bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP431: Improvement in the Outcomes of WFNS Grade V Subarachnoid Hemorrhage Patients Treated Endovascularly Over the Last 15 Years
Authors: Inamasu Joji , Sadato Akiyo , Hirose Yuichi
Published: July 2021

Background:
The outcomes of the grade V subarachnoid hemorrhage (SAH) patients have been dismal. Considering rapid advancement in techniques and devices in endovascular treatment (EVT), however, the outcomes of grade V SAH patients treated endovascularly may have been improved chronologically.

Methods:
A single-center, retrospective study was conducted to evaluate whether the outcomes of World Federation of Neurosurgical Societies (WFNS) grade V SAH patients treated endovascularly were improved chronologically during the last 15 years (January 2000- December 2014). Coiling has been the first-line treatment for WFNS grade V SAH patients in our institution since 2000, and 115 patients who underwent EVT were trichotomized based on the admission year: 2000-04 (n=44), 2005-09 (n=37), and 2010-14 (n=34). Demographics and the outcomes were compared among the three groups. The outcomes at discharge were evaluated with the Glasgow Outcome Scale (GOS) score, and GOS 4/5 were defined as favorable outcomes.

Results:
There were no significant intergroup differences in demographics. There were no significant differences in the frequencies of favorable outcomes (14% in 2000-04, 16% in 2005-09, and 26% in 2010-14). The in-hospital mortality rates were: 52% in 2000-04, 43% in 2005-09, and 24% in 2010-14. The mortality rate in 2010-14 was significantly lower than that in 2000-04 (p=0.01). The reason for chronological decrease in mortality may have been due to decrease in postoperative rebleeding and delayed cerebral ischemia (DCI), both of which were shown to have decreased chronologically: the frequencies of postoperative rebleeding were (11% in 2000-04, 8% in 2005-09, and 0% in 2010-14), and the frequencies of DCI were (36% in 2000-04, 26% in 2005-09, and 19% in 2010-14)

Conclusions:
The outcomes of grade V SAH patients treated endovascularly have been improved chronologically. The improvement is more marked in the reduction of mortality. Although the frequencies of patients discharged with favorable outcomes have also increased chronologically, the differences were not significant and the reason for the increase is unclear. While EVT may be viable option for grade V SAH patients, multi-center, prospective studies are warranted to verify its efficacy.
Abstract TP440: Heart Failure is Associated With Elevated von Willebrand Factor (vWF) Antigen but not Factor VIII (FVIII) in Acute Ischemic Stroke (AIS)
Authors: Samai Alyana , Albright Karen , Antzoulatos Eleni , Schluter Laurie , Martin-Schild Sheryl
Published: July 2021

Introduction:
von Willebrand Factor (vWF) and factor VIII (FVIII) contribute to thrombosis and are important risk factors in acute ischemic stroke (AIS). Elevated vWF has been correlated with depressed left ventricular (LV) function, but has not been examined in a cohort of patients with AIS, particularly with regard to concurrent elevation in FVIII.

Hypothesis:
We hypothesized that vWF is associated with HF and that combined elevation of vWF and FVIII would strengthen this association.

Methods:
From our prospective stroke registry, AIS patients >18 years of age admitted from 09/2011 to 01/2015 were included if both FVIII and vWF were measured during hospitalization and an echocardiogram was performed. Comparisons were done between the following groups: patients with normal (-) vs. elevated (+) vWF, patients with (-) vs. (+) FVIII, and patients with (-) vs. (+) levels of both factors.

Results:
Of 1,091 patients in the study period, 212 patients met inclusion criteria. In all groups, patients differed significantly according to history of DM. +vWF had higher frequency of female gender than -vWF, but did not differ according to any other demographic or baseline characteristics. +vWF patients had higher frequency of HF (p=0.007) and higher frequency of depressed LV function (p=0.028) compared to those with -vWF. vWF level correlated with HF (r=0.189, p=0.006) and reduced LV function (r=0.187, p=0.006). Similar findings were found with dual elevation, but we found no relationship between FVIII and HF. After adjustment for HTN, CAD, and DM, vWF remained an independent predictor of HF (OR 1.003, 95%CI 1.000-1.007, p=0.036). While we found no relationship between LV function and FVIII level, median vWF levels increased with decreasing LV function (p=0.027).

Conclusion:
The results of our study suggest an association between HF and elevated vWF in the setting of AIS, irrespective of FVIII elevation. These results suggest the potential utility of vWF as an independent biomarker for heart failure in the AIS patient population.
Abstract TP453: Physical Inactivity Associated With Vascular Depression or Apathy Leads to Hippocampal Atrophy and Memory Dysfunction in Community-dwelling Elderly Subjects: The Sefuri Study
Authors: Yao Hiroshi , Araki Yuko , Takashima Yuki , Nogami Kohjiro , Uchino Akira , Yuzuriha Takefumi , Hashimoto Manabu
Published: July 2021

Background and Purpose:
Vascular depression has negative effects on physical activity, which is a robust preventive factor against Alzheimer's disease or hippocampal atrophy. Therefore, we investigated the relationship among vascular depression (i.e., apathy associated with deep white matter lesions [DWMLs]), physical activity, hippocampal atrophy, and memory function using structural equation modeling (SEM).

Subjects and Methods:
We examined 213 non-demented elderly subjects without clinically apparent depression. All participants underwent Mini-Mental State Examination, Rivermead Behavioral Memory Test [RBMT] for episodic long-term memory, and a visual analogue version of the Starkstein’s apathy scale (Yao et al., Hypertens Res 2009;32:586). Physical activities were assessed with a questionnaire consisted of 3 components: leisure-time, work, and sport activities (Baecke et al., Am J Clin Nutr 1982;36:936). We evaluated the degree of hippocampal atrophy, using a software program the voxel-based specific regional analysis system for Alzheimer’s disease (VSRAD advance) based on SPM8 plus DARTEL (Diffeomorphic Anatomical Registration Through an Exponentiated Lie algebra).

