bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 18: Diffusion Weighted Imaging Lesions in Patients With Acute Intracerebral Hemorrhage: A Pooled Analysis of Individual Patient Data From MISTIE-III, ATACH-II, I-DEF, and ERICH
Authors: Murthy Santosh B , Cho Sung-Min , Gupta Ajay , Shoamanesh Ashkan , Avadhani Radhika , Gruber Joshua , Greige Tatiana , Lioutas Vasileios-Arsenios , Norton Casey , Mandava Pitchaiah , Falcone Guido J , Sheth Kevin N , Qureshi Adnan I , Goldstein Joshua N , Kidwell Chelsea , Selim Magdy , Woo Daniel , Kamel Hooman , Ziai Wendy C , Hanley Daniel F
Published: June 2021

Introduction:
The etiology and significance of diffusion weighted imaging (DWI) lesions in patients with acute intracerebral hemorrhage (ICH) remain unclear. We evaluated which factors were associated with DWI lesions, whether associated factors differed by ICH location, and whether DWI lesions were associated with functional outcomes.

Methods:
We pooled individual patient data from the MISTIE III trial, the ATACH-II trial, the i-DEF trial, and the ERICH study. We included only patients who underwent protocolized magnetic resonance imaging (MRI) of the brain. A poor functional outcome was defined as a modified Rankin Scale (mRS) score of 4-6 at 3-6 months. We used mixed effects logistic regression with the study database as a random effect.

Results:
Among 1,775 ICH patients, there were 621 (35.6%) lobar, 978 (55.9%) deep, and 148 (8.5%) infratentorial ICHs. Median time to MRI scan was 1.5 days (IQR, 1-4). DWIHLs occurred in 559 (31.5%) patients, with 190 (34.3%) in lobar ICH and 320 (57.8%) in deep ICHs. In mixed effects regression models, factors associated with DWIHLs included younger age factors associated with DWIHLs after acute ICH included younger age (OR, 0.98; 95% CI, 0.97-0.99), black race (OR, 1.59; 95% CI, 1.18-2.16), admission systolic blood pressure (SBP per 10 mm Hg, OR, 1.13; 95% CI, 1.05-1.22), cerebral microbleeds (OR, 1.71, 95% CI, 1.24-2.35), and leukoaraiosis (OR, 1.60; 95% CI, 1.14-2.25). Patients with DWIHLs had higher odds of mRS 4-6 (OR, 1.57; 95% CI, 1.24-1.99) compared to those without, after adjustment for demographics and ICH severity. In subgroup analyses, similar factors influenced DWIHLs in deep ICH. However, in lobar ICH, younger age, admission SBP, and leukoaraiosis were associated with DWIHLs. Presence of DWIHLs was independently associated with poor mRS in deep ICH but not in lobar ICH. There was no relationship between acute BP lowering and DWIHLs, regardless of location.

Conclusions:
In a large, heterogeneous cohort of ICH patients, our results are consistent with the hypothesis that DWIHLs represent the effects of chronic hypertensive vasculopathy and acute blood pressure elevation. Furthermore, DWIHLs portend poor prognosis after ICH, particularly in deep hemorrhages.
Abstract 184: Unraveling Disparities: Stroke Literacy, Self-Efficacy, and Perceptions of Care Among Spanish-Speaking Stroke Survivors
Authors: Cheng Pamela , Vickrey Barbara , Barry Frances , Ayala-Rivera Monica , Cheng Eric , McCreath Heather , Sanossian Nerses , Mehta Bijal , Dutta Tara , Razmara Ali , Song Shlee , Bryg Robert , Towfighi Amytis
Published: June 2021

Background:
Approximately 25 million people in the US are Limited English Proficient (LEP). LEP individuals are more likely to feel dissatisfied with the quality of healthcare when compared to the English proficient, but little is known about LEP stroke survivors.

Objective:
To evaluate differences in stroke literacy, self-efficacy, and perceptions of healthcare delivery in English and Spanish-speaking individuals enrolled in the Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED) trial.

Methods:
SUCCEED participants were given the option of receiving the intervention in English or Spanish. Baseline differences in stroke literacy (Schneider et al), self-efficacy (General Self-Efficacy Scale), and perceptions of care (Patient Assessment of Chronic Illness Care and Consumer Assessment of Healthcare Providers and Systems) were compared using T-test, Chi Square, and Fisher Exact in individuals who chose Spanish vs. English.

Results:
Of 487 participants, 207 preferred English and 280 chose Spanish. Despite feeling more worried about having a stroke (77 % vs. 67%), and feeling at risk of having a stroke (63% vs. 45%), Spanish-speakers were less likely to identify 3 stroke risk factors (19% vs. 33%, all p<0.05). Half of Spanish-speakers had difficulty understanding what was being told to them (50% vs. 30%), and less than half felt confident filling out medical forms (40% vs. 70%, both p<0.05). Spanish-speakers responded favorably about the ease of hospital admission or accessing medical care (80% vs. 55% and 72% vs. 53%), but responded negatively about providers spending enough time with them or explaining things in a way that was easy to understand (56% vs. 24% and 52% vs. 28%, all p<0.05). Spanish-speakers were more likely to feel that providers did not listen or respect what they had to say (52% vs. 22% and 44% vs. 17%, both p<0.05).

Conclusion:
Among stroke survivors, Spanish-speakers were more likely to have low stroke literacy, low self-efficacy, and a negative perception of healthcare delivery despite feeling that healthcare was accessible. Recognizing language barriers as a contributor to healthcare disparities, and tailoring interventions to address these barriers are crucial.
Abstract 47: Using Ultrasound and Inflammation to Improve Prediction of Ischemic Stroke: A Secondary Analysis of MESA
Authors: de Havenon Adam H , Wong Ka-Ho , McNally J Scott , Majersik Jennifer
Published: June 2021

Background:
The Multi-Ethnic Study of Atherosclerosis (MESA) is a large prospective epidemiologic study of the clinical factors that can predict transition from asymptomatic to symptomatic cardiovascular disease. Although prior studies have looked at ischemic stroke, they have not systematically examined the relationship between baseline ultrasound and inflammation measurements and subsequent primary stroke risk.

