bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP6: Peri-procedural Complications of Endovascular Treatment for Acute Stroke in SWIFT Trial
Authors: Akins Paul , Amar Arun P , Pakbaz Sean , Fields Jeremy
Published: July 2021

Background:
Management of patients with ischemic stroke after endovascular treatment requires knowledge of peri-procedural complications. The SWIFT trial compared two devices (Merci and SOLITAIRE) in a randomized, prospective study. We reviewed peri-procedural complications of endovascular treatment and related clinical and technical factors.

Methods:
The SWIFT database was searched for major peri-procedural complications defined as: symptomatic intracranial hemorrhage (sICH) within 36 hours, symptomatic subarachnoid hemorrhage (SAH), air emboli, vessel dissection, major groin complications, and emboli to new vascular territories.

Results:
Major peri-procedural complications occurred in 18/144 patients (12.5%) at the following rates: sICH (4.9%); SAH (3.5%), air emboli (1.4%), vessel dissection (4.2%), major groin complications (2.8%), and emboli to new vascular territories (0.7%). We did not observe any statistically significant associations of complications with: age (<65 y 13.8% vs. >65 y 11.6%); type of center (academic 9.3% vs non-academic 13.9%); duration of stroke symptoms (<6h 11.1% vs 14.7% >6 h), NIH stroke scale score (NIHSS<20 12% vs. NIHSS >20,13.9%), iv thrombolytics (no iv tPA 10.5% vs iv tPA15.2%), atrial fibrillation (absent 10.1% vs present 14.7%), site of vessel occlusion (ICA 19.2%; MCA 11.5%); rescue therapy administered after endovascular treatment (no rescue 11.9% vs rescue 14.9%); or device (Merci 14.5%; Solitaire 11.2%). Comparing the Merci to the Solitaire retrieval device, we observed the following peri-procedural events:

Conclusion:
Detailed knowledge of peri-procedural complications is important for managing stroke patients after endovascular treatment. Fewer endovascular complications were observed after with SOLITAIRE device treatment compared to Merci device treatment, particularly symptomatic cerebral hemorrhage. Device registries will be helpful to gain deeper understanding of rare events.
Abstract TMP69: Endoglin Deficiency Exacerbates Ischemic Brain Injury
Authors: Shen Fanxia , Degos Vincent , Han Zhenying , Choi Eun-Jung , Young William L. , Su Hua
Published: July 2021

Background and Objective:
Endoglin (Eng) deficiency causes hereditary hemorrhagic telangiectasia (HHT) and impairs myocardial repair. Pulmonary arteriovenous malformations in HHT patients are associated with a high incidence of paradoxical embolism in the cerebral circulation and ischemic brain injury. We hypothesized that Eng deficiency exacerbates ischemic brain injury.

Methods:
Eng heterozygous (

Eng
+/-

) mice and wild type (WT) mice underwent permanent distal middle cerebral artery occlusion (pMCAO). Infarct volume and CD68
+
cells were quantified 3 days and vascular density was determined 60 days after pMCAO. Behavior was assessed by corner test and adhesive removal test at 3, 15, 30 and 60 days after pMCAO. Matrix metalloproteinase 9
(Mmp9)
and
Notch1
expression in bone marrow (BM)-derived macrophages from

Eng
+/-

and WT were analyzed using real-time RT-PCR.

Results:
Eng
+/-
mice had a larger Infarct volume than WT mice (22±6% of the affected hemisphere vs. 16±6%, p=0.04).

Eng
+/-

mice had longer adhesive-removal time (p<0.05) and more frequent turning to the lesion side than WT mice at 15, 30 and 60 days (p<0.05) after pMCAO. Both groups had similar numbers of CD68
+
cells in the peri-infarct area at 3 days after pMCAO (370±80 vs 338±44 cells/mm
2
, p=0.37), but
Eng
+/-
mice had lower peri-infarct vessel density (417±69 vs 490±52 vessels/mm
2
, p=0.05) at 60 days after pMCAO. Up-regulation of
Mmp9
and
Notch1
expression in response to VEGF was attenuated in
Eng
+/-
BM-derived macrophages.

Conclusions:
Endoglin deficiency exacerbated brain injury and behavior dysfunction in mice after pMCAO and was associated with reduced angiogenesis. Although macrophage homing was not affected, reduced expression of two angiogenic-related genes,
Mmp9
and
Notch1
, by
Eng
+/-
BM-derived macrophages suggests a potential role of these cells in recovery from an ischemic injury.
Abstract TMP71: Role Of Histone Deacetylases in Stroke-induced Oligodendrogenesis
Authors: Kassis Haifa , Chopp Michael , Liu Xian Shuang , Roberts Cynthia , Zhang Zheng Gang
Published: July 2021

Background:
Histone deacetylases (HDACs) are a superfamily of isoforms that deacetylate lysine residues in histones. HDAC activity is essential for oligodendrocyte (OLG) differentiation. The present study measured spatial profiles of individual HDACs in white matter during brain repair after stroke.

Methods and Results:
Adult male Wistar rats (n=8) were subjected to permanent right MCA occlusion and sacrificed 8 days later. Immunohistochemistry was performed on brain coronal sections with antibodies against HDACs, NG2 (a marker of oligodendrocyte progenitor cells, OPCs), and APC (a marker of OLGs). The numbers of immunoreactive cells were counted in peri-infarct and contralateral corpus callosum. Double immunofluorescent staining revealed that stroke significantly (p<0.05) increased the number of HDAC1 (HDAC1+/NG2+ cells, 166±7 vs.105±6 in contralateral), HDAC2 (HDAC2+/NG2+ cells, 130±4 vs. 98±2), and HDAC4 (HDAC4+/NG2+ cells, 74±5 vs. 56±4) positive OPCs, but did not significantly change HDAC5 positive OPCs. However, stroke only significantly increased the number of HDAC2 positive OLGs (HDAC2+/APC+ cells, 466 ±15 vs. 420±10), whereas the number of HDAC1 positive OLGs significantly decreased (HDAC1+/APC cells, 438±24 vs. 533±15, p<0.05). HDAC activity affects the acetylation (Ac) status of histone proteins (HH) within chromatin. We found stroke significantly decreased Ac-HH3+ OPCs (49±2 vs. 64±2) and Ac-HH3+ OLGs (311±16 vs. 356±13), which is consistent with elevation of HDAC activity in both cell types.

