bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP188: Clinical Characteristics and Therapy Content of Stroke Patients admitted to Inpatient Rehabilitation Facility versus Skilled Nursing Facility
Authors: Lin David J , Feng Chunyang , Skolarus Lesli E , Burke James F
Published: January 2019

Introduction:
Post-stroke functioning is thought to be a key factor in selection of inpatient post-acute care setting after stroke (i.e. inpatient rehabilitation facility, IRF, or skilled nursing facility, SNF), but significant practice variation exists. There is also limited data on how therapy intensity differs between IRF and SNF. Here we describe the characteristics of patients admitted to IRF versus SNF and analyze the therapy content at each setting.

Methods:
This was a retrospective study of Medicare fee-for-service beneficiaries hospitalized in 2011 with a primary acute hospital stroke diagnosis (ICD-9 CM 431, 433.x1, 434.x1, 436). We quantified patient characteristics on admission to each setting and minutes of therapy using Medicare standard analytic files. The main outcome measures were Functional Independence Measure (FIM) in IRF settings and Pseudo-FIM (a cross-walk referenced score based on FIM-like assessments) in SNF settings.

Results:
Of the stroke hospitalizations in 2011, 31957 patients were discharged to IRF and 28327 to SNF. SNF patients were more likely to have dementia and g-tubes, while IRF patients were more likely to have received tPA. The initial FIM/pseudo-FIM motor and ADL scores were similar across the two populations mean (SD)— 24.3 (9.7) motor, 17.4 (6.8) ADL for IRF; 25.4 (8.3) motor, 16.5 (5.6) ADL for SNF. Patients at IRF received a mean of 906.9 minutes (median 832, IQR 712.4) of therapy over 15.5 (7.6) days, while patients at SNF received a mean of 785.8 minutes (median 585.1, IQR 708.4) over 29.3 (28.6) days. 34% of SNF patients received more total PT minutes than the median IRF patient.

Conclusions:
Surprisingly, baseline function was quite similar between stroke patients discharged to a SNF or an IRF. Also, because the average length of stay at SNF was much longer, the total amount of therapy received by patients between IRF and SNF was similar. This practice pattern variation may be a tool to identify optimal rehabilitation strategies.
Abstract WP189: Safety and Preliminary Efficacy of Cathodal Transcranial Direct Current Stimulation to Enhance Upper Limb Motor Function Early After Ischemic Stroke: a Double-blind, Randomized Clinical Trial
Authors: Boasquevisque Danielle S , Servinsckins Larissa , de Paiva Joselisa P , Junior Edson A , dos Santos Daniel G , de Assis Priscila S , Pires Danielle S , Meltzer Jed , de Freitas Paloma F , Speciali Danielli S , Lopes Priscila B , Peres Mario F , Silva Gisele S , Lacerda Shirley S , Conforto Adriana B
Published: January 2019

Introduction:
Transcranial direct current stimulation (tDCS) has the potential to improve upper limb motor outcomes after stroke.

Objective:
To evaluate the safety and preliminary efficacy of active cathodal compared to sham tDCS of the primary motor cortex of the unaffected hemisphere (ctDCSM1
UH
), within 72 hours to 6 weeks post-ischemic stroke.

Methods:
In this randomized, double-blind study, 30 patients with unilateral hand paresis were assigned to either active or sham ctDCSM1
UH
as add-on interventions to rehabilitation. The primary outcome was the frequency of adverse events. Secondary outcomes, compared before, immediately after treatment and three months later, included measures of upper limb motor performance and quality of life. Stroke volume was assessed before and after treatment.

Results:
Overall, tDCS was well tolerated and there were no serious adverse events. One subject in the active group reported paresthesias in the paretic arm during the first session of ctDCSM1
UH
. Heart rate increased significantly after active and decreased significantly after sham ctDCSM1
UH
but these changes were not clinically significant.

Upper limb motor impairment and quality of life improved significantly more in the sham than in the active group at three months post-treatment according to intention-to-treat and per-protocol analyses. The between-group difference in motor impairment was not clinically relevant. There were no recurrent strokes and lesion volumes did not increase significantly in either group.

Conclusions:
Active ctDCSM1
UH
was safe and well tolerated but the preliminary efficacy results do not support a beneficial role of this intervention within the first six weeks after stroke.
Abstract WP191: Short-term Follow-up After Early Home-based High-intensity Interval Training in Stroke
Authors: Steen Krawcyk Rikke , Vinther Anders , Caesar Petersen Nicolas , Faber Jens , K. Iversen Helle , Christensen Thomas , Lykke Lambertsen Kate , Rehman Shazia , Wirenfeldt Klausen Tobias , Rostrup Egill , Kruuse Christina
Published: January 2019

Background:
High-intensity interval training (HIIT) is superior to moderate-intensity continuous training (MICE) in improving aerobic fitness in patients with cardiovascular disease. Few studies have investigated the effect of HIIT in patients with stroke and none specifically in patients with small vessel disease stroke (SVDS).

Purpose:
We aimed to investigate the short-term effect of 12-weeks home-based HIIT post stroke in addition to usual care, versus usual care only.

Methods:
We included 71 patients with SVDS in a randomised controlled trial, intervention vs. control 1:1. At baseline and after 3 months we assessed: aerobic fitness (power output from the Graded Cycling Test with Talk Test (GCT-TT)), physical activity, fatigue, depression, well-being, stress, cognition, endothelial function, blood pressure, body mass index, and blood biomarkers.

