bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P307: Similar Rates of Early Cognitive Dysfunction after Intracerebral Hemorrhage and Acute Ischemic Stroke
Authors: Denny M. Carter , Bajgur Suhas S , Vu Kim Y , Karamchandani Rahul R , Sarraj Amrou , Savitz Sean I
Published: July 2021

Introduction:
Post-stroke cognitive dysfunction (CD) affects at least 1/3 of acute ischemic stroke (AIS) patients when assessed at 3 months. Limited data exists on CD in intracerebral hemorrhage (ICH). The role of early, in-hospital cognitive screening using the brief Montreal Cognitive Assessment (mini MoCA) is being investigated at our center.

Hypothesis:
We assessed the rates of early CD in ICH and AIS and hypothesized that even minor deficits from these disorders causes significant CD.

Methods:
1218 consecutive stroke patients admitted from 2/13 to 12/13 were reviewed; 610, 442 with AIS and 168 with ICH, with admission NIHSS and mini MoCAs were included in the final analyses. CD was defined as mini MoCA <9 (max 12). Poor outcome was defined as discharge mRS 4-6. Stroke severity was stratified by NIHSS score of 0-5, 6-10, 11-15, 16-20, 21-42 as in ECASS-I . Chi-squared tests and univariate logistic regression analyses were performed.

Results:
Baseline characteristics are shown in table 1. AIS and ICH groups were similar with regard to race, gender and stroke severity. ICH patients were younger, had longer stroke service lengths of stay and poorer outcomes than AIS patients (p=0.03, p<0.001, p<0.001). No difference was seen in rates of CD between AIS and ICH patients (60% vs. 57%, p=0.36, OR 1.2 (CI 0.8-1.7)). CD rates ranged from 36% for NIHSS 0-5 to 96% for 21-42 (figure 1). Older patients were twice as likely to have CD (p<0.001, OR 2.2 (CI 1.6 - 3.0)). Patients with CD had five times the odds of having a poor outcome compared to the cognitively intact (p<0.001, OR 5.2 (CI 3.4-7.7)). In univariate logistic regression analyses, age was a significant predictor of CD in AIS, but not in ICH (p= <0.001, p=0.06).

Conclusion:
Post-stroke CD is common across all severities and occurs at similar rates in AIS and ICH. More than 1/3 of patients with minor deficits (NIHSS 0-5) had CD in the acute hospital setting. Whether early CD is predictive of long term cognitive outcomes deserves further study.
Abstract T P308: Does Hospitalist Directed Care Reduce The Length Of Stay For Acute Ischemic Stroke Patients And Improve Adherence To The “Get With The Guidelines” Inpatient Quality Measures?
Authors: Hassan Ameer E , Sanchez Christian , Malik Ahmed A , Abantao Erlinda , Sanchez Olive , Jones-Fullingim Lisa , Tekle Wondwossen G , Qureshi Adnan I
Published: July 2021

Background:
Hospitalist directed care has shown significant association with improved lengths of stay with improvements in outcomes in several acute conditions. The hospitalist effect has not been studied in acute ischemic stroke management.

Objective:
To identify acute ischemic stroke patients admitted under a hospitalist, internist, family practice physician, or a specialist and compare the length of stay, discharge outcome, and adherence to the “Get with the Guidelines” (GWTG) stroke performance measures prior to discharge.

Methods:
We identified consecutive acute ischemic stroke patients over a 4-year period (June 2010-June 2014) from a private Gold Plus Target Stroke Honor Roll primary stroke center. We categorized all stroke admissions according to admitting physicians - hospitalist, internist, family practice, or specialty physician directed care. We collected demographics, risk factors and discharge outcomes based on the modified Rankin Scale (mRS). We analyzed all of the GWTG stroke inpatient quality measures (venous thromboembolism prophylaxis, statin on discharge, anthithrombotic by end of day 2, antithrombotic medication on discharge, atrial fibrillation discharged on anticoagulant) and compared rate of deficiencies between the four groups of admitting physicians.

Results:
A total of 1584 patients [mean age (± SD) 68.6±13.7 years; 55.6% men] were admitted with acute ischemic stroke. There was no statistically significant difference in length of stay between the 4 groups (p=0.4). There was a significant difference in the GTWG inpatient quality measures with the hospitalist group having the lowest rates of deficiencies seen with 5% of their admissions (p=0.03), and the internists have the highest rate of deficiencies with 16% of their admissions (p=0.01). The most common deficiency was not prescribing a statin at discharge (56% of total fallouts). There was no difference in poor outcomes on discharge (mRS 3-6) (p=0.2).

Conclusions:
There is a significant improvement in adherence to the GWTG inpatient stroke measures when an acute ischemic stroke patient is admitted under the care of a hospitalist. Prospective databases are recommended to evaluate if this leads to better long term outcomes.
Abstract T P360: Pediatric Acute Stroke Protocol Activation in a Children’s Hospital Emergency Department
Authors: Ladner Travis R , Mahdi Jasia , Harris Z L , Crossman Kristen , Abramo Thomas , Jordan Lori C
Published: July 2021

Introduction:
Many children’s hospitals, including ours, have instituted acute stroke protocols, with a pediatric acute stroke team that is alerted and responds urgently for children with acute brain attacks. The purpose of this study was to characterize the final diagnoses of children with brain attacks in the emergency department where the acute stroke protocol was activated.

Hypothesis:
We hypothesized that less than half of pediatric brain attacks would have a confirmed diagnosis of acute stroke.

Methods:
Clinical and demographic information were obtained from a quality improvement database and medical records for consecutive patients (age 0-20 y) presenting to a single institution’s pediatric emergency department where the acute stroke protocol was activated between April 2011 and December 2013. Activation of this protocol means that a neurology resident sees the child within 15 minutes and acute MRI is available. All values were assessed with descriptive statistics.

