bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP128: A Long Term Treatment Outcomes of Middle Cerebral Artery Stenosis Patients Treated With Medical Therapy
Authors: Yuki Ichiro , Ishibashi Toshihiro , Ikemura Ayako , Abe Yukiko , Kan Issei , Kato Naoki , Kaku Shougo , Nishimura Kengo , Murayama Yuichi
Published: October 2018

Purpose:
Little is known about the long term clinical outcomes of middle cerebral artery (MCA) stenosis / occlusion patients who are treated with medical therapy. The efficacy and safety of the medical treatment was evaluated by analyzing the clinical outcomes along and imaging analysis using CT Angiography (CTA) with an automatic measurement software.

Methods:
Patients who were diagnosed with middle artery stenosis or occlusion were prospectively enrolled in the study. Those who were diagnosed with moyamoya disease were excluded. Along with the rigorous medical treatment for atherosclerosis risk factors, Cilostazol 200mg/day was selected as the first line of medication, and switched to either aspirin 100mg/day or clopidogrel 75mg/day if necessary. CT Angiogram (CTA) was performed and a software for the measurement of stenosis on the stretched view was used for evaluating the degree of stenosis. The neurological findings as well as the degree of stenosis during the observation time were analyzed.

Results:
Of the 186 MCA stenosis / occlusion patients who visited our institution, 62 lesions in 60 patients who completed periodic CTA evaluation were selected for the study. 20 lesions (40.3%) were symptomatic at the time of diagnosis. 45 patients (75.0%) were treated with cilostazol and 22 (36.7%) underwent dual antiplatelet therapy. 7 patients (11.7%) were observed without any antiplatelet therapy. During the median observation time of 75.6 months, 24 patients (40.0%) showed angiographic improvement, and the median % area stenosis improved from 66.0% (IQR: 53.0 - 80.0) to 54.7% (48.6 - 77.5). Of the 29 patients who showed complete occlusion at the initial diagnosis, 17 (58.6%) showed any degree of recanalization. For those with symptomatic lesions, no patient developed major stroke on the ipsilateral side after completing the 3 months of initial treatment.

Conclusions:
Angiographic improvement of MCA stenosis was observed with successful prevention of major stroke associated with the disease. Majority of the patients who tolerated the complete occlusion at the time of initial treatment showed recanalization during the observation period. Medical treatment can be an effective therapeutic method for the MCA stenosis / occlusion patients.
Abstract WP131: Repeat Bypass Surgery for Moyamoya Disease Refractory to Previous Surgery
Authors: Kuroda Satoshi , Uchino Hart , Kashiwazaki Daina , Akioka Naoki , Kuwayama Naoya
Published: October 2018

Background and Purpose:
Surgical revascularization is known to reduce subsequent incidence of ischemic and hemorrhagic stroke with low morbidity in moyamoya disease. However, repeat bypass surgery is required for a certain subgroup of patients, although the information on indication, surgical technique, and outcome is limited. Therefore, this study was aimed to precisely analyze clinical features, surgical technique, and long-term outcome of repeat bypass surgery for refractory moyamoya disease.

Methods:
This study included totally 20 surgeries for18 patients who underwent repeat bypass surgery because previous surgery was inadequate in 10 surgeries (Group A) or because the posterior cerebral artery was further involved after surgery in 10 (Group B). There were 7 males and 11 females. Their age ranged from one to 69 years. Precise radiological examinations were performed before surgery, using MRI, cerebral angiography, and SPECT. In Group A, all patients who previously underwent inadequate surgery repeated headache attack, TIA, or hemorrhagic stroke, and underwent repeat bypass surgery targeted to the non-revascularized area, using STA-MCA anastomosis and/or indirect synangiosis as appropriate. On the other hands, occipital artery to posterior cerebral artery (OA-PCA) anastomosis and/or indirect bypass was required in Group B who developed disease progression in the PCA.

Results:
All 18 patients successfully underwent repeat bypass surgery. Postoperative course was uneventful. Postoperative examinations revealed good revascularization in the operated hemispheres and the improvement of cerebral hemodynamics. Headache attack and TIA disappeared within 6 months at the latest after surgery. During follow-up periods, one (5.6% per person) of 18 patients died of recurrent hemorrhagic stroke two years after repeat bypass surgery.

Conclusion:
Repeat bypass surgery is feasible and effective to reduce further incidence of headache attack, TIA, and ischemic and hemorrhagic stroke. Through precise radiological analysis, surgical procedures should be planned to yield maximal therapeutic effects.
Abstract WP132: Fatal Reversible Cerebral Vasoconstriction Syndrome: A Systematic Review of Case Series and Case Reports
Authors: Bayona Hernan F , Martínez Carlos F , Gøez Lina M , Valencia María C , Vargas Nicolle , Guzman Neidy F , Ramírez Natalia , Serna Laura , Peña Angelica , Corzo María P
Published: October 2018

Introduction:
Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by severe headaches and constriction of cerebral arteries related with stroke.

Hypothesis:
To describe the patients characteristics, radiological findings and clinical course of adults patients with fatal RCVS.

Methods:
A systematic literature search using MEDLINE and EMBASE was performed up to March 6, 2017. Studies reporting RVCS in adult patients with fatal outcomes were included.

Results:
Of 368 initially identified studies, 121 full text articles were reviewed, of which 6 publications describing 10 subjects were entered. The vast majority of the reports came from the U.S except for one report form Denmark that included a male patient. Almost all the cases occurred during pregnancy or post-partum. Only 40% subjects had a history of migraine. The clinical presentation involved headache although only 20% presented with thunderclap headache and 14.3% had seizures. A CT was performed in 71.4% of the patients and the rest had an MRI. Imaging results were diverse with trend towards PRESS and ICH. The main course of treatment included steroids in 70% of the subjects and only 30% received nimodipine. Time to death ranged from 7 to 24 days with a median of 11 days.

