bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W MP55: Intensive Speech Therapy Promotes Recovery in Chronic Post-Stroke Aphasia
Authors: Shamapant Shilpa , Adair Shelley , Grotta James C
Published: July 2021

Background:
Research suggests that Acute Post-Stroke Aphasia (APSA) improves with Intensive Speech Therapy (IST). However there is scarce research comparing IST for APSA vs Chronic Post-stroke Aphasia (CPSA), and the relation to Time Post Stroke (TPS). We hypothesized that IST creates improvement for both APSA and CPSA patients irrespective of TPS.

Methods:
We examined 26 participants chosen from the existing database of Austin Speech Labs, age range 23-79 yrs (mean 53 yrs). Clients that attended all eight weeks of therapy consistently were chosen. All clients received group and individual therapy using different computer applications every time they attended a session. The hours spent in therapy varied due to the individualized nature of the therapy program, but averaged 442 hours (range 80 -2,279 hours). Clients maintained their hours per week for at least eight weeks, which was defined as the IST “Boot Camp(BC)” interval. We classified clients into two groups, CPSA (n=12) and APSA (n=14) depending on TPS. CPSA clients had come to ASL at least one year post-stroke onset while APSA clients had come less than one year post-stroke. Two tests , Western Aphasia Battery (WAB) or Examining for Aphasia- Fourth Edition (EFA-4) were administered at enrollment and at discharge or every six months to avoid memorization. ASL Language Evaluation to test automatic speech, auditory comprehension, naming, reading, writing, and expressive language was done after every BC session.

Results:
APSA and CPSA clients differed on several levels. TPS was 1 to19.5 yrs, age was 23 - 75 yrs in CPSA compared to 0.08 - 0.75 yrs TPS, 30 - 79 yrs age in APSA. CPSA had four females(F) and nine males(M) while APSA had two F and 12 M. Using an independent samples test we found no significant differences in final scores between between APSA and CPSA participants across aphasia types. Secondly, using a bivariate correlation test, we found no correlation between TPS and post test scores across all categories. Lastly, age had no effect on treatment response; elderly and young clients improved equally with IST.

Conclusion:
IST can help CPSA clients as much as those with APSA. Research is continuing to determine the minimal and optimal length and duration of IST to produce and maintain improved language function.
Abstract W MP57: Effects of Wearable Robotic Training of Ankle and Mobility Rehabilitation in Acute Stroke
Authors: Chen Kai , Ren Yupeng , Harvey Richard L , Roth Elliot J , Zhang Li-Qun
Published: July 2021

Background and Purpose:
Stroke is the fourth leading cause of death in the US and is a leading cause of adult disability. It was reported that the first few months post stroke is critical in neural plasticity and motor recovery. Presently, effective treatment options for ankle impairment and mobility are limited, especially for in-bed acute stroke rehabilitation. In this study, wearable robotic training involving passive stretching and active movement training was investigated to determine its efficacy in improving stroke outcome.

Methods:
Eleven patients with acute stroke participated. This was completed in a clinical in-patient setting (45 min/session, 3~5х/week, total 18 session). Participants were aged 53.7±17.4 (mean±SD); robotic treatment was given averaged 40.5 days of stroke onset. They continued receiving standard inpatient physical therapy during the study. One way repeated measures ANOVA was used to compare clinical and biomechanical outcome measures across the repeated measures.

Results:
Preliminary results showed an improvement after the multiple sessions of training with F-M in LE increased from 14.8 ± 8.8 and 19.4 ± 8.2 (p<.01), STREAM score in LE from 32.1±21.4 to 47.9±30.1 (p=.02), the BBS increased from 35.2±17.8 to 38.0±18.2. Ankle active range of motion (AROM) in dorsiflexion increased from -5.7 ± 7.2° to 2.3 ± 8.1°(p=.004), ankle passive ROM in dorsiflexion from 14.0 ± 7.1° to 19.9 ± 5.3° (p=.002). Dorsiflexor strength increased from 0 ± 2.2 N m before training to 2.4 ±3.5 N m after training (p=.003). Plantarflexor strength increased from 6.7±9.9 Nm, to 12.6 ± 11.4 Nm (p=.004). Other measures showed no significant improvements, such as 6MWT increased from 302.0 ± 416.4 and 540.6 ± 563.4 feet, the MAS of ankle was 2.2 ± 1.1 to 1.6 ± 1.2.

Conclusions:
The use of robotic device demonstrated improvements in selected outcome measures in hospital settings, and it was efficiently administer in the clinic. The results suggest that impaired lower limbs of acute stroke can respond to controlled stretching and movement training in terms of muscle biomechanical properties and improve lower extremity functional activities in acute rehabilitation.The limitation of this study was its small sample size and lack of a control group.
Abstract W MP89: Silencing VEGF-B Diminishes the Neuroprotective Effect of Candesartan Treatment after Experimental Focal Cerebral Ischemia
Authors: Soliman Sahar , Ishrat Tauheed , Pillai Bindu , Ergul Adviye , Fagan Susan C
Published: July 2021

Background & Objective:
The pro-survival effect of VEGF-B has been documented in different in vivo and in vitro models. We have previously shown an enhanced VEGF-B expression in response to candesartan treatment after focal cerebral ischemia. In this study, we tested the hypothesis that VEGF-B expression contributes to candesartan-mediated recovery.

