bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP193: Trends in Prevalence and Clinical Impact of Socio-demographic Indicators and Multiple Chronic Conditions in Stroke and Transient Ischemic Attack
Authors: Yousufuddin Mohammed , Shultz Jessica , Sheely Heather , Alsawas Mouaz , Murad M.Hassan
Published: June 2021

Importance:
The increasing prevalence and clinical and clinical impact of chronic conditions (CCs) have been recognized as an important public health concern.

Objectives:
To evaluate trends in co-existing CCs and their association 30-day mortality and readmission rates in hospitalized patients with first-ever stroke and transient ischemic attack (TIA).

Design:
Retrospective study of patient hospitalized for first stroke or TIA.

Results:
Study cohort of 6,771 patients, hospitalized for first-ever stroke (n = 4,068 60.1%) and first-ever TIA (n = 2,703, 39.9%) with mean age 68.2 (standard deviation, ± 15.6) years, 51.4 % men, mean number of CCs 2.9 (± 1.7), 30-day mortality 8.6% and 30-day readmission rate 8.2%. The prevalence of multiple CCs was increased from 73.7% in 2005-2006 to 81.9% in 2013-2015, which was driven by a dramatic rise in the proportion of patient with ≥4 CCs from 27.4% to 46.4% during the study interval. In multivariable models, significant predictors of a) 30-day mortality were co-existing heart failure (HF) (odds ratio [OR] 1.45, 95% confidence interval [CI] 1.09-1.92), cardiac arrhythmia (OR 1.74, 95% CI 1.40-2.17), coronary artery disease(CAD) (OR 1.64, 95% CI 1.29-2.08), cancer (OR 1.67, 95% CI 1.31-2.14), and diabetes (HR 1.28, 95% CI 1.01-1.62) and b) 30-day readmission were co-existing HF (OR 1.45, 95% CI 1.06-1.99), chronic kidney disease (OR 1.55, 95% CI 1.17-2.04), CAD (OR 1.36, 95% CI 1.09-1.70), and cancer (OR 1.58, 95% CI 1.25-2.00), and patients with ≥4 co-existing CCs (OR 1.83, 95% CI 1.37-2.45).

Conclusions and Relevance:
In this large patient-population, we demonstrated a recent trend of continued increase in several CCs among hospitalized patients with acute stroke and TIA over 10-year period. Several CCs were associated with increased risk of 30-day all-cause mortality and readmission after initial hospitalization. Thus, interventions targeted to patients with CCs may improve these outcomes for patients with stroke and TIA.
Abstract TP195: Effect of Socioeconomic Inequality and Comorbidity on the Association Between Ambient Temperature and Ischemic Stroke
Authors: Cho Seong-Kyung , Cho Jaelim , Kim Changsoo , Noh Juhwan
Published: June 2021

Background:
Inconsistent findings have been reported regarding the effect of ambient temperature on ischemic stroke. Furthermore, little is known about how comorbidities and low socioeconomic status influence the association. We investigated the relationship between temperature and emergency department (ED) visits for ischemic stroke, and aimed to identify susceptible populations.

Methods:
Using medical claims data, we identified ED visits for ischemic stroke during 2005-2009 in Seoul, the Republic of Korea. We conducted piecewise linear regression analyses to find optimum temperature thresholds in summer and winter, and estimated the relative risks (RR) and 95% confidence intervals (CI) per 1°C change in temperature above/below the thresholds, adjusting for relative humidity, holidays, day of the week, and PM
10
and O
3
levels.

Results:
There were 63,564 ED visits for ischemic stroke during the study period. In summer, the risk of ED visits for ischemic stroke was not significant, with the threshold at 26.8°C. The RR of ischemic stroke visits was 1.055 (95% CI, 1.006-1.106) above 25.0°C in medical aid beneficiaries and 1.044 (1.007-1.082) above 25.8°C in patients with diabetes. In winter, the risk of ischemic stroke significantly increased as the temperature dropped below the threshold. The RRs were 0.618 (95% CI, 0.453-0.842) and 0.643 (0.501-0.824) for hypertensive and patients with diabetes, respectively.

Conclusions:
Temperature increases above a threshold were positively associated with ED visits for ischemic stroke in patients with diabetes and medical aid beneficiaries in summer. In winter, a decrease in temperature, to a point, significantly increased the risk of ischemic stroke visits.
Abstract TP200: Urinary Albumin/creatinine Ratio Should Be Associated With White Matter Lesion Severity in First-ever Stroke Patients
Authors: Suda Satoshi , Shimoyama Takashi , Takayama Yohei , Ouchi Takahiro , Arakawa Masafumi , Suzuki Shizuka , Okubo Seiji , Aoki Junya , Suzuki Kentaro , Mishina Masahiro , Kimura Kazumi
Published: June 2021

Background and purpose:
White matter lesion (WML) is an indicator of small vessel disease, however, the underlying pathological mechanisms has not been fully understood. In recent years, experimental and epidemiological studies have suggested that chronic kidney disease (CKD) is associated with endothelial dysfunction; thereby, a CKD state may initiate small vessel damage. Our aim was to investigate the association of estimated glomerular filtration rate (eGFR), urinary albumin/creatinine ratio (UACR), and WML in first-ever stroke patients.

Methods:
We retrospectively enrolled 284 consecutive patients (177 male; median age 72 years) admitted to our stroke center between May 2010 and January 2012. eGFR and UACR measurements were performed on admission. WML were assessed using the Fazekas classification. Severe WML was defined as Fazekas gradings of 2 or higher. The impact of the eGFR and UACR on WML was evaluated using multiple logistic regression analysis. Separate analyses were conducted according to severe WML and trichotomized eGFR level [60 mL/min ≤ eGFR (reference), 45 mL/min ≤ eGFR < 60 mL/min, and eGFR < 45 mL/min)] and UACR level [UACR < 30.0 mg/g creatinine (reference), 30.0 mg/g creatinine ≤ UACR < 300 mg/g creatinine, and 300 mg/g creatinine ≤ UACR].

