bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP150: Association Of Asymptomatic Cerebral Vasospasm With Outcomes In Aneurysmal Subarachnoid Hemorrhage
Authors: Shamshad Alizeh , Persad-Paisley Elijah M , Stretz Christoph , Potter Nicholas S , Wendell Linda C , Thompson Bradford , Reznik Michael , Furie Karen L , Mahta Ali
Published: February 2022

Cerebral vasospasm (cVSP) is a common complication in patients with aneurysmal subarachnoid hemorrhage (aSAH) and is associated with worse outcomes. However, clinical significance of asymptomatic cVSP remains poorly understood. We sought to determine the association between asymptomatic cVSP and hospital length of stay (LOS), duration of external ventricular drain (EVD), and functional outcome. We performed a retrospective cohort study of consecutive aSAH patients who were admitted to an academic referral center from 2016 to 2021. We included patients with confirmed aneurysmal etiology who received transcranial Doppler (TCD) with documented daily measurements. Multiple linear regression analysis was performed to test the association of asymptomatic cVSP (defined as elevated TCD velocities with no clinical correlation) and both hospital LOS and duration of EVD. Binary logistic regression analysis was used to test the association of asymptomatic cVSP and worse functional outcome (3-month modified Rankin scale 4-6). We included 223 patients (mean age 55.8 years [SD 13.4], 60% female, 70% white) with aSAH who survived hospitalization and had documented daily TCDs. Asymptomatic cVSP was seen in 32% of patients and delayed cerebral ischemia (DCI) was seen in 27% of patients. Only symptomatic cVSP was associated with prolonged hospital LOS (3.25 more days; p=0.034) independent of age, comorbidities, Hunt and Hess grades, modified Fisher scales, DCI, and other hospital complications. However, asymptomatic cVSP was associated with longer duration of EVD (3.78 more days; p=0.025) independent of common predictors including hydrocephalus and amount of cerebrospinal fluid daily output. Severity of vasospasm (ordinal variable: mild, moderate, or severe) was associated with longer duration of EVD (1.47 more days; p=0.016). Asymptomatic cVSP was not independently associated with worse functional outcome. In conclusion, isolated asymptomatic cVSP may not be associated with worse outcome but can contribute to interventions such as EVD prolongation. Clinical significance of asymptomatic cVSP and its management should be studied in multi-institutional prospective cohorts.
Abstract TP158: High Mortality In In-Hospital-Stroke Patients After Interhospital Transfer For Endovascular Therapy
Authors: Leitner Miriam Antonia , Hubert Gordian , Paternoster Laura , Leitner Moritz , Rémi Jan , Trumm Christoph , Haberl Roman , Hubert Nikolai
Published: February 2022

There are only few studies examining In-Hospital-Stroke- (IHS) patients with a large vessel occlusion and subsequent transfer to a comprehensive stroke center for endovascular therapy (EVT). However, this patient group is highly relevant given the substantial amount of IHS, the ongoing trend towards a more frequent use of EVT and the lack of EVT capacities in rural hospitals. Furthermore, these patients are particularly vulnerable, as IHS is associated with higher rates of pre-existing conditions and worse clinical outcomes. We retrospectively analyzed prospectively collected data of patients receiving EVT after interhospital transfer from 15 rural hospitals of the Telemedical Stroke Network in Southeast Bavaria, Germany (
TEMPiS
) between 02-2018 and 07-2020. Baseline characteristics, treatment times and outcomes were compared between IHS- and Out-of-Hospital-Stroke- (OHS) patients. Primary endpoint was mRS after 3 months. A total of 49 IHS-patients and 274 OHS-patients received EVT after interhospital transfer. IHS-patients had a higher prevalence of atrial fibrillation (55.3% vs. 35.9%, p= 0.012), diabetes (36.2% vs. 21.1%, p= 0.024) and use of oral anticoagulants (44.7% vs. 20.8%, p< 0.001). Severity of stroke was similar in both groups. Treatment times from symptom onset to first brain imaging, therapy decision or groin puncture were significantly shorter for IHS-patients. IHS-patients displayed significantly worse outcomes: 59.2% of them died within 3 months compared to only 28.5% of OHS-patients (p< 0.001). Additionally, they were less likely to achieve moderate outcomes (mRS 0-3) 3 months after stroke (20.4% vs. 39.8%, p= 0.010). A logistic regression analysis revealed that - after controlling for possible confounding variables such as severity of stroke, premorbid state, pre-existing conditions, age and gender - IHS was significantly associated with a higher chance of death (adjusted OR: 3.99 (95%-CI: 1.84-8.92), p< 0.001). The mortality rate of IHS-patients who underwent EVT after interhospital transfer was substantially higher than that of OHS-patients. Thus, this patient group may not benefit from this therapeutic approach. In future studies alternative approaches that circumvent interhospital transfer should be explored.
Abstract TP159: The Effect Of Diabetes Mellitus On Thrombus Composition In Patients With Stroke
Authors: Abbasi Mehdi , Arturo Larco jorge , Madhani Sarosh Irfan , Mereuta Oana M , Dai Daying , KADIRVEL Ram , Savastano Luis , Kallmes David F , Brinjikji Waleed
Published: February 2022

Introduction:
Outcomes of mechanical thrombectomy (MT) are influenced by the composition of thrombi. Amongst the risk factors affecting clot composition, diabetes mellitus (DM) may be associated with more thrombus structural and mechanical alterations resulting in fibrinolysis-resistant thrombi. However, extensive analysis of the composition of thrombi obtained from patients is needed to elucidate this relationship.

Hypothesis:
Thrombi retrieved from patients with DM may have different compositions compared to that of patients with no history of DM.

