bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 3093: Clinical Factors Associated With Hypotension Within 12 Hours Of Antihypertensive Therapy In Ed Stroke Patients
Authors: Adeoye Opeolu , Hart Kimberly W , Dahl Cendi , Waymeyer Peggy , Ewing Irene , Pancioli Arthur , Lindsell Christopher
Published: March 2022

Background:
Extremes of blood pressure (BP) have been associated with poor outcomes in acute stroke. Aggressive antihypertensive therapy in stroke patients with elevated blood pressure (BP) can lead to undesired hypotension. We sought to determine whether any pre-treatment factors are associated with undesired hypotension within 12 hours of initiating antihypertensive therapy in emergency department (ED) patients with neurological emergencies.

Methods:
This was a secondary analysis of an observational study conducted at an urban academic ED and two community EDs between November 2007 and March 2009. Patients with signs or symptoms of neurological emergencies treated with antihypertensives in the ED were eligible for enrollment if they were not enrolled in interventional clinical trials. Demographics, medical history, antihypertensive use, and BP measurements were abstracted in duplicate. Discrepant data were adjudicated by a third investigator. Based on American Heart Association guidelines, target BP was defined as a 20% reduction in systolic BP from that recorded immediately prior to treatment. Hypotension was defined as a systolic BP drop of > 40% from the pre-treatment level or systolic BP <100mmHg within 12hours of initiation of antihypertensives. Univariable Cox regression was used to evaluate factors associated with early hypotension.

Results:
One hundred patients were enrolled. Median age was 62years (range 36-96), 50 were male and 53 were black. The most common diagnoses were intracerebral hemorrhage (n=36), ischemic stroke (n=35) and hypertensive emergency (n=10). Hypotension occurred in 28 patients within 12hours of initiation of antihypertensive therapy. Median time from first treatment to hypotension was 211 minutes (range 2-629, IQR 98-355). In univariable analysis, lower baseline GCS and higher baseline BP were associated with post-treatment hypotension (
Table
).

Conclusions:
In this observational study, hypotension occurred frequently in ED patients with neurological emergencies who received antihypertensives. Since sicker patients with higher BP were more likely to become hypotensive, overly aggressive treatment in these patients may have accounted for the hypotension observed. Larger, future studies should see if these patients are indeed treated more aggressively.

Table.

Univariate predictors of hypotension
Abstract 31: Rate of Change in Memory Functioning Before and After Stroke Onset
Authors: Wang Qianyi , Capistrant Benjamin D , Ehntholt Amy , Glymour M Maria
Published: March 2022

Introduction:
Although memory impairment is both a predictor and a consequence of stroke, memory decline is common even in healthy elderly. We use a prospective cohort to describe the long-term trajectory of memory functioning before and after stroke and compare it with memory changes in stroke-free elderly.

Hypotheses:
Poor memory functioning in stroke survivors compared to stroke-free elderly reflects the combined effects of accelerated pre-stroke memory decline, a decrement of memory functioning at the time of stroke, and faster post-stroke declines.

Methods:
Participants age 50+ in the Health and Retirement Study (n=12,412) who were stroke-free at baseline were interviewed biennially for up to 10 years for onset of first self- or proxy-reported stroke (n=1,526). Segmented linear regression models were used to compare annual rates of change in memory functioning (expressed as z-scores based on a composite of immediate and delayed word list recall and proxy assessments) before and after stroke among three groups: 1,027 individuals who survived a stroke and participated in a subsequent cognitive assessment (stroke survivors); 499 individuals who died after stroke before the next cognitive assessment (stroke decedants); and 10,886 cohort members who remained stroke-free for the entire follow-up period. Models were adjusted for core demographics.

Results:
Before first stroke onset, individuals who later survived a stroke had lower memory functioning than those who remained stroke free throughout follow-up, but rate of memory decline was similar for the two groups (-0.034 points/year [95% CI: -0.04, -0.029] for stroke survivors vs. -0.028 points/year [-0.031, -0.025] for stroke free adults). Individuals who later died after stroke had significantly faster pre-stroke memory declines (-0.118 points/year; -0.155, -0.079). Among stroke survivors, memory declined an average of 0.157 points (-0.199, -0.116) at stroke onset, comparable to 5.6 years of age-related decline in stroke-free cohort members. In the years following stroke, rate of memory decline in stroke survivors accelerated only slightly compared to pre-stroke rate of decline, to -0.038 points/year (-0.048, -0.03).

Conclusions:
Although stroke induced large immediate decrements in memory, differences were apparent years before stroke onset. Pre-stroke rate of memory decline among future stroke survivors was similar to age-related memory decline in adults who remained stroke-free, but those who died after stroke had faster memory decline.
Abstract 3117: Role of Methamphetamine use on Severity of Initial Presentation and Clinical Outcomes in Aneurysmal Subarachnoid Hemorrhage
Authors: Beadell Noah , Thompson Eric , Delashaw Johnny , Cetas Justin
Published: March 2022

Introduction:
Methamphetamine is believed to have an effect on cerebral vasculature through its vasoactive properties. It has been linked to multiple medical complications, including subarachnoid hemorrhage in patients of a younger population. We hypothesized that methamphetamine use in patients with aneurysmal subarachnoid hemorrhage (aSAH) would be associated with more severe clinical presentations, adverse neurologic outcomes, and an increased incidence of vasospasm.