Results:
According to the Fazekas gradings, 91 patients (32.0%) had scale 0; 90 patients (31.7%), scale 1; 59 patients (20.8%), stage 2; and 44 patients (15.5%), scale 3. Age (
P
< 0.0001), sex (
P
= 0.0094), eGFR (
P
= 0.0173), UACR (
P
= 0.0001), hypertension (
P
= 0.0436), and brain natriuretic peptide (
P
= 0.0354) were significantly associated with severe WML. On multivariable logistic regression analysis, high UACR (≥ 39.6 mg/g creatinine), but not low eGFR (≤ 74 mL/min/1.73 m
2
), was independently associated with severe WML. In comparisons between trichotomized UACR level, severe WML were more frequent in UACR ≥ 300 mg/g creatinine group than in UACR < 30.0 mg/g creatinine group after multivariate adjustment (OR, 2.25; 95% CI, 1.04-5.00;
P
= 0.039). On the other hand, there was no significant association with trichotomized eGFR level and severe WML (OR, 1.51; 95% CI, 0.62-3.77;
P
= 0.3672).

Conclusions:
Our data suggest that a high UACR, but not eGFR, is independently associated with severe WML.
Abstract TP203: Reducing Stroke Burden in Uganda
Authors: Kaddumukasa Mark , Nakibuuka Jane , Kayima James , Katabira Elly , Blixen Carol , Sajatovic Martha
Published: June 2021

Background:
Stroke is a neurological condition with rapidly increasing burden in many low- and middle-income countries. Africa is particularly hard-hit due to rapid population growth, patterns of industrialization, adoption of harmful western diets, and increased prevalence of risk factors such as hypertension and obesity. Reducing stroke risk factors and teaching people to respond to stroke warning signs can prevent stroke and reduce burden. However, being able to address gaps in knowledge and improving both preventative and early-response care requires a clear understanding of practical and potentially modifiable topics.

Methods:
A cross sectional survey was conducted in urban Mukono district in central Uganda. Through a systematic sampling method, data were gathered from 440 adult participants who were interviewed about selected aspects of stroke knowledge, attitudes and perception, using a pretested structured questionnaire.

Results:
Of the 440 study participants enrolled for this study nearly 52% correctly reported that stroke involves the brain, while 57% reported that stroke is preventable. Majority of the participants 75.7% reported stress as a contributing factor. Only 45.7% of the study participants reported hypertension as a risk factor. Only two (0.5%) study participants identified cigarette smoking as a stroke risk factor. Of the eighty six study participants with hypertension only 39.5% knew hypertension as a risk factor and only 10.7% knew three or more stroke risk factors.

Conclusion:
Stroke knowledge is poor in urban Uganda. Individuals with hypertension had poor knowledge regarding stroke in spite their high risk for stroke. Stress and hypertension are the leading perceived risk factors in our settings. While stress is highly reported as a stroke risk factor in this study hypertension is likely a more amenable and practical intervention target.
Abstract TP204: Quality of Life of Caregivers Attending a Stroke Camp
Authors: Mathews Maureen , Beck Judith , Gibbons Michael , Bogner Anna , Jahnel Jan , Kramer Lauren , McNeil Clayton , Nair Deepak , Nunley Marylee , Schaer Larry , Swanson-Devlin Teresa , Couri Candace , Upadhyaya Manas , Wang David
Published: June 2021

Background:
Loneliness, depression, and isolation are common feelings among caregivers (CG) of stroke survivors. We have shown previously that the Retreat and Refresh Stroke Camp (RRSC) offers emotional support to CG. In this study, we focus on CG quality of life (QOL) to more appropriately plan programs to meet CG needs.

Methods:
QOL of stroke CG attending the RRSC in 2015 was assessed using the Adult Carer Quality of Life Questionnaire (ACQOLQ). Emails were sent to all CG with a link to the survey on Survey Monkey.

Results:
The ACQOLQ consists of 40 weighted questions (0-3) with both positive and negative wording. A score of 81+ indicates high quality of life and scoring 0-40 indicates a low quality of life. There are eight subcategories on the questionnaire including: support for caring, caring choice, caring stress, money matters, personal growth, sense of value, ability to care, and care satisfaction. Scoring 0-5 is low, 6-10 is midrange, and 11+ is high. 41 CG responded to the survey. 41.03% of caregivers care greater than 70 hours per week. Average duration of caring was 7.34 years. The average CG age was 61.55 (40/41 responses) ranging from 29 to 80. 85.37% of respondents were female and 95% were Caucasian. The average ACQOLQ score was 66.94, indicating a mid-range QOL. Seven had a high quality of life and 4 had a low quality of life. Of the eight subcategories, support for caring averaged 6.4; caring choice, 7.26; caring stress, 8.49; money matters, 7.83; personal growth, 8.07; sense of value, 9.13; ability to care, 10.15; and care satisfaction, 9.61.

