bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 57: Tenecteplase versus Alteplase for Acute Ischemic Stroke (TAAIS) trial: A Randomized Trial using Advanced CT Selection.
Authors: Parsons Mark W , Spratt Neil , Bivard Andrew , Campbell Bruce , Chung Kong , Miteff Ferdi , O'Brien Bill , McElduff Patrick , Bladin Christopher , Allen Chris , Bateman Grant , Donnan Geoffrey , Davis Stephen , Levi Christopher
Published: March 2022

Background.
Intravenous alteplase remains the only approved treatment for acute ischemic stroke. In pilot studies, intravenous tenecteplase shows promise as a potentially safer and more effective thrombolytic.

Methods.
TAAIS was a prospective, randomized, blinded-endpoint phase IIB trial. Seventy-five patients were centrally randomized to receive alteplase or one of two doses of tenecteplase (0.1 mg/kg and 0.25 mg/kg) <6 h after onset of ischemic stroke. Advanced CT imaging selection criteria included a perfusion CT (CTP) lesion at least 20% greater than the infarct core, with an associated vessel occlusion on CT angiography (‘dual-target’). Co-primary endpoints were: (i) Extent of reperfusion from baseline CTP to 24 hour perfusion-MR, and (ii) clinical improvement in acute to 24 h National Institutes of Health Stroke Scale (NIHSS) score. Secondary efficacy endpoints included excellent functional outcome at 90 days (modified Rankin Scale 0-1). Safety endpoints included large parenchymal hematoma (PH2).

Results
Twenty-five patients each were randomized to the 3 treatment groups. Mean baseline NIHSS for all patients was 14.4 (SD 2.6), and time to treatment was 2.9 h (SD 0.8). The pooled tenecteplase group showed both greater reperfusion and clinical improvement at 24 hours than the alteplase group (p<0.001). Despite superior efficacy, there was a trend (p=0.09) towards less PH2 in the pooled tenecteplase patients (2/50, 4%) than in the alteplase group (4/25, 16%). The higher dose of tenecteplase (0.25 mg/kg) was superior for all efficacy outcomes compared to alteplase, or tenecteplase 0.1 mg/kg. This included a high rate of 3-month excellent functional outcome (72%, vs 40% for alteplase, p=0.023).

Conclusions
Advanced CT selection identified stroke patients with improved clinical outcomes from tenecteplase compared to alteplase. This related to superior reperfusion seen with tenecteplase, particularly at the 0.25 mg dose.
Abstract 59: Immediate Transport of Drip and Ship Cases is Safe
Authors: Rymer Marilyn M , Summers Debbie , King Shelleen , Nunn Tony , Dorssom Joyce ,   Saint Luke's Stroke Team
Published: March 2022

Background:
Acute stroke treatment with intravenous (IV) tissue plasminogen activator (tPA) will increase if regions are organized and smaller hospitals can adopt the drip and ship model to administer IV tPA in consultation with a comprehensive stroke center prior to transfer. The Saint Luke’s Stroke Team has been working in that model for several years. We sought to determine if immediate transport with the IV tPA still running was safe, given that transport protocols are not standardized for BP control and neurological checks.

Methods:
We retrospectively reviewed consecutive drip and ship cases from 2008 through 2010 and analyzed the incidence of symptomatic intracerebral hemorrhage (SICH) and BP >180/105 on arrival, inaccurate stroke diagnosis, need for intra-arterial (IA) treatment, mortality rate, and clinical outcomes as well as the location and size of the referring facilities.

Results:
There were 1626 ischemic strokes over the 3 years, 717 (44%) of which were transferred. 145 (20%) of the transferred cases had IVtPA started at the referring hospital and then were immediately transported (drip and ship). Of the 63 referring hospitals, 29 were critical access hospitals of 25 beds or less. 90% were greater than 10 miles away, 63% were greater than 50 miles, and 25% were greater than 100 miles away. Mean age was 67.5 years. Mean admission NIHSS score was 10.4 (median 7 SD 9.3). Mean discharge NIHSS score was 3 (median 1 SD 6.9). There were 4 (2.7%) SICH on arrival. Two resulted in mortality and one of those had elevated BP on arrival (183/77). Fourteen cases (9.6%) had BP>180/105 on arrival. One of these was associated with SICH in transport and died (as noted).One other (admit BP 232/84) died without hemorrhage.10/14 had excellent clinical outcomes. Thirty-five (24%) went on to IA treatment. Mortality rate was 13.7% (20/145) and mRS 0-2 at 90 days was achieved in 72/114 (63%). mRS data was not available for the 2008 cases. Six cases (4.1%) were inaccurately diagnosed at the sending facility.

Conclusions:
Immediate transport of patients with IVtPA infusing is safe with a very low incidence of SICH en route. Over 90% of cases had BP <180/105 on arrival. The good clinical outcomes observed in 63% of cases (mRS0-2 at 90 days) relate, in part, to early treatment in referring hospitals. Hospitals of every size can effectively and safely treat stroke victims with IVtPA if they have access to consultation and transfer agreements with experienced stroke centers.
Abstract 61: Reperfusion Beyond 4.5 Hours Reduces Infarct Growth And Improves Clinical Outcome
Authors: Picanco Miguel R , Campbell Bruce C , Christensen Soren , Desmond Patricia M , Churilov Leonid , De Silva Deidre A , Butcher Kenneth S , Parsons Mark W , Levi Christopher R , Barber P. Alan , Bladin Christopher F , Donnan Geoffrey A , Davis Stephen M ,   Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET) Investigators
Published: March 2022

Background and purpose:
The ECASS 3 study demonstrated efficacy of intravenous thrombolysis up to 4.5h after stroke onset. It has been hypothesized that some patients have tissue at risk and an acceptably low hemorrhage risk beyond 4.5h. Imaging based selection may help identify these patients for late reperfusion therapies. No randomized data have shown efficacy of tPA or reperfusion later than 4.5h after onset. We analysed the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET) data to assess the effect of treatment and reperfusion on attenuation of infarct growth in the 4.5 to 6 hour time window.

