bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 4005: Longterm Survival Among Survivors Of Stroke And Myocardial Infarction In The Third National Health And Nutrition Examination Survey Mortality Follow-up Study.
Authors: Zacharatos Haralabos , Suri M Fareed K , Qureshi Adnan I
Published: July 2021

BACKGROUND:
Several studies have demonstrated that the adequacy of secondary prevention is better among survivors of myocardial infarction (MI) compared with the survivors of stroke. We investigated the hypothesis that long-term survival among stroke survivors is lower than survivors of myocardial infarction.

METHODS:
We identified stroke and MI survivors from a nationally representative sample of 11989 US adults aged 17 to 59 years who participated in the Third National Health and Nutrition Examination Survey Mortality Follow-up Study. We compared the long-term survival between survivors of stroke and MI and those without any cardiovascular disease using Cox proportional hazards analyses. Potential confounding factors in the association between stroke and MI with death (cardiovascular and all cause) included age, sex, race/ethnicity, hypertension, hyperlipidemia, diabetes mellitus, cigarette smoking, body mass index, and alcohol use.

RESULTS:
A total of 485 survivors with stroke and 774 survivors with MI were included in the analysis; 74 stroke related, 128 acute MI related, and 356 ischemic heart disease related deaths and 941 all causes deaths were reported during a mean follow-up period of 8.5+/-5.3 years. After adjusting for differences in age, sex, race/ethnicity, hypertension, diabetes mellitus, cholesterol level, cigarette smoking, body mass index, and alcohol use, there was no difference among stroke survivors in likelihood of all-cause mortality (relative risk [RR], 1.1 ; 95% confidence interval [CI], 0.9 to 1.3) and cardiovascular death (RR, 0.9; 95% CI, 0.7 to 1.2) compared with persons without cardiovascular disease.

CONCLUSION:
Survivors of stroke face the same reduction in long-term survival as survivors of MI in the community. Therefore, proportionate efforts are required in public education and secondary prevention to improve long-term survival in these patients.
Abstract 4007: Association between Post-discharge Oral Antiplatelet Use and Clinical Outcomes among US Patients Hospitalized for Transient Ischemic Attack or Stroke
Authors: Burton Tanya , Lang Kathy , Lacey Michael , Yu Yanni , Sander Stephen
Published: July 2021

Background:
More than 800,000 Americans have a stroke or transient ischemic attack (TIA) each year. Antiplatelets are recommended to reduce the risk of recurrence and other clinical events. Conflicting data exist regarding the relative efficacy of two common oral antiplatelets (OAPs): aspirin plus extended-release dipyridamole (ASA-ERDP) and clopidogrel (CLO).

Objective:
To examine clinical outcomes using real-world data among patients hospitalized for TIA or stroke and initially prescribed ASA-ERDP or CLO post-discharge.

Methods:
This retrospective claims study from a US commercial and Medicare health plan analyzed adults who had at least one hospitalization for TIA or stroke between 01/2007 and 07/2009 and at least one pharmacy claim for an OAP within 30 days of discharge. Patients were observed for one year before and after the first hospitalization or until death. Post-discharge outcomes included vascular events, clinically relevant bleeds, and all-cause death. The composite and individual outcome measures were modeled using logistic multivariate (MV) regression, adjusting for baseline demographics, comorbidities, costs, and initial OAP use.

Results:
In total, 6,377 subjects (2,085 ASA-ERDP; 4,292 CLO) met the inclusion criteria. ASA-ERDP had a lower unadjusted proportion with the composite endpoint than CLO (19.1% vs. 22.0%, respectively; p=0.01). Significant unadjusted outcomes in the composite were: CHF (8.1% vs. 10.8%; p<0.001), MI (2.4% vs. 4.0%; p=0.001), GI bleeds (3.5% vs. 4.7%; p=0.03), and other hemorrhagic events (2.0% vs. 3.0%; p=0.02). Unadjusted stroke/TIA readmission was not significant (9.1% vs. 9.0%; p=0.95). MV modeling indicated age, comorbidities, index stroke/TIA event, and baseline costs as significant risk factors associated with the composite endpoint. Compared to CLO, the initial use of ASA-ERDP post-discharge was associated with 15% lower risk in the composite endpoint (OR = 0.85; p=0.03), but GI bleeding was the only significant individual component (OR=0.56; p=0.003).

Conclusion:
This study suggests that in the year following discharge for TIA or stroke, patients who received ASA-ERDP had a lower likelihood of the composite endpoint, due partly to GI bleeding, than patients who received CLO.
Abstract 4013: The Hydration Influence on the Risk of Ischemic Stroke Outcome (THIRST-O) Study
Authors: Moussavi Mohammad , Siddique Usama , Carlowicz Cecilia , Hassanzadeh Bahareh , Channapragada Theja , Botros David , Rao Gautami , Kirmani Jawad F
Published: July 2021

Background:
Alterations in electrolyte balance and other basic elements such as serum osmolarity have been claimed to play a role in the pathophysiology of ischemic cerebrovascular disease. However, the relationship between the serum osmolarity pattern, clinical severity and outcome after an acute ischemic stroke is not fully understood. Acute ischemic stroke may be due to heperviscosity that is commonly secondary to dehydration. Also, there is a decreased sensation of thirst and ability to swallow fluids in post stroke patients. It is unclear whether these changes contribute to cerebral ischemic events. This study may add to our understanding of previously published findings of THIRST study.