Methods:
The primary outcome is incident ischemic stroke during follow-up. The predictors are 9 ultrasound-derived measurements and 5 serum measurements related to inflammation. We fit Cox models to ischemic stroke and adjusted for patient age, hypertension, diabetes, total cholesterol, and smoking. Using DeLong’s method, we compared the AUC of the baseline adjusted model to the AUC of the model with predictor variables that were significant in the Cox models, to determine if they improved stroke prediction.

Results:
We included 6,095 patients with an average age of 61.9 years. The primary outcome of ischemic stroke was seen in 107 patients (1.8%) and the mean follow-up time was 7.7 years. In the Cox models, we found that small artery elasticity (SAE), carotid distensibility (CD), carotid stenosis (CS), and interleukin-6 (IL6) were associated with incident stroke. The AUC of the baseline model to predict stroke, which included patient age, hypertension, diabetes, total cholesterol, and smoking, was 0.745. When we added tertiles of SAE, CD, IL6 and categories of CS, the AUC improved to 0.765 (p=0.021 for difference).

Conclusions:
In a multiethnic cohort of patients without CVD at baseline, we found several ultrasound measurements and a serum marker of inflammation which predicted the occurrence of a primary ischemic stroke. Adding these basic ultrasound and serum measurements significantly improved the prediction of stroke, which could have implications for primary prevention efforts.
Abstract 48: High-Resolution Vessel Wall Imaging of Cryptogenic Stroke: A 7T MRI Study
Authors: Roa Jorge A , Zanaty Mario , Ishii Daizo , Derdeyn Colin P , Bathla Girish , Limaye Kaustubh , Ortega-Gutierrez Santiago , Hasan David M , Samaniego Edgar A
Published: June 2021

Background:
High-resolution vessel wall imaging (HR-VWI) has emerged as a useful tool for characterization of intracranial vasculopathic processes. HR-VWI allows better characterization of the arterial wall and may aid in the identification of atherosclerotic plaques, intra-arterial hemorrhages such as in the case of dissections and/or increased contrast enhancement such as in vasculitis. 7T HR-VWI may provide additional information in the identification of stroke mechanism in patients with cryptogenic stroke.

Methods:
Patients with cryptogenic stroke were prospectively imaged with a 7T scan. Strokes were determined to be cryptogenic after an extensive diagnostic work-up was completed. T1-weighted (pre- and post-contrast), T2-weighted, TOF and SWAN sequences were obtained. Demographic and clinical information was gathered from electronic medical charts.

Results:
Seventeen patients were included. Mean age was 57.8 ± 16.3 years-old, and 10 (58.8%) were women. HR-VWI determined the etiology of AIS in all subjects: 12 (70.6%) intracranial atherosclerotic disease (ICAD), 3 small-vessel disease and 2 arterial dissections. Inter-observer agreement was κ = 0.92. Plaque enhancement was identified in 14 cases, and intraplaque hemorrhage in 1 case of arterial dissection. In a patient with angiography suggestive of Moyamoya disease, HR-VWI determined the presence of diffuse ICAD as the underlying cause of stroke.

Conclusion:
HR-VWI may be used in patients with cryptogenic stroke to identify the etiologic mechanism and guide treatment.

Figure:
Axial-DWI (A) shows an acute right-medullary infarct (arrow). (B) Right-VA stenosis (arrow) on CTA. 7T axial-SWAN (C) reveals focal-susceptibility (arrowhead) and intra-vessel hemosiderin (arrow) suggestive of IPH. Axial-T1 pre-contrast (D), post-contrast (E) and sagittal MPR (F) images show eccentric thickening/enhancement of right-VA (arrowheads), compared to normal-appearing left-VA (arrows D-E).
Abstract 59: The Efficacy of a Patient-Centered Self-Management Empowerment Intervention Program for First-Time Stroke Survivors: A Longitudinal Study
Authors: Chen Lu , Shen Xiaofang , Wang Fang , Lv Lin , Chen Yan
Published: June 2021

Keywords:
Patient-centered; Self-management; Empowerment; Stroke

Purpose:
To evaluate the efficacy of a patient-centered self-management empowerment intervention (PCSMEI) program for first-time stroke survivors on self-management behaviors, stroke related depression and quality of life.

Methods:
One hundred and forty-four first-time stroke survivors were recruited from a comprehensive hospital in China. Patients were randomly allocated into control group (CG: n=72) and intervention group (IG: n=72) after baseline measurement. The intervention group received patient-centered self-management empowerment intervention (PCSMEI) and the control group received a routine care. The data of self-management behaviors, stroke related depression and quality of life were collected at baseline (T0), on discharge (T1), one month post-discharge (T2) and three months post-discharge (T3). Descriptive and Generalized Estimating Equations Modelling (GEE) analyses were conducted to estimate the intervention effect over time.

Findings:
One hundred and twenty-six participants finished the study (IG: n=64; CG: n=62). Significant improvement in self-management behaviors in the intervention group were observed in stretching or strengthening at T2 and T3; cognitive symptom management at T1, T2 and T3. The depression level was lower in IG than that in CG at T1, T2 and T3. Significant difference in quality of life between the two groups were shown in Physical Component Summary (PCS) at T3 and in Mental Component Summary (MCS) at T2 and T3.

Conclusions:
The patient-centered self-management empowerment intervention program appears to be an effective and well-received solution to improve first-time stroke patients’ self-management behaviors, stroke related depression and quality of life.

