Health Factors Associated With Development and Severity of Poststroke Dysphagia: An Epidemiological Investigation

BACKGROUND

Dysphagia after stroke is common and can impact morbidity and death. The purpose of this population-based study was to determine specific epidemiological and health risk factors that impact development of dysphagia after acute stroke.

METHODS AND RESULTS

Ischemic and hemorrhagic stroke cases from 2010 and 2015 were identified via chart review from the GCNKSS (Greater Cincinnati Northern Kentucky Stroke Study), a representative sample of ≈1.3 million adults from southwestern Ohio and northern Kentucky. Dysphagia status was determined on the basis of clinical assessments and necessity for alternative access to nutrition via nasogastric or percutaneous endoscopic gastrostomy tube placement. Comparisons between patients with and without dysphagia were made to determine differences in baseline characteristics and premorbid conditions. Multivariable logistic regression determined factors associated with increased risk of dysphagia. Dysphagia status was ascertained from 4139 cases (1709 with dysphagia). Logistic regression showed that increased age, Black race, higher National Institutes of Health Stroke Scale score at admission, having a hemorrhagic stroke (versus infarct), and right hemispheric stroke increased the risk of developing dysphagia after stroke. Factors associated with reduced risk included history of high cholesterol, lower prestroke modified Rankin Scale score, and white matter disease.

CONCLUSIONS

This study replicated previous findings of variables associated with dysphagia (older age, worse stroke, right-sided hemorrhagic lesions), whereas other variables identified were without clear biological rationale (eg, Black race, history of high cholesterol, and presence of white matter disease) and should be investigated in future studies to determine biological relevance and potential influence in stroke recovery.

Health factors associated with development and severity of post-stroke dysphagia: an epidemiological investigation

Background and Purpose

Dysphagia is a common post-stroke occurrence and has been shown to impact patients' morbidity and mortality. The purpose of this study was to use a large population-based dataset to determine specific epidemiological and patient health risk factors that impact development and severity of dysphagia after acute stroke.

Methods

Using data from the Greater Cincinnati Northern Kentucky Stroke Study, GCNKSS, involving a representative sample of approximately 1.3 million people from Southwest Ohio and Northern Kentucky of adults (age ≥18), ischemic and hemorrhagic stroke cases from 2010 and 2015 were identified via chart review. Dysphagia status was determined based on bedside and clinical assessments, and severity by necessity for alternative access to nutrition via nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube placement. Comparisons between patients with and without dysphagia were made to determine differences in baseline characteristics and pre-morbid conditions. Multivariable logistic regression was used to determine factors associated with increased risk of developing dysphagia.

Results

Dysphagia status was ascertained from 4139 cases (1709 with dysphagia). Logistic regression showed: increased age, Black race, higher NIHSS score at admission, having a hemorrhagic stroke (vs infarct), and right hemispheric stroke increased risk of developing dysphagia after stroke. Factors associated with reduced risk included history of high cholesterol, lower pre-stroke mRS score, and white matter disease.

Conclusions

This study replicated many previous findings of variables associated with dysphagia (older age, worse stroke, right sided hemorrhagic lesions), while other variables identified were without clear biological rationale (e.g. Black race, history of high cholesterol and presence of white matter disease). These factors should be investigated in future, prospective studies to determine biological relevance and potential influence in stroke recovery.

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.

Abstract TP137: Ethnic/racial Variations Of Intracerebral Hemorrhage Genetics (erich-gene) Study Protocol

Introduction: Epidemiologic studies of intracerebral hemorrhage (ICH) have consistently demonstrated variation in incidence, location, comorbidity burden, age-of-onset, and outcome by race and ethnicity, and genetic studies have identified differences in risk mediated by genetic risk factors such as Apolipoprotein E (APOE). We report the design and methods of the largest multi-ethnic genome-wide association study (GWAS) of ICH risk and outcome conducted to date.

Methods: The Ethnic/Racial Variations of ICH Genetics (ERICH-GENE) study is an international, multi-center, genetic case-control study of ICH. Cases are individuals with confirmed primary ICH with biosample availability and consent compatible with shareable genome-wide genotyping or previous genotyping. Central neuroimaging phenotype harmonization of case status, hemorrhage location, and imaging characteristics of cerebral small vessel disease including leukoaraiosis, atrophy, microbleeds, intraventricular hemorrhage severity and volume of ICH measurements will be performed. Controls are ICH-free individuals of compatible age and race/ethnicity from existing studies and biorepositories.

Results: As of August 2021, 2,002 ICH cases have been collected and genotyped, in addition to 2,558 already-genotyped ICH cases from the multi-ethnic ERICH study. 5,600 total new ICH cases will be genotyped under ERICH-GENE, with planned meta-analyses across existing ICH GWAS datasets and international biobanks totaling >20,000 cases. We are on schedule to meet our genotyping goal within the study period. Non-European ancestry cases are being prioritized for genotyping and ~66% of the previously genotyped ERICH cases are black or Hispanic. From available cases, a total of 10,621 neuroimaging studies have been uploaded for central adjudication to date with 6,278 having undergone harmonization.

Conclusions: ERICH-GENE is a large, multi-ethnic, international, centrally harmonized GWAS of ICH risk and outcome that will identify genetic risk factors across diverse populations for biological discovery and population-specific risk stratification.

Abstract TP220: Clinical And Demographic Characteristics Associated With Poor Posterior Circulation Stroke Outcomes: Greater Cincinnati/Northern Kentucky Stroke Study

Background: Posterior circulation strokes (PCS) make up 20% of all strokes, yet there is poor understanding of what factors contribute to poor clinical outcomes. We investigated clinical and demographic characteristics associated with poor clinical outcomes in PCS using a population-based biracial cohort.

Methods: Greater Cincinnati Northern Kentucky Stroke Study (GSNKSS) 2010 and 2015 data was utilized to identify 1842 patients who were >20 years old with MRI-proven PCS. Eligible patients were then stratified based on functional outcomes (modified Rankin Scale<3 vs >/= 3, with >= 3 considered poor) according to demographics, stroke risk factors, tPA treatment, stroke location, and stroke mechanism. A multivariable logistic model was used to identify the predictors for poor functional outcomes.

Results: Age, higher NIHSS, higher baseline mRS, hypertension, temporal, thalamus, and brainstem location, and cardioembolic mechanism were associated with poor clinical outcomes (Table). After multivariable analysis, age, higher NIHSS, higher baseline mRS, hypertension, temporal, thalamus, and brainstem location, and cardioembolic mechanism remained associated with poor outcomes.

Conclusion: Understanding these factors associated with poor prognosis after posterior circulation stroke will allow for better prognostication and family counseling.

Abstract WMP77: Anticoagulation-Associated Intracerebral Hemorrhage Incidence Rates: A Longitudinal Population-Based Assessment

Background: Anticoagulant-associated intracerebral hemorrhage (AA-ICH) quintupled in the Greater Cincinnati/Northern Kentucky (GC/NK) region from 1988 to 1999 in association with increasing warfarin use. Direct-acting oral anticoagulants (DOACs), available in 2010, have evidence of less bleeding risk, while atrial fibrillation detection rates have increased. We sought to determine if rates of AA-ICH continued to increase in the last decade within a large, bi-racial population.

Methods: We identified all patients, 20 years or older, hospitalized with first-ever intracerebral hemorrhage (ICH) in GC/NK region in 1993/4, 1999, 2005, 2010 and 2015. AA-ICH was defined as ICH in patients prescribed warfarin, heparin or low molecular weight heparin, or a DOAC at the time of their ICH. Incidence rates were age-, sex- and race-adjusted to the 2010 US population. Change over time was tested using regression. All-cause case fatality was adjusted for age, sex and race and trend over time evaluated using a general linear model.

Results: There was no significant change over time in the incidence rate for total ICH or AA-ICH from 1993 through 2015 (Table). As compared to ICH patients without anticoagulant use, patients with AA-ICH were more likely to be older, white, have hypertension, diabetes mellitus, hyperlipidemia, prior ischemic stroke and atrial fibrillation, but less likely to smoke. The age-, sex- and race-adjusted 30-day case fatality for ICH overall and AA-ICH also did not change significantly from 1993/4 to 2015 (Table). Warfarin utilization increased in our ICH population from 1993/4 (7.6%) to 2005 (17.7%), then decreased through 2015 (11.8%/DOAC 6.4%); p<0.0001.