Results:
There were 100 cases of brain attack (mean age 11.3 y, SD 5.1 y, 55% male); 25 were confirmed strokes (Figure) and 3 children had a transient ischemic attack (TIA). Nine (36%) children with stroke were previously healthy. There were 17 (68%) ischemic strokes, 7 (28%) hemorrhages, and 1 (4%) sinovenous thrombosis. Non-stroke neurological emergencies were found in 13% of patients; the majority were meningitis (n=5) or neoplasm (n=3). Complex migraine was present in 17% and seizure in 12%. All children had urgent neuroimaging. MRI was the first study in 70%.

Conclusion:
Of pediatric brain attacks, 25% were stroke, 3% were TIA, and 13% were other neurological emergencies. Clinicians evaluating a child for possible acute stroke should consider these frequencies in their differential diagnosis. There are many stroke mimics, some life-threatening, underscoring the need for prompt evaluation and management of children with brain attacks.
Abstract T P361: Is There a ‘Stroke Belt’ for Ischemic Stroke Hospitalization among Children?
Authors: Lichtman Judith H , Leifheit-Limson Erica C , Wang Yun , Howard Virginia J , Goldstein Larry B
Published: July 2021

Background:
There are regional variations in adult stroke mortality and hospitalization rates in the US, with higher rates in the Southeastern part of the country (the ‘stroke belt’). At least one study found children in stroke belt states also have higher stroke-related mortality; whether they have higher hospitalization rates is unknown. We compared ischemic stroke hospitalization rates for adults and children in stroke belt and non-stroke belt states.

Methods:
Ischemic stroke discharges (ICD-9-CM 433, 434, 436) were identified for calendar years 2006 and 2009 in the Kids’ Inpatient Database (N=1,434; age 0-20y) and years 2007 and 2009 in the Nationwide Inpatient Sample (N=221,351; age ≥21y). Age-specific population estimates were obtained from US Census data. Hospitalization rates per 100,000 person-years (PY) were calculated in 5-year age increments and by region. Mixed Poisson regression was used to determine the hospitalization rate ratio between stroke belt and non-stroke belt states within age groups; logistic models estimated odds ratios for in-hospital mortality.

Results:
Hospitalization rates were higher for adults residing in the stroke belt, but were similar for children (1.2 and 1.4 per 100,000 PY; figure). Although adult hospitalization rates were 32%-52% higher in the stroke belt, after adjustment for age, race, and sex, there was no difference in childhood stroke hospitalizations based on stroke belt residence (rate ratio=0.89, 95% CI 0.70-1.12). In-hospital mortality did not differ by region for any age group.

Conclusions:
Consistent with prior studies, adults in the stroke belt had higher hospitalization rates than those in non-stroke belt states; however, there was no difference for children. Because higher stroke mortality has been reported for adults and children in the stroke belt, the lack of difference in hospitalization rates and in-hospital mortality may suggest a higher late case-fatality rate for children in the stroke belt.
Abstract T P362: Blood Pressure, Blood Glucose, Temperature and Outcome after Childhood Stroke
Authors: Grelli Kimberly N , Gindville Melissa , Walker C H , Jordan Lori C
Published: July 2021

Objective:
To determine the prevalence of abnormal blood pressure (BP), blood glucose and temperature in the acute phase after ischemic stroke (IS) and explore any relationship to outcome. We hypothesized that high and low BP, hyperglycemia, and fever after pediatric IS were all associated with poor outcome.

Methods:
We performed a retrospective review of children aged 1 month to 18 years with first IS admitted to a tertiary hospital between 2009 and 2013. Blood pressure, glucose and temperature readings recorded over the first 5 days after diagnosis. Morbidity or mortality and BP at 3 months post-stroke were documented. Hypertension (HTN) was defined as systolic or diastolic BP ≥95th% percentile for age, sex, and height for two consecutive recordings and two consecutive days.

Results:
Ninety-eight children were identified (median age 6 years). Prevalence of hypertension, hypotension, hyperglycemia and fever was 65%, 68%, 18%, and 41%, respectively. In multivariable analysis, the strongest association with poor outcome (defined as pediatric stroke outcome measure ≥1) was infarct size >4% of brain volume [odds ratio (OR) 5.3, CI 1.8-15.3, p=0.002]. Blood glucose ≥200mg/dL was also independently associated with poor outcome (OR 4.6, CI 1.3-16.3, p=0.015). Hypotension requiring treatment (p=0.02, Fisher Exact Test) and fever ≥37.8°C (p=0.03, X2=4.6) were associated with poor outcome in univariable testing only. Hypertension was not significantly associated with stroke size, poor outcome, or death. During the acute post-stroke period 18% were treated with anti-hypertensive medication. At 3-months post-stroke, 11 children had died; 90% of the survivors followed up. Of these, 15 of 78 (19%) were receiving anti-hypertensive medication, an additional 9 children were hypertensive but untreated.

Conclusions:
Abnormalities of BP, blood glucose and temperature are prevalent in children with IS during the first 5 days after diagnosis. Infarct size and hyperglycemia were associated with poor outcome, hypertension was not. Prospective studies involving systematic recording of BP, blood glucose and temperature are required to better assess whether these factors impact outcome and are amenable to intervention to reduce morbidity after stroke in children.
Abstract T P365: Childhood Stroke: ICD-9 Code Positive Predictive Values for Identifying Hemorrhagic and Ischemic Events
Authors: Khoury Jane C , Alwell Kathleen , Taylor J, Michael , Sucharew Heidi , Moomaw Charles J , Horn Paul , Yeramaneni Samrat , Peariso Katrina , Khatri Pooja , Broderick Joseph P , Kissela Brett M , Kleindorfer Dawn O
Published: July 2021

Introduction:
Childhood stroke event rates have been reported both using administrative databases and population-based epidemiological studies. The latter include verification of stroke as a case and categorization of type. Administrative databases allow cheaper, quicker estimation of rates and possible extrapolation of estimated rates to population-based rates. However, these estimations rely on the accuracy and interpretation of the ICD-9 coding.

