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Background: Although chronic kidney disease (CKD) is associated with worse stroke outcomes, data regarding the influence of CKD on intravenous thrombolysis outcomes are scarce. We sought to assess the efficacy and safety of intravenous thrombolysis for acute ischemic stroke with unknown onset time in patients with CKD. Methods: Patients with an acute stroke of unknown onset time from the EOS trials (Evaluation of Unknown Onset Stroke Thrombolysis) collaboration were evaluated using an individual patient-level database of randomized controlled trials comparing intravenous thrombolysis with placebo/standard treatment. CKD was defined as baseline estimated glomerular filtration rate of 2 Mixed-effect logistic-regression analysis was performed to evaluate treatment effects. A favorable outcome was defined as a modified Rankin Scale score of 0 to 1 at 90 days. Safety outcomes were symptomatic intracranial hemorrhage at 22 to 36 hours and 90-day mortality. Results: Baseline data on renal function were available for 688 of 843 patients. Of these, CKD was present in 146 (21%), including 69 of 351 patients receiving alteplase and 77 of 337 patients receiving placebo/standard treatment. Overall, treatment with alteplase was associated with higher odds of favorable outcome, and CKD did not modify the treatment effect ( P interaction =0.834). A favorable outcome was observed in 31 of 69 (46%) patients with CKD in the alteplase group and in 28 of 77 (36%) patients with CKD in the control group (adjusted odds ratio, 1.19 [95% CI, 0.55–2.58]). Among patients with CKD, symptomatic intracranial hemorrhage occurred in 2 patients (3%) in the alteplase group but in none of the controls ( P =0.133). At 90 days, death was reported in 3 patients (4%) in the alteplase group compared with 2 patients (3%) in the controls ( P =0.539). Conclusions: The present analysis indicates that the benefit of alteplase does not differ between stroke patients with unknown onset time with and without CKD, although the statistical power was lacking to confirm the efficacy in subgroups. This study only applies to mild-to-moderate or predialysis CKD.

Background: Race and ethnicity can have a major impact on the quality of care patients with acute ischemic stroke (AIS) receive. We sought to assess the impact of race and ethnicity on quality benchmarks of AIS therapy and clinical outcomes at a comprehensive stroke center (CSC). Methods: A retrospective analysis of AIS patients presenting to a CSC between 2015 to 2020 was performed. Data included demographics, NIH Stroke Scale scores, time to thrombolysis, discharge diabetic and hypertensive medications, length of stay (LOS), discharge functional status, 30-day readmission, and 30-day mortality. Quality benchmarks and outcomes were analyzed by the five most prevalent racial-ethnic groups including Non-Hispanic White (NHW), Hispanic, Black, Asian, Other and Unknown. Results: 3,735 AIS patients were identified. NHW represented 53.3% (n=1992),Black 21.3% (n=797), Hispanic 10.4% (n=390), Asian 7.2% (n=267), Other 4.6% (n=170) and Unknown 3.2% (n=119). There were no significant differences in door to needle (P=0.93), door to puncture time (P=0.98), intravenous thrombolysis (P=0.32) and mechanical thrombectomy utilization (P=0.19) by race-ethnicity. In univariable analysis, there was a higher rate of 30-day mortality in Unknown 23.5% vs NHW 7.3% (P< 0.0001). A significantly (P>0.05) higher rate of 30-day readmission was noted in NHW 20.3% vs Black 15.7%, Hispanics 15.6%, Others 11.8% and Unknown 8.4%. Black 67.6%, Hispanic 64.9% and Unknown 80.5% had a significantly (P2) vs NHW 60.3%. A significant difference (P Conclusions: Our analysis reveals persistent disparities in stroke outcomes, with Black and Hispanic patients suffering greater disability post stroke. Further investigation is needed to uncover how race-ethnicity mediates stroke care and outcomes.

Introduction: The determinants of fast and slow progressor phenotypes of infarct growth in anterior circulation large vessel occlusion (ACLVO) remain poorly understood. Previous studies have shown a potential link between baseline serum glucose and acute infarct growth. We assessed whether presenting serum glucose is independently associated with fast or slow progression of infarct growth in ACLVO stroke. Methods: Retrospective analysis of patients with acute stroke due to intracranial ICA or proximal MCA occlusion across two comprehensive stroke centers from 2014-2019. Baseline CTP or MRI were obtained within 24hours of stroke onset. Fast progressors (ischemic core > 70ml, 0-6 h) and slow progressors ( Results: A total of 350 participants were included (n=178 imaged < 6 hours of stroke onset; n=172 imaged at 6-24 hours of stroke onset). Amongst early presenters, the median glucose was 127 mg/dL for fast progressors (n=32) versus 122 mg/dL in non-fast progressors (n=146), p=0.45. Amongst late presenters, the median glucose was 122 mg/dL for slow progressors versus 133 in non-slow progressors (p=0.085). The correlation between serum glucose concentration and infarct growth rate was 0.03 (p=0.57). Conclusion: While a numerical trend suggesting lower glucose levels was observed in slow progressors, no significant correlation between hyperacute serum glucose and infarct growth rate was established.

Background: Language barriers can have a major impact on the quality of care that patients with acute ischemic stroke (AIS) receive. We sought to assess the impact of patient language on quality benchmarks of AIS therapy and clinical outcomes at a high-volume comprehensive stroke center (CSC). Methods: A retrospective analysis of AIS patients presenting to a CSC between 2015 to 2020 was performed. Data included demographics, NIH Stroke Scale scores (NIHSS), discharge diabetic and hypertensive medications, length of stay (LOS), discharge functional status, 30-day readmission, and 30-day mortality. Quality benchmarks and outcomes were analyzed by the five most prevalent primary languages including English, Spanish, Russian, Farsi, Korean and Other. All non-English speaking patients received medical interpretation via digital or in-person translation. Results: 3,812 AIS patients were identified. English language represented 80.2% (n=3091), Spanish 7.6% (n=238), Russian 4.1% (n=184), Farsi 3.0% (n=129), Korean 1.5% (n=47) and Other 3.6% (n=122).There were no significant differences in the rate of intravenous thrombolysis (P=0.52), door-to-needle time (P=0.91), door-to-puncture time (P=0.85), LOS (P=0.089) and 30 day readmission (P=0.74) among groups. In univariable analysis, Spanish 74.7%, Korean 84.4%, Russian 73.4%, Farsi 78.2% and Other 70.0% had significantly (P< 0.05) higher rates of post stroke disability (mRS> 2) compared to the English group 60.7%. A higher rate of 30-day mortality was noted in the Korean 17.8% compared to the English group 7.3%. The Spanish group had a higher rate of mechanical thrombectomy than the English group (11.8 vs 6.5%, P=0.009). Adjusting for age, sex, NIHSS and comorbidities, multivariable logistic regression models for post stroke disability (mRS>2) continued to show significant differences with Spanish (OR=1.66, P=0.008) and Farsi (OR=1.89, P=0.017) vs English. Conclusions: Our analysis reveals persistent disparities in AIS outcomes by primary language, with patients with limited English proficiency suffering worse disability after AIS. The effect of communication barriers on outcomes of stroke care in the inpatient setting requires further evaluation to close this gap.