Conclusion:
Most of the time RCVS has a benign course, however we described fatal cases from the literature mostly related with post-partum angiopathy. We found a trend in the onset with PRESS, ICH and diffuse cerebral edema with less subjects using nimodipine as main treatment. We described some markers for worse prognosis.

Table 1 Description of studies

Fig. 1
Abstract WP135: Location and Composition of Extracranial Carotid and Intracranial Atheroma in Symptomatic U.S. and Chinese Patients Detected by Vessel Wall Magnetic Resonance Imaging
Authors: Watase Hiroko , Gao Peiyi , Sui Binbin , Shen Mi , Balu Niranjan , Zhao Xihai , Li Rui , Sun Jie , Hippe Daniel S , Jarvik Gail P , Yuan Chun , Hatsukami Thomas S
Published: October 2018

Introduction:
Atherosclerosis of the extracranial carotid and intracranial arteries is an important contributor to stroke. Autopsy studies suggest that the location and components of atheroma may vary between different ethnic groups. Advances in cerebrovascular vessel wall imaging with 3D-magnetic resonance imaging (MRI) have provided a critical tool to assess these differences
in vivo
.

Hypothesis:
We tested the hypothesis that carotid culprit plaques are more common in U.S. patients, and that intracranial culprit plaques are more common in Chinese patients.

Methods:
As part of the ongoing Culprit Plaque in Acute Cerebral Infarction study, patients with acute anterior circulation ischemic stroke were recruited at the University of Washington and the Beijing Tiantan Hospital. Plaque presence, location, and composition (intraplaque hemorrhage [IPH], lipid core, calcification, disrupted luminal surface [DLS]) in the carotid and intracranial arteries on the symptomatic side were evaluated using a 3D multi-contrast vessel wall MRI protocol. Carotid and intracranial arteries were reviewed independently by an experienced reader blinded to clinical characteristics and ethnic group.

Results:
Twenty patients from the U.S. (median age: 59 years; 65% male) and 26 patients from China (58 years; 69% male) were evaluated. Of those, 18 U.S. patients (90%) and 20 Chinese patients (77%) had at least one plaque in either the carotid or intracranial arteries (p=0.4). Of those with plaque, 17 U.S. (94%) and 12 Chinese (60%) patients had carotid artery plaques (p= 0.02), and 11 U.S. (61%) and 19 Chinese (95%) patients had intracranial artery plaques (p=0.02). Features of possible culprit plaque (IPH and/or DLS) in the carotid artery were found in 8 U.S. patients (47%) but only 1 Chinese patient (8%) (p=0.04). Plaque composition in intracranial arteries was not significantly different between the two groups.

Conclusion:
Possible culprit plaques in the carotid artery were more common in symptomatic U.S. patients than Chinese patients, while intracranial plaques were more common in the Chinese patients. Accurate localization of the culprit plaque has important implications for treatment.
Abstract WP137: Premorbid Malnutrition as Assessed by Nutritional Risk Index is Associated With Poor Short-Term Outcome in Patients With Ischemic Stroke
Authors: Kim Tae Jung , Kang Min-Kyung , Lee Chan-Hyuk , Mo Heejung , Jeong Han-Yeong , Ko Sang-Bae , Yoon Byung-Woo
Published: October 2018

Introduction:
Malnutrition has negative consequences for stroke patients. However, impact of poor nutritional status before stroke onset on the functional outcome in patients with ischemic stroke remains unclear.

Hypothesis:
Therefore, we investigated the prognostic role of premorbid undernutrition using objective assessment method, Nutritional Risk Index (NRI), in patients with ischemic stroke.

Methods:
A consecutive 1,248 patients who were admitted within 7 days after ischemic stroke onset between March 2010 and December 2015 were included. We assessed initial nutritional status using NRI, and NRI formula as follows: NRI = (1.519 х serum albumin, g/dL) + {41.7 х present weight/ideal body weight (kg)}. The patients were categorized into three groups on the basis of NRI [No risk (NRI >97.5), Moderate risk (NRI 83.5–97.5), and Severe risk (NRI <83.5)]. We evaluated the short-term outcomes using a modified Rankin Scale (mRS) at three-months after stroke onset. We divided patients into two groups with favorable outcome (mRS score ≤2) and unfavorable outcome (mRS score ≥3). We compared the clinical characteristics and NRI between two groups.

Results:
Among the included patients (mean age, 67 years, male, 63.1%), 322 (25.8%) patients had unfavorable outcome. The unfavorable outcome group was older and more likely to have atrial fibrillation, lower body mass index, and higher initial NIHSS. The lower NRI patients (Moderate risk and Severe risk) were more frequent in unfavorable outcome group (50.7% vs. 32.0% and 12.7% vs. 2.7%, P <0.001). After adjustment for covariates, lower NRI groups were independently associated with a higher risk of unfavorable outcome [Odds ratio (95% confidence interval); Moderate risk 2.75 (1.23 – 6.13); Severe risk 4.29 (1.93 – 9.62), P for trend <0.001].

Conclusion:
This study demonstrated that the lower NRIs predicted unfavorable outcome at 3 months following ischemic stroke. This suggests that premorbid undernutrition could be a modifiable risk factor for prognosis following stroke.
Abstract WP141: Prediction of Subclinical Language Deficit Using Machine Learning Based on Post-stroke Functional Connectivity Derived From Low Frequency Oscillations
Authors: Mohanty Rosaleena , Nair Veena A , Tellapragada Neelima , Advani Hemali , Williams Leroy M , Prabhakaran Vivek
Published: October 2018

Introduction:
Post-stroke neuropsychological evaluation can take a long time to assess impairments in subjects with no overt clinical deficits. We focus on language network based on a five-minute non-invasive resting state functional MRI (rs-fMRI) to identify subclinical language deficit (SLD) using a machine learning classifier. Such a system could supplement neuropsychological test to detect SLD from functional connectivity (FC). Predictive ability of FC derived from slow-4 (0.027-0.073 Hz) and slow-5 (0.01-0.027 Hz) bands are compared to that derived from all low frequency oscillations (LFO; 0.01-0.1 Hz).

