Intracranial Aneurysm Classifier Using Phenotypic Factors: An International Pooled Analysis

Intracranial aneurysms (IAs) are usually asymptomatic with a low risk of rupture, but consequences of aneurysmal subarachnoid hemorrhage (aSAH) are severe. Identifying IAs at risk of rupture has important clinical and socio-economic consequences. The goal of this study was to assess the effect of patient and IA characteristics on the likelihood of IA being diagnosed incidentally versus ruptured. Patients were recruited at 21 international centers. Seven phenotypic patient characteristics and three IA characteristics were recorded. The analyzed cohort included 7992 patients. Multivariate analysis demonstrated that: (1) IA location is the strongest factor associated with IA rupture status at diagnosis; (2) Risk factor awareness (hypertension, smoking) increases the likelihood of being diagnosed with unruptured IA; (3) Patients with ruptured IAs in high-risk locations tend to be older, and their IAs are smaller; (4) Smokers with ruptured IAs tend to be younger, and their IAs are larger; (5) Female patients with ruptured IAs tend to be older, and their IAs are smaller; (6) IA size and age at rupture correlate. The assessment of associations regarding patient and IA characteristics with IA rupture allows us to refine IA disease models and provide data to develop risk instruments for clinicians to support personalized decision-making.

Risk Factors Associated With Mortality and Neurologic Disability After Intracerebral Hemorrhage in a Racially and Ethnically Diverse Cohort

Introduction

Intracerebral hemorrhage (ICH) is the most severe subtype of stroke. Its mortality rate is high, and most survivors experience significant disability.

Objective

To assess primary patient risk factors associated with mortality and neurologic disability 3 months after ICH in a large, racially and ethnically balanced cohort.

Design, Setting, and Participants

This cohort study included participants from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, which prospectively recruited 1000 non-Hispanic White, 1000 non-Hispanic Black, and 1000 Hispanic patients with spontaneous ICH to study the epidemiological characteristics and genomics associated with ICH. Participants included those with uniform data collection and phenotype definitions, centralized neuroimaging review, and telephone follow-up at 3 months. Analyses were completed in November 2021.

Exposures

Patient demographic and clinical characteristics as well as hospital event and imaging variables were examined, with characteristics meeting P < .20 considered candidates for a multivariate model. Elements included in the ICH score were specifically analyzed.

Main Outcomes and Measures

Individual characteristics were screened for association with 3-month outcome of neurologic disability or mortality, as assessed by a modified Rankin Scale (mRS) score of 4 or greater vs 3 or less under a logistic regression model. A total of 25 characteristics were tested in the final model, which minimized the Akaike information criterion. Analyses were repeated removing individuals who had withdrawal of care.

Results

A total of 2568 patients (mean [SD] age, 62.4 [14.7] years; 1069 [41.6%] women and 1499 [58.4%] men) had a 3-month outcome determination available, including death. The final logistic model had a significantly higher area under the receiver operating characteristics curve (C = 0.88) compared with ICH score alone (C = 0.76; P < .001). Among characteristics associated with neurologic disability and mortality were larger log ICH volume (OR, 2.74; 95% CI, 2.36-3.19; P < .001), older age (OR per 1-year increase, 1.04; 95% CI, 1.02-1.05; P < .001), pre-ICH mRS score (OR, 1.62; 95% CI, 1.41-1.87; P < .001), lobar location (OR, 0.22; 95% CI, 0.16-0.30; P < .001), and presence of infection (OR, 1.85; 95% CI, 1.42-2.41; P < .001).

Conclusions and Relevance

The findings of this cohort study validate ICH score elements and suggest additional baseline and interim patient characteristics were associated with variation in 3-month outcome.

Effect of Primary Prophylactic Antiseizure Medication for Seizure Prevention Following Intracerebral Hemorrhage in the ERICH Study

OBJECTIVES

Intracerebral hemorrhage (ICH) has the highest morbidity and mortality rate of any stroke subtype and clinicians often administer prophylactic antiseizure medications (ASMs) as a means of preventing post-stroke seizures, particularly following lobar ICH. However, evidence for ASM efficacy in preventing seizures and reducing disability is lacking given limited randomized trials. Herein, we report analysis from a large prospective observational study that evaluates the effect of primary prophylactic ASM administration on seizure occurrence and disability following ICH.

MATERIALS AND METHODS

Primary analysis was performed on 1630 patients with ICH enrolled in the ERICH study. A propensity score for administration of prophylactic ASM was developed and patients were matched by the closest propensity score (difference < 0.1). McNemar's test was used to compare occurrence of in-hospital seizure and disability, defined by modified Rankin Score (mRS) ≥ 3 at 3 months post ICH.

RESULTS

Of the 815 matched pairs of patients treated with primary prophylactic ASM, there was no significant difference in seizure occurrence (p = 0.4631) or disability (p = 0.4653). Subset analysis of 280 matched pairs of patients with primary lobar ICH similarly revealed no significant difference in seizure occurrence (p = 0.1011) or disability (p = 1.00) between prophylactically treated and untreated patients.

CONCLUSIONS

Although current guidelines do not recommend primary prophylactic ASM following ICH, clinical use remains widespread. Data from the ERICH study did not find an association between administering primary prophylactic ASM and preventing seizures or reducing disability following ICH, thus providing evidence to influence clinical practice and patient care.

Ethnic and Racial Variation in Intracerebral Hemorrhage Risk Factors and Risk Factor Burden

Importance

Black and Hispanic individuals have an increased risk of intracerebral hemorrhage (ICH) compared with their White counterparts, but no large studies of ICH have been conducted in these disproportionately affected populations.

Objective

To examine the prevalence, odds, and population attributable risk (PAR) percentage for established and novel risk factors for ICH, stratified by ICH location and racial/ethnic group.

Design, Setting, and Participants

The Ethnic/Racial Variations of Intracerebral Hemorrhage Study was a case-control study of ICH among 3000 Black, Hispanic, and White individuals who experienced spontaneous ICH (1000 cases in each group). Recruitment was conducted between September 2009 and July 2016 at 19 US sites comprising 42 hospitals. Control participants were identified through random digit dialing and were matched to case participants by age (±5 years), sex, race/ethnicity, and geographic area. Data analyses were conducted from January 2019 to May 2020.

Main Outcomes and Measures

Case and control participants underwent a standardized interview, physical measurement for body mass index, and genotyping for the ɛ2 and ɛ4 alleles of APOE, the gene encoding apolipoprotein E. Prevalence, multivariable adjusted odds ratio (OR), and PAR percentage were calculated for each risk factor in the entire ICH population and stratified by racial/ethnic group and by lobar or nonlobar location.

Results

There were 1000 Black patients (median [interquartile range (IQR)] age, 57 [50-65] years, 425 [42.5%] women), 1000 Hispanic patients (median [IQR] age, 58 [49-69] years; 373 [37.3%] women), and 1000 White patients (median [IQR] age, 71 [59-80] years; 437 [43.7%] women). The mean (SD) age of patients with ICH was significantly lower among Black and Hispanic patients compared with White patients (eg, lobar ICH: Black, 62.2 [15.2] years; Hispanic, 62.5 [15.7] years; White, 71.0 [13.3] years). More than half of all ICH in Black and Hispanic patients was associated with treated or untreated hypertension (PAR for treated hypertension, Black patients: 53.6%; 95% CI, 46.4%-59.8%; Hispanic patients: 46.5%; 95% CI, 40.6%-51.8%; untreated hypertension, Black patients: 45.5%; 95% CI, 39.%-51.1%; Hispanic patients: 42.7%; 95% CI, 37.6%-47.3%). Lack of health insurance also had a disproportionate association with the PAR percentage for ICH in Black and Hispanic patients (Black patients: 21.7%; 95% CI, 17.5%-25.7%; Hispanic patients: 30.2%; 95% CI, 26.1%-34.1%; White patients: 5.8%; 95% CI, 3.3%-8.2%). A high sleep apnea risk score was associated with both lobar (OR, 1.68; 95% CI, 1.36-2.06) and nonlobar (OR, 1.62; 95% CI, 1.37-1.91) ICH, and high cholesterol was inversely associated only with nonlobar ICH (OR, 0.60; 95% CI, 0.52-0.70); both had no interactions with race and ethnicity. In contrast to the association between the ɛ2 and ɛ4 alleles of APOE and ICH in White individuals (eg, presence of APOE ɛ2 allele: OR, 1.84; 95% CI, 1.34-2.52), APOE alleles were not associated with lobar ICH among Black or Hispanic individuals.

Conclusions and Relevance

This study found sleep apnea as a novel risk factor for ICH. The results suggest a strong contribution from inadequately treated hypertension and lack of health insurance to the disproportionate burden and earlier onset of ICH in Black and Hispanic populations. These findings emphasize the importance of addressing modifiable risk factors and the social determinants of health to reduce health disparities.

What is the median volume of intracerebral hemorrhage and is it changing?

OBJECTIVES

Population-level estimates of the median intracerebral hemorrhage (ICH) volume would allow for the evaluation of clinical trial external validity and determination of temporal trends. We previously reported the median ICH volume in 1988. However, differences in risk factor management, neuroimaging, and demographics may have affected ICH volumes. The goal of this study is to determine the median volume of ICH within a population-based cross-sectional study, including whether it has changed over time.

METHODS

The Genetic and Environmental Risk Factors for Hemorrhagic Stroke study was a population-based study of ICH among residents of the Greater Cincinnati/Northern Kentucky region from 2008 through 2012. This study utilizes those data and compares with ICH cases from the same region in 1988. Initial computed tomography images of the head were reviewed, and ICH volumes were calculated using consistent methodology.

RESULTS

From 2008 through 2012, we identified 1117 cases of ICH. The median volume of ICH was 14.0 mL and was lower in black (11.6) than in white (15.5) patients. Median volumes of lobar and deep ICH were 28.8 mL and 9.8 mL, respectively. Median ICH volume changed significantly from 1988 to 2008-2012, with age-and-race-adjusted volume decreasing from 18.3 mL to 13.76 mL (p = 0.025).

CONCLUSIONS

Median volume of ICH was 13.76 mL, and this should be considered in clinical trial design. Median ICH volume has apparently decreased from 1988 to 2008-2012.

Risk of intracerebral haemorrhage from hypertension is greatest at an early age

Introduction

The risk of intracerebral haemorrhage (ICH) associated with hypertension (HTN) is well documented. While the prevalence of HTN increases with age, the greatest odds ratio (OR) for HTN as a risk for ischemic stroke is at an early age. We sought to evaluate if the risk for ICH from HTN was higher in the youngest patients of each race.

