bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP3: Revascularization Endpoints in SWIFT
Authors: Jahan Reza , Liebeskind David , Nogueira Raul , Saver Jeffrey ,   for SWIFT Investigators
Published: July 2021

Background and Purpose —
The acute stroke literature contains numerous definitions of the critical end point of revascularization. We sought to determine relationship of AOL, TIMI and TICI recanalization scores with clinical outomces in the SWIFT randomized controlled trial of mechanical thrombectomy in ischemic stroke.

Methods —
One hundred and thirty-three angiograms evaluated for recanalization by the SWIFT core lab were available for analysis. AOL, TIMI and TICI scores were compared with one another and with 90-day functionally independent outcome (defined as modified Rankin Score (mRS) zero to 2) and good neurological outcome (GNO) (defined as mRS zero to 2 or equal to baseline mRS if baseline mRS greater than 2, or improvement of at least 10 points in NIHSS score).

Results —
Measured after use of randomized device but prior to any rescue therapy, AOL and TIMI scores showed moderate agreement (Spearman nonparametric correlation r=0.68 [confidence interval 0.59, 0.78]), while AOL and TICI were strongly correlated (r=0.76 [0.67, 0.84]) and TIMI and TICI even more so (r=0.88 [0.81, 0.94]). Using measurements after the end of the procedure, including any rescue therapy, functionally independent outcome was seen in 42.1% (45/107) of patients with AOL II/III scores (p<0.001), 50.0% (35/70) with TIMI 2/3 scores (p<0.001) and 44.9% (40/89) with TICI 2b/3 scores (p<0.001). GNO was seen in 57.0% (61/107) of patients with AOL II/III scores (p=0.003), 62.9% (44/70) with TIMI 2/3 scores (p=0.004) and 61.8% (55/89) with TICI 2b/3 scores (p<0.001). Based on receiver operating characteristic analysis, the three methods did not significantly differ from one another in predicting functionally independent outcome (AOL-TIMI p=0.11, TICI-TIMI p=0.28, AOL-TICI p=0.40) or GNO (AOL-TIMI p=0.31, TICI-TIMI p=0.76, AOL-TICI p=0.095).

Conclusions —
Measures of arterial patency (AOL) and reperfusion (TICI and TIMI) scores are moderately to strongly correlated and comparably predict neurologic outcome post embolectomy procedure for acute ischemic stroke.
Abstract TMP40: Revascularization in Patients with Moyamoya Decreases Abnormally High Posterior Circulation Arterial Flows Measured by Quantitative Magnetic Resonance Angiography
Authors: Navarro Ramon , Lober Robert , Feroze Abdullah , Khan Nadia , Steinberg Gary K
Published: July 2021

Introduction:
Moyamoya disease and syndrome are well known to affect the anterior cerebral circulation by progressive steno-occlusive disease of the supraclinoid internal carotid arteries. Less attention has been paid to changes in posterior arterial circulation hemodynamics in this condition. We sought to better understand the latter by using a relatively novel non-invasive imaging technique: quantitative magnetic resonance angiography (qMRA).

Hypothesis:
We assessed the utility of qMRA to detect changes in arterial posterior arterial circulation flows before and after surgical revascularization.

Methods:
Retrospective review of patients who met the following inclusion criteria: (1) diagnosis of moyamoya disease or syndrome with revascularization surgery at the Stanford University between September 2008 and March 2012; (2) preoperative and postoperative qMRA scans on record within a two-year time frame; and (3) high-quality qMRA images without motion artifact. Cerebral blood-vessel flow was quantified after non-contrast magnetic resonance imaging through the use of a commercially available software tool: non-invasive optimal vessel analysis (NOVA, VasSol, Chicago, USA).

Results:
A total of 191 patients underwent 281 surgeries in this period of time. Of these, a cohort of 64 patients (78% female, mean age 38.5 years, 55% unilateral disease) had preoperative and postoperative qMRA studies. Preoperative arterial flows in the posterior circulation were markedly elevated compared to normative data. These flows significantly decreased after revascularization (94% direct STA-MCA bypass): right posterior cerebral artery 145 ml/min pre-surgery, 123 ml/min post-surgery, p=0.005; basilar artery 264 ml/min pre-surgery, 222ml/min post-surgery, p=0.0038.

Conclusion:
Quantitative MRA shows that posterior circulation arterial flows are markedly increased in patients with moyamoya. After revascularization, there is an overall decrease in these flows that is significant in the basilar artery and right posterior cerebral artery. Further use of qMRA might be warranted to better understand moyamoya hemodynamics before and after surgery.
Abstract TMP50: A Polymorphism in
HDAC9
was Associated with Large Vessel Stroke in the Vienna and German Stroke Studies
Authors: Luke May M , Tong Carmen H , Catanese Joseph J , Devlin James J , Mannhalter Christine , Berger Klaus
Published: July 2021

Introduction
The International Stroke Genetics Consortium (ISGC) and the Wellcome Trust Case Control Consortium 2 (WTCCC2) performed a large genome wide association study of ischemic stroke and its subtypes (large vessel stroke (LVD), small vessel stroke (SVD), cardioembolic stroke (CE)), and identified a polymorphism in HDAC9 (rs11984041) associated with the LVD subtype of ischemic stroke.

Hypothesis
We assessed the hypothesis that rs11984041 is associated with LVD in two additional studies.

Methods
The genotype of rs11984041 was determined for participants of the Vienna Study (815 controls, 122 LVD, 165 SVD, 202 CE) and of the German Study (1040 controls, 495 LVD, 230 SVD, 462 CE). The association of rs11984041 with LVD was assessed by logistic regression. Heterogeneity of the effect of rs11984041 on LVD, CE or SVD was assessed by testing the equality of the corresponding regression coefficients from a multinomial logistic regression model.

