bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 29: Optimization Methodologies to Enhance Endovascular Thrombectomy Access in the United States
Authors: Sarraj Amrou , Grotta James C , Martin-Schild Sheryl , Kamal Haris , Sharrief Anjail Z , Carroll Kirsten , Shaker Faris , Pujara Deep K , McCullough Louise D , Savitz Sean I
Published: June 2021

Background:
Timely access to endovascular thrombectomy (EVT) centers is vital for best stroke outcome. We map current EVT access in the US then utilize modeling to optimize it.

Methods:
US designated stroke centers were mapped utilizing geo-mapping and stratified into EVT or non-EVT if they reported ≥1 thrombectomy code for acute ischemic stroke in 2017 to CMS. Direct EVT access, defined as the population with the closest facility to EVT centers, was calculated from validated trauma models adapted for stroke. Current 15 and 30 min access were described nationwide and in 4 states (TX, NY, CA, IL).

Two optimization models were utilized.

Model A

used a greedy algorithm to capture the largest population with direct access when flipping 10 non-EVT to EVT centers to maximize access.

Model B

used bypassing methodology to directly transport patients to EVT centers within 15 min from the closest non-EVT center.

Results:
Of 1941 stroke centers, 714 were EVT. Approximately 99 million/32% Americans have direct EVT access within 15 min while 111 million (36.0%) within 30 minutes (Fig 1).

There were 65 (43%) EVT centers in TX with 22% current 15 min access. Flipping the top 10 population density hospitals improved access to 32%, while bypassing resulted in 46% having direct access to EVT centers (fig 2 A-B). Direct access in CA was 26% which improved to 35% with flipping and 54% by 15 min bypassing from the closest non-EVT to EVT centers. Similar results were found in NY (current 21%, flipping 39%, bypassing 50%) and IL (15%, 27% and 35%, respectively), Tab 1.

Conclusion:
EVT access within 15 min is limited to less than 1/3 of the US population. Optimization methodology that increase EVT centers or bypass non-EVT to the closest EVT center both showed enhanced access. Results varied by states based on the population size and density. However, bypass showed more potential for maximizing direct EVT access. National and state efforts should focus on identifying gaps and tailoring solutions to improve EVT access.
Abstract 3: Quantitative Collateral Vessel Density Associated With the Prognosis of Mechanical Thrombectomy on Intracranial Large Vessel Occlusion: An Initial Study Based on CT Perfusion Imaging
Authors: Shi Zhang
Published: June 2021

Objective:
This study on acute ischemic stroke caused by large vessel occlusion (LAO) aims to explore the correlation between collateral circulation and the prognosis of mechanical thrombectomy (MT), and further evaluate the high-risk factors of the prognosis of MT by quantitatively measuring the collateral vessel density (CVD) using F-STROKE software.

Methods:
This study was retrospectively analyzed on 92 patients with acute ischemic stroke caused by LAO from January 2018 to October 2018. All patients underwent MT and CT perfusion (CTP) examination before operation. mRS evaluation was performed after 90 days. The patients were divided into two groups according to 90d-mRS (0-2 points: good prognosis; 3-6 points: poor prognosis) F-stroke software was used for CTP image analysis to quantitatively obtain core infarct volume, ischemic penumbra volume, mismatch ratio and CVD (CVD = the vessel volume of the hypoperfusion region / the volume of the hypoperfusion region). Multivariate logistic regression model was used for statistical analysis.

Results:
A total of 87 patients with LAO were included in this study, including 54 patients with good prognosis. The univariate analysis showed that core infarction volume (P=0.017), mismatch ratio (P=0.040), CVD (P=0.003) and symptom improvement (P<0.001) were associated with the prognosis after MT. As multivariate Logistic regression analysis shown, CVD (P=0.008; OR=13.296; 95%CI, 1.948-90.736) and symptom improvement (P=0.003; OR=13.824; 95%CI, 2.476-77.196) were two independent high-risk factors of the prognosis of MT. According to ROC (figure 1), the AUC value of CVD and symptom improvement were 0.839 and 0.790, respectively. When combining both of the two features to predict the prognosis of thrombolysis, the AUC value has been improved to 0.887.

Conclusion:
For patients with LAO who underwent MT, CVD was an independent quantitative predictor to the prognosis after MT surgery.
Abstract 33: Diagnostic Accuracy, Reperfusion Delay and Triage Scale Comparison: Real-World Paramedic Validation Results From the ACT-FAST Triage Algorithm for Thrombectomy
Authors: Zhao Henry , Smith Karen , Bernard Stephen , Stephenson Michael , Bladin Christopher , Ng Jo Lyn , Williams Cameron , Alemseged Fana , Mitchell Peter J , Desmond Patricia M , Parsons Mark W , Yassi Nawaf , Campbell Bruce C
Published: June 2021

Background:
Severity-based selection tools for large vessel occlusion (LVO) are limited by lack of validation in unselected prehospital stroke patients and concerns regarding delayed thrombolysis (tPA) and comprehensive stroke center (CSC) burdening. We examined these issues in a real-world validation of the two exam step (severe arm motor + speech or neglect) ACT-FAST LVO triage algorithm.

Methods:
The ACT-FAST statewide validation involved 15 metro and 17 rural hospitals in Victoria, Australia from Nov 2017-July 2019 with training of paramedics using an 8 min video. Prehospital paramedic assessments were correlated with hospital imaging to determine presence of LVO. Data were then examined for diagnostic accuracy, time saving for direct bypass to CSC using a validated Google maps model, rates and magnitude of delayed tPA in false-positive non-LVO infarcts, and extra CSC workload.

