bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 78: Risk Factors Associated with Failure of Aggressive Medical Therapy in the SAMMPRIS Trial
Authors: Waters Michael F , Hoh Brian L , Lynn Michael J , Turan Tanya N , Derdeyn Colin P , Fiorella David , Lane Bethany F , Sheehan Tiffany O , Janis Scott , Montgomery Jean , Chimowitz Marc I ,   SAMMPRIS
Published: July 2021

Background:
The SAMMPRIS trial showed that aggressive medical therapy was more effective than stenting for preventing stroke in high-risk patients with symptomatic intracranial stenosis. However, 15% of patients in the medical group still had a primary endpoint (any stroke or death within 30 days of enrollment or stroke in the territory beyond 30 days) during a median follow-up of 32.7 months. We sought to determine baseline risk factors that were associated with a primary endpoint in the medical arm of SAMMPRIS.

Methods:
Data on 227 patients randomized to the medical group in SAMMPRIS were analyzed. Baseline demographic features, vascular risk factors, qualifying event, brain imaging and angiographic features were analyzed. The hazard ratio and p-value from a Cox proportional hazard regression model relating time until a primary endpoint to each factor were calculated.

Results:
Female gender, diabetes, stroke as the qualifying event (especially non-penetrator stroke), old infarct in the territory of the stenotic artery, and > 80% stenosis were associated (p < 0.10) with a higher risk of the primary endpoint on univariate analysis (see accompanying table) (multivariate analysis will be available by the time of ISC). Variables not associated with a higher risk of a primary endpoint in the medical arm included: age, race, antithrombotic therapy at the time of a qualifying event, time from qualifying event to enrollment (< 7 days vs. > 7 days), and location of stenosis.

Conclusions:
Several features were associated with an increased risk of the primary endpoint in the medical group in SAMMPRIS. On univariate analysis, the most important risk factors were an old infarct in the territory of the stenotic artery and stroke (especially non-penetrator stroke) as the qualifying event. These features will be useful for identifying particularly high-risk patients who should be targeted for future clinical trials testing alternative therapies to aggressive medical management.
Abstract NS1: Nurse-Led Acute Stroke Team
Authors: Klassman Lynn , Peppa Royce , Pool Barbara , Brezinski Lisa , Tinsley Mary Ann
Published: July 2021

Background /Purpose:
Acute stroke treatment is reliant on a consistent team approach focused on evidence-based guidelines and time-sensitive treatments. Early efficient care is crucial in maximizing favorable patient outcomes; however door-to-tPA times at our institution were not consistently less than 60 minutes. As a result, a multidisciplinary team engaged in a rapid improvement event to review barriers and identify opportunities for quality improvement. One strategy was the establishment of a 24x7 nurse-led Acute Stroke Team (AST). The budget neutral AST role was implemented to oversee and assist in delivery of time-sensitive assessment and treatment of acute stroke patients.

Methods:
Nurses from the neurology/stroke unit were selected for AST based on clinical expertise in assessment, communication and leadership skills. Didactic education and clinical mentoring was provided by the Stroke Advanced Practice Nurse (APN). AST nurses were relieved by the unit charge nurse when they attended stroke alerts in the emergency department or in-hospital. A log sheet was utilized to record: date and time of stroke alert calls, amount of time off the unit, and issues/concerns. A Likert-scale survey distributed to multidisciplinary hospital departments post implementation assessed satisfaction with the AST role.

Results:
During the first year of AST: 1) AST attended 448 stroke alerts, 2) calls averaged about 40 minutes, 3) IV tPA administration increased from 17 to 32 times (increase of 88%), 4) door-to-tPA delivered within 60 minutes increased from 3 times to 13 times (333% increase), 5) door-to-tPA time decreased from average 100 minutes to 77 minutes (23% decrease). Multidisciplinary hospital departments strongly agreed that the AST nurse assessment was valuable during a stroke alert (78%), and that the AST nurse was considered an asset to the stroke program (91%).

Conclusions:
Addition of the AST nurse role to the hospital acute stroke response has increased tPA usage, improved door-to-tPA times, and enhanced department collaboration. AST nurses continue to expand their clinical knowledge and expertise regarding the continuum of stroke care, gain leadership skills, and appreciate their role in positive patient outcomes.
Abstract NS13: Road to Recovery after Stroke: Understanding Predictors of Discharge Destination, Functional Independence, and Quality of Life after Hospital Discharge
Authors: Paletz Laurie , Roberts Pamela , Aronow Harriet , Guerra Sonia , Yan Tingjian
Published: July 2021

Introduction:
Stroke is the leading cause of long-term disability and affects 795,000 people in the U.S. each year. This study was conducted to enhance knowledge of outcomes during recovery and the options for participating in rehabilitation and preventive care during patients’ transitions to the community. Comprehensive Stroke Certification charges hospitals with the task of expanding knowledge of functional and quality of life outcomes for all stroke patients through the continuum examining effects of stroke severity, functional impairment, and patient characteristics on discharge destinations, functional independence, and quality of life after discharge.

Methods:
Retrospective analysis of an acute stroke quality improvement database which includes measures collected by MedTel Outcomes LLC on all stroke patients one month after discharge. Included, is the Functional Independence Measure and standardized quality of life and participation measures. In the database are standardized measures from the medical record such stroke type, Modified Rankin score, and acute functional independence measure score for 719 patients with a 30-day follow-up phone assessment for functional and quality of life measures from January 1, 2011 to December 31, 2012.