Methods:
MT retrieved-thrombi from patients suffering from large vessel occlusion (LVO) stroke were included. Thrombi sections were stained with Martius Scarlet Blue (MSB) for main thrombus components including red blood cells (RBCs), white blood cells (WBCs), fibrin and platelet. Additionally, immunohistochemistry (IHC) was performed to identify neutrophil extracellular traps (NETs) (anti-citrulinated H3; CitH3; NETs-specific marker) and von Willebrand Factor (vWF) in thrombi. Slides were then scanned and analyzed and the thrombus composition was compared between patients with or without a DM diagnosis at the time of stroke presentation.

Results:
A total of 140 patients were included of which 35 had a diagnosis of DM at stroke presentation. Baseline characteristics (excluding age), IV-tPA use prior to MT, and MT outcomes (number of device passes and final mTICI score) were similar between DM and non DM patients. The overall average percentage of RBCs, WBCs, fibrin, platelet, NETs (CitH3), and vWF components in thrombi were 47.4%, 3.2%, 27.4%, 21.8%, 25.9% and 17.6%, respectively. Thrombi from patients with DM were not statistically significant different from those of patients with no DM in terms of RBCs (44.3 vs 48.4 p=0.37), WBCs (2.7 vs 3.3 p=0.05), fibrin (29.5 vs 26.7 p=0.37), platelet (23.3 vs 21.3 p=0.57), NETs (25.6 vs 22.3 p=0.54), and vWF (17.5 vs 17.7 p=0.96).

Conclusion:
DM has no effect on the composition of thrombi as no significant difference was found in thrombi obtained from patients with and without DM.
Abstract TP160: Use Of Tele-stroke In A Large Integrated Healthcare System Demonstrate No Disparities In Endovascular Treatment For Stroke
Authors: Zrelak Patricia A , Alexander Janet , Klingman Jeff , Nguyen-huynh Mai N
Published: February 2022

Background:
Race and sex disparities have been reported in endovascular stroke treatment, the most effective treatment to prevent long-term disability from stroke associated with large vessel occlusion (LVO). In this study, we sought to determine if there are racial and sex disparities in endovascular stroke treatment for patients with acute ischemic stroke due to LVO across 21 community hospitals, part of an integrated delivery system, using a centralized telestroke service and standardized process for rapid stroke evaluation and treatment.

Methods:
Study population included patients seeking care for suspected acute stroke that were diagnosed with a LVO at one of 21 Northern California Emergency Departments between January 1, 2016 and December 31, 2019. Patients were excluded if they were less than 18 years of age or had a canceled stroke alert. Logistic regression (SAS proc genmod) was used for multivariate models.

Results:
Of 1519 patients with LVO, 918 underwent endovascular treatment. There were no differences in sex, Healthcare membership (yes or no), or race in patients that received endovascular stroke treatment compared to those that did not in the multi-variate models (Table). As expected, increased age, greater initial NIHSS (greater than 6), arrival by Emergency Medical Service (yes or no), and shorter time to ED arrival were associated with increased treatment rates (Table). There were no significant differences by race or sex. There were no differences in 90-day mortality rates by race (p=0.085). Non-treatment was primarily associated with patient/family refusal and or poor functioning at baseline.

Conclusions:
Implementation of the telestroke plus standardized workflows within all facilities provided equitable care regarding race and gender on endovascular treatment odds.
Abstract TP162: Long-term Experience With Resolute Onyx Balloon Mounted Stent For Medically Refractory Intracranial Atherosclerotic Disease Evaluated By Wingspan Stent System Post Market Surveillance (WEAVE) Methodology
Authors: Hassan Ameer , Khalil Mohammad , Desai Sohum , Tekle Wondwossen
Published: February 2022

Background and Purpose:
Angioplasty and stenting is a therapeutic option for patients with medically refractory intracranial atherosclerotic disease (ICAD). We previously demonstrated the feasibility of using Resolute (R) Onyx Stent, a drug-eluting balloon mounted coronary stent (DES), for ICAD patients. WEAVE (Wingspan Stent System Post Market Surveillance) trial assessed the periprocedural safety of Wingspan Stents in ICAD patients. We present our on-going experience with R-Onyx in ICAD patients integrating WEAVE styled methodology to assess outcomes in our cohort.

Methods:
A prospectively maintained neuro-endovascular database was queried for intracranial angioplasty and stenting cases from October 2019 to June 2021. Patients with symptomatic ICAD despite maximum medical management with >70% stenosis who were treated with R-Onyx DES were included. Primary outcomes were assessed according to WEAVE trial criteria (ischemic or hemorrhagic stroke or death within 72 h of the procedure). Secondary outcomes were assessed by occurrence of stroke and/or in-stent restenosis evaluated 30 days post-procedure clinically or angiographically.

Results:
A total of 58 patients were eligible for analysis with a mean age of 63.66 years, and 63.8% (n=37) were males. A total of 42 patients had an indication for treatment consisting of recurrent stroke while 16 had recurrent transient ischemic attacks. A total of 62 R-onyx DES stents were used to treat 58 patients with symptomatic lesions with an average stenosis of 84.7%. All procedures were completed successfully with <30% residual stenosis and 1.7% (n=1) of patients having hemorrhage and death within 72 h. Out of 41 patients who had a long-term follow-up, 0 had a stroke. In terms of 6-month angiographic follow-ups, 1 patient had in-stent restenosis treated via angioplasty.

