bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP403: Kansas Initiative for Stroke Survival: a Statewide Program to Improve Stroke Outcomes
Authors: Rymer Marilyn , Shipley Craig , Rosterman Lee , Wang Yunxia , Abraham Michael , Nunn Tony , Lechtenberg Colleen , Sandt Janice
Published: March 2022

Comprehensive Stroke Centers (CSCs) provide leadership to the surrounding communities they serve. Until state certification is mandated through legislative action, CSCs may be the best actors to create and improve stroke systems of care. Our CSC is in a state with 83 out of 126 Critical Access Hospitals. We launched the Kansas Initiative for Stroke Survival (KISS) in 2012, offering training and resources on quality measures and protocols necessary to recognize and treat stroke. Hospitals were invited to do an assessment of what they needed to do to become “stroke ready” and sign an attestation that acute therapy could be administered with telephonic assistance from a tertiary center and a transfer plan in place. In the first two years, over sixty hospitals participated, but those enrolled in KISS as emergent stroke ready did not show sustained improvement in stroke care. Door to needle time increased 25% in the last year. In response, our CSC created an independent executive board, representing professionals from nursing, emergency medical services, management, and medicine, to lead a broader statewide approach to education and accountability. Our new goals are to develop a statewide capability map, distribute a quarterly newsletter highlighting efforts across the state, and develop a website with links to presentations, protocols, and statewide data. We have already redesigned the data survey to enhance reporting and analysis, community-level boot camps have been implemented, and a statewide peer review has begun. Our CSC leads the quarterly peer review along with education that covers topics impacting outcomes, such as time from door to thrombolytic therapy and endovascular case selection; the first conference had 27 participants across the state. Our experience demonstrates that CSCs can lead statewide improvements in stroke care and that hospitals around the state are receptive to that leadership. Collaboration between hospitals can improve stroke outcomes.
Abstract TP406: Mapping Stroke Team Network Structure and Function to Enhance Acute Stroke Care Quality Improvement Efforts
Authors: Loveless Mark O , Kamauu Aaron , Wilson Andrew
Published: March 2022

Background:
Acute ischemic stroke (AIS) clinical outcomes are time-dependent and are influenced by the organization and capability of the care delivery system. The focus of stroke care quality improvement has emphasized process and procedure. Integrating a systematic assessment of the structure and inter-dependencies of the stroke care team members has the potential to enhance the understanding of the overall function of the team and strengthen existing quality improvement efforts.

Objective:
Describe a multi-modal quality improvement approach consisting of process/clinical outcome measures, workflow analysis and personnel structure mapping of acute stroke care teams.

Method:
Key site-specific hospital characteristics, including the variability of stroke treatment processes of individual teams, were identified. A critical path analysis was created based on a standard acute stroke care process model. Stroke care team structures and inter-dependencies were mapped based on the responses to a short survey and the responses were analyzed using open source network analytic software (Gephi). Analysis results were interpreted in context of the characteristics of the hospital units.

Results:
The care team personnel structures were overlayed on the stroke care process pathways to create a final synthesis of the process and team structure ( (Example in figure below). Critical path analyses combined with previously unidentified opportunities to strengthen the individual team member interactions were linked to process/clinical outcomes. Opportunities for site-specific improvement in both process and personnel organization and communication were identified. Case studies will be presented.

Conclusion:
A clinical microsystems analytic approach that includes formal site-specific representations of the care team structure is feasible and provides a valuable addition to process analysis for quality improvement programs.
Abstract TP407: Implementation of Standardized Charting for Level 1 Stroke Cases in the Operating Room
Authors: Espaillat Kiersten , Buckner Paula
Published: March 2022

Introduction:
Appropriate documentation impacts patient care and quality monitoring. The required documentation elements for level 1 stroke cases varies and does not yet have a standardized format. Mounting evidence supports endovascular stroke treatment, decreasing time to treatment initiation will also likely be critical to improving patient outcomes. However, there is no clear way or format to document the various important time points during a case. We sought to provide a template for operating room nurses to be prompted to assess and record important patient and team information.

Methods:
We evaluated the closed charts from 2013 for patients who underwent Level 1 acute stroke surgical intervention. Charts for all patients who received acute stroke interventions in 2014 and 2015 were also reviewed. Review focused on seven key items; pre and post neurological assessment in the operating room, time puncture, to clot, to revascularization, of groin seal, and TICI score. These items were important based on patient care and the ability to review the efficiency of the team in starting a case.

Results:
There were 36 charts reviewed from 2013 for patients who underwent Level 1 acute stroke surgical intervention. There was no documentation of the seven key items in any of the 2013 charts. The standardized form was initiated in 2014 after an educational campaign. This method was continually evaluated and did show overall improvement. A deeper dive showed 23% of the Level 1 acute stroke surgical intervention charts were still missing all seven key items.

Conclusions:
The documentation of Level 1 acute stroke surgical intervention cases still remains a challenge. The current results demonstrate that further automation may be needed to ensure to proper care and documentation of these patients. The development of documentation should not be a burden, but rather aid in enhancing the quality of care for patients.
Abstract TP408: The First 24 hours Post-Stroke: Improving Timeliness of Blood Pressure Monitoring and Neurologic Assessment Completion
Authors: Barna Amy , Kjos Nick , McKee Jacelyn , Pronschinske Heather
Published: March 2022

Background:
In 2014 ischemic stroke orderset changes were implemented, increasing the frequency of blood pressure (BP) monitoring and neurologic assessments. Considering the significant practice change and criticality of the assessments, performance surrounding these specific order changes was evaluated. Data from a five month period (Feb 2014-June 2014) revealed the correct number of assessments completed in the first 24 hours was 50% (median) for BP and 64% (median) for neurologic assessments.