Objective:
The aim of the present study was to test whether the calculated serum osmolarity on admission and discharge have correlation with severity, as measured by National Institute of Health Stroke Scale(NIHSS); and outcome of ischemic stroke patients, as measured by Discharge Modified Rankin Scale (DCmRS).

Methods:
Consecutive patients presenting to a university affiliated community hospital within 24 hour of symptom onset, and a discharge diagnosis of acute ischemic stroke were identified. Their serum BUN level and calculated plasma Osmolality at the time of presentation and before discharge was compared. Correlation coefficient (Spearsman’s rho) and Mann Whitney test were performed. SPSS version 11 was utilized for data analysis.

Results:
A total of 540 patients met the study criteria. We divided the patients into two groups, Osmolarity more than 295 (group A= 217 patients) and less than 295 (group B=323 patients). The initial NIHSS (p=0.036) and DCmRS (p=0.19) were statistically different in both groups. We found a similar trend between day of discharge serum osmolarity and DCmRS.

Conclusion:
Our study suggests that high initial and discharge serum osmolarity has a negative impact on stroke severity and outcome especially in elderly patients. A future prospective randomized study is warranted.
Abstract 4030: Infarct Volume Thresholds for Prediction of Independent Functional Outcomes after Acute Ischemic Stroke
Authors: Nogueira Raul G , Jovin Tudor , Liebeskind David , Souza Leticia M , Hao Qing , Saver Jeffrey L , Furie Karen , Horev Anat , Yoo Albert J , Vora Nirav , Lev Michael H , Gupta Rishi
Published: July 2021

Background and Purpose:
The main premise of reperfusion therapy in acute ischemic stroke (AIS) is to prevent the conversion of the salvable penumbra into irreversible infarct core thereby reducing the final stoke size. Indeed, previous studies have demonstrated a strong correlation between final infarct volumes and functional outcomes. We sought to establish the optimal final infarct thresholds that best correlate with independent functional outcomes.

Methods:
Multicenter retrospective analysis across five large academic centers. Consecutive patients meeting the following criteria were included: (1) anterior circulation stroke; (2) available final stroke imaging volumetric analysis; (3) available modified Rankin scale (mRS) score at 90 days. Receiver operating characteristic (ROC) curves were created to help defining the optimal final stroke volume points that discriminate a 90-day mRS ≤2.

Results:
A total of 484 consecutive patients were identified. The mean age was 65.6±14.6 years. The mean baseline NIHSS was 14.2±7.1. The mean final stroke volume was 77.7±88.5cc (median, 40.5cc). A total of 201 out of the 484 (41.5%) of the patients achieved functional independence at 90 days. The ROC analysis demonstrated that final infarct volume (FIV) was a strong discriminator of independent outcomes with an area under the curve [AUC] of 0.778. The best cut-off point for discriminating 90-day mRS ≤2 was 35cc of FIV (70% specificity; 70% sensitivity). The AUC could be improved by excluding older patients. In patient <65 years, the AUC was 0.844 with an optimal discriminating point at 53cc (75% specificity; 75% sensitivity). The exclusion of patients >80 years yielded an AUC of 0.797 with an optimal FIV discriminating point at 40cc (72% specificity; 72% sensitivity). In this population, FIV of 29cc had 80% specificity and 62% sensitivity whereas FIV of 15cc had 90% specificity but only 40% sensitivity for an independent functional outcome.

Conclusions:
Final infarct volume is a strong surrogate for good outcomes after AIS. Our data suggest that the exclusion of patients with infarct volumes >35-40cc on baseline imaging may enhance the chances of a positive confirmatory clinical trial of reperfusion in AIS.

Figure:

Receiver operating characteristic (ROC) curves of Final Stroke Volume (cc) and Independent Functional Outcome (mRS ≤2) at 90 days.
Abstract 4037: Dynamic Cerebral Autoregulation in Patients with Subarachnoid Hemorrhage and Delayed Cerebral Ischemia
Authors: Reddy Varun , Otite Fadar , Puri Ajit , Zamani Amir , Serrador Jorge , Sorond Farzaneh
Published: July 2021

Introduction:
We have previously shown that early impairments in dynamic cerebral autoregulation are strongly associated with subsequent development of angiographic cerebral vasospasm. While angiographic cerebral vasospasm is associated with delayed cerebral ischemia (DCI), the relationship between cerebral autoregulation and DCI has not been previously investigated. Our study is designed to specifically test the relationship between early changes in dynamic cerebral autoregulation and subsequent development of DCI.

Methods:
Thirty-nine consecutive patients with acute non-traumatic subarachnoid hemorrhage (SAH) and adequate transcranial Doppler windows, presenting within 24 hours of symptom onset, have been prospectively studied so far. Daily 5-minute measures of continuous beat-to-beat bilateral middle cerebral artery (MCA) flow velocity and mean arterial blood pressure (MAP) recordings were obtained on days 1-10. Transfer function analysis of spontaneous MAP and MCA mean flow velocity (MFV) oscillations were performed in the very low (0.03-0.07 Hz), low (0.07-0.15 Hz), and high (0.15-0.3 Hz) frequency ranges. Non contrast head CTs were reviewed by a neurologist and neuroradiologist blinded to the autoregulatory and angiographic data. Infarctions present within 6 weeks after SAH, which could not be attributed to instrumentation or peri-op strokes, were identified as DCI.

