Abstract W P155: Racial Differences in Ischemic Stroke Subtypes: The Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS)

Background: It is well known that blacks have higher stroke incidence rates than whites. It is commonly believed that whites have more cardioembolic (CE) and large vessel (LV) ischemic strokes (IS). However, using data from 1993-94, we showed that blacks have higher rates of every IS subtype. We sought to see if this pattern persisted in 2010 within a large, biracial population of 1.3 million representative of the US.

Methods: The GCNKSS is a population-based stroke epidemiology study from five counties in the Greater Cincinnati region. During 2010, we captured all hospitalized strokes by screening ICD-9 codes 430-436. We also captured out-of-hospital strokes by sampling primary care offices and nursing homes. Study nurses abstracted all potential cases. Physicians adjudicated each possible event and then further subtyped IS based on available test results using established methods. Incidence rates per 100,000 and associated 95% confidence intervals (CI) were estimated for each subtype using first-ever IS, with weighting of out-of-hospital event sampling, then age- and sex- adjusted to the 2000 US population. Black/white risk ratios (RR) and 95% CI were also calculated.

Results: In 2010 there were 2219 IS in 2116 patients, and 1693 first-ever IS. Of the 1693 incident IS, 944 (57%) were female, 346 (21%) black, with mean age 69 years. There were 285 (18%) small vessel, 465 (27%) CE, 218 (12%) LV, 107 (6%) other identified cause, and 617 (37%) undetermined. The table shows incident IS rates by subtype and the associated RR. For each subtype of IS, blacks had a higher point estimate than whites in 2010. In 2010, the RR CI’s cross 1.0 for CE and LV, thus the RR is not statistically significant.

Conclusion: It is not clear if these data represent significant differences for CE and LV subtypes in 2010 or statistical variation between periods. Regardless, stroke prevention efforts for blacks should include strategies relevant to all IS subtypes, and not just those for small vessel disease.

Abstract T P367: Stable Childhood Stroke Rates Over 17 years: Report From a Population-Based Study

Background: We have published rates of childhood stroke using our population-based Greater Cincinnati Northern Kentucky Stroke Study for 1993/4 and 1999. We now report population-based rates from additional study periods of 2005 and 2010, and compare rates over time periods.

Methods: We identified all strokes in the Greater Cincinnati/Northern Kentucky (GCNK) region, a biracial population of 1.3 million, during 7/1/93 to 6/30/94 and calendar years 1999, 2005 and 2010. Stroke cases (both hemorrhagic and ischemic) were ascertained by screening for discharge ICD-9 codes 430 - 436 at all local hospitals, 437 - 438, 674 and 747 were also screened at the Children’s Hospital. Childhood stroke is defined as stroke in those <20 years of age at the time of onset. Incidence and overall stroke rates are estimated per 100,000, age-, sex- and race-adjusted to the 2000 US population.

Results: There were 14 strokes in children in 1993/4, 24 strokes in 1999, 15 strokes in 2005 and 17 strokes in 2010. Incidence rates by study period, overall, by race, sex and stroke type are reported in the table. We do not detect any significant change in the incidence rate over time. The overall (first ever or recurrent) stroke rate age-, sex- and race-adjusted to the 2000 US population under 20 years of age for the entire study period, is 4.4/100,000 (95% confidence interval: 3.4, 5.4),. Eleven children died within 30 days yielding an all-cause case fatality rate of 16%. Among all childhood stroke cases, 9 (13%) were identified at hospitals other than the Children’s Hospital.

Conclusions: The childhood stroke incidence rate of 4.1 per 100,000, in the GCNK study region has not changed significantly over 17 years Any study of pediatric stroke incidence should include screening of non-pediatric hospitals, as we found 13% of cases in adult hospitals.

Abstract 80: Trends in Anticoagulant-Associated Intracerebral Hemorrhage and Cardioembolic Ischemic Stroke

Background: The incidence of anticoagulant-associated intracerebral hemorrhage (AAICH) quintupled in our population in the 1990s, while rates of ischemic stroke attributed to atrial fibrillation remained stable. We now extend our study to examine incidence trends for these stroke subtypes through 2010.

Methods: We identified all patients presenting to an emergency department or hospitalized with first-ever ICH in the Greater Cincinnati/Northern Kentucky region during 1988, from 7/93-6/94, and during 1999, 2005, and 2010. AAICH was defined as ICH in patients receiving warfarin, heparin, or a direct thrombin inhibitor. Patients from the same region presenting to an emergency department or hospitalized with first-ever ischemic stroke were identified during 1993/4, 1999, 2005, and 2010. Incidence rates were calculated and adjusted to the 2000 United States population. Estimates of warfarin distribution (in the form of “counting units”) in the United States were obtained for the years 1988 through 2010 from the MIDAS database of IMS Health, Inc. Results: AAICH occurred in 9 of 184 ICH cases (5%) in 1988, 23 of 267 cases (9%) in 1993/4, 54 of 311 cases (17%) in 1999, 63 of 320 cases (20%) in 2005, and 53 of 303 cases (17%) in 2010 (p < .001 for trend). The annual incidence of AAICH increased in the 1990s but remained stable from 1999 to 2010 (p = .29, see table). Incidence rates of ischemic stroke due to atrial fibrillation were stable in the 1990s but increased from 1999 to 2010 (p = .03, see table). Warfarin distribution in the United States quadrupled on a per-capita basis between 1988 and 1999 and grew at a slower rate thereafter. Conclusions: The incidence of AAICH quintupled during the 1990s but stabilized in the 2000s. The incidence of ischemic stroke due to atrial fibrillation has not declined in our population in the last two decades, despite increasing warfarin use.

Abstract T MP92: Variation of Blood Pressure Response of Antihypertensive Agents in Acute Intracerebral Hemorrhage (ICH)

Objectives: Elevated blood pressure (BP) in ICH often requires urgent treatment. Prior studies have shown racial-ethnic differences in response to chronic antihypertensive treatment. Racial-ethnic differences and specific locations of ICH may impact the response to acute antihypertensive treatment (aHTN) in ICH. The aim of this study was to analyze variation of response to aHTN drugs by race-ethnicity and location of ICH.

