bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W MP20: Automation and Quantification of the Angiographic Capillary Blush in Patients with Acute Ischemic Stroke undergoing Endovascular Intervention
Authors: Tarpley Jason , Scalzo Fabien , Alger Jeffry R , Aghaebrahim Amin , Liang Conrad , Sheth Sunil , Noorian Reza , Ng Kwan , Jovin Tudor , Duckwiler Gary , Liebeskind David S ,   UCLA Stroke Investigators
Published: July 2021

Background:
In acute ischemic stroke, non-invasive perfusion imaging can guide the decision to perform endovascular intervention. A subset of these patients who are ineligible for IV TPA or for whom it has failed may benefit by going directly to endovascular intervention without delays imposed by non-invasive imaging. In these patients, an angiographic biomarker of viable brain tissue such as the capillary blush described by the Capillary Index Score (CIS) will be important for decision making in the angiography suite. Indeed, a favorable CIS score is associated with good outcomes when recanalization is achieved. However, any ordinal angiographic scale is observer dependent and limited by scale properties.

Methods:
Here we used our novel perfusion angiography software (PerfAngio) to extract cerebral blood volume (CBV) maps from conventional angiograms acquired during endovascular intervention at either UPMC or UCLA. Areas of angiographic blush were selected manually from a subset of the angiograms. These blush areas trained a machine learning model to identify features of angiographic blush from CBV maps to produce blush maps.

Results:
In the figure, we show PerfAngio’s blush map in a patient with acute proximal MCA occlusion prior to endovascular recanalization. At each pixel cool colors represent low likelihood of capillary blush and hotter colors represent higher likelihood of blush. These color maps allow for spatial characterization of the blush and quantifies it as a continuous variable rather than according to an ordinal scale.

Conclusions:
PerfAngio blush maps allow for automation and quantification of the blush seen during conventional angiography. These maps render data that does not depend on observer interpretation and provide spatial information about the capillary blush that is not captured by the CIS. Since PerfAngio blush maps can be acquired in real time, they are amenable for use in the angiography suite to inform the decision to recanalize or not.
Abstract W MP31: Penumbral Imaging-Based Thrombolysis with Tenecteplase is Feasible Up to 24 Hours After Symptom Onset
Authors: Riaz Parnian , Kate Mahesh P , Gioia Laura C , Buck Brian , Jeerakathil Thomas , Smyth Penelope , Shuaib Ashfaq , Emery Derek , Butcher Kenneth
Published: July 2021

Introduction:
Penumbral imaging-based selection of patients for thrombolysis with tenecteplase (TNK) has been shown to be feasible up to 6 h after onset. We aimed to demonstrate the feasibility and safety of thrombolysis in ischemic stroke patients with penumbral patterns presenting 4.5-24 h after symptom onset. Methods: We conducted an open label single arm trial. Acute ischemic stroke patients presenting between 4.5-24 h after symptom onset were assessed with perfusion imaging. Patients with pretreatment perfusion CT/MRI that demonstrated a perfusion deficit volume >15 ml and penumbra volume >20% of the infarct core were eligible for TNK treatment. They received 0.25 mg/kg IV TNK. The primary outcome was symptomatic hemorrhagic transformation. Patients screened with perfusion CT/MRI who met trial criteria, but were not enrolled in the study, formed a parallel cohort. Results: A total of 26 patients were screened with perfusion CT/MRI. Thirteen patients received TNK (mean±SD age = 62±12 y). The 13 parallel cohort patients were of similar age (55±18 y, p=0.257). Median (IQR) baseline NIHSS in TNK treated patients (13(9)) was similar to that in the parallel cohort (14(10), p=1.00). Median time to TNK treatment was 8.7 h(range: 5.1-23.3). Reperfusion and recanalization occurred in 54.5% and 50% of TNK treated patients at 24 h, respectively. Infarct growth at 24 h was attenuated in TNK treated patients (8.7 (31.3) ml) relative to the parallel cohort (53.0 (91.5) ml, p=0.017). Penumbral salvage volume was greater in TNK treated patients (51.7 (58.2) ml) than parallel cohort patients (-16.7 (112.2) ml, p=0.001). There was one symptomatic hemorrhage in the TNK group (ECASS grade PH1). Two other TNK treated patients developed asymptomatic hemorrhages (ECASS grade PH1). The rate of good functional outcome (modified Rankin Score ≤2) at day 90 was greater in TNK patients (8/12, 66.7%) than in the parallel cohort (2/13, 15.3%, p=0.015). Conclusion: Thrombolysis with TNK treatment in appropriately selected patients is feasible even up to 24 hours after onset. Randomized studies of penumbral imaging-based selection of TNK candidates in an extended therapeutic time window are warranted.
Abstract W MP53: The Prevalence and Characteristics of Attention Disorders in The Patients with First-onset Mild Hemorrhagic Stroke
Authors: Tokida Haruki , Nishigaki Masakazu , Kuriyama Masaru
Published: July 2021

Objectives:
Recent study revealed that over 50 % of stroke patients had some form of attention deficits. However, few reports focused on acute phase and mild stroke patients. This study aimed to investigate the prevalence of attention disorders and the change of their symptoms during the hospitalization in the patients with first-onset mild hemorrhagic stroke.

Methods:
Study subjects were 231 consecutive patients diagnosed as hemorrhage stroke and treated at our hospital from 2011 to 2012. Patients with severe hemorrhage (i.e., amount of bleeding >5cc), with previous history of cerebrovascular diseases or dementia, with decreased level of consciousness or with impaired activity of daily living were not eligible to this study. Neuropsychological assessments were conducted by speech therapists at 1 and 2 week after stroke onset using Clinical Assessment for Attention (CAT) and examined how they changed. CAT was a test battery developed by the Japan Society for Higher Brain Dysfunction to evaluate deficit of attention disorders.

