Long-term retreatment rates of cerebral aneurysms in a population-level cohort

BACKGROUND

The likelihood of retreatment in patients undergoing procedures for cerebral aneurysms (CAs) has an important role in deciding the optimal treatment type. Existing determinations of retreatment rates, particularly for unruptured CAs, may not represent current clinical practice.

OBJECTIVE

To use population-level data to examine a large cohort of patients with treated CAs over a 10-year period to estimate retreatment rates for both ruptured and unruptured CAs and explore the effect of changing treatment practices.

METHODS

We used administrative data from all non-federal hospitalizations in California (2005-2011) and Florida (2005-2014) and identified patients with treated CAs. Surgical clipping (SC) and endovascular treatments (ETs) were defined by corresponding procedure codes and an accompanying code for ruptured or unruptured CA. Retreatment was defined as subsequent SC or ET.

RESULTS

Among 19 482 patients with treated CAs, ET was performed in 12 007 (62%) patients and SC in 7475 (38%). 9279 (48%) patients underwent treatment for unruptured CAs and 10203 (52%) for ruptured. Retreatment after 90 days occurred in 1624 (8.3%) patients (11.2% vs 3.7%, ET vs SC). Retreatment rates for SC were greater in unruptured than in ruptured aneurysms (4.6% vs 3.1%), but the opposite was true for ET (10.6% vs 11.8%). 85% of retreatments were within 2 years of the index treatment. Retreatment was associated with age (OR=0.99, 95% CI 0.98 to 0.99), female sex (OR=1.5, 95% CI 1.3 to 1.7), Hispanic versus white race (OR=0.86, 95% CI 0.75 to 0.98), and ET versus SC (OR=3.25, 95% CI 2.85 to 3.71). The adjusted 2-year retreatment rate decreased from 2005 to 2012 for patients with unruptured CAs treated with ET (11% to 8%).

CONCLUSIONS

Retreatment rates for CAs treated with ET were greater than those for SC. However, for patients with unruptured CAs treated with ET, we identify a continuous decline in retreatment rate over the past decade.

Abstract 026: High In-Hospital Systolic Blood Pressure Variability and Poor Functional Outcomes in Primary Intracerebral Hemorrhage Patients

Introduction: High in-hospital SBP variability (HSBPV) is an emerging marker for poor outcomes among Intracerebral Hemorrhage (ICH) patients. We aimed to determine the risk of severe disability or death (SDD) at day-90 among ICH patients with HSPBV and explore pre-hospital factors associated with HSPBV.

Methods: Adult, radiologically confirmed primary ICH patients were prospectively enrolled and followed-up until day-90. All routinely collected SBP values were recorded for the inpatient stay. Inter and intra-patient SBPV was quantified using generalized estimating equations. Modified Rankin Scale (mRS) Score of 4 - 6 was defined as SDD. Poisson and logistic regression models were fit to determine the risk of day-90 SDD, and the association of pre-hospital characteristics with HSBPV.

Results: A total of 566 patients [mean age: 63.5, females 36.6% (207 of 566)] were included. Total in-hospital follow-up period was 4,908 days [median (IQR) per patient = 8.7 (3-11)]. Over 120,500 SBP readings were analyzed. Inter and intra-patient mean SBP standard deviation (SD) was 11.1 and 13.2, respectively. A SD of 13.0 was parameterized as a cut-off for HSBPV. HSBPV patients had a 17% higher adjusted risk of day-90 SDD (Relative Risk, 95% CI: 1.17, 1.02-1.35) (Table). Older age and female sex were independently associated with HSBPV after controlling for hemorrhage volume, pre-morbid mRS, and Glasgow Coma Scale (Figure).

Conclusion: Quantification of HSBPV is feasible utilizing routinely collected SBP readings. HSBPV is associated with poor outcomes. Elderly and female patients may be more likely to demonstrate HSBPV during hospitalization.

Estimates and Temporal Trend for US Nationwide 30-Day Hospital Readmission Among Patients With Ischemic and Hemorrhagic Stroke

IMPORTANCE

Readmission reduction is linked to improved quality of care, saves cost, and is a desirable patient-centered outcome. Nationally representative readmission metrics for patients with stroke are unavailable to date. Such estimates are necessary for benchmarking performance.

OBJECTIVES

To provide US nationwide estimates and a temporal trend for overall, planned, and potentially preventable 30-day hospital readmission among patients with ischemic and hemorrhagic stroke; to investigate the association between hospitals' stroke discharge volume, teaching status, and 30-day readmission; and to highlight reasons for 30-day readmission and explore the association of 30-day readmission in terms of mortality, length of stay, and cost of care among patients with stroke.

DESIGN, SETTING, AND PARTICIPANTS

Cohort, year-wise analysis of the Nationwide Readmissions Database between January 1, 2010, and September 30, 2015. The setting was a population-based cohort study providing national estimates of 30-day readmission. The database represents 50% of all US hospitalizations from 22 geographically dispersed states. Participants were adult (≥18 years) patients with a primary discharge diagnosis of intracerebral hemorrhage, acute ischemic stroke, or subarachnoid hemorrhage. Hospitals were categorized by their annual stroke discharge volume and were classified as teaching hospitals if they had an American Medical Association-approved residency program or had a ratio of full-time equivalent interns and residents to beds of 0.25 or higher.

