bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W P176: Relationship Between Right-to-Left Shunting and Microembolic Signals on Transcranial Doppler Monitoring
Authors: Ahmed Zubair A , Koffman Lauren , Michael Rebecca , Baus Leasa , Raber Larry , Katzan Irene
Published: March 2022

Background:
Transcranial doppler-monitoring (TCM) has been used to identify patients at risk for embolic stroke and aids in identification of stroke mechanism. Limited data exists on the occurrence of microembolic signals (MES) on TCM and the presence of right-to-left shunting (RLS), most commonly through a patent foramen ovale. Our objective was to determine if a relationship exists between the presence of a RLS on transcranial doppler-bubble (TCB) and MES on TCM, and if the degree of shunting correlated with increased number of MES.

Methods:
A retrospective chart review was conducted of 113 inpatients that underwent both TCB for the detection of a RLS and TCM during their admission for ischemic stroke at the Cleveland Clinic between 2011 and 2012. TCM was performed for 20 minutes in all patients. Both TCM and TCB used standardized protocols and machines. Data collected included demographics, presence of a shunt, and stroke mechanism.

Results:
Mean age of the study cohort was 57.9 years and 46.9% were female. RLS on TCB was found in 30.1% of patients and MES were seen on TCM in 33.6% of patients. The occurrence of MES was similar in patients with and without RLS (38.2% vs. 31.6% respectively) (p=0.50). In patients with undetermined stroke mechanism and RLS, there was a trend towards higher occurrence of MES (42.9% vs 30.8%, p=0.35). No significant difference was seen between the occurrence of MES and degree of shunting according to Spencer Grades I-IV (p=0.48). Patients with MES and RLS had an insignificantly greater number of MES than patients without RLS (59.8 vs 10.8. p=0.33). This difference in the number of MES was more pronounced in patients with undetermined stroke etiology (73.1 vs 14.4, p=0.42).

Conclusions:
There was no overall relationship between RLS and MES on TCM. However, the number of MES in patients with positive TCM was greater in those with a RLS compared to those without RLS, particularly in patients with undetermined stroke mechanism. Although, more data is needed, in patients with strokes of undetermined etiology, the presence of MES on TCD may suggest the presence of a RLS, especially if the number of MES is high.
Abstract W P179: Reducing Time to Treatment - The Role of Stroke Neurologist as First Responder
Authors: Ozark Shelly , Holmstedt Christine , Sabatino Perette , Turan Tanya
Published: March 2022

Background:
Stroke patient outcomes are improved by shortened time to thrombolysis. The importance of a stroke-trained neurologist as a first responder on the acute stroke care team has not been clearly defined.

Objective:
To determine the impact of early involvement of an attending stroke-trained neurologist on timeliness of acute stroke treatment.

Methods:
This was a single-center retrospective study performed at an academic tertiary referral center and certified stroke center. The pre-intervention period was from August 2011 to July 2012 and included 34 patients treated with IV r-tPA. August 2012 to May 2013 was the intervention period, wherein a stroke-trained attending neurologist led the brain attack team in the response to acute strokes (n=26 treated with IV r-tPA). Outcome data included door to treatment and door to CT times. Data were analyses using descriptive statistics and comparisons performed using the Student’s T- test.

Results:
Door to treatment time shortened from an average of 63.7 minutes pre-intervention to 40.8 minutes after the intervention (P= 0.0035). During the intervention, 84.6% of patients were treated in < 60 minutes, versus 47.1% prior to intervention. The percent of all stroke patients who were evaluated with CT in less than 25 minutes increased from 16.8% pre-intervention to 45.6% during the intervention.

Conclusion:
The use of a stroke-trained attending neurologist as a first responder and stroke team leader resulted in rapid patient evaluation and faster decision regarding thrombolytic therapy, improving time to treatment and time to CT.
Abstract W P191: Neurology Consultation During Assessment of Acute Stroke Patients With Mild or Rapidly Improving Symptoms
Authors: Olson-Mack Lindsay , Clarkson-Afshar Katherine , Richetts Renee , Bajkiewicz Christopher , Berger Lynn
Published: March 2022

Background:
Emergency Department (ED) physicians frequently cite mild and rapidly improving symptoms (RIS) as rationale for not treating acute ischemic stroke (AIS) patients with IV tPA. Approximately 33% of AIS not treated with IV tPA with RIS have poor short-term outcomes, evidenced by inability to ambulate on discharge, and not being discharged home. Determining treatment in an evolving infarct with waxing/waning symptoms is challenging. The decision not to proceed with IV tPA treatment may have lasting consequences and should be done in collaboration with neurology.

Methods:
A retrospective cohort study of 794 records was reviewed with patients presenting to the ED at a 5 campus hospital system from January to June 2013. Inclusion criteria: MD documentation of stroke symptoms within 3 hours of arrival to the ED and RIS as criteria for withholding IV tPA. Exclusion criteria: patients who received IV tPA, evidence of hemorrhage on imaging, time of onset unclear or greater than 3 hours, and patients transferred to outside facilities where discharge data was not available.

Results:
After applying criteria, 54 records were included in this review. Of the patients not treated with IV tPA for RIS, 8 patients (25%) were discharged to a skilled nursing facility (SNF) or an assisted living facility. A total of 7 patients (22%) presented on admission with a Modified Rankin Scale (mRS) of 2 or greater, while a total of 11 patients (35%) were discharged with a mRS of 2 or greater. As a health care system, neurology was consulted during the AIS assessment in 45 patients (83% of the time). Significant variations were found with geographic location and availability of in-house neurology for consultation. Campuses with telemedicine neurology or fellows covering stroke codes cited the rationale of RIS in approximately 14-18% of cases during the period studied. In contrast, the sites with neurology at the bedside for all stroke codes only cited RIS in 5-8% of cases during the study period.

