bluuebunny/crossref_metadata_2025 huggingface dataset:
Management of Vascular Risk Factors: An Undertreated Opportunity for Stroke Prevention
Authors: Cohen Stanley N , Muthukumaran Abirami , Reddy Dhana , Kankar Padmaja , Jolly Desmond A , Date Lesley
Published: March 2022

P150

Purpose:
To assess the quality of risk factor management before and after ischemic cerebrovascular disease.
Methods:
Records of 100 consecutive patients seen by the Stroke Service for TIA or stroke were reviewed. Control of modifiable risk factors including hypertension (HTN), hyperglycemia (DM), hypercholesterolemia (HCh), and obesity were recorded in the 3 months before the event (T-0), immediately after the event (T-1), and one year later (T-2). Not every risk factor was recorded in each time epoch for each patient.
Results:
History of HTN was present in 76, DM in 29, HCh in 33, and obesity in 45. At T-0, 33/71 had systolic blood pressure (SBP) >140, 23/64 had total cholesterol >200, 17/57 had LDL cholesterol >130, 10/22 had HbA1c >8 and 41/66 had body mass index (BMI) >25. At T-1, 72 patients had SBP ≥135. At T-2, only 19/72 controlled the SBP <140. Of the patients with known DM and a recorded HbA1c at T-1, 14/21 were ≥8. At T-2, 6/20 were ≥8. Of the 66 patients with no history of HCh, 16 had total cholesterol ≥200 and 8 had LDL ≥130 at T-0. Of those with known HCh, 11 had total cholesterol ≥200 and 9 had LDL ≥130 at T-0. At T-2, there were no data on LDL on 50 patients, while 30 had ≥100 and 9 were ≥130. Using body mass index (BMI) ≥25 as a marker for obesity, 45 of 62 patients were obese at T-1. At T-2, there were still 45/62 with a BMI ≥25.
Conclusions:
The majority of patients had at least one risk factor in poor control prior to the stroke or TIA. Our data indicate that risk factor management for primary prevention of stroke has considerable room for improvement. Following the stroke/TIA, management of DM, the area of our greatest risk management success, failed to achieve satisfactory control in 30% of patients at the end of 1 year. Treatment of obesity was our worst area, with no improvement from baseline. The 40% and 43% success rates for HCh and SBP are less than satisfactory. Our data indicate that stroke prevention may be enhanced with more aggressive management of known risk factors. While this study suffers from the problems inherent in small retrospective series, if validated by other studies, the implications are important.
Gender Differences in Unruptured Intracranial Aneurysm Formation: Risk Factors and Characteristics
Authors: Kongable Gail L , Helton Edward D , Torner James C , Wright Allison , Brown Robert D , Wiebers David O
Published: March 2022

P151

The International Study of Unruptured Intracranial Aneurysms (ISUIA)
Background and Purpose:

There are few data available defining gender-based differences in intracranial aneurysm (UIA) risk factors and occurrence. The ISUIA provides a unique setting for evaluating these issues.
Methods:
Fifty-three centers in the ISUIA entered 5,669 patients with UIA. 1531 patients are part of a retrospective follow-up of unoperated UIA between 1970 and 1991. Another 4,138 comprise a prospective cohort. Half (58%) of this group are operated and 42% are unnoperated. Data were collected regarding history of subarachnoid hemorrhage (SAH) and factors including characteristics of the UIA, family history of stroke, cigarette smoking and many other demographic and medical history.
Results:
Combined analysis of these two cohorts revealed that women had a UIA 3 times more frequently than men (75% vs. 25%). Women had more multiple aneurysms than men did (52% vs. 42%; p=0.001). Women had a higher proportion of cavernous and internal carotid artery UIAs (46.5%) while the men more often had anterior and middle cerebral artery UIAs (54.5%), p<0.001. Women had an arteriovenous malformation less frequently than men did (1.6% vs. 3.7%; p=0.001). Cigarette use was less prevalent in women than men (69% vs. 76%; p=0.001) and alcohol use was lower in women than men (12.3% vs. 29.8%; p=0.001). Women were more likely to be hypertensive, (40.3% vs. 36.2%; p=0.02) and had vascular headache more than men, (27.3% vs. 16.9%; p=0.001). Age at diagnosis of UIA and family history of aneurysm, SAH, or indeterminate hemorrhages were similar for men and women. Women in Group 1 (UIA, no prior SAH) more often used oral contraceptives and estrogen replacement therapy than women in Group 2 (UIA, prior SAH from a second aneurysm). Also, Group 1 women more often had a history of hypertension. Women in Group 2 used cigarettes, alcohol and stimulants and had a history of vascular headache more often.
Conclusions:

Women are more likely to harbor UIA than men. Aneurysm characteristics such as location and multiplicity may differ, between genders. Selected risk factors for aneurysm formation may explain these.
Prognosis of Lacunar Stroke Patients in Association with Leukoaraiosis
Authors: Benavente Oscar , Eliasziw Michael , Streifler Jonathan , Barnett Henry Jm
Published: March 2022