MAIN OUTCOMES AND MEASURES

Readmission was defined as any admission within 30 days of index hospitalization discharge. Using Centers for Medicare & Medicaid Services-defined algorithms, events were classified as planned or unplanned and as potentially preventable.

RESULTS

Based on study criteria, 2 078 854 eligible patients were included (mean [SE] age, 70.02 [0.07] years; 51.9% female). Thirty-day readmission was highest for patients with intracerebral hemorrhage (13.70%; 95% CI, 13.40%-13.99%), followed by patients with acute ischemic stroke (12.44%; 95% CI, 12.33%-12.55%) and patients with subarachnoid hemorrhage (11.48%; 95% CI, 11.01%-11.96%). On average, there was a 3.3% annual decline in readmission between 2010 and 2014, which was statistically significant for the period of investigation (odds ratio, 0.96; 95% CI, 0.95-0.97). Patients discharged from nonteaching hospitals with high stroke discharge volume were at a significantly higher risk of 30-day readmission, and the top 2 reasons for readmission were acute cerebrovascular disease and septicemia.

CONCLUSIONS AND RELEVANCE

This study suggests that nationally representative readmission metrics can be used to benchmark hospitals' performance, and a temporal trend of 3.3% may be used to evaluate the effectiveness of readmission reduction strategies.

Rationale and Design of a Statewide Cohort to examine efficient resource utilization for patients with Intracerebral hemorrhage (EnRICH)

Background

Intracerebral hemorrhage is a devastating disease with no specific treatment modalities. A significant proportion of patients with intracerebral hemorrhage are transferred to large stroke treatment centers, such as Comprehensive Stroke Centers, because of perceived need for higher level of care. However, evidence of improvement in patient-centered outcomes for these patients treated at larger stroke treatment centers as compared to community hospitals is lacking.

Methods / design

“Efficient Resource Utilization for Patients with Intracerebral Hemorrhage (EnRICH)” is a prospective, multisite, state-wide, cohort study designed to assess the impact of level of care on long-term patient-centered outcomes for patients with primary / non-traumatic intracerebral hemorrhage. The study is funded by the Texas state legislature via the Lone Star Stroke Research Consortium. It is being implemented via major hub hospitals in large metropolitan cities across the state of Texas. Each hub has an extensive network of “spoke” hospitals, which are connected to the hub via traditional clinical and administrative arrangements, or by telemedicine technologies. This infrastructure provides a unique opportunity to track outcomes for intracerebral hemorrhage patients managed across a health system at various levels of care. Eligible patients are enrolled during hospitalization and are followed for functional, quality of life, cognitive, resource utilization, and dependency outcomes at 30 and 90 days post discharge. As a secondary aim, an economic analysis of the incremental cost-effectiveness of treating intracerebral hemorrhage patients at higher levels of care will be conducted.

Discussion

Findings from EnRICH will provide much needed evidence of the effectiveness and efficiency of regionalized care for intracerebral hemorrhage patients. Such evidence is required to inform policy and streamline clinical decision-making.

Serial quantitative neuroimaging of iron in the intracerebral hemorrhage pig model

Iron released after intracerebral hemorrhage (ICH) is damaging to the brain. Measurement of the content and distribution of iron in the hematoma could predict brain damage. In this study, 16 Yorkshire piglets were subjected to autologous blood injection ICH model and studied longitudinally using quantitative susceptibility mapping and R2* relaxivity MRI on day 1 and 7 post-ICH. Phantom calibration of susceptibility demonstrated (1) iron distribution heterogeneity within the hematoma and (2) natural absorption of iron from 154 ± 78 µg/mL (day 1) to 127 ± 33 µg/mL (day 7). R2* in the hematoma decreased at day 7. This method could be adopted for ICH in humans.

Abstract TMP73: Rehabilitation for Patients With Primary Intracerebral Hemorrhage is Associated With Reduced 30-Day Hospital Readmissions

Introduction: Readmission (RA) after stroke is an established quality of care metric and is tied to reimbursements. Administrative databases lack stroke-specific severity indicators and information on post-discharge mortality. We report the cumulative incidence of 30-day RA for patients with primary intracerebral hemorrhage (ICH) from a statewide prospective cohort.

Methods: Eligible ICH patients are consented to participate in the cohort to assess the impact of level of care on patient-centered outcomes across Texas. Patients undergo inpatient evaluation, followed by 30- and 90-day assessments for functional, cognitive, quality of life, dependency, and resource utilization outcomes. We defined 30-day RA as any RA that was assessed 30 days post-acute care hospitalization for the index ICH event. We used survival analyses to provide hazard ratios (HR) and 95% confidence interval (CI), while modeling post-discharge mortality as a competing risk.