Patients and methods

The Ethnic/Racial Variations of ICH (ERICH) study is a prospective multicenter case-control study of ICH among whites, blacks, and Hispanics. Participants were divided into age groups based on race-specific quartiles. Cases in each race/age group were compared to controls using logistic regression (i.e., cases and controls unmatched). The probability of ICH among cases and controls for each race were compared against independent variables of HTN, quartile of age and interaction of quartile and age also using logistic regression.

Results

Overall, 2033 non-lobar ICH cases and 2060 controls, and 913 lobar ICH cases with 927 controls were included. ORs were highest in the youngest age quartile for non-lobar haemorrhage for blacks and Hispanics and highest in the youngest quartile for lobar haemorrhage for all races. The formal test of interaction between age and HTN was significant in all races for all locations with the exception of lobar ICH in whites (p = 0.2935).

Discussion

Hypertension is a strong independent risk factor for ICH irrespective of location among persons of younger age, consistent with the hypothesis that first exposure to HTN is a particularly sensitive time for all locations of ICH.

Racial Differences in Atrial Cardiopathy Phenotypes in Patients With Ischemic Stroke

OBJECTIVE

To test the hypothesis that thrombogenic atrial cardiopathy may be relevant to stroke-related racial disparities, we compared atrial cardiopathy phenotypes between Black vs White patients with ischemic stroke.

METHODS

We assessed markers of atrial cardiopathy in the Greater Cincinnati/Northern Kentucky Stroke Study, a study of stroke incidence in a population of 1.3 million. We obtained ECGs and reports of echocardiograms performed during evaluation of stroke during the 2010/2015 study periods. Patients with atrial fibrillation (AF) or flutter (AFL) were excluded. Investigators blinded to patients' characteristics measured P-wave terminal force in ECG lead V1 (PTFV1), a marker of left atrial fibrosis and impaired interatrial conduction, and abstracted left atrial diameter from echocardiogram reports. Linear regression was used to examine the association between race and atrial cardiopathy markers after adjustment for demographics, body mass index, and vascular comorbidities.

RESULTS

Among 3,426 ischemic stroke cases in Black or White patients without AF/AFL, 2,391 had a left atrial diameter measurement (mean, 3.65 ± 0.70 cm). Black race was associated with smaller left atrial diameter in unadjusted (β coefficient, -0.11; 95% confidence interval [CI], -0.17 to -0.05) and adjusted (β, -0.15; 95% CI, -0.21 to -0.09) models. PTFV1 measurements were available in 3,209 patients (mean, 3,434 ± 2,525 μV*ms). Black race was associated with greater PTFV1 in unadjusted (β, 1.59; 95% CI, 1.21-1.97) and adjusted (β, 1.45; 95% CI, 1.00-1.80) models.

CONCLUSIONS

We found systematic Black-White racial differences in left atrial structure and pathophysiology in a population-based sample of patients with ischemic stroke.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that atrial cardiopathy phenotypes differ in Black people with acute stroke compared to White people.

Can non-contrast head CT and stroke severity be used for stroke triage? A population-based study

BACKGROUND AND PURPOSE

Acute ischemic stroke (AIS) patients may benefit from endovascular thrombectomy (EVT) up to 24 h since last known normal (LKN). Advanced imaging is required for patient selection. Small or rural hospitals may not have sufficient CT technician and radiology support to rapidly acquire and interpret images. We estimated transfer rates using non-contrast head CT and stroke severity to select patients to be transferred to larger centers for evaluation.

METHODS

We identified all AIS among residents of the study region in 2010. Only cases age ≥ 18 with baseline mRS 0-2 that presented to an ED were included. Among cases that presented between 6 and 24 h from LKN, those without evidence of acute infarct on head CT and with initial NIHSS ≥6 or ≥ 10 were identified.

RESULTS

Of 1359 AIS cases, 448 (33.0%) presented between 6 and 24 h, of which 383 (85.5%) showed no evidence of acute infarct on CT. Of cases with no acute infarct on CT, 89/383 (23.2%) had NIHSS ≥6, of which 66 (74.2%) initially presented to a hospital without thrombectomy capabilities; and 51/383 (13.3%) had NIHSS ≥10, of which 40 (78.4%) presented to a non-thrombectomy hospital.

CONCLUSIONS

In our population, 40-66 AIS patients annually (0.8-1.3/week, or 3-5 patients/100,000 persons/year) may present to non-thrombectomy hospitals and need to be transferred using non-contrast CT and stroke severity as screening tools. Such an approach may sufficiently mitigate the impact of delays in treatment on outcomes, without overburdening the referring nor accepting hospitals.

Combining Imaging and Genetics to Predict Recurrence of Anticoagulation-Associated Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

For survivors of oral anticoagulation therapy (OAT)-associated intracerebral hemorrhage (OAT-ICH) who are at high risk for thromboembolism, the benefits of OAT resumption must be weighed against increased risk of recurrent hemorrhagic stroke. The ε2/ε4 alleles of the apolipoprotein E (APOE) gene, MRI-defined cortical superficial siderosis, and cerebral microbleeds are the most potent risk factors for recurrent ICH. We sought to determine whether combining MRI markers and APOE genotype could have clinical impact by identifying ICH survivors in whom the risks of OAT resumption are highest.

METHODS

Joint analysis of data from 2 longitudinal cohort studies of OAT-ICH survivors: (1) MGH-ICH study (Massachusetts General Hospital ICH) and (2) longitudinal component of the ERICH study (Ethnic/Racial Variations of Intracerebral Hemorrhage). We evaluated whether MRI markers and APOE genotype predict ICH recurrence. We then developed and validated a combined APOE-MRI classification scheme to predict ICH recurrence, using Classification and Regression Tree analysis.

RESULTS

Cortical superficial siderosis, cerebral microbleed, and APOE ε2/ε4 variants were independently associated with ICH recurrence after OAT-ICH (all P<0.05). Combining APOE genotype and MRI data resulted in improved prediction of ICH recurrence (Harrell C: 0.79 versus 0.55 for clinical data alone, P=0.033). In the MGH (training) data set, CSS, cerebral microbleed, and APOE ε2/ε4 stratified likelihood of ICH recurrence into high-, medium-, and low-risk categories. In the ERICH (validation) data set, yearly ICH recurrence rates for high-, medium-, and low-risk individuals were 6.6%, 2.5%, and 0.9%, respectively, with overall area under the curve of 0.91 for prediction of recurrent ICH.

CONCLUSIONS

Combining MRI and APOE genotype stratifies likelihood of ICH recurrence into high, medium, and low risk. If confirmed in prospective studies, this combined APOE-MRI classification scheme may prove useful for selecting individuals for OAT resumption after ICH.

White Matter Lesion Severity is Associated with Intraventricular Hemorrhage in Spontaneous Intracerebral Hemorrhage

BACKGROUND

Intraventricular hemorrhage (IVH) and white matter lesion (WML) severity are associated with higher rates of death and disability in intracerebral hemorrhage (ICH). A prior report identified an increased risk of IVH with greater WML burden but did not control for location of ICH. We sought to determine whether a higher degree of WML is associated with a higher risk of IVH after controlling for ICH location.

METHODS

Utilizing the patient population from 2 large ICH studies; the Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study and the Ethnic/Racial Variations of Intracerebral Hemorrhage study, we graded WML using the Van Swieten Scale (0-1 for mild, 2 for moderate, and 3-4 for severe WML) and presence or absence of IVH in baseline CT scans. We used multivariable regression models to adjust for relevant covariates.

RESULTS

Among 3023 ICH patients, 1260 (41.7%) had presence of IVH. In patients with IVH, the proportion of severe WML (28.6%) was higher compared with patients without IVH (21.8%) (P < .0001). Multivariable analysis demonstrated that moderate-severe WML, deep ICH, and increasing ICH volume were independently associated with presence of IVH. We found an increased risk of IVH with moderate-severe WML (OR = 1.38; 95%Cl 1.03-1.86, P = .0328) in the subset of lobar hemorrhages.

CONCLUSIONS

Moderate to severe WML is a risk for IVH. Even in lobar ICH hemorrhages, severe WML leads to an independent increased risk for ventricular rupture.

Temporal Trends in Stroke Incidence Over Time by Sex and Age in the GCNKSS

Background and Purpose- Sex differences in stroke incidence over time were previously reported from the GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study). We aimed to determine whether these differences continued through 2015 and whether they were driven by particular age groups. Methods- Within the GCNKSS population of 1.3 million, incident (first ever) strokes among residents ≥20 years of age were ascertained at all local hospitals during 5 periods: July 1993 to June 1994 and calendar years 1999, 2005, 2010, and 2015. Out-of-hospital cases were sampled. Sex-specific incidence rates per 100 000 were adjusted for age and race and standardized to the 2010 US Census. Trends over time by sex were compared (overall and age stratified). Sex-specific case fatality rates were also reported. Bonferroni corrections were applied for multiple comparisons. Results- Over the 5 study periods, there were 9733 incident strokes (56.3% women). For women, there were 229 (95% CI, 215-242) per 100 000 incident strokes in 1993/1994 and 174 (95% CI, 163-185) in 2015 (P<0.05), compared with 282 (95% CI, 263-301) in 1993/1994 to 211 (95% CI, 198-225) in 2015 (P<0.05) in men. Incidence rates decreased between the first and last study periods in both sexes for IS but not for intracerebral hemorrhage or subarachnoid hemorrhage. Significant decreases in stroke incidence occurred between the first and last study periods for both sexes in the 65- to 84-year age group and men only in the ≥85-year age group; stroke incidence increased for men only in the 20- to 44-year age group. Conclusions- Overall stroke incidence decreased from the early 1990s to 2015 for both sexes. Future studies should continue close surveillance of sex differences in the 20- to 44-year and ≥85-year age groups, and future stroke prevention strategies should target strokes in the young- and middle-age groups, as well as intracerebral hemorrhage.

Abstract 72: Temporal Trends in Stroke Incidence Over Time by Sex and Age in the Greater Cincinnati Northern Kentucky Stroke Study

Introduction: Data from the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) through 2010 showed that over time, stroke incidence rates decreased to a greater extent in men than in women. We aimed to determine whether this difference continued through 2015 and whether the differences are driven by particular age groups.

Methods: Within the GCNKSS population of 1.3 million, all incident strokes among residents ≥20 years old were ascertained at all local hospitals during 7/93–6/94 and calendar years 1999, 2005, 2010, and 2015. Out-of-hospital cases were sampled. Sex-specific incidence rates per 100,000 were adjusted for age and race, standardized to the 2010 U.S. Census. Trends over time by sex were compared (overall and age-stratified); a Bonferroni correction was applied for multiple comparisons.