Methods:
Sixty clinically non-aphasic, right-handed subjects were categorized into three age and gender matched groups based on stroke status, and normed verbal fluency score (VFS): 20 ischemic stroke subjects at higher risk of SLD (LD+; mean VFS = -1.77, mean age = 63.1 years) and 20 ischemic stroke subjects at lower risk of SLD (LD-; mean VFS = -0.05, mean age = 58.35 years), 20 healthy controls (HC; mean VFS = 0.21, mean age = 57.4 years). Anatomical T1-weighted and rs-fMRI scans were acquired within 14 days of stroke onset. A mask of 23 regions of interest (ROIs) was selected from the language network and blood-oxygen-level-dependent (BOLD) signal was extracted from each ROI corresponding to LFO, slow-4 and slow-5 bands. FC was computed by correlating time series from pairs of ROIs for all three frequency bands. A binary support vector machine (SVM) used 253 correlation indices to classify between groups: (a) LD+ vs LD-, (b) LD- vs HC (c) HC vs LD+. The classifier performance was assessed using leave-one-out cross-validation (LOOCV) with a univariate filter based feature selection.

Results:
LOOCV accuracies upon appropriate feature selection are reported by frequency band: Slow-4 band: 82.5% for (a), 90% for (b), 90% for (c). Slow-5 band: 85% for (a), 90 % for (b), 92.5% for (c). LFO: 82.5% for (a), 87.5% for (b), 90% for (c).

Conclusion:
Subjects at risk of SLD can be differentiated from healthy controls based on rs-fMRI with a high accuracy classifier, which otherwise could take longer to identify through neuropsychological assessment. Additionally, BOLD signal in the slow-5 band better characterized FC by providing a higher classification accuracy.
Abstract WP145: Depression in Stroke and TIA Survivors With Minimal or No Residual Deficits
Authors: Ferrante Francesca , Taboada Susan , Maran Ilavarasy , Grenier Laura , Taboada Isabelle , Staff Ilene , Nouh Amre M
Published: October 2018

Background:
Depression after stroke can severely inhibit a patient’s recovery. While it affects roughly a third of all stroke survivors, there is a lack of literature evaluating depression in patients with minimal or no residual deficits.

Objectives:
To evaluate variables associated with depression in patients with minimal or no residual deficits.

Methods:
A retrospective analysis of patients with mild stroke, intracerebral hemorrhage (ICH) or TIA at our institution who presented to the stroke clinic from December 2016-July 2017 was conducted. A questionnaire gathering clinical and sociodemographic information, as well as levels of depression, was administered. Patients were assessed using the PHQ-2 and PHQ-9 depression scales. A Wilcoxon Ranked Sum test was used to analyze variables affecting depression. Statistical significance was set at 0.05.

Results:
In total, 72 patients (58 ischemic, 5 ICH and 9 TIA) were identified. Approximately 4% (n=3) presented to clinic <6 weeks, 66.7% (n=48) 6-12 weeks, 23.6% (n=17) 12-24 weeks, and 5.6% (n=4) > 24 weeks from discharge. The median discharge NIH score was 1.5. Roughly 24% of patients (n=17) reported depression via the PHQ-9. Of these patients, 59% (n=10) reported depression prior to stroke and 41% (n=7) developed new depression. The median age was 62.5 years, 63.9% were female, and 70.8% Caucasian. Diabetic and unmarried patients reported significantly more depression (
p=0.005, 0.03)
while patients attending occupational therapy were less depressed (
p=0.010
). Age (
p=0.23
), history of cancer (
p=0.95
), prior stroke (
p=0.55
), incontinence (
p=0.
27), stroke location (Right:
p=0.72
; Left:
p=0.244
), ability to return to work (
p=0.64
), driving status (
p=
0.36), and discharge destination (
p=0.
09) did not significantly affect depression levels. Of the patients with no prior depression, 11.2% developed new depression after stroke.

Conclusion:
In our study, a quarter of stroke and TIA patients with little to no residual deficits reported depression and roughly 1 in 10 reported new depressive symptoms. Depression is still a prevalent and concerning outcome that can have a major effect on a patient’s functional status. Further studies of depression in patients with minimal to no symptoms are needed.
Abstract WP148: Functional Independence Score of Acute Stroke Patients Can Predict Favorable Clinical Outcome at 3 Months After Stroke Onset
Authors: Johno Takashi , Kawano Hiroyuki , Torii Masataka , Kamiyama Hiroshi , Amano Tatsuo , Honda Yuko , Suzuki Rieko , Okano Haruko , Unno Yoshiko , Yamada Shin , Okajima Yasutomo , Shiokawa Yoshiaki , Hirano Teruyuki
Published: October 2018

Background and Purpose:
Modified Rankin scale (mRS) score at 3-month after onset is widely used as clinical outcomes in stroke patients. Functional Independence Measure (FIM) is a valid tool to estimate the level of ADL. However, there were few studies whether FIM score in acute stroke patients can predict clinical outcomes at 3-month. Our aim is to reveal that FIM scores of acute stroke patients can predict favorable outcome (mRS 0-1 at 3-month).