Conclusions:
The ACQOLQ provides a benchmark for QOL assessment for the RRSC CG. We can surmise from this limited sample the camp may play a role in improving the self-worth and confidence of CG in addition to feelings of appreciation due to relatively high ‘ability to care’ and ‘carer satisfaction’ scores on average. Moreover, RRSC must reach out to at risk populations where stroke incidence is notably higher. The Camp Directors will use this information to develop more opportunities for CG to develop strategies for increasing CG freedom, money management, and general support for CG.
Abstract TP21: Is Presence of Diabetes Mellitus a Key Prognostic Factor among Patients Receiving Endovascular Treatment for Acute Ischemic Stroke?
Authors: Lee Seong-Joon , Hwang Yang-Ha , Hong Ji Man , Choi Jin Wook , Kang Dong-Hun , Kim Yong-Won , Kim Yong-Sun , Hong Jeong-Ho , Chang Hyuk Won , Kim Chang-Hyun , Ovbiagele Bruce , Sohn Sung-Il , Lee Jin Soo
Published: June 2021

Introduction:
Given the recent positive endovascular therapy trials for acute ischemic stroke (AIS), this therapeutic strategy is now being increasingly incorporated into routine clinical practice. Identifying prognostic factors among AIS patients receiving endovascular revascularization treatments (ERT) in the real world could be important for clinicians and patients. While the impact of diabetes mellitus (DM) on IV thrombolytic outcomes after AIS has been extensively investigated, there is a paucity of data assessing effects of DM on ERT outcomes after AIS. We evaluated the impact of comorbid DM on ERT for AIS.

Methods:
From Jan 2011 to Feb 2016, patients with AIS who underwent ERT for cervicocephalic occlusions were consecutively enrolled into the Acute Stroke due to Intracranial Atherosclerotic occlusion and Neurointervention - Korean Retrospective (ASIAN KR) registry from 3 hospitals. Patients were excluded if onset to puncture time over 8 hours, in-hospital stroke, or unavailable 3-month mRS. DM was diagnosed if a patient had the history, or hemoglobin A1c on admission was over 6.5. Univariate analysis was performed to compare the characteristics between DM and non-DM population. Multiple logistic regression analysis was used to validate the effect of comorbid DM on 3 month outcomes.

Results:
Of 721 patients, 667 (93%) were finally included, with 233 DM patients and 434 non-DM patients. In the univariate analysis, comorbidity with hypertension (71.2% vs. 58.3%, p=0.001) and dyslipidemia (36.7% vs. 26.7%, p=0.012) were more frequent in the DM population. Periprocedural factors such as target vessels, intravenous thrombolysis, and final reperfusion grades did not differ. Good outcomes with mRS 0-2 were less frequent in the DM population (43.3% vs. 53.7%, p=0.011). In the logistic regression analysis adjusting age, male sex, initial NIHSS, premorbid mRS, hypertension history, atrial fibrillation, intravenous thrombolysis, onset to puncture time and successful reperfusion, DM was an independent predictor of poor outcomes (mRS 3-6; 1.933, 1.274-2.933, p=0.002).

Conclusion:
In patients receiving ERT for AIS due to cervicocephalic artery occlusions, the presence of DM as a comorbidity confers greater odds of a poor functional outcome.
Abstract TP22: Outcomes After Endovascular Therapy in a Population With Mild Acute Ischemic Stroke: A 6.5 Year Observational Cohort Study at a High Volume Comprehensive Stroke Center
Authors: Frei Donald , Orlando Alessandro , Bellon Richard , Wagner Jeffrey , Fanale Christopher V , Jensen Judd , Bartt Russell , van Vliet Rebecca , McCarthy Kathryn , Bar-Or David
Published: June 2021

Introduction:
Despite suffering mild acute ischemic strokes (AIS, NIHSS≤7), patients have a non-zero risk of significant morbidity and mortality. Intra-arterial therapy (IAT) is clearly effective in non-mild AIS, but mild AISs have been excluded from IAT trials, limiting our understanding of their outcomes after IAT. The objective of this study was to report on patient outcomes in a mild AIS population who received IAT.

Methods:
We included all adults (≥18) with a mild AIS admitted over 6.5 years to a high-volume comprehensive stroke center and who received IAT. Patients were excluded for any contraindication to IAT (n=240). Outcomes were symptomatic ICH (sICH), in-hospital mortality, discharge mRS ≤2, and an improvement in NIHSS at discharge (>2 vs ≤2).

Results:
There were 55 patients included in the study (Table 1). Overall, patients were predominately aged 55-79 years, admitted with an NIHSS 4-7, or had hypertension. 72% of patients either had a cardioembolic or large vessel occlusion (LVO), and 73% arrived either 0h to 4.5h, or >6h to <12h from symptom onset. 15 patients also received IV-tPA. There were no sICHs. Mortality was 9%; a majority of deaths were in males, patients with ages 55-79, LVOs, or an early symptom to arrival time. 42% of patients showed a 3-point improvement in NIHSS at discharge; a majority of these patients were white, aged 55-79, or had hyperlipidemia. Ultimately, 45% were discharged with an mRS ≥2. There were no cerebral artery perforations or groin complications.

Conclusions:
These data highlight the safety of IAT in patients with mild AIS, mirroring the results seen in recent large randomized clinical trials showing efficacy of IAT in the non-mild AIS population. Patients in our study had a non-existent risk of sICH, and a mortality rate similar to literature examining IV-tPA administration in patients with mild AIS. Furthermore, a large proportion of patients showed a clinically meaningful improvement in NIHSS, or were discharged with a favorable mRS.
Abstract TP220: Is Fibrinogen a Reliable Lab to Follow in Acute Ischemic Stoke After Thrombolysis
Authors: Gulati Deepak , Nasir Muhammad , Dua Dharti , Torbey Michel
Published: June 2021

Background:
American Heart Association suggests empirical therapies (cryoprecipitate, FFP and platelets) for post-IVtpa hemorrhage but acknowledges the lack of evidence to support any specific therapy. Different institutions have developed care pathways for post-IVtpa sICH involving frequent fibrinogen level checks. During thrombolysis, circulating fibrinogen is decreased, and thus rapid administration of cryoprecipitate is recommended. A marker of fibrinogen of <100-150 mg/dL has been traditionally used as a cutoff to suggest effective thrombolysis or administration of cryoprecipitate or to assess the risk of bleeding complications. Monitoring of fibrinogen level has been used to guide the reversal therapy in the setting of post-IVtpa hemorrhage. This practice is not fully addressed in the literature.

