bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 144: High Intake of Caffeine use in Protective in Survivors of Stroke and Myocardial Infarction: the results of Third National Health and Nutrition Examination Survey Mortality Follow-up Study.
Authors: Qureshi Adnan I , Suri M Fareed K
Published: July 2021

BACKGROUND:
Caffeine competitively inhibits different adenosine receptors and their associated G protein to relax smooth muscle, and stimulate the central nervous system and cardiac contractility. High long-term consumption is proposed to be associated with a lower risk of cardiovascular disease and diabetes mellitus. We performed this study to determine the effect of regular caffeine in survivors of cardiovascular events.

METHODS:
We determined the association of caffeine use with stroke, acute MI, and cardiovascular disease related mortality and all-cause mortality in a nationally representative sample of 20 049 US adults aged 17 to 90 years who participated in the Third National Health and Nutrition Examination Survey Mortality Follow-up Study using Cox proportional hazards analyses. We categorized the participants based on total caffeine intake (by cups) determined by 24-hour dietary recall and each coffee cup was defined by 150-mg caffeine cup. We defined participants as nonusers if they responded to the caffeine use question as not used, as low intake users if they responded as using 1-2 cups per day, and as high intake users if they reported using 3 or more cups per day. Potential confounding factors in the association between caffeine use and outcome included age, sex, race/ethnicity, hypertension, hyperlipidemia, diabetes mellitus, cigarette smoking, body mass index, and alcohol use.

RESULTS:
A total of 334 survivors with stroke, 624 survivors with MI and 115 with both stroke and MI were included in the analysis; 58 stroke related, 117 acute MI related, and 305 ischemic heart disease related deaths and 785 all causes deaths were reported during a mean follow-up period of 9.0+−5.2 years. After adjusting for differences in age, sex, race/ethnicity, hypertension, diabetes mellitus, hyperlipidemia, cigarette smoking, and alcohol use, persons who reported high intake of caffeine had a significantly lower likelihood of stroke related death (relative risk [RR], 0.3; 95% confidence interval [CI], 0.1 to 0.8) and ischemic heart disease related deaths (RR, 0.6; 95% CI, 0.4 to 0.99). After adjusting for potential confounders, persons who reported high intake caffeine use had also a significantly lower likelihood of cardiovascular deaths (RR, 0.5; 95% CI, 0.3 to 0.8) and all cause deaths (RR, 0.7; 95% CI, 0.5 to 0.9).

CONCLUSION:
High intake of caffeine daily prominently reduced the stroke related mortality and also reduced to a lesser extent cardiovascular and all-cause mortality. Regular caffeine intake may represent an easy to implement secondary prevention strategy among survivors of MI and stroke
Abstract 146: White Blood Cell Count and Risk of Stroke in Men and Women: the European Prospective Investigation into Cancer-Norfolk Prospective Population Study
Authors: Li Yangmei , Liu Xinxue , Luben Robert N , Adler Amanda I , Wareham Nicholas J , Khaw Kay-Tee
Published: July 2021

Background and Objectives:
An elevated white blood cell (WBC) count has been reported to be associated with all-cause mortality and risk of cardiovascular diseases. While the relationship between leukocyte count and coronary heart disease has been well documented, evidence on the association with risk of stroke has been less consistent. The aim of this study was to investigate the relationship between WBC count and incidence of stroke in a large cohort of disease-free men and women, and to assess how far any associations might be explained by traditional risk factors for stroke.

Methods:
We examined the prospective association between full blood WBC count and incident stroke in 7,392 men and 9,049 women from the general population participating in the European Prospective Investigation into Cancer-Norfolk Study. Participants were aged 39-79 years, without known heart attack, stroke, and cancer at the baseline examination in 1993-1997 and were followed up for incident stroke till March 2008.

Results:
During the median follow-up of 12 years, 542 incident stroke cases were observed. The age- and sex- adjusted risk of incident stroke increased with the increase of WBC count. Compared to the lowest quartile of WBC count, the age- and sex- adjusted hazard ratios (HRs) and 95% CIs for stroke were 1.11 (0.86-1.45), 1.40 (1.10-1.79), and 1.65 (1.29-2.09) in the second, third, and fourth quartile, respectively. Adjusting for smoking attenuated the results, while further adjustment for socioeconomic and lifestyle risk factors changed the association very little. The association was further attenuated after adjustment for biological risk factors such as systolic blood pressure and a history of diabetes at baseline, but people with the highest quartile of WBC count still had a higher risk of stroke than those in the lowest quartile (HR 1.32, 95% CI 1.02-1.71). Every 2*10
9
/L increase in WBC count was associated with a hazard ratio of 1.14 (95% CI 1.02-1.26) for stroke in the fully-adjusted model which included age, sex, smoking status, BMI, social class, educational level, alcohol intake, physical activity, systolic blood pressure, a history of diabetes at baseline, and total serum cholesterol.

Conclusions:
A positive association between WBC count and stroke was observed in these middle-aged and older men and women. Adjustment for smoking attenuated the association while multivariate adjustment for other risk factors did not further change the results.
Abstract 156: Impact Of Obesity And Metabolic Syndrome In Stroke Patients Undergoing Intravenous Thrombolysis
Authors: Seet Raymond C , Zhang Yi , Wijdicks Eelco F , Rabinstein Alejandro A
Published: July 2021

Background:
The influence of high body mass index (BMI) in acute stroke patients treated with intravenous thrombolysis has not been extensively studied. Previous studies have observed an “obesity paradox” among stroke patients, where better outcomes were observed among overweight and obese patients. The purpose of this study is to determine the influence of obesity and risk components of metabolic syndrome to stroke recovery in patients undergoing intravenous recombinant tissue plasminogen activator (rtPA) treatment.