Methods:
Patients were randomized to placebo or tissue plasminogen activator (tPA) between 4.5-6h from stroke onset (without using imaging selection criteria). Pre-treatment DWI and day 90 T2-weighted lesion volumes (average of manually outlined lesions by 2 independent raters) were compared to assess the influence of tPA and reperfusion on absolute and relative infarct growth. Day 3 volume was used when day 90 data was missing. The effect of tPA on reperfusion was also assessed. Good clinical outcome was defined as a National Institute of Health Stroke Scale (NIHSS) at day 90 0-1 or improvement ≥ 8 from baseline. Good functional outcome was defined as modified Rankin Scale (mRS) 0-2.

Results:
Of 69 patients treated 4.5-6hrs hours after stroke onset, infarct growth could be assessed in 63. The median relative growth was significantly lower in the tPA group compared to placebo (0.94 vs 1.68, p=0.025). There was a nonsignificant trend towards lower absolute growth (-0.17mL vs 9.56mL, p=0.069). Reperfusion markedly reduced relative (0.80 vs 1.89, p<0.001) and absolute infarct growth (-2.49mL vs 39.50mL, p<0.001). Reperfusion was more likely in the tPA group (57.7 vs 25.0% p=0.026) and was associated with better clinical and functional outcomes (86.4% vs 28.1% p<0.001 and 72.7 vs 34.4% p=0.012).

Conclusion:
Thrombolysis after 4.5 hours reduced infarct growth and increased the rate of reperfusion. The strong positive effect of reperfusion on clinical and functional outcomes in this later time window is evidence of persisting salvageable ischemic penumbra. This supports continuing efforts to extend the treatment window for reperfusion therapies.
Abstract 67: Risk of Symptomatic Intracerebral Hemorrhage in Ischemic Stroke Thrombolysis: the SEDAN Score
Authors: Strbian Daniel , Meretoja Atte , Michel Patrik , Engelter Stefan , Sekoranja Bianchi Lucka , Ahlhelm Frank J , Mustanoja Satu , Kuzmanovic Igor , Sairanen Tiina , Forss Nina , Lyrer Philippe , Kaste Markku , Tatlisumak Turgut
Published: March 2022

Objectives
To develop a score for assessing the risk of symptomatic intracerebral hemorrhage (sICH) in ischemic stroke patients treated with iv thrombolysis.

Methods
The score was derived from a cohort of acute ischemic stroke patients treated with iv thrombolysis (n=972) at the Helsinki University Central Hospital (1995-2008). The predictive value of parameters associated with development of sICH (ECASS-2 criteria) was evaluated, and the score was developed according to the magnitude of logistic regression coefficients. The accuracy of the model was evaluated with 1000 bootstrap replicates. To test the performance of the score, we calculated area under receiver operating characteristic curve (AUC-ROC). We calculated absolute risks and likelihood ratios of sICH per increasing score points. The score was validated externally in merged cohort from 3 Swiss cities (Lausanne, Basel, and Geneva) including 828 ischemic stroke patients treated with iv thrombolysis.

Findings
The SEDAN score (0 to 6 points) consists of blood
S
ugar (glucose) at baseline [8.1-12.0 mmol/L (145-216 mg/dL)=1; >12.0 mmol/L (>216 mg/dL)=2],
E
arly infarct signs (yes=1) and (hyper)
D
ense cerebral artery sign (yes=1) on admission CT scan,
A
ge (>75=1), and
N
IH Stroke Scale on admission (>9=1). Accuracy of the score based on 1000 bootstrap replicates was 93.1% (91.4%-94.5%). AUC-ROC was 0.73 (0.67-0.79; p<0.001). Absolute risk for sICH in patients with increasing score points was: 1.4%, 2.9%, 8.5%, 12.2%, 21.7%, and 33.3% for 0, 1, 2, 3, 4, and 5 score points, respectively. Likelihood ratios were 0.19 (0.06-0.59), 0.40 (0.21-0.76), 1.23 (0.85-1.79), 1.85 (1.26-2.72), 3.68 (2.10-6.45), and 5.66 (2.40-13.40), respectively. Absolute risks in external validation were similar (1.0%, 3.5%, 5.1%, 9.2%, 16.9%, and 27.8%, respectively), and AUC-ROC was 0.77 (0.71-0.83; p<0.001).

Conclusions
The SEDAN score reliably assesses the risk of sICH in iv thrombolysis treated ischemic stroke patients and can support clinical decision-making in the high-risk patients. External validation of the score in the three Swiss cohorts supports its generalizibility.
Abstract 68: Risk Score for Intracranial Hemorrhage in Patients with Acute Ischemic Stroke Treated With Intravenous t-PA.
Authors: Menon Bijoy , Saver Jeffrey L , Prabhakar Shyam , Reeves Mat , Olson DaiWai M , Peterson Eric D , Hernandez Adrian F , Fonarow Gregg C , Schwamm Lee H , Smith Eric E
Published: March 2022

Background:
From Get With The Guidelines-Stroke (GWTG-Stroke), we identified characteristics of patients with IV t-PA related symptomatic ICH (sICH) within 36 hours of stroke symptom onset and derived and validated a prediction tool for determining sICH risk.

Methods:
The population consisted of 10,242 patients from 988 hospitals that presented directly to the emergency department and received IV t-PA within 3 hours of symptom onset who were entered into the GWTG-Stroke registry (January 2009 - June 2010). This sample was randomly divided into derivation (70%) and validation (30%) cohorts. Multivariable logistic regression model identified predictors of IV t-PA related sICH in the derivation sample from candidate demographic, medical history, and laboratory variables collected at admission; model beta coefficients were used to assign point scores for prediction.