Conclusion:
Our study reinforces the feasibility of R-Onyx DES for treatment of ICAD refractory to maximal medical management by reporting low periprocedural complication rates (1.7%) according to WEAVE methodology, which itself had a periprocedural complication rate of 2.6%, and low long-term frequencies of indications such as strokes and restenosis. These findings perhaps warrant randomized comparative studies between the stents.
Abstract TP168: Quantitative Cerebrovascular Reactivity Atlas In Children
Authors: Alhadid Kenda , Robertson Amanda , Walker Kirsten , Kassner Andrea , Shroff Manohar , Deveber Gabrielle A , Logan William , Dlamini Nomazulu
Published: February 2022

Introduction:
Cerebrovascular reactivity (CVR) can be measured by inducing carbon dioxide (CO
2
) changes in the circulation and measuring subsequent changes in blood flow with functional MRI blood oxygen level dependent sequences (BOLD). In clinical practice, abnormalities in CVR imaging can serve as a biomarker of ischemic risk. To characterize pathological aberrations in CVR, it is essential to have quantitative reference data as to what constitutes normal CVR across brain regions at various stages of development.

Methods:
Prospective enrollment of healthy children ages 6 to 18. Target N of 40. Two datasets are being generated within the atlas using two different methods of administering the vasoactive stimulus (CO
2
): a breath-hold CVR dataset (endogenous stimulus) and a RespirAct
TM
CVR dataset (exogenous). A test of normality is performed on CVR values for each voxel across subjects, with mean and standard deviation calculations. This will allow for generation of a Z-score for each CVR value per voxel in any clinical CVR study. Voxel-wide validation of breath-hold CVR values against the gold standard RespirAct
TM
CVR values will be performed using within subject t-test and between group comparisons. Subgroup analysis based on gender and age will also be performed.

Results:
Preliminary CVR data for 8 healthy right-handed children is presented (4 female, median age 13, range 9 -14 years). All participants tolerated CVR studies well and no side effects were reported. Group datasets acquired to date passed tests of normality with no significant differences in CVR values between the two methods found.

Conclusions:
This study will generate the first atlas of quantitative CVR-fMRI data in healthy children. Normative physiological data on CVR changes throughout childhood, and associations between CVR, blood pressure, age, and gender will be obtained. CVR imaging is performed clinically in patients with a risk of recurrent arterial ischemic stroke such as those with intracranial arteriopathies, sickle cell disease and other genetic and metabolic disorders. Our atlas can provide clinicians with objective measures regarding extent and distribution of CVR abnormalities, allow for stroke risk stratification, and aid in determining the optimal time for intervention.
Abstract TP176: Arrhythmia And Stroke Risk Among Migraineurs With Aura As Predicted By CHA
2
Ds
2
-VASc Scoring Tool
Authors: Zelnick Pamela , Kim Youngran , Jagolino-cole Amanda , Sheth Sunil , Burish Mark
Published: February 2022

Introduction:
Migraine with aura (MWA) is associated with increased risk of atrial fibrillation (AF) and stroke. A recent study found that among young adults with MWA, AF was the second most common cause of ischemic stroke behind high-risk patent foramen ovale. The CHA
2
DS
2
-VASc score predicts 1 year risk of thromboembolic events, and may further characterize stroke risk in this population.

Objectives:
We hypothesize that arrhythmias are more common in patients with MWA than migraine without aura (MWoA); and that among migraine patients with arrhythmia, MWA leads to higher ischemic stroke risk, as predicted by CHA
2
DS
2
-VASc.

Methods:
The American Registry for Migraine Research (ARMR) database consists of patient questionnaires and headache diagnoses from 9 headache centers. Data on history of arrhythmia can be used as a marker for AF and other arrhythmias with stroke risk. Patients in ARMR ages 18-86 with ICHD-3 diagnosis of migraine were divided into MWA or MWoA based on survey responses, and evaluated for history of arrhythmia. Predicted stroke risk in migraineurs with arrhythmia was then characterized by CHA
2
DS
2
-VASc score calculation.

Results:
2406 patients were included in the analysis (21.8% MWA, 78.1% MWoA). Patient groups had comparable age and gender composition. Arrhythmias were more common in MWA patients (N=30, 5.7%) than MWoA (N=11, 0.58%) after adjusting for age, gender, substance abuse and cardiac risk factors (p<0.05). Among patients with arrhythmia, there was no significant difference between median CHA
2
DS
2
-VASc score in MWA (1, IQR1-2) and MWoA (2, IQR 1-3) groups (p=0.32), nor among individual CHA
2
DS
2
-VASc scores (p=0.449). This persisted when score was dichotomized with a cutoff of 2.

Conclusions:
Arrhythmia is more prevalent in patients with MWA than MWoA. However, higher risk of stroke in arrhythmic patients with aura is not predicted by CHA
2
DS
2
-VASc. This suggests that increased stroke risk in these patients may be independent of other stroke risk factors, and perhaps linked to the arrhythmias themselves. Our findings support the need for further large-scale studies to evaluate arrhythmia in MWA patients, and bring into question whether routine screening for arrhythmia is of benefit for stroke prevention in select migraine patients.
Abstract TP177: Lipid Paradox In Acute Ischemic Stroke: Study Of Lipid Parameters On Outcomes After Intravenous Thrombolysis
Authors: Ming Chua , Toh Emma M , Yap Qai Ven , Chan Yiong Huak , Sia Ching-Hui , Yeo Leonard L , Lim Amanda Y , Tan Benjamin Y
Published: February 2022

Background:
Contradicting evidence exists regarding the role of lipids in intravenous (IV) thrombolysis with tissue plasminogen activator (tPA), with some studies suggesting low lipid levels are paradoxically associated with poorer post-thrombolysis outcomes.

