Randomized, controlled clinical trial of acoustic stimulation to reduce postconcussive symptoms

OBJECTIVE

Effective interventions are needed to address postconcussive symptoms. We report the results of randomized, sham-controlled trial of Cereset Research™ Standard Operating Procedures (CR-SOP), a noninvasive, closed-loop, allostatic, acoustic stimulation neurotechnology previously shown to improve insomnia.

METHODS

Military service members, veterans, or their spouses with persistent symptoms (Neurobehavioral Symptom Inventory [NSI] Score ≥23) after mTBI 3 months to 10 years ago, were randomized to receive 10 sessions of engineered tones linked to brainwaves (LB, intervention), or random engineered tones not linked to brainwaves (NL, sham control). The primary outcome was change in NSI, with secondary outcomes of heart rate variability and self-report measures of sleep, mood, and anxiety.

RESULTS

Participants (n = 106, 22% female, mean age 37.1, 2.8 deployments, 3.8 TBIs) were randomized 1:1 to LB or NL, with no significant differences between groups at baseline. Among all study participants, the NSI declined from baseline 41.0 to 27.2 after (P < 0.0001), with gains largely sustained at 3 months (31.2) and 6 months (28.4). However, there were no significant differences between the LB (NSI declined from 39.9 at baseline to 28.2 post-intervention, 31.5 at 3 months, and 29.4 at 6 months) and NL (NSI declined from 41.5 at baseline to 26.2, 29.9, and 27.3, respectively. Similar patterns were observed for the PCL5 and PHQ-9 and there was no difference in HRV between groups.

INTERPRETATION

Ten hours of acoustic stimulation while resting in a zero-gravity chair improves postconcussive symptoms. However, linking tones to brain electrical activity did not reduce symptoms more than random tones.

REGISTRATION

ClinicalTrials.gov - NCT03649958.

Cereset Research Standard Operating Procedures for Insomnia: A Randomized, Controlled Clinical Trial

Background

Interventions for insomnia that also address autonomic dysfunction are needed.

Objective

We evaluate Cereset Research™ Standard Operating Procedures (CR-SOP) in a pilot randomized, controlled trial. CR-SOP is a less operator-dependent, more generalizable innovation of HIRREM^®, a noninvasive, closed-loop, allostatic, acoustic stimulation neurotechnology demonstrated to improve insomnia and autonomic function.

Methods

Adults with Insomnia Severity Index (ISI) scores of ≥8 were randomized to receive ten sessions of CR-SOP, with tones linked to brainwaves (LB, intervention), or a sham condition of random tones not linked to brainwaves (NL, control). Measures were collected at enrollment and 0-14 days and 4-6 weeks post-allocated intervention. The primary outcome was differential change in ISI from baseline to 4-6 weeks post-intervention. Secondary self-report measures assessed sleep quality65 and behavioral outcomes. Ten-minute recordings of heart rate and blood pressure were collected to analyze autonomic function (heart rate variability [HRV] and baroreflex sensitivity).

Results

Of 22 randomized, 20 participants completed the allocated condition. Intention to treat analysis of change from baseline to the 4-6 week outcome demonstrated mean ISI score reduction of 4.69 points among controls (SE 1.40). In the intervention group, there was an additional 2.58 point reduction in ISI score (SE 2.13; total reduction of 7.27, P = .24). Sleep quality and some measures of autonomic function improved significantly among the intervention group compared to control.

Conclusions

This pilot study compared use of a standardized, allostatic, acoustic neurotechnology intervention with a sham, active control condition. The magnitude of change in insomnia severity was clinically relevant and similar to the findings in a prior, fully powered trial, but the differential improvement observed was not statistically significant. Significant improvements were demonstrated in sleep quality and some autonomic function measures.

Abstract P206: Improvement Of Autonomic Function, Sleep, Depression, Anxiety, And Stress In Military Personnel With Traumatic Stress After Use Of A Closed Loop Neurotechnology

Introduction: Symptoms associated with military-related traumatic stress (MTS) include insomnia, depression, anxiety, and impaired autonomic control. High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®) is a noninvasive, closed-loop acoustic stimulation technology that identifies dominant brain frequencies and translates them in real time into audible tones of variable pitch and timing, to support self-optimization of brain activity.

Objective: Evaluate changes in autonomic and symptoms scores after use of HIRREM in subjects enrolled in a pilot study for MTS.

Methods: Thirty-two service members or Veterans (1 female), mean (SD) age 40.8 (6.4), with MTS symptoms for 7.3 years (3.9), received 19.2 (1.0) HIRREM sessions over 12 days. Continuous recordings of blood pressure and heart rate, for analysis of baroreflex sensitivity (BRS) and heart rate variability (HRV), were done at V1 and V2. Symptom inventories collected before (Visit 1, V1), immediately after (primary outcome, V2, n = 32), and at 1, 3, and 6 months after completion of HIRREM included traumatic stress (PCL-M), insomnia (ISI), depression (CES-D), and anxiety (GAD-7). Paired t-tests were performed.

Results: HIRREM improved BRS measured as HF alpha (10.8 ms/mmHg, 2.5, p<0.001), Sequence Down (7.3 ms/mmHg, 2.1, p<0.001), Sequence Up (7.6 ms/mmHg, 2.4, p=0.001), and Sequence All (7.3 ms/mmHg, 1.8, p<0.001), as well as HRV; SDNN (14.1 ms, 3.6, p=0.005), rMSSD (12.8 ms, 2.6, p<0.05). MAP dropped 2.7 mmHg, 1.2, p<0.05 and SAP dropped 5.9 mmHg, 1.8, p=0.007. Mean symptom scores were reduced at V2; PCL-M [-12.9 (± 9.1), p<0.001], ISI [-6.3 (± 5.0), p<0.001], CES-D [-13.7 (±9.2), p<0.001], and GAD-7 [-6.7. (± 4.7), p<0.001]. Symptom scores improved 1-month post-HIRREM for all measures, and clinically relevant and significant benefits persist at 3 and 6 months.

Conclusions: These results suggest improved autonomic cardiovascular regulation and statistically significant reduction in scales associated with the use of HIRREM for symptoms of MTS. Controlled trials could provide important insights regarding both the mechanisms associated with the beneficial effects of HIRREM, and the functional disturbances underlying MTS.

Abstract P205: Use Of A Noninvasive, Closed-loop, Allostatic, Neurotechnology Reduced Blood Pressure And Improved Sleep In Heterogeneous Cohort

Introduction: Elevated blood pressure is a major modifiable risk for cardiovascular disease. Disturbed central control of cardiovascular regulation due to trauma, stress, anxiety or other causes can lead to rise in blood pressure. High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®) is a noninvasive, closed-loop, allostatic, acoustic stimulation neurotechnology using software algorithms to identify specific brain frequencies, and translate them in real time into audible tones, to support self-optimization of brain rhythms.

Objective: To evaluate the benefits of adding this nontraditional therapy on BP and symptoms of insomnia in subjects with normal or controlled BP, who are enrolled in an IRB-approved open label feasibility study evaluating HIRREM for diverse neuropsychological disorders.

Methods: 236 participants (105 female), mean (SD) age 43.1 (16.5), received 15.7 (4.8) HIRREM sessions over 22.6 (18.2) days, (9.3 (3.4) days with sessions). Brachial BP and insomnia score (ISI) were collected before, and 14.0 (14.0) days after HIRREM completion. Paired t-tests were performed.

Results: Before HIRREM, participants were divided in the following groups based on ACC/AHA 2017 BP guidelines, normal n=78, elevated n=36, stage 1 n=50, stage 2 n=57, stage 3 n=14 and crisis n=2. There were no changes in medications throughout the study duration. The use of HIRREM was associated with significant reduction in systolic BP (from 126.1 (19.0) to 123.5 (17.0) mmHg, p=0.007), and diastolic BP (from 75.3 (10.6) to 73.0 (9.0) mmHg, p<0.001), with no change in heart rate. Many participants moved to lower BP stage after V2 with the number of participants within normal BP at V2 increasing from 78 to 88. ISI score decreased from 13.2 (7.2) to 6.7 (5.6), p<0.0001. This change met the clinically meaningful drop in ISI of 6 points or more.

Conclusion: These data provide evidence of significant benefits of adding a closed-loop therapy for blood pressure reduction and improving sleep. Further studies are indicated to better define the role of this promising intervention to improve sleep, depression, anxiety, and cardiovascular outcomes.

Continuous updating of individual headache forecasting models using Bayesian methods

OBJECTIVE

To illustrate the benefits of deploying individual headache forecasting models using continuous updating with Bayesian methods.

BACKGROUND

The ability to reliably forecast headache attacks within an individual over time would enhance the study of attacks and allow preemptive treatment. However, deploying a suitable forecasting model in a clinical setting will likely involve several unique challenges related to heterogeneity in the predictor weights, limited or sparse data, and the need for a quick "warm-up." The use of Bayesian methods offers solutions to each of these specific challenges.

METHODS

This was a post hoc analysis of a cohort study of individuals with episodic migraine attacks. Individuals completed daily diaries that allowed the estimation of several forecasting models, each using different types of ancillary information incorporated into formal prior probability distributions. An in silico analysis was conducted that mimicked the deployment of these models in a clinical-like setting where the parameters of the models were continuously updated and evaluated each day using root mean square error (RMSE).