Methods:
Patients with acute ischemic stroke who received intravenous rtPA within three-hour from symptom onset at St. Marys Hospital, Mayo Clinic, Rochester, between April 2006 and January 2011, were included in this study. Information on vascular risk factors, stroke severity, and baseline hemodynamic and laboratory indices, were collected. Study outcomes, consisting symptomatic intracerebral hemorrhage (sICH) and poor functional recovery (modified Rankin scale >2), were compared between obese (body mass index, BMI >30 kg/m
2
), overweight (BMI 25-30 kg/m
2
) and normal weight (BMI <25 kg/m
2
) patients. The association between BMI, risk components of the metabolic syndrome and dose of rtPA per kg body weight to stroke outcomes were assessed in a multivariable model.

Results:
A total of 158 patients (mean age, 75 years; baseline NIHSS, 11), frequency-matched by age and baseline stroke severity, were included in this study. No differences in the frequency of SICH and poor functional recovery were observed among obese, overweight and normal weight patients, before and after adjusting for their baseline characteristics. A linear trend towards worse stroke recovery was observed in patients with a greater number of metabolic risk components (p-trend=0.043). By contrast, there were no significant associations between the number of risk components of metabolic syndrome with respect to sICH. Using stepwise regression analyses, age, baseline stroke severity and the number of risk components of the metabolic syndrome accounted for 52% variation in functional recovery following rtPA treatment.

Conclusions:
Acute stroke outcomes do not differ between obese and overweight patients. The presence of metabolic risk factors contributes significantly to functional outcomes following rtPA treatment. These results suggest that decreasing the prevalence of metabolic syndrome in the community could reduce the societal burden of stroke-related disability.
Abstract 194: Impact of Primary Stroke Centers On a Comprehensive Stroke Center
Authors: Albright Karen C , Boehme Amelia , Hicks William , Bursaw Woody , Mullen Michael , Grotta James , Savitz Sean
Published: July 2021

Introduction:
The creation of primary stroke centers (PSCs) accredited by The Joint Commission (TJC) has increased access of care to a higher number of patients with acute ischemic stroke (AIS) in greater metropolitan areas. However, PSCs in many regions of the US do not conduct clinical trials in acute stroke. We hypothesized that creation of PSCs in the greater Houston area has led to changes in the demographics of our stroke admissions.

Methods:
Consecutive patients admitted to the UT Houston stroke team from 1/1/2005-12/30/2010 were screened. Records were reviewed for demographic and clinical information. Patient characteristics were compared among years using Chi-square and Kruskal-Wallis.

Results:
Over the 5 year period, 6,036 patients were admitted to our stroke service. The number of admissions increased from 674 in 2005 to 1,234 in 2010. Transfers from outside hospitals trended up from 24.6% (n=166) of all admissions in 2005 to 41.8% (n=516) in 2010. With the increase in transfers, the number of ICH transfer cases has increased over the past 5 years (
Fig
). Among all ischemic strokes, the percent of large artery occlusions (LAOs) presenting within 6-hrs from symptom onset fell from 34.3% (69/201) in 2005 to 16.4% (45/274) in 2010. Minor strokes (NIHSS 0-5) have increased from 37.4% (141/377) in 2005 to 42.5% (239/562). Overall, IV t-PA treatment rates remained unchanged, ranging from 29.7% to 37.0% from 2005 to 2010 (p=.490). Among AIS patients presenting within 6-hrs, study enrollment fell from 41.8% (84/201) in 2005 to 26.3% (72/274) in 2010.
Figure
1 shows the changing demographics of our admissions plotted against the number of hospitals that have attained TJC PSC accreditation.

Conclusion:
As PSCs have arisen in the greater Houston area, we have seen a shift in the demographics of our stroke admissions including an escalating number of transfer patients. Among ischemic stroke patients, the number of LAOs has been decreasing overtime and the number of mild strokes has been increasing. These results are likely due, in part, to the transport of patients by EMS to the nearest PSCs who then preferentially request transfer of ICH cases to comprehensive stroke centers (CSCs). Consequently, the number of patients enrolled into clinical trials (the majority of which have been based on ischemic stroke and LAOs) has substantially decreased at our center. PSCs should be encouraged by accreditation committees to work with CSCs and participate in clinical research. To that end, PSCs may need investments in staff and resources to conduct clinical trials testing new stroke therapies.
Abstract 2145: The Long-term Trajectory Of Functional Decline Before And After Stroke: The Northern Manhattan Study
Authors: Dhamoon Mandip , Moon Yeseon P , Paik Myunghee C , McLaughlin-Mora Consuelo , Sacco Ralph L , Elkind Mitchell S
Published: July 2021

Background:
Previous research in our population showed a steeper long-term decline in functional status after first ischemic stroke among those with Medicaid or no insurance compared to those with Medicare or private insurance. With only post-stroke data, it was unknown whether these findings were caused by the stroke. We sought to compare the long-term trajectory of functional status before and after ischemic stroke.

Methods:
The Northern Manhattan Study contains a prospective, population-based study of stroke-free individuals >40 years of age, followed for a median of 10 years. The Barthel index (BI) was assessed annually. Generalized estimating equations were used to assess functional decline over time before and after stroke. The 6 months after stroke were ignored, since the course of recovery during this period is well documented, and our interest was the long-term course of functional status. Follow-up was censored at the time of recurrent stroke. Sociodemographic and medical risk factors were included and results were stratified by insurance status. Linearity of the curves was evaluated by plotting residuals against time and with a lowess curve.

