochondrial constituents, consistent with their unique electrochemistry.

Methods:
We examined the redox chemistry of PEG-HCCs interaction with mitochondrial constituents, the reductants NAD(P)H, ascorbic acid and their targets, cytochrome C (CytC) and the mitochondrial viability indicator, resazurin. Subcellular distribution was visualized with deconvolution microscopy. In-vitro protection against mitochondrial toxins was assessed.

Results:
PEG-HCCs showed a broad redox wave ranging from -0 to -1500 V similar to the endogenous shuttle ubiquinone. They dramatically catalyzed the reduction of resazurin and CytC by NAD(P)H and ascorbic acid through a ternary complex. PEG-HCCs were co-localized with mitochondrial membranes within 5 min of incubation in cultured neurons (Fig. blue: nucleus; green: mitochondria; yellow: colocalized PEG-HCCs). PEG-HCCs give protection in-vitro from mitochondrial complex toxins including sodium cyanide (NaCN) (5 mM NaCN 54% of baseline viability vs 104% with PEG-HCCs + NaCN; p=0.0065).

Conclusions:
These experiments indicate PEG-HCCs are able to support electron shuttling as a potential mechanism of sustaining mitochondria after injury. In-vitro studies indicate cells can be protected from mitochondrial toxins. Work is ongoing to identify the functional groups that facilitate this shuttling effect to optimize their potential as stroke therapies.
Abstract WP356: Recruitment and Retention of Minorities in a Safety-Net Setting: Lessons From the
S
econdary Stroke Prevention by
U
niting
C
ommunity and
C
hronic Care Model Teams
E
arly to
E
nd
D
isparities (SUCCEED) Trial
Authors: Towfighi Amytis , Ayala-Rivera Monica , Barry Frances , McCreath Heather , Moreno Lilian , Martinez Diamond , Lopez Enrique , Valdez Sarah , Fernandez Maura , Cheng Eric M , Sanossian Nerses , Mehta Bijal , Dutta Tara , Razmara Ali , Song Shlee , Bryg Robert , Rao Neal , Willis Phyllis , Cunningham William , Ganz David , Factor Diane , Ibrahim Nancy , Vickrey Barbara G
Published: January 2019

Background:
Minority, disadvantaged populations are often underrepresented in secondary stroke prevention trials despite known disparities in risk factor control. When they do enroll, retention is poor due to competing needs, transiency, unstable housing, transportation barriers, and inconsistent telephone access.

Methods:
We recruited 487 English- or Spanish-speaking adults (age >40 yrs) with a recent TIA or ischemic/hemorrhagic stroke, and systolic BP ≥130 mm Hg or diagnosed hypertension and SBP≥120mm Hg, from 4 Los Angeles County-Department of Health Services hospitals and 1 stroke center serving low income zip codes. We used recruitment and retention strategies from a prior trial; leadership and staff met regularly to track progress and design and implement new strategies. Meeting notes were reviewed to compile approaches .

Results:
Average age was 57.1 years; race/ethnicity was 71.4% Hispanic, 17.6% black, 6.4% Asian; 72.5% were born outside the US; 62.6% had not graduated high school; 40% rarely spoke English at home. Follow-up data collection was 440/487 (90%) at 3 months, 382/487 (78%) at 8 months, and 394/475 (83%) of eligibles at 12 months. Prior recruitment strategies used were bilingual research assistants (RAs) from similar cultural backgrounds, inpatient clinical team introduction of potential enrollees to RAs, embedding RAs on the inpatient unit, piloting and tailoring recruitment scripts prior to study initiation, and allowing potential participants to discuss the study with others prior to enrollment. Prior retention strategies used were obtaining ≥3 contact numbers at enrollment and reviewing medical records for upcoming appointments. New retention strategies developed and applied were offering in-home assessments, providing transportation, offering weekend/evening visits, using phone, mail, and registered mail to contact participants, routinely using the same RA for a given participant, and reminding patients of prior interactions with RAs/visits.

Conclusion:
To maximize retention and recruitment, the combined approach of beginning with a broad set of previously effective strategies, and tracking and developing new ones over the course of the trial was effective. Trial Registry Trial Number: NCT01763203
Abstract WP358: Impact of an Emergency Department-Based Acute Stroke MRI Protocol on Cost, tPA Administration, and Hospital Length of Stay
Authors: Orlando Chris , Needham Laura , McNally Scott , Ekstrom Erin , Chauhan Nabeel , Anzai Yoshimi , de Havenon Adam
Published: January 2019

Background:
MRI is more sensitive for the detection of ischemic stroke than CT, but is not routinely used in the Emergency Department (ED) due to limited availability, prolonged scan time, and higher cost.