Results:
sICH within 36 hours was noted in 496 patients (4.8%). The multivariable adjusted independent predictors of increased risk of sICH post IV t-PA were increasing age (17 points), higher baseline NIHSS (42 pts), higher systolic BP (21 pts), higher blood glucose (8 pts), Asian race (9 pts, compared to all other races) and male gender (4 pts). In secondary analyses, we did not find an increased risk of sICH in patients taking warfarin when INR ≤ 1.7. The risk score demonstrated good discrimination (C-statistic 0.71) and excellent calibration as demonstrated by the Hosmer-Lemeshow statistic (P=0.48) and plot of predicted versus observed mortality in the whole cohort. (
Figure
)

Conclusions:
The GWTG-Stroke sICH risk score provides clinicians with a validated method to determine the risk of symptomatic ICH in patients treated with IV t-PA within 3 hours of stroke symptom onset. Figure: Observed vs Predicted % risk of sICH post IV t-PA in the derivation and validation cohort.
Abstract 69: Does Advanced Imaging Delay Time to Administration of Intravenous rt-PA in the Acute Ischemic Stroke Patient?
Authors: Lima Andrey , Sapkota Sharmila , Auchus Alexander P. , Sugg Rebecca
Published: March 2022

Background:
Faster administration of intravenous recombinant tissue plasminogen activator (IV rt-PA) is associated with better outcomes in acute ischemic stroke (AIS) patients. Cerebral imaging is essential to determine inclusion and exclusion criteria, yet there are no universal imaging protocols for the AIS patient. Furthermore, multimodal imaging can lead to longer times of acquisition and interpretation. We assess the change in treatment times in our institution before and after modification of our imaging protocol.

Methods:
We performed a retrospective analysis comparing time to Computed Tomography (CT) interpretation and time to IV rt-PA treatment in AIS patients at our institution for three months before and after implementing imaging protocol changes. We defined these groups as the multimodal imaging group which received Non-contrast Computed Tomography of the head (NCCTH), CT Arteriogram (CTA), and CT Perfusion (CTP), versus the NCCTH only group. We performed statistical analysis using Fisher exact test comparing treatment groups in goal time to CT interpretation (< 45 minutes from time of arrival to Emergency department (ED) to completion of CT interpretation) and rt-PA administration (< 60 minutes from time of arrival to ED to initiation of rt-PA infusion).

Results:
During the six month period, we identified 110 AIS patients who underwent activation of our emergent CT protocol. The multimodal group contained 43 patients while the NCCTH only group contained 67. The mean Time to CT interpretation was 130 (range 11-557) in the multimodal group vs. 87 (12-361) in the NCCTH only group with 16% vs. 37% receiving CT evaluation within 45 minutes of presentation (p=0.02). The mean Time to IV rt-PA administration was 72 minutes (range 19-138) in the multimodal group and 60 minutes (32-94) in the NCCTH only group with 29% vs. 50% receiving IV TPA within 60 minutes (p=0.02).

Conclusion:
The use of multimodal imaging may provide useful information for AIS treatments beyond IV rt-PA; however, such advanced imaging was a source of delay for treatment at our institution. Streamlining the imaging protocol at our institution has improved our achievement of rt-PA administration time goals.
Abstract 7: Has Patient Selection for Carotid Endarterectomy and Stenting changed over time? Carotid revascularization in the postCREST era.
Authors: Bhattacharya Pratik , Damani Rahul , Rayes Mahmoud , Chaturvedi Seemant
Published: March 2022

The results of CREST (Carotid Revascularization Endarterectomy versus Stenting Trial), announced in February 2010 added further insight to the issue of patient selection for carotid revascularization. Carotid artery stenting (CAS) was equivalent to carotid endarterectomy (CEA), perhaps better in the younger age group. CEA patients developed more perioperative myocardial infarctions, and CAS patients incurred more perioperative strokes. Our hypothesis was that following the announcement of the CREST results, characteristics of patients undergoing CAS would change to include younger patients and more cardiac disease compared with those undergoing CEA.

Methods:
a retrospective chart review was conducted of all carotid revascularization procedures performed at four hospitals in a metropolitan region. The study duration was from June 2009 (8 months prior to CREST) through May 2011 (16 months after CREST). Demographics and high surgical risk criteria were recorded. Comparisons were drawn between patients receiving the procedures prior to and after CREST.

Results:
The study included 483 procedures. Of the 174 preCREST procedures, 64(36.8%) were CEA and 110(63.2%) were CAS. Of the 309 postCREST procedures, 112(36.2%) were CEA and 197(63.8%) were CAS. The proportion of patients undergoing CEA for asymptomatic carotid disease did not change significantly (76.6% preCREST vs. 69.6% postCREST: p=0.42). There was a significant increase in the proportion undergoing CAS for asymptomatic disease (52.7% preCREST vs 65.5% postCREST: p=0.04). The patients undergoing CAS for nonspecific symptoms such as dizziness also increased(5.5% preCREST vs. 18.3% postCREST: p=0.002). The median age did not change significantly for either CEA(68.5years preCREST vs. 69.0years postCREST: p=0.95) or CAS(73.0years preCREST vs. 70years postCREST: p=0.23). The proportion of CAS patients ≥70 years somewhat decreased(58.2% preCREST vs.50.3% postCREST: p=0.18). In the CEA subgroup, there was a reduction in the proportion of patients with congestive heart failure (10.9% preCREST vs.2.7% postCREST: p=0.07) and recent myocardial infarction/angina(4.7% preCREST vs.0 postCREST: p=0.06). There was an increase in the proportion of patients undergoing CAS with congestive heart failure(27.3% preCREST vs.37.6% postCREST: p=0.05).