Purpose:
Develop improvement initiative to increase adherence to stroke orderset monitoring frequencies.

Methods:
To discuss current workflows and identify barriers to performance a quality improvement session was held with representatives from bedside staff, Neuroscience Unit leadership, and the Quality Department. Three improvement areas were identified: awareness regarding time sensitivity of assessments, variance in role completing BP monitoring, and patient inaccessibility at assessment due time. Focus areas were shared with the unit-based committee for action plan development. To address timing of assessments and provide a means of consistent communication, a bedside checklist was developed. To address variance in role completing BP monitoring it was decided that RNs would complete BP monitoring during the first 24 hours considering it coincided with the completion of the neurologic assessment. To address patients being inaccessible at assessment due times, it was decided that assessments would be completed prior to anticipated appointments that would otherwise prevent adherence to monitoring requirements.

Results:
Data was collected monthly via electronic reports and manual chart review. After implementation of process improvement activities (July 2014-Mar 2015) the correct number of assessments completed in the first 24 hours was 94% (median) for BP and 96% (median) for neurologic assessments.

Conclusions:
Bedside staff was highly engaged in this process improvement work. RNs found the bedside checklist to be an effective means of managing the frequent assessments necessary in caring for an acute stroke patient. A data focused improvement initiative resulted in consistent adherence to stroke orderset monitoring frequencies.
Abstract TP409: Continuous Quality Improvement Implementation Across a Large Stroke Network of Affiliated Rural Hospitals
Authors: Bellamy Lisa M , Elkins Kelley L , Dobbs Michael R
Published: March 2022

Background and Purpose:
The stroke care network (SCN) currently includes 27 hospitals (one CSC, seven PSCs and four critical access facilities) and is responsible for nearly 7000 stroke discharges annually. Vital to our network’s mission is to improve care quality through a cooperative, evidence-based, standardized approach. Data submission began in February 2014 with 24 hospitals. The network compiled data results for a full year with a baseline purpose of analyzing submission and data trends.

Methods:
All affiliates receive standardized quality education upon joining the SCN. A data report form was used to collect and submit monthly stroke data elements quarterly. Door to CT Interpretation (OP-23), eight in-patient stroke core measures and the dysphagia performance measure were among many other quality metrics. Data was compiled for system analysis.

Results:
For calendar year 2014, 14 of 24 (58%) affiliate hospitals submitted data. The lowest scoring quality measures were STK-4: thrombolytic therapy (38%, N7), STK-8: stroke education (63%, N13) and (STK[PM]-7): dysphagia screening (59%, N6). Average time for CT interpretation was 46 minutes (range: 20-77 minutes). For stroke core measures, average was 73% for all appropriate measures (range: 38% (STK-4) - 88% (STK-2: discharged on antithrombotic)).

Conclusions:
Data submission is not yet uniform across the network, but areas to focus on quality have already emerged from the results—STK-4, STK-8, and (STK[PM]-7). In addition to program advisory services to improve submission compliance, the network proposal includes focused initiatives as a system, targeting tPA, patient education and dysphagia screening. Strengths of the continuous quality improvement initiative will include collaboration, sharing of best practices and a strong base in evidence.
Abstract TP410: Utilizing the Stroke Team Coordinator to Improve End of Life Discussions
Authors: Hamm Theresa
Published: March 2022

Background and purpose:
End of life decision making is becoming an ever increasing focus for stroke patients and their care-givers. The American Heart Association recognized the importance of this process and the need for study in this area in a 2014 scientific statement. This remains a difficult discussion for many providers to engage in given the often difficult prognostication involved in this population. We hypothesize that including the stroke coordinator in end of life discussions will facilitate a consistent message for both families and providers, allowing less opportunity for the passage of conflicting information.

Methods and Results:
The stroke coordinator cross trained and joined the palliative care committee, and the palliative care nurse joined the stroke team, to ensure ease of communication and collaboration. Additionally, the stroke team coordinator now participates in family care conferences in which end of life options are being discussed. The stroke team coordinator convenes with all providers prior to the family care conference to evaluate co-morbidities as well as stroke severity, thus allowing a holistic discussion with the family.

Outcomes:
The stroke team coordinator brings a unique perspective to end of life conversations. While physicians provide clinical data around stroke severity and co-morbidities the stroke coordinator discusses outcomes and quality of life. By exploring with families what a loved one would consider an acceptable quality of life we are able to more fully assist the family to make difficult decisions. Expertise in palliative care assists in those conversations and allows family to feel comfortable understanding the options available. Most importantly, a frank discussion around feeding issues is essential to assure families that withholding tube feedings will not cause the patient distress.

Conclusion:
The stroke team coordinator is in a unique position to provide leadership and guidance through often difficult and murky end of life discussions proving to be a valuable resource for this process.
Abstract TP411: Banner Health Stroke Coordinator Collaboration Lowers Door to Needle Times for the Banner Health System of Primary Stroke Centers
Authors: Bremer Jane A , Duke Kimberley A , Holland Donna L , Lombardo Carmen , Wikas Angie , Smith Evelyn , Liable Deborah A , Milakovich Rebecca D
Published: March 2022

Background and Purpose:
The Banner Health (BH) System includes 7 hospitals that are certified as Primary Stroke Centers (PSCs) by The Joint Commission. Each PSC employs a Stroke Coordinator to oversee the stroke program, monitor data, and ensure compliance with Joint Commission standards. Many of the Coordinators struggled with unique difficulties and barriers within their individual programs. In October 2012, the Stroke Coordinators decided to form a committee and meet monthly with a focus on standardizing processes within the stroke programs across the BH System. This collaboration and sharing of common struggles and best practices has led to a decrease in door-to-needle times throughout the BH System and an increase in the utilization rate of this emergency treatment.