Results:
We found that the patients in the intervention group spent more time on vigorous-intensity activity than the usual care group. Home-based HIIT was feasible, with no adverse events reported. No significant difference was detected in GCT-TT power output between groups. Further, we found no significant differences between the groups in general well-being (depression, stress, fatigue, cognition, and quality of life). Insulin levels decreased slightly in the active group (p=0.048).

Conclusion:
Importantly, this study shows that patients with SVDS can engage in home-based HIIT when encouraged weekly by phone, and provided either a stationary bicycle or choosing a high intensity activity of their own interest. However, increased activity was not reflected in short-term effect on aerobic fitness. This may be due to a lower than requested intensity or duration of activity. We need more investigations on long-term effects, and how to further increase physical activity and aerobic fitness.
Abstract WP197: Recurrent Falls After Stroke: A One-Year Follow-Up of the Fall Study of Gothenburg
Authors: Samuelsson Carina M , Hansson Per-Olof , Persson Carina U
Published: January 2019

Introduction:
It is important to early after stroke identify those individuals at risk of falling and the key determinants of falling after discharge from the hospital, as that knowledge may offer possibilities for early preventive actions. The aim was to investigate the occurrence of at least two falls within the first year after stroke onset after discharge from a stroke unit, and to identify factors in the acute phase after stroke that predict these recurrent falls.

Subjects:
A total of 490 consecutive individuals with acute stroke, median aged 77 (IQR 67-84) years, of whom 248 (50.6%) were men.

Methods:
The dependent variable was recurrent falls within the first year after stroke onset after discharge from a stroke unit. Fall data was collected at six and 12 months after stroke onset using a standardized questionnaire. The independent baseline variables were related to function, activity, participation, environmental factors and personal factors and assessed within four days after admission to the stroke unit. The association between baseline variables and recurrent falls was examined using univariable and multivariable logistic regression analyses.

Results:
Within six and 12 months after stroke onset, 67 of 376 respondents (18%) and 80 of 348 respondents (23%), respectively, had experienced recurrent falls after discharge. Poor postural control, assessed using the modified version of the Postural Assessment Scale for Stroke Patients (SwePASS), (SwePASS score ≤ 24) [odds ratio (OR) 4.23, 95% confidence interval (CI) 1.99-9.03, p=0.0002]; moderate postural control (SwePASS score 25-30) [OR 2.75, 95% CI 1.34-5.64, p=0.0057] and use of a walking aid [OR 2.05, 95% CI 1.16-3.60, p=0.013] were independent early predictors of recurrent falls after discharge within the first 12 months after stroke onset. In addition to these determinants, also fall in hospital [OR 2.48, 95% CI 1.16-5.31, p=0.019] was a predictor of recurrent falls during the first six months.

Conclusion:
Recurrent falls after discharge from a stroke unit within the first year after stroke onset were experienced by nearly one-quarter of the individuals and predicted by poor and moderate postural control and the use of a walking aid during the acute phase after a stroke.
Abstract WP20: Tandem Occlusions; Does Pretreatment With Thrombolytics Matter
Authors: Frey Jessica , Adcock Amelia K , Alvi Muhammad , Vu Phong , Duru Bruno , Kabbani Yasser , Kane Patrick , Rai Ansaar
Published: January 2019

Introduction:
Tandem occlusions are a significant treatment challenge for which no standard intervention protocol has been determined. IV tPA alone generally has a poor outcome for tandem occlusions while endovascular therapy (EVT) is thought to produce the best possible outcome. The purpose of this study was to evaluate the safety and efficacy of IV tPA used prior to EVT for tandem occlusions.

Hypothesis:
IV tPA plus EVT may improve clinical outcome over EVT alone without more adverse events.

Methods:
There were 56 patients with tandem occlusions over a 3 year period out of 309 (18%) patients with an LVO. The primary clinical outcome was National Institutes of Health (NIH) stroke scale and modified Rankin Scale (mRS) at discharge. Secondary outcomes were discharge disposition (Good: home or acute rehabilitation, Poor: all others), recanalization (Good: TICI ≥ 2B), and mortality. T-test was used to compare outcomes between the group that received EVT plus tPA versus EVT alone. Reasons patients did not receive tPA included recent surgery, therapeutic anticoagulation, or outside treatment window.

Results:
23/ 56 (41%) tandem occlusion patients received EVT; 15 (65%) also received tPA. NIH scores on presentation were the same between the group receiving EVT plus tPA and EVT alone (17.13, p = 0.9984), and there was no significant difference between the two groups in respect to discharge NIH (no tPA: 5.0, yes tPA: 6.0; p = 0.7487), discharge mRS (no tPA: 4.25, yes tPA: 3.67; p = 0.4349), TICI scores (63% as compared to 80% with tPA), mortality ( no tPA: 37.5%, yes tPA: 13%; p =0.419), or good discharge disposition (no tPA: 50%, yes tPA 60% p = 0.432).

