bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WMP31: Vessel Wall Enhancement is Associated With Clinical and Imaging Markers of Aneurysm Instability
Authors: Sommaruga Samuel , Cord Branden , Molhotra Ajay , Johnson Michele , Minja Frank J , Gunel Murat , Sheth Kevin , Herbert Ryan , Melnikov Fjodor , Schaller Karl , Mandell Daniel , Bijlenga Philippe , Falcone Guido J , Matouk Charles C
Published: October 2018

Objective:
It remains unclear whether patients with unruptured intracranial aneurysms (UICAs) should be treated. Vessel wall enhancement (VWE) in vessel wall MRI is emerging as a useful biomarker of aneurysm instability. We sought to evaluate whether VWE correlates with clinical and radiological markers of aneurysm instability in patients with UICAs.

Methods:
We conducted a retrospective analysis of a prospective cohort of patients with UICAs imaged with vessel wall MRI. Two blinded reviewers evaluated the presence of VWE. Univariate and multivariate logistic regression modelling was utilized to assess for association between VWE and (1) presence of cranial nerve palsy (CNP) and thunderclap headache on presentation, two well-established clinical markers of aneurysm instability; and (2) aneurysm size, a well-established radiological marker of aneurysm instability.

Results:
94 patients with UICAs were included in the analysis; of these, 34 (36%) had VWE, 60 (64%) did not, 10 (11%) had CNP, 14 (15%) presented with thunderclap headache, and 40 (43%) had aneurysms >7mm in size. Inter-rater reliability for VWE ascertainment was excellent (kappa 0.86, 95%CI 0.75-0.97). 9 out of 10 patients (90%) with CNP had VWE (association testing not possible due to sparse counts). In multivariable analysis, thunderclap headache (OR 8.55, 95%CI 1.89-45.64; p=0.007) and aneurysm size (1.26, 95%CI 1.10-1.50; p=0.003) were independently associated with VWE.

Conclusions:
VWE independently associates with clinical and radiological markers of aneurysm instability. Prospective studies are needed to evaluate the clinical utility of this imaging biomarker.
Abstract WMP34: Association Between Unruptured Intracranial Aneurysm and Downstream Stroke
Authors: Chen Monica L , Gupta Ajay , Gialdini Gino , Merkler Alexander E , Navi Babak B , Kamel Hooman
Published: October 2018

Introduction:
Case reports suggest that unruptured intracranial aneurysms may serve as a nidus for thrombus formation and downstream embolic stroke. However, few data exist to support an association between unruptured aneurysms and ischemic stroke.

Hypothesis:
Unruptured intracranial aneurysms are more common ipsilateral than contralateral to the side of cerebral infarction.

Methods:
We conducted a within-subjects study among acute ischemic stroke patients prospectively enrolled in the Cornell AcutE Stroke Academic Registry (CAESAR) who had magnetic resonance imaging (MRI) of the brain and angiography (MRA) of the head within 14 days of admission. The presence and characteristics of aneurysms were retrospectively ascertained from the neuroradiologist’s clinical report of the MRA findings by a reviewer blinded to the study hypothesis. McNemar’s test for paired data was used to compare the prevalence of unruptured aneurysms ipsilateral versus contralateral to the side of cerebral infarction. Aneurysms without sidedness (basilar and anterior communicating artery) were not counted as aneurysms in the analysis.

Results:
Among 1,310 patients registered in CAESAR during 2011-2014, 686 patients met our inclusion criteria, of whom 75 (10.9%; 95% confidence interval [CI], 8.6-13.3%) had an intracranial aneurysm (33 on the left versus 39 on the right). The prevalence of aneurysms did not differ significantly on the side ipsilateral versus contralateral to the infarction (risk ratio [RR], 1.1; 95% CI, 0.7-1.6). There was no significant association between aneurysms and ipsilateral stroke in sensitivity analyses that included only the 554 patients with stroke in a single arterial territory (RR, 1.1; 95% CI, 0.5-2.2), included only the 282 patients with cryptogenic stroke (RR, 1.4; 95% CI, 0.8-2.4), or included only the 221 patients with cryptogenic stroke in a single arterial territory (RR, 2.0; 95% CI, 0.7-5.4).

Conclusions:
Contrary to our hypothesis, we found no significant association between unruptured intracranial aneurysms and ipsilateral ischemic stroke in a single-center stroke registry.
Abstract WMP38: Acute Administration of Chlorpromazine and Promethazine Reduces Brain Apoptosis in Ischemic Stroke
Authors: Stone Christopher , Peng Changya , Geng Xiaokun , Ding Yuchuan
Published: October 2018

Introduction:
In recent studies conducted by our lab, acute administration of chlorpromazine and promethazine (C+P) in ischemic stroke has been shown, through the induction of a metabolically-slowed, hibernation-like state, to reduce infarct size and neurological deficit, and thus to exert a neuroprotective effect on infracted subjects. Although its mechanism has not been fully elucidated, this effect is associated with alterations in the expression of protein kinase C-δ (PKC-δ) and Akt. Because PKC-δ and Akt are also known to be involved in the regulation of apoptotic cell death after ischemic stroke, we hypothesized that treatment with C+P would result in reductions in post-ischemic apoptosis. Additionally, because the neuroprotective effect of C+P is associated with reductions in NADPH oxidase (NOX) expression and activity, and because of the involvement of NOX in the PKC-Akt apoptotic pathway, we hypothesized that adding a NOX inhibitor would potentiate the anti-apoptotic effect of C+P.