Results:
When possible confounders were entered into the logistic regression model, the independent predictors of hippocampal atrophy (the highest quintile of VSRAD z-score) were age (OR per 10 years 3.257, 95%CI 1.988-5.338), and leisure-time physical activity (OR per 1-point 0.810, 95%CI 0.707-0.928). Path analysis based on SEM indicated that the direct paths from DWMLs to apathy (β= -0.18, p<0.01) and from apathy to leisure-time activity (β= 0.23, p<0.001) were significant. Furthermore, the direct paths from leisure-time activity to hippocampal atrophy (β= -0.18, p<0.01) and from hippocampal atrophy to memory dysfunction (RBMT) (β= -0.26, p<0.001) were significant. The presented model reasonably fit the data: goodness of fit index = 0.97, adjusted goodness of fit index = 0.93, comparative fit index = 0.97, and root mean square error of approximation = 0.04.

Conclusions:
Based on the present SEM analysis, we propose a hypothesis that physical inactivity associated with vascular depression would lead to hippocampal atrophy or Alzheimer’s disease.
Abstract TP460: Dominant Imaging Markers for Post Stroke Cognitive Performance in the TABASCO Study
Authors: Kliper Efrat , Ben Assayag Einor , Ben-Bashat Dafna , Auriel Eitan , Shenhar-Tsarfaty Shani , Shopin Ludmila , Molad Jeremy , Seyman Estelle , Korczyn Amos D , Bornstein Natan M
Published: July 2021

Introduction:
Post-stroke patients are at high risk of developing cognitive decline. Previous studies have examined only limited magnetic resonance imaging (MRI) parameters for prediction of cognitive status following stroke

Aim:
To determine radiological markers associated with different cognitive domains in post-stroke patients.

Materials and Methods:
Patients from the TABASCO (Tel-Aviv Brain Acute Stroke Cohort), a prospective cohort of first-ever mild-moderate ischemic stroke patients, were Included (N=141). All patients underwent a 3T MRI and were cognitively assessed at admission and 2 later. Multiple regression models were used to assess which of the imaging measures best associated with cognitive scores 2 years after the index event.

Results:
After controlling for both age and education, the comparisons between cognitively intact and impaired patients revealed significant differences between the two groups in relative CSF volume, white matter lesion (WML) load and white matter microstructural integrity, reflected as mean diffusivity (MD), radial diffusivity (Dr) and axial diffusivity (Da) values (
p’s
<0.05). Multiple regression analyses demonstrated the significant role of hippocampi MD to serve as a common predictor for all three cognitive scores. Relative WML load significantly contributed to the global score and executive function.

Discussion:
Our results highlight the role of hippocampal MD and WML load as markers for cognitive performances. We suggest that these imaging markers best demonstrated "brain intergrity"
Abstract TP49: Irreversible Ischemic Lesion Characterization: Does CBV_ASPECTS Add to CT_ASPECTS?
Authors: Padroni Marina , Coscojuela Pilar , Boned Sandra , Ribó Marc , Cabero Jordi , Rodriguez-Luna David , Pagola Jorge , Muchada Marian , Tomasello Alejandro , Juega Jesus M. , Sanjuan Estela , Molina Carlos , Rubiera Marta
Published: July 2021

Introduction:
The best technique for selecting acute stroke patients for reperfusion therapies is not defined yet. ASPECTS is a useful score for assessing the extent of early ischemic signs in the anterior circulation on non-contrast CT (CT). Cerebral blood volume (CBV) on CT perfusion (CTP) defines the core lesion assumed to be irreversibly damaged. Whether CBV provides additional information over CT in the initial ASPECTS assessment is unknown. We aim to explore the advantages of CBV_ASPECTS over CT_ASPECTS in the prediction of final infarct volume.

Methods:
Consecutive patients with middle cerebral or internal carotid artery occlusion who underwent endovascular reperfusion treatment according to initial CT_ASPECTS≥7 were studied. CBV_ASPECTS was assessed blindly later-on. Recanalization was defined as TICI2b3. Final infarct volumes were measured on follow-up imaging. We defined an irrelevant ASPECTS difference (IAD) as: CT_ASPECTS - CBV_ASPECTS≤1.

Results:
Sixty-five patients, mean age 67±14, median NIHSS:16(10-20) were studied. Recanalization rate was: 78.5%. Median CT_ASPECTS was 9(8-10), and CBV_ASPECTS 8(8-10). Mean time from symptom onset to CT was 219±143 min. 50 patients (76.9%) showed an IAD. The ASPECTS difference was inversely correlated to the time from symptom onset to CT (r:-0.36, p<0.01). A ROC curve defined 120 minutes as the best cut-off time point after which the ASPECTS difference becomes irrelevant. The rate of IAD was significantly higher after 120 minutes (89.5% Vs 37.5; p<0.01). CBV_ASPECTS but not CT_ASPECTS correlated to the final infarct (r:-0.33, p<0.01). However, if CT was done >2 hours after symptom onset, then CT_ASPECTS was correlated to final infarct (r:-0.39, p=0.01). No other variables were associated with CT-CBV_ASPECTS difference.