P152

Background:
Leukoaraiosis (LA) is a frequent finding on CT scans of patients with vascular risk factors and cerebrovascular disease, particularly in those with lacunar stroke. Both conditions appear to be linked by a common pathophysiological mechanism, namely small vessel disease.
Objective:
To characterize the relationship between lacunar stroke and LA, and to correlate with the risk of recurrent lacunar stroke. Patients &
Methods:
Baseline CT scans of NASCET participants with stroke as the index event were assessed for the presence and severity of LA by two readers independently unaware of clinical data.
Results:
Four groups based on the type of index stroke and on the presence of LA were formed: a) no lacunar stroke & no LA (n=437), 2) non lacunar stroke & LA (n=153), c) lacunar stroke & no LA (n=365), d) lacunar stroke & LA (n=76). Baseline characteristics different among the groups were: age >65 years (53, 76, 56, 63% respectively p<0.001), hyperlipidemia (30, 20, 37, 29% respectively p=0.002), smoking (42, 28, 41, 45, 42% respectively p=0.02) and degree of carotid stenosis 50–99% (52, 44, 45, 34% respectively p=0.01). Patients with LA were 2.9 times more likely to have multiple lacunes on CT (p=0.001). The risk of lacunar stroke at 5 years increased across the four groups (5, 8, 10 and 11% respectively p=0.02), after adjusting for all baseline characteristics.
Conclusions:
The presence of leukoaraiosis in lacunar stroke patients is associated with higher number of lacunar infarcts and strongly predicts the likelihood of developing a subsequent lacunar stroke. Our findings support the hypothesis that both conditions are caused by the same pathological entity in this patient population.
Acute Stroke: A population based study of factors influencing delays in hospital arrival. Preliminary results.
Authors: Gilligan Amanda K , Thrift Amanda G , Dewey Helen M , Macdonell Richard Al , Prof Geoffrey A Donnan
Published: March 2022

P155

For acute stroke therapy, most stroke patients are ineligible due to delays in presenting to hospital. Previous studies have largely been hospital based, lacking specific information about the factors influencing non hospitalised patients. To plan for acute stroke care in the new millennium, we need to identify factors that may help increase the proportion eligible for these treatments. Arrival times were assessed for patients accrued in the NorthEast Melbourne Stroke Incidence Study (NEMESIS), a large population based stroke incidence study in Australia. Patients were identified using multiple overlapping sources including 60 hospitals. Stroke onset and hospital arrival times were assessed by review of medical records and interviews with the patient or next of kin. In this preliminary analysis, we assessed 254 stroke events among 244 patients. Two hundred and twenty seven were first-ever-in-a-life time strokes. The mean age was 75 years and 40% were male. In 254 events, 7% never attended hospital and 9% were in-patient strokes. Non attenders were older (mean age 79 years), predominantly female (88%) and 65% resided in nursing homes. Median hospital arrival time for the remaining 84%, was 9.1 hours (range 25 minutes to 1 month). Thirty percent of patients presenting to hospital arrived within 3 hours of the event, and 74% within the first 24 hours. Delays were greater with contact with the General Practitioner, living alone or in patients with a history of dementia. Factors associated with earlier arrival included ambulance transport, dense hemiplegia, impaired consciousness and sub-arachnoid haemorrhage. In this preliminary analysis, we have identified factors that affect hospital arrival times. Many non hospitalised patients may be ineligible for treatment due to pre existing disability or old age, reflected in their need for nursing home accommodation. Of those who attend hospital, potentially a greater proportion of the stroke population could be eligible for acute therapies if delays in arrival could be addressed. Strategies to improve early attendance need to be targeted at both the patient and the General Practitioner.
New Single Nucleotide Polymorphisms in the Shear Responsive MCP-1 Promoter Region in Atherosclerosis.
Authors: Nyquist Paul Alan , Hamm Theresa , Nagle Jim , Kauffman Debra , DeGraba Thomas J
Published: March 2022

P160

Background:
Atherosclerosis represents a complex chronic inflammatory process influenced in part by genetic factors. Polymorphisms in the key regulators of inflammation are hypothesized to increase the susceptibility for the development of atheroma. Single nucleotide polymorphisms (SNPs) affect the secretion of inflammatory mediators such as monocyte chemoattractant protein one (MCP-1). MCP-1 has been shown to affect atherosclerosis development and SNPs affecting its secretion may affect the occurrence of atherosclerosis in humans. The aim of this study is to examine the frequency of SNPs in the promoter region of MCP-1 in patients with atherosclerosis versus controls.
Methods:
DNA was obtained from patients presenting for carotid endarterectomy and controls. A region of the MCP-1 promoter spanning -2746 to +440 bases relative to the transcriptional start site was sequenced.
Results:
The MCP-1 distal regulatory region was sequenced and two known SNPs were identified at base -2518 and base -2076 from the transcriptional start site. A “G” substitution at -2518 is associated with increased secretion of MCP-1. No association between atherosclerosis and these two SNP’s was observed. Two new SNPs consisting of a C/G substitution at bases -302 and -868 from the transcriptional start site were discovered. Allele frequency for the C -301 SNP represented 33%% of the control population and 61% of the atherosclerotic population. There was a trend toward higher C allele frequency in the atherosclerotic population (P=0.10). The power of this analysis (0.35) was limited by the relatively small control sample size (n=16).
Conclusion:
We report the discovery of two novel SNPs in the MCP-1 promoter region. The SNP at the -301 base site that is activated by shear forces such as elevated blood pressure. This region is a highly conserved region with a high prevalence of the -301 polymorphism suggesting some effect on gene function. Work is on going to characterize the frequency of the C allele in populations with atherosclerosis as well as its effect on MCP-1 secretion.
The Importance of the Electrocardiogram in TIA Evaluation
Authors: Elkins Jacob S , Sidney Stephen , Gress Daryl R , Go Alan S , Johnston S. Claiborne
Published: March 2022