Results:
Among 3298 participants, 261 had an ischemic stroke during follow-up, of which 51 died within 6 months of stroke. Among the remaining 210 participants, mean age at stroke (standard deviation) was 77+9 years, 38% were male, 52% were Hispanic, 37% had diabetes, and 31% had coronary artery disease. There was no difference in functional decline over time before and after stroke (p= 0.51), with a decline of 0.96 BI points per year before stroke (p<.0001) and 1.24 after stroke (p=0.001). However, when stratified by insurance status, among those with Medicaid or no insurance, in a fully adjusted model, there was a difference in slope before and after stroke (p=0.04), with a decline of 0.58 BI points per year before stroke (p=0.02) and 1.94 after stroke (p=0.001). Other predictors of worse functional status were increasing age, female sex, diabetes, and being married.

Conclusion:
In this large, prospective, population-based study with long-term follow-up, there was a significantly steeper decline in functional status after ischemic stroke compared to before stroke among those with Medicaid or no insurance, after adjusting for confounders. The cause of this differential decline is not known but may be related to poor control of risk factors, silent strokes, or an effect of socioeconomic status.
Abstract 2173: Abbreviated 7-Item NIHSS for Inpatient Acute Stroke Management
Authors: Parreira Jennifer , Nauser Julie
Published: July 2021

Background:
Each year, nearly 800,000 people experience a new or recurrent stroke. To assess changes in neurological status during hospitalization, nurses are required to complete the 15-item National Institute of Health Stroke Scale (NIHSS), which is time consuming and therefore, may not be completed as thoroughly as it should. To ensure these patients are being effectively and adequately assessed, there is a need for an abbreviated NIHSS, which can be completed in a shorter time frame. Purpose: The purpose of this study was to determine the merits of an abbreviated NIHSS using seven items considered to be key to determining changes in neurological status.

Methods:
Over a six month period, 100 scores from the 15-item NIHSS were collected on a sample of 92 acute care stroke patients who had a mean age of 64.2; 52% were female. Seven items were calculated, which included level of consciousness, left and right arm motor movement, left and right leg motor movement, speech fluency, and speech clarity. To assess internal consistency reliability of the 7-item NIHSS, Cronbach's
α
was computed. To assess criterion validity, the 7-item NIHSS and 15-item NIHSS were correlated using Pearson's
r
.

Results:
The 15-item NIHSS ranged from 1 to 37, with a mean of 8.6. The 7-item NIHSS ranged from 0 to 24, with a mean of 4.9. For the 7-item NIHSS, Cronbach's
α
was .82 and Pearson's
r
was .96 (p<.001), when correlated with the 15-item NIHSS.

Conclusions:
Assessment of the acute stroke patient using the 15-item NIHSS is time-consuming, and therefore, may be underutilized. An abbreviated 7-item NIHSS demonstrated satisfactory evidence of internal consistency reliability and criterion validity, when correlated with the 15-item NIHSS, suggesting the 7-item version may be a suitable alternative to the longer version. More psychometric testing is warranted to fully evaluate reliability and validity of the 7-item NIHSS.
Abstract 2226: Predictors Of tPA Non-responders According To Location Of Vessel Occlusion
Authors: Mendonça Nuno , Rodríguez-Luna David , Boned-Riera Sandra , Rubiera Marta , Ribó Marc , Pagola Jorge , Piñeiro Socorro , Meler Pilar , Ålvarez-Sabín José , Montaner Joan , Molina Carlos
Published: July 2021

Background and purpose:
Information on the clinical and hemodynamic profile of IV tPA non-responders, at different location of arterial occlusion, may improve the selection of candidates for rescue reperfusion therapies. Therefore, we aimed to investigate predictors of failing IV tPA therapy according to occluded vessel and location of clot.

Methods:
We prospectively evaluated consecutive patients with an acute ischemic stroke admitted within the first 6 hours of onset. Five hundred and forty-eight patients with documented intracranial occlusion were included. Patients were categorized according to site of vessel occlusion into 4 distinct groups: proximal MCA occlusion (n=251), distal MCA occlusion (n=194), ICA T occlusion (n=61) and BA occlusion (n=42). Recanalization was assessed on TCD at 1 hour of tPA bolus.

Results:
Among patients with proximal MCA occlusion, the presence of severe extracranial ICA stenosis or occlusion (OR 2.36, 95% CI 1.15-4.84, p=0.02) and age >74 years (OR 1.84, 95% CI 1.02-3.31, p=0.04) independently predicted no recanalization (NR). No independent predictors of NR were identified in patients with distal MCA occlusion. In patients with ICA T occlusion, history of hypertension (OR 12.77, 95% CI 2.12-76.88, p=0.05) and absence of atrial fibrillation (OR 0.12, 95% CI 0.02-0.71, p=0.02) emerged as independent predictors of NR. Similarly, among patients with BA occlusion, atrial fibrillation was as an independent predictor of NR (OR 0.13, 95% CI 0.03-0.72, p=0.02).