RESULTS

Individuals (N = 95) were followed for 50 days and contributed 3359 days of nonmissing diary data. During the observation period, there were 1293/3359 (38.5%) days with a headache attack. Self-reported baseline headache frequency was associated with the corresponding predicted probability of future attacks, r = 0.15-0.39. At Day 25, the correlation between baseline information and predicted attack likelihood was r = 0.29 (95% CI: 0.09-0.47). Additionally, the use of prior probability distributions for model parameters improved the model fit, especially early in the deployment of the models (e.g., Day 5 RMSE 0.45 vs. 0.43). Models using informative prior probability distributions outperformed the models estimated without this information during the first 42 days of observation, although performance became more similar as more data were collected.

CONCLUSIONS

This analysis demonstrates the value of Bayesian methods in using additional available information to improve forecasting model performance, especially early in the deployment of a forecasting model. To obtain the full value of such models or to apply any model in clinical settings, a model with adequate discrimination and calibration will be needed.

Effects of an Allostatic Closed-Loop Neurotechnology (HIRREM) on Brain Functional Connectivity Laterality in Military-Related Traumatic Stress

BACKGROUND AND PURPOSE

Brain asymmetries are reported in posttraumatic stress disorder, but many aspects of laterality and traumatic stress remain underexplored. This study explores lateralization changes in resting state brain network functional connectivity in a cohort with symptoms of military‐related traumatic stress, associated with use of a closed‐loop neurotechnology, HIRREM.

METHODS

Eighteen participants (17 males, mean age 41 years [SD = 7]) received 19.5 (1.1) HIRREM sessions over 12 days. Whole brain resting magnetic resonance imaging was done pre‐ and post‐HIRREM. Laterality of functional connectivity was assessed on a whole brain basis, and in six predefined networks or regions. Laterality of connectivity within networks or regions was assessed separately from laterality of connections between networks or regions.

RESULTS

Before HIRREM, significant laterality effects of connection type (ipsilateral for either side, or contralateral in either direction) were observed for the whole brain, within networks or regions, and between networks or regions. Post‐HIRREM, there were significant changes for within‐network or within‐region analysis in the motor network, and changes for between‐network or between‐region analyses for the salience network and the motor cortex.

CONCLUSIONS

Among military service members and Veterans with symptoms of traumatic stress, asymmetries of network and brain region connectivity patterns were identified prior to usage of HIRREM. A variety of changes in lateralized patterns of brain connectivity were identified postintervention. These laterality findings may inform future studies of brain connectivity in traumatic stress disorders, with potential to point to mechanisms of action for successful intervention.

High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM) improves symptoms and autonomic function for insomnia: A randomized, placebo-controlled clinical trial

INTRODUCTION

Effective insomnia interventions that also address autonomic dysregulation are lacking. We evaluate high-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM® ), in a randomized, controlled clinical trial. HIRREM is a noninvasive, closed-loop, allostatic, acoustic stimulation neurotechnology, to support self-optimization of brain rhythms.

METHODS

One hundred and seven adults (mean age 45.7, SD ± 5.6, 73 women), with Insomnia Severity Index (ISI) scores of ≥15, received ten, 90-min sessions of HIRREM, with tones linked to brainwaves (LB, 56), or random tones not linked to brainwaves (NL, 51), as an active, sham placebo. Outcomes were obtained at enrollment (V1), 1-7 days (V2), 8-10 weeks (V3), and 16-18 weeks (V4) after intervention. Primary outcome was differential change in ISI from V1 to V3. Secondary measures assessed depression (BDI), anxiety (BAI), quality of life (EQ-5D), and a sleep diary. Ten minute recordings of HR and BP allowed analysis of heart rate variability (HRV) and baroreflex sensitivity (BRS).

RESULTS

Of 107 randomized, 101 completed the intervention. Intention-to-treat analysis (107) of change from V1 to V3 revealed a mean reduction of ISI in NL of -4.93 (SE ± 0.76) points, with additional, significant reduction of -2.05 points (0.74) in LB (total reduction of -6.98, p = .045). Additional reduction of -2.30 points (0.76) was still present in the LB at V4 (p = .058). Total ISI reduction from V1 to V4 was -5.90 points for NL and -7.93 points in LB. There were group differences (p < .05) for multiple HRV and BRS measures (rMSSD, SDNN, HF alpha, and Seq ALL), as well as total sleep time, sleep onset latency, and sleep efficiency. There were no serious adverse events.

CONCLUSIONS

Results of this controlled clinical trial showed clinically relevant reduction of insomnia symptoms with HIRREM, over, and above an active, sham control, with associated, durable improvement in autonomic cardiovascular regulation.

Rapid Implementation of Outpatient Teleneurology in Rural Appalachia: Barriers and Disparities

Objective

To describe rapid implementation of telehealth during the COVID-19 pandemic and assess for disparities in video visit implementation in the Appalachian region of the United States.

Methods

A retrospective cohort of consecutive patients seen in the first 4 weeks of telehealth implementation was identified from the Neurology Ambulatory Practice at a large academic medical center. Telehealth visits defaulted to video, and when unable, phone-only visits were scheduled. Patients were divided into 2 groups based on the telehealth visit type: video or phone only. Clinical variables were collected from the electronic medical record including age, sex, race, insurance status, indication for visit, and rural-urban status. Barriers to scheduling video visits were collected at the time of scheduling. Patient satisfaction was obtained by structured postvisit telephone call.

Results

Of 1,011 telehealth patient visits, 44% were video and 56% phone only. Patients who completed a video visit were younger (39.7 vs 48.4 years, p < 0.001), more likely to be female (63% vs 55%, p < 0.007), be White or Caucasian (p = 0.024), and not have Medicare or Medicaid insurance (p < 0.001). The most common barrier to scheduling video visits was technology limitations (46%). Although patients from rural and urban communities were equally likely to be scheduled for video visits, patients from rural communities were more likely to consider future telehealth visits (55% vs 42%, p = 0.05).

Conclusion

Rapid implementation of ambulatory telemedicine defaulting to video visits successfully expanded video telehealth. Emerging disparities were revealed, as older, male, Black patients with Medicare or Medicaid insurance were less likely to complete video visits.

0541 Exploratory Study of Closed-Loop, Artificial Intelligence Driven Neurotechnology Improves Self-Reported Symptoms of Insomnia, Stress, and Anxiety in First Responders

Introduction

First responders (FR) have decreased life expectancy, attributed to work-related exposure to traumatic stress and circadian disruption. In prior studies, High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®) reduced symptoms and improved heart rate variability (HRV) in law enforcement personnel. HIRREM is operator dependent, difficult to scale, and many medications were excluded for prior studies. Cereset Research™ (CR) uses HIRREM core technology, echoing tones linked to brainwaves, with updated components, artificial intelligence (AI) driven protocols, and software management of designs to improve scalability. We report symptom changes in a series of first responders enrolled in an exploratory study evaluating CR for self-reported symptoms of insomnia, stress, or anxiety, including subjects taking previously excluded medications.

Methods

11 adults (4 females) meeting criteria for insomnia (ISI, of ≥8 points for ≥1 month), stress (PSS of ≥14), or anxiety (GAD-7 of ≥5), who are also FR, enrolled in this ongoing exploratory trial. Subjects receive six to twelve 60 minute sessions of CR, plus continued current care. Data collection is at baseline (V1), 0-21 days post-intervention (V2), 4-7 weeks later (V3), and 4-7 weeks thereafter (V4). Primary outcome is change in autonomic cardiovascular regulation at V3, with change in ISI, PSS, GAD-7, CES-D, and PCL-C as secondary outcomes. We report interim results for symptom outcomes at V3. HRV and baroreflex sensitivity results are pending.

Results

2 dropped out during follow-up. For n=9, median change from V1 to V3 ISI score: -6; PSS score: -4; GAD-7: -4; CES-D: -3; and PCL-C: -8. The cohort moved to no anxiety and low stress categories from V1 to V3.

Conclusion

Results suggest relevant symptom reductions among FR following use of CR, as seen previously with HIRREM for law enforcement, even with additional medications. This informs future randomized clinical trials using this scalable, non-drug intervention. Updated results will be presented.

Support: Support

Research grant received from, The Susanne Marcus Collins Foundation, Inc.

0542 Exploratory Use of Artificial Intelligence Driven Acoustic Neuromodulation Improved Sleep, Depression, Anxiety, and Stress in Adults with Persisting Post-Concussion Symptoms

Introduction

In prior studies, High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®) reduced persisting post-concussion symptoms (PPCS) of insomnia and depression and improved heart rate variability (HRV), but is operator dependent, with difficulty scaling. Cereset Research™ (CR), a noninvasive, closed-loop, artificial intelligence (AI) driven, acoustic neuromodulation technology uses the same core technology, echoing tones linked to brainwaves, but includes updated components, standardized AI driven protocols, software management of designs, and shorter sessions to improve scalability. This open label trial explores use of CR for PPCS.

Methods

5 adults (1 female, median age = 48, 31-64) with PPCS received a median of 8 CR sessions (range 7-9, 60 minutes each) over 11 (5-18) days as part of an open label IRB-approved exploratory study of CR for diverse health conditions. Data is collected at baseline (V1), 0-21 days (V2), 4-7 weeks later (V3), and 4-7 weeks thereafter (V4). Pre- and post-CR symptom inventories included concussion (RPQ), insomnia (ISI), depression (CES-D), anxiety (GAD-7), PTSD (PCL-C), and stress (PSS). Primary outcome is change in autonomics at V3 via HRV (SDNN and rMSSD) based on 10-minute BP and HR recordings using a BIOPAC device. Formal analysis of HRV outcome is pending, but we report preliminary changes in symptom outcomes.