Results:
In 517 completed assessments, 58% involving non-EVT centers and including 114 (22%) LVO, ACT-FAST sensitivity was 81% (92/114) and specificity was 81% (325/403; 89% if ICH are not regarded as false-positive) for LVO. Figure compares to other LVO scales. Bypass to CSC was modelled to save median 71 min for analysis of 29 thrombectomy patients requiring inter-hospital transfer. Of 27 non-LVO infarcts with false positive ACT-FAST, only 4 (15%) received tPA at a non-CSC center, and bypass would have only added median 10 mins in these cases. The increase in CSC presentation using ACT-FAST triage was estimated to be 2-3.3 patients/week using estimated 7,200 suspected stroke cases/year across entire metro Victoria.

Conclusion:
In comprehensive real-world validation, the simple ACT-FAST algorithm detected LVO or ICH in almost 80% of positive assessments with highly favorable comparison to other scales. Prehospital bypass to CSC substantially reduces thrombectomy delay, and appears to strongly outweigh negatives of bypassing false positive cases on tPA delay and CSC overburdening.
Abstract 35: Dispatcher Impression of Stroke: Concordance With Paramedic Identification and Effect on Allocation of Standard Ambulances and Mobile Stroke Units
Authors: Nour May , Kazan Clayton , Steeneken Nicole , Brown Kevin M , Villareal Bryan , Harrell Kenny , Liebeskind David S , Bosson Nichole , Gausche-Hill Marianne , Chidester Cathy , Saver Jeffrey L ,   LA County EMS Stroke Data Collaborative
Published: June 2021

Background:
EMS 911 dispatchers must rapidly assess patient calls and allocate appropriate responding resources including, for stroke, advanced (rather than basic) life support standard ambulances and, in an increasing number of regions, specialty Mobile Stroke Units. While dispatcher accuracy in distinguishing stroke from other high risk conditions is not crucial for selecting ALS rather than BLS response, specialized MSU response necessitates a higher level of accuracy.

Methods:
We analyzed all transports between January 2018-August 2019 identified as stroke by dispatchers at sendout or by paramedics upon patient assessment in a large urban EMS system -LA County FD EMS, serving 4.1 million lives, 59 cities, 3,000 square miles, via 174 fire stations. Dispatchers are instructed to decide upon the appropriate diagnosis and responding resource within 60s of start of 911 call conversation. “Dispatcher Impression” (DI) and on scene paramedic “Provider Impression” (PI) were compared, and other care metrics analyzed.

Results:
In total, 12,528 runs were evaluated, of which 79.1% (9913) were dispatched as stroke and paramedics identified stroke in 47.6%. The sensitivity of dispatcher impression of stroke was 56.2% and the positive predictive value was 33.9%. The most common paramedic impressions in non-concordant patients dispatched as stroke were: generalized weakness in 24% (1587), altered mental status in 17% (1111), and syncope in 6% (403). In patients with a dispatcher impression of non-stroke but paramedic impression of stroke, the most common dispatcher impressions were: sick person in 29% (758), unconscious in 28.7% (750), and seizure in 4.6% (121). In dispatcher impressions of stroke, 100% were dispatched at ALS level; and in dispatcher impressions of non-stroke but eventual paramedic impression of stroke, 98.3% were dispatched at ALS level. Patient age over/under 40 & patient sex did not modify rates of dispatcher - paramedic impression concordance.

Conclusions:
Dispatchers identify more than half of paramedic-identified stroke patients and allocate appropriate ALS standard ambulances in almost all stroke patients. However, for efficient attaching of specialized MSU resources, improved dispatcher identification of stroke is desirable.
Abstract 37: Increased Mean Transit Time and Blood Brain Permeability in Asymptomatic White Matter Lesions of Ischemic Origin
Authors: Dewey Blake , Xu Xiang , Knutson Linda , Jog Amod , Prince Jerry , Barker Peter , Van Zijl Peter , Leigh Richard , Nyquist Paul A
Published: June 2021

Introduction:
White matter lesions of presumed ischemic origin (WMH) have been associated with increased risk of stroke, cognitive and motor decline, and are a subject of public health research. Engineering new MRI pipelines allowing for determination of mean transit time (MTT), and blood brain barrier permeability (BBBP), within WMH lesions is required for long-term population-based studies of lesion progression in patients with dementia and vascular cognitive impairment.

Methods:
WMH lesion volumes in 24 asymptomatic individuals was determined using an automated segmentation methodology, S3DL, with manual correction to remove false positives. A double contrast injection scheme was used to measure both K
trans
using dynamic contrast enhanced (DCE) imaging and K
2
using dynamic susceptibility contrast (DSC) imaging which also provided perfusion-related measures. BBBP was measured as k
2
within segmented WMH lesions and compared with normal white and gray matter.

Results:
The mean transit time (MTT) was found to be significantly prolonged (8.11, p<0.001Wilcoxon Signed-Rank Test) in WMH lesions when compared to normal appearing white and gray matter. There was no significant difference in DCE-K
trans
(0.018, p=0.351) between the lesions and the white/gray matter. Permeability measured in the WMH lesions using the DSC-K
2
method was increased and was correlated withincreasing total WMH lesion volume (spearman correlation 0.44; p< 0.046).

Conclusion:
In this first study using an advanced WMH lesion automated segmentation pipeline, we measured DCE and DSC perfusion and permeability variables within WMH lesions and compared them to normal white and grey matter in healthy people. We observed increasing MTT, within WMH lesions as compared to unaffected white and gray matter. Using the DSC-K
2
method, BBBP was higher within WMH lesions in these asymptomatic people, and correlated with increasing total lesion volume.
Abstract 39: GLP-1 Agonists Improve Cerebrovascular Integrity and Vascular Induced Cognitive Impairment and Dementia Beyond Glycemic Control via Restoration of Brain Pericytes Functions in Diabetic Mice
Authors: Bailey Joseph M , Ghaly Mark , Barrett Amy C , Hafez Sherif , Coucha Maha M , Abdelsaid Mohammed A
Published: June 2021

We have previously shown that diabetes causes pericyte-dysfunction that leads to loss of vascular integrity and vascular-induced cognitive impairment and dementia (VCID). Glucagon-like peptide-1(GLP-1), used in the management of type-2 diabetes mellitus, improves cognitive functions in diabetic patients beyond glycemic control, yet the mechanism is unknown. In the present study, we hypothesis that GLP-1 agonist improves VICD through prevention of diabetes-induced pericytes dysfunction in a non-glucose dependent way.