Conclusions:
Opportunities for education exists with ED staff in the treatment of RIS. This study also highlights the potential importance for neurology at the bedside for treatment of AIS with IV tPA and warrants additional research.
Abstract W P202: Sex Differences in Transforming Growth Factor B Activated Kinase-1 Signaling Following Experimental Stroke
Authors: Roy-O'Reilly Meaghan , Howe Matthew , McCullough Louise
Published: March 2022

Introduction:
Evidence suggests that post-stroke inflammation and outcome is influenced by sex, yet the mechanistic processes behind these disparities remain largely unknown. Studies have shown that ischemic damage following experimental stroke is reduced in young female mice when compared to their male counterparts and that this protective effect can be diminished by ovariectomy (OVX). TGF-B activated kinase (TAK-1) is an important mediator in inflammatory signaling. TAK decreases following cerebral ischemia and inhibition of TAK reduces infarct size following experimental stroke. TAB2 is an activating binding partner that binds to TAK-1 following stimulation, allowing TAK-1 auto-phosphorylation and activation of the p38/MAPK and JNK inflammatory pathways. Post-stroke regulation of TAK levels and activation may contribute to the ischemic resistance seen in females.

Hypothesis:
We hypothesized that female mice would have a greater decrease in TAK1 and activated p-TAK1 than their male counterparts following experimental stroke.

Methods:
Male, intact female and ovariectomized female (OVX) mice were subjected to 90-minute middle cerebral artery occlusion (MCAO) and sacrificed at 24 hours post-stroke. Protein levels of TAK-1, TAB2, pTAK and JNK were examined by Western Blot.

Results:
TAK and pTAK levels were reduced following stroke in female, male and OVX mice. Baseline levels of both TAK1 and pTAK were lower in female mice and the loss of TAK, pTAK and TAB2 following stroke was more dramatic. JNK levels were lower in female mice than in male mice at baseline (p<.05) and following stroke (p<.01), while the OVX females exhibited intermediate JNK.

Conclusions:
Female mice exhibit lower baseline JNK levels and do not demonstrate a stroke-induced increase in JNK, indicating a protective resistance against stroke-induced inflammation. The dramatic loss of TAB2 in females results in less binding and activation of TAK, reducing inflammation and conferring neuro-protection. OVX mice showed an intermediate phenotype, indicating that estrogen may play a role in TAK regulation following stroke.
Abstract W P205: Specific Deficiency of Brain ABCA1 Increases Inflammation and White Matter Damage and Worsens Functional Outcome After Stroke
Authors: Cui Xu , Chopp Michael , Cui Yisheng , Wang Yun , Roberts Cynthia , Karasinska Joanna M , Hayden Michael R , Chen Jieli
Published: March 2022

Background:
ATP-binding cassette transporter A1 (ABCA1) plays a critical role in HDL-cholesterol production and has been identified as a potent anti-inflammatory molecule in macrophages and other immune cells. However, direct experimental support of this hypothesis in cerebral ischemia is lacking. Using specific deficiency of brain ABCA1 mice, we therefore tested whether ABCA1 plays a role in neuro-inflammation and white matter damage after stroke.

Methods:
Adult male brain ABCA1 knockout control (floxed, ABCA1
fl/fl
) and brain ABCA1 knockout (floxed, nestin-Cre positive, ABCA1
-B/-B
) mice were subjected to permanent extraluminal distal middle cerebral artery occlusion (dMCAo) by transcranial ligation of distal MCA with a 10-0 filament. Animals were sacrificed 7 days after MCAo. A battery of functional outcomes, infarct volume, and immunostaining for analysis of inflammation and white matter damage were performed.

Results:
There is no significant difference in blood level of total cholesterol, triglyceride and HDL before and after MCAo between ABCA1
-B/-B
and ABCA1
fl/fl
mice. However, ABCA1
-B/-B
mice showed: 1) increased infarct volume (21.67%±2.95%, n=14, p=0.022) compared with ABCA1
fl/fl
(11.57%±1.58%, n=9); 2) decreased functional outcome evaluated by the adhesive removal and basket tests performed at 1, 3 and 7 days after MCAo (p<0.05); 3) increased inflammation in the ischemic brain, including: (a) decreased the number of CD163 (M2 macrophage marker, anti-inflammatory) positive cells, but an increased the ratio of ED1 (M1 macrophage marker, pro-inflammatory)/CD163 positive cells; (
b
) increased matrix metalloproteinase-9 (MMP-9) expression measured by immunostaining; (
c
) increased number of NFkB positive cells; 4) increased white matter damage: decreased density of Luxol Fast Blue (myelin marker, p<0.01) and Bielshowsky silver (axon marker, p<0.05) compared to ABCA1fl/fl mice.

Conclusions:
Specific deficiency of brain ABCA1 increases inflammation and white matter damage in the ischemic brain, which may play important roles in increasing infarct volume and decreasing functional outcome after stroke. These data indicate that ABCA1 plays an important role in inhibiting neuro-inflammation in the ischemic brain after stroke.
Abstract W P207: Association of Increased Expression of NOX4 With Susceptibility to Hypoxia-Induced ROS Overproduction and ICAM-1 and VCAM-1 Upregulation in Brain Microvascular Endothelial Cells
Authors: Shimoda Yusuke , Abumiya Takeo , Kawabori Masahito , Shichinohe Hideo , Nakayama Naoki , Kazumata Ken , Houkin Kiyohiro
Published: March 2022

Background and Purpose:
NADPH oxidase 4 (NOX4) is the predominant source of reactive oxygen species (ROS) in the endothelial cells. It has been demonstrated that brain microvascular endothelial cells (BMECs) is more susceptible to stress-induced cellular responses compared with endothelial cells from other larger vessels. The aim of this study is to examine susceptibility to hypoxia-induced cellular reactions in BMECs compared with aortic endothelial cells (AECs) in terms of association of NOX4 expression with ROS production.