Results

6 subjects have enrolled for sleep trouble related to PCCS, with 1 lost to follow-up after receiving intervention. For V1-V2 (n=5), median change in RPQ score is -23, ISI -10, CES-D -16, GAD-7 -7, PCL-C -16, and PSS -7. For V1-V3 (n=4), median change in RPQ -19, ISI -10.5, CES-D -6, GAD-7 -4.5, PCL-C -14.5, and PSS -3. No serious adverse events reported.

Conclusion

Preliminary results suggest similar, clinically meaningful reductions in ISI score, and concussion symptoms, as seen with HIRREM, suggesting promise as a scalable, non-drug intervention for insomnia with PPCS. Updated results will be presented.

Support: Support

Research grant received from, The Susanne Marcus Collins Foundation, Inc.

Pilot Trial of a Noninvasive Closed-Loop Neurotechnology for Stress-Related Symptoms in Law Enforcement: Improvements in Self-Reported Symptoms and Autonomic Function

Background

Law enforcement officers have decreased life expectancy, attributed to work-related exposure to traumatic stress and circadian disruption. Autonomic dysregulation is reported with traumatic stress and chronic insomnia.

Objective

We explore potential benefits for reduced symptoms related to stress and insomnia and improved autonomic function associated with open label use of high-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®), in a cohort of sworn law enforcement personnel.

Methods

Closed-loop noninvasive therapies utilizing real-time monitoring offer a patient-centric approach for brain-based intervention. HIRREM® is a noninvasive, closed-loop, allostatic, neurotechnology that echoes specific brain frequencies in real time as audible tones to support self-optimization of brain rhythms. Self-report symptom inventories done before and after HIRREM included insomnia (ISI), depression (CES-D), traumatic stress (PCL-C), anxiety (GAD-7), perceived stress (PSS), and quality of life (EQ-5D). Ten-minute recordings of heart rate and blood pressure allowed analysis of baroreflex sensitivity (BRS) and heart rate variability (HRV).

Results

Fifteen participants (1 female), mean (SD) age 45.7 (5.6), received 12.2 (2.7) HIRREM sessions, over 7.9 in-office days. Data were collected at baseline, and at 22.8 (9.2), and 67.2 (14.1) days after intervention. All symptom inventories improved significantly (P < .01), with durability for 2 months after completion of the intervention. The use of HIRREM was also associated with significant increases (P < .001) in HRV measured as rMSSD and BRS measured by high-frequency alpha index. There were no serious adverse events or drop outs.

Conclusion

These pilot data provide the first report of significant symptom reductions, and associated improvement in measures of autonomic cardiovascular regulation, with the use of HIRREM in a cohort of law enforcement personnel. Randomized clinical trials are warranted.

Abstract WP282: Predictors of Candidacy for Endovascular Therapy in Telestroke Patients Transferred to a Comprehensive Stroke Center

Endovascular therapy (EVT), with IV tPA if eligible, is the standard of care for large vessel occlusion (LVO) in acute ischemic stroke. Many patients transferred from outside hospitals to comprehensive stroke centers (CSCs) for potential EVT are found to be ineligible. We aimed to determine predictors of EVT candidacy for suspected LVO strokes in patients transferred from telestroke network hospitals within 24 hours of last known normal time.

Methods: All adult patients transferred after telestroke consultation to our CSC emergency department with acute ischemic stroke and suspected LVO from November 2017 to June 2018 were retrospectively reviewed. This time frame was chosen due to practice changes following the establishment of an extended EVT time window. Data analyzed included demographics, risk factors, BP, NIHSS, presence of cerebellar signs and cortical signs (i.e., aphasia, gaze palsy, visual field defect, neglect). With EVT candidacy as the dependent variable, stepwise logistic regression was done with the significance level both for a factor to enter and stay in the model set at 0.15.

Results: A total of 133 patients (mean age 67.5 ± 16 years, 47.4% women, 85.7% White, 14.3% non-White) were identified. EVT was performed in 36 of 133 patients (27%). The mean NIHSS for EVT patients was 13.1 ± 6.7 compared to 8.5 ± 8.0 for non-EVT patients (p=0.0030). Each unit increase in NIHSS was associated with being more likely to receive EVT (p=0.10). Cortical signs were present in 32 of 36 EVT patients (88.9%) compared to 57 of 97 non-EVT patients (58.8%) (p=0.0010). The presence of cortical signs was associated with receiving EVT (OR 4.60, 95% CI 1.30-16.26; p=0.02). A history of CHF was associated with being less likely to receive EVT (OR 0.31, 95% CI 0.10-1.02, p=0.05). There was a trend toward non-White race being associated with receiving EVT (OR 2.91, 95% CI 0.88-9.62; p=0.08).

Conclusion: The presence of cortical signs, more so than the collinear variable of higher NIHSS, was a significant predictor of candidacy for EVT. Non-White race and CHF are variables that will need to be validated in future studies. These findings, combined with further studies, could help telestroke physicians establish improved selection criteria for transfer of stroke patients to CSCs for EVT.

Abstract TMP75: Gender Disparities in International Stroke Conference Leadership

Background: Increasing data demonstrate a gender gap in career progression in neurology including underrepresentation of women in high impact neurology journal authorship and American Academy of Neurology recognition awards. We examined gender differences in leadership roles at the International Stroke Conference (ISC) from 2014-2018.

Methods: As a retrospective analysis of conference data, this study was exempt from review by the institutional review board. Names of program committee members, early career development leaders, award recipients, invited speakers, and moderators for those sessions were taken from the Final Program from the 2014-2018 ISC. Conference leader gender was determined by name inspection and internet search. In a few instances of ambiguity, common gender association of the name was used. Self-reported ISC attendance demographics were obtained through the American Heart Association (AHA). Chi square test or Fisher exact test was used to compare demographics of invited leadership with attendance.

Results: Between 29.9% and 44.7% of conference attendees were women. Attendees who did not disclose gender increased from 7.38% to 33.02%. Female membership on the program committee increased from 14.3% in 2014 to 48.2% in 2018. Women represented a minority of invited speakers, moderators and award recipients across all years, however, there were increases in female representation over time (see table).

Conclusions: Women are less likely than men to hold leadership positions at the ISC. This is significant as such opportunities can play a valuable role in networking and career progression. It is reassuring that this gender gap has been decreasing over time, however, the AHA and program committee may wish to consider additional strategies to narrow this gap.

Abstract WP297: Impact of the Extended Thrombectomy Window on a Large, Comprehensive Stroke Center Run Telestroke Network

Background: The Wake Forest (WF) Telestroke Network, founded in 2009, is the largest in North Carolina serving 20 hospitals. WF Baptist Medical Center is a Comprehensive Stroke Center (CSC) and referral site for endovascular therapy from many regional hospitals, including 11 within our telestroke network. In December 2017, following dissemination of the DAWN and DEFUSE trial results, we adopted a 24 hour thrombectomy window at WF. In January 2018, education was provided at telestroke sites to facilitate identification of candidates for extended thrombectomy (ET). It has been unclear how the extended window will impact CSC systems. We evaluated the impact of ET on telestroke calls, transfers, and thrombectomy volumes within our state and regional telestroke network.

Method: Telestroke activations and consultations within our state network for the months pre and post ET protocol implementation were compared (July -December 2017 vs January - May 2018). Stroke transfers from regional telestroke hospitals and resultant thrombectomy procedures conducted at WF were compared (July - November 2017 vs December 2017-June 28 2018). Patients transferred for primary hemorrhage were excluded. Monthly volumes were compared using the Kruskal-Wallis Test.

Results: Monthly network activations increased, though not significantly, following education on ET window (median 109.5 vs 153 p = 0.07). Monthly consultations remained steady (median 50.5 vs 54 p= 0.20). Stroke transfers per month remained steady (median 28 vs 27 p= 0.74) while thrombectomies increased (median 1 vs 4 p=0.03).

Conclusions: Though thrombectomy volumes increased, the impact on telestroke consultations and transfer volumes at our institution has not been substantial since adoption of the 24 hour thrombectomy window. While the ET window has led to more calls to our 20 site telestroke network, likely for triage of later presenting patients, it was not significant in this small sample. Further evaluation will examine this trend. Regional transfers to WF have remained stable, as the majority of patients with large stroke are transferred for inpatient stroke care. With a previously established transfer arrangement, the extended window has not led to overtriage from our regional hospitals.

Abstract WP270: Can Left Atrial Volume Index Be Used to Identify Patients With Asymptomatic Atrial Fibrillation After Acute Ischemic Stroke or Transient Ischemic Attack?

Introduction: Detecting atrial fibrillation (AF) after an ischemic stroke may be challenging. We aimed to determine whether using the left atrial volume index (LAVi) can help screen patients at risk of having AF after an ischemic stroke or transient ischemic attack (TIA).