P164

Background:
Current guidelines recommend the use of the electrocardiogram (ECG) in the evaluation of patients with TIA, but data supporting its value in acute management are sparse.
Methods:
Patients who presented to one of 16 emergency departments in an HMO in Northern California and received a diagnosis of TIA March 1997 through February 1998 were enrolled. Patients were followed for 90 days after presentation with TIA. Clinical, demographic and outcome information were obtained from computerized databases and review of medical records. A cardiovascular event was defined as a hospitalization or death due to myocardial infarction, ventricular arrhythmia, congestive heart failure, or unstable angina. Stroke and recurrent TIA required neurologist confirmation. Analyses were performed with chi-square tests and multivariable logistic regression, adjusting for other clinical predictors with stepwise elimination of variables not contributing (p>0.10).
Results:
In a cohort of 1327 TIA patients with ECGs performed at presentation, there were 39 cardiovascular events, 145 strokes, 182 recurrent TIAs, and 34 deaths during 90-day follow-up. ECG revealed a new diagnosis of atrial fibrillation in 28 patients (2%). The risk of cardiovascular events was greater in those with any abnormal ECG findings (4.2% vs. 0.6%, p<0.001). The association remained significant after adjustment for medical history and signs (OR 6.8, 95% CI 1.6–28.5, p=0.009). Left ventricular hypertrophy, atrial fibrillation, and atrioventricular conduction abnormalities were each independently associated with more than doubling of risk of cardiovascular events. Abnormal ECG findings were not significantly associated with risk of stroke or death.
Conclusions:
Short-term cardiovascular morbidity is substantial after TIA. ECG reveals new atrial fibrillation in a significant portion of TIA patients, and can identify a group of patients that is at a substantially higher risk of short-term cardiovascular events. Urgent cardiac evaluation is probably indicated in TIA patients with abnormal ECGs.
The role of gama aminobutyric acid (GABA) in acute ischemic stroke
Authors: Davalos Antonio , Leira Rogelio , Serena Joaquin , Castellanos Mar , Aneiros Angel , Castillo Jose
Published: March 2022

P171

Background:
GABA neurotransmission causes membrane hyperpolarization which may counterbalance the toxic effects of glutamate during cerebral ischemia. Although the neuroprotective action of a GABA agonist (Clomethiazole) on acute ischemic stroke is currently being investigated, the importance of GABA in human stroke is unknown.
Objective:
to analyze whether the concentrations of GABA were related to early stroke outcome in 258 patients with an acute hemispheric cerebral infarction.
Methods:
GABA was measured using HPLC in blood and CSF samples obtained within 24h from stroke onset, and in blood 48h after admission. Stroke was classified according to Bamford’s scheme. Deterioration was diagnosed if Canadian stroke scale dropped 1 or more points during the first 48h after inclusion. The relative importance of GABA for neurologic worsening was evaluated by logistic regression analysis.
Results:
GABA concentrations (nmol/L) in plasma and CSF were significantly lower in TACS (108±86 and 44±20) than in PACS (240±164 and 87±60), LACS (377±136 and 134±43), and POCS (374±137 and 134±35) (all p<0.0001). There was a significant linear correlation between plasma and CSF values of GABA (r=0.70, p<0.001). Neurologic deterioration occurred in 87 patients (33.7%). In TACS and PACS, mean plasma and CSF levels of GABA at admission were three fold lower in patients with progressing stroke than in those without worsening (all p<0.0001); in LACS and POCS they were 40% lower in patients with progression (p<0.01). GABA concentrations of less than 190 nmol/L in plasma (OR,13.0; 95%CI, 3.8 to 44.8), and of less than 82 nmol/L in CSF (OR,20.3; 95%CI, 5.6 to 71.8) were significantly associated with neurologic worsening after adjusting for age, inclusion delay, serum glucose, body temperature, and stroke severity on admission, and ultimate infarct volume. Mean plasma GABA levels did not change at 48h in patients with deterioration, but increased a 17% in those who improved or remained stable (Wilcoxon, p<0.001).
Conclusions:
Early neurologic deterioration in acute ischemic stroke is related to low GABA concentrations in blood and CSF, particularly in patients with total or partial anterior circulation syndromes.
NON-INVASIVE MONITORING OF INTRACRANIAL PRESSURE AND COMPLIANCE
Authors: Paulat Klaus , Brucher Rainer , Russell David
Published: March 2022

P174

Introduction:
Increasing intracranial pressure (ICP) is one of the most dangerous complications following acute stroke. Monitoring of ICP provides the physician with data for rational treatment management but to date this must be carried out by invasive methods which carry a considerable risk of serious complications.
Methods:
In this study we have assessed a new non-invasive method for measuring ICP and compliance in 10 healthy controls. ICP variations were assessed by measuring tympanic membrane ICP propagation using a specially designed pressure transducer. Cerebral compliance was measured by simultaneously assessing the Windkessel volume displacement of the cerebral arteries. This is achieved by measuring the cross-section transcranial Doppler power index in the middle cerebral arteries with corrections for the Doppler frequency distributions (frequency corrected power). ICP was increased step-wise using a tilt-table (11–12 measurements in all subjects). This increases cerebral venous pressure which is the hydrostatic pressure relative to the right atrium and is known to be transformed into an equivalent ICP increase due to the valve function of the bridging veins. Compliance was calculated at each ICP value.
Results:
The pressure increases measured by tympanic membrane propagation and the calculated ICP increases showed a linear relationship in all 10 subjects. Compliance curves also showed typical decreases in compliance with increasing ICP.
Conclusion:
This study has shown that it is now possible to non-invasively monitor intracranial pressure and compliance. This new method should be assessed in extensive clinical studies.
Hyperacute stroke diffusion- and perfusion-weighted MRI distinguishes t-PA responders
Authors: Parsons Mark W , Barber P Alan , Darby David G , Tress Brian M , Donnan Geoffrey A , Davis Stpehen M
Published: March 2022