Conclusion:
Although not statistically significant, the group that received EVT plus tPA had lower mRS scores, lower mortality rates, increased reperfusion and a higher percentage of discharge to home or acute rehab as compared to the group receiving EVT alone. This suggests that tPA plus EVT may be more effective in treating tandem occlusions without accruing additional adverse effects. Limitations of this study include the small sample size and retrospective nature, demonstrating the need for larger and prospective studies in the future.
Abstract WP200: Deficits in Proprioception Associated With Supramarginal Gyrus Lesions After Stroke - A Case Series Approach
Authors: Chilvers Matthew J , Hawe Rachel L , Findlater Sonja E , Dukelow Sean P
Published: January 2019

Proprioception is our sense of limb position and movement without vision. Impaired proprioception leads to difficulty performing activities of daily living. While proprioceptive deficits are common after stroke, the neural correlates underlying them are relatively unknown. Recent voxel based lesion analysis evidence suggests that a cluster of regions is implicated in these deficits, including the supramarginal gyrus (SMG) and S1. Using a case series approach, we assessed the impact of different lesion combinations on proprioception, encapsulating SMG with and without S1 and other brain regions in this network. Robotic assessments of proprioception (position matching and kinaesthesia) and MRI/CT scans were acquired for 217 individuals around 1-week post stroke. Across both robotic assessments, performance was compared to a normative model of healthy controls to detect the presence of proprioceptive deficits. Lesions on scans were marked by a trained assessor and then verified by a neurologist. Individuals with lesions to combinations of SMG, S1, insula and operculum were extracted. The extent of damage to each region was determined using the Automated Anatomical Labelling and Catani atlases. A total of 62 subjects with lesion combinations of interest were identified and analysed in more detail (13 SMG lesions). The extent of SMG damage was small, ranging from 0.03% to 25.95%. Position sense deficits were common for both right (6/6) and left SMG (6/7) lesions. Even in the absence of S1 lesions, these deficits remained prevalent. Deficits in kinaesthesia were more common in individuals with combined SMG and S1 lesions than in those without concurrent S1 lesions. Deficits in both proprioceptive assessments were uncommon in those with left S1 lesions in the absence of SMG lesions. Those with right S1 lesions displayed greater deficits than those with left S1 lesions. Results indicate that brain areas beyond S1 must be considered to better understand proprioceptive deficits and develop better strategies for improving proprioceptive function after stroke. The contributory influence of each area should be further explored in isolation.
Abstract WP203: Frequency of Post-stroke Depression Among Hypertensive Black and Hispanic Stroke Survivors
Authors: Ogunlade Adebayo O , Payano Leydi , Joseph Jennifer , Williams Stephen K , Spruill Tanya , Teresi Jeanne , Williams Olajide , Ogedegbe Gbenga
Published: January 2019

Introduction:
Post-stroke depression (PSD) is estimated to affect one-third of stroke survivors and is associated with long-term disability but scarce data exist in minority populations. This analysis examined the frequency and correlates of PSD in a cohort of Black and Hispanic stroke survivors.

Methods:
We analyzed baseline data from an ongoing clinical trial comprising 450 Blacks and Hispanics with recent stroke from New York City stroke centers. Participants were interviewed at baseline to assess depressive symptoms using the Patient Reported Outcomes Measurement Information System (PROMIS) Depression Measure. PSD was defined as a PROMIS score ≥55 indicating at least mild depression. Other data collected included demographics, clinical factors, health-related quality of life, functional independence (Barthel Index), stroke-related disability and executive functioning (Frontal Assessment Battery).

Results:
Data was available for 209 Hispanics and 202 Blacks. The sample was 44% female with average age 61.7±11.1 years. Socioeconomic status was low with 72.6% of participants having annual income <$25,000 and 49.3% having less than high school education. PSD was identified in 32.4% of the sample. In bivariate analyses, participants with vs. without PSD were more likely to be female (54.2% vs. 39.2%, p=.003), on disability (44.0% vs. 25.9%, p<.001) and have annual income <$25,000 (81.6% vs 68.3%, p=.011). Participants with vs. without PSD also had lower baseline systolic BP (146.6±12.0 vs. 150.4±15.9, p=.005), were more likely to have ≥3 comorbid conditions (39.6% vs. 26.3%, p=.014), and had worse scores on all measures of physical disability, functional independence, cognitive function and quality of life (p≤.01). In multivariate analysis, PSD was associated with younger age, lower quality of life and not being married (p<.05). In addition, foreign-born participants were more likely than US-born participants to have PSD (OR=3.34, 95% CI=1.40-7.97, p=.006).

Conclusions:
PSD was common in this cohort of minority stroke survivors and was associated with cognitive and physical disability. The finding of a higher rate in foreign-born survivors is novel and warrants further research regarding long-term effects of PSD in this population.
Abstract WP204: Low-grade Inflammation is Associated With Apathy Indirectly Through Deep White Matter Lesions in Community-dwelling Older Adults
Authors: Yao Hiroshi , Mizoguchi Yoshito , Monji Akira , Yakushiji Yusuke , Takashima Yuki , Uchino Akira , Yuzuriha Takefumi , Hashimoto Manabu
Published: January 2019

Background:
Low-grade inflammation is implicated in the pathogenesis of small vessel disease of the brain. Furthermore, systemic inflammation has been associated with apathy. Because our previous study showed the association between deep white matter lesions (DWMLs) and apathy, we investigated the association between inflammation, DWMLs, and apathy.

Methods:
We analyzed the brain magnetic resonance imaging (MRI) findings in 259 community-dwelling adults (122 men and 137 women) with a mean age of 64.8 years. Serum concentrations of high-sensitivity C-reactive protein (CRP) were measured by a quantitative enzyme-linked immunosorbent assay with a sensitivity of 22 ng/L. Each item of the Starkstein apathy scale was quantified on a visual analogue scale. The association between silent brain lesions and CRP was tested using the forward stepwise method of logistic regression analysis. We used structural equation modeling (SEM) to test the contribution of inflammation and silent brain lesions to the apathetic behavior.