Methods:
Silencing VEGF-B expression was achieved by bilateral intracerebroventricular injection of lentiviral particles containing short hairpin RNA against VEGF-B (KD) or vehicle (NTC). Middle cerebral artery (MCA) was occluded for 90 minutes. At reperfusion, animals received either intravenous saline or candesartan. Neurobehavioral outcome was assessed 24, 48 and 72 hours after the insult and infarct size was measured at 72 hours. In an additional set of experiment, middle cerebral artery was occluded for 3h followed by 21h reperfusion. Rats were sacrificed at 24h post-MCAO and brains perfused for evaluation of vascular markers (edema and hemoglobin content).

Results (Table):
Candesartan-treated animals showed a significant reduction in the infarct size and edema accompanied by functional recovery in Bederson, beam walk, paw grasp and grip strength performance only in the presence of VEGF-B. In addition, candesartan-treated animals showed significantly reduction of hemoglobin content, a marker for hemorrhage and edema at 24 h after MCAO.

Conclusion:
Our results suggest VEGF-B plays a critical role in mediating candesartan’s neuronal and vascular protective effect after stroke. Identifying growth factors that mediate recovery after ischemic stroke presents possible targets for stroke therapeutics.
Abstract W MP99: Race/Ethnic and Sex Differences in EMS Transport among Hospitalized U.S. Stroke Patients: Analysis of the National Get With The Guidelines-Stroke Registry
Authors: Mochari-Greenberger Heidi , Xian Ying , Hellkamp Anne S , Schulte Phillip J , Bhatt Deepak L , Fonarow Gregg C , Schwamm Lee H , Smith Eric E
Published: July 2021

Background:
Calling 911 is the recommended first step when stroke symptoms occur. Differences in activation of emergency medical services (EMS) may contribute to race/ethnic and sex disparities in stroke outcomes. The purpose of this study was to determine whether EMS utilization varies among a contemporary, diverse national sample of hospitalized acute stroke patients.

Methods:
We analyzed data from 398,798 stroke patients admitted to 1,613 Get With The Guidelines-Stroke participating hospitals from 10/1/11-3/31/14. Multivariable logistic regression was utilized to evaluate the associations between race/ethnic group and sex, with EMS use, adjusting for potential confounders.

Results:
Patients were 50.4% female, 69% white, 19% black, 8% Hispanic, 3% Asian, 1% other; 85.9% ischemic stroke. Overall 58.6% of stroke patients were transported to the hospital by EMS. EMS utilization differed by sex and race/ethnic group (interaction p<0.001). White females were most likely to use EMS (62.0%) and Hispanic males were least likely to (52.2%). Age, health insurance coverage, and history of prior stroke or TIA varied significantly among race/ethnic groups (p<0.0001). After adjustment for both patient and hospital characteristics, Hispanic and Asian men and women were less likely than their white counterparts to utilize EMS; black females were less likely than white females to utilize EMS (Table).

Conclusion:
EMS use was low overall and differential by race/ethnicity and sex. These contemporary data support a need for targeted initiatives to increase EMS transport among U.S. stroke patients.
Abstract W P10: Lower Intraprocedural Mean Arterial Pressure Predicts Good Outcome and Lower Mortality in Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke
Authors: John Seby , Uchino Ken , Wisco Dolora , Toth Gabor , Hui Ferdinand , Gomes Joao , Buttrick Maureen , Stecker Margaret , Hussain Muhammad S
Published: July 2021

Introduction:
Several factors influence the outcome of patients who undergo intra-arterial therapy (IAT) for acute ischemic stroke (AIS). The influence of intra-procedural hemodynamics on functional outcome and mortality has not been studied. There is no data to guide intraprocedural blood pressure (BP) management and it is unknown whether systolic, diastolic, or mean arterial pressure (MAP) is important for determining outcomes.

Methods:
Retrospective study of patents that underwent IAT for anterior circulation AIS between 1/08- 12/12 was conducted. Detailed intra-procedural hemodynamics, demographics, NIH stroke scale score, IV tPA use, thrombus location, recanalization grade, intracranial hemorrhage were collected. Outcomes measured were in-hospital mortality and 30-day good outcome defined as modified Rankin Scale score of 0-2. Successful recanalization was defined as TICI 2b-3 and ICH was classified into parenchymal hematoma (PH1+2) and hemorrhagic infarction (HI 1+ 2).

Results:
The cohort in the analysis consisted of 190 patients (56% females, mean age 67 + 15 years). Thirty-six (19%) patients died in-hospital, and 25 (17%) achieved an mRS 0-2. Intra-procedural maximum systolic BP (SBP) and maximum MAP were significantly lower in the good outcome group (Table 1). In multivariable logistic regression analysis, maximum MAP was an independent predictor of good outcomes along with baseline CT ASPECTS score, and successful recanalization. Maximum MAP was also an independent predictor of mortality along with age and presence of PH 1+2 ICH.

Conclusions:
Maximum intraprocedural MAP was an independent predictor of good outcome and mortality in in patients undergoing IAT for AIS. This results may have implications for intraprocedural BP management.
Abstract W P101: Combination of MST-188 and Tissue Plasminogen Activator Extends the Therapeutic Window of Stroke
Authors: Zhang Li , Zhang Zheng Gang , Emanuele Martin , Chopp Michael
Published: July 2021

Background and Purpose:
The utilization of tissue plasminogen activator (tPA) for stroke treatment is hampered by its narrow therapeutic window and hemorrhagic complication. MST-188 (Vepoloxamer) is a proprietary tri-block copolymer with rheological and membrane-protective properties. The current study investigated whether MST-188 enhances the therapeutic effect of tPA on ischemic damage in a rat model of embolic focal cerebral ischemia.