P181

Background:
There is an urgent need to better select candidates for t-PA based on knowledge of cerebral pathophysiology rather than a rigid time window.
Methods:
We therefore studied 14 consecutive patients with acute hemispheric stroke with diffusion- (DWI) and perfusion-weighted imaging (PWI) prioe to 3 hours of stroke onset, and again at days 3 and 90. Seven patients received intravenous t-PA, 6 were imaged prior to t-PA. The 7 patients that did not receive t-PA were used as a control group as they each fulfilled clinical criteria for t-PA administration.
Results:
12/14 patients had PWI > DWI mismatch, 5/7 in the t-PA group and all 7 in the control group. One of the 2 exceptions was the only patient who received t-PA prior to imaging. The second DWI > PWI patient was treated with t-PA, but died due to hemorrhagic transformation. Of the PWI > DWI mismatch patients, there was no major infarct expansion in 4/5 of the t-PA group, whilst all 7 patients not receiving t-PA had major infarct expansion (chi squared = 7.2, p=0.01). In addition, the extent of acutely hypoperfused tisse salvaged from infarction was greater in the t-PA group (mean 64% vs mean 29%; p=0.02). All 7 of the t-PA patients had major reperfusion, as opposed to 3/7 control patients (chi squared = 4.9, p = 0.03).
Conclusions:
Patients with PWI > DWI mismatch treated with t-PA had attenuation of infarct expansion and greater salvage of acutely hypoperfused tissue from infarction. This is best explained by thrombolysis-enhanced reperfusion. This study suggests that patients with PWI > DWI mismatch have the greatest potential to benefit from thrombolytic therapy. As 75% of patients still have PWI > DWI mismatch at 6 hours after stroke onset, we postulate that patients with this pattern may still have salvageable tissue with t-PA beyond the currently accepted 3 hour window. We aim to further test this hypothesis in a multicentre, randomised, placebo-controlled trial in acute stroke patients presenting 3–6 hours after symptom onset.
Outcomes following thrombolysis for posterior circulation stroke
Authors: Tsao Jack W , Smith Wade S , Hemphill J. Claude , Bonovich David C
Published: March 2022

P189

There is relatively less information about indications and outcome for thrombolysis in posterior circulation stroke as compared to anterior circulation stroke. Prior randomized studies either excluded this group of patients (PROACT-II), or used inclusion criteria that made enrollment less likely (NINDS rt-PA, ECASS I & II). Medical records were reviewed for all patients who received intravenous (IV) or intraarterial (IA) thrombolytic therapy for posterior circulation ischemic stroke at the University of California, San Francisco between October 1993 and February 2000. NIHSS was measured at baseline, 1 day, and at discharge, and a Glasgow Coma Scale (GCS) was measured at baseline. A retrospective modified Rankin Scale (mRS) was measured at last follow-up. A mRS≤2 was considered a good outcome. Data were analyzed using the Wilcoxon rank-sum test. 20 patients received thrombolytic therapy: 9 IV rt-PA; 9 IA urokinase; 2 IA rt-PA. Mean age was 57 (range 25–87). 11 of 20 patients were treated within 12 hours (1.5 hours-16 days) of symptom onset. Mean initial NIHSS score was 20 (range 2–39), and GCS was 10 (range 3–15). One day following thrombolytic therapy the mean NIHSS was 13 (range 0–36, p<0. 01), with 16 of the 20 patients having overall improvement (11 of these patients with 5 or more points) despite continued disability. No intracranial hemorrhages were observed. Six patients died of complications between 2 days and 2 weeks, and 3 of these patients were treated >12 hours after stroke onset. At hospital discharge the 8 survivors treated in under 12 hrs had a mean NIHSS of 4 (range 0–13), and the 6 survivors treated beyond 12 hrs had a mean NIHSS of 10 (range 3–20, p<0.10). 7 and 2 patients in the two groups, respectively, had a mRS≤2 (p<0.05, compared to baseline Rankin). Ten patients had an initial GCS of 7 or less, with 9 having motor posturing at the time of presentation. Only 2 of these patients (20%) had a good outcome (ages 25 & 42). Thus, thrombolysis within 12 hours may benefit patients with posterior circulation stroke. Decreased level of consciousness and lack of purposeful movement, as evidenced by a GCS≤7 or motor posturing, respectively, are predictive of poor outcome, even with thrombolytic treatment.
Intra-arterial therapy following intravenous alteplase for severe ischemic stroke
Authors: Hill Michael D , Newcommon Nancy , Barber Philip A , Demchuk Andrew M , Buchan Alastair M
Published: March 2022