Conclusion: Despite increased incidence rates of AA-ICH in the late 1980s to 1990s, we observed no overall change in incidence or case-fatality rate from AA-ICH over the full 20-year period despite higher rates of atrial fibrillation detection which may be explained by higher rates of DOAC (vs warfarin) use.

An afucosylated anti-CD32b monoclonal antibody induced platelet-mediated adverse events in a human Fcγ receptor transgenic mouse model and its potential human translatability

To assess the safety and tolerability of NVS32b, a monoclonal, afucosylated, anti-CD32b (FCGR2B) antibody we used a humanized transgenic (Tg) mouse model that expresses all human Fc gamma receptors (FCGRs) while lacking all mouse FCGRs. Prior to its use, we extensively characterized the model. We found expression of all human FCGRs in a pattern similar to humans with some exceptions, such as low CD32 expression on T cells (detected with the pan CD32 antibody but more notably with the CD32b-specific antibody), variation in the transgene copy number, integration of additional human genes, and overall higher expression of all FCGRs on myeloid cells compared to human. Unexpectedly, NVS32b induced severe acute generalized thrombosis in huFCGR mice upon iv dosing. Mechanistic evaluation on huFCGR and human platelets revealed distinct binding, activation and aggregation driven by NVS32b in both species. In huFCGR mice, the anti-CD32b antibody NVS32b binds platelet CD32a via both Fc and/or CDR (complementarity determining region) causing their activation while in human, NVS32b-binding requires platelet pre-activation and interaction of platelet CD32a via the Fc portion and an unknown platelet epitope via the CDR portion of NVS32b. We deemed the huFCGR mice to be over-predictive of the NVS32b-associated human thrombotic risk. Impact: In this study we elucidated the mechanism based on the thrombotic adverse events observed in huFCGR mice upon NVS32B dosing and were able to identify this safety liability which led to program termination. Therefore, this mouse model could be useful in research of immunotherapies targeting or involving FCGRs. Potential biological implications resulting from species differences in the FCGR expression pattern are nevertheless important to consider.

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.

Hematoma expansion is more frequent in deep than lobar intracerebral hemorrhage

OBJECTIVE

To test the hypothesis that patients with deep intracerebral hemorrhage (ICH) would encounter hematoma expansion (HE) more frequently compared to patients with lobar ICH.

METHODS

Patients with ICH with neuroimaging to calculate HE were analyzed from the multicenter Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) cohort. Patients with laboratory coagulopathy or preceding anticoagulant use were excluded to assess relationships of ICH location alone (deep vs lobar) with HE, defined as >33% relative growth. Odds ratios (ORs) and 95% confidence intervals (CIs) for these relationships were estimated with logistic regression. Sensitivity and specificity determined HE thresholds best associated with poor 3-month outcomes (modified Rankin score 4-6) stratified by location.

RESULTS

There were 1,049 patients with deep and 408 patients with lobar ICH analyzed. Deep ICH locations were more likely to have HE (adjusted OR 1.57, 95% CI 1.08-2.29) after adjustment for age, sex, race, baseline hematoma size, and intraventricular hemorrhage. However, this difference was nonsignificant (adjusted OR 1.35, 95% CI 0.81-2.24) after controlling for time from symptom onset to admission CT in a subgroup analysis of 729 patients with these data. Yet, the threshold of HE best associated with poor outcomes was smaller in deep (30%) compared to lobar (50%) ICH.

CONCLUSIONS

While HE was more frequent in deep than lobar ICH, this could be due to differences in symptom onset to admission CT times in our cohort. However, patients with deep ICH appear particularly vulnerable to the deleterious effects of small volumes of HE. Further studies should clarify whether ICH location needs to be considered in HE treatment paradigms.

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 TP221: Cerebellar Infarction Presentations: A Population-Based Study From the Greater Cincinnati/Northern Kentucky Stroke Study

Background: Cerebellar lesions reportedly account for 2-7% of acute infarct visits, but this may be an underestimate since prior studies were not population-based or from the modern imaging era. Cerebellar symptoms are also often nonspecific such that increased MRI use might lead to a higher proportion of stroke due to cerebellar lesions. Details about presenting features of cerebellar infarcts and baseline medication use are also not well known.

Methods: We used the 2010 Greater Cincinnati/Northern Kentucky Stroke Study. Strokes were identified by screening ICD9 codes 430-436 and physician verification. Infarct location was categorized as isolated cerebellar, mixed cerebellar (cerebellar plus ≥1 other location), or non-cerebellar. Isolated dizziness was defined as dizziness/vertigo without other focal symptoms. Atherosclerotic cardiovascular disease (ASCVD) 10-year risk scores were calculated. Descriptive statistics and multivariable logistic regression were used to compare infarct categories.

Results: Isolated cerebellar lesions occurred in 4.6% (90/1940; 95% CI, 3.7%-5.7%) of infarct events. An additional 4% (77/1940; 95%CI, 3.1%-4.9%) were mixed cerebellar infarcts. Mixed cerebellar infarcts had clinical characteristics more similar to non-cerebellar events than to cerebellar events. The multivariable model found an association of isolated cerebellar infarct with low NIHSS (odds ratio [OR] 2.3, 95% CI 1.1-4.8) and any dizziness/vertigo (OR 5.1, 95% CI, 2.4-10.6), but not with isolated dizziness/vertigo, age, or sex. Median ASCVD scores were high in all infarct categories (21, interquartile range [IQR] 9-35 for isolated cerebellar; 32, IQR 15-42 for mixed cerebellar; 31, IQR 16-52 for all others). Both cerebellar and non-cerebellar strokes had a high frequency of baseline antiplatelet or anticoagulant use (52.1% vs 56.2%), whereas baseline statin therapy was less common in isolated cerebellar infarcts (34.1% vs 43.8%).

Conclusions: This population-based study during the modern imaging era found that about 5% of stroke cases have isolated cerebellar infarcts and nearly 9% have any cerebellar infarct. Both cerebellar and non-cerebellar presentations have high baseline vascular risk and antiplatelet/anticoagulant use.

Sociodemographic Disparities in Long-Term Mortality Among Stroke Survivors in the United States

Background and Purpose- It is unclear whether disparities in mortality among stroke survivors exist long term. Therefore, the purpose of the current study is to describe rates of longer term mortality among stroke survivors (ie, beyond 30 days) and to determine whether socioeconomic disparities exist. Methods- This analysis included 1329 black and white participants, aged ≥45 years, enrolled between 2003 and 2007 in the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) who suffered a first stroke and survived at least 30 days after the event. Long-term mortality among stroke survivors was defined in person-years as time from 30 days after a first stroke to date of death or censoring. Mortality rate ratios (MRRs) were used to compare rates of poststroke mortality by demographic and socioeconomic characteristics. Results- Among adults who survived ≥30 days poststroke, the age-adjusted rate of mortality was 82.3 per 1000 person-years (95% CI, 75.4-89.2). Long-term mortality among stroke survivors was higher in older individuals (MRR for 75+ versus <65, 3.2; 95% CI, 2.6-4.1) and among men than women (MRR, 1.3; 95% CI, 1.1-1.6). It was also higher among those with less educational attainment (MRR for less than high-school versus college graduate, 1.5; 95% CI, 1.1-1.9), lower income (MRR for <$20k versus >50k, 1.4; 95% CI, 1.1-1.9), and lower neighborhood socioeconomic status (SES; MRR for low versus high neighborhood SES, 1.4; 95% CI, 1.1-1.7). There were no differences in age-adjusted rates of long-term poststroke mortality by race, rurality, or US region. Conclusions- Rates of long-term mortality among stroke survivors were higher among individuals with lower SES and among those residing in neighborhoods of lower SES. These results emphasize the need for improvements in long-term care poststroke, especially among individuals of lower SES.