Results
Carriers of the minor (T) allele of rs11984041 (23.3% of LVD cases and 17.4% of controls), compared with noncarriers, had increased risk for LVD: the odds ratios (OR) were 1.92 (95%CI 1.25-2.96) for the Vienna Study and 1.33 (95%CI 1.02-1.74) for the German Study. Adjusting for covariates including sex, age, diabetes, and hypertension did not materially change the ORs. Heterogeneity of the effects of rs11984041 on LVD vs CE was significant in the Vienna Study (p = 0.009) and in the German Study (p = 0.005). Heterogeneity of the effects of rs11984041 on LVD vs SVD trended toward significance in the Vienna Study (p = 0.088) and was significant in the German Study (p = 0.047). Adjusting for covariates did not materially change the heterogeneity test p values.

Conclusions
The HDAC9 polymorphism rs11984041 was associated with the LVD stroke subtype in the Vienna Study and the German Study. These results replicated the ISGC/WTCCC2 findings.
Abstract TMP66: Intravenous Thrombolysis is Associated with Lower Risk of Severe Disability and Death among SPAN-100 Positive Acute Ischemic Stroke Patients
Authors: Ovbiagele Bruce , Reeves Mat , Johnston S. C , Bath Philip , Saposnik Gustavo ,   on behalf of the VISTA Collaboration
Published: July 2021

BACKGROUND:
Clinicians are cautious about administering intravenous thrombolysis (tPA) to acute ischemic stroke (AIS) patients who are very elderly and/or have severe neurological deficits. The Stroke Prognostication using Age and NIHSS (SPAN) index combines age plus stroke severity (NIHSS) to create a binary measure (≥ 100 vs. < 100) to predict clinical outcome. We evaluated the effectiveness of tPA by SPAN-100 index status among a large sample of AIS patients.

METHODS:
Data on 7140 AIS participants in the Virtual International Stroke Trials Archive (VISTA) collaboration. Outcome measures included severe disability or death at 3 months (defined as modified Rankin Scale {mRS} 4-6) and death alone. Effect of tPA on outcomes was assessed using multivariable logistic regression adjusting for SPAN-100 status.

RESULTS:
Among all patients, 743 (10.5%) were SPAN-100 positive (≥ 100), and 2731 (38.2%) received tPA treatment. Of those treated with tPA, SPAN-100 positive patients were more likely to experience severe disability or death (73.2% vs. 36.3%; p<0.0001) or death alone (33.6% vs. 11.4%; p<0.0001) than SPAN-100 negative patients. However, among SPAN-100 positive patients, tPA was associated with a significantly lower risk of severe disability and death, and tPA had a significantly greater treatment effect among SPAN-100 positive vs. SPAN-100 negative patients (Table). Logistic regression analyses showed significant interactions between SPAN-100 status and tPA (mRS of 4-6 <0.001; death 0.029) confirming that tPA had a greater treatment effect among SPAN-100 positive vs. SPAN-100 negative patients, even after adjustment for age and NIHSS.

CONCLUSIONS:
Despite the low probability of a favorable outcome, tPA reduces the risk of severe disability and death among SPAN-100 positive AIS patients. SPAN-100 index can be readily used in emergency care settings to identify high risk AIS patients who may be less prone to catastrophic outcomes after tPA treatment.
Abstract TMP74: Stroke And Pulmonary Embolism, Clinical Features, Risk Factors And Outcome
Authors: pongmoragot jitphapa , Rabinstein Alejandro , Nilanont Yongchai , Selchen Daniel , Swartz Rick , Zhou Limei , saposnik gustavo ,   UTSP program
Published: July 2021

Introduction:
Pulmonary embolism (PE) is an uncommon medical complication after stroke. Predisposing factors include deep vein thrombosis (DVT) in patients with hemiplegia or an underlying hypercoagulable state. However, little information is known regarding PE in stroke patients.

Objective:
We evaluated clinical characteristics, predisposing factors, and outcomes in stroke patients who developed PE.

Methods:
We included patients with an acute ischemic stroke (AIS) admitted to the participating institutions in the Registry of the Canadian Stroke Network between 2003 to 2008. Pulmonary embolism was diagnosed by nuclear imaging within 30 days of the stroke case index. Demographic data and clinical variables were collected. Logistic regression and survival analyses were completed to determine the association of risk factors with the outcomes of interest.

Outcome Measures:
primary outcome was death or disability at discharge defined as the modified Rankin scale >3. Secondary outcomes include admission to the Intensive Care Unit, disposition, and length of hospital stay, death at 3 months and at 1 year.

Results:
Among 11,287 patients with AIS, PE was found in 89 (0.78%) of patients. The development of PE was associated with higher risk of death in 30 days (25.8%vs 13.6%;p <0.001) and 1 year, (47.2% vs 24.6%;p <0.001). Disability was also more common in stroke patients with PE (85.4% vs 63.6% without PE; p <0.001). Mean length of stay was longer in stroke patients with PE (36 vs 16 days; p<0.001). Past medical history of cancer or deep vein thrombosis, history of cardiac arrest or deep vein thrombosis during admission were associated with PE. After adjustment, PE was associated with lower survival at 30 days (p value = 0.0012) and 1 year (p value < 0.0001) (Figures 1 & 2 represent survival function).

Conclusions:
In this large study, PE occurs in approximately 1% of AIS patients. PE was associated with higher disability, longer length of stay and lower short and long-term survival.
Abstract TP120: Plasma D-dimer Level and Cerebral Infarction Volume in Patients With Nonvalvular Atrial Fibrillation
Authors: Matsumoto Mari , Sakaguchi Manabu , Okazaki Shuhei , Furukado Shigetaka , Tagaya Masafumi , Etani Hideki , Shimazu Takeshi , Yoshimine Toshiki , Mochizuki Hideki , Kitagawa Kazuo
Published: July 2021

Introduction and Hypothesis:
The purpose of this study was to investigate the association between plasma D-dimer level at admission and infarct size in non-valvular atrial fibrillation (NVAF) patients.