Purpose:
To determine the significance of fibrinogen level in relation to thrombolysis in acute ischemic stroke (AIS) based on our single center experience.

Methods:
We retrospectively reviewed fibrinogen levels in two groups of patients with AIS who presented to our comprehensive stroke center. First group included 50 patients who received IVtpa including two patients w/ post-IVtpa sICH and second group included 50 patients with AIS who could not receive IVtpa due to contraindication. Fibrinogen level was checked in immediate post-IVtpa period usually within 2hr of IVtpa or 6hr from onset.

Results:
The mean fibrinogen level in first group with patients with AIS who received IVtpa is 321.65 mg/dl with range from 102 to 533 mg/dl. Normal reference range is 220-410mg/dl. The mean fibrinogen level in second group without IVtpa is 376mg/dl with range from 124 to 583mg/dl. The fibrinogen level in two patients with post-IVtpa sICH was 216 and 282 mg/dl.

Conclusions:
No significant correlation is found between fibrinogen level (<100mg/dl) and IVtpa use. We also found no significant change in fibrinogen level in patients with post-IVtpa sICH even though there are only two cases included so far. Above finding suggests that we should focus our research on mechanism other than decrease fibrinogen level to be an underlying cause of post-IVtpa hemorrhage in order to develop agent for better reversal and to prevent continued hematoma expansion.
Abstract TP232: Disparities in Access to Stroke Research in the State of Texas
Authors: Wu Tzu-Ching , Ankrom Christy M , Bambhroliya Arvind B , Borzorgui Shima , Savitz Sean I
Published: June 2021

Objective:
Access to care is an important healthcare goal but access to research is also important to patients. We sought to gain an understanding of the status of stroke research among the various stroke designated hospitals in the state and to identify regions and facilities that lack access to stroke research.

Methods:
Texas Department of State Health Service (TDSHS) designated stroke facilities (DSF) were surveyed using a standardized questionnaire via telephone/email to confirm stroke center status, presence of a dedicated stroke coordinator, use of telestroke services, and participation in stroke research. Stroke discharge data were obtained from TDSHS and stroke volume (by ICD) were estimated for 2013 for all non-DSF. Census data were obtained from the US Census Bureau.

Results:
In total, 109/136 (80%) TDSHS DSF responded to the survey. Only 32/109 (29%) of the TDSHS DSF are participating in stroke research, mostly in the 4 metropolitan areas (fig 1). We identified 16 non-DSF that have 100-149 stroke discharges, and another 21 non-DSF that have ≥ 150 stroke discharges (fig 1). Over half (53%) of the DSF in the state are utilizing telestroke services.

Conclusions:
Most clinical stroke research conducted in Texas is in the 4 metropolitan markets. Our findings demonstrate that over 50% or ~14 million Texans reside outside of the 4 markets and therefore may lack access to stroke research. To increase access, we identified several non-DSF in the state with substantial stroke discharges (fig 1). Academic centers and non-DSF partnering through telemedicine and other relationships should be considered to expand throughout the state opportunities for participation in stroke research.
Abstract TP237: In Hyperacute Recanalization Therapy, Early Hospital Arrival Should Improve Outcome in Patients With Large Artery Occlusion but Not Without It
Authors: Aoki Junya , Suzuki Kentaro , Suda Satoshi , Okubo Seiji , Mishina Masahiro , Kimura Kazumi
Published: June 2021

Introduction:
Early hospital arrival form symptom onset has been related to the good outcome. However, it has been unknown whether in hyperacute recanalization therapy, early hospital arrival improves outcome in patients with and without large artery occlusion (LAO). We evaluated the association of onset-to-door (OTD) time with clinical outcome after hyperacute recanalization therapy in patients with and without LAO.

Methods:
Consecutive stroke patients treated using hyperacute recanalization therapy including intravenous thrombolysis using tissue-plasminogen activator (tPA) and endovascular therapy (EVT) were studied. Good outcome was defined as mRS ≤2 at hospital discharge. All patients were divided into patient with and without LAO.

Results:
From 2014 September to 2016 July, 129 (median age, 73 [64-82] years; 86 [67%] males) patients were analyzed. tPA alone was administered in 65 (50%) patients, EVT alone in 33 (26%), and tPA and EVT in 31 (24%). At discharge, 67 (52%) patients achieved the good outcome. Ninety-one patients (71%) were classified into the LAO group and 38 (29%) were into the non-LAO group. The OTD was similar between the LAO and the non-LAO groups (1.57 [0.87-3.42] h vs. 1.38 [0.76-2.68], p=0.420). Forty-six (51%) patients in the LAO and 21 (55%) patients in the non-LAO groups had good outcome (p=0.701). Regarding patients with LAO, age, OTD, and NIHSS score were significantly associated with good outcome (p=0.021, 0.014, and 0.001). Multivariate regression analysis also showed the OTD was the independent negative factor for good outcome (OR 0.77, 95%CI: 0.65-0.91, p=0.003). On the other hand, when we analyzed patients without LAO, OTD and NIHSS score were also significantly associated with good outcome (p=0.009, and 0.004). However, multivariate regression analysis did not show the OTD was the independent factor for good outcome (OR 0.83, 95%CI: 0.58-1.18, p=0.299). Only NIHSS score was independently related to it (OR 0.80, 95%CI: 0.67-0.96, p=0.018).