Results: Thus far, 158 patients have been enrolled with RA information available for 104. The overall RA rate is 5.1 / 1000 person-days (CI: 3.1-8.3). Among the various factors evaluated (Table 1), 30-day RA is significantly higher for patients with a higher ICH score (HR: 5.67, CI: 1.45-22.19), whereas post-discharge rehabilitation (as compared to discharge to home) appears to reduce the risk of RA, even after accounting for institution-free period of observation (HR: 0.11, CI: 0.01-0.86). Among patients with a high ICH score, those discharged home had significantly higher risk of RA as compared to those who received rehabilitation (Figure 1). Enrollment is continuing; updated analyses will be presented.

Conclusion: Stroke-specific disease severity factors are important to identify to develop effective preventive strategies against RA, and need to be controlled for when comparing RA metrics across patient populations. Influence of post-stroke rehab on curtailing RA for ICH patients needs to be explored further.

Abstract 87: Population-Level Analysis of the Impact of SAMMPRIS on Intracranial Atherosclerosis Management

Introduction: Released in 2011, the SAMMPRIS trial found significantly lower rates of stroke or death in patients with symptomatic intracranial atherosclerotic disease (sICAD) treated with medical management (MM) vs. percutaneous angioplasty and stenting (PTAS), 5.8% vs. 14.7%. However, the intensity with which MM was pursued has called into question the generalizability of the study. We report temporal trends in treatment for sICAD and 30-day event rates in a state-wide cohort, spanning the pre- and post-period of the SAMMPRIS trial.

Methods: Using the Healthcare Cost and Utilization Project database on all discharges from acute care hospitals in Florida (2005-2014), we identified patients admitted for sICAD (defined as ICAD with TIA or stroke), and PTAS or angioplasty alone (AA). Patients were excluded for any diagnosis of ICH, SAH, AVM, aneurysm or trauma.

Results: Among 8,745 patients with sICAD, 541 (6.2%) were treated with PTAS and 230 (2.6%) with AA. The mean(SD) age was 74±13 years, 52% were female, and 60% were white, 24% black and 13% Hispanic. 22% of patients were smokers, 43% had diabetes, and 86% HTN. All patients carried a diagnosis of dyslipidemia. Over the 10-year period, the number of patients diagnosed with sICAD increased; PTAS and AA treatments increased until 2011 and then decreased (Figure). 30-day rates of stroke, hemorrhage or death were comparable in the PTAS vs. AA groups (15.9% vs. 19.5%, p=0.24), and significantly lower in sICAD patients treated without PTAS or AA (6.0%, p<0.0001 vs. both PTAS and AA).

Conclusion: Analysis of population-level data demonstrates reduction in the use of PTAS and angioplasty coinciding with the release of SAMMPRIS. Importantly, 30-day event rates for patients with sICAD treated with MM were comparable to the low rates achieved in the trial.

Abstract 24: Nationwide Trends and Disparities in Utilization of Inpatient Rehabilitation for Stroke Patients

Introduction: Transfer to an inpatient rehabilitation (IR) facility (IRF) provides multiple benefits to stroke patients including improvements in functional independence measures, neurological impairments, stroke-related medical complications, and reduction in readmissions. We report nationwide trends and disparities in post-stroke IR utilization.

Methods: We analyzed the National Inpatient Sample for years 2006 - 2011 and used ICD-9 codes to identify adult patients with ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage. Institutionalized care (IC) included transfer to skilled nursing and long term care facilities. We fit survey design multivariable logistic regression models to determine nationally representative trends in IR utilization and report crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) for factors associated with IR utilization, including level of care (LOC) as defined by teaching status of the hospital.

Results: Based on our criteria 3,112,120 patients were included in analyses, of whom 16.2% utilized IRF. There was a significantly increasing trend in post-stroke IR utilization over the period of investigation (OR 1.06, 95%CI 1.04-1.09), with 19.5% patients discharged to IRF in 2011 (Figure 1). Older age and female gender were independently associated with decreased IR utilization (Table 1). Patients utilizing IR had significantly greater odds of being discharged from a teaching hospital after controlling for demographic, clinical, comorbidity, and resource utilization factors (OR 1.40, 95% CI 1.23 - 1.47).

Conclusion: Our analysis indicates overall low nationwide IR utilization. However, there is an increasing trend in utilization of IR, albeit with age, gender, and LOC disparities. After adjustments, patients discharged from non-teaching hospitals are 29% less likely to receive IR. Further studies should focus on barriers to utilizing post-stroke IR, including socioeconomic status.

Abstract TP310: Inter- Rater Reliability of Telephonic Modified Rankin Scale Obtained for a Telestroke Network

Introduction: The modified Rankin Scale (mRS) has been established as a standard measurement of stroke disability and is widely used in major stroke clinical trials. Previous studies compared inter-rater reliability between face-to-face and telephone assessments; we aimed to evaluate the reliability of the mRS between two rater’s assessments both conducted by telephone.

Objective: Identify the inter-rater reliability of mRS of patients interviewed twice by mRS-certified raters over telephone.

Methods: Patients seen by telemedicine (TM) between 03/2017-04/2017 at UTHealth Lone Star Stroke Consortium spoke sites with discharge diagnosis of ischemic or hemorrhagic stroke and contacted via telephone. They underwent a structured telephone interview conducted by two trained raters of the UTHealth TM research team. The 2 interviews were conducted within 2 weeks of each other. Scoring agreement was measured using the κ statistic.