Methods: We included individuals recruited through the Ethnic/Racial Variations of Intracerebral Hemorrhage study with elevated BP on presentation and received labetalol, nicardipine, or hydralazine as the initial aHTN or who received no treatment despite elevated BP. We excluded individuals treated with multiple aHTN, treated with other aHTN, or lacking documentation of dose. The primary outcome measure was mmHg change in BP per 10 mg of drug administered. Changes in BP were tested using the Wilcoxon rank sum test.

Results: A total of 1153 cases were available for analyses (35% white, 34% black, 31% Hispanic). Blacks were most likely to be treated acutely (52%), followed by Hispanics and whites (41%; 34%; p<0.01). For all three aHTN drugs, no significant racial-ethnic difference in systolic (SBP) or diastolic (DBP) response was found (p=0.92 for SBP; p=0.17 for DBP). Neither SBP nor DBP response differed by drug for lobar (p=0.36 SBP; p=0.25 DBP), deep (p=0.99 SBP; p=0.29 DBP) or posterior fossa (p=0.26 SBP, p=0.11 DBP) locations.

Conclusion: In this large, multiethnic study of ICH, we are unable to detect a difference in BP response to hydralazine, labetalol, and nicardipine across race-ethnicity or locations of ICH. This finding suggests that the most commonly used aHTN agents in ICH regimens do not need to be tailored to ethnicity or ICH location. A larger cohort may provide greater power to detect a smaller difference between the agents.

Abstract T MP77: Intraventricular Hemorrhage and Long-term Incontinencea and Dysmobility After Intracerebral Hemorrhage

Background: After intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH) is associated with worse short- and long-term disability.

Similar to other ventricular diseases, we hypothesized that IVH may be associated with urinary incontinence and gait disturbance.

Methods: The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study is a multi-center, prospective, study of ICH among whites, blacks, and Hispanics. Baseline CT images were analyzed for ICH location and volume, and IVH volume and presence. Incontinence and dysmobility were obtained by Barthel Index at 3 months post stroke. Multivariable logistic regression analysis was used to assess risk factors for incontinence and dysmobility. ICH and IVH volumes were log transformed to minimize extreme volumes influence on models.

Results: Between 8/1/10 and 12/31/13, 2276 cases of ICH were enrolled. Of these, 250 died and 372 were lost to follow-up by 3 months. After removing cases with premorbid modified Rankin (mRankin) >3, lacking Barthel index or imaging, IVH was present in 487 (37.7%) of 1290 cases. Hypertension (88% vs. 84%; p=0.03), larger ICH volume (median 11.1 ml vs. 7.9 ml; p<.0001), and deep ICH (67% vs. 49%; p<.0001) were associated with IVH. Age, sex, anticoagulant use, and pre-stroke mRankin were not. At 3 months, cases with IVH were more likely to have incontinence (41% vs. 20%; p<.0001) and impaired mobility (58% vs. 33% <.0001). After controlling for ICH volume, age, pre-stoke mRS, baseline Glasgow Coma Scale, and sex, IVH volume was independently associated with incontinence and dysmobility (Table).

Conclusion: We found that IVH after ICH is associated with developing long-term incontinence and dysmobility similar to other non-stroke ventricular disease patients. This finding may explain, in part, how IVH continues to affect outcomes after the resolution of IVH.

Abstract 24: Race/Ethnic Differences in Microbleed Characteristics and Association of Microbleeds with Poor Outcomes in the ERICH Study

Background: Microbleeds have been reported in up to 60% of patients with primary intracerebral hemorrhage (ICH) and are an important marker of a progressive, small vessel cerebral vasculopathy. The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study explored the characteristics of microbleeds and their impact on long-term functional outcome.

Methods: ERICH is a multi-center prospective study designed to recruit white, black, and Hispanic cases of ICH. At least every 5th ICH patient enrolled undergoes an MRI. All MRIs are interpreted by a core laboratory blinded to clinical data.

Results: Among 642 patients with a gradient echo (GRE) sequence, 49% had ≥1 microbleeds (mean 13, median 4). Blacks had the highest rate of microbleeds at 54% compared to 48% for Hispanics, and 42% for whites (overall p=0.046; blacks vs. white p=0.018). There was a significant racial/ethnic difference in the overall rate of microbleeds in lobar locations (79% in whites, 73.5% in blacks, 61% in Hispanics, p<0.0001). A multivariable logistic regression model predicting the presence of microbleeds included hypertension (OR=1.62, p=0.037), severity of white matter disease (12 point scale, 1 point OR=1.36, p<0.0001), elevated white blood cell count (10 3 /μL OR=1.06, p=0.012), and race/ethnicity (overall p value 0.111; compared to white, black OR=1.53, p=0.056; Hispanic OR=1.49, p=0.078). The presence of microbleeds was associated with poor outcome (6 month mRS 4-6, OR=2.21, p=0.001) in a logistic regression analysis that included ICH volume (1 cc OR=1.04, p<0.001), Glasgow Coma Scale score (OR=0.82, p<0.001), intraventricular hemorrhage (OR=1.98, p=0.003), and age (5 year OR=1.21, p<0.001).

Conclusions: This study demonstrates substantial differences in microbleed rates across race/ethnicities. This is the first study to report an intermediate microbleed rate among Hispanics relative to white and black ICH cases. In addition to hypertension and leukoaraiosis, our model suggests that inflammation may be an important factor contributing to microbleeds. As a biomarker of progressive vasculopathy and poor outcome, microbleeds may provide a valuable surrogate measure in future studies of therapies targeting optimal approaches to risk factor control.

Abstract T MP68: Validating the Association of Peripheral Monocyte Count with 30-Day Case-Fatality in Intracerebral Hemorrhage

Introduction: Preclinical models suggest an inflammatory response mediated by monocytes may contribute to secondary injury after intracerebral hemorrhage (ICH). We recently found an association of absolute monocyte count (AMC) with 30-day case fatality following ICH. We sought to validate this finding in an independent cohort of ICH patients.

Hypothesis: AMC is independently associated with 30-day case-fatality following ICH.