Preliminary Findings:
Over 75% of patients had hemiparesis, & over 90% survived 30-days post discharge and were living in the community. At follow-up, mostwere independent in self-care, and half were independent in mobility excluding stairs. Those with right brain involvement had a complicated, slower recovery. Those with left brain involvement,had lower functional scores and a higher percentage of them were not living in the community, rather, living in institutions.

Conclusions:
All patients experiencing a stroke should have evidence-based information on their options & what to expect during their recovery during their transitions into the community. The data base is useful as a source of outcome data for comparative effectiveness and to build a regional collaborative outcomes database for Comparative Effectiveness Research and quality benchmarking. Findings can be used to understand the functional trajectory of recovery based on severity of stroke and other factors.
Abstract NS16: Performance-based Testing Identifies Cognitive Deficits Missed by Screening Methods Used in Mild Stroke
Authors: Edwards Dorothy F , Morrison Mary T , Giles Gordon M
Published: July 2021

Background:
Recent data suggests that approximately 50 % of ischemic strokes are in the mild range (NIHSS ≤ 6). Persons with mild stroke have minimal motor, language or sensory impairment and often receive no rehab services. However about 30 % these patients are unable to fully return to pre-stroke roles and responsibilities due to subtle but disabling cognitive impairment.

Aim:
To assess the contribution of performance based testing (PBT) to the identification of executive function (EF) deficits undetected by traditional screening methods in a cohort of individuals with mild stroke reporting difficulties in participation as measured by the Stroke Impact Scale (SIS)

Methods:
The Impact of Mild Stroke on Community Reintegration and Quality of Life study followed a cohort of persons with first ischemic stroke with NIHSS scores ≤ 5 from acute admission to 1 yr follow-up. Neurocognitive, functional ,and self-report measures were administered at baseline, day 90, 6 mo. and 1 yr. PBTs assessing executive function were administered at 6-mo follow-up; The Executive Function Performance Test (EFPT) evaluates 4 complex IADL task s and The Multiple Errands Test (MET) requires performance of a series of tasks in a dynamic real-world environment . A score of < 80 on the SIS Participation scale SIS indicates failure to fully resume roles and responsibilities.

Results:
90 patients (Mdn NIHSS=3; Mean age 60 ± 10.8 ) with first ischemic stroke were evaluated . All had MRS scores ≤ 1; 89 % were independent on the FIM (≥108) and normal cognition ( Short Blessed Test ≤ 4). Of these, 39 % reported scores less than 80 on SIS Participation. The EFPT identified 46 % of this group as performing in the impaired range. Further assessment of those unimpaired on the EFPT with the more demanding MET found an additional 22 % as impaired: 68% of patients scoring as “normal” on standard measures had impaired PBT scores.

Conclusions:
We identified individuals with occupational therapy rehabilitation needs unrecognized by standard measures. We recommend a hierarchical approach to evaluation of persons with mild stroke reporting difficulties in participation with PBT used in those scoring unimpaired/independent on standard outcome measures
Abstract NS19: Exploring Clinician Perspectives of Treating Acute Stroke with Thrombolytic Therapy: Results of a Multi-Center Qualitative Research Study
Authors: Gialde Elizabeth , Spertus John , Chhatriwalla Emily , Garavalia Brian , Summers Debbie , Rymer Marilyn , Decker Carole
Published: July 2021

Study Objectives:
Multiple guidelines endorse recombinant tissue plasminogen activator (rt-PA) in eligible patients with acute ischemic stroke (AIS), but only 4-6% of patients are treated. Clinician doubts about treatment benefits or operational barriers may be among the reasons for not treating potentially eligible patients. Through qualitative interviews, we sought to better understand the issues and perspectives for AIS treatment from Emergency Medicine Physicians (EMP) and Neurology and Emergency based Advanced Practice Nurses (APN) looking for similarities and differences.

Methods:
A multidisciplinary research team conducted in-depth interviews of 23 EMPs from 11 sites, and 20 APNs from 18 sites across the US. An interview guide was designed to elicit their current experience using rt-PA in AIS, approach to discussing rt-PA with patients and families, and cultural attitudes.

Results:
EMPs (male = 74%; 12 average years of experience) and APNs (male = 5%; 9.4 average years of experience) described two themes as shared perspectives: Timely Presentation and Neurology Presence were both thought to be important facilitators to receive rt-PA. However, differing perspectives emerged in four themes: Knowledge of Long-term Outcomes; Impression of Data; Communication of Risk and Benefit; and Use of Written/Educational Material (Table). The themes and representative quotes are presented by subject number and years in practice.

Conclusions:
While common perspectives were described, mainly contrasting beliefs emerged, most of which provide an opportunity to develop future strategies to improve guideline adherence for rt-PA use in AIS for each discipline.
Abstract NS8: The Effects of Introducing a Nurse Practitioner Stroke Champion into the Emergency Department
Authors: Olson-Mack Lindsay , Reardon Jacqueline , Hedden Elton , Carino Rowena , VanWyk Cynthia , Letzkus Pamela , Clarkson-Afshar Katherine
Published: July 2021

Background and Purpose:
Emergency Department (ED) physicians often manage acute stroke patients without Neurology support at the bedside. Without guidance, they are left to rapidly assess, diagnose and treat acute stroke patients with minimal follow up on treatment effectiveness and patient outcomes. We hypothesized that introducing a Nurse Practitioner (NP) as Stroke Champion into an ED that did not have access to in-house Neurology would drive awareness of acute stroke care, and positively change practice to decrease door to needle times.