Results: In total over the five study periods, there were 9721 incident strokes (ischemic, ICH, and SAH); 56.4% were women. Incidence of ischemic strokes decreased from 254 (95%CI 236,272) in 1993/4 to 177 (95%CI 164,189) in 2015 among men (p<.0001 for trend over time) and from 204 (95%CI 192,217) in 1993/4 to 151 (95%CI 141,161) in 2015 among women (p<.0001). Incidence of ICH/ SAH did not change significantly over time in either sex. In age-stratified analyses, among women, incidence of all strokes decreased among older adults (65–84 years) but not in other age categories (Figure). Among men, incidence over time decreased among older adults (65–84 and ≥ 85 years) but increased in young adults (20–44 years).

Conclusions: Stroke incidence decreased between the early 1990s and 2015 for both sexes, contrary to previous data on trends through 2010 which demonstrated a significant decrease in men but not women. Temporal changes are being driven by the 65–84 year age group in both men and women, as well as the ≥ 85 age group in men. Future prevention strategies should target young and middle age adults for both sexes as well as those over 85 for women.

Abstract WMP51: Ischemic Stroke Rates in Those With Diabetes in the Black and White Population: An Update

Background: We previously reported an increased incidence of stroke in the population with diabetes. This was particularly pronounced in those under 65 years of age. With guidelines now including glycemic monitoring during hospitalization, we examined incidence attributable to diabetes in 2010 and 2015.

Methods: Ischemic strokes in the 5-county Greater Cincinnati/Northern Kentucky region were ascertained, then physician verified, at all 15 area hospitals using ICD-9 codes 430 to 436 or ICD10 codes I60 to I68. First ever ischemic strokes in patients aged 20 years and older were included in this analysis. Population age-specific rates of diabetes were estimated using the 2009-2010 and 2015-2016 NHANES databases, then applied to local population numbers, extracted from the US Census Bureau website, to estimate the denominator for calculation of incidence rates. Incidence rates were adjusted by age race and sex, as appropriate, to the 2010 US population. Diabetes was defined as reported in the electronic medical record or glycohemoglobin A1c &gt 6.4% during hospitalization.

Results: There were a total of 4141 ischemic strokes; 55% female and 22% black. Stroke rates continue to be substantially higher in those with diagnosed diabetes, than those without diabetes overall and for those less than 65 years in both time periods, as well as those 65 years and older except for the black population in 2010. Racial disparities continue in both the less than 65 and 65 years and older age groups. Stroke rates were higher for Blacks in the less than 65 year age group for those both with and without diabetes; with risk ratios ranging from 1.3 to 2.7. Of note the stroke rate has decreased between 2010 and 2015 for those with diabetes <65 years of age. (Table)

Conclusions: The population with diabetes continues to be at increased risk of stroke, especially in those less than 65 years of age and those of black race.

Ischemic Stroke and Bleeding: Clinical Benefit of Anticoagulation in Atrial Fibrillation After Intracerebral Hemorrhage

Background and Purpose- Patients with intracerebral hemorrhage (ICH) and atrial fibrillation (AF) are at risk for ischemic events. While risk calculators (CHA₂DS₂-VASc and HAS-BLED) have been validated to assess risk for ischemic stroke and major bleeding in AF patients, decisions about anticoagulation must consider the net clinical benefit of anticoagulation. Furthermore, stroke and bleeding risk are highly correlated, making decisions more difficult. Methods- We examined patients in the GERFHS III study (Genetic and Environmental Risk Factors for Hemorrhagic Stroke)-a population-based retrospective study of spontaneous ICH patients without a structural or traumatic cause in the Greater Cincinnati/Northern Kentucky region between July 2008 and December 2012. CHA₂DS₂-VASc and HAS-B(L)ED (minus L because labile international normalized ratio was unavailable) scores were calculated for ICH patients with AF. Using a Markov state transition model, we estimated net clinical benefit of anticoagulation relative to no treatment in quality-adjusted life years (QALYs). We defined minimal clinically relevant benefit as 0.1 QALYs. Results- Among 1186 cases of spontaneous ICH, 95 cases had AF and met our survival criteria. Within 1 year, 8 of 95 (8%) would be expected to have a major bleeding event on anticoagulation, and 5 of 95 (5%) of patients would be expected to have an ischemic stroke off anticoagulation. Sixty-eight of 95 (71%) patients would have higher risk for major bleeding than for ischemic stroke. Anticoagulation with directly acting anticoagulants would result in no clinically significant gain or loss in 73%. Roughly 12% would gain >0.1 QALYs, and 15% would lose >0.1 QALYs. Among patients receiving aspirin, most have no significant net clinical benefit or loss. Overall, anticoagulation of the entire cohort would result in an aggregate loss of 0.92 QALYs. Conclusions- Our analysis suggests that universal anticoagulation after ICH would be associated with a net loss of QALY. Additional factors should be considered before anticoagulating patients with AF after ICH. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00930280.

Hemicraniectomy for Supratentorial Primary Intracerebral Hemorrhage: A Retrospective, Propensity Score Matched Study

BACKGROUND AND PURPOSE

Spontaneous supratentorial intracerebral hemorrhage (ICH) contributes disproportionately to stroke mortality, and randomized trials of surgical treatments for ICH have not shown benefit. Decompressive hemicraniectomy (DHC) improves functional outcome in patients with malignant middle cerebral artery ischemic stroke, but data in ICH patients is limited. We hypothesized that DHC would reduce in-hospital mortality and poor functional status (defined as modified Rankin scale ≥5) among survivors at 3 months, without increased complications.

METHODS

We performed a retrospective, case-control, propensity score matched study to determine whether hemicraniectomy affected outcome in patients with spontaneous supratentorial ICH. The propensity score consisted of variables associated with outcome or predictors of hemicraniectomy. Forty-three surgical patients were matched to 43 medically managed patients on ICH location, sex, and nearest neighbor matching. Three-month functional outcomes, in-hospital mortality, and in-hospital complications were measured.

RESULTS

In the medical management group, 72.1% of patients had poor outcome at 3 months compared with 37.2% who underwent hemicraniectomy (odds ratio 4.8, confidence interval 1.6-14). In-hospital mortality was 51.2% for medically managed patients and 16.3% for hemicraniectomy patients (odds ratio 8.5, confidence interval 2.0-36.8). There were no statistically significant differences in the occurrence of in-hospital complications.

CONCLUSIONS

In our retrospective study of selected patients with spontaneous supratentorial ICH, DHC resulted in lower rate of in-hospital mortality and better 3-month functional status compared with medically managed patients. A randomized trial is necessary to evaluate DHC as a treatment for certain patients with spontaneous supratentorial ICH.

Impact of Cerebral Small Vessel Disease on Functional Recovery After Intracerebral Hemorrhage

Background and Purpose- In this study, we aim to investigate the association of computed tomography-based markers of cerebral small vessel disease with functional outcome and recovery after intracerebral hemorrhage. Methods- Computed tomographic scans of patients in the ERICH study (Ethnic and Racial Variations of Intracerebral Hemorrhage) were evaluated for the extent of leukoaraiosis and cerebral atrophy using visual rating scales. Poor functional outcome was defined as a modified Rankin Scale (mRS) of ≥3. Multivariable logistic and linear regression models were used to explore the associations of cerebral small vessel disease imaging markers with poor functional outcome at discharge and, as a measure of recovery, change in mRS from discharge to 90 days poststroke. Results- After excluding in-hospital deaths, data from 2344 patients, 583 (24.9%) with good functional outcome (mRS of 0-2) at discharge and 1761 (75.1%) with poor functional outcome (mRS of 3-5) at discharge, were included. Increasing extent of leukoaraiosis (P for trend, 0.01) and only severe (grade 4) global atrophy (odds ratio, 2.02; 95% CI, 1.22-3.39, P=0.007) were independently associated with poor functional outcome at discharge. Mean (SD) mRS change from discharge to 90-day follow-up was 0.57 (1.18). Increasing extent of leukoaraiosis (P for trend, 0.002) and severe global atrophy (β [SE], -0.23 [0.115]; P=0.045) were independently associated with less improvement in mRS from discharge to 90 days poststroke. Conclusions- In intracerebral hemorrhage survivors, the extent of cerebral small vessel disease at the time of intracerebral hemorrhage is associated with poor functional outcome at hospital discharge and impaired functional recovery from discharge to 90 days poststroke.

Identification and Validation of Hematoma Volume Cutoffs in Spontaneous, Supratentorial Deep Intracerebral Hemorrhage

Background and Purpose- Clinical trials in spontaneous intracerebral hemorrhage (ICH) have used volume cutoffs as inclusion criteria to select populations in which the effects of interventions are likely to be the greatest. However, optimal volume cutoffs for predicting poor outcome in deep locations (thalamus versus basal ganglia) are unknown. Methods- We conducted a 2-phase study to determine ICH volume cutoffs for poor outcome (modified Rankin Scale score of 4-6) in the thalamus and basal ganglia. Cutoffs with optimal sensitivity and specificity for poor outcome were identified in the ERICH ([Ethnic/Racial Variations of ICH] study; derivation cohort) using receiver operating characteristic curves. The cutoffs were then validated in the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage-2) by comparing the c-statistic of regression models for outcome (including dichotomized volume) in the validation cohort. Results- Of the 3000 patients enrolled in ERICH, 1564 (52%) had deep ICH, of whom 1305 (84%) had complete neuroimaging and outcome data (660 thalamic and 645 basal ganglia hemorrhages). Receiver operating characteristic curve analysis identified 8 mL in thalamic (area under the curve, 0.79; sensitivity, 73%; specificity, 78%) and 18 mL in basal ganglia ICH (area under the curve, 0.79; sensitivity, 70%; specificity, 83%) as optimal cutoffs for predicting poor outcome. The validation cohort included 834 (84%) patients with deep ICH and complete neuroimaging data enrolled in ATACH-2 (353 thalamic and 431 basal ganglia hemorrhages). In thalamic ICH, the c-statistic of the multivariable outcome model including dichotomized ICH volume was 0.80 (95% CI, 0.75-0.85) in the validation cohort. For basal ganglia ICH, the c-statistic was 0.81 (95% CI, 0.76-0.85) in the validation cohort. Conclusions- Optimal hematoma volume cutoffs for predicting poor outcome in deep ICH vary by the specific deep brain nucleus involved. Utilization of location-specific volume cutoffs may improve clinical trial design by targeting deep ICH patients that will obtain maximal benefit from candidate therapies.

Association of Apolipoprotein E With Intracerebral Hemorrhage Risk by Race/Ethnicity: A Meta-analysis

Importance

Genetic studies of intracerebral hemorrhage (ICH) have focused mainly on white participants, but genetic risk may vary or could be concealed by differing nongenetic coexposures in nonwhite populations. Transethnic analysis of risk may clarify the role of genetics in ICH risk across populations.