Methods:
Male Wistar rats (n=10) subjected to embolic middle cerebral artery occlusion (MCAO) were treated post stroke with the combination of MST-188 (300 mg/kg at 3.5h, IV; followed by a second dose of 2,000 mg/kg at 9.5h, IP) and tPA (10 mg/kg at 4h, IV). Ischemic rats treated with tPA (10 mg/kg at 4h, IV) alone, or saline were used as control groups (n=10/group). An array of behavioral tests were performed at 1 and 7 days after MCAO. Ischemic lesion volume was measured 7 days after MCAO.

Results:
All rats exhibited neurological deficits measured by the Longa scale 30 min after MCAO. Treatment with tPA alone failed to reduce infarct volume and neurological functional deficits compared with saline treated rats. However, MST-188 in combination with tPA significantly (p<0.05) reduced neurological functional deficits measured by the adhesive removal test (90±29 at 1d and 63±39 seconds at 7d) and modified neurological severity score (mNSS, 9±2 at 1d and 6±3at 7d) compared with rats treated with tPA alone (116±9 at 1d and 96±17 seconds at 7d by adhesive removal test, 11±1 at 1d and 9±1 at 7d by mNSS) and saline (113±12 at 1d and 95±16 seconds at 7d by adhesive removal test, 11±1 at 1d and 8±1 at 7d by mNSS). Histopathological analysis showed that the combination of MST-188 with tPA treatment significantly reduced lesion volume (21±10%, p<0.05) compared with rats treated with tPA alone (35±12%) and saline (34±11%). No significant differences of the incidence of gross hemorrhage were detected among groups.

Conclusions:
MST-188 enhances the therapeutic effect of tPA without increasing the incidence of hemorrhagic transformation when tPA is administered 4h after embolic MCAO.
Abstract W P129: Armamentarium Of Neurorestorative Therapies: A Clinico-Functional Paradigm For Stroke Recovery
Authors: Bhasin Ashu , Srivastava MV Padma , Srivastava MV Padma , Bhatia Rohit
Published: July 2021

Background:
The limited time window of neuroprotectants has enabled restorative therapies to be aggressively used in research to repair a disabling stroke. Cell based, electrotherapeutics and growth factor based therapeutics help in axonal remodeling, neuronal plasticity inducing cortical reorganization. The present paper studied the efficacy of cell transplantation, motor learning regimes (CIMT, rTMS and virtual reality) on clinical scores and functional imaging.

Methods:
Patients with stroke between 3 to 18 months of index event, MRC grade of wrist (mass flexion/ extension) at least = 2, NIHSS of between 4 and 15 were recruited and assessed at baseline, 3 and 6 months using MRC scale, ashworth tone, fugl meyer and barthel index along with functional imaging. Twenty patients were transplanted with 50 million autologous stem cells intravenously followed by virtual reality therapy for 8 weeks with respective controls. Fifteen patients are currently administered CIMT + r TMS and CIMT alone for 2 weeks. rTMS is applied over DLPFC (dorso lateral prefrontal cortex) region of the lesioned stroke hemisphere using an intensity of 120% RMT of the non-stroke hemisphere. MEP (Motor Evoked Potential) in paretic flexor muscle is recorded with each session lasting for 45min.

Results:
No cell related adverse reactions were observed. Barthel index was statistically significant amongst the two groups (p=0.04).Increased laterality index with a high voxel counts of BA 4, 6 and a high corticospinal fiber number was observed at follow up in stem cell group. An increase of 17.1% in FL ratio and 28% in the FN ratio was found between baseline and one year follow up (95%CI-12.3-3.4, p=0.06) in all stem cell patients as compared to the controls. In ongoing patients, baseline FM score (mean of 34.2/66) increased to 47.8 (follow up) with a percentage gain of 34.2 % after the CIMT+ rTMS session and baseline mean MEP 72% with 8%gain as compared to CIMT alone. No significant difference was observed in MRC (p=0.67) and ashworth scale (p=0.98) between the two groups.

Conclusion:
Above mentioned neurorestorative therapies aid in recovery through re building of neuronal circuits (cell therapy) and principles of learning. Proof of concept intervention strategies need to be developed in future trials.
Abstract W P15: Decreasing Time to Treatment in Endovascular Therapy for Acute Ischemic Stroke: A Single Institution’s Experience
Authors: Shah Veer A , Hawkins Angela M , Holloway William E , Martin Coleman O , Akhtar Naveed
Published: July 2021

Background and Purpose:
Time has consistently been cited as a fundamental variable to improve clinical outcomes in stroke. We identified potential to reduce ‘Door to Imaging’ and ‘Door to Groin Puncture’ times at our institution by streamlining the flow process for acute stroke management by the multidisciplinary team.

Methods:
Retrospective analysis was performed over a 3-month period on all patients who underwent mechanical thrombectomy for symptomatic stroke. Time-interval metrics collected included time from patient arrival to the start of imaging, start of groin puncture and start of revascularization. We then identified weak links in the pathway of stroke care and implemented strategies for change, including early notification of the interventionist by stroke neurologists or the ‘Code Neuro’ stroke nurse, the patient being taken directly to CT on arrival to the Emergency Department if hemodynamically stable and point of care processing of blood tests. Other interventions included enhancement of pre-hospital work-up by Emergency Medical Services and a unified paging system. Following these interventions, another analysis of time-interval metrics was undertaken on a second population of patients, also over a 3-month period.