P190

Background
Intravenous alteplase may not be efficacious for the majority of patients with proximal large vessel occlusion. Intra-arterial thrombolysis improves outcome in MCA occlusion but delays occur between the decision to proceed to interventional therapy and its application. Initial administration of intravenous alteplase prior to an intra-arterial approach may provide better outcomes due to earlier exposure of thrombus to alteplase and subsequently improved re-canalisation rates. Criteria for patient selection are undefined.
Methods
Case series with 90d outcomes. Between February 1999 and July 2000, 7 patients ranging in age from 40–84 years were treated with an IV/IA approach. All patients received IV alteplase within 3h of stroke onset. Two patients had basilar occlusions and six had MCA M1 stem or one or both M2 branch occlusions. Patients were selected using one or both of pre-treatment TCD examination (n=5) or large DWI/PWI mismatch with MRA documented occlusion (n=3). One patient with an MCA occlusion had severe vessel tortuosity and did not receive IA alteplase because access to the thrombus was not possible.
Results
The median NIHSS score was 19 (range 10–24). Intra-arterial therapy was started between 2–3h of symptom onset in all cases. Angiographic recanalisation was successful in all patients who had an intervention (6 of 7 patients). One patient underwent vertebral artery angioplasty instead of thrombolysis. Two patients died or were severely disabled (mRS 5–6), one from contralateral recurrent MCA stroke several days post-procedure and one with a severe basilar artery stroke. The remaining 4 patients with MCA occlusions had excellent neurological outcomes and were independent at 90d. There were no symptomatic hemorrhages.
Conclusions
Selection of patients for IV/IA therapy is aided by early cerebrovascular imaging. IV/IA therapy can be performed within 3h of stroke onset and can result in excellent outcomes for patients with the most severe of ischemic strokes.
Regional and Racial Variations in the Use of Thrombolytic Therapy for Acute Stroke at US Academic Medical Centers: The UHC Stroke Benchmarking Project
Authors: Tong David C , Grosvenor David
Published: March 2022

P198

BACKGROUND:
Few national data are available regarding current status stroke thrombolytic use in the US. This information is important to identify trends in acute stroke management and potential barriers to therapy. To address this issue, the UHC Stroke Benchmarking Project recently assessed the status of thrombolytic therapy in a survey of academic medical centers around the country.
METHODS:
Between 11/17/99 and 12/27/99, a comprehensive questionnaire was retrospective completed on a consecutive sample of acute stroke patients admitted to each participating hospital. Extensive demographic information regarding the use of thrombolytic therapy in these patients was also obtained.
RESULTS:
42 hospitals participated in the study. The hospitals were evenly distributed between the Northeast (n=11), Midwest (n=10), South (n=9) and West (n=12). Overall, of the 1196 patients included in the study, 66 (5.5%) received thrombolytic treatment (55 IV, 11 IA). 190 patients were considered IV thrombolytic eligible, and 32.8% of these received thrombolytic treatment. There were significant regional and racial variations in thrombolytic use. The rate of thrombolytic use was lowest in the South (1.2%) and highest in the MW (9.5%). 64.3% of thrombolytic eligible patients received treatment in the MW, while only 7.7% of eligible patients received treatment in the South (OR 10.3, CI 2.4–44.5, p<0.005). Logistic regression analysis also revealed that Caucasians had a significantly greater probability of treatment than non-Caucasians (OR 3.7 CI 1.4–9.9, p=0.0056).
Conclusion:
At academic medical centers, a low proportion of patients receive thrombolytic therapy. Moreover, these data indicate that there are significant regional and race specific differences in thrombolytic therapy which should be addressed in order to increase the rate of thrombolytic use nationwide. The UHC database could be a useful mechanism by which monitor such changes in acute stroke care.
Feasibility of Ambulatory Carotid Artery Stenting
Authors: Al-Mubarak Nadim , Roubin Gary S , Vitek Jiri J , New Gishel , Iyer Sriram S
Published: March 2022

P202

Background:
Ambulatory procedures have been shown to increase patient’s comfort and cost-efficacy. We sought to determine the feasibility of ambulatory carotid stenting in a series of patients undergoing the procedure.
Methods:
Patients were electively admitted and discharged the same-day if they had successful uncomplicated carotid stenting and had demonstrated complete vascular access site hemostasis following ambulation 4–6 hours after the procedure. Patients were followed for neurological events and vascular access site complications.
Results:
A total of 76 same-day carotid stenting procedures were performed on 73 patients (76 arteries). There were 53 (73 %) males and the mean age was 70 ± 8 years. Seventy-nine percent of the patients were asymptomatic on presentation. Fourteen patients (18 %) had prior ipsilateral CEA, 3 (4%) had prior ipsilateral neck radiation and 6 (8 %) had contralateral occlusions. Successful access site hemostasis was achieved in all patients, using suture-mediated vascular sealing devices in 75 cases (99%). In one case hemostasis was achieved manually after failure of the sealing device. Late follow-up currently available on 62 (98%) patients at a mean of 4 ± 3 months. There have been no neurological events, deaths, repeat procedures or significant access site complications. One patient developed serous discharge from the access site at 6 weeks without evidence of infection or hematoma and was managed conservatively without complications.
Conclusion:
Ambulatory carotid stenting is feasible and safe. This approach will foster the applicability of the procedure by increasing patient s comfort and potentially reducing procedural costs.
Outpatient Low-Molecular Weight Heparin for Conversion to Warfarin in Non-Valvular Atrial Fibrillation
Authors: Boughman Lori , Rymer Marilyn M , Knell Maureen , Carroll Cathy , Thrutchley Duane
Published: March 2022