Methods: All adult patients who were admitted to our comprehensive stroke center with ischemic strokes or TIA from January 2017 to January 2018 were retrospectively analyzed. Demographics, risk factors, stroke etiology and transthoracic echocardiography (TTE) data were collected. AF detection was based on either in-hospital cardiac telemetry and/or a 14-day or 30-day ambulatory ECG monitoring. Reference values for LAVi were derived from 2015 Guidelines from the American Society of Echocardiography. TTE and ECG parameters were analyzed using Fisher’s exact test for categorical variables and non-parametric tests for continuous variables.

Results: We identified 334 patients with ischemic strokes and TIA without documented AF (66 ± 11 years, 49% females, 70% White, 23% African American, 6% Other). The mean total days of cardiac monitoring was 9.8 ± 7.2 days and it was lower in patients with AF vs without AF (3.8 ± 5.0 days vs. 10.6 ± 7.1 days, p < 0.0001). Newly diagnosed AF was detected in 37 of 334 patients (11%). Of the 241 patients with normal left atrium (LA), 15 (6%) were diagnosed with AF; 10 of 49 (20%) with mildly dilated LA; 5 of 23 (22%) with moderately dilated LA; 7 of 21 (33%) with severely dilated LA. The proportions of AF detection differed significantly between the LA categories ( p < 0.0001). The mean LAVi was higher in patients with AF vs without AF (40.0 ± 13.8 mL/m 2 vs. 28 ± 10.5 mL/m 2 , p < 0.001), and in those with cardioembolic strokes (34.7 ± 13.3 mL/m 2 , p < 0.0001). The mean LAVi for non-cardioembolic strokes including cryptogenic, small vessel and large vessel were 29.3 ± 10.2 mL/m 2 , 28.6 ± 8.5 mL/m 2 , 26.2 ± 12.8 mL/m 2 , respectively.

Conclusion: Our data demonstrates a significant association between higher LAVi on routine TTE and detecting AF using non-invasive ECG monitoring in patients with ischemic strokes or TIA. Use of LAVi measured during the stroke hospitalization may help identify patients who would benefit from additional non-invasive cardiac monitoring post-discharge.

Functional Brain Network Changes Following Use of an Allostatic, Closed-Loop, Acoustic Stimulation Neurotechnology for Military-Related Traumatic Stress

BACKGROUND AND PURPOSE

Post‐traumatic stress disorder is associated with connectivity changes in the default mode, central executive, and salience networks, and other brain regions. This study evaluated changes in network connectivity associated with usage of High‐resolution, relational, resonance‐based electroencephalic mirroring (HIRREM^®; Brain State Technologies, Scottsdale, AZ), a closed‐loop, allostatic, acoustic stimulation neurotechnology, for military‐related traumatic stress.

METHODS

Eighteen participants (17 males, mean age 41 years [SD = 7], 15 active duty) enrolled in an IRB approved pilot trial for symptoms of military‐related traumatic stress. Participants received 19.5 (1.1) HIRREM sessions over 12 days. Symptoms, physiological and functional measures, and whole brain resting MRI were collected before and after HIRREM. Six whole brain functional networks were evaluated using summary variables and community structure of predefined networks. Pre to postintervention change was analyzed using paired‐sample statistical tests.

RESULTS

Postintervention, there was an overall increase in connectivity of the default mode network (P = .0094). There were decreases of community structure in both the anterior portion of the default mode (medial prefrontal cortex, P = .0097) and in the sensorimotor (P = .005) network. There were no statistically significant changes at the whole brain level, or in the central executive, salience, or other networks analyzed. Participants demonstrated significant improvements in clinical symptoms, as well as autonomic cardiovascular regulation, which have been reported previously.

CONCLUSIONS

Use of closed‐loop, allostatic, acoustic stimulation neurotechnology (HIRREM) was associated with connectivity changes in the default mode and sensorimotor networks, in directions that may have explained the subjects’ clinical improvements.

Improvements in Heart Rate Variability, Baroreflex Sensitivity, and Sleep After Use of Closed-Loop Allostatic Neurotechnology by a Heterogeneous Cohort

Background

Heart rate variability (HRV) is an indicator of dynamic adaptability of the autonomic nervous system. Few interventions target upstream, cerebral cortex components of the heart–brain system for autonomic management. We report changes in HRV and baroreflex sensitivity (BRS), associated with use of a noninvasive, closed-loop, allostatic, computer-guided, acoustic stimulation neurotechnology.

Methods

Over 5 years, 220 subjects with heterogeneous neurological, cardiovascular, and psychophysiological conditions consecutively enrolled in a naturalistic, single-arm study exploring clinical effects associated with use of the neurotechnology. Of those, 202 completed the study protocol and 160 had recordings adequate to analyze HRV and BRS. Mean age was 44.0 (SD 19.4), with 130 women. Participants received a mean of 16.1 (5.2) sessions, over 24.2 days (23.3), with 9.5 (3.8) actual intervention days. Sessions included real-time analysis of brain electrical activity and software algorithm-guided translation of selected frequencies into patterns of acoustic stimulation (audible tones of variable pitch and timing), to facilitate auto-calibration of neural oscillations. Outcomes including 10-min supine, at-rest recordings of blood pressure and heart rate, and inventories for insomnia (ISI) and depression (CES-D or BDI-II), were obtained at baseline and 15.3 (16.7) days after the last session.

Results

Compared to baseline, significant increases (all p < 0.001) were observed for measures of HRV across all participants including the mean percentage change for SDNN 24.2% (SE 0.04), and RMSSD, 42.2% (0.08), and BRS [Sequence Up, 55.5% (0.09), Sequence Down, 77.6% (0.23), and Sequence All, 53.7% (0.07)]. Significant improvements were noted in SAP, MAP, and DAP, as well as natural log of HF, and total power. Self-reported ISI was reduced (ISI, −6.4 points, SD 5.6, p < 0.001). The proportion reporting clinically significant depressive symptoms reduced from 48.2% at baseline to 22.1% at follow-up. Linear regression showed that rightward asymmetry predicted lower SDNN (p = 0.02). Exploratory analysis showed a trend for improved balance of temporal lobe high-frequency amplitudes over the course of initial sessions.

Conclusion

These findings indicate that use of a noninvasive, allostatic, closed-loop neurotechnology appears to have robust potential for public health efforts to support greater flexibility in autonomic cardiovascular regulation, through self-optimization of electrical activity at the level of the brain.

Forecasting Individual Headache Attacks Using Perceived Stress: Development of a Multivariable Prediction Model for Persons With Episodic Migraine

OBJECTIVE

To develop and validate a prediction model that forecasts future migraine attacks for an individual headache sufferer.

BACKGROUND

Many headache patients and physicians believe that precipitants of headache can be identified and avoided or managed to reduce the frequency of headache attacks. Of the numerous candidate triggers, perceived stress has received considerable attention for its association with the onset of headache in episodic and chronic headache sufferers. However, no evidence is available to support forecasting headache attacks within individuals using any of the candidate headache triggers.

METHODS

This longitudinal cohort with forecasting model development study enrolled 100 participants with episodic migraine with or without aura, and N = 95 contributed 4626 days of electronic diary data and were included in the analysis. Individual headache forecasts were derived from current headache state and current levels of stress using several aspects of the Daily Stress Inventory, a measure of daily hassles that is completed at the end of each day. The primary outcome measure was the presence/absence of any headache attack (head pain > 0 on a numerical rating scale of 0-10) over the next 24 h period.

RESULTS

After removing missing data (n = 431 days), participants in the study experienced a headache attack on 1613/4195 (38.5%) days. A generalized linear mixed-effects forecast model using either the frequency of stressful events or the perceived intensity of these events fit the data well. This simple forecasting model possessed promising predictive utility with an AUC of 0.73 (95% CI 0.71-0.75) in the training sample and an AUC of 0.65 (95% CI 0.6-0.67) in a leave-one-out validation sample. This forecasting model had a Brier score of 0.202 and possessed good calibration between forecasted probabilities and observed frequencies but had only low levels of resolution (ie, sharpness).

CONCLUSIONS

This study demonstrates that future headache attacks can be forecasted for a diverse group of individuals over time. Future work will enhance prediction through improvements in the assessment of stress as well as the development of other candidate domains to use in the models.

Successful use of closed-loop allostatic neurotechnology for post-traumatic stress symptoms in military personnel: self-reported and autonomic improvements

BACKGROUND

Military-related post-traumatic stress (PTS) is associated with numerous symptom clusters and diminished autonomic cardiovascular regulation. High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®) is a noninvasive, closed-loop, allostatic, acoustic stimulation neurotechnology that produces real-time translation of dominant brain frequencies into audible tones of variable pitch and timing to support the auto-calibration of neural oscillations. We report clinical, autonomic, and functional effects after the use of HIRREM® for symptoms of military-related PTS.

METHODS

Eighteen service members or recent veterans (15 active-duty, 3 veterans, most from special operations, 1 female), with a mean age of 40.9 (SD = 6.9) years and symptoms of PTS lasting from 1 to 25 years, undertook 19.5 (SD = 1.1) sessions over 12 days. Inventories for symptoms of PTS (Posttraumatic Stress Disorder Checklist - Military version, PCL-M), insomnia (Insomnia Severity Index, ISI), depression (Center for Epidemiologic Studies Depression Scale, CES-D), and anxiety (Generalized Anxiety Disorder 7-item scale, GAD-7) were collected before (Visit 1, V1), immediately after (Visit 2, V2), and at 1 month (Visit 3, V3), 3 (Visit 4, V4), and 6 (Visit 5, V5) months after intervention completion. Other measures only taken at V1 and V2 included blood pressure and heart rate recordings to analyze heart rate variability (HRV) and baroreflex sensitivity (BRS), functional performance (reaction and grip strength) testing, blood and saliva for biomarkers of stress and inflammation, and blood for epigenetic testing. Paired t-tests, Wilcoxon signed-rank tests, and a repeated-measures ANOVA were performed.