Methods:
The Greater Cincinnati/Northern Kentucky Stroke Study measures temporal trends in the incidence rates in a biracial population of 1.3 million. Discharge lists with primary and secondary ICD-9 codes 430-436 from 16 area hospitals for 2010 were obtained; 437-438, 674 and 747 were also included at the Children’s hospital. Detailed information from medical records of potential cases was abstracted by trained research nurses and reviewed by stroke physicians, who determined if the event was a case and, also the event type (hemorrhagic stroke, infarction or transient ischemic attack(TIA)).

Results:
A total of 89 potential events in children <20 years of age were reviewed, yielding 19 confirmed cases. Positive predictive values (PPV) for the primary ICD-9 codes for specific types varied from 0% to 100%. Primary and secondary ICD-9 codes, event types, and percent correct are presented in the Table.

Conclusions:
Childhood stroke cases captured through selected ICD-9 codes: 430-432, 434.x1, 434.9 and 435.9 (marked with an asterisk in the table) in the primary position would yield 14 strokes/TIAs, and underestimate the number of events by 26%. However, using both primary and secondary codes they would yield 34 strokes//TIAs, and overestimate the number of events by 79%. Population-based epidemiology studies are essential to monitor the validity of using ICD-9 codes to estimate childhood stroke/TIA incidence.
Abstract T P37: Routine CT Angiography in Acute Stroke Does Not Delay Acute Stroke Care
Authors: Silva Gisele S , Miranda Renata C , Massaud Rodrigo M , Vacari Andreia M , Cendoroglo Neto Miguel
Published: July 2021

Introduction:
Vascular imaging is increasingly used for diagnosis of arterial occlusions in acute ischemic stroke. Hypothesis:We hypothesized that time intervals using a CTA based acute ischemic stroke protocol are not increased when compared to an earlier non-CTA based protocol. Methods: We evaluated a database of consecutive patients admitted to a Brazilian tertiary hospital with acute ischemic stroke from February 2009 to March 2014 and reviewed our stroke quality measures data to determine if the time required to obtain CTA prolonged door-to-neuroimaging, door to radiology report and door-to-needle times. Patients were categorized into: Group 1 (February 2009 to October 2013) (Non-contrast CT Scan based acute stroke protocol) and Group 2 (November 2013 to August 2014) (CTA based acute stroke protocol). Time intervals were compared between the two groups.Results: We evaluated 415 consecutive patients, 20 of whom (4.8%) had a CTA in the acute phase (Group 2). Patients in groups 1 and 2 had similar onset-to-door times (1.86 [0.75-3.58] versus 2.75 hours [1.0-8.49], p=0.09); door to neuroimaging times (27.6 [18.6-46.8] versus 37.8 minutes [23.4-46.2], p=0.28 ) and door to radiology report intervals (39 [27-60.6] versus 53.4 minutes[35.4-61.2], p=0.09). The frequency of treatment with recanalization therapies ( either intravenous thrombolysis or endovascular procedures) was similar between groups 1 (30%) and 2 (21%), p=0.33, as well as door to needle times (p=0.09). Conclusions: CTA based acute stroke care does not significantly delay time to neuroimaging or thrombolysis in routine clinical practice.
Abstract T P370: Blood Transfusions in Pediatric Sickle Cell Disease Normalize Cerebral Blood Flow While Maintaining Constant Cerebral Oxygen Metabolism
Authors: Ford Andria L , An Hongyu , Guilliams Kristin , Fields Melanie , Eldeniz Cihat , McKinstry Robert , Shimony Joshua , Vo Katie D , Ragan Dustin , Hulbert Monica L , Lee Jin-Moo
Published: July 2021

Background:
Chronic blood transfusions (Tx) reduces stroke risk in pediatric sickle cell disease (SCD). Cerebral blood flow (CBF) is elevated in SCD, likely representing a compensatory mechanism to maintain cerebral oxygen metabolism (CMRO2) in the setting of reduced arterial oxygen content (CaO2) from chronic anemia. When exhausted compensatory mechanisms are unable to meet oxygen demands, stroke ensues. We measured MR-derived CBF and oxygen extraction fraction (OEF) pre- and post-Tx, hypothesizing that Tx ‘resets’ the CBF baseline by increasing CaO2 via increased hemoglobin (Hb), while maintaining cerebral oxygen delivery and metabolism.

Methods:
SCD children on chronic Tx were enrolled in a prospective, observational MRI study. MR-CBF and MR-OEF were acquired before and 2 hours after exchange Tx. MR-CBF and MR-OEF were measured using pseudocontinuous arterial spin labelling and a novel asymmetric spin echo sequence, respectively. CaO2 =1.35 x [Hb] x SaO2. CMRO2 = CaO2 x CBF x OEF.

Results:
Two SCD children underwent MRI pre- and post-Tx (six more are anticipated prior to ISC). For subject #1 (18 yo F with overt stroke), mean global CBF was 128 and 98 ml/min/100g pre- and post-Tx, respectively, indicating a 24% CBF reduction. For subject #2 (6 yo F with elevated transcranial Doppler velocities), mean global CBF was 189 and 129 ml/min/100g pre- and post-Tx, respectively, a 32% CBF reduction (Fig). Both Hb and CaO2 were increased after Tx, resulting in unchanged oxygen delivery (CaO2 x CBF) post-Tx. Moreover, OEF and CMRO2 were not significantly different pre- and post-Tx, consistent with our hypothesis that CBF increases to maintain oxygen delivery.