Methods:
Control and diabetic mice were randomly assigned for saline or Exendin-4 (GLP-1 agonist 30 ng/kg/day), delivered through osmotic pump over 28 days. Vascular integrity was assessed by measuring cerebrovascular neovascularization indices (Vascular density, tortuosity, and branching density). Cognitive functions were evaluated with Barnes maze and Morrison Water maze. Human brain microvascular pericytes, HBMPCs, were grown in high glucose 25 mM/ sodium palmitate 200 uM (HG/Pal) to mimic diabetic conditions. HBMPCs were treated with/out Exendin-4 and assessed for oxidative stress and angiogenic properties.

Results:
Diabetic mice treated with GLP-1 agonist showed a significant reduction in all cerebral pathological neovascularization indices (P<0.05). Exendin-4 vascular protective effects were accompanied by significant improvement of the learning and memory functions of diabetic mice (P<0.05). Our results showed that HBMPCs expressed the GLP-1 receptor. Treating HBMPCs exposed to diabetic conditions with GLP-1 agonist restored pericyte functions, decreased diabetes-induced inflammation, oxidative stress, and migration (P<0.05).

Conclusion:
Our results provide novel evidence that GLP-1 agonist produces neurovascular protective effects in part through targeting pericytes. Restoration of pericyte functions in diabetes represents a novel therapeutic target for diabetes-induced vascular remodeling and VCID.
Abstract 42: Association of White Matter Hyperintensity Progression and Cognitive Decline: A Secondary Analysis of the ACCORDION MIND Study
Authors: de Havenon Adam H , Yeatts Sharon , Gottesman Rebecca , Turan Tanya , Rost Natalia , Prabhakaran Shyam
Published: June 2021

Introduction:
Retrospective and epidemiological studies have shown that white matter hyperintensity (WMH) is associated with vascular dementia, but WMH progression on serial MRIs has not been examined in a prospective study of diabetic patients, who have a higher risk of the adverse outcomes associated with WMH including dementia.

Methods:
This is a secondary analysis of the Memory in Diabetes (MIND) substudy of the Action to Control Cardiovascular Risk in Diabetes Follow-on Study (ACCORDION). The primary outcome was 4 cognitive tests measured at a baseline visit and month 80 follow-up visit, including Rey’s Auditory Verbal Learning Test (RAVLT), Mini Mental Status Examination (MMSE), Stroop test, and Digit Symbol Coding (DSC). The primary predictor was WMH progression, represented as the WMH volume on the month 80 MRI with the baseline WMH volume included in the model. We predicted change in the cognitive scores by modelling their association with WMH progression.

Results:
We included 262 patients, with a mean (SD) baseline age of 62.7 (5.3) years and 56.1% male. The mean (SD) WMH volume on the baseline and month 80 MRIs was 1.9 (3.0) and 4.3 (6.0) mL, respectively. The change in WMH was significantly associated with the change in RAVLT score in the linear regression model (β Coef -0.132, p=0.029). (Table). The mean (SD) RAVLT at baseline and month 80 was 8.0 (2.4) and 8.5 (2.8).

Conclusions:
WMH progression in diabetic patients is associated with worse performance on memory testing over an 80 month period. Though preliminary and not able to account for location of WMH, our results are consistent with the hypothesis that WMH progression is harmful to cognition in diabetics. The SPRINT MIND trial recently reported that intensive blood pressure control attenuates WMH progression and development of mild cognitive impairment, but excluded patients with diabetes. Against this backdrop, our data suggest that diabetics should be included in future trials to reduce WMH progression.
Abstract 46: A New Rehabilitation Strategy to Improve Gait Speed and Balance Self-Efficacy Following Stroke
Authors: Rose Dorian K , DeMark Lou , Conroy Christy , Fox Emily , Clark David
Published: June 2021

Introduction:
Impaired balance and decreased balance confidence contribute to slow gait speed and increased fall risk post-stroke. Standard balance exercises and gait training do not adequately address these impairments. Backward Walking Training (BWT), incorporating the unique postural and lower extremity motor control demands of walking backward, may reduce these gait impairments. This study compared the effects of BWT to Forward Walking Training (FWT) on forward and backward gait speed, dynamic balance and balance confidence.

Methods:
Thirty adults with first time stroke (18 male; 15 right hemisphere lesion; mean time post-stroke 12.7±6.6 months; mean age 58.8±10.1 yrs; mean Lower Extremity Fugl-Meyer Motor Score 22.7±1.4) were randomized to receive eighteen exercise sessions (3x/week for 6 weeks) of BWT (n=15) or FWT (n=15) consisting of 20 minutes training on a treadmill with Body Weight Support followed by 20 minutes overground. Gait was facilitated by a physical therapist-led team. Speed, limb loading and bout duration were progressed across sessions. The Ten Meter Walk Test (10MWT), Activities-Specific Balance Confidence (ABC) Scale, 3-meter Backward Walk Test (3MBWT), Functional Gait Assessment (FGA) and spatial-temporal gait characteristics were assessed pre- and post-intervention.