Conclusion:
Our data indicate that stroke induces different expression profiles of class I (1 and 2) and II (4 and 5) HDACs in OPCs and OLGs, suggesting that these HDACs could play distinct roles in stroke-induced oligodendrogenesis.
Abstract TMP77: Baseline Nihss-adjusted Time Window For Iv Tpa In Acute Stroke
Authors: Muchada Marian , Rubiera Marta , Pagola Jorge , Rodriguez- Luna David , Flores Alan A. , Sanjuan Estela , Piñeiro Socorro , Meler Pilar , Kallas Julia , Ribo Marc , Alvarez- Sabin Jose , Molina Carlos A.
Published: July 2021

Background:
Updated metaanalysis have shown that beneficial effect of iv tPA on functional outcome decreases progressively overtime until 4.5 h. However, given the differential pattern of arterial occlusion, stroke severity and speed of ischemic lesion growth among candidates for reperfusion, the time window should be adjusted accordingly. We aim to identify time windows for different categories of stroke severity and occlusion location.

Methods:
Were included patients treated according to the criteria of the European Summary of Product Characteristics for alteplase treatment < 4.5h in a Universitary Hospital from 2001- 2011. Patients were grouped according to NIHSS severity in minor NIHSS ≤ 8, moderate stroke NIHSS 9-15, severe stroke NIHSS ≥ 16. We sequentially analyzed time-to-treatment to achieve favorable outcome as mRS ≤ 2 at 3 months.

Results:
640 patients were included, of whom 123 patients (19.22%) with minor stroke, 205 (32.5%) with moderate stroke and 312 (48.75%) with severe stroke. The rate of favorable outcome was 79.8%, 62.5%, 24.2% respectively. In patients with minor stroke time-to-treatment did not predict outcome (OR 1.005, 95% CI: 0.997- 1.012; p = 0.264). After adjusting for age and occlusion location only age was a independent variable (OR 1.198; 95% CI: 1.054-1.336; p= 0.001). In patients with moderate stroke time-to-treatment ≤ 240 minutes predict favorable outcome (OR 0.041, 95% CI 0.160- 0.962; p= 0.041), although only age and occlusion location, were independent predictors: (OR 1.061, 95% CI 1.024- 1.098; p= 0.001) and (OR 2.968, 95% CI 1.293- 6.614; p= 0.010), respectively. In patients with severe stroke time-to-treatment ≤ 90 minutes predict favorable outcome (OR 0.428, 95% CI 0.186-0.985; p= 0.046). Adjusting for proximal occlusion, age and time-to-treatment before 90 minutes were independent variables: age (OR 1.045, 95% CI 1.014-1.077, p= 0.004) and time-to-treatment (OR 0.267, 95% CI 0.088- 0.809, p= 0.020)

Conclusions:
The impact of time-to-treatment on favorable outcome varies widely depending on baseline stroke severity. The window for favorable outcome was <90min for severe strokes and extends to <240min in moderate stokes. However, time-to-treatment appeared unrelated to functional outcome in minor stroke.
Abstract TP100: Meningeal Mast Cells Can Exacerbate Stroke Pathology In Mice
Authors: Arac Ahmet , Grimbaldeston Michele A , Nepomuceno Andrew R , Olayiwola Oluwatobi , Pereira Marta P , Vogel Hannes , Tsai Mindy , Galli Stephen J , Bliss Tonya M , Steinberg Gary K
Published: July 2021

Inflammation critically contributes to post-stroke brain damage. Mast cells (MCs), perivascular cells best known as effector cells involved in the development of inflammatory processes, have been reported to exacerbate stroke pathology. Unlike other immune cells, mature MCs do not circulate but are resident in virtually all anatomical sites, including brain parenchyma and meninges. Thus a key question is which tissue-specific MCs are important after stroke. To address this, we used ‘mast cell knock-in’ mouse models whereby genetically MC-deficient mice were selectively repaired of their MC deficiency by engraftment of in vitro grown mast cells.

Methods:
Two different MC-deficient mouse models (KitW-sh/W-sh and KitW/W-v) were used. For each model, 3 groups were tested: wild-type, MC-deficient, and MC-engrafted. Mice were subjected to 30 min occlusion of the middle cerebral artery. Brain swelling and infarct size were assessed by T2-weighted MRI and histology. The immune response was quantified by flow cytometry.

Results:
MC-deficient mice had less brain swelling at 3d post-stroke, and smaller lesions at 3d and 2wk post-stroke than their corresponding wild-type or systemically MC-engrafted groups, implying that MCs exacerbate ischemic injury. MC-deficient mice also had fewer brain granulocytes at 3d post-stroke compared to the other two groups. However, no MC-dependent changes in granulocyte numbers in blood and spleen were observed at 3d, suggesting a role for central nervous system (CNS) MCs in modulating granulocyte trafficking to the brain and stroke pathology. Analysis of the CNS MC distribution in wild-type and MC-engrafted mice revealed equivalent numbers of MCs in meninges in both groups but almost no MCs in brain parenchyma of MC-engrafted groups. This suggests that meningeal MCs, rather than parenchymal MCs, are key effectors of stroke pathology. To test this, MCs were engrafted locally into the meninges. These meningeal MC-engrafted mice had significantly more brain swelling, larger infarcts, and more brain granulocytes after stroke than MC-deficient mice.