Clinical Relevance:
This program may be effective for first-time stroke patients.
Abstract 96: Greater Clinical Impact of Thrombectomy Compared to Thrombolysis in First Year of Melbourne Mobile Stroke Unit Operation
Authors: Zhao Henry , Coote Skye , Easton Damien , Langenberg Francesca , Stephenson Michael , Smith Karen , Bernard Stephen , Kim Joosup , Cadilhac Dominique , Churilov Leonid , Brooks Mark , Asadi Hamed , Thijs Vincent , Chandra Ronil , Ma Henry , Desmond Patricia M , Mitchell Peter J , Yassi Nawaf , Yan Bernard , Campbell Bruce C , Parsons Mark W , Donnan Geoffrey A , Davis Stephen M
Published: June 2021

Introduction:
The role of mobile stroke units (MSU) in earlier provision of thrombolysis (tPA) is well described, but the effect on endovascular thrombectomy (EVT) is less clear. Despite the theoretical advantages of improved triage and prehospital activation of EVT services, only a small effect on hospital arrival to EVT start has so far been described. We aimed to analyze the clinical benefit of EVT and tPA from operation of the Melbourne MSU in the first year.

Methods:
First ambulance dispatch to reperfusion treatment commencement (DTT) times between MSU patients receiving reperfusion therapy from November 2017-18 were compared to consecutive control cases during MSU operating hours presenting across metropolitan Melbourne for tPA, and direct and metropolitan transfer patients presenting to the Royal Melbourne Hospital for EVT. Median time difference between MSU and controls was regarded as the 50
th
quantile using quantile regression analysis. Comparative disability avoidance was estimated for EVT and tPA using calculated time savings.

Results:
In the first calendar year, the MSU operated for 30.5 service (7-day) weeks. Prehospital tPA was administered to 52 patients, with median time differences for dispatch-to-hospital/scene-arrival of -30 minutes (p<0.0001) and arrival-to-tPA of -17 minutes (p=0.001), resulting in overall DTT time saving of 47 minutes compared to controls. In the same timeframe, 26 patients received EVT with median time difference of -51 minutes (p<0.0001) compared to controls. Prehospital notification resulted in median time difference of -17 minutes (p=0.001) for EVT center-arrival to groin puncture. Using published estimates of disability avoidance per minute of time saved for each reperfusion therapy, the clinical impact of the EVT time saving for the 26 MSU patients is equivalent to the clinical impact of 67 tPA patients treated on the MSU.

Conclusion:
The clinical impact of Melbourne MSU operation on earlier provision of EVT was greater than that of tPA in the first year of operation, reflecting facilitated triage to EVT centers and early prehospital notification. In locales where EVT capability is limited or unevenly distributed such as Melbourne, facilitation of EVT is likely to be a central driver of MSU operation.
Abstract 97: Cerebrovascular Trained Advance Practice Nurse Practitioners Can Safely and Accurately Administer Alteplase as Well as Their Neurology Physician Colleagues via Telemedicine
Authors: Moore Kari D , Liu Ruolan , Wise Elizabeth , Shah Jignesh , Eaton Calhoun Mary Jo , Haboubi Michael
Published: June 2021

Background:
Acute Ischemic Stroke (AIS) treatment is time sensitive. Many hospitals lack neurology expertise on site to assess patients and assist emergency medicine colleagues with administration of thrombolytic therapy. Telestroke services have been shown to be as safe for administering thrombolytic therapy as on-site neurological expertise. Neurologists covering acute stroke services on-site and via telemedicine are in short supply. Advance Practice Registered Nurses (APRNs) specializing in stroke and cerebrovascular disease have helped fill the gap, however, data are lacking on APRN acute telestroke coverage, thrombolytic administration, and patient outcomes.

Purpose:
The aim was to determine whether cerebrovascular trained APRNs covering our 24/7/365 CSC telestroke service could accurately and safely administer alteplase as well as our neurology physician colleagues.

Methods:
All consecutive AIS telestroke consults were reviewed at 2 rural community hospital spoke sites from 1/1/17-7/1/19. Telestroke call was shared among neurologists and 2 APRNs. Both APRNs have > 10 years of cerebrovascular disease experience. Nationally accepted AHA guidelines for inclusion/exclusion for alteplase (tPA) administration were followed and documented accordingly up to 4.5 hours from onset.

Results:
A total of 1,515 telestroke consults were performed (427 MD, 1088 APRN). Of those, 121 were diagnosed with suspected AIS, met criteria for tPA, and it was administered.

Conclusions:
APRNs at our CSC providing telestroke coverage at 2 rural community hospitals resulted in no statistical difference in stroke care delivery and patient outcomes compared to our physician colleagues. Incorporating APRNs into telestroke call coverage needs further study to better define necessary telehealth training, curriculum, standardized professional competencies, and consideration of state laws.
Abstract TMP12: The Effect of Anesthesia Type on Endovascular Thrombectomy Outcomes is Modified by Stroke Size: A Secondary Analysis From the SELECT Study
Authors: Sarraj Amrou , Chen Peng R , Hassan Ameer , Grotta James C , Sitton Clark , Abraham Michael , Vora Nirav , Blackburn Spiros , Cai Chunyan , Pujara Deep , Reddy Sujan , Parsha Kaushik , Imam Bita , Shaker Faris , Kamal Haris , Gupta Rishi , Martin-Schild Sheryl , Hicks William J , Arora Ashish , Haussen Diogo , Barreto Andrew D , Riascos Roy F , Lansberg Maarten , Savitz Sean I , Albers Gregory W
Published: June 2021

Background:
The effect of anesthesia choice on endovascular thrombectomy (EVT) outcomes is unclear.