Objective

To evaluate associations between established differences in ICH risk by race/ethnicity and the variability in the risks of apolipoprotein E (APOE) ε4 alleles, the most potent genetic risk factor for ICH.

Design, Setting, and Participants

This case-control study of primary ICH meta-analyzed the association of APOE allele status on ICH risk, applying a 2-stage clustering approach based on race/ethnicity and stratified by a contributing study. A propensity score analysis was used to model the association of APOE with the burden of hypertension across race/ethnic groups. Primary ICH cases and controls were collected from 3 hospital- and population-based studies in the United States and 8 in European sites in the International Stroke Genetic Consortium. Participants were enrolled from January 1, 1999, to December 31, 2017. Participants with secondary causes of ICH were excluded from enrollment. Controls were regionally matched within each participating study.

Main Outcomes and Measures

Clinical variables were systematically obtained from structured interviews within each site. APOE genotype was centrally determined for all studies.

Results

In total, 13 124 participants (7153 [54.5%] male with a median [interquartile range] age of 66 [56-76] years) were included. In white participants, APOE ε2 (odds ratio [OR], 1.49; 95% CI, 1.24-1.80; P < .001) and APOE ε4 (OR, 1.51; 95% CI, 1.23-1.85; P < .001) were associated with lobar ICH risk; however, within self-identified Hispanic and black participants, no associations were found. After propensity score matching for hypertension burden, APOE ε4 was associated with lobar ICH risk among Hispanic (OR, 1.14; 95% CI, 1.03-1.28; P = .01) but not in black (OR, 1.02; 95% CI, 0.98-1.07; P = .25) participants. APOE ε2 and ε4 did not show an association with nonlobar ICH risk in any race/ethnicity.

Conclusions and Relevance

APOE ε4 and ε2 alleles appear to affect lobar ICH risk variably by race/ethnicity, associations that are confirmed in white individuals but can be shown in Hispanic individuals only when the excess burden of hypertension is propensity score-matched; further studies are needed to explore the interactions between APOE alleles and environmental exposures that vary by race/ethnicity in representative populations at risk for ICH.

Stroke Center Certification Is Associated With Improved Guideline Concordance

Measurement of quality of stroke care has become increasingly important, but data come mostly from programs in hospitals that choose to participate in certification programs, which may not be representative of the care provided in nonparticipating hospitals. The authors sought to determine differences in quality of care metric concordance for acute ischemic stroke among hospitals designated as a primary stroke center, comprehensive stroke center, and non-stroke center in a population-based epidemiologic study. Significant differences were found in both patient demographics and in concordance with guideline-based quality metrics. These differences may help inform quality improvement efforts across hospitals involved in certification as well as those that are not.

Abstract 17: Apolipoprotein E and Intracerebral Hemorrhage: A Trans-Ethnic Meta-Analysis

Introduction: Risk of lobar and non-lobar intracerebral hemorrhage (ICH) varies among blacks, whites and Hispanics. We sought to determine whether these differences could be due to variability in the effects of Apolipoprotein E (APOE) epsilon (ε) alleles, the most potent genetic risk factor for ICH.

Methods: Primary ICH cases and controls were collected from US and European sites contributing to the International Stroke Genetic Consortium (ISGC). We meta-analyzed the effects of APOE allele status on ICH risk applying a two-stage clustering approach based on race/ethnicity and the contributing study. Models were adjusted for age, sex, history of hypertension, hypercholesterolemia, warfarin, statin and antiplatelet use, smoking and alcohol use. A propensity score analysis was used to model the influence of APOE against the burden of hypertension across races/ethnicities.

Results: 13,124 subjects (54.5% male, median age 66 years) were included. In whites, APOE ε2 (odds ratio (OR)=1.85, 95% confidence interval (CI)=1.27-2.69, p<0.001) and APOE ε4 (OR=1.94, 95% CI=1.58-2.38, p<0.001) were independently associated with lobar ICH risk, however within self-identified Hispanics and blacks, no associations were found (Figure). After propensity score-matching for hypertension burden, APOE ε4 was associated with lobar ICH risk among whites (OR=1.12, 95% CI=1.08-1.17) and Hispanics (OR=1.07, 95% CI=1.01-1.15, p=0.01), but not blacks (OR=1.02 95% CI=0.98-1.07, p=0.251). APOE ε2 and ε4 did not show an effect on non-lobar ICH risk in any race/ethnicity.

Conclusion: APOE ε4 and ε2 alleles affect lobar ICH risk variably by race and ethnicity. Associations are confirmed in whites but can be shown in Hispanics only when the excess burden of hypertension is propensity score-matched. Further studies are needed to explore interactions between APOE alleles and environmental exposures that vary by race and ethnicity in representative populations at risk for ICH.

Abstract WP265: Racial Differences in Left Atrial Size Among Patients With Ischemic Stroke

Introduction: Blacks in the U.S. face twice the risk of ischemic stroke as whites, and this disparity is not fully explained by established stroke risk factors. Although atrial fibrillation (AF) is a major risk factor for stroke, blacks are less often diagnosed with AF than whites. It is unclear whether this paradox exists because AF is less thoroughly ascertained in blacks compared to whites or because blacks have less predisposing substrate and thus a truly lower risk of AF.

Hypothesis: Based on our prior work, we hypothesized that black patients with ischemic stroke less often have left atrial enlargement, a major predisposing factor for AF.

Methods: We compared left atrial size in black versus white patients in the Greater Cincinnati/Northern Kentucky Stroke Study, a study of racial disparities in stroke incidence in a nationally representative population of 1.3 million. We obtained reports of echocardiograms performed for stroke evaluation among patients in the 2010 and 2015 study periods. Patients with known AF or atrial flutter were excluded. Investigators blinded to patients’ characteristics abstracted left atrial diameter from echocardiogram reports. Linear regression was used to examine the association between race and left atrial diameter after adjustment for demographics, body mass index, and comorbidities.

Results: Among 2,980 cases of ischemic stroke without AF, the median age was 66 years, 52% were female, and 30% were black. The overall mean left atrial diameter was 3.65 (±0.69) cm. Despite a higher burden of vascular risk factors and comorbidities, blacks had significantly smaller left atrial diameters (mean difference, -0.10 cm; 95% CI, -0.04 to -0.17 cm). This difference persisted after adjustment for demographics, comorbidities, and body mass index (adjusted mean difference, -0.15 cm; 95% CI, -0.09 to -0.21 cm).

Conclusions: In a population-based sample, we found that black patients with ischemic stroke had smaller left atrial size than white patients. Our results suggest that the paradox of greater stroke risk but lower AF risk in blacks compared with whites at least partly stems from a lesser degree of AF substrate in blacks.

Abstract WP73: Brain Health Predicts Outcome in Patients With Intracerebral Hemorrhage

Introduction: Intracerebral hemorrhage (ICH) results in high mortality and high rate of disability among survivors. The effects of preexisting small vessel disease (SVD) on functional outcomes after ICH is uncertain and understanding manifestations of brain health such as white matter lesions (WML) and atrophy are a top priority for developing prognostic indicators. Our objective was to determine whether WML and brain atrophy is associated with functional outcomes in ICH patients.

Hypothesis: We hypothesized that higher burden of WML and atrophy will have a poor outcome independent of age, ICH volume, ICH location, IVH, and presenting Glasgow Coma Scale (GCS) score.

Methods: The Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS) III study is a prospective study of hemorrhagic stroke in the Greater Cincinnati/Northern Kentucky region. We utilized the interviewed cohort from the study and systematically graded WML using the Van Swieten Scale (0-4) and measured brain atrophy (2 linear measurements) in baseline head CT scans. The outcome measures included modified Rankin Scale (mRS) at 3 months. Primary outcome was disability or death (mRS 3-6).

Results: A total of 441 CT scans were graded; 48 patients were excluded due to missing mRS. Among the included 393 ICH patients (mean±SD age 71.5± 13.8; 48% females), old age, high ICH volume, low GCS score, severe WML (Van Swieten score 3-4), and atrophy were significantly associated with poor outcomes (mRS 3-6) in univariate analysis. In multivariate analysis, severe WML (p=0.039), atrophy (p= 0.0131), old age (p<0.0001), GCS (p<0.001), ICH location (p<0.0001 for deep, p=0.0033 for infratentorial) and ICH volume (p<0.0001) were associated with poor outcomes.

Conclusion: Poor brain health manifesting as cerebral SVD markers of WML and atrophy are simple and independent baseline predictors of poor outcome in acute ICH. Further study for inclusion into outcome measures such as ICH Score should be considered.

Abstract WP436: White Matter Lesion Severity is Associated With Intraventricular Hemorrhage in Patients With Intracerebral Hemorrhage

Background: Both intraventricular hemorrhage (IVH) and white matter lesion (WML) severity are associated with higher rates of death and disability among cases of intracerebral hemorrhage (ICH). Prior reports suggest higher WML burden is associated with propensity of IVH. However, those analyses were not stratified by location. Our objective was to investigate the hypothesis that a higher degree of WML would be associated with a higher risk of IVH after controlling for ICH location.

Methods: The Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS) III study was a prospective study of hemorrhagic stroke in the Greater Cincinnati/Northern Kentucky region. We utilized the interviewed cohort from the study and systematically graded WML using the Van Swieten Scale (0-4) and presence or absence of IVH in baseline head CT scans. Additional variables included ICH volume, location of ICH and vascular risk factors. We used multiple logistic regression with backward elimination to adjust for relevant covariates.

Results: Among the included 426 ICH patients (mean± SD age 71.2± 13.8; 49% females), 161 (38%) had presence of IVH. In patients with IVH, the proportion of severe WML (39.7%) was significantly higher compared with patients without IVH (27.2%) (p=0.0044). The median volume of ICH was 14.4 mL (IQR, 4.9-46.3) in patients with IVH as compared with 8.9 ml (IQR, 2.6-20.8) in patients without IVH (p<0.0001). In multivariate analysis, moderate WML, severe WML, deep ICH location, and increasing ICH volume were independently associated with presence of IVH.

Conclusion: Moderate to severe white matter lesions are a risk for intraventricular hemorrhage. Further studies are needed to determine if greater severity of IVH or subsequent rupture into IVH are associated with higher grades of WML.

Abstract WMP54: Updated Population Trends in Substance Abuse Preceding Stroke in Young Adults: 1993/1994 to 2015

Objective: To update trends on documented substance abuse among young adults (18-54 years old) with stroke within the Greater Cincinnati/Northern Kentucky Stroke Study population, to include preliminary results from 2015.

Background: Substance abuse is associated with stroke. In our population, we previously reported increases in overall substance abuse, smoking history, and use of alcohol or drugs <24 hours prior to stroke onset. We also found increased illicit drug use in the 35 to 54 age group from 1993/94 through 2010. We now report trends after adding 2015 preliminary results.