Results:
Data on a total of 20 patients prior to change implementation and 22 patients after change were analyzed. The results obtained are tabulated as shown:

Conclusion:
This quality improvement project was able to successfully demonstrate a reduction in various time-interval metrics following a targeted, and ongoing, initiative to optimize specific response mechanisms in the acute stroke process pathway.
Abstract W P171: Findings of Magnetic Resonance Imaging and Carotid Duplex as Predictors of Recurrent Brain Infarction -Bingo Cerebral Infarction Study 1-
Authors: Nakazaki Kiyoshi , Takeshima Shinichi , Kuriyama Masaru
Published: July 2021

Introduction:
To retrospectively evaluate whether findings of magnetic resonance imaging (MRI) and carotid duplex are predictors of recurrent cerebral infarction.

Methods:
Between 2007 and 2010, 1324 patients underwent carotid duplex, magnetic resonance angiography, fluid-attenuated inversion recovery imaging, and T2*-weighted imaging during first admission for cerebral infarction and were discharged with a modified Rankin Scale (mRS) score of 0-3. Of the 1324 patients, 1138 (86.0%) were followed up (median age, 70 years; male:female ratio, 64%:36%). Atherothrombotic infarction, lacunar infarction, cardiogenic embolism, and other infarctions occurred in 435, 430, 246, and 27 patients, respectively.

Results:
The median follow-up duration was 44.5 months; 84.4% patients underwent follow-up MRI. New ischemic brain events occurred in 213 patients (18.7%). Transient ischemic attack occurred as the first new ischemic brain event in 44 patients. New asymptomatic cerebral infarction appeared in 100 patients before or without new ischemic brain events. Symptomatic cerebral infarction (SCI) recurred in 172 cases (15.1%), and the median duration between discharge and recurrence was 18.6 months (range, 0.2-69.5 months). Atherothrombotic infarction, lacunar infarction, and cardiogenic embolism recurred in 64, 64, and 42 patients, respectively. At the last follow-up, mRS score was 0-3 in 1029 patients and 27 patients died. Intracranial artery stenosis and micro-bleeding were significant predictors of SCI after lacunar infarction. Pre-admission asymptomatic old cerebral infarction was a significant predictor of SCI after 3 subtypes. Internal carotid artery stenosis >50% on carotid duplex was a significant predictor of SCI after atherothrombotic infarction.

Conclusion:
Findings of MRI and carotid duplex may be important predictors of recurrent cerebral infarction.
Abstract W P183: Analysis of Infarct Patterns in the Stroke Patients with Patent Foramen Ovale
Authors: Shin Dong Hoon , Shin Dong Jin
Published: July 2021

Background and Purpose:
Patent foramen ovale (PFO), a persistence of the embryonic defect in the interatrial septum, is found in 25% of the general population. The role of patent foramen ovale (PFO) as a risk factor for stroke is still controversial. To find out the role of PFO in the stoke mechanism, we investigated the clinical and magnetic resonance imaging (MRI) findings in stroke patient with PFO.

Methods:
Consecutive patients over 3 years, who were diagnosed with stroke and PFO at the Gachon University Gil Hospital, were analyzed. We divided into three groups, as follows: (1) highly associated with PFO (high-risk PFO, multiple acute ischemic lesions on diffusion-weighted image without the stenosis of relevant artery, n=46), less likely associated with PFO (low-risk PFO, acute ischemic lesions within the territory with the stenosis of supplying artery, n=35), undetermined associated with PFO (undetermined PFO, acute ischemic lesions in perforating artery territory without the stenosis of relevant artery, n=53). We compared the clinical, laboratory parameters, and MRI patterns among the three groups.

Results:
Study population (n=134) had a mean age of 50.7±9.1. There was no statistically significant difference of prevalence of well-known risk factors such as hypertension, diabetes, hyperlipidemia, smoking, and previous history of stroke/coronary artery disease among the groups. RoPE score in high-risk PFO group was significantly higher than RoPE score in low-risk PFO group (Turkey’s post hoc test, p=0.047). Multiple regression analysis revealed that PFO associated with higher RoPE score is more possible cause of stroke (OR 1.57 per 1-point increase; 95% CI 1.09-2.27; p=0.016) and PFO with acute infarct in perforating artery territory is less likely cause of stroke (OR 0.067 perforating artery territory infarct (+); 95% CI 0.019-0.240; p<0.0001).

Conclusions:
In 34.3% of the stroke patient with PFO, PFO seemed to play a important role in development of stroke. PFO may be the incidental findings when the lesions were found in deep perforating artery area without relevant artery stenosis and PFO combined with high RoPE score should be considered as cause of stroke.
Abstract W P190: Contrast Transcranial Doppler Detects More Intra and Extra-Cardiac Right-to-Left Shunts than Trans-Esophageal Echocardiogram
Authors: Korya Daniel , Chaudhry Saqib , Khan Nile , Torok Ildiko , Galea Bernard , Gill Sonia , Mehta Siddhart , Panezai Spozhmy , Moussavi Mohammad , Kirmani Jawad F
Published: July 2021

INTRODUCTION/OBJECTIVES:
Paradoxical embolism is initially evaluated with a contrast trans-thoracic echocardiogram (cTTE), since the more sensitive method of contrast trans-esophageal echocardiogram (cTEE) is also more invasive. An adequate valsalva is essential to raise intra-thoracic pressures, but since the patient is sedated for the procedure, it is not always possible with cTEE. The amount of RLS through a PFO depends on strain rate and duration of the Valsalva maneuver. CTCD is a non-invasive method of detecting RLS that has been shown to be as good as cTEE. The goal of this study was to evaluate whether or not cTCD could be more effective at detecting RLS.

MATERIALS AND METHODS:
A review and evaluation of medical records and imaging was done on patients with embolic stroke from 2012-2013 at a university affiliated comprehensive stroke center. Patients had embolic stroke and a cTCD to be included. A subgroup of patients who had cTCD also had a cTEE. Patients who were positive for RLS on cTCD were compared with those who had RLS on cTEE. Statistical analysis was performed to determine significance and potential for future complications.