RESULTS

Clinically relevant, significant reductions in all symptom scores were observed at V2, with durability through V5. There were significant improvements in multiple measures of HRV and BRS [Standard deviation of the normal beat to normal beat interval (SDNN), root mean square of the successive differences (rMSSD), high frequency (HF), low frequency (LF), and total power, HF alpha, sequence all, and systolic, diastolic and mean arterial pressure] as well as reaction testing. Trends were seen for improved grip strength and a reduction in C-Reactive Protein (CRP), Angiotensin II to Angiotensin 1-7 ratio and Interleukin-10, with no change in DNA n-methylation. There were no dropouts or adverse events reported.

CONCLUSIONS

Service members or veterans showed reductions in symptomatology of PTS, insomnia, depressive mood, and anxiety that were durable through 6 months after the use of a closed-loop allostatic neurotechnology for the auto-calibration of neural oscillations. This study is the first to report increased HRV or BRS after the use of an intervention for service members or veterans with PTS. Ongoing investigations are strongly warranted.

TRIAL REGISTRATION

NCT03230890 , retrospectively registered July 25, 2017.

Abstract P484: Improved Heart Rate Variability, and Symptoms of Insomnia and Stress, With Use of a Closed-loop, Allostatic Neurotechnology in Law Enforcement Officers

Background: Law enforcement officers have decreased life expectancy, attributed to work-related exposure to traumatic stress and circadian disruption. Autonomic dysregulation is reported with traumatic stress, and chronic insomnia. Closed-loop therapies with real time monitoring for modulation of biological function offer a precision-guided, patient-centric strategy for brain-based therapies. High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®) is a noninvasive, closed-loop, allostatic, acoustic stimulation neurotechnology using software generated algorithms to identify specific brain frequencies, and translate them in real time into audible tones, to support self-optimization of brain rhythms.

Objective: To evaluate benefits for autonomic function, and symptoms of insomnia and stress, in a relatively healthy cohort of law enforcement officers, who enrolled in an IRB-approved, open label feasibility study evaluating HIRREM for diverse neuropsychological disorders. Measures done before and after HIRREM included symptom inventories for insomnia (ISI), depression (CES-D), traumatic stress (PCL-C), anxiety (GAD-7), and perceived stress (PSS). Ten minute recordings of heart rate and blood pressure allowed analysis of baroreflex sensitivity (BRS) and heart rate variability (HRV).

Results: 7 participants (1 female), mean (SD) age 47 (4.5), received 10.7 (2.6) HIRREM sessions over 11.3 (4.6) days (7.3 in office days). Data were collected before, and 22.6 (1.8) days after HIRREM completion. Use of HIRREM was associated with significantly increased HRV measured as rMSSD [from 25.3 (7.0) to 43.1 (13.0) ms, p=0.02]. BRS measured by high frequency alpha index improved [from 11.3 (8.0) to 20.1 (11.0) ms/mmHg, p=0.03]. All symptom inventories improved significantly (p<0.05), even with the small cohort. There were no adverse events or drop outs.

Conclusion: These pilot data provide the first report of significant autonomic cardiovascular benefits, and associated symptom improvements, with use of a closed-loop, allostatic therapy for a cohort of sworn law enforcement officers. Further studies are warranted to test the efficacy of this technology in a larger law enforcement cohort

Abstract P483: Healing a Broken Heart Using a Closed-loop, Allostatic, Neurotechnology: A Case Study in a Patient Suffering From Takotsubo Syndrome

Background: Stress cardiomyopathy or Takotsubo syndrome (TS) is an acute, reversible disorder of the heart characterized by left ventricular dysfunction, usually triggered by a stressful event. Excessive sympathetic excitation and shift in symapthovagal balance are proposed as mechanisms. High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®) is a noninvasive, closed-loop, allostatic, neurotechnology using software algorithms to identify specific brain frequencies, translating them in real time into audible tones, to support self-optimization of brain rhythms and improve autonomic balance.

Objective: To evaluate benefits of HIRREM on autonomic function and symptom reduction in a 55 year old female enrolled in an IRB-approved open label feasibility study, after TS diagnosis.

Results: The participant received 13 HIRREM sessions over 11 days (9 in office days). Data were collected before, and 21 days after HIRREM completion. Baseline brain patterns had prominent right dominance at temporal lobes (sympathetic pattern), which balanced by the end of the sessions. Cardiovascular autonomic balance also shifted away from sympathetic towards parasympathetic. This was seen as reduced LF/HF ratio (from 1.89 to 0.63), increased heart rate variability (rMSSD from 27 to 40.8 ms), and baroreflex sensitivity (from 11.8 to 24.4 ms/mmHg). Blood pressure dropped from 132/90 to 121/88 with no change in heart rate despite discontinuation of her ACE inhibitor medication due to her BP being “too low.” HIRREM use was also associated with clinically meaningful improvements in multiple symptom inventories including insomnia (ISI) from 15 to 6, depression (CES-D) from 16 to 2, anxiety (GAD-7) from 18 to 2, and perceived stress scale (PSS) from 30 to 14. The patient reported resolution of a feeling of heaviness and discomfort in the chest after starting HIRREM sessions.

Conclusion: These data provide the first report of potential cardiovascular benefits of a non- pharmacological therapy to patients suffering from broken heart syndrome.

Abstract P485: Use of a Noninvasive, Closed-loop, Allostatic, Neurotechnology Reduced Blood Pressure and Improved Heart Rate Variability in a Pre-hypertensive Cohort

Background: Prehypertension increases risk for hypertension and cardiovascular disease, but effective interventions have not been defined. Disturbed central control of cardiovascular regulation due to trauma, stress, anxiety or other causes can lead to prehypertension and impaired heart rate variability (HRV). High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®) is a noninvasive, closed-loop, allostatic, acoustic stimulation neurotechnology using software algorithms to identify specific brain frequencies, and translate them in real time into audible tones, to support self-optimization of brain rhythms.

Objective: To evaluate the benefits of this nontraditional therapy on BP and autonomic function, subjects with untreated systolic BP of 120 to 139 or diastolic BP of 80 to 90 mmHg at baseline, who had enrolled in an IRB-approved open label feasibility study evaluating HIRREM for diverse neuropsychological disorders.

Results: 66 participants (40 female), mean (SD) age 43.3 (16.5), received 16 (5.7) HIRREM sessions over 22.4 (19.2) days, (9.5 (4.2) days with sessions). Data were collected before, and 14.4 (16.6) days after HIRREM completion. Use of HIRREM was associated with significantly reduced systolic (from 127.5 (8.0) to 122.9 (14.0) mmHg, p=0.011), and diastolic (from 82.0 (8.0) to 78.0 (9.0) mmHg, p= 0.014) arterial pressure, with no change in heart rate. HRV measured as SDNN increased (from 42.0 (17.0) to 50.0 (28.0) ms, p=0.002). Baroreflex sensitivity measured by sequence method improved (from 13.2 (8.0) to 17.2 (12.0) ms/mmHg, p=0.0001), with a trend for reduced sympathovagal tone measured by LF/HF ratio (from 2.5 (2.2) to 2.0 (1.8), p=0.068). There were no adverse events.

Conclusion: These data provide the first report of significant cardiovascular benefits of a closed-loop allostatic therapy for prehypertension. Blood pressure reduction and HRV improvement may prevent progression to more serious cardiovascular symptoms and diseases. Further studies are indicated to investigate the mechanism of the benefits associated with this promising intervention.

Clinical, hemispheric, and autonomic changes associated with use of closed-loop, allostatic neurotechnology by a case series of individuals with self-reported symptoms of post-traumatic stress

BACKGROUND

The objective of this pilot study was to explore the use of a closed-loop, allostatic, acoustic stimulation neurotechnology for individuals with self-reported symptoms of post-traumatic stress, as a potential means to impact symptomatology, temporal lobe high frequency asymmetry, heart rate variability (HRV), and baroreflex sensitivity (BRS).

METHODS

From a cohort of individuals participating in a naturalistic study to evaluate use of allostatic neurotechnology for diverse clinical conditions, a subset was identified who reported high scores on the Posttraumatic Stress Disorder Checklist (PCL). The intervention entailed a series of sessions wherein brain electrical activity was monitored noninvasively at high spectral resolutions, with software algorithms translating selected brain frequencies into acoustic stimuli (audible tones) that were delivered back to the user in real time, to support auto-calibration of neural oscillations. Participants completed symptom inventories before and after the intervention, and a subset underwent short-term blood pressure recordings for HRV and BRS. Changes in temporal lobe high frequency asymmetry were analyzed from baseline assessment through the first four sessions, and for the last four sessions.

RESULTS

Nineteen individuals (mean age 47, 11 women) were enrolled, and the majority also reported symptom scores that exceeded inventory thresholds for depression. They undertook a median of 16 sessions over 16.5 days, and 18 completed the number of sessions recommended. After the intervention, 89% of the completers reported clinically significant decreases in post-traumatic stress symptoms, indicated by a change of at least 10 points on the PCL. At a group level, individuals with either rightward (n = 7) or leftward (n = 7) dominant baseline asymmetry in temporal lobe high frequency (23-36 Hz) activity demonstrated statistically significant reductions in their asymmetry scores over the course of their first four sessions. For 12 individuals who underwent short-term blood pressure recordings, there were statistically significant increases in HRV in the time domain and BRS (Sequence Up). There were no adverse events.