Conclusions:
Elevated CBF is likely a compensatory mechanism to maintain constant oxygen delivery in SCD children who have chronically low CaO2. In our subjects, Tx improved CaO2, allowing CBF to normalize. This reduced hemodynamic stress likely contributes to the lower stroke risk in chronically transfused SCD children.
Abstract T P371: Utility of Cerebral Oximetry with Cerebral Blood Volume Index (CBVI) in Detecting Pediatric Strokes
Authors: Abramo Thomas J , Jordan Lori , Harris Zeah , Meredith Mark , Meredith Mark , Crossman Kristen , Williams MD Abby , Nicks Todd , Melguizo Castro Maia
Published: July 2021

Pediatric Strokes are increasing with recognition and imaging delays. Limited pediatric stroke knowledge, vague signs & symptoms and no reliable stroke detection tools is the cause. Improving recognition improves outcomes.

Objective:
To assess utility of Left & Right Cerebral rcSO2 and cerebral blood volume index (CBVI) in Pediatric Stroke Alert and Altered Mental Status (AMS) patients.

Methods:
Observational study of Stroke Alert & AMS patient’s Cerebral rcSO2 and CBVI. Stroke rcSO2 and CBVI values in stroke patients were compared to controls & AMS (no cerebral pathology) patients.

Results:
Controls (N=133), Stroke alert (N=25) & AMS stroke (N=52)'s rcSO2, CBVI means were consistent 0-60 minutes. Lower rcSO2 with or without CBVI readings correlated with stroke (Left rcSO2, CBVI (P<0.0001), Right rcSO2 (P=0.0038), CBVI (p=0.0006)). A 19.1% rcSO2 side difference had 100% PPV for stroke. Across 0-60 minutes, rcSO2, CBVI were consistent for stroke & type (Hemorrhagic or Ischemic) (P<0.0001). Left Stroke’s rcSO2, CBVI were lower than Right Strokes (P<0.0001). Hemorrhagic ipsilateral stroke and contralateral side had lower rcSO2, CBVI (P<0.001) then Ischemic.

Conclusion:
The rcSO2, CBVI difference between sidess objectively and consistently detected stroke, location, and stroke types (Hemorrhagic or Ischemic). A 19.1% rcSO2 differencehad had 100% PPV for detecting strokes demonstrating cerebral oximetry’s utility. Cerebral Oximetry with CBVI has shown its’ potential as an objective screening tool for identify pediatric strokes and types. Cerebral Oximetry with CBVI has potential for expediting stroke recognition and decreasing imaging time.
Abstract T P375: Risk Factors for Peri-procedural Stroke in Children With Cardiac Disease
Authors: Asakai Hiroko , Stojanovski Belinda , Galati John C , Cardamone Michael , Hutchinson Darren , Cheung Michael M , Mackay Mark T
Published: July 2021

BACKGROUND:
Cardiac disease is identified in up to 30% of children with stroke, with almost one quarter occurring in the perioperative period. This has potentially devastating implications for long term neurodevelopmental outcomes. The aim of the study was to investigate risk factors of peri-procedural stroke in children with cardiac disease.

METHODS AND PATIENTS:
We performed a retrospective case-control study of all children under <18 years of age who had an arterial ischemic stroke (AIS) after a cardiac procedure at a tertiary pediatric hospital between January 1993-December 2010. Each case was matched with 2 controls for cardiac diagnosis, procedure type, age and date of procedure. The following variables were analysed; (1) Procedural details: cardiopulmonary bypass (CPB) time, circulatory arrest time, intraoperative blood pressure, oxygen saturation and haemoglobin, (2) Post procedural details: length of intensive care unit stay, length of hospital stay, length of mechanical ventilation, mechanical circulatory support, complications including infection and arrhythmia, clinical parameters including blood pressure and oxygen saturation (SpO2), laboratory data including serum lactate, haemoglobin and haematocrit.

RESULTS:
A total of 52 children with AIS were identified. Univariable analysis identified post-procedural infection (OR 7.3, CI 2.0-26, p=0.002) and length of ICU stay (OR 4.7, CI 1.9-12, p<0.001) to be strongly associated with AIS, followed by post-procedure arrhythmia (OR 3.0, CI 0.9-11, p=0.089), other post-procedure complications (OR 3.1, CI 1.1-8.6, p=0.029) highest post-procedure Sp02 (OR 2.4, CI 0.97-5.7, p=0.058) and previous history of cardiac catheterization (OR 2.2, CI 0.9-4.9, p=0.071). In a multivariable analysis, post-procedural infection (OR 5.6, CI 1.3-15, p=0.022) and length of ICU stay (OR 3.2, CI 1.1-9, p=0.031) were identified as risk factors for AIS.

Conclusion:
Although the study is limited to a single center cohort, length of ICU stay and post procedural infection were identified as risk factors for AIS. These findings demonstrate these factors to be important areas to focus attention for stroke prevention in children with cardiac disease.
Abstract T P386: The Clinical Implications of Assessing Platelet Responsiveness to Aspirin Using Whole Blood Platelet Aggregation versus Urinary 11-Dehydrothromboxane Testing
Authors: Westphal Erica S , Gengo Francis , Galdun Patrick , Rainka Michelle , Bates Vernice
Published: July 2021

Background:
Whole blood aggregometry (WBA) is a direct measure of the effects of aspirin (ASA) on platelet aggregation while the measurement of urinary thromboxane B2 (TXB2) quantitates the metabolite produced by the ASA inhibited COX-1 enzyme. The objectives of this study were to a) compare indirect urine testing to a direct measure of platelet activity, b) determine the impact on clinical decision making if only TXB2 were measured, and c) compare time to obtain results from both procedures.