Method:
We used data from a prospectively collected observational registry in single stroke center between January 2016 and March 2017. Baseline NIHSS score, acute FIM score (=within 3 days from admission to the stroke unit), discharge FIM score (=at discharge from the stroke unit), and mRS score (before stroke, at 3-month) were collected. The relationship between discharge FIM score and mRS score at 3-month were examined using Spearman’s rank correlation test. Logistic regression analyses were used to reveal the predictors of favorable outcome.

Results:
Of 678 patients were admitted to our stroke center due to acute stroke, 410 patients whose clinical data could be obtained (60%; mean age, 74±13 years; male, 57%; the median of length of hospital stay, 21 days; 75% with ischemic stroke) were enrolled. The median of the baseline NIHSS score, acute and discharge FIM scores were 5 (interquartile range [IQR], 2-16), 53 (IQR 22-83), and 86 (IQR 32-119), respectively. Discharge FIM score strongly correlated with mRS score at 3 month (ρ=-0.86; p<0.01). In univariate logistic regression analysis, male sex, acute ischemic stroke, premorbid mRS score, baseline NIHSS score, acute FIM score, the length of hospital stay, and discharge FIM score were associated with favorable outcome. In multivariate logistic regression analysis, male sex (odds ratio [OR] 2.28; 95% confidence interval [CI] 1.21-4.36; p=0.01), premorbid mRS score (OR 0.45; 95% CI, 0.26-0.74; p=0.01), length of hospital stay (OR 0.96; 95% CI 0.93-0.99; p=0.02), and discharge FIM score (OR 1.07; 95% CI 1.05-1.09; p<0.01) were independent predictors of favorable outcome.

Conclusions:
FIM score at discharge from the stroke unit can predict favorable clinical outcome at three months. Our results can help stroke physicians to expect stroke patients’ status in the chronic phase.
Abstract WP15: Stent Retriever Thrombectomy After Intravenous Tissue Plasminogen versus Intravenous Tissue Plasminogen Activator Alone In Japan : J-ASPECT Japan
Authors: Kurogi Ai , Onozuka Daisuke , Hagihara Akihito , Kada Akiko , Nishimura Kunihiro , Kamitani Satoru , Okuchi Kazuo , Nagata Izumi , Matsuda Shinya , Nakamura Fumiaki , Suzuki Akifumi , Ono Junichi , Nakagawara Jyoji , Toyoda Kazunori , Yoshimura Shinichi , Miyachi Shigeru , Shiokawa Yoshiaki , Ogasawara Kuniaki , Ido Keisuke , Kurogi Ryota , Nishimura Ataru , Arimura Kouichi , Iihara Koji
Published: October 2018

Objective:
We performed a nationwide study to evaluate the effectiveness of stent-retriever in addition to intravenous thrombolysis in acute ischemic stroke patients in the ‘‘real-world’’ settings.

Methods:
This was a retrospective cohort study using the Diagnosis Procedure Combination nationwide inpatient database in Japan. Patients with acute ischemic stroke who were admitted to hospitals between April 1, 2013, and March 31, 2014 were identified. The rate of functional independence (modified Rankin scale score, 0 to 2) at discharge and mortality at 30 days were compared between patients who received intravenous thrombolysis alone (IVT group) and those who received stent-retriever after intravenous thrombolysis (IVET group) using 1:1 propensity score-matching.

Results:
In total, 71,519 acute ischemic patients were identified in a year. Among those, 3,367 patients were eligible (3,110 in IVT group and 257 in IVET group). Post-matching, 134 pairs of patients were analysed. The rate of functional independence at discharge was higher in IVET group than in IVT group (odds ratio 1.96, 95% CI 1.16-3.35; p=0.012). In addition, there was no significant differences in mortality at 30 days between the two groups (odds ratio 1.80, 95% CI 0.81-4.23; p=0.153).

Conclusion:
This nationwide study revealed that mechanical thrombectomy with stent-retriever in addition to intravenous thrombolysis improves functional outcomes in patients with acute ischemic stroke, and with no evidence of increased mortality. A randomized clinical trial seems warranted.
Abstract WP151: Targeted Engagement of the Premotor Component of the Motor Network After Stroke
Authors: Stewart Jill C , Baird Jessica , Foster Allison , Fritz Stacy L , Fridriksson Julius
Published: October 2018

Introduction:
Dorsal premotor cortex (PMd) is an important neural correlate of motor recovery after stroke. A protocol that targets engagement of this component of the motor network through changes in task demands may be a useful rehabilitation tool. Therefore, the purpose of this study was to determine the response to a period of practice targeted at PMd using a well-defined behavioral condition (action selection).

Methods:
Twelve individuals post-stroke (age: 56.9±7.7 years; months post-stroke: 46.5±46.7; UE FM motor score: 41.8±14.9) completed a task that required right or left movement of a joystick with the weaker hand under two conditions. In the Select Condition, the individual moved right or left based on an abstract, visual rule; this condition has been shown to activate PMd. In the Execute Condition, the individual moved the same direction on every trial. The task was practiced for four consecutive days and completed during functional MRI on Days 1 and 4.

Results:
Accuracy improved and reaction time (RT) cost (Select RT-Execute RT; represents the relative increase in planning time for the Select condition) decreased over practice (
p
=0.005). On Day 1, Select Condition performance led to increased activation compared to Execute performance in bilateral PMd, bilateral parietal, and contralesional prefrontal cortices as expected. On Day 4, the increase in activation during the Select condition was overall less with a significant interaction in three contralesional brain regions: PMd, dorsolateral prefrontal, and anterior cingulate. Individuals with greater activation in the task relevant network (ipsilesional PMd and cingulate cortices, bilateral parietal cortices) on Day 1 had better performance (lower RT cost) on Day 4. Behavioral performance on Day 1 did not predict performance on Day 4 (
p
=0.941).