Conclusions:
Our results support the conclusion that meningeal MCs can exacerbate stroke pathology. Hence, targeting these cells may be a novel therapeutic strategy for stroke.
Abstract TP117: MiR-15a/16-1 Cluster Inhibits Angiogenesis In Mouse After Ischemic Stroke
Authors: Yin Ke-Jie , Hamblin Milton , Zhang Jifeng , Zhu Tianqing , Chen Yuqing E
Published: July 2021

Angiogenesis may occur as a natural defense response against neurological diseases. Accumulating studies have shown that post-ischemic angiogenesis promotes functional recovery after ischemic stroke and is related to longer survival time in ischemic stroke patients. MicroRNAs (miRs) have been documented as a novel family of noncoding small RNAs that negatively modulate protein expression in various organisms. Recent studies have revealed important roles for miRs in regulating angiogenesis. However, the function of miRs in the angiogenic processes after ischemic stroke is unknown. We have previously demonstrated that the miR-15a/16-1 cluster has an anti-survival role in ischemia-induced endothelial cell death. Here we further investigate the role of the miR-15a/16-1 cluster in the regulation of post-ischemic angiogenesis. We have shown that expression of the miR-15a/16-1 cluster is significantly increased in the cerebral vasculature at the penumbral area 7 days after mouse middle cerebral artery occlusion (MCAO). Accordingly, in comparison with the wild-type animals, endothelial cell (EC)-selective miR-15a/16-1 transgenic overexpression leads to reduced cerebral blood vessel formation, increased brain infarction and neurological deficits in mice 7 days post-MCAO. Mechanistically, lentivirus-mediated miR-15a/16-1 gain- or loss-of-function reduces or increases FGFR1 and VEGF mRNA or protein levels in mouse cerebral vascular endothelial cell cultures, respectively. Through the bioinformatics analysis, 3’UTR luciferase reporter assays, and immunoassays, we further found that miR-15a and miR-16-1 bind to the 3’UTR of FGFR1 or VEGF mRNA, and directly inhibit FGFR1 and VEGF activities. Our findings suggest the miR-15a/16-1 cluster can suppress post-ischemic cerebral angiogenesis through direct inhibition of endothelial FGFR1 and VEGF activities. Elucidating the molecular mechanism of miR-15a/16-1 cluster-mediated angiogenesis will provide new insights into the understanding of miR function in the post-ischemic neurovascular remodeling and neurological recovery and open a new area with potential promise for further development of neurorestorative therapies after ischemic stroke.
Abstract TP137: Increased Survival of Malignant Middle Cerebral Artery Stroke Patients with Midline Shift and High Glasgow Coma Scale Undergoing Decompressive Hemicraniectomy
Authors: Ojeda Chris , Chitravanshi Nitya , Reid Patrick C , Duffis Ennis J , Prestigiacomo Charles J , Gandhi Chirag D
Published: July 2021

Intro:
Ischemic stroke of the middle cerebral artery often results in malignant cerebral edema leading to rapid clinical decline and midline shift. Decompressive hemicraniectomy (DHC) has been shown to improve clinical outcome in cases of malignant infarct but indications of when to perform it have not been well classified. This study focuses on patients who suffered malignant middle cerebral artery (MMCA) infarct and entered with mild brain injury (initial Glasgow Coma Scale≥13). Survival rates were compared among patients who received DHC versus medical treatment with a focus on midline shift.

Hypothesis:
Patients entering for MMCA with a Glascow Coma Scale ≥13who develop midline shift will have reduced mortality due to DHC relative to those with an entirely medical treatment.

Methods:
Retrospective review was performed on all cases consulted for neurological surgery from 2007-2012 at University Hospital. Patients were selected on the criteria of MMCA infarct. Midline shifts used were recorded prior to surgery or in the absence of surgery, 2-4 days post infarct. The primary endpoint was mortality at discharge. Multiple regression analysis was performed comparing the patient outcome to the degree of midline shift and if DHC occurred.

Results:
In total, 91 patients were referred to neurological surgery and 34 qualified with an initial Glasgow Coma Scale ≥13. Of those, 10 received a DHC, all with a midline shift and a survival rate of 70% (7/10). Exclusively medical treatment was done on 24 patients, 7 had midline shift reported with a survival rate of 29% (2/7) and 17 with no shift had a survival rate of 100% (17/17).The total medical survival rate was 79% (19/24). Regression analysis showed statistical significance (p<0.05) with mortality as the dependent variable and degree of midline shift (mm) and if DHC occurred as independent variables with GraphPad InStat 3.10.

Conclusion:
A statistically significant increase in survival has been found with use of DHC for MMCA infarct patients with a high Glasgow Coma Scale who have midline shift.
Abstract TP166: Noninvasive Fractional Flow on MRA Predicts Stroke Risk of Intracranial Stenosis in SONIA/WASID
Authors: Liebeskind David S , Kosinski Andrzej S , Lynn Michael J , Scalzo Fabien , Fong Albert K , Fariborz Pari , Chimowitz Marc I , Feldmann Edward ,   for the SONIA and WASID Investigators
Published: July 2021

Background:
Intracranial stenosis carries a high risk of recurrent stroke, but there is no noninvasive method to identify high-risk lesions. Fractional flow, or the pressure gradient across a stenosis, may identify hemodynamic effects and ischemic risk beyond percent stenosis of an artery. TOF-MRA signal intensity correlates with blood flow and may serve as a useful, noninvasive risk marker. We hypothesized that diminished TOF-MRA signal intensity distal to an intracranial stenosis predicts stroke risk.

Methods:
TOF-MRA of the intracranial circulation acquired prospectively in the SONIA-WASID trials was digitized to enable measurement of relative signal intensity immediately distal and proximal to symptomatic intracranial stenoses. The distal/proximal signal intensity ratio (SIR) was calculated from 3 mm regions of interest distal and proximal to symptomatic stenoses, correcting for background intensity and blinded to outcome. Univariate and multivariate analyses included clinical variables, SIR, and invasive angiography measures (luminal stenosis, TICI, collateral grade) to identify predictors for risk of stroke in the territory in this SONIA-WASID cohort.