Results:
Patients with DCI had significantly higher Hunt and Hess (H&H) scores (median=4 vs 3, p<0.0001) compared to those without DCI. There was no difference in MAP (p=0.746), right MCA (p=0.8327)) or left MCA MFV (p=0.4278) between patients with and without DCI across all time points. Patients with DCI had a lower transfer function phase in the very low frequency (autoregulatory frequency) range. Subgroup analysis of patients with H&H scores ≥3 (N=14) showed that those with DCI had significantly lower phases on day 3 compared to those without DCI (-13±80 vs. 63±26, p=0.048).

Conclusion:
Our preliminary data show that dynamic cerebral autoregulation, as measured by transfer function phase in the autoregulatory frequency range, is significantly impaired in the early days after SAH and that this early impairment is associated with the development of DCI. We are continuing to collect data on additional patients with SAH to confirm our findings in a larger cohort. Impairments in dynamic cerebral in the early days post SAH may be reliable predictors for identifying patients at higher risk of delayed cerebral ischemia.
Abstract 5: Early and Long-term Safety of Stenting and Endarterectomy in Symptomatic and Asymptomatic Patients Outside Randomized Trials
Authors: De Rango Paola , Lenti Massimo , Cieri Enrico , Cao Piergiorgio , Giordano Giuseppe , Simonte Gioele , Farchioni Luca , Verzini Fabio
Published: July 2021

Objective.
Due to the different stroke risk exposure, advisability of carotid revascularization by carotid stenting (CAS) or endarterectomy (CEA) strictly depends on patients’ symptomatic status. Periprocedural and 5-year data of 2196 consecutive procedures (1080 CAS, 1116 CEA) based on physician-guided indication for CEA vs CAS and performed after training outside randomized trials, were reviewed for safety.

Methods.
684 symptomatic and 1512 asymptomatic patients were analyzed for periprocedural stroke/death and 5-year death or stroke incidence. Kaplan-Meier survival curves with type-of-procedure interaction were employed.

Results.
Symptomatic patients were older (71.9y vs 71.04y), less frequently females (25.3% vs 30.8%) and treated more by CEA (60.8%) than by CAS (p<0.001). Asymptomatic patients were more likely affected by cardiac disease, peripheral disease and hyperlipidemia. Periprocedural stroke/death was higher in symptomatic than in asymptomatic patients (3.5% vs 1.9%;OR 1.8, 95%CI1.07-3.2) without significant differences between CAS and CEA in both symptomatic (4.5%CAS vs 2.9%CEA) and asymptomatic (2.2% CAS vs 1.6% CEA) groups. Symptomatic patients showed higher 5-year mortality and stroke incidence: survival rate was 78.4% in symptomatic and 85.5% in asymptomatic (p<0.0001). Late stroke freedom was 93.5% in symptomatic and 97.7% in asymptomatic (p=0.001). There were no differences, according to the procedure (CAS vs CEA) for treatment, in survival (Symptomatic: 85% vs 75%; Asymptomatic: 83% vs 83%) or late stroke incidence (Symptomatic: 93% vs 93%; Asymptomatic: 97% vs 97%).

Conclusions.
Symptomatic patients show higher risks after carotid revascularization and 5-year outcomes are inferior to those of asymptomatic patients regardless of the surgical procedure. Periprocedural stroke/death rates, either by CAS or CEA, are within the complication threshold rates suggested in current guidelines for both symptomatic and asymptomatic patients.
Abstract 6: Relationship between Center-Volume and Complication Rates in the Carotid Revascularization Endarterectomy versus Stenting Trial
Authors: Gonzales Nicole R , Garcia Lawrence A , Clair Daniel G , Barr John , Orlow Steven , Tom MeeLee , Hughes Susan E , Longbottom Mary E , Sheffet Alice J , Voeks Jenifer H , Brott Thomas G
Published: July 2021

Background
There is evidence that center-volume of cases affects outcomes for both carotid endarterectomy (CEA) and stenting (CAS). We sought to evaluate the effect of center-volume by site on complication rates in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).

Methods
In CREST, the primary composite endpoint was any stroke, myocardial infarction, or death within 30 days or ipsilateral stroke in follow-up. Certification was achieved by 477 surgeons performing more than 12 procedures per year with complication rates less than 3% for asymptomatic patients and less than 5% for symptomatic patients; 224 interventionists were certified after a rigorous training and credentialing process that included a lead-in registry. CREST centers were divided into tertiles based on the number of patients enrolled into the study, with Group 1 composed of 82 sites each enrolling <25 patients, Group 2 with 24 sites enrolling 25-51 patients and Group 3 with 10 sites enrolling >51 patients. Differences in periprocedural event rates for the primary composite endpoint and its components were compared using logistic regression adjusting for age, sex, and symptomatic status within site-volume level.

Results
The safety of CAS and CEA did not vary by site-volume during the periprocedural period as indicated by occurrence of the primary endpoint (p=0.54) or by stroke and death (p=0.87).

Conclusion
Complication rates (as indicated by the primary endpoint and its components) were low in CREST and were not associated with center-volume. The data are consistent with the value of rigorous training and credentialing in trials evaluating endovascular devices and surgical procedures; because of ongoing entry of new interventionalists and surgeons into CREST, operator experience independent of center-volume cannot be addressed.
Abstract 60: Outcomes Following Sonothrombolysis in Severe Acute Ischemic Stroke
Authors: Barlinn Kristian , Tsivgoulis Georgios , Barreto Andrew D , Mikulik Robert , Saqqur Maher , Demchuk Andrew M , Schellinger Peter D , Molina Carlos A , Howard George , Alexandrov Andrei V
Published: July 2021

Background&Purpose:
A recent meta-analysis showed that sonothrombolysis is safe and can double the rate of early recanalization in acute ischemic stroke (AIS). We sought to explore whether patients with severe strokes could clinically benefit from ultrasound amplification of tPA-induced recanalization.