Conclusions:
The utilization of CAS for asymptomatic carotid disease and nonspecific symptoms has increased after CREST. There is a trend towards patients with cardiac disease getting CAS more often. In spite of an increased risk of perioperative stroke among the elderly CAS patients, half of the CAS procedures postCREST were performed in subjects ≥70 years. Careful consideration of the choice of carotid revascularization procedures is warranted in the light of the CREST study.
Abstract 80: Application of the ABCD2 Score to Assess the Risk of Stroke in Dizzy Patients Presenting to 19 Emergency Departments
Authors: Kim Anthony S , Sidney Stephen , Klingman Jeffery G , Johnston S. Claiborne
Published: March 2022

Background:
Dizziness is a very common Emergency Department (ED) complaint and can be a harbinger of stroke, yet there is no consensus on how to reliably and efficiently assess this risk. The ABCD2 score was originally developed to predict the short-term risk of stroke after transient ischemic attack and has showed promise when applied to dizzy patients presenting to a single tertiary care center ED. We sought to further validate the performance of the ABCD2 score by applying it across dizzy patients presenting to multiple community-based EDs.

Methods:
We conducted a nested-case control study within a cohort of all adults who presented to 19 EDs of a large Northern California integrated health program with a primary triage complaint of dizziness over a one-year period. Cases were defined as patients with an ischemic or hemorrhagic stroke at presentation or within 7 days and were identified using systematic search of electronic health records and medical record review by a vascular neurologist. An equal number of controls were randomly selected from among the remaining dizzy patients without stroke. Components of the ABCD2 score (age, blood pressure, clinical features, and diabetes) were collected from medical records by a trained medical record abstractor masked to the study outcomes. As in a prior study, since the duration of symptoms was not readily available, all patients were assumed to have had symptoms for greater than one hour. We calculated descriptive statistics, compared scores among cases and controls using the Wilcoxon rank-sum test, and assessed the discrimination performance of the ABCD2 score for stroke using ROC curves and the c-statistic. We used the sampling fraction to extrapolate these results to the cohort at large.

Results:
In a cohort of 9,566 ED patients with dizziness, 147 (1.54%) had a stroke. The mean ABCD2 score was 4.72 (SD 1.2) in cases and 3.66 (SD 1.1) in controls (p<0.001). The c-statistic for the ABCD2 score as a predictor of stroke was 0.73 (95% CI 0.67-0.79)_slightly lower than the previously reported experience from a single academic center ED of 0.79 (95% CI 0.73-0.85). Extrapolating these data to the entire cohort, those with the lowest score had a predicted risk of stroke of less than one in 500 (0.17%) whereas those with the highest score had a risk of stroke of 11.0%.

Conclusion:
The ABCD2 score holds promise as a way to stratify the risk of stroke in ED patients with dizziness when applied across multiple EDs and identifies low-risk group where neuroimaging may not be warranted. However, formal evaluation of other clinical predictors and prospective validation is required before applying this score at the bedside to better target neuroimaging studies to the most appropriate patients without adversely impacting outcomes.
Abstract 82: Diagnostic Accuracy of Plasma Glial Fibrillary Acidic Protein (GFAP) for the Differentiation between Intracerebral Hemorrhage and Cerebral Ischemia in Patients with Symptoms of Acute Stroke
Authors: Foerch Christian , Steinmetz Helmuth , Sitzer Matthias
Published: March 2022

Background:
Explorative studies have identified glial fibrillary acidic protein (GFAP) as a blood biomarker candidate indicating intracerebral hemorrhage (ICH) in patients with symptoms suspicious of acute stroke. GFAP is released rapidly in the presence of an expanding intracerebral bleeding, whereas a more gradual release occurs in case of cerebral ischemia. This study focused on determining the diagnostic accuracy of plasma GFAP in a prospective multicenter approach.

Methods:
Within a one-year recruitment period, patients suspicious of having acute (i.e. symptom onset <4.5 hours before hospital admission) hemispheric stroke were prospectively included in 14 stroke centers in Germany and Switzerland. A single blood sample was derived at hospital admission. GFAP plasma concentrations were measured using an electrochemiluminometric immunoassay. The final diagnosis was established at hospital discharge, classified as ICH, ischemic stroke, or stroke mimic, respectively.

Results:
N=205 patients were included (39 with ICH, 163 with ischemic stroke, three stroke mimics). GFAP concentrations were markedly elevated in patients with ICH as compared to patients with ischemic stroke (median [interquartile range] 1.91µg/l [0.41-17.66] vs. 0.08 [0.02-0.14], p<0.001). Diagnostic accuracy of GFAP for differentiating ICH from ischemic stroke and stroke mimics was high (AUC=0.915 [95%CI 0.847-0.982], p<0.001). A GFAP cut-point of 0.29µg/l provided a sensitivity of 0.84 and a specificity of 0.96 for differentiating ICH from ischemic stroke and stroke mimics.

Conclusions:
A GFAP plasma test performed within 4.5 hours of symptom onset is accurate in differentiating between ICH and ischemic stroke. If applied as a point-of-care measure in the pre-hospital setting, it would open the gate towards an optimized triage and a hyperacute treatment of patients with symptoms suspicious for acute stroke.
Abstract 83: Hyperacute Matrix Metalloproteinase-2 Levels Predict Early Neurological Deterioration in Acute Ischemic Stroke
Authors: Lorenzano Svetlana , Li Hua , Muzikansky Alona , Rost Natalia , Batista Leonardo , Chutinet Aurauma , Lev Michael H , Harris Gordon J , Feske Steven , Furie Karen L
Published: March 2022

Objectives:
Clinical evolution after an acute ischemic stroke can be variable and patients may experience early neurological improvement (ENI) or early neurological deterioration (END). It is still unclear if inflammation, MMPs and oxidative stress, as mediators of brain damage, might be also responsible for the neurological impairment during the acute stage of an ischemic stroke. Using data from a prospective, hospital-based cohort of AIS patients, we sought to establish whether the baseline levels of these biomarkers correlate with and predict these different clinical courses.