Results: Total of 65 patients were in-window for 90 day mRS telephone interviews; excluding deaths, mRS of 30 patients were collected by both interviewers. The overall agree ment between two raters was 43.3% (13 cases). It was most common to disagree by one category (10 cases, 33.3%). The unweighted kappa value (κ) for inter-rater agreement was 0.29 (p = 0.0006), and the weighted kappa value (κ w ) was 0.50 (p = 0.0000).

Conclusion: Unlike previous studies, we found reliability of mRS obtained via structured telephone interview in our TM population is uncertain. The inter-rater reliability of mRS assessed by telephone shows discrepancies between interviewers, as >50% of patients did not receive the same score. Our study is limited by small sample size and further studies are needed to confirm our findings. With clinical trials relying on telephone mRS for longitudinal measurement of patient outcome and some requiring mRS on the same patient multiple times during a study, it is important mRS be both reliable and reproducible between different raters.

Abstract 92: Endovascular Thrombectomy Access in the United States: the Current Status and an Optimization Model

Background: Endovascular therapy (EVT) is established for acute ischemic strokes (AIS) with large vessel occlusion (LVO). Timely direct access to EVT-capable centers is integral for EVT utilization and success. We describe and map current EVT access then utilize modeling to optimize it.

Methods: US designated stroke centers were identified and mapped utilizing geo-mapping. Centers were stratified into EVT or non-EVT if they reported ≥1 thrombectomy code for AIS in 2016 to Centers for Medicare and Medicaid Service. Ground and air transportation times (30, 60 and 90 min) to EVT centers were calculated from validated trauma models previously adapted for stroke. An optimization model utilizing a greedy algorithm was employed to maximize population ground access within 60 min, as the standard “golden hour” for patients. Ground transport was utilized over air given current transport practices for stroke. A second optimization was done for 30 minutes to give LVOs the best chance to be taken directly to EVT centers, increasing probability of good outcomes.

Results: 1645 stroke centers were identified (577 were EVT capable). Approximately 137 million/44%, 195 million/63%, 234 million/76% Americans had 30, 60 and 90 min EVT ground access ; leaving 37% of the population beyond 60 min driving distance to EVT centers. 172 million/56%, 268 million/87%, 296 million/96% of the Americans have air access within 30, 60 and 90 mins. 50 hospitals were identified for “flipping” from non-EVT to EVT, which improved 60 min ground access from 63% to 71% giving access to almost 20 million more Americans. 50 hospitals were flipped to improve the 30 min ground access from 44% to 49%, increasing the coverage by 15 million. Figure 1 shows the current and optimized EVT access map.

Conclusion: Only 2/3 of the US population has direct access to EVT within an hour. State and national Efforts should focus on improving access and shorten times to EVT to give patients the best chance for excellent outcome after large strokes.

Abstract 111: Endovascular Therapy for Mild Strokes: How Low Should We Go?

Background: Endovascular therapy (EVT) is the standard of care for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) with NIHSS ≥ 6. LVO patients may present with mild (NIHSS <6) but disabling deficits and were not well represented in RCTs resulting in a NIHSS cutoff of ≥ 6 on AHA guidelines. Milder deficits may not justify EVT risk-benefit ratio. To generate practice level data, we evaluated EVT treatment effect in mild stroke.

Methods: A retrospective cohort from 8 USA and Spain centers of AIS with LVO in the anterior circulation with NIHSS ≤ 6 presenting within 24 hrs (1/12 to 3/17) was pooled. EVT patients were compared with those only treated with medical management (MM). 90 day mRS (0-1 excellent) was chosen as the primary outcome as an appropriate goal for mild stroke. Multivariable analyses compared the treatment effects and their interactions with NIHSS, both as an ordinal and dichotomized (0-3 vs 4-5) variable. Adjustment was made for age, time LSN to EVT center arrival, IV-tPA, occlusion site and ASPECTS. Within center correlation was accounted for.

Results: 223 patients were included (EVT 105, MM 118). The two groups had similar baseline age (65.7 and 66.3 yrs, p=0.73), ASPECTS (9.4 and 9.3 p=0.53), %IV t-PA (39% and 36% p=0.65) and median (IQR) time mins to EVT center 156(66.5-301) and 212(90-387) p=0.09, EVT and MM respectively. There was no difference in outcomes (54.6% EVT vs 53.4% MM) when all patients (NIHSS 0-6) were assessed (aOR 0.94, 95% CI 0.62-1.40, p=0.94); same for NIHSS 0-5 (55.1% EVT vs 55.6% MM), (aOR 0.95, 95% CI 0.71-1.26, p=0.95). For NIHSS 0-3, MM had better outcomes (51.9% EVT vs 74.6% MM), (aOR 0.39, 95% CI 0.25-0.61, p<0.01). For NIHSS 4-5, results favored EVT (57.1% EVT vs 22.2% MM), (aOR 4.04, 95% CI 2.56-6.38, p<0.01). Fig 1, 2 show CIs of EVT and MM as related to NIHSS.