Conclusion:
Impact of early hospital arrival on clinical outcome after hyperacute recanalization therapy differed between patients with and without LAO. In hyperacute recanalization therapy, early hospital arrival should improve outcome in patients with LAO but not without it.
Abstract TP238: Current Practices of Obtaining Informed Consent for Acute Stroke Therapies
Authors: Mendelson Scott J , Gordon Elisa , Courtney D. Mark , Holl Jane , Prabhakaran Shyam
Published: June 2021

Objective:
The objective of this national survey of clinicians providing acute stroke care was to examine current practice patterns regarding the informed consent process for tPA as well as ERT.

Background:
Improvement in the consent process for stroke interventions has been a suggested target to further reduce delays in timely reperfusion. Currently there is no standard means of obtaining informed consent for acute stroke interventions.

Methods:
A survey instrument was distributed nationally to 809 neurologists, emergency medicine physicians, interventionists, internal medicine physicians, and nursing staff via email. Analysis was then performed using descriptive statistics, Chi-square test for categorical comparisons, and multivariable logistic regression analyses to determine independent factors contributing to consent practices. Free-text entries were separately analyzed for thematic content.

Results:
The survey response rate was 33% (268/809). Respondents were in practice an average of 13.1 (+/- 9.5) years. Only 21% of respondents reported never requiring informed consent for tPA given within the 3-hour time window, whereas 37% always require informed consent. In multivariable models, practicing emergency medicine (OR 5.8, 95% CI [2.9-11.5]) and working at a non-academic medical center (OR 2.1, 95% CI [1.0-4.3]) were associated with always requiring informed consent. Over half of respondents (52%) reported experiencing delays because of informed consent for tPA. Waiting for a patient’s family to reach consensus about treatment was the most often reported delay. Almost all providers (90.5%) identified the risk of intracranial hemorrhage as necessary content to disclose, and the majority (87.4%) reported a verbal description of risk and benefits as the preferred means of delivering information. Most respondents (56%) always obtain informed consent for ERT and most (59%) did not experience delays because of informed consent.

Conclusions:
Most respondents to a national survey typically obtain informed consent for acute stroke therapies and most have encountered delays in administering tPA because of the informed consent process. Decreasing the time to obtain informed consent may be a future target to improve stroke outcomes.
Abstract TP24: Trends in Iv r-tpa and Thrombectomy Treatment Rates Before and After the LVO RCT’s in a Regional Tele-stroke Network
Authors: Pierre Louis Naregnia , Nalluri Suman , Kim Benny , Anand Aashish , Shams Tanzila , Chugh Chandril , Janardhan Vallabh
Published: June 2021

The presentation of endovascular stroke trials at international stroke conference was a land mark event in acute stroke therapy. This study aims to analyze the rates of utilization of IV r-tPA, with or without mechanical thrombectomy before and after the 2015 International Stroke Conference (ISC) in a large regional tele-stroke network.

Methods:
A systematic review of prospective telestroke and procedure database was performed for 18 months prior and 18 months post conference. There were three groups included in the analysis. The first group consisted ischemic stroke patients presented within 12 hours of onset including inpatient events, transfers from primary centers and rural clinics. The second group consisted of patients who received IV r-tPA, and the third group consisted of patients who received IV r-tPA and/or underwent mechanical thrombectomy for a demonstrated LVO.

Results:
A total of 2628 consecutive ischemic stroke events presented within 12 hours of onset were evaluated. In the pre-ISC conference group, there were 1135 ischemic stroke patients. IV r-tPA was given 535 times(47.1%) and mechanical thrombectomy was utilized in addition to IV r-tPA or alone 42 times(3.7%). In the post-ISC conference group, there were 1493 ischemic stroke patients. IV r-tPA was given 642 times(43%) and mechanical thrombectomy was utilized in addition to IV r-tPA or alone 132 times(8.84%). The Chi Square statistical test was performed comparing these groups. When comparing the rate of IV r-tPA usage, there was a significant decrease from the pre-ISC conference group to the post-ISC conference group (P= 0.04). When comparing the rate of mechanical thrombectomy performed, there was a significant increase of greater than double the percentage of thrombectomy procedures performed in the post conference group compared to the preconference group (p< 0.001).

Conclusion:
There was a significant decrease in IV r-tPA usage but a greater than double the increase in the thrombectomy rate . This may be secondary to increased awareness of benefit of thrombectomy at referral centers. Slightly lower rates of IV r-tPA usage may be secondary to an increase in transfers of patients outside of the 0-4.5 hr window but were deemed candidates for thrombectomy.
Abstract TP257: Thrombolytic Treatment and Complications in Stroke Mimics
Authors: Gatton Barbara , Weissman Benjamin , Muller Jonathan , Bove Joseph A , Melville Laura , Melniker Lawrence , Gaeta Theodore , Benjamin Jeffrey , Bove Joseph , Salgado Miran
Published: June 2021

Background:
Patients with symptoms that simulate Acute Ischemic Stroke (AIS), but are ultimately determined to have another diagnosis are referred to as Stroke Mimics (SM). SM are reported to be 1.4% to 30% of Emergency Department (ED) cases, and reducing door-to-needle time (DTN) has been associated with increased treatment of SM (from 6.7% to 30%). The risk of tPA in SM patients is unclear. We are challenged with the conflicting goals of timely administration of therapy and mitigating unnecessary risk. We successfully reduced DTN and were interested to see if that effected SM.

Objectives:
To evaluate the impact of DTN on diagnostic accuracy in patients receiving tPA in the ED; and to determine the associated complication rate in patients with AIS compared to SM.

Methods:
We performed a retrospective cohort study of patients receiving tPA for suspected AIS between 2013-2015. Patients were identified through our Stroke registry and confirmed by pharmacy audit of tPA orders. We performed a structured chart review and provide a descriptive analysis of variables.

