bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W P131: Light to Moderate Alcohol Intake and Lower Risk of Ischemic Stroke: A Matched Case-Control Study in Korean Population
Authors: Lee Soo Joo , Cho Yong-Jin , Ko Young-Chai , Hong Keun-Sik , Cha Jae Kwan , Kim Dae-Hyun , Park Jong-Moo , Kang KyuSik , Park Tai Hwan , Park Sang-Soon , Kim Joon-Tae , Lee Jun , Lee Kyung Bok , Han Moon-Ku , Lee Ji Sung , Lee Juneyoung , Bae Hee-Joon
Published: March 2022

Background:
Heavy alcohol intake has consistently been identified as a risk factor for all type of stroke, whereas the effect of moderate drinking is less certain. Previous researches have limitation in declaring the dose-response relationship between alcohol intake and stroke because of the heterogeneity of stroke subtypes, the potential different effects across sex, race/ethnic group and the amounts of alcohol consumed.

Objective:
To determine the dose-response relationship between alcohol intake and risk of ischemic stroke in Korean population.

Methods:
We undertook a prospective multicenter matched case-control study in 9 hospitals between January 2011 and January 2012. Cases were patients hospitalized due to first-ever ischemic stroke within 7 days of onset, confirmed by diffusion-weighted MRI. Controls, obtained from the database of the 4th Korean National Health and Nutrition Examination Survey (KNHANES IV-V, between 2007-2010), had no history of stroke, and were matched with cases for age (± 3 years), sex and education level. All participants completed an interview using structured questionnaire about alcohol intake and past medical history.

Results:
During the study period, 1848 cases (mean age, 66.1 years; male, 58.9%) were enrolled and were matched to 3589 controls. Conditional logistic regression analysis found that light to moderate alcohol intake, up to 3-4 drinks (drink=10g ethanol) per day, was significantly protective for ischemic stroke after adjusting for hypertension, diabetes, hyperlipidemia, current smoking and body mass index (<1 drink: OR 0.38, 95% CI 0.32-0.45; 1-2 drinks: OR 0.45, 95% CI 0.36-0.57; 3-4 drinks: OR 0.54 95% CI 0.39-0.74; ≥5 drinks OR 1.08 95% CI 0.84-1.40) in comparison to never drinking. These associations were not different among the subtypes of ischemic stroke. However, subgroup analysis according to sex revealed that the threshold of alcohol intake might differ by sex with respect to risk of ischemic stroke; decrease of risk up to <1 drink in women vs. up to 3-4 drinks in men.

Conclusion:
Our findings suggest that light to moderate alcohol intake is associated with reduced risk of ischemic stroke and the margin of its protective effect may be different between men and women in the Korean population.
Abstract W P15: ADAPT Technique: A Direct Aspiration First Pass Technique for Stroke Thrombectomy
Authors: Turk Aquilla S , Frei Don , Baxter Blaise , Fiorella David , Mocco J , Siddiqui Adnan , Turner Raymond , Chaudry Imran
Published: March 2022

Background:
The development of new revascularization devices has improved recanalization rates and time. We report our initial results with a new technique utilizing a direct aspiration first pass technique with large bore aspiration catheter as the primary method for vessel recanalization.

Methods:
A retrospective evaluation of a prospectively captured database of 81 patients at 6 institutions was performed on patients where the ADAPT technique was utilized. The device manufacturer suggested retail prices was tracked for all devices used during the procedure. The data represents the initial experience with this technique.

Results:
The ADAPT technique alone was successful in 63 of 81 (78%) cases. Eighteen cases required the additional use of a stent retriever or a Penumbra aspiration separator to achieve recanalization. The average time from groin puncture to at least TICI 2b recanalization was 34 minutes and 93% of cases were successfully revascularized. TICI 3 recanalization was achieved 53% of the time. On average, patients presented with an admitting NIHSS of 16 and improved to NIHSS of 6 by the time of hospital discharge. There were three procedural complications, none resulting in clinical sequelae.

Discussion:
This initial experience highlights the importance of the technique with which new stroke thrombectomy devices are used may be as crucial as the device itself. The ADAPT technique is a fast, simple and effective first approach to acute ischemic stroke thrombectomy. Utilizing the latest generation of large bore aspiration catheters in this fashion has allowed us to achieve excellent clinical and angiographic outcomes.
Abstract W P152: Obesity Increases Risk of Ischemic Stroke in Young Adults
Authors: Mitchell Andrew B , Cole John W , McArdle Patrick F , Cheng Yu-Ching , Mitchell Braxton D , Kittner Steven J
Published: March 2022

Background and Purpose:
Increased body mass index (BMI) has been associated with ischemic stroke in older populations, but its association with stroke in younger populations, in whom the life-long burden of obesity-associated risk factors is presumably lower, is not known. In light of the current obesity epidemic and evidence for an increasing incidence of stroke in young adults, this topic deserves further investigation.

Methods:
We investigated the association between BMI and early-onset ischemic stroke using data from a case-control study in the greater Baltimore-Washington area. Cases ages 15-49 (n=1201) and age-gender-race balanced controls (n=1154) were recruited between 1992 and 2008. Presence of hypertension and diabetes was obtained by interview. Study participants were placed into CDC-defined weight categories of underweight (BMI < 18.5 kg/m2), normal weight (18.5 to 24.9), overweight (25.0 to 29.9), and obese (BMI ≥ 30 kg/m2). Logistic regression modeling was used to evaluate the association between BMI and ischemic stroke.