>Design/Methods: Using ICD-9 discharge codes 430-436, potential acute stroke events are identified among 18- to 55-year-old residents of the 5 county study region. Five one-year study periods are included (7/93-6/94, 1999, 2005, 2010, 2015). Study nurses abstract all events which then undergo physician review. We searched for trends in smoking history, illicit drug use, heavy alcohol consumption, overall substance abuse (current smoking, alcohol, and illicit drug), and urine/blood test positive for alcohol or illicit drugs at presentation.

Results: There were 2220 stroke events (75 % ischemic). Sex and age distribution remained stable; however, percent black increased from 35% to 46% between 1993/94 and 2015, as did the proportion of ischemic strokes (74% to 77%). Current smoking and alcohol use remained stable while illicit drug use increased significantly overall and within the age subgroups of 18-34 years and 35-54 years (see table).

Conclusions: Illicit drug use continues to increase among young adults with stroke. Even though the possibility of testing bias needs to be explored further, our reported results are likely an under estimation of true rates as there are no readily available tests for new designer drugs which have become more available since the early 2000’s. Future analysis will also focus on the relationship between our findings and the U.S. opioid epidemic.

Abstract WP360: Sex Differences in Patient Centered Outcomes Obtained from Electronic Medical Records in the Greater Cincinnati Northern Kentucky Stroke Study

Introduction: Previous data have shown worse post-stroke outcomes in women than men based on non-patient centered outcomes (modified rankin score (mRS)) obtained via patient contact. Our aim was to compare sex differences in post-stroke outcomes in a population-based cohort using patient-centered outcome measures obtained from the electronic medical record (EMR).

Methods: Patients with ischemic stroke (IS) who presented to a single healthcare system (4 hospitals and outpatient facilities) in Northern Kentucky during 1/2015-12/2015, a subsample of the Greater Cincinnati Northern Kentucky Stroke Study, were included. Those who died prior to study time points were excluded. Cases of IS were ascertained by trained study nurses using ICD codes and EMR review. Outcomes (mRS and quality of life (EQ5D)) were estimated from EMR, a method previously shown to have good interrater agreement with telephone follow-up. EQ5D measures health-related quality of life across 5 dimensions. Utility weighted mRS (UW-mRS) were calculated by applying validated weights to mRS. Outcomes at 3- and 6-months were compared by sex using ordinal logistic regression for mRS and linear regression for UW-mRS and EQ5D, adjusted by demographics, pre-stroke mRS, stroke severity, and co-morbidities.

Results: We included 382 cases; 51% were women, 94% were white. Women were older (median (IQR) 71 (61-81) vs. 66 (57-77)) than men, but pre-stroke mRS was similar (median (IQR) 1 (0-3) vs. 1 (0-2)). NIHSS was similar by sex (median 3 IQR (1-6) vs. 2 (1-5)). After adjustment, 3- and 6-month outcomes were similar by sex.

Conclusions: In our cohort, sex differences in unadjusted outcomes may be related to age, pre-stroke functional status, co-morbidities, and depression, as differences were not present in adjusted models. Relatively minor strokes in our cohort may also explain similar outcomes by sex. Future studies should strive to identify intervenable targets to improve patient-centered outcomes post-stroke.

Abstract TMP57: Racial Disparities in Recurrent Stroke Rates: Preliminary Results From the Greater Cincinnati/Northern Kentucky Population in 2015

Introduction: The REGARDS study previously reported a lack of racial disparity in recurrent ischemic stroke (IS) events, despite large racial differences in incident IS. We sought to evaluate recurrent stroke rates at 1 year after an index ischemic (IS) or hemorrhagic (ICH and SAH) stroke or TIA within a large, biracial population representative of the US in terms of % blacks and sociodemographics with a large number of index events

Methods: The Greater Cincinnati/Northern Kentucky Stroke Study ascertained all hospitalized strokes and TIAs among residents of a 5-county population of 1.3 million in 7/1/14-12/31/14 (blacks only) and 2015 (all residents), as well as recurrent strokes (but not TIAs) in 2016. One year risk of recurrent stroke was estimated by Kaplan-Meier analysis. Association between recurrent stroke and demographics/risk factors was assessed by proportional hazards analysis.

Results: Among the 2014-15 cases, there were 3883 index events (2512 IS, 374 ICH, 92 SAH, 900 TIA, 5 unknown type). Median age was 70 (IQR 59, 81); 27% were black and 54% female. Recurrent events within 12 months of the index event occurred in 319 patients (276 IS, 38 ICH, 5 SAH). Those with recurrence were more likely black than those without (34% vs 27%, p<0.01). No differences between those with recurrence and those without was seen for age at index event (median 70 vs 70, p=0.33) or sex (female 56% vs 54%, p=0.44). One-year risk of recurrent stroke was 9.3% overall (11.3% black, 8.6% white); 10.0% after index IS, 11.2% for ICH/SAH, 7.2% after TIA. Hazard ratio for risk of recurrent stroke for blacks compared with whites, adjusted for age and sex, was 1.38 (95% CI 1.09, 1.75).

Discussion: The risk of recurrent stroke was significantly associated with index event type and stroke risk factors (hypertension, diabetes, smoking, and prior stroke). Black race was not a significant independent predictor of recurrent stroke after adjusting for other known stroke risk factors.

Abstract WP442: Cause of Death After Intracerebral Hemorrhage in the Longitudinal Follow-up of ICH Survivors in ERICH (ERICH-L) Study

Introduction: Anticoagulant therapy after intracerebral hemorrhage (ICH) in patients with atrial fibrillation or deep vein thrombosis has been associated with a marked reduction of death. Prevention of ischemic stroke could explain this reduction. We sought to describe the causes of death after discharge and beyond 30 days in a longitudinal follow-up of a multi-racial/ethnic cohort of ICH. We hypothesized that recurrent ICH and ischemic stroke are the most common cause of death after ICH.

Methods: The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study was a prospective, multi-center, case-control study of ICH among whites, blacks, and Hispanics. Subjects previously in the ERICH study were approached for enrollment in the Longitudinal Follow-up of ICH Survivors (ERICH-L) study. A standardized research interview was completed over the phone and 959 contacts were made with participants and surrogates to capture outcomes of interest at 6-month intervals, including information on ICH recurrence, ischemic stroke, cognitive performance, and cause of death. The median follow-up was 4.3 years with an IQR of 3.2-5.4. The cause of death categories were ICH, cardiac, ischemic CVA, other, cancer, pulmonary, renal, endocrine, accidents, infection, dementia and unknown.

Results: There were 180 deaths (18.8%) reported by surrogates contacted in the ERICH-L study. Of those, 63 causes of death were unknown or considered unverifiable. The most common cause of death reported was decline from the index ICH (32.7%). The next most common cause of death was cardiac (14%), other (12.1%), infection (11.2%), cancer (10.3%) and ischemic stroke (1.9%). Some examples reported as other are liver failure, old age, myelodysplastic syndrome, suicide and Parkinson’s Disease. Recurrent ICH occurred in 4 out of 107 known causes of death. By year 5, cardiac causes surpassed ICH as the cause of death.

Conclusion: Cardiac causes of death were more common than either recurrent ICH or ischemic stroke, surpassed only by decline from the index ICH. Future efforts to prevent causes of death after ICH should address cardiac disease and risk factors. This finding may explain the effect of restarting anticoagulant or antiplatelet therapy and improved mortality.

Abstract 11: Stroke in the Young: Preliminary Results for Temporal Trends in the Age of Stroke Incidence in a Large, Bi-Racial Population

Introduction: Previously, we reported that stroke incidence in the young (age < 55) significantly increased in both blacks and whites over four study periods between 1993 and 2010. Here we further describe this temporal trend, adding data from 2015.

Methods: The Greater Cincinnati/Northern Kentucky region includes 2 southern Ohio and 3 contiguous Northern Kentucky counties (estimated population, 1.3 M). Our study determined first-ever hospital-ascertained strokes that occurred in the population from 7/1/93 to 6/30/94 and in calendar years 1999, 2005, 2010, and 2015 by screening ICD9 (and ICD10, in 2015) codes of all inpatient and emergency department visits. Cases were abstracted by study nurses and verified by study physicians. Results for 2015 are preliminary. The denominator for the calculation of incidence rates (in those aged ≥20 years) was extracted from the U.S. Census Bureau website (www.census.gov). Age- and race -specific incidence rates with 95% confidence intervals (CI) were calculated assuming a Poisson distribution. We tested for differences in age trends using Student’s t-test, X 2 , and Poisson regression as appropriate.

Results: The mean± SD age of stroke was 71.3±13.6 in 1993-94, 70.9±14.4 in 1999, 68.4±15.5 in 2005, 68.5±15.6 in 2010, and 68.7±15.4 in 2015 (p<0.0001 for trend). The proportion of all strokes under age 55 went from 12% to 15% to 20% to 22%, then 18% in 1993-94, 1999, 2005, 2010, and 2015, respectively. Poisson regression showed a shift toward younger strokes across the five periods studied (p<0.0001). Age-specific stroke incidence rates by study period are presented in the Table.

Discussion: The disturbing trend of increasing stroke in the young (age < 55) has leveled off slightly since 2010 but is still of great public health significance as younger strokes carry the potential for greater lifetime burden of disability. Further study is needed to determine the reasons for these results, including examination of race-specific trends.

Abstract 75: Predictors of Poor Outcome After Intracerebral Hemorrhage: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study

Introduction: Intracerebral hemorrhage (ICH) is the most severe subtype of stroke with a high mortality rate and majority of survivors suffering significant disability. The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study prospectively recruited 1000 white, 1000 black and 1000 Hispanic spontaneous ICH cases. Herein, we report the main results of the predictors of 3 month outcome after ICH.

Hypothesis: We hypothesized that ICH Score variables of age, ICH volume, ICH location, presence of intraventricular hemorrhage (IVH), and presenting Glasgow Coma Scale would predict long-term disability in addition to prior validation of mortality.

Methods: Between 2010-2015, cases were prospectively recruited with uniform phenotype definitions, centralized neuroimaging review and with telephone follow-up at 3 months. Apolipoprotein E genotyping was performed centrally. Individual characteristics were screened for association under a logistic regression model, 90-day mRS ≥ 4 versus 0-3, and those meeting P<0.2 were entered into multivariate model building where the final model was determined by minimum AIC score. Analyses were repeated removing subjects with withdrawal of care.

Results: The Table presents the prevalence/average of each variable entering the final multivariate model for association with poor (mRS 4-6) compared to good (mRS 0-3) outcome at 3 months. When analyses were repeated excluding withdrawal of care, overall Graeb (IVH) score fell out of the model (with presence of IVH replacing it) but the remaining variables were retained and in the same direction of effect. C-statistic for the multivariate model = 0.884 compared to 0.763 for ICH score alone (p=1.7E-22).