Methods:
We performed a retrospective review of patients who were admitted to the OHSU Neurosurgery service with aSAH between January 2005 and January 2011. The cases included patients who used methamphetamine, as documented by personal or family report and toxicology screening. We performed a multivariate analysis to examine the role of age, Hunt and Hess and Fisher grade on presentation, length of stay and Glascow outcome score.

Results:
An analysis of 374 patient charts included by criteria of having aSAH. Of these, 28 (7%) had a history of or were currently using methamphetamine as documented by a positive toxicology screen. On average the methamphetamine users were ten years younger (45.2 vs 55.9, p < 0.001). Despite the young age they had significantly higher Hunt and Hess grades (3 vs 2.5 and 2, p <0.001) than non-methamphetamine users and age-matched controls, respectively. Methamphetamine users had significantly higher rates of vasospasm (92.9% vs 71.1%, p= 0.015) than non-users, but there was no difference when compared to age-matched controls (92.9% vs 89.3%, p= 0.639). Methamphetamine users also had significantly lower Glascow outcome scores than age-matched non-user counterparts (3 vs 5, p<0.001) but not compared to the entire non-meth user group (3 vs 4, p=0.170). There was no difference in the length of stay (18 vs 16, p=0.431 and 18 vs 14, p= 0.250) for the methamphetamine user group verses both all non-users and age-matched controls.

Conclusion:
Methamphetamine use is associated with more severe clinical presentation and worse neurologic outcome compared to age-matched controls. Young patients have similar rates of vasospasm regardless of methamphetamine use.
Abstract 3120: Clinical Profile, In-hospital and Long-term Mortality Rates of Hispanic Puerto Ricans Hospitalized with Acute Stroke
Authors: Zevallos Juan C , Yarzebski Jorge , Rodriguez-Mercado Rafael , Santiago Fernando , Gonzalez Juan A , Nobo Ulises , Rodriguez Abiecer , Goldberg Robert J
Published: March 2022

Background:
Stroke mortality varies considerably according to race/ethnicity and place of residence. However, limited information is available about contemporary in-hospital death rates and one-year mortality in Hispanics hospitalized with acute stroke. We sought to examine the clinical characteristics, in-hospital, and one-year mortality death rates of Puerto Rican Hispanic patients hospitalized with an acute stroke.

Design/Methods:
Observational study using data from the Puerto Rico Stroke Registry. The study population consisted of patients hospitalized with an initial (first) acute stroke in 11 medical centers of Puerto Rico in 2007. In-hospital mortality was calculated as the percentage of patients hospitalized with an initial acute stroke who died during the index hospitalization, one-year all-cause mortality was determined through the review of death records in the Puerto Rico Department of Health Vital Statistics Records.

Results:
Of the 1528 consecutive patients hospitalized with an acute stroke, 1299 (85%) had an ischemic stroke. The mean age was 70 (+/- 28) years, and 53% were women. Patients hospitalized with an acute stroke had a considerable prevalence of comorbidities: 86% had hypertension, 52% had diabetes, 26% had hyperlipidemia, and 9% were current smokers. The overall in-hospital mortality rate was 11% and the one-year all-cause mortality rate was 26%. In comparison with men, women were older (71 years vs. 68 years), more likely to be hypertensive (89% vs. 83%, p=0.001), had similar odds of dying during hospitalization (OR=1.1 [95%CI= 0.8-1.6]), and more likely to die one year after hospital discharge (OR=1.3 [95%CI= 1.1-1.5]).

Discussion:
Our findings indicate a high in-hospital and one year mortality rates after an initial acute stroke in Hispanic Puerto Ricans. Given the high, short and long-term, death rates associated with acute stroke, monitoring the clinical characteristics, death rates and factors associated with an increased risk of dying remains warranted.
Abstract 3152: Telemedicine is Cost Effective in Acute Ischemic Stroke
Authors: Conners James J , Ouyang Bichun , Prabhakaran Shyam
Published: March 2022

Introduction:
Rapid availability to stroke specialists remains a critical hurdle in thrombolysis for acute ischemic stroke in many regions of the United States. Remote consultation is often utilized with varying success. Telemedicine use has been increasing but it is unclear if this is cost effective when compared to simple telephone consultation.

Hypothesis:
We assessed the hypothesis that telemedicine is cost effective for acute ischemic stroke patients.