Results:
Among the study subjects, 46 patients met the selection criteria and 16 patients (34.8%, 6 men, mean age was 66) were identified as having attention disorders. Bleeding lesions were left putamen (n=3), right putamen (n=9) and right thalamus (n=4). Significant improvements were observed in two types of focused attention and auditory selective attention measures: percentage of correct answers of Visual Cancellation Task (VCT, p=0.027) and Auditory Detection Task (ADT, p = 0.01). Additionally, working hours in VCT was significantly shortened, and the false-negative rate was also significantly decreased (p= 0.028). In ADT, the false-positive rate was significantly decreased (p= 0.012). No significant changes were observed in other type of tasks.

Discussion:
More than one-third of patients showed attention deficits even though they had mild stroke. Only focused and selective attentions were improved in acute phase of mild stroke. These results suggested that improvement in focused and selective attention precede improvement in other attentional functions.
Abstract W MP64: Incident Stroke and Alcohol Consumption among Older Adults
Authors: Cunningham Solveig A , Mosher Aleena , Judd Suzanne E , Matz Lisa M , Kabagambe Edmond K , Moy Claudia S , Howard Virginia J
Published: July 2021

Background:
Alcohol consumption may reduce the risk of stroke. While both stroke and alcohol consumption patterns differ by race and sex, it is not known to what extent alcohol consumption contributes to the elevated risk of stroke in some groups, particularly in men and blacks in general.

Methods:
Risk of stroke was studied in 25,162 black and white adults aged 45+, in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Information on alcohol consumption was obtained by telephone interview at baseline. Participants are contacted every 6 months by telephone for self- or proxy-reported stroke; medical records are retrieved and adjudicated by physicians Proportional hazard models, adjusted for demographic, socioeconomic, and stroke risk factors , were used.

Results:
Participants’ mean age was 64.7 years; 40% were black and 56% were women with 867 stroke events and a median follow-up time of 7.6 years. Compared to current drinkers, non-drinkers had 36% higher hazards of incident stroke which was significantly higher consistent across all race-sex groups except black men. Risks were particularly high among past drinkers (50% higher than among current drinkers), as would be expected since many may have stopped drinking due to health problems. However, risks were also elevated among lifetime abstainers. Differences in stroke risks were explained by demographic and socioeconomic differences between drinkers and non-drinkers. Among those who are current drinkers, those who consumed <1 drink per week had significantly lower hazards of stroke than moderate drinkers, and these protective factors remained marginally significant after accounting for demographic, socioeconomic, behavioral and health characteristics.

Conclusions:
Results suggest that individuals who do not currently consume alcohol may experience higher risks of stroke, which may be due in part due to socio-demographic and other characteristics associated with consuming alcohol.
Abstract W MP78: Intravascular Volume Delpetion in Hypertensive ED Stroke Patients
Authors: Lewandowski Christopher , Miller Joseph , Rodriquez Lauren , Suszanski Julian , Levely Jessica
Published: July 2021

Objective:
The hypertensive response in acute stroke may mask patients who could be volume depleted. Our objective was to determine the incidence of stroke patients that are volume depleted despite hypertension. This is a pilot study using sonographic markers of volume status as compared to common clinical indicators of volume status.

Methods:
This was a prospective cohort study of suspected ischemic stroke patients with a NIHSS ≥ 4 and symptoms onset < 24 hours. Exclusion criteria were pregnancy, age < 18, or ICH. Trained investigators performed a sonographic assessment of volume status. An IVC collapsibility index (IVC-CI) > 50% was used to define volume depletion. Investigators collected demographic and clinical information, and laboratory markers of dehydration (elevated blood urea nitrogen to creatinine ratio, hemoconcentration or high serum osmolality). A standardized questionnaire was given to treating clinicians who were blinded to the IVC-CI. They indicated their assessment of the patient's volume status. The analysis excluded subjects ultimately diagnosed with a stroke mimic. Analysis incorporated descriptive and regression statistics using SAS 9.3. The local IRB approved the study.

Results:
23 subjects were enrolled, 4 had stroke mimics and were excluded from analysis. Mimics consisted of psychogenic disorders and myelopathy. The mean age was 64 years, 89% were Black, 68% female, and 95% had preexisting HTN. The mean NIHSS was 9.2, the mean time from symptom onset 309 minutes and the mean presenting SBP 170 ± 31 mmHg. 68% of subjects had a cortical infarct on MRI and the remaining had lacunar infarcts. The mean IVC-CI was 70 ± 21% and 84% (95% CI 68 - 100%) of subjects had IVC-CI > 50%. Laboratory markers of dehydration were present in 5% of subjects. Treating physicians classified 29% as subjects as hypovolemic. There was no correlation between IVC-CI and SBP, NIHSS, infarct location or laboratory markers of dehydration (r = 0.04 - 0.29, p > 0.23).