Conclusion: ICH score elements were validated as predictive of 3 month outcome. Novel baseline characteristics such as white matter hyperintensity as well as subsequent clinical events that may affect outcomes were identified. Location specific results to be presented.

Abstract TP269: Predictors of Drug Screens Among Stroke Patients in the Greater Cincinnati Northern Kentucky Stroke Study: Preliminary Findings for 2015

Introduction: Previous studies have shown biases in screening for toxicologic substances among stroke patients but have limited generalizability. Our objective was to investigate predictors of the use of drug screens among stroke patients in a large population based study.

Methods: The Greater Cincinnati Northern Kentucky Stroke Study is a population-based study of stroke cases ascertained from a biracial population of 1.3 million people in a 5-county region of southern Ohio/northern Kentucky. All hospital ascertained cases of stroke (ischemic (IS), transient ischemic attack (TIA), hemorrhagic (ICH), subarachnoid hemorrhage (SAH)), occurring during calendar year 2015 were included. Trained study nurses abstracted data on whether a drug screen was ordered (between emergency department (ED) presentation and hospital discharge). Screening tests for alcohol were not included. Multivariable logistic regression was used to identify predictors of use of a drug screen. Potential predictors were patient sex, age, race, select comorbidities, smoking status, stroke severity (NIHSS), treatment location and stroke type.

Results: Of 3865 stroke cases (53.8% women, 20.8% black, mean age 69.7(14.8) years), 12.0% had a drug screen performed. Adjusted, black race (aOR 1.93 95%CI 1.52-2.44), current smoking (aOR 1.97 95%CI 1.58-2.47), higher NIHSS (aOR 1.22 95%CI 1.15-1.28 per 5 unit increase) and being treated in an academic ED (aOR 2.04, 95%CI 1.62-2.55) increased the likelihood of a drug screen, while female gender (aOR 0.75 95%CI 0.60-0.93) and older age (aOR 0.61 per 10 years, 95%CI 0.56-0.66) decreased the likelihood.

Conclusions: In a large population based study of stroke patients, drug screens were more likely to be ordered in men, blacks, smokers, younger patients, and those seen in academic EDs. It is unknown whether these trends are similar among hospitalized patients with other diagnoses. Additionally, current evidence suggests that such differential testing may lead to missed counselling opportunities in those not tested as well as lower likelihood of thrombolytic treatment in those who are tested. Future research should investigate the yield of such drug screens and explore whether guidelines in ordering drug tests could help to avoid testing biases.

Abstract TP60: Comparison of Predicted vs. Actual Enrollment Into the NIH StrokeNet DEFUSE 3 Trial: Effectiveness of a Population-Based Epidemiology Feasibility Assessment in Improving Enrollment Into Clinical Trials

Introduction: The NIH StrokeNet trial network aims to improve recruitment and retention into stroke clinical trials. In addition to StrokeNet infrastructure, a population-based feasibility assessment is performed prior to submission to NIH. We sought to describe the impact of this assessment on the design and recruitment efficiency of the DEFUSE 3 trial, the first trial to be proposed and completed entirely within NIH StrokeNet.

Methods: We identified all ischemic stroke (IS) cases in the region in 2005 by screening all local hospital ICD-9 codes 430-436 among residents of the Greater Cincinnati/Northern Kentucky (GCNK) region, a biracial population of 1.3 million through chart abstraction and physician review. Initial proposed, and final revised DEFUSE 3 trial entry criteria were analyzed for population-based eligibility.

Results: DEFUSE 3 is an acute reperfusion ischemic stroke (IS) trial conducted at 38 US centers between 5/16-5/17. Initial inclusion/exclusion criteria proposed by trial PIs predicted that 2.4% (46 of 1843 in 2005) of IS patients would be eligible for DEFUSE-3. After criteria revision, this increased to 4.0% (74/1843). Four exclusion criteria were changed by study PIs after receiving feedback: upper age limit, baseline disability, time since last seen normal, and NIHSS (Table). Overall, 57% (104/182) of enrolled patients qualified via the broadened study entry criteria. In subsequent implementation, the trial randomized 0.47 patients per site per month which was nearly twice the expected enrollment rate.

Conclusion: Feedback from formal epidemiologic feasibility assessment to trial investigators during multicenter clinical trial design led to a broadening of entry criteria, and more than half of eventually enrolled patients were eligible only because of the expanded criteria. Iterative trialist-epidemiologist interaction is a promising approach to improve multicenter clinical trial planning and efficient study conduct.

Comparison of Genetic and Self-Identified Ancestry in Modeling Intracerebral Hemorrhage Risk

Background: We sought to determine whether a small pool of ancestry-informative DNA markers (AIMs) improves modeling of intracerebral hemorrhage (ICH) risk in heterogeneous populations, compared with self-identified race/ethnicity (SIRE) alone.

Methods: We genotyped 15 preselected AIMs to perform principal component (PC) analysis in the ERICH study (a multi-center case-control study of ICH in whites, blacks, and Hispanics). We used multivariate logistic regression and tests for independent samples to compare associations for genetic ancestry and SIRE with ICH-associated vascular risk factors (VRFs). We then compared the performance of models for ICH risk that included AIMs and SIRE alone.

Results: Among 4,935 subjects, 34.7% were non-Hispanic black, 35.1% non-Hispanic white, and 30.2% Hispanic by SIRE. In stratified analysis of these SIRE groups, AIM-defined ancestry was strongly associated with seven of the eight VRFs analyzed (p < 0.001). Within each SIRE group, regression of AIM-derived PCs against VRFs confirmed independent associations of AIMs across at least two race/ethnic groups for seven VRFs. Akaike information criterion (AIC) (6,294 vs. 6,286) and likelihood ratio test (p < 0.001) showed that genetic ancestry defined by AIMs achieved a better ICH risk modeling compared to SIRE alone.

Conclusion: Genetically-defined ancestry provides valuable risk exposure information that is not captured by SIRE alone. Particularly among Hispanics and blacks, inclusion of AIMs adds value over self-reported ancestry in controlling for genetic and environmental exposures that influence risk of ICH. While differences are small, this modeling approach may be superior in highly heterogeneous clinical poulations. Additional studies across other ancestries and risk exposures are needed to confirm and extend these findings.

Racial/ethnic variation of APOE alleles for lobar intracerebral hemorrhage

OBJECTIVE

APOE ε2 and ε4 alleles have been associated with lobar intracerebral hemorrhage (ICH) in predominately white populations; we sought to evaluate whether this held true among black and Hispanic populations.

METHODS

The Ethnic/Racial Variations of Intracerebral Hemorrhage study is a prospective, multicenter case-control study of ICH among white, black, and Hispanic participants. Controls were recruited to match cases based on age, ethnicity/race, sex, and geographic location. APOE genotyping and ICH location was determined blinded to clinical data.

RESULTS

There were 907 cases of lobar ICH and 2,660 controls with APOE results. Both APOE ε2 (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1-2.0, p = 0.01) and APOE ε4 (OR 2.0, 95% CI 1.5-2.6, p < 1 × 10^-4) were associated with lobar ICH among white participants. Among black participants, neither APOE ε2 (OR 1.0, 95% CI 0.7-1.5, p = 0.97) nor APOE ε4 (OR 1.0, 95% CI 0.7-1.4, p = 0.90) were independent risk factors for lobar ICH. Similarly, among Hispanic participants, neither APOE ε2 (OR 1.0, 95% CI 0.6-1.8, p = 0.89) nor APOE ε4 (OR 1.2, 95% CI 0.8-1.7, p = 0.36) were associated with lobar ICH. Hypertension was a significant risk factor for lobar ICH in all 3 racial/ethnic groups.

CONCLUSION

In contrast to Caucasian patients, in which amyloid risk factors predominate in lobar ICH, we found that hypertension was the predominant risk factor for lobar ICH. While APOE alleles are a risk factor for lobar ICH in white patients, they appear to have a much lower effect in lobar ICH in African American and Hispanic American populations. This suggests APOE ε2 and APOE ε4 do not affect lobar ICH risk homogeneously across ethnic populations. In addition, hypertension has a prominent role in lobar ICH risk, particularly among minorities.

Hypertension and intracerebral hemorrhage recurrence among white, black, and Hispanic individuals

OBJECTIVE

To clarify whether recurrence risk for intracerebral hemorrhage (ICH) is higher among black and Hispanic individuals and whether this disparity is attributable to differences in blood pressure (BP) measurements and their variability.

METHODS

We analyzed data from survivors of primary ICH enrolled in 2 separate studies: (1) the longitudinal study conducted at Massachusetts General Hospital (n = 759), and (2) the ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage) study (n = 1,532). Participants underwent structured interview at enrollment (including self-report of race/ethnicity) and were followed longitudinally via phone calls and review of medical records. We captured systolic BP (SBP) and diastolic BP measurements, and quantified variability as SBP and diastolic BP variation coefficients. We used multivariable (Cox regression) survival analysis to identify risk factors for ICH recurrence.

RESULTS

We followed 2,291 ICH survivors (1,121 white, 529 black, 605 Hispanic, and 36 of other race/ethnicity). Both black and Hispanic patients displayed higher SBP during follow-up (p < 0.05). Black participants also displayed greater SBP variability during follow-up (p = 0.032). In univariable analyses, black and Hispanic patients were at higher ICH recurrence risk (p < 0.05). After adjusting for BP measurements and their variability, both Hispanic (hazard ratio = 1.51, 95% confidence interval 1.14-2.00, p = 0.004) and black (hazard ratio = 1.98, 95% confidence interval 1.36-2.86, p < 0.001) patients remained at higher risk of ICH recurrence.

CONCLUSION

Black and Hispanic patients are at higher risk of ICH recurrence; hypertension severity (average BP and its variability) does not fully account for this finding. Additional studies will be required to further elucidate determinants for this health disparity.

Pediatric Stroke Rates Over 17 Years: Report From a Population-Based Study

We previously published rates of pediatric stroke using our population-based Greater Cincinnati Northern Kentucky Stroke Study (GCNK) for periods July 1993-June 1994 and 1999. We report population-based rates from 2 additional study periods: 2005 and 2010. We identified all pediatric strokes for residents of the GCNK region that occurred in July 1, 1993-June 30, 1994, and calendar years 1999, 2005, and 2010. Stroke cases were ascertained by screening discharge ICD-9 codes, and verified by a physician. Pediatric stroke was defined as stroke in those <20 years of age. Stroke rates by study period, overall, by age and by race, were calculated. Eleven children died within 30 days, yielding an all-cause case fatality rate of 15.7% (95% confidence interval 1.1%, 26.4%) with 3 (27.3%) ischemic, 6 (54.5%) hemorrhagic, and 2 (18.2%) unknown stroke type. The pediatric stroke rate of 4.4 per 100 000 in the GCNK study region has not changed over 17 years.

