bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WMP105: Time is Brain Following Ich: Time to Evacuation Impacts Functional Outcome After Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation
Authors: Kellner Christopher P , Song Rui , Nistal Dominic , Samarage Milan , Dangayach Neha , Liang John , McNeill Ian , Troiani Zachary , Bederson Joshua , Mocco J
Published: June 2021

Introduction:
Preclinical data have demonstrated a time-dependent benefit to early intracerebral hemorrhage (ICH) evacuation while clinical data have been less clear. Here we present long term functional outcome after minimally invasive endoscopic intracerebral hemorrhage evacuation with a focus on time to evacuation (TTE).

Methods:
Minimally invasive endoscopic ICH evacuation was performed on patients with supratentorial ICH who fit prespecified clinical inclusion and exclusion criteria agreed upon by a multidisciplinary group of physicians in the health care system. Retrospective analysis of prospectively collected data was performed on patients who were treated from December 2015 to October 2018. Demographic, clinical, and radiographic factors previously demonstrated to impact functional outcome in ICH were included in a multivariate logistic regression to identify factors predicting favorable outcome (modified Rankin Scale 0-3) at 6 months post-hemorrhage.

Results:
Ninety patients underwent MIS endoscopic ICH evacuation within 72 hours of ictus. In a multivariate analysis, factors that were identified to predict a positive outcome included age (per decade, OR 0.48, 95% CI 0.28-0.82) presence of intraventricular hemorrhage (OR 0.23, 95% CI 0.07-0.79), cortical location (OR 19.89, 95% CI 3.37-117.39), early evacuation (per hour, OR 0.95, 95% CI 0.92-0.99). Patients who underwent evacuation within 24 hours were 5 times more likely to achieve a favorable outcome (OR 5.29, 95% CI 1.52-18.41). Early evacuation did not correlate with increased risk of rebleeding.

Conclusion:
Time to evacuation significantly impacts long term outcome in minimally invasive endoscopic ICH evacuation. Every one hour evacuation is delayed results in a 5% reduction in the odds of achieving a favorable long-term outcome.
Abstract WMP17: Computerized Tomography Perfusion to Characterize Lack of Clinical Improvement After Recanalization in Acute Ischemic Stroke
Authors: Garcia-Tornel Alvaro , Olive-Gadea Marta , Ribo Marc , Rodriguez-Luna David , Pagola Jorge , Muchada Marian , Requena Manuel , Deck Matias , Boned Sandra , Juega Jesus , Rodriguez-Villatoro Noelia , Piñana Carlos , Hernandez David , Tomasello Alejandro , Molina Carlos A , Rubiera Marta
Published: June 2021

A significant proportion of patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) present poor functional outcome despite recanalization. We aim to investigate computed tomography perfusion (CTP) patterns after EVT and their association with outcome

Methods:
Prospective study of anterior large vessel occlusion AIS patients who achieved complete recanalization (defined as modified Thrombolysis in Cerebral Ischemia (TICI) 2b - 3) after EVT. CTP was performed within 30 minutes post-EVT recanalization (POST-CTP): hypoperfusion was defined as volume of time to maximal arrival of contrast (Tmax) delay ≥6 seconds in the affected territory. Hyperperfusion was defined as visual increase in cerebral blood flow (CBF) and volume (CBV) with advanced Tmax compared with the unaffected hemisphere. Dramatic clinical recovery (DCR) was defined as a decrease of ≥8 points in NIHSS score at 24h or NIHSS≤2 and good functional outcome by mRS ≤2 at 3 months.

Results:
One-hundred and forty-one patients were included. 49 (34.7%) patients did not have any perfusion abnormality on POST-CTP, 60 (42.5%) showed hypoperfusion (median volume Tmax≥6s 17.5cc, IQR 6-45cc) and 32 (22.8%) hyperperfusion. DCR appeared in 56% of patients and good functional outcome in 55.3%. Post-EVT hypoperfusion was related with worse final TICI, and associated worse early clinical evolution, larger final infarct volume (p<0.01 for all) and was an independent predictor of functional outcome (OR 0.98, CI 0.97-0.99, p=0.01). Furthermore, POST-CTP identified patients with delayed improvement: in patients without DCR (n=62, 44%), there was a significant difference in post-EVT hypoperfusion volume according to functional outcome (hypoperfusion volume of 2cc in good outcome vs 11cc in poor outcome, OR 0.97 CI 0.93-0.99, p=0.04), adjusted by confounding factors. Hyperperfusion was not associated with worse outcome (p=0.45) nor symptomatic hemorrhagic transformation (p=0.55).

Conclusion:
Hypoperfusion volume after EVT is an accurate predictor of functional outcome. In patients without dramatic clinical recovery, hypoperfusion predicts good functional outcome and defines a “stunned-brain” pattern. POST-CTP may help to select EVT patients for additional therapies.
Abstract WMP23: Likelihood of Undergoing Endovascular Stroke Therapy in Centers With High vs Low Utilization of CT Perfusion Imaging
Authors: Lee Songmi , Lopez-Rivera Victor , Fan James , Savitz Sean I , Yoo Albert J , McCullough Louise D , Giancardo Luca , Sheth Sunil A
Published: June 2021

Introduction:
CT Perfusion (CTP) is frequently used to evaluate patients with large vessel occlusion (LVO) acute ischemic stroke (AIS) for possible endovascular stroke therapy (EST). However, the accuracy of its infarct core and penumbral predictions are uncertain, and as such, may rule out patients who would otherwise have received EST without CTP-based selection.

Methods:
From our prospectively maintained multicenter registry, we identified AIS patients between January 2018 and February 2019. Data were collected from 4 comprehensive stroke centers - one center often performs CTP on nearly all AIS evaluations (CTP-H) and 3 centers perform CTP for uncertain findings on non-contrast CT (CTP-L). All 4 CSCs are covered by a single group of Vascular Neurologists and NeuroInterventionists with standardization of quality practices. Logistic regression adjusted for age, NIHSS, CT ASPECTS as ordinal variables, time of presentation (0-6 hrs. vs 6-24 hrs.), and occlusion location was used to assess the likelihood of undergoing EST. Results are provided as median [IQR] and OR [95% CI].