Results:
189 patients with site-based 50-99% symptomatic intracranial stenosis in SONIA-WASID had TOF-MRA available. In a univariate analysis, the hazard ratio (HR) for stroke in the territory of the symptomatic artery with SIR < 0.9 (i.e. SIR below median) was 5.2 (1.8, 15.3; p=0.001) as compared to SIR ≥ 0.9. In a multivariate analysis correcting for baseline blood pressure, LDL, percent stenosis, recency of symptoms, TICI and downstream collaterals, the HR for SIR < 0.9 was 10.9 (2.0, 58.9; p=0.001). Only collaterals also had a significant independent association with stroke risk, HR 13.8 (3.4, 55.5; p<0.001). In the subset of patients with < 70% stenosis, a SIR < 0.9 maintained a significant association with recurrent stroke in the territory (p=0.006), with a two year event rate of 17.3%.

Conclusions:
Fractional flow assessed by TOF-MRA SIR may be a useful noninvasive tool to identify high-risk intracranial lesions, even in patients with moderate (< 70%) degrees of stenosis, and may be suitable for selection of high-risk patients for clinical trials or aggressive treatments.
Abstract TP208: Medullary Infarction is Associated with Severe Sleep Disordered Breathing
Authors: Fujii Shuichi , Shibazaki Kensaku , Sakai Kenichiro , Aoki Junya , Uemura Junichi , Kimura Kazumi
Published: July 2021

Background and Purpose:
A relationship between presence or severity of sleep disordered breathing (SDB) and site of lesion in ischemic stroke patients has been unclear. Our aim of the present study was to investigate the relationship between presence or severity of SDB and site of ischemic lesions in stroke patients.

Subjects and Methods:
Between April 2010 and March 2012, consecutive ischemic stroke patients within 24 hours of onset were prospectively enrolled. Ischemic lesions were identified by MRI on admission. Patient underwent sleep study to evaluate the presence and severity of SDB within 7 days after admission. SDB was defined as a respiratory disturbance index (RDI; apnea/hypopnea events per hour) ≥ 5, and severe SDB was defined as a RDI ≥ 40. We investigated the relationship between presence or severity of SDB and clinical characteristics including site of ischemic lesions.

Results:
A total of 214 patients (mean age 71.3, male 132) were enrolled. Supratentrial lesion was observed in 166 (77.6%) patients and right side lesion in 101 (47.2%) patients. Sites of ischemic lesions were as follows; cortex (n=11), subcortex (n=35), cortex plus subcortex (n=75), basal ganglia (n=57), thalamus (n=13), midbrain (n=3), pons (n=27), medulla (n=11), and cerebellum (n=22). Sleep study was performed at 4 days (median). The median RDI (IQR) was 20 (10-34). SDB patients were found in 187 (87%) patients. There were no significant differences in frequency of each site of lesions between SDB and non-SDB patients. Severe SDB was observed in 42 (19.6%) patients. Age (75 (70-83) vs. 72 (64-78), p=0.047), NIHSS score on admission (3 (1-10) vs. 7 (2-12), p=0.047), the frequency of atrial fibrillation (41% vs. 22%, p=0.012) and medullary lesions (12% vs. 4%, p=0.027) were significantly higher in severe SDB patients than non-severe SDB. Multivariate regression analysis demonstrated that medullary lesions (OR 5.5, 95%CI 1.41-21.8, p=0.014) was independently associated with severe SDB.

Conclusions:
Medullary lesion in stroke patients should be associated with severe SDB.
Abstract TP214: Hyperacute Plasma F2-Isoprostanes Predict Infarct Growth in Acute Ischemic Stroke
Authors: Lorenzano Svetlana , Rost Natalia S , Green Rebecca E , Thankachan Tijy , Dipietro Allison J , Arai Ken , Som Angel T , Pham Loc-Duyen D , Harris Gordon J , Lo Eng H , Feske Steven K , Blumberg Jeffrey B , Furie Karen L
Published: July 2021

Objectives:
Oxidative stress occurs as part of the earliest response to ischemia and is likely to play an important role in the pathogenesis of ischemic cerebral injury. We sought to evaluate whether hyperacute plasma concentrations of F2-isoprostane (F2-isoP), a biomarker of lipid peroxidation, predict infarct growth (IG), as a mediator of brain damage.

Methods:
We prospectively measured plasma F2-isoP, high sensitivity-C reactive protein, matrix metalloproteinase-2 and -9, Oxygen Radical Absorbance Capacity assay, and urinary 8-hydroxydeoxyguanosine in acute ischemic stroke (AIS) patients presenting within 9 h of symptom onset. Patients with a baseline DWI MRI and a 48-h DWI or CT scan were included to evaluate the final infarct volume (FIV). Baseline DWIV and FIV were analyzed using semi-automated volumetric method. IG was defined as the difference between FIV and baseline DWIV.

Results:
Of 489 AIS subjects, 220 [mean (SD) age 70.1 (15.1) y; 43.4% female; 40.5% treated with IV tPA] had both baseline DWI and follow-up imaging. Of these, 170 had IG of any size, and they were more likely to be male (p=0.032), to have prior transient ischemic attack (p=0.035) or diabetes mellitus (p=0.026), higher NIHSS score (p=0.001) and blood glucose levels (p=0.003) at admission, and higher median (IQR) baseline levels of F2-isoP [56.2 (36.4-75.3) vs. 42.0 (27.0-61.8) pg/mL, p=0.009]. Baseline F2-isoP and FIV (Spearman’s rho=0.19, p=0.009) as well as absolute IG volume (IGV) (Spearman’s rho=0.20, p=0.005) were significantly correlated. In a multivariable logistic regression model including all variables associated with IG at univariate p-value <0.05, as well as age and IV tPA, baseline F2-isoP emerged as an independent predictor of IG (OR 2.57, 95% CI 1.37-4.83; p=0.003). In linear regression model, baseline F2-isoP was independently associated with IGV (p=0.004). Inclusion of other biomarkers did not change the significance of F2-isoP in predicting IG (Bonferroni p <0.005).