Results:
In our study period, 97 patients were treated with tPA for the presumptive diagnosis of AIS, 90 (92.8%) had a final diagnosis of AIS, while 7 (7.2%) were SM. The only complications of treatment with tPA reported were in the AIS group, 4 (15%) and 1 (4.2%) in 2013/2014 repectively. There were no complications reported in either group in 2015. This reduction in complications was achieved while reducing the DTN to less than 45 min in 50% of patients and less than 60 min in 75% of patients.

Conclusion:
While doubling the number of patients treated, we reduced the DTN and the complication rate in AIS patients. Contrary to prior studies, we found a decrease in the number of SM treated. None of the SM patients had a complication. The reduction in DTN and SM over time suggests that our screening of tPA candidates is appropriate.
Abstract TP268: Induction Profile of Mesencephalic Astrocyte-derived Neurotrophic Factor by Cerebral Ischemia and its Implication for Neuroprotection
Authors: Belayev Ludmila , Hong Sung-Ha , Mukherjee Pranab K , Menghani Hemant , Khoutorova Larissa , Bazan Nicolas G
Published: June 2021

Introduction:
Mesencephalic astrocyte-derived neurotrophic factor (MANF) has been identified as a secretion protein, which biases immune cells toward an anti-inflammatory phenotype, thereby promoting tissue repair after various injuries to neurons in vivo or in vitro. However, the function of MANF during and after brain ischemia is still not known. The purpose of our study was to examine the characteristics and implication of MANF expression induced by focal cerebral ischemia. In addition we investigated if docosahexaenoic acid (DHA) potentiates MANF mRNA expression and provides additional neuroprotection.

Methods:
Male SD (280-320) rats were anesthetized with isoflurane and subjected to 2 h of middle cerebral artery occlusion (MCAo) by intraluminal suture. DHA (5 mg/kg; n=13) or vehicle (saline; n=8) was administered IV at 3 h after the onset of MCAo. Neurological function was evaluated during occlusion (60 min) and on days 1, 3 and 7 after MCAo. MANF mRNA expression, protein levels, and apoptosis were measured by immunohistochemistry and Western blotting.

Results:
Behavioral deficit was significantly improved by treatment with DHA compared to vehicle on days 1, 3 and 7. MANF was found to be extremely upregulated in the ischemic penumbra. The expression of MANF was neuronal in the cortex and dentate gyrus. DHA administration significantly increased the number of MANF
+
/NeuN
+
cells in the cortex (by 76.6 %) and dentate gyrus (by 20.5 %) compared to saline-treated animals. The number of MANF/NeuN-positive cells was not different in the subcortex, CA1 and CA3 regions between DHA- and saline-treated groups. Treatment with DHA increased MANF
+
/GFAP
+
cells in the subcortex (by 27.7 %) and dentate gyrus (by 38.0 %) compared to the vehicle-treated brains. Total and cortical infarct volumes were attenuated by DHA treatment by 48 % and by 73 % compared to vehicle treatment at 24 h after MCAo.

Conclusion:
MANF mRNA expression and protein levels are increased after focal cerebral ischemia. It was found to be extremely upregulated in the ischemic penumbra and dentate gyrus. The expression of MANF was mostly neuronal and astrocytic. DHA potentiates MANF expression and provides additional neuroprotection.
Abstract TP269: Distinct Molecular Mechanisms of Htra1 Mutants in Manifesting Heterozygotes With Carasil
Authors: Nozaki Hiroaki , Kato Taisuke , Nihonmatsu Megumi , Saito Yohei , Mizuta Ikuko , Noda Tomoko , Koike Ryoko , Miyazaki Kazuhide , Kaito Muichi , Ito Shoichi , Makino Masahiro , Koyama Akihide , Shiga Atsushi , Uemura Masahiro , Sekine Yumi , Murakami Ayuka , Moritani Suzuko , Hara Kenju , Yokoseki Akio , Kuwano Ryozo , Endo Naoto , Momotsu Takeshi , Yoshida Mari , Nishizawa Masatoyo , Mizuno Toshiki , Onodera Osamu
Published: June 2021

Introduction:
Cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL), an autosomal recessive inherited cerebral small vessel disease (CSVD), involves severe leukoaraiosis, multiple lacunar infarcts, early-onset alopecia, and spondylosis deformans. High-temperature requirement serine peptidase A1 (HTRA1) gene mutations cause CARASIL by decreasing HTRA1 protease activity. Although CARASIL is a recessive inherited disease, heterozygous mutations in the HTRA1 gene were recently identified in 11 families with CSVD. Because CSVD is frequently observed in elderly individuals, it is unclear which mutants truly contribute to CSVD pathogenesis. Here, we found heterozygous mutations in the HTRA1 gene in individuals with CSVD and investigated the differences in biochemical characteristics between these mutant HTRA1s and mutant HTRA1s observed in homozygotes.

Methods:
We recruited 113 unrelated index patients with clinically diagnosed CSVD. The coding sequences of the HTRA1 gene were analyzed. We evaluated HTRA1 protease activities using casein assays and oligomeric HTRA1 formation using gel filtration chromatography.

Results:
We found 4 heterozygous missense mutations in the HTRA1 gene (p.G283E, p.P285L, p.R302Q, and p.T319I) in 6 patients from 113 unrelated index patients and in 2 siblings in 2 unrelated families with p.R302Q. These mutant HTRA1s showed markedly decreased protease activities and inhibited wild-type HTRA1 activity, whereas 2 of 3 mutant HTRA1s reported in CARASIL (A252T and V297M) did not inhibit wild- type HTRA1 activity. Wild-type HTRA1 forms trimers; however, G283E and T319I HTRA1, observed in manifesting heterozygotes, did not form trimers. P285L and R302Q HTRA1s formed trimers, but their mutations were located in domains that are important for trimer-associated HTRA1 activation; in contrast, A252T and V297M HTRA1s, which have been observed in CARASIL, also formed trimers but had mutations outside the domains important for trimer- associated HTRA1 activation.