Introduction: Endovascular therapy is a treatment option for patients with severe symptomatic intracranial atherosclerotic disease (ICAD). The utilization of angioplasty and stenting has varied since the development of stents for this disease in 2005. This study assesses the longitudinal trends for endovascular treatment of ICAD in the U.S. Methods: We performed a data search from the National Inpatient Sample (NIS) database using ICD9 and ICD10 procedure codes from 2008 through 2019. Data was collected for patients with stroke from ICAD who underwent stenting or angioplasty alone. We also assessed the utilization of stenting or angioplasty in thrombectomy cases for large vessel occlusion (LVO), the use of drug eluting stents, patient demographics, regional trends, length of stay, and mortality statistics. Results: Between 2008 and 2019, the nadir of ICAD stenting cases in the U.S. was in 2011 (n=242). There was over a 207% increase in stenting cases in 2015 (n=730), and another increase of 47% in ICAD stenting in 2018 and 2019 (2018=965, 2019=1,175). There was a significant increase in stenting for ICAD over the entire study period (p=0.003). The data also shows a significant increase in the use of stenting as adjunctive therapy to thrombectomy for LVO. In 2011, stenting with thrombectomy in LVO represented 17.8% (43/242) of patients stented with stroke from ICAD. In 2019, these cases represented 48.1% (565/1,175) of the patients stented. Over the study period, this increase in stent use during LVO treatment was significant (p Conclusion: There has been a progressive increase in stenting for ICAD since the nadir of this procedure in 2011 which is statistically significant. This increase was seen in patients with severe symptomatic ICAD, but also in patients undergoing thrombectomy for acute LVO with ICAD. Positive clinical stenting trials such as WEAVE and the post-hoc analysis from SAMMPRIS, and the increase in endovascular therapy for LVO appear temporally related to these changes.

INTRODUCTION We aim to report 3 cases of central nervous system (CNS) vasculitides, in which high-resolution magnetic resonance vessel wall imaging (HR-VWI) findings were instrumental in the diagnosis and management. CASE REPORT Case 1: A 41-year-old obese, smoker female with arterial hypertension presented with recurrent transient ischemic attacks. Computed topography angiography demonstrated bilateral middle cerebral artery (MCA) stenosis. HR-VWI revealed uniform enhancement and thickening of the arterial wall, suggestive of MCA vasculitis. The patient reported chronic calf rash that was biopsied and revealed unspecified connective tissue disease. With immunomodulation, patient remained asymptomatic and 6-month surveillance HR-VWI showed improved MCA stenoses.Case 2: A 56-year-old male with herpes simplex virus 1 encephalitis was treated with antiviral therapy and improved clinically. Two months later, the brain magnetic resonance imaging revealed new temporo-parietal edema and distal MCA hyperintense vessels. HR-VWI showed MCA concentric smooth contrast enhancement, that was attributed to postinfectious vasculitis and had resolved on follow-up HR-VWI.Case 3: A 41-year-old male presented with 1-week of headache and encephalopathy. Brain magnetic resonance imaging revealed punctate multifocal acute ischemic infarcts and no contrast-enhancement. HR-VWI showed multifocal diffuse enhancement of distal cerebral vasculature. Patient subsequently developed branch retinal artery occlusion and hearing loss and was diagnosed with Susac syndrome. No recurrent symptoms were noted after immunotherapy initiation. CONCLUSIONS In these 3 cases, HR-VWI identified distinctive vascular inflammatory changes, which were crucial to guide the etiological workup, positive diagnosis, surveillance neuroimaging, and targeted treatment. HR-VWI is an important diagnostic tool in CNS vasculitides, by providing nuanced information about arterial wall integrity and pathology.

Introduction: Despite pharmacological and practical advantages for tenecteplase (TNK) over alteplase (ALT), no differences were observed in percent of symptomatic intracranial hemorrhage (sICH) in randomized trials (fewer than 900 total patients for either treatment). We compared rates of sICH in patients treated with either drug, using a large, multicenter, international registry. Methods: The CERTAIN collaboration is an ongoing registry of deidentified patient-level data of thrombolytic treated ischemic stroke from various hospitals/programs in New Zealand, Australia, and the United States that have used ALT or TNK since July 1, 2018. Standardized data were abstracted and harmonized from local or regional clinical registries. We defined sICH as clinical worsening of at least 4 points on NIHSS, attributed to parenchymal hematoma, subarachnoid or intraventricular hemorrhage. We used logistic regression for binary variables, adjusting sICH differences for age, baseline NIHSS, thrombectomy, and source hospital network and Mann-Whitney test for continuous baseline variables. Results: A total of 7891 patients were included in the initial analysis. The TNK group was older, more likely to be male, had higher NIHSS, and more frequently underwent mechanical thrombectomy (Table. Sample Characteristics). The sICH rate was 3.71% for ALT and 2.13% for TNK: adjusted OR (95%CI) = 0.49 (0.31-0.76) p=0.002. For patients not undergoing thrombectomy after thrombolytic, the sICH rate was 3.00% for ALT and 1.74% for TNK, adjusted OR (95%CI) = 0.48 (0.27-0.87), p=0.016. For thrombectomy treated cases, sICH rate was 6.80% for ALT and 2.80% for TNK, adjusted OR (95%CI) 0.60 (0.31-1.16), p=0.129. Conclusion: In this preliminary analysis from a large, multicenter registry, ischemic stroke treated with tenecteplase was associated with a lower rate of sICH than with alteplase. An updated analysis with patient data from additional sites will be presented at the Conference.

The coronavirus disease 2019 pandemic has changed the way we engage patient care, with a move toward telemedicine-based health care encounters. Teleneurology is now being rapidly embraced by neurologists in clinics and hospitals nationwide but for many, this paradigm of care is unfamiliar. Exposure to telemedicine in neurology training programs is scarce despite previous calls to expand teleneurology education. Programs that provide a teleneurology curriculum have demonstrated increased proficiency, accuracy, and post-training utilization among their trainees. With the current changes in health care, broad incorporation of teleneurology education in resident and fellow training after this pandemic dissipates will only serve to improve trainee preparedness for independent practice.

Background: Acute stroke care is constantly evolving and often necessitates rapid change. When COVID-19 struck our community, our team determined that we needed to change our approach to emergent stroke cases without sacrificing efficiency and safety. Our goals with the changes in our hyperacute stroke response pathway (called Code Brain) in our ED was to minimize COVID-19 exposure to our team, reduce PPE usage, and maintain an environment of safety and readiness, all while providing the same high-quality stroke care. Purpose: The purpose of this study was to determine if the changes we made to our Code Brain pathway in the ED effected our door-to-needle time for tissue plasminogen activator (t-PA) administration our door-to-groin puncture (DTG) times, or our CT scan turn-around times (CT TAT) under 45 minutes percentage. Implementation: It was decided that the stroke team RNs would respond to the bedside and a neurology resident or fellow would respond via telemedicine robot at bedside. The stroke team nurse is the safety monitor who ensures proper PPE use. The patient is moved through the Code Brain pathway with the telemedicine robot in tow, assuring constant contact with the patient by the stroke physician and stroke nurse. We implemented our revised Code Brain pathway on March 17, 2020. We retrospectively collected data from November 2019 to July 2020 and extracted our DTN, DTG and CT TAT times for a 4 ½ month comparison. Results: From November 2019 through March 17, 2020, our DTN median time was 39 minutes, DTG median time was 101 minutes, and CT TAT under 45 minutes was 97%. From March 18, 2020 to July 2020, our DTN median time was 54 minutes, DTG median time was 101 minutes, and CT TAT under 45 minutes was 95%. Variables to consider are the length of time it takes to apply the appropriate PPE for the stroke nurse, obtaining the telemedicine robot from our ED storage area and connectivity issues. Conclusion: Although we radically changed the way we approach our Code Brain patients, our response and treatment times changed only slightly. We will continue to streamline this process for optimal outcomes.