Results:
Among 2,317 patients with AIS, median age was 67 [57-78], 48% were female and 48% were white. The CTP rates at the 3 CTP-L centers were 18%, 31%, and 36%, while CTP rate at CTP-H center was 74% among all AIS patients (p<0.0001). 309 (43%) patients with LVO presented to CTP-L centers and 404 (57%) to the CTP-H center. For LVO patients presenting at CTP-L centers, median age was 70 [60-80], 52% were female, and 42% were white, while at CTP-H center median age was 68 [59-78], 44% were female and 57% were white. ASPECTS scores (CTP-L 9 [7-10] vs CTP-H 8 [6-9], p>0.05) and proportion of ICA/MCA occlusions (72% vs 77%; p>0.05), were comparable among centers, but LVO patients presenting at CTP-L centers had a lower NIHSS (11[4-18] vs 14[7-20]; p<0.01). For patients presenting 0-6 hrs, a higher number presented at the CTP-H center (20% vs 27%; p<0.05). In adjusted logistic regression, patients presenting with LVO to the CTP-H center were less likely to undergo EST (OR 0.51 [0.29-0.89]; p<0.05).

Conclusion:
In this study of 4 CSCs staffed by the same group of physicians, routine utilization of CTP in EST patient selection was associated with reduced likelihood of EST in patients with LVO.
Abstract WMP4: Predictors of Functional Recovery After Thrombectomy in Posterior Circulation Stroke - Insights From the STAR Collaboration
Authors: Alawieh Ali M , Eid Maya , Anadani Mohammad , Sattur Mithun , Chalhoub Reda , Maier Ilko , Feng Wuwei , Goyal Nitin , Starke Robert M , Rai Ansaar , Fargen Kyle , Psychogios Marios-Nikos , De Leacy Reade , Keyrouz Salah , Dumont Travis , Kan Peter , Lena Jonathan , Liman Jan , Arthur Adam , Elijovich Lucas , Mccarthy David , Saini Vasu , Wolfe Stacey Q , Mocco J , Fifi Johanna , Nascimento Fábio , Giles James , Allen Michelle , Grossberg Jonathan , Spiotta Alejandro M
Published: June 2021

Introduction:
Endovascular thrombectomy (ET) for treating acute stroke in the real-world has expanded beyond the selection criteria used in major trials, and currently includes posterior circulation strokes. Posterior circulation stroke is believed to have worse outcomes than anterior circulation stroke, and its outcomes following ET are still being studied. We explored the major determinants of functional recovery after ET for posterior circulation stroke in a large cohort of patients from the Stroke Thrombectomy and Aneurysm Registry (STAR).

Methods:
STAR includes patients undergoing ET for acute ischemic stroke at 12 comprehensive stroke centers in the US and globally. Data on patient demographics, technical and clinical outcomes was reviewed retrospectively from patient charts and procedure notes. Primary outcomes was the modified Ranking Score (mRS) at 90 days dichotomized into favorable (mRS 0-2) and poor outcome (mRS 3-6).

Results:
A total of 3850 patients were reviewed, of which 345 patients (mean age 60±14) were treated for posterior circulation stroke with predominantly basilar artery occlusion (80%). Patients were treated using aspiration thrombectomy (ADAPT, 39%), stent retriever thrombectomy (31%), combined approach (19%) or intracranial stenting (7%). The overall rate of favorable outcome was 33%. Patients with diabetes, high NIHSS on admission, and proximal occlusions had significantly higher odds of poor functional outcomes on multivariate analysis (p<0.05). Compared to ADAPT thrombectomy, significantly higher odds for poor outcomes were observed with the use of stent retriever (aOR=0.84, p<0.01) or primary combined approach (aOR=2.85, p=0.05). The advantage of ADAPT on functional recovery compared to stent retrievers persisted when regression models were limited to patients with successful recanalization, or with basilar artery occlusions. No differences in complication and hemorrhage rates were observed.

Conclusions:
Despite similar rates of functional recovery after ET for anterior circulation stroke between stent retriever and ADAPT, our analysis demonstrates that in posterior circulation stroke, ADAPT may lead to better functional outcomes compared to stent retriever without differences in safety profiles.
Abstract WMP43: Long-term Mortality in Moyamoya Patients According to Presentation Type and Bypass Surgery in South Korea
Authors: Jang Dong-Kyu , Im Sang-Hyuk , Kim Hoon , Park Sang Kyu , Han Kyung Do
Published: June 2021

Background:
Survival outcomes in moyamoya patients according to initial presentation type and bypass surgery have not been clearly revealed.

Methods:
We investigated mortality in moyamoya disease (MMD) patients using Korean National Health Insurance database from 2006 to 2015 allowing wash-out period of previous 4 years. MMD type was classified into ischemic, hemorrhagic, and asymptomatic MMD. Bypass surgery group included the patients who underwent bypass surgery within 1 year after MMD diagnosis. Survival analysis was performed according to initial presentation type and bypass surgery using Kaplan-Meier method and Cox proportional hazard model.

Results:
The total number of patients with newly diagnosed MMD was 12146 with a female-to-male ratio of 1.81, of which ischemic type was identified in 3671 (30.2%), hemorrhagic type was in 2449 (20.2%), and asymptomatic type was in 6026 (49.6%) patients, respectively. There were 3942 (32.5%) patients in bypass surgery group and 8204 (67.5%) patients in non-bypass group. The 5- and 10-year survival rates in ischemic, hemorrhagic, and asymptomatic type were 92.5% and 88.9%, 85.3% and 76.3%, and 96.3% and 94.3%, respectively (Log-rank test; P<0.001, P<0.001). After adjusting age, sex, and presentation type, bypass surgery demonstrated HRs of 0.597 (95% CI 0.486-0.733, P<0.001) and 0.595 (95% CI 0.429-0.719, P<0.001) for 5- and 10-year mortality, respectively.