Methods:
The BH Stroke Coordinator Committee objectives:

-Stroke Core Measure review and development of a consistent process to resolve outliers

-Standardization of stroke alert and Core Measure tracking mechanisms

-Implementation of consistent metric reporting

-Sharing of best practices

-Joint Commission standard compliance

The Stroke Coordinator Committee reports to the BH System Interdisciplinary Neuroscience Clinical Consensus Group (Neuro CCG). The Neuro CCG approves revisions and updates to stroke care as indicated from the Stroke Coordinator Committee at the BH System level.

Results:

Conclusion:
Collaboration among the Stroke Coordinators and standardization of stroke care across the BH system resulted in lowering the average door-to-tPA times and increasing the tPA utilization across all 7 BH Primary Stroke Centers.
Abstract TP412: Stroke Survivors’ Perceptions About Risk Factor Management: Challenges and Opportunities
Authors: White Carole L , Patterson Michele , Motz Deb , Williamson Richard , Caron Jean-Louis , Birnbaum Lee A
Published: March 2022

Background:
Adherence to medications and recommended lifestyle changes are effective strategies to reduce recurrent stroke, yet implementation remains sub-optimal. We lack information from the stroke survivor’s perspective about effective ways to promote engagement in managing risk. The aim was to explore their experiences in risk factor control and identify opportunities for using health information technology (HIT) to support self-management.

Methods:
Using a mixed methods design, focus groups (n=8) were convened to explore management of risk after stroke. Results from the focus groups guided the development of a survey, administered to a new group of stroke survivors (n=82) to collect information specifically about blood pressure (BP) management and use of HIT.

Results:
Focus group participants described stroke as a call to action to improve health. Themes consistent across groups were: recognizing signs/symptoms of stroke and feeling efficacious to act, knowing risk factors and doing the right things, and challenges and support for doing the right things. Most described using some form of HIT to support risk factor management, such as home BP monitoring, setting phone alarms for medications, and accessing information online. Among survey respondents, 60% reported uncontrolled BP at the time of stroke, with only 37% taking BP medications regularly before stroke and improvement to 75% following stroke. Of those with a home BP monitor (50%), most reported regular monitoring and were 6.2 times (95% CI: 2.1, 18.2) more likely to know their target BP than those without a monitor. Almost all participants reported mobile phone ownership (93%), mostly Smartphones (66%). While 43% use the internet to access health information, only 18% had visited stroke specific sites such as the American Stroke Association. The majority (80%) identified roles for technology and was interested in HIT to support their risk factor control.

Conclusions:
Stroke survivors described challenges related to managing risk factors after stroke as well as potential opportunities for HIT. We need to do more to engage stroke survivors and the wide of adoption of mobile phones suggests an innovative method for motivating and supporting stroke survivors in self-management of risk factors.
Abstract TP42: Early Neurological Deterioration in Patients With Single Infarct in the Territory of Lenticulostriate Artery Territory
Authors: Yamamoto Yasumasa , Nagakane Yoshinari , Tomii Yasuhiro
Published: March 2022

Purpose:
Early neurological deterioration (END) in the acute phase of penetrating artery infarction is not uncommon. Recently, atherosclerotic status has been reported to contribute to END. Considering such findings, we further explored factors associated with END in patients with single infarctions in the lenticulostriate artery territory (LSA).

Methods:
We studied 523 consecutive patients with LSA who entered our hospital within 24 hours after onset. We categorized subjects into 3 groups: no END, minor END and major END. Minor END was defined as worsening or fluctuation by 1-2 points in the National Institutes of Health Stroke Scale (NIHSS) but recovered afterward. Major END was worsening by 2 or more points in the NIHSS and afterwards thoroughly progressed. LSA infarcts on the first DWI were divided into proximal and distal types. The proximal type was further divided into anterior and posterior type based on the intermediate point in the corona radiating adjacent to the lateral ventricle. Systolic blood pressures in an emergency room (SBP) were categorized into 5 groups as follows: G1; < 140mmHg, G2; 140-159, G3; 160-179; G4; 180-200 and G5; > 200. NIHSS on admission was dichotomized and higher NIHSS was defined as ≥4. Atherosclerotic diseases of the intracranial middle cerebral artery were assessed on MRA as follows: normal, mild stenosis (< 50%) and severe stenosis (> 50%). Central values of modified Rankin scale one month after ictus in 3 END groups were no END (n=302): 1, minor END (n=112): 1 and major END (n=109): 4, respectively. We then calculated the odds ratios (OR) of predictive factors for major END.

Results:
Predictive factors found significant by uni-variate analysis were female, anterior and posterior proximal type, mild stenosis, higher NIHSS and G4 and G5 of SBP. Multivariate analysis revealed that anterior proximal type (OR and 95% p< 0.0001), posterior proximal type (156.1, p< 0.0001), mild stenosis (3.0, p=0.014) and higher NIHSS (4.3, p=0.0002) were found to be independently associated with major END.