Methods:
In the prospective multicenter cohort study of imaging selection for EVT (SELECT), patients were stratified based on their anesthesia type into general anesthesia (GA) and conscious sedation (CS). EVT times and outcomes were compared. Further we assessed the impact of ischemic core size (rCBF<30%) on the correlation between anesthesia type and EVT outcomes.

Results:
Of 361 enrolled, 285 received EVT. 129 (45%%) received GA and 156 (54%) CS. The baseline characteristics were similar, except for presentation NIHSS (GA 17(13-21), CS 15(11-20), p=0.027) and ischemic core volume (GA 14.1 cc (0-38) vs CS 6.3(0-26.1), p=0.034). GA was associated with numerically longer arrival to GP times 92 (68—115) vs. 85(60-117) mins, p=0.58. After adjustment for baseline imbalances, patients who received CS had a shift toward better outcome (adj cOR 1.72, 95% CI=1.08-2.75, p=0.022) with higher functional independence rates 56.8% vs 48.8%, p=0.75. Furthermore, GA was associated with higher mortality rates (19% vs 9%, p=0.017), figure 1A.

In patients with core volume ≥ 50 cc, there was a trend for a shift towards better outcomes (adj cOR=5.84, 95%CI= 0.90-38.00, P=0.065), figure 1B while there was no difference in patients with core volume < 50 cc (adj cOR=1.01 (95%CI 0.53-1.94, P=0.96), figure 1C. There was an interaction between core volume size and anesthesia type on functional outcome (p=0.042). For every 10cc increase in the core volume, the odds of attaining better functional outcome decreased by 29% (adjusted cOR: 0.71, 95% CI=0.61-0.83, p<0.001) with GA as compared to only 16% (adjusted cOR: 0.84, 95% CI=0.73-0.96, p=0.01) with CS.

Conclusion:
Conscious sedation was associated with a shift towards better EVT outcomes. This effect was driven by patients with larger ischemic core volumes and has implications for randomized trials of conscious sedation vs general anesthesia.
Abstract TMP22: Dynamic Worsening of Epileptiform Abnormalities Following Subarachnoid Hemorrhage is Associated With Poor 3-Month Outcomes
Authors: Lissak India A , Zafar Sahar F , Anderson Kasey , Kim Jennifer A , Westover M. Brandon , Kimberly W. Taylor , Rosenthal Eric S
Published: June 2021

Objective:
Worsening epileptiform abnormalities (EAs) and deteriorating background activity are common continuous electroencephalography (cEEG) patterns that predict subsequent clinical deterioration following subarachnoid hemorrhage (SAH). While worsening EAs and background deterioration both imply cortical dysfunction, we sought to clarify if these patterns have a different association with clinical outcomes.

Methods:
We enrolled patients with SAH undergoing
>
3 days of cEEG monitoring enrolled in a prospective outcome study with a modified Rankin Scale (mRS) assessment at 3 months. Worsening EAs included new or increasing burden of sporadic epileptiform discharges, lateralized rhythmic delta activity (LRDA), lateralized periodic discharges (LPD), or generalized periodic discharges (GPD). Background deterioration was defined as decreasing Alpha Delta Ratio (ADR), Relative Alpha Variability (RAV) or worsening focal slowing. We evaluated the association between these cEEG patterns and 3-month mRS >3 and examined whether the influence on outcome was independent of delayed cerebral ischemia (DCI).

Results:
Of 59 patients meeting inclusion criteria (3-month mRS median 3 [IQR 1-5]), worsening EAs developed in 23 (39%) and new background deterioration in 24 (41%), whereas 24 patients (41%) developed neither finding and 12 (20%) developed both. Patients with worsening EAs were more likely to have a poor 3-month mRS compared to those without worsening EAs (OR 6.44; 95%CI 1.99-20.9; p=0.001). Developing new background deterioration was not significantly associated with poor 3-month outcome (OR 1.56, 95%CI 0.53-4.59; p=0.42). There was no additive effect on poor outcome of developing both findings. In a multivariate logistic regression, the effect of worsening EAs on 3-month mRS was independent of DCI.

Interpretation:
While both worsening EAs and new background deterioration have previously been associated with DCI, only worsening EAs influences poor long-term outcome. Further investigation may clarify if distinct mechanisms underlie these differences.
Abstract TMP34: Longitudinal Calcium Imaging Reveals Circuit Switching and Abnormal Response Fidelity in Somatosensory Vip Interneuron Circuits in the Stroke Damaged Brain
Authors: Brown Craig E , Motaharinia Mohammad
Published: June 2021

Although inhibitory cortical interneurons play a critical role in regulating brain excitability and function, the effects of stroke on these neurons is poorly understood. In particular, interneurons expressing vasoactive intestinal peptide (VIP) specialize in inhibiting other classes of inhibitory neurons, and thus serve to modulate cortical sensory processing. To understand how stroke affects this circuit, we imaged VIP neuron structure and function (using GCaMP6s) before and after focal stroke in forelimb somatosensory cortex. Stroke led to a significant loss of peri-infarct pre-synaptic boutons and dendritic spines that was followed by a wave of bouton/spine production. Larger-scale changes, such as pruning/growth of axons or dendritic branches was observed, albeit on a limited scale. Functionally, the fraction of forelimb responsive VIP interneurons and their response fidelity (defined as the % of forelimb responsive trials) was significantly reduced in the first week after stroke. The loss of responsiveness was most evident in highly active VIP neurons (defined by their level of responsiveness before stroke), whereas less active neurons were minimally affected. Of note, a small fraction of VIP neurons that were minimally active before stroke, became responsive afterwards suggesting that stroke may unmask sensory responses in some neurons. Although VIP responses to forepaw stimulation generally improved although not fully from 2-5 weeks recovery, the variance in response fidelity after stroke was comparatively high and therefore less predictable than that observed before stroke. Lastly, stroke related changes to synaptic structure and response properties were both restricted to within 400μm of the infarct border. These findings reveal the dynamic and resilient nature of VIP neurons and suggest that a sub-population of these cells are more apt to lose sensory responsiveness during the initial phase of stroke, whereas some minimally responsive cells are progressively recruited into the forelimb sensory circuit. Furthermore, stroke appears to disrupt the predictability of sensory evoked responses in these cortical interneurons which could have important consequences for sensory perception.
Abstract TMP58: Major Risk Factors and the Risk of All, Ischemic, and Hemorrhagic Stroke in Half a Million Women and Men in the UK Biobank
Authors: Peters Sanne , Carcel Cheryl , Millet (deceased) Elizabeth , Woodward Mark
Published: June 2021