Conclusion:
This study showed that MMD patients had different survival courses according to initial presentation type. Adult MMD patients with hemorrhagic presentation had the worst survival outcome. Bypass surgery group survived longer than non-bypass group did in MMD patients in real-world setting.
Abstract WMP55: HIV Viral Load and Stroke Risk
Authors: Harding Barbara , Avoundjian Tigran , Heckbert Susan R , Whitney Bridget M , Nance Robin M , Tirschwell David L , Kalani Rizwan , Ho Emily L , Becker Kyra J , Zunt Joseph , Chow Felicia , Huffer Andrew , Mathews W C , Eron Joseph , Moore Richard , Marra Christina M , Burkholder Greer , Saag Michael , Kitahata Mari M , Crane Heidi , Delaney Joseph C
Published: June 2021

Background:
Among people living with HIV (PLWH), elevated plasma HIV RNA (viral load, [VL]), indicative of increased inflammation, may be associated with greater risk of stroke.

Methods:
Among adult PLWH receiving clinical care at six Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) sites across the U.S. from January 2006 through January 2015, first ischemic or hemorrhagic stroke was identified from adjudicated clinical events. We considered baseline and time-updated VL. Baseline viral load was defined as the most recent viral load before 2006 or at CNICS cohort entry (if after 2006). Cox proportional hazards models were used to assess the relationship between baseline VL and time-updated VL and stroke. We estimated hazard ratios for risk of stroke (all stroke, and ischemic and hemorrhagic stroke separately) comparing the 75
th
percentile of VL (“high VL”) to the 25
th
percentile (“low VL”). All models were adjusted for age, sex, race/ethnicity, CNICS site, diabetes, treated hypertension, statin use, smoking, nadir CD4, BMI, hepatitis C virus coinfection, and baseline ART use. The hemorrhagic stroke model was also adjusted for FIB-4.

Results:
Among 16,648 PLWH over an average follow-up of 4.7 years, there were 146 total strokes (119 ischemic; 19 hemorrhagic). At baseline, the median VL was 41 copies/mL (IQR: 24, 3860). Individuals with high baseline VL were 1.57 times more likely to have a stroke than individuals with low baseline VL (95% CI: 1.22, 2.04). In addition, high baseline VL was associated with increased risk of ischemic stroke (HR: 1.48; 95% CI: 1.11, 1.97) and hemorrhagic stroke (HR: 2.5; 95% CI: 1.25, 4.98). The HR for all strokes comparing high VL and low VL individuals using time-updated VL was 1.84 (95% CI: 1.42-2.40).

Conclusion:
Our findings suggest that higher VL is associated with stroke risk after adjusting for traditional stroke risk factors, and may have a greater impact on incidence of hemorrhagic stroke. In addition to reducing HIV-related morbidity and mortality, improving HIV care may also reduce stroke risk.
Abstract WMP7: Clinical Outcome After Multiple Retrieval Attempts in Endovascular Treatment for Acute Ischemic Stroke
Authors: Flottmann Fabian , Leischner Hannes , Fiehler Jens , Thomalla Götz , Deb-Chatterji Milani , Maros Matt
Published: June 2021

Introduction:
Dedicated analyses scrutinizing the deteriorating benefit of multiple endovascular thrombectomy attempts are lacking. Here, we present insights into choosing the optimal number of retrieval attempts (RA) based on multicentric data of the German Stroke Registry (GSR).

Materials & Methods:
In this retrospective multicenter (n=17) study, 2611 patients of the GSR were included. In 1244 patients with complete datasets, clinical outcome was correlated with the number of retrieval attempts. The framework of generalized linear mixed-effects models was used, and the primary clinical outcome was modified Rankin scale (mRS) at 90 days <= 2. The main co-factor of interest was the number of successful RA while the model was also adjusted for confounders such as age, sex, admission NIHSS, ASPECTS, intravenous thrombolysis (IVT), type of anesthesia, time from groin puncture to final angiographic series, and reperfusion (thrombolysis in cerebral infarction [TICI]) score.

Results:
Age (ß=0.94, p<0.001), admission NIHSS (ß=0.89, p<0.001) and general anesthesia (ß=0.62, p=0.0063) showed significant negative-, while ASPECT-score (ß=1.19, p=8.6x10
-5
) and IVT (ß=1.34, p=0.044) showed positive association with mRS2 after adjusting for all covariates. Compared to the reference group of 0 successful RA, successful reperfusion after one RA showed the strongest trend (ß=3.14, p=0.096) toward functional independence. Similarly, the estimated effect of 2nd to 5th RAs stayed positive but non-significant. Six or more RAs had a negative effect (ß =0.55, p=0.45) on functional independence.

Conclusion:
There is decreasing clinical benefit of every retrieval attempt in EVT. However, successful reperfusion achieved after up to 5 retrieval attempts seems to be beneficial compared to failure of reperfusion.
Abstract WMP75: Development of a Theragnostic Probe for Stem Cell Tracking and Enhancing the Therapeutic Efficacy in a Mouse Model of Focal Ischemia
Authors: Shi Xiaojing , Zhang Lu , Zhang Zhijun , Wang Yongting , Yang Guo-Yuan , Tang Yaohui
Published: June 2021

Objectives:
Mesenchymal stem cell therapy has shown therapeutic potential for ischemic stroke. However, low cell viability and lack of multimodal imaging to track stem cell distribution limit its clinical translation. Here we developed a multifunctional probe to track stem cell viability and migration in a mouse model of focal brain ischemia.

Methods:
A theragnostic probe was developed by cobalt protoporphyrin IX (CoPP), with photoacoustic imaging detectability into
125
Iodine modified mesoporous silica nanoparticles (
125
I-CoPP@MSN). The effect on cell viability and differentiation were examined
in vitro
. Adult male ICR mice (n=40) were subjected to 90 min transient middle cerebral artery occlusion.
125
I-CoPP@MSN labeled stem cells were transplanted into the peri-infarct region after 1 day of brain ischemia. Grafted cells was monitored by SPECT and photoacoustic imaging. The cell survival was evaluated by bioluminescence imaging.