Prehospital neurological deterioration in stroke

BACKGROUND AND PURPOSE

Patients with stroke can experience neurological deterioration in the prehospital setting. We evaluated patients with stroke to determine factors associated with prehospital neurological deterioration (PND).

METHODS

Among the Greater Cincinnati/Northern Kentucky region (population ~1.3 million), we screened all 15 local hospitals' admissions from 2010 for acute stroke and included patients aged ≥20. The GCS was compared between emergency medical services (EMS) arrival and hospital arrival, with decrease ≥2 points considered PND. Data obtained retrospectively included demographics, medical history and medication use, stroke subtype (eg, ischaemic stroke (IS), intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH)) and IS subtype (eg, small vessel, large vessel, cardioembolic), seizure at onset, time intervals between symptom onset, EMS arrival and hospital arrival, EMS level of training, and blood pressure and serum glucose on EMS arrival.

RESULTS

Of 2708 total patients who had a stroke, 1092 patients (median (IQR) age 74 (61-83) years; 56% women; 21% black) were analysed. PND occurred in 129 cases (12%), including 9% of IS, 24% of ICH and 16% of SAH. In multivariable analysis, black race, atrial fibrillation, haemorrhagic subtype and ALS level of transport were associated with PND.

CONCLUSION

Haemorrhage and atrial fibrillation is associated with PND in stroke, and further investigation is needed to establish whether PND can be predicted. Further studies are also needed to assess whether preferential transport of patients with deterioration to hospitals equipped with higher levels of care is beneficial, identify why race is associated with deterioration and to test therapies targeting PND.

Effect of Hyperosmolar Therapy on Outcome Following Spontaneous Intracerebral Hemorrhage: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study

PURPOSE

We aimed to identify the effect of hyperosmolar therapy (mannitol and hypertonic saline) on outcomes after intracerebral hemorrhage (ICH) in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study.

METHODS

Comparison of ICH cases treated with hyperosmolar therapy versus untreated cases was performed using a propensity score based on age, initial Glasgow Coma Scale, location of ICH (lobar, deep, brainstem, and cerebellar), log-transformed initial ICH volume, presence of intraventricular hemorrhage, and surgical interventions. ERICH subjects with a pre-ICH modified Rankin Scale (mRS) score of 3 or lower were included. Treated cases were matched 1:1 to untreated cases by the closest propensity score (difference ≤.15), gender, and race and ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic). The McNemar and the Wilcoxon signed-rank tests were used to compare 3-month mRS outcomes between the 2 groups. Good outcome was defined as a 3-month mRS score of 3 or lower.

RESULTS

As of December 31, 2013, the ERICH study enrolled 2279 cases, of which 304 hyperosmolar-treated cases were matched to 304 untreated cases. Treated cases had worse outcome at 3 months compared with untreated cases (McNemar, P = .0326), and the mean 3-month mRS score was lower in the untreated group (Wilcoxon, P = .0174). Post hoc analysis revealed more brain edema, herniation, and death at discharge for treated cases.

CONCLUSIONS

Hyperosmolar therapy was not associated with better 3-month mRS outcomes for ICH cases in the ERICH study. This finding likely resulted from greater hyperosmolar therapy use in patients with edema and herniation rather than those agents leading to worse outcomes. Further studies should be performed to determine if hyperosmolar agents are effective in preventing poor outcomes.

Towards phenotyping stroke: Leveraging data from a large-scale epidemiological study to detect stroke diagnosis

Objective

1) To develop a machine learning approach for detecting stroke cases and subtypes from hospitalization data, 2) to assess algorithm performance and predictors on real-world data collected by a large-scale epidemiology study in the US; and 3) to identify directions for future development of high-precision stroke phenotypic signatures.

Materials and methods

We utilized 8,131 hospitalization events (ICD-9 codes 430–438) collected from the Greater Cincinnati/Northern Kentucky Stroke Study in 2005 and 2010. Detailed information from patients’ medical records was abstracted for each event by trained research nurses. By analyzing the broad list of demographic and clinical variables, the machine learning algorithms predicted whether an event was a stroke case and, if so, the stroke subtype. The performance was validated on gold-standard labels adjudicated by stroke physicians, and results were compared with stroke classifications based on ICD-9 discharge codes, as well as labels determined by study nurses.

Results

The best performing machine learning algorithm achieved a performance of 88.57%/93.81%/92.80%/93.30%/89.84%/98.01% (accuracy/precision/recall/F-measure/area under ROC curve/area under precision-recall curve) on stroke case detection. For detecting stroke subtypes, the algorithm yielded an overall accuracy of 87.39% and greater than 85% precision on individual subtypes. The machine learning algorithms significantly outperformed the ICD-9 method on all measures (P value<0.001). Their performance was comparable to that of study nurses, with better tradeoff between precision and recall. The feature selection uncovered a subset of predictive variables that could facilitate future development of effective stroke phenotyping algorithms.

Discussion and conclusions

By analyzing a broad array of patient data, the machine learning technologies held promise for improving detection of stroke diagnosis, thus unlocking high statistical power for subsequent genetic and genomic studies.

Heritability of circle of Willis variations in families with intracranial aneurysms

Background

Intracranial aneurysms more often occur in the same arterial territory within families. Several aneurysm locations are associated with specific circle of Willis variations. We investigated whether the same circle of Willis variations are more likely to occur in first-degree relatives than in unrelated individuals.

Methods

We assessed four circle of Willis variations (classical, A1-asymmetry, incomplete posterior communicating artery and fetal circulation) in two independent groups of families with familial aneurysms and ≥2 first-degree relatives with circle of Willis imaging on MRA/CTA. In each (index) family we determined the proportion of first-degree relatives with the same circle of Willis variation as the proband and compared it to the proportion of first-degree relatives of a randomly selected unrelated (comparison) family who had the same circle of Willis variation as the index family’s proband. Concordance in index families and comparison families was compared with a conditional logistic events/trials model. The analysis was simulated 1001 times; we report the median concordances, odds ratios (ORs), and 95% confidence intervals (95%CI). The groups were analysed separately and together by meta-analysis.

Results

We found a higher overall concordance in circle of Willis configuration in index families than in comparison families (meta-analysis, 244 families: OR 2.2, 95%CI 1.6–3.0) mostly attributable to a higher concordance in incomplete posterior communicating artery (meta-analysis: OR 2.8, 95%CI 1.8–4.3). No association was found for the other three circle of Willis variations.

Conclusions

In two independent groups of families with familial aneurysms, the incomplete PcomA variation occurred more often within than between families suggesting heritability of this circle of Willis variation. Further studies should investigate genetic variants associated with circle of Willis formation.

Abstract TMP61: Acute Ischemic Stroke Emergency Department Arrival Times in the Extended Time Window Within a Population

Introduction: With the recent positive clinical trial extending the time window for endovascular therapy out to 24 hours, we sought to describe the arrival times of acute ischemic stroke patients within the 6-24 hour time frame within a large biracial population representative of the US in terms of % black, age, and socioeconomic indicators.

Methods: We identified all ischemic stroke (IS) cases by screening all local hospital ICD-9 codes 430-436 among residents of the Greater Cincinnati/Northern Kentucky Stroke Study region, a biracial population of 1.3 million in 2010. Study nurses abstracted relevant information from the medical record, including symptom onset and ED arrival times, and all potential cases were physician reviewed. Arrival time was defined as the elapsed time between symptom onset time (either the witnessed onset time, or time last seen normal) and time of ED arrival. Only cases presenting to an ED were included in this analysis. Student’s t-test and Wilcoxon rank sum tests were used as appropriate.

Results: In 2010, there were 1980 IS cases presenting to a local emergency department, who were 21.3% black, 55.1% female, with a median age of 69.4 (SD 14.9). See Figure for distribution of arrival times. Patients arriving > 6 hours were significantly younger (age 68.8 vs. 70.7, p=0.007), more frequently female (56.6% vs. 52.0%, p = 0.05) and had less severe infarcts (NIHSS median (IQR) was 3 (1-6) vs. 4 (1-11), p<0.0001), compared to those arriving </= 6 hrs. No significant differences by race or baseline disability were observed.

Discussion: In our population, inclusion of 6-24hr ED arrival times allows 34% more of our ischemic stroke population to be arriving within a timeframe of possible intervention/reperfusion therapy. Further exploration of eligibility criteria, in addition to time, for extended time-window embolectomy within a population is needed to assist centers as they change their systems of care.

Abstract 192: Anticoagulation Decision-Making in ICH Patients With Atrial Fibrillation: Quality-Adjusted Decision Model Outcomes

Background: While patients (pts) with atrial fibrillation (AF) face a risk of ischemic events, AF pts with intracerebral hemorrhage (ICH) are at increased risk of bleeding with anticoagulation (AC). Optimal decision-making must weigh the tradeoffs between these competing risks. Our goal was to analyze the impact of AC decisions on projected quality-adjusted life years (QALYs) pts with both ICH and AF within a population.

Methods: The Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study is a population-based evaluation of spontaneous ICH among residents of the five-county Greater Cincinnati/Northern Kentucky study region. The study period was 7/08-12/12. Pts with ICH and AF surviving the hospital stay were included. Medical history and demographics were entered into the Atrial Fibrillation Decision Support Tool, which is a 29-state Markov decision analytic model that projects patient-level QALYs for 7 thromboprophylaxis treatment strategies, using published event rates from CHADSVASC, HAS-B(L)ED, the Friberg ICH prediction model and clinical trials of anticoagulants (including warfarin and direct anticoagulants, DOACs), as well as published rates of outcomes for each possible event.

Results: In the study period, there were 1186 cases of spontaneous ICH, 232 with a-fib, of which 123 were excluded because of inpatient death/discharge to hospice. Among the 109 cases, the aggregate net loss for AC was 16.9 QALYs; however there were 10 cases (9%) that gained > 0.1 QALYs with AC. The table displays a heat map showing aggregate gain/loss of QALYs with AC (compared with no treatment) for the cohort, displayed by their CHADSVASC and HASBED scores.

Conclusion: We found that 91% of our ICH pts with AF would have either no change or a loss of QALYs with AC. However, given lower bleeding rates with DOACs, anticoagulation may be beneficial in a very select subset of AF pts with ICH. Thresholds for AC treatment should be considered carefully in this population.

Abstract WP162: Outcomes and Long-Term Mortality After Ischemic Stroke in the Young: A Preliminary Analysis From the Greater Cincinnati/Northern Kentucky Stroke Study

Introduction: There is a trend towards ischemic stroke (IS) occurring at younger ages. We sought to better characterize outcomes and mortality over 3 years by age at time of stroke within a large, biracial population.