Methods:
We created a decision tree model to compare telemedicine (with videoconferencing and image sharing) to telephone consultation. We estimated probabilities and utilities from the available literature and calculated incremental cost-effectiveness ratios (ICER). We used actual costs of telemedicine equipment, installation, and physician fees based on our own experience ($50,900 per hospital per year). We assumed equal access to standard medical treatments between the two approaches; an 8-hospital spoke system; and 60 patients assessed for acute stroke per year at each spoke hospital. However, we estimated higher tissue plasminogen activator (tPA) utilization among telemedicine-treated patients (28% vs 23%) based on the STRokE-DOC trial. We performed sensitivity analyses to assess all assumptions in our model. An ICER < $50,000/QALY was considered cost-effective.

Results:
In the first year after stroke, telemedicine resulted in a gain of 0.00459 QALY, but with an additional cost of $799 compared to telephone only (ICER = $174,074/QALY). In the long term (over 30 years), telemedicine resulted in a gain of 0.0282 QALY at an additional cost of $497 (ICER = $17,624/QALY). Using a long term sensitivity analysis, ICER remained < $50,000/QALY when the absolute difference in tPA utilization (telemedicine vs. telephone) was > 2.5%. When the absolute difference in tPA use is > 12%, telemedicine had cost-saving effects (ICER < 0). Cost-effectiveness was also sensitive to number of patients: 30 or more patients must be evaluated with telemedicine per hospital annually to remain cost-effective. Telemedicine remained cost-effective when varying its program costs from $500 to $1,500 per patient.

Conclusions:
Assuming that telemedicine consultations increase the use of tPA for acute ischemic stroke patients by at least 2.5%, we found that it is cost-effective compared to telephone only consultations. However, 30 patients must be assessed annually per spoke hospital to remain cost-effective. Telemedicine stroke networks need to consider these aspects when assessing their societal impact and when justifying their considerable costs.
Abstract 3162: Enhancement Of Antioxidative Activity Facilitates Cell Transplantation Therapy For Stroke
Authors: Wakai Takuma , Sakata Hiroyuki , Chan Pak H
Published: March 2022

Background:
Recent studies show that neural stem cells (NSCs) transplanted in the brain provide a potential therapy not only for ischemic stroke, but also for hemorrhagic stroke. However, the low survival rate of grafted NSCs in the brain might preclude a therapeutic effect. We focused on the effect of oxidative stress against grafted cells and hypothesized that conferring antioxidant properties to the NSCs before transplantation into the host tissue may overcome cell death in the hostile host environment and enhance neuroprotection after transplantation.

Methods:
NSCs were obtained from the striatum of copper/zinc-superoxide dismutase (SOD1) transgenic mice, manganese-superoxide dismutase (SOD2) transgenic mice and wild-type mice. The NSCs were exposed to several kinds of oxidative stress (oxygen-glucose deprivation and reoxygenation, hemoglobin, H2O2, NO), and preconditioning was performed before exposure to oxidative stress. Preconditioning with IL-6 induced SOD2 up-regulation via Janus activating kinase-signal transducer activator of transcription 3 in NSCs and preconditioning with minocycline up-regulated Nrf-2, which is a crucial component of the endogenous antioxidant system. Cell viability was assessed with LDH assay, WST-1 assay and TUNEL staining. To examine survival of the grafted cells in the ischemic region in vivo, they were transplanted into the cortical ischemic penumbra 6 hours after ischemia, and TUNEL staining was performed 2 days after transplantation. Neurological evaluation was performed before and 1, 7, 14, 21 and 28 days after transplantation.

Results:
Death of transgenic (SOD1 and SOD2) NSCs and preconditioned (PC) NSCs was significantly decreased compared with wild-type non-PC NSCs after exposure to oxidative stress. Furthermore, these NSCs showed that hydroethidine signals, which represent superoxide production, were suppressed under oxidative conditions. Preconditioning reduced the number of TUNEL-positive grafted cells in the ischemic brain 2 days after transplantation compared with non-PC NSCs (IL-6 by 40%, n=4, p<0.005; minocycline by 76%, n=4, p<0.001). Minocycline PC NSCs also showed a significant reduction in infarct volume (by 15%, n=7, p<0.05, cortex lesion size/contralateral) and showed functional recovery from 1 through 28 days after transplantation compared with the non-transplanted control group (n=7).

Conclusion:
Our results suggest that enhanced antioxidative activity in NSCs before transplantation provides improved survival of NSCs in the stroke brain. The increased survival of these NSCs may provide therapeutic potential for neuroprotection in stroke patients.
Abstract 3177: Drip and Ship V-code use in the United States - an Analysis of the Nationwide Inpatient Sample (NIS)
Authors: Conners James J , Ouyang Bichun , Prabhakaran Shyam
Published: March 2022

Objective:
Non-stroke center hospitals often utilize a “drip-and-ship” (DS) method in which the acute ischemic stroke (AIS) patients are emergently transferred to stroke centers after treatment with intravenous tissue plasminogen activator (IV tPA). In October 2008, a new ICD-9 ″V-code″ was approved by the Centers for Medicare and Medicaid Services to identify these patients. We analyzed the use of this V-code in the Nationwide Inpatient Sample (NIS) in order to characterize rates of use, regional differences, and safety among AIS patients in the United States (US).