Results:
Although CRP level distribution was highly skewed (median: 0.589 mg/L, interquartile range: 0.292-1.326 mg/L), log-transformed CRP values (log10 CRP) were normally distributed. Medium to high tertiles of CRP were associated with metabolic syndrome. Logistic regression analysis revealed that log10 CRP (odds ratio [OR]: 2.90; 95% confidence interval [95%CI]: 1.25-6.71) was independently associated with confluent but not total DWMLs. Metabolic syndrome and age were also associated with confluent DWMLs. Path analysis based on SEM indicated that the direct path from log10 CRP to DWMLs was significant (β = 0.12, P = 0.039). The direct paths from metabolic syndrome to log10 CRP and to DWMLs were also significant. The direct path from DWMLs to apathy was significant (β = –0.17, P = 0.007) as was the direct path from education to apathy (β = 0.18, P = 0.003). However, the direct path from log10 CRP to apathy was not significant. The measures of model fitness showed that the presented model reasonably fit the data.

Conclusions:
Independent of common vascular risk factors, elevated serum CRP levels were associated with confluent DWMLs. Although DWMLs were associated with apathy, direct association between inflammation and apathy was not shown.
Abstract WP205: Seasonal Variation in Stroke Incidence in Black versus White Medicare Beneficiaries
Authors: Baig Tehniyat , Chen Monica L , Sahu Ananya , Valverde Twiggs Julien , Kamel Hooman
Published: January 2019

Introduction:
The increased risk of ischemic stroke in black versus white U.S. residents is not fully explained by known risk factors. Influenza has been implicated as a stroke risk factor, and studies have shown that blacks less often receive influenza vaccination than whites. We investigated whether there is an increased black-white racial disparity in stroke incidence during flu season.

Methods:
We performed a retrospective cohort study using inpatient and outpatient claims between 2008-2015 from a nationally representative 5% sample of Medicare beneficiaries. We included patients of black or white race who were ≥66 years old. The outcomes were ischemic stroke outside of influenza season versus during influenza season, defined as December through March based on reports of peak influenza activity from the Centers for Disease Control and Prevention. We calculated incidence rates and used Cox regression models adjusted for demographics and vascular risk factors to examine the association between black race and ischemic stroke.

Results:
Among 1,511,393 white and 138,026 black beneficiaries, blacks were slightly younger (mean age, 72.7 vs 73.5), more often female (60.5% vs 56.9%), and less likely to have atrial fibrillation but more likely to have hypertension, diabetes, heart failure, and chronic kidney disease. During a 4.7 (±2.2) years of follow-up, 61,188 patients experienced a stroke. During influenza season, stroke incidence was 1.08 (95% CI, 1.02-1.11) per 100 person-years in blacks versus 0.72 (95% CI, 0.69-0.72) per 100 person-years in whites. Outside of influenza season, stroke incidence was 1.22 (95% CI, 1.19-1.26) per 100 person-years in blacks versus 0.80 per 100 person-years in whites (95% CI, 0.80-0.81). Blacks had a similarly increased hazard of stroke both during influenza season (HR, 1.58; 95% CI, 1.52-1.66) and outside of influenza season (HR, 1.58; 95% CI, 1.53-1.63).

Conclusion:
In a cohort of elderly U.S. patients, we found that the black-white disparity in stroke risk was not more pronounced during influenza season. Our findings do not support the hypothesis that influenza contributes to the black-white disparity in stroke risk.
Abstract WP206: Outcomes of Acute Ischemic Stroke in Patients With Alcohol Abuse: 10 Year National Estimate
Authors: Singh Tejinder , Savani Chirag , Yi Xiyan , Kumar Varun , Pathak Ambarish , Chib Anjula , Renati Swetha
Published: January 2019

Background:
Excessive alcohol intake is associated with increased risk of stroke. Those with alcohol abuse are also at risk for developing cardiomyopathy, liver disease, anemia and thrombocytopenia. We seek to evaluate the impact of alcohol use on acute ischemic stroke patients using the Nationwide Inpatient Sample.

Methods:
We derived our study cohort from Nationwide Inpatient Sample (NIS) database (2005-2014) to identify AIS using appropriate ICD-9CM codes in primary diagnosis field, alcohol abuse by variable “cm_alcohol” provided by NIS and Intravascular thrombolysis utilization by procedure code 99.10 in any procedural field. Differences between categorical variables were tested using the chi-square test and continuous variables using the Student t-test.

Results:
We identified 4332783 patients with acute ischemic stroke (AIS) in our study group, of which 141113 (3.3%) patients were alcohol abusers. Patients with alcohol abuse and AIS were younger (61 vs. 71.5years; p<0.0001) and predominantly male (80.3%). They were more likely to receive thrombolysis (7.2% vs. 5.7%; p<0.0001) and mechanical thrombectomy (1% vs. 0.7%; p<0.0001).

Patients with a history of alcohol abuse and AIS who received thrombolysis had a higher co morbidity index and were more likely to be treated at a large or teaching hospital. They also had an increased risk of intracranial bleeding (1% vs. 0.3%; p<0.0001) and major bleeding (10% vs. 3.3%; p<0.0001). Longer median length of stay (5 vs. 4 days; p<0.0001) and higher median cost (17603 vs 9275 dollars; p<0.0001) were also noted. There was increased in-hospital mortality among those alcohol abuse patients who received thrombolysis (6.3% vs. 3.7%; p<0.0001).