Methods:
Cultured bovine BMECs and AECs were incubated in the modular incubator chamber pre-filled with anoxic gas (95%N
2
/5% CO
2
) at 37°C. Time course changes of ROS production, cell death occurrence, and mRNA expression of NOX4, ICAM-1, VCAM-1, HIF-1α, VEGF and GAPDH were examined in BMECs and AECs until 4 hours after hypoxia. ROS production, cell death occurrence, and mRNA expression were evaluated with DHE staining, Live/Dead cell kit, and RT-PCR, respectively.

Results:
Basal ROS production was significantly higher in BMECs than in AECs (p<0.01). After hypoxia ROS production and cell death were more prominently increased in BMECs compared with AECs with time. While expression levels and pattern of HIF-1α and VEGF were similar in the both cells, expression levels of NOX4, ICAM-1, and VCAM-1 were quite different in the both cells. While the expression levels of NOX4, ICAM-1, and VCAM-1 in AECs were very low at all the time points, those expression levels in BMECs were significantly higher at the basal condition (p<0.01) and were increased more at 2 hours and decreased at 4 hours after hypoxia.

Conclusions:
It was demonstrated in BMECs but not in AECs that NOX4 expression was high and increased more after hypoxia, which is consistent with the increase of ROS production and ICAM-1 and VCAM-1 expression. Increased expression of NOX4 is likely associated with susceptibility to hypoxia-induced ROS overproduction and ICAM-1 and VCAM-1 upregulation in BMECs.
Abstract W P22: Is Hemoglobin A1c (HbA1C) Level an Independent Predictor of Adverse Outcomes in Patients With Acute Ischemic Stroke Undergoing Endovascular Treatment?
Authors: Chaudhry Saqib A , Zafar Taqi T , Saeed Ali , Adil Malik M , Afzal Mohammad , Jadhav Vikram , Hassan Ameer E , Hussain Syed I , Qureshi Adnan I
Published: March 2022

Background:
There is controversy whether acute or chronic hyperglycemia increases the rate of adverse outcomes in patients undergoing endovascular procedures.

Objective:
To evaluate the relationship between hemoglobin A1c (HbA1c), a marker of chronic hyperglycemia, and post-thrombolytic intracerebral hemorrhage (ICH), mortality and independence at discharge.

Methods:
Consecutive patients with acute ischemic stroke who underwent emergent endovascular treatment over seven years at three comprehensive stroke centers were included. HbA1c levels were collected within seven days of the procedure and strata was defined as (≤6.0%, 6.1 to 7.0% and >7.1%). Patient characteristics and outcomes were analyzed including age, use of intravenous rt-PA, and use of additional mechanical thrombolysis. The rates of post-thrombolytic ICH and independence at discharge (modified Rankin score (mRS) = 0-2) and inpatient mortality were analyzed after adjusting for potential confounders.

Results:
There were 185 patients who received endovascular treatment for acute ischemic stroke; mean ±standard deviation (SD) age was 66.7 ± 15.6, and 82 (44.3%) were women. Rates of post-thrombolytic ICH was higher in patients with higher levels of HbA1c [11.6% in ≤6.0 strata, 15.7% in 6.1-7.0 strata, and 22.6% in ≥7.1 strata]. Rate of independence at discharge was lower in patients with higher levels of HbA1c [36.8% in ≤6.0 strata, 25.5% in 6.1-7.0 strata, and 23.3% in ≥7.1 strata] while inpatient mortality was higher [13.6% in ≤6.0 strata, 15.7% in 6.1-7.0 strata, and 26.7% in ≥7.1 strata]. Adjusting for age, admission NIHSS score, gender, medical comorbidities, recanalization and type of endovascular treatments, the HbA1C strata correlated with an increase in post-thrombolytic ICH (odds ratio [OR], 1.96, 95% confidence interval [CI], 0.94-4.13, p= 0.074). We did not find any relation between increasing HbA1C and independence at discharge or inpatient mortality: (p= 0.6320) and (p= 0.6112), respectively.

Conclusion:
Chronic hyperglycemia increases the risk of post-thrombolytic ICH following endovascular treatment in acute ischemic stroke patients through mechanisms not yet clearly understood.
Abstract W P229: Reduction of Peroxiredoxin 5 Concentration in Patients following Ischemic Stroke
Authors: Kunze Allison , Zierath Dannielle , Tanzi Patricia , Becker Kyra J
Published: March 2022

Background:
There is a marked inflammatory response within the brain after stroke. Peroxiredoxins (PRXs) are endogenous anti-oxidant proteins, but recent data suggest that PRXs may be responsible for initiating inflammation in the brain following cerebral ischemia. In this study we evaluated the relationship between PRX5 and biomarkers of inflammation following ischemic stroke.

Methods:
In a prospective study of patients with ischemic stroke, PRX5 concentrations were determined by standard ELISA in plasma samples (N=98) obtained at 3 days after stroke onset. Relationships between stroke severity, biomarkers of inflammation and stroke outcome were explored.

Results:
At 3 days after stroke, PRX5 concentrations were significantly lower in patients with severe stroke (NIHSS ≥17; 37.6 ng/mL [28.5, 45.3]) as compared to patients with moderate stroke (NIHSS 6-16; 48.0 ng/mL [36.5, 88.6]) or mild stroke (NIHSS ≤5; [40.5, 76.3]);
P
=0.001. PRX5 was inversely correlated with the number of white blood cells, neutrophils, and monocytes as well as with plasma CRP, TNF-α, IL-6, IL-10 and IL-2. None of these correlations remained significant after controlling for stroke severity. Patients with higher plasma PRX5 at 3 days were more likely to have good outcome (mRS≤2) at 3 months (
P
=0.019), but this relationship was lost after controlling for stroke severity.

Discussion:
Plasma concentrations of PRX5 are decreased in patients with severe stroke and inversely correlated with biomarkers of inflammation. These data suggest that the initiator of systemic inflammation after stroke is not PRX5. Further, they show that severe brain injury leads to a loss of circulating anti-oxidant proteins.
Abstract W P236: Predictors of thrombolysis in Young Adults with Ischemic Stroke
Authors: Ali Syed F , Schwamm Lee H , Singhal Aneesh B
Published: March 2022

Introduction:
Approximately 10% to 22.5% of ischemic strokes occur in young adults (18-49 years). We examined factors associated with IV tPA use in young adult stroke (YAS) patients.