Results:
125
I-CoPP@MSNs have high efficiency for labeling cells without affecting their viability and differentiation.
125
I-CoPP@MSNs increased the viability of stem cells subjected to H
2
O
2
-induced oxidant stress
in vitro
, compared with controls (
p
<0.05). Photoacoustic and SPECT imaging showed that 90±8% of graft cells were localized in the injection site and tended to migrate at 1 day after injection. The SPECT/CT signal started to decrease from 4 to 8 days.
125
I-CoPP@MSN labeling increased graft cell viability, reduced brain atrophy volume, and improved behavioral outcomes, compared to the controls (
p
<0.05). Immunostaining results showed that the number of CD31
+
and DCX
+
cells were increased in CoPP@MSN labeled group than that in controls (p<0.05).

Conclusion:
We conclude that
125
I-CoPP@MSNs is a novel probe for the real-time tracking and enhancing its therapeutic efficacy in ischemic stroke therapy.
Abstract WMP80: Live Animal Imaging Reveals Delayed But Sustained Neutrophil Recruitment to Both Ischemic and Non-Ischemic Cortical Cerebrovasculature in a Mouse Transient Stroke Model
Authors: Batra Ayush , Nadkarni Neil A , Muller William A , Sullivan David P
Published: June 2021

Background:
Treatment for acute ischemic stroke (AIS) relies on early restoration of blood flow; however, injury persists despite reperfusion. The innate immune response plays a pivotal role in reperfusion injury, but the mechanisms and timing of neutrophil recruitment to the cerebrovasculature (CBV) during AIS remain unclear. We sought to characterize the neutrophil response in the CBV following ischemia/reperfusion using a transient middle cerebral artery occlusion (tMCAO) AIS model.

Methods:
Fluorescent reporter mice underwent 90-minute tMCAO confirmed with LSCI or surgery without occlusion (sham). Real-time confocal intravital microscopy of the CBV was performed at 24 and 72 hrs post-reperfusion through cranial windows in ischemic and non-ischemic hemispheres. Neutrophil recruitment (adhesion, rolling) and extravasation were quantified in vivo over both hemispheres. Neutrophil extravasation was further quantified using whole mount sections. Infarct volume was measured by 2,3,5-triphenyltetrazolium chloride staining.

Results:
An increase in neutrophil rolling, adhesion and extravasation was observed within the ischemic hemisphere compared to sham (p < 0.01) at 24 and markedly 72 hrs. Non-ischemic hemispheres showed increased neutrophil rolling and adhesion, but not extravasation, compared to sham surgery (p < 0.05). Whole mount sections demonstrated increased cortical and subcortical neutrophil extravasation in the ischemic hemisphere only (p < 0.01).

Conclusions:
Early neutrophil recruitment to the ischemic hemisphere following tMCAO was present at both the CBV and within the infarcted parenchyma at 72 hours. Acute neutrophil recruitment at the CBV in the non-ischemic hemisphere, but not the cortex, suggests that AIS triggers a global inflammatory response within the CBV. Targeted neutrophil-specific therapies during reperfusion may reduce global inflammation at the CBV, and potentially mitigate secondary neuronal injury.
Abstract WP104: Defining a Target Population to Effectively Test a Neuroprotective Drug
Authors: Olivé-Gadea Marta , Requena Manuel , Garcia-Tornel Álvaro , Deck Matías , Muchada Marian , Boned Sandra , Rodríguez Noelia , Juega Jesús , Rodríguez-Luna David , Pagola Jorge , Rubiera Marta , Molina Carlos , Ribó Marc
Published: June 2021

We aim to define a target population of stroke patients treated with EVT, in whom a potential neuroprotective (NP) drug has highest chances to show clinical and radiological positive effects.

Methods:
we studied stroke patients treated with EVT. CBF<30% on admission CTP determined infarct core. Final infarct volume (FIV) was measured on 24-48h CT and NIHSS at discharge/day 5 (dNIHSS). We analyzed the clinical impact of absolute (1cc) and relative (30%) NP-mediated FIV reductions in dNIHSS. Segmented linear regressions were used to identify significant breakpoints in FIV/dNIHSS association. Models were adjusted for age, sex and baseline NIHSS.

Results:
We included 211 patients, mean FIV was 39(±58)cc and median dNIHSS 6(1-15). FIV strongly correlated to dNIHSS (rs=0.74; p<0.01). We defined 3 subgroups: minimal (≤1cc), moderate (2-80cc) and large (≥80cc) FIV. A) FIV ≤1 (22.3% of patients): mean FIV was 0.23±0.4cc, median NIHSS was 1(0-3). Neither absolute (1cc) nor 30% relative (-0.07±0.1cc) FIV reduction showed a significant impact in dNIHSS (±0 points). B) FIV 2-80cc (59.7%): mean FIV was 22.9±18.3cc, median dNIHSS was 7(2-13). Per each cc FIV reduction dNIHSS decreased by 0.23 (CI 0.17-0.29) points. A 30% reduction in mean FIV (6.9cc) may lower dNIHSS 1.6 points. C) FIV≥80cc (18%): mean FIV was 143±66cc, median dNIHSS was 19(12-30). Per each cc FIV reduction dNIHSS decreased by 0.07 (CI 0.03-0.12). A 30% reduction in mean FIV (43cc) may reduce dNIHSS 3 points. An infarct core <5cc (Sn 73%, Sp 75%; AUC 0.8, CI 0.74-0.86) predicted FIV ≤1cc. An infarct core≥30cc predicted FIV≥80cc (Sn 71%; Sp 85%; AUC 0.87; CI 0.8-0.93).

Conclusion:
One in 4 patients will develop minimal FIV, including these patients in NP trials may dilute a treatment effect and reduce odds of positive results. In large FIV patients, mild relative clinical impacts may become relevant due to substantial absolute FIV reductions. Admission CTP may help sorting patients according to expected drug effect profile.
Abstract WP114: Effect of Prestroke Aspirin on Infarct Volume
Authors: Yoon Hosang , Ryu Wi-Sun
Published: June 2021

Objective:
To investigate if prestroke aspirin use affects infarct volume, generally and by subtype.