P206

Background:
Patients with non-valvular atrial fibrillation (NVAF) are often hospitalized on IV heparin until target INRs are achieved. SQ LMWH has been shown to be safe and effective for OP treatment of DVT, but has not been widely used in NVAF. We discharged 35 patients with NVAF on SQ LMWH and analyzed safety, cost and satisfaction.
Methods:
Patients with NVAF who were being held in the hospital only for conversion of heparin to warfarin and who met other entry criteria were enrolled. Baseline CBC, coagulation profile, neurologic exam and demographic data were obtained. Patients were instructed in the use of LMWH and warfarin and then discharged on dalteparin 100 units/kgm BID. Ten patients also chose to monitor their own INRs with a point of care testing device (Coagucheck). Eight patients elected to have a home health nurse administer the dalteparin. When two consecutive INRs were therapeutic, dalteparin was discontinued. Actual cost of outpatient care was calculated. Inpatient costs were projected based on the number of days it took to reach the therapeutic INR values. Ten days after enrollment patients responded to a phone survey regarding thrombotic and/or bleeding complications, readmission to ED or hospital and satisfaction.
Results:
31 patients completed the entire process. 51%(18/35) were >70 years old. There were no significant thrombotic or bleeding complications, no readmissions and one ED visit for minor bleeding at a venupuncture site (INR=2.5). 71%(22/31) reported minor bruising. Patients using Coagucheck monitored INRs 2x as frequently as patients using the lab. Outpatient costs including the cost of dalteparin, INR testing, home health visits, coagucheck supplies and 1 ED visit totaled $20,324 or $616 per patient. Projected inpatient costs including the cost of room, IV heparin, PTT and INR testing totaled $123,261 or $3,735 per patient. This represented a cost saving of $3,119 per patient. 91%(28/31) were satisfied or very satisfied with the OP treatment and 87%(27/31)reported they would use it again.
Conclusions:
Outpatient SQ LMWH is a safe, cost-effective and attractive alternative to inpatient IV heparin in patients with NVAF.
Aspirin dose and thromboxane metabolism in African American stroke patients
Authors: Bruno Askiel , McConnell Joseph P , Mansbach Harry H , Cohen Stanley N , Tietjen Gretchen E , Bang Nils U
Published: March 2022

P214

Purpose:
To evaluate thromboxane metabolism in African American stroke patients on different doses of aspirin.
Methods:
Consecutive African American patients within 3 month of non-cardioembolic stroke and not being treated with anticoagulation were recruited. Antithrombotic therapy at the time of sample collection was not prespecified and varied according to the practice patterns of the different attending physicians who treated the patients during their acute stroke. The thromboxane metabolite 11-dehydrothroboxane B2 (11-DTB2) was measured by enzyme immunoassay in random urine samples collected at the time of enrollment.
Results:
99 patients were enrolled but 15 could not give a urine sample at the time of enrollment. Data on the remaining 84 patients were evaluable. There were 49 men and 35 women aged 36–87 (mean 62) years. Based on antithrombotic treatment during sample collections, we divided patients into four groups: no aspirin N=16 (no antithrombotic drugs N=4 or ticlopidine N=12), aspirin 81–325 mg/d N=19 (81 mg/day N=1, 325 mg/day N=18), aspirin 650 mg/d N=19, aspirin 975–1300 mg/d N=30 (975 mg/d N=2 and 1300 mg/d N=28). After log transformation of the 11-DTB2 values the geometric means in the no aspirin, 81–325 mg/d, 650 mg/d, and 975–1300 mg/d groups were 1355, 912, 758, and 731 pg/mg creatinine, respectively. Based on one way ANOVA, the mean 11-DTB2 concentration was significantly different between the 4 groups (p=0.03). There was a significant negative relationship between aspirin dose and 11-DTB2 concentration (Pearson Correlation, r = -0.26, P=0.02).
Conclusion:
In African American stroke patients thromboxane production appears to be progressively inhibited by aspirin doses up to 650 mg/d. The clinical significance of this effect by aspirin doses ≤650 mg/d remains to be determined.
Effect of angiotensin converting enzyme inhibitor on vascular reactivity in patients with chronic cerebral infarction
Authors: Sato Mika , Nagata Tomoyuki , Hirata Yutaka , Hatazaww Jun
Published: March 2022

P223

Background and Purpose:
Based on the results from the laboratory settings, angiotensin converting enzyme (ACE) inhibitors are known to have an effect to improve cerebral blood flow in hypertensive animals, in addition to their antihypertensive effects. By using a positron emission tomography (PET), the present study endeavored to evaluate the effect of Cilazapril on vascular and metabolic reserve in patients with chronic cerebral infarction. Subjects and
Methods:
The present study included 9 hypertensive patients with chronic cerebral infarction. The subjects’ mean age was 67.4 years. By using PET, cerebral blood flow (CBF), cerebral oxygen metabolism (CMRO2), oxygen extraction fraction (OEF) and vascular transit time (VTT) were measured during resting state. To evaluate the vascular reactivity (VR), CBF was also measured during CO2 inhalation (hypercapnia) and hyperventilation (hypocapnia). Cilazapril (1mg/day) was administered for 35–93 (mean 64) days and the PET studies were repeated before and after the treatment with Cilazapril. Local values were obtained from 20 regions of interest located which were located in the thakamus, basal gangila and cerebral cortices. Using Student’s t-test, mean CBF, CMRO2, OEF, CBF/CBV and VR were compared before and after the treatment.
Results:
There was no significant change in the mean CBF, CMRO2, OEF or VTT before and after the treatment. The mean VR to hypercapnia was 4.68 ± 2.52 (%CBF/mmHg) at baseline, and 5.75 ± 4.35 (%CBF/mmHg) after the treatment. The VR to hypercapnia increased significantly after the treatment (p<0.01) The mean VR to hypocapnia was 2.59 ± 1.11 (%CBF/mmHg) at baseline and 2.99 ± 1.94 (%CBF/mmHg) after the treatment. There was a tendency toward the increase in VR to hypocapnia.
Conclusion:
The increase in VR to hypercapnia after the treatment may indicate an improvement in vascular reserve in patients with chronic cerebral infarction. As suggested by previous experimental studies, Cilazapril may have a beneficial effect on cerebral vascular reserve in those with chronic hypoperfusion by improving the compliance of the small vessels which dilate during hypercapnia.
Bone marrow stromal cells of bcl-2 transgenic mice express widespread Bcl-2 protein and reduce apoptosis in a serum-free medium
Authors: Wang Lei , Li Yi , Chen Jieli , Chopp Michael
Published: March 2022