Introduction: Exposure to telestroke in neurology residency is sparse despite its implementation in daily practice. Due to COVID-19, we increased our utilization of telestroke. Given this change in workflow, we investigated how residents utilize telestroke for “Code Brain” (CB) acute stroke evaluations and if expanding the use of telestroke in neurology residency programs is justified. Methods: We retrospectively compared the number of CB evaluations, door to needle (DTN) times, door to decision (DTD) times, and NIHSS from March - June 2019 (in-person evaluations) against those in March - June 2020 (telestroke evaluations). We limited our study to resident-involved cases. Nighttime and weekend CBs are run by a neurology resident and are remotely supervised. Daytime CBs can be run by a resident, fellow, or attending. We assumed that nighttime CBs are resident-run and daytime evaluations are the stroke team’s evaluation. Statistical analysis was performed using R. Results: There were a total of 217 CBs in March - June 2019 and 115 in March - June 2020. In 2019, there were 120 daytime and 97 nighttime CBs; in 2020 there were 62 and 53. The mean DTN for the day for 2019 and 2020 was 45.9 ± 23.2 and 48.4 ± 20.2 (P=0.08). The mean DTN during the night for 2019 and 2020 was 67.3 ± 53.7 and 53.8 ± 25.8 (P=0.64). The mean DTD during the day for 2019 and 2020 was 48.1 ± 41.0 and 44.9 ± 37.6 (P=0.25). The mean DTD during the night for 2019 and 2020 was 60.9 ± 51.1 and 65.8 ± 94.6 (P=0.68). Using a generalized linear model approach to correct for shift (day/night), age, NIHSS, we found no significant differences in DTN or DTD before and after implementing resident-run telestroke. Using Cohen’s approach (1988) we estimated a Type 2 error probability at 7%. Discussion: Our findings show that resident-run telestroke CBs are comparable to CBs run by fellows and attendings as DTN and DTD were not significantly different between the CBs run by residents in-person or via telestroke. These metrics are also comparable for CBs in which a fellow or attending are supervising or running the CB. Implementing resident-run telestroke consultation showed no effect on DTN or DTD after accounting for patient age, NIHSS, or the time of day. These data should reassure programs seeking to grant telestroke privileges to trainees.

Background: Agonism of protease-activated receptor 1 (PAR1) potently protects neurons and vasculature in the central nervous system during stroke. We evaluated the effects of 3K3A-APC, a recombinant variant of activated protein C active at PAR1, in acute ischemic stroke patients during conventional recanalization with thrombolysis or thrombectomy or both. We hypothesized that 3K3A-APC would reduce post-treatment hemorrhage and symptomatic neurologic deterioration. Methods: Using the NeuroNEXT trial NN104 (RHAPSODY) database, susceptibility weighted and gradient echo images were graded for intracerebral hemorrhage size according to radiographic criteria described in ECASS (Hemorrhagic infarction type 1 and 2 and parenchymal hematoma type 1 and 2) at four time points (0, 7, 30, and 90 days after treatment). Of 110 participants enrolled, 101 had appropriate imaging for analysis. Images were evaluated and graded by two blinded, independent raters with an expert providing consensus reads. Utilizing NIHSS following drug treatment, neurological worsening was defined as an increase in NIHSS ≥ 4 points. We compared placebo versus drug administration using multi-variate regression. Results: Of 101 participants evaluated, those receiving placebo (n=41) were significantly more likely to have hemorrhage at any time compared with those receiving any amount of drug (n=60) (p = 0.04; CI: 1.080 - 7.544; OR = 2.73). Age was found to be the only significant variable leading independently to increased neurological worsening (p = 0.038; CI: 1.015-1.193; OR = 1.086). Conclusion: The neuroprotectant 3K3A-APC showed significant reduction in hemorrhagic transformation when co-administered with conventional recanalization therapy. Further studies are underway for determining the effect of 3K3A-APC on functional outcome.

Background: Minority and socioeconomically disadvantaged individuals are underrepresented in secondary stroke prevention trials. Little is known about factors associated with study retention in these populations. Objective: To evaluate the impact of sociodemographic characteristics on retention in the Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED) trial. Methods: 487 participants ≥40 years with stroke/TIA were recruited from 4 safety-net hospitals and 1 stroke center serving low income zip codes. Strategies for boosting retention included: having bilingual research assistants from similar cultures establish rapport and follow participants; culturally and linguistically tailoring materials; arranging visits around participants’ schedules; offering transportation, and conducting assessments in the home and community. We compared sociodemographic characteristics among those retained at 12 months (n=412) vs. those not retained (n=75) using t-test, Chi Square, and Fisher exact tests. Independent factors associated with retention were determined using logistic regression. Results: Average age was 57 years, 18% were black, 71% were Hispanic, 58% were Spanish-speaking, and 72% were born outside the US. 12-month retention was 85%. On bivariate analysis, factors associated with retention were: Spanish-speaking, Hispanic ethnicity, younger age, born outside the US, and married status (all p Discussion: In this secondary prevention trial of stroke survivors from predominantly minority backgrounds, younger age, marriage, and insurance were associated with retention, suggesting that addressing barriers in the elderly, and those without insurance or spousal support may be beneficial. Financial constraints were associated with retention suggesting that study participation appealed to more socioeconomically vulnerable individuals.

Background: Approximately 25 million people in the US are Limited English Proficient (LEP). LEP individuals are more likely to feel dissatisfied with the quality of healthcare when compared to the English proficient, but little is known about LEP stroke survivors. Objective: To evaluate differences in stroke literacy, self-efficacy, and perceptions of healthcare delivery in English and Spanish-speaking individuals enrolled in the Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED) trial. Methods: SUCCEED participants were given the option of receiving the intervention in English or Spanish. Baseline differences in stroke literacy (Schneider et al), self-efficacy (General Self-Efficacy Scale), and perceptions of care (Patient Assessment of Chronic Illness Care and Consumer Assessment of Healthcare Providers and Systems) were compared using T-test, Chi Square, and Fisher Exact in individuals who chose Spanish vs. English. Results: Of 487 participants, 207 preferred English and 280 chose Spanish. Despite feeling more worried about having a stroke (77 % vs. 67%), and feeling at risk of having a stroke (63% vs. 45%), Spanish-speakers were less likely to identify 3 stroke risk factors (19% vs. 33%, all p Conclusion: Among stroke survivors, Spanish-speakers were more likely to have low stroke literacy, low self-efficacy, and a negative perception of healthcare delivery despite feeling that healthcare was accessible. Recognizing language barriers as a contributor to healthcare disparities, and tailoring interventions to address these barriers are crucial.