Methods:
8mg/kg C+P with or without a NOX inhibitor was administered intraperitoneally to Sprague-Dawley rats subjected to 2h MCAO, followed by 6 or 24h reperfusion. The amount of apoptotic cell death in control, non-treatment ischemic, and all treatment ischemic groups was quantified using ELISA for cytoplasmic histone-associated DNA fragments. Levels of pro-apoptotic (caspase-3, BAX, and AIF) and anti-apoptotic (Bcl-2 and Bcl-xL) proteins were determined by Western blot.

Results:
Rats treated with C+P followed by 6h and 24h reperfusion demonstrated significant reductions in apoptotic cell death, increased expression of anti-apoptotic proteins, and decreased expression of pro-apoptotic proteins, compared with counterparts in the non-treatment ischemic group. Rats treated with C+P together with a NOX inhibitor exhibited further reductions in apoptotic cell death.

Conclusion:
These results demonstrate that C+P administration causes significant reductions in apoptotic cell death following ischemic stroke, when measured both at 6 and 24h reperfusion, and that addition of a NOX inhibitor potentiates this reduction. Therefore, the neuroprotective function observed upon C+P administration appears to involve the prevention of post-stroke apoptosis.
Abstract WMP5: Triage to a Comprehensive Stroke Center Based on CT Perfusion Imaging versus No CT Perfusion Imaging at the Spoke Hospital
Authors: Aguilar-Salinas Pedro , Aghaebrahim Amin , Cortez Gustavo M , Sauvageau Eric , Hanel Ricardo
Published: October 2018

Background and Objective:
Use of Computed Tomographic Perfusion (CTP) imaging at a referring hospital may help triage and shorten door-to-puncture time for patients with acute ischemic stroke.

Methods:
We conducted a single center retrospective review of a prospectively maintained database of consecutive ischemic stroke patients transferred to our center for consideration of endovascular therapy. Patients were divided into two groups. Group 1 consisted of patients transferred from a facility where CTP (using automated RAPID software) was routinely performed and group 2 consisted of patients transferred from a facility that did not perform perfusion imaging.

Results:
We identified a total of 132 patients all of whom were transferred to our center from April of 2014 to April of 2017. There were no differences in baseline characteristics between two groups. A total of 34 patients were transferred from a facility with RAPID CTP (Group 1) and 98 were transferred from a facility with no CTP (Group 2). Door-to-puncture time was significantly lower for patients in Group 1 compared with Group 2 (median [IQR], 12 [8 - 16] minutes and 48.5 [32.8 - 71.8] minutes, p<.001). Despite having additional imaging in Group 1, there was no difference in door-in and door-out times at the referring facilities compared with group 2.

Conclusions:
We found that triaging from a primary stroke center with CTP ability significantly reduced door-to-puncture time as compared with transferred patients with no perfusion imaging without any significant delay in transfer process.
Abstract WMP50: A Shift in the Population Distribution of Systolic Blood Pressure as a Contributor to the Decline in Stroke Mortality
Authors: Lackland Daniel T , Howard Virginia J , Moy Claudia S , Cushman Mary , Oparil Suzanne , Safford Monika M , Kleindorfer Dawn O , McClure Leslie A , Judd Suzanne E , Flaherty Matthew , Kissela Brett M , Unvergazt Fredrick Z , Howard George
Published: October 2018

Introduction:
Between 1960 and 2006, stroke mortality in the U.S. has declined a remarkable 65% for white men (123.4 ◊ 42.8 per 100,000), 61% for white women (108.6 ◊42.3 per 100,000), 67% for non-white men (178.4 ◊ 59.5 per 100,000) and 70% for non-white women (175.2 ◊ 52.0 per 100,000). With hypertension being the predominant risk factor for stroke, we examined the population shift in systolic blood pressure (SBP) levels over this period.

Methods:
The Charleston Heart Study (CHS) and Evan County Study (EC) were population-based cohorts recruiting black and white participants in the early 1960’s, conducted in the coastal plain regions of SC and GA respectively. REasons for Geographic And Racial Differences in Stroke (REGARDS) is a population-based study recruiting black and white participants in the contiguous U.S. For purposes of this report, CHS/EC participants were limited to those over 45 years, and REGARDS participants were restricted to residents of the coastal plain of NC/SC/GA.

Results:
SBP data are available on 1,988 whites and 1,172 blacks from CHS/EC, and from 4,057 whites and 2,237 blacks from REGARDS. Dramatic changes in the distribution of SBP have occurred over these 40+ years, with the 25
th
percentile of CHS/EC being consistently above the 75
th
percentile for REGARDS (see figure). For example, for whites aged 65-74, the 25
th
, 50
th
, and 75
th
percentile of SBP in CHS/EC was 144-162-184 mmHg, compared to 118-126-137 mmHg in REGARDS. For blacks, the corresponding percentiles were 158-180-204 mmHg in CHS/EC, and 119-129-140 mmHg in REGARDS. In CHS/EC, 125 of 1988 (6%) whites, and 245 of 1172 (20%) blacks had a SBP of 200+ mmHg; compared to only 4 of 4057 (0.1%) whites and 3 of 2235 (0.1%) blacks in REGARDS.

Discussion:
A dramatic shift in the distribution of systolic blood pressure, likely related to both population shifts in blood pressure and the advent of antihypertensive therapy, is likely a major contributor to the steep decline in stroke mortality.
Abstract WMP58: Ambulatory Care for Secondary Prevention of Stroke in Rural versus Urban Areas in Ontario, Canada
Authors: Jeyakumar Geerthana , Tu Jack V , Austin Peter C , Hall Ruth , Chu Anna , Khan Anam M , Jin Albert Y , Martin Cally , Manuel Douglas , Silver Frank L , Swartz Rick , Kapral Moira K
Published: October 2018

Introduction:
Residents of rural areas may have limited access to certain health care services. However, little is known about rural-urban differences in stroke secondary prevention care, or in the risk of recurrent stroke and death. We used linked population-based administrative databases from the province of Ontario, Canada, to assess the association between rural residence and ambulatory processes of care for secondary stroke prevention, as well as the incidence of recurrent stroke.