Conclusions:
Elevated hyperacute plasma F2-isoP concentrations independently predict IG and IGV in AIS patients. If validated in future studies, measuring plasma F2-isoP might be helpful in the acute setting to stratify AIS patients for progression and relative severity of ischemic injury.
Abstract TP241: Race-ethnic Differentials Time and Acute Stroke Emergency Presentation: The ASPIRE Study
Authors: Boden-Albala Bernadette , Edwards Dorothy F , Wing Jeffrey J , Clair Shauna S , Fernandez Stephen , Morgenstern Lewis , Hsui Amie , Kidwell Chelsea
Published: July 2021

BACKGROUND:
There is sparse data about the nature of race-ethnic disparities in the acute stroke setting including differentials in stroke preparedness. The aim of this analysis was to explore race-ethnic differentials in time to arrival for acute stroke in a racial and ethnically diverse urban setting.

METHODS:
ASPIRE is a multi-dimensional intervention program (community, hospital, and EMS) for acute stroke preparedness targeted to increase IV tPA utilization in underserved black communities in the DC metro area. We prospectively identified stroke admissions and EMS utilization including acute stroke arrival time parameters for the 6 month pre and post intervention periods. Cox proportional hazards models were used to examine predictors of arrival time. Proportionality of the hazards was checked.

RESULTS:
In the 6 month pre-intervention period, data was collected on 943 stroke cases; 53% female; 74% black; mean age 67 yrs. Of the subjects from the pre-intervention period with arrival times less than 48 hrs, the median arrival time to the emergency department (ED) was 9 hours; 20% presented under 3 hours. In multivariable Cox PH models, subjects were 38% more likely to arrive earlier if they had arrived by EMS (HR: 1.38, 95%CI: 1.21-1.58). Black subjects were 25% less likely to arrive earlier (HR: 0.75, 95%CI: 0.60-0.93), but this effect was dampened over time (p=0.03). The model included the interaction between black race and time and adjusted for insurance status, risk factors (hypertension and diabetes), gender, age and prior stroke. Ina gender by race analysis, there was a trend towards black women being less likely to arrive earlier to the ED (HR 0.78, 95% CI 0.6 -1.0). However, overall, there was no race-ethnic interaction with arrival by EMS.

CONCLUSIONS:
Contrary to the perceived perception by the community suggesting there is a disparity in EMS utilization by the black DC community, we found no overall significant racial difference in EMS utilization for acute stroke. While there was a trend towards delayed overall arrival in black females, this was independent of EMS utilization.
Abstract TP242: Intravenous rt-PA Therapy for Acute Ischemic Stroke in the Kagawa Prefecture in Japan -Results and Patient Characteristics
Authors: Hayashi Naoki , Osaka Naohiro , Kawauchi Masamitsu , Yoshino Kimihiro , Kannuki Seiji , Masaoka Tetsuya , Kagawa Msahiro , Kawakita Kenya , Tamiya Takashi
Published: July 2021

Background and Purpose:
The Kagawa prefecture is the region of Japan with the highest utilization rate of intravenous (i.v.) rt-PA treatment per 100,000 people over the age of 65. We retrospectively reviewed patient characteristics and results of this therapy for seven stroke centers in the Kagawa prefecture over the last three years.

Methods:
273 patients received i.v. rt-PA treatment between January 1, 2009 and December 31, 2011. Stroke subtype, NIHSS at admission, mRS (modified Rankin Scale) at discharge, mRS by each obstructed artery, incidence of symptomatic intracranial hemorrhage (sICH), and location at the onset were recorded for all patients.

Results:
The mean age was 73.9 years and male/female ratio was 1.55. The proportion of cardioembolic stroke was 53.1%. The mean baseline NIHSS was 13.8 points. Excellent outcome (mRS 0 to 1) at discharge was present in 19.2%, favorable outcome (mRS 0 to 2) in 31.4%, and poor outcome (mRS 5 to 6) in 31.0%. The overall mortality (mRS 6) was 11.4% and sICH occurred in 5.1%. Cardiogenic infarction had less favorable outcomes than other stroke subtypes. Excellent outcome was achieved in 29.0% of M2 occlusions, 9% in Ml occlusions and 5.9% in ICA occlusions. Patients with ICA occlusion had the worst prognosis with poor outcome in 55.9% compared to 43.3% for Ml occlusion and 18.4% for M2 occlusion. The mortality of ICA occlusion was 35.3%.

Conclusions:
Our patient background and safety characteristics (such as incidence of sICH and mortality) are comparable to the Japanese J-MARS post-marketing surveillance study. However, our outcomes are less favorable than those in previous reports. Cardiogenic infarction and major artery occlusion (such as Ml or ICA) are particularly poor prognostic factors. Sixteen neurological institutes can administer i.v. rt-PA treatment in Kagawa, all with access to MRI scanners 24/7. Despite this excellent medical environment, problems remain related to regional and topographic factors such as patients living on islands and mountainous areas. In this study, we report the challenges, treatment strategies and results for the treatment of acute stroke in the Kagawa prefecture.
Abstract TP249: Drip, Drive, and Retrieve - New Application of Mobile Neuro IVR Team -
Authors: Takenobu Yohei , Ishii Akira , Yoshida Kazumichi , Kikuchi Takayuki , Ando Mitsushige , Yamao Yukihiro , Chihara Hideo , Takezawa Masahiro , Koike Kaoru , Miyamoto Susumu
Published: July 2021

[Background and Purpose]
Neuro-interventional radiology (NIVR) is increasingly recognized as an essential option for acute stroke treatment. However, the access to NIVR physician or NIVR-capable hospital is still limited. Patient transfer system between primary stroke centers (PSCs) and comprehensive stroke centers has a problem about deterioration during transfer, insufficient information transmission, small area coverage, and loss of time. We organized a mobile NIVR team consisting of 6-7 board certified NIVR physicians, and concluded a NIVR alliance program with affiliating PSCs. The team performed procedures at the local sites on request of PSCs.