Conclusions:
Behavioral practice targeted at the premotor component of the motor network can change the activation pattern in task-related regions. Additionally, the degree to which the task-related network is recruited initially may predict who responds best to behavioral practice targeted at that network. These finding may have implications for the structure of motor practice during rehabilitation after stroke.
Abstract WP163: Green Space and 30-Day Readmissions Following Ischemic Stroke in Medicare
Authors: Wilker Elissa , Di Qian , Wang Yun , Schwartz Joel , Dominici Francesca
Published: October 2018

Background/Aim:
Exposure to ambient air pollution has been associated with elevated incidence of ischemic stroke, but less is known about how green space may affect post-stroke prognosis. We investigated the impact of Normalized Difference Vegetation Index (NDVI) on all-cause readmissions following ischemic stroke among older adults in the United States.

Methods:
Participants were Medicare beneficiaries ≥65 years of age hospitalized with a principal discharge diagnosis of ischemic stroke from 2008 to 2013. Logistic regression was used to evaluate associations between green space at the residential ZIP code level, determined as a 365-day average of NDVI prior to hospital admission, and readmission within 30 days post-discharge. Models were adjusted for individual and area level demographic and lifestyle characteristics, PM
2.5
in the prior year, and National Climatic Data Center (NCDC) region (Ohio Valley, Upper Midwest, Northeast Northwest, South, Southeast, Southwest, West, Northern Rockies and Plains). Sensitivity analyses included random effects meta-analysis combining estimates from models for each NCDC region and restricted cubic splines to examine region-specific exposure-response relationships.

Results:
There were 1,248,426 participants (565,367 men (45%), mean ± standard deviation age 79±8) and 174,336 (14%) were readmitted within 30 days. An interquartile range difference in NDVI (0.18) was associated with lower odds of readmission (OR=0.98, 95% Confidence Interval (CI) 0.97, 0.99). The pooled estimate combining data from all regions was OR= 0.99 (95%CI: 0.97, 1.007) with substantial heterogeneity observed across the regions (I
2
=53%, p=0.03). Evaluation of restricted cubic splines suggested a steeper slope at levels of exposure below 0.4 in several of the regions including the Northeast, Ohio Valley and West and wide confidence intervals at higher levels.

Conclusions:
Our findings suggest that NDVI may be a predictor of prognosis following stroke in some regions of the United States and that these associations may also vary by other weather and land-use characteristics.
Abstract WP165: Thyroid Function is Associated With Stroke Severity, Discharge Outcomes, and Quality of Life After Ischemic Stroke
Authors: Cole Sydni M , Corado Carlos , Lin Chen , Mendelson Scott J , Prabhakaran Shyam
Published: October 2018

Objective:
Data regarding the relationship between thyroid function and ischemic stroke (IS) are conflicting and limited by small sample sizes. In a large prospective cohort, we evaluated whether thyroid function at index hospitalization is associated with stroke severity or functional outcomes.

Methods:
Consecutive patients with IS were enrolled in observational cohort study which prospectively collected demographic (age, sex, race, insurance), clinical (NIHSS score, baseline function, risk factors, TOAST subtype), imaging (infarct volume), hospital treatments, and outcome data at 3 months. Thyroid stimulating hormone (TSH) levels upon admission were captured from the Enterprise Data Warehouse. Outcomes included discharge ambulation and modified Rankin Scale (mRS) and Neuro-QOL upper extremity, lower extremity, and cognition T-scores at 3 months. We assessed the association between TSH (log transformed and quartiles) levels and discharge and 3-month outcomes using bivariate and multivariate linear and logistic regression, as appropriate.

Results:
Among 559 patients (mean age 64.5±15.9 years; 51.2% male; 31.3% black; 8.4% Hispanic), TSH values were correlated with age (r
s
=0.115, p=0.007), initial NIHSS score (r
s
=-0.097, p=0.022) but not infarct volume (r
s
=-0.054, p=0.227). The lowest quartile of TSH (<1.02 mU/L) was associated with black race (42.6 vs. 27.5%, p=0.001), non-Medicare status (61.7 vs. 51.9%, p=0.044), and non-ambulatory status at discharge (38.3 vs. 28.5, p=0.029). In multivariate analyses adjusting for baseline mRS, initial NIHSS score, private insurance, cardioembolic stroke subtype, and reperfusion therapy, the lowest quartile of TSH was associated with non-ambulation at discharge (adj. OR 1.82, 95% CI 1.10-3.03). At 3-months, ln(TSH) was associated with Neuro-QOL upper extremity (adj. beta 0.98, 95% 0.11-1.85) and cognition T-scores (adj. beta 0.81, 95% 0.07-1.55) but not lower extremity T-scores (p=0.410) and 3-month mRS (p=0.453).

Conclusions:
Lower TSH levels are associated with more severe strokes, non-ambulatory status at discharge, and worse upper extremity and cognitive HRQOL scores at 3 months. The mechanism by which thyroid function alters stroke outcomes is unknown and requires study.
Abstract WP166: Longitudinal Outcomes of Medicare Beneficiaries With Transient Ischemic Attack: a GWTG-Stroke Study
Authors: Shah Shreyansh , Liang Li , Smith Eric E , Bhatt Deepak L , Fonarow Gregg C , Heidenreich Paul A , Peterson Eric D , Bettger Janet P
Published: October 2018

Background:
We sought to examine the longitudinal outcomes following admission for transient ischemic attack (TIA) among Medicare beneficiaries admitted at GWTG-Stroke participating hospitals and to examine this varies by ABCD
2
score categories.