CONCLUSION

Closed-loop, allostatic neurotechnology for auto-calibration of neural oscillations appears promising as an innovative therapeutic strategy for individuals with symptoms of post-traumatic stress.

TRIALS REGISTRATION

ClinicalTrials.gov #NCT02709369 , retrospectively registered on March 4, 2016.

Carotid Intima-media Thickness Measurements: Relations with Atherosclerosis, Risk of Cardiovascular Disease and Application in Randomized Controlled Trials

Advances in the field of carotid ultrasound have been incremental, resulting in a steady decrease in measurement variability. Improvements in edge detection algorithms point toward increasing automation of CIMT measurements. The major advantage of CIMT is that it is completely noninvasive and can be repeated as often as required. It provides a continuous measure since all subjects have a measurable carotid wall. It is also relatively inexpensive to perform, and the technology is widely available. A graded relation between raising LDL cholesterol and increased CIMT is apparent. Increased CIMT has been shown consistently to relate the atherosclerotic abnormalities elsewhere in the arterial system. Moreover, increased CIMT predicts future vascular events in both populations from Caucasian ancestry and those from Asian ancestry. Furthermore, lipid‑lowering therapy has been shown to affect CIMT progression within 12–18 months in properly designed trials with results congruent with clinical events trials. In conclusion, when one wants to evaluate the effect of a pharmaceutical intervention that is to be expected to beneficially affect atherosclerosis progression and to reduce CV event risk, the use of CIMT measurements over time is a valid, suitable, and evidence‑based choice.

A Preliminary Study of the Effectiveness of an Allostatic, Closed-Loop, Acoustic Stimulation Neurotechnology in the Treatment of Athletes with Persisting Post-concussion Symptoms

BACKGROUND

Effective interventions are needed for individuals with persisting post-concussion symptoms. High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®) is an allostatic, closed-loop, acoustic stimulation neurotechnology, designed to facilitate relaxation and self-optimization of neural oscillations.

METHODS

Fifteen athletes (seven females, mean age 18.1 years, SD 2.6) with persisting post-concussion symptoms received 18.7 (SD 6.0) HIRREM sessions over a mean of 29.6 (SD 23.2) days, including 11.3 (SD 4.6) in office days. Pre- and post-HIRREM measures included the Rivermead Post-Concussion Symptoms Questionnaire (RPQ, n = 12), the Insomnia Severity Index (ISI, n = 15), the Center for Epidemiologic Studies Depression Scale (CES-D, n = 10), short-term blood pressure and heart rate recordings for measures of autonomic cardiovascular regulation (n = 15), and reaction time by the drop-stick method (n = 7). All participants were asked about their physical activity level and sports participation status at their post-HIRREM data collection visit and 1 to 3 months afterward.

RESULTS

At the post-HIRREM visit, subjects reported improvements in all three inventories (RPQ mean change 19.7, SD 11.4, Wilcoxon p = 0.001; ISI mean change -4.1, SD 4.1, Wilcoxon p = 0.003; CES-D mean change -12.0, SD 10.0, Wilcoxon p = 0.004), including statistically significant reductions in 14 of the 16 individual items of the RPQ. There were also statistically significant improvements in baroreflex sensitivity, heart rate variability in the time domain (SDNN), and drop-stick reaction testing (baseline mean distance of 23.8 cm, SD 5.6, decreased to 19.8 cm, SD 4.6, Wilcoxon p = 0.016). Within 3 months of the post-HIRREM data collection, all 15 had returned to full exercise and workouts, and ten had returned to full participation in their athletic activity.

CONCLUSIONS

The use of HIRREM by a series of athletes with persisting post-concussion symptoms was associated with a range of improvements including, for the majority, return to full participation in their sport. The findings do not appear to be consistent with constituents of the placebo effect. A larger controlled trial is warranted.

Abstract P602: Reduced Symptoms And Improved Heart Rate Variability Associated With Use Of Closed-Loop Noninvasive Neurotechnology By Migraineurs

Introduction: Migraine is associated with impaired autonomic function, reduced heart rate variability (HRV), increased sympathetic activity, and symptoms of insomnia and depression. High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM) is a noninvasive, closed-loop acoustic stimulation neurotechnology that identifies dominant brain frequencies and translates them into audible tones, to support self-optimization of brain rhythms.

Objective: We have reported use of HIRREM is associated with improved autonomic balance in a diverse cohort. We explored for effects of HIRREM in a cohort with self-reported migraine enrolled in an IRB-approved open label feasibility study of HIRREM for diverse neuropsychological disorders.

Methods: Fifty-two subjects (42 female), mean (SD) age 38.0 (18.6), received 15.9 (3.9) HIRREM sessions (90-120 minutes each) over 9.0 (2.7) days of in-office intervention. Outcomes collected before (V1), and 13.6 (14.4) days after HIRREM completion (V2) included measures of autonomic regulation (baroreflex sensitivity, BRS, and HRV), inventories for insomnia (ISI), depression (CES-D), traumatic stress (PCL-C), and headache (MIDAS). Paired t-tests were performed. Measures of BRS and HRV (n=52) improved from V1 to V2, including HF Alpha (+8.0 ms/mmHg (SE 2.2), p<0.0012), SDNN (+6.1 ms (1.9), p=0.002), and rMSSD ms (+7.6 (2.5), p=0.004). Sympathetic tone to blood vessels and mean arterial pressure were significantly reduced. There were improvements in symptoms at V2, including ISI (n=52): -6.2 (5.7), p<0.0001; CES-D (n=38): -8.0 (9.8), p<0.0001; PCL-C (n=30): -8.2 (11.3); p<0.001; and MIDAS (n=33): -14.9 (41.7), p<0.01). No serious adverse events were reported.

Conclusions: This exploratory study shows improved measures of autonomic balance, reduced sympathetic tone, improved sleep and mood. Data suggest that HIRREM is a promising intervention that merits further investigation to mitigate the myriad effects of migraine

Abstract P627: Improved Autonomic Cardiovascular Regulation and Reduced Symptoms Associated with Use of Closed-loop Noninvasive Neurotechnology by Healthcare Workers

Introduction: Chronic stress in healthcare workers is associated with insomnia and risk for adverse health outcomes. High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM) is a noninvasive, closed-loop acoustic stimulation neurotechnology that identifies dominant brain frequencies and translates them into audible tones, to support auto-calibration and self-optimization of brain rhythms.

Objective: We explore use of HIRREM in a cohort of healthcare workers enrolled in an IRB-approved open label feasibility study of HIRREM for diverse neuropsychological disorders.

Methods: Twenty five employees (16 female), mean (SD) age 45.8 (13.9), received 14.8 (4.7) HIRREM sessions (90-120 minutes each) over 9.0 (3.6) days of in-office intervention. Data was collected before (V1), and 15.4 (11.7) days after completion (V2). Outcomes included BP and HR recordings for autonomic cardiovascular regulation (baroreflex sensitivity, BRS, and heart rate variability, HRV), with inventories for insomnia (ISI), depression (CES-D), traumatic stress (PCL-C), quality of life (EQ-5D global rating), and drop stick reaction testing (RXT). Paired t-tests were performed.

Results: BRS and HRV (n=17) improved from V1 to V2, including Sequence ALL (+2.4 ms/mmHg (SE 2.8), p=0.15), SDNN (+8.9 ms (4.1), p=0.04), and rMSSD ms (+9.2 (4.9), p=0.07). There were significant improvements in symptoms and function at V2; ISI (n=25): -8 (5.3), p<0.0001; CES-D (n=20): -7.3 (13.4), p=0.02; PCL-C (n=19): -12.1 (12.4); p<0.001; EQ-5D (n=16): +10.8 (12.5), p<0.01; RXT (n=18): -4.6 cm (5.5), p<0.01. There were no serious adverse events.

Conclusions: This exploratory study shows improved measures of cardiovascular regulation, and reduced insomnia, depression, and stress associated with use of HIRREM in a cohort of employees at an academic medical center. Data suggest that HIRREM is a promising intervention that merits further investigation to mitigate effects of chronic stress and improve wellness.

Abstract P625: Improvement of Autonomic Function and C-Reactive Protein in Military Personnel with Traumatic Stress After Use Of a Closed Loop Neurotechnology

Objective: Evaluate changes in autonomic cardiovascular control and inflammatory markers associated with use of High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM) in subjects enrolled in a pilot study for symptoms of military-related traumatic stress (MTS).

Introduction: Symptoms associated with MTS include insomnia, depression, anxiety, activated inflammatory response and impaired autonomic control. HIRREM is a noninvasive, closed-loop acoustic stimulation technology that identifies dominant brain frequencies and translates them in real time into audible tones of variable pitch and timing, to support self-updating and self-optimization of brain activity.