Introduction: Intracranial atherosclerotic disease (ICAD) correlates highly with transient ischemic attack (TIA) and acute ischemic stroke (AIS). Magnetic Resonance (MR) vessel wall imaging (VWI) is an emerging non-invasive imaging modality for directly assessing ICAD lesions. Methods: We retrospectively analyzed MR-VWI from 42 TIA patients and 45 AIS patients with ICAD. All patients fulfilled the following criteria: (1) stenosis >30% of a middle cerebral artery (MCA), (2) symptoms contralateral to stenotic MCA, (3) no coexisting stenosis at other major vessels; (4) lack of compelling evidence to other etiologies of stroke/TIA. Vascular lesions were analyzed with MR-VWI with respect to the stenosis degree, vessel wall irregularity, plaque burden (PB), remodeling index (RI), plaque-wall contrast ratio (CR) and plaque enhancement grade (EG). Results: EG (OR 3.88, 95%CI 1.42-10.57, P=0.006) was a risk factor for AIS while PB (OR 0.65, 95%CI 0.27-1.54, P=0.008) was a risk factor for TIA. In patients with 30-70% degree stenosis, CR (OR 5.38, 95%CI 1.39-20.75, P=0.008) was a risk factor for stroke, while PB (OR 0.4, 95%CI 0.1-1.65, P=0.006) remained a risk factor for TIA. Conclusions: In our study, PB appeared as a risk factor for TIA but not for AIS. This suggests that unstable plaque accounting for AIS may have a wide range of PB. We further found that CR and EG are more associated with AIS than TIA. Lesions with high CR and strong enhancement may be more prone to producing the permanent ischemic injury. Further study is needed to elucidate the role of MR-VWI in differential diagnosis and management of TIA and AIS.

Background: Minority, disadvantaged populations are often underrepresented in secondary stroke prevention trials despite known disparities in risk factor control. When they do enroll, retention is poor due to competing needs, transiency, unstable housing, transportation barriers, and inconsistent telephone access. Methods: We recruited 487 English- or Spanish-speaking adults (age >40 yrs) with a recent TIA or ischemic/hemorrhagic stroke, and systolic BP ≥130 mm Hg or diagnosed hypertension and SBP≥120mm Hg, from 4 Los Angeles County-Department of Health Services hospitals and 1 stroke center serving low income zip codes. We used recruitment and retention strategies from a prior trial; leadership and staff met regularly to track progress and design and implement new strategies. Meeting notes were reviewed to compile approaches . Results: Average age was 57.1 years; race/ethnicity was 71.4% Hispanic, 17.6% black, 6.4% Asian; 72.5% were born outside the US; 62.6% had not graduated high school; 40% rarely spoke English at home. Follow-up data collection was 440/487 (90%) at 3 months, 382/487 (78%) at 8 months, and 394/475 (83%) of eligibles at 12 months. Prior recruitment strategies used were bilingual research assistants (RAs) from similar cultural backgrounds, inpatient clinical team introduction of potential enrollees to RAs, embedding RAs on the inpatient unit, piloting and tailoring recruitment scripts prior to study initiation, and allowing potential participants to discuss the study with others prior to enrollment. Prior retention strategies used were obtaining ≥3 contact numbers at enrollment and reviewing medical records for upcoming appointments. New retention strategies developed and applied were offering in-home assessments, providing transportation, offering weekend/evening visits, using phone, mail, and registered mail to contact participants, routinely using the same RA for a given participant, and reminding patients of prior interactions with RAs/visits. Conclusion: To maximize retention and recruitment, the combined approach of beginning with a broad set of previously effective strategies, and tracking and developing new ones over the course of the trial was effective. Trial Registry Trial Number: NCT01763203

Introduction: Recent patent foramen ovale (PFO) closure trials have demonstrated efficacy in secondary stroke prevention. Transcranial Doppler (TCD) can reliably detect the presence of PFO, with sensitivity comparable to echocardiography. We sought to compare the sensitivity of TCD in detecting right to left shunt (RLS) using transesophageal echocardiogram (TEE) criteria as described in the CLOSE and REDUCE trials. Methods: We retrospectively reviewed all TCD studies at our institution who also had TEE studies. We excluded patients who had their PFO closed prior to one of these studies being performed. We classified the size of the PFO based on both REDUCE and CLOSE criteria (large was defined as greater than 25 microbubbles and greater than 30 microbubbles, respectively) and compared to the size based on the Spencer grade. Results: A total of 525 TCD bubble studies were performed at our institution from May 2013 to June 2018, 220 of which also underwent TEE. Using TEE as the gold standard, TCD detected 97.61% (41/42) of any moderate-large RLS and 100% (10/10) of any large RLS. The single patient who had a moderate RLS on TEE, but not TCD had a poor Valsalva during the TCD study. TCD detected 33 patients with RLS not detected on TEE [33% (33/100)], 33.3% of which were considered significant (Spencer grades 3-5). Conclusion: TCD is comparable to TEE in detecting moderate-to-large RLS based on REDUCE/CLOSE criteria. TCD detected an appreciable amount of RLS (a third of which were Spencer grades 3-5) not detected by TEE. Further study is needed to clarify the role of PFO closure in patients with significant RLS on TCD, but no RLS on TEE. TCD is a good alternative screening tool for RLS as compared with TEE methods from recent positive trials.

Introduction: Cognitive decline after transient ischemic attacks (TIA) or stroke is common. Evaluation with the Montreal Cognitive Assessment (MoCA) tool has shown a decrease in cognitive scores in more than 30% of patients at 1 year. We hypothesize that indirect revascularization with EDAS plus intensive medical management (IMM) would decrease the rate of decline. Methods: This is a prospective study of EDAS plus IMM in symptomatic patients with intracranial arterial stenosis of more than 70%. Patients had MoCA evaluations at baseline, 1 month, 6 months, and 12 months after EDAS. Differences in MoCA at baseline and follow-up were compared using mixed model repeated measures ANOVA. Results: Thirty-one patients with no aphasia or neglect were included. Mean age was 48.3 +/- 16.6 years. Twenty-one were females (70%). The mean MoCA scores at baseline and 12-months were 23.6 +/- 4.3 and 25.5 +/- 4.1, respectively. MoCA ≥ 1 improvement was seen in 78.9% at 12 months. However, differences in MoCA scores at these time points did not reach statistical significance (p= 0.49, Fig. 1). Only 9% of patients had a decline of ≥2 MoCA points at 12 months. These results are comparable to the twelve month MoCA data from the SAMMPRIS trial, which showed a mean MoCA for IMM of 25.4 +/- 3.73 and for percutaneous angioplasty and stenting (PTAS) of 25.6 +/- 3.89. The rate of decline of MoCA scores after EDAS plus IMM was significantly less than the reported natural history after TIA or strokes outside the SAMMPRIS trial (9% vs. 30%, p=0.03). Conclusion: Compared to historical data, the decline in MoCA scores after TIA and stroke was lower in patients treated with EDAS plus maximum medical therapy and has similar effects to those reported in the SAMMPRIS IMM and PTAS groups.