Results:
Unadjusted analysis indicated a significant association between BMI and ischemic stroke; the overweight group had an OR of 1.2 (95% CI 1.0- 1.5) and the obese group had an OR of 1.8 (95% CI 1.5- 2.2) when compared to the normal weight reference group. But these heightened risks were highly attenuated after further adjustment for hypertension and diabetes mellitus. There was no significant difference in stroke risk between the overweight and normal weight groups. Obese males (OR of 1.3, 95% CI 0.9- 1.8), but not obese females, had an increased stroke risk compared to their normal weight counterparts.

Conclusion:
We observed a moderate association between BMI and early-onset ischemic stroke that increased in a dose-response fashion. The attenuation of stroke risk in high BMI groups following adjustment for hypertension and diabetes suggest that the effects of obesity may be mediated in part through these and other obesity-related conditions.
Abstract W P160: Comparison of Arterial Stiffness and White Matter Hyperintensities according to Stroke Subtypes
Authors: Shin Dong Hoon , Lee Young Bae , Shin Dong Jin
Published: March 2022

Introduction:
Arterial stiffness, which can be measured by pulse wave velocity (PWV), is recognized as one of cardiovascular risk and may be directly involved in the process of atherosclerosis. White matter hyperintensities (WMHs) are receiving increasing attention as a risk factor for stroke and is associated with cognitive impairment, silent brain infarction (SBI), cerebral microbleeds, a poor functional outcome after stroke, and mortality. Hypertension, diabetes, age have been known as risk factors of arterial stiffness and WMHs. The hypothesis of our study is that marker of arterial stiffness and WMHs could have different values in different TOAST subtypes because each TOAST subtype has related to the different pathogenesis.

Materials and Methods:
We investigated all patients with a diagnosis of acute ischemic stroke admitted to the Department of Neurology at Gachon University Gil Medical Center between March 2012 and February 2013 retrospectively. The type of acute ischemic stroke was classified according to the TOAST classification. Carotid-femoral pulse wave velocity (PWV) was evaluated by Applanation tonometry (SphygmoCor) and WMHs are graded according to the Fazeka's and modified Fazeka's grading system.

Results:
We analyzed PWV, WMHs according to the TOAST in 230 patients with acute ischemic stroke. Lacunar subtype was significantly associated with hypertension, diabetes, and hyperlipidemia (p=0.040, p=0.005, p=0.016, respectively). PWV values, Fazeka's and modified Fazeka's grade in lacunar subtype were significantly higher compared to values observed in large artery atherosclerosis, cardio-embolic infarct, and stroke of other determined etiology subtypes (p=0.015, p=0.047, p=0.044, respectively). An increased PWV is significantly well correlated with the degree of WMHs.

Discussion:
Our study showed that hypertension, diabetes and hyperlipidemia were highly associated with lacunar subtype and arterial stiffness and WMHs in lacunar subtype are the highest among stroke subtypes. Therefore care of hypertension, diabetes and hyperlipidemia may be more important management in lacunar subtype than in other stroke subtypes.
Abstract W P178: Multiple Concurrent Strategies are Required to Achieve Door-to-Needle Time Under One Hour for Thrombolysis of Acute Ischemic Stroke in the Majority of Patients
Authors: Linzey Jennifer , Rosete Jane , Berger Paulo , Corey William , Neil William , Yerxa Marion
Published: March 2022

Introduction:
Reducing door-to-needle time (DTNT) for acute ischemic stroke (AIS) thrombolysis is a major public health priority. Various strategies to reduce DTNT have been evaluated in academic but less so in community hospital settings. At our hospital, weekly debriefings of all AIS cases were conducted to develop process improvement strategies using a rapid cycle test of change model; which allows for quickly implementing changes in organizational structure.

Methods:
Paired t-test was used to compare mean DTNT before and after implementation of changes. First, stroke patients arriving by ambulance were transferred directly to CT scan, eliminating the time delay of gurney transfers. In response to a delay due to IV tubing issues, pharmacy included tubing with the t-PA. Next, the algorithm was changed to allow ED staff to order t-PA while neurologist was en route. Later, a neurologist was assigned to be on-site at the hospital for immediate response. Pharmacy began hand delivering t-pa after a delay in communication of when it was ready. After triage delays for posterior territory strokes, ED began pre-shift nursing messages and displayed posters that emphasized atypical stroke symptoms. A single pharmacy phone number was used and “t-pa alert” was called overhead for all thrombolysis candidates. Finally, graphs highlighting DTNT among involved hospital staff were placed in a visible area to encourage competetion for timeliness.

Results:
At the start of the quality improvement initiative, average DTNT was 84 minutes, and 13% of patients were treated within an hour. Over 3 years of process changes, DTNT was reduced to 57 minutes, and 68% of AIS patients were treated within an hour.

Conclusion:
Multiple concurrent strategies are needed to achieve and maintain a DTNT under 60 minutes in the majority of AIS patients in a community hospital.
Abstract W P181: Getting Under Twenty Minutes: Use of the Computed Tomography Direct Protocol to Improve Door to Needle Times
Authors: Kozlowski Mark , Whaley Michelle , Fanale Christopher , Spencer Byron
Published: March 2022

Background:
Our institution is a comprehensive stroke center in Englewood, Colorado with 55,000 visits to the emergency department (ED) annually. Our 2012 mean door to needle (DTN) time was 41 minutes, with a fastest DTN of 22 minutes. Inspired by the 2012 Finnish study touting mean DTN times of less than 20 minutes, ED leaders developed and implemented the computed tomography (CT) Direct protocol using lean principles to decrease mean door to CT first slice times.

Purpose:
Use of the CT Direct protocol will decrease DTN times.