Results:
Pre- to post-intervention increases in the 3MBWT (BWT: 0.23±0.4 to 0.32±0.06 m/s ; FWT 0.21±0.4 to 0.23±0.04 m/s: ), ABC (BWT: 55.2±5.2% to 61.8±7.1% ; FWT: 52.9±6.5% to 53.5±6.2%: ), 10MWT (BWT: 0.42±0.07 to 0.51±0.08 m/s ; FWT: 0.44±0.08 to 0.47±0.07 m/s ) and backward paretic step length (BWT: 0.19±0.04 to 0.34±0.03 cm ; FWT: 0.21±0.03 to 0.20±0.04 cm were greater for the BWT than the FWT group. These gains were all statistically significant (p < 0.01). Group differences in FGA did not reach statistical significance.

Conclusions:
The greater increase in backward paretic step length, backward walking speed and balance confidence observed in the BWT group are all known contributors to reduced fall risk. BWT may be an important addition to the rehabilitation plan for individuals post-stroke. A longitudinal examination of fall incidence following BWT is the next important step in determining the overall utility of this novel rehabilitation approach.
Abstract 49: Male Sex is Associated With Cervical Artery Dissection in Patients With Fibromuscular Dysplasia
Authors: Arnaud Charlotte , Boulanger Marion , Lorthioir Aurélien , Amar Laurence , Azarine Arshid , Azizi Michel , Boyer Louis , Chatelllier Gilles , Jeunemaitre Xavier , Mousseaux Elie , Oppenheim Catherine , Thony Frédéric , Plouin Pierre-Francois , Persu Alexandre , Olin Jeffrey , Touze Emmanuel
Published: June 2021

Background:
Cervical artery dissection (CeAD) is one of the most frequent manifestations of fibromuscular dysplasia (FMD). However, the risk factors for CeAD are unknown. We investigated factors associated with CeAD in the ARCADIA (Assessment of Renal and Cervical Artery Dysplasia) registry and performed a pooled analysis of published and unpublished data.

Methods:
Patients included were women and men ≥18 years, diagnosed with renal, cervical, or intracranial artery FMD, prospectively recruited at 16 university hospitals in France and Belgium. Diagnosis of CeAD was established by stroke specialists in each participating center, according to standard diagnostic criteria. Associations between CeAD and potential determinants were assessed by calculations of crude and adjusted odds ratios.

Results:
Among 469 patients (415 women) with FMD, 68 (14.5%) had CeAD. CeAD patients were younger, more likely to be men and to have a history of migraine, and less likely to have a history of hypertension, than non-CeAD patients. In the multivariate analysis, male sex (OR=2.75 ; CI95% 1.39-5.46), history of migraine (OR=1.93 ; 1.08-3.44), age >50 years (OR=0.41 ; 0.23-0.74), history of hypertension (OR=0.35 ; 0.19-0.63), and the number of vascular beds involved by FMD >=3 (OR=2.46 ; 1.13-5.35) remained significantly associated with CeAD. We collected data from 2 published studies and unpublished data from the US and the European Registries. There was no overlap between studies. In a pooled analysis (289 CeAD in 1933 patients), male sex was significantly associated with CeAD (pooled OR=2.04 ; 1.41-2.95, I2=0%, Figure).

Conclusion:
In patients with FMD, male sex and multisite involvement are associated with of CeAD, in addition to other previous known risk factors.
Abstract 55: Comparison of Sequential Multi-Detector CT and Cone-Beam CT Perfusion Maps in 54 Subjects With an Acute Ischemic Stroke
Authors: Eisenmenger Laura , Capel Kelly , Garrett John , Li Ke , Li Yinsheng , Ahmed Azam , Niemann David , Griner Dalton , Samaniego Edgar , Ortega-Gutierrez Santiago , Derdeyn Colin , Schafer Sebastian , Strother Charles , Chen Guang-Hong , Aagaard Kienitz Beverly
Published: June 2021

Introduction:
Time from diagnostic imaging to groin puncture highly correlates with outcome and often accounts for delays between hospital arrival and EVT. Our study comparing image quality and information content of MDCTP and CBCTP provides feasibility data for selected AIS patients to go straight to the angio-suite for comprehensive imaging and treatment.

Methods:
AIS patients eligible for EVT underwent MDCTP, then a CBCTP study on arrival in angio-suite. Of 939 admitted June 2017-April 2019, 226 (24%) received EVT. Of these 54 (35%) were enrolled to receive additional CBCTP imaging. Inability to obtain consent and co-morbidities were major causes for non-enrollment. Times from the start of MDCTP to angio-suite and from angio-suite arrival to first arterial image were recorded. Acquired CBCTP data were reconstructed and processed with an in-house toolbox. MDCTP and CBCTP data were matched for slice thickness and angulation and were processed using RAPID CTP (iSchemaView, Inc.). The rCBF, rCBV, MTT, tMAX maps were randomized to generate 3 unique evaluation sets. 3 neuroradiologists scored diagnostic image quality, artifacts, mismatch pattern detection and EVT indication using 5-point Likert scales. Stroke laterality was compared with the clinical standard for diagnostic accuracy.

Results:
Accuracies for stroke diagnosis are 97% [95%, 97%] with MDCTP and 92% [90%, 95%] with CBCTP. Cohen’s Kappa between observers is 0.90 for MDCTP-based diagnosis and 0.89 for CBCTP-based diagnosis. Scores of CBCTP to make the stroke diagnosis, detect mismatch pattern, and make treatment decision were non-inferior to corresponding scores for MDCTP (alpha=0.05) within 10% of the whole score range. Subjective scores of MDCTP for image quality and artifacts were slightly superior to those of CBCTP (1.8 vs. 2.3, p<0.01).