Conclusions:
This pilot study suggests that despite being hypertensive, the majority of ED stroke patients have US indications of volume depletion and may be able to tolerate volume expansion. Future studies may identify which patients have improvement in cerebral perfusion with volume expansion.
Abstract W P14: Significant Correlation between Neurological and Functional Recoveries in the Natural History of Acute Ischemic Stroke from Large Vessel Occlusion
Authors: Janardhan Vallabh , Yoo Albert J , Frei Donald F , Ammar Lynne , Kuo Sophia S , Ueda Dawn , Nguyen Nam , Bose Arani , Sit Siu Po ,   for the Penumbra FIRST Trialists
Published: July 2021

Purpose:
There have been conflicting reports on the correlation between neurological and functional recoveries in acute ischemic stroke. NIHSS and mRS scores not always correlated in patients after treatment. Since the inconsistencies could be related to the variable effectiveness of treatments, the aim of this study was to test their correlation in patients with large vessel proximal occlusion who are eligible but not treated with endovascular therapy. In addition, we analyzed the data based on trichotomized ASPECTS scores to minimize the confounding influence of the infarct core.

Methods:
The FIRST Trial is a prospective natural history study of a stroke cohort eligible for but untreated by endovascular therapy and ineligible or refractory to IV rtPA. NIHSS and mRS scores were measured in 93 patients at admission, 24 hour and 7 days after hospital presentation and were analyzed by logistic regression against different core infarct volume as indexed by ASPECTS scores of 8-10, 5-7, and 0-4.

Results:
Median admission NIHSS score was 18 (IQR 14-23, N=93). The mean and mean increase at 24 h NIHSS both showed correlations with trichotomized ASPECTS, p=0.0064 and 0.0202, respectively. NIHSS at 24 h and 7 days displayed a strong relationship with 90 day mRS 0-2 (p=0.0002, N=67; p=0.0003, N=66). NIHSS had a strong correlation to 90 day mRS scores (continuous), with high 7 day scores correlated with high mRS scores and 7 day NIHSS change negatively correlated to 90 day mRS scores (Spearman correlations, all p<0.0001). Significant correlations were seen between 24 h and 7 day NIHSS and 90 day mRS by trichotomized ASPECTS (both p=0.04275). In addition, controlling for trichotomous ASPECTS groups, 7 Day NIHSS score was the best predictor of mRS 90d 0-2 (OR= 0.717, p= 0.0018).

Conclusion:
These data indicate that there is a strong correlation between neurological and functional recoveries in the natural history of acute ischemic when the confounding influences of treatment and the infarct core are taken into account.
Abstract W P140: Post-stroke Oculomotor Abnormalities evident during Objective Eye Tracking but Not under Clinical Assessment
Authors: Rizzo John-Ross , Hudson Todd , Kowal Briana , Wiseman Michal , Raghavan Preeti
Published: July 2021

Introduction:
Visual abnormalities and manual motor control have been studied extensively after stroke, but an understanding of oculomotor control post-stroke has not.

Recent studies have revealed that in visually guided reaches arm movements are planned during eye movement execution, which may contribute to increased task complexity. In fact, in healthy controls during visually guided reaches, the onset of eye movement is delayed, its velocity reduced, and endpoint errors are larger relative to isolated eye movements.

Our objective in this experiment was to examine the temporal properties of eye movement execution for stroke patients with no diagnosed visual impairment. The goal is to improve understanding of oculomotor control in stroke relative to normal function, and ultimately further understand its coordination with manual motor control during joint eye and hand movements.

We hypothesized that stroke patients would show abnormal initiation or onset latency for saccades made in an eye movement task, as compared to healthy controls.

Methods:
We measured the kinematics of eye movements during point-to-point saccades; there was an initial static, fixation point and the stimulus was a flashed target on a computer monitor. We used a video-based eye tracker for objective recording of the eye at a sampling frequency of 2000 Hz (SR Research, Eyelink). 10 stroke subjects, over 4 months from injury and with no diagnosed visual impairment, and 10 healthy controls completed 432 saccades in a serial fashion.

Results:
Stroke patients had significantly faster onset latencies as compared to healthy controls during saccades (99.5ms vs. 245.2ms, p=0.00058).

Conclusion:
A better understanding of the variations in oculomotor control post-stroke, which may go unnoticed during clinical assessment, may improve understanding of how eye control synchronizes with arm or manual motor control. This knowledge could assist in tailoring rehabilitative strategies to amplify motor recovery. For next steps, we will perform objective eye and hand recordings during visually guided reaches post-stroke to better understand the harmonization or lack thereof after neurologic insult.
Abstract W P153: HEALS Hypertension Control Program for Stroke Prevention in African American Communities
Authors: Dodani Sunita , Arora Sahel , Kraemer Dale
Published: July 2021

Stroke is the 4th leading cause of death and a leading cause of severe, long-term disability in US. African Americans (AAs) are at an elevated risk for cerebrovascular diseases. An approach of proven efficacy is to target a major modifiable risk factor for stroke, hypertension (HTN), and to do so using lifestyle changes (i.e., diet and exercise). The objective of this study was to implement and assess the efficacy of an evidence-based, socio-culturally tailored, lifestyle intervention called HEALS (Healthy Eating And Living Spiritually) adopted and modified from PREMIER and DASH studies in AA churches in Northeast Florida.

Methods:
3- months HEALS program was delivered by trained church members to the high risk church members who were; a) church parishioners 25-75 years; and b) newly or known diagnosed with HTN/pre-HTN as per JNC-7 criteria. The outcomes were analyzed using ANOVA and Wilcoxon rank tests.

Results:
Of the 36 eligible, 32 (90%) provided complete information on outcomes and were included in the analysis. At baseline, 15 (42%) participants were pre-HTN, 9 (25%) had Stage 1 HTN, and 12 (33%) had Stage 2 HTN. Retention of 89% was observed at the end of 3- month HEALs intervention. After the completion of the 3-months intervention, the mean reduction in systolic blood pressure (SBP) and diastolic BP (DBP) were 6.72mmHg (p=.0425) and 4.00 mmHg (p=.0073), respectively. A mean weight reduction of 1.7 kg was also significant (p=0.0023). Further, positive trends in healthy eating occurred for the majority of the participants (60%), more than half consumed dark green or other vegetables frequently, while 75% consumed at least one fruit daily or weekly. Lower percentages (44%) reported consumption of 100% fruit juices or cooked beans regularly.