Methods:
Restricted cubic spline regression, multivariable-adjusted logistic regression and risk score models evaluated associations of five lipid parameters with poor functional outcome (90-day modified Rankin Scale >2), symptomatic intracranial hemorrhage (SICH), and mortality among 1004 acute ischemic stroke (AIS) patients who received IV tPA in a comprehensive stroke center.

Results:
There was a U-shaped relationship of low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) with all three outcomes using spline regression. Quartile (Q) 2 and Q4 of non-HDL-C were associated with increased odds of SICH (OR 4.2, 95% CI 1.2-15.0, p=0.026 and OR 5.1, 95% CI 1.4-18.2, p=0.011) compared to Q3. Similar quartile associations were found for total cholesterol (TC), and for LDL-C/HDL-C ratio with poor functional outcome. Q1 and Q2 of HDL-C were associated with increased odds of poor functional outcome (OR 1.6, 95% CI 1.0-2.5, p=0.043 and OR 1.6, 95% CI 1.0-2.4, p=0.042) compared to Q4. Only Q3 of LDL-C/HDL-C ratio was associated with increased odds of large-artery atherosclerotic stroke (OR 1.9, 95% CI 1.0-3.7, p=0.039) compared to Q1.

Conclusion:
In AIS patients who received IV tPA, a U-shaped relationship was found between non-HDL-C and SICH. Low LDL-C was associated with increased odds of mortality, while HDL-C may be protective against poor functional outcome.
Abstract TP178: AI Based Personalized Stroke Predictor For Patient Awareness And Treatment Compliance
Authors: Colangelo Giorgio , Montiel Estefania , Herrera Didier , Ribo Marc , Rubiera Marta , Molina Carlos A
Published: February 2022

Personal prediction of stroke recurrence based on modifiable factors may enhance patient compliance to treatments and healthy lifestyles while optimizing resources of health centers. Vascular risk factors, socio-economic indicators and habits correlate with stroke morbidity and further recurrence. We aimed to estimate stroke recurrence probability as a function of time (3 months, < 1 year and > 1year), both at individual level and with larger classes of individuals. Clinical and socioeconomic public healthcare-based dataset of 41325 patients admitted with stroke diagnosis in 88 public hospitals over 6 years were analyzed.

Overall, 8509 patients presented a stroke (one or more) recurrence (20.6%), with the following temporal distribution: 3 months, 1 year and > 1 year, 57%, 17% and 26% respectively. We developed a supervised-machine learning based study and identified modifiable and non-modifiable risk factors with stronger impact on risk of stroke recurrence. An algorithm able to provide individualized risk of stroke recurrence at 3 and 12 months was developed (AUROC = 0.80, for balanced classes). The risk can be continuously updated according to the status of modifiable risk factors.

We also calculated the survival curve for each patient, to detect different risk recurrence periods along time.

a) ROC curve for the three classes predicted.

b) Feature importance to explain the model for features modifiable by the patient or not
c) Probability over time of “No stroke recurrence” in an example patient according to optimal (orange) or poor (blue) control of vascular risk factors

Machine learning analyses can improve risk prediction and offer individualized information to patients that can be used as feedback for secondary prevention strategies. Our approach is compatible with prevention strategies which, by continuous patient communication and feedbacks, make patients more likely to comply with treatment prescribed or lifestyle changes suggested.
Abstract TP179: Candidate Genes For Small Vessel Ischemic Stroke: A Gwas Pilot Study
Authors: El Husseini Nada K , Jiang Rong , Bennett Ellen , Goldstein Larry B
Published: February 2022

Background:
The genetic basis of small vessel stroke (SVS) is poorly understood. Few genetic loci have been identified that may provide insights into SVS pathogenesis. We sought to identify genetic associations with incident SVS.

Methods:
A GWAS analysis was performed on a prospective cohort of patients enrolled in the American Stroke Association- Bugher Small Vessel Intracranial Disease Whole Genome Association Study which included patients from 4 hospitals in North Carolina recruited between December 2007-August 2012. Patients with SVS in the prior 2 years confirmed clinically and on neuroimaging were compared to a control group who had no previous history of stroke. A logistic regression model with SVS as the outcome and single nucleotide polymorphisms (SNPs) as the main predictor was performed and adjusted for baseline demographics and clinical characteristics, including age, race/ethnicity, sex, tobacco use, history of hypertension, diabetes, hyperlipidemia, atrial fibrillation, history of stroke/TIA, and principal components. Because of the relatively small sample size, SNPs with p-values <1E-4 were considered significant.

Results:
The cohort included 139 patients who had SVS and 64 controls. Among this cohort, 50% were men and 38% African-American. The mean age of the study group was 63-years. Sixteen SNPs in 9 genes met the statistical cutoff for association with SVS. These were involved in extracellular matrix integrity (CHD23, CLDN14, SPTBN1), neuronal differentiation (DSCAML1), cholesterol transport (GRAMD1B), transcriptional regulation (JARID2, LINC02111, LINC01993) and voltage-gated potassium channel (KCND2).

Conclusion:
In this pilot GWAS study, several loci variations were associated with SVS. Although this study is hypothesis generating, previous studies have also shown an association of SVS with genes involved in extracellular matrix integrity. In addition, we found it interesting that SNPs in both CLDN14 and CDH23 genes, which have been linked to non-syndromic sensorineural deafness, are also more common in SVS. Some forms of sensorineural deafness have been associated with cognitive impairment and stroke, and if a genetic association is confirmed, it would suggest a common pathophysiology may link the two conditions.
Abstract TP18: Progressive White Matter Degeneration After Ischemic Stroke
Authors: Kern Kyle C , Wright Clinton B , Leigh Richard
Published: February 2022

Background:
White matter degeneration after ischemic stroke may herald post-stroke cognitive decline. FLAIR white matter hyperintensity (WMH) reflects tissue injury and accumulates around the infarct and in remote regions. But WMH volumetry is insensitive to regional or short-term progression. We compared WMH volumetry to a voxel-wise approach for detecting FLAIR WMH change longitudinally after stroke.