Methods:
We studied a sub-population of the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort, comprised of individuals between ages 40 to 105 years with a history of stroke prior to January 1, 2008. We defined rural communities as those with a population size of ≤ 10, 000, and compared screening and treatment for hypertension, hyperlipidemia, diabetes mellitus and smoking in rural and urban areas, as well as the incidence of recurrent stroke, adjusting for age, sex and baseline risk factors.

Results:
In our study sample of 86,811 individuals with prior stroke, the prevalence of vascular risk factors was similar in both rural and urban residents. Rural residents (n=10,988) had fewer mean annual visits to family physicians (5.2 vs. 6.7; p<0.001) and specialist physicians (2.5 vs. 3.5; p<0.001) and were less likely to be screened for hyperlipidemia (67.9% vs. 81.5%; p <0.05) compared to their urban counterparts. There were no rural-urban differences in prescription of medications for hypertension, diabetes and hyperlipidemia, and no differences in control of diabetes. The incidence of recurrent stroke was slightly higher in rural compared to urban areas (12.0 vs. 11.5 per 1000 person years, adjusted hazard ratio 1.09; 95% confidence interval 1.01 to 1.18).

Conclusions:
Rural and urban residents with prior stroke had similar prevalence and treatment of vascular risk factors, however, rural residence was associated with fewer physician visits, less screening for hyperlipidemia, and a slight increase in the risk of recurrent stroke. Ongoing efforts are needed to maintain equitable access to recommended ambulatory care services for secondary stroke prevention, and to address other social determinants of health in rural communities.
Abstract WMP6: Predictors of Times to Reperfusion in the TRACK Trevo Stent-retriever Registry
Authors: Prabhakaran Shyam , Zaidat Osama O , Castonguay Alicia C , Haussen Diogo C , English Joey D , Satti Sudhakar R , Chen Jennifer , Farid Hamed , Veznedaroglu Erol , Binning Mandy J , Puri Ajit , Vora Nirav A , Budzik Ron D , Dabus Guilherme , Linfante Italo , Janardhan Vallabh , Alshekhlee Amer , Abraham Michael G , Edgell Randall , Taqi Asif , El Khoury Ramy , Mokin Maxim , Majjhoo Aniel Q , Kabbani Mouhammed , Froehler Michael T , Finch Ira , Ansari Sameer A , Novakovic Roberta , Nguyen Thanh N , Nogueira Raul G
Published: October 2018

Background:
Time to mechanical thrombectomy is a significant driver of outcomes in acute ischemic stroke (AIS) patients presenting with large vessel occlusion (LVO). We aimed to evaluate predictors of onset to groin puncture (OTG), groin puncture to reperfusion (GTR), and onset to reperfusion (OTR) times in AIS patients treated with the Trevo stent-retriever.

Methods:
The investigator-initiated TRACK registry recruited 23 clinical sites to submit demographic, clinical, site-adjudicated angiographic, and outcome data on consecutive patients treated with the Trevo device. We included patients treated <8 hours from last known normal (LKN). Times for LKN, groin puncture, and TICI 2b/3 reperfusion were available to calculate OTG, GTR, and OTR times. Using multivariable linear regression, we evaluated potential predictors of times including demographics, risk factors, baseline NIHSS score, intravenous tPA use, inter-facility transfer, perfusion imaging selection, type of anesthesia, location of LVO, use of rescue intra-arterial therapies, and number of passes.

Results:
Among 433 patients analyzed (mean age 66.8 +/- 14.6 years; median NIHSS score 18; 88% anterior circulation), the median times were: OTG 240, GTR 64, and OTR 321 minutes. In multivariable analysis (Table), the independent predictors were: 1) OTG: transfer status and general anesthesia (GA) use; 2) GTR: 1 pass attempt only, use of rescue therapy, GA use, and baseline mRS >1; and 3) OTR: transfer status, use of perfusion imaging, anterior circulation LVO, use of rescue therapy, and 1 pass attempt only.

Conclusions:
Major pre-treatment contributors to delays to reperfusion in AIS patients treated <8 hours in the TRACK registry included inter-facility transfer (+82.5 minutes) and use of perfusion imaging (+30.6 minutes). Reducing inter-facility transfer delays, direct transport to thrombectomy-capable hospitals, and minimizing perfusion imaging would have major impact on reducing treatment times.
Abstract WMP66: Infection and Coagulopathy in Left Ventricular Assist Device (LVAD)-Associated Intracranial Hemorrhage: A Case-Crossover Study
Authors: Cho Sung-Min , Lee Tiffany , Starling Randall , Uchino Ken
Published: October 2018

Introduction:
Left ventricular assist device (LVAD)-associated intracranial hemorrhage carries a high morbidity and mortality rate. Despite the common occurrence, the etiology of intracranial hemorrhage is uncertain. We aim to explore the impact of infection and coagulopathy on intracranial hemorrhage in a case-crossover study.

Methods:
We reviewed consecutive patients with intracranial hemorrhage in a prospectively collected data of LVAD patients from a single, tertiary center from October 2004 to December 2016. Information on infection and international normalized ratio (INR) values were collected at the time of hemorrhage and 1 month prior to the ictus as controls. Cerebral angiogram studies were reviewed to investigate the presence of infectious intracranial aneurysm (IIA).