Conclusion:
The study provided much-needed information on the translation and sustainability of evidence-based lifestyle modification in community-based settings, particularly within churches, which represent the most influential institution in the community lives of AA. HEALS program can serve as a cost-effective model for stroke prevention. Future longitudinal randomized controlled studies on HEALS effectiveness are needed.
Abstract W P158: Underutilization of Guideline-Concordant Cardiac Screening among Patients with Cerebrovascular Disease
Authors: Sico Jason J , Baye Fitsum , Myers Laura E , Concato John , Williams Linda S , Bravata Dawn M
Published: July 2021

Introduction:
Guidelines recommend the use of cardiac stress testing to screen for occult coronary heart disease (CHD) among patients with TIA and ischemic stroke who have a ‘high risk’ Framingham Risk score (FRS). It is unclear whether TIA/stroke patients regularly receive guideline-concordant cardiac stress testing.

Methods:
Administrative data from a sample of 10,923 Veterans from admitted to Veterans Health Administration (VHA) facilities with a TIA or mild stroke in fiscal year 2011 were analyzed. Patients were excluded (n=6947) on the basis of a history of CHD, receipt of cardiac stress testing within 18-months prior to cerebrovascular event, patients who died within 90 days of discharge or were discharged to hospice, and those with missing/unknown race. A FRS was calculated for each patient based on: age, gender, race, systolic blood pressure, blood pressure treatment (yes/no), diabetes, smoking status (smoker/non-smoker), and cholesterol (total and high-density lipoprotein). Patients with an FRS ≥20 were classified as ‘high risk’ of having CHD. Administrative data were used to identify whether cardiac stress testing was performed within 6-months after the cerebrovascular event.

Results:
Of the 3976 TIA/mild stroke patients, 53.9% (2322) had FRS ≥ 20. A higher proportion of patients with FRS ≥ 20 that received cardiac screening were younger, white men with diabetes and without a history of cancer, compared with patients with a FRS ≥ 20 that did not receive testing. Cardiac stress testing was not performed more frequently for ‘high risk’ (4.5%; 104/2322) versus ‘low/intermediate risk’ (4.7%; 77/1654) FRS (OR = 0.96; CI
95
:071-1.30).

Conclusions:
Guideline concordant cardiac screening is underutilized among patients with TIA and minor ischemic stroke. Additional research is required to: 1) better understand clinicians’ understanding of and approach to cardiac screening for patients with cerebrovascular disease at high risk for CHD; and 2) determine whether cardiac screening improves post-TIA/stroke outcomes.
Abstract W P173: Providing Education on Primary Risk Factors for Stroke to African American Females 18 Years and Older
Authors: Mathews Maureen , Wang David
Published: July 2021

Stroke is fourth leading cause of death and primary contributor to adult disability in US. Mortality has declined in past 10 years, but prevalence has increased; indicating public risk factor education should be a higher priority. Education is especially important for high-risk individuals

Methods:
this project assessed knowledge and motivation for behavioral changes in African American females (AAF) >18 years of age before/after a presentation regarding stroke risk factors. A community-based program utilizing video and group discussions was developed using AHA/ASA/NSA resources. A post intervention tool included demographic information and participants’ knowledge regarding stroke symptoms/risk factors. Results are used to plan future education programs

Results:
fifty-one AAF attended a presentation and completed a survey. Participants were divided into three groups for analysis: 18-35 yo, young; 36-55 yo, middle-aged; and 56+ yo, older. There were 12(24%) young participants, 19 (37.2 %)middle-aged participants, and 20 (39.2%) were older. Prior to educational sessions, participants reported having learned about stroke primarily from television, 28 (55%); doctor, 28 (55%); and family, 25 (50%). Participants identified stroke risk factors as hypertension, 16 (31%); smoking, 10 (20%); obesity, 10 (20%); diabetes, 6 (12%); atrial fibrillation, 3 (6%); and hyperlipidemia, 2 (4%). Participants plan to reduce risk factors through exercise, 17 (33%); diet,11 (22%); and medications, 9 (18%). Forty-four (86%) of participants would call 911 for suspected stroke. The FAST acronym was used to educate participants on signs/symptoms of stroke. The post education survey showed majority of participants were able to name at least one/three signs for stroke, including facial droop, 31 (61%); arm/leg weakness, 28 (55%); and speech changes, 28 (55%).

Conclusion:
participant responses support literature indicating multiple sources of information are necessary to increase/improve public awareness of stroke risk factors/symptoms. However, ongoing education needed for public to retain knowledge of stroke. Considering cultural differences in populations when designing stroke educational programs is important to utilize the most effective media.
Abstract W P185: Clinical Predictors of Stroke, TIA and Mimic among Patients with Transient Neurological Dysfunction Admitted to an Emergency Department Observation Unit
Authors: Siket Matthew S , Tran Virginia M , Baird Janette R , Madsen Tracy E , Merck Lisa H , Napoli Anthony M , Paolucci Gino , Seigel Todd A , Silver Brian
Published: July 2021

Background:
In patients with resolved symptoms, transient ischemic attack (TIA) is distinguished from ischemic stroke by neuroimaging evidence of acute infarction. DW-MRI has been shown to be more sensitive at detecting infarction than CT, but is not uniformly available in the acute setting.