[Methods]
Between 2008 and 2012, we concluded a NIVR alliance program with 7 affiliated PSCs. The team dispatched NIVR physicians to the PSCs immediately after receiving "rescue call." Clinical information including medical images was updated in real-time and interactive manner during travel.

[Results]
We received 23 calls and reacted to all cases. We treated 8 cases of acute ischemic stroke (6 mechanical thrombectomy, 3 carotid stenting, 5 for non-responder to intravenous rt-PA), and 15 for subarachnoid hemorrhage (14 aneurysm embolization, one parent artery occlusion). The mean travel distance was 39.0 km (min - max: 6.3 - 90.3). For acute ischemic stroke, the mean "door-to-puncture time" was 154 minutes (min - max: 130 - 168). For subarachnoid hemorrhage, procedure was performed on the onset or the next day. All the procedure were successfully performed and no deterioration related to procedure were observed.

[Conclusions]
The new application of NIVR delivery system can safely enable to avoid deterioration during transfer, cover larger area without delay, and enlarge the opportunity to access NIVR therapy for acute stroke patients.
Abstract TP254: Clot Dissolution Is Better With Ultrasound Assisted Thrombolysis For Fresh Clots With Higher Cholesterol Content
Authors: Ahmad Aftab , yeo leonard L , Zhou Yufeng , Murugappan Kanna S , sharma vijay
Published: July 2021

Background:
Intravenous tissue plasminogen activator (IV-tPA) remains the only drug for arterial recanalization in acute ischemic stroke (AIS). Clot composition differs according to the stroke etiology- clot from heart being fresh and rich in fibrin while the clot from an ulcerated plaque is rich in cholesterol. These characteristics might influence the therapeutic response to tPA as well as ultrasound-enhanced thrombolysis. We evaluated the impact of cholesterol content and age of the clot on its dissolution with tPA and ultrasound in an in-vitro model.

Methods:
Clot was prepared by mixing horse blood with Calcium-chloride solution. Cholesterin was added to increase cholesterol level up to 100 mg/dL. Periodic serum replacement was used to ‘age’ the clot. The clots were exposed to continuous 2-MHZ diagnostic transcranial Doppler (TCD) ultrasound (acoustic intensity 340mW/cm2) during thromolysis with tPA (355 IU/ml). Efficiency of thrombolysis was calculated as the percentage of clot weight-loss after 60 minutes. Clot characteristics after lysis were evaluated with surface emission microscope (SEM).

Results:
Significant increase in the weight of clot occurred with its increasing age (from 2 to 10 hours, the clot-weight increased from 37.28±2.87mg to 51.56±5.34mg; p<0.005). Exposure to ultrasound and tPA resulted in significant reduction in the clot-weight at 1 hour (from 35.50±3.23% to 24.71±2.11%; p<0.005). Although, no significant differences were noted between clot-cholesterol levels and lysis with TCD or tPA alone, combination of these modalities induced significant lysis in clots with higher cholesterol levels (clot-weight reduced by 41.68±2.3%) as compared to clots with normal cholesterol (30.60±4.10%; p<0.005). SEM demonstrated thicker and denser fibrin network in aged clots while higher number of activated platelets were noted on the surface of cholesterol-rich clots.

Conclusion:
Ultrasound-assisted thrombolysis with tPA work better for fresh thrombi with higher cholesterol levels. Our findings provide insights into the differential recanalization rates in acute ischemic stroke of various etiologies
Abstract TP276: Stroke in Infective Endocarditis: Impact of Management on Outcome Over 3 Decades
Authors: Kursun Oguzhan , Topcuoglu Mehmet A , Karatas Hulya , Buonanno Ferdinando S , Singhal Aneesh B
Published: July 2021

Background:
Stroke is a common, serious complication of infective endocarditis (IE). It is not known how recent advances in management have changed the profile and outcome of IE-related stroke.

Methods:
We retrospectively reviewed data of all inpatients with ICD-9 diagnostic codes of IE admitted to our tertiary hospital from 1980-2011. Original Duke Criteria were used to confirm the diagnosis. Data was compared over 3 time epochs: 1980-1990 (E1), 1991-2000 (E2) and 2001-2011 (E3).

Results:
Of 1151 hospitalizations (1083 adults), 277 included IE-related stroke (76% ischemic, 13% hemorrhagic, 10% both). There was an increasing rate of stroke over the 3 epochs (E1 25%, E2 30%, E3 45%; p<0.001), perhaps due to increased detection from increasing MRI use (E1 6%, E2 27%, E3 67%; p<0.001). Stroke patients had mean age 56 yrs, 63% male, 93% definite IE per Duke Criteria and 83% native valve infection. Organism types were staph 40%, strep 30% and other 30%. Trans-esophageal echo was performed in 53%. Over time there was no change in age, gender, and organism type; however there was an increasing frequency of native valve infection (E1 74%, E2 82%, E3 88%; p=0.04), ‘definite’ IE (E1 80%, E2 94%, E3 100%; p<0.001), cardiovascular risk factors (hypertension, diabetes, etc), and more patients underwent TEE (E1 9%, E2 67%, E3 68%; p<0.001). Brain imaging showed higher detection of multiple (vs. single) lesions (E1 67%, E2 66%, E3 88%; p<0.001), and ischemic (vs. hemorrhagic) strokes (E1 74%, E2 84%, E3 95%; p<0.001), presumably due to increasing MRI use, although the frequency of anticoagulant use also decreased (E1 45%, E2 35%, E3 26%; p=0.04). There was a trend towards improved outcome (p=0.12) with fewer deaths in 2001-2011 vs. 1980-2000 (22% vs. 33%; p=0.06). Logistic regression showed that age, anticoagulant use, stroke type, MRI performance, but not organism type or time epoch, predicted death at discharge.