Methods:
The NP started in the 24-bed ED in June 2012. The average daily census of the ED for 2012 was 135 patients per day, and from January to June 2012, ED physicians initiated 46 stroke codes. Although Neurologists were available via telephone, ED physicians were left to accurately assess and initiate stroke codes, determine eligibility, and order IV tPA. In collaboration with the Stroke Medical Director, the Stroke NP conducted multiple education sessions regarding timing metrics in acute stroke care and door to tPA goals with ED clinicians, radiology, lab and pharmacy departments. Data was shared with stakeholders monthly to drive performance improvement initiatives.

Results:
Rapid improvements were made in all metrics. Mean time to CT first image improved by 19.3 minutes (37.3 to 18.0 minutes) in 6 months, and to 14.7 minutes in 1 year. CT result mean turn-around-time decreased by 19 minutes (from 54.0 to 29.1 minutes) in the first 6 months, and by 22.6 minutes (from 54.0 to 26.0 minutes) at 12 months. Likewise, laboratory result turn-around-times dramatically decreased by a mean of 15.9 minutes (54.4 to 38.5 minutes) over 6 months, and by a mean of 23 minutes (54.4 to 31.0 minutes) within 12 months. IV tPA treatment rates increased from 5% to 14.4% of all ischemic strokes. Door to IV tPA treatment times decreased by a mean of 33.9 minutes (104.5 to 70.6 minutes) in 6 months, and by 46.8 minutes (from 104.5 to 57.7 minutes) within the year.

Conclusions:
Introducing an NP into the ED to serve as Stroke Champion can provide added support to improve care of acute stroke patients by expediting assessment and treatment.
Abstract T MP10: Pittsburgh Response to Endovascular Therapy (PRE) Score Predicts Likelihood of Benefit From Endovascular Therapy in Anterior Circulation Large Vessel Occlusions
Authors: Rangaraju Srikant , Aghaebrahim Amin , Streib Christopher , Sun Chung-Huan , Ribo Marc , Muchada Marion , Nogueira Raul , Michael Frankel , Gupta Rishi , Jadhav Ashutosh P , Jovin Tudor G
Published: July 2021

Background:
Endovascular therapy seems to benefit a subset of patients with acute large vessel occlusions (LVO). The aim of this study was to develop a clinically useful tool to identify patients with anterior circulation large vessel occlusions who are likely to benefit from endovascular therapy.

Methods:
Adults with anterior circulation LVOs were included. In the derivation cohort (2008-2012) from Grady Memorial hospital (GMH), independent predictors (p<0.2) of good outcome (mRS 0-2 at 90 days) were determined using logistic regression. Highly weighted factors were used to derive the PRE score as a predictor of good outcome. Four risk-quartiles were created based on observed rates of good outcomes. The PRE score was validated in the UPMC database (n=322, 2007-2013) and in a database from Unitat d'Ictus Vall d'Hebron (UIVH), Barcelona (n=203, 2009-2012). Performance of PRE was compared with HIAT-2, THRIVE and ASPECTS in predicting good outcome.

Results:
In the derivation cohort (N=247, mean age 66±1, median NIHSS 18), independent predictors of good outcome included age (OR 0.96, 0.94-0.98), NIHSS (OR 0.92, 0.87-0.98) and ASPECTS (OR 1.96, 1.6-2.5). The PRE score was calculated as follows: PRE Score = Age + 2 x NIHSS - 10 x ASPECTS. PRE predicted good outcomes in the derivation cohort (AUC 0.79) as well as in the validation cohorts (UPMC: AUC 0.79 and UIVH: AUC 0.72) and comparative rates of good outcome were observed in the four PRE quartiles. PRE < 25 was associated with good outcome (OR 6.0, 3.5-10.5), and controlling for TICI 2B/3 reperfusion status further strengthened this association (OR 12.8, 4.5-36.2). PRE (AUC 0.79) performed better than HIAT2 (AUC 0.75), THRIVE (AUC 0.73) and ASPECTS (AUC 0.57) in predicting good outcomes after endovascular therapy.

Conclusions:
The PRE score is a validated tool to predict benefit from endovascular therapy in patients with anterior circulation LVO. PRE can aid in the selection of patients for endovascular reperfusion therapy.
Abstract T MP103: Long-Term Outcomes of Elderly Patients with Intracerebral Hemorrhage and Atrial Fibrillation
Authors: Stamplecoski Melissa , Fang Jiming , Kapral Moira K , Silver Frank L
Published: July 2021

Background:
There has been limited investigation into the long-term outcomes of elderly patients with intracerebral hemorrhage (ICH) and atrial fibrillation (AF). Although ICH is associated with high short-term mortality, the long-term mortality of those patients with AF who survive a first ICH is unknown, as is the true incidence of recurrent ICH, ischemic stroke and major bleeding. The aims of this study were to examine the long-term outcomes of a cohort of patients with ICH and AF and to identify factors associated with long-term survival.

Methods:
We used the Ontario Stroke Registry (OSR) to identify a population-based cohort of patients ≥ 65 years of age with ICH and AF who were admitted to one of Ontario’s 150 acute care hospitals between 2002 and 2011. Linkage to health administrative databases was performed to assess mortality at 30 days, 1 year and 2 years as well as rates of recurrent ICH, ischemic stroke and major hemorrhage at 1 year. Prescription drug utilization in the year following hospital discharge was assessed through linkage to the Ontario Drug Benefits (ODB) database. Multivariable logistic regression was used to identify factors associated with long-term survival in these patients.

Results:
Of the 1,236 elderly patients diagnosed with ICH, 329 (26.6%) had AF. Of those patients discharged alive, 21.1% were prescribed warfarin in the year following discharge. Mortality was 42.6% at 30 days, 58.7% at 1 year and 66.9% at 2 years. The all-cause readmission rate at 1 year was 12.1%, 5.0% for ischemic stroke, 3.5% for recurrent ICH and 7.5% for major bleeding. Multivariable analysis showed that being prescribed an antihypertensive agent (HR 0.151, p<0.0001), a statin (HR 0.463, p=0.0102) or warfarin (HR 0.136, p=0.0056) after ICH was associated with a decreased risk of death at 1 year.