RESULTS:
A total of 1,033 patient records were reviewed and of those 130 patients (55% women) had embolic stroke and a cTCD, 35 were positive for a RLS based on the presence of microbubbles in the cerebral circulation, and 95 were negative. Of the 35 patients with positive cTCD, 45% (n=16) also underwent cTEE; however, only 44% (n=7) of those had positive results for RLS. Conversely, 56% (n=9) of the patients who were shown to have RLS on cTCD were missed on cTEE (without cardiac septal defects). Of the 95 patients who had negative cTCD, 19 of them also underwent cTEE and all were negative on cTEE.

CONCLUSION:
Using cTCD to detect microbubbles in cerebral arteries appears to be more reliable and accurate for discovering RLS of intra or extra-cardiac origin. For embolic ischemic strokes, we recommend using cTCD as a first-line study and suggest it should be the new “gold standard”. Randomized, prospective studies should be conducted to further validate this data.
Abstract W P215: Validation of Achievement of Target Blood Drug Levels by Paramedic Infusion Start in a Large, Pivotal Prehospital Stroke Trial
Authors: Shkirkova Kristina , Starkman Sidney , Sanossian Nerses , Eckstein Marc , Stratton Samuel , Pratt Frank , Conwit Robin , Hamilton Scott , Saver Jeffrey L ,   FAST-MAG Investigators
Published: July 2021

Background:
Paramedic start of research stroke therapies in the ambulance is a promising approach to accelerating treatment for acute ischemic stroke. However, intravenous (IV) infusions are not a standard element of paramedic practice, so prehospital IV regimens require innovations in care processes.

Methods:
In the Field Administration of Stroke Therapy - Magnesium (FAST-MAG) phase 3 trial, 1700 patients were randomized within 2 hours of symptom onset to receive IV magnesium sulfate (Mg) or placebo, with field initiated 15 minute loading dose and 24 hour maintenance infusion upon hospital arrival. The drug delivery regimen included paramedic use of fixed lumen size, gravity-controlled tubing in the field, providing controlled delivery without setting an infusion pump, and a shrink-wrapped study kit carried in the ambulance including the randomized hospital maintenance dose in addition to the field loading dose.

Results:
Among the patients randomized to active treatment, Mg levels in the first 72 hours were assessed 987 times in 572 patients. Mean patient age was 70 (SD ±14), and 45% were female. During the period of active infusion (first 24 hours), treatment arm mean Mg level was 3.88 (SD ±1.1) in contrast with placebo arm mean level of 1.92 (SD ±0.3), achieving the study target of doubling of serum Mg (Figure). Mg levels rapidly increased with the field bolus and climbed minimally during next 24 hours. Mg levels declined steadily during hours 25-48 and normalized in hours 49-72. In the first 24 hours, Mg levels were not affected by patient age, race-ethnicity, weight, or BMI, but were affected by sex, with higher levels in women, 4.42 vs 3.82, p=0.02.

Conclusion:
In this large-scale ambulance trial, the combined prehospital and hospital treatment regimen achieved targeted levels for the magnesium intervention. Intravenous delivery of therapeutic agents by paramedic personnel is a viable strategy for future stroke hyperacute treatment trials.
Abstract W P228: Results Of A Turkish Comprehensive Stroke Center Quality Program. A median Of Door To Needle Time Of 60 Minutes Is Achievable With MRI Based Diagnostic Paradigm
Authors: Koyuncu Bahar , Pourmohammed Reza , Tavukcu Ozkan Sedef , Tolun Reha , Krespi Yakup
Published: July 2021

BACKGROUND:
Quality measures provide the basis for evaluating and improving treatment of stroke patients based on scientific evidence. In this study, the first year results of a quality program of acute ischemic stroke patients who were admitted within the first 24 hours after the onset in a Turkish comprehensive stroke center were reviewed.

METHODS:
Between September 2012 and August 2013, 161 patients were consecutively admitted to Memorial Stroke Center; they were mainly diagnosed with MRI. Institutional quality program, which include Joint Commission International primary and comprehensive stroke center quality indicators, is maintained prospectively and the threshold values of performance were defined as 80% and above.

RESULTS:
Fifty three percent of the cases were male and the mean age was 68. Median onset to door time was 233 minutes. Median door to imaging time for the patients admitted within 4.5 hours was 15 minutes. Median imaging duration was 25 minutes. Median and mean door to end of imaging was 40 and 43 minutes respectively. Forty patients underwent acute revascularization therapy; 23 only IV r-TPA, 10 bridging, 7 only endovascular therapy. From eligible patients, 88,9% received IV thrombolysis and 78.9% received endovascular treatment within appropriate time window. The median door to needle time was 65 minutes both for patients in the 4,5 and 6 hours from onset. Only 25% percent of patients receiving IV r-TPA were treated within 40 minutes after arrival. The median door to the groin puncture and groin puncture to recanalization time were 84 and 105 min respectively. There was no symptomatic bleeding in revascularized patients. The percent of good prognosis (mRS 0-2) and mortality was 62,5% and 8,8% respectively.