Subjects&Methods:
We compared functional outcomes at 3 months among randomized AIS patients with pre-treatment NIHSS scores >=10 in the Combined Lysis of Thrombus in Brain Ischemia (CLOTBUST), Transcranial Ultrasound in Clinical Sonothrombolysis (TUCSON) and pilot randomized clinical safety study of sonothrombolysis with microspheres (Definity study). Patients had proximal arterial occlusions identified by baseline TCD and received intravenous (IV) tPA or IV tPA plus continuous 2-hour TCD ultrasound monitoring (=sonothrombolysis). Favorable outcome was defined as modified Rankin Scale (mRS) 0-1 at 3 months. Sustained complete recanalization was defined as Thrombolysis in Brain Ischemia (TIBI) flow grades 4-5 assessed by TCD at 2 hours after tPA bolus. Symptomatic intracranial hemorrhage (sICH) was defined using ECASS-2 definition as imaging evidence of ICH with clinical worsening (NIHSS >=4) within 72 hours from stroke onset.

Results:
A total of 139 AIS patients with severe stroke due to proximal arterial occlusions (mean age 69±13years, 56% men, median NIHSS 17, interquartile range 14-21, range 10-34) were randomized in CLOTBUST (n=105), TUCSON (n=21) and Definity (n=13). A total of 60 (43%) and 79 (57%) patients were randomized to IV tPA and sonothrombolysis, respectively. Patients treated with IV tPA and sonothrombolysis did not differ in terms of age, baseline stroke severity, baseline TIBI grades and onset-to-treatment time. Symptomatic ICH rates were similar in patients treated with IV tPA and sonothrombolysis (5.0% vs. 5.1%; p=0.987). More patients achieved sustained complete recanalization in the sonothrombolysis than in the IV tPA group (38.0% vs. 18.3%; p=0.012). Favorable outcome (mRS 0-1) tended to be more prevalent in the sonothrombolysis than in the IV tPA group (36.6% vs. 23.2%; p=0.104).

Conclusions:
Our data point to a signal-of-efficacy and provide basis to determine the sample size of a phase 3 randomized trial of sonothrombolysis in patients with severe strokes (
NCT01098981
).
Abstract 63: Basilar Artery Occlusion due to Vertebral or Basilar Dissection in the Basilar Artery International Cooperation Study (BASICS)
Authors: de Freitas Gabriel R , Engelter Stefan T , Puetz Volker , Schonewille Wouter J
Published: July 2021

Introduction:
Since there are few reports of patients with stroke secondary to basilar artery occlusion (BAO) due to dissection, there are scarce data on its risk factors, clinical presentation, prognosis and best treatment options.

Methods:
The Basilar Artery International Cooperation Study (BASICS) was a large prospective, observational registry of consecutive patients who presented with an acute symptomatic BAO. We assessed clinical, radiological and therapeutical data of patients with BAO secondary to radiologically confirmed vertebral or basilar artery dissection. Stroke severity at time of treatment was dichotomized as severe (coma, locked-in state, or tetraplegia) or mild to moderate (any deficit that was less than severe). Outcome was assessed at 1 month. Poor outcome was defined as a modified Rankin scale score of 4 or 5, or death. Patients were divided into three groups according to the treatment they received: antithrombotic treatment only (AT), which comprised antiplatelet drugs or systemic anticoagulation; primary intravenous thrombolysis (IVT), including subsequent intra-arterial thrombolysis; or intra-arterial therapy (IAT), which comprised thrombolysis, mechanical thrombectomy, stenting, or a combination of these approaches.

Results:
In 32 (5.4%) of 592 patients with BAO, the stroke etiology was dissection. Twenty patients were men, mean age was 45.2 (± 12.7 SD) years. Fourteen patients had no vascular risk factors. Seven patients were current smokers; history of hypertension was present in 4, of dyslipidemia in 4 and other risk factors in 6 patients. Prodromal symptoms (e.g. headache, neck pain, vomiting) were present in 24 patients. History of TIA prior to BAO was recorded in 5 patients and minor stroke in 9. Twenty one patients had a progressive stroke, in 6 symptoms fluctuated and 4 presented with a maximum deficit from onset. Deficits at time of treatment were severe in 22 patients and mild to moderate in 10. Initial CT scan was normal in 9 patients, 13 had a dense basilar sign and 13 presented with early ischemic changes. In most (20) patients the BAO was in the proximal third, in 8 it was located in the distal third and in 4 in the middle third. Eleven patients were treated with only AT (3 antiplatelets, 8 anticoagulation), 9 with IVT and 12 with IA. Three patients- all treated with IA - had symptomatic hemorrhage. Overall, 18 (56%) patients had a poor outcome (AT 9 of 11, IVT 2 of 9, IA 7 of 12, p=0.03, Fisher’s exact test).

Conclusions:
Dissection is a rare cause of BAO that affects mainly younger patients, with few or no vascular risk factors. Patients often present with prodromal symptoms, and a progressive stroke. Initial CT changes are common and the proximal third of the basilar artery is the main localization of occlusion. As in other causes of BAO, prognosis is poor and in this registry patients treated with IVT had a lower rate of poor outcome.
Abstract 75: A Retrospective Multicenter Study of Solitaire™ FR for Revascularization in the Treatment of Acute Ischemic Stroke
Authors: Dávalos Antoni , Gralla Jan , Bonafé Alain , Chapot René , Andersson Tommy , Mendes Vitor
Published: July 2021

Background & purpose:
To evaluate safety and efficacy of the Solitaire FR in the treatment of patients with acute ischemic stroke (AIS) secondary to large artery occlusion.