Hypothesis:
We sought to identify predictors of stroke diagnosis among a cohort of clinically suspected TIA patients undergoing an accelerated diagnostic protocol in an emergency department observation unit (EDOU).

Methods:
We prospectively studied 189 patients treated in the EDOU of a single tertiary care academic medical center. Patients underwent DW-MRI of the brain (unless contraindicated), and bedside neurologist evaluation. A CT scan of the brain was considered optional prior to EDOU admission. We compared the odds of extremity weakness, sensory loss, facial droop, visual disturbance, slurred speech, aphasia, dizziness, and headache between patients with final diagnosis of stroke, TIA and mimic. This study was approved by the hospital IRB.

Results:
Thirty-one patients (16%) were diagnosed with an acute ischemic stroke, 85 (45%) TIA, and 73 (39%) mimic. Mean age was 64.8 years (SD = 15.5; range = 30-90). DW-MRI was performed on 92% of patients. A CT scan was also performed in 80% of patients diagnosed with stroke and 0 were diagnostic. Median ABCD2 scores were 4 for stroke and TIA (IQR 3-5) and 3 for mimic (IQR 2-4). Only headache symptoms predicted lower odds of stroke (OR 0.22; 95% CI: 0.05-0.96). Both headache (OR 1.44; 95% CI: 1.03-2.03) and visual disturbance (OR 3.14; 95% CI: 1.49-6.65) increased the odds of mimic diagnosis, but were also present in 13% and 10% of stroke patients respectively. Slurred speech (OR 0.48: 95% CI: 0.25-0.93); aphasia (OR 0.34 95% CI: 0.15-0.76) and facial droop (OR 90.36: 95% CI: 0.14-0.94) significantly predicted lower odds of mimic diagnosis.

Conclusions:
In our investigation of patients with transient neurologic dysfunction in an EDOU, stroke diagnosis was common and could not be predicted by clinical variables alone. Early DW-MRI should be considered in all TIA patients, especially those reporting slurred speech, aphasia or facial droop.
Abstract W P192: Echocardiographic findings in Acute Ischemic Stroke are Implicated in Specific Subtypes of Ischemic Stroke
Authors: Lee Jun , Kwon Jung-Im , Kim Na-Young , Noh Hyun-Du
Published: July 2021

Background & Significance:
Echocardiographic left ventricular hypertrophy (LVH) and left atrial enlargement (LAE) reflect mortality and morbidity from cardiovascular disease. We aimed to investigate the association between echocardiographic findings and stroke subtypes and its implication in acute ischemic stroke.

Methods:
We retrospectively reviewed the records of 1692 patients with acute ischemic stroke, who were admitted within 7 days after symptom onset. Stroke subtypes were categorized according to the SSS-TOAST classification. LVH was defined as left ventricular mass index (LVMI) >115 g/m2 in men and >95 g/m2 in women, and moderate to severe LAE was defined as left ventricular volume index (LAVi) ≥34 ml/m2 in both gender. The demographic data and echocardiographic findings [LVMI, LAVi, and left atrial anterior-posterior diameter (LAD) and presence of LVH or LAE] were compared in each stroke subtype.

Results:
A total of 1002 patients who were classified as patients with large-artery atherosclerosis (LAA, n=525), patients with cardioembolism (CE, n=296), and patients with small vessel occlusion (SVO, n=181) were included. Echocardiographic variables showed trends in which larger LVMI, LAD, and LAVi in CE group compared with two other groups. Multivariate analysis was performed as comparison with SVO after adjusting for age, gender, hyperlipidemia, diabetes mellitus, and history of smoking. LVH and LVMI were significant independent predictors of LAA (OR 1.6, 95%CI 1.0-2.5, p=0.04 in LVH and OR 1.1, 95%CI 1.0-1.2 by increased LVMI 10g/m2, p=0.036), and all of moderate-to-severe LAE, LVH, LVMI, LAD and LAVi were significant independent predictors of CE (OR 16.7, 95%CI 8.3-33.7, p<0.001 in LAE; OR 2.4, 95%CI 1.5-3.8, p<0.001 in LVH; OR 1.2, 95%CI 1.11-1.3 by increased LVMI 10g/m2, p<0.001; OR 1.2, 95%CI 1.1-1.2 by increased LAD 1 mm, p<0.001; OR 1.2, 95%CI 1.1-1.2 by increased LAVi 1 ml/m2, p<0.001).

Conclusions:
Our studies demonstrate echocardiographic LVMI, LAD and LAVi are linked to specific stroke subtypes even after adjusting for established cardiovascular risk. These results suggest that consideration of echocardiographic indices is helpful to understand the pathomechanism in the ischemic stroke.
Abstract W P205: Potential Hematological Biomarkers of Stroke in Cancer Patients
Authors: Bobrow Dylan , Kothadia Kajal J , Kamel Hooman , Iadecola Costantino , Elkind Mitchell S , Peerschke Ellinor I , Soff Gerald A , DeAngelis Lisa M , Navi Babak B
Published: July 2021

Introduction:
Cancer patients can develop hypercoagulability, leading to stroke. The pathophysiology of cancer-mediated hypercoagulability, however, is poorly understood and biomarkers associated with stroke in cancer patients are uncertain.

Methods:
We performed a pilot cross-sectional study at a tertiary-care cancer center to evaluate potential hematological biomarkers of stroke in cancer patients. From October 2013 through May 2014, we prospectively identified 15 inpatients with active systemic cancer and acute ischemic stroke and 15 inpatients with active systemic cancer and no stroke. Using collected plasma, we compared six potential biomarkers of stroke, selected in advance based on expert opinion and prior data, which included markers of coagulation (thrombin-antithrombin complex and D-dimer), platelet function (P-selectin), and endothelial activation state (sICAM-1, vICAM-1, and thrombomodulin). We used the Wilcoxon rank-sum test to compare biomarker levels between groups.