Conclusions:
In patients with ICH and AF, the incidence of recurrent ICH is lower than the incidence of ischemic stroke or major bleeding at 1 year. Although ICH is associated with high short-term mortality, the 2 year mortality rate for those patients who survive the first 30 days remains stable. Although ICH is often considered a relative contraindication for anticoagulation, this study demonstrates a reduction in long-term mortality in ICH patients treated with warfarin.
Abstract T MP44: Different Predictors of Treatment Gains in Lacunar and Non-lacunar Stroke
Authors: Burke Erin , Dodakian Lucy , See Jill , Riley Jeff D , McKenzie Alison , Le Vu , Cramer Steven C
Published: July 2021

Introduction:
Numerous predictors of treatment-induced behavioral gains after stroke have been identified. However, only a few types of predictors have generally been examined at a time. The current study examined multiple categories of established predictors in parallel among patients enrolled in a motor therapy study, hypothesizing that brain injury and function are of greatest predictive value. Furthermore, given that clinical relationships often differ according to stroke pathophysiology, the hypothesis was also tested that predictors of treatment gains vary according to stroke subtype.

METHODS:
Patients with age>18 yr, stable arm paresis, and stroke 11-26 wks prior were enrolled in a study (NCT01244243) that provided 3 weeks of standardized robotic arm therapy. The primary outcome measure was change in Fugl-Meyer (FM) and Action Research Arm Test (ARAT) scores. A total of 6 categories of baseline assessments were evaluated as potential predictors of treatment gains: [1] demographics/history, [2] behavior, [3] genetics, [4] neurophysiology (TMS), [5] brain injury (3T MRI), and [6] brain function (3T fMRI). For each category, the strongest bivariate predictor of gains (when significant) was advanced into a multivariate model.

RESULTS:
At baseline, the 29 patients had substantial motor deficits (FM=36±15), medium-sized infarcts (33±48cc; 8 lacunar, 21 non-lacunar), and were 4.3 months post-stroke. Patients improved significantly (p<0.0005) on the FM (3.7±3.5) and ARAT (4.1±6.3) scores. In non-lacunar stroke, extent of corticospinal tract injury and baseline behavior survived as predictors of treatment gains in the multivariate model (r=0.60, p=0.02). In lacunar stroke, the model found that extent of activation within ipsilesional primary motor cortex was the sole predictor of gains (r=0.79, p=0.02).

CONCLUSIONS:
Measures of brain injury, brain function, and behavior are the strongest predictors of arm motor gains among patients in the early phase of chronic stroke. Different factors predict gains across stroke subtypes. Current results may be useful for patient selection in a clinical trial setting, where effective stratification can reduce variance and increase study power.
Abstract T MP50: Appropriate Stroke Team Activations Through Use of Los Angeles Pre-hospital Stroke Scale (LAPSS)
Authors: Power Martha , Bittner Frank , Horstman Patricia , Lander Owen , Marshall Thomas , Sherman Jay , Smith Tanya , Gutmann Laurie
Published: July 2021

Background and Purpose:
Target Stroke
SM
aims to reduce the Door to Needle (DTN) times to 60 minutes or less in eligible ischemic stroke patients. They advocate Emergency Medical Service (EMS) pre-notification, a rapid triage protocol,stroke team notification, and a single call activation system
1
. Prior to February 2013 the Stroke Team averaged 92.8 Stroke Team Activations monthly. This volume placed a burden on the Stroke Team and ancillary departments. DeLuca and colleagues noted a possible criticism of Stroke Code in that patients with symptoms mimicking a stroke may overload the stroke personnel
2.
We set out to decrease unnecessary stroke team activations without missing an opportunity to treat an eligible patient.

Methods:
A retrospective chart review was performed on all Stroke Team Activations between February and July 2012. We identified the volume of cancelled activations, number of patients too late or symptoms too mild, stroke mimics and treatments provided. The Los Angeles Pre-hospital Stroke Scale (LAPSS) was chosen as a screening tool for Medical Command to use with EMS personnel. The Stroke Team Activation time was shortened from 8 to 6 hours from last known well. The Emergency Department physicians had override authority for Activations. The revised Stroke Team Activation Guideline was disseminated in early 2013. To assess the utility of LAPSS as a Stroke Team Activation tool we compared the pre-LAPSS to the post-LAPSS data. A report completed by Medical Command on all requested Stroke Team Activations was also reviewed.

Outcomes:
A total of 557 patients were reviewed pre-LAPSS and 426 post-LAPSS. In comparison, the updated Stroke Team Activation Guideline resulted in a decrease of stroke team activations by 23.5%. Average DTN times remained under 60 minutes. A higher percent of patients seen were treated with rtPA (8.6% pre vs. 9.9% post). We have not missed the opportunity to treat an eligible stroke patient.

Conclusion:
A higher percentage of patients can be treated with DTN times under 60 minutes without overburdening the Stroke Team when procedures are in place for optimum specificity to identify those patients who would benefit from rapid team activation and stroke intervention.
Abstract T MP67: Physical Activity Reduces Stroke Risk Among Women in the California Teachers Study Cohort
Authors: Wang Sophia S , Lakshminarayan Kamakshi , Elkind Mitchell , Voutsinas Jenna , Lacey James , Zhong Chengyi , Ma Huiyan , Chung Nadia , Woo Daniel , Bernstein Leslie
Published: July 2021

Background:
Major modifiable stroke risk factors are well-established, yet strategies for effective prevention remain challenging. Developing stroke prevention strategies for women is critical due to: (i) the higher fatality and disability rate that women suffer compared to men, (ii) the unique risks to women such as from post-menopausal hormone therapy use, and (iiii) the aging female population. We evaluated three important modifiable stroke risk factors- obesity, hormone therapy, and physical activity, in the California Teachers Study cohort to identify potential stroke prevention strategies.