Methods:
We identified 124 patients with consecutive ischemic stroke and NVAF who were admitted within 48 hours of symptom onset. We measured infarction volume from CT taken after 3±1 days from the onset. Relationships were analysed between infarction volume, risk factors, preadmission medications and admission conditions. We also assessed the functional outcome by tertile of D-dimer level (≦ 0.83, 0.83-2.16, ≧ 2.16 μg/mL) in patients with preadmission modified Rankin Scale (mRS) score of 0-1.

Results:
Infarction volume significantly correlated with D-dimer level (r=0.309, p < 0.001) (Figure 1), systolic blood pressure (r=0.201, p=0.026), diastolic blood pressure (r=0.283, p=0.002), National Institutes of Health Stroke Scale (NIHSS) score on admission (r=0.546, p < 0.001) and mRS score at discharge (r=0.557, p<0.001). Multivariate regression analyses showed that the D-dimer level was significantly associated with infarction volume (p=0.043) after adjustment with known risk factors. In patients with a preadmission mRS score of 0-1 patients (n=108), D-dimer level was significantly associated with NIHSS score at admission (r=0.318, p<0.001) and mRS score at discharge (r=0.310, p=0.001).Significant difference existed among tertiles (p = 0.003)(Figure 2).

Conclusions:
Plasma D-dimer level on admission is significantly related to infarction volume and functional outcome, following cardioembolic stroke in NVAF patients.
Abstract TP123: Open-label Phase I Clinical Study to Assess the Safety and Efficacy of Cilostazol in Patients Undergoing Carotid Artery Angioplasty and Stent Placement
Authors: Hassan Ameer E , Zacharatos Haralabos , Grigoryan Mikayel , Chaudhry Saqib A , Tekle Wondwossen G , Khan Amir , Siddiq Farhan , Rodriguez Gustavo J , Tummala Ramachandra , Taylor Robert A , Jagadeesan Bharathi , Suri M Fareed K , Qureshi Adnan I
Published: July 2021

Background:
One month dual antiplatelet therapy, with Aspirin and Clopidogrel, following intra- and/or extra-cranial stent placement is the standard of care to prevent in- stent thrombosis. Cilostazol, a novel antiplatelet drug, with vasodilatory effects and smooth muscle cell proliferation inhibition, has recently been demonstrated to be safe and efficacious in secondary stroke prevention and has a safety profile comparable to both Aspirin and Clopidogrel.

Objective:
To evaluate the safety and clinical efficacy of Cilostazol and Aspirin therapy following internal carotid angioplasty and stent placement prior to and one month post-procedure.

Methods:
We conducted a Phase I open label, non-randomized single center prospective study. All patients received Aspirin (325 mg/day) and Cilostazol (200 mg/day) for at least 3 days before internal carotid stenting. The two anti-platelet agents were continued for one month after the procedure and then patients were continued on aspirin daily. The primary efficacy end point was the 30-day composite occurrence of death, stroke, TIA, and unplanned endovascular revascularization. The primary safety end point was bleeding. Bleeding complications were classified as major (hemoglobin decrease >5 g/dl), minor (hemoglobin decrease 3-5 g/dl), or insignificant.

Results:
Twelve patients (mean age 66±12 years; 10 men) were enrolled and underwent internal carotid angioplasty and stent placement. One patient discontinued Cilostazol after the first dose, prior to stent placement, secondary to non-specific dizziness. Another patient did not follow study protocol and continued anticoagulation dose enoxoparin with Aspirin and Cilostazol resulting in symptomatic intracerebral hemorrhage 15 hours following successful stent placement; ultimately leading to withdrawal of care. None of the patients that successfully completed the study, and followed protocol, experienced any complications at 1-month and 3-month follow up.

Conclusion:
The use of Cilostazol and Aspirin for carotid angioplasty and stent placement appears to be safe but protocol compliance needs to be emphasized. Further studies are required to analyze the effectiveness and role of Cilostazol in neurointerventional procedures.
Abstract TP13: CT Perfusion-Guided Patient Selection for Acute Stroke Intervention Reduces In-Hospital Mortality
Authors: Chalouhi Nohra , Ghobrial George , Tjoumakaris Stavropoula , Dumont Aaron S , Gonzalez L Fernando , Witte Samantha , Davanzo Justin , Starke Robert M , Randazzo Ciro , Flanders Adam E , Hasan David , Chitale Rohan , Rosenwasser Robert , D’Ambrosio Robin , Muller Kathleen , Jabbour Pascal
Published: July 2021

Background and Purpose:
Perfusion studies are increasingly used to triage acute stroke patients for endovascular recanalization therapies. However, the potential benefit of such an approach remains unproven. We compared the safety and efficacy of computed-tomography-perfusion-(CTP)-guided to time-guided mechanical recanalization in acute ischemic stroke (AIS) patients.

Methods:
A comparative analysis was conducted on 132 patients, 94 undergoing CTP-guided and 38 undergoing time-guided (maximum 8 hours from symptom onset) mechanical recanalization at our institution. The rates of recanalization, intracranial hemorrhage (ICH), in-hospital mortality, and overall clinical outcomes were compared. A multivariable logistic regression analysis was carried out to determine predictors of in-hospital mortality.