Hypothesis:
A 24/7 ED-based rapid MRI (8 minutes scan time) for the diagnosis of acute ischemic stroke will reduce direct costs, tPA administration to stroke mimics, and length of stay.

Methods:
We included patients who were admitted to the ED under our Brain Attack stroke activation and had either a CT perfusion (CTP) (2013-2015) or, after it became available, a rapid MRI (2015-2018). The primary outcomes are total direct cost (reported as % of the mean cost for CTP due to data reporting restrictions), % of tPA administration given to stroke mimics, hospital length of stay in days.

Results:
Our cohort includes 215 patients, aged 58.6±19.4 years and 45% male. Acute ischemic stroke was the discharge diagnosis in 79/215 (37%) of patients. The most common non-stroke diagnoses were psychiatric or unmasking (n=57, 27%), complicated migraine (n=43, 20%), seizure (n=13, 6%), and TIA (n=12, 6%). Comparing patients with CTP to those with MRI, including after restricting to patients with stroke mimic (n=136), the rapid MRI was associated with a significant decrease in costs, tPA administration to stroke mimics, and hospital length of stay (Tables 1 and 2). There was also an increase in the number of discharges home from the ED for patients who had the MRI.

Conclusion:
The introduction of a rapid MRI protocol in our emergency department appears cost-effective and may lead to more accurate decision-making for tPA administration and emergency department disposition in patients suspected of having acute stroke.
Abstract WP367: Effect of the Introduction of a New Pathway for Prevention of Venous Thromboembolisim (VTE) Including Neuromuscular Electrical Stimulation (NMES) on Symptomatic VTE on Immobile Stroke Patients
Authors: Williams Jodie , Natarajan Indira , Moss Claire , Lambert Caroline , Richards Lucy , Roffe Christine
Published: January 2019

Background:
Venous Thromboembolism (VTE) prophylaxis using Intermittent Pneumatic Compression (IPC) is not possible in all stroke patients. We introduced a new VTE pathway which includes Neuromuscular Electrical Stimulation of the peroneal nerve using the geko
TM
device (Firstkind Ltd UK) as an alternative prevention strategy for this patient group. In addition, compliance with VTE prophylaxis was reviewed 4-hourly as part of comfort rounds.

Methods:
This is a prospective audit of the new pathway. All stroke patients admitted to the Acute Stroke Unit at Royal Stoke University Hospital between 1 Nov 2016 and 3 Mar 2018 were included. In line with UK guidelines patients unable to mobilize independently were prescribed IPC in addition to standard measures, e.g. hydration, mobilization, and aspirin where indicated, unless patients were palliative, fully anticoagulated, or refused the intervention. Patients who could not use IPC (intolerance, falls risk, out of stock) were switched to the geko
TM
device.

Results:
In total 999 stroke patients were included. Of these 187 (18.7%) required no prophylaxis, 125 (12.5%) were fully anti-coagulated, and 687 (68.7%) required mechanical VTE prophylaxis (MP). Of these 463 (67.3%) received IPC and 122 (17.7%) the geko
TM
device as their only intervention. A further 81 (11.8%) patients became intolerant to IPC and were prescribed the geko
TM
as a secondary intervention and 21 (3.1%) refused treatment. The geko
TM
was used in 203 (29.5% of MP). At 90 days there were 15 (1.5%) VTE (symptomatic DVT or PE). Of these 13 occurred in the MP group: 11 (6 DVT, 5 PE) in the ‘IPC only cohort’, 1 in ‘IPC with secondary geko
TM
’, 0 in the ‘geko
TM
only’ cohort, and 1 (PE) in ‘refused prophylaxis’. A further 2 VTE where recorded: 1 (DVT) in ‘prophylaxis not required’ and 1 (DVT) in ‘on anticoagulant’. The geko
TM
was used for a mean of 9 days/patient and was well tolerated without serious adverse events.

Conclusion:
The new strategy of increased surveillance, and use of the geko
TM
device where indicated, for patients who cannot use IPC was associated with a low overall incidence of symptomatic VTE (1.5%). The incidence in high risk immobile patients requiring MP was 1.9% (13/687), which is lower than the 6.6% in a comparable patient population in the CLOTS-3 study.