Results:
Of 477 persons with LVAD, 47 (10%) developed intracranial hemorrhage (27 intracerebral, 14 subarachnoid, and 6 subdural hemorrhages). Of 47 (median age 58 [interquartile range 47-67]; 39 male), 27 (54%) persons had active infection at the time of intracranial hemorrhage, and 7 (15%) at 1 month prior to the ictus. The relative risk of intracranial hemorrhage due to active infection compared to the infections at 1-month was 2.4 (95% CI 1.6-3.5; p<0.0001). Using a paired t-test, the mean INRs at the time of intracranial hemorrhage were also significantly higher at the time of hemorrhage compared to those at 1-month (2.6±1.9 vs. 1.8±0.8; p=0.01). Thirteen persons underwent cerebral angiogram (7 subarachnoid hemorrhage, 6 intracerebral hemorrhage). Four (57%) IIAs were identified only in SAH patients who also had acute bloodstream infections. In contrast, none of intracerebral hemorrhages had IIAs.

Conclusions:
Active infection and elevated INR increase the risk of LVAD-associated intracranial hemorrhage. Bloodstream infection and subarachnoid hemorrhage are associated with the presence of IIA in LVAD.
Abstract WMP7: Cost-Effectiveness of Combined Thrombectomy with Intravenous Thrombolysis vs Thrombectomy Alone for Acute Ischemic Stroke
Authors: Lin Michelle P , Urrutia Victor C , Marsh Elisabeth B , Llinas Rafael H
Published: October 2018

Introduction:
Meta-analysis of 13 studies suggested that combined mechanical thrombectomy (MT) with intravenous thrombolysis (IV-tPA) is more effective than MT alone. Limited economic analyses have explored this topic. We aimed to determine the cost-effectiveness of combined vs MT alone therapy in patients with large-vessel occlusive stroke.

Hypothesis:
Combined MT with IV-tPA is more cost-effective than MT alone.

Methods:
Markov model was constructed to simulate health outcomes and costs of two therapies (combined MT with IV-tPA, MT alone) over a 20 years lifetime horizon. The model incorporated an acute phase (0-90 days) and a rest of life phase (>90 days) with modified Rankin categories at 90days as the primary health states. Probabilities, utilities, and cost data were obtained from published sources. Incremental costs, quality-adjusted life-year (QALY), net monetary benefits, incremental cost-effectiveness ratio (ICER) were derived from the models. The willingness-to-pay was set to ICER $50,000/QALY.

Results:
Table 1 summarizes the base-case values and cost-effectiveness outcomes. Combined MT and IV-tPA led to improved quality-of-life and increased life expectancy; however, it was at slightly higher costs compared to MT alone. Combined MT with IV-tPA yielded 13.5 QALYs and accrued $220,227 in lifetime costs, whereas MT alone yielded 12.5 QALYs and accrued $185,714 in lifetime costs. Combined MT with IV-tPA costs $1,468 per QALY higher than MT alone group. The higher costs in combined therapy were driven by the costs of long-term care in stroke survivors with severe disability. Net monetary benefit was higher in the combined therapy by 14,988 points suggesting that combined MT with IV-tPA was more cost-effective than MT alone.

Conclusions:
Combined MT with IV-tPA is more cost effective than MT alone in patients with large vessel occlusive stroke. Randomized clinical trials to directly compare between combined MT with IVT vs MT alone seem warranted.
Abstract WMP71: Using Machine Learning to Classify Ischemic Stroke Subtype From Electronic Heath Records
Authors: Garg Ravi P , Oh Elissa , Rosenman Marc B , Naidech Andrew M , Kording Konrad P , Prabhakaran Shyam
Published: October 2018

Objective:
The TOAST classification for ischemic stroke (IS) is critical to determining management and predicting outcome. The adjudication process is done manually by highly trained stroke clinicians. This is time-consuming, error-prone, and limits scaling to large datasets. However, electronic medical records (EMR) could be leveraged to automate this process. We hypothesized that machine learning enabled natural language processing (NLP) for multiclass classification could determine the TOAST subtype from free text stored in the EMR.

Methods:
We selected 1099 IS patients from an observational registry with TOAST subtyping confirmed by board-certified vascular neurologists. We analyzed text-based EMR data including progress notes and radiology reports. For each patient, we concatenated notes into one large single document. We tokenized the results into a “bag of words” based representation using n-grams (unigrams, bigrams and trigrams). We did five-fold cross validation in order to avoid overfitting. To reduce the high dimensionality of features, we used principal component analysis (150 components) and L1 regularized logistic regression and then combined the features thus obtained within each fold. Next, several classification methods - K nearest neighbors, Support Vector Machines, Random Forests, Extra Trees classifiers, Gradient Boosting Machines, Xtra-Gradient Boosting and Stack ensembles - to assess the accuracy and discrimination of machine learning techniques for TOAST subtyping compared to manual subtyping (gold standard). We performed receiver operating characteristics analysis to assess discrimination of each model.

Results:
Our best classification method achieved an accuracy of 41 +/- 5% using radiology reports alone and 64 +/- 4% using progress notes alone. Combining radiology reports and progress notes, we achieved an accuracy of 66 +/- 5% with high discrimination (90 +/- 4%).

Conclusions:
Compared to manual approaches, automated machine learning and NLP can discriminate TOAST subtypes using EMR data with moderate accuracy and high discrimination. The automated pipeline, if validated, could enable large-scale stroke epidemiology research using EHRs nationwide.
Abstract WMP8: Clinical Outcomes After Mechanical Thrombectomy in Acute Ischemic Stroke Patients Aged 65 Years and over: a Subgroup Analysis of the Stratis Registry
Authors: Mueller-Kronast Nils H , Jahan Reza , Liebeskind David S ,   STRATIS Investigators
Published: October 2018

Background:
Mechanical thrombectomy (MT) with stent retrievers for treatment of acute ischemic stroke due to large vessel occlusion has become standard of care. In this study, we aimed to evaluate clinical outcomes in patients aged 65 and over based on data collected in a large real world registry and compared the outcomes to those reported in the randomized trials.