P225

Stem cell transplantation is a vibrant area of research with the goal of treatment of uncurable diseases. Bone marrow stromal cells (MSCs, including marrow stem and progenitor cells) have been employed to improve neurological functional recovery after stoke and injury. Grafted cell death is a common feature of intracerebral transplantation. Bcl-2 has been shown to protect a variety of cell types from apoptoic cell death. We tested the hypothesis that MSCs harvested from bcl-2 transgenic mice promote survival and decrease apoptosis of cells in vitro. MSCs were harvested from adult male C57BL/6 transgenic mice (n=4) overexpressing bcl-2, and from normal control C57BL/6 mice (n=4). Cells were cultured in regular medium, Iscove s Modified Dulbecco s medium (IMDM) supplemented with 10% fetal bovine serum (FBS); and then isolated by their adherence to the plastic dishes from non-adherent hematopoietic cells at 72 h of incubation. To examine the effect of bcl-2 on cell death induced by serum deprivation. MSCs were washed and incubated with the serum-free medium. Immunostaining and Western blot were used to identify Bcl-2 protein expression, and TUNEL staining was used to identify in situ DNA fragmentation of apoptotic cells. Immunocytochemical staining indicated that 100% of MSCs harvested from bcl-2 transgenic mice express Bcl-2 protein. Western blot showed that Bcl-2 protein was 8 times more intense in the MSCs harvested from transgenic mice than that from normal control mice at 12 days cultured in regular medium. After 48 h cultured in the serum-free medium, 5.8% of MSCs from bcl-2 transgenic mice were presented apoptoic morphology, compared with 39% of MSCs from normal controls. Our finding demonstrates that the overexpression of bcl-2 gene in the MSCs reduces apoptotic cell death.
Physical Therapist Prediction Accuracy of Discharge Placement from Acute Care.
Authors: Landgraff Nancy C , Whitney Susan L , Wrisley Diane , Berlin Jamie
Published: March 2022

P228

Background:
The clinical impression of the Physical Therapist is requested in the determination of patient placement after an acute stroke. There is little evidence to determine if physical therapists are accurately making these recommendations. Also, there is little consensus regarding factors physical therapists consider when making these decisions. It is unknown if years of clinical experience affects placement judgment. The purpose of this retrospective chart review was to address the following questions: How accurate were the physical therapists in predicting placement and did experience affect the accuracy of the prediction?
Methods:
A retrospective chart review of 64 medical records of persons admitted to The University of Pittsburgh Medical Center Stroke Institute during 1999 was conducted. Data collected included client demographics, elements of the medical and social history, and measures obtained from the initial evaluation and the therapist s recommendation for discharge placement.
Results:
Spearman rank correlation coefficients were calculated between the predicted and actual discharge location, and to determine the association of the accuracy of prediction and other factors from the client s history or evaluation.An accurate prediction was made 73 % of the time. A moderate correlation was found between the predicted and actual discharge location. (r =.655). Fair but significant correlations were found between the accuracy of prediction and the following factors: the extent of brain damage (r=-.423), bowel and bladder function (r= .357), National Institutes of Health Stroke Scale score (r=.391), and the client s abilities to perform balance (r=.399), sit to stand (r=.483), and locomotion (r=.411). No significance was found between the therapist s years of experience and correct placement decisions. Physical therapists with a minimum of 3 years of experience evaluated 77% of the patients..
Conclusions:
In this retrospective chart review, physical therapists were accurate in their predictions of placement location for persons with an acute stroke. The physical therapists years of experience did not appear to significantly affect accuracy
Can Prophylactic Acetaminophen Prevent Hyperthermia in Acute Stroke?: Results of the Normothermia and Stroke Outcome (NOTHOT) Pilot Clinical Trial
Authors: Kalafut Mary A , Llanes Jennifer , Kidwell Chelsea , Starkman Sidney , Saver Jeffrey L
Published: March 2022