Background:
Prestroke aspirin use may reduce initial stroke severity and improve functional outcome at discharge, especially in the large artery atherosclerosis (LAA) stroke. We investigated whether prestroke aspirin use is associated with infarct volume and the effect of prestroke aspirin on infarct volume is different between LAA versus non-LAA strokes.

Methods:
A total of 4427 patients were included. The association between infarct volume on DWI and prior aspirin use was assessed by multiple linear regression analysis. To adjust a significant imbalance between aspirin users vs. non-aspirin users, the augmented inverse-probability weighting (AIPW) and propensity score matching were used.

Results:
Mean age was 67.7(SD 12.4) years and 58.7% were male. 19.6% (n=869) took aspirin before stroke. Prestroke aspirin had an inverse relation with log-infarct volume (P = 0.007) and the effect was significantly modified by LAA versus non-LAA strokes (P for interaction = 0.02). In LAA stroke (n=2336), prestroke aspirin use was independently associated with log-infarct volume (standardized beta = -0.047; P = 0.032). In non-LAA stroke (n=2091), prestroke aspirin was not associated with infarct volume (P = 0.27). Using AIPW and propensity score matching, the mean difference of log-infarct volume between prestroke aspirin user versus non-aspirin uses was -0.28 (95% CI -0.52 to -0.04, P = 0.009) and -0.39 (95% CI -0.67 to -0.11, P = 0.02) in LAA strokes. In non-LAA strokes, AIPW and propensity score matching showed that prestroke aspirin use was not associated with infarct volume (P = 0.27 and P = 0.85, respectively).

Conclusions:
Our results showed that prestroke aspirin use is negatively associated with initial infarct volume on DWI in LAA strokes but not in non-LAA strokes.
Abstract WP124: Ataste 2: Assessment of Anti-Hypertensive Treatment and Acute Stroke Treatment Efficiency 2
Authors: Sorace Brian , Meyer Brett , Meyer Dawn , Agrawal Kunal
Published: June 2021

Introduction:
Treatment of acute ischemic stroke (AIS) with tPA must be rapid for timely cerebral reperfusion. Anti-hypertensive (AHT) medication may be required to lower blood pressures prior to tPA. Optimal AHT use and its impact on tPA times is unclear. We examined treatment with IV bolus only (IVB), IV continuous infusion only (IVCI), or both bolus and infusion (BBI) AHTs on door-to-needle time (DTN) in AIS patients eligible for IV tPA. We hypothesized that 1) DTN would be significantly longer in patients requiring IV AHT before treatment and 2) DTN would be significantly lower in patients treated with IVCI compared to IVB or BBI.

Methods:
We analyzed all stroke codes who received IV tPA at our comprehensive stroke center from July 1, 2008 to June 30, 2019. Subjects were grouped by those that required IV AHT prior to IV tPA (med+tPA) and those that did not (no-med+tPA). The three medication groups were IVB, IVCI, or BBI. Variables examined were initial and immediate pre-treatment blood pressures, NIHSS, mRS, and initial blood glucose. The primary outcome was DTN between groups.

Results:
Overall, 288 patients were included in the analysis. Approximately 12% (n=35) of patients required IV AHTs before tPA. There was a significant difference between the med+tPA and no-med+tPA groups in 1) median NIHSS (12.5, 10; p=0.040) and initial mean glucose (142, 122.5; p<0.001), respectively. DTN was significantly longer in med+tPA vs no-med+tPA mean (77.5 min, 56.4 min; p=0.036). Systolic blood pressures (SBP) were significantly higher in patients requiring AHT treatment (initial SBP: med+tPA 175.5 mmHg, no-med-tPA 144.1 mmHg, p=0.001). There was no difference in DTN between IVB, IVCI, or BBI groups when compared to the no-med+tPA group (p=0.351, 1.000, & 0.997). There was no difference in the 90-day mRS between IVB, IVCI, or BBI compared to control (p=0.236, 0.339, & 0.326).

Conclusions:
Fewer patients required AHT than expected suggesting lower rates of baseline hypertension in our region. Type of AHT agent used did not significantly impact DTN. This may be due to the small sample size of patients receiving blood pressure medication prior to tPA in this study. Further prospective studies are needed to examine the optimal AHT treatment modality on DTN.
Abstract WP132: Does Systemic Hypertension Impact Recanalization of Coiled Aneurysms?
Authors: Cho Young Dae
Published: June 2021

Purpose:
It is well known that hypertension is a significant factor in the formation, growth, and rupture of aneurysms; and recanalization of coiled aneurysms is affected by hemodynamic stress. At present, however, the impact of hypertension on recanalization of coiled aneurysms has not been adequately investigated. We examined the relation between hypertension and subsequent outcomes of coiled aneurysms, using a matched patient analysis.

Methods:
A total of 715 subjects undergoing coil embolization of intracranial aneurysms between 2011 and 2013 were selected for study. Time-of-flight magnetic resonance (TOF-MRA) or conventional angiography was used (singly or together) to gauge degrees of occlusion after coiling, applying the Raymond classification in grading recanalization. Patients with hypertension were grouped as controlled or uncontrolled, based on blood pressure (BP) readings at outpatient clinics. Hypertensive and non-hypertensive subjects were matched (1:1) for several relevant variables.

Results:
Overall, 484 patients (67.7%) were hypertensive (controlled, 338; uncontrolled, 146). During the follow-up period (28.6±9.7 months), 129 aneurysms (18.0%) displayed recanalization (minor, 58; major, 71). Patient age, concomitant diabetes, hyperlipidemia, aneurysm size, neck size, depth-to-neck ratio, and aneurysm type differed significantly in hypertensive and non-hypertensive groups. However, group incidences of cumulative recanalization were similar (p=0.297). After 1:1 matching, the cumulative recanalization rate (13.5%) in hypertensive and non-hypertensive counterparts (14.3%) again proved similar (p=0.578). In hypertensive group, in addition, recanalization showed no relation to controlled and uncontrolled subgroup (OR=1.000, p>0.999).