Conclusions:
In acute stroke patient CBV_ASPECTS correlates with final infarct volume. However, when CT is performed after 120 minutes from symptoms onset CBV_ASPECTS does not add relevant information to CT_ASPECTS.
Abstract TP54: Topographical Aspects Collateral Score is a Useful Prognostic Factor in Thrombolysed Anterior Circulation Acute Ischemic Stroke Patients
Authors: Yeo Leonard , Paliwal Prakash , Hock Luen Teoh , Rathakrishnan Rahul , Soon Derek , Ting Eric , Ho-Fai Wong , Sharma Vijay
Published: July 2021

Background:
the ASPECTS- collateral score on CT-angiograms was shown to be successful in prognosticating functional outcomes and complications during intravenous thrombolysis in acute ischemic stroke (AIS). We studied predetermined topological information to see if any specific region had more prognostic value.

Methods:
consecutive patients from 2010-2014 with intracranial internal carotid artery, M1 or M2 middle carotid artery occlusions treated with intravenous thrombolysis were included. The primary outcome measure was good clinical outcome (3-month modified Rankin Scale score 0-1). We scored each region as 0= no collaterals, 1= poor compared to contralateral and 2= good collaterals. Prognostic value of the 6 cortical ASPECTS-collateral regions in predicting outcomes was determined by multivariable logistic regression.

Results:
310 patients were included (Median age, 66.1±14.5 years; median National Institutes of Health Stroke Scale (NIHSS)- 18 points (range 3-36). Inter-rater reliability for ASPECTS-collaterals was good (κ=0.78). There was no Statistical collinearity among ASPECTS-collateral regions. Using multivariable logistic regression, only the M5 region (odds ratio, 2.72, 95%CI 1.52-4.84, p =0.001), age (OR 0.957 per yr 95%CI 0.936-0.978, p <0.001), Diabetes (OR 0.367, 95%CI 0.193- 0.700, p =0.002) and NIHSSS (OR 0.878 per point, 95%CI 0.836-0.922, p=0.001) were significantly associated with good outcomes. When compared with NIHSS, the receiver operating characteristic curves for NIHSS+M5 (area under the curve, 0.749) correlated well with clinical severity scores. Addition of M5 collateral score showed a statistically significant additive effect to the NIHSS score for predicting good outcomes (Z score: -1.684, p=0.045).

Conclusions:
Involvement of the parietal region (M5) regions is a reliable predictor of clinical outcome in anterior circulation large artery occlusion. This simple radiological marker can strengthen the clinical NIHSS score and may be considered during prognostication
Abstract TP63: Lacunarization After Endovascular Treatment: a Surrogate Marker of Good Functional Outcome
Authors: Cardona Pedro , Quesada Helena , Lara Blanca , Cayuela Nuria , Ustrell Xavier , Garces Moises , Mora Paloma , Barranco Roger , De Miquel M Angeles , Escrig Ana Maria , Rubio Francisco
Published: July 2021

Introduction:
Multiple randomized trials have demonstrated that endovascular treatment (EVT) in selected stroke patients is associated with good clinical outcome (90 days mRankin 0-2: 44-60%). However the percentage of good functional outcome could be improved if we consider patients without cortical clinical impairment with presentation of classical lacunar syndrome despite non-lacunar radiological infarct.

Methods:
Consecutive patients with ischemic stroke who received endovascular reperfusion were retrospectively analyzed between May 2010 and April 2015. On admission NCCT (non-contrast CT) and CTASI (CT Angiography Source Image) were performed in stroke patients according to our hospital guidelines. We independently applied the ASPECT score in all baselines NCCT, CTASI and follow-up NCCT 24H, and magnetic resonance (MR) during hospitalization. Five pure clinical lacunar syndromes (CLS) were recorded within 24h exam after EVT in our stroke unit and 90 days follow-up

Results:
We review 428 thrombectomies of patients with acute ischemic stroke. Ninety-five percent of occlusions were located in middle cerebral artery or terminal internal carotid, (49% women, mean age 65+/-13 years; NIHSS at admission: 17; baseline mRS 0-1:96%). Successful recanalization (TICI 2b-3) was achieved in 81%. At 3 months good functional outcome (mRS 0-2) was seen in 51% and death occurred in 13%.

CLS were indentified in 42% patients within 24h after EVT. This clinical syndromes were associated to ASPECT score in 24 NCCT and CTASI in patients with recanalization 2b-3 (p:0.003), but only 4% had a defined radiological lacunar stroke on MR.

CLS turned out to be one of independence predictors of good outcomes (Rankin 0-2 at 90d) after adjustment for ages, sex and baseline NIHSS scores (OR 1.85; CI:1.4-3.1; p:0.001). Also CLS were still present in 34% of patients with Rankin>2 at 90d (Rankin 3:26%; Rankin 4:7%)

Conclusions:
These results suggest that a neurological exam 24h after EVT with identification of pure lacunar syndrome can predict favorable functional outcome at 90days. This group of patients presents radiological findings with an unusual location and size with regard to CLS.

We suggest to consider patients with CLS as good outcome after EVT regardless 90d mRankin>2.
Abstract TP99: In vivo Tracking of Bone Marrow Stromal Cells Using 111 In-oxine Labeling and SPECT Following Transplantation for Cerebral Infarct of Rats
Authors: Saito Hisayasu , Kuroda Satoshi , Zhao Songji , Kubo Naoki , Kuge Yuji , Tamaki Nagara , Shichinohe Hideo , Houkin Kiyohiro
Published: July 2021

Background:
This study investigates the effect of 111In-oxine incorporation on the viability of bone marrow stromal cells (BMSCs) in vitro, and the applicability of 111In-oxine labeling and single-photon emission computed tomography (SPECT) imaging of the BMSCs transplanted in rat model of cerebral infarct in vivo.