Conclusions:
Absence of atrial fibrillation independently predicts persistent occlusion at 1-h after tPA bolus in patients with ICA T and BA occlusions. The use of relevant predictors of NR and a rapid neurovascular evaluation may improve the selection of patients for more aggressive rescue strategies.
Abstract 2254: Very Brief Focal Ischemia Simulating Human TIAs Induces Aβ Aggregate and Activates Prolonged Autophagy in Rats
Authors: Zhan Xinhua , Sharp Frank R
Published: July 2021

Objective
Very brief periods of focal ischemia in humans called Transient Ischemic Attacks (TIAs) are viewed as being benign. However, our recent animal studies demonstrate that brief periods of focal ischemia can produce microinfarcts associated with neuronal apoptosis and glial Hsp70 positive inclusions. Recent studies of inclusions show they are associated with misfolded proteins that can aggregate and form inclusions, or the proteins can be destroyed via the catabolic process of autophagy. These processes have been shown to occur in Alzheimer’s Disease (AD) where evidence of β amyloid (Aβ) aggregates and cellular autophagy are described. Since there is increasing evidence that cerebral ischemia is linked to AD, we postulated that protein aggregates possibly including Aβ and autophagy would occur following cerebral ischemia. The aims of this study were to demonstrate that brief focal cerebral ischemia induces: Aβ aggregation; Aβ cleavage into “non-toxic” and toxic Aβ 1-42 fragments; and autophagy of cells in brain.

Methods
Middle cerebral artery occlusion (MCAO) was produced in adult SD rats using the suture method. Rats subjected to 20 minutes of ischemia were sacrificed at 4 or 8 weeks. Antibodies against Rodent Aβ (R Aβ, detects all cleaved fragments of Aβ), Aβ 1-42 (detects only the toxic fragment), and LC3b (Atg8 marker of autophagy) were used.

Results
All immunoreactive cells were ipsilateral to the MCAO. No immunoreactivity was observed contralateral to the MCAO in the opposite hemisphere. 1. At 4 weeks post ischemia, R Aβ was expressed in focal areas of the caudate-putamen, globus pallidum and cortex. Aβ 1-42 staining was negative at 4 weeks in all structures. At 8 weeks post ischemia, the pattern of the R Aβ expression was similar to 4 weeks except that it appeared in CA1 hippocampal neurons. At 8 weeks Aβ 1-42 was induced in caudate-putamen, globus pallidum, hippocampal CA1 region, and cortex where it partially co-localized with R Aβ. R Aβ and Aβ 1-42 co-localization in hippocampus occurred in few cells, possibly GABAergic interneurons. 2. LC3b, an autophagy marker, was expressed in the penumbra of microinfarcts of the cortex at 8 weeks. Almost all Aβ 1-42 positive aggregates co-localized with LC3b.

Conclusions
1. Brief focal ischemia induced Aβ only on the ischemic side of the brain; 2. Brief ischemia produced “non-toxic” and toxic Aβ 1-42 fragments; 3. Most cells expressing Aβ 1-42 are undergoing autophagy.
Abstract 2260: Interhospital Transfers in the Colorado Stroke System
Authors: Smith Don B , Hughes Richard L
Published: July 2021

Background:
Stroke systems have been called a “critical next step in improving patient outcomes.” A desired feature is for hospitals unable to function as primary stroke centers to transfer appropriate patients for timely acute care. Recommendations imply that systems should be deliberately designed, but in Colorado an informal system is emerging without coordinated statewide action. We sought to assess the performance of this system with regard to hospital transfers.

Methods:
The Colorado Stroke Registry (CSR), a Get With The Guidelines-Stroke® database, shared by 39 hospitals, captures clinical data for ∼70% of Colorado strokes. Using data from CSR and the Colorado Hospital Association, we examined transfers during 2007-2009 to assess the effect of transfer on acute thrombolysis and to gain insight into factors that may determine whether transfer occurs.

Results:
12,241 records had stroke-events during 2007-2009. Ischemic strokes (IS) were 56.7% of these. Transient ischemic attacks (TIA), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and non-specified stroke accounted for 23.7%, 4.6%, 11.3%, and 3.7%, respectively. Hospital transfers were noted in 1,487 records (12.1%). Nearly 80% of transfers were to only 6 (15%) of the 39 hospitals. The likelihood of transfer to a hospital was significantly correlated with hospital volume (P = 0.0045). Compared to IS, transfer was less likely for TIA but more likely for ICH and SAH (OR: 0.28, 1.59, 4.37, respectively; P <0.0001 for each). Transfer was more likely for: men than women (13.4% v 11.0%, P <0.0001); whites than blacks (11.8% v 5.3%, P <0.0001); and Hispanics than non-Hispanics (13.3% v 12.1%, P=0.002). Transfers were younger with higher NIHSS scores (mean age: 63.9 v 70; mean NIHSS 9.7 v 7.1, P <0.0001 for both). Transfer was less likely if additional medical problems were recorded (11% v 20.1%, P< 0.0001) or if primary insurance was Medicare rather than commercial (5.9% v 10.1%, P<0.0001). Day of week did not predict transfer. In a multivariate logistic model of transfer for IS, these variables were independently predictive: age, NIHSS and absence of additional problems. IS transfers were more likely to receive IV tPA (22.9% v 10.7%, P<0.0001) and more likely to die in-hospital (8.6% v 4.5%, P<0.0001), but no more likely to have clinically significant ICH following tPA (3.7% v 5.7%, P=0.324).