Methods:
Using our institutional GWTG database, we analyzed 5,120 consecutive stroke admissions (01/2004 - 03/2013). Univariate and multivariable models explored factors associated with IV tPA use.

Results:
YAS comprised 12% of the cohort (n=619). Compared to older adults, YAS patients were more often Hispanic and non-Caucasian, had significantly less vascular risk factors and lower median NIHSS scores. Fifteen percent (n=94) of YAS patients received IV tPA. Atrial fibrillation was present in 3.4% YAS cases (all above age 38). In univariate analysis, factors associated with IV tPA use in the YAS cohort included Caucasian race, atrial fibrillation and higher NIHSS, but only atrial fibrillation and higher NIHSS were independently associated with tPA use in multivariable analysis (Table). Of all YAS patients receiving IV tPA, 2/94 (2.1%) had symptomatic intracranial hemorrhage and another 2/94 (2.1%) had serious systemic hemorrhage within 36hr of IV tPA administration.

Conclusion:
In the YAS population, those with higher NIHSS scores and atrial fibrillation are more likely to receive IV tPA. These data suggest that more severe strokes and those with a recognized cardioembolic mechanism are more likely to get thrombolysis. Reassuringly, the rate of IV tPA bleeding complications is quite low in YAS patients. Further studies should investigate reasons for non-treatment with thrombolysis and outcomes in YAS patients with less severe presentations.
Abstract W P246: Diagnostic Value of Lobar Hemorrhages for Cerebral Amyloid Angiopathy in Hospital and Community-based Individuals: A Pathological Correlation Study
Authors: Martinez-Ramirez Sergi , Romero Jose-Rafael , Gurol M.Edip , Ashkan Shoamanesh , McKee Ann C. , van Etten Ellis , Pontes-Neto Octavio , Ayres Alison , Auriel Eitan , Himali Jayandra J. , Beiser Alexa S. , DeCarli Charles , Stein Thor , Alvarez Victor E. , Frosch Matthew , Rosand Jonathan , Greenberg Steven M. , Seshadri Sudha , Viswanathan Anand
Published: March 2022

Objectives:
To determine and compare the accuracy of the Boston criteria for the diagnosis of cerebral amyloid angiopathy (CAA) applied to: 1) a large hospital-based cohort; 2) a cohort of community-dwelling individuals.

Methods:
Among patients seen at a single academic medical center and participants enrolled in the Framingham Heart Study (FHS) we identified all individuals having had brain MRI (including hemosiderin-specific sequences) and pathological assessment of CAA at age ≥55. CAA was defined as Vonsattel degree ≥2, except in non-autopsy studies, where any vascular amloyid deposition was considered diagnostic of CAA. We excluded cases with: 1) non-lobar ICH; 2) alternative clinical diagnosis for the lobar hemorrhage/es; 3) CAA-negative studies based on small brain biopsy samples (greater diameter <1 cm) or clot evacuations with none or rare vessels identified; 4) autopsy studies not grading CAA. We determined sensitivity and specificity of “possible CAA” (1 lobar hemorrhage) and “probable CAA” (>1 strictly lobar hemorrhage) in both cohorts.

Results:
The study included 143 cases: 96 from the hospital cohort (mean age at time of MRI 74.1±8.2 years, 47.9% women, 47.9% autopsy studies, 54.2% cases with any lobar microbleed, 44.8% with any lobar ICH) and 47 from FHS (mean age at time of MRI 83.4±10.9 years, 48.9% women, 100% autopsy studies, 17% cases with any lobar microbleed, no lobar ICH cases). Hospital cohort: CAA prevalence was 72.6%. Specificity/sensitivity of “possible CAA” and “probable CAA” were 78.2%/33.3% and 92%/57.7%. Community cohort: CAA prevalence was 47%. Specificity/sensitivity of “probable CAA” were 88%/3%.

Discussion:
Specificity of detection of multiple lobar hemorrhages on MRI (“probable CAA”) for moderate-severe CAA is similarly high in both hospital and community cohorts. This increases the opportunity to identify individuals with CAA for observational studies and emerging anti-amyloid therapeutic trials. In view of its poor sensitivity, “probable CAA” diagnosis represents an inadequate screening tool for exclusion of CAA in both populations.
Abstract W P247: Dynamic Characterization of CT Angiographic Spot Sign
Authors: Chakraborty Santanu , Alhazzaa Mohammed , Wasserman Jason , Sun Kelly , Stotts Grant , Hogan Mathew , Demchuk Andrew , Aviv Richard , Dowlatshahi Dar
Published: March 2022

Background and purpose:
Standard (static) CT angiography is used to identify the intracerebral hemorrhage (ICH) spot sign. We used dynamic CT-angiography to describe spot sign characteristics and measurement parameters over 60-seconds of image acquisition.

Methods:
We prospectively collected consecutive patients with acute ICH presenting within 6 hours of symptom onset who underwent whole brain dynamic CT-angiography (dCTA). Spot parameters (earliest appearance, duration, Maximum Hounsfield unit (HU), time to maximum HU, time to spot diagnosis (based on HU>100 or >120) and spot volume) and hematoma volumes were measured using volumetric analysis software.

Result:
We enrolled 34 patients: three were excluded due to secondary causes of ICH. In the 31 patients with primary ICH, there were 13 males with median age 70 and baseline hematoma volume 33 ml. In our series, 13 patients (42 %) had positive dCTA spot sign. The spot was visualized as an expanding 3-dimensional structure that temporally evolved in its morphology over the scanning period. Median time to spot appearance was 21s (range 15-35 seconds). This method allowed tracking spots where they continued until end of venous phase (persistent leak) with median duration of 39s (range 25-45 seconds). The median maximum HU was 204, and median time to maximum HU was 30.8s. Median time to spot diagnosis was 20.8s using either the HU 100 or 120 definitions.