DISCUSSION:
Results of our quality data are in line with the literature despite use of an MR-based diagnostic paradigm. Only 1 of 4 patients received thrombolysis within 40 minutes, but this is mainly due to treatment decisional and starting process after the end of imaging, which should and can be shortened.
Abstract W P23: A Multi-Center Assessment on the Effect of Using Eptifibatide Drip During Endovascular Procedures on the Functional Outcome of Patients Presenting with Acute Ischemic Stroke
Authors: Dababneh Haitham , Sakian Sina , Zheng Huo Xiang , Kumar Rajesh , Azhar Salman , Arcot Karthikeyan , Bashir Asif , Hussain Mohammed , Farkas Jeffrey , Tiwari Ambooj
Published: July 2021

Background:
Endovascular procedures are associated with injuries to the vasculature. Interventionists have adopted the use of intravenous anti-platelet agents. Eptifibatide drip has been utilized in advanced stroke treatment to increase recanalization in ischemic strokes. This study compares the outcome and mortality between those individuals that received Eptifibatide drip and those who did not.

Materials:
This is a retrospective analysis of all patients (n= 161) who presented to the hospitals with ischemic stroke and considered for advanced stroke therapy between January 2009 and July 2014. Statistical analysis was performed using GraphPad Prism. We divided the groups into two: (A) Eptifibatide drip (B) No Eptifibatide drip. We compared the effect of using Eptifibatide drip on the functional outcome using modified Rankin Scale (mRS). mRS score of 2 or less defines a good functional outcome and an mRS of 6 defines mortality. All variables were included in the analysis.

Results:
161 patients included in this study had all the variables and received Endovascular treatment. Group analysis including n, gender, mean age, mean NIHSS, Afib%, DM% and Prior Stroke % was as follows: A) 66, 47%, 71.6±16.7, 16.0±7.1, 28.3%, 25% and 31.7% B) 95, 62.5% female, 74.5±16.3, 16.5±7.7, 44.2%, 30.5% and 23.2%. We found that patients who underwent endovascular procedures in group A experienced a better outcome and lower mortality as compared to those patients in group B (95% CI, 0.1761-0.3953, P<0.001); (95% CI,-0.4761- -0.2569, P<0.001).

Conclusion:
The use of Eptifibatide drip during endovascular procedures may result in a better functional outcome and lower mortality after the procedures as compared to other devices. We plan to further investigate the use of Eptifibatide drip in prospective study.
Abstract W P248: miRNA Profiling of the Ischaemic Penumbra
Authors: Ord Emily N , McCabe Chris , McDonald Catriona , McClure John D , Macrae I M , Work Lorraine M
Published: July 2021

MicroRNAs (miRNAs) are small non-coding RNA molecules (20 - 24 nucleotides) that inhibit mRNA translation. Demonstrated to have key roles in normal CNS development & function, they have also emerged to have effecter roles in the pathogenesis & endogenous repair mechanisms following stroke. To select 2 miRNAs to modulate therapeutically we profiled miRNA expression of the evolving (24h) & final (72h) peri-infarct tissue of adult spontaneously hypertensive stroke-prone rats (SHRSP) following 45 min transient middle cerebral artery occlusion (tMCAO). T2-weighted magnetic resonance imaging (MRI) was used for accurate dissection of the peri-infarct tissue, with equivalent brain regions taken from time-matched shams (n=6/group). Of the 754 miRNAs evaluated (TaqMan® human miRNA microarray card v3.0 Applied Biosystems) 89 were determined as differently regulated following tMCAO. 22 of these miRNAs were relevant in stroke & were thus validated by Taqman® qRT-PCR using specific probes (n=9 /group). 5 miRNAs were successfully validated; miR-34b & miR-520b were selected as miRNAs of interest due to their novelty, time of endogenous regulation & targets. An in vitro study to determine whether upregulation/knock-down of these miRNAs would demonstrate functional effects in classical hypoxic pathways was performed. A rat neuronal cell line (B50) & glial cell line (B92) were subjected to 9hr hypoxia (1% O2 -serum) & 24h reoxygenation (+serum) +/- miR-34b or miR-520b regulation. Upregulation of either miRNA in B50 cells demonstrated a reduction in apoptosis, assessed qualitatively by Caspase-3 immunocytochemistry & quantitatively by cell death detection ELISA (p<0.01 vs hypoxic non-treated cells (NTC)). Upregulation of either miRNA in B92 cells significantly reduced superoxide production, assessed by electron paramagnetic resonance (p<0.001 vs hypoxic NTC). MiR-520b significantly lowered levels of lipid peroxidation in B92 cells, assessed by malondialdehyde assay, & both were significantly effective in B50 cells (p<0.01 vs hypoxic NTC). These data suggest miR-34b & -520b upregulation ameliorates damage following hypoxia/reperfusion in cerebral cell lines. Future studies will assess the effect of modulating these miRNAs in vivo.
Abstract W P26: Itemized NIHSS Subsets Predict MRI Positive Strokes In Patients With Mild Deficits
Authors: Yaghi Shadi , Herber Charlotte , Willey Joshua Z , Andrews Howard , Marshall Randolph S , Lazar Ronald M , Boden-Albala Bernadette M
Published: July 2021

Background:
While imaging is useful in confirming the diagnosis of ischemic stroke, negative diffusion weighted imaging (DWI) is reported in up to 10% of patients. We aim to (1) identify predictors of MRI-positive stroke from the itemized NIHSS, and (2) to correlate subsets with infarct volume.

Methods:
Data were derived from the Stroke Warning Information and Faster Treatment study from 2006 to 2009 among patients with mild deficits (NIHSS 0-5) and attending physician final diagnosis of stroke. Using Medical Image Processing, Analysis, and Visualization (MIPAV, NIH) (Version 7.1.1), we calculated lesion volume (cm3) from DWI sequence. Univariate models studied the association between itemized NIHSS subsets, including cortical deficits (visual field cut, aphasia, or neglect), and presence of DWI hyperintensity and lesion volume. Multivariable regression assessed factors predicting DWI-positive strokes; p<0.05 was considered significant.