Conclusions:
Without centralized planning, a system of acute stroke care is evolving in Colorado. In the system, transfers are common for IS, SAH, and ICH. 15% of hospitals receive nearly 80% of transfers. Transfer is more common for IS patients who: are younger, have higher NIHSS scores and lack additional problems. Transferred IS patients are more likely to receive IV tPA but not to have clinically significant ICH after thrombolysis.
Abstract 23: Loss of Astrocytic AMPK Leads to Exacerbation of Stroke in Mice
Authors: Li Jun , Tarabishy Sami , Xu Yan , Venna Venugopal , McCullough Louise D
Published: July 2021

Background:
AMP-activated protein kinase (AMPK) is emerging as a key sensor of brain energy balance. It acutely regulates cellular metabolism and chronically regulates gene expression, reducing energy storage and increasing energy production (glycolysis et al.). AMPK is rapidly activated in stroke. However, its role may be complex and cell dependent as the two major types of brain cells are metabolically distinct. Neurons have minimal key enzymatic activity to produce ATP via glycolysis, do not oxidize fatty acids efficiently, and have no glycogen stores. Activating AMPK in neurons may be deleterious by causing metabolic failure. In contrast, astrocytes can perform glycolysis, oxidize fatty acids to form ketones, and store glycogen providing energy supply for ischemic neurons. We hypothesize that astrocytic AMPK deletion will exacerbate the outcome following stroke.

Methods:
We used a Cre-lox system to generate conditional astrocytic AMPKα knockout (KO) mice. Extensive behavior screening was carried out to detect potential neurological deficits of the KO mice prior to their utilization. Stroke was induced by reversible middle cerebral artery occlusion (60 minutes) in male KO mice and WT control mice. Stroke outcome was determined with TTC staining at 72 hrs. Functional recovery following stroke was assessed using corner tests at sacrifice. Data are presented as mean±sem.

Results:
On baseline behavior tests, astrocytic AMPK KO mice displayed no difference from WT (n=4) in spontaneous locomotor activity by open field test (WT 4421±567 vs. KO 4850 ±879, p>0.05,), limb coordination by rotarod (WT 111.3±23 vs. KO 121.3±18, p>0.05), cognitive/memory formation using Novel Object Recognition test (WT 62.1±3.3 vs. KO 63.9±3.6, p>0.05), or integrated sensorimotor function on the corner test (WT 0.52±0.05 vs. KO 0.50±0.04, p>0.05). Following stroke, KO mice showed significantly larger infarcts than WT (n=7) (Cortex WT: 49.8±5.3% vs. KO 67.1±2.4%, p<0.05; Striatum: WT 65.2±4.8% vs. KO 77.8±2.7%, p<0.05; Total: WT 147.2±3.8% vs. 69.0±2.8%, p<0.05). Interestingly, we also observed evidence of increased hemorrhagic transformation in KO mice after stroke. We found a significant exacerbating effect on behavior as the KO mice had more sensorimotor dysfunction in the corner test (WT 0.65±0.04 vs. KO 0.90±0.04, p<0.05, n=7). There were no differences in physiological parameters between AMPK astrocytic KO and WT control groups. In addition, local cerebral blood flow measured by Laser Doppler Flow was equivalently reduced during ischemia and was restored equally in early reperfusion.

Conclusion:
Astrocytic AMPK is protective in experimental cerebral ischemia. Our study highlights the importance of examining AMPK cell-selectively in stroke and cast light on the complex metabolic interactions between astrocytes and neurons in stroke.
Abstract 2355: 2d Perfusion Color Mapping Can Predict Hyperperfusion Syndrome After Carotid Artery Stenting
Authors: Yoshimura Ryo , Tanaka Yuko , Kono Kenichi , Okada Hideo , Fujimoto Takeshi , Shintani Aki , Terada Tomoaki
Published: July 2021

Background:
Hyperperfusion syndrome (HPS) is one of the most important complications during carotid artery stenting (CAS), which presents headache, seizure, focal neurological deficits due to intracerebral hemorrhage. It is essential to predict HPS because of its high morbidity or mortality. 2D perfusion color mapping (2DPCoM) enables to clarify cerebral perfusion status using only digital subtraction angiography (DSA) and its workstations. We report 2DPCoM can predict HPS.

Materials and Methods:
778 patients who had performed CAS have registered. All of the patients were analyzed with SPECT before and after CAS, including acetazolamide study. Transcranial doppler (TCD) have been performed before, during, and after CAS if possible. HPS was defined neurological deficits and intracerebral or subarachnoid hemorrhage with CT or MRI. DSA was performed with Allura Xper FD20/10 (Philips). 2DPCoM was analyzed with 6ml/sec contrast medium infusion from common carotid artery for 1 second. Maximum enhancement, start to peak, average wash-in rate (AWR) , Area-under-curve (AUC), mean transit time (MTT) were revealed. The data were compared with SPECT and TCD.

Results:
6/778 cases have presented HPS. All of the patients manifested misery perfusion (Powers stage 2) before CAS with SPECT. Mean middle cerebral artery flow velocity markedly increased after CAS with SPECT. 2DPCoM showed remarkable hyperperfusion state after CAS, especially MTT. MTT of all HPS cases dramatically changed >25% before and after the procedure.

Discussion:
2DPCoM has a lot of potential for evaluating cerebral hemodynamics with great ease compared with SPECT or TCD. It needs no more devices or drugs, needs only ‘one injection, one click, and one minute’. It might be useful for intracranial percutaneous transluminal angioplasty/stenting, symptomatic vasospasm following subarachnoid hemorrhage, and some other hemodynamic diseases.

Conclusion:
2D perfusion color mapping requires only one more infusion. It needs no more devices and one-click analysis within less than 1 minute. It is very useful modality during CAS for analyzing cerebral perfusion status.
Abstract 2455: Cilostazol For Men, But Aspirin For Women In Stroke Prevention For Patients With Cerebral Infarction - Pooled Analysis Of CSPS 2 And CASISP -
Authors: Shinohara Yukito , Huang Yining
Published: July 2021

Objectives
It has been reported that aspirin is effective for primary stroke prevention in women, but not men. Here, we conducted subgroup analysis of pooled results of Cilostazol versus Aspirin for Secondary Ischemic Stroke Prevention [CASISP] in China (Lancet Neurol 7: 494 - 499, 2008) and Cilostazol Stroke Prevention Study 2 [CSPS 2] in Japan (Lancet Neurol 9: 959 - 968, 2010) to evaluate gender differences in the effects of cilostazol and aspirin in secondary stroke prevention.