Methods: The Ethnic/Racial Variations of ICH (ERICH) study is a prospective, multi-center, case-control study of ICH among Caucasian, Black, and Hispanic patients. In 241 adult patients with nontraumatic ICH within 24 hours of symptom onset, demographic information, Glasgow Coma Scale (GCS), ICH volume, 30-day case-fatality, total white blood cell (WBC) count, absolute neutrophil count (ANC), AMC, and hemoglobin concentration were determined. Participating centers were requested to obtain WBC differentials on the 30 most recently enrolled cases. After receiving data on 411 subjects, we excluded 170 subjects whose initial WBC was >24 hours from onset and in those where monocytes and neutrophils were not available, resulting in 241 cases for the analysis. Linear regression was used to evaluate factors associated with ICH volume (log transformed), and logistic regression for factors associated with 30-day case-fatality.

Results: Mean age was 62.8 years (SD ± 14 years), 61.8% were men and 33.6% were Black. Median ICH volume was 9.7ml (IQR 4.3-26.7). After adjusting for patient age and initial hemoglobin, higher ANC (p= 0.001) and total WBC count (p=0.0005) were associated with larger ICH volume, whereas AMC was not (p=0.14). After adjusting for age, GCS, and ICH volume, baseline AMC was independently associated with higher 30-day case-fatality (OR 5.24, 95% CI 1.62-16.89, p=0.0056) whereas ANC (OR 0.85, CI 0.15-4.68, p=0.85) and WBC count (OR 0.58, CI 0.04-7.67, p=0.68) were not.

Conclusions: In this independent cohort an association between higher admission monocytes and case fatality was corroborated independent of known clinical variables. This suggests a specific role of monocytes in secondary injury following ICH. Inflammatory and neuronal apoptotic pathways mediated by monocytes may be a target for neuroprotection in ICH.

Abstract W P227: Analysis of Gender and Time to Arrival Among Ischemic Stroke Patients in the Greater Cincinnati/ Northern Kentucky Stroke Study

Background/ Purpose: Some studies of stroke patients report longer pre-hospital delays in women but vary in their inclusion of factors such as living situation and stroke severity. Other literature suggests gender differences in pre-hospital delays are more prominent in older age groups. The aim of our study was to investigate the relationship between gender and time to ED arrival and the influence of age and stroke severity on this relationship.

Methods: Ischemic stroke patients ≥20 years old presenting to 16 area hospitals within a 5 county region of Greater Cincinnati/ Northern Kentucky during 2010 were included. Data on time from symptom onset to ED arrival and covariates were abstracted by study nurses and reviewed by study physicians. Data were analyzed using logistic regression with time to arrival dichotomized at ≤ 3 hours, overall and stratified by NIHSS and age categories.

Results: 2026 strokes (54% women, 22% black) were included. Time to arrival was not significantly different in women (geometric mean 335 minutes (95% CI 306 - 368) vs. 302 (95%CI 273 – 334), p =.14), and 24% of women vs. 27% of men arrived within 3 hours (p=0.20). More women lived alone (30% vs. 23%, p<.01). Women had a higher median age (74, IQR 60 - 84 vs. 67, IQR 57 – 79, p<.01) and were less likely to have mild stroke (NIHSS≤5) (67% vs. 74%, p<.01). Gender was not associated with delayed time to arrival (OR=1.00, 95%CI 0.79 - 1.27), after adjusting for age, NIHSS, race, insurance status, marital status, living situation, EMS use, pre-stroke mRS, wake-up stroke, night arrival, and prior stroke. Interactions between gender and age and gender and NIHSS were not significant. Those with NIHSS≤5 or who lived alone were less likely to arrive within 3 hours (Table).

Conclusions: After adjusting for factors including age, NIHSS, and living alone, women and men with ischemic stroke had similar times to arrival. The relationship between gender and time to arrival did not change significantly across age or NIHSS categories.

Abstract NS20: Discharge Disposition After Intracerebral Hemorrhage

Introduction: We sought to explore factors that determine discharge disposition after ICH to home-like environment vs. medical facility in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study.

Methods: ERICH is a multi-center, prospective case-control study of ICH among white, black, and Hispanic patients. Hospital discharge data at 19 study centers were collected through chart review. Analysis was restricted to those with pre-stroke modified Rankin Scale (mRS) < 3, available ICH volume, and survivors. ICH volumes were log transformed to minimize the influence of extreme values on modeling.

Results: Between 8/1/10 and 12/31/13, 2276 ICH cases were enrolled, of whom 1499 qualified for analysis (564 black, 513 Hispanic, and 422 white). Univariate analysis examined demographics, past medical history, ICH location, discharge mRS, intraventricular extension, social status (education level, marital. status, employment), and type of insurance. Of the 1499 cases, 541 (36.1%) were discharged to home-like settings (home, relative, or friend) and 958 (63.9%) to medical care (rehabilitation, skilled nursing facility), assisted living, hospital/acute care). In multivariable modeling (Table), significant predictors of discharge disposition were measures of severity (i.e., ICH volume, Glasgow Coma Scale) and ICH location. In addition, types of insurance, age, and ethnicity were significant. Specifically, black ICH cases were more likely to go to a medical facility than Hispanics rather than discharge to home after controlling for severity measures.

Conclusion: Age, ethnicity and insurance status were independent predictors of discharge to a medical facility rather than to home even after controlling for stroke severity measures of ICH volume and presenting GCS. Future analysis is needed to look at 3 month functional outcome was affected by the discharge disposition.

Abstract W MP111: The Impact of Fever on Presentation in Intracerebral Hemorrhage: The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study

Background: Fever on presentation has been demonstrated to be an independent predictor of poor-outcome after ICH. However, prospective data with post-discharge outcomes are limited.

Methods: Associations between fever (≥38°C) on presentation and 3-month outcomes were sought among patients in ERICH, a multicenter, triethnic case-control study of ICH. Patients with missing CT or Glasgow Coma Score (GCS) and those lost to 3-month follow-up were excluded. Rates of fever on presentation were compared across admission characteristics, hospital complications, and 3-month outcomes. Additionally, a multivariate analysis was performed to determine factors associated with fever on presentation.