Methods:
Rat BMSCs were labeled with 111In-oxine (10 Bq/cell). Cellular retention of radioactivity, cell survival, and proliferation capacity were evaluated for 7 days. The rats were subjected to permanent middle cerebral artery occlusion. The 111In-oxine labeled BMSCs were stereotactically (1.0 х 1000000 cells) or intravenously (3.0 х 1000000 cells) transplanted at 7 days after the insult. Using SPECT, the behaviors of BMSCs were serially monitored during 14 days after transplantation. The distribution of engrafted cells was examined, using fluorescence immunohistochemistry.

Results:
Labeling efficiency was 35.8 ± 18.6 %, with 36.5 ± 20.6 % of 111In remaining in the BMSCs at 7 day. The radiolabeling did not affect cell viability, whereas proliferation capacity was significantly reduced. In vivo SPECT imaging clearly visualized that the transplanted BMSCs gradually migrated toward the peri-infarct area during 14 days after transplantation in the intracerebral group, but not in the intravenous group. The BMSCs were widely distributed in the peri-infarct area and some of them expressed neural cell markers in the intracerebral group, but not in the intravenous group.

Conclusions:
111In-oxine labeling preserved viability of the BMSCs, while moderately impairing their proliferation capacity. SPECT imaging of 111In-oxine labeled BMSCs was valuable in monitoring the behaviors of donor cells into the rodent brain, and the results would also suggest that the intracerebral administration is more effective to deliver the BMSCs to the cerebral ischemic lesions than the intravenous administration. SPECT imaging of 111In-oxine labeled BMSCs may be a valuable modality to track the transplanted cells in the host brain non-invasively and serially in clinical situation.
Abstract WMP100: Factors Influencing Outcome After Childhood Arterial Ischemic Stroke
Authors: Gajera Jay , Stojanovski Belinda , Mackay Mark T
Published: July 2021

Introduction:
Stroke is among the top 10 causes of death in children. Survivors face many potential years of disability but few studies have explored factors which contribute to poor outcome. Our aims were to describe factors associated with mortality, neurological disability and recurrence in a population of Australian children with arterial ischaemic stroke (AIS).

Methods:
Prospective consecutive single centre cohort study of children 1 month-18 years with AIS, from 2003-2013, who underwent standardised diagnostic work up. The NINDS common data element framework was used to select risk factors, laboratory and radiological variables of interest. The Paediatric Stroke Outcome Measure (PSOM) was used to classify neurological outcome at 12 months and the CASCADE system was used to classify aetiology. Recurrence was defined as clinical (completed stroke/TIA) or radiological event with new infarction. Chi
2
analyses were used to identify risk factors for poor outcome.

Results:
A total of 126 cases of childhood AIS were identified. 6% of children died, 27% had recurrent events (21 clinical, 5 radiological strokes, 9 TIAs). 63% of children had poor neurological outcome (total PSOM≥2) with motor disability (53%) being most common. Male gender, prothrombotic disorders and cortical infarct location were significantly associated with mortality (P<0.05). Hemiparesis, facial weakness, visual disturbance or altered consciousness at presentation, non-atherosclerotic arteriopathies and infection were significantly associated with poorer neurological outcome (p<0.05). Arteriopathies, multiple infarcts and haemorrhagic transformation were associated with recurrence (p<0.05).

Conclusion:
The economic and social costs of childhood AIS are likely substantial because long term neurological deficits are common. The finding that arteriopathies are a risk factor for recurrence is consistent with data from overseas. These findings will inform development of longitudinal multicentre Australian studies of childhood AIS.
Abstract WMP108: Endovascular Therapy in Children With Large Vessel Occlusion: a Clinical Series of Five Cases
Authors: Bryndziar Tomas , Gonzalez Nestor R , Tateshima Satoshi , Rao Neal M , Hinman Jason D , Ali Latisha K , Jahan Reza , Liebeskind David S , Duckwiler Gary R , Saver Jeffrey L , Szeder Viktor
Published: July 2021

Background & Purpose:
Children were excluded from the recent positive mechanical thrombectomy trials and the literature on endovascular therapy in this population needs to be built. We report here case series of pediatric patients who received mechanical thrombectomy at our institution.

Methodology:
Our prospectively collected UCLA acute stroke database from 2000 to present was retrospectively reviewed. Only patients <18 years old with large vessel occlusion who underwent acute endovascular therapy were included in this study. Demographic, clinical, pre- and post-intervention imaging, and the interventional procedure data were analyzed. The Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score at presentation and at discharge, as well as pediatric-modified Rankin Scale (Ped-mRS) up-to 90 days were used.

Results:
All five patients (ages 2-15) suffered an embolic stroke. Three of them had congenital heart disease and one had repeated episodes of syncope and bradycardia. No risk factors other than PFO were identified in the fifth patient. Occlusion sites were ICA-M1 (n=2), M1 (n=2), and M1-M2 (n=1). IV tPA was used in one case. Time from last known well to reperfusion ranged from 3h to 9h 28min and the patients’ initial collaterals were scored between grades 2 - 3. AOL score of 3 was achieved in all cases, TICI 2a in two and TICI 2b in three cases. Merci was used in two cases, Penumbra, Solitaire and Mindframe Capture were used each in one case. One patient developed intracerebral hemorrhage that required hemicraniectomy. The PedNIHSS score at discharge ranged from 0 to 8 and the Ped-mRS score up-to 90 days ranged from 0 to 4, with 80% of children having Ped-mRS ≤ 3.