Introduction: Intracranial atherosclerotic disease (ICAD) is one of the most common causes of ischemic stroke worldwide. Despite aggressive medical management, the rate of recurrent stroke is 13% at 1 year. Intracranial vessel wall imaging (VWI) is a noninvasive, “looking-beyond-the-lumen” imaging method that can directly characterize the geometric and signal features of ICAD lesions. The present work sought to assess the feasibility of quantitatively monitoring regression or progression of ICAD plaques using VWI-based methods. Methods: Eight ischemic stroke patients (1F, 7M; age 27-66 ys) treated with intensive medical therapy underwent initial (4 days - 4 months of onset) and follow-up 3D VWI (6-13 months). Images were randomized and reviewed by two neuroradiologists to determine the culprit lesion in each subject. A custom-designed deep-learning-based intracranial vessel analysis method was used to segment vessel wall boundaries and quantify the following features of the culprit lesion, including peak normalized wall index (NWI), plaque volume, pre-contrast plaque-wall contrast ratio (CR), and post-contrast plaque enhancement ratio (ER). Results: No subjects except for subject #4 had a recurrent stroke during the follow-up period. The four plaque features exhibited different change patterns as shown in Figure . Subject #1 and #4 demonstrated an increase in plaque ER, volume, and peak NWI; subject #7 demonstrated an increase in plaque CR, volume and peak NWI. Other patients had a decrease or no change in these features. Conclusions: In this work, the interrogated plaque features demonstrated regression in most of patients after intensive medical therapy. Elevated values in some of these features appeared positively associated with stroke recurrence. Temporal changes in these features may have a strong indication on culprit lesions’ response to medical therapy. In conclusion, it is feasible to quantitatively monitor plaque-level treatment response.

Background: MR WITNESS was a safety trial giving tPA to acute ischemic stroke (AIS) patients with unwitnessed onset with MRI findings of early stroke. A DWI-positive, FLAIR negative pattern has been shown to identify strokes Methods: Core readers blinded to enrollment status and clinical presentation reviewed MRI of screened patients. The MR WITNESS algorithm enrolled subjects with no visible FLAIR or a pre-specified SIR < 2. SIR consistency was measured with intraclass coefficient (ICC) and reader agreement assessed with Fleiss’ Kappa. Statistical analysis included 2-sided Fisher’s Exact test or Wilcoxon Exact test as appropriate. Results: 201 subjects were screened. 153 baseline MRIs with DWI lesions were reviewed. ICC was 71% (P Discussion: Although SIR reads between Core and sites showed good agreement, there was still variability in the absolute values. This demonstrates the potential limitation of subjective lesion volume delineation. Automated approaches should be investigated.

Introduction: Although early hemorrhagic transformation (HT) in acute ischemic stroke has been studied, less is known about patients who develop hemorrhage after the acute phase. We hypothesized that patients with late hemorrhage (LH) would have more severe strokes than those without, and tested this hypothesis in a cohort of thrombolysed patients from the MR WITNESS trial. Methods: Subjects were recruited from 10 sites between Jan 2011-Oct 2015. MR WITNESS enrolled subjects if they were last seen between 4.5 and 24 hours prior to evaluation, but otherwise qualified for IV tPA in the 3-4.5 hr window per AHA guidelines, and if their brain MRI findings indicated very early infarction: either no FLAIR hyperintensity or subtle hyperintensity, ie signal increase Results: Among the 80 patients included in the MR WITNESS cohort, 53 met our inclusion criteria and were analysed. When compared to those with no HT, patients with LH had larger baseline infarct volumes and perfusion defects, as well as more frequent proximal vessel occlusion at baseline (all p Conclusion: Patients with LH demonstrate a more severe imaging profile at baseline and a worse functional outcome at 90 days when compared to patients without hemorrhage. Understanding the underlying pathophysiology of LH may shed light on to the mechanisms of acute and subacute brain injury.

Introduction: Stroke risk more than doubles each decade after the age of 55. In patients with intracranial atherosclerosis (ICAS), the SAMMPRIS study showed that individuals 60 years or older had a higher risk of recurrent stroke or death (17%) than younger patients (12%) despite intensive medical management (IMM). In prior studies, an antiangiogenic profile has been associated with higher rates of failure to IMM in stroke. The purpose of this study is to evaluate the hypothesis that aging is an independent predictor of higher circulating levels of antiangiogenic factors endostatin and angiostatin in ICAS. Methods: Prospective observational longitudinal study of circulating angiogenic factors in 74 patients with ICAS treated medically. Patients with ICAS greater than 70% had angiostatin and endostatin measured in duplicate via ELISA at baseline and were followed for 6 months. Mixed model analysis was performed for the outcome variables endostatin and angiostatin. Predictor variables included age, gender, smoking history, hypertension (HTN), hyperlipidemia (HLD), Diabetes 2, obesity, coronary artery disease (CAD) and peripheral artery disease (PAD). Classification and regression tree (CART) analysis were used to select the threshold age for the longitudinal model. Results: Age was a significant independent predictor of higher levels of endostatin (p=0.002) and angiostatin (p Conclusion: Aging is a significant independent predictor of elevated antiangiogenic circulating factors, which are associated to failure to IMM in ICAS. Antiangiogenesis can potentially represent a common path for multimorbidity of advanced age.

Background: Multiple types of mechanical circulatory support (MCS) devices are commonly used in heart failure patients. These devices carry risk for neurologic complications, specifically cardioembolic stroke. Alterations in blood flow play a role in the pathophysiology, however there is limited data regarding cerebrovascular hemodynamics in MCS patients. We used transcranial Doppler (TCD) to define hemodynamics of commonly used MCS devices. Methods: We retrospectively examined charts from 2/2013 through 6/2016 for patients with MCS who underwent TCD, and obtained the following: peak systolic,end-diastolic velocities, mean flow velocities, pulsatility indices (PI) and number of high-intensity transient signals (HITS). Waveform morphologies were compared between devices. Results: Of 1,796 TCDs studies screened, 62 TCD studies were from 32 MCS patients. Of these, 21 were on extracorporeal membrane oxygenation (ECMO), 15 had a left ventricular assist device (LVAD), 18 had total artificial heart (TAH), and 2 had intra-aortic balloon pumps (IABP). Waveforms in patients supported by ECMO demonstrated continuous flow without clear systolic peaks. The averaged mean MCA velocity was 57.57 (SD= 21.00) cm/sec and mean PI is 0.35 (0.17). LVAD averaged mean MCA velocity was 57.57 (14.38) cm/sec and mean PI of 0.45 (0.28). PIs were low in patients with continuous-flow LVADs. Impella patients had morphologically distinct pulsatile waveforms compared to other types of VADs. IABP had averaged mean velocity of 56.21 (14.78) cm/sec and mean PI of 0.77 (0.15). These waveforms demonstrated pronounced diastolic upstrokes not present in other devices. In TAH patients, mean MCA velocity was 73.69 (33.00) cm/sec and PI of 0.86 (0.40). Emboli detection was performed in 46 studies, and HITS were detected in 29 (63%). Of these 15 (51%) were administered 100% oxygen which suppressed >50% HITS in 10 (67%) patients. Conclusion: Patients supported by MCS devices produce unique and characteristic waveforms on TCD studies. Further studies will describe normative values in this special population. HITS were not universally present and intermittently suppressible by oxygen, suggesting some may be gaseous in nature. Risk of stroke in patients with MCS and HITS is under study.