Conclusions:
In this study, a direct to angio-suite workflow provided non-inferior perfusion imaging for AIS patient triage while saving nearly one hour per patient.
Abstract 6: Identifying Late Progressing Patients With Persistent Penumbra in DEFUSE 3 With the 24-Hour Tmax/DWI Ratio
Authors: Sarraj Amrou , Lansberg Maarten , Marks Michael P , Mlynash Michael , Heit Jeremy J , Savitz Sean I , Albers Gregory W
Published: June 2021

Background:
DEFUSE 3 infarct volumes at 24 hours did not significantly differ in the EVT vs. medical management only (MM) groups. We hypothesized that this lack of difference was due underestimation of the final infarct volume among patients who had persistent penumbral tissue 24 hrs after randomization that subsequently progressed to infarction. Furthermore, these patients could be identified based on a persistent Tmax>6s perfusion lesion that was larger than the 24 hr DWI lesion volume (Tmax/DWI >1).

Methods:
Patients were stratified into those with 24 hr post-randomization Tmax/DWI < 1 vs ≥ 1. The primary outcome was 90-day mRS. We correlated and compared the 24 hr Tmax/DWI ratio to other reperfusion parameters (mTICI ≥ 2b, 24hrs >90% reduction in Tmax and/or recanalization on CTA/MRA).

Results:
182 patients, 92 were randomized to EVT, 90 to MM. 24 hr post-randomization Tmax and DWI volume were assessable for 75 EVT and 69 MM. DWI volumes did not differ between EVT and MM median (IQR) ml 35.0 (17.6-81.6) vs 41.0(25.4-106.2), P=0.185. The Tmax/DWI 24 hrs ratio was 0 (0-0.07) for EVT and 0.77(0.23-1.79) for MM, p<0.001. Patients with Tmax/DWI < 1 had a higher odds of achieving functional independence (39% vs. 9%, aOR=9.9 (95%CI=2.3-42.8, p=0.002), a trend towards lower mortality rates (12% vs 34%, p=0.002; aOR=0.34 (95% CI 0.11-1.03), p=0.057 (Fig 1) and early large improvement (24 hrs NIHSS decrease ≥ 8 points or 0-1): 29% vs. 9%, p=0.034. Patients were more likely to have a ratio < 1 following mTICI ≥ 2b reperfusion (96% vs. 62%) or >90% reduction in Tmax (100% vs. 56%), p<0.001. As compared with other reperfusion parameters, the Tmax/DWI ratio had a comparable correlation with 90 days functional independence adjusted AUC: Tmax/DWI ratio=0.85; mTICI=0.86 vs 90%; Tmax reduction=0.88).

Conclusion:
The Tmax/DWI ratio 24-hours after EVT vs medical therapy identifies patients with persistent penumbra who have a poor prognosis and may benefit from additional therapeutic interventions.
Abstract 60: Impact of Monthly Testing and Tutorials on Accuracy and Confidence of Telestroke Nurse Recognition of Anterior Circulation Large Vessel Occlusion CT Perfusion Patterns
Authors: Snider Emily K , Chang Brenda , Helms Anna Maria , Williams Laura , Singh Sam , Asimos Andrew W
Published: June 2021

Introduction:
A distinguishing feature of our Stroke Network is Telestroke (TS) nurses (RNs) who remotely facilitate TS evaluations. To facilitate expeditious transfer the TS RNs, need to immediately identify CT perfusion (CTP) studies demonstrating patterns consistent with internal carotid artery (ICA), middle cerebral artery (M1), and first branch of the M1 (M2) large vessel occlusion (LVO) acute ischemic strokes (AIS).

Methods:
We developed a 6-month series of tutorials and tests (12 CTP scans/month) for 16 TS RNs to recognize CTP patterns consistent with ICA, M1 or M2 LVO AIS. We simultaneously conducted a prospective cohort study of these nurses on the impact of these tutorials and tests.

Results:
TS nurses demonstrated good accuracy in detecting ICA, M1 or M2 LVO presence during the first three months of teaching (83-94% accurate).This improved to excellent during the last three months (99-100%), during which the likelihood of correctly identifying the presence of any one of these LVOs was greater than in the first three months (OR 1.99, 95% CI: 1.83-2.17, p<0.001). The probability of correctly identifying ICA or M1 occlusions was much higher than correctly identifying all other LVOs (OR 68, 95% CI: 45-102, p<0.001). The likelihood of being at a higher confidence level compared to lower confidence levels in identifying any LVOs as being ICA or M1 was higher than in identifying other LVOs (OR 2.14, 95% CI: 1.6-2.8, p<0.001), but over time confidence for determining LVO presence did not differ significantly after controlling for subject variation.

Conclusion:
A series of structured tutorials significantly increased the odds of TS nurses correctly identifying anterior circulation LVOs, with the benefit of these tutorials and test reviews peaking and plateauing at four months. Participating in TS nurse tutorials was associated with high odds and confidence for correctly identifying LVOs as being ICA or M1.
Abstract 64: Transradial Approach: The Future of Neurointervention-A Muticenter Collaboration
Authors: Almallouhi Eyad , Al Kasab Sami , Starke Robert , Lena Jonathan R , Sweid Ahmad , Chalouhi Nohra , Tonetti Daniel , Zussman Benjamin M , Stone Jeremy G , Gross Bradley A , Privett Brian , Gooch Reid , Chen Stephanie , Li Yangchun , Yavagal Dileep , Peterson Eric , Jabbour Pascal , Spiotta Alejandro M
Published: June 2021

Introduction:
Transradial approach (TRA) has gained significant popularity in the neuroendovascular world over the past few years. The purpose of this study is to report early experience in TRA from high volume centers.

Methods:
We reviewed charts from 4 institutions in the United States to include consecutive patients who underwent diagnostic or interventional neuroendovascular procedure through TRA from July 2018 to July 2019. Collected data included baseline characteristics, procedural variables, whether there was crossover to transfemoral access and complications.