Methods:
We prospectively measured hs-CRP, MMP-2 and MMP-9 (analyzed using an ELISA assay), F2 isoprostane (F2isoP), urinary 8-hydroxydeoxyguanosine (8OHdG), the Oxygen Radical Absorbance Capacity Assay (ORAC) on consecutive acute stroke patients (<9 hours from symptom onset) in a multicenter acute ischemic stroke biomarker study. Clinical and demographic data including NIHSS scores at baseline, 48 hours, and discharge, stroke subtype, imaging, and 3 month mRS were collected. Patients with acute infection, active malignancy, or systemic inflammatory disorder were excluded. END was defined as a worsening of presenting symptom with an increase ≥4 points NIHSS at 48 hours or death at 48 hours. Multivariate logistic regression model was used to adjust for the effects of potential confounding variables.

Results:
Of 528 subjects enrolled in the study we included 132 patients, mean age 71.8 (s.d. 13.8), 48.5% female, 56.1% treated with t-PA in the analysis of which 33 (25%) had END. In univariate analyses, age (76.8±11.1 vs 70.1±14.3; p=0.015), diabetes mellitus (36.4% vs 18.2%, p=0.05), chronic renal failure (18.2% vs 3.0%, p=0.003), systolic blood pressure (164.2±34.5; p=0.05), creatinine (1.3±0.5 vs 1.1±0.3 mg/dl; p=0.025), infarct growth (54.6% vs 48.5%; p=0.06) and baseline MMP-2 (407.9±166.9 vs 332.4±133.9; p=0.013), were associated with END. Baseline NIHSS was significantly lower in patients with END (9.2±5.4 vs 12.3±5.9; p=0.009). At 48 hours MMP-2 levels decreased both in patients with END and ENI (p=0.11). After adjustment for all the confounding variables, MMP-2 remained an independent predictor of END (OR 1.005, 95%CI 1.001-1.009, p=0.013).

Conclusions:
High hyperacute levels of MMP-2 independently predict END in acute ischemic stroke patients. Hence, high baseline MMP-2 levels might play an active role in determining brain injury in the acute phase and can become a valuable specific surrogate marker of stroke progression.
Abstract NS 10: eHealth is Necessary in Stroke Education
Authors: Johnson James
Published: March 2022

Introduction:
The use of the internet and new technologies to conduct electronic outreach and education (e-Outreach) will help to decrease stroke morbidity and mortality. Due to the near omni-presence of the internet and computers in society today, it is necessary to utilize these electronic resources to truly conduct outreach and educate the public.

Background:
In 2004, a phone-based survey of 800 households in Alameda County found that only 10% of those surveyed held a basic-level of knowledge about stroke. In that same year, 50% of stroke patients died before reaching the emergency department. Based on these data, a stroke outreach and education committee was created which did not limit its outreach to physical interactions but also incorporated e-Outreach. With at least 60% of the U.S. population owning a computer and 85% owning a mobile device, using the internet and electronic devices for stroke education can eliminate some of the barriers that prevent populations - which are not connected to health care facilities - from being educated about stroke.

Purpose:
To prevent strokes and educate the community on how to identify and react to the signs and symptoms of stroke. To provide guidelines on how to conduct e-Outreach in the area of stroke.

Methods/Results:
After an evaluation of the community's needs, different methods to conduct e-Outreach were chosen based on available educational materials and relevant technologies. Three chosen methods include: (1) publish a biannual newsletter through a web-based service (∼300 readers per issue); (2) produce a stroke film and then post it on YouTube (∼140 views per month and over 4000 views in total, worldwide); and (3) develop and pilot a "stand-alone touch-screen computer" (kiosk) program in a church (∼200 users in the first three months) to reach populations that do not regularly use the computer/internet nor attend regular medical appointments. Monthly goals were set at various stages of this process and evaluated to monitor the progress.

Conclusion:
The use of e-Outreach has been a huge success in conducting outreach and education. e-Outreach has proven to be far more effective in reaching a more broad population than was previously possible and automated tracking systems made the evaluation process more efficient. Leveraging the free resources available through these technologies has proven an excellent addition to our in-person outreach methods. Our plans to expand our e-Outreach efforts include using text messages for stroke education and developing a computer application that will allow users to do a self-examination using the Act F.A.S.T. test. Additionally, we plan to conduct another survey (incorporating e-Outreach methods) in Fall 2011 to gauge the level of stroke literacy and outcome of stroke death prior to reaching the emergency room.
Abstract NS 5: Lean Manufacturing Process Improvement Techniques Applied to Improve Treatment for Acute Ischemic Stroke in the ED
Authors: Williams Jennifer , Panagos Peter , McCammon Craig , Ford Andria , Lee Jin-Moo
Published: March 2022

Background:
Identification and treatment of acute ischemic stroke (AIS) in the emergency department (ED) requires coordinated efforts between all members of the healthcare team. In an ED that historically treats 4-10 patients a month as potential AIS, the mean door to treatment time was 60 minutes (N=132). The ED Acute Stroke Committee (EDASC) identified the opportunity to improve the existing process through the use of lean methodology, setting a goal of door to treatment time of 30 minutes for AIS patients in a large, urban teaching hospital.