Conclusion:
Dynamic CT Angiography allows a 3-dimensional assessment of spot sign formation during acute ICH; this is the first study to quantitatively describe spot sign formation and morphology using dCTA.
Abstract W P248: Cerebral Tissue Iron Quantification on MRI Following Intracerebral Hemorrhage
Authors: Chaudhary Neeraj , Pandey Aditya S , Gemmete Joseph J , Merchak Kevin , Chenevert Tom , Xi Guohua
Published: March 2022

Purpose:
Intracerebral hemorrhage (ICH) is a fatal subtype of Hemorrhagic stroke. Tissue iron at the periphery of ICH has been demonstrated to be neurotoxic in animal models. No robust method to quantify tissue iron following ICH currently exists. Our aim is to determine a robust algorithm based on MRI to quantify tissue iron in the wake of ICH.

Methods:
Following Institutional review board approval we constructed an MRI phantom. Eight 4 cc vials with 50 % decreasing dilutions of Ferraheme (iron for IV therapy) were prepared starting from 0.6 mg/ml ending at 0.005 mg/ml. The vials were stuck to the undersurface of the lid of a water bath container and scanned in a 3T MRI with T2* sequences. The T2* signal magnitudes were calculated for each concentration. Subsequently a human control brain and two patients with left basal ganglia ICH were scanned with identical parameters. The T2* signal magnitude was calculated at 3 ROIs at the periphery of the ICH.

Results:
The R2* maps demonstrated a near linear correlation with the iron concentration in the phantom. The control T2* signal magnitude corresponded to 0.01 mg/ml iron concentration. The two patients on ICH day 7 had measurements of iron concentration of 0.04 mg/ml (4 x baseline) at the periphery of the hematoma. This corresponds favorably to a threefold increase in measured tissue iron levels in animal ICH model studies.

Conclusion:
Our experiment demonstrates that quantitative susceptibility measurements on MRI may be a robust technique to assess iron level in brain tissue following ICH. Encouraged by the results we have applied to the NIH (#GRANT11426089) for funding to be able to evaluate the validity of the algorithm. Tissue iron quantification by MRI may assist in judging severity of ICH and act as a surrogate marker for assessing treatment with iron chelator.
Abstract W P253: Swirl Sign is a Robust Predictor of Spot Sign and Poor Outcome in Ultra-early ICH Patients
Authors: Ovesen Christian , Havsteen Inger , Christensen Anders , Krarup Christine , Christensen Hanne
Published: March 2022

Background:
Spot sign on computed tomography angiography (CTA) is a marker of on-going bleeding and poor outcome in ICH patients. CTA is not as widely available as non-contrast CT (NCCT). The swirl sign is a less well described marker of on-going bleeding on NCCT. We investigated, if the swirl sign can predict spot sign on CTA and as well as its ability to predict poor outcome in ultra-early ICH patients.

Method:
We included 137 patients with spontaneous ICH admitted within 4.5 hours from symptom onset from April 2009 to January 2013. Standard work up included NCCT and CTA. The swirl sign on NCCT was defined as regions of hypo- or isodensity located within the hyperdens haematoma with brain parenchyma as reference. Modified Rankin Scale (mRS) was assessed at 3 months (out-patient clinic or by telephone).

Results:
Of the 35 (25.5%) patients with a swirl sign on NCCT, 27 (77%) also had spot sign on CTA. This yields a high specificity and negative predictive value (0.92 and 0.86 respectably) and a slightly lower sensitivity and positive predictive value (0.66 and 0.77 respectably). The swirl sign emerged as a highly significant predictor of the spot sign (OR 15.5 CI: 5.6-42.8), adjusted for admission haematoma volume and time to scan.

Swirl sign was associated with poorer median [IQR] outcome after 3 months (5 [4-6] vs. 3 [2-5], p < 0.0001). Swirl sign was an independent predictor of poor outcome (mRS 5-6) (OR 3.28 CI: 1.15-9.34) adjusted for age, admission NIHSS, and admission haematoma volume. The presence of both spot and swirl sign did not add to the prediction of poor outcome.

Conclusion:
Swirl sign is a valid marker for the presence of spot sign. The swirl sign entails poor outcome irrespective of other independent predictors. Further studies are needed to evaluate the value of the swirl sign in clinical decision-making and trials.
Abstract W P258: Magnitude of Acute Blood Pressure Decrease Does Not Predict the Presence of Diffusion-Restricted Lesions in Patients With Intracerebral Hemorrhage
Authors: Gioia Laura C , Choi Victor , Kate Mahesh , Emery Derek , Butcher Kenneth
Published: March 2022

Introduction:
Recent studies have shown an association between aggressive blood pressure (BP) reduction in intracerebral hemorrhage (ICH) and the presence of acute ischemic lesions on diffusion-weighted MR imaging (DWI). However, these findings were based on admission or nadir BP measurements. We tested the hypothesis that the magnitude of acute BP decrease is associated with DWI lesions

Methods:
We conducted a retrospective analysis of 51 ICH patients who underwent MR imaging with DWI sequences. DWI lesion volumes were measured using planimetric methods. Systolic BP (SBP), diastolic (DBP), and MAP were recorded at baseline, 1,2,6,12, and 24h. Weighted average BP was calculated as the area under the curve of BP measures over 24h. High SBP, low SBP, and high MAP load (calculated as the fraction of time spent >180, <150, or >130 mmHg, respectively) were also determined.