Results:
The two groups were comparable with respect to baseline characteristics with the exception of longer mean time interval from stroke onset to endovascular intervention in the CTP group (7.2 vs. 4.3 hours, p=0.006). The rate of partial-to-complete recanalization did not differ between the CTP and the non-CTP group (78.7% vs. 81.6%, respectively, p=0.71). Symptomatic and overall ICH occurred respectively in 8.5% and 18.1% in the CTP group versus 15.8% and 31.6% in the non-CTP group (p=0.06). The overall in-hospital mortality rate was significantly lower in the CTP group (15.9% vs. 36.8%, p=0.040). Likewise, mean modified Rankin Scale at discharge was 3.8 in the CTP group versus 4.4 in the non-CTP group (p=0.042). In multivariable analysis, CTP-based patient selection was an independent negative predictor of in-hospital mortality (OR= 3.2; 95% CI, 1.2-8.2; p=0.01).

Conclusions:
CTP-based patient selection was associated with lower ICH and mortality rates, with better overall patient outcomes. Our results suggest a significant benefit with CTP-guided patient selection and support the implementation of CTP-based protocols for triage of AIS patients for recanalization therapies.
Abstract TP140: Impact of Pre-procedural Antiplatelet Therapy on Vascular Events After Carotid Artery Stenting: Investigation on Devices and Anti-platelet Therapy for Carotid Artery Stenting (IDEALCAST)
Authors: Yamagami Hiroshi , Sakai Nobuyuki , Matsubara Yoshihiro , Okada Yasushi , Yokoi Hiroyoshi , Ezura Masayuki , Matsumaru Yuji , Miyachi Shigeru , Terada Tomoaki , Hyodo Akio ,   IDEALCAST Investigators
Published: July 2021

Background and Purpose:
Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is recommended for a standard pre-procedural management for carotid artery stenting (CAS). However, impact of other pre-procedural antiplatelet drug on vascular events after CAS is still unknown.

Methods:
In a prospective, multicenter, observational study, we analyzed data from 934 patients underwent elective CAS for > 50 % stenosis in symptomatic or > 80% stenosis in asymptomatic carotid arteries. Data on pre-procedural antiplatelet drugs was obtained at patients’ enrollment, and all patients were followed for 1 year after the stenting. The primary endpoint was the composite of death, any stroke, transient ischemic attack, myocardial infarction, and serious systemic bleeding.

Results:
Of the 934 patients (818 men, 72 ± 7 years old), 476 patients were treated with aspirin and clopidogrel (51.0%, A+CLP group), 162 with aspirin and cilostazol (17.3%, A+CSZ group), 62 with clopidogrel and cilostazol (6.6%, CLP+CSZ group), 118 with asprin, clopidogrel and cilostazol (12.6%, TAPT group), and 116 with other combinations (12.4%, Other group). As patients background, a history of ischemic stroke was more frequent in A+CSZ and CLP+CSZ groups, and a history of ischemic heart disease or revascularization was more frequent in A+CLP and TAPT groups than in other groups. There was no significant difference in other factors. Incidences of primary endpoint were as follows: 12.6% in A+CLP, 5.6% in A+CSZ, 8.1% in CLP+CSZ, 14.4% in TAPT, and 15.5% in Other group. In multivariate analysis, combination of aspirin and cilostazol was associated with lower risk for primary endpoint compared with aspirin and clopidogrel (hazard ratio, 0.39; 95% confidence interval, 0.18 to 0.75, P=0.004).

Conclusions:
Combination of aspirin and cilostazol can decrease the risk of vascular events or death after CAS. A prospective randomized controlled trial is necessary to clarify the effect of pre-procedural antiplatelet therapy on vascular events after CAS.
Abstract TP148: The Hydration Influence on the Risk of Ischemic Stroke Outcomes (THIRST-EXPANSION STUDY)
Authors: Moussavi Mohammad , Rodriguez Gustavo , Alario Joseph , Sodhi Ravjot , Nizam Aaron , Dababneh Haitham , Panezai Spozhmy , Kirmani Jawad F
Published: July 2021

Introduction:
Extensive studies have not been done in patients presenting with ischemic stroke regarding hydration status. It is unclear whether all of the elements of hydration status affect disability on discharge. Our past study suggests that high serum osmolality has a negative impact on ischemic stroke severity. This continuation of our prior study aims to test the effect of all laboratory elements of dehydration on severity and outcome of ischemic stroke patients.

Methods:
We conducted a retrospective analysis of ischemic stroke patients admitted between 2004 and 2009 at a community teaching hospital. Serum BUN/Creatinine and serum osmolality (sOsm) was calculated at initial presentation. sOSm, BUN/Cr, hematocrit and bicarbonate levels were analyzed for association with NIHSS and mRS. Patients were divided into two groups by sOsm as follows: (1) sOsm < 295, (2) sOsm ≥ 295; and two groups by BUN/Cr as follows: (3) BUN/Cr < 20, (4) BUN/Cr ≥ 20. Discharge mRS score was compared between (1) and (2); and (3) and (4) to determine the effect of sOsm and BUN/Cr on stroke outcomes. All data was analyzed using SPSS software version 20.

Results:
Of 1350 patients, 543 (mean age = 72.5 +/-14.2, 56% female) were included. There was a significant difference between the mean admission NIHSS in (1) 8.57, n = 222 and (2) 7.09, n = 319, p < .05 and between (3) 8.90, n = 219 and (4) 6.87, n = 322, p < .05. There was a significant difference in the mean mRS score between (1) 2.92, n = 222 and (2) 2.54, n = 317, p < .05, and (3) 2.92, n = 218 and (4) 2.56, n = 321, p < .05. The same results were found when comparing discharge sOsm values to predict patient outcome. Discharge sOsm correlated with mRS (r = .147, p < .05). Initial BUN/Cr correlated with NIHSS (r = .128, p < .05) and mRS (r = .107, p < .05) and final BUN/Cr with mRS (r = .161, p < .001). Bicarbonate levels at admission correlated with NIHSS at admission (r = -0.134), p < 0.05. Hematocrit levels at discharge correlated with mRS (r= -0.183), p <0.001.