Methods:
Ischemic stroke patients enrolled in an observational cohort study underwent serial MRI acutely, at 1 month and every 3 months thereafter. Patients with 6 to 12-month follow-ups were included. WMH lesion volumes were automatically segmented on serial FLAIR MRI. In the hemisphere contralateral to the infarct from 30 days onward, we compared longitudinal change in WMH volume to a voxel-wise regression of FLAIR signal change over time. We used T1 images as an intermediate to nonlinearly align serial FLAIR images to individual templates. FLAIR intensities were normalized, corrected for local expansion/contraction, and smoothed. Within voxels identified as lesion at any timepoint, significant WMH change was determined relative to the normal appearing white matter and converted to a percentage of the intracranial volume.

Results:
22 ischemic stroke patients (mean age 73 ± 8 years, NIHSS 4 ± 4, infarct volume 10.3 ± 23 cc) had on average 3 follow-ups over 343 days. In the non-stroke hemisphere, volumetry revealed lesion growth in 12. Mean lesion increase was 0.01 ± 0.20% per year. In voxel-wise analysis 15 patients had increasing FLAIR signal. Intensity increased in mean 0.11 ± 0.23% of intracranial voxels. Lesion growth was associated with the volume of voxel-wise signal increase (Beta = 0.51, p = 0.018). In the stroke hemisphere, progressive WMH expansion of peri-infarct tissue, consistent with Wallerian degeneration, was present in 10 patients. WMH regression, consistent with atrophy and infarct cavitation, was present in 14. Stroke hemisphere WMH expansion was associated with initial NIHSS (B = 0.58, p = 0.0086) while regression was associated with acute infarct volume (B = 0.80, p < 0.001).

Conclusions:
Voxel-wise longitudinal WMH analysis detects progressive white matter degradation and regional variation continuing 30 days after stroke.
Abstract TP180: Secular Trends For Demographics, Characteristics, Management, And Clinical Outcome Of Young Adults With Acute Ischemic Stroke.
Authors: Kim Jonguk , Lee Keon-joo , Kim Jun Yup , Kang Jihoon , Kim Beom Joon , Han Moon-Ku , Choi Kang-Ho , Kim Joon-Tae , Shin Dong-Ick , Cha Jae-kwan , Kim Dae-Hyun , Kim Dong-Eog , Ryu Wi-Sun , Park Jong-moo , Kang Kyusik , Kim Jae , Lee Soo Joo , Oh Mi-Sun , Cho Yong-Jin , Choi Jay Chol , Sohn Sung Il , Hong Jeong-ho , Park Tai Hwan , Lee Kyung Bok , Kwon Jee-hyun , Kim Wook-Jo , Lee Jun , Lee Ji Sung , Lee Juneyoung , BAE Hee-joon
Published: February 2022

Background:
The incidence of stroke in young adults is increasing with the growing prevalence of stroke risk factors among young adults over the last decades. However, studies on secular trends in the young-age stroke population are scarce.

Methods:
We extracted data of acute ischemic stroke (AIS) patients aged 18-50 (n=7053; age, 43±6; male, 72%) from the multicenter stroke registry in South Korea. Demographics, risk factors, stroke characteristics, management, and clinical outcomes in young adults with AIS were summarized according to calendar year (2008-2019). Trends analysis was conducted using a linear regression model for continuous variables and the Mann-Kendall trend test for categorical variables.

Results:
There was no significant change between 2008 and 2019 in the proportions of young adults among female patients (7.1% to 7.0%, p=0.44). However, the proportions of young adults within male patients tended to decrease (12.4% to 10.7%; p=0.001) The prevalence, and awareness of risk factors were unchanged during the study period. Regarding stroke subtypes, there was a significant increase in other determined etiology (8% to 20%; p<0.001) and a tendency to decrease in large artery atherosclerosis (26% in 2008; 34% in 2009 to 26% in 2019; p=0.28). The endovascular thrombectomy (EVT) rate increased (2% to 8%; p<0.001), but the intravenous thrombolysis rate (8.8% to 10.6%) and door-to-needle time (38 to 36 min) did not change. Use of dual antiplatelet (DAPT; 29% to 55%; p=<0.001) increased and direct oral anticoagulants (DOACs) in patients with atrial fibrillation tended to increase (11.7% in 2013 to 44.8% in 2019; p=0.07; DOAC began to be used in 2013 in Korea). However, the use of anticoagulants among young adult patients having atrial fibrillation tended to decrease (80% to 66%; p=0.054). Clinical outcomes, including a 3-month modified ranking scale 0-2 (84.6% to 85.2%), 1-year mortality (2.8% to 2.4%), and stroke recurrence rate (4.5 to 5.6%), did not improve during the study period.

Conclusions:
Among young adults with ischemic stroke, the EVT rate and use of DAPT or DOACs increased. Still, awareness of risk factors, door-to-needle time, and anticoagulation for atrial fibrillation required more attention to improve clinical outcomes.
Abstract TP181: Pre-existing Depression And Stroke During Pregnancy
Authors: Christopher Kara M , Abdelsalam Ahmed , Ferber Megan , Madden Colleen , Miremadi Brian B , Ilorah Chike , Linares Guillermo , Edgell Randall C
Published: February 2022

Introduction:
There is increasing evidence linking depressive symptoms and stroke. While several studies have investigated the association between depression and stroke in the elderly population, there are few that have examined the relationship in pregnant women. Additionally, health inequities persist in pregnancy which may increase the burden of depression on pregnant Black women. The current study examined the impact of depression on stroke during pregnancy.