Conclusion:
In conclusion, patients with alcohol abuse and AIS had a thrombolysis rate of 7.2%. After thrombolysis, they were more likely to have intracranial bleeding, major bleeding and in-hospital mortality. We postulate that the increased rate of bleeding complications may be secondary to underlying coagulopathy or decreased liver clearance in those with alcohol abuse.
Abstract WP207: Clinical Characteristics of Methamphetamine Associated Acute Ischemic Stroke
Authors: Walia Sandeep , Ng Kwan
Published: January 2019

Background:
Methamphetamine (MA) abuse is an increasing worldwide epidemic with associations to acute ischemic strokes (AIS); however, exact effects have been underreported. In this single center study, we characterize effects of MA on AIS in terms of demographics, presentation, and clinical significance.

Methods:
We performed a retrospective analysis of 654 patients admitted to UC Davis Medical Center from 2016-2017 with primary diagnosis of AIS. Patients’ presenting characteristics, suspected stroke etiologies based on TOAST criteria, and clinical outcomes were compared between AIS with and without positive urine drug screen for MA.

Results:
Fifty patients with methamphetamine positive (MA+) AIS and 252 patients with methamphetamine negative (MA-) AIS were identified. MA+ AIS were predominantly male (0.78 vs 0.50, p=0.005) and significantly younger (56.2 vs 69.7, p<0.001) compared to MA-AIS. In general, patients with MA+ had a more severe presentation with higher systolic pressures (175.1 vs 157.6, p<0.001) and diastolic pressures (105 vs 86.23, p<0.001). Overall, the two groups did not differ in terms of presenting NIHSS, rates of TPA administration, length of stay, or ICU length of stay. In terms of etiologies, MA+AIS had significantly higher incidence of small vessel strokes (0.41 vs 0.20, p= 0.0017) whereas large vessel occlusions were significantly more predominant in MA-AIS (0.22 vs 0.10, p=0.04). Analysis of MRI burden of deep white matter (DWM) lesions based on Fazekas scale demonstrated significantly lower proportion of moderate to severe disease burn in MA +AIS (0.17 vs 0.49, p=0.0001). Overall, MA+AIS trended to an improved modified rankin scale at discharge, however this was not statistically significant.

Conclusion:
There is an earlier age of onset with significantly higher presenting blood pressures in MA+AIS and interestingly similar initial NIHSS, length of ICU stay, and hospital stay compared to MA-AIS. The majority of MA+AIS presented with small vessel strokes and significantly lower burden of deep white matter disease. This suggests that the cerebral small vessels may be more sensitive to the sympathomimetic nature of MA that may be driving transient hypertension and cerebral vasoconstriction as the potential pathogenesis.
Abstract WP209: Trends in Mortality, Length of Stay and Effect of Teaching Hospital Status in Subarachnoid Hemorrhage Patients in the United States From 2000-2014
Authors: Rawla Prashanth , Vellipuram Anantha , Thandra Krishna Chaitanya
Published: January 2019

Background and Purpose:
Subarachnoid Hemorrhage (SAH) is a significant cause of morbidity and mortality in the United States. Mortality and length of stay (LOS) are significant in cases of SAH. The primary objective of our study was to analyze the mortality rate, LOS associated with SAH hospital admissions from 2000 to 2014. We also analyzed if teaching status of the hospital has any effect on LOS and mortality.

Methods:
Nationwide inpatient sample (NIS) database was used to identify SAH admissions in all patients from 2000 to 2014 using ICD-9-CM code 430 as the principal discharge diagnosis. NIS is the largest all-payer inpatient care database in the United States, containing data on more than 7 million hospital stays. It has a large sample size which is ideal for developing national and regional estimates.

Results:
A total of 376,263 discharges with a diagnosis of SAH were analyzed from 2000 to 2014 from the NIS database. The number of hospitalizations increased from 24,993 in 2000 to 25,775 in 2014. In-hospital mortality decreased from 25.85% in 2000 to 18.86% in 2014 a decrease of 27.04% (P < 0.0001). Mean LOS has remained the same from 11.8 days to 12 days during the same period. Mortality rates and LOS in non-teaching hospitals was 30.26% and 9.2 days in 2000 and 28.71% and 6.9 days in 2014(P < 0.0001). Mortality rates and LOS in teaching hospitals was 23.3% and 13.2 days in 2000 and 18.28% and 12.5 days in 2014(P < 0.0001).

Conclusion:
Overall in-hospital mortality associated with SAH has decreased over the years. The decrease in mortality can be attributed to early diagnosis and early institution of aggressive treatments. LOS in teaching hospitals is considerably higher which can be attributed to the complex co-morbid cases admitted and transferred to teaching hospitals. Mortality from SAH in non-teaching hospitals is significantly higher. Further research needs to be done to find the disparities in mortality rates based on teaching status of the hospital.
Abstract WP212: Trends in Acute Ischemic Stroke Hospitalizations by Age Groups, Length of Stay, Mortality and Hospital Costs in the United States From 2000-2014
Authors: Rawla Prashanth , Vellipuram Anantha , Khatri Rakesh , Maud Alberto , Rodriguez Gustavo J , Cruz-Flores Salvador
Published: January 2019

Background and Purpose:
Acute Ischemic Stroke (AIS) is a significant cause of long term disability. The primary objective of our study was to analyze the trends in AIS hospitalizations by age groups, Length of Stay (LOS), Mortality and hospital costs in the United States over a 15-year period from the years 2000 to 2014.