Conclusion: Though limited by a non-randomized comparison, the data suggest a possible benefit for EVT in mild strokes with NIHSS 4-5. In NIHSS ≤3, the intervention had no additive benefit.

Abstract 88: Sphingolipid Profiling Identifies Large Vessel Occlusions at Early Time Points: Results of the ASPIRE-Stroke Study

Background: Rapid identification and transport of patients with large vessel occlusions (LVO) to endovascular-capable hospitals has become increasingly important. We previously demonstrated that brain-specific sphingolipids (SLs) serve as useful plasma markers of brain injury. Here, we test and validate SL biomarkers to differentiate LVO from non-LVO acute ischemic stroke (AIS) and stroke mimics.

Methods: We enrolled consecutive patients with symptoms concerning for AIS and performed SL profiling using HPLC-MS/MS on blood samples obtained at hospital arrival. MS data were aligned and automated peak picking was performed using XCMS, and SLs were identified by exact mass. A classification method using SL plasma concentrations was created using step-wise logistic regression in a derivation arm, and then tested in an independent validation arm.

Results: Among 184 patients with AIS or AIS-mimics, 84 (46%) were female and age was 73 years (IQR 63-84). 81 (44%) were diagnosed with AIS, 32 (17%) with TIA, and 71 (39%) as stroke mimics. Median time from last known well to blood collection was 124 minutes (IQR 65-275) and Los Angeles Motor Scale was 1 (IQR 0-2). Among patients with AIS, median NIHSS was 3 (IQR 2-8) and 33 (41%) had LVO on CTA or MRA. Among 24 SLs definitively identified, 3 (12.5%) were ceramides, 3 (12.5%) were sphingosines, and 18 (75%) were sphingomyelins. Using step-wise regression, a panel of 8 SLs differentiated LVO from non-LVO AIS or stroke mimic with very good accuracy (AUC 0.76 in derivation; 0.72 in validation), comparable to LAMS alone (AUC 0.73). Combining the SL panel with LAMS resulted in superior discrimination (AUC 0.84 in derivation; 0.79 in validation and Figure).

Conclusions: Plasma levels of SLs accurately differentiate LVO from non-LVO AIS and stroke mimics at early time points. A point-of-care SL assay in the field may help triage LVO patients to appropriate centers.

Abstract WP225: Similar Outcomes for Patients Treated With Off-Label vs On-Label Tissue Plasminogen Activator via Telestroke

Introduction: As acute ischemic stroke (AIS) management via Telestroke (TS) increases and the inclusion criteria for tPA expands, it is crucial to evaluate the long term outcomes of patients treated with off-label tPA. Off-label tPA, was defined as treating patients with at least one exclusion criteria, which is either being outside the time window (more than 4.5 hours after last known well time) or having relative contraindications per the AHA 2013 scientific statement for the early management of patients with AIS.

Objective: To compare outcomes of AIS patients who were treated with off-label tPA to those who were treated with on-label tPA via TS.

Methods: From 9/2015-12/2016, we identified 424 suspected AIS patients who were treated with tPA in our TS registry of patients who were evaluated by video consultation at one of 17 spoke hospitals. We compared the baseline characteristics and the outcomes of patients who received off-label vs on-label tPA.

Results: Of 424 suspected AIS patients who were treated with tPA, 86 (20.3%) received off-label tPA. Of 86 patients who received off-label tPA, 60 (69.8%) had relative contraindications and 35 (40.7%) were outside the time window. There was no significant difference between age, gender and race/ethnicity in receiving off-label tPA. Patients with more severe strokes were more likely to receive off-label tPA (p=0.023). The outcome measures including tPA complications, discharge disposition, length of stay and 90-day mRS were not significantly different between off-label and on-label groups after controlling for baseline characteristics.

Conclusion: Our study suggests that patients evaluated via telestroke with more severe stroke were more likely to receive off-label tPA. There was no significant difference between outcome measures of the off-label and on-label group suggesting that the off-label group does not have more tPA complications or worse outcome.

Abstract TP339: Utilization of Comprehensive Stroke Center Services for Patients With Primary Intracerebral Hemorrhage

Introduction: Intracerebral hemorrhage (ICH) patients are routinely transferred to comprehensive stroke centers (CSCs) for neurosurgical and neurocritical care. We compared transferred (TP) and directly presenting (DP) ICH patients at our CSC, and explore the factors associated with non-utilization of CSC Services (NCS).

Methods: We identified primary ICH patients, admitted between 01/01/2016 and 03/31/2017, from our Stroke Registry. We used logistic regression to compare demographics, disease severity, and outcomes between TP and DP, and report odds ratios (OR) and 95% confidence intervals (CI). We categorized patients who did not stay in the neurocritical care unit and did not undergo neurosurgical procedures (including extra-ventricular drain) as NCS patients. We used receiver operative curve (ROC) analyses to determine the discriminatory potential of routinely used severity scales in identifying NCS patients and report area under the curve (AUC).