Methods:
We used data from the National Inpatient Sample (NIS, 2015-2018). Our sample included women between the ages of 20-44 with a maternal or neonatal admission diagnosis. Data were analyzed using weighted logistic regression models in SAS version 9.4. Covariates included age, insurance status, history of hypertension (HTN), high cholesterol (HCL), physical health comorbidities (PHC), and obesity status. PHC included those defined by the Elixhauser Comorbidity Software from AHRQ, except for hypertension, diabetes, and obesity. Depression was determined using of ICD-9 or ICD-10 codes. All analyses were stratified by race.

Results:
Overall, depression was associated with an increase in the incidence of stroke during pregnancy (aOR=1.55, 95%CI 1.11-2.18), however when stratified by race, Black women with depression had nearly 3 times higher odds of stroke (aOR=2.91, 95% CI 1.67-5.07) compared to Black women who did not have depression; there was not a statistically significant effect of depression on stroke among White women or Latinas.

Conclusions:
This study shows that, among Black women, depression is related to an increased odds of stroke during pregnancy, regardless of HTN and HCL history. While stroke primarily affects older adults, this study shows that it is important to ensure proper prenatal care and monitor Black women during pregnancy for signs and symptoms of stroke, especially if they have a PHC or history of depression.
Abstract TP182: Association Between Type 2 Myocardial Infarction And 90-day Ischemic Stroke Readmission In Elderly: Insights From National Database
Authors: Elsharnoby Hadeer , Maraey Ahmed , Kayani Waqas , Khalil Mahmoud , Salem Mahmoud , Rahman Hamood , Kichloo Amir
Published: February 2022

Background:
Type 2 myocardial infarction (T2MI) is an ischemic myocardial injury in the context of oxygen supply/demand mismatch in the absence of a primary coronary event. Chronic myocardial injury was linked to increased risk of stroke in the long term follow up. However, association between T2MI and stroke in short term follow up is unclear due to limited available data.

Objective:
To study the impact T2MI on 90-day readmission with ischemic stroke or transient ischemic attack (TIA) in elderly hospitalized patients.

Methods:
The study is a retrospective analysis of national readmission database (NRD) of year 2018 for patients ≥ 65 years. Patients were excluded if they had stroke, myocardial infarction other than T2MI or prior stroke in index admission. Patients admitted between October and December to allow 90 days follow up. International classification of disease, tenth edition (ICD 10-CM) was used to identify diagnoses. Multivariate logistic regression model was used to calculate adjusted odds ratio (aOR) and adjust for potential confounders (figure 1).

Results:
A total of 6,643,620 patients were admitted in 2018 that met our criteria. T2MI was present in 88,282 (1.3%) index admissions. A total of 1,549,951 patients were readmitted to the hospital within 90 days of whom 36,981 (2%) patients were diagnosed with stroke or TIA. Patients readmitted with stroke were more likely to be female (56% vs 55%, P=0.005), had complicated hypertension (46% vs 35%, P<0.001), complicated diabetes mellitus (28% vs. 20%, P<0.001), and congestive heart failure (35% vs 26%, P<0.001). T2MI was associated with increased risk of 90-day stroke readmission (aOR: 1.21, 95%CI [1.09-1.35], P<0.001).

Conclusion:
In our large retrospective study, T2MI was found to be an independent predictor of 90-day readmission with stroke or TIA in hospitalized elderly patients. Further studies are warranted to identify optimum strategy of risk stratification and management of such patient.
Abstract TP183: Risk And Predictors Of Relapse After Smoking Cessation In Patients With Ischemic Stroke And Transient Ischemic Attack
Authors: Parikh Neal S , Zhang Cenai , Navi Babak , Kamel Hooman
Published: February 2022

Introduction:
Smoking cessation is an integral part of secondary prevention after stroke and TIA. Relapse after successful smoking cessation in this population is poorly understood.

Methods:
This is a retrospective cohort analysis of patients enrolled in the international Insulin Resistance Intervention After Stroke (IRIS) trial, which included 3,876 nondiabetic patients with ischemic stroke or TIA. In IRIS, patients were asked about smoking status at the time of the index event, at randomization, and annually thereafter for 5 years. For this analysis, we included patients who quit smoking by randomization. Patients with active smoking at any follow-up visit were categorized as relapsed. We used time-to-event analysis to estimate cumulative relapse rates. We used univariate Cox proportional hazards regression to assess possible predictors of relapse: demographics, index event type (stroke vs TIA), country of origin, cardiovascular comorbidities, and duration/intensity of smoking.

Results:
At the time of stroke/TIA, 1,072 patients were active smokers. By randomization, a median of 3 (IQR, 2-5) months later, 450 (42%) had quit smoking. The mean age of the 450 quitters was 58 years, and 35% were women. They had smoked a median of 20 (IQR, 10-25) cigarettes/day for a median of 40 (IQR, 34-46) years. Over a mean follow-up of 3.8 years, 156 patients relapsed. The 5-year cumulative relapse rate was 38% (95% CI, 34-43%), with 21% (95% CI, 18-25%) relapsing within 1 year (Figure). Age, sex, index event type, duration and intensity of smoking were not associated with relapse. However, patients at US sites (vs non-US sites) were more likely to relapse (HR, 1.46; 95% CI, 1.01-2.10), as were patients with more cardiovascular comorbidities (HR, 1.28; 95% CI, 1.05-1.55; for each additional condition).