Methods:
Nationwide inpatient sample (NIS) database was used to identify AIS admissions in all patients from 2000 to 2014 using ICD-9-CM codes 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, and 436 as the principal discharge diagnosis. NIS is the largest all-payer inpatient care database in the United States, containing data on more than 7 million hospital stays. It has a large sample size which is ideal for developing national and regional estimates.

Results:
A total of 554,226,249 discharges with a diagnosis of AIS were analyzed from 2000 to 2014 from the NIS database. Hospitalization rates for AIS increased significantly from years 2000 to 2014 for ages 18-44 (relative percentage change (RPC): +33.75%) and ages 45-64(RPC: +41.21%). Hospitalization rates for AIS have significantly decreased in the age group 65-84 (RPC: -16.69%). In-hospital mortality decreased from 6.97% in 2000 to 4.4% in 2014. Mean LOS has decreased from 6.19 days to 4.2 days during the same period. Mean hospital costs have gone up from $6,975 to $12,322.

Conclusion:
Overall in-hospital mortality and LOS associated with AIS has decreased over the years. AIS US hospitalizations have significantly increased in the age groups from 18-64 while there was a significant decrease in the rate of hospitalizations in the age groups 65-84. Further research needs to be done to identify the risk factors contributing to a substantial rise in AIS hospitalizations in young to middle age adults.
Abstract WP214: Differential Impact of Stroke Risk Factors Across the Age Spectrum: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study
Authors: Howard George , Cushman Mary , Banach Maciej , Kissela Brett M , Kleindorfer Dawn O , Soliman Elsayed Z , Judd Suzanne E , Long Leann , Howard Virginia J
Published: January 2019

Introduction:
With the “graying of America” an increasing proportion of stroke events occur in the very old; however, risk models to predict stroke were developed in studies with few elderly participants. We hypothesized that, among those aged 45+, predictive factors for stroke differ in older than younger people.

Methods:
REGARDS enrolled 30,231 black and white adults 45 and older in 2003-7. We considered 3 age strata (45-65, 66-73 and 74+) with approximately equal number of stroke events, and hence equal statistical power to detect risk factor associations. Age specific race-sex adjusted associations of risk factors were assessed using proportional hazards models. We used bootstrap techniques to test the likelihood of specific risk factors being selected for a prediction model in each of the 3 age groups. This was based on the percentage of times each risk factor was selected for inclusion by backwards elimination in 1000 bootstrap model.

Results:
27,123 stroke-free participants were followed for 9.4 years, during which 1,114 ischemic strokes occurred (379, 364 and 371 across age groups). Among those age 65 and younger, risk factors with the strongest association with incident stroke were heart disease, hypertension, atrial fibrillation, diabetes, and chronic kidney disease (HRs >2; see table). Hypertension, diabetes, heart disease, smoking, atrial fibrillation, and frailty were selected in the multivariable model for those age 45-65. The impact of some factors decreased at older age 74+, where atrial fibrillation, LVH, smoking, hypertension and frailty emerged as most important.

Conclusions:
Many “traditional” stroke risk factors were defined in middle-aged populations (and were confirmed here); however, a different milieu of risk factors are important for stroke risk prediction in the elderly.
Abstract WP221: Relation Between Blood Pressure and Stroke Mortality in the United States Veteran Population
Authors: Aparicio Hugo J , Tarko Laura M , Gagnon David R , Costa Lauren , Ho Yuk-Lam , Demissie Serkalem , Djousse Luc , Cho Kelly , Seshadri Sudha , Wilson Peter W
Published: January 2019

Introduction:
Improved control of hypertension is largely credited for declines in stroke incidence and mortality. Previous studies have reported worse outcomes after ischemic stroke with lower blood pressures prior to the stroke. We investigated the relationship between pre-stroke systolic blood pressure (SBP) and mortality after ischemic stroke among U.S. Veterans.

Methods:
This longitudinal analysis assessed mortality risk after incident stroke in a national sample of Veterans Health Administration hospitalizations between 2002 and 2007. We included patients who had admission ICD-9 codes for ischemic stroke (433.x1, 434, and 436, excluding 434.x0) and ≥1 outpatient blood pressure measurements 1 to 18 months prior to stroke. We defined 6 categories of average baseline SBP: <120, 120-129, 130-139, 140-149, 150-159, and ≥160 mm Hg. Multivariable Cox analyses were used to relate baseline SBP to all-cause and vascular mortality determined using the National Death Index.

Results:
There were 29,458 hospitalizations (mean age 67±12 years, 98% male) for incident stroke. During 4.1±3.3 years mean follow-up, there were 15,489 deaths (54%). There were 6,629 vascular deaths (23%). In a fully adjusted model, with high normal pre-stroke SBP (130-139) as the reference, risk of all-cause mortality was increased for patients with very low-to-normal SBP (<120), normal SBP (120-129), and very high SBP (≥160) (Table 1A). The risk of vascular mortality increased with very low (<120) and very high (≥160) SBP levels, but was not increased with normal SBP (120-129) (Table 1B).

Conclusions:
In U.S. Veterans hospitalized with first-ever stroke, very low and very high pre-stroke systolic blood pressure levels increased risk of all-cause and vascular mortality. Optimal SBP targets after stroke, particularly in patients with low pre-stroke SBP, merit further investigation.
Abstract WP223: Ischemic and Hemorrhagic Stroke in Native Americans
Authors: King Zachary A , Beekman Rachel , Chu Stacy Y , Leasure Audrey C , Orgrass Hailey A , Gilmore Emily , Sansing Lauren H , Matouk Charles C , Sheth Kevin N , Falcone Guido J
Published: January 2019

Introduction:
Stroke is a leading cause of morbidity and mortality in the United States, affecting an estimated 15 million people each year. Native Americans (NAs) account for 1.5% of the population. Several recent studies have focused on how stroke affects minority groups. However, existing data on stroke in NAs are extremely limited. We aimed to characterize the demographic and clinical characteristics of this population and identify predictors of in-patient mortality.