Methods:
We identified TIA hospitalizations from GWTG-Stroke and linked these with Medicare claims for January 1, 2011 to December 31, 2014 to determine 1-year event rates of mortality, all-cause hospital readmission, composite outcome of mortality and all-cause readmission, and readmissions related to ischemic stroke (IS) and major vascular events. Patients were identified as high risk (ABCD
2
score ≥ 4) or low risk (ABCD
2
score 0-3) to assess differences in outcomes by risk group.

Results:
Of 394,920 patients from 1,779 hospitals with IS/TIA, 77,819 (19.7%) had a diagnosis of TIA at hospital discharge. Mean age was 80 years and 39.4% were male. Outcomes at 1-year included mortality in 11.9%, all-cause readmission 44.2%, composite of mortality/all-cause readmission 47.1%, ischemic stroke related admission 3.5%, and readmission related to major vascular events 5.3%. Of the 40,825 patients with complete data to calculate an ABCD
2
score, 86% were high risk (n=35,118) and 14% low risk (n= 5,707). There was a significant difference between these two groups in adjusted risk for 1-year outcomes of mortality, mortality/all-cause readmission and ischemic stroke admission but not major vascular readmission (Table 1).

Conclusions:
There was a high rate of adverse events including mortality and ischemic stroke admission, among Medicare beneficiaries admitted with TIA at GWTG-Stroke participating hospitals. The ABCD
2
score identified TIA patients at higher risk of adverse outcomes.
Abstract WP167: Low Fasting Blood Glucose and Risks of Vascular and Mortality Outcomes in General Population: A Systematic Review and Meta-Analysis
Authors: Liao Hung-Wei , Saver Jeffrey , Yeh Hsin-Chieh , Wu Yi-Ling , Lee Meng , Ovbiagele Bruce
Published: October 2018

Background and Purpose:
Although low fasting blood glucose may imply poor nutrition status or hyperinsulinemia, whether low fasting blood glucose level increases future risks of stroke, cardiovascular disease, and mortality remain unsettled. We conducted a meta-analysis to examine the effect of low fasting blood glucose on subsequent major vascular outcomes in general populations without previous cardiovascular disease history.

Methods:
We searched PubMed and EMBASE from 1966 to June 2017. We included prospective cohort studies, which evaluated the effects of low and normal fasting glucose levels (4.7-5.5 mmol/L) on future risks of stroke, coronary heart disease, cardiovascular disease, and mortality. We analyzed data with cutoff levels of low fasting glucose level < 4.6 mmol/L and 4.0 mmol/L, respectively. Hazard ratio and 95 % confidence intervals were used to measure association between low fasting glucose levels and the risks of outcomes using random effect models.

Results:
We included 10 articles (consisting of 129 prospective cohort studies) that met our criteria; 3,277,497 participants were included in current meta-analysis. Comparing with the normal glucose group, low fasting blood glucose defined as < 4.6 mmol/L was not associated with the risk of stroke (adjusted HR 1.02, 0.99 to 1.06) or coronary heart disease (adjusted HR 1.02, 0.96 to 1.08), but was associated with an increased risk of all-cause mortality (adjusted HR 1.36, 1.06 to 1.75) (Fig 1 A), and total cardiovascular events (adjusted HR 1.03, 1.02 to 1.05). Using < 4.0 mmol/L as a cutoff level for low fasting blood glucose showed similar results (Fig 1B).

Conclusions:
Low fasting blood glucose is not associated with increased risk of stroke or coronary heart disease, but is associated with an increased all-cause mortality in the general population.
Abstract WP169: Midlife to Late-Life Changes in Blood Pressure and Cerebral Blood Flow in Old Age: the AGES-Reykjavik Study
Authors: Sabayan Behnam , Moonen Justine , Sigurdsson Sigurdur , van Buchem Mark , Meirelles Osorio , Gudnason Vilmundur , Launer Lenore
Published: October 2018

Introduction:
Adverse changes in blood pressure (BP) over the life course can lead to adverse cerebrovascular outcomes, including reduced blood flow. In this life-course, longitudinal, population-based study, we investigated the link between midlife to late life changes in BP and cerebral blood flow (CBF) in old age.

Methods:
From the Age, Gene/Environment Susceptibility (AGES)–Reykjavik Study (2002-2011), 2491 individuals (mean age (SD): midlife 49.7 (6.1) and late-life 79.8 (4.7) years old) were included. BP was measured at three different time points: 1 in mid-life, and 2 in late-life measured 5 years apart (mean follow-up time 30.1 years). With linear mixed models, annual changes in BP were estimated for each participant (mmHg/year). Participants were categorized in tertiles of changes in systolic, pulse pressure and diastolic BP. Total CBF was measured in the last late-life visit with the Phase-Contrast MRI and standardized for brain parenchymal volume (mL/min/100mL).

Results:
Overall, each mmHg/year increase in systolic BP was associated with 3.2 mL/min/100 mL (95% CI: 0.7-5.7)) higher CBF. Mean (SE) CBF in low, middle and high tertiles of change in systolic BP were 56.0 (0.4), 56.6 (0.4) and 57.5 (0.4) mL/min/100mL respectively (P for trend: 0.01). A similar increase in total CBF was observed for an increase in pulse pressure: each mmHg/year increase in pulse pressure was associated with 6.3 mL/min/100mL (95% CI: 3.8-8.7) higher total CBF. In contrast, an increase in diastolic BP was linked with lower CBF: each mmHg/year increase in diastolic BP was associated with 6.3 mL/min/100mL (95% CI: 3.3-9.4) lower CBF. Mean (SE) CBF in low, middle and high tertiles of changes in diastolic BP were 57.3 (0.4), 57.3 (0.4) and 55.5 (0.4) mL/min/100mL respectively (P for trend: <0.001). All these associations were independent of sociodemographic and cardiovascular factors and antihypertensive medications.