Cigarette Smoking History and Functional Outcomes After Spontaneous Intracerebral Hemorrhage

Background and Purpose- Although cigarette use may be a risk for intracerebral hemorrhage (ICH), animal models suggest that nicotine has a potential neuroprotective effect. The aim of this multicenter study is to determine the effect of smoking history on outcome in ICH patients. Methods- We analyzed prospectively collected data from the Ethnic/Racial Variations of Intracerebral Hemorrhage study and included patients with smoking status data in the analysis. Patients were dichotomized into nonsmokers versus ever-smokers, and the latter group was further categorized as former (>30 days before ICH) or current (≤30 days before ICH) smokers. The primary outcome was 90-day modified Rankin Scale score shift analysis. Secondary outcomes were in-hospital mortality and mortality, Barthel Index, and self-reported health status measures at 90 days. Results- The overall study cohort comprised 1509 nonsmokers and 1423 ever-smokers (841 former, 577 current, 5 unknown). No difference in primary outcome was observed between nonsmokers versus ever-smokers (adjusted odds ratio [aOR], 1.041; 95% CI, 0.904-1.199; P=0.577). No differences in primary outcome were observed between former (aOR, 0.932; 95% CI, 0.791-1.178; P=0.399) or current smokers (aOR, 1.178; 95% CI, 0.970-1.431; P=0.098) versus nonsmokers. Subgroup analyses by race/ethnicity demonstrated no differences in primary outcome when former and current smokers were compared with nonsmokers. Former, but not current, smokers had a lower in-hospital mortality rate (aOR, 0.695; 95% CI, 0.500-0.968; P=0.031), which was only observed in Hispanics (aOR, 0.533; 95% CI, 0.309-0.921; P=0.024). Differences in self-reported health status measures were only observed in whites. Conclusions- Cigarette smoking history does not seem to provide a beneficial effect on 90-day functional outcome in patients with ICH.

Abstract 38: Racial Differences in Intracerebral Hemorrhage Risk: The REasons for Geographic and Racial Differences in Stroke Study (REGARDS)

Introduction: Intracerebral Hemorrhage (ICH) risk is higher in blacks vs whites in the U.S. especially at younger ages. We used the REGARDS study to determine what prospectively assessed factors may underlie black-white differences in ICH risk.

Methods: REGARDS recruited black and white individuals aged 45+ in the U.S. to explain regional and racial differences in stroke risk. Cox models with an age*race interaction term estimated the age-dependent hazard ratio (HR) of black versus white individuals for ICH. The 95% confidence interval (CI) of the percent attenuation of the age-dependent hazard ratio (HR) from the baseline to the final model was calculated using bootstrapping.

Results: Among 29,694 REGARDS participants (55% women; 41% black), 160 ICH events occurred over 254,440 person-years of follow-up (median 9.5 years). The point estimate for the black-white HR for ICH decreased with increasing age, being 4.8, 2.7, and 1.5 at ages 45y, 55y, and 65y (Table, Baseline Model). In a final model, the point estimate for ages 45, 55, and 65 decreased to 3.9, 2.3, and 1.4, corresponding to a 24% (95% CI 11%. 100%), 24% (95% CI 16%, 100%), and 20% (95% CI 14%, 100%) decrease in the HR at ages 45y, 55y, and 65y. No increased ICH risk was seen in blacks over 65y. When added individually to the baseline model, none of the risk factors except diet (modeled as 6 principle components of dietary patterns) attenuated the association of black race with ICH risk.

Conclusions: A quarter of the association of race with ICH may be explained by the risk factors studied here. Diet, particularly salt intake, may play a large role in black-white differences of ICH risk. While the absolute number of ICH events limits our analysis, prospective assessment of risk factors is a huge strength. Future primary and secondary ICH prevention efforts, particularly in younger blacks, should assess efficacy of dietary interventions.

Abstract TP446: Predictors of Surgical Intervention in Patients With Spontaneous Intracerebral Hemorrhage

Objective: Despite no clear evidence from randomized trials, surgical intervention of spontaneous intracerebral hemorrhage (ICH) still occurs. We sought to describe the characteristics of patients undergoing surgical intervention in ICH.

Methods: Data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study were analyzed, and ICH patients were categorized into surgical intervention or nonoperative management groups. Patients with primary intraventricular hemorrhage (IVH) and those without data regarding the use of surgical intervention data were excluded. Multivariable models were developed to identify predictors of surgical intervention.

Results: The study cohort comprised 2,947 patients, and surgical intervention was performed in 289 (10%). Younger age (p<0.001), lower baseline modified Rankin Scale score (mRS; p<0.001), higher admission Glasgow Coma Scale (GCS; p=0.007), larger ICH volume (p<0.001), infratentorial ICH location (p<0.001), lobar ICH location (p<0.001), lack of IVH (p=0.001), ICP monitoring (p<0.001), and mannitol use (p<0.001) were independent predictors of surgical intervention. Younger age (p<0.001), lower baseline mRS score (p=0.002), larger ICH volume (p<0.001), lobar ICH location (p<0.001), ICP monitoring (p<0.001), and mannitol use (p<0.001) were independent predictors of surgical interventions in supratentorial ICHs. Larger ICH volume (p<0.001), ICP monitoring (p<0.001), and mannitol use (p=0.005) were independent predictors of surgical interventions in infratentorial ICHs.

Conclusion: We identified multiple factors associated with surgical intervention for patients with ICH. Younger age, good neurological function at baseline, large ICH volume on presentation, and lobar or infratentorial hematomas were independently associated with surgical intervention in ICH patients. Additional studies are necessary to determine the risk to benefit profile of ICH surgery.

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 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 TP438: Cigarette Smoking History and Functional Outcomes After Spontaneous Intracerebral Hemorrhage

Objective: While cigarette use may be a risk for intracerebral hemorrhage (ICH), animal models suggest that nicotine has a potential neuroprotective effect. The aim of this multicenter study is to determine the effect of smoking on outcome in ICH patients.

Methods: We analyzed prospectively collected data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, and included patients with smoking status data in the analysis. Patients were dichotomized into non-smokers versus ever-smokers, and the latter group was further categorized as former (>30 days before ICH) or current (≤30 days before ICH) smokers. The primary outcome was 90-day modified Rankin Scale (mRS) score shift analysis. Secondary outcomes were in-hospital mortality and mortality, Barthel Index, and self-reported health status measures at 90 days.

Results: The overall study cohort comprised 1,509 non-smokers and 1,423 ever-smokers (841 former, 577 current, 5 unknown). No difference in primary outcome was observed between non-smokers versus ever-smokers (aOR=1.041 [0.904-1.199], p=0.577). No differences in primary outcome were observed between former (aOR=0.932 [0.791-1.178], p=0.399) or current smokers (aOR=1.178 [0.970-1.431], p=0.098) versus non-smokers. Subgroup analyses by race/ethnicity demonstrated no differences in primary outcome when former and current smokers were compared to non-smokers. Former, but not current, smokers had a lower in-hospital mortality rate (aOR=0.695 [0.500-0.968], p=0.031), which was only observed in Hispanics (aOR=0.533 [0.309-0.921], p=0.024). Differences in self-reported health status measures were only observed in whites.

Conclusion: Cigarette smoking history does not appear to provide a beneficial effect on 90-day functional outcome in patients with ICH.

Abstract WP455: Intracranial Pressure Monitoring in Patients With Spontaneous Intracerebral Hemorrhage

Objective: The role of ICP monitoring in patients with spontaneous ICH is unknown, andthe associated complications may offset its benefits. The aim of the study was to compare the outcomes of ICH patients who underwent ICP monitoring to those who were managed by care-guided imaging and/or clinical exam alone.

Methods: This was aretrospective, matched cohort analysis from a multicenter, prospective study with recruitment of 3,000 multi-ethnic cases of spontaneous ICH between September 2010 and October 2015. ICH patients with ICP monitoring were propensity-score matched, in a 1:1 ratio, to those without ICP monitoring. The primary outcome was mortality at 90 days. Secondary outcomes were in-hospital mortality, use of hyperosmolar (mannitol or hypertonic saline) therapy, surgical ICH evacuation, length of hospital stay, and the following 90-day outcomes: modified Rankin Scale (mRS) excellent (0-1) and good (0-2), Barthel Index, and health-related quality of life (HRQoL) (EuroQol Group 5-Dimension [EQ-5D] and EQ-5D Visual Analog Scale [VAS] scores).