Methods:
We evaluated claims data from acute care hospitals in California between 2005-2011. California has the largest NA population in the United States. Validated ICD-9 codes were used to identify first time primary ischemic (AIS) and hemorrhagic stroke (ICH) admissions and ascertain comorbidities and in-hospital mortality. We used univariate and multivariate logistic regression to compare baseline characteristics across race/ethnic groups and to identify independent predictors of in hospital mortality.

Results:
We identified 283,107 first time strokes in California between 2005 and 2011, including 234,471 AIS (83%) and 48,636 ICH (17%). Of these, 851 (0.3%) were NAs (Age 66 [SD14], female sex 444 [53%]), including 698 AISs (82%) and 153 (18%) ICHs. For AIS, NAs had intermediate prevalence of relevant vascular risk factors, including history of smoking (15% vs 18% in Blacks and 11% in Whites, p<0.001) and diabetes (46% vs 48% in Hispanics and 26% in Whites, p<0.001). NAs with AIS were the least likely to receive palliative care (1% vs 4% in Whites, p<0.001). In ICH, NAs had the second highest proportion chronic kidney disease (13% vs. 17.5% in Blacks and 8.1% in Whites, p<0.001) and the highest proportion of diabetes (41% vs. 37% in Hispanics and 21% in Whites, p<0.001). In-hospital mortality was similar to other minorities (4% and 26% for AIS and ICH, respectively; all p>0.2). In both AIS and ICH, predictors of in hospital mortality were similar to other minority groups.

Conclusions:
Native Americans constitute an important yet understudied minority population in stroke. NA have high prevalence of modifiable risk factors including diabetes and smoking.
Abstract WP224: Decline of Carotid Endartarectomy and Stenting From 2009 to 2013 Among U.S. Elderly With Ischemic Stroke
Authors: Man Shumei , Schold Jesse , Uchino Ken
Published: January 2019

Background:
The patterns of carotid revascularization procedures after ischemic stroke have evolved in the U.S. and around the world. We aimed to examine the rate and trend of carotid revascularization procedures (carotid endartarectomy and stenting) among U.S. elderly hospitalized for acute ischemic stroke.

Methods:
We examined the prevalence of carotid endartarectomy and stenting in Medicare beneficiaries aged 65 years and older who were hospitalized between January 2009 and December 2013 with a primary discharge diagnosis of acute ischemic stroke. The data of patient information were obtained from the Medicare Provider Analysis and Review file. Patients who underwent carotid endartarectomy and stenting were identified using the ICD-9 CM codes.

Results:
A total of 1,070,574 Medicare beneficiaries were hospitalized for ischemic stroke between 2009 and 2013. The number and rate of carotid endarterectomy and stenting has declined. The number of carotid endarterectomy decreased the most, from 9768 (4.3%) in 2009 to 8404 (3.9%) in 2010, 7434 (3.6%) in 2011, 7183 (3.5%) in 2012 and 6851 (3.3%) in 2013 (P<0.05), a relative decrease of 30%. The carotid stenting declined at a lesser degree, from 2259 (1.0%) in 2009 to 2012 (0.9%) in 2010, 1915 (0.9%) in 2011, 1733 (0.8%) in 2012, and 1568 (0.8%) in 2013 (P<0.05), a relative decrease of 31%.

Conclusion:
From 2009 to 2013, carotid revascularization procedures after ischemic stroke for presumed symptomatic carotid stenosis has decreased by about 30%.
Abstract WP225: Exploring the Relationship between Sleep Duration and Stroke Severity in Mild/moderate Stroke and TIA patients: Evidence from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) Study
Authors: Fouladi Nashta Niloofar , Park Christopher , Roberts Eric T , Goldmann Emily , Parikh Nina S , Appleton Noa , Boden-Albala Bernadette
Published: January 2019

Introduction:
Prior research has shown that sleep duration is associated with risk of stroke and other cardiovascular events. However, evidence is sparse linking sleep duration with stroke severity. The aim of this study is to investigate the association between pre-stroke sleep duration and stroke severity at hospital admission in a cohort of mild/moderate stroke and TIA survivors.

Methods:
The present analysis used baseline data from the DESERVE study, a randomized controlled trial of a skills-based educational intervention. Sleep duration was measured using patients’ self-reported average hours of sleep per night during the past four weeks. Hours of sleep were then categorized into four groups with three non-normative groups, “Very Short Sleep” (1-4 hours), “Short Sleep” (5-6 hours), and “Long Sleep” (9-12 hours), and one normative sleep group (7-8 Hours). Stroke severity was assessed using the National Institute of Health Stroke Scale (NIHSS). The distribution of NIHSS was not normal; therefore the Kruskal Wallis test was used to assess bivariate associations. Multivariable analysis was conducted for sleep duration and stroke severity assuming a negative binomial distribution, due to overdispersion of variance. The final model was adjusted for gender, age, race/ethnicity, stroke history, hypertension, alcohol, and BMI.