Introduction: Inversion-recovery prepared variable-flip-angle 3D FSE (IR-SPACE) was recently proposed as a whole-brain vessel wall MRI method to assess intracranial vessel wall (IVW) abnormalities. Compared with conventional SPACE or 2D FSE, it provides more heavily T1 weighted (T1w) contrast that, based on extensive research on carotid atherosclerosis, is highly sensitive to vulnerable atherosclerotic plaque features - intraplaque hemorrhage and inflammation. It was hypothesized that, using the new approach, the prevalence of HT 1 S plaques is higher in the symptomatic side in patients with recent anterior circulation ischemic stroke. Methods: From Oct 2015 to Aug 2016, 33 patients with ischemic stroke ( 50% were consecutively recruited. The MRI protocol included regular brain MRI and intracranial MRA followed by pre- and post-contrast IR-SPACE. After excluding those with nonatherosclerosis etiology (5) and uninterpretable images (3), 25 patients were available for image review by two independent blind readers. Plaques defined as eccentric wall thickening with or without luminal stenosis were first identified and were then categorized as either hyper-intense or iso-intense using adjacent normal vessel wall for reference. Results: In 25 patients, 65 plaques were identified, with 40 and 25 at the symptomatic and asymptomatic side, respectively. HT1S was shown in 32 plaques on pre-contrast IR-SPACE and in 23 plaques on post-contrast IR-SPACE on the symptomatic side, with 22 plaques in both scenarios. On the asymptomatic side, the incidence of HT1S was lower (i.e. 7 on pre-contrast, 4 on post-contrast, 1 in both). Conclusion: In the current study, IR-SPACE revealed higher prevalence of HT1S in the symptomatic side. Pre-contrast scans identified more HT1S plaques than post-contrast scans, and almost all (22/23) of these HT1S plaques shown on post-contrast images also demonstrated HT1S feature on pre-contrast images. Further classification of these HT1S plaques according to the likelihood to cause stroke will help elucidate the clinical relevance of the above findings and this analysis is underway.

Introduction: Patients with stroke due to intracranial atherosclerosis (ICAS) are more likely to have coronary and peripheral vascular disease abnormalities than patients with other etiologies. We have found in prior studies that in patients with ICAS, an increased antiangiogenic profile was significantly associated with recurrent TIA and stroke. The purpose of this study is to evaluate the hypothesis that the previously identified profile of circulating antiangiogenic factors is associated with atherosclerotic multimorbidity in patients with ICAS. Methods: Prospective observational longitudinal study of circulating angiogenic factors in 74 patients with ICAS treated medically. Patients with ICAS greater than 70% had pro and antiangiogenic factors measured in duplicate via ELISA. Angiogenic profiles were defined by principle component analysis. A nominal logistic regression model was fit for the outcome variable atherosclerotic multimorbitdity, defined as the presence of atherosclerosis in more than one vascular bed. The predictor variables were age, gender, smoking history, hypertension, hyperlipedimia, and the profiles of circulating angiogenic factors. Results: An angiogenic profile characterized by high levels of HGF and the antiagiogenic factors endostatin, angiostatin, and VEGFR-1 was significantly associated to the presence of atherosclerotic multimorbidity (OR = 1.9; 95% CI = 1.2 - 3.3; p = 0.01). Smoking history, hypertension, and hyperlipidemia were poor predictors of atherosclerotic multimorbidity in this cohort. Commonly related risk factors for atherosclerosis were not associated with the predictive antiangiogenic profile. Conclusion: Our results indicate that antiangiogenesis is a stronger predictor of systemic atherosclerosis than classically recognized risk factors, and it may represent a common path for multimorbidity in patients with ICAS.

Introduction/Hypothesis: We were interested in studying patient outcomes with acute cerebrovascular disease (ACVD) who had concomitant acute or chronic renal insufficiency (RI). Methods: We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database (1998-2009) and identified 1,760,415 adult ACVD patients among 92,848,710 patients enrolled. Using SAS 6.4 and applying SPSS 22 the outcome variables mortality, length of hospital stay (LOS), HC (HC) >$20,000, and disposition (home or any care facility) were selected. Logistic regression analyses were performed adjusting for the covariates hypertension (HTN), diabetes mellitus (DM), age, race, sex, number of comorbidities, and care complexity (numbers of inpatient procedures) among all ACVD with and without RI. Results: Mean age was 71 years (SD 15) with 76% >65 years old; 54% female gender; 55% Whites, 11% Blacks, 6% Hispanics. Among all ACVD, 66% had HTN, 28% DM, RI 9%, LOS 7.6 days (SD 9.8), in-patient mortality 12%; disposition home 42% and facility 44%, and mean HC $36,010 (SD $63,331). After covariate adjustment, the mortality rate of ACVD patients with RI was 24% vs 11% (P Conclusions: Acute or chronic RI was present in 9% of patients with ACVD. RI was associated with significantly greater risks of in-patient mortality, LOS, and discharge to a facility. In subgroup analyses, the overall HC were greater in patients with acute RI. Patients undergoing HD experienced a similar negative impact on all outcome parameters except for disposition status. The negative impact of RI on vital outcome parameters in ACVD patients should be considered, i.e., when indicating the administration of contrast for imaging.

Introduction: T1-weighted variable-flip-angle 3D turbo spin-echo (TSE), has emerged as a vessel wall MRI technique promising for elucidating underlying intracranial vessel wall pathologies associated with stroke. Whole-brain 0.5-mm isotropic-resolution 3D TSE has recently been proposed at 3 Tesla. However, its scan time of 12 min renders it impractical for a clinical setting. This work aimed to design an expedited protocol and conduct a pilot study to demonstrate its potential for diagnosis of wall abnormalities. Methods: To expedite the acquisition, one may exploit an elliptical data sampling strategy and prolonged echo train length (ETL). However, this would reduce image SNR and compromise vessel wall delineation. On the other hand, SNR is intimately related to refocusing flip angles that are calculated for a prescribed tissue with specific T1 and T2 values (denoted as simulation T1 and T2). In this work, the effects of simulation T2 and ETL on the SNR/CNR performance were first explored on 9 healthy subjects. An optimized imaging protocol was then determined from a narrowed range of choices on 7 healthy subjects and finally applied to a pilot study of 10 patients with known wall disease. Results: Wall SNR, wall-CSF CNR, and white-gray matter CNR generally increased with simulation T2 and decreased with ETL. Optimization was focused on a narrowed range of protocol choices (ETL = 52; T2 = 140, 170, 200 ms) which enable a scan time of 8 min. ETL=52/T2=170ms was shown (Figure a.) to provide significantly higher (t-test) SNR/CNR performance than the original 12-min protocol (ETL=36/T2=100ms). With the 8-min protocol pre/post contrast, wall abnormalities (Figure b.) were correctly detected in all patients. Conclusion: An 8-min whole-brain intracranial vessel wall imaging protocol is developed which has demonstrated the potential of accurately identifying various wall abnormalities. A large-scale trial on using the technique for diagnosis of stroke etiology is underway.