Methods:
The CT Direct protocol details the process of the first few minutes after a stroke alert patient arrives to the facility. The Launch Pad was created and is a designated hallway spot located directly between the emergency medical services (EMS) entrance and CT. Formal signage was installed denoting this special area. The patient arrives to the Launch Pad for rapid registration, brief EMS presentation of history of present illness, medications, and assessment findings. The patient stays on the EMS pram until transport to the CT table and does not enter the ED room until after imaging is completed. An eight week pilot study was performed in 2013 utilizing the CT Direct protocol. This data was compared against information collected during the same period of time in 2012. All stroke alerts brought to the facility via EMS or private car were included in the data sample. Stroke alerts called for patients transferred from an outside hospital were excluded.

Results:
In the control group (2012) there were 29 stroke alerts called with a door to first slice (DFS) CT mean of 24 minutes and DTN of 43 minutes. This is compared to the CT Direct group (2013) data with 38 stroke alerts called with a mean DFS CT of 20 minutes and DTN of 35 minutes. During the pilot study, the stroke team achieved a record DTN of 17 minutes for one patient, as well as DTN times between 20 and 29 minutes in 3 other patients. Statistical analysis was performed, but failed to demonstrate significance due to small sample size.

Conclusions:
Use of the CT Direct protocol decreased the DFS CT by 5 minutes and DTN by 8 minutes. Further study is recommended with a sample size of 214.
Abstract W P185: A Smartphone Application Can Aid in the Evaluation, Treatment, and Clinical Trial Enrollment of the Acute Stroke Patient
Authors: Nguyen Claude , Wu Tzu-Ching , Barreto Andrew , Grotta James , Savitz Sean
Published: March 2022

Introduction:
During treatment of patients with acute stroke, practitioners must perform many tasks simultaneously, including diagnosing, treating, and screening/enrolling in clinical trials. These tasks must often be performed in parallel, and in the most timely manner possible. Especially for those unfamiliar with local processes or resources, a smartphone application can aid in these tasks.

Description:
A smartphone application compatible with iOS and Android operating systems was constructed for the Stroke Team at the University of Texas at Houston. It features a hierarchical structure (Figure 1), with four components. First, a phone dialer function allows access to critical personnel directly from the phone (Figure 2). Second, references for clinical trials and other data such as treatment protocols is available (Figure 3). Next, a timekeeper function allows recording of benchmark times (including symptom onset, arrival time, head CT acquisition time, and tPA administration time); once times are recorded, the application updates time windows in real-time (Figure 4). Finally, a tool allows users to screen patients for eligible clinical trials automatically: by entering basic data such as age, modified Rankin Scale and NIHSS (Figure 5), the application determines whether the patient may be eligible for ongoing clinical trials (Figure 6). The application allows emailing of these data to the user for inclusion in official documentation, or notification of appropriate personnel.

Conclusion:
A smartphone application that centralizes various disparate resources may allow for more efficient management of the acute stroke patient. Further, such an application may allow easy screening for clinical trials by new practitioners as they learn of the various inclusion criteria for their studies.
Abstract W P188: Achieving Sub-20min tPA Door-to-needle Times - the Importance of Patient Details on Prenotification and Point-of-care INR
Authors: Campbell Bruce , Yassi Nawaf , Weir Louise , Ugalde Melissa , Hand Peter , Yan Bernard , Hocking Grant , Truesdale Melinda , Davis Stephen M , Meretoja Atte
Published: March 2022

Background and purpose:
Institutions around the world have re-engineered acute stroke care to achieve dramatic reductions in tPA door-to-needle times (DNT). We investigated the effects of specific process elements on DNT.

Methods:
The “code stroke” system at Royal Melbourne Hospital was systematically evaluated and redesigned in 2012 to take patients directly from triage to CT on ambulance stretchers and deliver tPA on the CT table. We studied the 12 months post implementation data within business hours (when stroke team members were located in the hospital) for effects of variably utilized key components of the new system - ambulance pre-notification including patient name and date of birth (allowing transfer direct to CT), and point-of-care (POC)-INR.

Results:
In the 12 months post-implementation, 40/80 (50%) of patients who received tPA were treated in-hours. In-hours DNT reduced from pre-implementation median 43 min to 23 min (p<0.001). However, only 33% of the patients had full pre-notification including name and date of birth. In these patients median DNT was 16 min vs. pre-notification without personal details 22 min, p=0.02. Patients with no prenotification which prevented transfer direct to CT had significant delays (median DNT 51 min; p<0.001 vs prenotification). After-hours where the system remained unchanged there was no change in DNT (median 67 min vs. 65 min; p=0.87). Patients possibly taking warfarin previously required laboratory INR pre-tPA (median DNT 77 min; range 38-92 min). Subsequently 6/80 (7.5%) patients were treated after confirming sub-therapeutic POC-INR (25 min; range 14-34 min).

Conclusions:
Pre-notification and going direct to CT have the greatest impact in reducing treatment delays. Combined, these simple, resource-neutral procedures halved our median DNT. The optimal pre-notification includes patient details, allowing pre-registration, pre-ordering of CT, and access to prior medical history during transport. POC-INR is helpful in select patients.
Abstract W P193: Early Involvement of Stroke Neurologist Allows Efficient Tissue Plasminogen Activator Administration in Member Hospitals of a Telemedicine Network
Authors: Bhattacharya Pratik , Parliament Connie , Alcorn Paula , Rajamani Kumar , Norris Gregory , Xavier Andrew , Majjhoo Aniel , Madhavan Ramesh
Published: March 2022

The Michigan Stroke Network provides telestroke services at 32 hospitals across Michigan. These include several critical access hospitals and free standing emergency rooms (ERs). The network conducts ongoing education of member hospitals, emphasizing rapid recognition of symptoms and early activation of the stroke network. Our hypothesis was that prompt communication with a stroke neurologist will facilitate processes and decision making; reducing door to needle times for patients receiving tPA

Methods:
Data was collected for all video consultations. For patients who received tPA, time of symptom onset, time of arrival at member hospital, time of call to network and door to needle times were recorded. Data from January 2012-March 2013 are presented in this abstract; further prospective data collection is ongoing.