Conclusion:
This large retrospective study spanning 3 decades shows important changes in the profile of IE-related stroke. While patient demographics and organism type appear unchanged, there is a higher rate of stroke detection and lower rates of complications such as brain hemorrhage and death rates, suggesting efficacy of recent diagnostic and management advances.
Abstract TP287: Prolongation of Hospital Stay Following Acute Ischemic Stroke
Authors: Siegler James E , Fowler Bethena D , Boehme Amelia K , Albright Karen C , Martin-Schild Sheryl
Published: July 2021

Introduction:
Prolonged length of stay (pLOS) is associated with increased costs and risk for hospital-acquired conditions as well as worse prognosis. Awareness of risk factors for pLOS may help neurohospitalists reduce LOS by heighted preventative measures..

Hypothesis:
Admission information and hospital course may help predict pLOS, and this directly correlates with functional outcome.

Design/Methods:
Patients with acute ischemic stroke (AIS) admitted to our center between 7/2008-12/2010 were retrospectively identified. Exclusion criteria were presentation >48hrs since last seen normal (LSN) and unknown time of LSN. pLOS was defined as hospitalization extended for ≥24 hours more than would be necessary to prepare the patient for discharge as determined by review of progress notes. Causes of pLOS were categorized as follows: neurological complications, medical complications (included hospital-acquired infections), imaging, procedures, and disposition. We investigated admission data elements associated with pLOS.

Results:
Of the 596 patients included, 190 (31.9% of patients) had pLOS. Patients with pLOS were more likely to have hypertension (83.8% vs. 71.8%, p=0.0033) and higher admission NIHSS (8 vs. 5, p=0.0002) than patients without pLOS. LOS was prolonged for >1 reason in 40 (60.6%) cases. The most common reason for pLOS was a medical complication (61.6%), followed by delays in disposition arrangement in nearly half (45.3%).A larger proportion of patients with pLOS developed an infection (37.4% vs. 18.4%, p<0.0001). A larger proportion of patients with pLOS were discharged to inpatient rehabilitation (42.3% vs. 24.2%, p<0.0001) and skilled nursing facilities (9.6% vs. 5.0%, p=0.0387) while a smaller proportion were discharged to home (32.7% vs. 52.5%, p<0.0001).

Conclusions:
In our population, a large percentage of patients who suffer from AIS are hospitalized for periods longer than necessary. Major reasons for pLOS are hospital-acquired infection and delayed disposition. Because pLOS increases the risks of hospital-acquired infection and deconditioning, and it consumes more healthcare dollars, it is important to minimize the risk of infection and plan patient disposition early during hospitalization.
Abstract TP299: Lone Intraventricular Hemorrhage Frequently Harbors Vascular Malformations And Has Better Clinical Outcomes Than When Associated With Small Parenchymal Component
Authors: Taqui Ather , Koffman Lauren , Hussain Muhammad S , Uchino Ken
Published: July 2021

Background:
Primary intraventricular hemorrhage (PIVH) is an uncommon neurological event which can cause significant morbidity. The current literature comprises of small case series that include two types of PIVH: 1) blood restricted to the ventricular system only 2) predominant IVH plus a small parenchymal component.

Hypothesis:
We hypothesized that these two types represent different clinical entities and have key differences in their clinical, diagnostic and prognostic profiles.

Methods:
We performed a retrospective chart review over last 3 years from our center’s database. Neuroradiology reports of initial CT scans from all cases of intracranial hemorrhage (ICH) were reviewed to capture patients. Then CT images were reviewed and classified into pure IVH or IVH with small intraparenchymal hemorrhage within 15mm of the ventricular wall (IVH/sICH). Exclusion criteria included presence of subarachnoid hemorrhage and head trauma.

Results:
Out of 846 ICH patients, 25 patients (3%) were identified as pure IVH and 26 (3.1%) as IVH/sICH. Median ages were 72 and 61 years, and females were 17 (68%) and 14 (54%) without significant difference. Pure IVH was found to have significantly higher rate of cerebral angiogram performance (60% vs 26.9%, p=0.02), more frequent etiology of arteriovenous malformations (AVM) or arteriovenous fistula (32% vs 3.8%, p=0.01), better early clinical outcomes measured by median modified Rankin score at discharge (4 vs 5, p=0.05) and lower in-hospital mortality (0% vs 23.1%, p=0.02). IVH/sICH group was found to have significantly higher rate of focal findings on presentation (p=0.02) and past history of HTN (p=0.02). No significant differences were found between the groups in clinical presentation, admission blood pressure, pre-admission antiplatelet and anticoagulation therapy, severity of IVH on CT, CT angiogram findings, and in-hospital complication and treatment.

Conclusion:
Clinical presentation was not different between pure IVH and IVH with small parenchymal component. Pure IVH patients received a more aggressive diagnostic approach, had more frequent diagnosis of vascular malformation, and had better early clinical outcomes.
Abstract TP301: Warfarin Increases Risk of Future Intracerebral Hemorrhage in Patients Presenting with Isolated Lobar Microbleeds on MRI
Authors: van Etten Ellis S , Auriel Eitan , Haley Kellen E , McNamara Kristen A , Ayres Alison M , Vashkevich Anastasia , Schwab Kristin , Rosand Jonathan , Viswanathan Anand , Greenberg Steven M , Gurol M Edip
Published: July 2021

BACKGROUND/OBJECTIVES:
Lobar microbleeds (LMB) are increasingly identified on brain MRI of older adults, suggesting a diagnosis of cerebral amyloid angiopathy (CAA) in the absence of intracerebral hemorrhage (ICH). Identifying the baseline characteristics and risk of future ICH of these subjects is important to understand their prognosis and safety of antithrombotic use in this setting.

METHODS:
Baseline characteristics (demographics, risk factors, APOE genotype), markers of CAA severity (LMB counts, white matter hyperintensity volume), and finally outcomes during a mean follow up of 4 years (incidence rate of ICH and case-fatality) were compared between 62 CAA patients without and 747 with ICH diagnosed using Boston criteria upon enrollment. The association between antithrombotic use and risk of incident ICH was explored in patients presenting with isolated LMBs after adjusting for covariates listed above.