Conclusion:
Mechanical thrombectomy may be a safe and feasible treatment option in pediatric stroke patients with large vessel occlusion.
Abstract WMP13: Predictive Value of Rapid-assessed Cerebral Blood Volume and Cerebral Blood Flow Ct Perfusion Thresholds on Final Infarct Volume Following Successful Reperfusion: Analysis of The SWIFT PRIME Trial Data
Authors: Mokin Maxim , Levy Elad , Saver Jeffrey L , Goyal Mayank , Bonafe Alain , Cognard Christophe , Jahan Reza , Albers Gregory W ,   for the SWIFT PRIME Investigators
Published: July 2021

Background and purpose:
Advanced CT perfusion (CTP) imaging can estimate the size of the ischemic core, which can be used for selection of patients for endovascular therapy. The relative cerebral blood volume (rCBV) and cerebral blood flow (rCBF) thresholds chosen to identify ischemic core influence the accuracy of prediction. The purpose of this study was to analyze the accuracy of various rCBV and rCBF thresholds for predicting 27 hour infarct volume using RAPID automated analysis software.

Methods:
Patients from the SWIFT PRIME study with baseline and 27 hour follow-up CT perfusion scans were included if they had complete reperfusion based on Tmax>6s perfusion maps obtained at 27 hours. Patients from both the tPA and endovascular groups were included. Infarct volume was determined on MRI (FLAIR images) or CT scans obtained 27 hours after symptom onset. The predicted ischemic core volume on rCBV and rCBF maps using thresholds ranging between 0.2 and 0.8 was compared with the actual infarct volume to determine the most accurate thresholds.

Results:
Among the 47 subjects, the following baseline CTP thresholds most accurately predicted the actual 27 hour infarct volume: rCBV=0.34 (Median absolute error (MAE)=11.5 ml); rCBV=0.36, MAE=9.9 ml; rCBV=0.4, MAE=12.5 ml; rCBF=0.3, MAE=8.8 ml; rCBF=0.32, MAE=7.3; and rCBF=0.34, MAE=7.8.

Conclusions:
Brain regions with rCBF ≤ .32 or rCBV ≤ .36 provided the most accurate prediction of infarct volume in patients who achieved complete reperfusion with median absolute errors less than 10 ml. Our data support the value of automated image analysis software as a tool for accurate prediction of ischemic core lesion volume.
Abstract WMP15: Hyperperfusion on Arterial Spin Labeling: Objective Decision Support Using Pattern Recognition
Authors: Scalzo Fabien , Yu Songlin , Patel Sagar , Liebeskind David , Wang Danny
Published: July 2021

Background:
Hyperperfusion detected on arterial spin labeling (ASL) images acquired after stroke onset has been shown to correlate with subsequent hemorrhagic transformation (HT). Presence of hyperperfusion is typically detected by visual review of arterial spin labeling cerebral blood flow (CBF). Such a review is subjective as it is challenged by inter-reader variability, noise, and lack of standard threshold. We present in this study a quantitative hyperperfusion detection model that can provide an objective decision support for the interpretation of ASL CBF maps and rapidly delineate hyperperfusion regions.

Methods:
ASL Cerebral blood flow (CBF) maps of acute stroke patients presenting with an occlusion in the MCA territory were coregistered to a standardized atlas space. To achieve reliable detection of ASL hyperperfusion, we formalize the problem as a nonlinear classification that relates regional voxel intensity values to the corresponding binary label (normal or hyperperfused). Our method takes into account the healthy contralateral hemisphere and its CBF intensity values during the determination of hyperperfusion of a voxel. Each input feature vector combines the regional intensity values at the voxel of interest, its contralateral matched region, and the distribution of the difference between them. Each input vector is associated to a label corresponding to the presence of hyperperfusion that was manually established by consensus between experts. The predicted hyperperfusion regions were compared to a groundtruth that manually established by two researchers.

Results:
A total of 361 ASL scans were collected from 221 patients (age=72±17 years; 45% males). Hyperperfusion was detected in 76 patients that were subsequently used in our analysis. An AUC of 83±5% was reached after a leave-one-out cross-validation, which corresponds to the accuracy in detecting hyperperfusion compared to manual delineation of hyperperfusion on ASL CBF maps.

Conclusion:
Pattern recognition based on a nonlinear regression can provide an accurate and objective measure of hyperperfusion on ASL CBF images and could therefore improve the detection of hemorrhagic transformation in acute stroke patients.
Abstract WMP25: Periprocedural Predictors of Acute Ischemic Stroke and Mortality in Endovascular Treatment of Unruptured Intracranial Aneurysm
Authors: Mehta Tapan V , Hussain Mohammed , Narwal Priya , Mazaris Paul , Inoa-Acosta Violiza , Ollenschleger Martin , Spiegel Gary , McCullough Louise
Published: July 2021

Introduction:
Periprocedural risk of ischemic stroke (IS) in patients undergoing endovascular treatment for unruptured intracranial aneurysms (EUIA) can be as high as 40%, with clinically significant strokes occurring in 3-10% of patients. There is limited data on how typical vascular risk factors can increase peri-procedural risk of IS and mortality in patients undergoing EUIA.

Methods:
We queried the Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample (NIS) data between 2004 and 2012. ICD-9 codes 437.3 (intracerebral unruptured aneurysm) and 39.72 (endovascular repair/embolization of head and neck vessel) were used to identify the study population. Multivariate logistic regression model was used to identify independent predictors of IS and mortality after controlling confounders including age, race, sex, atrial fibrillation (Afib), diseases of endocardium, alcohol, smoking, diabetes mellitus, hypertension, use of anticoagulants, use of antiplatelet agents, carotid artery stenosis, atherosclerosis and hyperlipidemia. We also investigated whether Afib, DM, hypertension and hyperlipidemia in possible combinations further increased the risk of IS and mortality.