Results:
Over 15 months, 249 consultations were performed, resulting in 42(16.8%) tPA administrations and 110(44.2%) transfers for endovascular therapy or post tPA care. A door to needle time<60 min was achieved in 17 of 42(40.4%). Three patients received tPA for symptoms starting within the hospital. Of 33 patients who arrived within 2 hours of symptom onset, 27(81.8%) received tPA within 3 hours.

When the stroke network was activated within 20min of patient arrival, 9/10 patients received tPA within 60 min; whereas if the network was not activated within 20min, only 8/29 achieved this target(p=0.0009). In conclusion, involving the on-call neurologist in a telemedicine network facilitates early decision making and results in shorter door to needle times. Quality improvement initiatives within a hospital network should concentrate on improving front end processes for early identification of stroke symptoms and prompt communication with the stroke neurologist.
Abstract W P195: Standardized Patient Simulation Can Be Incorporated Into Emergency Medicine Resident Training on Performance of the National Institutes of Health Stroke Scale
Authors: Stegmaier Mary , McLendon Loren , Smotherman Carmen , Jacobson Lisa , Hodges Wayne , Falk Diane , Schnepel Loretta , Kraemer Dale , Hall Jennifer , Dodani Sunita , Silliman Scott
Published: March 2022

Introduction:
The National Institutes of Health Stroke Scale (NIHSS) quantifies physical impairment caused by stroke. Emergency Medicine (EM) physicians must be competent to perform the NIHSS as scale cut points are utilized to identify patients with acute ischemic stroke who may be candidates for thrombolytic therapy. Simulation is a teaching method that integrates imitation of real life scenarios into educational exercises. This study discerned if standardized patient simulation can be adopted into an educational exercise aimed at training EM residents to adequately perform the NIHSS.

Methods:
This preliminary study was completed with EM residents, in various years of training, from a single academic center. All residents attended a lecture on performance of the NIHSS. Each resident then performed the NIHSS on 2 patients with chronic, fixed neurological deficits. Residents were observed by a NIHSS certified healthcare professional who gave immediate feedback on examination technique. Data was analyzed with basic statistics using means and standard deviations (± SD).

Results:
Twenty eight EM residents, 7 NIHSS certified healthcare professionals (1 Neurologist, 5 Neurology residents, 1 nurse), and 7 patients participated in the trial. Mean certifier NIHSS score of patients was 2.7 (SD ±1.6). Resident score exactly correlated with certifier score in 11/56 examinations (20%), was within ±2 points of the certifier score in 28 examinations (50%), and within ±3 or 4 in 17 examinations (30%). Average time to complete one patient examination was 5 minutes 36 seconds (SD ±1 min 3 sec). In a post exercise survey, all residents rated this training experience as being beneficial to their medical training.

Conclusions:
An educational format incorporating didactic and return demonstration aimed at training a large group of EM residents to competently perform the NIHSS is practical. Immediate feedback on examination technique and a relatively short time to complete the educational exercise are advantages of this format compared to on-line training modules often used to educate physicians. Further refinement of this exercise is necessary before it can be used for the purpose of NIHSS certification.
Abstract W P208: Treatment of Sodium Hydrogen Sulfide With Normothermia Reduces Neuronal Damage in the Striatum After Cardiac Arrest in Mice
Authors: Nakayama Shin , Taguchi Noriko , Tanaka Makoto
Published: March 2022

Hydrogen sulfide donor, sodium hydrogen sulfide (NaHS), can induce hypothermia and attenuates ischemia reperfusion injury. The cerebroprotective mechanism of sulfide remains unclear. In order to exclude the hypothermic effect of sulfide, this study was designed to test whether NaHS treatment in mice after cardiac arrest (CA) and cardiopulmonary resuscitation (CPR), followed by maintaining forced normothermia improved outcomes.

Methods:
Adult male mice (20-26 g) were subjected to CA induced by intravenous KCL. After 8 min of CA, CPR was initiated with intravenous epinephrine, ventilation with 100% oxygen and chest compressions (rate 300/min). Mice were randomly assigned to 4 groups. In the normothermia group, mice were treated with either NaHS (3mg/kg) (n=20) or vehicle (n=19) intraperitoneally at 1 hr after CPR, then kept their head temperature above 35.0°C using a heating pad for 6 hr. In the hypothermia group, mice were treated with either NaHS (3mg/kg) (n=16) or vehicle (n=16) and kept at room temperature (26.0°C). Four days after CA/CPR, neurobehavioral assessments were performed and brains were removed for histological evaluation of neurons in the CA1 hippocampal region and the striatum.

Results:
Head temperature decreased in the hypothermia groups after CPR. The mean head temperature at 6 hr after CPR in the hypothermia group was significantly lower in mice with NaHS compared to mice with vehicle (NaHS: 31.7 ± 2.4°C vs vehicle 34.0 ± 2.4°C). In the hypothermia group, neuronal injury in the striatum was small and similar between mice with NaHS and mice with vehicle (NaHS: 14 ± 10% vs vehicle: 20 ± 12%). In the normothermia group, injured neurons of the striatum was significantly less in mice with NaHS compared to mice with vehicle (NaHS: 22 ± 7% vs vehicle: 35 ± 22%, P<0.05). No difference was found in the CA1 region among all groups. Data are expressed as mean±SD.