Results: We included 958 patients in our analyses. TP had significantly lower disease severity and shorter length of stay. Overall, 33.7% of patients were NCS, and NCS patients were more likely to be TP as compared to DP [OR (CI): 1.60 (1.18-2.16)]. NCS patients also had a significantly lower median National Institutes of Health Stroke Scale (NIHSS) and ICH scores, and higher median Glasgow Coma Scale (GCS) score on presentation (Table 1). All three scales had a fair-good individual discrimination for classifying NCS patients (AUC for GCS, NIHSS, ICH Score: 0.71, 0.77, and 0.80 respectively). After dichotomizing GCS at 10 and categorizing NIHSS at 0-5 / 6-15 / 16+, the combined AUC for all three scales was 0.84 (Figure 1).

Conclusion: A third of ICH patients presenting at CSC do not utilize neurosurgical / neurocritical care. Identification and triage of these patients may help optimize ICH care. Disease severity scales may be helpful in classification of these patients. Further validation studies are warranted.

Abstract TP97: Physiological Plasma Concentrations of Atorvastatin and Simvastatin Enhance the Immunomodulatory Effects of Mesenchymal Stromal Cells on Stroke Derived Monocytes

Background: Mesenchymal stromal cells (MSCs) are being investigated as a stroke therapy both in preclinical and clinical trials. MSCs may promote recovery through secretome release and immunomodulation. Approximately one-third of stroke patients are on statins. With cell therapy gaining momentum, we explored the effect of two statins on MSCs.

Methods: Clinical grade bone marrow MSCs from 3 healthy donors at passage 2 were thawed and re-suspended in serum free media. Monocytes (Mo) were isolated from peripheral blood of healthy humans and stroke patients. MSCs and Mo were cultured alone as well as in co-culture and exposed to different doses of atorvastatin and simvastatin. At 24 and 48 hours of incubation, viability of MSCs was measured using ATP assay. 5-bromo-2’-deoxyuridine (BrdU) assay was used to measure proliferation. Media from treated MSCs was analyzed for secretomes and treated cells were analyzed for gene expression changes. Data were averaged for 3 donors.

Results: Both atorvastatin and simvastatin decreased the viability and proliferation of MSCs (Fig. 1A-B), but at physiologically relevant doses both were maintained above 90%. Clinically relevant doses of both drugs decreased the secretion of TNF-α and IL-6 from MSCs upto two fold (Fig. 1C-D). IL-6 expression decreased and IL-10 expression increased dose-dependently in MSCs (data not shown). When co-cultured with Mo from control vs stroke patients, both statins at physiologically relevant doses increased VEGF release and decreased the secretion of IL-6, IL-8 and MCP-1 (Fig. 1E-H).

Conclusion: Exposure of MSCs to statins can alter their immunomodulatory function. Furthermore, these effects are consistent across two commonly prescribed drugs. Our results suggest that stroke trials involving use of intravenous MSCs should consider the impact of statins on MSC function.

Abstract TP278: Decade-Long Trends in Recanalization Therapy at a Large Regional Comprehensive Stroke Center in Texas

Introduction: Recanalization therapy (RT) is the cornerstone of acute ischemic stroke (AIS) management. We present 10-year trend in RT at our center, and explore effects of increasing telemedicine (TM) access and a Mobile Stroke Unit (MSU).

Methods: We identified suspected AIS patients between 01/01/2007-12/31/2016 from our prospectively managed registry. Patients presented directly (DP), were transferred-in (TP) from a regional referring hospital with or without TM consultation, or via the MSU. Pre-established TM/MSU period was from 01/01/2007-12/31/2011. We used logistic regression to explore temporal trends among patient groups, report odds ratios (OR) with 95% confidence intervals, and quantile regression to determine the difference in median (DIM) treatment times.

Results: We reviewed 9,464 suspected AIS cases. 44.8% were in pre-TM/MSU and 55.2% TM/MSU period. Over 10 years, the proportion of DP has significantly reduced [OR 0.84 (0.83-0.86)], whereas non-TM TP has increased [OR 1.05 (1.03-1.06)]. In TM/MSU period, the proportion of TM patients has significantly increased each year [OR 2.00 (1.85-2.16)]. Fig. 1 shows the proportional distribution. 29.3% of patients were treated with tPA; significantly higher during the TM/MSU period compared to pre-TM/MSU [(31.5% vs 21.5%, OR 1.21 (1.11 - 1.33)]. Median onset to needle time was significantly shorter for the TM/MSU period [140(99-193) vs 157(119-198), DIM -17(-10.7,-23.2)], as was the proportion of symptomatic intracranial hemorrhage (sICH) [(1.7% vs 4.2%), OR 0.40(0.25-0.64)]. With each increasing year, a significantly greater proportion of patients were discharged home after controlling for age and NIHSS [OR 1.12 (1.10-1.14)].

Conclusion: Over a decade, we saw a steady increase in proportion of tPA treated cases. With the introduction of TM and the MSU at our institution, more AIS patients received RT, with faster onset to treatment, fewer sICH complications, and improved discharge disposition.