Results: The ICP and no ICP monitoring cohorts comprised 566 and 2,434 patients, respectively. The matched cohorts each included 420 patients. The 90-day and in-hospital mortality rates were similar between the matched cohorts. Infection rate was higher in the ICP monitoring cohort (5.7% vs. 1.2%, aOR=5.066, p=0.001).Shift analysis 90-day mRS favored no ICP monitoring (aOR=1.628, p<0.001). The following outcomes were lower in the ICP monitoring cohort: excellent (6% vs. 15%; aOR=0.375, p<0.001) and good (16% vs. 30%; aOR=0.465, p<0.001) outcome, Barthel Index (median 15 vs. 45; aβ=-12.050, p<0.001), EQ-5D score (median 0.178 vs. 0.437; aβ=-0.064, p=0.026), and ED-5Q VAS score (median 40 vs. 50; aβ=-6.662, p=0.004) at 90 days. In a subgroup analysis of patients with admission GCS score ≤8, despite lower EQ-5D scores at 90 days in the ICP monitoring cohort, no difference in 90-day mortality, in-hospital mortality, excellent or good outcome, 90-day of mRS scores, ED-5Q VAS scores, and Barthel Index were observed between the ICP and no ICP monitoring cohorts.

Conclusion: The findings of this study do not support the routine utilization of ICP monitoring in patients with ICH.

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.

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.

Abstract WP176: Temporal Trends in Public Awareness of Stroke: Knowledge is Key

Introduction: Recognition of stroke symptoms is vital for accessing medical care and administration of thrombolytics and/or endovascular therapy for ischemic stroke. Awareness of stroke warning signs and risk factors is key to treatment and prevention, respectively.

Methods: Surveys were conducted in 1995, 2000, 2005, 2011 and 2016 to respondents randomly drawn to reflect the age, race and sex distribution of the ischemic stroke population in the Greater Cincinnati/ Northern Kentucky Stroke Study. All surveys are based in the same biracial population of 1.3 million, subjects were contacted using random-digit dialing. Open-ended questions regarding stroke risk factors and warning signs were asked and demographic and stroke risk factor information collected. Multiple regression was used to examine changes over time and adjust for covariates.

Results: Over the 20-year period, 10,393 surveys were completed. Survey respondents were 60% female, 27% black, with median age 67 years. As depicted in the Table, knowledge of risk factors and warning signs has significantly increased over time, however not within the past 5 years. This is also true after adjustment for age, race, sex and education of the respondents. Female sex and higher education levels were significantly associated with higher knowledge, but age and race had no independent effect.

Conclusions: Public awareness of stroke risk factors and warning signs has improved over the past 20 years, although progress has slowed during the past five years despite numerous national and regional stroke awareness campaigns. Knowledge of risk factors continues to be significantly worse than knowledge of warning signs. Further study of the effectiveness of stroke public awareness campaigns are needed.

Abstract WP327: CHADSVASC and HASBED Scores in Patients With Intracerebral Hemorrhage and Atrial Fibrillation

Background: Patients with intracerebral hemorrhage (ICH) and atrial fibrillation (a-fib) are at risk for having future ischemic events after stopping anticoagulation. Risk calculators (CHA 2 DS 2 -VASc and HAS-BLED) have been validated to assess risk for ischemic stroke and for major bleeding in a-fib patients. We sought to compare the distribution of these scores among ICH patients with a-fib within a large biracial population.

Methods: The Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study included a population-based retrospective chart review of spontaneous ICH among residents of the five-county Greater Cincinnati/Northern Kentucky region between 7/2008 and 12/2012. CHA 2 DS 2 -VASc (risk of ischemic stroke) and HAS-BED (risk of bleeding with anticoagulation; minus “L” because “labile INR” was unavailable) scores were calculated for all ICH patients with a-fib who survived the hospital stay. Published risk coefficients for each score were used to calculate predicted ischemic and bleeding events within one year of onset.

Results: Among 1186 cases of spontaneous ICH, 232 had a-fib, of which 123 patients were excluded due to inpatient death or discharge to hospice. Among the remaining 109 cases, 7-8 would be expected to have a major bleeding event (on anticoagulation), and about 6 patients would be expected to have an ischemic stroke within one year (off anticoagulation), with 73 of the 109 patients having higher risk for major bleeding than for ischemic stroke. The correlation between the two scores was weak (Spearman r=.220, p=.021).

Discussion: Comparison of CHA 2 DS 2 -VASc and HAS-BED scores suggest a higher CHA 2 DS 2 -VASc threshold for considering anticoagulation is needed for ICH a-fib patients to balance their higher risk of major bleeding. Further evaluation of the consequences of ischemic stroke and major bleeding would be needed to better understand the best treatment strategies for our patients.

Abstract TP181: Prior Antiplatelet Use and Baseline Stroke Severity: A Population-Based Study

Introduction: There is conflicting evidence on the association of antiplatelet (AP) use prior to admission with baseline ischemic stroke (IS) severity. We evaluated this association within a large, bi-racial population.

Methods: We identified all hospital-ascertained cases of IS that occurred in 2010 (including ED arriving, direct admits, and in-hospital strokes) within a population of 1.3 million. Specific AP used prior to presentation for IS were aspirin, clopidogrel, dipyridamole, prasugrel, and cilostazol. We excluded those on an anticoagulant (AC) medication for this analysis. Baseline IS severity was defined as NIH stroke scale score (NIHSS) on admission. A multivariable linear regression model including demographic and clinical variables with log-transformed NIHSS as the dependent variable was used to evaluate the effect of prior AP use on stroke severity (results shown as percentage change in NIHSS).

Results: In 2010, there were 2259 IS cases, of which 1982 (22% black, 55% female, median age 70 years [58, 81]) were included in the analysis, and 998 (50%) had history of prior AP use. Unadjusted, minor stroke (NIHSS ≤5) was slightly less common in those with prior AP use compared with those without (68% vs. 72%; p=0.04). In the multivariable model among patients with history of atrial fibrillation (AF) yet not on AC, a significant 23% reduction in NIHSS (average NIHSS 6.00 to 4.88, p=0.02) was seen in those with prior AP use. No such association was found in patients with no history of AF. The table displays the multivariable model of stroke severity.

Conclusion: We found that prior AP use did not have significant association with baseline stroke severity in the multivariable analysis. However, a subgroup of patients with history of AF had significantly less severe strokes with prior antiplatelet use.

Abstract WMP50: A Shift in the Population Distribution of Systolic Blood Pressure as a Contributor to the Decline in Stroke Mortality

Introduction: Between 1960 and 2006, stroke mortality in the U.S. has declined a remarkable 65% for white men (123.4 ◊ 42.8 per 100,000), 61% for white women (108.6 ◊42.3 per 100,000), 67% for non-white men (178.4 ◊ 59.5 per 100,000) and 70% for non-white women (175.2 ◊ 52.0 per 100,000). With hypertension being the predominant risk factor for stroke, we examined the population shift in systolic blood pressure (SBP) levels over this period.

Methods: The Charleston Heart Study (CHS) and Evan County Study (EC) were population-based cohorts recruiting black and white participants in the early 1960’s, conducted in the coastal plain regions of SC and GA respectively. REasons for Geographic And Racial Differences in Stroke (REGARDS) is a population-based study recruiting black and white participants in the contiguous U.S. For purposes of this report, CHS/EC participants were limited to those over 45 years, and REGARDS participants were restricted to residents of the coastal plain of NC/SC/GA.

Results: SBP data are available on 1,988 whites and 1,172 blacks from CHS/EC, and from 4,057 whites and 2,237 blacks from REGARDS. Dramatic changes in the distribution of SBP have occurred over these 40+ years, with the 25 th percentile of CHS/EC being consistently above the 75 th percentile for REGARDS (see figure). For example, for whites aged 65-74, the 25 th , 50 th , and 75 th percentile of SBP in CHS/EC was 144-162-184 mmHg, compared to 118-126-137 mmHg in REGARDS. For blacks, the corresponding percentiles were 158-180-204 mmHg in CHS/EC, and 119-129-140 mmHg in REGARDS. In CHS/EC, 125 of 1988 (6%) whites, and 245 of 1172 (20%) blacks had a SBP of 200+ mmHg; compared to only 4 of 4057 (0.1%) whites and 3 of 2235 (0.1%) blacks in REGARDS.

Discussion: A dramatic shift in the distribution of systolic blood pressure, likely related to both population shifts in blood pressure and the advent of antihypertensive therapy, is likely a major contributor to the steep decline in stroke mortality.

Abstract WMP55: Temporal Trends of Sex Differences in Transient Ischemic Attack Incidence Within a Population

Introduction: Previously we reported that ischemic stroke incidence is declining over time for men but not women. We sought to describe temporal trends of sex differences in TIA incidence within a large, biracial population.