Results:
Each group comprised 14 patients with solid cancer and one patient with hematological cancer. All patients in the cancer and stroke group had stage 4 disease, while only 60% of the cancer and no stroke group had stage 4 disease. Age and demographics were similar between groups. Median levels of thrombin-antithrombin complex, D-dimer, P-selectin, sICAM-1, and vICAM-1 were significantly increased in cancer patients with stroke, but thrombomodulin was not (Table). Our results were substantially unchanged in a sensitivity analysis limited to patients with only stage 4 cancer.

Conclusion:
These preliminary data suggest that thrombin-antithrombin complex, D-dimer, P-selectin, sICAM-1, and vICAM-1 could serve as the focus of future prospective studies to elucidate the potential predictive, diagnostic, or etiologic role of hematological biomarkers for stroke in the cancer population.
Abstract W P212: The Effect Of Pre-hospital Notification On Time To Head Ct, Stroke Specialist Arrival, And Tpa Administration For Hispanic Patients With Acute Stroke
Authors: McCoy Jonathan , Fader Ralph , Donovan Colleen , Eisenstein Robert , Ohman-Strickland Pamela , McKinney James
Published: July 2021

Background:
Hispanics have an increased incidence of ischemic stroke but may be less likely to use Emergency Medical Services (EMS) for stroke care.

Objective:
To examine disparities in pre-hospital triage and emergent evaluation of Hispanic stroke patients. We hypothesized that Hispanic stroke patients with pre-hospital notification experience less delay in emergent evaluation but the reduction may not be as pronounced as general stroke patients.

Methods:
Retrospective cohort study of all emergency department patients alerted as Brain Attack (BAT) between January 1, 2009 and August 31, 2012, at an urban comprehensive stroke center. We collected demographics, co-morbidities, and stroke severity from a quality assurance database. Outcome variables included EMS utilization, pre-hospital BAT activation, head CT timing & tissue plasminogen activator (TPA) timing. Effects of ethnicity and pre-hospital notification on evaluation and treatment times were measured using multivariate logistic regression models. The study was IRB approved.

Results:
During the study period, 832(64 Hispanic) patients were alerted as Brain Attacks. Hispanic patients were younger 56±17 vs. 68±16 years (p<0.0001), had trends for less EMS utilization (walk-in 35% vs. 22%) and lower NIHSS 9.3±4.3 vs. 12.8±8.3 (p=0.06), but did not differ in comorbidities. Patients with pre-hospital notification had significantly shorter times to stroke specialist arrival, door to head CT, and door to TPA irrespective of ethnicity. However, ethnicity did have independent effect on time to TPA administration. Please see Table 1.

Conclusion:
Pre-hospital notification is associated with faster stroke evaluation and treatment, including among Hispanic patients with acute stroke. Further study is needed to examine if outreach to increase EMS utilization will decrease disparities in this population.
Abstract W P219: Enhancing Delivery of Reperfusion Therapies for Ischemic Stroke: Towards Equity Through Organization
Authors: Gallofre Miquel , Abilleira Sònia , Argimon Josep , Constante Carles
Published: July 2021

Introduction:
Delays in hospital arrival are the most relevant impediment to effective dissemination of thrombolysis. Organization is crucial to overcome such difficulties. Objective: to report on the achievements of a region-wide organized stroke network in terms of numbers of acute stroke patients assessed by stroke experts, numbers of patients treated with any reperfusion therapy and their geographical distribution, and clinical outcomes.
Methods:
In mid 2006 the government-based Stroke Program (SP) of Catalonia (7.5 millions) established a regionalized system of acute stroke care (Stroke Code System, SCS) that involves professionals and health administrators. Any acute stroke patient must be referred to the nearest referral hospitals, currently including 14 PSC and 11 community hospitals connected to the telestroke network covered by a centralized, 24-hour, on-call service made up with vascular neurologists. As for stroke admissions, the Hospital Discharge Database is used. Telestroke-based assessments are included in the TICat registry and reperfusion therapies are notified to the government-mandated SONIIA registry. In both registries completeness is guaranteed by SP.
Results:
Since dissemination of the SCS, numbers of stroke patients undergoing timely expert assessment have gradually increased: from 2,000 in 2006 to 4,800 assessments in 2013 (20% and 44% of all stroke admissions, respectively). Similarly, numbers of IV thrombolysis have risen from 329 in 2006 to 1,106 in 2013. In the areas primarily covered by telestroke hospitals, the population thrombolysis rate reached 13*100,000 in 2013. Overall, the population reperfusion treatment rate increased from 4.6*100,000 in 2006 to 14.5*100,000 in 2013, with some hospitals and their catchment areas achieving rates over 20*100,000. As for clinical outcomes, reperfusion therapies are safe and effective and metrics improve over time. IV thrombolysis has been mapped out to show a clear territorial dissemination (2005 on).
Conclusion:
Regionalization and organization of the SCS has had a quantifiable and favorable effect in terms of numbers of acute stroke patients receiving early diagnosis and specific reperfusion therapies, as well as clinical outcomes.
Abstract W P221: Temporal Trends in Door-to-needle Time and Patient Characteristics in Patients Treated With Intravenous Thrombolysis: Analysis of the Sits-east Registry
Authors: Haršány Michal , Kadlecová Pavla , Csiba Laszlo , Czlonkowska Anna , Fekete Klara , Gdovinová Zuzana , Jatuzis Dalius , Bašic Kes Vanja , Kobayashi Adam , Kõrv Janika , Krespi Yakup , Švigelj Viktor , Tsivgoulis Georgios , Vilionskis Aleksandras , Mikulík Robert
Published: July 2021

Introduction:
Shorter door-to-needle time (DNT) improves treatment efficacy in acute ischemic stroke (AIS) patients. Still, there are groups of patients at increased risk of longer DNT. The goal of our study was to determine temporal trends of DNT. The second goal was to identify if baseline characteristics of patients treated with intravenous thrombolysis changed throughout the years and if such change (e.g. treating older patients) could have affected DNT.