Methods:
We searched the NIS, a database representative of 20% of inpatient admissions in the US, to identify patients with primary diagnosis of stroke using ICD-9 codes (430, 431, 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, or 436) in the last quarter of 2008 and all of 2009. We searched for “drip and ship” coding using the V-code (v45.88) among any of the 15 listed diagnostic codes and for secondary diagnoses of brain hemorrhage (430 or 431) complicating ischemic stroke. We included primary diagnoses of hemorrhage (430 or 431) only if ischemic stroke treatment was provided (DS, thrombolysis on day 0, or any mechanical embolectomy by procedure codes: v45.88, 99.10, and 39.72). We compared demographics, hospital characteristics, and outcomes in DS vs. non-DS thrombolysis patients using univariable statistics.

Results:
Of the 140,698 AIS discharges from October 2008 to December 2009, 4314 (3.1%) received intravenous thrombolysis and 929 (0.66%) were DS patients based on V-code reporting. V-code reporting increased in each quarter (0.5 to 0.8%, p<0.001 for trend) but varied by geographic region (highest in Midwest: 0.9% vs. lowest in South: 0.3%, p<0.001). The vast majority of DS patients were discharged from teaching hospitals compared to non-DS thrombolysis patients (82.9 vs. 60.9%, p<0.001). DS and non-DS patients were similar by age, sex, weekend admission, and urban location of the receiving hospital. Secondary hemorrhage was significantly lower in DS patients (3.2 vs. 4.9%, p=0.028) while in-hospital mortality was not different (8.6 vs. 10.3%, p=0.118).

Conclusion:
In our analysis, we found that the “drip-and-ship” method is not uncommon and appropriate coding is increasing in the US. The practice is most prevalent in the Midwest and most patients are transferred to teaching hospitals. The safety of this method appears similar to non-DS tPA use for ischemic stroke. Further studies are needed to validate our findings.
Abstract 3190: Increased Inflammatory Response in Aged Mice is Associated with More Severe Neuronal Injury at the Acute Stage of Ischemic Stroke
Authors: Shen Fanxia , Jiang Lidan , Kuo Robert , Degos Vincent , Walker Espen J. , Su Hua , Young William L.
Published: March 2022

Background and Purpose:
Stroke occurs mostly in patients with advanced age and older patients have a less favorable prognosis than younger patients. To understand the underlying mechanisms involved in this phenomenon, we tested the hypothesis that an increased inflammatory response to acute ischemic injury in the aged mice leads to more severe brain damage and functional deficits.

Methods:
An ischemic stroke model was created in two- (young) and twelve-month-old (aged) C57BL/6 mice (n=6) through permanent occlusion of the left distal middle cerebral artery (pMCAO). Infarct volumes in the brain sections were quantified at one day after pMCAO by Cresyl Violet staining. Sensorimotor function was assessed using corner test and adhesive removal test before, 3, and 14 days after pMCAO. Macrophage/microglia (CD68+ cells) and apoptotic neurons (TUNEL+ and NeuN+) in the ischemic region were quantified one day after pMCAO. The interleukin-6 (IL-6) and interleukin-1 β (IL-1β) levels in the ischemic brain tissue were measured using ELISA at one and three days after pMCAO.

Results:
At one day post pMCAO, infarct volume was larger in aged mice than in young mice (31±3/mm3 vs 27±5, p= 0.05), Comparing aged mice to young mice, more TUNEL+ neurons (22±5 vs 15±5, p=0.04) were detected in the infarct region. Both young and aged mice showed significant sensorimotor dysfunction on day 3 and 14 post pMCAO; turning more frequently to the left on the corner test and taking longer time to remove tape on left paws. More severe functional deficits were detected on aged mice by adhesive removal test at day 14 post pMCAO (12±5 seconds vs 6±3, p=0.01, aged vs young). There were more CD68+ cells in the peri-infarct region in aged mice compared to young mice (79±22/ 40X objective field vs 58±18, p=0.01). Infarct volume was positively correlated with both the numbers of CD68+ cells (R2= 0.80) and TUNEL+ neurons (R2= 0.86). Compared to young, cytokine levels also increased in aged mice at one day (IL-6: 308 ±152 pg/mg vs 147±44, p=0.03; IL-1β: 96±35 vs 55±8, p=0.02) and three days (IL-6: 149 ±53 vs 90±27, p=0.03; IL-1β: 55 ±14 vs 38± 5, p= 0.02) after pMCAO.

Conclusion:
Our data suggest that a higher inflammatory response at the acute stage of ischemic stroke in aged mice is associated with more severe neuronal injury (larger infarct volume and more apoptotic neurons) and long-term functional deficits. The upstream mechanisms responsible for the enhanced response will require additional studies. However, modulating inflammatory response in the aged population at the acute stage might be a strategy to reduce neuronal injury and improve functional recovery in older stroke patients with monitoring of brain inflammation a feasible means of risk stratification.
Abstract 3199: Factors Associated with Favorable Response to Hyperbaric Oxygen Therapy among Patients Presenting with Iatrogenic Cerebral Arterial Gas Embolism
Authors: Tekle Wondwossen G , Adkinson Cheryl , Chaudhry Saqib A , Jadhav Vikram , Hassan Ameer , Rodriguez Gustavo J , Qureshi Adnan I
Published: March 2022

Background:
Iatrogenic cerebral arterial gas embolism (CAGE) is an uncommon but potentially fatal condition. Hyperbaric oxygen (HBO
2
) treatment is the only first line treatment for patients with CAGE presenting with acute neurological deficits.