Introduction: In patients with cryptogenic strokes, the discovery of a right to left shunt (RLS) may change management. Recent data suggest that transcranial doppler with agitated saline bubble study (TCD) has a higher sensitivity in RLS detection than transesophageal echo (TEE). We evaluated whether or not TCD could guide optimization of stroke care as indicated by a change in stroke management. Methods: We reviewed 370 inpatient and outpatient TCD studies performed at Cedars-Sinai Medical Center between May 2013 and May 2015. We recorded TCD, TEE and neurology consult results. Spencer grade (both at rest and with Valsalva) and change in management were determined. A change in management was classified as a change in medication, additional diagnostic testing ordered, or consideration of PFO closure. Results: We found 42 patients with both TEE and TCD. Patients were negative for shunt on both TEE and TCD (13); positive both on TEE and TCD (15); positive for right-to-left shunt on TEE and negative on TCD (1); and negative on TEE, but positive on TCD (13). Average age was 46.2 years, ranging from 28 to 67 years. Seven of 13 patients had a change in management after discovery of the RLS on TCD: 4 PFO closure through trial enrollment; 2 initiated on anticoagulation; 1 hypercoagulable work up. Of the 6 patients without change in management, all had a Spencer grade of 2 or less. Conclusion: TCD is a sensitive and reliable, non-invasive study to detect RLS. The ability to perform a Valsalva maneuver accounts for a higher sensitivity for RLS detection. Given the superior sensitivity over TEE and potential to change management, TCD should be the preferred screening test for RLS in cryptogenic stroke patients.

Background and Purpose— Toward the goal of designing a clinical trial using imaging parameters to treat stroke patients with unknown onset time, we investigated the timing of changes on MRI in patients with well-defined stroke onset. Methods— Hypothesis-generating (n=85) and confirmatory (n=111) samples were scored by blinded readers for fluid-attenuated inversion recovery (FLAIR) hyperintensity in diffusion-positive regions. Reader-measured signal intensity ratio (SIR) of the lesion to contralateral tissue was compared with SIR measured by coregistration. Results— Lesion conspicuity increased with time on FLAIR ( P =0.006). Qualitative assessment of FLAIR-negative vs FLAIR hyperintensity (k=0.7091; 95% CI, 0.61–0.81) showed good interrater agreement. Subtle hyperintensity was less reliably categorized (k=0.59; 95% CI, 0.47–0.71). Reader-measured SIR P =0.04) for a given reported time from stroke symptom onset. Conclusion— The SIR on FLAIR provides a quantitative tool to identify early ischemic strokes. In developing SIR thresholds, right hemisphere lesions may confound the accurate estimate of stroke onset time. Image coregistration for thrombolytic trial enrollment is not necessary. A SIR

Background: Nearly twenty years after demonstrating the efficacy of IV tPA in clinical trials, it continues to be widely underused. Fibrinolytic therapy is heavily restricted by a long list of laboratory, radiographic, and clinical inclusion/exclusion criteria. We sought to evaluate whether patients who received IV-tPA in violation of these criteria had different outcomes. Methods: We included all ischemic stroke patients who received IV tPA (no intra-arterial therapy) and were followed to 90 -days. Group A: IV-tPA use despite contraindication (protocol violation), Group B: IV-tPA protocol-adherent. We compared baseline variables and demographics (age, sex, race, ethnicity, diabetes, hypertension, atrial fibrillation, cerebrovascular disease, baseline NIHSS, and smoking). We analyzed the frequency of symptomatic intracranial hemorrhage (sICH) and gastrointestinal bleeding (GIB). Measures of good clinical outcome included modified Rankin Scale (mRS) 0-1 and discharge home. Results: A total of 660 tPA-treated patients were included from October 2003 to August 2014, Group A included 22 patients; group B included 638. Group A had 2 patients under 18 years of age, 4 with bleeding risks (low platelets, elevated PTT, or known bleeding diathesis), 4 with recent surgery, trauma, or clinical bleeding, 2 with recent stroke or past ICH, one patient with abnormal glucose accounting for the deficit, and 11 patients outside the time window, rapidly improving, or no disabling deficit. Baseline demographics and stroke severity were similar, except for diabetes, which was more common in Group A (45.5% vs. 24.3%, p=0.04). There was no difference in sICH (4.55 vs. 3.46%, p=0.55) or GIB (0 vs. 0.6%, p>0.99). Good clinical outcomes were similar (mRS 0-1 38.5% vs. 33.2%, p=0.77; discharge home 65.0 vs 61.8%, p=0.82). Conclusions: Clinical outcomes and bleeding risks were similar between patients who received IV tPA despite contraindications. Our analysis is limited by small numbers in Group A. Larger patient samples are needed to better understand the role of individual contraindications.

Introduction: The risk of intracranial hemorrhage (ICH) following IV-rtPA is 20%, and symptomatic ICH is 6%. Due to this concern, many practitioners obtain a 24-hour safety image after administration of t-PA for acute ischemic stroke (AIS). We sought to determine whether 24-hour safety imaging influenced clinical management or outcomes Methods: We conducted a retrospective analysis of suspected AIS patients treated with IV t-PA at our medical center between January 2012 and February 2014. Medical records were reviewed for clinical decision-making, neurologic deterioration, and ICH. All patients were examined on admission by NIHSS-certified neurologists. Baseline characteristics were captured from a department database. A stepwise linear regression was used to identify variables predicting change in management and discharge modified Rankin scores (mRS). Results: Our study included 172 patients who received IV t-PA. After exclusion for endovascular treatment, clinical research trials that required follow-up imaging, and missing demographics, 116 patients were included in the final analysis. Neurologic deterioration was seen in 20 (17.2%) patients, intracranial hemorrhage was seen in 19 (16.3%) patients, and clinical management changed in 11 (9.4%) patients. Clinical deterioration was the only variable that predicted a change in management (logistic regression p2 =0.43, p Conclusion: Our data suggests frequent examination for neurologic deterioration is superior to 24-hour imaging in guiding clinical decision making. These findings should be investigated prospectively.