Results: A total of 1644 patients out of 2276 enrolled by 12/31/2013 met inclusion criteria for the analysis. Fever on presentation with ICH was present in 2.4% of patients. In univariate analyses, fever was associated with (all data are % febrile in each group): ICH volume (<15mL: 1.7% , 15-30mL: 2.3%, 30-45mL: 4.7%, 45-60: 6.6%, >60: 2.9%, p=0.03), higher ED GCS (3-4: 1.8%, 5-12: 3.0% 13-15: 6.6%, p=0.004), and WBC > 10 (yes, 3.4% vs. no, 1.7% p=0.03). Additionally, borderline significance was seen with race (white 3.1%, black 2.9%, Hispanic 1.1%, p=0.06) and ICH Location (lobar 3.9%, primary IVH 3.8%, Deep 1.6%, Brainstem 2.2%, cerebellum 1.7%, p=0.06). Fever on presentation was not associated with 3-month outcomes (mRS 0-2: 2.1%;3-5:1.9%; 6: 3.2%, p=0.45). In a multivariate analysis, fever was associated with GCS (OR 0.9, 95% CI 0.83-0.97) and white or black race (reference Hispanic; white OR 3.0 95% CI 1.14-7.88; Black OR 2.68, 95% CI 1.04-6.96).

Conclusion: Fever is relatively uncommon at admission and does not appear to be associated with poor outcomes.

Abstract W MP110: INR reversal of Oral Anticoagulant-Associated Intracerebral Hemorrhage

Background: The use of oral anticoagulants (OAC) is associated with poor outcome in intracerebral hemorrhage (ICH). In this study we investigated the effect of delayed INR reversal and the factors influencing it in patients with OAC-associated ICH (OAC-ICH).

Methods: Data were obtained from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study which is a prospective, multi-ethnic multicenter study of ICH. Exclusion criteria included missing initial hematoma volume, INR or ED arrival time and being on heparin. Baseline characteristics, INR at baseline and 12h, hematoma location and volume, treatment received, hematoma expansion at 24h, and mortality at 3 months were recorded. INR reversal was defined as INR<1.4 at 12h post admission. Variables associated with INR reversal and case fatality at 3 months in non-OAC users and OAC users with and without INR <1.4 were compared.

Results: A total of 1,746 of 2,276 subjects were included in the analysis. A higher proportion of OAC users (n=185) were white and had hypertension, diabetes, hypercholesterolemia, and lobar ICH than non-users (P<0.05). Baseline INRs for the OAC group were 3.1 (28.7%). Subjects on OAC received fresh frozen plasma (FFP, 44%) monotherapy, either recombinant factor VII or prothrombin complex (FVII/PCC, 7%), or a combination of FFP/FVII/PCC (11%). Increasing age (OR=0.96, 95% CI 0.94-0.98), elevated baseline INR (OR=0.34, 95% CI 0.26-0.43), and use of FFP only (OR=0.07, 95% CI 0.04-0.13) was associated with lack of INR reversal at 12h. Median INR at 12h (IQR) were 1.4 (1.3-1.6), 1.1 (0.9-1.1), and 1.0 (1.0-1.3) for the FFP, PCC/FVII, and FFP/FVII/PCC groups, respectively (p1.4 did not influence the rate of hematoma expansion at 24h. Case fatality at 3 months was 22% for non-OAC-ICH, 34% for OAC-ICH with INR<1.4, and 44% for OAC-ICH with INR>1.4 (p=.0005).

Conclusion: In the ERICH study, patients treated with FFP monotherapy were less likely to have a normalized INR at 12h and this was associated with increased case fatality at 3 months. The use of FVII/PCC may shorten time to INR correction and improve outcome in OAC-ICH.

Abstract T MP37: Incidence of New or Worsening Renal Insufficiency (RI) Among Stroke Patients Receiving IV Contrast Dye: A Population-Based Study

Background: CT angiography (CTA) and conventional angiogram provide timely vascular anatomical information in stroke patients. However, the iodinated contrast dye may cause renal injury. Within a large, biracial population, we examined in-hospital incidence of new or worsening RI in stroke patients and its association with administration of intravenous (IV) dye.

Methods: All residents of the Greater Cincinnati/Northern Kentucky region ≥ 20 years of age with ischemic stroke (IS), subarachnoidhemorrhage (SAH), or intracerebral hemorrhage (ICH) who presented to an emergency department in 2010 and survived at least two days were included. Medical records from the acute hospitalization were retrospectively reviewed, and age, race, sex, stroke risk factors, admission serum creatinine (Cr), vascular imaging, and metformin use were abstracted. Incidence of RI was assessed and stratified by use of IV dye. RI on presentation was defined as history of RI or ESRD or Cr ≥ 1.5 on admission. Development of RI during the hospital stay was defined as renal failure/insufficiency after day 2 of hospitalization or new dialysis documented in the record.

Results: In 2010, 2350 stroke patients in the region met inclusion criteria (86% IS, 11% ICH, 3% SAH); mean age 69 years (SD 15), 22% black, 54% female. Among these patients, 22% had RI at baseline, 25 (3%) developed new RI, while 11 (2% had worsening RI during hospitalization). Among all 2350 patients, 340 (14%) had IV dye-based vascular imaging.

Table presents demographics and incidence of new or worsening RI stratified by IV dye administration.

Discussion: Incidence of new or worsening renal insufficiency in stroke patients in this population based study was extremely low (36/2350;

1.5%). One patient had severe enough RI to warrant new dialysis. We did not find an association between IV dye and new or worsening RI. This confirms prior single-center reports that the risk of severe renal complications after contrast dye is extremely low.

Abstract W MP71: Effect of Race/Ethnicity on Oral Anticoagulant-Associated Intracerebral Hemorrhage

Background: Oral anticoagulant (OAC) use is associated with poor outcome in intracerebral hemorrhage (ICH). The aim of this study was to determine if race/ethnic differences exist in this condition.