Conclusions:
In our mouse model of CA/CPR, CA induced spontaneous hypothermic response, which was enhanced by NaHS treatment. When the head temperature was kept constant, NaHS exerted neuroprotective effect in the striatum after CPR.
Abstract W P221: Argonaute 2 Mediates Sildenafil-Promoted Axonal Outgrowth
Authors: Zhang Yi , Chopp Micheal , Liu Xianshuang , Zhang Zheng Gang
Published: March 2022

Molecular mechanisms are not fully known for the inhibitory effect of chondroitin sulfate proteoglycans (CSPGs) on axonal outgrowth. The present study investigated the effect of CSPGs on miRNA expression and the role of Argonaute 2 (Ago2) in mediating Sildenafil-induced axonal outgrowth under CSPG conditions.

Primary rat embryonic cortical neurons were cultured in a microfluidic chamber which separates somata and axons. Selective application of CSPGs within the axonal compartment markedly inhibited axonal outgrowth (567±15 μm vs 688 ± 21 μm in control, n=5, p<0.05). Axonal application of Sildenafil, a PDE5 inhibitor, completely reversed the inhibitory effect of CSPG on axonal outgrowth (671±17 μm, n=5). Analysis of miRNA PCR array showed that axonal application of CSPGs robustly changed miRNA profiles not only in axons but also in somata, indicating that axonal signals regulate soma miRNAs. Sildenafil inversely altered miRNA up- and down-regulated by CSPGs, including miR-29c, miR-9a, miR-20b, miR-298 and miR-34a. Attenuation of Ago2, a regulator of miRNA activity, in neurons by siRNA abolished Sildenafil-increased axonal outgrowth under CSPG conditions, suggesting that miRNAs are required for Sildenafil-enhanced axonal outgrowth. One of putative targets of miR-29c is integrin β1. Western blot analysis showed that CSPGs and Sildenafil reduced and increased, respectively, axonal integrin β1 and its downstream protein, focal adhesion kinase, suggesting that miR-29c regulates these protein levels. To examine cause-effect of integrin β1, we applied a neutralizing antibody against integrin β1 into the axonal compartment and found that the antibody attenuated the Sildenafil-reversed inhibitor effect of CSPGs on axonal outgrowth (523±34 μm vs 671±17 μm in Sildenafil, n=5, p<0.01).

In conclusion, the present study indicates that axonal signals induced by CSPGs and Sildenafil change miRNA profiles in the entire neuron and that Sildenafil abolishes the CSPG inhibitory effect on axons via Ago2.
Abstract W P228: Delayed Decompression Hemicraniectomy in Massive Hemispheric Infarction Reduces Mortality but Does Not Improve Functional Outcome
Authors: Batra Amit , dinesh Nivdeh , Yeo Leonard , Sakar Nabin , kawnayn Ghulam , Tsai Tseng , Chou Ning , Sai Liang , Paliwal Prakash , Ahmad Aftab , Seet Raymond C , Chan Bernard P , Sharma Vijay , Teoh Hock Luen
Published: March 2022

Background:
Massive hemispheric infarctions associated with extensive cerebral edema are associated with grave prognosis. Decompressive hemicraniectomy improves outcomes if performed within 48-hours of stroke-onset. In Asia, surgical decompression is often performed late, often after significant clinic-radiological deterioration occurs. We report our experience with decompressive hemicraniectomy when performed after clinical deterioration, radiologolic herniation or pupil dilatation.

Methods:
In this retrospective review, we identified acute anterior circulation ischemic stroke patients who underwent ‘delayed’ decompressive hemicraniectomy at our tertiary institution during 2006-2012. We defined ‘delayed’ surgical intervention as the decompressive hemicraniectomy performed after rapid neurological deterioration (drop of 2 or more points on the Glasgow Coma Scale), evidence of cerebral herniation on clinical and/or neuroimaging criteria. Poor functional outcomes were assessed by modified Rankin score 4-6 points at 90 days.

Results:
A total of 54 patients (11males, mean age 56 years; range 26-77 years) were included in this study, 36 (67%) male. Mean NIHSS at the time of hospital admission was 21 points (range 12-29). All patient developed clinical deterioration, pupil dilatation and/or radiological signs of cerebral herniation before decompressive surgery. Median time elapsed between stroke onset and surgery was 50.5 hours (range 11-144). Poor functional outcomes were noted in 40 (74%) with mortality in 16 (30%). Univariate analysis revealed higher age, late time to surgery, pupil dilatation and rapid neurological deterioration before surgery associated with poor outcomes. However logistic regression revealed only delayed hemicraniectomy (OR 1.153 per hour increase; 95% confidence interval 1.036-1.283, p=0.009) as the independent predictor of poor functional outcome.

Conclusions:
Although delayed decompressive hemicraniectomy in massive hemispheric ischemic stroke reduces mortality, it results in poor functional outcomes. Our results support early surgical intervention, independent of clinical deterioration or radiological herniation for reducing disabilities and the burden on the families.
Abstract W P231: Relationship Between Perioperative Levels of Circulating Biomarkers and Thromboembolic Events Developing After Carotid Artery Stenting
Authors: Kanamaru Hideki , Maruyama Daisuke , Ishii Daizo , Kobayashi Norikata , Yamauchi Keita , Morita Kenichi , Satow Tetsu , Kataoka Hiroharu , Iihara Koji
Published: March 2022

Objective:
To evaluate the relationship between the perioperative levels of circulating biomarkers and the development of thromboembolic events after carotid artery stenting (CAS) in patients receiving dual antiplatelet therapy including clopidogrel.

Patients and Methods:
In the present study, we examined 47 consecutive patients (mean ± SD age, 71.2 ± 5.9 years; 44 men) with carotid artery stenosis who were treated with CAS from February 1, 2011, to July 31, 2013. We prospectively evaluated the levels of circulating biomarkers (high-sensitivity C-reactive protein [hs-CRP], interleukin 6, serum amyloid A, vascular cell adhesion molecule 1 [VCAM-1], intercellular adhesion molecule 1, plasminogen activator inhibitor type 1, and fibrinogen) during the periprocedural period (at 4 days and 1 day preoperatively as well as at 1 day and 3 days postoperatively). The presence of thromboembolic events was determined by diffusion-weighted magnetic resonance imaging (MRI) performed 72 h after CAS.