Methods:
STRATIS was a prospective, multicenter, observational, single-arm registry designed to capture a “real world experience” without requiring specialized imaging, age limits or technique exclusions at academic and non-academic centers in the USA. Patients with large vessel occlusion acute ischemic stroke were enrolled within 8 hours from symptom onset. In this post hoc analysis, a subgroup of patients aged ≥65 years were evaluated and then compared in a patient level analysis with the interventional arm of the pooled randomized SEER cohort.

Results:
Of the total 984 patients enrolled in STRATIS, 603 patients aged ≥65 years were included in the analysis. Mean age was 77.2; 47.8% were male. Median baseline NIHSS was 18 and 61.5% received IV tPA. Median times from stroke onset to puncture, and puncture to TICI 2b/3 or completion, were 207 and 38 minutes, respectively. Final mTICI ≥2b (per core lab) was achieved in 88.2%. sICH was seen in 1.4%. At 90 days, 51.8% achieved mRS 0-2 and all-cause mortality was 18.6%. Results comparing STRATIS and SEER intervention cohorts of patients aged ≥65 years are presented in the table. mTICI ≥2b rate was significantly higher in STRATIS. In unadjusted analysis, similar rates of mRS 0-2, mortality and sICH were observed. In an adjusted analysis, the odds for achieving mRS 0-2 were significantly higher in STRATIS compared to SEER intervention cohort (OR 1.43; 95%CI 1.03-1.99; p=0.03).

Conclusion:
STRATIS documents that MT can be safely performed in patients aged 65 and over in a real world setting with comparable technical and clinical outcomes to those observed in the randomized trials.
Abstract WMP96: Racial Variation in Comfort Measures Only Status in Patients With Intracerebral Hemorrhage
Authors: Ormseth Cora H , Falcone Guido J , Jasak Sara D , Mampre David M , Leasure Audrey C , Miyares Laura C , Hwang David Y , James Michael L , Testai Fernando D , Becker Kyra J , Tirschwell David L , Langefeld Carl D , Woo Daniel , Sheth Kevin N
Published: October 2018

Introduction:
Prior studies of critically ill patients found that non-whites are less likely to pursue comfort measures only status (CMOs). We sought to identify determinants of CMOs in a large multi-ethnic cohort study of intracerebral hemorrhage (ICH).

Methods:
We analyzed cases enrolled from 2010 to 2015 in the Ethnic/Racial Variations of ICH (ERICH) study, a multi-center study in the USA. Clinical, demographic and radiologic data on non-traumatic ICH patients were prospectively collected. Univariate and multivariate logistic regression was used to evaluate the association between ethnicity/race and CMOs after adjustment for potential confounders.

Results:
2705 ICH cases were included in this study (mean age 62 (14), female sex 1119 [41%]). Of these, 912 were black (34%), 893 Hispanic (33%) and 900 white (33%). CMOs patients comprised 276 (10%), 64 (7%), 79 (9%) and 133 (15%) of the entire cohort and the black, Hispanic and white cohorts, respectively (p<0.001) (Table 1). In multivariate analysis, black patients were half as likely as white patients to be made CMO (OR 0.50, 95% CI 0.34-0.75; p=0.001) and there was a trend for Hispanic patients to have CMOs less often than white patients (OR 0.72, 95% CI 0.49-1.06, p=0.093) (Table 2). Other factors associated with CMOs included age, premorbid modified Rankin Scale, dementia, admission Glasgow Coma Scale, ICH volume, intraventricular hematoma volume, lobar and brainstem bleeds and intubation.

Conclusion:
Black patients were less likely than white patients to be made CMO after controlling for potential confounders. Further investigation is warranted to understand the causes and implications of racial disparities in CMO decisions.
Abstract WMP97: Nationwide Trends of Thirty Day Readmission Rate: Intracerebral Hemorrhage
Authors: Mehta Tapan , Patel Smit , Male Shaliesh , Lakshminarayan Kamakshi , Ezzeddine Mustapha
Published: October 2018

Introduction:
Primary intracerebral hemorrhage (ICH) has high mortality (20-40%) and morbidity (60-80%). Thirty day unplanned readmission (30RR) has been suggested to be as high as 12-18 % in various studies. Our study examines causes and predictors of readmission in ICH patients using Nationwide Readmission Database (NRD).

Methods:
We used the year 2013 NRD which represents one of the largest sample of discharges (unweighted 14 million discharges). The patients with ICH were identified by primary discharge diagnosis with ICD9-CM code 431 (Age>18). 30RR were calculated for patients admitted between January and November 2013 by excluding elective readmissions. Survey procedures were implemented to adjust for stratified cluster design of NRD. The independent predictors of 30RR were identified by logistic regression.

Results:
The NRD-2013 contained 28,284 ICH admissions (weighted N = 63,181) with 11.9% all cause 30RR. Infections 18.89% [sepsis (11.76%), Urinary tract infections (4.13%), pneumonia (2.08%), others (0.92%)], acute cerebrovascular event (18.71%), acute renal failure (4.25%), epilepsy (2.65%), aspiration pneumonitis (2.55%) were top causes of 30RR. The multivariate predictors for higher 30RR were Cardiorespiratory failure [OR (Odds Ratio) 1.19, p=0.004], Cancer (OR 1.49, p=0.001), high risk VTE (venous thromboembolism) (OR 1.22, p= 0.023), discharged to home health care (OR 1.21, p<0.001) and discharged against medical advice (OR 3.8, p<0.001) compared to regular home discharge. Hospitalizations paid with private insurance (OR 0.80, p= 0.024) or self/no charge/other payment methods (OR 0.69, p<0.001) were predictors of lower 30RR.