Methods:
We reviewed medical records and neuroimaging of consecutive CAGE patients treated with HBO
2
at a state referral hyperbaric facility over a 22 year period. We analyzed the effect of demographics, source of intra-arterial gas, signs and symptoms, results of imaging studies, time between insult and HBO
2
treatment, and response to HBO
2
treatment in 36 consecutive patients. Favorable outcome was defined by complete resolution or improvement of CAGE signs and symptoms. Unfavorable outcome was defined by unchanged or worsened neurologic signs and symptoms or in hospital death.

Results:
A total of 26 (72%) of the 36 patients had favorable outcome. Patients with favorable outcome were younger compared to those with unfavorable outcome (mean age [years, SD] 44.7± 17.8 vs. 58.1 ± 24.1, p-value=0.08). Time-to-HBO
2
≤ 6 hours was significantly associated with favorable outcome compared ≥ 6 hrs (p-value = 0.025). Cardiopulmonary symptoms associated with CAGE were significantly more common in venous source of gas compared to arterial (p-value = 0.024) but did not influence the rate of favorable outcomes. Two of 36 patients were treated with thrombolytics due to acute focal deficits and suspected ischemia - one with intravenous and the second one with intra-arterial thrombolysis. The later patient developed fatal intracerebral hemorrhage.

Conclusions:
A high proportion of CAGE patients treated with HBO2 had favorable outcomes. Young age and time-to-HBO
2
≤ 6 hours were associated with higher rate of favorable outcome. Timely diagnosis and differentiation from thrombo-embolic ischemic events is an important determinant of successful HBO2 treatment.
Abstract 3204: Acute Mechanical Embolectomy Use in the US Doubled from 2008 to 2010
Authors: Khatri Pooja , Meganathan Karthikeyan , Adeoye Opeolu , Hornung Richard , Kleindorfer Dawn O
Published: March 2022

BACKGROUND:
Intravenous recombinant tissue plasminogen activator (rtPA) therapy has been established by randomized clinical trials for administration within 4.5 hours. Both the MERCI Retrieval Device and the Penumbra Aspiration System are options for endovascular mechanical embolectomy based on single-arm studies of treatment initiated within 8 hours. Both devices receive Centers for Medicare and Medicaid Services (CMS) reimbursement at a higher rate than IV rtPA. In this context, we sought to determine if embolectomy use is increasing over time, and further characterize this group.

METHODS:
We reviewed the Premier Perspective Database for ischemic stroke-related hospitalizations (ICD-9 codes 433.x1, 434.x1 and 436) of patients of 18+ years during 2008, 2009 and 2010 fiscal years. This database includes all payor sources, and additional demographic and drug utilization data, from a sampling of 15% of US hospitals. We identified 187,764 (92%) from such hospitalizations representing first admissions. Use of reperfusion therapies was determined through the thrombolysis procedure code (99.10), pharmacy records (use of 50 or 100 mg Alteplase vials), hospital billing information (notation of the Penumbra or MERCI device), and/or the mechanical thrombectomy procedure code (39.74). We also compared characteristics of those treated with mechanical embolectomy versus thrombolysis alone.

RESULTS:
An increasing proportion of ischemic strokes were treated with reperfusion therapies each year: 4.1%( 2482/61096) in 2008, 4.7% (2983/63093) in 2009, and 5.4% (3451/63575) in 2010 (p<0.001). Embolectomy use almost doubled (191%), and also increased as a proportion of reperfusion treatments by 37%, over the last three years: 11.1% (275/2482) in 2008, 11.9% (354/2983) in 2009, and 15.2% (524/3451) in 2010 (p<0.001). Overall, those who received embolectomy, as compared to rtPA alone, were younger (66.7 vs 69.5 mean years; p<0.001), with higher mortality rates (28% vs 11%; p<0.001), at larger hospitals (43% vs 37% >500 beds; p<0.001), at teaching hospitals (68% vs 49%; p<0.001), at urban hospitals, (95.5% vs 93.2%;p=0.003), on Medicare (63% vs 57%; p<0.001), and of Caucasian race (72.45 vs 67.4%;p<0.001). Multimodal imaging use, based on CT-perfusion on patient bills, was more common among those treated with embolectomy than rtPA alone (4.0 vs 1.8% in 2008, p=0.021; 17.8 vs 5.6% in 2009, p<0.001; 24.2 vs 6.7% in 2010, p<0.001).