Conclusions:
Posterior rather than anterior proximal type was strongly associated with major END probably due to the anatomical fact that corticospinal tracts crossed the LSA territory at the postero-superior quadrant.
Abstract TP425: Post-stroke Blood Pressure Trajectory and Mortality Risk: Analysis of Racial/Ethnic Differences in the New York City Health and Hospitals Corporation
Authors: Seixas Azizi , Spruill Tanya , Williams Stephen K , Butler Mark , Gyamfi Joyce , Jean-Louis Girardin , Ogedegbe Gbenga
Published: March 2022

Background:
The racial/ethnic differences in post-stroke blood pressure (BP) trajectory and mortality risk are not fully understood. The current paper investigated differences in average systolic BP (SBP) during the 6 months following stroke and effects of average post-stroke BP on mortality risk among Blacks and Hispanics.

Hypothesis:
Greater post-stroke BP levels will increase risk of mortality

Methods:
We examined BP measurements in 6,016 stroke survivors within the New York City Health and Hospitals Corporation (NYC HHC) during the 6 months following stroke. Based on the average of all SBP measurements in this period, patients were classified into three groups: (1) SBP =140 mm Hg and =150 mm Hg). We used inverse probability weighting (IPW) to control for group differences in demographic factors, comorbidity, and anti-hypertensive medication use. We examined how 6 month SBP average related to mortality following stroke using Cox regression analysis. The mean duration of follow up after stroke was 2.6±1.5 years.

Results:
The mean age was 57.9±13.0 years, 57.4% of patients were female, 49.1% were Black and 37.3% were Hispanic. Blacks were more likely than Hispanics to have an average post-stroke SBP >=150mm Hg (27% versus 17%). Group 1 (SBP <140) and Group 3 (SBP>=150) had higher risks of mortality (Group 1 HR=1.26, 95%CI=1.13-1.41; Group 3 HR=1.29, 95%CI=1.13-1.48) when compared to Group 2 (SBP 140-150). When controlling for ethnicity, these differences are no longer significant. In stratified analyses, the increased hazard in Group 1 was maintained in the sub-sample of Blacks (HR=1.47, 95%CI=1.25-1.72) but not in Hispanics (HR=0.95, 95%CI=0.79-1.15). The difference between Group 2 and Group 3 was not significant in either Black or Hispanic sub-samples.

Conclusion:
Our findings demonstrate that having a post-stroke SBP below 140 mm Hg or above 150 mm Hg significantly increased individuals’ mortality risk, adjusting for demographic factors, comorbidity, number of BP readings, and location of healthcare. Post-stroke BP trajectory differed between Blacks and Hispanics, and had different effects on mortality. These findings have important implications for post-stroke hypertension care.
Abstract TP43: Delayed Phase Blood Pool Assessment of Multiphase-CTA in Acute Stroke Provides Further Information Beyond Non-Contrast CT
Authors: Famuyide Akinrinola O , d’Esterre Christopher D , Qazi Emmad , Njam Mohamed , Khan Khayam , Menon Bijoy K , Barber Phillip
Published: March 2022

Introduction:
Multiphase CT-Angiography (mCTA) can provide dynamic parenchymal hemodynamic information, including proper microvascular ‘blood pool’ assessment. Our objective was to determine which ASPECTS scoring method between non-contrast CT (NCCT), and delayed phase blood pool assessment on mCTA best predicted final infarct. This can contribute to decision making for endovascular therapy.

Hypothesis:
ASPECTS on delayed phase blood pool analysis would best predict final infarct score.

Methods:
Patients with TICI 0, 2b, or 3 reperfusion who met criteria for thrombolysis and endovascular therapy were included. ASPECTS scores were calculated on admission NCCT. Blood pool ASPECTS were calculated as discrete areas of hypodensity on delayed phase mCTA. Baseline scores were compared to final infarct score on follow-up CT/MRI. Sensitivities and specificities were calculated and then stratified by brain region to determine the most predictive method.

Results:
Fifty-three patients were analyzed (25/53= TICI 0, 10/53= TICI 2b, 15/53= TICI 3). Delayed phase blood pool mCTA showed similar sensitivities for ganglionic regions and improved sensitivities for supraganglionic regions. Delayed phase blood pool analysis of mCTA showed improved specificity in ganglionic regions over NCCT (Table 1, Figure 1).

Conclusion:
In conclusion, blood pool assessment on delayed phase mCTA has the capability to identify additional at risk tissue beyond that defined by NCCT.
Abstract TP436: Precision Medicine Using Quantitative Electroencephalography for Blood Pressure Augmentation in Penumbral Salvage After Subarachnoid Hemorrhage
Authors: Sy Heustein , Kapinos Gregory , Shafeeq Hira
Published: March 2022

Delayed cerebral ischemia (DCI) complicates aneurysmal subarachnoid hemorrhage (SAH) in 20 to 30 percent of cases. DCI is treated initially with hemodynamic augmentation to improve cerebral perfusion. AHA/ASA guidelines recommend induced hypertension in the treatment of DCI, but at the same time recognize that insufficient scientific data support this practice. There is little practical guidance on how to augment blood pressure - i.e. extent and duration of blood pressure augmentation. Oftentimes, intensivists determine blood pressure goals by serial neurologic exams, which may be limited in poor clinical grade SAH.

We assessed the hypothesis that quantitative electroencephalography (EEG) has an adjunctive value to the clinical exam that can be used to monitor response to blood pressure augmentation in SAH.