Conclusion:
In an over 30 years of midlife to late-life follow up, we observed that individuals with increasing systolic BP and pulse pressure have higher CBF in old age. Conversely, increase in diastolic BP is associated with lower CBF. The mechanisms behind the link between long-term BP alterations and CBF need to be elucidated.
Abstract WP178: Impact of White Matter Hyperintensity on Severity and Outcome of Acute Ischemic and Hemorrhagic Stroke: The Japan Stroke Data Bank
Authors: Sonoda Kazutaka , Sato Shoichiro , Nakamura Fumiaki , Sasahara Yusuke , Nishimura Kunihiro , Miyamoto Yoshihiro , Toyoda Kazunori , Kobayashi Shotai , Minematsu Kazuo ,   The Japan Stroke Data Bank Investigators
Published: October 2018

Introduction:
Extensive forms of white matter hyperintensity (WMH) are a consequence of and indicative for advanced cerebral small vessel disease, and thus are reportedly associated with higher risks for stroke, dementia, and mortality. Our aim was to analyze impact of WMH on severity and outcome in patients with acute ischemic and hemorrhagic stroke using data from a nationwide stroke registration.

Methods:
We studied patients hospitalized with acute stroke in 103 participating centers of the Japan Stroke Data Bank from 2001 to 2015. Deep WMH was evaluated with magnetic resonance imaging (MRI) and classified with Fazekas grade. We examined associations of WMH with National Institutes of Health Stroke Scale (NIHSS) on admission and poor outcome (modified Rankin Scale of 3 - 6) at discharge using multivariable models.

Results:
We studied a total of 28,469 patients with MRI imformation. In patients with ischemic stroke (n = 24,591; women, 40%; and age, 72.5±12.1 years), median NIHSS was 4 (interquartile range [IQR] 2-9); and 10,073 (41%) had poor outcome. WMH grades of 0, 1, 2, and 3 were observed in 23%, 45%, 25%, and 6%, respectively. In multivariate analysis adjusted by age and sex, WMH grade was independently related to higher admission NIHSS (incidence rate ratio [IRR] of grade 3 versus 0, 1.33; 95% confidence interval [CI], 1.30-1.35, P for trend <0.001). In multivariate analysis adjusted by age, sex, and admission NIHSS, WMH grade was related to poor outcome (odds ratio [OR] of grade 3 versus 0, 3.08; 95% CI 2.63-3.60; P for trend <0.001). In patients with intracerebral hemorrhage (n = 3,878; women, 42%; and age, 66.9±14.2), median NIHSS was 10 (IQR 4-20); and 2,393 (62%) had poor outcome. WMH grade of 0, 1, 2 and 3 were observed in 28%, 43%, 22%, and 7%, respectively. In multivariate analysis adjusted by age and sex, WMH was independently related to higher NIHSS (IRR of grade 3 versus 0, 1.35; 95%CI, 1.30-1.40). In multivariate analysis adjusted by age, sex, and admission NIHSS, WMH grade was related to poor outcome (OR of grade 3 versus 0, 1.99; 95% CI 1.28-3.11; P for trend <0.001).

Conclusions:
Extensive forms of WMH influenced on severity and outcome in both acute ischemic stroke and intracerebral hemorrhage in a nationwide hospital-based patient cohort.
Abstract WP180: Recanalization Predicts Prognosis After Cerebral Venous Thrombosis: A Systematic Review and Meta-analysis
Authors: Honig Asaf , Sepehry Amir , Suryanarayan Deepa , Field Thalia S
Published: October 2018

Background:
Guidelines recommend a 3-12 month duration of anticoagulation for cerebral venous thrombosis (CVT) and a repeat venogram at 3-6 months to assess recanalization. However, the relationship between recanalization and prognosis is not well defined. We performed a systematic review and meta-analysis to clarify the association between venous recanalization and prognosis in CVT.

Methods:
We performed a literature search to identify all published studies that evaluated recanalization and prognosis in adult patients with a diagnosis of CVT treated with anticoagulation. Studies were identified using MEDLINE and EMBASE databases (1946 - 2017). Recanalization was ascertained by repeat venogram (CT, MR or conventional) and degree of recanalization was characterized as complete, partial or absent. Prognosis was defined using the modified Rankin Scale (mRS, 0-1 = excellent outcome).

Results:
We found 675 articles and conference abstracts. Thirty-five were appropriate for full-text review and 11 had information regarding recanalization and clinical outcome, accounting for 450 subjects in total. All but one study had clinical and neuro-imaging reassessments within 12 months. Eighty-five percent had complete or partial recanalization within one year. Eighty-seven percent had an excellent outcome (mRS 0-1). As compared with complete or partial recanalization, those with no recanalization had a significantly increased odds of an mRS of 2-6 (OR 3.3, 95% CI 1.5 - 7.2, p=0.003). There was no significant difference in odds of worse prognosis for those with partial recanalization versus full recanaliation. No recanalization also carried a higher odds of CVT recurrence (OR 7.2, 95% CI 1.5 - 33, p=0.01) and chronic headache (OR 3.8, 95% CI 1.6 - 9.0, p=0.002).

Conclusion:
Absence of recanalization is associated with a poorer prognosis in CVT patients. There does not appear to be a dose-response relationship with regards to degree of recanalization (partial versus complete) and prognosis.
Abstract WP186: The Quality of Secondary Prevention after Stroke or Transient Ischemic Attack is Worse in Survivors With Disability
Authors: Olaiya Muideen T , Cadilhac Dominique A , Kim Joosup , Srikanth Velandai K , Ung David , Thrift Amanda G
Published: October 2018

Introduction:
Severity of stroke impacts functional outcomes after stroke, but the role of this disability on secondary prevention is unclear. We investigated the effect of disability status on secondary prevention outcomes, such as the management of risk factors, knowledge regarding secondary prevention, and long-term unmet needs.