Methods:
Patients ages 18 to 90 who were on a stable dose of ASA for at least 14 days and had a confirmed stroke/TIA in the past 90 days were included. Patients were excluded if they used any medication that altered platelet function. Once consented, as per standard of care, blood was collected for WBA as well as a urine sample for a salicylate test for compliance. As per protocol, urine was sent out to have TXB2 levels measured in pg/mg of CR. Non-responsiveness was defined as aggregation to collagen 1 ug/mL >10 ohms of impedance, ohms ratio of collagen 1 to 5 ug/mL >.5, or arachidonic acid (AA) >6 ohms. Borderline patients were classified as either responsive or non-responsive for analysis according to the treatment decisions that were made based on clinical judgment. ABCD
2
scores were calculated and TXB2 test turnaround time was noted.

Results:
In 58 patients TXB2 reported only 11 as non-responsive to ASA while WBA found 18 as non-responsive and 4 as borderline. Chi square analysis found significantly different proportions of participants to be responsive or non-responsive to ASA (p=.024) through each test. ASA therapy was adjusted based on WBA results typically the next day while mean turnaround time for TXB2 was 7.29 days. ABCD
2
scores based on risk factors predicted 10.5 ischemic events while only two actually occurred.

Conclusions:
WBA testing reported significantly more patients to be ASA non-responsive, allowing therapy changes to be made immediately. TBX2 testing failed to identify many patients that were ASA non-responsive and results did not become available for 1 to 2 weeks.
Abstract T P405: Improvement in Midline Shift is Associated with Survival After Decompressive HemiCraniectomy in Large Hemispheric Infarctions
Authors: Ramiro Joanna I , Dhar Rajat , Feen Eli , Kumar Abhay
Published: July 2021

Background and Purpose:
It remains uncertain which patients with malignant edema after large hemispheric infarction (LHI) remain at risk of death despite decompressive hemicraniectomy (DHC). We investigated factors associated with in-hospital mortality in a cohort of patients with LHI who underwent DHC.

Methodology:
This retrospective cohort study conducted over a five-year period identified 24 LHI patients who underwent DHC. Patient demographics, pre- and post-DHC clinical and neuro-imaging data were recorded (including midline shift [MLS] at the level of lateral ventricles). These variables were then analyzed in relation to in-hospital mortality.

Results:
Patients were predominantly male (17/24), with mean age of 55±15 years and baseline NIHSS score of 18.5± 4. Despite DHC, performed at a median of 52 hours, mortality still occurred in 9 patients (38%), with 11 (46%) going to acute rehabilitation and remainder to long-term care facility (LTC). Patients had a mean pre-operative MLS of 11 ± 3 mm. When compared with a head CT obtained 48 hours after DHC, MLS improved the most in patients going to rehabilitation (by 6 ± 4.2 mm), compared to those going to LTC (3.2 ± 5 mm), while the least improvement was seen in those who died (1 ± 5 mm). Survivors had significant improvement in MLS (5.3 ± 4.4 mm) compared to the non-survivors (1 ± 5 mm), p = 0.04. The survivors were also significantly younger (50 ± 17 years) compared to those who died (62 ± 7 years). Thirteen patients (54% of the cohort) received intracranial pressure (ICP) monitors ipsilateral to the infarct during DHC but measured ICPs were statistically similar in survivors vs non-survivors. Other variables (baseline NIHSS score, MLS and time to surgery) did not predict death in the cohort.

Conclusion:
Mortality remains high in LHI patients even after DHC. Improvement in MLS after DHC appears to separate survivors from non-survivors while post-DHC ICPs do not. However, our sample size is small and additional studies with larger population sizes are required for validation of our findings.
Abstract T P410: Angiopoietin-1 Mimetic Peptide Treatment Promotes White Matter Remodeling And Improves Cognitive Function In Rats With Vascular Dementia
Authors: Venkat Poornima , Chopp Michael , Zacharek Alex , Ning Ruizhuo , Van Slyke Paul , Dumont Daniel , Roberts Cynthia , Chen Jieli
Published: July 2021

Background and Purpose:
Vascular Dementia (VaD) affects cognitive and memory function. Clinically, a series of minor or silent strokes induce subcortical lesions and may lead to VaD. In this study, we developed a multiple microinfarct-based mild VaD model in retired breeder rats and tested the therapeutic effects of an Angiopoietin-1 mimetic peptide, Vasculotide (VT) on cognitive decline and white matter (WM) damage.

Methods:
Male retired breeder rats were subjected to a multiple microinfarct model (500 70-100 μm cholesterol crystals injected into the internal carotid artery) and treated with 1) PBS 2) VT (3 μg/Kg, i.p. injection) starting at 1 day for 14 days (n=6/group). Neurological and cognitive deficits were evaluated 2 and 6 weeks later. Rats were sacrificed on 7th week.

Results:
The multiple microinfarct model induced cognitive decline in retired breeder rats starting at 2 weeks which persisted to 6 weeks after surgery. Significant (p<0.05) loss in short term memory was observed using the Novel Object Recognition Task and memory loss was evident from the Odor Test. Anxiety-like behavior was observed during Open Field evaluation. Compared to non surgery rats, VaD significantly decreased neurite branching and spine density measured by Golgi staining; induced significant WM damage identified by decreased axon and myelin density, decreased oligodendrocyte progenitor cells and oligodendrocyte number; and decreased synaptic protein expression in the corpus callosum and striatum. VaD also significantly increased RAGE (Receptor for Advanced Glycation Endproducts) expression in the brain. Treatment of VaD with VT significantly (p<0.05) improved cognitive function and memory, decreased anxiety, significantly attenuated WM damage, increased neurite branching and spine density and synaptic protein expression as well as decreased RAGE expression compared to VaD control rats (p<0.05).