Background:
Major differences between women and men exist in the clinical presentation, medical care, and prognosis and outcomes of stroke. We assessed the sex-specific association of major risk factors and the risk of incident stroke, including its major subtypes, among women and men.

Methods:
Between 2006-10, the UK Biobank recruited over 500,000 participants aged 40-69 years across the UK. During 9 years of follow-up, 4,662 (44% women) cases of stroke were recorded among 471,971 (56% women) individuals without a history of cardiovascular disease at baseline. Cox regression models yielded adjusted hazard ratios (HRs), and women-to-men ratios of HRs (RHR), for stroke associated with seven risk factors.

Results:
The incidence rate per 10,000 person years was 8.66 (8.29; 9.04) in women and 13.96 (13.44; 14.50) in men for any stroke; 6.06 (5.75; 6.38) in women and 11.35 (10.88; 11.84) in men for ischaemic stroke, and 1.56 (1.41; 1.73) in women and 2.23 (2.02; 2.45) in men for haemorrhagic stroke. The magnitude of the relationship between increases in indices of blood pressure, body anthropometry, and lipid levels, diabetes mellitus, and atrial fibrillation and the risk of any stroke was similar between men and women. Hypertension (stage 2), current smoking, and a low socioeconomic status, respectively, were associated with a greater HR of any stroke in women than men; the RHRs were 1.36 (1.26; 1.47), 1.18 (1.02; 1.36), and 1.17 (1.03; 1.33). Diabetes was associated with a higher HR of ischaemic stroke in women than men (RHR: 1.25 [1.00; 1.56]). Atrial fibrillation was associated with a higher HR of haemorrhagic stroke in women than men (RHR: 2.80 [1.07; 7.36]). The incidence of stroke was higher among men than women for all risk factors, except type 1 diabetes and atrial fibrillation (haemorrhagic stroke only).

Conclusion:
Several risk factors are more strongly associated with the risk of any stroke or stroke subtypes in women compared with men. Despite this, the incidence of stroke in the presence of risk factors generally remains higher among men than women.
Abstract TMP65: The Effects of Standardized Nursing Protocols on Stroke Code Time Metrics - A Multi-Site Telestroke Study
Authors: Provencher Michelle , Figueroa Stephen , Novakovic Robin , Hynan Linda , Vahidy Farhaan , Olson DaiWai , Goldberg Mark
Published: June 2021

Introduction:
Emergency Departments utilizing telestroke technology are less likely to meet American Heart Association/American Stroke Association’s recommended Door to Needle goal of less than 45 minutes. The Nursing Driven-Acute Stroke Care (NAS-Care) study tested effects of standardized stroke protocols on key workflow best practices.

Methods:
Seven non-academic stroke hospitals in the Lone Star Stroke Consortium’s network participated in this prospective, multi-site, baseline-controlled study from February 2015 - December 2018. After three months of blinded baseline data collection, the following interventions were implemented: NIHSS certification, nursing education including mock stroke codes, and a standardized flowsheet for code organization and documentation. The NAS-Care Run Sheet was also used to collect six months of post-intervention data.

Results:
Six hospitals completed the study. Study enrolment was halted after interim analysis of 447 patients, 180 in the pre-intervention control group and 267 in the post-intervention follow-up. The proportion of patients receiving alteplase was 18.9% (control) and 18.4% (intervention, NS). In the interim analysis, Door-to-ED Provider and Door-to-CT times were reduced after intervention while Door-to-Specialists and Door-to-Needle times were not significantly improved (table).

Conclusion:
Standardized nursing education and protocols improved staff-dependent initial stroke time metrics in Emergency Departments utilizing telestroke. Additional workflows for telestroke physicians may be required to optimize alteplase administration metrics. Final results of the NAS-Care study will be presented at the International Stroke Conference.
Abstract TMP69: Pre-Mixing IV TPA for Acute Ischemic Stroke Treatment: Impact on Door to Needle Times, SICH Rates, Patient Selection, and Amount of Drug Wasted With Associated Costs
Authors: Sessa Joy , Sherman Veronica , Doctor Norman , Rogers Bradley , Ham Jared , Vinitskaya Irina , DiMartini Gina , Mehta Brijesh
Published: June 2021

Acute ischemic stroke (AIS) is a significant concern in the United States with 795,000 people suffering strokes annually (Benjamin, 2019). The irreversible effects of a minute of acute brain ischemia is significant—1.9 million neurons lost (Saver, 2006). Thrombolytic therapy has been a key component of stroke treatment with McTaggart, (2015) recommending a 30 minute door to needle (DTN) goal. Target Stroke II (2017) recommends pre-mixing tPA. However, little is known about the safety and efficacy of this practice.

This study retrospectively reviewed 211 AIS patients treated at 2 stroke centers to measure the efficacy & safety of a standardized pre-mix criteria for tPA administration. Variables included DTN times, SICH rates, rate of tPA vials wasted & reimbursed, and patient selection (acute infarct on imaging). Study inclusion criteria: adults (≥ 18 years) without contraindications to tPA, baseline NIHSS
>
4, onset of focal neurological deficits < 4.5 hrs, not on anticoagulants, & initial SBP
<
185.