Results:
A total of 50,478 EUC cases were identified, of which 10,600 (20.9%) reported an IS event. A total of 661 (0.01%) died of which 115 (17.4%) had an IS event. After controlling for confounders, age >70 (OR 1.521 95% CI 1.145- 2.020, P< 0.01) and diabetes (OR 1.426, 95%CI 1.092-1.861, p 70 (OR 2.472, CI 1.616-3.782, p<.01)and Afib (OR 2.697, CI 1.509-4.819, p<.01) independently increased risk of mortality in endovascular treated patients. A fib, DM, hypertension and hyperlipidemia in different potential combinations did not increase peri-procedural risk of IS and mortality.

Conclusions:
In patients undergoing EUIA, Age >70 is an independent risk factor for IS and mortality. Diabetes independently increased risk of IS but not mortality; Afib independently increased risk of mortality but not IS.
Abstract WMP36: Management of Hypertension in Primary Care Safety-net Clinics in the United States: A Comparison of Community Health Centers and Private Physician’s Offices
Authors: Fontil Valy , Bibbins-Domingo Kirsten , Nguyen Oanh , Guzman David , Goldman Elizabeth
Published: July 2021

Introduction:
Community health centers (CHCs) provide care to a disproportionate share of vulnerable populations who are at highest risk for uncontrolled hypertension. It is unknown how hypertension treatment at CHCs reflects guideline-concordant therapy compared to private practice.

Methods:
We used the National Ambulatory Medical Care Surveys (NAMCS) from 2006 to 2010 to examine four guideline-concordant treatment practices in non-pregnant adults with hypertension: Initiation of a new medication for uncontrolled hypertension, use of fixed-dose combination drugs for patients on multiple antihypertensive medications, use of thiazide diuretics among patients with uncontrolled hypertension on ≥3 antihypertensive medications, and use of aldosterone antagonist for resistant hypertension, comparing use at CHCs to private physician’s offices overall and by payer group.

Results:
Medicaid patients at CHCs were as likely as privately insured individuals to receive a new medication for uncontrolled hypertension (AOR 1.0, 95% CI 0.6-1.9), while Medicaid patients at private physicians’ offices were less likely to receive a new medication compared to the privately insured (AOR 0.3, 95% CI 0.1-0.6). Use of fixed-dose combination drugs was lower at CHCs (AOR 0.6, 95% CI 0.4 – 0.9). There was no difference in thiazide use (adjusted OR 0.7, 95% CI 0.4 – 1.5). Aldosterone antagonist use in resistant hypertension was extremely low in both settings (< 3%).

Conclusion:
Compared to private practice, CHCs are more likely to intensify hypertension treatment for patients with Medicaid but less likely to use fixed-dose combination drugs for patients taking multiple medications. Increasing physician use of fixed-dose combination drugs may be particularly helpful in improving hypertension control at CHCs where there are higher rates of uncontrolled hypertension.
Abstract WMP45: Manipulation of the Microbiome Improves Functional Recovery After Ischemic Stroke
Authors: Jandzinski Michal , Venna Venugopal , Chauhan Anjali , Graf Joerg , McCullough Louise D
Published: July 2021

Background:
Circulating inflammatory markers increase with age. This pro-inflammatory milieu makes the organism less capable of coping with stressors such as stroke. Age related inflammation occurs in both the brain and peripheral tissues like the gastro-intestinal tract. There is increasing recognition that commensal bacteria in the GI tract are altered with age or with germ-free housing, affecting the brain. The change occurs most notably in the ratio of two major phyla of the microbiome, the
Firmicutes
and
Bacteroidetes
. Young age is associated with a low ratio of the two but this ratio increases with age, which has been linked to many diseases including obesity, hypertension, and diabetes which are major risk factors for stroke.

Hypothesis:
We hypothesized that there would be age-related differences in the microbiome, and that restoration of a young microbiome would improve functional recovery in aged mice.

Methods:
Fecal transplants from young and aged donors were administered to recipient animals after suppression of endogenous microbial compositions through concentrated Streptomycin. This allowed for successful colonization of the gut with the newly transplanted microbiome. A transient middle cerebral artery occlusion (MCAO) was used in young (3-4 month) and aged (18-20 month) male mice 4 weeks after transplant. Functional recovery was assessed by neurological deficit scores, the hang wire test, and open field activity. The Y-maze was used to assess cognitive impairment.

Results:
We successfully reversed the microbiomes of aged organisms and gave young animals “aged” biomes. Animals with “aged” microbiomes prior to stroke had worsened functional recovery based on all behavioral tests. The “aged” biome increased mortality rates most notably in the young recipients which had over 50% mortality. Aged mice had significantly improved functional recovery as assessed by the HW test (
P < 0.05
) and NDS after reconstitution of “young” microbiome prior to stroke compared to aged control animals with the normal “aged” microbiomes.

Conclusion:
Aged mice have high
Firmicutes
and
Bacteroidetes
relative abundances. Manipulation of the microbiome in young and aged mice is possible. Restoration of a youthful biome improved functional recovery in aged mice.
Abstract WMP53: Sex Differences n Long-term Mortality and Disability After Stroke: The International Stroke Outcomes Study
Authors: Phan Hoang T , Reeves Mathew J , Blizzard Leigh , Thrift Amanda , Cadilhac Dominique , Heeley Emma , Sturm Jonathan ,   INSTRUCT Study Investigators, Gall Seana
Published: July 2021

Introduction:
It is uncertain why women suffer worse long-term outcomes after stroke than men. We examined sex differences in mortality and disability 1 and 5 years after stroke and identified factors contributing to these differences.