Methods:
Retrospective study of consecutive patients presenting with AIS treated with Solitaire FR as the first choice device to restore blood flow in 6 experienced European sites according to the hospitals’ stroke protocols (direct IA, bridging IV t-PA/IA and failed or contraindicated IV t-PA). Sites provided patient information at pre-procedure, procedure, 24hrs, discharge and 90 days. An independent Core Lab evaluated TICI scores on the pre-procedure and post-procedure angiograms. Recanalization was defined as TICI 2 or 3 post Solitaire FR device use and prior to any rescue therapy. Baseline and post-treatment brain CT or MRI were also centrally reviewed for symptomatic ICH classification (PH2 + death or neurologic deterioration). Good early neurological outcome was defined as NIHSS score improvement of ≥10 points or NIHSS 0,1 at discharge, and favourable functional outcome as modified Rankin Scale (mRS) score ≤ 2 at day 90. Patients with missing mRS data were judged to have worst possible outcome for data analysis.

Results:
Of the 206 patients treated with Solitaire FR, the device was used as first line treatment in 141 patients (mean age, 66; median NIHSS, 18): 74 patients were treated with IV t-PA prior to endovascular treatment, 56 had contra indication to IV t-PA and 11 were directly treated IA. Safety and efficacy results in the overall and IV t-PA treated patients are shown in the
table
. The mean number of recoveries was 1.8 and median time from groin puncture to successful revascularization was 45 minutes.

Conclusions:
This retrospective, uncontrolled study shows that Solitaire FR is safe and achieves good revascularization rates and functional outcomes in patients with AIS and large artery occlusion.
Abstract 79: A Population-based Study Of Arterial Diameters In Dolichoectasia: The Northern Manhattan Study.
Authors: Gutierrez Jose , Gardener Hannah , Bagci Ahmet , DeRosa Janet T , Santiago Maria , Rundek Tatjana , Ekind Mitchell S , Alperin Noam , Sacco Ralph , Wright Clinton B
Published: July 2021

Background:
Dolichoectasia (DE) of cerebral vessels has been associated with adverse neurological outcomes, including stroke. The subjectivity of the DE diagnosis is a limiting factor in the study of this condition. We examined arterial diameters of intracranial vessels in relation to a diagnosis of DE using standard criteria.

Methods:
The Northern Manhattan Study (NOMAS) is a multiethnic, community-based cohort of stroke-free participants. Participants who underwent head MRA were rated for the presence or absence of DE based on symmetry, parenchymal impingement, and Smoker criteria (posterior circulation). We used a semi-automated 3D tool to measure vessel lumen cross-sectional areas, and estimated artery diameters.

Results:
There were 718 NOMAS participants with MRA data available (mean age 72±8 years, 62% women, 56% Hispanic, 23% black, 18% white). Dolichoectasia was more frequent in the posterior circulation (25%), followed by the anterior circulation and both territories (12% for each). Diameters were obtained from 7,207 arteries. All dolichoectatic vessels had greater diameters compared to non-dolichoectatic vessels. Subjects with basilar artery DE had larger non-DE internal carotid artery diameters (at least 0.2 mm larger, P=0.003) but controlling for total cranial volume made this difference non-significant. The intra-rater reliability for visual DE ratings was poor to good (kappa=0.34-0.68) but reliability of vessel diameter measurements was excellent (intraclass correlations >0.85).

Conclusions:
The subjective attribution of DE corresponds with larger arterial diameters. Having DE in one artery seems to be associated with larger non-DE arteries. This is suggestive of a dilatatory propensity in patients with DE. Using arterial diameters appears to be reliable method to study this dilatatory arteriopathy.
Abstract 8: Radiation and modifiable Stroke Risk Factors in adult Survivors of Pediatric Cancer: Results from the Childhood Cancer Survivor Study
Authors: Mueller Sabine , Fullerton Heather J , Stratton Kayla , Leisenring Wendy , Weathers Rita E , Stovall Marilyn , Armstrong Gregory T , Goldsby Robert E , Packer Roger J , Robison Leslie L , Krull Kevin R
Published: July 2021

Background:
Radiation therapy has vascular sequelae including moyamoya (brain radiation), and accelerated cervical atherosclerosis (neck radiation). However, the impact of cranial radiation therapy (CRT) and modifiable stroke risk factors such as hypertension (HTN) on stroke risk in adulthood remains poorly understood.

Objective:
To assess long-term incidence rates and risk factors for stroke in survivors of childhood cancer followed by the Childhood Cancer Survivor Study (CCSS).

Methods:
CCSS is a multi-institutional longitudinal cohort study of 14,358 survivors of childhood cancer diagnosed between 1970 and 1986, and 4,023 randomly selected sibling controls. The age-adjusted incidence rates of self-reported late-occurring first-stroke (≥ 5 years after cancer diagnosis) were calculated for survivors compared to siblings. Multivariable Cox Proportional Hazards models were used to identify independent stroke predictors.