Methods: Data were obtained from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study which is a prospective multicenter study of ICH. Exclusion criteria included missing initial hematoma volume or being on heparin or LMWH. Baseline and clinical characteristics, laboratory and imaging data at presentation and 24h, and mortality at 3 months were compared by OAC use and race/ethnicity. ANOVA was used to identify factors affecting initial hematoma volume by location and OAC use. Logistic regression was performed to evaluate risk of hemorrhage based on race/ethnicity.

Results: A total of 2,020 of 2,276 cases met the inclusion criteria and were included in the analysis (627 whites, 739 blacks, and 654 Hispanics) of which 214 (10.5%) were on OAC (54% white, 22% black, and 23% Hispanic). History of hypertension, diabetes, hypercholesterolemia, previous stroke, and atrial fibrillation, elevated INR at admission, infratentorial location, and dementia were associated with OAC use (p<.001). There were no differences in initial hemorrhage volume by race/ethnicity. Among OAC users, median INRs were 2.10 (1.67-2.80) white, 1.89 (1.30-3.05) black, and 2.53 (1.60-3.60) Hispanic (p=0.06). Compared with whites, blacks on OAC were more likely to have deep hemorrhages (OR=1.5, 95%CI=1.2-1.9). Lobar ICH was less commonly seen in blacks (OR= 0.6, 95%CI 0.5-0.7) and Hispanics (OR 0.7, 95%CI 0.5-0.9). No differences were seen in infratentorial ICH. Use of OAC predicted higher case fatality at 3-months (OR=1.7, CI=1.1-2.6). In the subgroup analysis this association remained statistically significant for blacks only (OR=3.2, CI=1.4-7.0).

Conclusion: In the largest prospective study in ICH we found that location and outcome in OAC-associated ICH differ among subjects of different racial/ethnic background. Our findings indicate that OAC-associated ICH is a heterogeneous condition and identifies blacks as a group with increased case fatality rate.

Abstract W P374: Population-Based Eligibility for a Stroke Prevention Trial Evaluating Novel Anticoagulants and Embolic Strokes of Uncertain Etiology: Similar Eligibility as for IV Rt-PA

Introduction: The RESPECT-ESUS trial is proposed to evaluate the best stroke prevention strategy for patients with strokes of uncertain etiology. This trial will compare a novel anticoagulant with antiplatelet agents to prevent recurrent stroke among cryptogenic stroke patients. We sought to evaluate the eligibility for this trial within a large, biracial population representative of the US.

Methods: All adult ischemic stroke patients in 2010 among residents of the 5-county Greater Cincinnati/Northern Kentucky region (population 1.3 million) were ascertained from all local hospitals via ICD-9 codes 430-436. Inclusion and exclusion criteria supplied by the corporate sponsor as of 6/30/14 were applied to the ischemic stroke population. Per trial protocol, a complete workup was defined as brain and both intra- and extracranial vascular imaging, ECHO, telemetry, and EKG.

Results: Of 1894 ischemic stroke patients without hemorrhagic transformation who survived the hospital stay (and not sent to hospice), 138 (7.4%) would have been eligible for RESPECT-ESUS. Inclusion and exclusion criteria are listed in the Table. If we were to assume that every stroke patient received a complete workup and no further etiologies were identified, the “hypothetical” eligibility could be as high as 18.7%.

Discussion: We found that the potential eligibility for the RESPECT-ESUS trial to be low, and in fact is similar to population-based estimates of rt-PA eligibility (6%-8%). Extrapolation of eligibility across the US would be further limited by presentation to an enrolling center and consent refusal rates. Our estimates are based on information obtained during hospitalization, which may over- or underestimate eligibility within the 3-6 month post-event enrollment window. It is likely that centers that participate in the trial will have more complete diagnostic workups, which was a major exclusion in our population, especially the requirement for intracranial vascular imaging.

Abstract W P178: Temporal Trends of Emergency Department Arrival Times after Acute Ischemic Stroke: a Population-Based Study

Introduction: The largest exclusion criterion for thrombolysis in ischemic stroke (IS) continues to be delayed time of presentation to the ED. We hypothesized that public education regarding IS would lead to improved ED arrival times over two decades within our large biracial population.

Methods: We identified all IS patients > 20 years old that presented to an ED by screening ICD-9 codes 430-436 among residents of the Greater Cincinnati/Northern Kentucky Stroke Study region, a biracial population of ~ 1.3 million. Study periods were 7/1/93-6/30/94 and calendar years of 1999, 2005, and 2010. Study nurses abstracted relevant information from the medical record, including symptom onset and ED arrival times, and all potential cases were physician reviewed.

Results: There were 1,749 total IS in 1993/94; 1,959 in 1999; 1830 in 2005; and 1912 in 2010. See Figure that displays the distribution of IS patients with known symptom onset time progressively arriving later in each study period. Arrival times stratified by race and gender showed whites arriving later in 2010 than prior study periods (p=0.02). Similarly, males arrived later in more recent periods (p=0.04). Mild IS (NIHSS <5) were less likely to arrive within 3 hrs p <0.001). Additionally, the percentage of mild IS within our population increased over time (55.8% in 1993/94 vs 62.9% in 2010, p<0.0001). After accounting for the increase in mild IS over time, temporal trends in overall arrival times were no longer significant.

Discussion: We found that IS patients arrived at progressively later times from 1993/4-2010, and this was driven by an increasing proportion of mild IS patients. It is unknown if this increase in prevalence of mild IS patients is due to improved public awareness of mild stroke symptoms, better detection with MRI, or better management of comorbities. More research is needed to determine the reasons for delayed arrival to medical attention, since time from onset dominates the exclusion of patients from rt-PA.

Abstract T MP94: Venous Thromboembolism Complications In Patients With Intracerebral Hemorrhage

Introduction: Intracerebral hemorrhage (ICH) is often more severe than ischemic stroke. Venous thromboembolism (VTE), such as deep vein thrombosis (DVT) and pulmonary embolism (PE) can extend length of stay and impede recovery. For ICH patients, there is the added challenge of timing and dosage of anticoagulation used to prevent VTEs. We sought to describe the rate of VTE and factors associated with it among ICH cases in a multi-ethnic population.