Treatment group patients (n=107) received pre-mixed tPA (mixed prior to resulted NCCT). Retrospective comparison group patients (n=104) met the same inclusion parameters as the treatment group.

Study results: median DTN time for the comparison group: 30 min (StD=19.6); treatment group: 20 min (StD=13.5) (p = 0.00002), a 33% decrease in DTN time. SICH rates for the comparison group: 1.4%; treatment group: 0.8%. tPA vials wasted: comparison group: 13%, treatment group: 22%, a 9% increase in vial wastage when pre-mixing tPA. The percentage of wasted vials reimbursed by the manufacturer was 100% for both groups. Patient selection accuracy was 66% for the comparison group and 51% for the treatment group, a 15% accuracy decrease for the pre-mix group.

In conclusion, implementing a pre-mix criteria for tPA decreased DTN times significantly without increasing SICH rates. Use of a pre-mix criteria did not demonstrate improved patient selection, evidenced by the lower rate of acute infarcts on imaging in pre-mixed patients. Although the drug wastage increased in the treatment group, reimbursement rates remained at 100%. Utilizing a standardized pre-mix criteria for tPA is a safe, effective way to decrease door to needle times without compromising financial stability.
Abstract TMP8: Nationwide Analysis of Endovascular Thrombectomy Provider Specialization
Authors: Stein Laura K , Fifi Johanna , Tuhrim Stanley , Mocco J , Dhamoon Mandip
Published: June 2021

Introduction:
Endovascular thrombectomy (ET) has the greatest benefit of all acute ischemic stroke (AIS) therapies. However, ET trials were performed in centers with rigorous protocols, expert procedural skill, and cerebrovascular specialists. Systems of care are evolving to meet LVO clinical demand nationwide, and real-world data are needed regarding case volumes and provider specialty to better evaluate expertise, quality, and capacity.

Methods:
Using de-identified 100% inpatient Medicare data from 2016-2017 for individuals aged
>
65 years in the US, we utilized validated International Classification of Diseases, 10
th
Revision, Clinical Modification codes to identify admission with AIS and treatment with ET. We identified proceduralist specialty by linking the ET proceduralist National Provider Identifier (NPI) to the provider specialty listed in the NPI database, grouping specialty into: radiology, neurology, neurosurgery, other surgical, and internal medicine. We calculated the number of proceduralists and hospitals who performed ET, the ET team specialty composition by hospital, and the number of proceduralists who perform ET at multiple hospitals.

Results:
Among 13,311 AIS patients treated with ET, 2,754 different proceduralists treated at 641 hospitals. The median number of proceduralists per hospital was 4. 11.7% (n=322) of proceduralists performed ET at multiple hospitals. The ET team included a neurology- or neurosurgery-trained proceduralist at 64.9% (n=407) of hospitals that performed ET, and included both in 25.6% (n=160) of teams. At 175 hospitals that performed <5 ET cases, surgery- and internal medicine-trained proceduralists treated 26.9% and 12.8% of total cases, respectively, but only 1.9% and 2.4% at the 151 hospitals that performed >30 ET. As hospital case volume increased, there was a progressive increase in the proportion of cases performed by neurosurgeons and neurologists.

Conclusion:
Nationally, 65% of ET teams include a neurology- or neurosurgery-trained proceduralist, more often in higher volume hospitals. A minority of LVO stroke is treated by proceduralists who perform ET at multiple hospitals. A better understanding of the impact of ET team structure on access to care and outcomes is essential.
Abstract TMP98: Increased Fractalkine and Decreased RANTES Concentrations Predict Progression of Carotid Stenosis Severity at Twenty Months
Authors: Ramirez Jimenez Arleen , Khattab Mohamad , Vincent Andrea , Dale George , Kirkpatrick Angelia
Published: June 2021

Introduction:
Studies have demonstrated that progression of carotid stenosis severity in asymptomatic patients is associated with increased stroke risk. Identifying stenosis progression mechanisms would improve risk prediction and development of novel targeted treatments. We now examine the association between soluble mediators of inflammation, cell adhesion, angiogenesis and coagulation and progression of stenosis severity in asymptomatic carotid stenosis.

Methods:
Asymptomatic patients with 50-79% carotid stenosis were enrolled and carotid Doppler surveillance performed every 6-12 months. Plasma was obtained at baseline for measurement of 50 plasma biomarkers of inflammation, cell adhesion, and angiogenesis. Carotid stenosis progression was confirmed by blinded adjudication. Variables associated with progression of stenosis severity (p<0.15) were included in multivariate analysis. Variables retained as significant were included in cox proportional hazard analysis.

Results:
We enrolled 108 patients (96% male, 34% smokers, average HgA1c 6.6% and average LDL 86 mg/dL). Stenosis severity progressed in 14 (13%) over 20 ± 11 months. Fractalkine (p=0.018), IL-7 (p=0.087), IL-18 (p=0.087), PAI1 (p=0.0871), IL-13 (p=0.0939), and RANTES (p=0.0097) were included in multivariate analysis. Fractalkine (OR = 5.5, p=0.0157) and RANTES (OR = 0.133, p=0.0127) were retained in the final model. Fractalkine concentrations ≥16.9 pg/ml yielded a HR of 4.67 (95% CI 1.3, 16.8; p=0.0093) and RANTES concentrations ≥430 pg/ml yielded a HR of 0.16 (95% CI 0.036, 0.728; p=0.0121) for stenosis progression.