Methods: Among the biracial population of 1.3 million in the Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS) region, all first-ever transient ischemic attacks (TIAs) among area residents (≥20 years old) were identified at all local hospitals. Out of hospital cases were ascertained using a sampling scheme. All cases were reviewed by study physicians. Sex-specific TIA incidence rates over time (during 7/93-6/94 and calendar years 1999, 2005, and 2010) were determined. Incidence rates were calculated using the age-, race-, and sex-specific number of TIAs divided by the population in that group; rates were standardized to the 2010 U.S. population. Statistical testing for differences over time was done using linear regression models adjusted for age and race. The delta method was used to estimate the ratio of female to male TIA incidence and the associated standard error (SE).

Results: There were a total of 3203 patients with incident TIA; 54% were female, and 12% were black. Overall, mean age for men was 66 (SE 0.36) compared to 71 (SE 0.33) for women, p=0.01. Compared with men, women had lower rates of TIA in all 4 study periods, and TIA incidence rates were stable over time for women (p=0.19) and men (p=0.12). (See table). TIA patients were younger in 2010 than in 1993/4 and 1999 (P<0.05) with means of 68 (SE 0.53), 70 (SE 0.50) and 71 (SE 0.47) respectively.

Conclusions: Within the GCNKSS population, women had lower TIA incidence rates than men. In contrast to what we have previously described in ischemic stroke incidence, neither the sex difference in incidence nor the sex-specific incidence rates are changing over time. Further research is needed to understand the drivers of higher TIA incidence in men and the lack of change in TIA incidence over time.

Abstract WMP52: Prevalence of Undiagnosed Risk Factors in Patients With First-Ever Ischemic Stroke

Introduction: Undiagnosed RF (URF) are a missed opportunity for primary stroke prevention. We sought to determine the prevalence of URF (RF newly diagnosed during inpatient evaluation) among first-ever ischemic stroke (IS) cases within a large, bi-racial population.

Methods: Within the population-based Greater Cincinnati/Northern Kentucky (GCNK) stroke study catchment area of 1.3 million, we ascertained all hospitalized first-ever acute IS in 2010 among individuals ≥20 years old through screening of ICD-9 codes 430-436, with all cases verified by study physicians. We evaluated the prevalence of undiagnosed diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLD), and atrial fibrillation (AF) among all IS patients and those with each risk factor. We also evaluated the association between URF and insurance status (private, Medicaid/Medicare, or uninsured) for each RF using chi-square tests.

Results: There were 1737 first-ever IS cases in the GCNK region in 2010 (55.8% female, 19.5% black, median age 71). Of these, 21% had at least one URF (Table), most commonly HLD (13%) or HTN (6%). Among patients with a given risk factor, 21% of those with HLD, 13% with AF, 9% with DM, and 7% with HTN were undiagnosed prior to inpatient evaluation for first-ever IS. Uninsured individuals (48%) were significantly more likely than those with private (22%) or government (20%) insurance to have at least one URF.

Conclusions: One in five IS patients had at least one URF upon presentation with their first-ever stroke, and URF were more prevalent among uninsured individuals. Our data reinforce the importance of screening for URF during IS evaluation and highlight the importance of earlier detection of treatable RF.

Future research should evaluate factors that may predict URF, such as insurance status, race, or sex.

New mutations in GJA8 expand the phenotype to include total sclerocornea

This project expands the disease spectrum for mutations in GJA8 to include total sclerocornea, rudimentary lenses and microphthalmia, in addition to this gene's previously known role in isolated congenital cataracts. Ophthalmic findings revealed bilateral total sclerocornea in 3 probands, with small abnormal lenses in 2 of the cases, and cataracts and microphthalmia in 1 case. Next-generation sequencing revealed de novo heterozygous mutations affecting the same codon of GJA8 : (c.281G>A; p.(Gly94Glu) and c.280G>C; p.(Gly94Arg)) in 2 of the probands, in addition to the c.151G>A; p.(Asp51Asn) mutation we had previously identified in the third case. In silico analysis predicted all of the mutations to be pathogenic. These cases show that deleterious, heterozygous mutations in GJA8 can lead to a severe ocular phenotype of total sclerocornea, abnormal lenses, and/or cataracts with or without microphthalmia, broadening the phenotype associated with this gene. GJA8 should be included when investigating patients with the severe anterior segment abnormality of total sclerocornea.

Age, Sex, and Racial Differences in Neuroimaging Use in Acute Stroke: A Population-Based Study

BACKGROUND AND PURPOSE

Limited information is available regarding differences in neuroimaging use for acute stroke work-up. Our objective was to assess whether race, sex, or age differences exist in neuroimaging use and whether these differences depend on the care center type in a population-based study.

MATERIALS AND METHODS

Patients with stroke (ischemic and hemorrhagic) and transient ischemic attack were identified in a metropolitan, biracial population using the Greater Cincinnati/Northern Kentucky Stroke Study in 2005 and 2010. Multivariable regression was used to determine the odds of advanced imaging use (CT angiography/MR imaging/MR angiography) for race, sex, and age.

RESULTS

In 2005 and 2010, there were 3471 and 3431 stroke/TIA events, respectively. If one adjusted for covariates, the odds of advanced imaging were higher for younger (55 years or younger) compared with older patients, blacks compared with whites, and patients presenting to an academic center and those seen by a stroke team or neurologist. The observed association between race and advanced imaging depended on age; in the older age group, blacks had higher odds of advanced imaging compared with whites (odds ratio, 1.34; 95% CI, 1.12-1.61; P < .01), and in the younger group, the association between race and advanced imaging was not statistically significant. Age by race interaction persisted in the academic center subgroup (P < .01), but not in the nonacademic center subgroup (P = .58). No significant association was found between sex and advanced imaging.

CONCLUSIONS

Within a large, biracial stroke/TIA population, there is variation in the use of advanced neuroimaging by age and race, depending on the care center type.

Abstract 17: Prehospital Deterioration During Transport by Emergency Medical Services for Stroke Patients: A Population-Based Study

Introduction: Stroke patients can experience neurological change in the prehospital setting. We sought to identify factors associated with prehospital neurologic deterioration.

Methods: Among the Greater Cincinnati/Northern Kentucky region (pop. ~1.3 million), we screened all 15 local hospitals’ admissions from 2010 for acute stroke, and included patients with age ≥20 and complete EMS records. Glasgow Coma Scale (GCS) at hospital arrival was compared with GCS evaluated by EMS, with decrease ≥2 points considered neurologic deterioration. Data obtained included age, sex, race, medical history, antiplatelet or anticoagulant use, stroke subtype [ischemic (IS), ICH, or SAH] and IS subtype (e.g., small vessel, large vessel, cardioembolic), seizure at onset, time from symptom onset to EMS arrival, time from EMS to hospital arrival, blood pressure and serum glucose on EMS arrival, and EMS level of training. Univariate analysis was completed using Wilcoxon rank sum test for continuous measures and chi-square or Fisher’s exact test for categorical measures. Multivariate analysis was completed on variables with p ≤ 0.20 in the univariate analysis.

Results: Of 2708 total stroke patients, 1097 (870 IS, 176 ICH, 51 SAH) had EMS records (median [IQR] age 74 [61, 83] years; 56% female; 21% black). Onset to EMS arrival was ≤4.5 hours for 508 cases (46%), and median time from EMS to hospital arrival was 26 minutes. Neurological deterioration occurred in 129 cases (12%), including 9.1% of IS and 22% of ICH/SAH. In multivariate analysis, black race, atrial fibrillation, ICH or SAH subtype, and ALS transport were associated with neurological deterioration.

Conclusion: Atrial fibrillation may predict prehospital deterioration in stroke, and preferential transport of patients with acute worsening to centers capable of managing hemorrhagic stroke may be justifiable. Further studies are needed to identify why race is associated with deterioration and potential areas of intervention.

Abstract 56: An Exome Array Analysis of Ischemic Stroke in the Genetics of Early Onset Stroke Study

Background: Ischemic stroke is a heterogeneous trait and its genetic architecture is poorly understood. The genetic contribution may be stronger for stroke occurring at younger (vs. older) ages. To identify additional stroke susceptibility variants, we genotyped participants in the Genetics of Early Onset Stroke (GEOS) with the exome array and conducted association analyses with the goal of identifying functional risk variants by interrogating the protein-coding portion of genes.