Methods: ERICH is a multi-center, prospective case-control study of ICH among white, black, and Hispanic patients. Data were collected by hospital chart review and personal interview. CT Images were collected and analyzed by a neuroimaging core. Past medical history and acute clinical data were examined for association with VTE during the hospital stay.

Results: Between 8/1/10 and 12/31/13, 2276 cases of ICH were enrolled. CT data are available for 2038 patients. Of these, 63 had VTE complications: 41-DVT, 16-PE, and 6 - both DVT and PE. In univariate analysis, Blacks, previous history of DVT, low GCS at presentation, increased ICH volume, presence of intraventricular hemorrhage (IVH),and need for intubation. In comparison, patients at higher risk for PE were those with past medical history of PE and required intubation (Table). In addition, patients with DVT and PE had higher modified Rankin Scale at both hospital discharge and 3 months. In multivariate analysis, only previous VTE, the need for intubation and the presence of IVH were associated with DVT or PE.

Conclusion: We confirmed within a large and ethnically diverse ICH patient population that clinically diagnosed VTE events are relatively rare at 3%. The strongest risk factor for development of DVT/PE was a prior history of DVT/PE. But the most prevalent risk factor was a need for intubation. Further study is needed to understand the efficacy of VTE preventative strategies among ICH patients.

Abstract 97: Ischemic Lesions in Intracerebral Hemorrhage Associated with Drop in Blood Pressure and Poor Outcomes in the ERICH Study

Background: Up to 1/3 of patients with primary intracerebral hemorrhage (ICH) have acute ischemic lesions remote from the hematoma visualized on diffusion-weighted MRI (DWI). Prior reports associated these lesions with large blood pressure fluctuations in the acute hospital setting. Here, the Ethnic/Racial variations of Intracerebral Hemorrhage (ERICH) study explored predictors of ischemic lesions in primary ICH and their impact on long-term outcomes.

Methods: ERICH is a multi-center, prospective study of ICH among white, black, and Hispanic patients. At least every 5th patient undergoes a study MRI interpreted by a central core blinded to clinical data. We calculated change in mean arterial pressure (delta MAP) by taking the difference in highest and lowest blood pressure prior to MRI.

Results: For the 601 cases with a DWI MRI, mean±SD age was 61±14 years, mean ICH volume was 16±18 cc, 55% were male, 79% had hypertension and 26% had ≥1 DWI lesions. The frequency of DWI lesions differed by ethnicity (blacks 33%, Hispanics 24%, whites 20%, overall p=0.005). The multivariable logistic regression analysis identified lower age (10 year OR=0.68, p<0.001), higher delta MAP (10 unit OR=1.16, p<0.001), higher WMD score (1 unit OR=1.164, p<0.001) and presence of microbleeds (OR=2.122, p=0.001) as predictors of DWI lesions. After controlling for age, ICH volume, IVH and admission GCS, presence of DWI lesions was associated with 6 month poor outcome (MRS 4-6, OR=1.25, p=0.02; Figure).

Conclusions: The ERICH study confirms that large fluctuations in blood pressure during the acute hospitalization period predict DWI lesions, and that DWI lesions predict poor outcomes. We hypothesize that substantial reductions in blood pressure precipitate acute small vessel ischemia in those ICH patients with a more severe underlying diseased vasculature. Further studies are needed to determine whether there is a level of acute blood pressure reduction at which the risks outweigh the benefits.

Abstract W MP73: EMS Triage of Stroke Patients by Stroke Severity: Estimated Impact and Call to Action

Background: Severely affected stroke patients in most U.S. communities are often brought to the nearest or requested community hospital rather than to a comprehensive stroke center. We hypothesized that the additional time to transport these severely affected stroke patients directly to a comprehensive stroke center rather than to a nearby community hospital within the Greater Cincinnati/Northern Kentucky (GCNK) Region would be less than a mean of 15 minutes.

Methods: We included all stroke subjects in the GCNK region during 2005 who were >= age 20, had a documented time of symptom onset, were transported by EMS, lived at home, and had their stroke at home. Pt home addresses and hospitals were geocoded and travel time estimated using road class speed limits for the route with the shortest driving time to the presenting hospital as well as the comprehensive stroke center. The estimated baseline NIHSS was abstracted from hospital medical records and severe strokes were defined as an estimated NIHSS >=15.

Results: Of 2628 hospitalized stroke subjects during 2005, 1019 arrived by EMS of which 469 had a clearly documented time of stroke onset. Of these, 348 occurred at home. Of the 348, 8 could not be geocoded. Of the remaining 340 subjects, 90 (26%) had an NIHSS >=15. The types of strokes and estimated travel times for these 340 subjects are listed in the Table below.

Conclusions: Within the GCNK region, triage of severe stroke patients by EMS personnel from a patient’s home to a comprehensive stroke center, rather than to a nearby or requested community hospital, would add only an average of 6 additional minutes in travel time and would have little effect upon start of IV t-PA therapy. Such triage of stroke patients transported by EMS would facilitate rapid interventional therapy for severe ischemic strokes and assessment, treatment, and neurocritical critical care for ICH and SAH

Abstract T P365: Childhood Stroke: ICD-9 Code Positive Predictive Values for Identifying Hemorrhagic and Ischemic Events

Introduction: Childhood stroke event rates have been reported both using administrative databases and population-based epidemiological studies. The latter include verification of stroke as a case and categorization of type. Administrative databases allow cheaper, quicker estimation of rates and possible extrapolation of estimated rates to population-based rates. However, these estimations rely on the accuracy and interpretation of the ICD-9 coding.

Methods: The Greater Cincinnati/Northern Kentucky Stroke Study measures temporal trends in the incidence rates in a biracial population of 1.3 million. Discharge lists with primary and secondary ICD-9 codes 430-436 from 16 area hospitals for 2010 were obtained; 437-438, 674 and 747 were also included at the Children’s hospital. Detailed information from medical records of potential cases was abstracted by trained research nurses and reviewed by stroke physicians, who determined if the event was a case and, also the event type (hemorrhagic stroke, infarction or transient ischemic attack(TIA)).