Results:
A total of 1272 patients were included in the series (age 57.2 ± 15.3, 46.3% females). Out of those, 1054 (82.9%) patients underwent diagnostic cerebral angiograms and 218 (17.1%) underwent interventional procedures. Successfully completed procedures included aneurysm primary coiling (62 patients), stent assisted coiling (44 patients), flow diversion (40 patients), balloon assisted coiling (21 patients), and stroke thrombectomy (24 patients). The large vessels were selected as following: right vertebral artery (VA) in 74.2% of the cases, right internal carotid artery (ICA) in 75.4% of the cases, left VA in 51.4% of the cases, left ICA in 69.1% of the cases. Crossover to femoral access was required in 82 (6.4%) patients (most common cause was inability to reach the target vessel in 13 patients). None of the included patients had major complication related to the access site. Minor complications related to access site were seen in 30 (2.4%) patients. Of those, 11 patients had forearm hematoma, 8 had mild-moderate vasospasm, 6 had forearm pain, and 5 had oozing from the access site.

Conclusion:
In this early stage of transforming to radial-first approach for neurointerventions, TRA was reasonably safe with relatively low complication rate for both diagnostic and interventional procedures. Wide range of procedures were completed successfully using TRA.
Abstract 79: Mechanisms of Early Recurrence in Intracranial Atherosclerotic Disease (MyRIAD) Study: Participants, Clinical and Imaging Outcomes
Authors: Romano Jose G , Prabhakaran Shyam , Nizam Azhar , Feldmann Edward , Sangha Rajbeer , Campo-Bustillo Iszet , Cotsonis George A , Liebeskind David S ,   MyRIAD Investigators
Published: June 2021

Introduction:
ICAD is a common cause of stroke. MyRIAD is designed to identify mechanisms of ischemia and predictors of recurrence in ICAD. Here we present the study population baseline characteristics and key outcomes.

Methods:
MyRIAD is an NIH/NINDS funded prospective multicenter observational study of patients with recent (
<
21 days) stroke or TIA (recurrent or with DWI) caused by IAD 50-99% without planned angioplasty/stenting. The primary outcome is ischemic stroke in the territory within 1 year of follow up; secondary outcomes are TIA at 1 year and new infarcts on MRI at 6-8 weeks. Qualifying events and clinical and imaging outcomes are centrally adjudicated.

Results:
MyRIAD enrolled 105 participants. The MyRIAD cohort (Table) had significant atherosclerotic risk factors and received aggressive medical therapy. Of 101 participants with clinical follow up (mean 243
+
126 days), the primary outcome of stroke in the territory at 1 year occurred in 9 (8.6%, 13.4/100 person-years), while 7 (6.7%, 10.4/100 person-years) had a TIA. A study MRI at 6-8 weeks was available for comparison to baseline MRI in 87 participants (mean time from qualifying event to follow up imaging 51
+
16 days). A new DWI/FLAIR infarct in the territory of the symptomatic vessel was noted in 22 participants (25.3%).

Conclusions:
MyRIAD detected an 8.6% 1-year stroke recurrence and a much higher 25.3% rate of recurrent infarction in the first weeks after qualifying stroke/TIA, emphasizing the need to develop better therapeutic interventions for ICAD.
Abstract 81: Translesional Pressure Gradient Alters the Relationship Between Blood Pressure and Stroke Recurrence in Symptomatic Intracranial Atherosclerotic Disease
Authors: Feng Xueyan , Chan Ka Lung , Abrigo Jill , Lan Linda , Soo Yannie , Leung Thomas W , Leng Xinyi
Published: June 2021

Objective:
Patients with symptomatic intracranial atherosclerotic stenosis (sICAS) have a high risk of stroke recurrence. There is debate over an optimal blood pressure (BP) lowering target in secondary stroke prevention in such patients, when some factors (e.g., impaired cerebral perfusion) may alter the relationship between BP and risk of stroke recurrence. In this study, we investigated whether translesional pressure gradient across sICAS lesions would also alter such relationship.

Methods:
We recruited patients with sICAS (50-99% stenosis) confirmed in CT angiography (CTA). Computational fluid dynamics (CFD) models were built based on CTA to simulate blood flow across sICAS and calculate the translesional pressure ratio (PR, the ratio of pressures distal and proximal to a lesion). PR ≤ median was defined as low PR, indicating larger translesional pressure gradient and hence restricted downstream perfusion. The primary outcome was recurrent ischemic stroke in the same territory in 1 year. We investigated the interaction of PR and mean systolic BP (SBP) during follow-up in determining the risk of the primary outcome.

Results:
Among 157 patients, the median PR was 0.93. Multivariate Cox regression revealed significant PR-SBP interaction on the primary outcome (p=0.025): in patients with normal PR, the risk of primary outcome significantly decreased with lower SBP during follow-up (for 10 mmHg decrement: HR 0.46; p=0.018); however, in those with low PR, mean SBP ≤130 mmHg was associated with significantly increased risk of primary outcome, compared with 130<SBP<150mmHg (HR 5.08; p=0.043) (Figure).

Conclusion:
Intensive BP lowering may increase the risk of stroke recurrence in sICAS patients with a large translesional pressure gradient, warranting further investigation. PR by CFD models may yield a promising indicator to differentiate sICAS patients for different BP management strategies for better secondary stroke prevention.
Abstract 85: Periodontal Disease Association With Large-Artery Atherothrombotic Stroke
Authors: Mascari Rachel , McMillian Brittiny , Orofino Christine , Byrd Amanda , Hicklin David , Nichols Cynthia , Curtis James , Yallapragada Anil , Kothari Ravish , Sen Souvik
Published: June 2021

Introduction:
Periodontal disease (PD) is associated with incident and recurrent ischemic stroke. We investigated whether PD is associated with specific stroke subtype.