Methods:
Individual patient data pooling study of incident strokes (ischemic and hemorrhagic) from 1987-2013 obtained from 12 population-based cohorts from Australasia, Europe, South America and the Caribbean. Data on socio-demographics, stroke-related factors and pre-stroke health were obtained for each patient and harmonized between studies. Poisson modelling estimated the mortality rate ratio (MRR) for women compared to men at 1 year (12 studies) and 5 years (7 studies) post-stroke. Log binomial regression estimated the relative risk (RR) of poor outcome (modified Rankin scale>2 or Barthel Index <20) for women compared to men at 1 year (9 studies) and 5 years (6 studies) after stroke. Multivariable models were adjusted for potential confounders including age, pre-stroke dependency, stroke severity and comorbidities.

Results:
A total of 16557 first-ever-stroke patients with follow-up data to 1 year and 12,839 with follow-up to 5 years were included. The pooled crude mortality was greater in women than men at 1-year (MRR 1.37 95% CI 1.27-1.48) and 5 years (MRR 1.25 95% CI 1.13-1.39). However, these sex differences were reversed after adjustment for confounders at both 1 year (MRR 0.94 95% CI 0.82-1.06) and 5-years post stroke (MRR 0.74 95% CI 0.66-0.84). Similarly, the pooled crude RR for disability after stroke was greater in women than men at 1-year (RR 1.28 95% CI 1.17-1.39 and 5-year (RR 1.32 95% CI 1.18-1.47), but these sex differences disappeared after adjustment at both 1 year (RR 1.08 95%CI 0.98-1.18) and 5-years post stroke (RR 1.08 95% CI 0.97-1.20). The key contributors to worse outcomes in women were greater age, pre-stroke dependency, severe strokes and atrial fibrillation (AF, mortality only) compared with men.

Conclusion:
Worse outcomes in women were mostly due to age and potentially modifiable factors of stroke severity and AF providing potential targets to reduce the impact of stroke in women.
Abstract WMP61: Drip-and-Ship versus Front-Door Strategy of Preceding Intravenous Thrombolysis in Patients Receiving Endovascular Therapy; An Analysis From the Clinical Research Center for Stroke-5th division Registry in Korea
Authors: Park Hong-Kyun , Park Seong-Ho , Han Moon-Ku , Kim Beom Joon , Park Jong-Moo , Kang Kyusik , Lee Soo Joo , Ko Youngchai , Cha Jae-Kwan , Kim Dae-Hyun , Park Tai Hwan , Lee Kyung Bok , Lee Jun , Hong Keun-Sik , Cho Yong-Jin , Lee Byung-Chul , Yu Kyung-Ho , Kim Dong-Eog , Cho Ki-Hyun , Kim Joon-Tae , Choi Jay Chol , Kim Wook-Joo , Shin Dong-Ick , Yeo Min-Ju , Sohn Sung Il , Hong Jeong-Ho , Jang Min-Uk , Lee Ji Sung , Lee Juneyoung , Bae Hee-Joon
Published: July 2021

Background:
The widespread use of drip-and-ship strategy in acute ischemic stroke (AIS) is confined by the safety concerns during transfer. However, recent development of endovascular therapy (EVT) might add the advantage of higher recanalization rate to this strategy. We evaluated the effectiveness and safety of drip-and-ship versus conventional (front-door) strategy of preceding intravenous thrombolysis (IVT) in large artery occlusion stroke patients receiving EVT.

Method:
From a prospective multicenter stroke registry (CRCS-5) database, we identified AIS patients treated with IVT and EVT within 8 h of onset and admitted to the 14 participating centers between 2008 and 2013. Safety outcomes were symptomatic intracranial hemorrhage (sICH), and 3-month mortality. Effectiveness outcome was a 3-month modified Rankin Scale (mRS) score. We performed multivariable logistic regression analysis using generalized estimating equation to estimate adjusted odds ratio (OR) and 95% confidence interval (CI) of the drip-and-ship versus the front-door.

Results:
Of 16929 AIS patients registered during 64 months, 480 were treated with IVT and EVT within 8 h, and 61 (13%) were categorized into drip-and-ship group. Mean onset to IVT and IVT to EVT times were 117±51 and 187±69 minutes in drip-and-ship strategy and 127±59 and 75±38 minutes in front-door strategy, respectively. Forty-eight drip-and-ship cases were matched to 146 front-door cases by age and initial NIH stroke scale (NIHSS). Compared to the front-door cases, the drip-and-ship cases were more likely to be a habitual smoker, and treated with standard dose alteplase. sICH developed in 5.5% of the front-door strategy and 10.4% of the drip-and-ship strategy (p=0.146). After adjustment for age, initial NIHSS, pre-stroke mRS score, and variables with p<0.1 from bivariate analysis, the ORs (95% CIs) of the drip-and-ship strategy were 2.48 (0.73 - 8.44) for sICH, 0.95 (0.50 - 1.81) for shift to lower score of 3-month mRS, and 1.15 (0.37 - 3.62) for 3-month mortality.

Conclusion:
The drip-and-ship strategy did not improve functional recovery at 3 months, and the safety issues might still exist in patients receiving EVT. However, there is a possible underestimation of initial stroke severity in drip and ship patients.
Abstract WMP62: Achieving Ultra-Fast Door-to-Needle Times With a “Treat-in-CT” Acute Stroke Protocol
Authors: Ford Andria L , Williams Jennifer A , Hoff Brian , Curfman David , Wiesehan Rebecca , Steinkruger Michael , Moy Hawnwan Phil , Heitsch Laura , Panagos Peter , Lee Jin-Moo
Published: July 2021

Background:
Ultra-early thrombolysis [onset-to-treatment time (OTT) < 90 min], leads to better clinical outcomes. We utilized lean manufacturing principles to re-choreograph patient flow such that tPA was delivered in the CT scanner rather than moving the patient to a separate treatment room. We tested the efficiency and safety of a “Treat-in-CT” protocol comparing metrics and outcomes before and after implementation.