Results:
In total, 14 (29.8%) patients indicated new lesions on diffusion-weighted MRI. We noted a significant correlation between the degree of stenosis and the presence of thromboembolic events (p < 0.01). However, the baseline characteristics (age, sex, and risk factors) were not correlated. Increased preprocedural levels of VCAM-1 was significantly associated with new lesions on diffusion-weighted MRI (p < 0.01). None of the other biomarkers were correlated with new lesions.

Conclusion:
The VCAM-1 level at 1 day prior to CAS are predictive of thromboembolic events developing within 3 days after the procedure. Our data suggest that endothelial dysfunction are associated with thromboembolic events in patients undergoing CAS.
Abstract W P235: Predictors of Platelet Transfusion in Patients with Intracerebral Hemorrhage
Authors: Guerrero Waldo R , Gonzales Nicole R , Sekar Padmini , Castillo Jorge , Moomaw Charles J , Worrall Bradford B , Langefeld Carl D , Martini Sharyl R , Flaherty Matthew , Sheth Kevin N , Osborne Jennifer , Woo Daniel
Published: March 2022

Background and Objectives:
Data on the impact of platelet transfusions (PTx) on outcomes after intracerebral hemorrhage (ICH) are conflicting. Current guidelines state that PTx in ICH patients with a history of antiplatelet (AP) use is considered investigational. We examined the use of PTx in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study hypothesizing that PTx use would be highly variable and influenced by the need for surgery.

Methods:
ERICH is a prospective observational case-control study designed to find risk factors for ICH among whites, blacks, and Hispanics. We used a backward-elimination logistic regression of baseline demographic and clinical data to compare those who did and did not receive PTx. We examined patterns of PTx across ERICH centers grouped by location.

Results:
As of 1/1/2013, 19 centers enrolled 1341 cases of ICH of whom 10% (138) received PTx. Multivariable logistic regression demonstrated that race was not a predictor of PTx, but older age (OR 1.02), AP use (OR 4.47), thrombocytopenia (OR 14.37), hematoma evacuation (OR 3.25), and history of stroke (OR 1.68) were significantly associated with use of PTx.

Roughly 27% (37/138) of patients who received PTx were not on an antiplatelet agent or had platelet counts >100K. Overall, 23% of patients with ICH on AP received PTx, but it varied from 0%-74% among the ERICH centers (Fig). Six centers administered PTx to <10% of patients and 3 centers administered PTx in ≥ 50% of patients.

Conclusion:
We need further studies to determine if any patient population should receive PTx and to develop greater consistency regarding the use of PTx in the ICH population.
Abstract W P238: Early Initiation of New Oral Anticoagulants May be Safe in Acute Stroke and TIA Patients with Nonvalvular Atrial Fibrillation
Authors: Ebata Takuya , Shibazaki Kensaku , Sakai Kenichirou , Aoki Jyunnya , Saji Naoki , Kimura Kazumi
Published: March 2022

Background and Purpose:
Recently, new oral anticoagulants (NOAC) such as the direct thrombin inhibitor and the factor Xa inhibitor have been developed and studied in multicenter, prospective, randomized trials. However, patients with acute stroke or transient ischemic attack (TIA) were not included into these studies. The aim of this study was to investigate whether early initiation of NOAC for acute stroke or TIA patients with nonvalvular atrial fibrillation (NVAF) are safe.

Methods:
Between March 2011 and June 2013, stroke or TIA patients with NVAF who started NOAC within 2 weeks were enrolled retrospectively. Symptomatic intracerebral hemorrhage (ICH), hemorrhagic transformation (HT) on T2*-weighted MRI, recurrence of stroke or TIA, systemic embolism and any bleeding complications after initiation of NOAC were evaluated. Furthermore, we divided the patients into two groups according the presence of new HT after initiation of NOAC (new HT group and non HT group) and investigated the factors associated with new HT were investigated using multivariate logistic regression analysis.

Results:
70 patients (43 males; mean age 76.2 years) started NOAC; 64 (91%) patients had stroke, and 6 (9%) had TIA. The median (interquartile range) interval from onset to treatment with NOAC was 2 (1-6) days. Dabigatran was used in 55 patients (78.6%) and rivaroxaban in 15 (21.4%). None of the patients had recurrent stroke or TIA, systemic embolism. Symptomatic ICH during hospitalization was not observed. However, only one patient had symptomatic ICH at 49 days after stroke onset. HT on initial T2* and new HT on follow up T2* were 6 (8.6%) and 13(18.6%), respectively but they were asymptomatic. Of 6 patients who had HT on the initial T2*, enlargement of hemorrhage on follow-up T2* (hemorrhagic infarction (HI) Type 1→HI Type 2) was observed in 1 patient, but it was asymptomatic. Compared with the non-HT group, the HT group had a higher frequency of persistent AF, prior hypertension, and NIHSS score on admission. Multivariate logistic regression analysis showed that NIHSS score on admission >6 (Odds ratio, 51.2; 95% Confidence Interval, 3.916-669.944, P=0.003) was independently associated with new HT.