Results:
Median (IQR) time to MRI was 3.0(4.5) days. Seven patients (14%) demonstrated DWI lesions. Mean DWI volume was 0.97±0.62 ml; 50% of lesions were cortical and 60% were ipsilateral to the hematoma. Median hematoma volume (ml) (16.0(45) vs. 10.5(22), p=0.23) and leukoaraoisis volume (1.8(5.5) vs. 5.6(15.9), p=0.25) did not differ between DWI+ and DWI- patients, respectively. Mean baseline SBP was similar in both groups (171±28 vs. 161.9±28), p=0.44). Weighted mean average SBP in DWI+ patients (158.3±7.5 ml) was similar to that in DWI- patients (143.6±20.4, p=0.21) as was the weighted mean average MAP (102.8±4.3 vs. 98.4±16, p=0.12, respectively). The median 24h decrease in SBP in DWI+ (-20.3 (40.1) mmHg) was similar to that in DWI- patients (-12.7(21), p=0.91). Similarly, high SBP load (5.8% vs. 7.4%, p=0.82), low SBP load (22.5% vs. 60.0%, p=0.16) and high MAP load (6.3% vs. 4.2%,p=0.71) did not differ between groups. Treatment with IV antihypertensive agents was similar in DWI+ (28.6%) and DWI- (29.5%) patients (p=1.00).

Conclusions:
The magnitude of BP decrease, IV treatment and BP load over 24 hours are not predictive of sub-acute ischemic lesion development. These data do not support a hemodynamic mechanism of DWI lesion formation.
Abstract W P261: Predictors of the Need for Intensive Care Unit Admission Following Supratentorial Intracerebral Hemorrhage
Authors: Klaas James , Braksick Sherri , Kofronova Petra , Mandrekar Jay , Rabinstein Alejandro , Brown Robert D
Published: March 2022

Background:
Current guidelines recommend that initial management of patients with an intracerebral hemorrhage (ICH) occur in a neuroscience intensive care unit (ICU). However, some patients can be safely managed without ICU care. We evaluated factors that may predict the need for ICU level of care.

Methods:
We reviewed the medical records of all adult patients with supratentorial ICH presenting within 72 hours of symptom onset seen from 2009-2012. Patients admitted for palliative care or ICH due to a known structural lesion were excluded. Criteria defining need for ICU level of care were: need for intubation/mechanical ventilation, hyperosmolar therapy, neurosurgical procedure, prolonged ICU admission, or significant clinical deterioration. A univariate and multivariable logistic regression analysis was performed on patient demographics, medical comorbidities, time to presentation, vital signs, GCS/FOUR score, medications, laboratory studies, and imaging to identify independent predictors of the need for ICU admission.

Results:
229 patients met inclusion criteria. Based on our triage criteria, 128 patients (56%) required ICU level of care. Multivariable analysis identified five factors that best predicted the need for ICU admission: younger age, shorter time to presentation, lower FOUR score, larger hemorrhage volume, and use of anticoagulants at presentation (table). Intraventricular hemorrhage and GCS score were not significant predictors on the multivariable analysis.

Conclusion:
Age, time to presentation, FOUR score, hemorrhage volume, and use of anticoagulants predict the need for ICU care after ICH. These variables will be used to develop a formula to aid clinicians in appropriate initial triage of patients with ICH.
Abstract W P291: Crime Scene Investigation: Using Simulation to Assess and Demonstrate Annual Competencies
Authors: Hundt Elizabeth
Published: March 2022

Background:
It is a requirement to have licensed and unlicensed care-givers demonstrate clinical competency on an annual basis to ensure the safety of patients. It is often accomplished by the use of didactic education and skill demonstration without observing a patient safety assessment.

Purpose:
The purpose of using an alternative method to assess and confirm annual competencies was to create a situation that would more accurately reflect the skills required by the licensed and unlicensed personnel in the Neurologic Intensive Care Unit.

Methods:
Staff completed computer based learning modules that were determined by the critical care department. After the didactic was completed, personnel reserved a time for competency check-off in a patient room with a simulated patient situation. The providers were given a “report” utilizing common patient diagnoses and procedures in the ICU. A mannequin was surrounded by typical ICU monitoring devices and equipment with a focus on high-risk situations. The nurses and PCT’s were then allotted time to assess the patient and environment, identifying the errors and risks discovered in the simulated patient scenario. Correct identification of the known dangers and errors and being able to state the necessary corrections resulted in confirmed competency for the year.

Results/Lessons Learned:
All care-givers in the Neuro ICU verbalized satisfaction using this method of competency assessment. Staff felt as if it was an accurate demonstration of the skills required to care for critically ill patients presented in a manner that was enjoyable. The benefits to the Clinical Nurses Specialist included identification of common errors or dangers that were over-looked, which formed the teaching plan for unit-based education for the coming year.

Conclusions:
Simulation based skills check-off is an effective and efficient method to ascertain annual competency. Care givers were satisfied with the opportunity to demonstrate their skills in an environment that mimicked their daily practice. While accomplishing the requirement the CNS was also able to assess the learning needs of staff members.
Abstract W P298: Retrospective Review of Inpatient CODE STROKE and Evaluation of the Implementation and Outcomes
Authors: Curtis Adam , Radtke Jennifer , Day Theresa , Blair Sabrina , Henry Jennifer , Heidel Robert E
Published: March 2022

Background /Purpose:
The goal of this study is to evaluate the effectiveness of an inpatient code stroke (ICS) process in achieving benchmarks. This study investigated the effects of an ICS on:

•Discovery to CT result (DCT)

•Discovery to MD evaluation (DMD)

•Documentation of last known normal (LKN) and NIH stroke scale (NIHSS)

The expected results are decreased DCT and DMD times, and increased compliance with documentation of NIHSS and LKN.

Methods:
A multidisciplinary team developed the ICS by integrating the existing ED code stroke and rapid response team processes. All staff received education on recognition of stroke warning signs and activation of ICS prior to implementation. A retrospective case control analysis between subjects with pre and post protocols as the primary predictor and DCT as the primary outcome endpoint. An independent sample t-test between DCT and DMD time (in minutes) was conducted. Unadjusted odds ratios were calculated to assess associations in categorical variables.