Results:
Of 611 patients with a discharge diagnosis of stroke, 498 underwent MRI and 29.5% were DWI negative. On multivariate analysis, predictors of a positive DWI were NIHSS score of 3-5 (OR= 2.5, 95%CI:1.1-5.5), motor deficits (OR= 1.9, 95%CI:1.1-3.4), and ataxia (OR=3.0, CI:1.5-6.1). All patients with neglect and visual deficits were DWI positive (table). The mean lesion volume in cm3 was larger in patients with NIHSS 3-5 vs. NHSS 0-2 (49.0 vs. 17.3, p=0.002), cortical deficits (112.6 vs. 22.9, p<0.001), neglect (236.6 vs. 29.7, p<0.001), and visual deficits (245.7 vs. 26.4, p<0.001). Other subsets showed no differences.

Conclusion:
NIHSS score subsets predict DWI positivity and lesion volume in mild strokes. The presence of neglect or visual field deficit on the NIHSS subsets is highly likely to have an MRI correlate even in patients with low NIHSS.
Abstract W P269: High vs. Moderate-intensity Statin Therapy After Ischemic Stroke: Findings from PROSPER
Authors: Greiner Melissa A , O'Brien Emily , Xian Ying , Bhatt Deepak L , Maisch Lesley , Hannah Deidre , Lindholm Brianna , Smith Eric E , Schwamm Lee H , Olson Daiwai M , Peterson Eric D , Fonarow Gregg C , Pencina Michael J , Hernandez Adrian F
Published: July 2021

Background:
Current treatment guidelines recommend high-intensity statin therapy for patients with a history of stroke. However, older patients with higher comorbidity were under-represented in trials and dosing varies in clinical practice. We compared the effectiveness of high vs moderate-intensity statins on clinical outcomes in older patients from the GWTG-Stroke registry.

Methods:
We studied statin-naïve ischemic stroke patients ≥65 years from GWTG-Stroke linked to Medicare claims from 2008-2011 who were discharged on statins. Outcomes included home time days (days alive and not in acute or post-acute care facility), major adverse cardiovascular events (MACE), mortality, all-cause, stroke and CV readmission within 2 years of discharge. We estimated unadjusted and adjusted associations between statin intensity and outcomes using negative binomial and Cox proportional hazards models. Inverse-weighted estimates of the probability of high-intensity statin (IPW) were used to adjust for treatment selection.

Results:
Of 29,631 ischemic stroke patients discharged on statins, 9,145 (31%) received high-intensity statins. Patients receiving high-intensity statins were younger and had higher LDL-C compared with patients on moderate-intensity statins. The high-intensity statin group had 5 fewer home time days and higher all-cause readmission within 2 years, but other observed outcomes were similar (Table). Except for a slightly higher hazard of all-cause readmission with high-intensity statin use, there were no significant differences in MACE, hemorrhagic stroke, or other outcomes after IPW adjustment (Table).

Conclusions:
We found no differences in MACE or home time days within 2 years of initiation of high vs. moderate-intensity statin therapy following ischemic stroke. These findings can inform patients and clinicians regarding the risk-benefit associated with statin dosing after ischemic stroke.
Abstract W P275: Validation of Stroke Meaningful Use Measures in a National EHR System
Authors: Phipps Michael , Fahner Jeff , Sager Danielle , Coffing Jessica , Maryfield Bailey , Williams Linda
Published: July 2021

Background:
The Affordable Care Act included eight stroke indicators in its Meaningful Use (MU) program. This project evaluated stroke MU measures in national VHA data and determined sources of error in using centralized electronic health record (EHR) data.
Methods:
We converted local SQL queries that generated stroke indicators to run on VA Central Data Warehouse (CDW) data, mapping each local data element to the corresponding CDW data element and table. Numerator (NM) and denominator (DN) results were generated from CDW data in a sample of 2200 ischemic stroke admissions in 11 VA hospitals. Local and CDW NM and DN results were compared to chart review. NM and DN mismatch reports were iteratively examined to identify, categorize, and correct sources of error. We calculated passing rates, sensitivity and specificity for the NMs and DNs, and an overall accuracy kappa statistic.
Results:
Results for two measures (VTE prophylaxis and antithrombotic (AT) by day 2) are shown in the Table. The most common error in VTE prophylaxis was failure to identify mechanical prophylaxis devices (171/185 NM false negative errors), and in the AT measure was failure to identify a contraindication to therapy (50/59 DN false positive errors). Errors impacting multiple indicators included difficulty identifying Comfort Care status, discrepancies between electronic and charted medication administration, and difficulty identifying medications given in the ER. Passing rates (chart review vs. EHR) were higher with chart review for VTE (87% vs 76%) but similar for AT (91% vs 90%).
Conclusions:
Stroke MU indicators can be relatively accurately generated from existing EHR systems but accuracy decreases in central compared to local data sources. To improve stroke MU measure accuracy, EHRs should include standardized data elements for devices, Comfort Care status, recording contraindications, and medications given in the ER.
Abstract W P288: Using “Big Data” Analytics and Visualization for Quality Improvement in Stroke Care
Authors: Kavanagh Sara J , Bray Benjamin , Paley Lizz , Campbell James T , Vestesson Emma , Hoffman Alex M , Rudd Anthony G
Published: July 2021

Introduction:
The Sentinel Stroke National Audit Programme (SSNAP) is the new national stroke register of England and Wales. It has been designed to harness the power of “Big Data” to produce near real-time data collection, analysis and reporting. Sophisticated data visualization is used to provide customized analytics for clinical teams, administrators, healthcare funders and stroke survivors and carers.