Conclusion:
Unlike other aspects of evolving aneurysms (ie, formation, growth, or rupture), recanalization of coiled aneurysms is seemingly unaffected by systemic hypertension.
Abstract WP167: Changing Face of Carotid Revascularization Procedures in the United States
Authors: Chaudhry Saqib A , Akhtar Iqra N , Huang Wei , Hassan Ameer E , Chaudhry Mohammad Rauf A , Siddiq Farhan , Gomez Camilo R , Suri Fareed K , Qureshi Adnan I
Published: June 2021

Background:
Carotid revascularization procedure, carotid endarterectomy (CEA) and carotid stent placement (CAS), are some of the most common procedures performed in United States and expected to change due to wider adoption of CAS. We performed this study to determine the changes in utilization of CEA and CAS in United States using nationally representative data.

Methods:
We used the National Inpatient Sample (NIS) from 2005 to 2014 to assess the changes in utilization of CEA and CAS over last 10 years in patients with symptomatic and asymptomatic carotid artery stenosis. NIS is the largest all payer dataset that includes diagnoses, admissions and discharge, demographics, and outcomes data of patients admitted to short stay non-Federal hospitals in the United States. We analyzed patterns of changes in utilization in various subsets of patients with carotid artery stenosis.

Results:
A total of 1,186,182 patients underwent carotid revascularization procedures during study period; 1,032,148 (87.1%) and 154,035 (12.9%) were CEA and CAS, respectively. The overall carotid revascularization procedures decreased over last 10 years (11.1% in 2005 to 8.4%in 2014, trend test p <.0001). Carotid revascularization in symptomatic patients increased (7.64% in 2005 to 11.01% in 2014, trend test p <.0001) while it decreased in asymptomatic patients (92.36% in 2006 to 88.99% in 2014, trend test p <.0001). There was an overall decrease in CEA (11.6% in 2005 to 8.3% in 2014, trend test <.0001) while in CAS remained unchanged (8.1% in 2005 to 8.9% in 2014, p=NS). There was an increase in carotid revascularization in teaching hospitals (40.9% in 2005 to 67.1% in 2014, trend test p <.0001) while decrease in non-teaching hospitals (50.9% in 2006 to 27.1% in 2014, trend test p <.0001). There was a decrease in carotid revascularization procedures in patients aged ≥80 years (19.8% in 2005 to 18.7% in 2014, trend test p <.0001) and CEA (19.6% in 2006 to 18.8% in 2014, trend test P<.0001) and CAS (21.2% in 2006 to 18.6% in 2014, trend test p=<.0001).

Conclusion:
Although CAS is increasing in a disproportionate manner within patient subgroups in United States, overall carotid revascularization procedures have decreased for unclear reasons.
Abstract WP197: Patient-Reported Physical Outcomes Measures in Mild-to-Moderate Stroke and TIA Patients
Authors: Radman Meghan , Jones Sara , Sissine Mysha , Bushnell Cheryl , Duncan Pamela
Published: June 2021

Introduction:
Mild-to-moderate stroke and TIA patients are discharged directly home, but may have residual physical disability. The purpose of this study was to compare distributions of three patient-reported outcome measures: PROMIS GPH, Stroke Impact Scale-16 (SIS-16), and simplified modified Rankin (Rankin).

Methods:
PROMIS GPH includes global ratings of physical activities, physical health, pain and fatigue, SIS-16 includes ADLs, IADLs, and physical activities, and Rankin includes ADLs, IADLs, and overall comparison of function to pre-stroke function. Outcomes were measured at 90-days post-hospital discharge in 1768 stroke and TIA patients discharged directly home in the COMprehensive Post-Acute Stroke Services Study. Ceiling effects (frequency of maximum score) were evaluated for each measure. Differences in SIS-16 and PROMIS GPH scores across levels of Rankin were compared using the Kruskal-Wallis test. Spearman correlation coefficients were calculated between PROMIS GPH, SIS-16, Rankin, and individual items of the PROMIS GPH.

Results:
At hospital baseline, patients were 68 ± 13 years of age, 50% female, 72% stroke, 28% TIA, and with mean ± SD NIHSS of 2.3 ± 3.6. At 90 days, mean ± SD were 45.8 ± 9.8 for PROMIS GPH, 82.1 ± 19.7 for SIS-16, and 1.2 ± 1.3 for Rankin. Ceiling effects for the PROMIS GPH were (3.1%), SIS-16 (24.8%) and Rankin (38.9%). PROMIS GPH and SIS-16 scores differed significantly (p < 0.0001) across categories of the Rankin. Correlations with Rankin were moderate for SIS-16 (r=-0.64; 95% CI -0.67, -0.62) and PROMIS GPH (r=-0.54; 95% CI -0.58, -0.51). Correlations between SIS-16 and PROMIS GPH items were strong for physical activities (r=0.75; 95% CI 0.63, 0.77) and moderate for physical health (r=0.55; 95% CI 0.52, 0.59), fatigue (r=0.50; 95% CI 0.47, 0.54) and pain (r=0.44; 95% CI 0.40, 0.48). Of 438 patients at SIS-16 ceiling, the mean ± SD for global assessment of physical activities, physical health, pain, and fatigue on a scale of 0-5 were 4.8 ± 0.6, 3.7 ± 0.9, 4.4 ± 0.9, and 4.2 ± 0.7, respectively.

Conclusion:
PROMIS GPH may better detect physical health differences in mild-to-moderate stroke and TIA patients. Variability in global assessments of physical health, pain, and fatigue contribute to the lower PROMIS GPH ceiling effects.
Abstract WP205: Home-Based Virtual Reality Therapy for Hand Recovery After Stroke
Authors: MacLellan Adam , Legault Catherine , Parikh Alay , Lugo Leonel , Kemp Stephanie , Mlynash Michael , Buckwalter Marion , Flavin Kara , Lansberg Maarten
Published: June 2021

Background:
Stroke is the leading cause of disability worldwide, with many stroke survivors having persistent upper limb functional impairment. Aside from therapist-directed rehabilitation, few efficacious recovery tools are available for use by stroke survivors in their own home. Game-based virtual reality systems have already shown promising results in therapist-supervised settings and may be suitable for home-based use.

Objective:
We aimed to assess the feasibility of unsupervised home-based use of a virtual reality device for hand rehabilitation in stroke survivors.