CONCLUSIONS:
Mechanical embolectomy use has almost doubled in the US over the last three years, and is associated with a substantially higher rate of CT-based multimodal imaging use. As healthcare resources are increasingly being used to treat patients with mechanical embolectomy, it becomes imperative that the effectiveness of mechanical embolectomy and associated CT-based multimodal imaging selection be determined in definitive clinical trials.
Abstract 3212: Aggravated Intraventricular Hemorrhage and White Matter Lesions: A Nationwide Cohort of Intracerebral Hemorrhage Patients
Authors: Kim Beom Joon , Lee Seung-Hoon , Ryu Wi-Sun , Kim Chi Kyung , Oh Mi-Young , Chung Jong-Won , Kim Dohoung , Park Hong-Kyun , Yoon Byung-Woo
Published: March 2022

Background.
Intraventricular hemorrhage (IVH) secondary to intracerebral hemorrhage (ICH) is an important indicator of poor outcome. Location and size of hematoma have been known to associate with IVH, but other clinical and neuroimaging predictors are yet to be discovered. Among them, white matter lesion (WML), which reflects accumulation of chronic sublethal ischemic injuries and periventricular edema, may signify vulnerability of individual brain, hence being associated with development and aggravation of IVH.

Methods.
A total of 1,604 ICH patients were collected through 33 stroke centers in South Korea with nationwide coverage. We excluded 199 subjects whose computed tomography (CT) scans were taken more than 48 hours after symptom onset, 89 subjects whose images were of poor quality, 42 subjects who had primary IVH without ICH and 12 subjects who were misclassified. Finally, 1,262 acute ICH patients were included in our analysis dataset. Clinical, laboratory, and imaging information was collected during admission. Experienced stroke neurologists independently reviewed CT scans of included patients for rating WML (van Swieten method) and IVH scores, with good inter-rater agreements. IVH score is a recently proposed semi-quantitative and validated method for estimating volume of IVH. Functional outcomes included Glasgow coma scale score and mortality status at the end of 2006.

Results.
Among the 1,262 ICH patients, 343 subjects (27.2%) were found to have IVH. Patients with IVH are older and had higher level of blood glucose and ICH volume. The proportion of subjects with extensive WML was significantly higher in patients with IVH then those without IVH (33.8% vs. 16.3%; P <0.01). The association between WML and IVH remained significant after controlling for relevant covariates (OR 1.43 and 95% CI 1.02 - 2.02 for mild WML; OR 2.66 and 95% CI 1.83 - 3.87 for extensive WML; compared to no WML). Estimated mean of IVH score of extensive WML group was also significantly higher than that of no WML group (estimated mean ± standard error; 11.5 ± 0.5 vs 9.4 ± 0.5; P =0.01 from analysis of covariance with Tukey’s post-hoc multiple comparison). For outcomes after ICH, presence of IVH was associated with increased odds of having surgical management (OR 3.48 and 95% CI 2.54 - 4.76), lower Glasgow coma scale score (OR 1.90 and 95% CI 1.46 - 2.48), and higher risk of long-term mortality (HR 1.30 and 95% CI 1.03 - 1.64).

Conclusion.
From this study, we documented that WML was associated with development and increased volume IVH in acute ICH patients. WML would be considered in diagnosis and management of ICH patients with IVH.
Abstract 3213: Rheolytic Thrombectomy as First-line Treatment for Venous Sinus Thrombosis: Safety and Efficacy.
Authors: Dashti Shervin , Yao Tom , Hu Yin
Published: March 2022

BACKGROUND:
Cerebral venous sinus thrombosis (CVT) is an uncommon cause of stroke. Current standard of care treatment is systemic anticoagulation. Although many patients make a good recovery on anticoagulation alone, others deteriorate due to intracranial venous hypertension, that may even lead to intracranial hemorrhage or death. Mechanical thrombectomy or intra-sinus thrombolytic therapy is often not successful in these patients because the damage is already too extensive by the time these therapies are initiated.

OBJECTIVE:
We present a series of patients with CVT who underwent rheolytic thrombectomy with the AngioJet (Possis Medical Inc., Minneapolis, MN) as a first-line treatment followed by standard anticoagulation therapy.

METHODS:
We retrospectively reviewed prospectively maintained endovascular database at two tertiary care referral centers. IRB approval was obtained at each institution. The available clinical and imaging data were compiled at each respective institution and analyzed in aggregate.

RESULTS:
Over 24 months, 14 patients (8 females, 6 men; age range 17-73 years, median age 44 years) with CVT were treated with rheolytic thrombectomy. Immediate (partial or complete) recanalization of the thrombosed intracranial sinuses was achieved in all patients. After the procedure, the clinical status of 11 patients (79%) improved significantly and that of one patient (7%) improved marginally. The average clinical follow-up was 12 months (range 3 to 16 months). Clinical and radiographic (computed tomography venography or magnetic resonance venography) follow-up was available for 8 patients, all of whom demonstrated patent sinuses and were symptom-free. There was one procedural complication (an asymptomatic perforation of a cerebellar vein) and no operative mortality.