Conclusions:
The mutant HTRA1s observed in manifesting heterozygotes might result in an impaired HTRA1 activation cascade of HTRA1 or be unable to form stable trimers.
Abstract TP280: AF and Urgent Bleeding Management Strategies: Effect of Online CME
Authors: Spyropoulos Jelena
Published: June 2021

Introduction:
Although anticoagulant therapy with non-vitamin K antagonist oral anticoagulants (NOACs) has demonstrated safety in multiple clinical trials in the setting of stroke prevention in atrial fibrillation (SPAF), a small percentage of patients experience urgent bleeding, which may require advanced bleeding management strategies, including NOAC reversal.

Hypothesis:
A video-based online continuing medical education (CME) activity can improve the knowledge and competence of cardiologists regarding strategies for managing anticoagulant-related urgent bleeding events

Methods:
An online CME activity was developed as a 25-minute roundtable discussion with 4 leading experts. The activity included a transcript of the discussion and a downloadable slide deck to highlight and reinforce key data. The effects of education were assessed using a linked pre-assessment/post-assessment study design. For all questions combined, the McNemar’s chi-square test was used to assess differences from pre- to post-assessment. P values are shown as a measure of significance; P values <.05 are statistically significant. Cramer’s V was used to calculate the effect size (>30=large effect size, 0.16-0.30=medium effect size, <0.16=small effect size)

Results:
For cardiologists who participated in the CME activity, comparison of individually linked pre-assessment question responses to the respective post-assessment question responses demonstrates statistically significant improvements (N = 187;
P
=0.002). A total of 33% of cardiologists answered all 4 pre-assessment questions correctly with 48% answering all post-assessment questions correctly. Significant mprovements were demonstrated: 1) A 23% relative improvement in the knowledge of the mechanism of action for idarucizumab (70% pre-assessment vs 86% post-assessment; P<0.001; V=0.194); 2) A 22% relative improvement in the knowledge of the specificity of andexanet alfa (69% vs 84%; P<0.05; V=0.176).

Conclusion:
The statistically significant improvements observed in this online CME roundtable discussion demonstrate the benefits of educating the appropriate target audience base with aptly designed educational activities.
Abstract TP297: Type II Myocardial Infarction is Significantly Associated with Admission NIHSS and Discharge Disposition Following Ischemic Stroke
Authors: M. Alkhachroum Ayham , Miller Benjamin , Chami Ahmad Tarek , Tatsuoka Curtis , Sila Cathy
Published: June 2021

Introduction:
Troponin elevations due to Type II myocardial infarction (T2MI) are associated with increased mortality after hemorrhagic stroke but there is little data on stroke severity or outcome following ischemic stroke.

Methods:
All stroke discharges from UH-Case Medical Center between 1/2013- 4/2015 were reviewed for demographics, vascular risk factors, admission stroke severity, labs, echocardiogram results and discharge disposition. Troponin levels were normal (<0.04ng/ml), high (0.04-0.5ng/ml), or critical (>0.5ng/ml). A T2MI was diagnosed by a trending troponin elevation; patients with T1MI were excluded. Analyses used SPSS.

Results:
Troponin levels were normal in 65%, high in 28% and critical in 7% in 1655 patients (1052 ischemic stroke, 434 intracerebral hemorrhage, 169 subarachnoid hemorrhage) and were associated with admission stroke severity (figure). Ischemic stroke patients were mean age 69 yrs (20-101), 50.4% female with mean admission NIHSS 9.3 (0-36). T2MI was associated with higher NIHSS >10 (p=.000), SCr (p=.000) and age (p=.005), lower LDL (p=.000) and SBP (p=.012), and history of AF (p=.021), CAD (p=.000), and HF (p=.000). The significant association with admission NIHSS (p=.002) persisted after adjustment for age (p = .056), gender, LDL (p = .007), CAD (p= .023), heart failure (p = .003), atrial fibrillation, systolic BP, A1C, BMI, and SCr (p=.009). Initial troponin levels for the 8.3% who died or DC to hospice were high in 43% and critical in 24%. Initial and peak troponin levels were significantly associated with DC disposition (p=.000).

Conclusion:
Elevated troponin due to T2MI is significantly associated with admission ischemic stroke severity, persisting after adjustment of other risk factors, and predicts a poorer outcome. Troponin levels should be obtained on admission for acute stroke to establish the diagnosis of T2MI and capture its impact as a major comorbid condition.
Abstract TP3: What Hospital Characteristics Drive Faster Thrombectomy For Emergent Large Vessel Occlusion (ELVO)?
Authors: Tarpley Jason , Lucas Lindsay , Ho Joseph T , Ovando Renee , Baraban Elizabeth
Published: June 2021

Introduction:
Recent thrombectomy trials for ELVO have reverberated the importance of speed in reperfusion therapy. Identifying hospital practices and features associated with faster door to thrombectomy times is critical to evolving our hospital systems to effectively deliver this powerful therapy.

Methods:
A multi-hospital, Get with the Guidelines stroke registry was used to identify AIS patients who received intra-arterial (IA) intervention between January 2012 and May 2016. Transferred patients were excluded since their door to reperfusion times don’t typically include a primary evaluation. Patients were categorized as having door to reperfusion (Door-to-IA) time over 135 minutes or Door-to-IA time below or equal to 135 minutes. A multivariate logistic regression model was used to identify which of the following variables were associated with Door-to-IA times over 135 minutes: age, gender, IV alteplase treatment, admit NIHSS score, patient arrival time to hospital, hospital certification (primary stroke center (PSC) versus comprehensive stroke center (CSC)), hospital annual IA treatment volume, and hospital annual percentage of transfers for thrombectomy.