Methods:
Lean methodologies were chosen as a process improvement strategy. Used historically by automobile manufacturers, lean was employed by our healthcare organization to improve a process by identifying and eliminating waste. Frontline team members met to standardize the process, provide clear visual cues to steps in the process in order to identify deviations immediately and return the process to optimal performance. The EDASC invited emergency nurses, physicians, technicians, radiology staff, neurology physicians and nurses, social workers and EMS providers to a 2.5 day event in January 2011. After reviewing the current process from screening through treatment, identifying all steps that were not value added. Based on the identified inefficiencies, the team created the ideal process. Two key nursing changes were identified: (1) the use of a specific nursing screening template to ensure critical screening and assessment questions were asked by every nurse for both walk-in and EMS patients and (2) standardization of mixing and administration of tPA when ordered by the treating physician.

Results:
Protocol changes were implemented March 1, 2011. For improvement in screening, new computerized documentation templates guided the nurse in specific screening questions at triage and with EMS providers when calls were received from the field. The enhanced screening documentation led to decreased likelihood of activation for non-stroke patients while increasing the number of actual AIS patient evaluations. After initial implementation, review of each stroke activation for a one week period refined the screening tool and allow for immediate modification. For expediting tPA preparation and delivery, use of computerized templates for the mixing and administration of tPA ensured consistency of process. Overall, the protocol changes applied from the lean process led to a decrease in time from patient arrival to tPA treatment from 60 minutes before the protocol change to a median of 37 minutes (N=37) after the protocol changes.

Conclusions:
Rapid process improvement using lean tools creates opportunities to radically alter a process of care in a short implementation period. Standardized screening for ischemic stroke by nursing staff at patient arrival can eliminate delays in care and expedite tPA administration.
Abstract NS 8: Aiming for Excellence: Targeting Stroke Patient Education
Authors: Wright Katie M , Brackman Jennifer M , Werstler Judy , McGee Angela
Published: March 2022

Background and Issues
Patient education is a required component of hospitalization. Effective patient education in acute stroke care is a critical part of the patient experience because it greatly impacts the hospital and recovery phases. In order to effectively manage co-morbidities and positively impact modifiable risk factors, efficient patient education is required. Due to the detail and amount of education required for stroke patients, the education the nursing staff was providing was inconsistent. Therefore, a detailed education plan was developed in order to guide the nursing staff in providing detailed and comprehensive stroke education that aligned with the required components set forth by The Joint Commission.

Purpose
A three-phase education pathway was developed in order to highlight the five required components of patient education. The pathway was developed to ensure comprehensive and consistent patient education was being provided. Critical elements were identified for each of the three phases and are considered to be required components of the education and treatment plan. These elements center on the stroke performance measures and clinical practice guidelines in order to ensure the provision of evidence-based stroke care.

Methods
The education is initiated upon admission and is used throughout the hospital stay. During daily interdisciplinary rounds, the plan is reviewed and modifications are made as necessary. The bedside nurse oversees the completion of the education plan by obtaining updates from the interdisciplinary team each shift.

Results
Since implementation of the tool in early 2008, we have seen great improvement with adherence to the required components of stroke education as well as with the stroke performance measures. Each of the stroke measures have remained above the national benchmark (Get With The Guidelines, 2011). In addition, stroke patient satisfaction specific to discharge preparation has increased annually since the inception of the pathway and currently our performance is in the 89
th
percentile nationally (Press-Ganey, 2011). Finally, re-admission rates for the TIA patient population have decreased from 8.26% to 5.5% (Aultman Hospital Annual Report, 2010). Re-admission rates for the ischemic stroke population have also decreased from 10.92% to 10.4%.

Conclusions
Continued focus on the importance of comprehensive, patient-specific education is required in order to maintain the integrity of the stroke program. In addition, exemplary education during the acute hospital phase positively impacts readmission rates which in turn impacts financial stability. Opportunities for improvement in the area of preventing re-admissions were identified and were included in the 2011 performance improvement plan.
Abstract 103: Temporal Trends in Patient Characteristics and Use of IV tPA in Acute Ischemic Stroke Patients Treated at GWTG-Stroke Hospitals
Authors: Schwamm Lee H , Ali Syed F , Reeves Mathew J , Smith Eric E , Saver Jeffrey L , Messe Steven , Bhatt Deepak L , Grau-Sepulveda Maria V , Peterson Eric D , Fonarow Gregg C
Published: March 2022

Intro:
Substantial efforts over the past decade have been made to increase rates of IV tPA use in the US. We sought to determine changes in patient characteristics and rates of tPA use over time among hospitalized stroke patients.

Methods:
We analyzed all acute ischemic stroke (AIS) patients (n=1,093,895) and those arriving ≤ −2 hr and treated with IV tPA ≤ 3 hr of onset (n=50,798) from 2003-2011 in the GWTG-Stroke registry. Categorical data were analyzed by Pearson Chi-square and continuous data by Wilcoxon test, with multivariable GEE models (with and without NIHSS) for analysis of calendar time effect.

Results:
IV tPA use increased from 4.0% to 7.0% in all AIS admissions, and 42.6% to 77.0% in AIS patients arriving ≤ 2hr and tPA treated ≤ 3 hr (p <0.001) (Figure). In univariate analysis, IV tPA use increased over time in those aged >85 yr, non-white, and with milder strokes (NIHSS 0-4) (Table). Door-to-image time (median 24 vs. 20 min) and door-to -tPA time (median 81 vs. 72 min) also improved, with ~65% of tPA treated patients getting CT <25 min of arrival (Table). Multivariable GEE analysis of the effect of calendar year on rates of tPA use (n= 45656) found an adjusted OR of 1.37 (95%CI 1.35 - 1.40; p < 0.0001) per year. Including NIHSS in the model (n=39814) did not change the results substantially (OR=1.32, CI 1.29 - 1.35; p<0.0001) per yr.