Conclusion:
30RR for ICH is 11.9%. Infection is the most common cause of 30RR followed by acute cerebrovascular event, acute renal failure, epilepsy, and aspiration pneumonitis. In addition to medical comorbidities, discharge disposition predicted increased readmission risk. Hospitalizations paid by private insurance had reduced risk of readmissions compared to Medicare. Strategic intervention targeting major causes of readmissions and vulnerable population is required to further reduce morbidity, mortality and healthcare cost utilization related to readmission after ICH.
Abstract WMP99: Progression of White Matter Injury After Intracerebral Hemorrhage: An MRI Study
Authors: Wang Deren , Norton Casey , Helenius Johanna , Lioutas Vasileios-Arsenios , Xu Xiaomeng , Liu Ming , Selim Magdy
Published: October 2018

Background:
White matter injury (WMI) is observed after experimental intracerebral hemorrhage (ICH). Supporting clinical data are sparse. We assessed the presence, extent, and progression of WMI in ICH patients.

Methods:
Retrospective review of data from consecutive 65 patients with spontaneous supratentorial ICH who had baseline brain MRI within 7 days of ICH onset and repeat MRI afterwards (median 83 days). We used Fazekas scale (FZS) to grade the severity of WMI. Clinical and imaging characteristics of patients with and without WMI progression were compared by uni- and multi-variate logistic regression analyses.

Results:
For the entire cohort, the mean total FZS score increased from 2.9±1.6 on baseline to 3.3±1.6 on repeat MRI (p=0.00; Z=-4.38). The progression of WMI was noted both ipsi- and contra-lateral to the ICH; the mean score increased from 2.9±1.6 to 3.1±1.5 (p=.00; Z=-3.56) in the contralateral hemisphere and 2.8±1.6.to 3.1±1.6 (p=.00; Z=-4.49) in the ipsilateral hemisphere. Similar results were noted when subjects were stratified based on ICH location; lobar (n =51) and deep (n =14). The severity of WMI was greater in lobar than deep ICH [3.2±1.5 vs. 2.1±1.4 on initial MRI (p=0.03), and 3.5±1.5 vs. 2.6±1.6 on repeat scan (p=0.06)]. However, the extent of WMI progression did not differ by ICH location. Seventeen patients with lobar and 6 with deep ICH (35.4%) showed evidence of WMI progression. The characteristics of patients with and without WMI progression were comparable. The time interval from baseline to repeat MRI did not differ between the groups (p=0.68). Only, baseline ICH volume [p=0.049; OR 1.038; 95%CI=1.00-1.08] and presence of intraventricular hemorrhage [p=0.004; OR 5.69; 95%CI=1.64-19.78] emerged as predictors of WMI progression. Patients with WMI progression had worse 3-month outcome, defined as mRS >2, (34.8% vs. 11.9%; p<0.05 on uni- and multivariate analyses).

Conclusions:
WMI progresses over time in ICH patients, and is associated with worse outcome. This novel finding could represent a potential therapeutic target. Future prospective larger studies are needed to confirm our findings.
Abstract WP103: Exogenous Growth Differentiation Factor 11 Reduces Atrophy and Decreases Gliosis After Stroke in Aged Mice
Authors: Chauhan Anjali , Hudobenko Jacob , Mohan Eric , Zhu Liang , McCullough Louise D
Published: October 2018

Introduction:
Drugs and mechanical devices for retrieving blood clot are effective; however, they must be used within few hours of stroke onset. No pharmacological therapy has been shown to be effective in the recovery phase of stroke, which occurs days after the initial insult. Growth differentiation factor (GDF) 11, a member of transforming growth factor beta superfamily, has been effective in ameliorating age associated cardiac hypertrophy, skeletal muscle dysfunction and decreased neurogenesis in older mice. Therefore, we
hypothesized
; exogenous GDF11 will improve tissue loss and functional outcomes in old mice.

Methods:
Middle cerebral artery occlusion (MCAo) (n=32) or sham surgery (n=12) was induced in old male mice (19-20 months). Five days after MCAo, GDF11 (0.1mg/kg) and BrdU (75 mg/kg) was administered for 5 days. Y maze, Barnes maze was performed on day 14, 21 and 28-post ischemia. Tail suspension and open field was performed on day 29 and day 30 respectively. The mice were euthanized on day 30-post stroke for assessment of tissue loss, gliosis and neurogenesis.

Results:
Cerebral atrophy was significantly lower in the MCAo GDF11 (13.1 ± 1.62) vs MCAo vehicle treated group (22 ± 2.06) (p<0.05). Additionally, a reduced mortality was observed in MCAo GDF11 group (p=0.09). Exogenous GDF11 resulted in reduced GFAP
+
cells (p<0.05) and Iba-1
+
cells (p=0.17) in the peri-infarct cortex of MCAo GDF11 group. Moreover, an increase in CD31
+
cells was seen in the MCAo GDF11 group, though this did not reach significance (p=0.12). On behavior task, there was no difference in spontaneous alterations and escape latency between MCAo GDF11 vs MCAo vehicle treated groups as assessed on Y and Barnes maze respectively. Additionally, no effect of GDF11 was seen on motor function or immobility when assessed on open field and tail suspension test respectively. Five days of exogenous GDF11 did not increase neurogenesis in the MCAo GDF11 group.