Conclusions:
Our results show that increased Fractalkine and decreased RANTES concentrations predicted carotid stenosis severity progression at 20 months. Fractalkine is increased in human coronary and carotid artery plaques and prolongs survival of monocytes/macrophages contributing to atherosclerosis progression in Apo E -/- mice. RANTES binds endothelial CCR receptors facilitating migration of T cells and monocytes into the intima. Decreased RANTES levels have been linked to adverse coronary artery disease outcomes. Further study to clarify the role of Fractalkine and RANTES in atherosclerosis progression is warranted.
Abstract TP102: Human Placental Mesenchymal Stem Cells Derived Exosome-Angiotensin Converting Enzyme-2 Dependent Protection in Ischemic Stroke Injury
Authors: Barzegar Mansoureh , Wang Yuping , Yun Jungmi W. , Chernyshev Oleg , Kelley Roger , Alexander Jonathan S.
Published: June 2021

Following thrombolytic therapy for stroke, ischemia/reperfusion (I/R) mediated inflammation often disrupts the blood brain barrier (BBB). This can enhance expression of endothelial adhesion markers and perturb normal blood flow regulation. Proposed benefits of stem cell therapy (SCT) in stroke, besides long-term trans-differentiation into neural cells, include secretion of protective factors, which partly depends on exosomes released by stem cells. We evaluated human placenta mesenchymal stem cells (hPMSC) as potential ameliorative SCT in an acute ischemic stroke model. We hypothesize that hPMSC would achieve site-specific suppression of post-ischemic immune cell transmigration, preservation of the BBB and maintenance of blood flow via ‘paracrine’ signaling pathways in acute stroke injury.We found that intraperitoneal (IP) administration of hPMSC at the time of reperfusion, using the middle cerebral artery occlusion (MCAO)/reperfusion model, produced significant protection (
p
=0.0001) of the ipsilateral hemisphere. We also demonstrated that hPMSC-treated MCAO mice exhibited significantly greater neurological recovery (
p
<0.0001) compared to untreated MCAO, an effect which was accompanied by significant restoration of blood flow (
p
<0.01) to the MCAO-stressed brains. Using Evans Blue dye assay, we also observed significant (
p
=0.004) improvement of BBB integrity in ipsilateral hemispheres of hPMSC-treated mice vs MCAO controls. Furthermore, we determined that hPMSC-derived
exosomes
contribute to paracrine based protection of hPMSC in MCAO model. Importantly, we found that hPMSC/exosome protection is mediated partly by the function of angiotensin converting enzyme 2 (ACE2). To evaluate the contribution of ACE2 in protection of the brain after ischemic stroke, we first demonstrated that hPMSC and their exosomes express ACE2. Second, mice injected with hPMSC which had been pre-treated with the specific ACE2 inhibitor (10μM) MLN-4760, showed tissue injury and neurological behavior similar to that seen in untreated MCAO.We conclude that pleiotropic factors associated with hPMSC administration can have a favorable impact on blood flow, BBB integrity potentially alleviating the detrimental effects of ischemic stroke.
Abstract TP104: Post Stroke Depressive-Like Behaviors in Middle-Aged Female Rats is Associated With Gut Dysbiosis and Improved by Mir363-3p
Authors: Stewart Courtney , Panta Aditya , Branyan Taylor , Sohrabji Farida
Published: June 2021

Background:
Post-stroke depression (PSD) occurs in one-third of stroke survivors, is more prevalent in women, and negatively impacts quality of life and recovery. Our previous work showed that acyclic middle-aged female rats display depressive behaviors after stroke, and IV treatment with mir363-3p attenuates these behaviors. Serotonin has been implicated in affective behaviors, and loss of this neurotransmitter is also associated with decreased neurogenesis in the hippocampus. The present study determined (a) whether stroke affected tryptophan, a gut metabolite, and precursor for serotonin, and cell proliferation in the hippocampus and (b) whether serum tryptophan levels and hippocampal cell proliferation was restored by mir363-3p.

Methods:
Ischemic stroke was induced by stereotaxic delivery of endothelin-1 to the MCA of middle-aged female rats. Animals received a single injection of mir363-3p or scrambled oligos 4h after stroke. Depressive-like behaviors were assessed by the Effort-based sucrose consumption test, Social Interaction and Forced Swim Test 3 months after stroke. Blood was collected at termination. Serum tryptophan levels were quantified by ELISA. Bacterial composition was analyzed by 16S sequencing of fecal samples. Ki67 immunohistochemistry was performed on brain tissue collected at termination and quantified within the dentate gyrus by two blind observers.

Results:
Animals subjected to stroke exhibited depressive-like behaviors and had decreased tryptophan levels as compared to sham treated animals. This is also accompanied by microbiota dysbiosis as measured by an elevated ratio of Firmicutes to Bacteroidetes. Mir363-3p treatment increased tryptophan levels as compared to scrambled controls and were no different from sham (non-stroke) animals. Moreover, miR363-3p treated rats exhibit a significantly more dentate gyrus-specific Ki67 expression a proliferation marker.

Conclusions:
Together, these data indicate that miR363-3p attenuates post stroke depression via a mechanism that prevents microbiota dysbiosis and increases hippocampal cell proliferation.
Abstract TP105: The Neuroprotective Efficacy of Regional Cerebral Hypothermia Induced via a New Intrajugular Cooling Method in Experimental Ischemic Stroke
Authors: Duan Yunxia , Huber Mitchell , Wu Di , Ji Xunming , Ding Yuchuan
Published: June 2021

Background:
Therapeutic hypothermia as a neuroprotective strategy after stroke has been well established in animal models, but its application in humans has been limited by logistical challenges. To provide a solution to these challenges, this study was designed to determine the hypothermic and neuroprotective efficacy of infusing cold saline directly into the internal jugular (IJ) vein, and compare the effects of IJ regional cerebral hypothermia to those achieved by intra-carotid (IC) artery regional hypothermia in an ischemic stroke model.