Conclusion:
Our study suggests that patients with BUN/Cr and sOsm above normal levels at admission and dishcarge have worse outcome at discharge. We also found a correlation between other laboratory variables of dehydration status, namely hematocrit levels and outcome. A future prospective randomized study is warranted.
Abstract TP154: Device Malfunction Related Adverse Events in Patients Undergoing Carotid Angioplasty and Stent Placement: An analysis of the FDA Manufacturer and User Facility Device Experience Database
Authors: Kainth Hunar S , Kainth Daraspreet S , Gilani Waqas I , Gilani Sarwat I , Adil Malik M , Qureshi Adnan
Published: July 2021

Background:
Carotid angioplasty and stenting (CAS) has emerged as a less invasive treatment alternative to carotid endarterectomy and the frequency of CAS is increasing. A large scale analysis of the device malfunction related adverse events associated with carotid stenting has not previously been undertaken.

Methods:
Adverse events reported to the United States FDA Manufacturer and User Facility Device Experience were analyzed. This data includes voluntary reporting of adverse events related to medical device use. We analyzed the characteristics of device related adverse events which included hypotension, bradycardia, hyperperfusion syndrome, transient ischemic attack (TIA), stroke, carotid artery spasm, myocardial infarction, cardiac arrest, and vessel dissection from 2010 to 2012 in the United States.

Results:
From 2010 to 2012, there were a total of 1211 adverse events reported to the FDA related to CAS. The most common adverse event was stroke, which represented 39.3% of the clinical adverse events. Adverse device deployment was most commonly affected by intraprocedural malfunction of the stent, which occurred in 22.0% of reported events, followed by incomplete coverage by the stent requiring a second stent, 15.5% of events. In addition, vessel tortuosity, 11.0% of events, and vessel calcification, 4.5%, played a role in adversely affecting stent deployment. The stents most commonly involved in intraprocedural malfunction were the Carotid Wall Monorail stent and the Acculink carotid stent, which represented 29.5% and 30.8% of the failures respectively. The clinical events associated with device malfunction were stroke (n=464), TIA (n=186), carotid artery spasm (n=30), and carotid dissection (n=8).

Conclusions:
This is the first large scale study to report on the device malfunction related adverse events associated with carotid stent placement. The most common device complication relates to intraprocedural malfunction of the stent, which represents 22% of reported failures.
Abstract TP168: Angiography-Like Grading of Carotid Artery Stenosis with B-Flow Ultrasound: 3D-Ultrasound Supported Comparison with Computer Tomography Angiography Results in a High Accuracy
Authors: Macharzina Roland , Böhme Tanja , Fan Nian , Beschorner Ulrich , Vach Werner , Weber Johannes , Neumann Franz-Josef , Zeller Thomas
Published: July 2021

Background:
Evaluation of various imaging modalities for grading internal carotid artery (ICA) stenosis can be performed by comparison of minimal lumen diameters (MLD) as well as percent ICA-stenosis calculated with a healthy distal reference segment (NASCET method). The two dimensional B-Flow (BF) ultrasound (US) imaging method displays stenoses in a similar fashion as reference methods like multi-slice CT-angiography (MS CTA) and in part like catheter angiography.

Aim:
to evaluate the accuracy of BF-US carotid stenosis grading at NASCET locations adjusted with 3D-color-Doppler ultrasound by comparison with MSCTA.

Methods:
Patients were screened by doppler US velocity criteria after informed consent. 3D-US was made for distance taking and search for anatomical markers. CTA were compared with BF-US in 91 ICA stenoses of 69 patients at identical projections of longitudinal sections. 58 low to high grade ICA stenoses were imaged by selective angiography and compared with CTA. Diameters of stenosed ICA were rendered coaxial on CTA. Angiography was made with AXIOM (Siemens, Germany), MSCTA with SOMATOM (Siemens, Germany); Ultrasound Logic 9 with 8 Mhz linear scanner for BF-US and a 10 Mhz 3D-US probe, GE, USA. All readings were by two independent observers for each technique. Quantitative angiography was done with MEDIS software (Netherlands), Bland-Altman analysis and statistics with SPSS (USA). Identical planes were finally confirmed by overlay technique of BF with 3D-US and CTA in addtition to the use of anatomical markers.

Results:
Degree of stenosis was slightly understimated by CTA compared with angiography with mean differences (±SD) of -0.4% (±6.1%) for longitudinal sections. In this cohort, discrimination of binary 50% NASCET stenosis with BF-US had a 90% sensitivity, 94% specifity and an accuracy of 91%; discrimination of binary 70% NASCET stenosis with BF-US had a sensitivity of 88%, specifity of 93% and an accuracy of 92%.

Conclusion:
diagnostic performance of CTA proved to be excellent compared with angiography and 3D-US adjusted BF-US measurements were highly accurate, when using corresponding projections. BF-US may be a valuable additional tool for screening and confirmation of CAS for therapeutic stratification.
Abstract TP175: Impact of Living Alone on Stroke Outcomes: Results from the Registry of the Canadian Stroke Network
Authors: Reeves Mathew J , Fang Jiming , Prager Marla , Kapral Moira
Published: July 2021

Background:
Social isolation is a risk factor for poor health outcomes and living alone is a commonly used proxy measure for social isolation. We examined the relationships between living alone and stroke outcomes in patients enrolled in the Registry of the Canadian Stroke Network.

Methods:
Between 2003-2008, 24526 patients with ischemic stroke, hemorrhagic stroke, or TIA were admitted to 11 Ontario registry hospitals. Patients not living at home (n= 7364), repeat stroke admissions (n=1246) or with missing data (n= 1946) were excluded. Outcomes included onset to arrival time ≤2.5 hrs, discharge to home, mortality (in-hospital, 30-day, 1-year, 3-year), and readmission (1-year). The independent effects of living alone on outcomes were determined using multivariable logistic regression.