Methods: Incident IS were ascertained during the 2005 and 2010 study periods of our population based epidemiology study via ICD-9 codes 430-436. Research nurse coordinators performed medical record abstraction on all potential events, which were then adjudicated by study physicians as case/not a case. Abstractions included discharge or 30-day outcomes (if available) as measured by modified Rankin scale (mRS). Mortality for IS events out to 3 years was determined via all available information including the Social Security Death Index. We compared the outcomes and post-stroke mortality by 20-55 (young stroke) versus >55 years, and by decade. Descriptive statistics are reported as n (%), and mean (SD) or median (25 th and 75 th %ile) as appropriate. The primary analysis examined the effect of age, race and sex using regression, life table and proportional hazards models.

Results: Results are shown in the table. IS in the young occurred more frequently among black cases. The median rNIHSS was 3 although the NIHSS distribution trended towards more severe IS in the older age group. Young strokes had lower baseline and 30-day mRS. The mortality rate was greater in the older ages, at each time point and overall. After adjusting for race, sex and stroke severity the hazard ratio for lower survival in the strokes >55 years old was 4.03 (95% CI 3.15, 5.17).

Conclusion: IS patients < 55 years old are less likely to die after stroke. Young stroke occurs in demographically different populations than older strokes and this group would benefit from further study.

Abstract WMP91: Post-Stroke Healthcare Utilization: Patterns in Stroke Follow-up Care in a Community Hospital System - A Preliminary Analysis From the Greater Cincinnati/Northern Kentucky Stroke Study

Introduction: Immediate post-stroke discharge destination is easily determined. Long-term disposition and healthcare utilization is more difficult to study due to the variability in outcomes, including multiple transitions for many patients. We sought to longitudinally determine place of residence and physician follow-up in a defined population.

Methods: Our population-based stroke epidemiology study retrospectively ascertains hospitalized ischemic and hemorrhagic strokes via ICD-9/10 codes within 5 counties in the greater Cincinnati metropolitan region. For this study, post-stroke dispositions and physician encounters for ischemic strokes that presented to one healthcare system of 4 community hospitals from 1/1/15 to 12/31/15 were analyzed by mining patient electronic medical records (EMRs). Disposition was analyzed at discharge, 3, and 6 months post-stroke, and outpatient and emergency department (ED) visits, and hospital admissions, were tabulated at 3, 6, and 12 months. The first post-discharge physician encounter was also assessed, and time to encounter was considered. Previous analysis has shown that this network is relatively self-contained with few transfers to other health systems, making it ideal for this study.

Results: See figure for details. Only 17% of the cohort saw a neurologist within 1 year, whereas 73% saw a primary care provider (PCP) and 37% saw a cardiologist. PCPs accounted for 56% of the first post-stroke encounters. Over 24% of the cohort visited the ED or were re-hospitalized before having their first outpatient visit.

Conclusions: In a community setting, PCPs are responsible for the majority of post-stroke care, and fewer than one in five patients sees a neurologist post-stroke. Future work will include additional analysis to determine whether the results from this health system are consistent with others in our region.

Abstract 127: Untreated Hypertension After Intracerebral Hemorrhage

Objective: We previously reported that 46.9% of acute intracerebral hemorrhage (ICH) patients had untreated hypertension (HTN) on admission. We sought to investigate the prevalence of untreated HTN among patients at follow-up after ICH.

Methods: ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage) is a prospective multi-center study of ICH among whites, blacks, and Hispanics. Cases were enrolled at 42 recruitment sites. Subjects’ ethnicity, history of HTN, type of insurance, HTN medications, and level of education were collected. Patients were considered to have HTN if they received this diagnosis prior to or during initial ICH admission. Stroke events at follow-up included ischemic stroke, transient ischemic attack, subarachnoid hemorrhage, and recurrent ICH. Medication use was also recorded at follow-up.

Results: Of 3,000 cases of ICH, there were 1,822 with HTN who had at least one follow-up, of which 9.4% had untreated HTN. Compared with treated patients at 3 months, those untreated at 3 months more frequently were white or Hispanic (p=0.0064), female (p=0.0236), over 65 years old (p<0.0001), or on Medicare (p<0.0001). Among those treated at 3 months, 60.5% were prescribed beta blockers, 54.9% calcium channel blockers, 52.9% ACE inhibitors, 31.5% diuretics, 16.6% vasodilators, 12.6% angiotensin receptor blockers, 10.3% alpha agonists, 2.8% nitrates, 2.5% alpha blockers, and 3.7% others. Stroke events occurred by 12 months in 5.5% of treated compared with 5.6% of untreated patients.

Conclusions: Despite a high rate of untreated HTN at admission, the rate at follow-up was substantially lower. Overall, Hispanics were more likely and blacks less likely to be untreated than whites. Despite the lack of difference in stroke events identified among treated versus untreated patients, there was limited power to identify differences in a short-term follow-up due to a low rate of stroke recurrence and a low proportion of untreated HTN.

Abstract 132: Utility of Prophylactic Antiepileptic Drug Administration on Seizure Prevention and Disability Following Intracerebral Hemorrhage in the Ethnic/Racial Variations of Intracerebral Hemorrhage Study

Background & Purpose: Intracerebral hemorrhage (ICH) has the highest morbidity and mortality rate of any stroke subtype and clinicians often administer prophylactic anti-epileptic drugs (AEDs) as a means of preventing post-stroke seizures, particularly following lobar hemorrhage (LH). However, evidence for AED efficacy in preventing seizures and reducing disability is lacking given difficulty executing randomized prospective trials. We report an analysis of data from a large prospective observational study of ICH that evaluates the effect of prophylactic AED administration on seizure occurrence and disability following ICH.

Methods: Primary analysis was performed on 1636 patients with ICH enrolled in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study with subset analysis completed in patients with primary LH (n=562). A propensity score for administration of prophylactic AED was based on age, gender, race, ICH volume, location, presence of intraventricular hemorrhage, ventriculostomy, surgery, GCS, history of ischemic stroke, diabetes, sepsis, dementia, alcohol use and illicit drug use; patients were matched by the closest propensity score (difference <0.1). McNemar’s test was used to compare the occurrence of seizure and disability, defined by Modified Rankin Score (mRS) ≥ 3 at 3 months post ICH, in the treated and untreated groups. Similarly, analysis was performed on patients with LH by matching 281 treated patients with 281 untreated patients.

Results: Of the 818 matched pairs of patients who were treated with prophylactic AEDs, there was no significant difference in seizure occurrence (p=0.6799) or disability (p=0.6521). Subset analysis of 281 matched pairs of patients with LH revealed no significant difference in seizure occurrence (p=0.1161) or disability (p=0.9146) between those treated with prophylactic AED and untreated patients.

Conclusions: While prophylactic AED treatment of ICH is not recommended by current guidelines, clinical use remains widespread. Data from the large prospective ERICH study clearly reveal lack of efficacy in administering AEDs for prevention of seizures and reduction of disability following ICH, thus providing strong evidence to influence clinical practice and patient care.

Abstract WP345: Pre-Intracerebral Hemorrhage Antiplatelet and Anticoagulant Use and Differences in Hospital Course; A Population-Based Study

Objective: Patients on antiplatelet (AP) or anticoagulant (AC) agents cause more alarm when they develop intracerebral hemorrhage (ICH) compared with non-users. This analysis aimed to quantitatively evaluate the differences in the hospital course of ICH patients based on underlying AP and/or AC use, using a population-based cohort.

Methods: Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) was a population-based study of spontaneous ICH among residents of the five-county Greater Cincinnati/Northern Kentucky region between July 2008 and December 2012. Baseline demographics, medications, hospital course, and discharge disposition were collected. Initial and subsequent computed tomography (CT) images of the head were reviewed to assess ICH location, volume, and presence of intraventricular hemorrhage (IVH). Change in ICH volume was calculated when repeat CT image was available.

Results: There were 1121 cases of ICH during the study period. A higher proportion of white patients were on AP or AC than other races (56.4% vs. 39.7%, p<.0001). The majority of patients with subsequent imaging experienced an increase in ICH size. Patients taking AC pre-ICH had a larger increase in volume despite more frequent use of pro-thrombotic therapy. There was no difference in IVH incidence based on AP or AC use. Length of stay and surgical hematoma evacuation rates were similar among the groups. Inpatient mortality was higher in AC users (44.4% vs. 21.3%, p<.0001), but was virtually the same for AP users as for non-users. Of 272 pre-ICH AP users, 86 (31.6%) were discharged on AP (8 on dual AP). Of 91 pre-ICH AC users, 11 (12%) were discharged on AC.

Conclusion: Pre-ICH AC use was associated with greater ICH volume increase and inpatient death. There was no significant difference in number of IVH, rate of surgical treatment, or length of stay. Inpatient mortality did not differ between AP users and non-users.

Abstract 53: Comparison of Genetic Ancestry versus Self-Identified Race and Ethnicity as Risk Factor for Intracerebral Hemorrhage

Introduction: Vascular risk factors (VRFs) and their net effects vary across ethnic populations. We hypothesized that use of DNA-based ancestry informative markers (AIMs), compared with self-reported race/ethnicity (SIRE), would result in better prediction of VRFs and thus improve risk modeling in intracerebral hemorrhage (ICH) across U.S. minority populations.

Methods: Using data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study (a multi-center case-control study of ICH in whites, blacks, and Hispanics), we utilized 15 AIMs to perform principal component (PC) analysis using variance-standardized relationship matrix dimension reduction. Multivariate logistic regression and tests for independent samples (X 2 and Mann-Whitney U tests) were used to compare PC-defined ancestry and SIRE in their association with VRFs, and to estimate effects within each SIRE. Finally, we compared models for ICH risk including AIMs vs. SIRE.

Results: Among 4,935 subjects enrolled, 34.7% were blacks, 35.1% whites, and 30.2% Hispanic. PC analysis showed population structure not captured by SIRE [Figure]. Within each self-reported population, PCs values remained significantly associated with VRFs (p <0.001). Regression of PCs against VRF confirmed independent associations of PCs with hypertension across all SIRE (p <0.01) and with diabetes, hypercholesterolemia, coronary artery disease and atrial fibrillation with differing effects between populations. Akaike information criterion (6294 vs. 6286) and Davidson-MacKinnon J test (p <0.001) verified that AIMs significantly improved the ICH risk prediction model over SIRE alone.

Conclusions: AIMs, particularly among Hispanics and blacks, provide a more detailed assessment of risk exposures in studies that include representative U.S. populations, compared with SIRE alone. This more inclusive ancestry modeling may be a useful tool to improve risk prediction accuracy across other phenotypes