Methods: Eighteen service members or Veterans (1 female), mean (SD) age 40.9 (7.0), with MTS symptoms for 6 years (3.4), received 19.5 (1.1) HIRREM sessions over 12 days. Continuous recordings of blood pressure and heart rate, for analysis of baroreflex sensitivity (BRS) and heart rate variability (HRV), were done before and immediately after completion of the HIRREM intervention. Blood samples were also collected (n = 14) for measurement of catecholamines, cytokines, C-reactive protein and the renin angiotensin system (RAS) components. Paired t-tests were performed. After HIRREM, there was improved BRS measured as HF alpha (9.6 ms/mmHg, SE 3.1, p = 0.005), Sequence Down (7.6 ms/mmHg, 2.4, p = 0.005), Sequence Up (8.4 ms/mmHg, 3.0, p = 0.01), and Sequence All (7.6 ms/mmHg, 2.2, p = 0.002), as well as HRV; SDNN (12.0 ms, 3.5, p = 0.02), rMSSD (13.2 ms, 3.0, p < 0.001), LF power (1023.0 ms 2 , 346, p = 0.007), HF power (398.0 ms 2 , 142.0, p = 0.01), and total power (1420.8 ms 2 , 450.8, p = 0.005). C-reactive protein (36%, p = 0.057) was also reduced. There were no significant changes in the catecholamine, cytokines or RAS. There were no adverse events or dropouts.

Conclusions: These interim results suggest improved autonomic cardiovascular regulation, across multiple measures of BRS and HRV, and reduction in CRP associated with the use of HIRREM for symptoms of MTS. Confirmation of these results in a larger cohort may provide important insights regarding both the mechanisms associated with the beneficial effects of HIRREM, and the functional disturbances underlying MTS.

Use of an allostatic neurotechnology by adolescents with postural orthostatic tachycardia syndrome (POTS) is associated with improvements in heart rate variability and changes in temporal lobe electrical activity

Autonomic dysregulation and heterogeneous symptoms characterize postural orthostatic tachycardia syndrome (POTS). This study evaluated the effect of high-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM^®), a noninvasive, allostatic neurotechnology for relaxation and auto-calibration of neural oscillations, on heart rate variability, brain asymmetry, and autonomic symptoms, in adolescents with POTS. Seven subjects with POTS (three males, ages 15–18) underwent a median of 14 (10–16) HIRREM sessions over 13 (8–17) days. Autonomic function was assessed from 10-min continuous heart rate and blood pressure recordings, pre- and post-HIRREM. One-minute epochs of temporal high-frequency (23–36 Hz) brain electrical activity data (T3 and T4, eyes closed) were analyzed from baseline HIRREM assessment and subsequent sessions. Subjects rated autonomic symptoms before and after HIRREM. Four of seven were on fludrocortisone, which was stopped before or during their sessions. Heart rate variability in the time domain (standard deviation of the beat-to-beat interval) increased post-HIRREM (mean increase 51 %, range 10–143, p = 0.03), as did baroreflex sensitivity (mean increase in high-frequency alpha 65 %, range −6 to 180, p = 0.05). Baseline temporal electrical asymmetry negatively correlated with change in asymmetry from assessment to the final HIRREM session (p = 0.01). Summed high-frequency amplitudes at left and right temporal lobes decreased a median of 3.8 μV (p = 0.02). There was a trend for improvements in self-reported symptoms related to the autonomic nervous system. Use of HIRREM was associated with reduced sympathetic bias in autonomic cardiovascular regulation, greater symmetry and reduced amplitudes in temporal lobe high-frequency electrical activity, and a trend for reduced autonomic symptoms. Data suggest the potential for allostatic neurotechnology to facilitate increased flexibility in autonomic cardiovascular regulation, possibly through more balanced activity at regions of the neocortex responsible for autonomic management.

Clinical trial registry “Tilt Table with Suspected postural orthostatic tachycardia syndrome (POTS) Subjects,” Protocol Record: WFUBAHA01.

A groundwork for allostatic neuro-education

We propose to enliven educational practice by marrying a conception of education as guided human development, to an advanced scientific understanding of the brain known as allostasis (stability through change). The result is a groundwork for allostatic neuro-education (GANE). Education as development encompasses practices including the organic (homeschooling and related traditions), cognitive acquisition (emphasis on standards and testing), and the constructivist (aimed to support adaptive creativity for both learner and society). Allostasis views change to be the norm in biology, defines success in contexts of complex natural environments rather than controlled settings, and identifies the brain as the organ of central command. Allostatic neuro-education contrasts with education focused dominantly on testing, or neuroscience based on homeostasis (stability through constancy). The GANE perspective is to view learners in terms of their neurodevelopmental trajectories; its objective is to support authentic freedom, mediated by competent, integrated, and expansive executive functionality (concordant with the philosophy of freedom of Rudolf Steiner); and its strategy is to be attuned to rhythms in various forms (including those of autonomic arousal described in polyvagal theory) so as to enable experiential excitement for learning. The GANE presents a variety of testable hypotheses, and studies that explore prevention or mitigation of the effects of early life adversity or toxic stress on learning and development may be of particular importance. Case studies are presented illustrating use of allostatic neurotechnology by an adolescent male carrying diagnoses of Asperger’s syndrome and attention-deficit hyperactivity disorder, and a grade school girl with reading difficulties. The GANE is intended as a re-visioning of education that may serve both learners and society to be better prepared for the accelerating changes of the 21st century.

Rightward dominance in temporal high-frequency electrical asymmetry corresponds to higher resting heart rate and lower baroreflex sensitivity in a heterogeneous population

OBJECTIVE

Explore potential use of a temporal lobe electrical asymmetry score to discriminate between sympathetic and parasympathetic tendencies in autonomic cardiovascular regulation.

METHODS

131 individuals (82 women, mean age 43.1, range 13-83) with diverse clinical conditions completed inventories for depressive (CES-D or BDI-II) and insomnia-related (ISI) symptomatology, and underwent five-minute recordings of heart rate and blood pressure, allowing calculation of heart rate variability and baroreflex sensitivity (BRS), followed by one-minute, two-channel, eyes-closed scalp recordings of brain electrical activity. A temporal lobe high-frequency (23-36 Hz) electrical asymmetry score was calculated for each subject by subtracting the average amplitude in the left temporal region from amplitude in the right temporal region, and dividing by the lesser of the two.

RESULTS

Depressive and insomnia-related symptomatology exceeding clinical threshold levels were reported by 48% and 50% of subjects, respectively. Using a cutoff value of 5% or greater to define temporal high-frequency asymmetry, subjects with leftward compared to rightward asymmetry were more likely to report use of a sedative-hypnotic medication (42% vs. 22%, P = 0.02). Among subjects with asymmetry of 5% or greater to 30% or greater, those with rightward compared to leftward temporal high-frequency asymmetry had higher resting heart rate (≥5% asymmetry, 72.3 vs. 63.8, P = 0.004; ≥10%, 71.5 vs. 63.0, P = 0.01; ≥20%, 72.2 vs. 64.2, P = 0.05; ≥30%, 71.4 vs. 64.6, P = 0.05). Subjects with larger degrees of rightward compared to leftward temporal high-frequency asymmetry had lower baroreflex sensitivity (≥40% asymmetry, 10.6 vs. 16.4, P = 0.03; ≥50% asymmetry, 10.4 vs. 16.7, P = 0.05).

CONCLUSION

In a heterogeneous population, individuals with rightward compared to leftward temporal high-frequency electrical asymmetry had higher resting heart rate and lower BRS. Two-channel recording of brain electrical activity from bilateral temporal regions appears to hold promise for further investigation as a means to assess cortical activity associated with autonomic cardiovascular regulation.

Transcranial Doppler Sonography: Atypical Dicrotic Pulse Waveforms in a Man with HIV Infection and Severe Cardiomyopathy

A 27-year-old human immunodeficiency virus--positive man presented with abdominal pain. Computed tomography of the abdomen revealed large right pleural effusion, pericardial effusion and marked ascites with diffuse intra- and extraperitoneal lymphadenopathy. Echocardiography showed severely reduced left ventricular systolic function. After drainage of pleural and pericardial fluid, the patient developed severe hypotension and hypoxic respiratory failure. Extra- and intracranial neurovascular sonography demonstrated low carotid artery flow volume and dicrotic pulse waveforms in all vessels insonated bilaterally. This case report demonstrates an atypical dicrotic waveform pattern of transcranial Doppler in advanced ventricular dysfunction with shock.

A bihemispheric autonomic model for traumatic stress effects on health and behavior

A bihemispheric autonomic model (BHAM) may support advanced understanding of traumatic stress effects on physiology and behavior. The model builds on established data showing hemispheric lateralization in management of the autonomic nervous system, and proposes that traumatic stress can produce dominant asymmetry in activity of bilateral homologous brain regions responsible for autonomic management. Rightward and leftward dominant asymmetries are associated with sympathetic high arousal or parasympathetic freeze tendencies, respectively, and return to relative symmetry is associated with improved autonomic regulation. Autonomic auto-calibration for recovery (inverse of Jacksonian dissolution proposed by polyvagal theory) has implications for risk behaviors associated with traumatic life stress. Trauma-induced high arousal may be associated with risk for maladaptive behaviors to attenuate arousal (including abuse of alcohol or sedative-hypnotics). Trauma-induced freeze mode (including callous-unemotional trait) may be associated with low resting heart rate and risk for conduct disorders. The model may explain higher prevalence of leftward hemispheric abnormalities reported in studies of violence. Implications of the BHAM are illustrated through case examples of a military special operations officer with history of traumatic brain injury and post-traumatic stress disorder, and a university student with persisting post-concussion symptoms. Both undertook use of a noninvasive closed-loop neurotechnology - high-resolution, relational, resonance-based, electroencephalic mirroring - with ensuing decrease in hemispheric asymmetry, improvement in heart rate variability, and symptom reduction. Finally, the BHAM aligns with calls for researchers to use brain-behavioral constructs (research domain criteria or RDoC, proposed by the National Institutes of Mental Health) as building blocks for assessment and intervention in mental health science.