Results:
Overall, 22.5% (n= 3146/13970) of patients were living alone at home prior to admission. Compared to patients living at home with others, patients living alone were significantly more likely to be ≥80 years of age (41.6% vs. 28.8%), female (62.7% vs. 41.4%), white (58.9% vs. 53.7%), widowed (53.5% vs. 11.5%), or single (21.7% vs. 3.7%), and significantly less likely to have diabetes (21.8% vs. 24.8%) or dyslipidemia (32.2% vs. 37.3%). The prevalence of severe stroke was similar (12.4% vs. 14.9%). Patients living alone were less likely to arrive ≤2.5 hrs after onset (32.9% vs. 42.7%) or be discharged to home (61.1% vs. 68.2%), however, differences in mortality or readmission rates were minimal (Table). Adjustment for confounding variables did not appreciably change these results.

Conclusions:
Patients living alone had delayed hospital arrival and were less likely to return home, but were not at increased risk of death or readmission. Further research is needed to understand the inter-relationships between living alone, social isolation, and poor stroke outcomes, especially given the increasing prevalence of living alone in developed countries.
Abstract TP181: Serum Eiocosapentaenoic Acids Is Protective Against White Matter Lesions
Authors: Takano Daiki , Yamazaki Takashi , Maeda Tetsuya , Satoh Yuichi , Ikeda Yasuko , Nakase Taizen , Nagata Ken
Published: July 2021

[Introduction]
White matter hyperintensities (WMH) are considered manifestation of arteriosclerotic small vessel disease and WMH burden increases risk of ischemic stroke and cognitive decline. There are only a few evidences concerning the relationship between polyunsaturated fatty acids (PUFA) and WMH. The present study was designed to elucidate the association between WMH and PUFA profile including eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and arachidonic acid (AA) in patients with Alzheimer’s disease (AD).

[Methods]
The present study was based on 119 patients who were diagnosed as having a probable AD according to the NINCDS-ADRDA criteria. Their mean age was 78.3 years old. All subjects underwent neuropsychological evaluation including mini mental state exam (MMSE) and 1.5-Tesla MRI. Fasting blood samples were also collected for the PUFA measurements. We measured the ratio of serum EPA, DHA and AA concentration to the total PUFA concentration. The WMH were evaluated on T2-weight images and classified into periventricular hyperintensity (PVH) and deep white matter hyperintensity (DWMH). The severity of WMH was graded 5 categories. We investigated the relationship between WMH and PUFA profiles.

[Results]
The EPA ratio correlated negatively with both PVH (rs=-0.2036, p=0.0264) and DWMH grade (rs=-0.3155, p=0.0005). It remained still significant after adjustment for age, sex, statins use, antithrombotics use, mean blood pressure and presence of hypertension (standardized partial regression coefficient(β)=-0.2516, p=0.0122 for PVH, β=-0.3598, p=0.0001 for DWMH). Neither DHA nor AA ratio correlated with DWMH or PVH grade. The EPA ratio but not DHA or AA ratio correlated positively with total MMSE score (rs=0.2310, p=0.0115).

[Conclusions]
Our data revealed that the serum EPA was protective against WMH as well as cognitive decline in AD patients. Pathophysiology underlying WMH is complex and the possible mechanisms involved in the pathogenesis of WMH encompass incomplete brain ischemia, increased permeability of blood-brain barrier, and inflammation responses. The relationship between serum EPA and WMH can be partly explained by those anti-ischemic and anti-arteriosclerotic effects of EPA.
Abstract TP221: Using Berlin Questionnaire and Epworth Sleepiness Scale to Identify Stroke Patients at Risk for the Sleep Apnea Syndrome
Authors: Camilo Millene , Eckeli Alan , Sander Heidi , Fernandes Regina , Leite Joao , Pontes-Neto Octavio
Published: July 2021

Background:
Sleep-disordered breathing (SDB) is frequent in the acute phase of stroke. Obstructive sleep apnea (OSA) has been found in 62% of stroke patients. The impact of OSA is significant after ischemic stroke, including early neurological deterioration, poor functional outcome and increased long-term mortality. However, performing polysomnography (PSG) for all patients with acute stroke for diagnose OSA is still impracticable. Therefore clinical tools to select patients at higher risk for OSA would be essential. The aim of this study was to determine the validity of the Berlin Questionnaire (BQ) and the Epworth Sleepiness Scale (ESS) to identify stroke patients in whom the PSG would be indicated.

Methods:
Subjects with ischemic stroke were stratified into high and low risk groups for SDB using a BQ. The ESS ≥ 10 was used to define excessive daytime sleepiness. The BQ and ESS were administered to the relatives of stroke patients at hospital admission. All patients were submitted to a full overnight PSG at the first night after symptoms onset. OSA severity was measured by the apnea-hypopnea index (AHI).

Results:
We prospectively studied 40 ischemic stroke patients. The mean age was 62 ± 12.1 years and the obstructive sleep apnea (AHI ≥ 15) was present in 67.5%. On stratifying risk of OSA in these patients based on the QB, 77.5% belonged to the high-risk and 50% to the ESS ≥ 10. The sensitivity of QB was 85%, the specificity 35%, the positive predictive value 74% and the negative predictive value 55%. For ESS was respectively 63%, 85%, 89% and 52%. The diagnostic value of the BQ and ESS in combination to predict OSA had a sensitivity of 58%, a specificity of 89%, a positive predictive value of 95% and a negative predictive value of 38%.