Methods
The analysis included 2410 men (cilostazol 1200, aspirin 1210) and 981 women (cilostazol 497, aspirin 484) from the two independent studies. Incidences of stroke as well as baseline patient characteristics, were compared between men and women in each group. Subgroup analysis, with stroke as an endpoint, was also conducted regarding age (≥60 yrs vs <60 yrs), smoking and drinking habit, complications, stroke subtypes etc. in both genders.

Results
At baseline, the rates of patients with smoking and drinking habits and with diabetes mellitus were higher in men versus women, and the rates of older (≥60 yrs) patients and those with hypertension and dyslipidemia were higher in women versus men in both the cilostazol group and aspirin group. However, there was no significant difference in the baseline characteristics of men or of women between the cilostazol and aspirin groups. In men, stroke was significantly reduced by cilostazol versus aspirin (cilostazol 2.89%/person·year, aspirin 4.50%/person·year; p=0.0032). But, in women, aspirin was slightly, though not significantly, more effective than cilostazol (2.40% vs. 2.66%; p=0.7498). Intracranial hemorrhage was also significantly reduced in men by cilostazol versus aspirin (p<0.001, 0.25% vs 1.22%), but not in women (p=0.8813, 0.53% vs 0.48%). Cilostazol was significantly more effective than aspirin in men with older age (≥60 yrs), drinking habit or lacunar infarction. But these differences were not observed in women. Furthermore, hemorrhagic side effects such as gastrointestinal hemorrhage were not different in women in the aspirin group compared with the cilostazol group.

Conclusions
Gender differences in efficacy of antiplatelet agents appear to exist for secondary stroke prevention. Cilostazol was more effective in men, but aspirin may be the first choice drug for women.
Abstract 2472: The Negative Impact of Spasticity on the Health-Related Quality of Life of Stroke Survivors
Authors: Gillard Patrick , Sucharew Heidi , Varon Sepideh , Alwell Kathleen , Moomaw Charles , Woo Daniel , Khatri Pooja , Flaherty Matthew L , Adeoye Ope , Ferioli Simona , Kleindorfer Dawn , Kissela Brett
Published: July 2021

Background:
Spasticity can lead to numerous symptomatic and functional problems that can cause substantial disability. No published studies have quantified the independent effect spasticity has on the health-related quality of life (HRQoL) of stroke survivors.

Objective:
To assess the hypothesis that spasticity has a negative impact on HRQoL among stroke survivors.

Design:
In 2005, as part of the Greater Cincinnati/Northern Kentucky Stroke Study, a cohort of 460 ischemic stroke patients were interviewed during hospitalization and then followed over time. Detailed in-person interviews and medical record abstractions were undertaken during the early post-stroke period to capture key information about demographics; pre-stroke level of functioning; social, family, and medical histories; medications; laboratory results; and stroke severity. Follow-up interviews at 3 months, 1 year, and 2 years gathered information on HRQoL as measured by the Short Form-12 (SF-12), EuroQol-5D (EQ-5D), and Stroke Specific Quality of Life (SSQOL). SF-12 scores are divided into mental (MCS) and physical (PCS) components that range from 0 to 100, with higher scores indicating better health. EQ-5D scores range from 0 (death) to 1 (perfect health). SSQOL scores are stroke specific and range between 0 and 5, with lower scores indicating better HRQoL. HRQoL differences between stroke survivors with and without spasticity (as reported by the patient) were cross-sectionally compared using generalized linear models, adjusting for age, race, stroke severity, pre-stroke function, and comorbidities.

Results:
Of the 460 ischemic stroke patients, 328 had spasticity data available at the 3-month interview, with 54 (16%) reporting spasticity following their stroke. The patients included in the 3-month analysis had a mean age of 66 years; 49% were female, and 26% black. Patients who reported spasticity at 3 months had lower mean PCS, EQ-5D index, and SSQOL total score compared with patients without spasticity (
Table
). Similar differences in HRQoL were also observed at year 1 and year 2 (data not shown).

Conclusions:
We found statistically and clinically meaningful differences in HRQoL between stroke survivors with and without spasticity at 3 months, 1 year, and 2 years following stroke. Clinically, these results suggest an opportunity to improve HRQoL among stroke survivors with effective spasticity management.
Abstract 2492: Predicting Lack of Development of Delayed Cerebral Ischemia after Subarachnoid Hemorrhage
Authors: Crobeddu Emanuela , Mittal Manoj K , Dupont Stefan , Lanzino Giuseppe , Rabinstein Alejandro A
Published: July 2021

INTRODUCTION
After aneurysm treatment, patients with subarachnoid hemorrhage (SAH) are typically kept in the intensive care unit (ICU) to be monitored for signs of delayed cerebral ischemia (DCI). Identifying patients at very low risk of developing this complication who could be safely transferred out of the ICU early could have a very positive financial impact.

METHOD
We analyzed 307 consecutive patients admitted to the intensive care unit from October 2001 to June 2011. Demographic, clinical and neuroimaging data were recorded. The relationship between these variables and absent DCI was analyzed using univariate and multivariate logistic regression models.