Methods:
In July 2014, a LEAN rapid improvement event was conducted to design a “Treat-in-CT” stroke protocol. Several changes included: (1) Vital signs monitors and point of care glucose and INR were placed near the scanner. (2) Computer monitors were placed in the scanner to allow for rapid charting and order entry. (3) Local EMS crews, physicians, nursing staff, and CT technicians were trained on parallel work-flow in the scanner. The “Treat-in-CT” protocol went live 10/1/2014. We directly compared the “Pre” and “Post” Treat-in-CT epochs (1/2013-9/2014 and 10/2014-8/2015, respectively) with regard to baseline variables, metrics, and outcomes. Non-parametric statistics were used with p<0.05 required for significance.

Results:
In the Pre- and Post-Treat-in-CT epochs, 139 and 74 patients were treated with IV tPA, respectively. Baseline variables were similar between the two epochs. Median door-to-needle time was lower in the Post-Treat-in-CT epoch: 38 min pre vs. 29 min post (p=0.002) with a trend towards lower OTT: 131 min pre vs. 100 min post (p=0.07). To ensure that efficiency did not impact safety, favorable discharge location (87% pre vs. 81% post, p=0.3), symptomatic hemorrhage rate (2.9% pre vs. 1.5% post, p=1.0), stroke mimic rate, and 90 day mRS were compared and did not differ.

Conclusions:
The AHA Target: Stroke-Phase II guidelines recommend administration of tPA bolus while in the CT scanner. A “Treat-in-CT” acute stroke protocol using efficient choreography and parallel processing expedited tPA delivery without compromising safety.
Abstract WMP72: Onset-to-Arrival Time Varies by Race and Stroke Severity
Authors: Sauser-Zachrison Kori , Land Thomas , Soare Thomas W , Christie Anita , Nasuti Laura , Schwamm Lee H
Published: July 2021

Introduction:
Shortening onset-to-arrival (OTA) time among acute ischemic stroke (AIS) patients is an important public health goal in order to increase the proportion of patients eligible for disability-reducing treatment. Understanding factors associated with delays in OTA will help to focus educational interventions.

Hypothesis:
AIS patients with greater stroke severity are more likely to arrive early (OTA≤3.5 hours); and among AIS patients arriving acutely (within 8 hours), stroke severity will also predict shorter OTA time.

Methods:
Prospective study of all AIS patients presenting to the 60 of 70 Massachusetts hospitals participating in the Coverdell Registry from 2005-13, excluding patients transferred from another acute care facility or with symptom onset after hospital arrival. Logistic and linear regression analyses identified predictors of OTA within 3.5 hours, and predictors of shorter OTA among patients presenting within 8 hours, accounting for clustering by hospital.

Results:
Among 51,631 AIS patients, 6,904 patients (13.4%) were transferred or presented from another acute care facility and complete time data were documented in 82% of the remaining patients for a final sample of 36,680. Median OTA was 6.2 hours (IQR 1.2-18.8 hours). Predictors of OTA within 3.5 hours included stroke severity, younger age, male gender, race, private insurance, ambulance arrival, later year of presentation, and medical history (Table). Among the 19,831 patients arriving acutely (OTA≤8 hours), predictors of shorter OTA duration included stroke severity, non-black race, ambulance arrival, and medical history (Table).

Conclusions:
Black patients and patients with lower NIHSS are more likely to have delayed arrival. Future work should focus on reducing disparities in care-seeking behavior.
Abstract WMP91: Hyponatremia is Associated with Higher Mortality in Intracerebral Hemorrhage: Interact 1 and 2 Pooled Analysis
Authors: Carcel Cheryl , Sato Shoichiro , Zheng Danni , Heeley Emma , Arima Hisatomi , Yang Jie , Wu Guojun , Zhang Shihong , Delcourt Candice , Lavados Pablo , Robinson Thompson , Lindley Richard , Wang Xia , Chalmers John , Anderson Craig
Published: July 2021

Background and Aim:
There is little evidence on the prognostic significance of hyponatremia in patients with intracerebral hemorrhage (ICH). The aim of this study was to clarify the association of hyponatremia with clinical outcomes and to determine the relationship between hyponatremia and hematoma and perihematomal edema growth.

Methods:
This study was a subsidiary, post-hoc analysis of INTERACT 1 and 2; which were randomised controlled trials of patients with acute spontaneous ICH with elevated systolic blood pressure (BP), randomly assigned to intensive (target systolic BP < 140 mmHg) or guideline-based (< 180 mmHg) BP management. Hyponatremia was defined as serum sodium < 135 mEq/L. The primary clinical outcome was death at 90 days. The outcomes of the CT substudies were absolute growth of hematoma and perihematomal edema volume in 24 hours.

Results:
Among 3002 patients with information on sodium and clinical outcomes, 349 (12%) had hyponatremia, which was associated with death at 90 days (multivariable-adjusted OR, 2.03; 95% CI, 1.41-2.91; p=0.0001). In the hematoma growth and perihematomal edema growth analyses, there were 1241 and 790 patients included, respectively. No associations were observed for hematoma growth or perihematomal edema growth during the first 24 hours.

Conclusions:
Hyponatremia is associated with higher mortality at 90 days in patients with spontaneous ICH. Hyponatremia does not appear to affect perihematomal edema growth or hematoma volume growth.