RESULTS:
Female gender (52% vs. 37% p=0.023) and hypertension (67% vs. 53% p=0.025) were more common in patients presenting with ICH, other baseline characteristics did not differ. Patients presenting without ICH had more LMBs (median 10 vs. 1 p<0.001), and higher white matter hyperintensity volume (38cc±32 vs. 27cc ±24 p=0.008) than patients with ICH even after correction for other covariates. Patients without ICH on enrollment had a lower but non-trivial incidence rate of ICH during follow-up (4.8 per 100 person-years vs. 9 per 100 person-years; RR: 0.56, 95%CI 0.27-0.97). The case-fatality rates were similar between these groups (p=0.5). In patients presenting without ICH, the use of Warfarin was an independent predictor of future ICH (p=0.02) in the multivariate model. Patients using either ASA 325mg/day OR Clopidogrel OR ASA/Dipyridamol had higher risk of future ICH (p=.049) but this association did not remain significant in multivariate model. Use of ASA 81mg daily was not a predictor of incident ICH risk.

CONCLUSIONS:
Patients presenting with LMBs on MRI have a clinical, genetic, and neuroimaging profile suggestive of severe CAA pathology. They have a considerable risk of incident ICH albeit lower than patients who had a prior lobar ICH. The use of warfarin increases the risk of future ICH in patients with isolated LMBs on MRI.
Abstract TP304: Conjugate Eye Deviation in Acute Intracerebral Hemorrhage: Stroke Acute Management With Urgent Risk-factor Assessment and Improvement (SAMURAI) -ICH Study
Authors: Sato Shoichiro , Koga Masatoshi , Yamagami Hiroshi , Okuda Satoshi , Okada Yasushi , Kimura Kazumi , Shiokawa Yoshiaki , Nakagawara Jyoji , Furui Eisuke , Hasegawa Yasuhiro , Kario Kazuomi , Arihiro Shoji , Nagatsuka Kazuyuki , Minematsu Kazuo , Toyoda Kazunori
Published: July 2021

Background and Purpose:
Conjugate eye deviation (CED) occurs frequently in patients with acute stroke. The purpose of this study was to elucidate the factors that correlate with CED, as well as the relationship between CED and outcomes, in patients with acute intracerebral hemorrhage (ICH).

Methods:
A total of 211 patients with acute supratentorial ICH were recruited in a multicenter, prospective study. Both on admission and 72 hours later, CED was assessed with an NIH Stroke Scale “best gaze” subscore of ≥1. Hematoma location and volume were assessed on CT within 2.5 hours of onset.

Results:
Ninety-six (45%) patients had CED on admission. On multivariable analysis, right-sided lesion (OR 2.36, 95% CI 1.18-4.93), hematoma volume (OR 1.07, 95% CI 1.04-1.10 per 1 mL), and baseline GCS score (OR 0.66, 95% CI 0.53-0.80 per 1 point) were independently associated with CED. After adjusting for sex, age, intraventricular extension of the hematoma, baseline GCS score, and hematoma volume, the presence of CED both on admission and 72 hours later was an independent predictor of death or dependency at 3 months post-stroke (OR 5.77, 95% CI 2.27-16.94). The optimal cutoff volume of hematoma related to CED was ≥13.5 mL for patients with putaminal hemorrhage (sensitivity, 76%; specificity, 72%) and ≥7.7 mL for patients with thalamic hemorrhage (sensitivity, 82%; specificity, 83%).

Conclusions:
The persistence of CED was a significant predictor of death or dependency after acute supratentorial ICH even after adjusting for initial severity and hematoma volume. CED can be evoked by a relatively smaller thalamic hematoma than a putaminal hematoma. Bedside assessment of CED appears to provide valuable information related to chronic outcomes of patients with ICH.
Abstract TP307: Validation of Clinical Prediction Scores in Patients with Primary Intracerebral Hemorrhage
Authors: Zarghouni Mehrzad , Garrett John S , Daoud Yahya A , Layton Kennith F
Published: July 2021

Background and Purpose:
Despite advances in medical and surgical management, intracerebral hemorrhage (ICH) continues to be associated with significant mortality and morbidity. Several clinical prediction scores (CPS) have been developed to aid in predicting the clinical outcome based upon initial presentation. This study aimed to validate and compare several of the most recently developed CPS to their traditional counterparts.

Methods:
We retrospectively reviewed 501 consecutive patients with ICH who were admitted from the Emergency Department to the a large healthcare system in Dallas, TX between the dates of 6/1/2009 and 6/1/2011. To validated and compared the FUNC, oICH, and ICH-GS CPS the area under the receiver operating characteristic curves were calculated based upon the ability to predict 90 day mortality and good neurologic outcome (GNO) at the time of discharge, defined as a Glasgow Outcome Score of >4. The sensitivity, specificity, and predictive values of the different ICH scores were computed to determine the test’s ability to identify those without GNO.

Results:
Of the 501 patients with intracranial hemorrhage, 104 were excluded due to a recognized etiology of their ICH. Complete data was not available in 31 patients. In the resultant 366 patients, the overall mortality at the time of discharge was 114 (31%), 30 (9.5%) of which underwent craniotomy. Of the 252 patients who survived to discharge, 91/252 (36%) survived with GNO. Both the FUNC (AUC: 0.873) and ICH-GS (AUC: 0.888) had similar predictive values and outperformed the oICH (AUC: 0.743) in predicting 90 day mortality (p=<0.001). Similar performance was seen in predicting neurologic outcome at discharge. Table 1. Analysis of ROC Area Under the Curve (AUC) by Outcomes and CPS scores
* Significant different from the other two CPS Scores

Conclusion:
Overall, the FUNC and ICH-GS CPS appear superior to the oICH in our population.