Introduction The decision to perform endovascular intervention in patients with acute ischemic stroke (AIS) may be guided by physiologic imaging such as CT perfusion (CTP) demonstrating a salvageable penumbra, but such studies can delay transfer to the angiography suite. Flat Panel Detector CT (FPD-CT) allows pre, intra and post-procedural physiologic assessment using rotational images acquired on the angiography table; however these measurements have not been correlated with conventional perfusion techniques. We began a prospective, observational comparison of standard, multi-slice CTP with FPD-CT perfusion for AIS interventions, and report our initial results. Methods Patients with AIS that are candidates for endovascular intervention and have standard CTP images available were enrolled in the study after obtaining informed consent and following the IRB approved protocol. FPD-CTP images were obtained with aortic contrast injection and commercially available workstation image assessment (Siemens, Erlangen, Germany) before and after intervention, and compared with standard CT perfusion and follow up images. Results A total of 3 cases have been enrolled. All demonstrated anatomic correlations between perfusion defects in the standard CTP and the FPD-CTP. Case example: A 58 year old man developed left sided hemiplegia and standard CTP demonstrated a right MCA defect with a small core infarction (Fig 1 A). Pre-intervention FPD-CTP showed the same defect pattern (Fig 1 B), and successful mechanical thrombectomy was performed (Fig 1 C,D). Post-intervention FPD-CT showed reversal of perfusion defect outside the core infarct (Fig 1 E). The patient had good clinical recovery and only small infarct on follow up CT (Fig 1 F). Conclusions Early experience with FPD-CTP imaging shows correlation with standard CTP images and reversal of perfusion defect following successful recanalization, suggesting it may be a valuable aid for decision making in AIS intervention.

Objective: Dabigatran etexilate (DE) is an FDA-approved reversible direct thrombin inhibitor to prevent acute ischemic strokes (AIS) in patients with non-valvular atrial fibrillation. There is increasing literature on the management of patients on coumadin who present with AIS, however there is a paucity of the same in reference to newer oral anticoagulants such as DE. We studied patients on DE who presented with AIS to better understand their clinical and laboratory characteristics. Methods: We retrospectively collected data on patients who had AIS and were on DE from 3 large stroke centers in California and Texas from December 2010 to August 2012. Data included baseline demographics, coagulation parameters, creatinine, GFR, use of IV rt-PA or intra-arterial thrombectomy (IAT), and duration of being off of DE prior to AIS. Descriptive statistics were used to evaluate the dataset. Results: Twenty-seven patients were identified, 16 (40.7%) were women, and the mean age was 70.6 (±13.7) years. Medication dosage was known for 17 patients:14 (82%) were taking 150 mg BID, 2 (11.8%) took 75 mg BID, and 1 (5.8%) took 75 mg daily. The median aPTT and INR were 37.1s (23.6s- >200s) and 1.1 (0.89-1.95) respectively. The median creatinine was 1.1 (0.7-1.6) and median GFR was 64ml/min/1.73m 2 (32-97). Sixteen (49.7%) of patients were actively taking DE prior to their acute event. One patient stopped it 48 hours, another 72 hours, and one 2 week prior to the AIS. Eleven (40.0%) of patients were concomitantly taking either aspirin or Plavix. Three were treated with IVtPA, two of which were taken for (IAT). None had hemorrhagic transformation. One patient had only IAT. Conclusions: To our knowledge this is the largest cohort of patients in the post-marketing phase of DE with acute ischemic strokes. The majority of the patients presented while actively taking DE, and more than half had normal INRs and aPTTs. As the use of DE and other novel oral anticoagulants increases, it will become imperative to create guidelines on how to manage these patients in the setting of AIS.

Background: In the United States, between 200 and 500 thousand Transient Ischemic Attacks (TIAS) are reported yearly, only 50% report symptoms to their physician. Rapid action is of critical importance to reduce risk of brain injury. TIA is a chance for timely lifestyle changes or medical intervention. Momentary signs could precede a potentially fatal stroke or could be a stroke. TIA is recognized as an emergent warning sign of underlying disease. Hospital admission is costly and may be unacceptable to symptom free patients. We developed a rapid work up, CODE TIA, to faciltate patient stays of less than 23 hours. Method: We reviewed methods to decrease length of stay(LOS), decrease unnecessary tests ordered, treat & educate patients to prevent stroke where appropriate, send them home, treated in a reasonable time frame. We conducted extensive staff education. A CODE TIA sticker was created & placed on the front of TIA patients’ charts to alert staff to the time left until the proposed discharge.TIA order sets were developed and MDs were educated to use them. A TIA checklist for nurses was created to follow patient’s progress & any pending tests. A TIA pathway handout was also created for patients. This visual record enables the patient to participate in their own care and track their progress.The stroke team meets monthly to discuss data & opportunities for improvement. For example, discharge delays occurred while waiting for bubble studies (TEE with echocontrast). We trained & certified all stroke nurses to administer echocontrast.Delays for echocardiography were eliminated. Results: The LOS was 3.66 days for patients diagnosised with TIA.The data shows that the CODE TIA program is successful. We have decreased the LOS dramatically. Since August, we had 59 patients the TIA pathway. Of these,31(52%) converted to a regular stay if co-morbidities or diagnosis of stroke was discovered. Interestingly, 28 (47%) patients went home in 0.92 days. That is a 74.9% decrease in the patient’s LOS. Patients diagnosed withTIA, not on pathway, had a LOS of 1.6 days. Conclusion: A directed TIA pathway, with extensive education, order sets, patient materials & aggressive stroke team involvement yielded significant reduction in LOS.Outcome studies needed to assure stroke risk reduction.

Objectives: In the clinical setting, the extent of mismatch on MRI is frequently assessed with an approximate “XYZ/2” method but the agreement with the “gold standard” planimetric volume and the “visual evaluation” methods are not known. In a published study, we established that the visual evaluation and planimetric methods are equivalent as far as mismatch classification. The objectives of this study were to quantify the agreement of the approximate method with the “gold standard” and “visual evaluation” methods and to compare the mismatch classification results. Methods: Patients were selected from the Lesion Evolution of Stroke and Ischemia On Neuroimaging (LESION) database if they: had an acute ischemic stroke, were treated with intravenous rt-PA only, and had a pre-treatment MRI with evaluable maps including trace or isotropic b1000 DWI and MTT images. A trained rater viewed the images on the PACS, placed the two perpendicular linear measurements, “X” and “Y”, on the slices with the largest DWI and MTT lesion areas, and then used a “XYZ/2” formula where “Z” was the product of the slice thickness and the total number of slices containing the lesion. A separate expert rater measured the planimetric volumes on a slice-by-slice basis with a semiautomated segmentation tool followed by manual editing. Expert readers evaluated the MRI scans for the presence of qualitative mismatch. The expert readers were not the trained reader that performed the approximate volume measurements. Quantitative mismatch was considered present if MTT volume - DWI volume ≥50 ml. Mismatch classifications using the ≥ 50 ml definition were compared by constructing contingency tables. Results: A total of 194 patients met the study criteria and had median DWI and MTT planimetric volumes of 13.06 ml and 99.27 ml respectively. For both the DWI (n=170) and MTT (n=164), 94% of the measurements were within two standard deviations of the difference between the planimetric and approximate volume measurements. Comparing the planimetric and approximate volume measurements, the Spearman correlation coefficients were 0.855 and 0.886 for the DWI and MTT measurements respectively (p Conclusions: The approximate “XYZ/2” method is sufficient for classifying the presence of MRI determined mismatch in acute stroke patients and therefore is a potential tool when using MRI determined mismatch as an inclusion criteria for clinical trials.