Methods:
A portfolio of cutting edge data visualisation outputs, including team level slidedecks, performance charts, dashboards , and interactive maps, was produced. Visualisations for patients and the public were co-designed with stroke survivors. Stakeholder feedback regarding accessibility and usefulness of the resources was sought via online polls.

Results:
Key SSNAP results are made accessible electronically every three months in a range of bespoke graphical formats. Individualised slidedecks and data summaries are produced for every hospital, funding group, and region to enable provider level performance and quality reporting and regional and national benchmarking. Dynamic maps enhance dissemination and use of results. Real time root cause analysis tools help teams identify areas of improvement. Feedback reports unprecedented utility of these resources for clinical teams, funders, regional and national health bodies, patients and the public in identifying areas of good practice and requiring improvements, highlighting variations, and driving change.

Conclusion:
SSNAP is a potential new model of healthcare quality measurement that uses recent developments in big data analytics and visualization to provide information on stroke care quality that is more useful to stakeholders. Similar approaches could be used in other healthcare settings and populations.
Abstract W P299: Impact of an Institutional Guideline on Implementing Early Decompressive Hemicraniectomy (DHC) for Large Middle Cerebral Artery Stroke
Authors: Olm-Shipman Casey , Marquevich Victoria , Rosand Jonathan , Patel Aman , Eskandar Emad , Cordier Aurelie , Ayres Alison , Schwamm Lee H , Singhal Aneesh B
Published: July 2021

Background:
Recent AHA Acute Stroke Guidelines endorse DHC (Class 1, Level B) based on clinical trials showing benefit of early DHC on outcome and mortality. In 2011, our multidisciplinary quality improvement team developed a process to translate DHC guideline recommendations into clinical practice.

Methods:
Our consensus guideline includes a tool (STATE Criteria, based on inclusion/exclusion criteria of DHC clinical trials) to rapidly identify and triage potential DHC candidates, and provide specific guidelines for pre- and post-surgical management, adjunctive therapy, and DHC after IV/IA thrombolysis. Patients meeting all STATE Criteria including age ≤ 60 years are sent for urgent DHC. Patients meeting all criteria except age ≤ 60 years receive DHC only if age < 75 years and Neurology and Neurosurgery teams reach consensus about benefit. Patients not meeting criteria are observed and referred for DHC if criteria are met within 48 hours of onset. The guideline was disseminated to all stakeholders via email, conferences, and intranet. In this study, we retrospectively analyzed process and outcome measures for DHC before and after guideline implementation in February 2011.

Results:
Of 1518 stroke patients age ≤ 60 years admitted between January 2007 and April 2014, 47 (3%) received DHC (22 pre- and 25 post-guideline implementation; 28% female, 13% Hispanic). Mean admission NIHSS was similar (17±7 vs 18±5; p=.82). Mean time from admission to DHC improved significantly from 45±30 hours to 29±18 hours (p=0.04). The percentage of patients undergoing DHC beyond 48 hours decreased from 27% to 16% (p=0 .35). The degree of midline shift evident on CT or MRI prior to DHC significantly decreased from 9±4 mm to 5±4 mm (p=.01). There was no significant difference in length of stay, frequency of tracheostomy, gastrostomy, pneumonia, or urinary tract infection, or percentage of patients who died within 30 days of DHC.

Conclusion:
Our institutional guideline has facilitated the rapid identification and triage of patients with large MCA stroke to DHC. Follow-up is ongoing to determine the impact of our guideline on functional outcome after stroke.
Abstract W P300: Ethnic Differences in Post-Stroke Quality of Life in the Brain Attack Surveillance in Corpus Christi (BASIC) Project
Authors: Reeves Sarah L , Brown Devin , Baek Jonggyu , Morgenstern Lewis B , Lisabeth Lynda D
Published: July 2021

Background:
Mexican Americans (MAs) have worse stroke outcomes than non-Hispanic whites (NHWs), which could translate into worse quality of life (QOL). Our objective was to investigate ethnic differences in post-stroke QOL across multiple domains in a bi-ethnic community.

Methods:
Ischemic stroke survivors, identified through the population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project in Nueces County, Texas, participated in in-person interviews 90 days post-stroke from May 2010 - June 2012. The validated short form stroke-specific QOL (SSQOL) was used to assess overall, physical, and psychosocial QOL; scores range from 1-5 with higher scores representing greater QOL. Tobit regression was used to model unadjusted associations between ethnicity and the 3 QOL domains. Models were then adjusted for the following demographic and clinical factors obtained from the medical record and patient interview: age, sex, education, insurance status, marital status, nursing home residence before stroke, prestroke modified Rankin scale, prestroke Informant Questionnaire on Cognitive Decline in the Elderly, initial NIH stroke scale, risk factors, BMI, and a comorbidity index.

Results:
A total of 335 ischemic strokes with complete data were identified (66% MA, 34% NHW). QOL was lower among MAs compared to NHWs, both overall (mean difference=-0.3, p=0.02) and in the physical domain (mean difference=-0.4, p=0.008); however, there was no difference in the psychosocial domain (p=0.22). After adjustment for demographic and clinical factors, MAs continued to experience poorer QOL compared to NHWs overall (mean difference=-0.5,p=0.049) and in the physical domain (mean difference=-0.3, p=0.006).

Conclusions:
Ethnic disparities in stroke outcome extend to QOL, with MAs experiencing substantially worse post-stroke QOL than NHWs. Interventions are urgently needed to improve stroke outcomes among the rapidly growing MA stroke population.