P232

Objective:
To explore the safety and efficacy of round-the-clock acetaminophen administration to prevent hyperthermia in acute ischemic stroke patients.
Background:
Fever is a frequent occurrence among stroke patients and large cohort studies have identified early fever as an independent risk factor for poor functional outcome. Conventional management is to use antipyretics only in response to the appearance of fever. A pre-emptive strategy of prophylactic antipyretic therapy has not been previously studied.
Methods:
Sixteen consecutive patients presenting within 24 hrs of ischemic infarction were given acetaminophen 650mg q 4 hrs for 72 hrs or until discharge. Oral temperatures were recorded q 4 hrs. Cooling blankets were ordered for T >37.6
0
C. These results were contrasted with a historical control cohort of 16 consecutive patients who were admitted within 24 hrs of stroke onset treated with conventional reactive antipyretic therapy.
Results:
In the acetaminophen group, mean age was 71.4 and 62.5% were male. Mean admission NIHSS score was 8.9. Mean time from stroke onset to first dose of acetaminophen was 12.9 hrs. Mean temperature at presentation was 36.6
0
C for the acetaminophen group vs. 36.4
0
C for controls (p=NS). 44% of the acetaminophen group developed elevated body temperature vs. 40% of controls (p=NS). Mean temperature during the first 24 hrs of treatment with acetaminophen was 36.8
0
C vs. 36.8
0
C for controls. Corresponding numbers for the second and third 24-hour periods were 36.9
0
C for the acetaminophen group vs. 37.1
0
C for controls (p=0.02) and 36.9
0
C for the acetaminophen group vs. 36.9
0
C for controls. Across the 72 hr treatment period, mean temperature was 36.9
0
C for the acetaminophen group vs. 37.0
0
C for controls (p=0.05).
Conclusion:
This pilot trial demonstrates acetaminophen administered round the clock significantly lowers average body temperature in the first 72 hrs after ischemic stroke. A randomized controlled clinical trial is needed to determine whether acetaminophen mediated body temperature lowering results in smaller infarct volume and improved clinical outcomes.
A Prospective Single Center Study to Evaluate Safety and Short-term Efficacy of Angioplasty and Stent Placement for Intracranial Atherosclerotic Disease
Authors: Qureshi Adnan , Ali Zulfiqar , Suri M Fareed K , Ringer Andrew J , Kim Stanley H , Guterman Lee R , Hopkins L N
Published: March 2022

P240

Background and Purpose:
Intracranial atherosclerotic disease (ICAD) is associated with a 7% to 10% annual incidence of ischemic stroke. Although percutaneous transluminal angioplasty (PTA) has been introduced for revascularization of ICAD, the treatment experience is limited. We prospectively studied the safety and efficacy of PTA and/or stent placement for ICAD at a tertiary-care referral hospital.
Methods:
Each patient was evaluated by a neurologist prior to, immediately following and 24 hours after the procedure. PTA and/or stent placement were performed using routine techniques as either single or multiple procedures. Any complications related to the procedure in 1-month interval were recorded. Pre- and post-angiograms were analyzed to evaluate response to endovascular revascularization.
Results:
A total of 25 patients (29 procedures) were treated (mean age 62.6 ± 12.6 years) for ≥ 50% stenosis in the internal carotid artery (n=4), middle cerebral artery (n=8), vertebral artery (n=11), or basilar artery (n=2). The procedures included PTA (n=20), primary stenting (n=8), or combination of both (n=1). There was an improvement in stenosis (mean ±SD) from 85 ±13% to 23.8 ±23.4%. The overall stroke rate per procedure was 6%; all strokes were minor. One patient died from post-procedural intracerebral hemorrhage. Systemic bleeding complications were observed in 6% of the procedures (3% major and 3% minor).
Conclusions:
Endovascular revascularization for treatment of ICAD appears to be feasible with a low complication rate. Further studies are required to evaluate the long-term efficacy of these procedures in reducing the risk of ischemic stroke in patients with ICAD.
Abstract 103: Genetic Markers for Hypertension and Body Mass Index are also Associated with Risk of Intracerebral Hemorrhage
Authors: Falcone Guido J , Devan William , Biffi Alessandro , Cortellini Lynelle , Valant Valerie , Ayres Alison M , Schwab Kristin , Rost Natalia , Goldstein Joshua N , Viswanathan Anand , Greenberg Steven M , Rosand Jonathan
Published: March 2022

Background:
Genetic variation plays a substantial role in risk of intracerebral hemorrhage (ICH). Because a number of genetic variants associated with Hypertension (HTN) and Body Mass Index (BMI) have already been identified, and both HTN and BMI influence risk of ICH, we sought to determine whether the cumulative burden of HT and BMI genes increases risk of ICH.

Objective:
To test the hypothesis that increasing numbers of risk alleles for HTN and high BMI produce additive increments in ICH risk.

Methods:
Prospective study of consecutive individuals with ICH admitted to the Massachusetts General Hospital between 2004 and 2009, and gender- and age-matched controls. Fourteen SNPs associated with HTN and 42 with high BMI were identified (p-values <5x10E-8) from previous reports and genotyped in our cohort using Illumina 610-QuadBead. Genetic markers unavailable on this platform were imputed. Association analysis for each marker was completed using logistic regression under additive effects model, with gender and age as covariates. The combined effect on ICH of genetic variants for HTN and high BMI was evaluated using a score-based approach. The score for a given individual was calculated as the beta from the regression analysis for each marker, multiplied by the number of risk alleles carried by that subject. The resulting quintile-based score and ICH case-status were the independent and dependent variables, respectively, of a logistic regression model that had gender and age as covariates. Bonferroni-corrected p-values < 0.5/12 = 0.004 were considered significant.

Results:
A total of 661 subjects were included: 392 cases (186 deep, 194 lobar, 12 multifocal) and 269 controls; mean age 73±9, males 341 (52%). Increasing burdens of risk alleles were associated with increasing risk of ICH in both lobar and deep locations (
Table
).

Conclusion:
Higher values of a genetic score of HTN and high BMI risk alleles were associated with an increased risk of ICH. This association was more pronounced for deep ICH.