Abstract WP88: In a Pro-inflammatory Environment, Mesenchymal Stromal Cells Exert Anti-inflammatory and Pro-angiogenic Effects on Endothelial Cells

Background: Cell-based therapies such as mesenchymal stromal cells (MSCs) have increasingly shown great promise for ischemic stroke recovery. An understudied target of MSCs may be endothelial cells (ECs). Our study explored the interactions between MSCs and ECs and how this interaction alters EC functionality when exposed to an inflammatory cell stimulus.

Methods: Primary brain ECs were isolated from postnatal 1-4 day old C57BL/6 mice. Primary MSCs were isolated from the bone marrow of C57BL/6 mice. At passage 3, both the primary cells were individually seeded at 50,000 cells per well. To simulate a stroke-like inflammatory environment, we exposed MSCs and ECs to Lipopolysaccharides (LPS) (doses ranging from 0.01ug/ml to 100ug/ml). 24 hours post-LPS exposure, conditioned media from MSCs was collected and added to the treated ECs. At 24 hours of incubation, media was collected from the ECs and IL-6 and VEGF concentrations were measured using ELISA. Viability of ECs following LPS exposure was measured using MTT assay.

Results: Treatment of the ECs using MSC conditioned media significantly reduced the release of IL-6, a pro-inflammatory cytokine at dose ranges of 1ug/ml to 100ug/ml of LPS (Fig. 1A-B). The release of VEGF, a pro-angiogenic cytokine, was significantly increased (Fig. 1C-D). There was no significant change in viability of ECs following different LPS doses (data not shown).

Conclusion: MSCs may release soluble factors that modulate the responses of endothelial cells. MSCs exert anti-inflammatory and pro-angiogeneic effects on ECs in a pro-inflammatory setting. These results identify new targets to better understand how MSCs improve recovery in stroke animal models.

Abstract TP267: Uncertainty-Based Individual Health Preferences for Patients With Primary Intracerebral Hemorrhage

Introduction: Value-based care and patient-perceived outcomes are increasingly important. Standard Gamble (SG) derived utilities directly measure patients’ preferences for health states and form the basis of health economic analyses. We describe distribution of and factors associated with SG utilities (SGU) in a cohort of intracerebral hemorrhage (ICH) patients, and explore changes in SGU over 90 days post-discharge.

Methods: Our study is a multisite cohort aiming to evaluate the comparative effectiveness of ICH patient management at various levels of care across Texas. Consented patients undergo assessments including SG in-hospital, and 30 and 90 days post-discharge. The SG assesses patients’ risk-taking behavior toward achieving a perfect health status, and outputs utility on a scale of 0 - 1 (Figure 1). Median and interquartile range (IQR) are reported for inpatient and day-90 SGU. Quantile regression was used to evaluate factors associated with SGU. Difference in median (DIM) and 95% confidence interval (CI) for the difference are reported.

Results: 158 patients have been enrolled. Inpatient and day-90 SG was obtained from 132 and 54 patients respectively. Median inpatient SGU are significantly lower for older patients, white patients (compared to black patients), and those with higher ICH scores (Table 1). Median day-90 SGU was higher than inpatient SGU (DIM: 0.27; 95% CI: 0.08-0.46). Age >65 and higher ICH score were independently associated with lower SGU (Age: DIM -0.30; 95% CI -0.49, -0.11) (ICH Score: DIM -0.59; 95% CI -0.97, -0.21). Patients with mRS scores 0-3 at day 90 had higher SGU values compared to those with mRS scores 4-5 (DIM: 0.25, 95% CI: 0.09 - 0.41). Enrollment continues; updated analyses to be presented.

Conclusion: Direct assessment of preferences for a morbid condition like ICH provides unique insight into patient values. Assessment of SGU may be routinely conducted in ICH patient studies to generate evidence for comparative effectiveness.

Abstract NS5: It Takes a Village: And Other Lessons Learned from a Large Volume Comprehensive Stroke Center

Introduction: The Joint Commission (TJC) certification as a Comprehensive Stroke Center (CSC) entails coordination across multiple units of clinical / academic institutions, and the demands on resources are daunting. Certification standards lack resource allocation recommendations. We present data on workload quantum and resource requirements based on experiences from a TJC certified, high-volume CSC.

Methods: We conducted a desk audit of frequency-based CSC staff activities. An outside team member conducted interviews, followed by collective adjudication for precise categorization. Redundant and overlapping tasks were removed iteratively, and activities were cross-linked with other sources (meeting minutes, individual calendars, on-call schedules). Person-time per task is a product of number of hours and team members. Person-Hours/Day (PHD) were determined by factoring task frequency. PHDs were used to calculate Full Time Employee (FTE) requirements. Volumes were obtained from our CSC registries.

Results: Our CSC received 2,840 patients between 4/1/2016 and 3/31/2017. Among ischemic stroke patients, 30.5% received IV tPA and 119 underwent intra-arterial thrombectomy. Overall, 60 independent activities were divided into 7 mutually exclusive categories (Table 1). Daily, weekly, and monthly activities collectively constituted 83.3% of all the activities. A total of 67.43 PHDs were computed of which data processes are the most resource consumptive (32.07 PHD) followed by core measures tracking (13.8 PHD) (Figure 1). Collectively, the top two activities account for 68% of all PHD and approximate a requirement of six FTEs. Details of activities will be presented.