Conclusion:
Multiple microinfarcts can induce significant WM damage and cause decline in cognition and memory. VT treatment promotes WM remodeling, synaptic plasticity and anti-inflammation which in concert may contribute to the improvement in cognition and memory.
Abstract T P411: Correlation of Neurocognitive Function and Brain Lesion Load on Magnetic Resonance Imaging in Patients with Systemic Lupus Erythematosus
Authors: Roldan Paola , Jung Rex , Sibbitt William , Roldan Carlos
Published: July 2021

Background:
Neurocognitive dysfunction and brain injury on MRI are common in patients with systemic lupus erythematosus (SLE) and are associated with increased morbidity and mortality. However, brain MRI is expensive, non-specific, and does not necessarily predict neurocognitive dysfunction. In contrast, neurocognitive assessment is a clinical tool that is easily available, inexpensive, safe, and may better select patients who require an MRI or other cerebrovascular imaging.

Methods:
76 patients with SLE [71 women, age 36±12 years] and 26 age-and-gender matched healthy subjects [22 women, age 34±11 years] underwent neurocognitive testing for assessment of global neurocognitive function, attention, memory, processing speed, executive function, and motor function (expressed as z-scores). All 102 subjects underwent brain MRI. T1 weighted, fluid attenuated inversion recovery, and diffusion weighted images were obtained. Whole brain and hemispheric lesion load in cm
3
were determined using a semi-automated method.

Results:
All assessments of neurocognitive function were significantly worse in SLE patients than in controls, including global cognitive function (-1.82±1.90 versus -0.07±0.52,), attention (-1.80±2. versus -0.06±0.82,), memory (-1.23±1.15 versus -0.056±0.81 ), processing speed (-1.38 ±1.63 versus -0.06±0.93 ), executive function (-2.39±2.96 versus -0.10±0.79,) and motor function (-3.14±5.90 versus -0.06±0.63) (all p≤0.003). Also, white matter brain lesion load of the whole brain, left hemisphere, and right hemisphere were greater in SLE patients than in controls (1.10±2.65 versus 0.10±0.28 cm
3
, 0.41±0.98 versus 0.04±0.13 cm
3
and 0.68±1.97 versus 0.057±0.16 cm
3
, respectively, all p≤0.02]. Neurocognitive scores in each domain were significantly negatively correlated with brain lesion load of the whole brain, left and right hemispheres (r = 0.33 - 0.46, all p≤0.02, Pearson Correlation Coefficients
)
.

Conclusions:
In SLE patients each neurocognitive domain score correlates negatively with brain lesion on MRI. These findings suggest that neurocognitive testing may be an effective initial clinical tool to assess for ischemic brain injury in SLE patients.
Abstract T P44: Grade of Cortical Vessel Signs on Susceptibility-weighted Imaging Predicts Outcomes in Acute Stroke Patients
Authors: Komatsu Teppei , Sakuta Kenichi , Shimoyama Takashi , Terasawa Yuka , Mitsumura Hidetaka , Kono Yu , Iguchi Yasuyuki
Published: July 2021

Introduction:
Cortical vessel signs (CVSs) on susceptibility-weighted MR imaging (SWI) are frequently observed in acute ischemic stroke patients. However, the clinical implications of this sign have not yet been clearly defined. We assumed the hypothesis that grade of CVSs on SWI predicts outcomes in acute stroke patients.

Methods:
We retrospectively enrolled stroke patients who presented with anterior circulation cerebral infarction within 24 hours after onset. We excluded patients with no SWI. CVSs was defined as more veins or lager veins with a greater signal loss on SWI than those in the opposite normal hemisphere. CVSs was graded as 1) absent, 2) subtle as presence of CVSs less than 1/3 of the anterior circulation perfusion lesion, or 3) prominent as presence of CVSs more than 1/3 of the perfusion lesion. Unfavorable outcome was defined as discharge modified Rankin scale score 4-6.

Results:
We included 114 patients from October 2012 to June 2014, 71% of patients were men, median age was 71 years, and the average initial NIHSS score was 7 (range 0-32). CVSs was seen in 53 (47%) of patients. There were 14 patients (13%) with subtle CVSs, and 39 patients (35%) with prominent CVSs. Unfavorable outcome was as follows: 15% of patients with none CVSs, 43% with subtle CVSs, and 59% with prominent CVSs (figure 1). As with grade of CVSs, proportional rate of unfavorable patients gradually increased (P < 0.01).

Conclusions:
Grade of CVSs on SWI can predict outcomes in acute stroke patients.
Abstract T P45: Automated CSF Segmentation to Quantify Cerebral Edema Following Large Hemispheric Ischemic Stroke
Authors: Chen Yasheng , Yuan Qingyang , Dhar Raj , Guilliams Kristin , Heitsch Laura , Vo Katie , Ford Andria , Lin Weili , An Hongyu , Shen Dinggang , Lee Jin-Moo
Published: July 2021

Introduction:
Cerebral edema with resultant mass effect is a potentially fatal consequence of ischemic stroke, but early and sensitive biomarkers of brain tissue compression are lacking. To quantify brain mass effect, we developed a novel, automated segmentation method to delineate CSF spaces in CT images from ischemic stroke patients.