Conclusions:
The NOAC may be safe in acute stroke or TIA patients with NVAF.
Abstract W P241: Early Anti-Coagulation in Acute Cardio-Embolic Stroke is Safe But Does Not Prevent Recurrent Stroke: A Single Centre Review
Authors: Hahn Chris L , Hill Michael D
Published: March 2022

Background:
Atrial fibrillation is the most common arrhythmia in older adults and a common cause of stroke. Patients with acute cardio-embolic stroke from atrial fibrillation are at high risk for recurrence with up to 50% of recurrent stroke occurring within 2 weeks of the index event. Anti-coagulation with heparinoids within 48 hours of stroke has been shown to increase risk of symptomatic intracranial hemorrhage (ICH) with no clear benefit on early stroke recurrence.

Methods:
This study was a retrospective chart review of consecutive patients who were admitted to the stroke service at the Foothills Medical Centre between 2009 and 2011. All patients with an acute stroke with a cardio-embolic etiology and a diagnosis of atrial fibrillation either by history or on electrocardiogram within two years of stroke were reviewed. We hypothesized that anti-coagulation within two weeks of stroke, appropriately begun because of a diagnosis of atrial fibrillation, decreased rates of recurrent stroke without causing an increase in rates of symptomatic ICH.

Results:
During the three-year period 324 patients were identified with cardio-embolic stroke secondary to atrial fibrillation. Within two weeks of stroke onset 63.0% (203/324) of patients were therapeutic on anti-coagulation with warfarin being the most common anti-coagulant used (67.6%). Patients who were anti-coagulated had a smaller mean stroke volume (18.9 cc vs 49 cc) and lower mean NIHSS at presentation (7 vs 9) but otherwise did not differ in baseline characteristics. Three (0.9%) patients had a clinically significant ICH; only one patient was actively anti-coagulated at the time of ICH, one was taking aspirin only and one was on aspirin and low dose enoxaparin for prevention of deep vein thrombosis. Recurrent stroke occurred in 16 patients (4.9%) within the two-week period. Anti-coagulation did not significantly reduce the risk of recurrent stroke (RR 0.67 95% CI 0.19 - 2.36).

Conclusion:
Anti-coagulation within 2 weeks of acute stroke in patients with atrial fibrillation appears to be safe among patients with smaller infarcts. Large studies would be needed to show if anticoagulation actually reduced the rate of early recurrent cardioembolic stroke.
Abstract W P244: Effect of Remote Limb Ischemic Conditioning on CBF as Measured by Arterial Spin Labeling in Human Stroke
Authors: Andersen Forrest S , Forseen Scott , Yanasak Nathan , Gilbert Bruce C , Switzer Jeffrey A , Nichols Fenwick T , Bruno Askiel , Jacob Sneha , Close Brian , Kim Albert , Hoda Narsul , Hess David C
Published: March 2022

Background:
Remote limb ischemic conditioning (RLIC) is a promising treatment for ischemic stroke. We have previously shown that RLIC increases cerebral blood flow, reduces infarct size, and improves outcome in a murine thromboembolic stroke model (Hoda N et al. Stroke. 2012; 43:2794). We hypothesized that RLIC will increase CBF in hypoperfused areas in acute stroke patients as detected by MRI Arterial Spin Labeling (ASL)

Methods:
Patients with an acute ischemic stroke within 14 days and with a persistent mismatch defined by a perfusion defect measured by ASL that was at least 20% larger than the area of infarction as measured by diffusion weighted imaging (DWI) were eligible. Patients underwent 4 cycles of blood pressure cuff inflation (x200 mm Hg) for 5 minutes and deflation for 5 minutes on the leg or arm, 1- 2 times per day. MRI ASL, DWI, and 3D T1-weighted Fast Spoiled Gradient-Echo (FSPGR) images were taken before and 60 minutes after the last cycle of RLIC to measure CBF. Two neuroradiologists analyzed the images.

Results:
After 3 of 4 RLIC sessions, the CBF improved and the mismatch decreased by at least 15%. In the one patient without a reduction in mismatch, the RLIC was performed on the arm and not the leg.

Conclusions:
1.) RLIC increased CBF as measured by ASL in stroke patients with a persistent diffusion-perfusion mismatch. 2.) Since it can be repeated multiple times on the same patient, ASL may be a useful biomarker of the conditioning response in humans. 3.) Further work in a larger sample of patients is needed to define the optimal regimen of RLIC and to determine the utility of ASL as a biomarker.
Abstract W P25: A Meta-analysis of Randomised Controlled Trials of Endovascular Treatment for Acute Ischaemic Stroke
Authors: Birns Jonathan , Bhalla Ajay , Chen Ruoling
Published: March 2022

Introduction:
Initial randomised controlled trials (RCTs) showed endovascular treatment of acute ischaemic stroke (AIS) to improve recanalization and functional outcome but recent RCTs have failed to show clinical benefit.

Methods:
MEDLINE, EMBASE and Cochrane databases were searched for RCTs of endovascular treatment for AIS. Additional RCTs were identified from bibliographies of retrieved articles. Data was extracted on patient characteristics, study intervention, 90-day functional outcome and mortality, 24-hour symptomatic intracerebral haemorrhage (sICH), and post-procedural recanalization. Studies were reviewed independently by 2 trained readers and RCTs of differing methodology were evaluated separately to maintain homogeneity.