CONCLUSION:
The mainstay of treatment for venous sinus thrombosis has been systemic anticoagulation therapy. More invasive endovascular approaches have been used only in a handful of cases as a last resort. We preliminary evidence in support of the efficacy and safety of mechanical rheolytic thrombectomy as a first-line treatment for acute CVT. In our series, this strategy promptly restored intracranial venous outflow with rapid symptomatic and neurological improvement in some patients.
Abstract 3242: Brain-derived Neurotrophic Factor Val66Met Polymorphism is Associated with Worsening of Functional Outcome in Patients Undergoing Resection of Unruptured Brain Arteriovenous Malformations
Authors: Westbroek Erick M , Pawlikowska Ludmila , Lawton Michael T , McCulloch Charles E , Young William L , Kim Helen
Published: March 2022

Background:
Brain-derived neurotrophic factor (BDNF) is a neuroprotective agent rapidly elevated after brain injury and necessary for recovery. A functional polymorphism in the BDNF gene, Val66Met, is associated with decreased BDNF secretion, and associated with worse outcome and slower recovery in Met carriers. Thus, we hypothesized that BDNF genotype might be associated with functional outcome following brain arteriovenous malformation (BAVM) resection. Because the effect of resection on a brain previously injured by hemorrhage might be less, we separately considered patients who presented with and without a hemorrhage.

Methods:
Val66Met was genotyped in 258 patients undergoing BAVM resection at UCSF with outcome data. Subjects were stratified into two groups based on hemorrhagic state at initial presentation (hemorrhage n=120, non-hemorrhage n=138). Poor outcome was defined as worsening on the modified Rankin scale (mRS) between pre-treatment (but post-hemorrhage) and last post-treatment follow-up visit. Univariate and multivariate logistic regression analysis, adjusting for age, gender, white race/ethnicity, AVM size, and length of follow up was performed. Sensitivity analysis was conducted by repeating the analysis in 158 Caucasian patients. Additionally, 4 BDNF tag SNPs (rs7124442, rs10767665, rs11030102, and rs12288512) were genotyped in 138 Caucasian patients.

Results:
Carriers of the Met allele of Val66Met had poor outcome after surgery among non-hemorrhaged patients (OR=2.4, CI=1.1-5.2, p=0.03), but there was not a statistically significant result among hemorrhaged patients (OR=0.7, 95% CI=0.2-2.0, p=0.5). The association remained after multivariable adjustment (non-hemorrhaged: OR=2.8, 95% CI=1.2-6.5, p=0.01; hemorrhaged: OR=1.0, 95% CI=0.3-3.2, p=1.0). In the Caucasian subgroup, similar results were observed; among non-hemorrhaged patients, Met carriers had poor outcome in univariate (OR=2.1, CI=0.8-5.6, p=0.1) and multivariate analysis (OR=3.0, CI=1.1-8.8, p=0.04). No association was established among hemorrhaged patients. No association was observed with other BDNF tag SNPs.

Conclusions:
The Val66Met polymorphism in BDNF is associated with poor surgical outcome in unruptured BAVM patients. These results warrant further investigation in larger studies but suggest that BNDF could play an important role in evaluating surgical risk.
Abstract 3243: A Comparison of Vascular Neurologist Interpretation versus Radiology Reports of Computed Tomographic Imaging for Determining Eligibility of Intravenous Thrombolysis in Patients with Acute Ischemic Stroke
Authors: Hassan Ameer E , Majidi Shahram , Janjua Nazli A , Tekle Wondwossen G , Chaudhry Saqib A , Qureshi Adnan I
Published: March 2022

Background:
Computed tomographic (CT) scan is the gold standard imaging for determining acute ischemic stroke patient eligibility for intravenous thrombolysis (IV t-PA). In most institutions neurologists or clinicians interpret the intial CT images to determine eligibility, although some institutional protocols require the neuroradiologist interpretation.

Objective:
To evaluate the variability of determining eligibility for IV rt-PA by vascular neurologist interpretation of CT scan versus review of the radiology interpretation (presented in final report) in patients with acute ischemic stroke.

Methods:
We compiled a database of all IV rt-PA treated ischemic stroke patients at our academic institutions based on vascular neurologists’ CT scan interpretation . The patients’ CT scan reports were reviewed by an independent board certified vascular neurologist who was blinded to all clinical information except that all patients were being considered for IV rt-PA to determine eligibility for IV rt-PA. The reviewer’s responses were then compared with the treating team’s decision to identify discrepancy between decisions and assess impact on clinical outcome (including 24 hour NIHSS score and discharge modified Rankin scale), symptomatic hemorrhage (sICH), and asymptomatic hemorrhage (aICH).