Three patients with aneurysmal SAH in the neurocritical care unit were connected to quantitative EEG. To detect a decline in neuronal activity, we measured the amount of EEG variability, reactivity, amplitude as well as the changes in alpha-delta ratio. Induced hypertension through fluid challenge and inotropic support was tailored to reach the clinical and/or electrographic ischemic threshold, i.e. blood pressure levels that ameliorated clinical examination or the EEG.

Induced hypertension tailored to quantitative EEG data was tolerated well. We observed that neurologic examination of the patient (i.e. wakefulness, alertness, mental status, motor strength) following blood pressure augmentation correlated with quantitative EEG data. Furthermore, quantitative EEG added value to clinical exam, allowing for more precise increments in hemodynamic augmentation. Tapering of inotropic support was also done more safely and in a timely manner with EEG changes that preceded mild clinical impairments.

In conclusion, we demonstrated in a case series that blood pressure augmentation can be guided by quantitative EEG data, which correlated with the neurologic exam. Further research can be done to determine if induced hypertension guided by quantitative EEG can reduce mortality and morbidity in patients with aneurysmal SAH.
Abstract TP441: Linagliptin Decreases Diabetes-induced Cerebral Pathological Neovascularization in a Blood Glucose-independent Manner
Authors: Abdelsaid Mohammed , Williams Raeonda , Hardigan Trevor , Ergul Adviye
Published: March 2022

Objective:
Diabetes promotes dysfunctional neovascularization and cerebrovascular remodeling in diabetes. We showed that glycemic control with metformin prevents and restores diabetes-mediated pathological remodeling and neovascularization of the cerebrovasculature. Our recent data suggest that linagliptin, a dipeptidyl-peptidase-4 (DPP-4) inhibitor used for glycemic control, prevents vascular remodeling independent of glycemic control in diabetes. In this study, we test the hypothesis that linagliptin prevents dysfunctional neovascularization in a blood glucose independent manner in diabetes.

Methods:
24 week old diabetic Goto-Kakizaki (GK) (Hemoglobin A1C >6.5%) and nondiabetic Wistar rats were treated for 4 weeks with either vehicle chow or chow containing 166mg/kg linagliptin. At termination, FITC-dextran was injected to full and visualize the vasculature and brain sections were imaged by confocal microscopy for vascular density, tortuosity, vascular volume, and surface area measurements in 3 dimensional reconstruction of the cortex and striatum regions. Retinal acellular capillary formation was measured as another surrogate marker for pathological neovascularization in diabetes (n=3-4). Brain microvascular endothelial cells (BMVEC) isolated from control or diabetic rats were also treated with (100 nM) linagliptin and tested for angiogenic properties with cell migration and tube formation assays.

Results:
Linagliptin reduced all indices of cerebral neovascularization compared with control rats (Table, n=3-5). In addition linagliptin significantly decreased retinal acellular capillaries and normalized the augmented angiogenic properties of diabetic BMVEC (p<0.05).

Conclusions:
These results suggest that linagliptin offers therapeutic potential and effective in reversing established pathological neovascularization. Mechanisms underlying glucose independent effects of linagliptin remain to be determined.
Abstract TP444: Exploring Peripheral Mirnas as Biomarkers for Human Ischemic Stroke
Authors: Kelly Stephen , Wang Shu , Uhegwu Nnamdi , Porbeni Charles , Moussavi Mohammed , Kirmani Jawad , Gizzi Martin
Published: March 2022

Introduction.

While genomic array studies have shown that cohorts of messenger RNA (mRNA) levels in blood can be used to delineate between stroke types, there are some drawbacks with this approach. Not least the relatively poor stability of mRNA in blood. We are exploring the utility of circulating microRNAs (miRNAs) as biomarkers of ischemic stroke. miRNAs are small (∼22 nt) evolutionarily conserved single-stranded, non-coding RNA species that function as potent regulators of gene expression. They suppress gene expression by hybridizing with the 3’ untranslated region (3’UTR) of target messenger RNAs (mRNAs) and trigger mRNA degradation and/or translational repression. miRNAs are contained within several cellular and non-cellular compartments in the blood and are more stable in the bloodstream than messenger RNAs.

Methods.

Fifteen patients diagnosed with acute ischemic stroke (initial National Institutes of Health Stroke Scale of 5 or greater) and six no-stroke controls were enrolled in this study. Three blood samples were drawn from each patient into PAXgene tubes. Sample 1 was drawn within 5 hours of stroke, before IV tissue plasminogen activator t-PA treatment. Sample 2 was drawn at 24 hours following stroke onset, after IV rt-PA, thrombectomy and IA rt-PA. Sample 3 was drawn at 7 days post-stroke. RNA quality and concentration was determined and cDNA libraries generated to perform deep sequencing analysis on a SOLiD Sequencer.

Results.

Our data strongly suggests that miRNA expression profiles in peripheral blood are significantly altered in patients with ischemic stroke compared with control patients. We found 23 miRNAs that are differentially expressing in ischemic patients versus controls. Fifteen of these miRNAs were significantly decreased in ischemic stroke, while 8 were significantly increased in ischemic stroke. Moreover, comparison of the miRNA expression levels in the blood of a patient presenting with signs of ischemic stroke, but who was diagnosed with a transient ischemic attack (TIA) and released without treatment, grouped with control patients upon analysis.

Conclusion.