Results:
A total of 82 records (pre n=25, post n=57) of inpatients experiencing acute onset of stroke symptoms were examined revealing mean DCT times pre/post-protocol, respectively, of 53.3 (SD 27.6) and 49.7 (SD 18.1). No statistically significant improvement (p=.54) was identified. DMD evaluation time also failed to demonstrate a significant difference between pre/post-protocol times (9.3, 11.3, p=.45). Post-protocol documentation of the NIHSS revealed no significant change (p=.27); however, documentation of LKN was 14.4 times more likely (95% CI 3.98-51.83).

Conclusion:
Implementation of the ICS resulted in a two-fold increase in identification of acute onset of stroke like symptoms. Compliance with documentation of LKN increased significantly which may be the result of the educational initiative and contributed to our increased volume of ICS. In conclusion, though the results of DCT and DMD are not statistically significant, they are promising. The 4 minute decrease in DCT time and narrowing SD suggest that the process has improved flow for in-house acute stroke patients.
Abstract W P30: Middle Cerebral Artery (MCA) Mid-to-distal M1 Segment Occlusion Masquerading as Isolated Central Facial Palsy (I-CFP)
Authors: Bavarsad Shahripour Reza , Sands Kara A , Lyerly Michael J , kumar Geyanendra , Sisson April , Alexandrov Anne W , Cure Joel K , Alexandrov Andrei V
Published: March 2022

Background & Purpose:
Acute MCA occlusions produce well-known syndromes. Historically, I-CFP was largely attributed to lacunar syndromes affecting the corona radiata region or pons. With an advent of multimodal early vascular imaging, we sought to revisit lesion localization with I-CFP.

Subjects & Methods:
Consecutive patients with symptoms of acute cerebral ischemia admitted to the inpatient service from January 2008 to December 2012 had NIHSS scores obtained by a certified neurologist unaware of the purposes of this study. All patients with I-CFP with or without dysarthria and without weakness (total NIHSS scores less than 3) underwent routine multimodal neurovascular imaging consisting of at least two of the following: CT-angiography, MRA, or standardized TCD. All ischemic lesions were localized by MRI within 72 hours from symptom onset.

Results:
Of the 2202 consecutive patients, 879 (35%) had an NIHSS <3 (mean age 63±15 years, 46% women): 9 stroke patients (0.4%) presented with an I-CFP ± dysarthria. Of these, only 1 had a lesion in corona radiata and patent MCA, and 1 had pontine lesion without a proximal vessel occlusion (2/9, or 22%). The remaining 7 patients (78%) had mid-to-distal M1 MCA occlusions (artery-to-artery or cardioembolic stroke mechanism) with 6/7 (86%) having a prominent early anterior temporal artery on imaging or flow diversion on TCD. Corresponding ischemic lesions affecting cortical areas in the frontal lobe are shown in Figure.

Conclusions:
Contrary to the current teaching of lesion localization for I-CFP, the majority of our acute patients had mid-to-distal MCA obstruction and cortical rather than lacunar lesions. This underscores the role of early vascular imaging in patients presenting with mild symptoms that could radically change management. Favorable anatomy and collateralization of flow can explain sparing of the rest of the MCA territory.

Figure
Abstract W P308: Racial Disparities in IV rt-PA Use Persist at Primary Stroke Centers
Authors: Aparicio Hugo J , Carr Brendan G , Kasner Scott E , Albright Karen C , Kallan Michael J , Kleindorfer Dawn O , Mullen Michael T
Published: March 2022

Background:
Primary Stroke Centers (PSCs) utilize more recombinant tissue plasminogen activator (rt-PA) than non-PSCs. The impact of PSCs on racial and ethnic disparities in rt-PA usage is unknown. We sought to evaluate for differential access to PSCs and disparities in rt-PA use using an administrative database.

Methods:
The Nationwide Inpatient Sample was used from 2004-2010, limited to states that publicly reported both hospital identity and race/ethnicity. Patients ≥18 years with a primary ICD9 diagnosis of ischemic stroke (433.x1, 434.x1, 436) were included. Data from The Joint Commission was used to identify PSCs and determine if evaluating hospitals were certified at admission. Rt-PA was defined by ICD9 code 99.10. Multivariable models were constructed, additionally adjusting for year, age, sex, insurance, medical comorbidities, a DRG-based mortality risk indicator, ZIP code median income, and hospital characteristics.

Results:
Data from 26 states met eligibility criteria, including 304,152 discharges of which there were 71.5% White, 15.0% Black, 7.9% Hispanic, and 5.6% Other (Asian/Pacific Islander, Native American, or other). Overall, 24.7% of White, 27.4% of Black, 16.2% of Hispanic, and 29.8% of Other patients presented to PSCs. A higher proportion received rt-PA at PSCs than non-PSCs in all racial/ethnic groups (White 7.6% vs 2.6%, Black 4.8% vs 2.0%, Hispanic 7.1% vs 2.4%, Other 7.2% vs 2.5%). In the fully adjusted model Blacks were less likely to receive rt-PA than Whites at non-PSCs (OR=0.58, 95% CI 0.50-0.67) and PSCs (OR=0.63, 95% CI 0.54-0.74). This disparity was consistent across all subgroups (Figure 1).

Conclusions:
Black patients were less likely to receive rt-PA than White patients at both non-PSCs and PSCs. Relatively fewer Hispanic patients were evaluated at PSCs, though they received rt-PA at a rate similar to White patients. More research is necessary to understand the patient and provider factors underlying these disparities.
Abstract W P31: Are Current Lipid Profile Measurements Reliable for Monitoring Carotid Plaque??
Authors: Jani Vishal B , Arora Shilp , Patel Nilay , Hussain Sayed , Qureshi Adnan , DeMarco Kevin
Published: March 2022

Objective:
To test the hypothesis that lipid indices have a role in monitoring lipid-rich necrotic core (LRNC) burden and to see if this varies with statin exposure.