Methodology:
Twenty subacute/chronic stroke patients with upper extremity impairment were enrolled in this prospective single-arm study. Participants were instructed to use the Neofect Smart Glove 5 days per week for 8 weeks, in single sessions of 50 minutes or two 25-minute sessions daily. We measured (1) compliance to prescribed rehabilitation dose, (2) patient impression of the intervention, and (3) efficacy measures including the upper extremity Fugl-Meyer (UE-FM), the Jebsen-Taylor hand function test (JTHFT) and the Stroke Impact Scale (SIS).

Results:
Seven subjects (35%) met target compliance of 40 days use, and 6 subjects (30%) used the device for 20-39 days; there were no age or gender differences in use. Subjective patient experience was favorable, with ninety percent of subjects reporting satisfaction with their overall experience, and 80% reporting perceived improvement in hand function (figure 1). There was a mean improvement of 26.6±48.8 seconds in the JTHFT (
p
=0.03) and 16.1±15.3 points in the domain of the SIS that assesses hand function (
p
<0.01). There was a trend towards improvement in the UE-FM (2.2±5.5 points,
p
=0.10).

Conclusions:
A novel virtual reality gaming device is suitable for unsupervised use in stroke patients and may improve hand/arm function in subacute/chronic stroke patients. A large-scale randomized controlled trial is needed to confirm these results.
Abstract WP217: A New Index for Multiple Chronic Conditions Predicts Post-Stroke Functional Outcome: A Machine Learning Approach in the Brain Attack Surveillance in Corpus Christi Project
Authors: Jiang Xiaqing , Wang Lu , Morgenstern Lewis , Cigolle Christine , Lisabeth Lynda
Published: June 2021

Introduction:
Multiple chronic conditions (MCC) diminish the pre-stroke reserve that aids post-stroke adaptation and recovery. Through machine learning, we developed a MCC index that integrates pre-stroke comorbid conditions, functional and cognitive factors, as well as their interactions, to predict post-stroke functional outcome (FO) in a bi-ethnic, population-based cohort study.

Methods:
Ischemic stroke patients (2008-2017) were interviewed at baseline and 90 days. FO score (range 1-4, higher scores worse) at 90 days was measured by averaging 22 activities of daily living (ADL)/instrumental activities of daily living (IADL) and dichotomizing the score into favorable (1-3) and unfavorable FO (>3, a lot of difficulty with ADL/IADLs). Multiple linear regression was fit with a Lasso penalty to select predictors among 22 chronic conditions from ICD codes and medical records, pre-stroke function, cognitive impairment, social support, marital status, depression, age, initial stroke severity (NIHSS) and all pairwise interactions. We developed an MCC index by weighting selected predictors using β-coefficients. Adjusted R
2
, discrimination and calibration of the model were assessed.

Results:
Among 1,035 stroke survivors, 69% were Mexican American, 51% were female, mean age was 68 (SD=12), and median initial NIHSS was 4 (IQR:2-8). Median FO score was 2.36 (IQR:1.55-3.41); 32% had unfavorable FO. The final model contained the pre-stroke modified Rankin Score (mRS), initial NIHSS, age, congestive heart failure (CHF), weight loss, diabetes, other neurological disease, initial NIHSS х pre-stroke mRS, dementia х age, CHF х renal failure and pre-stroke mRS х history of stroke/TIA, which explained 44% of variability in FO score. The MCC index was well calibrated (p=0.28) and predicted unfavorable FO well (c-statistic, 0.84) in the internal validation dataset.

Conclusion:
A new MCC assessment tool was developed and validated to improve the prediction of post-stroke FO. Weight loss, other neurological disease and interactions between MCC were discovered as novel predictors. Efforts to improve stroke prognosis may benefit from a better understanding, prevention and management of MCC in population at high risk for stroke.
Abstract WP218: Increased Systolic Blood Pressure Variability Among Diabetic Patients is Associated With Higher Risk of Incident Stroke: A Secondary Analysis of ACCORDION
Authors: de Havenon Adam H , Wong Ka-Ho , Mistry Eva , Anadani Mohammad , Yaghi Shadi , Vahidy Farhaan , Tirschwell David , Rost Natalia
Published: June 2021

Background:
Increased blood pressure variability (BPV) has been associated with stroke risk, but never specifically in patients with diabetes.

Methods:
This is a secondary analysis of the Action to Control Cardiovascular Risk in Diabetes Follow-On Study (ACCORDION), the long term follow-up extension of ACCORD. Visit-to-visit BPV was analyzed using all BP readings during the first 36 months. The primary outcome was incident ischemic or hemorrhagic stroke after 36 months. Differences in mean BPV was tested with Student’s t-test. We fit Cox proportional hazards models to estimate the adjusted risk of stroke across lowest vs. highest quintile of BPV and report hazard ratios along with 95% confidence intervals (CI).

Results:
Our analysis included 9,241 patients, with a mean (SD) age of 62.7 (6.6) years and 61.7% were male. Mean (SD) follow-up was 5.7 (2.4) years and number of BP readings per patient was 12.0 (4.3). Systolic, but not diastolic, BPV was higher in patients who developed stroke (Table 1). The highest quintile of SBP SD was associated with increased risk of incident stroke, independent of mean blood pressure or other potential confounders. (Table 2, Figure 1). There was no interaction between SBP SD and treatment arm assignment, although the interaction for glucose approached significance (Table 2).

Conclusion:
Higher systolic BPV was associated with incident stroke in a large cohort of diabetic patients. Future trials of stroke prevention may benefit from interventions targeting BPV reduction.
Abstract WP224: Should Carotid Bruit Be Abandoned as a Marker of Carotid Stenosis and Cardiovascular Disease in Older Persons? The Cardiovascular Health Study
Authors: Qureshi Adnan I , Saeed Omer , Aslam Hunain
Published: June 2021

Importance:
Auscultation for carotid bruit has been considered part of physical examination for over five decades.

Objective:
To test whether a carotid bruit (CB) can identify patients with internal carotid artery stenosis (50% or greater) and those at risk of myocardial infarction (MI), ischemic stroke and/or death among elderly persons.