Results: A total of 89 potential events in children <20 years of age were reviewed, yielding 19 confirmed cases. Positive predictive values (PPV) for the primary ICD-9 codes for specific types varied from 0% to 100%. Primary and secondary ICD-9 codes, event types, and percent correct are presented in the Table.

Conclusions: Childhood stroke cases captured through selected ICD-9 codes: 430-432, 434.x1, 434.9 and 435.9 (marked with an asterisk in the table) in the primary position would yield 14 strokes/TIAs, and underestimate the number of events by 26%. However, using both primary and secondary codes they would yield 34 strokes//TIAs, and overestimate the number of events by 79%. Population-based epidemiology studies are essential to monitor the validity of using ICD-9 codes to estimate childhood stroke/TIA incidence.

Analysis of tissue plasminogen activator eligibility by sex in the Greater Cincinnati/Northern Kentucky Stroke Study

BACKGROUND AND PURPOSE

Sex differences in recombinant tissue-type plasminogen activator (r-tPA) administration are present in some populations. It is unknown whether this is because of eligibility differences or the modifiable exclusion criterion of severe hypertension. Our aim was to investigate sex differences in r-tPA eligibility, in individual exclusion criteria, and in the modifiable exclusion criterion, hypertension.

METHODS

We included all ischemic stroke patients ≥18 years among residents of the Greater Cincinnati/Northern Kentucky region who presented to 16-area emergency departments in 2005. Eligibility for r-tPA and individual exclusion criteria were determined using 2013 American Heart Association (AHA) and European Cooperative Acute Stroke Study (ECASS) III guidelines.

RESULTS

Of 1837 ischemic strokes, 58% were women, 24% were black. Mean age in years was 72.2 for women and 66.1 for men. Eligibility for r-tPA was similar by sex (6.8% men and 6.1% women; P=0.55), even after adjusting for age (7.0% and 5.9%; P=0.32). Similar proportions of women and men arrived beyond 3- and 4.5-hour time windows, but more women had severe hypertension. There were no sex differences in blood pressure treatment rates among those with severe hypertension (14.6% women and 20.8% men; P=0.21). More women were >80 years and had National Institutes of Health Stroke Scale (NIHSS) >25.

CONCLUSIONS

Within a large, biracial population, eligibility for r-tPA was similar by sex. Women were more likely to have the modifiable exclusion criterion of severe hypertension but were not more likely to be treated. Women were more likely to have 2 of the 5 ECASS III exclusion criteria. Undertreatment of hypertension in women is a potentially modifiable contributor to reported differences in r-tPA administration.

Affected twins in the familial intracranial aneurysm study

BACKGROUND AND PURPOSE

Very few cases of intracranial aneurysms (IAs) in twins have been reported. Previous work has suggested that vulnerability to IA formation is heritable. Twin studies provide an opportunity to evaluate the impact of genetics on IA characteristics, including IA location. We therefore sought to examine IA location concordance, multiplicity, and rupture status within affected twin-pairs.

METHODS

The Familial Intracranial Aneurysm study was a multicenter study whose goal was to identify genetic and other risk factors for formation and rupture of IAs. The study required at least three affected family members or an affected sibling pair for inclusion. Subjects with fusiform aneurysms, an IA associated with an AVM, or a family history of conditions known to predispose to IA formation, such as polycystic kidney disease, Ehlers-Danlos syndrome, Marfan syndrome, fibromuscular dysplasia, or moyamoya syndrome were excluded. Twin-pairs were identified by birth date and were classified as monozygotic (MZ) or dizygotic (DZ) through DNA marker genotypes. In addition to zygosity, we evaluated twin-pairs by smoking status, major arterial territory of IAs, and rupture status. Location concordance was defined as the presence of an IA in the same arterial distribution (ICA, MCA, ACA, and vertebrobasilar), irrespective of laterality, in both members of a twin-pair. The Fisher exact test was used for comparisons between MZ and DZ twin-pairs.

RESULTS

A total of 16 affected twin-pairs were identified. Location concordance was observed in 8 of 11 MZ twin-pairs but in only 1 of 5 DZ twin-pairs (p = 0.08). Three MZ subjects had unknown IA locations and comprised the three instances of MZ discordance. Six of the 11 MZ twin-pairs and none of the 5 DZ twin-pairs had IAs in the ICA distribution (p = 0.03). Multiple IAs were observed in 11 of 22 MZ and 5 of 10 DZ twin-pairs. Thirteen (13) of the 32 subjects had an IA rupture, including 10 of 22 MZ twins.

CONCLUSIONS

We found that arterial location concordance was greater in MZ than DZ twins, which suggests a genetic influence upon aneurysm location. The 16 twin-pairs in the present study are nearly the total of affected twin-pairs that have been reported in the literature to date. Further studies are needed to determine the impact of genetics in the formation and rupture of IAs.

Genome-wide association study of intracranial aneurysm identifies a new association on chromosome 7

BACKGROUND AND PURPOSE

Common variants have been identified using genome-wide association studies which contribute to intracranial aneurysms (IA) susceptibility. However, it is clear that the variants identified to date do not account for the estimated genetic contribution to disease risk.

METHODS

Initial analysis was performed in a discovery sample of 2617 IA cases and 2548 controls of white ancestry. Novel chromosomal regions meeting genome-wide significance were further tested for association in 2 independent replication samples: Dutch (717 cases; 3004 controls) and Finnish (799 cases; 2317 controls). A meta-analysis was performed to combine the results from the 3 studies for key chromosomal regions of interest.

RESULTS

Genome-wide evidence of association was detected in the discovery sample on chromosome 9 (CDKN2BAS; rs10733376: P<1.0×10(-11)), in a gene previously associated with IA. A novel region on chromosome 7, near HDAC9, was associated with IA (rs10230207; P=4.14×10(-8)). This association replicated in the Dutch sample (P=0.01) but failed to show association in the Finnish sample (P=0.25). Meta-analysis results of the 3 cohorts reached statistical significant (P=9.91×10(-10)).