We have convincing preliminary data showing that miRNA expression profiles in peripheral blood following ischemic stroke are significantly altered.
Abstract TP455: Treatment With Trifluoromethoxyphenyl-3 (1propionylpiperidin-4-yl) Urea Improves Cognitive Functions and Endothelium Dependent Dilation in Penetrating Arterioles From Hypertensive Rats With Bilateral Common Carotid Stenosis
Authors: Matin Nusrat , Fisher Courtney , Hammock Bruce , Jackson William F , Dorrance Anne M
Published: March 2022

Soluble epoxide hydrolase (sEH) converts epoxyeicosatrienoic acids (EETs), arachidonic acid metabolites produced by cytochrome 450 enzymes, into less metabolically active compounds. sEH inhibitors have been proposed to have vascular and neural protective effects in stroke models. Studies from our lab showed that bilateral carotid artery stenosis (BCAS), a physiologically relevant model of cognitive impairment, impairs endothelium dependent dilation in penetrating arterioles (PAs) from stroke prone spontaneously hypertensive rats (SHRSPs). We hypothesized that treatment of SHRSPs with BCAS with the sEH inhibitor, trifluoromethoxyphenyl-3 (1propionylpiperidin-4-yl) urea (TPPU) would alleviate cognitive dysfunction and improve endothelium dependent dilation in PAs. Data are shown as mean ± SEM, vehicle vs TPPU, and p <0.05 (an n=3 to 12 in each group). After 8 weeks of BCAS, TPPU treated rats showed improved short-term memory (novel exploration quotient, 90 minutes retention time: 0.5 ± 0.06 vs 0.6 ± 0.04), evaluated by novel object recognition test. PA reactivity and structure was assessed by pressure myography. TPPU restored endothelial function of PAs from SHRSP with BCAS, as evidenced by increased dilation to carbachol (% dilation at 10-6M: 2.7 ± 2.9 vs 16.5 ± 3.9). Inhibition of EET production with MS-PPOH (10-5M), enhanced dilation in PAs from TPPU treated SHRSP with BCAS (% dilation at 10-5M of carbachol, TPPU vs TPPU+MS-PPOH: 14.9 ± 2.9 vs 23.4 ± 3.5), while dilation in vehicle treated SHRSPs remained unaltered (% dilation at 10-5M, vehicle vs vehicle+MS-PPOH: 2.9 ± 2.9 vs -0.7 ± 5.1, p=0.96). This suggests that inhibiting EET production may unmask a compensatory dilatory mechanism in PAs from TPPU treated rats. Interestingly, PAs from TPPU treated rats were less sensitive to NO as evidenced by a reduction in the EC50 for NO- donor, sodium nitroprusside (logEC50: -7.1±0.14 vs -5.7± 0.2). This reduced sensitivity may be due to an overproduction of NO in PAs from TPPU treated rats. There was no difference in passive structure of the PAs with chronic TPPU administration. These data suggest that TPPU improves short-term memory after BCAS and this may be associated with improved endothelium-dependent dilation in the PAs.
Abstract TP51: Cerebral Blood Flow Threshold for Infarction After 3 Hours of Ischemia Determined in a Porcine Model of Stroke
Authors: Wright Eric , d'Esterre Christopher , Morrison Laura , Cockburn Neil , Kovacs Michael , Lee Ting-Yim
Published: March 2022

Introduction:
CT Perfusion (CTP) derived ischemia-time dependent thresholds may help with treatment decision making by allowing infarct delineation at admission and prediction of infarct growth over time. The accepted 3h ischemia-time cerebral blood flow (CBF) infarction threshold had been determined by Jones et al in primates using hydrogen clearance. The same threshold from CTP has not been determined. We used a porcine acute stroke model to find this threshold with contemporaneous CTP and PET imaging.

Hypothesis:
CTP derived 3h ischemia-time infarction CBF threshold will be near 12 mL100g
-1
min
-1
as determined in primates.

Methods:
Cerebral ischemia was induced in the left hemisphere of 11 pigs by injecting endothelin-1 (ET-1) into the cortex. CTP scans were acquired subsequently at 10 min and then 30 min intervals throughout the experiment. At 2.5h, 18F-FFMZ was injected, PET acquisition started at 3h. A median CBF map was produced after co-registering maps from each CTP study. Median CBF maps, PET images, average images from the baseline CTP study, and blood volume (BV) maps from the 10min post ET-1 CTP study were co-registered. ROIs were drawn over the cortex on the affected and contralateral side and superimposed onto all images. Infarct was identified on PET images with a threshold derived from the contralateral ROI. Average images were used to remove white matter from the affected side ROI. Blood vessels were excluded on BV maps with a threshold derived from the affected side ROI. Remaining infarct and non-infarct ROIs were superimposed onto the median CBF map and pixel values were imported into Matlab for ROC analysis.

Results:
Of 11 animals, 6 developed infarction. The optimal CBF infarction thresholds determined from the ROC curves were 10.1, 8.9, 15.0, 13.2, 12.1, and 16.2mL100g
-1
min
-1
. The average threshold was 12.6 ± 2.8 mL100g
-1
min
-1
.

Conclusions:
CTP derived CBF threshold for infarction at 3-h ischemia time agrees well with the accepted literature value. Infarction thresholds at other ischemia times can be found using this model by varying the time between ET-1 injection and PET imaging.
Abstract TP7: Intraarterial Treatment for Acute Ischemic Stroke due to Dissection: Retrospective Series of 24 Cases
Authors: Jensen Judd , Salottolo Kristin , McCarthy Kathryn , Frei Donald , Loy David , Wagner Jeffrey , Whaley Michelle , Bar-Or David
Published: March 2022

Introduction:
Cervical artery dissection is a recognized cause of acute ischemic stroke (AIS). Intra-arterial treatment (IAT) may be a complementary option to IV tPA and antithrombotic therapy.