Conclusion:
Stroke/TIA survivors with early smoking cessation have a high rate of relapse, highlighting a need to engage this at-risk population in sustained cessation interventions.
Abstract TP186: Heterogeneity Of Endovascular Treatment Effect: A Comparison Of Subgroup Identification Methods In Acute Stroke Trials
Authors: Ademola Ayoola , Hildebrand Kevin , Almekhlafi Mohammed , Menon Bijoy K , Demchuk Andrew M , Goyal Mayank , Hill Michael D , Thabane Lehana , Sajobi Tolulope
Published: February 2022

Background:
Trials’ data are increasingly re-analyzed to identify treatment effect heterogeneity: that is, subgroups of patients who have either enhanced or adverse effects in a trial. This study investigates the robustness of subgroup identification methods in an acute stroke trial.

Methods and Analysis:
The Model-based recursive partitioning (MOB), Stochastic Subgroup Identification based on Differential Effects Search (Stochastic SIDEScreen), and Virtual Twin (VT) methods would be used to detect heterogeneity in Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial.

Results:
In the ESCAPE trial, patients in the intervention group had a higher rate of functional independence (90-day mRS 0-2) than those in the control group (OR=2.6; p<0.001, and 95% CI=1.7–3.8). The three methods identified patients with differential treatment effects. The MOB identified 2-terminal subgroups, with the NIHSS > 11 group showing a significant treatment effect (OR=3.67; p<0.001 and 95% CI=2.11–6.40), while the subgroup of with a maximum NIHSS score of 11 did not (OR=1.63; p=0.463 and 95% CI=0.44–6.05). The stochastic SIDEScreen identified 4-terminal subgroups, but the group of patients with NIHSS greater than 9 and older than 54 years had a significant treatment effect (OR=4.92; p<0.001, and 95% CI= 2.66–9.10). Other three subgroups, like patients with a maximum NIHSS score of 9 and older than 54 years (OR=2.17, p=0.34, and 95% CI=0.44–10.65), did not have a significant treatment effect. VT identified 6-terminal subgroups; the subgroup consisting of patients older than 56 years and NIHSS > 11 had significant treat effect (OR=5.11; p<0.001 and 95% CI=2.68–9.73). As other renaming 4 subgroups, the subgroup consisting of younger patients and with a maximum NIHSS score of 11 did not show a treatment effect (OR=1.60, p=0.64, and 95% CI=0.39–6.30).

Conclusion:
Data-driven subgroup identification methods provide insight into the heterogeneity of treatment effects in acute stroke trials. Information about the identified subgroups might inform the development of clinical practice guidelines for acute stroke management.
Abstract TP19: Sex Differences In The Impact Of Stroke On Retrieval Of Remote Fear Memory And Mir20a-3p Treatment
Authors: Sampath Dayalan , Markowsky Kylee , Branyan Taylor , Sohrabji Farida
Published: February 2022

Preamble:
Stroke is the major cause of death and disability worldwide. In addition to the immediate disability, stroke also results in diffuse secondary damage to regions distal to the ischemic region. Here we used the contextual fear conditioning test to assess the integrated functioning of affective and cognitive circuits after stroke in males and females, as well as the impact of mir20a-3p on this long term behavior.

Methodology:
Middle-aged (acyclic) females and males were injected stereotaxically with endothelin-1 in the left middle cerebral artery (MCA) region to create an ischemic stroke. Mir20a-3p mimics or scrambled oligo was administered
i.v.
4h and 24h after stroke. Tests of sensory motor function including adhesive tape removal (ART) were performed prior to and after stroke. Long term cognitive changes were assessed by contextual fear conditioning (CFC) and the novel object recognition test (NORT).

Results:
Sensory motor deficits induced by stroke were abrogated with mir20a-3p treatment in both sexes. Contextual fear conditioning was evaluated by percent freezing during acquisition, extinction and retrieval. Sex differences were noted in fear extinction even prior to stroke, with males displaying resistance to extinction. At 30 days post-stroke, % freezing was no different from the pre-stroke extinction in females, while males showed a significant decrease in freezing rates after stroke, irrespective of treatment. In females, remote fear memory retrieval was reduced in vehicle-treated stroke rats, while the mir20a-3p treated group did not differ significantly from their pre-stroke levels. In contrast, both vehicle and mir20a-3p treated males showed a significant decline in freezing in response to fear retrieval. In female vehicle treated rats, the retrieval of remote fear memory continued to be impaired even at 100d post stroke(p<0.05), but preserved in miR20a-3p treatment group, indicating a persistent cognitive impairment and treatment effect.

Conclusion:
While mir20a-3p treatment improved sensory motor performance in both sexes, fear related memories were better preserved in females at 30 days, suggesting that neuroprotectants may have similar effects in the short term but may diverge in a sex specific manner in the chronic phase.
Abstract TP191: Three-month Daily Blood Pressure Monitoring Predicts Incident Stroke In CADASIL
Authors: Chen Chih-hao , Liao Yi-Chu , Cheng Yu-Wen , Chung Chihping , Lee Yi-Chung , Tang Sung-Chun
Published: February 2022

Introduction:
CADASIL is a hereditary small vessel disease caused by
NOTCH3
mutations. Whether superimposed hypertension had harmful effects on these populations was unknown.