RESULTS
DCI did not develop in 169 patients (57.9%). Among factors at admission, age ≥ 68 years (p=0.0003; OR 3.16, 95% CI 1.67-6.39), WFNS I-III at presentation (p= 0.0003;OR 2.73, 95% CI 1.57-4.79), WFNS I-III at worst (p= 0.0003; OR 2.39, 95% CI 1.48-3.87), WFNS I-III post resuscitation (p= 0.0006; OR 2.85 95% 1.56-5.32), modified Fisher grade 1-2 (p= 0.0021; OR 2.43, 95% CI 1.37-4.47), absence of intracranial hematoma (p= 0.0042; OR 2.26, 95% CI 1.29-4.01), absence of intraventricular hematoma (p=0.045; OR 1.61, 95% CI 1.01-2.58), absence of cerebrospinal fluid diversion (p= 0.0002; OR 2.54, 95% CI 1.56-4.20) and aneurysm in the posterior circulation (p=0.0253; OR 1.74, 95% CI 1.07-2.87) were associated with absence of DCI. On multivariate analysis, a model including age ≥ 68 years (p= 0.0003; OR 3.23, 95% CI 1.68-6.62), WFNS at presentation I-III (p= 0.0092; OR 2.18, 95% CI 1.21-3.99) and modified Fisher grade 1-2 (p=0.02; OR 2.04, 95% CI 1.11-3.89) was independently uniformly predictive of the absence of DCI (specificity and positive predictive value of 100%; p<0.0001).

CONCLUSION
We propose a new model that can reliably identify a group of patients with aneurysmal SAH who have very low risk of developing DCI. These patients could be candidates for early transfer to the general ward after treatment of the ruptured aneurysm.
Abstract 2510: Hemodialysis Is A Risk Factor For Short Or Long Term Mortality In Ischemic Stroke Patints.
Authors: Shiromoto Takashi , Shibazaki Kensaku , Iguchi Yasuyuki , Aoki Junya , Uemura Jyunichi , Shimoyama Takashi , Kimura Kazumi
Published: July 2021

Background and purpose
Hemodialysis(HD) is reported to be a risk factor for cerebrovascular events and poor prognosis. However, it is unclear whether HD is a risk factor for short or long term mortality in ischemic stroke patients. The aim of the present study was to investigate whether a short or long term mortality of stroke patient
s
receiving HD is higher than those without HD.

Methods
From April 2007 to May 2010, we retrospectively enrolled ischemic stroke patients within 24h of stroke onset who admitted to our hospital. We divided patients into two groups according to presence and absence of receiving HD(HD group and non-HD group) . We compared clinical characteristics and the mortality rate at discharge and 1year after stroke onset between the two groups. The factors associated with death were investigated by multivariate logistic regression analysis.

Results
687 patients (417 males; (61.4%), mean age 72.4 ± 11 years) were enrolled. 29 patients (4.0%) had HD. HD group was younger(69.8±14.2 vs. 73.0±11.9 year,P<0.001), and hypertension(97%vs. 68%, P<0.001) and basilar artery occlusion(10% vs. 2%, P=0.01) were more frequently observed than non-HD group . In-hospital mortality was 6.7% (46/687 patients). HD group was high mortality rate compared with non HD group(21%vs. 6%, P=0.002). Multivariate logistic regression analysis demonstrated that higher NIHSS score on admission, (OR 1.2, 95% CI 1.109-1.207, P <0.001), basilar artery occlusion (OR 3.6, 95% CI 1.031-12.36, P = 0.05), and HD(OR 7.8, 95%CI 2.259-26.79, P = 0.001) were independent factors associated with in-hospital death. Next, after hospital discharge, 14.5% of patients died within 1 year. HD group was high mortality rate compared with non HD group(50%vs. 13%, P<0.001). On multivariate regression analysis, age per 1year increase(OR 1.0, 95%CI 1.015-1.078, P = 0.03), poor functional outcome (modified Ranking Scale (3-5)) at discharge (OR 2.0, 95%CI 1.635-2.599, P <0.001), and HD(OR 26.4, 95%CI 7.532-92.503, P <0.001) were independent factors associated with death within 1year of stroke onset. Therefore, HD was independently associated with short or long term mortality.

Conclusions;
HD is a risk factor for short or long term mortality in ischemic stroke patients.
Abstract 2574: Impact of Smoking Cessation on the Rish of Subarachnoid Hemorrhage: A Nationwide Multicenter Case-Control Study
Authors: Park Hong-Kyun , Kim Chi K , Lee Seung-Hoon , Ko Sang-Bae , Kim Beom Joon , Ryu Wi-Sun , Oh Mi-Young , Yoon Byung-Woo
Published: July 2021

Background:
Subarachnoid hemorrhage (SAH) is the most devastating cerebrovascular disease. Cigarette smoking is one of the established risk factor for SAH, but on the relationship between smoking cessation, the risk of SAH has not been properly elucidated.

Methods:
We performed a nationwide multicenter case-control study from 33 hospitals in Korea. A total of 426 SAH cases and 426 age and sex-matched controls were enrolled. The participants were asked about their smoking habits, including information about the amount and duration of smoking and the time at quitting smoking. The other data about life-style and medical history were also collected with structured questionnaires which trained interviewers administered.

Results:
One-hundred forty eight SAH patients (37.4%) were current smokers compared with one-hundred three (24.2%) controls, giving an adjusted odds ratio of 2.84 (95% confidence interval, 1.63 to 4.97) after controlling possible confounders. According to cumulative dose of smoking (pack-years), the risk of SAH increases dose-dependently. Compared with current smokers, past smokers whose quitting duration was 5 or more years had a significant 59% reduced risk of SAH. However, previously heavy smokers (≥ 20 cigarettes per day) had a 2.3-times increased risk of SAH compared with never smokers.