Results:
During a mean follow-up of 23.3 years, 292 survivors reported a late-occurring stroke of which 125 (42.8%) occurred in CNS tumor survivors who constituted only (13%) of the survivor population. The age-adjusted stroke rate per 100,000 person-years at age 23 was 77 (95% CI 62 - 96) for all pediatric cancer survivors and 292 (95% CI 208-409) for CNS tumor survivors compared to 9.3 (95% CI 4 - 23) for siblings. CRT increased stroke risk in a dose dependent manner and cumulative incidence continues to rise decades after diagnosis (see
Figure
). Treatment with 30-49 Gy CRT had a relative stroke risk of 5.9 (95% CI 3.5-9.9) compared to 11.0 (95% CI 7.4-16.5) in the 50+ Gy CRT group. The cumulative incidence of stroke 20 years post diagnosis was 0.7% (95% CI 0.5 - 1.0) for no CRT, 2.9% (95% CI 1.4 - 4.4) for 30-49.9 Gy CRT, and 4.9% (95% CI 3.4-6.4) for ≥ 50 Gy CRT. HTN increased stroke risk by 4-fold. If diabetes was present together with HTN in CNS tumor survivors, the RR increased from 2.9 (95% C.I. 1.6-5.3) for HTN alone to 14.4 (95% CI 5.7 - 36.2).

Conclusion:
Survivors of pediatric cancer treated with CRT have an increased stroke risk that is dose dependent and increases with age. Modifiable risk factors such as HTN and diabetes further increased this risk and should be monitored and treated aggressively in these survivors to reduce the risk of late-occurring stroke.
Abstract 84: An Index to Identify Cryptogenic Stroke Patients whose Stroke is likely Attributable to Patent Foramen Ovale
Authors: Kent David M , Ruthazer Robin , Weimar Christian , Serena Joaquín , Mas Jean-Louis , Homma Shunichi , Michel Patrik , Elkind Mitchell S , Nedeltchev Krassen , Mono Marie-Luise , Mattle Heinrich , DiTullio Marco , Thaler David E
Published: July 2021

Background:
A patent foramen ovale (PFO) discovered in the setting of a cryptogenic stroke (CS) may be incidental or pathogenic. Based on Bayes theorem, the proportion of CS that is PFO-attributable among patients found to have a PFO has been shown to be related to PFO prevalence in CS versus control patients. However, the prevalence of PFO in CS patients is itself dependent on the presence or absence of other risk factors. We exploited this relationship to create an index to stratify CS patients with PFO by their likelihood that the CS is PFO-attributable.

Methods
This project is part of the Risk of Paradoxical Embolism (RoPE) Study, an international, multicenter collaboration that has combined data for patients with CS and cryptogenic TIA who have known PFO status from 12 component studies (n=3665). For this study, we included those subjects within the 7 databases enrolling subjects both with and without PFO (n=3023). We used generalized linear mixed models to identify variables associated with the presence of a PFO, accounting for clustering within study. Based on this model, we created a simple index. Bayes theorem was used to estimate the PFO-attributable fraction in each stratum assuming a PFO prevalence in the general population of ∼25%.

Results:
Variables negatively associated with the presence of a PFO included: age (odds ratio [OR] = 0.97 per 1 year increase, p <0.0001); diabetes (OR= 0.65, p < 0.001); hypertension (OR =0.68, p < 0.0001); smoking (OR = 0.70, p<0.60); prior stroke or TIA (OR = 0.78, p=0.04). Cortical stroke on neuroimaging (OR = 1.46, p < 0.001) was also associated with PFO. Based on this, a simple index was created in which the
absence
of each stroke risk factor was assigned a point, with age dichotomized at 50 years. PFO prevalence in each stratum is shown in the
table
for patients < age 60, i.e. the subset of patients likely to be considered for PFO closure trials.

Conclusion:
Even among CS patients in the younger age range considered eligible for closure trials, there is considerable heterogeneity in the distribution of risk factors for stroke and other characteristics that identify subgroups of CS patients with variation in PFO prevalence. This reflects substantial and clinically important variation in the probability that a discovered PFO is likely to be pathogenic rather than incidental. This score may be useful in selecting patients for closure trials, or for stratification within trials, particularly if combined with a recurrence risk model.
Abstract 87: Assessment of Stroke Caregiver Readiness: A Primary Prevention Strategy
Authors: Lutz Barbara J , Young Mary Ellen
Published: July 2021

Introduction:
More than 3.5 million family caregivers provide assistance with activities and instrumental activities of daily living for stroke survivors living at home. Studies consistently indicate that stroke family caregivers are inadequately assessed and under prepared for their new caregiver roles and responsibilities as stroke survivors transition home from inpatient rehabilitation. Several tools exist to assess caregivers once they have assumed the caregiving role, however, there are no tools assess stroke caregiver readiness prior to discharge. Research has indicated the need for a thorough and systematic pre-discharge assessment of the caregiver’s ability to assume the caregiving role. The purpose of this presentation is to describe ten critical stroke caregiver readiness assessment domains and to discuss their relevance for long-term outcomes for stroke survivors and family caregivers.

Methods:
In this grounded theory study, data were collected from19 persons with stroke and 19 family caregivers. Semi-structured interviews were conducted during inpatient rehabilitation and within 6 months post-discharge. First interviews focused on expectations for recovery and caregiving needs post-discharge. Follow-up interviews focused on how families managed the transition from rehabilitation to home and how their initial expectations matched the reality of their post-discharge experience. Interviews were analyzed using dimensional analysis and coded in NVivo data management software.

Findings:
Participants indicated that stroke was an overwhelming, life changing crisis event. Family members felt abandoned, isolated, and under prepared to assume the fulltime caregiving role as stroke survivors transitioned home. They described using ineffective or risky caregiving strategies that resulted in safety and health issues for both stroke survivors and caregivers. Ten pre-discharge caregiver readiness assessment domains were identified in the interviews and a corresponding stroke caregiver readiness assessment interview guide was developed.