Methods: The GEOS Study was initiated as a biracial population-based study of cases with first-ever ischemic stroke 15 to 49 years of age (n=828) and matched controls (n=850). All participants underwent exome-chip genotyping. Logistic regression was used to calculate associations in European-Caucasians (EUR) and African-Americans (AA), and summary results were combined by meta-analysis.

Results: Our analyses revealed four highly associated variants for all-stroke and several others that were stroke subtype specific. Among these for all-stroke, we identified a missense variant in VWDE (rs6460939 (K (AA G ) --> N (AA C )), which encodes the Von Willebrand Factor D and EGF domain-containing protein. This protein plays a role in intracellular calcium ion binding within a variety of cell-types. The association was present in both European-Caucasians (OR = 1.34, p = 0.002) and African-Americans (OR = 1.32, p = 0.01), and was strengthened in a meta-analysis of both ethnic groups (OR = 1.41, p = 8.95 х 10 -6 ). The frequency of the effect C allele was 0.46 in EUR and 0.55 in AA. Efforts in additional data sets to further replicate this association, and the others identified, are ongoing.

Conclusion: Exome-based analyses in the setting of young-onset stroke is a productive methodology to identify genetic risk variants.

Abstract 134: A Telephone Approach for Sceening for Stroke RIsk: The REGARDS Telephone Stroke Risk Score

Introduction: The ability to identify a stroke/TIA-free population at high risk for stroke is important for risk assessment in the general population, and also a critical step to make a primary stroke prevention trial feasible. The standard for risk stratification is the Framingham Stroke Risk Score (FSRS); however, its use requires a clinic visit for blood pressure and ECG assessment, and laboratory measurement of glucose levels. The feasibility of a primary prevention trial would be greatly enhanced by a brief interview, potentially conducted over the telephone or web, to identify a high-risk population.

Methods: A general population sample consisting of 23,983 REGARDS participants aged 45+ who reported being stroke and TIA free at baseline was characterized on 11 self-reported characteristics: age, race, sex, self-reported diagnosis of medical conditions (hypertension, diabetes, atrial fibrillation, and myocardial infarction), smoking, previous stroke symptoms, self-reported general health, and education. Participants were followed for incident stroke, with associations assessed by proportional hazards.

Results: Over an average follow-up of 8.2 years, 564 incident strokes occurred. The self-reported characteristics were strongly related to stroke risk (see table), and proved marginally more predictive of stroke risk (c-statistic = 0.7268; 95% CI: 0.7078 - 0.7459) than the FSRS (c-statistic = 0.7222; 95% CI: 0.7025 - 0.7419). The annual stroke risk was 1.4% (95% CI: 1.2 - 1.7) for those in the highest decile of the telephone risk score. The Spearman correlation between the FSRS and the REGARDS telephone risk score was 0.848 (95% CI: 0.844 - 0.851).

Discussion: The REGARDS Telephone Stroke Risk Score can be calculated using data collected over the telephone, at a web site, or in person. It can identify a population at high risk for stroke as well as the FSRS clinic-based assessment can, making it an efficient stroke risk assessment tool.

Abstract TMP76: Stroke Quality-of-care Metrics in Comprehensive and Primary Stroke Centers and Non-stroke Centers

Introduction: Measuring the quality of stroke care has become increasingly important, but real-world data are limited, especially because many hospitals do not track their own statistics. We sought to determine differences in quality-of-care metrics for ischemic stroke (IS) among non-stroke centers, primary stroke centers (PSC), and comprehensive stroke centers (CSC).

Methods: The Greater Cincinnati/Northern Kentucky (GCNK) Stroke Study measures temporal trends in the incidence of stroke in a biracial population of 1.3 million. Adult IS cases in 2010 from the GCNK region were ascertained from all local hospitals via ICD-9 codes 430-436 using retrospective chart review. Hospitals included 10 non-stroke centers, 2 PSCs, and 1 PSC that earned CSC status in 2013. Differences in IS patients’ demographics, medical histories, and quality measures were evaluated among hospital categories using chi-square, Fisher’s exact, and Kruskal-Wallis tests. Quality measures were matched to Get With The Guidelines-Stroke (GWTG-S) when possible, although data regarding the appropriateness for non-treatment were not available.

Results: In 2010, there were 1,981 IS patients in our population (55% female, 21% black) with a median age of 71 years. Of these, 83 were transferred to a different hospital type. There were significant differences in the demographics and medical histories of IS patients, as well as the majority of quality measures, with the CSC and PSCs demonstrating greater compliance with most metrics. (Table)

Conclusions: We found significant hospital-level differences in both premorbid patient characteristics and quality-of-care metrics depending on the hospital stroke certification status. To our knowledge, this is the first measurement of best-practice care specifically involving hospitals not participating in national quality improvement programs, such as GWTG-S. These differences may help inform quality improvement efforts across hospital types.

Abstract TP207: Sex Differences in Cardiovascular Risk Profiles of Patients with Diabetes in the Greater Cincinnati/ Northern Kentucky Stroke Study

Introduction: Diabetes mellitus (DM) carries a greater stroke risk for females than males, possibly because of a difference in cardiovascular risk profiles between females and males with DM. Our aim was to compare the sex-specific risk factor profiles for patients with DM with those without DM among patients with acute ischemic stroke (AIS) in the Greater Cincinnati/ Northern Kentucky Stroke Study (GCNKSS).

Methods: The GCNKSS ascertained cases of AIS in 2005 and 2010 among adult (age ≥20 years) residents of a biracial population of 1.3 million. Past and current stroke risk factors, obtained via chart review, were compared between those with and without DM using chi-square to examine bivariate differences and multiple logistic regression to examine sex-specific profiles. P < 0.05 was considered statistically significant.

Results: There were 3515 patients with incident AIS; 1919 (55%) were female, 697 (20%) were black, and 1146 (33%) had DM. A lower proportion of females with DM were over 65 years old compared with those without DM. The proportion of males >65 with DM was not significantly different from that of males without DM. Among both females and males with DM, significantly more were Black, obese, and had histories of hypertension, high cholesterol, CAD and myocardial infarction compared to those without DM. In sex-specific adjusted analyses, women with DM were significantly less likely to be over 65 and more likely to have CAD than women without DM, whereas age and CAD were not significant factors in differentiating the profiles of men with and without DM.

Conclusions: The result that females had their strokes at a younger age if they had a history of DM, and that no such age difference existed in males, suggests that DM is more severe and has a greater negative impact on females than males. As opposed to males, females with DM were also more likely to have CAD compared to those without DM, consistent with a possible sex difference in the association between DM and vascular disease.

Abstract WP213: Comparison of Clinical and Imaging Characteristic of Cryptogenic Stroke to Known Ischemic Subtypes

Introduction: Cryptogenic stroke is defined as not attributable to an identified source despite standard evaluation. The absence of small vessel or large artery disease in such evaluation suggests that cryptogenic stroke may be largely cardioembolic. We hypothesized that cryptogenic stroke would be similar to cardioembolic stroke in clinical and imaging characteristics.

Methods: The Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) is a population-based study that tracks the regional incidence of stroke. A convenient subsample from the 2010 GCNKSS ischemic stroke cohort (N= 368) was selected for detailed neuroimaging analysis. The study physician subtyped cases based on clinical, radiographic and laboratory findings (carotid ultrasound, echocardiography, vascular imaging). Subtypes included cryptogenic, cardioembolic, large-vessel, small-vessel, undetermined, and other. Three radiologists performed imaging analysis including number of acute infarcts, location and white matter hyperintensity (WMH). Infarct volume was segmented using manual tracing.

Results: Of 368 ischemic stroke cases with imaging data, subtypes were 26.4% cryptogenic, 16.3% large vessel, 15.5% small vessel, 24.7% cardioembolic, 5.4% undetermined, and 11.7% other. Compared to cardioembolic, cryptogenic stroke patients were younger, had less hypertension, higher alcohol use, smaller infarct volume and differed in location of stroke. Cryptogenic stroke had more clinical and radiological features in common with large and small-vessel stroke (Table). Undetermined and other had no significant differences to cryptogenic.

Conclusion: Contrary to our hypothesis, cryptogenic stroke was different from cardioembolic stroke and appeared more similar to large vessel stroke in clinical and radiological characteristics. Further testing on a larger sample size to evaluate the impact of cardiac event monitoring on subtype distribution is needed.