Conclusion:
The authors report that the cigarette smoking increases the risk of SAH dose-dependently. According to smoking cessation, stopping smoking may decrease the risk time-dependently, and this beneficial effect of smoking cessation could be decreased in previously heavy smokers. Our results suggest that the vigorous efforts to stop smoking should be performed to reduce the risk of SAH.
Abstract 2734: Thrombolytics, Treatment, Transfer, and Triage: Improving Access to Stroke Care in Eastern North Carolina
Authors: Small Cristine W , Freeman Susan D , Becker Dawn K , McGrath Katie A , Gullette Alexandria B
Published: July 2021

Background:
We are a Certified Primary Stroke Center (PSC) at a regional health system serving 29 counties in eastern North Carolina. High poverty rates, socioeconomic, and demographics factors, create challenges for access to care in the heart of the stroke buckle.
Purpose:
This endeavor promotes best practice for acute stroke care and optimizes outcomes for patients. The PSC serves as the hub, offering supportive resources to community hospitals with an immediate feedback loop that fosters a seamless transfer process through a
drip and ship
model. As a result of outreach efforts in the region, an increased number of patients will receive thrombolytic therapy. Implementation of this model creates a community network that is well prepared to become a true stroke system of care.

Methods:

Development of a comprehensive transfer protocol that includes an algorithmic decision tree and continuous quality feedback loop

Ongoing data analysis and sharing

Key stakeholder collaboration

24/7 resource availability

Immediate feedback loop to include phone calls

Results:
Regional transfers to our facility after t-PA, increased steadily each year from six in 2006 to 52 in 2010, illustrating a significant increase in t-PA utilization. Clinical outcomes were tracked throughout the hospital course to identify stroke severity and disposition. This resulted in a comprehensive analysis of all regional transfers post t-PA, prompting evaluation of t-PA utilization based on phone consults and the feasibility of triage for admission to an ICU or IU based on 18 months of clinical data.

Last NIHSS < 12, favorable outcomes

71% of regional transfers had a last NIHSS < 12, 61% were discharged home, 34% Rehab, 5% SNF

Regional and PSC average NIHSS comparison: Regional first NIHSS was13, last NIHSS - 9.9; PSC first NIHSS -11.5, last NIHSS 5.2

Conclusions:
An increased number of patients are receiving thrombolytic therapy in our community hospitals as a result of outreach efforts in the region. Regional partnerships continue to grow. With growth comes an increased responsibility to explore every aspect of acute stroke treatment that may impact overall clinical outcomes. While the clinical efficacy of t-PA for stroke has been proven in numerous clinical trials, we are obligated as a PSC to take stroke care to the next level and continuously evaluate opportunities for improvement that will guide us to maximize EVERY patient’s outcome.
Abstract 2739: Cardioembolic Stroke Is Frequent in the Late Recurrence After Transient Ischemic Attack
Authors: Hoshino Takao , Nagao Takehiko , Mizuno Satoko , Shimizu Satoru , Uchiyama Shinichiro
Published: July 2021

Background
The high risk of stroke after transient ischemic attack (TIA) has been widely recognized, although the differences of clinical characteristics between early and late recurrent stroke were not well-known.
Materials and methods
The subjects were 133 consecutive ischemic stroke patients who were admitted to our hospital within one week of onset, and had previously diagnosed as “definite TIA” by trained stroke neurologists. They were divided into five groups according to the interval between prior TIA and subsequent stroke; (1) within 48 hours, (2) 48 hours to 1 week, (3) 1 week to 1 month, (4) 1 month to 3 months, and (5) after 3 months (group 1 to 5, respectively). Then, we compared clinical characteristics and prognosis between the patients who presented recurrent stroke within and after 1 week subsequent to TIA (early recurrence group and late recurrence group, respectively).

Results
Of the 133 acute stroke patients (mean age 69.9 years, male 66.9%), 46 (34.9%) were in group 1, 28 (21.2%) in group 2, 23 (17.4%) in group 3, 18 (13.6%) in group 4, and 17 (12.9%) in group 5. As to stroke subtypes, most of the non-cardioembolic strokes were frequently observed shortly after TIA, while the percentage of cardioembolism remained high even the time from prior TIA passed (
Figure
). The prevalence of atrial fibrillation (Af) was higher (39.7% vs. 21.3%,
P
=0.034), and dyslipidemia was lower (41.4% vs. 64.0%,
P
=0.014) in the late recurrence group than in the early recurrence group. The percentages of patients with hypertension, diabetes mellitus, and higher ABCD
2
score (≥3 or ≥5) were similar in both groups. Among 42 patients with Af, 14 (33.3%) were premorbid, 16 (38.1%) were diagnosed when TIA presented, and 12(28.6%) were diagnosed when stroke presented. In the late recurrence group, 37/58 patients (63.8%) had a poor outcome (modified Rankin Scale ≥3) at 3 month of stroke onset, significantly higher than the 29/75 (38.7%) patients in the early recurrence group (
P
=0.005).

Conclusions
The frequency of cardioembolic stroke dose not decline during the time course after TIA, while most of the non-cardioembolic stroke recur early after TIA. This might be responsible for the poorer functional outcome in late recurrent stroke. More than quarter of Af patients had been asymptomatic before stroke, which suggests the need for repeated examinations to detect Af in patients with TIA of unknown etiology.