Conclusions:
The QB even applied to the bed-partners of stroke patients is a useful screening tool for OSA.
Abstract TP222: Cortical Differences in Patients With Stroke and Depressive Symptoms
Authors: Lima Fabricio O , Yoshida Hélio M , Silva Elvis L , Campos Brunno M , Avelar Wagner M , Fernandes Paula T , Li Li M
Published: July 2021

Background and Purpose:
The association of post-stroke depression and lesion location is still controversial. In the present study, we sought to investigate the association between depressive symptoms (DS) during the chronic phase of stroke and cortical differences detected by voxel-based morphometry analysis (VBM).

Methods:
Patients with stroke admitted to a single academic medical center were followed prospectively. Only those with first, unilateral, anterior circulation ischemic stroke were selected. DS were assessed by the Beck Depression Inventory (BDI) and categorized in two levels (< 10 = absent/minimal and ≥ 10 = present). MRI (3T Philips Achieva, Best-Netherlands) was performed in the same day of the assessment. T1 images (TE=3.20 ms, TR= 7000 ms, FOV 240 x 240 x 180 mm) with 1mm3 isotropic voxel size were used for the VBM. Modulated, normalized, smoothed gray matter (GM) with affine transformation plus non-linear warping was used. Data were processed and analyzed using the VBM8 toolbox for SPM8 software (UCL, London-UK). Voxel-wise GM differences between patients with absent/minimal symptoms were compared to patients with symptoms. The independent samples t-test was used. An uncorrected two-sided p-value < 0.001 was considered as statistically significant.

Results:
Forty-nine patients, 60±14 years (47% with left sided stroke) were analyzed. The median time from stroke onset to evaluation was 180 days (IQR 117-410). Seventeen patients were categorized as absent/minimal DS and 32 as present. Patients with DS showed a reduction of GM predominantly in the right precuneus (T=4.7). Other areas included the left cerebellar tonsil (T=3.95), right supplementary motor area (T=3.6) and left precuneus (T=3.5) - figure.

Conclusion:
Patients in the chronic phase of ischemic stroke presenting with DS showed an association mainly with right sided cortical volumetric reduction, including the precuneus and supplementary motor area.

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Abstract TP223: Role of Plasma Biomarkers in Diagnosis of Ischemic Stroke Subtypes
Authors: Lorenzano Svetlana , Rost Natalia S , Arai Ken , Thankachan Tijy , Green Rebecca E , Dipietro Allison J , Som Angel T , Pham Loc-Duyen D , Harris Gordon J , Blumberg Jeffrey B , Feske Steven K , Lo Eng H , Furie Karen L
Published: July 2021

Objectives:
Identifying underlying stroke etiology plays critical role in acute management and secondary prevention strategies. Despite advanced diagnostics, up to 35% of ischemic strokes (IS) remain undetermined. We sought to evaluate the association between IS subtypes and plasma levels of biomarkers as representative of distinct etiologies underlying stroke subtypes.

Methods:
We prospectively measured plasma high sensitivity-C reactive protein (hs-CRP), matrix metalloproteinase (MMP)-2 and MMP-9, F2-isoprostane (F2-isoP), Oxygen Radical Absorbance Capacity assay (ORAC), homocysteine and urinary 8-hydroxydeoxyguanosine (8OHdG), in patients presenting within 9 hours from acute ischemic stroke (AIS) onset. Stroke subtype was assigned by a stroke neurologist according to the Causative Classification of Stroke System (CCSS) criteria.

Results:
There were 489 AIS subjects enrolled in this study [mean (SD) age 70.1 (15.1) y; 43.4% female; median (IQR) NIHSS 6 (3-13); 40.7% received IV tPA]. Among these AIS, 51% were of cardioembolic (CE), 17% of atherothrombotic, 7% of lacunar, 5% of other, and 20% of undetermined subtype. Patients with CE stroke were older and more likely to be female, non-smokers, have atrial fibrillation and congestive heart failure, but not carotid stenosis (all p<0.05). CE stroke subtype was also associated with greater stroke severity, and baseline levels of MMP-2 (p= 0.001) and ORAC (p= 0.008), as compared to other CCSS subtypes. In multivariate logistic regression analysis including all univariate predictors with p<0.05 as well as treatment with IV t-PA, baseline MMP-2 (OR 2.8, 95% CI 1.3-5.8; p= 0.006) and ORAC (OR 2.6, 95% CI 1.3-5.1; p= 0.007) was independently associated with CE stroke subtype. Conversely, the “other” stroke subtype was associated with lower levels of MMP-2 (OR 0.1, 95% CI 0.02-0.3; p= 0.001), and homocysteine levels were independently correlated with undetermined subtype (OR 2.2, 95% CI 1.2-4.1; p= 0.008).

Conclusions:
In AIS patients, hyperacute plasma biomarkers are associated with specific stroke subtypes, reflective of the underlying pathophysiology. If validated in future studies, plasma biomarkers may play valuable role in early diagnosis and guide management of specific AIS subtypes.
Abstract TP229: Measurement of Multiple Blood Markers to Predict Long- term Outcome in Ischemic Stroke
Authors: Oh Seung-Hun , An Se-A , Lee Han-Bin , Kim Jinkwon , Kim Ok-Joon
Published: July 2021

Background and Purpose:
There is no single blood marker for prediction of prognosis in ischemic stroke. We investigated whether multiple blood markers enhance the predictability of long-term outcome following ischemic stroke.

Methods:
Blood concentrations of neuronal markers (NSE, VSNL-1, H-FABP, and Ngb), astroglial markers (S100B and GFAP), inflammatory markers (IL-6, TNF-α, WBC count, and CRP), blood-brain barrier marker (MMP-9), and haemostatic markers (D-dimer and PAI-1) were compared with favorable and poor outcome groups regard to 3 month clinical outcome. Multivariate logistic regression analysis, area under receiver operator characteristic (AUROC) curve, and net reclassification improvement (RNI) index were performed to examine whether adding blood markers to baseline clinical model (age, sex, initial NIHSS score, and atrial fibrillation) improves discrimination for poor and good outcome.