Methods:
The California Teachers Study comprises 133,479 women who enrolled in 1995 and have since been continuously followed. Using linked California state hospitalization data from 1996-2010, 3126 stroke events were defined as ischemic (N=2416; ICD-9 433, 434, 436) or hemorrhagic (N=710; ICD-9 430-432, excluding 432.1) and were validated by medical record review. Information about obesity, physical activity, hormone therapy, and medical history was collected at baseline and in follow-up questionnaires. Multivariable-adjusted hazards ratios and 95% confidence intervals were estimated by fitting Cox proportional hazards models with follow-up through 2010.

Results:
Consistent with previous reports, current post-menopausal hormone therapy use was associated with a 1.3-fold increased risk for stroke (95% CI=1.03-4.85). Moderate to strenuous physical activity in the 3 years before enrollment (but not lifetime activity) decreased stroke risk by 20% (HR=0.79, 95% CI=0.71-0.98). This decreased risk among physically active women was similar among current hormone therapy users, and appears to counteract the increased risk observed with current hormone therapy use. We found no association between obesity and stroke that was independent of diabetes.

Conclusions:
Recent physical activity reduces stroke risk and appears to counteract the increased risk associated with post-menopausal hormone therapy use.
Abstract T MP99: What Are the Blood Pressure Levels Associated With the Lowest Stroke Rates in the Elderly? Findings From the Reasons for Geographic and Racial Differences in Stroke (regards) Cohort Study
Authors: Banach Maciej , Bromfield Samantha , Howard George , Howard Virginia J , Zanchetti Alberto , Aronow Wilbert S , Ahmed Ali , Safford Monika M , Muntner Paul M
Published: July 2021

OBJECTIVES:
To identify the blood pressure (BP) level associated with the lowest stroke incidence in elderly persons taking antihypertensive medication in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study.

METHODS:
We categorized 13,948 REGARDS participants with hypertension into 3 age groups: 55-64, 65-74 and ≥75 years old and 5 levels of treated systolic BP (SBP): <120 (reference group), 120-129, 130-139, 140-149, and ≥150 mmHg, and 4 levels of diastolic BP (DBP) levels: <70 (reference group), 70-79, 80-89, and ≥90 mmHg. Participants without a history of stroke were followed for a median of 5.7 years (maximum 8.5 years) for incident stroke (n=425).

RESULTS:
For participants at age 55-64 SBP level <120 mmHg and DBP <70 mmHg were associated with the lowest risk of stroke (incidence
per
1,000 person-years: 2.4, 95%Cl: 1.4-4.0 and 2.5, 95%Cl: 1.3-4.7, respectively). Higher stroke risk was observed at SBP ≥140 mmHg. For those aged 65-74, stroke incidence was increased at SBP ≥130 mmHg and at lower DBP levels (with the lowest stroke risk for DBP ≥90 mmHg). For participants ≥75 years SBP ≥150 mmHg was associated with the highest risk of stroke (incidence rate: 15.0, 95%Cl: 10.5-21.3) but no increased risk was observed for SBP between 120-149 mmHg. For DBP, stroke incidence was highest for DBP <70 mmHg (adjusted incidence rate: 9.8; 95%Cl: 6.8-14.1), and lowest for DBP ≥90 mmHg (adjusted incidence rate: 6.5; 95%Cl: 2.9-14.5) (see table).

CONCLUSIONS:
These results suggest that the lowest risk for stroke for the participants between 55-64 years old are at BP levels <140/70 mmHg, for persons 65-74 we should aim at SBP levels <130 mmHg, and for the oldest patients at SBP <150 with DBP ≥90 mmHg for both groups. For participants aged ≥65 a caution should be kept with the reduction of DBP <90 mmHg, what requires further investigations.

Key words:
blood pressure, elderly, hypertension, treatment, mortality, stroke.
Abstract T P102: Outcomes of Tailored Angioplasty for Symptomatic Intracranial Atherosclerosis: A Prospective Cohort Study after Sammpris
Authors: Zhongrong Miao , Ligang Song , David S. Liebeskind , Liping Liu , Ning Ma , Xianwei Wang , Yilong Wang , Dapeng Mo , Feng Gao , Xingquan Zhao , Kehui Dong , Dong Zhang , peiyi Gao
Published: July 2021

Background and Purpose:
High periprocedural complication rate is a key limitation of endovascular treatment of intracranial atherosclerotic disease (ICAD) despite potential risk reduction of recurrent stroke. Based on the SAMMPRIS trial, with modification of the target population and tailored angioplasty, we prospectively evaluated efficacy and safety of a novel endovascular approach for patients with ICAD.

Methods:
From November 2011 to October 2012, 156 patients were consecutively recruited into a prospective single-center study. Patients were divided into 3 groups based on 4 angioplasty methods: Apollo (A) Group, Gateway/Gateway+Stent (G-GS) group, and Gateway+Wingspan (GW) Group. The primary endpoints were successful procedure rate and any vascular event within 30 days.