Conclusion:
Exogenous GDF11 reduced tissue damage, decreased gliosis and enhanced angiogenesis in old mice. However, no benefit of GDF11 treatment was observed on long-term functional outcomes.
Abstract WP107: Estrogen Deficiency Induces Microbiota Dysbiosis Impacting Stroke Outcome in Female Rats
Authors: Park Min Jung , Sohrabji Farida
Published: October 2018

Introduction:
Stroke is more prevalent in older population, and among this demographic, older women are at a higher risk for stroke, with worse outcomes and poorer recovery. Recent advances have suggested that intestinal bacteria affect stroke outcome and cardiovascular events. Emerging evidence suggests that interactions between gut microbiota and estrogens are critical in maintaining homeostasis in healthy premenopausal individuals. However, the mechanistic link between estrogen deficiency and gut microbiome among acute brain disorders has not been well established.

Methods:
Fecal samples from adult (cyclic, 5 months old) and middle-aged (acyclic, 12 months old) Sprague-Dawley female rats at pre (0d) and post (5d) middle cerebral artery occlusion (MCAO) were analyzed by Illumina-sequencing of the 16S rRNA gene. Animals were tested for infarct volume and sensory motor performance pre and/or post stroke. Rats were sacrificed at the early (2d) or late (5d) acute phase after MCAO to collect serum and tissue samples for histological and biochemical analyses.

Results:
Diversity of the gut microbiome was significantly decreased in estrogen-deficient middle-aged females at 0d (pre stroke) compared to estrogen-sufficient adult animals. Middle-aged rats at 5d post stroke had the most profound alterations in their microbiome, as significant separations were observed on PCoA plots of Unifrac distances. Middle-aged rats presented a larger infarct size as well as a significantly worse sensory motor function at 2d and 5d post MCAO as compared to adult female rats. Middle-aged rats had significantly increased gut leakiness at 5d post stroke compared to adult group. Moreover, the gut microbiome community was significantly altered by reproductive age, as evidenced by the increased members of
Bacterroidates
(
S24-7
and
Parabacteroides
); and decreased members of the genus
Akkermansia
; and decrease members of the genus
Bacillus
in middle-aged female rats, suggesting a role for these bacteria in estrogen deficiency and stroke severity.

Conclusions:
These data provide the first evidence that reproductive age induces microbiome dysbiosis and gut leakiness in middle-aged female rats and underscores the link between microbiota and stroke outcome and severity.
Abstract WP110: Spontaneous Motor Recovery After Cerebrolysin Treatment in a Mouse Model of Stroke
Authors: Zeiler Steven R , Hubbard Robert , Pinilla-Monsalve Gabriel , Winter Stefan , DeBoer Scott
Published: October 2018

Background and Purpose:
Most functional upper extremity motor recovery occurs in the first 4 weeks after ischemic stroke in humans and in the first week in rodent models. The majority of functional recovery in humans is spontaneous (i.e. occurs as a result of endogenous repair processes rather than rehabilitative interventions). In mouse models of stroke, recovery is impaired when post-stroke rehabilitation is delayed and there is very little spontaneous recovery. Cerebrolysin is a polypeptide preparation shown to enhance neuronal plasticity and to promote motor recovery in patients after stroke. In mice, we tested the hypothesis that Cerebrolysin can act early after stroke to enhance spontaneous motor recovery.

Methods:
Adult C57Bl/6 mice were trained to perform a skilled prehension task to an asymptotic level of performance, after which they underwent photocoagulation-induced stroke in the caudal forelimb area (rodent primary motor cortex). The mice were then randomized to receive Cerebrolysin or saline injections beginning 24-hours post-stroke. Both groups were then retrained at the same prehension task by a blinded investigator. Stroke volumes were compared using immunohistochemistry.

Results:
We have previously shown that training-associated recovery of prehension is complete if training is initiated after a 1-day delay but incomplete if training is initiated after a 7-day delay, even with additional training days. However, daily Cerebrolysin administration after stroke was associated with complete recovery of prehension by day 8, even in the absence of training. Stroke volumes were similar across all groups.

Conclusions:
We conclude that Cerebrolysin administration during an early time window can lead to spontaneous recovery of motor function without a protective effect on stroke volume. This is one of the first demonstrations of spontaneous motor recovery in a rodent stroke model. Our mouse model, with all of the attendant genetic benefits, should allow us to determine at the cellular and molecular level how endogenous plasticity and medications like Cerebrolysin interact to mediate recovery.
Abstract WP113: Evidence of Ongoing Platelet Activation in Micro-emboli Negative Recently Symptomatic versus Asymptomatic Carotid Stenosis
Authors: Murphy Stephen , Lim Soon Tjin , Kinsella Justin , Tierney Sean , Egan Bridget , Feeley Martin , Murphy Sinead , Walsh Richard , Collins Ronan , Coughlan Tara , O’Neill Desmond , Harbison Joseph , Madhavan Prakash , O’Neill Sean , Colgan Mary Pat , Cox Dermot , Moran Niamh , Hamilton George , McCabe Dominick
Published: October 2018

Introduction:
Cerebral microembolic signals (MES) predict increased stroke risk in carotid stenosis however micro-emboli negative symptomatic patients also demonstrate increased risk compared to asymptomatic patients. Enhanced platelet activation may contribute to this risk disparity.

Methods:
We performed a prospective, observational analytical study assessing platelet counts, platelet activation status, and the relationship between platelet activation and MES in asymptomatic versus symptomatic moderate (≥50-69%) or severe (≥70-99%) carotid stenosis. Full blood count measurements were performed, and whole-blood flow cytometry used to quantify platelet surface activation marker expression (CD62P and CD63) and circulating leucocyte-platelet complexes. Bilateral simultaneous Transcranial Doppler (TCD) ultrasound monitoring of the middle cerebral arteries was performed to classify patients’ MES status.