METHODS:
Cohort of 73 symptomatic carotid stenosis patients were identified with MR angiogram imaging to assess their carotid LRNC percentage determined by 2 independent radiologists and corresponding lipid profiles . Patients were further stratified into two groups as statin naïve (< 30 day exposure to statin) and term statin group (> 1 month exposure to statin).Simple linear regression was performed between with the dependent variable of LRNC size and independent variables of LDL: HDL ratio, TG :HDL ratio and HDL alone.

RESULTS:
Of 73 patients with LRNC percentage reported 26 were statin naive and 47 were term statin users. Overall LDL:HDL, TG:HDL-C and HDL-C were associated (r,P){moderately(0.37, 0.049)}, {weakly(0.23,0.049)}, {Moderately (-0.30 ,0.01)} LRNC size respectively. Patients with statin naive status, LDL:HDL, TG:HDL-C and HDL-C were associated (r,P){strongly (0.6,0.001)},{not(0.37,0.06)},{Strongly(-0.45,0.02)} with LRNC size respectively. After Stratifying with statin status (Term Statin), LDL:HDL, TG:HDL-C and HDL-C were not associated (r,P) {0.18,0.2),(0.17,0.2),(-0.24,0.1)} with LRNC size respectively. Furthermore, longer duration of statin exposure did not reveal a greater reduction in the size of necrotic core (r=-0.004, P=0.96)(see figure).

Conclusions:
Lipid indices correlate better with carotid plaque morphology in statin naïve patients. After starting statin the same indices correlate poorly with LRNC. Poorly controlled hyperlipidemia is a riskfactor for atherosclerosis, but lack of correlation between LRNC size and lipid levels after patients have been placed on statin therapy suggests the individual patient response to clearing LRNC with statin therapy is heterogenous. Persistent large LRNC with statin may improve lipid but, not the future risk of stroke.
Abstract W P314: Comprehensive Stroke Centers Improve Survival in Hemorrhagic Stroke
Authors: McKinney James S , Cheng Jerry , Rybinnik Igor , Paolucci Ugo , Kostis John B
Published: March 2022

Introduction:
Comprehensive stroke centers (CSCs) have been shown to improve clinical outcomes and mitigate disparities in treatment of ischemic stroke patients. CSCs likely also improve outcomes in stroke patients with hemorrhagic stroke.

Methods:
We used the Myocardial Infarction Data Acquisition System (MIDAS) database, which includes demographic and clinical data on patients discharged with a primary diagnosis of intracerebral hemorrhage (ICD-9 431) and subarachnoid hemorrhage (ICD-9 430) from all non-federal acute care hospitals in New Jersey between 1996 and 2011. Out-of-hospital deaths were assessed by matching MIDAS records with New Jersey death registration files. The primary outcome variable was all-cause mortality within 90 days of hospital admission. The primary independent variable was CSC versus primary stroke center (PSC) and non-stroke center (NSC) admission. Covariates included patient demographics, comorbid conditions, and neurosurgical treatment. Multivariate logistic and Cox regression models were used to measure the effect of available covariables.

Results:
39,134 patients were admitted with a hemorrhagic stroke during the study period. Baseline variables are presented in the Table. Neurosurgical intervention rates were low overall, but patients admitted to CSCs were more likely to have a craniotomy/craniectomy (OR 2.09, CI 1.79-2.44), ventricular drain or intracranial pressure monitor (OR 8.97, CI 7.39-10.88), surgical clipping/repair/occlusion of an aneurysm/vessel (OR 3.66, CI 3.31-4.04), or endovascular repair/occlusion of an aneurysm/vessel (OR 22.30, CI 16.28-30.53). CSC admission reduced adjusted 90-day mortality (HR 0.96, CI 0.93-0.99).

Conclusions:
Hemorrhagic stroke patients admitted to CSCs are more likely to receive neurosurgical and endovascular treatments and be alive at 90 days.
Abstract W P319: Isolated National Institute of Health Stroke Scale Subscore Worsening is Predictive of Poor Outcomes in Acute Ischemic Stroke Patients
Authors: Pineda Denise A , Dawson Erica L , Albright Karen C , Siegler James E , Kumar Andre D , Gillette Michael A , Boehme Amelia K , Beasley T. Mark , Martin-Schild Sheryl
Published: March 2022

Background and Objective:
Neurological deterioration is common and contributes to poor outcome after acute ischemic stroke (AIS). The aim of this study is to determine if National Institutes of Health Stroke Scale (NIHSS) subscore changes, in the absence of an increase in total NIHSS score, are associated with poor outcomes.

Methods:
We conducted a retrospective analysis on patients with AIS who presented to our center (07/08-12/10). Two-point ND was defined as ≥2-point worsening on the total NIHSS within 24 hours of admission. NIHSS subscore neurologic deterioration (sND) was defined as a ≥1-point worsening on one or more individual NIHSS item, in the absence of 2-point ND, within 24 hours of admission. Poor functional outcome at the time of discharge (discharge mRS >2) was the primary outcome measure and was compared among patients who experienced sND, those who experienced 2-point ND, and patients with no worsening. Individual NIHSS worsening of particular items on the scale were analyzed.

Results:
A total of 522 patients met inclusion criteria. Patients with sND were at increased odds of poor functional outcome (discharge mRS >2, OR 2.08, 95% CI 1.33-3.25, p=0.001) even after adjusting for age, baseline NIHSS score, and glucose on presentation (Table 1). The association of sND with unfavorable discharge disposition was not maintained after covariate adjustment (OR 1.45, 95% CI 0.82-2.55, p=0.200). The odds of poor functional outcome and unfavorable discharge disposition were highest for isolated deterioration of level of consciousness (LOC) 1a followed by a worsening for motor in any limb (Table 2).

Conclusion:
In our population of patients with AIS, an isolated sND in the absence of 2-point ND was shown to be predictive of poor outcome. This suggests that sND, specifically for LOC 1a and motor limbs, should be included in the scope of the ND definition.