Abstract 139: Trends in Ischemic Stroke Subtype Over a 17-Year Period

Introduction: Overall US stroke incidence rates have declined. Prior analysis of the Cincinnati region has demonstrated more thorough diagnostic workups coinciding with decreased proportion of cryptogenic and increased proportion of cardioembolic strokes over time in those patients presenting to the ED. We now examine trends in population-based incidence rates of stroke subtypes.

Methods: Within the Greater Cincinnati/Northern Kentucky catchment area of 1.3 million, all strokes were ascertained between July 1993 and June 1994 and in 1999, 2005 and 2010. Incidence rates per 100,000, age-, race- and sex-adjusted to the 2000 US population, and associated 95% confidence intervals were calculated. Changes in stroke-subtype proportions over time were examined using a general linear model.

Results: There were a total of 6859 incident ischemic strokes (1709 in 1993/94, 1778 in 1999, 1681 in 2005, and 1691 in 2010; age ≥20 years), of which 1290 (18.8%) were black and 3846 (56.1%) female. The Table shows subtype-adjusted incident rates by study period. Incidence rates of both small- and large-vessel etiology showed no significant change over time. Incidence rates of both cardioembolic and other known etiology increased significantly over time, whereas incidence rates of unknown subtype decreased significantly.

Conclusions: In our large, biracial population-based cohort, while overall stroke incidence rates have been stable or declining over the last 17 years, trends for individual stroke subtypes have varied. Consistent with our prior analyses, more strokes have been attributed to cardioembolic etiology, whereas strokes attributable to small-vessel and large-vessel etiology have remained stable. The increase in cardioembolic strokes may be due to age and/or prolonged cardiac monitoring. Future analysis of age-adjusted rates for atrial fibrillation over time is warranted.

Abstract WP305: Impact Of Metformin on Survival Following Ischemic Stroke in Patients With Diabetes: The Greater Cincinnati Northern/Kentucky Stroke Study (GCNKSS)

Introduction: Metformin, an oral antidiabetic drug, is associated with reduced risk of diabetic related endpoints, including stroke. Evidence from animal studies show neuroprotective properties of metformin via the AMP-activated protein kinase pathway. We examined if these neuroprotective effects of metformin may extend into improved survival among stroke patients.

Methods: All stroke patients within the Greater Cincinnati/Northern Kentucky catchment area of ∼ 1.3 million were identified using ICD-9 discharge codes (430-436) in 2005 and 2010. Cases were abstracted by study nurses and verified by physician review. Patients surviving to hospital discharge with a history of diabetes or diagnosed with diabetes during hospitalization (DM) were categorized into four groups based on recorded medication use: metformin monotherapy, metformin combotherapy, other antidiabetic drug therapy, and no antidiabetic medications. The primary outcome was all cause case fatality at 3 years following stroke. Covariates considered were age at onset, sex, race, BMI, baseline NIHSS and mRS, smoking status, history of comorbidities, and glucose level on admission. Cox proportional hazard models were used to estimate the risk of case fatality.

Results: Overall, 37% (1,471) of the 4,015 ischemic stroke patients (>= 20 years of age) met criteria for DM. Patients with DM (vs non DM) were 65 (vs 66) years of age, 55% (vs 56%) female, and 27% (vs 18%) black. Of patients with DM, 10% were on metformin monotherapy, 28% metformin combotherapy, 50% other antidiabetic drugs, and 13% no antidiabetic drugs. In adjusted analysis, at 3 years post stroke, patients on metformin monotherapy or combotherapy had similar risk of case fatality compared with non-DM and had lower risk of case fatality compared with DM on no drug therapy (Table).

Conclusions: Use of metformin, either alone or in combination with other antidiabetic drugs may provide a long term survival benefit among stroke patients with diabetes.

Abstract WP232: Prevalence of Positive Troponins and Association With Abnormal Echocardiograms in Acute Ischemic Stroke

Background and Purpose: Acute Ischemic Stroke (AIS) patients may have high sensitivity serum troponin (cTn) levels drawn upon admission, although it is unclear how frequently cTn levels are elevated, and whether these levels are associated with cardiac causes of stroke as seen on echocardiogram. We investigated the prevalence and positivity of cTn and echocardiogram testing within a large biracial population that is representative of the US.

Methods: Within a catchment area of 1.3 million we screened local hospital admissions in 2010 using ICD-9 discharge codes 430-436 and ascertained all physician-confirmed AIS cases by standardized retrospective chart review, including diagnostic test results. Any positive cTn was defined by the standard 99 th percentile cutoff. Echocardiogram findings of interest were defined as in the table. Logistic regression was used for analyses, controlling for age, sex, race and prior history of cardiac disease.

Results: Of the 1999 AIS cases that presented to an ED in the region 1706 (85.3%) had a cTn drawn and 1590 (79.5%) had an echocardiogram. A positive cTn was seen in 353/1706 (20.7%) and 160/1590 (10%) had an echocardiogram finding of interest. Of the 1377 that had both tests performed, a positive cTn was associated with an abnormal echocardiogram ( adjusted OR 2.9 95% CI 2-4.2 ). A negative cTn did not significantly alter the odds of having an abnormal echocardiogram ( Negative Likelihood Ratio=0.66 ).

Conclusion: Testing with serum cTn and echocardiogram was common within our population. Troponinemia above the 99 th percentile was prevalent and was associated with clinically relevant structural cardiac disease on echocardiogram. However absence of troponinemia was not informative regarding the probability of a normal echocardiogram, and therefore does not obviate the need for echocardiography in this at risk population.

Abstract 149: Association of Ischemic Stroke Location and Demographic Variables with Percutaneous Endoscopic Gastrostomy Placement

Introduction: PEG is often necessary in patients with dysphagia after ischemic strokes (IS) to prevent aspiration. As cranial nerve nuclei responsible for swallowing are in the brainstem; it seems intuitive that IS in the posterior circulation (PC) would cause dysphagia requiring PEG. We describe current clinical practice patterns within a large, biracial population.

Methods: Within the Greater Cincinnati/Northern Kentucky region (population ∼1.3 million) we screened all 15 local hospitals’ admissions in 2010 using ICD-9 discharge codes 430-436. All cases were study physician confirmed. IS location was determined by brain imaging or study physician clinical impression. Demographic and clinical variables included age, race, sex, insurance status, baseline rNIHSS, atrial fibrillation (AF), dysphagia, thrombolysis, bi-hemispheric stroke, community or academic hospital, and volume of stroke admission. Logistic regression was used to evaluate associations between PEG and clinical/demographic characteristics.

Results: Our sample included 2168 patients with IS; 118 underwent PEG placement. The overall population was 55% women and 22% black. Of the PEG patients,62% were women and 32% were black. Median (range) age was 74 (66-83) yrs in PEG patients and 71 (58-82) in those without PEG. In patients with PC only stroke, 16/457 (3.5%) had a PEG, while 83/1365 (6.0%) of anterior circulation only stroke required PEG and 19/346 (5.5%) of patients with both anterior and PC stroke required PEG. Findings were not explained by differences in hospice/mortality rates. In multivariable analysis, black race, rNIHSS, AF, and dysphagia were strongly associated with PEG (table).

Conclusions: PC strokes were not more likely to undergo PEG placement compared to anterior circulation IS within our population. Further investigation is needed to understand the associations of PEG with black race and AF, including possible racial differences in approach to end-of-life care.

Abstract TP371: Comparison of Three Stroke Severity Scales With Mortality Within an Intracerebral Hemorrhage Population: a Population-based Study

Introduction: The 2015 AHA/ASA guidelines recommend documentation of a stroke severity scale in the initial evaluation for intracerebral hemorrhage (ICH) patients. We describe the distribution of three stroke severity scores and their association with 30 day mortality within a population.

Methods: We identified all ICH patients ≥ 20 years old in 2010 among residents of the Greater Cincinnati/Northern Kentucky region, a biracial population of ∼1.3 million. We screened area hospitals’ discharge ICD-9 codes for potential cases. Study nurses abstracted relevant information from hospital charts, and study physicians verified the cases of ICH. Data included NIH stroke scale determined retrospectively (rNIHSS) (range of scores (0-42), Glasgow coma scale (GCS) (0-15), and ICH score (0-6). Cases whose rNIHSS could not be evaluated due to coma were assigned a score of 35. Multiple logistic regression was used to examine association with mortality.