Results:
Complete TCD data from 28 asymptomatic patients were compared with 35 symptomatic patients in the ‘early phase’ (≤4 weeks) and 30 of these patients in the ‘late phase’ (≥3 months) after TIA/ischaemic stroke. The %MES positive patients were higher in early symptomatic (31.4%; P = 0.027), but not in late symptomatic (6.7%; P = 0.996) vs. asymptomatic patients (7.1%). There were no significant differences in platelet counts, mean platelet volume, %CD62P or %CD63 expression between early/late symptomatic and asymptomatic MES negative patients (P>0.05). There were however, a significantly higher %circulating lymphocyte-platelet complexes in early symptomatic vs. asymptomatic patients (2.7% vs. 2.17%;P=0.02)

Discussion:
Increased lymphocyte-platelet complex formation in recently symptomatic vs. asymptomatic MES-negative patients indicates enhanced platelet activation in this early symptomatic subgroup. Platelet biomarkers, in combination with TCD, have the potential to aid risk-stratification in carotid stenosis.
Abstract WP115: Risk Factors for Stroke After Kidney Transplantation
Authors: Tantisattamo Ekamol , Vutthikraivit Possawat , Ratanasrimetha Praveen
Published: October 2018

Introduction:
Cardiovascular disease (CVD) remains the common cause of morbidity and mortality in kidney transplant recipients. Cerebrovascular accident (CVA) is highly prevalent in general population. Several cardiovascular co-morbidities are conveyed in kidney transplant recipients after successful kidney transplantation but the incidence of CVA in this population is uncommon.

Hypothesis:
We hypothesize that renal-related risk factors for CVA occur after successful kidney transplantation.

Methods:
A nested case-control study from a closed cohort of advanced chronic kidney disease (CKD) or end-stage renal disease (ESRD) patients undergoing kidney transplantation between January 2006 and May 2017 was conducted. CVA is defined by brain imaging lesions consistent with localized neurological deficits. Three control patients were matched with 1 case based on age and date of kidney transplantation identified at the same time when the first episode of CVA of each case occurred (incidence density sampling method).

Results:
From a total of 752 kidney transplant recipients, 5 new CVA cases and 15 controls were identified during a 2-year period between September 2015 and July 2017. Mean age+/-SEM was 45.10±6.95 VS 46.57±3.02 years. In case group, 60% was male and African American; whereas, 53.33% was female and 40% was African American in the control group. Several traditional risk factors for CVD were not associated with CVA except diastolic hypertension defined as DBP <90 mmHg (OR 52, 95%CI 2.616 to 1,033.827). Compared to control group, mean DBP in cases was 17±6.31 mmHg higher (93±3.03 VS. 76±3.56, p=0.015, 95%CI -30.3083 to -3.6917). For renal-related factors, mean serum creatinine and serum phosphorus were significantly higher and mean serum albumin was significantly lower in the cases than the controls (p=0.003, <0.001, and 0.020).

Conclusion:
Although traditional risk factors for CVA remains after kidney transplantation, only DBP is associated with CVA and other renal-related factors including impaired renal allograft function, hyperphosphatemia, and hypoalbuminemia appears to increase the risk for CVA. Further studies are required to identify other risks and elucidate mechanistic studies of CVA in kidney transplant recipients.
Abstract WP119: Leukoaraiosis Attenuates Diagnostic Accuracy of Large Vessel Occlusion Scales
Authors: Mayasi Yunis M , Silver Brian , Goddeau Richard P , Jun-O’connell Adalia , Moonis Majaz , Puri Ajit , Henninger Nils
Published: October 2018

Background and Purpose:
Preclinical stroke scales may help identify patients likely to have large vessel occlusion (LVO) to facilitate rapid triage to thrombectomy-capable stroke centers. Scale misclassification may result in inaccurate decisions and possible harm. Pre-existing leukoaraiosis has been shown to attenuate the association between deficit type and stroke severity. We sought to determine whether leukoaraiosis affects the predictive ability of 5 commonly used LVO scales.

Materials and Methods:
We retrospectively analyzed 274 consecutive stroke patients with available brain MRI and vessel imaging. The following LVO scales were used: 3 Item Stroke Scale (3I/SS), Field Assessment Stroke Triage for Emergency Destination (FAST-ED), Rapid Arterial Occlusion Evaluation (RACE), Vision, Aphasia, Neglect (VAN) score, and Cincinnati Prehospital Stroke Severity Scale (CPSSS). For diagnostic scale accuracy, we assessed sensitivity, specificity, positive predictive value, negative predictive value, and kappa. Multivariable logistic regression was used to determine the scales’ predictive ability after adjustment for leukoaraiosis and potential confounders.

Results:
In unadjusted analyses, all scales predicted LVO (n=46; P<0.01, each), though leukoaraiosis attenuated diagnostic accuracy and was associated with more false negative diagnoses. After adjustment, the FAST-ED (OR 3.2 [1.1-9.5]; P=0.033), and RACE (OR 3.7 [1.3-10.8]; P=0.015) but not 3I/SS (OR 5.4 [0.86-33.9]); P=0.073), VAN (OR 2.5 [0.8-7.2]), and CPSSS (OR 2.8 [1.0-8.0]) predicted LVO.

Conclusion:
The diagnostic accuracy of the tested LVO scales was attenuated by moderate-tosevere leukoaraiosis. If confirmed, this information may aid acute decision making and the design of studies that require LVO scale screening of patients likely to have concomitant leukoaraiosis.