Results:
In multivariate analysis, plasma IL-6 (OR, 1.013, per 10 pg/ml, 95% CI, 1.04 - 1.23, P = 0.003) was independently associated with poor outcome 3 months after onset, and hFABP (OR, 1.05, per 1 ng/ml, 95% CI, 1.00 - 1.09, P = 0.048), WBC (OR, 1.22, per 103/uL, 95% CI, 1.00 - 1.49, P = 0.046), and S100B (OR, 1.05, per 10 pg/ml, 95% CI, 1.01 - 1.09, P = 0.017) showed a marginal association with poor outcome. Addition of single blood marker to baseline clinical model did not improve discrimination for poor outcome from good outcome. Addition of four blood markers including IL-6, hFABP, WBC, and S100B to baseline clinical model showed improvement of discrimination for poor outcome from good outcome (AUROC: 0.95, NRI index, 0.14, p = 0.02).

Conclusions:
Combination of neuroglial and inflammatory blood markers including IL-6, hFABP, WBC count, and S100B has an additive predictive value for stroke outcome.
Abstract TP231: Clinical Characteristics of TIA with Atrial Fibrillation
Authors: Kuronuma Yuka , Uehara Toshiyuki , Kimura Kazumi , Okada Yasushi , Hasegawa Yasuhiro , Tanahashi Norio , Suzuki Akifumi , Takagi Shigeharu , Nakagawara Jyoji , Nagao Takehiko , Nagahiro Shinji , Ogasawara Kuniaki , Uchiyama Shinichiro , Matsumoto Masayasu , Iihara Koji , Minematsu Kazuo ,   The Japan TIA Rsch group 09-11
Published: July 2021

Objectives:
Patients with transient ischemic attack (TIA) are at high risk of early stroke, indicating a need for urgent diagnostic workup and treatment. Atrial fibrillation (AF) is one of important causes for TIA. The purpose of this study was to investigate characteristics of TIA patients with AF, using data of a multicenter retrospective study.

Methods:
The subjects of this study were TIA patients admitted to 13 stroke centers within 7 days after onset between 2008 and 2009. The definition of TIA used in this study was that of clinical symptoms lasting less than 24 hours, regardless of imaging findings. We compared baseline characteristics and diffusion weighted-MRI (DWI) findings between patients with AF and those without AF.

Results:
A total of 464 patients (69 ± 13 years in age, 172 women) were enrolled. We diagnosed 79 patients (17%) as having AF. TIA patients with AF were older (74 ± 9 vs. 67 ± 14 years old, P = 0.0001) and more likely to have a longer length of hospital stay (15 ± 9 vs. 14 ± 20 days, P = 0.046) than those without AF. Of 464 TIA patients, 458 patients (99%) underwent head MRI. DWI lesion was detected in 96 (21%) patients. There was no difference of DWI positivity rate between patients with or without AF (28% vs. 20%, P = 0.10). Compared to patients without AF, patients with AF were more likely to have a single lesion on DWI (86% vs. 51%, P = 0.005). DWI lesion of ≥15 mm was found more frequently in TIA patients with AF than in those without AF (45% vs. 22%, P = 0.04).

Conclusions:
This study demonstrated that TIA patients with AF were older and had a longer length of hospital stay than those without AF. In addition, characteristics of DWI findings differed between TIA patient with AF and those without AF; TIA patients with AF were more likely to have a single lesion with a size of ≥15 mm.
Abstract TP232: A Biomarker Algorithm that Represents Time from Stroke Symptom Onset
Authors: Doll Danielle N , Brooks Steven D , Rellick Stephanie L , VanGilder Reyna L , Cantor Alan , Sallam Maha , Barr Taura L
Published: July 2021

Background and Purpose:
Time of onset is critical when treating ischemic stroke (IS). The purpose of this project was to investigate the use of our 9 gene profile to develop a biomarker algorithm that represents time from stroke onset for use in the clinical setting to improve utilization of tissue plasminogen activator (tPA) and streamline appropriate secondary prevention.

Methods:
Peripheral blood samples were collected from n=34 IS patients’ ≥18 years of age within 24 hours from symptom onset and 24-48 hours later. Total RNA was extracted from whole blood in Paxgene RNA tubes, amplified, and hybridized to Illumina HumanRef-8v2 bead chips. Gene expression was compared in a univariate manner between patients at both time points using
t
-test in GeneSpring. Inflation of type one error was corrected by Bonferroni. A linear regression was used to model the change in gene expression as a linear function of time when controlling for age.

Results:
The mean age of the sample was 71.9± (14.6
sd
) years. Mean time from symptom onset to acute blood draw was 9:29± (6:2
sd
) hours (range 2:35-23:02); to follow up blood draw was 29:24± (7.1
sd
) hours (range 18:45-43:30); and time between acute and follow up blood draw was 19:55± (3.3
sd
) hours (range 13:30-27:32).
CA4
and
ARG1
expression significantly decreased >1.5 fold, and LY96 expression by >2-fold between baseline and follow up. This decrease in expression was associated with an increase from time of stroke onset and remained significant for only
LY96
expression when controlling for age.
ARG1
and
CA4
expression were significantly lower in older patients.

Conclusions:
Our profile provides evidence that the expression of
LY96
,
CA4
, and
ARG1
in the peripheral blood may serve as a surrogate for determining the time of stroke onset. In clinical practice, an algorithm based on this biomarker profile and other clinical covariates could be used when time of onset is unknown. To increase the accuracy of our biomarker algorithm, it will be important to determine the effects of age, stroke severity, and other clinical covariates on the expression of these genes over time.