Methods:
Prospectively collected data from the Safe Implementation of Treatments in Stroke - EAST (12 Central/Eastern European countries) registry between January 2005 and August 2013 were analyzed. Baseline patient characteristics over period 2005-2013 were analyzed descriptively and using ANOVA. DNT and association between DNT and the patient characteristics were analyzed using linear logistic regression. Obtained regression coefficients and descriptive statistics were used to simulate average DNT values in individual years during 2005-2013. Several simulations were performed (e.g. for patients above 80 years).

Results:
Altogether, all 13401 patients treated with thrombolysis within 4.5 hours of symptom onset between January 2005 and August 2013 with available DNT were analyzed. Mean DNT during 2005-2013 was 74.4min with slightly improving trend over time. We found almost 6-fold increased proportion of octogenarians in 2013 compared to 2005. Patients with lower and higher NIHSS, prestroke mRS 0-2, arriving sooner to hospital, and treated in a center with less experience (<50 pts per year/center) had longer DNT between 2005 and 2013. In patients arriving within 60min to hospital DNT was longest 88min in 2007 and shortest 75min in 2013. Change in baseline characteristics during 2005-2013 can explain only small proportion of DNT (R-squared decreased from 50% in 2005 to 17% in 2013).

Conclusions:
Although DNT is improving, it remains long especially for some subgroups of patients, e.g. those arriving early to hospital after symptom onset. Every AIS patient should be treated as fast as possible.
Abstract W P224: Higher Pre-Hospital Blood Pressure Prolongs Door to Needle Thrombolysis Times
Authors: Navalkele Digvijaya , Cai Chunyan , Rahbar Mohammad , Pandurengan Renganayaki , Wu Tzu-Ching , Sarraj Amrou , Barreto Andrew , Grotta James , Gonzales Nicole
Published: July 2021

Background:
Per American Heart Association guidelines, blood pressure (BP) should be < 185/110 to be eligible for intravenous tissue plasminogen activator (tPA). It is shown that door to needle (DTN) time is prolonged in patients who require anti-hypertensive medications prior to thrombolysis in the emergency department (ED). To our knowledge, no studies have focused on pre-hospital BP and its impact on DTN times. We hypothesize that DTN times are longer for patients with higher pre-hospital BP.

Methods:
We conducted a retrospective review of acute ischemic stroke patients who presented between 1/2010 and 12/2010 to our ED through Emergency Medical Services (EMS) within 3-hrs of symptom onset. Patients were identified from our registry and categorized into two groups: Pre-hospital BP ≥ 185/110 (Pre-hsp HBP) and < 185/110 (Pre-hsp LBP). BP records were abstracted from EMS sheets. Two groups were compared using two-sample t-test or Wilcoxon rank sum test for continuous variables and Chi-square test or Fisher’s exact test for categorical variables.

Results:
A total of 107 consecutive patients were identified. Out of these, 75 patients (70%) were treated with tPA. Among the patients who received thrombolysis, 35% had pre-hospital BP ≥ 185/110 (n= 26/75). Greater number of patients required anti-hypertensive medications in ED in high BP group compared to low BP group (Pre-hsp HBP n= 14/26, 54%; Pre-hsp LBP n= 13/49, 27%, p < 0.02). Mean door to needle times were significantly higher in Pre-hsp HBP group. (mean ± SD 87.5± 34.2 Vs. 59.7±18.3, p<0.0001). Analysis of patients only within the Pre-hsp HBP group (n= 26) revealed that DTN times were shorter if patients received pre-hsp BP medications compared to patients in the same group who did not receive pre-hsp BP medication (n= 10 vs 16; mean ± SD 76.5 ± 25.7 Vs. 94.3 ± 37.7, p = 0.20)

Conclusion:
Higher pre-hospital BP is associated with prolonged DTN times and it stays prolonged if pre-hospital high BP remains untreated. Although the later finding was not statistical significant due to small sample size, pre-hospital blood pressure control could be a potential area for improvement to reduce door to needle times in acute ischemic stroke.
Abstract W P231: Efficacy Of Clinically Tested Laropiprant In Minimizing Brain Injury Following Intracerebral Hemorrhage
Authors: Ahmad Abdullah S , Mendes Monique , Dore Sylvain
Published: July 2021

Background and Purpose:
The significant association of PGD2 and its receptor DP1 in vasculature, blood, and brain warrants further examination of their role in intracerebral hemorrhage. In this study, we tested whether deletion of DP1 receptor or its inhibition by selective antagonist Laropiprant improves functional and anatomical outcomes following ICH by limiting intracranial bleeding.