Methods:
In this cross-sectional study, PD was assessed in ischemic stroke and TIA patients. Moderate-severe PD was determined by full-mouth examination by a dentist. Clinical information including stroke etiological subtype (TOAST) was collected at admission. Based on vascular imaging, strokes caused by large-artery atherothrombosis were further analyzed to distinguish those caused by either intracranial atherosclerosis (ICAS) or extracranial atherosclerosis (ECAS). They were also classified as anterior or posterior circulation disease.

Results:
Consecutive patients (N=265) were enrolled (age 64 ± 12.8, 49% white, 46% black, 5% other and 56% male) between 2015-17. A third (N=87) were found to have PD. Twenty percent (N=42) of strokes were caused by large-artery atherothrombosis. In this group, there was a significantly higher proportion of patients with PD compared with those without PD (24% vs.12%, X
2
p=0.01). Patients with PD also had a significantly higher proportion (12% vs 5%) of stroke due to posterior circulation disease (crude OR 3.0, 95% CI 1.1-7.9, p=0.03), not anterior circulation disease (14% vs. 7%; crude OR 2.2, 95% CI 0.9-5.2, p=0.08). This association with posterior circulation disease persisted after adjustment for age, race, hypertension, diabetes, hyperlipidemia, smoking status, coronary artery disease, atrial fibrillation, and hemoglobin A1C (adjusted OR 3.1 95% CI 1.04-9.1, p=0.004). In addition, those with PD had a significantly higher rate of stroke due to ICAS compared to those without PD (20% vs. 8%; crude OR 2.6, 95% CI 1.3-5.6, p=0.01), while there was no significant difference between the groups for strokes due to ECAS (9% vs. 3%; crude OR 2.2, 95% CI 1.0-8.7, p=0.06). PD remained significantly associated with ICAS after adjustment for the same covariates (adjusted OR 2.6, 95% CI 1.1-5.8, p=0.004).

Conclusion:
We report a significantly higher proportion of stroke due to large-artery atherothrombosis in patients with PD compared to those without PD. We report an independent association between PD and ICAS, as well as posterior circulation disease.
Abstract 86: Increasing World-Wide Stroke Burden, 2010-2017
Authors: Goldstein Larry B
Published: June 2021

Introduction:
Although stroke-related mortality decreased over the last 3- decades, there is concern that morbidity and death rates may have increased over recent years.

Methods:
World-wide data available from the Institute for Health Metrics Evaluation’s Global Health Data Exchange (ghdx.healthdata.org/gbd) was analyzed to determine changes in stroke incidence, prevalence, death rates and associated disability adjusted life years (DALYs) between 2010-2017.

Results:
Over the 7-year period, global stroke incidence increased by 5.3% (148, 95% Uncertainty Interval, 140-157 to 156, 95% UI 146-168 per 100,000), prevalence by 19.3% (1,143, 95% UI 1,099-1,192 to 1,364, 95% UI 1,289-1,441 per 100,000), mortality by 5.3% (79, 95% UI 78-80 to 81, 95% UI 79-83 per 100,000) and DALYs by 2.7% (1,683, 95% UI 1,626-1,739 to 1,728, 95% UI 1,656-1,798 per 100,000). The Figure gives global trends for each metric between 1990-2017 (+/- 95% UI) and shows an increase in incidence and prevalence over the entire period with initial declines in mortality and DALYs that leveled off between about 2005-2013 and subsequently increased.

Conclusion:
The global burden of stroke is increasing. As other data suggest that most of the previous decline in stroke-related mortality was related to improvements in risk factor control, these data indicate that population level programs to reduce risk may need to be reinforced.
Abstract 94: Artificial Intelligence-Based Application to Detect and Quantify Stroke Symptoms
Authors: Ribo Marc , Reznik Anna , Ciolli Ludovico , Ohanyan Sona , Brancaleoni Laura , Sanhueza Daniela , Sivan-Hoffmann Rotem
Published: June 2021

Assessment of patients suspected to have an acute stroke at the prehospital level or non-stroke centers may be challenging. We aimed to validate a novel Artificial Intelligence (AI) based application (CVAid) for smartphones able to score neurological deficit in acute stroke patients.

Methods:
Acute stroke patients, admitted in two different stroke units, and healthy volunteers were studied. A certified stroke neurologist determined NIHSS at bedside. A different user recorded a short neurological exam, using CVAid application. The software processed the video file presenting comprehensive neurological exam per NIHSS test to a remote neurologist on a dedicated tablet. Two different remote neurologists (remote1 and remote2) determined NIHSS reviewing neurological exam in the tablet. CVAid performed also a completely automated AI analysis of facial features, to detect stroke symptoms.

Results:
A total of 75 patients were included in the study, 64 (85.3%) stroke patients and 11 (14.7%) healthy volunteers. Correlation between bedside and remote1 NIHSS was r=0. 861 (p<0.001). Correlation between remote1 and remote2 NIHSS was r=0.865 (p=0.001). The CVAId facial recognition system showed an accuracy of 87% in stroke symptom detection, sensitivity 95%, Specificity 80%, false negative 5%, false positive 20%.

Conclusions:
An AI based application efficiently allowed remote neurological evaluation of stroke patients. The automated algorithm was able to accurately triage healthy volunteers from patients suffering a stroke. Feeding the machine learning system with additional patients and development of additional automated analysis beyond facial recognition will increase the system accuracy.
Abstract NS4: Implementing an In-Patient Family Support Group in a Comprehensive Stroke Center
Authors: Wasserman, RN, BSN Jessica , Smith, BS Dewanda
Published: June 2021

Background:
We identified that during the acute critical phase of stroke the families felt removed from the process. All focus is on stabilizing the patient while families are bystanders. Stroke creates a ripple effect; it doesn’t just happen to the patient it also happens to those around them. The purpose of initiating a Support Group was to provide an environment where family and friends are given a voice and support.