Results:
Overall technical success rate was 96.8% (151/156). Intracranial stenting was successful in 97.6% of patients in group A and only 91.2% in group G-GS with no significant differences between three groups (p=0.213). The 30-day composite stroke or death rate was 4.5% (7/156). Stroke occurred in 4 patients of group A and in 3 patients of group GW. 140 (89.7%) patients had no any neurological deficit and no patient died during 30-day follow-up.

Conclusions:
Individual treatment of ICAD using tailored devices according to lesion morphology was feasible and safe in patients with limited collateral circulation.
Abstract T P115: Racial/Ethnic Differences in Post-Stroke Rehabilitation Utilization and Functional Outcomes in the South Carolina Stroke Belt
Authors: Ellis Charles , Boan Andrea D , Turan Tanya N , Ozark Shelly , Bachman David , Lackland Daniel T
Published: July 2021

Background:
Significant racial and ethnic disparities in stroke incidence, severity, morbidity and mortality have been consistently reported, but there are limited reports on racial/ethnic differences in post-stroke rehabilitation utilization and long term functional outcomes.

Objective:
To examine racial and ethnic differences in post-stroke rehabilitation utilization and functional outcomes.

Methods:
We examined one year follow-up data collected as part of the STEP-South Carolina Project that was designed to measure clinical, treatment, and functional outcomes in post-stroke patients. We used univariate and multivariate regression analyses adjusted for stroke severity to examine racial-ethnic differences in rehabilitation utilization (occupational therapy, physical therapy, speech therapy) and functional outcomes using a 20 question measure of activities of daily living (ADL) & instrumental activities of daily living (IADL) performance, life participation and driving.

Results:
Data from 162 stroke survivors (106 White, 56 Black) were collected at one year follow-up. As shown in the table, no significant differences were found between Blacks and Whites for rehabilitation utilization. In multivariate comparisons controlling for NIHSS, Blacks were less likely to report independence in overall functional performance outcomes as well as specific measures of toileting, walking, transportation, laundry and shopping. In addition, fewer Blacks reported driving at one year post-discharge.

Conclusions:
Fewer Blacks exhibited ADL and IADL independence at one year post-stroke after controlling for stroke severity, despite the fact that there were no racial-ethnic differences in rehabilitation utilization. Future studies are needed to further understand the reason for this disparity in recovery
Abstract T P117: Impact of Medicaid Coverage on Utilization of Inpatient Rehabilitation Facilities
Authors: Skolarus Lesli , Burke James F , Morgenstern Lewis B , Meurer Will , Adelman Eric , Kerber Kevin , Callaghan Brian , Lisabeth Lynda
Published: July 2021

Objective:
Optimal post-acute care is associated with improved stroke outcomes. Among working age stroke patients discharged to institutional post-acute care, those with Medicaid are less likely to be discharged to an inpatient rehabilitation facility (IRF) than those with private insurance, a finding which may be influenced by state Medicaid coverage. We hypothesized that stroke patients residing in states where Medicaid does not cover IRFs would be less likely to be discharged to an IRF than patients residing in states where Medicaid covers IRFs.

Methods:
Working age ischemic stroke patients with Medicaid were identified from the 2010 Nationwide Inpatient Sample (NIS) using ICD-9 CM codes 433.x1, 434.x1 and 436. Medicaid coverage of IRFs (yes versus no) was ascertained for 45 states with NIS data by review of state Medicaid websites. The primary outcome was discharge to IRF (versus other discharge destinations). We fit a hierarchical logistic regression model that included patient-level factors (demographics and stroke severity measures (length of stay, t-PA use and Charlson comorbidity score)), and a state policy variable representing whether a State’s Medicaid pays for IRF, with a random intercept for hospital. Based on this model, we estimated the probability of utilization of IRFs in states with Medicaid coverage of IRFs compared to those without.

Results:
Medicaid did not cover IRFs in 4 (TN, TX, SC, WV) out of 45 states. Compared to stroke patients residing in states with Medicaid coverage of IRF, stroke patients hospitalized in states without Medicaid coverage of IRF were less likely to be discharged to an IRF (12.8% (7.5-18.0%) vs. 19.4% (17.0-21.8%), p=0.02) after adjusting for patient and hospital factors.

Conclusion:
Working age stroke patients with Medicaid who reside in states where Medicaid does not cover IRFs have less utilization of IRFs than patients residing in states where Medicaid covers IRFs. As the Medicaid population expands under the Patient Protection and Affordable Care Act and the number of working age stroke patients increase, careful attention to state Medicaid policy for post-acute care and analysis of its effects are warranted.
Abstract T P123: Non-invasive Brain Stimulation for Motor Function of Chronic Stroke Patients
Authors: Park Eunhee , Kwon Tae Gun , Chang Won Hyuk , Kim Yun-Hee
Published: July 2021

Objective:
The purpose of this study was to investigate the effect of dual-mode noninvasive brain stimulation (NBS) by combining transcranial direct current stimulation (tDCS) over the unaffected primary motor cortex (uM1) and high-frequency repetitive transcranial magnetic stimulation (rTMS) over the affected M1 (aM1) on motor functions and corticomotor excitability in chronic stroke patients.

Methods:
Seventeen chronic stroke patients (12 men; mean age 58.7 years; 12 infarctions and 5 hemorrhages) participated in this double blinded random-order crossover study. All participants received three randomly arranged, dual-mode stimulations with 24 hours of washout period; Condition 1, simultaneous application of 10 Hz rTMS over the aM1 and cathodal tDCS over the uM1; Condition 2, simultaneous application of 10 Hz rTMS over the M1a and anodal tDCS over the uM1; Condition 3, 10 Hz rTMS over the aM1 and sham tDCS over the uM1. Corticomotor excitability using motor evoked potential (MEP) amplitude and hand motor functions using the sequential motor task were assessed before and after stimulation.