Methods:
CTs from sixteen acute ischemic stroke patients (median NIHSS 16.5, median age 61.5 yrs, 14-92 hrs after stroke onset) were included after informed consent was obtained. After infarction, conventional CSF segmentation using Hounsfield unit (HU) thresholding is suboptimal due to infarct hypodensity. Utilizing manually delineated infarct and CSF spaces as training samples, we augmented conventional HU threshold segmentation with level sets, sparse regression and random forest segmentation methods. Using leave-one-out cross-validation, the combined approach was compared to HU thresholding using Dice ratios (a measure of the overlap between the segmented and the ground-truth CSF spaces).

Results:
Shown is an example of a CT brain slice segmented by HU thresholding and the combined strategy: false negative (red), false positive (green), and true positive (yellow). The Dice ratios for HU thresholding and the combined approaches were 58.2±16.3% and 68.9±14.6%, respectively, demonstrating the significantly improved performance for the combined strategy (p=0.0014).

Conclusions:
We have developed an advanced image segmentation strategy to delineate CSF spaces which outperforms conventional HU thresholding. An automated CSF segmentation strategy will permit quantification of cerebral edema in a large population of stroke patients, as required for genetic studies, for example.
Abstract T P47: Feasibility of Rapid Short Sequence Magnetic Resonance Imaging for Screening Stroke Mimics within the IV-tPA Treatment Window - A Pilot Study
Authors: Goyal Nitin , Tsivgoulis Georgios , Male Shailesh , Bhaskaran Deepak , Alexandrov Andrei , Zand Ramin
Published: July 2021

Background & Purposes:
Up to 30 percent of patients presenting with acute onset of neurological symptoms may suffer from stroke mimics (SMs). MRI is highly sensitive for detection of acute ischemia; however, its clinical utility in the acute stage is limited secondary to the complexity, availability, and time required for a comprehensive brain MRI. In this pilot study, we investigated the feasibility of rapid short sequence (RSS) MRI to screen possible SMs while keeping the door-to-needle (DTN) time below one hour.

Subjects & Methods:
We developed clinical criteria to clinically suspect possible SMs and deployed RSS MRI in those patients presenting with acute stroke like-symptoms. Our RSS MRI protocol takes 5-6 minutes and includes DWI, ADC, and FLAIR sequences. The patients also received a non-contrast CT head at the time of ER presentation as standard of care. The new processes to our code stroke protocol included adding MRI technicians to the code stroke, the stroke nurse or physician filling out the MRI screening sheet and transporting the patient to the MRI suite. The stroke physicians were also available at the MRI console to read the MRI and the stroke team was on standby to initiate IV tPA infusion in the MR suite, if it was indicated.

Results:
In a 9-month period, we evaluated 35 patients, who met our criteria for possible SMs, using RSS MRI (mean age 49, 78% women, median NIHSS 4). Three patients had diagnosis of an acute ischemic stroke on RSS MRI and received IV TPA while still in the MR suite. The DTN time ranged from 48 to 58 minutes. The median door-to-imaging time was 43 minutes (range 38-49). All of our patients with a RSS MRI negative for acute stroke had a final diagnosis other than stroke.

Conclusions:
Our preliminary results show that RSS MRI can be rapidly obtained in selected patients without delaying the DTN time. This screening method avoids unnecessary IV-tPA administration to SMs.
Abstract T P5: Sequential and Post-procedure ASPECTS Predict Clinical Outcome in Mechanical Thrombectomy of Acute Anterior Circulation Ischemic Stroke
Authors: Yoo Albert J , Zaidat Osama O , Chaudhry Zeshan A , Berkhemer Olvert A , González R. G , Goyal Mayank , Demchuk Andrew M , Menon Bijoy K , Mualem Elan , Buell Hope , Kuo Sophia S , Sit Siu Po , Bose Arani ,   for the Penumbra PICS Investigators
Published: July 2021

Purpose:
Final ASPECTS has been shown to predict patient outcomes after endovascular therapy in stroke. The goal of this study was to compare sequential ASPECTS imaging pre-treatment and post-treatment in predicting outcome.

Methods:
The PICS Study is a prospective registry of clinical and imaging data in proximal artery occlusion patients treated with the Penumbra System. In multivariate analysis, variables assessed for relationship to 90 day mRS included age, gender, time to reperfusion, occlusion location, ASPECTS, and NIHSS. ASPECTS scores were assessed by a central core laboratory, blinded except for stroke side.

Results:
In this study, 141 patients with mean age 67.9 ± 15.6 and median admission NIHSS score 16.0 (IQR 12.0-21.0) met study criteria. Univariate predictors of 90 day mRS included age, baseline NIHSS, 7 day/discharge NIHSS as well as post-treatment ASPECTS. After adjusting for age and baseline NIHSS, post procedure ASPECTS showed a stronger relationship with good outcome (p<0.0001) than pre-treatment ASPECTS (p=0.0520). Change in ASPECTS was also a significant predictor of 90 day mRS (p=0.0046) in the multivariate analysis.

Conclusion:
Sequential and post procedure ASPECTS are better predictors of clinical outcome following endovascular therapy than pre-ASPECTS. Final infarct volume quantified using ASPECTS serves as a surrogate biomarker for long-term functional outcome.
Abstract T P51: MRI Characteristics of the Evolution of Lacunar Infarct Lesions
Authors: Okazaki Shuhei , Hornberger Eva , Griebe Martin , Gass Achim , Hennerici Michael G , Szabo Kristina
Published: July 2021