Results: There were 304 ICH patients with ICH scores available. Mean (±SD) age was 69 (±16) years, 160 (53%) were female, and 76 (25%) were black. Median (IQR) values for the severity scores were rNIHSS 7 (1, 22), GCS 14 (9, 15), and ICH score 2 (1, 3) (Figure). Models that examined the scales individually and controlled for age, sex, and race showed odds ratios (OR) (95% CI) for 30 day mortality of 1.5 (1.2, 1.9) for each 5 point increase in rNIHSS, 1.5 (1.4, 1.6) for each 1 point decrease in GCS, and 4.59 (3.34, 6.64) for each 1 point increase in ICH score. With both rNIHSS and ICH score in the same model there was an increased odds of 30 day mortality of 1.5 (1.3, 2.0) for each 5 point increase in rNIHSS and increased odds of 2.8 (1.9, 4.0) for each one point increase in ICH score independently.

Conclusion: We found that the rNIHSS in combination with ICH score provides additional predictive information with regard to 30 day mortality, and we recommend further prospective study for validation.

Abstract WP190: Clinical Features of Sarcoid Patients With Ischemic Stroke

Background: Current knowledge on ischemic stroke in sarcoid patients stems from sporadic case reports. The mechanism is thought to be related to granulomatous involvement of brain vasculature. However, clinical, demographic, and radiographic features of sarcoid patients with ischemic stroke are lacking. If sarcoid patients are at higher risk for ischemic stroke event, we hypothesized that the risk factors for ischemic stroke and stroke subtype distribution would differ between sarcoid and non-sarcoid ischemic stroke patients.

Methods: Cases of ischemic stroke were identified for the years 2005 and 2010 from the population-based Greater Cincinnati/Northern Kentucky Stroke Study (population 1.3 million). Ischemic stroke cases were physician study confirmed and patients with a history of sarcoid were identified through medical chart review. Clinical variables were compared between stroke patients with history of sarcoid and those with no prior sarcoid history.

Results: A total of 4258 cases of ischemic stroke were identified; of them, only 18 had prior diagnosis of sarcoid (0.04%). Brain MRI showed diffusion restriction in 14 out of 15 (93%) MRIs performed in sarcoid patients. The table presents risk factor and subtype data on sarcoid patients compared with non-sarcoid patients.

Conclusions: We identified only a few cases of prior sarcoid history in our two-year ascertainment of ischemic stroke patients in our population. In comparison with stroke patients with no prior history of sarcoid, the sarcoid patients tended to be of younger age at presentation, female, have a history of diabetes and hyperlipidemia, and more likely of African descent, perhaps related to the diagnosis of sarcoid itself. We were unable to detect differences in stroke subtype distributions between sarcoid and non-sarcoid ischemic stroke patients.

Developing an Atrial Fibrillation Guideline Support Tool (AFGuST) for shared decision making

OBJECTIVE

Patient values and preferences are an important component to decision making when tradeoffs exist that impact quality of life, such as tradeoffs between stroke prevention and hemorrhage in patients with atrial fibrillation (AF) contemplating anticoagulant therapy. Our objective is to describe the development of an Atrial Fibrillation Guideline Support Tool (AFGuST) to assist the process of integrating patients' preferences into this decision.

MATERIALS AND METHODS

CHA2DS2VASc and HAS-BLED were used to calculate risks for stroke and hemorrhage. We developed a Markov decision analytic model as a computational engine to integrate patient-specific risk for stroke and hemorrhage and individual patient values for relevant outcomes in decisions about anticoagulant therapy.

RESULTS

Individual patient preferences for health-related outcomes may have greater or lesser impact on the choice of optimal antithrombotic therapy, depending upon the balance of patient-specific risks for ischemic stroke and major bleeding. These factors have been incorporated into patient-tailored booklets which, along with an informational video, were developed through an iterative process with clinicians and patient focus groups.

KEY LIMITATIONS

Current risk prediction models for hemorrhage, such as the HAS-BLED, used in the AFGuST, do not incorporate all potentially significant risk factors. Novel oral anticoagulant agents recently approved for use in the United States, Canada, and Europe have not been included in the AFGuST. Rather, warfarin has been used as a conservative proxy for all oral anticoagulant therapy.

CONCLUSIONS

We present a proof of concept that a patient-tailored decision-support tool could bridge the gap between guidelines and practice by incorporating individual patient's stroke and bleeding risks and their values for major bleeding events and stroke to facilitate a shared decision making process. If effective, the AFGuST could be used as an adjunct to published guidelines to enhance patient-centered conversations about the anticoagulation management.

Abstract W P271: Reasons Why rt-PA Was Not Given: Physician Documentation vs. Chart Abstraction

Introduction: Joint Commission primary stroke center (PSC) certification requires explicit physician documentation as to why rt-PA is not given to an ischemic stroke patient who presents within two hours of onset. We hypothesized that many reasons for non-treatment could be inferred from the medical record even if physician documentation was absent, and we sought to evaluate this within a large, biracial population in a region containing four PSC and eleven non-PSC hospitals.

Methods: All ischemic stroke patients ≥20 years of age who presented to an emergency department within two hours of onset in 2010 and resided in the Greater Cincinnati/Northern Kentucky (GCNK) region were included. For each case, medical records from the acute hospitalization were retrospectively abstracted by research nurses, who recorded physician-documented reasons for non-treatment and recorded at least one exclusion criterion applicable to the patient. Chi-square test was used to compare physician documentation rates between PSC and non-PSC hospitals.

Results: There were 374 patients included in this analysis. Mean age was 69.8 (SD 15.0), 50.8% were female, and 19.8% were black. Of the 374, 96 (25.7%) were treated with rt-PA. Of the 278 patients who were not treated, 82 presented to PSCs and 196 presented to non-PSCs. At PSCs, physicians documented exclusion criteria 58.5% of the time, while nurses abstracted exclusion criteria in 92.7%. At non-PSCs, the rate of physician documentation was 43.9% and that of nurse abstraction was 94.5%. Rate of physician documentation was statistically significantly higher at PSCs than non-PSCs (p=0.03).

Discussion: Within our population, we found that physicians documented the rationale for non-treatment with rt-PA less than half of the time. However, study nurses were able to abstract exclusion criteria from the chart in 94% of cases. Physician documentation, though still poor, was better at primary stroke centers than other hospitals. Allowing objective rt-PA exclusions to be abstracted from the medical record may allow a more accurate understanding of reasons for non-treatment at the hospital level.

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

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

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

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

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

Abstract W P284: Frailty Is an Independent Predictor of Functional Status at Hospital Discharge in Acute Ischemic Stroke Patients

Introduction: Frailty, a state of cumulative decline in multiple systems, is commonly evaluated in geriatrics outcome but rarely for stroke. We sought to determine if frailty is an independent predictor of functional status after accounting for age, pre-stroke function, stroke severity and other factors.

Methods: Clinical data from ischemic stroke admissions in the Cincinnati/Northern Kentucky Stroke Study during 2005 were obtained. Functional status was measured using the modified Rankin Scale (mRS) with categories ≤1, 2, 3, ≥4. Using established methods, we developed a frailty score using 35 age-related deficits that included comorbidities, symptoms, clinical and lab values (range 0-35 points). We modeled mRS at discharge using an ordinal logistic regression with proportional odds, adjusting for age, race, sex, stroke severity (NIHSS score > 5 vs ≤ 5), pre-stroke functional status (mRS) and EMS (ambulance) arrival. The independent association between the frailty score (expressed as a 1 deficit or point change) and poorer functional status at discharge (higher mRS) was determined.

Results: A total of 1906 ischemic strokes surviving to discharge were included. The median age was 72 years, 23% black, 55% female, median NIHSS 3 (IQR 2, 6) and median frailty score 6 (IQR 3, 8). The distribution of mRS ≤1, 2, 3, or ≥4 at discharge was 19%, 17%, 27%, and 37%, respectively. The final model (Table) illustrates that frailty score, age, stroke severity, pre-stroke function, and EMS use were all significant predictors. A 1 deficit (point) increase in the frailty score was independently associated with a 10% increase in the odds of a higher discharge mRS.

Conclusions: Frailty was independently associated with poorer functional status at discharge even after accounting for age, stroke severity and pre-stroke function. These data suggest that a measure of frailty could improve the predictive accuracy and clinical utility of stroke outcome models.

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

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

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

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

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