Methods:
Middle cerebral artery occlusion was established in rats using an intraluminal filament. Regional cerebral hypothermia was then achieved by infusion of 6 ml of 0 °C isotonic saline by micro-catheter into the right IJ or right IC for 30 minutes immediately after the initiation of reperfusion. Infarct sizes, neurological deficits, edema volume, blood brain barrier (BBB) damage, BBB associated molecules (MMP-9 and AQP-4), and apoptosis associated proteins (Bcl-2 and cleaved Caspase-3) were measured.

Results:
Both IJ and IC infusion led to a significant, rapid reduction in brain temperatures while having a minimal effect on rectal temperatures. Infarct sizes were significantly reduced at 24 hours after reperfusion by IC and IJ treatments. Neurologic deficits were also significantly improved by IC and IJ infusion compared to control models over a 28-day observation period. Both IC and IJ significantly reduced Evans Blue leakage and edema volume compared with control groups. MMP-9 and AQP-4 expression were also reduced, Bcl-2 increased, and cleaved Caspase-3 decreased in the IC and IJ groups.

Conclusion:
Compared to IC infusion, IJ infusion conferred a similar degree of regional cerebral hypothermia and neuroprotection following ischemic stroke. Given the ease of establishing vascular access via the internal jugular vein and the powerful neuroprotection that hypothermia provides, IJ regional brain cooling could be utilized as a promising hypothermia-induction modality due to its safe, quick, and effective features.
Abstract TP106: Automated Assessment of Behavioral Function After Experimental Stroke
Authors: Chiang Terrance , Harvey Sean , Pendharkar Arjun V , Cheng Michelle Y , Steinberg Gary K
Published: June 2021

Introduction:
Manual scoring of behavior tests is commonly used for assessing motor deficits after stroke, however, it is labor intensive and subject to bias. These limitations lead to inconsistent assessment between research groups and non-reproducible data. In this study, we investigated the feasibility of an automated motor deficit assessment system, Erasmus ladder, in two ischemic stroke models.

Methods:
Distal middle cerebral artery occlusion (dMCAO n=10) or transient middle cerebral artery occlusion (tMCAO 30 minutes, n=15) were performed on male C57BL6J mice (11-13 weeks) to generate cortical ischemic stroke, with. Naïve mice (n=10) were used as controls. Immunohistochemistry was performed on brains collected at post-stroke day (PD) 30 to assess for infarct size (MAP2) and inflammation (CD68). Mice without infarct in both cortex and striatum were excluded from the study. Behavior was assessed using Erasmus ladder at pre-stroke baseline (4 unperturbed and 4 perturbed sessions) and on PD 7, 14, 21, and 28 (all perturbed sessions).

Results:
Erasmus ladder detected significant motor deficits in the tMCAO model, specifically in the pre- and post- perturbed times as well as several key step types (HH long). Analyses in the tMCAO model reveal changes in various step patterns and their capability to react to the perturbation (obstacle). These significant motor deficits after tMCAO were detectable until PD28. We also observed a sustained decline in the use of affected limb compared to unaffected limb until PD28. While this trend is also present in dMCAO model, motor deficits were detected in the dMCAO only at early timepoints (PD7) and the difference subsided by PD28.

Conclusion:
We have assessed the data collected by Erasmus ladder on mice that underwent two commonly used stroke models (tMCAO and dMCAO). Our data showed that Erasmus ladder can detect long term motor deficit including reduced use of affected limb, step pattern, and motor reaction to obstacle. This automated instrument is effective in detecting motor deficits in the tMCAO model and thus, can be used to evaluate treatments for enhancing recovery after stroke.
Abstract TP125: Stent as a Treatment for Cranio-Cervical Artery Dissection: Improved Major Adverse Cardiovascular Events-Free Survival
Authors: Vezzetti Alex , Rosati Lauren , Graham Cole , Moftakhar Roham , Mangubat Erwin , Sen Souvik
Published: June 2021

Introduction:
Cranio-Cervical Artery Dissection (CeAD) is a relatively common cause of cerebrovascular event in young subjects for which no clear treatment strategy is established. We evaluated the incidence of major adverse cardiovascular events (MACE) in CeAD patients treated with and without stent placement.

Methods:
COMParative effectiveness of treatment options in cervical Artery diSSection (COMPASS) is a single high-volume center prospective longitudinal registry that enrolled consecutive CeAD patients over a 2-year period. Patients were ≥18 years of age with confirmed extra- or intracranial CeAD on imaging. Enrolled participants were followed for 1-year evaluating MACE as the primary end-point.

Results:
One-hundred eleven patients were enrolled (age 53 ± 15.9, 56% Caucasian, 50% male, BMI 28.9 ± 9.2). Grade 1, 2, 3, and 4 blunt vascular injury noted in 16%, 33%, 19%, and 32%, respectively. Forty-percent of dissections were due to known trauma. A predisposing factor was noted in the majority (78%), including violent sneezing, carrying heavy load, sports/recreation activity, chiropractic manipulation, and abrupt/prolonged head rotation. Stent was placed in 11 (10%) subjects (extracranial carotid n=8; intracranial carotid n=2; extracranial vertebral n=2) at the physician’s discretion. Similar to the CADISS trial, there was no significant difference between antiplatelet/anticoagulant groups in terms of MACE. Stented patients experienced fewer MACE than non-stented patients (log rank p=0.1), as depicted in the Kaplan-Meier curve (Figure 1). The CeAD patients with stents did not experience any MACE events in the 1-year follow-up.

Conclusion:
In this single high-volume center cohort of CeAD patients, we report a promising strategy of MACE prevention using stent placement. This data will help sample size estimation for a future randomized trial.