Methods:
We analyzed data from the Cardiovascular Health Study a population-based, prospective observational cohort study of risk factors for cardiovascular disease in adults 65 years or older. CB was auscultated and maximum percent stenosis was assessed using duplex ultrasound at baseline visit. Longitudinal follow-up was conducted for a mean (SD) of 13 (6.2) years to identify incidence of ischemic stroke, MI and death using annual extensive clinical examinations and 6 monthly clinic visits, and contact by phone to ascertain occurrence of cardiovascular events. We performed Cox proportional hazards analysis to determine the effect of CB on incidence of MI, stroke and death during follow up after adjusting for potential confounders.

Results:
The mean (SD) age of the entire cohort (n = 5888) was 72.8 (5.6) years; 2466 (41.9%) were men. CB was identified in 361 (6.1%) of 5888 persons. Carotid stenosis (50% or greater) was identified in 79 of 361 person with CB (sensitivity of 28.6%). No CB was auscultated in 197 out of 276 patients with carotid stenosis (specificity of 94%). During follow-up, higher proportion of persons with CB experienced ischemic stroke (10.8% versus 7.2%, p=.01), MI (15.0% versus 8.9%,p=<.0001) and death (36.3% versus 21.7%,p=<.0001). There were no differences in the risk of stroke (HR 1.2, 95% CI 0.9-1.5) between persons with CB compared with those without CB in the multivariate analysis after adjusting for age, gender, race hypertension, diabetes and smoking. There was a significantly higher rate of death among persons with CB (HR 1.3, 95% CI (1.1-1.5; p-<.01) and MI (HR 1.4, 95% CI 1.0-1.8; p-.03) compared with those who did not after adjusting for potential confounders.

Conclusions:
In this study, CB was a not a reliable marker for identification of carotid stenosis and those at risk for ischemic stroke. The current analysis does not support continued use of carotid bruit as part of physical examination.
Abstract WP236: The Urban-Rural Divide: Risk Factor Prevalence in Ischemic Stroke Patients Across Two Decades
Authors: Jillella Dinesh V , Crawford Sara , Tang Anne S , Lopez Rocio , Uchino Ken
Published: June 2021

Introduction:
Regional disparities exist in stroke incidence and stroke related mortality in the United States. We aimed to elucidate the stroke risk factor prevalence trends based on urban versus rural location.

Methods:
From the National Inpatient Sample database the comorbid stroke risk factors were collected among hospitalized ischemic stroke patients during 2000-2016. Crude and age-and sex-standardized prevalence estimates were calculated for each risk factor during the time periods 2000-2008 and 2009-2016. We compared risk factor prevalence over the defined time periods using regression models, and differences in risk factor trends based on patient location categorized as urban (metropolitan with population of ≥ 1 million) and rural (neither micropolitan or metropolitan) using interaction terms in the regression models.

Results:
Stroke risk factor prevalence significantly increased from 2000-2008 to 2009-2016. When stratified based on patient location, most risk factors increased in both urban and rural groups. In the crude model, the urban to rural trend difference across 2000-08 and 2009-16 was significant in hypertension (p<0.0001), hyperlipidemia (p=0.0008), diabetes mellitus (p<0.0001), coronary artery disease (p<0.0001), smoking (p<0.0001) and alcohol (p=0.02). With age and sex standardization, the urban to rural trend difference was significant in hypertension (p<0.0001), hyperlipidemia (p=0.0007), coronary artery disease (p=0.01) and smoking (p<0.0001).

Conclusion:
The prevalence of vascular risk factors among ischemic stroke patients has increased over the last two decades. There exists an urban-rural divide, with rural patients showing larger increases in prevalence of several risk factors compared to urban patients.
Abstract WP244: Applicability of the Compass Trial Criteria Among Stable Outpatients With Established Atherothrombotic Disease or Major Risk Factors
Authors: Cantu-Brito Carlos , Chiquete Erwin , Ruiz-Sandoval Jose L , Flores-Silva Fernando
Published: June 2021

Background and Purpose:
The objective of this study were to describe the proportion of patients eligible for the COMPASS trial among stable outpatients with either established atherothrombotic disease or major vascular risk factors, and to analyze 6-month incident stroke risk according vascular risk factors at baseline.

Methods:
We prospectively recruited 5,101 stable outpatients in 172 sites, within the Mexican INDAGA cohort study. Inclusion criteria were age >18 years and established atherothrombotic disease [history of either acute coronary syndromes (ACS), acute ischemic stroke (AIS)/transient ischemic attack (TIA) or peripheral artery disease (PAD)] or major vascular risk factors (age <55 years plus ≥2 major vascular risk factors, or age ≥55 years plus ≥1 vascular risk factors). Among these patients, we applied the selection criteria of the COMPASS trial for analysis, dividing the population in no COMPASS criteria met and COMPASS criteria met, and this last group subdivided among patients with previous AIS/TIA and without this antecedent, in order to stratify the risk for stroke during 6-month follow-up (incident AIS/TIA).

Results:
Among 5,101 stable outpatients with either established atherothrombotic disease (n=2,827) or major vascular risk factors (n=2,274), a total of 1,927 (37.8%) met COMPASS trial criteria: 1,054 (54.7%) with established cerebrovascular disease (past history of AIS/TIA) and 873 (45.3%) without. During 6-month follow-up, there were 89 incident AIS/TIA (39 AIS and 54 TIA): 1.7% among the whole population and 2.2% among the COMPASS subgroup. AIS/TIA occurred in a similar frequency among the COMPASS subgroup with established cerebrovascular disease (1.6%) and COMPASS without cerebrovascular disease (0.9%) (P=0.18). After a Cox-proportional hazards model, independent predictors of incident AIS/TIA were age ≥65 years (HR: 1.99, 95% CI: 1.29-3.07) and established cerebrovascular disease at baseline (HR: 1.61, 95% CI: 1.02-2.53).

Conclusions:
The majority of stable outpatients at vascular risk met COMPASS selection criteria and could be good candidates for low-dose rivaroxaban in addition to aspirin. Short-term predictors of AIS/TIA were old age and history of cerebrovascular disease