Methods:
The weekly Family and Friends Stroke Support Group was launched in January 2019 in the Family Center, a waiting room between the Neuro-critical Care and Neuro Intermediate Units. A flyer was posted in these Units, the Family Center, and included in education packets. After the inaugural session it was noted that there needed to be a process to increase attendance. Daily rounds were initiated to invite loved ones of current stroke patients to the support group. Discussions included: stroke education, community resources, and access to chaplain services. An open agenda offered a safe space for attendees to share their stories, thoughts, and questions. We measured the response to our intervention by reviewing Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.

Results:
Over seven months 122 family members and friends attended the Support Group, an average of 4.5 per session. The overall response by attendees was how they enjoyed the group sessions as depicted in this reoccurring statement: “I really needed this time to talk through my emotions with other people going through the same thing it’s so encouraging!” This initiative significantly improved the patient and family experience as reflected in the HCAHPS score domains. There was an improvement of 4.2% (on a 9-10/10 scale) in the Overall Global Rating of the Hospital domain and of 8.5% (with Strongly Agreed selected) in the Good Understanding and Management of Health domain.

Conclusion:
A hospital based in-patient Family Support Group is beneficial to the family experience in an acute stroke setting as evidenced by improved HCAHPS scores. Daily rounds and participation of staff ensure the Support Group is well attended. Overall response of attendees has been positive: “This support group has been great I didn't even know I needed to talk until I did, thank you so much!”
Abstract TMP100: Biology of Stroke: Role of ELL2, GLIPR1, MAPKAPK3 Genes in Identifying Atrial Fibrillation Cause of Stroke
Authors: Jickling Glen , Sharp Frank , Jauch Edward ,   BASE Investigators
Published: June 2021

Background:
An accurate test to identify atrial fibrillation in ischemic stroke populations would be of significant clinical utility. Using the Biomarkers of Acute Stroke Etiology (BASE) trial (NCT02014896) dataset, our goal was to utilize a database of genes appearing in literature determine if gene expression accurately differentiate patients with atrial fibrillation from those with large artery stroke.

Methods:
BASE enrolled suspected stroke patients presenting to 20 hospitals within 24 hrs of symptom onset. Final gold standard diagnosis and stroke etiology were determined by an adjudication committee using all hospital data but blinded to RNA test results. Whole blood, obtained in PAXgene tubes, was frozen at -20C within 72 hrs and analyzed at a core lab (Ischemia Care, LLC, Dayton, OH) using Affymetrix HTA micro arrays. Genes were filtered to those appearing in stroke literature resulting in 543 potential signature genes. A two-way random forest classifier was built through cross validation of the training data resulting in a 3 gene diagnostic signature with robust performance conserved across literature consisting of ELL2, GLIPR1, MAPKAPK3 genes.

Results:
Overall, 99 patients were enrolled with NIHSS>5, 68 (69%) with atrial fibrillation cause of stroke and 31 (31%) with large artery stroke; (48%) were male, and median (IQR) age was 74.4 (66.1,81.7). Median (IQR) time from symptoms to blood collection was 420 (322, 472) minutes. Coexistent pathology at presentation included high blood pressure 84 (85%), hyperlipidemia 45 (45%), diabetes 31 (31%), and coronary artery disease 38 (38%). Three genes were able to differentiate atrial fibrillation from large vessel stroke; C-statistic 0.86 (0.52-1.0, 95% CI), sensitivity 0.93 (0.56-1.0, 95% CI) and specificity of 0.58 (0.35-0.81, 95% CI ).

Conclusion:
RNA expression of ELL2, GLIPR1, MAPKAPK3 genes differentiates atrial fibrillation stroke patients from those with large artery stroke, and may have therapeutic and outcome implications.
Abstract TMP103: Meditation for Post-Stroke Depression: A Pilot Randomized Controlled Trial
Authors: Beauchamp Jennifer E , Chaoul Alejandro , Cron Stanley , Casameni Montiel Tahani , Payen Samuel , Prossin Alan , Love Mary , Okpala Munachi , Savitz Sean , Sharrief Anjail
Published: June 2021

Background and Purpose:
Despite the high prevalence of post-stroke depression (PSD) and negative impact on stroke survivors (SS) and their informal caregivers ([IC]; e.g., unpaid spouses), treatment of PSD is inadequate. Meditation has been associated with improved psychological outcomes. The purpose of this study was to establish the feasibility and acceptability of a 12-week randomized controlled trial (RCT) of a meditation intervention with SS and IC. Secondary objectives were to explore the effects of the intervention on symptoms of PSD, anxiety, and pain.

Methods:
Participants were randomized to the 4-week meditation intervention (n=27 SS; n=16 IC) or expressive writing control (n=14 SS; n=7 IC). Descriptive statistics were used to examine feasibility. Acceptability data included interviews and field notes. Repeated measures analysis with linear mixed models were used to test for change over time in Center for Epidemiological Studies Depression Scale (CES-D), State-Trait Anxiety Inventory (STAI), and Brief Pain Inventory (BPI) Severity and Intensity subscale scores.

Results:
Of the 92 eligible, 71 (77%) enrolled. Of the 64 randomized (7 were lost-to-follow-up or withdrawn due to ineligibility prior to randomization), 25 (39%) completed the study. The mean intervention attendance rate was 55%. Assessment completion rate for the intervention was 96%. For intervention SS, BPI severity scores were significantly lower at 8 weeks (p=.0270), while non-significant reductions across CES-D and STAI scores were noted. For intervention IC, a significant reduction in STAI-Trait scores was noted at 4 weeks (p=.0262). Data indicated distance was a primary barrier; however, the majority voiced favorable responses to the meditation.

Conclusions:
A meditation RCT in the post-stroke environment is acceptable; however, consideration needs to be given to the feasibility of an in-person, multiple-visit intervention. Further efficacy testing is needed in a larger RCT.