Results:
MEP amplitude was significantly increased after condition 1 and 3, respectively (p<0.05). The changes of MEP amplitude were significantly higher in condition 1 than condition 2 (p<0.05). In sequential motor task, the movement time was significantly decreased after condition 1 and 3, respectively (p<0.05). The change of movement time was significantly larger in condition 1 than the other conditions (p<0.05).

Conclusions:
Simultaneous stimulation of cathodal tDCS over the uM1 produced enhancement of 10 Hz rTMS effect over the aM1 in patients with stroke. These results suggest the dual-mode NBS as a method of enhancing motor function probably by inducing interhemispheric interaction of bilateral primary motor cortices in chronic stroke patients (Supported by the National Research Foundation of Korea grant (No.2011-0016960) and a KOSEF grant (M10644000022-06N4400-02210)).
Abstract T P13: Reversed Ischemic Attack (Ria): Proposal for a New Terminology in the Era of Thrombolytic Therapy
Authors: Jovin Tudor , Jankowitz Brian , Jadhav Ashutosh P
Published: July 2021

Background and Purpose:
Cerebral ischemic attacks are classically known to cause either permanent injury in the case of ‘stroke’ or transient dysfunction without permanent injury in the case of ‘TIA’. The latter occurs due to timely restoration of cerebral blood flow and implies a spontaneous process. With thrombolytic therapy (intravenous or intra-arterial) complete reperfusion is possible and can lead in some patients to complete reversal of the ischemic insult both clinically and radiographically. This entity is inadequately characterized by the current stroke terminology.

Methods:
A retrospective review of a prospectively maintained database identified 800 patients who underwent acute endovascular reperfusion therapy. Inclusion criteria were: complete clinical recovery without evidence of infarction on follow up MRI (DWI sequence).

Results:
We identified 8 patients. Intravenous alteplase followed by intra-arterial therapy was administered in 37.5% of cases. Admission NIHSS ranged from 8-21 and recanalization occurred between 45-490 minutes of symptom onset. The site of occlusion was as follows: left internal carotid artery terminus (2, 25%), middle cerebral artery M1 segment (5, 62.5%) and middle cerebral artery M2 segment (1, 12.5%).

Conclusions:
A hitherto unreported condition of complete clinical and radiographic recovery after reperfusion therapy for large vessel intracranial occlusion is being described. Review of an endovascular database comprising 800 consecutive cases, revealed that the incidence of this entity is 1%. We postulate that in parallel to an increase in efficacy and utilization of revascularization modalities along with an increase in assessment of vessel patency prior to intravenous thrombolysis, recognition of this phenomenon will increase and propose the term ‘Reversed’ Ischemic Attack (RIA) to address a deficiency in terminology currently associated with this condition.
Abstract T P135: Geographic Microtargeting: Identifying High Risk Stroke Populations
Authors: Mackey Jason , Sucharew Heidi , Hossain Monir , Jones David E , Alwell Kathleen , Moomaw Charles J , Kissela Brett M , Woo Daniel , Khatri Pooja , Flaherty Matthew L , Adeoye Opeolu , Ferioli Simona , Broderick Joseph P , Kleindorfer Dawn O
Published: July 2021

Introduction:
Though the incidence of acute ischemic stroke is decreasing overall in the US, improvement is not occurring uniformly. A high-yield strategy might be to identify and target micropopulations of very high-risk patients.

Methods:
All acute ischemic strokes among residents in the Greater Cincinnati/Northern Kentucky (GCNK) region (estimated population: 1.3 million) at least 20 years of age were identified using ICD-9 codes of 430-436 and verified by physician review in the calendar years 1999 and 2005. Each patient residing at home was geocoded according to listed home address; institutionalized patients were excluded. We calculated crude incidence rates for the 346 census tracts and used stroke events for numerators and 2000 Census data for denominators. We produced incidence maps for 1999 and 2005 and a rate change map for comparison.

Results:
We identified 2330 acute ischemic strokes in the GCNK region in 1999 and 2165 in 2005. After excluding recurrent events, events in institutionalized patients, and events in patients without geocodable addresses, we identified 1942 patients in 1999 and 1766 patients in 2005 for this analysis. Overall incidence was 189/100,000 in 1999 and 167/100,000 in 2005. The interquartile range of incidences in the census tracts was 124 - 270/100,000 in 1999 and 112 - 243/100,000 in 2005. Rates by year and rate difference are shown in the Figure. There were 23 census tracts with rates >300/100,000 in both study years and 21 census tracts with a rate increase >200/100,000 from 1999 to 2005.

Discussion:
Stroke incidence varies widely in census tracts in the GCNK region. We identified several micropopulations in which targeted efforts might result in reductions of stroke burden on the population. Further investigation of the impact of socioeconomic status and risk factors in these micropopulations will help tailor stroke reduction efforts. Microtargeting deserves further study in stroke education and prevention endeavors.
Abstract T P14: Multi-modality Treatment of Acute Ischemic Strokes Improves Patient Outcome at Discharge vs Intravenous Tissue Plasminogen Activator
Authors: Dababneh Haitham , Bashir Asif , Hussain Mohammed , Misthal Sara , Moussavi Mohammad , Kirmani Jawad F
Published: July 2021

Background and Purpose:
Since the introduction of Intravenous Tissue Plasminogen Activator (IV tPA) and mechanical thrombectomy, the management of acute ischemic stroke has advanced. The objective of this analysis is to compare treatment modalities and the outcome among stroke patients.