Results:
We identified 229 AIS patients from ten hospitals who received IA intervention between January 2012 and May 2016. Of those, 49% (n=113) had Door-to-IA times over 135 minutes and 51% (n=116) had Door-to-IA time below or equal to 135 minutes. Patients with Door-to-IA times over 135 minutes were more likely to be older (adjusted odds ratio (AOR) = 1.02 per year; p=.040), treated at a PSC (AOR = 2.26; p=.028), and treated at a hospital with a higher percentage of transfers (AOR = 1.08 per percentage point; p<.001). IV-alteplase treatment, gender, NIHSS, patients’ arrival time and volume were not significant.

Conclusion:
Comprehensive stroke centers had shorter Door-to-IA times than Primary Stroke Centers in our system. However, hospital annual IA treatment volume did not impact Door-to-IA and centers with larger transfer volume actually had worse Door-to-IA times for patients evaluated and treated locally. This suggests that high volume centers with a larger volume of transferred patients may have tuned their practices to treating transfers rather than treating local ELVO patients.
Abstract TP300: Re-admissions in Patients With First Onset of Stroke - Looking Beyond Organ Systems
Authors: Khan Umer , Yee Chen Hui , Widjaja Louis S , Chan Bernard P , Paliwal Prakash , Seong Raymond S , Wong Lily Y , Chia Magdalene L , Sharma Vijay K , Merchant Reshma , Teoh Hock Luen , Seetharaman Santhosh
Published: June 2021

Background:
Patients who suffer from a stroke are susceptible to multiple complications, with readmission rates ranging from 20-40% per year, and approximately 25% of readmissions occurring within the first month
1
. Major reasons contributing to readmissions include recurrent stroke (24%), infection (12%), chest pain or myocardial infarction (10%), worsening of stroke symptoms (7%), arrhythmias (7%), and congestive heart failure (3%)
2
. However, additional potentially reversible risk factors have not been extensively studied.

Methods:
This retrospective study was conducted at a tertiary hospital in Singapore and included 1283 patients who were admitted for stroke between Jan 2014 and Oct 2015. All patients who had previous history of stroke or died on initial presentation were excluded from the study, leaving 957 patients with first stroke presentation. The dates and diagnoses of readmissions in the first 90 days were collected. Elective admissions or readmissions due to recurrent strokes or coronary syndromes were excluded to focus on readmissions due to infections, medication side effects, falls, or care coordination issues.

Results:
Out of 957 patients, 129 (13.4%) were readmitted within 90 days. 98 (10.2%) were readmitted once in 90 days, while 31 (3.2%) were readmitted multiple (2-7) times. The single readmission group showed a bi-modal distribution with 35.7% of readmissions occurring in the first 15 days, 15.3% in 15-30 days, 34.7% in 30-60 days, and 24.5% in 60-90 days after discharge.

In the single readmission group, 36.7% of patients were readmitted for infections (15.3% were urinary tract infections, 21.4% were chest infections), 12.2% were admitted for congestive heart failure symptoms, and 17.3% were admitted for falls or care coordination issues. A majority (59%) of readmitted patients were over the age of 70. 24% of the patients had a middle cerebral artery (MCA) stroke, and 34% had a decrease in function of activities of daily living on discharge.

Conclusion:
This study helps to highlight high risk groups for readmissions i.e. patients over the age of 70 years, reduction in function on discharge, and patients with MCA strokes, suitable for targeted interventions in order to reduce rate of readmissions in patients with first stroke.
Abstract TP31: Safety and Feasibility of Argatroban, Tissue Plasminogen Activator and Intra-arterial Therapy in Stroke (artss-ia Study)
Authors: Barreto Andrew D , Shen Loren F , Misra Vivek , Chen Peng R , Blackburn Spiros , Dannenbaum Mark , Broderick Joseph , Adeoye Opeolu , Grotta James C
Published: June 2021

Background and Objectives:
A randomized trial of IV-tPA + thrombin-inhibition with argatroban in non-endovascular stroke patients (
ARTSS-2
) recently demonstrated safety and signal of efficacy compared to tPA alone. The current study, ARTSS-IA, intended to study the safety and feasibility among concurrent IV-tPA, high-dose argatroban
and
endovascular therapy (ET) in large vessel occlusion.

Methods:
Eligible patients received IV-tPA (0.9mg/kg) and had CT-angiogram-proven intracranial large vessel occlusions requiring <6-hours ET. During IV-tPA, a 100 μg/kg argatroban bolus was followed by 12-hour infusion to target an aPTT 2.25 times baseline. Feasibility, defined as ability to combine treatments without ET delays, was compared to data from consecutive tPA+ET treatments. Safety was incidence of symptomatic intracerebral hemorrhage (sICH).

Results:
Between 6/15 and 5/16, all pre-planned 10 patients were enrolled: median age=68.5 (IQR 12-24; range 52-92), median NIHSS=19.5 (range 6-25) and 70% male. Occlusions were proximal MCA (n=6), terminal ICA (n=1) and proximal PCA (n=1). All patients began argatroban before ET and completed 12-hour infusions. Study patients experienced trivial or no time delays in metrics (i.e., imaging to groin-puncture, groin-to-clot, etc) compared to non-ARTSS-IA patients during the same time (figure). Embolectomy with stentreivers were performed in all but 1 patient, a proximal PCA occlusion deemed too hazardous for device passage. All the remaining 9 patients achieved excellent angiographic reperfusion (TICI ≥2b); with 7 achieving complete reperfusion (TICI=3). There were no sICH, systemic hemorrhages, or ET complications. 24 hour NIHSS scores were markedly lower (median=7, IQR 2-16, range 1-21). At 90-days, 6 (60%) patients were functionally independent (mRS=0-2) and none died.

Conclusion:
In patients treated with IV tPA and ET, adjunctive argatroban appears safe and high rates of reperfusion warrant further study.