Results:
12 RCTs were identified with 1910 subjects (mean(SD) age 65(3); 58% male; median(IQR) baseline NIHSS 17(3)) and mean(SD) time for endovascular intervention 4.9(2.9) hours. In 4 RCTs (n=350) comparing intra-arterial thrombolysis (IAT) with no thrombolysis, patients treated with IAT had significantly improved 90-day modified Rankin scale (mRS)<1 (OR: 1.68; 95% CI: 1.20-2.34), 90-day mRS<2 (OR: 1.98; 95% CI: 1.21-3.24) and recanalization (OR: 3.71; 95% CI: 2.80-4.93), reduced 90-day mortality (OR: 0.67; 95% CI: 0.47-0.96) but increased 24-hour sICH (OR: 4.65; 95% CI: 2.73-7.59). In 2 RCTs (n=201) comparing stent-retriever with clot-retrieval devices, patients treated with stent-retrievers had significantly improved 90-day mRS<1 (OR: 1.69; 95% CI: 1.11-2.58), 90-day mRS<2 (OR: 2.56; 95% CI: 1.49-4.38) and recanalization (OR: 1.60; 95% CI: 1.19-2.16), a trend to reduced 90-day mortality (OR: 0.66; 95% CI: 0.41-1.04) and no significant difference in 24-hour sICH (OR: 0.68; 95% CI: 0.18-2.57). No significant differences in patient outcomes were demonstrated in analyses of 3 RCTs (n=443) comparing IAT with intravenous thrombolysis (IVT) or 3 RCTs (n=809) incorporating combined IAT and IVT interventions.

Conclusions:
IAT for AIS improves recanalization, functional outcome and mortality compared with placebo but not compared with or in addition to IVT. For patients receiving endovascular intervention, stent-retriever devices provide better outcome data than clot-retrieval devices.
Abstract W P252: Bleeding and Infection Risk with External Ventricular Drainage and Thrombolysis for Intraventricular Hemorrhage
Authors: Dey Mahua , Stadnik Agnieszka , Zhang Lingjiao , McBee Nichol , Kase Carlos , Carhupoma Ricardo , Ram Malathi , Lane Karen , Hanley Daniel , Ziai Wendy , Awad Issam
Published: March 2022

Introduction:
Retrospective series report varying rates of bleeding and infection with external ventricular drainage (EVD). There have been no prospective studies of these risks with systematic surveillance, threshold definitions or independent adjudication.

Hypothesis:
Risks of bleeding and infection in the ongoing CLEAR Phase III trial are not higher than those previously reported in EVD case series or earlier dose finding trials.

Methods:
Cases were prospectively enrolled after placement of EVD for obstructive IVH and randomized to receive thrice daily injections of 1mg/1ml of recombinant tissue plasminogen activator or placebo until clearance of the IVH or maximum 12 doses. All cases received daily CT scans and sampling of cerebrospinal fluid (CSF) for the first week. We counted any detected new hemorrhage or expansion of prior bleed on CT scan by >5ml in volume or > 5mm in diameter, after placement of the EVD until 30 days after its removal. Symptomatic bleeds and infections were adjudicated by an independent committee, based on previously articulated criteria. Meta-analysis of published series of EVD placement was compiled using STATA software.

Results:
Growing or unstable hemorrhage was reported as a cause of exclusion from the trial in 42 of 3,794 cases (1.1%) screened for CLEAR III. The first 175 cases enrolled in CLEAR III have completed adjudication of adverse events. Twenty-five subjects (14.3%) experienced one or more new bleeds or expansions, including 2 symptomatic hemorrhages (1.1%). Four cases (2.3%) had culture proven bacterial meningitis or ventriculitis, although many manifested varying sterile CSF pleocytosis in reaction to IVH. These rates were at the lower respective ranges of confidence intervals presently defined in meta-analysis of published series of EVD.

Conclusion:
The rates of new bleeds and bacterial meningitis/ventriculitis are very low with EVD for IVH, despite multiple daily injections, blood in the ventricles, the use of thrombolysis in half the cases and generalization to > 60 trial sites. Any independent risk related to thrombolysis awaits unblinding of results at trial completion.
Abstract W P255: Prior Use of Statins May Reduce Hematoma Growth in Intracerebral Hemorrhage Patients
Authors: Siddiqui Fazeel M , Olson Daiwai M , Sekar Padmini , Moomaw Charles J , Rosand Jonathan , Kidwell Chelsea , Martini Sharyl , Vashkevich Anastasia , Stutzman Sonja , Osborne Jennifer , Langefeld Carl D , Hall Christiana E , Woo Daniel
Published: March 2022

Introduction:
Higher incidence and growth of intracerebral hemorrhage (ICH) has been reported with primary hypocholesterolemia. Statins have been associated with improved outcome in ICH patients, although they lower low density lipoprotein (LDL) cholesterol. Our study explores whether lower admission LDL secondary to statin use is associated with admission ICH hematoma volumes (HV) or hematoma growth (HG).

METHODS:
Data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, a multicenter case-control study designed to examine ethnic variations in the risk, presentation, and outcomes of ICH, were analyzed to explore the association of statin use and LDL with HV and HG. The Kruskal-Wallis test was used to examine differences in initial volume between groups, and the Wilcoxon Signed-Rank test was used to examine differences in HV between patients’ first two CT scans.

RESULTS:
Among cases enrolled prior to January 2013, 544 (mean±SD age=60.9±14.1, 60.3% male) had both admission LDL data and CT scan within 24 hours of onset. Four groups were defined: 1) statin use and LDL<70, n=42 (7%); 2) statin use and LDL≥70, n=79 (14%); 3) no statin use and LDL<70, n=58 (10%); and 4) no statin use and LDL≥70, n=365 (67%). There was no difference in admission HV among groups (p=.69). Follow up (f/u) imaging was available for 350 (64.3%) cases: n for the 4 groups was 26 (7%), 47 (13%), 35 (10%), and 242 (69%). Compared with baseline CT, the non-statin users had significantly higher f/u HV (p<.0001), whereas f/u HV was unchanged for statin users (p=.529). Group analysis showed decreased HV in group 1 and increased HV in group 4 (Figure 1).

CONCLUSION:
There was no association between LDL<70 with or without statin use and admission HV. When compared with non-statin users, statin users, especially with LDL<70, had reduced HG on f/u scans. Further studies are needed to explore these findings.