Methods:
Wildtype (WT) and DP1-/- C57Bl/6 mice were subjected to ICH by giving a single dose of collagenase in the striatum. Neurologic deficits, brain injury volume, and edema volume were calculated at 72h. In another set of cohorts, WT mice were subjected to ICH followed by single i.p. injection of Laropiprant. To test whether the beneficial effects of DP1 receptor inhibition could be through reduced intracranial bleeding, non-ICH WT and DP1-/- mice were tested for tail bleeding time following the Laropiprant treatment. To further test the effect of Laropiprant on ex-vivo coagulation, mouse blood was mixed with vehicle or Laropiprant and the uncoagulated content was quantified. Finally, the role of DP1 inhibition in modulation gliosis was also tested by performing immunoreactivity for Iba1 on the brain sections of WT and DP1-/- mice.

Results:
A significant decrease in the injury volume (4.8±1.7mm3 vs 14.1±4.5mm3; p<0.001) and edema volume (4.5±1.8mm3 vs 13.2±4.1mm3; p<0.001) in DP1-/- was observed. Similarly, WT mice treated with Laropiprant also exhibited significantly lower brain damage (6.2±2.2mm3 vs 12.7±5.1mm3; p<0.01) as compared with the vehicle treated group. Interestingly, the tail bleeding time was also significantly lower in Laropiprant group (219.4±75.2sec; p<0.001) as compared with the vehicle group (345.2±45.6sec), and similarly the uncoagulated content was also lower in Laropiprant group (356.2±53.6μL; p<0.001) as compared with the vehicle group (486.4±26.7μL). Interestingly, a significant decrease in Iba1 immunoreactivity was observed in DP1-/-.

Conclusions:
Together, the data suggests that inhibition of the DP1 receptor after ICH attenuates functional and anatomical deficits partially by minimizing intracranial bleeding and neuroinflammation.
Abstract W P245: Impaired Response to Post-Stroke Candesartan Treatment in a Model of Type 2 Diabetes: Relationship to Angiotensin Receptors Expression
Authors: Fouda Abdelrahman Y , Soliman Sahar , Kozak Anna , Pillai Bindu , Ergul Adviye , Fagan Susan C
Published: July 2021

Introduction:
Angiotensin type 1 receptor (AT1) blockers (ARBs) provide beneficial effects in preclinical stroke research, that are mediated through the indirect aniogtensin type 2 receptor (AT2) stimulation. However, most of the studies have been conducted in normoglycemic animals. This study is the first to test the effect of post-stroke treatment with the ARB, candesartan, in the presence of pre-existing diabetes. Methods: Type II diabetic Goto-Kakizaki (GK) rats (n=14, blood glucose = 162.6±15.9 mg/dL), were subjected to 3 h MCA suture occlusion, and randomized to either IV saline or candesartan (1 mg/kg) at reperfusion. Blood pressure (BP), behavioral outcome, vascular integrity and molecular analysis were assessed at 24 h. AT1 and AT2 expression was examined at 24 h and compared to sham GKs and normoglycemic Wistar rats subjected to same experimental conditions. Results (Table): In GKs, candesartan reduced the stroke-induced elevation in BP only modestly. In contrast to previous studies in normoglycemic Wistars, candesartan failed to improve neurobehavioral outcome, preserve vascular integrity or reduce oxidative/nitrative stress or apoptotic markers after stroke in GK rats. Interestingly, stroke reduced the expression of AT2 in both hemispheres of GKs. Such an effect was not ameliorated by candesartan treatment. Conversely, stroke upregulated AT2 expression in the contralesional hemispheres of Wistars, an effect that was augmented by candesartan. Conclusion: GK rats have reduced sensitivity to post-stroke candesartan treatment. AT2 downregulation after stroke and failure of candesartan to rescue its expression could be the reason. This study highlights the importance of studying stroke therapeutics in animal models with co-morbid conditions that better reflects the stroke patient population.
Abstract W P25: Anatomically-Weighted Predictive Algorithms Improve MRI-Based Tissue Outcome Predictions After Acute Ischemic Stroke
Authors: Bouts Mark J , McIntosh Elissa , Bezerra Raquel , Diwan Izzuddin , Mocking Steven J , Garg Priya , Kimberly William T , Arsava Ethem , Copen William A , Schaefer Pamela W , Ay Hakan , Singhal Aneesh B , Wu Ona
Published: July 2021

Background:
In acute ischemic stroke (AIS) patients, multi-parametric MRI-based predictive algorithms have shown promise in identifying tissue at risk of infarction, but do not consider the intrinsic variations of normal or pathological tissue. We hypothesized that extending MRI-based algorithms to take into consideration tissue type will improve predictions of tissue outcome.

Methods:
We retrospectively analyzed AIS patients who received neither revascularization nor experimental interventional treatment, who underwent MRI within 12 h from the time since they were last known well and who had follow-up imaging >4 days. Perfusion- and diffusion-parametric maps were combined to predict tissue outcome using 2 models: 1) a generalized linear model (GLM) trained with data from the whole ipsilateral hemisphere (sGLM), irrespective of tissue type, or 2) an anatomically-weighted GLM (aGLM) that was calculated using a weighted average to combine results from models generated using entire white or gray matter regions only. Both methods were evaluated using jack-knifing and predicted and follow-up regions were compared in terms of accuracy (measured as area under the receiver operator characteristic curve, AUC), Dice similarity index (DSI) and root mean square error (RMSE).

Results:
Results from 109 patients (65% male, median 68 y IQR [55-77], NIHSS 14 [9-25]) showed that, compared to sGLM, aGLM’s predictions had higher DSI (0.48 [0.19-0.59], P<0.001), and AUC (0.89 [0.86-0.94], P=0.001) and lower RMSE (0.32 [0.29-0.35], P<0.001), all demonstrating improved performance.

Discussion:
We showed that anatomically-weighted algorithms may better capture differences in tissue vulnerability in acute ischemic stroke, contributing to improved MRI-based tissue outcome predictions.