Conclusion:
Stroke survivors and family caregivers are extremely vulnerable as they transition home from inpatient rehabilitation leaving them at risk for poorer health, depression, and increased risk for injury. In order to prevent these deleterious outcomes, caregivers should be assessed, and potential areas of risk identified and addressed prior to discharge from inpatient rehabilitation. As new interventions are developed to improve survival rates for persons with stroke, we must also develop and implement primary prevention strategies for family members who are called upon to provide care following discharge to protect their health and improve the long-term recovery outcomes for the stroke survivor.
Abstract 9: Risk of Stroke and Stroke Recurrence in Pediatric Cancer Survivors treated with Cranial Radiation Therapy
Authors: Mueller Sabine , Sear Katherine , Hills Nancy K , Chettout Nassim , Afghani Shervin , Lew Leanne K , Tolentino Erica Z , Haas-Kogan Daphne A , Fullerton Heather J
Published: July 2021

Background:
Among childhood cancer survivors, cranial radiation therapy (CRT) increases risk of self-reported first-stroke; there are no published estimates of recurrent stroke.

Objective:
To assess rates and predictors of first and recurrent stroke in childhood cancer survivors treated with CRT.

Methods:
In a retrospective cohort study of all children who received CRT at one institution,1980-2009, we performed chart abstraction (n=321) and phone interviews (n=101) to measure first and recurrent stroke; we confirmed stroke through imaging review. Incidence of first-stroke was calculated as the number of first strokes per person-years of observation after radiation. We used survival analysis techniques to determine the cumulative incidence of first stroke after radiation, and recurrent stroke after first stroke; we used Cox proportional hazards models to examine potential predictors of first stroke.

Results:
Median age of children at the time of CRT treatment was 8 years (IQR 4-13 years). A total of 17 first-strokes (12 ischemic, 2 hemorrhagic, 3 unknown sub-type) were identified at a median age of 25 years (IQR 17-34 years): 6 from chart review, 8 from interview, 3 from both. Imaging was available in 12 cases and consistent with stroke in all. The overall rate of first-stroke was 594 (95% CI 346 - 949) per 100,000 person-years. The risk of stroke persists for decades after treatment (see
Figure
). Males had a 4-fold hazard of first stroke compared to females (95% CI 1.1 - 14;
P
=0.034). Race and treatment with chemotherapy did not affect the stroke risk; dose effect of CRT could not be assessed due to a narrow dose range in our cohort. There were 5 recurrent strokes (2 ischemic, 2 hemorrhagic, 1 unknown) at a median of 6 months after first stroke (range 5.6 months to 8.9 years); brain imaging was available in 4 cases and consistent with stroke in all. The cumulative incidence of recurrent stroke was 21% (95% CI 7.5-53) at 1 year post first-stroke, 29% (95% CI 12-61) at 5 years, and 43% (95% CI 19-78) at 10 years.

Conclusion:
Survivors of childhood cancer who received CRT are at high risk for first and recurrent stroke. Larger studies are needed to identify predictors of recurrence to design secondary stroke prevention strategies.
Abstract 91: Nurses Activate Inpatient Stroke Alerts Faster than Physicians and are Equally Competent at Identifying Stroke Patients versus Stroke Mimics
Authors: George Pravin , Newey Christopher , Wisco Dolora , McNeil Julie , Winfield Michelle , Gebel James
Published: July 2021

Introduction:
In-hospital “stroke alerts” are typically activated when a patient’s neurological status acutely deteriorates. Acute inpatient strokes represent an excellent potential opportunity for definitive treatment, but over triaging causing false alarms was a challenge at our institution, especially in the cardiology/CT surgery units, where many stroke mimic patients were being seen. Our stroke nurse, stroke coordinator, and stroke team physicians designed and implemented a formal collaborative educational initiative to improve quality and timeliness of stroke pager calls.

Hypothesis:
Non- neurological nurses educated to recognize stroke signs and symptoms who activate the stroke team will identify at least as great a proportion of true stroke patients as physicians.

Methods:
We retrospectively analyzed prospectively collected inpatient stroke team calls on 93 inpatients over one year’s time. The person (physician versus nurse) calling the stroke alert was identified via shared electronic medical record review. We compared the proportion of patients (via chi-square analysis) who after formal chart review had a true diagnosis of stroke (versus mimic). Neurological floor and neuro-ICU patients were excluded.

Results:
Nurses initiated 59/93 stroke team calls (63%) during the study period. Overall, 59% (37/59) of nurse- activated calls were for patients whom ultimately were determined to have had a true stroke as compared to 63% of physician-activated calls (20/34); p=0.71; 60% of stroke alerts came from the cardiology/CT surgery nursing units, and the accuracy of nurses on these units was 67% as compared to 53% for other non- neurological nursing units. (p=.323). Nurses activated the stroke team faster (median 2 hours [25
th
, 75
th
%ile 0.5hr, 6 hrs]) than physicians (median 4.9hrs [25
th
, 75
th
%ile 1.3, 21.3 hrs]), p=.0096 {Wilcoxon Rank Sum}.