Methods:
We recruited 100 participants in the prospective cohort of Taiwan CADASIL Registry with documented
NOTCH3
mutations
,
as well as 18 age- and sex-matched controls. Daily blood pressure (BP) and heart rate (HR) were recorded by the participants with a standardized home-based sphygmomanometer for consecutive 90 days. Linear analysis of the variability parameters was done. Neuroimaging markers of small vessel disease on brain magnetic resonance imaging and any incident stroke was documented.

Results:
Participants with
NOTCH3
mutations are more likely to have stroke history and use antithrombotic or antihypertensive medications than controls. However, the systolic, diastolic BP, and pulse pressure were comparable, except for higher mean HR (77.3±10.0 vs 70.7±8.3,
P
=0.01) in the
NOTCH3
group. In participants with
NOTCH3
mutations, higher 90-day mean systolic and diastolic BP correlated with more cerebral microbleeds, while the mean, standard deviation, coefficient of variation, and average real variability of 90-day HR positively correlated with number of lacunes. During median follow-up of 24 months, there were 8 stroke events (5 ischemic, 3 hemorrhagic). Participants with persistent hypertension (90-day mean systolic/diastolic BP > 130/80 mmHg) were more likely to have incident stroke (log-rank
P
= 0.04), and the effects persisted (hazard ratio 5.29, 95% CI 1.12 - 25.1) after adjustment of number of cerebral microbleeds.

Conclusions:
In participants with
NOTCH3
mutations, persistent hypertension had detrimental effects on the severity of cerebral microbleeds as well as incident stroke. Aggressive blood pressure control seems beneficial in hereditary small vessel disease.
Abstract TP193: Atrial Fibrillation Burden Is Not Associated With Recurrent Cerebrovascular Events In Anticoagulated Stroke Patients: An Arest Trial Sub-study
Authors: Fradley Michael , Pothineni Naga , Deng Wei , Tran Nhi , Burgin William , Oliveira Guilherme , Labovitz Arthur J , Beckie Theresa , Rose David
Published: February 2022

Introduction:
The burden of Atrial Fibrillation (AF) has previously been associated with a higher stroke risk in non-anticoagulated patients. We aim to find whether there is also an association between AF burden and recurrent cerebrovascular events in anticoagulated AF patients after their initial acute ischemic stroke (AIS) or transient ischemic attacks (TIA).

Methods:
The AREST study (Apixaban for Early Prevention of Recurrent Embolic Stroke and Hemorrhagic Transformation) was a multi-center, randomized controlled trial of early apixaban versus warfarin at one week post-TIA or two weeks post-AIS, in AF patients from 2015 to 2019. Subjects received either 30-day continuous electrocardiographic monitoring or an implantable device (i.e., pacemaker, loop recorder, or defibrillator). Logistic regression and Kendall's tau-b test were utilized to identify an association between AF burden and the proportion of subjects who developed recurrent cerebrovascular events.

Results:
Of 91 subjects enrolled into AREST, heart rhythm monitoring was assessed in 49 (54%); over half (59%) clustered at the extreme ends of the distribution, at either low (≤1%) or high (≥99%) AF burden. Higher AF burden was not significantly correlated with an increased risk of recurrent stroke or TIA (Odds Ratio = 0.99 [95% confidence interval (CI), 0.98-1.0]; p=0.518). Moreover, there was no statistically significant association between AF burden and the composite outcomes after adjusting for either apixaban or warfarin.

Conclusions:
AF Burden was not found to be associated with recurrent cerebrovascular events in patients taking oral anticoagulant after an AIS or TIA. Further research is needed to confirm these findings.
Abstract TP194: Radiation And Stroke Death Risk In Diffuse Large B-cell Lymphoma Patients, A Population Based Study.
Authors: Baek Jeffrey S , Szeja Sean S
Published: February 2022

Objective:
Radiation (RT) is associated with vascular changes, which carotid studies have linked with stroke risk. Previous studies have reported an increased risk of stroke following RT for squamous cancers of head & neck (HN), or Hodgkin’s lymphomas, though with variations in dose and anatomical radiation targets. Hence the effects of low dose radiation to only the HN remains unclear. We used a national database with long-term follow up to quantify the association of RT and stroke death (SD) in patients with diffuse large B cell lymphoma (DLBCL) of the HN.

Materials/Methods:
Patients 30 or older with DLBCL, stage I-II of a known primary site besides CNS or mediastinum from 1983-2013 were obtained for analysis from the SEER database. Cause of death coding was filtered for Cerebrovascular Disease. Chi square, T-test, and Kaplan-Meier analysis were performed with log-rank test and Cox accounting for age, sex, RT, and year of diagnosis.

Results:
33945 patients met inclusion criteria with a median follow up of 44 months. SD occurred in 410 patients in median time 62 months. RT was given in 3855 of 8312 (46%) HN and 7686 of 25633 (30%) of non-HN patients. The 10 year-SD rate was 2.2 / 2.8 % (p=0.77) for HN receiving/ not receiving RT (noRT), and 1.8 / 2.1 % for non-HN patients (p=0.40). When combining both RT and noRT patients, HN patients did show a trend towards higher SD risk compared with non-HN patients, 2.5 vs 2.0%, (p=0.053), though this did not appear to be driven by RT. On univariate analysis of HN patients, there was no difference in the effects of RT on the SD rate in any subgroup. Multivariate analysis did not identify any increased risk of SD associated with RT, either (HR = 0.87, p=0.63).

Conclusions:
This study did not identify any increased risk of stroke death from RT in patients with early stage DLBCL of the head & neck, although there was a trend suggesting stroke rates may be higher in patients with disease located in head & neck compared to other sites regardless of whether they received RT. Higher chemotherapy doses for non-RT patients may be a relevant confounding variable. Confirmation with pooled analyses and meta-analysis may be useful.