Results:
A total of 453 patients were included in the analysis (51% Female; 28% Non-Hispanic white, 35% Non-Hispanic black, 31% Hispanic, and 6% Other; mean age 64.6). Median NIHSS was significantly different across the sleep categories, (Very Short Sleep=4; Short Sleep=2; Normative Sleep=2; Long Sleep=1; p=0.0024). The unadjusted model did not show significant differences in stroke severity between non-normative groups and the normative group (Very Short Sleep, p=0.068; Short Sleep, p=0.235; Long Sleep, p=0.203). Further adjustment for sociodemographic and clinical factors did not alter the pattern of results.

Conclusions:
We found no significant association between normative and non-normative sleep duration and stroke severity among mild/moderate stroke and TIA survivors. However, future studies may be needed to examine this relationship with a greater range of stroke severity.
Abstract WP227: White Matter Hyperintensities and Recurrent Stroke Risk in Stroke Patients With Small-Vessel Disease Burden
Authors: Park Jongho , Heo Sung Hyuk , Lee Min Hwan , Kwon Hyuk Sung , Kwon Sun U. , Lee Ji Sung
Published: January 2019

Background and Purpose:
Although white matter hyperintensities (WMH) on magnetic resonance imaging (MRI) are linked to an increased risk of infarct growth, the impact of WMH severity on the long-term risk of recurrent stroke is currently unknown. This study aimed to evaluate the association between WMH severity and the risk of recurrent vascular events among ischemic stroke patients with small-vessel disease (SVD).

Methods:
Data from participants (n = 1,454) in the PreventIon of CArdiovascular Events in iSchemic Stroke Patients with High Risk of Cerebral HemOrrhage trial were reviewed. The severity of WMH in baseline brain MRI scans was assessed using the Fazekas scale. The association between WMH severity and stroke (ischemic or hemorrhagic) and major vascular events (MVEs, a composite of stroke, myocardial infarction, or vascular death) was assessed.

Results:
Study patients were having significant burden of SVD; Fazekas score 0 (n=2), 1 (n = 426), 2 (n = 650), and 3 (n = 376) and median Fazekas scale was 2 (mean follow-up 1.9 ± 1.3 years). The stroke incidence rate per 100 person-years was 2.6% in the Fazekas 0-1 group, 3.6% in Fazekas 2, and 7.0% in Fazekas 3, and the rates for MVEs were 3.3%, 4.3%, and 7.6%, respectively. Compared with the Fazekas 0-1 group, the Fazekas 3 group was associated with a higher risk of stroke (adjusted hazard ratio, 2.69; 95% confidence interval, 1.61–4.50;
P
< 0.001), ischemic stroke (2.56; 1.44–4.55;
P
= 0.001), hemorrhagic stroke (3.26; 1.04–10.25;
P
= 0.043), and MVEs (2.27; 1.43–3.61;
P
= 0.001).

Conclusions:
In this study of Asian patients with SVD who had experienced a non-cardioembolic stroke or transient ischemic attack, advanced WMH (Fazekas 3) was independently associated with a greater than 2-fold increased risk of recurrent stroke during the 2-year follow-up period, when compared with the milder WMH group (Fazekas ≤ 1). Increasing WMH severity may, therefore, be a useful prognostic indicator of patients at high risk of recurrent vascular events.
Abstract WP229:
H
ealthy
E
ating and
L
ifestyle After
S
troke (HEALS): A Pilot Trial of a Lifestyle Intervention for Stroke Survivors in the Safety-Net
Authors: Towfighi Amytis , Hill Valerie A , Valle Natalie P , Cheng Eric M , Mittman Brian , Ayala-Rivera Monica , Barry Frances , Moreno Lilian , Dombish Heidi , Espinoza Annaliese , Wang Debbie , Ochoa Dina , Vickrey Barbara
Published: January 2019

Background:
Although healthy lifestyle practices mitigate stroke risk and mortality, few stroke survivors adhere to them, particularly among socioeconomically disadvantaged communities. We developed and pilot tested a lifestyle management intervention, HEALS, to improve stroke survivors’ diet and physical activity and tested it in a diverse population receiving care at a safety-net county facility.

Methods:
One hundred English- or Spanish-speaking participants with stroke or TIA were randomly assigned to a 6-week weekly occupational therapist-led group lifestyle intervention vs. usual care. Each 2 hour session included didactics, goal setting, activities, and peer exchange. Primary outcomes measured at baseline and 6 months were body mass index, abdominal obesity, fruit/vegetable intake, and physical activity. Secondary outcomes were blood pressure, high-density lipoprotein cholesterol, and glycosylated hemoglobin. Outcomes were compared with repeated measures analysis. Effect sizes for continuous variables were determined using partial eta-squared. A nested formative evaluation assessed facilitators and barriers to implementation, acceptance, and adherence to the intervention.

Results:
Mean age was 60 years, 62% were men, 68% were Hispanic, 60% were Spanish-speaking, 35% had ≤8
th
grade education, 31% were working at enrollment, and 69% had modified Rankin scale <3. Seventy-three percent participated in at least one HEALS session. Over one third (37%) attended all 6 sessions. There were no significant changes in primary or secondary outcomes at 6-months, even after adjusting for number of sessions attended. Effect sizes for primary outcomes were small (<0.05). Focus group participants recommended more sessions for a longer treatment duration, additional information on diet and physical activity, and monetary incentives for participation. Providers agreed with a need for a longer treatment duration and suggested more robust provider training and fidelity checks to ensure standardized program delivery.

Conclusions:
The HEALS intervention was feasible in a safety-net setting, but the effect sizes were small. An RCT of a longer-duration intervention, with more formal provider training, may be warranted.