Clinical reasoning: acute-onset homonymous hemianopia with hyperglycemia: seeing is believing

A 32-year-old woman with a history of bipolar disorder, polycystic ovarian syndrome, and hypertension and a 4-year history of uncontrolled type 2 diabetes mellitus (DM) presented with bifrontal headache, elevated blood sugars (>500 mg/dL), and abrupt-onset left homonymous hemianopia upon awakening. Vital signs included temperature 98.0°F, blood pressure 160/89 mm Hg, and heart rate 67 bpm. Neurologic examination showed dense left homonymous hemianopia with macular sparing and without other focal findings.

HIRREM™: a noninvasive, allostatic methodology for relaxation and auto-calibration of neural oscillations

Disturbances of neural oscillation patterns have been reported with many disease states. We introduce methodology for HIRREM™ (high-resolution, relational, resonance-based electroencephalic mirroring), also known as Brainwave Optimization™, a noninvasive technology to facilitate relaxation and auto-calibration of neural oscillations. HIRREM is a precision-guided technology for allostatic therapeutics, intended to help the brain calibrate its own functional set points to optimize fitness. HIRREM technology collects electroencephalic data through two-channel recordings and delivers a series of audible musical tones in near real time. Choices of tone pitch and timing are made by mathematical algorithms, principally informed by the dominant frequency in successive instants of time, to permit resonance between neural oscillatory frequencies and the musical tones. Relaxation of neural oscillations through HIRREM appears to permit auto-calibration toward greater hemispheric symmetry and more optimized proportionation of regional spectral power. To illustrate an application of HIRREM, we present data from a randomized clinical trial of HIRREM as an intervention for insomnia (n = 19). On average, there was reduction of right-dominant temporal lobe high-frequency (23-36 Hz) EEG asymmetry over the course of eight successive HIRREM sessions. There was a trend for correlation between reduction of right temporal lobe dominance and magnitude of insomnia symptom reduction. Disturbances of neural oscillation have implications for both neuropsychiatric health and downstream peripheral (somatic) physiology. The possibility of noninvasive optimization for neural oscillatory set points through HIRREM suggests potentially multitudinous roles for this technology. Research is currently ongoing to further explore its potential applications and mechanisms of action.

Transcranial Doppler velocities in a large, healthy population

BACKGROUND

Transcranial Doppler (TCD) ultrasonography has been extensively used in the evaluation and management of patients with cerebrovascular disease since the clinical application was first described in 1982 by Aaslid and colleagues TCD is a painless, safe, and noninvasive diagnostic technique that measures blood flow velocity in various cerebral arteries. Numerous commercially available TCD devices are currently approved for use worldwide, and TCD is recognized to have an established clinical value for a variety of clinical indications and settings. Although many studies have reported normal values, there have been few recently, and none to include a large cohort of healthy subjects across age, race, and gender. As more objective, automated processes are being developed to assist with the performance and interpretation of TCD studies, and with the potential to easily compare results against a reference population, it is important to define stable normal values and variances across age, race, and gender, with clear understanding of variability of the measurements, as well as the yield from various anatomic segments.

METHODS

To define normal TCD values in a healthy population, we enrolled 364 healthy subjects, ages 18-80 years, to have a complete, nonimaging TCD examination. Subjects with known or suspected cerebrovascular disorders, systemic disorders with cerebrovascular effects, as well as those with known hypertension, diabetes, stroke, coronary artery disease, or myocardial infarction, were excluded. Self-reported ethnicity, handedness, BP, and BMI were recorded. A complete TCD examination was performed by a single experienced sonographer, using a single gate nonimaging TCD device, and a standardized protocol to interrogate up to 23 arterial segments. Individual Doppler spectra were saved for each segment, with velocity and pulsatility index (PI) values calculated using the instrument's automated waveform tracking function. Descriptive analysis was done to determine the mean velocities and PI, and all data were analyzed for changes by decade of age, sex race, handedness, BMI, and BP.

RESULTS

Among the key intracranial segments, mean blood flow velocities (MBFV) were highest in the MCA and lowest in the PCA across all ages, sexes, and ethnic groups. There was no difference in the MBFVs between left and right side segments of the Circle of Willis, with the exception of the distal M1 (P = .022) and the C1 (P < .0001), both slightly higher on the left. MBFV were higher among women than men in all segments except for the OA. MBFV decreased with advancing age in both men and women, but this was specific to Caucasian subjects. There were lower velocities in the OA for non-Caucasians. The PI was lower in the left VA (P < .0001), and for most segments was lower in women than men. The PI increased with age in all segments for women, but only in some segments for men, and this finding was also specific to Caucasian subjects. The yield of usable data ranged from 99.7% for the VA and BA, to 88.2% for C2.

CONCLUSION

Our study provides normal, reference TCD values for a large cohort of healthy subjects across a wide range of age, sex, and race groups. We observed decreased MBFV and increased PI with aging, and higher MBFV in women. There were few differences in MBFV related to side or ethnicity, but the MFBV and PI changes with age were specific to Caucasians. We provide means and standard deviations of MBFVs across various demographic groups in key intracranial arteries. Such normal TCD values across age, gender, and ethnic groups in healthy subjects represent a useful reference tool for detecting individuals with TCD values outside normal limits and at increased vascular risk. TCD studies in large multiethnic populations are still required to determine differences in brain hemodynamics across various ethnic groups.

Open label, randomized, crossover pilot trial of high-resolution, relational, resonance-based, electroencephalic mirroring to relieve insomnia

Effective noninvasive interventions for insomnia are needed. High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM™) is a noninvasive, electroencephalography (EEG)-based method to facilitate greater client-unique, autocalibrated improvements of balance and harmony in cortical neural oscillations. This study explores using HIRREM for insomnia. Twenty subjects, with an Insomnia Severity Index (ISI) score of ≥15 (14 women, mean age 45.4, mean ISI 18.6), were enrolled in this randomized, unblinded, wait-list control, crossover, superiority study. Subjects were randomized to receive 8-12 HIRREM sessions over 3 weeks, plus usual care (HUC), or usual care alone (UC). Pre- and post-HIRREM data collection included ISI (primary outcome), and many secondary, exploratory measures (CES-D, SF-36, HR, BP, neurocognitive testing, and VAS scales). The UC group later crossed over to receive HIRREM. ISI was also repeated 4-6 weeks post-HIRREM. All subjects completed the primary intervention period. Analysis for differential change of ISI in the initial intervention period for HUC versus UC showed a drop of 10.3 points (95% CI: -13.7 to -6.9, P < 0.0001, standardized effect size of 2.68). Key secondary outcomes included statistically identical differential change for the crossed-over UC group, and persistence of the effect on the ISI up to > 4 weeks post-HIRREM. Differential change in the HUC group was also statistically significant for CES-D (-8.8, 95% CI: -17.5 to -0.1, P = 0.047), but other exploratory outcomes were not statistically significant. For all receiving HIRREM (n = 19), decreased high-frequency total power was seen in the bilateral temporal lobes. No adverse events were seen. This pilot clinical trial, the first using HIRREM as an intervention, suggests that HIRREM is feasible and effective for individuals having moderate-to-severe insomnia, with clinically relevant, statistically significant benefits based on differential change in the ISI. Effects persisted for 4 weeks after completion of HIRREM. Larger controlled clinical trials are warranted.

Telestroke to improve acute stroke care in North Carolina

Effective, albeit time-limited, treatment is available for acute ischemic stroke but is underutilized in North Carolina. There is a mismatch between stroke resources and expertise and the services available at many hospitals where patients seek initial care. Video telecommunications can improve access to stroke expertise and to potentially life-saving therapies.

Stroke fast track reduces time delay to neuroimaging and increases use of thrombolysis in an academic medical center in Thailand

Delays between hospital arrival and neuroimaging prevented patients from receiving thrombolysis. We report impact of Stroke Fast Track (SFT) on time to imaging, and rates of recombinant tissue plasminogen activator (rt-PA) in eligible patients. Characteristics, time intervals, and rates of rt-PA were evaluated in 464 patients with suspected acute stroke within 7 days (2005-2006). Complete time intervals were available on 380. Median times between emergency room arrival, brain computerized tomography (CT), and CT results were 25 and 45 minutes, respectively, for patients arriving <3 hours from onset, 40, and 65 minutes for those arriving >3 hours, and 35 and 60 minutes for all patients, which is significantly shorter than 2.5 hours to CT in 2004, prior to SFT (P < .0001). Although not different in time to first physician, patients arriving >3 hours had longer times to CT and CT results (P < .001). Overall, 5.5% of ischemic stroke patients received intravenous rt-PA, including 27.1% of those arriving within 3 hours, which represented 100% of all eligible patients, compared with 0% in 2004. SFT reduced time delay in neuroimaging and increased use of rt-PA in Thailand. Continuous quality improvement is needed to achieve best results in each setting, and to insure optimal care for acute stroke patients.