Conclusion:
The frequency of IV tPA use among all AIS patients, regardless of contraindications, and among eligible patients without contraindications arriving within two hours nearly doubled from 2003-2011. Treatment with tPA has expanded over the past decade to include more stroke patients with milder deficits, non-white race-ethnicity, and in the oldest old.
Abstract 106: Intra-aneurysmal Flow Disruption: A New Approach For The Endovascular Treatment Of Intracranial Aneurysms. Preliminary Clinical Experience.
Authors: Pierot Laurent , Januel Anne-Christine , Raoult Hélène , Papagiannaki Chrysanthi , Kadziolka Krzysztof , Herbreteau Denis , Gauvrit Jean-Yves , Cognard Christophe , Cognard Christophe
Published: March 2022

Purpose:
Standard coiling is now the first line approach for the treatment of intracranial aneurysms. However, this technique has some limitations, including treatment of wide-neck and large and giant aneurysms and recanalizations. Therefore, new techniques and devices are needed. The objective of intra-saccular flow disruption is the modification of aneurysmal flow by placing a device in the aneurysm sac. Preliminary clinical experience in French centers is presented.

Materials and Methods:
Computational fluid dynamics and pre-clinical testing (canine cross-over carotid bifurcation model) were used to develop an intra-saccular flow disrupter design, designated as WEB (Sequent, Aliso Viejo, CA). The WEB is a self-expanding, oblate, braided nitinol mesh, composed of an inner and outer braid held together by proximal, middle, and distal radio-opaque markers and creating two compartments: one distal and one proximal. Clinically, 19 patients (15F/4M, age: 42-66 years) harbouring unruptured or recanalized aneurysms were treated between June 2011 and July 2012 in four French centers, using an intra-aneurysmal flow-disrupter (WEB). Aneurysm location was middle cerebral artery (9 aneurysms), basilar artery (4), internal carotid artery (3), and anterior communicating artery (3). Aneurysm size was 5-10mm in all but one aneurysm. Neck size was < 4mm in 3 aneurysms and ≥4mm in 16 cases.

Results:
Clinically, the device was successfully deployed in all but one case. In one anterior communicating artery aneurysm, superselective catheterization of the aneurysm sac was impossible. Two thromboembolic events were observed with favorable outcome in both cases (mRS ≤2). No intraoperative rupture was observed. In two cases, the device was not appropriately selected (too small) and additional coiling was performed. In all cases, disruption of the intra-aneurysmal flow was rapidly obtained. Mid-term follow-up results are presented.

Conclusion:
Intra-saccular flow disruption using WEB is a completely new endovascular approach to treat some types of aneurysm, particularly wide-neck bifurcation aneurysms. This preliminary clinical experience shows the safety and efficacy of the device when used in appropriately selected cases.
Abstract 109: Surpass NeuroEndograft for Endovascular Treatment of Intracranial Aneurysms -Single Center Clinical and Angiographic Results
Authors: vries joost d , boogaarts jeroen , wakhloo ajay
Published: March 2022

Purpose:
The Surpass NeuroEndograft (Surpass FD, Tel Aviv, Israel), a low porosity, high pore density flow diverting (FD) device, was evaluated for the treatment of intracranial aneurysms in a single center.

Materials and Methods:
A total of 45 aneurysms in 35 patients were treated. To achieve the calculated flow disruption between the parent artery and aneurysm and required for an occlusion, single devices, tailored to local boundary conditions, were placed endovascularly in parent arteries and covering the aneurysm. Implanted devices measured 2.9-5.3mm in diameter with a length of 10-50mm. Thirty-five aneurysms had complete neck coverage after implantation and ten bifurcation aneurysms had a planned incomplete neck coverage.

Results:
Six-month follow-up angiography available for 28 aneurysms with complete neck coverage, showed a complete occlusion in 27 aneurysms and a less than 50% occlusion in one, resulting in a 96% occlusion rate. Five aneurysms with incomplete neck coverage had complete occlusion at six months follow-up, and four had less than 50% occlusion. There were two parent artery occlusions, leading to a permanent stroke in one patient. There were no other permanent neurological morbidities and there was no mortalitiy., thus permanent morbidity in these series was 2,9%. Infarctions caused by occlusion of perforating arteries covered by the implant during the follow-up period were not seen.

Conclusion:
Preliminary data demonstrate in treatment of complex aneurysms the efficacy of a new generation of FD device.
Abstract 115: Venous Phase Acquisition Is the Best Bolus Timing to Increase Spot Sign Detection in ICH, But Frequency and Extent of Hematoma Expansion Are Greater in Spot Signs Detected in the Arterial Phase of CTA
Authors: Rodriguez-Luna David , Dowlatshahi Dar , Aviv Richard I , Molina Carlos A , Silva Blas Yolanda , Dzialowski Imanuel , Lum Cheemun , Czlonkowska Anna , Boulanger Jean-Martin , Kase Carlos S , Gubitz Gord , Bhatia Rohit , Padma Vasantha , Roy Jayanta , Stewart Teri , Hill Michael D , Demchuk Andrew M ,   PREDICT/Sunnybrook ICH CTA study group
Published: March 2022

Background:
Although the PREDICT study validated the spot sign for predicting significant hematoma expansion (HE) in acute intracerebral hemorrhage (ICH), the sensitivity was 51% and PPV 61%. Recent studies suggest that second pass imaging can increase the yield of contrast extravasation. The present analysis aimed to determine the frequency of spot sign depending on the phase of image acquisition, and whether an early phase spot sign has greater HE compared to later phases.

Methods:
The PREDICT study was a multicentric, prospective, observational cohort study of ICH patients presented <6 hours. A blinded neurologist measured the Hounsfield units of an arterial and venous structure at three levels on CTA source images. The nearest structure to ICH was chosen to classify each study into the phase of acquisition. CTA were classified in 10 phases from early triggering to steady state, including arterial peak (5), arterial-venous equilibrium (6), and venous peak (7). Significant HE was defined as ICH enlargement >33% or >6mL at 24 hours.