CONCLUSIONS

We detected a novel region associated with IA susceptibility that was replicated in an independent Dutch sample. This region on chromosome 7 has been previously associated with ischemic stroke and the large vessel stroke occlusive subtype (including HDAC9), suggesting a possible genetic link between this stroke subtype and IA.

Infection after intracerebral hemorrhage: risk factors and association with outcomes in the ethnic/racial variations of intracerebral hemorrhage study

BACKGROUND AND PURPOSE

Risk factors for infections after intracerebral hemorrhage (ICH) and their association with outcomes are unknown. We hypothesized there are predictors of poststroke infection and infections drive worse outcomes.

METHODS

We determined prevalence of infections in a multicenter, triethnic study of ICH. We performed univariate and multivariate analyses to determine the association of infection with admission characteristics and hospital complications. We performed logistic regression on association of infection with outcomes after controlling for known determinants of prognosis after ICH (volume, age, infratentorial location, intraventricular hemorrhage, and Glasgow Coma Scale).

RESULTS

Among 800 patients, infections occurred in 245 (31%). Admission characteristics associated with infection in multivariable models were ICH volume (odds ratio [OR], 1.02/mL; 95% confidence interval [CI], 1.01-1.03), lower Glasgow Coma Scale (OR, 0.91 per point; 95% CI, 0.87-0.95), deep location (reference lobar: OR, 1.90; 95% CI, 1.28-2.88), and black race (reference white: OR, 1.53; 95% CI, 1.01-2.32). In a logistic regression of admission and hospital factors, infections were associated with intubation (OR, 3.1; 95% CI, 2.1-4.5), dysphagia (with percutaneous endoscopic gastrostomy: OR, 3.19; 95% CI, 2.03-5.05 and without percutaneous endoscopic gastrostomy: OR, 2.11; 95% CI, 1.04-4.23), pulmonary edema (OR, 3.71; 95% CI, 1.29-12.33), and deep vein thrombosis (OR, 5.6; 95% CI, 1.86-21.02), but not ICH volume or Glasgow Coma Scale. Infected patients had higher discharge mortality (16% versus 8%; P=0.001) and worse 3-month outcomes (modified Rankin Scale ≥3; 80% versus 51%; P<0.001). Infection was an independent predictor of poor 3-month outcome (OR, 2.6; 95% CI, 1.8-3.9).

CONCLUSIONS

There are identifiable risk factors for infection after ICH, and infections predict poor outcomes.

Meta-analysis of genome-wide association studies identifies 1q22 as a susceptibility locus for intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is the stroke subtype with the worst prognosis and has no established acute treatment. ICH is classified as lobar or nonlobar based on the location of ruptured blood vessels within the brain. These different locations also signal different underlying vascular pathologies. Heritability estimates indicate a substantial genetic contribution to risk of ICH in both locations. We report a genome-wide association study of this condition that meta-analyzed data from six studies that enrolled individuals of European ancestry. Case subjects were ascertained by neurologists blinded to genotype data and classified as lobar or nonlobar based on brain computed tomography. ICH-free control subjects were sampled from ambulatory clinics or random digit dialing. Replication of signals identified in the discovery cohort with p < 1 × 10(-6) was pursued in an independent multiethnic sample utilizing both direct and genome-wide genotyping. The discovery phase included a case cohort of 1,545 individuals (664 lobar and 881 nonlobar cases) and a control cohort of 1,481 individuals and identified two susceptibility loci: for lobar ICH, chromosomal region 12q21.1 (rs11179580, odds ratio [OR] = 1.56, p = 7.0 × 10(-8)); and for nonlobar ICH, chromosomal region 1q22 (rs2984613, OR = 1.44, p = 1.6 × 10(-8)). The replication included a case cohort of 1,681 individuals (484 lobar and 1,194 nonlobar cases) and a control cohort of 2,261 individuals and corroborated the association for 1q22 (p = 6.5 × 10(-4); meta-analysis p = 2.2 × 10(-10)) but not for 12q21.1 (p = 0.55; meta-analysis p = 2.6 × 10(-5)). These results demonstrate biological heterogeneity across ICH subtypes and highlight the importance of ascertaining ICH cases accordingly.

Abstract T P340: Delays in Seeking Medical Attention in Intracerebral Hemorrhage

Background: Intracerebral hemorrhage (ICH) is associated with early neurological deterioration and death. Prior studies showed that delays in seeking medical attention may occur among minorities. In this study we investigated the factors affecting time from symptom onset to ER arrival (TOA) in a race/ethnic enriched population.

Methods: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) is a prospective study of spontaneous ICH. Baseline characteristics, presenting symptoms, first contact (911 vs. ER vs. primary physician), ICH volume, location and intraventricular extension, insurance status, GCS at presentation, and TOA were collected. Data was analyzed using generalized linear models and Spearman’s rank correlations. TOA was natural log transformed and a multivariate model was developed using backward elimination (P-value=0.05).

Results: A total of 1158 subjects were enrolled; 28 were excluded due to lack of TOA. Of the 1,030 included 59% were men with 24% whites, 41% blacks, and 35% Hispanics. Mean age was 61±15 years, mean Glasgow Coma Scale (GCS) at presentation was 12.4±3.7 (median=15), and median TOA was 431 min (interquartile range 106-820). Location of ICH was 56% deep, 28% lobar, 8% cerebellum, and 5% brainstem. Approximately 29% of subjects had no medical insurance, 36% had medicare, 18% medicaid, 36% private insurance, and 1% VA insurance. In univariate analysis women, use of 911, EMS run, different presenting symptoms, lobar and deep location, and low GCS were associated with shorter TOA. In multivariate model only women (p=0.05), GCS (p=0.04), use of 911 (p<0.001), EMS run (p<0.001), and weakness and dysarthria as presenting symptoms remained significant. Ethnicity was not a significant predictor (p=0.79). These variables explain 23.3% of the variation in TOA.

Conclusion: Ethnicity and insurance status did not affect time to presentation. Women, use of 911, EMS run, weakness and lower GCS were associated with shorter TOA in ICH. Increased education in target populations with higher incidence of ICH such as minorities on stroke signs/symptoms and use of 911 may expedite access to medical care. Further studies are needed to determine the impact of TOA on outcome.