Background and Purpose:
Morphological changes of lacunar infarct are not well defined. The purpose of the present study was to describe the MRI characteristics of the evolution of symptomatic lacunar infarcts.
Methods:
From a prospectively collected stroke database, 62 definite lacunar infarct patients with baseline and follow-up MRI (≥ 90 days of stroke onset) were analyzed. We investigated the incidence of cavitation, the infarct volume change, and the positional relationship between lacunar infarcts and preexisting white matter lesions (WMLs).
Results:
Median follow-up period was 26 months (range 3-99 months). Cavitation was observed in 38 patients (61%) and 25 lacunar infarct lesions (40%) overlapped with WMLs. Age, hypertension, baseline infarct diameter, baseline infarct volume, and baseline National Institute of Health Stroke (NIHSS) score were associated with cavitation (Figure). In a multiple logistic regression analysis, age (odds ratio per 5-year increase: 1.34; 95% confidence interval (CI): 1.03_1.80; p=0.03) and baseline infarct volume (odds ratio per 1-ml increase: 4.7; 95%CI: 1.6_19.7) were independent predictors of cavitation. There was a significant volume reduction between baseline and follow-up infarct lesions (median volume reduction rate: 44%, p<0.001).
Conclusions:
More than one third of symptomatic lacunar infarcts developed no cavitation and 40% of lacunar infarct lesions overlapped with WMLs. The incidence of cavitation strongly depended on the patient’s age and baseline infarct volume. Our data indicate the continuity between lacunar infarcts and WMLs.
Abstract T P57: TEG Does Not Correlate with Clot Subtype or Clinical Response to tPA
Authors: McDonald Mark M , Wetzel Jeremy , Elliott Andrea , Bowry Ritvij , Kawano-Castillo Jorge F , Cai Chunyan , Sangha Navdeep , Messier Jessica , Hassler Amanda , Archeval-Lao Joancy , Parker Stephanie , Rahbar Mohammad H , Grotta James C
Published: July 2021

Background:
Thromboelastography (TEG) measures coagulation status in venous blood. tPA thrombolysis is affected by multiple variables including whether clots are erythrocyte or platelet-rich. We hypothesized that TEG would correlate with clot subtype and response to tPA including rapid clinical improvement (RCI), recanalization, and hemorrhagic transformation (HT).

Methods:
176 acute ischemic stroke patients between 11/09 and 06/14 treated with tPA were prospectively enrolled. Venous blood for TEG was drawn before and 10 minutes after tPA bolus. Pre-tPA measures of speed and strength of clot formation (R, Delta, K, Angle, MA, and G) and post-tPA measure of clot lysis (LY30) were analyzed. Hyperdense artery (HDA) on CT was a biomarker for erythrocyte-rich clot. RCI was defined as 8 point improvement on NIHSS or total NIHSS of 0,1 at 36 hours. HT was defined as any blood on follow up imaging within 36 hours. Recanalization was defined as resolution of baseline vascular occlusion on follow up CT or MR angiogram within 36 hours. Multivariable linear regression models compared TEG parameters after adjusting for potential confounding and interactive effects.

Results:
No differences in pre- or post-tPA TEG were found between patients with (n=32) or without (n=102) RCI. Also, there was no correlation between TEG and HDA on CT. Clot strength was decreased in patients with recanalization (lower MA and G, p = 0.02 and p = 0.03). Clotting was slightly prolonged (longer delta, p = 0.046) in patients with HT.

Discussion:
Our data do not show a robust association between TEG and clot subtype or clinical response to tPA. It is likely that arterial clot lysis is determined by factors unrelated to coagulation status as measured by TEG in the venous circulation. Though we found a correlation between TEG and recanalization, the number of patients with recanalization data was too small to detect an effect on clinical outcome. Similar to our previous findings, speed of clot formation may be related to risk of bleeding.

Conclusion:
It is unlikely that TEG will be useful in guiding tPA therapy. Future research should focus on local arterial influences on clot lysis. Further study of TEG in hemorrhage is indicated.
Abstract T P78: Neurovascular Changes Characterize Split-belt Adaptation in Chronic Stroke Survivors: Preliminary Results
Authors: Rand Troy , Fayad Pierre , Mukherjee Mukul
Published: July 2021

Background & Purpose:
While previous studies have implicated localized cortical regions in the recovery of locomotor function in stroke survivors, very little is known about the mechanisms that underlie the recovery of locomotor adaptation in stroke survivors. Locomotor adaptation in stroke survivors is hampered due to the deterioration in bilateral coordination during gait. In an ongoing study, bilateral incoordination in gait was targeted with a split-belt paradigm and cortical neurovascular changes during the adaptation task were recorded with Functional Near Infrared Spectroscopy (fNIRS).

Subjects & Methods:
In this study, chronic stroke survivors walked on a split-belt treadmill while wearing an fNIRS device. In a series of trials participants walked in baseline, split-belt, and catch conditions. A continuous wave fNIRS system, the ETG-4000 Optical System (Hitachi Medical Corporation, Tokyo, Japan) utilizing two different wavelengths (~695 and ~830 nm) sampling at 10 Hz, was used to measure cortical activity. Task-related cortical activity was computed based on the amount of oxygenated (OxyHb) hemoglobin during the locomotor adaptation task. Our paradigm yielded 24 channels on each side of head. Baseline levels of oxyhemoglobin were calculated for 30 seconds before starting each trial with the subjects standing in quiet stance. The differences from baseline were calculated during the first and last 30 seconds of each trial to determine initial changes and changes due to adaptation.

Results:
Preliminary results from the study demonstrated the following for the primary motor and associated cortices: 1) higher levels of oxyhemoglobin on the non-affected side in comparison to the affected side, 2) Increased oxyhemoglobin during initial adaptation in comparison to baseline, 3) early to late split-belt adaptation was characterized by a reduction in oxyhemoglobin and 4) In the catch trial, there was an increase in oxyhemoglobin.

Conclusion:
Characteristic neurovascular changes were demonstrated in chronic stroke survivors during locomotor adaptation that enhance our mechanistic understanding of adaptive changes after stroke and can potentially impact neuro-rehabilitation.