Methods:
This is a retrospective analysis of all patients (n=142) that presented to our hospital with ischemic stroke and received treatment between January 2009 and July 2012. We divided the patients into two groups based on the treatment they received: A) patients received only IV tPA B) patients received both IV tPA and mechanical thrombectomy. Analysis of variance was used to compare the difference of the means between the two groups. Uni- and multivariate logistic regression models were used to compare the association of different treatment modalities with the modified rankin scale (mRS) at discharge. Discharge status was dichotomized based on an mRS greater than 2 as a poor outcome. Multivariate models were created adjusting for age, gender, NIHSS, hypertension (HTN), diabetes mellitus (DM), and hyperlipidemia (HLD). All measurements were done using the SAS software version 9.2.

Results:
Group analysis including n, gender, mean age, mean NIHSS and mortality at discharge was as follows: A) 104, 50% female, 73±14, 12±7, 6.73% B) 38, 50% female, 71±14, 18±7, 7.89%. When controlling for age, gender, DM, HTN, and HLD, patients in group B had a better outcome than group A (OR 0.3, 95% CI, 0.09-0.96) despite presenting with a worse NIHSS. There was no difference in mortality between the two groups. There was a significant association between NIHSS at admission and mRS at discharge (OR 1.2, 95% CI, 1.13-1.29). There was also a significant association between having DM and a poor outcome (OR 3.94, 95% CI, 1.37-11.37).

Conclusion:
In our patient subset, multi-modality treatment of acute stroke is safe and associated with a better clinical outcome than IV tPA alone at discharge. Further prospective studies are needed to corroborate our findings.
Abstract T P161: Atrial Fibrillation is Associated With Increased Risk of Silent Cerebral Infarction: A Systematic Review and Meta-analysis
Authors: Kalantarian Shadi , Buonanno Ferdinando S , Gollub Randy , Retzepis Kallirroi , Mansour Moussa , Ruskin Jeremy N
Published: July 2021

Background:
Several studies report an association between atrial fibrillation (AF) and silent cerebral infarcts (SCIs), but no meta-analysis has been done to provide a pooled estimate.

Methods:
We searched 5 electronic databases -MEDLINE, PsycINFO, Cochrane Library, CINAHL, and EMBASE- and manually screened bibliographies of pertinent articles. The main outcome of interest was evidence of brain infarcts on imaging or autopsy with no attributable clinical symptoms. Only peer-reviewed prospective and non-prospective studies of patients with no clinical history of stroke or prosthetic valves were included. Random effects meta-analyses using the DerSimonian and Laird method were performed. A sensitivity analysis was carried out restricted to studies which reported adjusted risk estimates. To examine the proportionate excess risk of SCIs associated with AF, we estimated the population-attributable risk (PAR) for each study and reported the pooled PAR.

Results:
Of 964 retrieved abstracts, 12 were included (Image). A total of 8461 patients (786 with AF and 7675 without AF) were included in the analysis. 366 (46.56%) patients with AF and 1633 (21.28%) patients without AF had SCIs. AF was significantly associated with SCIs in patients with no clinical stroke history (odds ratio (OR) [95% confidence interval (CI)] = 2.11[1.23, 3.61], I2=80.9%). Pooled PAR [95%CI] was 0.16[0.09, 0.23]. Removing one study at a time did not change the significance of the results or the heterogeneity. The result of the analysis restricted to studies with adjusted ORs remained similar (OR [95% CI] = 2.58 [1.30, 5.14], I2= 73.1%). Among the studies with adjusted ORs, only one included lesions of< 3mm in their definition of SCIs. Removing this study from the secondary analysis eliminated the heterogeneity without changing the results substantially.

Conclusions:
AF is associated with a more than twofold increase in the odds of SCI. Similar to clinical stroke, about 16% of SCIs are attributable to AF.
Abstract T P171: Impaired Brachial Flow-mediated Dilatation in Patients With Symptomatic Nontraumatic Intracranial Arterial Dissections
Authors: Iwata Tomonori , Mori Takahisa , Miyazaki Yuichi , Tanno Yuhei , Kasakura Shigen , Yoshioka Kazuhiro
Published: July 2021

Background:
Non-traumatic intracranial arterial dissections (IADs) are characterized by the sudden disruption of the internal elastic lamina in intracranial arteries. It is still unknown why IADs occurs. There are few reports concerned with relationship between the endothelial function and IADs.

Purpose:
The purpose of our retrospective study was to investigate whether or not patients with nontraumatic IADs had normal endothelial function.

Methods:
Included for retrospective analysis were patients with symptomatic nontraumatic IADs (1) who were admitted to our institution from 2012 to 2013 and (2) who underwent an endothelial function test during hospitalization. Headache patients admitted to outpatient clinic were selected as a control matched for sex and age. The endothelial function was assessed using flow-mediated dilatation (FMD). We investigated ankle brachial index (ABI) and pulse wave velocity (PWV) to determine the degree of atherosclerosis. Patients’ characteristics, brachial FMD, ABI and PVW were assessed in two groups.

Results:
During study periods, there were 14 patients (median age 45.5 years, IQR 38-53.5 years) with nontraumatic IADs. Fourteen patients of the control had median age of 47 years (IQR: 44-53.5 years). The locations of IADs were the vertebral artery (n=10), the internal carotid artery (n=3) and the superior cerebellar artery (n=1). Between two groups, there were no significant differences of clinical features, atherosclerotic risk factors, ABI and PWV except FMD, indicating that most of them did not suffer from atherosclerosis. However, FMD in IADs was significantly lower than in control (4.85 vs. 7.4, p<0.01)

Conclusion:
ur results suggest that the endothelial function of intracranial arteries might be impaired in patients with symptomatic nontraumatic IADs in spite of no atherosclerotic change.