Conclusion: Adequate planning and continual assessment of resources is imperative to optimal CSC operations and patients’ quality of care. Resources are significantly volume driven. Integrative nature of data processes are central to CSC functioning and necessitate resource evaluation.

Abstract TP61: Determinants of CT Perfusion Misrepresentation of Ischemic Core in Endovascular Stroke Therapy

Introduction: CT Perfusion (CTP) has become an essential tool in determining candidates for endovascular stroke therapy (EST), particularly in later time windows. However, the reliability of CTP to define infarct core may vary based on time of onset and other clinical factors.

Methods: From our prospective institutional registry, we identified patients between 1/2014 - 3/2017 that underwent EST with successful reperfusion (TICI 2b/3), pre-procedure CTP and 24hr MRI. Source CTP data were analyzed using OleaSphere (La Ciotat, France) rCBF<30% and RAPID (IschemiaView, CA) rCBF<30%. Mismatch (MM) was defined as >10cc disparity between CTP core and 24hr DWI. Multivariate logistic regression assessed factors associated with MM (p<0.05 significant, p<0.10 trend).

Results: Among 109 patients (60 with RAPID) studied, mean age was 63±15, median NIHSS 19[15.5-22], median ASPECTS 8 [7-10], and occlusion location ICA in 19 (17%) and M1 in 90 (83%). CTA collateral grades were 0-2a in 70 (64.2%) and 2b/3 in 36 (35.8%). Median time from onset to CT (LKW-CT) was 128 [77-212] min, and from CTP to recanalization (CTR) of 142.5[111.5-169.5] min. MM occurred in 84 (77%, 8(7.3%) infarct shrinking and 76 (69.7%) infarct growth) using Olea and 38 (63.3%, 1(1.7%) infarct shrinking and 37(61.7%) infarct growth) using RAPID. In adjusted multivariable regression, MM was significantly associated with larger CTP core and lower NIHSS with RAPID (ORs 1.06, 0.87) and larger CT core and poor collaterals with Olea (ORs 1.04, 0.35). Infarct growth was significantly associated with core size, NIHSS and a trend towards LKW-CT in RAPID (ORs 1.05, 0.88, 1.78 and Figure), and collaterals in Olea (OR 0.31). CTR was not associated with infarct growth.

Conclusion: MM between CTP core and MRI infarct occurs frequently, with both infarct growth and shrinkage. The likelihood of infarct growth appears to be related to LKW-CT and collaterals, suggesting that CTP thresholding in later time windows may need to adjusted.

Recent progress in translational research on neurovascular and neurodegenerative disorders

The already established and widely used intravenous application of recombinant tissue plasminogen activator as a re-opening strategy for acute vessel occlusion in ischemic stroke was recently added by mechanical thrombectomy, representing a fundamental progress in evidence-based medicine to improve the patient’s outcome. This has been paralleled by a swift increase in our understanding of pathomechanisms underlying many neurovascular diseases and most prevalent forms of dementia. Taken together, these current advances offer the potential to overcome almost two decades of marginally successful translational research on stroke and dementia, thereby spurring the entire field of translational neuroscience. Moreover, they may also pave the way for the renaissance of classical neuroprotective paradigms.

This review reports and summarizes some of the most interesting and promising recent achievements in neurovascular and dementia research. It highlights sessions from the 9th International Symposium on Neuroprotection and Neurorepair that have been discussed from April 19th to 22nd in Leipzig, Germany. To acknowledge the emerging culture of interdisciplinary collaboration and research, special emphasis is given on translational stories ranging from fundamental research on neurode- and -regeneration to late stage translational or early stage clinical investigations.

Association Between Splenic Contraction and the Systemic Inflammatory Response After Acute Ischemic Stroke Varies with Age and Race

Animal models have demonstrated the deleterious contribution of splenic immunocytes on secondary brain injury after stroke. While previous work has demonstrated splenic contraction (SC) in patients with acute ischemic stroke (AIS) and intracranial hemorrhage (ICH), no clinical studies have examined the relationship between the systemic inflammatory response syndrome (SIRS) with SC in stroke patients. This is a retrospective analysis of a previous prospective observational study where daily spleen sizes were evaluated in 178 acute stroke patients. Spleen contraction was based on previously established normograms of healthy volunteers from the same study. SC from the first 24 h of stroke onset was evaluated against criteria for SIRS for the first 5 days of admission after AIS. Ninety-one patients had verified AIS without concurrent infection at admission. SIRS was not associated with SC at admission. African-American patients with early SIRS had higher odds of having SC. Older patients with persistent SIRS at 72 h had lower odds of SC. At 48 h, there was significantly higher lymphocytosis and lower neutrophils present in patients with SC. Patients with SIRS at 72 h were more likely to have worse discharge mRS. This study provides evidence for an association among SC and SIRS in African-American patients suggesting that spleen changes could be a biomarker for detecting SIRS in this population. Our data also indicate a counter association between SC and a lack of SIRS in patients older than 75. Further studies are needed to ascertain how age affects this association.