Hypothesis/Purpose:
To describe a large series of patients with dissection treated with IAT.

Methods:
Demographics, clinical characteristics, treatment, and outcomes were summarized for all dissection patients treated with IAT from 1/2010 - 5/2015. Outcomes included functional independence (modified Rankin score ≤ 2 at 90 days or discharge, or discharge home), recanalization, procedural complications, sICH, and mortality. Data are presented as median (interquartile range) or (n).

Results:
Of 161 patients with dissection, 24 (15%) were managed with IAT and comprise our population, which was primarily male (75%) aged 52 (42-59.5) and NIHSS of 13 (12 -16). Internal carotid artery dissections (ICAD, 18) were more common than vertebral artery dissections (VAD, 6); three patients had bilateral dissections (1 ICAD, 2 VAD). In all but two patients there was associated intracranial embolus. Dissections were idiopathic (17), traumatic (5) or cough-related (2). Eleven patients were treated with IV tPA. IAT techniques included thrombectomy (19), IA thrombolysis (17), stent (13), and angioplasty (7). The majority of patients had multiple techniques: 2 (2 -3). Functional independence was achieved in 63% (12/19). There were four deaths, none were attributable to IAT. There was one sICH and three procedural complications (2 groin pseudoaneurysm, one catheter induced acute dissection). Among the 6 VADs, 2 were left untreated and the remaining 4 were successfully recanalized (100%). All 6 VADs had a basilar artery occlusion; recanalization was successful in 2 and partial in 4 cases. Among the 18 ICADs, 6 were left untreated and the remaining 12 were successfully recanalized (100%). Sixteen of 18 ICADs had middle cerebral artery occlusion; recanalization was successful in 4, partial in 10, and unsuccessful in 2 cases.

Conclusions:
Despite the additional intravascular risk, outcomes appear to be similar to those presented in large RCTs with stroke from all causes, suggesting utility of IAT when performed in patients with dissection.
Abstract TP83: Sulfonylurea Pretreatment Does Not Impact Acute Ischemic Stroke Outcomes Following Intravenous Thrombolysis
Authors: Tsivgoulis Georgios , Goyal Nitin , Zand Ramin , Male Shailesh , Iftikhar Sulaiman , Chang Jason , Elijovich Lucas , Alexandrov Anne W , Malkoff Marc D , Alexandrov Andrei V
Published: March 2022

Background&Purpose:
Experimental and retrospective clinical data have indicated that sulfonylurea drugs (SUD) may confer protection against cerebral swelling and hemorrhagic transformation in AIS. We sought to determine whether pretreatment and in-hospital use of SUD may be associated with better outcomes in diabetic AIS patients treated with IVT.

Subjects&Methods:
We retrospectively analyzed prospectively collected data of consecutive AIS treated with IVT during a three-year period. Pre-treatment NIHSS, NIHSS at 48 hours and modified Rankin Scale (mRS) at discharge were documented. Symptomatic intracerebral hemorrhage (sICH) was defined as imaging evidence of ICH with NIHSS increase of 4 points within 72 hours. Early neurological improvement was defined as a NIHSS-score decrease of ≥4 points or a NIHSS-score of 0 at 48 hours. Cerebral edema was documented by neuroradiology reports. Favorable functional outcome (FFO) was defined as mRS of 0-1.

Results:
A total of 148 diabetic AIS patients fulfilled the study inclusion criteria (mean age 64±11 years, 49% men, median admission NIHSS-score: 8 points). We identified 42 patients pre-treated with SUD (mean age 65±11 years, 50% men, median admission NIHSS-score: 8 points) all of whom continued to receive these medications during hospitalization. Demographic characteristics, vascular risk factors and admission NIHSS-scores did not differ (p>0.1) between patients pretreated (cases) and non-pretreated with SUD (controls). The prevalence of complications and favorable outcomes did not differ (p>0.1) between cases and controls: sICH (2% vs. 5%), cerebral edema (5% vs 4%), early neurological improvement (42% vs 43%), in-hospital mortality (12% vs 5%) and FFO (22% vs 32%).

Conclusions:
Pretreatment and in-hospital use of SUD appears not to be associated with early favorable outcomes and lower likelihood of potential complications in diabetic AIS patients treated with IVT.
Abstract TP87: Time and Risk Factor of Rebleeding After Coil Embolization of Ruptured Cerebral Aneurysms
Authors: Imamura Hirotoshi , Tani Shoichi , Adachi Hidemitsu , Arimura Koichi , Funatsu Takayuki , Beppu Mikiya , Sakai Nobuyuki
Published: March 2022

Objective:
The risk of rebleeding is reported higher in ruptured cerebral aneurysms treated with endovascular coiling than in patients treated with surgical clipping. In this study, we evaluate the time and risk factors of rebleeding after coil embolization of ruptured cerebral aneurysms.

Methods:
From April 2001 to August 2014, we performed coil embolization on 288 ruptured cerebral aneurysms. We evaluated the frequency, time and risk factors of rebleeding in terms of patient background, location, size, ratio of dome to neck, volume embolization ratio (VER), and remnant flow into aneurysms immediately after embolization.