Results:
Overall (n=378), 77.5% of CTA were acquired in arterial phases. The spot sign occurred in 29.6%, and there was a trend to more frequent detection in the venous phases (37.6% vs. 27.3%, p=0.066) and in later image acquisition phases (p=0.141; Fig). HE analysis was limited to 318 patients: 26.7% presented spot sign and 32.4% experienced significant HE. In spot-sign positive group, there was a trend that HE occurred more frequently in earlier image acquisition phases (p=0.193, Fig). Similarly, median total hematoma enlargement (ICH+IVH) was greater in earlier phases (p=0.041; Fig).

Conclusions:
This analysis highlights improved spot sign detection with later image acquisition in venous phase of CTA. However spot signs identified in the arterial phase are associated with more frequent hematoma expansion and greater extent. A two phase CTA is optimal in ICH patients and should include image acquisition in the arterial and venous phases.
Abstract 12: MR-Oxygen Metabolic Index (OMI) is Superior To Diffusion-Perfusion Mismatch For Predicting Tissue Fate in the Ischemic Penumbra
Authors: Lee Jin-Moo , Ford Andria , An Hongyu , Chen Yasheng , Vo Katie D , Powers William J , Lin Weili
Published: March 2022

Background:
MR oxygen metabolic index (OMI) is an MR approach closely related to PET-CMRO
2
. We directly compared infarct probabilities in predicted penumbral tissue defined by OMI to that of diffusion-perfusion mismatch (DPM) in a cohort of acute stroke patients.

Methods:
38 acute ischemic stroke patients were imaged at 3.0 hr (tp1), 6.2 hr (tp2), and 1 month (tp3) after onset. Dynamic susceptibility contrast and asymmetry spin echo measured CBF and OEF, respectively. OMI=CBFxOEF. Co-registered voxels were normalized to the non-ischemic hemisphere. OMI- and DPM-derived thresholds (for core/penumbra and penumbra/oligemia) were directly compared by examining infarct probabilities (IP) in 4 tissue categories subdivided by reperfusion status: (1) tissue that died regardless of reperfusion (
core
); (2) tissue that died without reperfusion (
penumbra_non-reperfused
); (3) tissue that survived with reperfusion (
penumbra_reperfused
); and (4) tissue that survived regardless of reperfusion (
oligemia
). “Average prediction error” (APE), a metric combining the differences for each tissue group’s predicted IP from the ideal IP (Table). The predictive abilities of OMI- vs. DPM thresholds were applied to each patient and the IP for each of the 4 tissue groups was calculated and averaged across the population, and compared using Wilcoxon signed rank test. Previously determined OMI thresholds were 0.22 and 0.42 relative to the non-ischemic hemisphere; DPM thresholds were based on DEFUSE-2 criteria [core=ADC<600mm
2
/s, Tmax>6s; penumbra=ADC >600mm
2
/s, Tmax>6s; oligemia=ADC>600mm
2
/s, Tmax<6s].

Results:
Infarct probabilities for OMI and DPM are shown (Table): IP

penumbra_non-reperfused

was higher with OMI compared to DPM (74% vs. 56%, p<0.0001), while IPs in the other 3 tissue groups did not differ. APE was significantly lower for OMI than for DPM (15% vs. 22%, p=0.03).

Conclusions:
OMI thresholds predict reperfusion-dependent tissue outcome in the penumbra better than DPM.
Abstract 13: Asymmetry of Deep Medullary Veins in Susceptibility Weighted Imaging is associated with Poor Collaterals in Patients with Acute Ischemic Stroke
Authors: Oh Mi-Young , Ko Sang-Bae , Kim Chi Kyung , Lee Seung-Hoon , Ryu Wi-Sun , Kim Chang Hun , Kim Min Jung , Yoon Byung-Woo
Published: March 2022

Background:
Susceptibility Weighted Imaging (SWI) is a high spatial resolution of MR imaging technique showing magnetic inhomogeneity that could demonstrate increased oxygen extraction in ischemic hemisphere. The aim of this study was to investigate whether the asymmetry of deep medullary veins (DMVs) on SWI could indicate the poor collateral flow, which results in the hemodynamic derangement in acute ischemic stroke.

Methods:
Consecutive 132 patients with acute middle cerebral artery infarction within 6 hours from symptom onset were included. The DMVs of ipsilesional region of interests (ROIs) and contralateral ROIs were evaluated; score 0: no DMVs, score 1: moderately visibility of DMVs, and score 2: obviously visibility of DMVs. Asymmetry is defined as the difference in the scores of DMVs between both hemispheres. Collateral status on conventional angiography was graded 0 to 4 based on the ASTIN/SIR collateral flows grading system. Poor collateral flow is defined as grade 0-1. Early neurological deterioration was defined as an increase in the NIHSS score by ≥4 points during the first 48 hours after admission. Multivariable logistic regression analysis was used to examine the association between the presence of asymmetry of DMVs and poor collateral flow or clinical outcomes.

Results:
Of 132 patients, 74 (56.1%) had asymmetry of DMVs. Asymmetry of DMVs was independently associated with the poor collateral status (OR; 42.1, 95% confidential interval 1.99.-89.81, p=0.02) after adjusting confounders. Moreover, patients with asymmetry of DMVs were likely to have more profound infarction growth (OR; 6.01, 95% CI, 1.21-29.88, p=0.03) and results in the early neurological deterioration (OR; 5.49, 95% CI, 1.21-28.57, p=0.03).

Conclusion:
Asymmetry of DMVs is independently associated with poor collateral status which affects the clinical deterioration in patients with acute middle cerebral artery stroke.