Conclusions:
Non- neurological nurses educated on stroke recognition and stroke team activation are as accurate at identifying inpatient acute stroke patients as physicians, and do so more than twice as fast on average as physicians. Intensive, focused, collaborative education of nursing staff in high-risk for inpatient stroke units, who typically more frequently assess patients than physicians, may via rapid and accurate identification improve inpatient stroke outcomes.
Abstract NS 4: Non-Invasive Oscillometric Blood Pressure Monitoring in tPA Treated Patients: Is Mean Arterial Pressure Associated with Patient Outcomes?
Authors: Alexandrov Anne W , Chaudhary Asad A , Sisson April , Sands Kara , Rawal Pawan , Shiue Harn J , Fowler Beth , Shahripour Reza B , Albright Karen C , Alexandrov Andrei V
Published: July 2021

Background:
Blood pressure (BP) parameters for management of tPA treated patients are well known among experienced stroke clinicians, and violation of systolic and diastolic BP limits have previously been shown to be associated with symptomatic intracerebral hemorrhage (sICH) in tPA treated patients. Non-invasive oscillometric BP monitoring measures a “true” mean arterial pressure (MAP), and then algorithmically defines what systolic and diastolic pressure "might" be. Because this form of BP monitoring has become the national standard, we examined the occurrence of MAP BP elevations to determine their association with sICH and treatment outcome in acute ischemic stroke patients that received systemic tPA.

Methods:
Two-years of consecutive systemic tPA cases were retrieved from our Stroke Center database and arterial blood pressures for the first 24 hours from time of bolus were entered from auto-recordings in our electronic medical records. Protocol violations in MAP were defined as greater than 120 mm Hg at any point in the first 24 hours from time of bolus. Off-label treatment with intravenous tPA beyond 4.5 hours from symptom onset was identified a priori as a potential counfounder to stroke outcome. Symptomatic intracerebral hemorrhage was defined as an increase in the NIHSS of ≥ 4 points. Spearman’s correlation was used to assess the relationship between MAP and post-tPA NIHSS score.

Results:
191 tPA cases were identified for inclusion in the analysis with 150 (79%) receiving their tPA at our Comprehensive Stroke Center and another 41 (21%) administered as a telephone-consult supported drip and ship. Patients were 65.5±16 years of age with median admission NIHSS scores of 12 (IQR=7-17). All patients had normal CT scans or minor changes consistent with acute stroke without hypo-attenuation. A total of 77 (40%) patients experienced a MAP violation overall. There were 11 isolated systolic BP violations, 4 isolated diastolic BP violations, and 21 isolated MAP violations that were otherwise not detectable by a violation in systolic or diastolic parameters, averaging 123.3±2 mm Hg. A total of 2 (1%) sICHs occurred in the sample, and of these 1 was associated with on-label peri-treatment BP protocol violations affecting systolic, diastolic and MAP parameters. An increased reduction in post-tPA NIHSS points was significantly associated with higher MAPs (r=.92; p=.008).

Conclusions:
Evidence-based guidelines are silent on MAP limits, and MAP is rarely monitored clinically in tPA treated patients despite dependence on the MAP for assignment of systolic and diastolic pressures in oscillometric BP monitoring. Our findings suggest that an improved understanding of the contribution of MAP-dependent oscillometric methods to BP monitoring in acute stroke patients is warranted.
Abstract 11: Comparison Of Various Methods Of Assessment Of Intracranial Collaterals On The Pretreatment Ct-angiograms To Predict Outcomes In Acute Anterior Circulation Ischemic Stroke
Authors: yeo leonard L , wakerley benjamin , Ahmad Aftab , Paliwal prakash , ng kay , chong ong C , Ong Jonathan , hock luen teoh , chan bernard , seet raymond , venketsubramanian narayanaswamy , rathakrishnan rahul , kusuma yohanna , sharma vijay
Published: July 2021

Background:
The presence of effective collateral blood flow patterns may influence response to intravenously administered tissue plasminogen activator (IV-tPA) in acute ischemic stroke (AIS). We compared various existing methods of scoring collaterals on the pre-treatment computed tomographic angiogram (CTA) of the brain for a reliable prediction of functional outcome in AIS patients.

Methods:
Consecutive AIS patients treated with IV-tPA within 4.5 hours of symptom-onset during 2007-2011 were included. Data were collected for demographics, vascular risk factors, National Institute of Health Stroke Scale (NIHSS) scores and stroke subtypes. Intracranial collaterals were evaluated by 2 independent blinded neuroradiologists via 4 predefined criteria- Miteff’s system that grades middle cerebral artery (MCA) collateral branches with respect to the sylvian fissure; Maas system that compares collaterals on the affected hemisphere against the unaffected side; modified Tan’s scale where collaterals in 50% or more of the MCA territory are classified as good; and a 20-point collateral grading scale in regions corresponding to Alberta Stroke Program Early CT score (ASPECTS) methodology. Good functional outcomes at 3-months were determined by modified Rankin scale (mRS) scores of 0-1.

Results:
CTA was performed in 115 patients with anterior circulation AIS before IV-tPA bolus. Median age 66yrs (range 35-92), 42% males, median NIHSS 19 points (range 3-30) and median onset-to-treatment time 155 minutes. Overall, 52 (45.2%) patients achieved good functional outcome at 3-months. Univariable analysis revealed younger age, absence of diabetes, lower pre-tPA NIHSS scores and good collaterals according to ASPECTS methodology as significantly associated with good functional outcomes. On multivariable logistic regression, only lower NIHSS (OR 1.111 per NIHSS point; 95% CI 1.023-1.206, p=0.013) and good collaterals by ASPECTS methodology (OR 1.117 per point; 95%CI 1.006-1.241, p=0.039) were found as independent predictors of good outcomes.

Conclusion:
Of the existing intracranial collaterals scoring systems, only the ASPECTS methodology serves as a reliable predictor of favorable outcomes at 3-months in patients with anterior circulation AIS.