Results:
We suffered 6 rebleedings (2.1%) within 24 hours after the initial coil embolization (early-rebleeding), and 6 rebleedings (2.1%) within 1 year after the embolization in the patients who we could follow up, and 3 rebleedings (late-rebleeding) 1 year later. All of early-rebleeding occurred within 12 hours. 5 of 6 rebleedings within 1 year after the embolization occurred within 3 months from 30 days after, and one patient who was administered warfarin suffered rebleeding 13 days after the treatment. Antihypertensive therapy after the embolization tended to prevent early-rebleeding (p=0.092), but we revealed no significant factor related to early-rebleeding. We demonstrated significant differences between ratio of dome to neck and rebleeding within 1 year after (p=0.035), and between angiographic result and rebleeding within 1 year after (p=0.001).

Conclusions:
Most of rebleeding after coil embolization occurred within 12 hours or within 3 months from 30 days after the treatment. We recommend antihypertensive therapy and the angiogram 1month after the coil embolization at our institution.
Abstract TP90: A Pilot Study of the Mineralocorticoid Receptor Blocker Eplerenone in Hypertensive Patients with Unruptured Cerebral Aneurysms
Authors: Satomi Junichiro , Tada Yoshiteru , Kanematsu Yasuhisa , Kuwayama Kazuyuki , Yagi Kenji , Kinouchi Tomoya , Nakajima Kohei , Matsushita Nobuhisa , Korai Masaaki , Mure Hideo , Kitazato Keiko , Nagahiro Shinji
Published: March 2022

Background:
There are no pharmacological therapies for patients with unruptured cerebral aneurysms. Elsewhere we showed that the mineralocorticoid receptor antagonist eplerenone prevented the formation of cerebral aneurysms in ovariectomized rats. This pilot study was designed to evaluate whether it can be used to prevent the growth and rupture of cerebral aneurysms in humans with hypertension.

Methods:
Between August 2011 and May 2014, 82 patients with 89 aneurysms were enrolled in an open-label uncontrolled clinical trial. Of these, 81 patients (88 unruptured aneurysms) were followed for a mean of 21.2 months (153.7 aneurysm-years). All patients had a history of hypertension and were treated with eplerenone (20 - 100 mg per day). The primary endpoints were rupture and enlargement of the intracranial aneurysms.

Results:
The mean aneurysmal size was 4.6 ± 2.6 mm. During follow-up period that included 153.7 aneurysm-years, 3 aneurysms enlarged and one large thrombosed aneurysm rupture. The annual rupture was 0.65% overall and 13.16% for aneurysms larger than 10 mm. No aneurysms smaller than 9 mm ruptured. The annual rate for reaching the primary endpoint was 2.60% overall. It was 1.37% for aneurysms smaller than 9 mm and thus seems to be lower than in other studies. Eplerenone had no protective effects in aneurysms larger than 10 mm. In the course of our study, 12 patients (14.8%) permanently discontinued taking the eplerenone.

Conclusions:
Our observations suggest that it is clinically feasible to prevent growth and rupture of cerebral aneurysms smaller than 9 mm by treatment with eplerenone. Protocols for large clinical trial are needed to assess the possible long-term clinical benefits the drug may confer on patients with unruptured cerebral aneurysms.
Abstract TP94: Effect of Flow Diversion on Large and Giant Aneurysms: an MRI-DSA Correlation Follow-up Study
Authors: John Seby , Bain Mark , Hussain Muhammad S , Toth Gabor
Published: March 2022

Background:
There is sparse literature on the effect of flow diversion (FD) on large or giant intracranial aneurysms. We assessed the effects of FD with Pipeline stent on aneurysm sac size using MRI follow-up

Methods:
All patients at our institution who underwent FD for treatment of intracranial aneurysms were retrospectively identified. Aneurysms with maximum dimension > 20mm, with pre and post treatment MRI were selected. These aneurysms were not previously treated, and did not receive adjunctive devices for current treatment. The largest diameter in 2-dimensions was measured on the MRI sequence that best demonstrated the aneurysm sac, and compared on serial scans. MRI changes were compared to DSA where aneurysm occlusion was graded by the O'Kelly-Marotta (OKM) scale.

Results:
Between 6/2011-4/2015, 87 patients with 96 aneurysms were treated with FD. Eighteen patients had aneurysm >20mm. Pre and post treatment MRI were available in 12/18 (67%) patients. This included 9 (75%) females, with mean age 65.5 years. All aneurysms were unruptured and symptomatic. Nine (75%) patients had cavernous/ophthalmic aneurysms, and 3 had basilar aneurysms. Average largest aneurysm diameter was 26.7 (range 21-37) mm. Pipeline was used in all patients (mean 1.9, range 1-5 stents), with 8 (67%) requiring > 1 stent. At the first MRI follow-up (median 4, range 1-18 months), 4 (33%) aneurysms decreased in size, 6 (50%) remained stable, 1 (8%) increased in size. The stent thrombosed in the last patient. At the last MRI follow-up (median 10.5, range 1-48 months), 9 (75%) aneurysms decreased in size and 2 (16%) remained stable from baseline. No aneurysm completely resolved. DSA follow-up was available in 10 (83%) patients (median 9, range 1-25 months). Patients with decreased size on MRI had OKM grade C2, C3 or D, while aneurysms with stable size had OKM grade B3. The one patient with initial increased size on MR had corresponding OKM grade D (no filling).

Conclusion:
Majority (75%) of large aneurysms decrease in size on serial MRIs after FD treatment. This corresponds with no filling or early remnant on DSA. Rare aneurysms increase in size despite no filling on DSA, which suggests caution when using only DSA follow-up post treatment. These findings require further study.