Methods:
Post-hoc analysis of a clinical trial of community-dwelling adults with stroke/TIA in Melbourne, Australia. Demographic/clinical data were obtained from hospital records, while standardised assessments were conducted for disability, cardiovascular risk, and mood. Disability was defined using the modified Rankin Scale (mRS): no disability (mRS=0), no significant disability (mRS=1), or slight to severe disability (mRS 2-5). Two-year outcomes included the standardized cardiovascular Framingham risk score, unmet needs, and knowledge of risk factors and medications prescribed for secondary prevention. Multivariable regression models were used to determine the effect of disability status on outcomes.

Results:
From January 2010 to November 2013, 563 survivors of stroke/TIA were recruited: median age 70.1 years, 65% males, 79% ischemic stroke, and 29% with no disability. After a 2-year follow-up, 86% provided outcome data. In the multivariable regression analyses, when compared to participants with no significant disability, those with slight/severe disability had greater cardiovascular risk scores (odds ratio 1.33, 95% CI 1.00-1.76). A dose-response effect was found for disability status and long-term unmet needs, with more unmet needs reported among those with no significant disability (incidence risk ratio 1.55, 95% CI 1.21-1.99) or with slight/severe disability (incidence risk ratio 1.64, 95% CI 1.24-2.16), than in those with no disability. We found no effect of disability status on knowledge of risk factors or medications.

Conclusions:
After a 24-month follow-up, survivors of stroke/TIA with disability had worse risk profiles and more unmet needs than those with no disability, and may benefit from targeted care post-discharge.
Abstract WP188: Impact of Carotid Plaque Burden on Long-Term Outcomes in Ischemic Stroke Patients With Atrial Fibrillation
Authors: Park Hyungjong , Kim Young Dae , Heo Ji Joe , Nam Hyo Suk
Published: October 2018

Background:
Atrial fibrillation (AF) is a major risk factor for ischemic stroke, myocardial infarction, congestive heart failure and long term mortality. Atherosclerosis disease may co-exist in ischemic stroke patients with AF. Until now, there is limited information on the impact of concomitant carotid atherosclerosis on long-term outcomes in ischemic stroke patients with AF. Thus, we investigated where there are differences in long-term mortality among ischemic stroke patients with AF.

Methods:
Total 343 ischemic stroke patients with AF who underwent carotid ultrasonography between January 2007 and December 2013 were enrolled in this study. Total number of carotid artery plaque and maximal thickness among carotid plaques were assessed using B-mode ultrasound. For measuring carotid plaque burden, we made the carotid plaque burden score, which was calculated by multiplying the total number of carotid artery plaques and the maximal thickness. The association between carotid plaque burden score and long-term mortality was investigated using Cox hazard model.

Results:
After a mean follow up period of 3.2 years, total 69 patients (20.1%) dead. Mean carotid plaque burden score was 11.76 ± 15.32 (mean ± Standard Deviation). In univariate analysis, age ((HR, 1.07; 95% Confidence Interval [CI], 1.01-1.10, P<0.001), initial National Institute of Health Stroke Scale (HR, 1.09; 95% CI, 1.06-1.13, P<0.001), and plaque score (HR, 1.02; 95% CI, 1.01-1.03, P<0.001) were significantly associated with all-cause mortality in ischemic stroke patients with AF. In multivariate analysis, after adjusting conventional cardiovascular risk factor, carotid artery plaque burden score was independently associated with all-cause mortality in ischemic stroke patients with AF (HR, 1.03;95% CI, 1.01-1.04, P<0.001).

Conclusion:
Carotid plaque burden is an independent predictor of all-cause mortality in ischemic stroke patient with AF. Intervention of atherosclerosis may help to improve long term outcome in ischemic stroke patients with AF.
Abstract WP19: Endovascular Recanalization for Acute Stroke Patients With Low Aspects
Authors: Ioku Tetsuya , Imai Keisuke , Hamanaka Masashi , Yamazaki Hidekazu , Itsukage Masahiro , Tsuto Kazuma , Yamamoto Atsushi
Published: October 2018

Background:
Several studies have suggested that stroke patients with an ASPECT score (ASPECTS) ≥7 benefit from endovascular recanalization.

Objective:
The purpose of the study was to examine the benefit of endovascular recanalization for stroke patients with low ASPECTS.

Materials and Methods:
Among 373 consecutive stroke patients treated with endovascular recanalization at our hospital from March 2007 to March 2017, those with ASPECTS ≤6 were included in the study and classified into three groups based on ASPECTS of 6 (APS6), 5 (APS5), and ≤4 (APS4). Preprocedural factors, procedures, and angiographic and clinical outcomes were compared among the three groups.

Results:
A total of 111 patients were included in the analysis, with 41, 37, and 33 in the APS6, APS5, and APS4 groups, respectively. Median age (74, 76, and 80 years, respectively), median baseline NIHSS (21, 21, and 24), occluded site (ICA-MCA: 14-27, 14-23, and 21-12), intravenous rt-PA (5, 3, and 4), complete recanalization (TICI 2b/3: 34, 25, and 19), and median onset to recanalization time (329, 385, and 360 min) did not differ significantly among the three groups. However, the APS4 group had a lower favorable outcome rate (mRS 0-2 at 3 months: 27%, 16%, and 6%) and higher 3-month mortality (12%, 11%, and 21%).

Conclusions:
In stoke patients with low ASPECTS, endovascular recanalization is beneficial in those with ASPECTS of 6. Results were equivocal in those with ASPECTS of 4, suggesting a need for caution with the indication for recanalization in these patients.