Results:
A total of 171 acute ischemic stroke patients, were included in the study and had received IV rt-PA. The mean age (±SD) was 61±14 years, the mean (±SD) NIHSS score was 7±2. The independent reviewer decided to treat with IV t-PA in 123 (72%) of cases after review of radiology reports. The most common reasons for deciding against thrombolysis were findings of early ischemic changes, possible established infarct, or inability to exclude ICH in the radiology report. Assuming equal variances, the clinical improvement based on NIHSS and mRS at discharge, sICH, and aICH were not significantly different with IV rt-PA treatment between those who were treated but would be excluded and those who will be included based on a review of radiology reports.

Conclusion:
The study demonstrates that administering IV rt-PA to patients based on vascular neurologist interpretation of CT scan versus review of the radiology interpretation does not lead to significant differences in clinical outcome, aICH, or sICH and should not be a pre-requisite to avoid delays in IV rt-PA administration.
Abstract 3255: Potential Synergy between Advanced Primary Stroke Centers and Level I or II Trauma Centers in United States
Authors: Khan Asif A , Chaudhry Saqib A , Hassan Ameer E , Rodriguez Gustavo J , Suri M. F , Lakshminarayan Kamakshi , Qureshi Adnan I
Published: March 2022

Objective:
Emergency Medical Response, transport, and triage of stroke patients is very similar to more established trauma systems. Several institutions have used pre-existing trauma systems to develop effective stroke networks. Our goal is to determine the number of Primary Stroke Centers (PSC) that exist concurrently with designated higher level trauma centers (level I or level II) and associated characteristics.

Methods:
We identified all the advanced PSCs certified in 2010, and concurrently, the advanced higher level trauma centers. We determined the number of PSCs located within higher level trauma centers and compared the characteristics of institutions with co-existing PSC-trauma center versus PSCs without associated trauma center. Additional data was collected on institutional bed numbers; total number of discharges, residency and fellowship training programs based in these centers, and existing affiliation with university were identified.

Results:
Of 788 existing designated PSCs; co-existing PSC-trauma center was found in 252 (32%) centers with PSCs co-existing with level I trauma centers in 138 (17.5%) hospitals. The remaining 536 (68%) PSCs are based in hospitals without trauma centers. In a proof of concept analysis in one state, PSCs with level I trauma facility were found to have the highest rates of thrombolytic administration as compared to the PSC with level II and PSCs without trauma facility (12.8% vs. 3.8% vs. 4.9%).

Conclusions:
Despite evidence of higher capability among institutions with co-existing PSC trauma center, two third of PSCs are in hospitals without advanced trauma systems. These findings have implications for establishing stroke systems in United States.
Abstract 3257: Prevalence and Correlates of PTSD After Stroke
Authors: Goldfinger Judith Z , Fei Kezhen , Balakrishnan Revathi , Diefenbach Michael A , Edmondson Donald , Kronish Ian M , Tuhrim Stanley , Horowitz Carol R
Published: March 2022

Background
Stroke survivors may be at increased risk for post-traumatic stress disorder (PTSD), yet detailed data on prevalence and contributing factors are lacking. Harlem residents and local researchers, alarmed by high rates of stroke in their community and frustrated by the difficulty of engaging stroke survivors in prevention programs, aimed to determine the prevalence and correlates of PTSD in a cohort of survivors of stroke and transient ischemic attack (TIA).

Methods
Harlem residents and researchers employed community-based participatory research to develop a recurrent stroke prevention intervention. English and Spanish speaking adults over 40 were eligible for inclusion if they reported a stroke or TIA within the past five years. Baseline assessments included blood pressure, direct LDL cholesterol and validated self-report scales for demographics, stroke impact (modified Rankin scale), medical co-morbidities (Charlson co-morbidity index), and the widely-used 17-item PTSD Checklist Specific for stroke (PCL-S). A PCL-S score of 25 connotes a positive screening test, while a score greater than 50 is highly specific for PTSD. We recruited participants from community and clinical sites. To create a model of correlates for PTSD (PCL-S score > 50), we used logistic regression.

Results
The 379 enrollees had a mean age of 64 years, 62% were women, 79% were Black or Latino, 28% never completed high school, and more than half earned under $15,000 yearly. Most (75%) had PCL-S scores greater than 25, including 69 (18%) who scored above 50. Using logistic regression, and controlling for gender, race, education, and income (c-statistic of 0.835, p<0.0001), PTSD was associated with younger age (odds ratio 0.94, 95% CI 0.91-0.97), increased disability post-stroke (OR 1.93, 95% CI 1.49-2.51), and greater burden of medical co-morbidities (OR 2.17, 95% CI 1.09-4.31). In addition, participants with PTSD were more likely to smoke (30% vs. 13%, p=0.0003) and have elevated LDL cholesterol > 100 mg/ dl (59% vs. 39%, p=0.003), both major risk factors for recurrent stroke. There was no significant difference in blood pressure control between the patients with and without PTSD.

Conclusion
PTSD is common after stroke, especially in younger people with more disability and more co-morbidity. We recommend that clinicians screen patients for PTSD after stroke and offer supportive therapy.
Abstract 3261: Vascular Protection Mediates Neuroprotection: Role of VEGF-A and B
Authors: Soliman Sahar , El-Remessy Azza , Cronic Lydia , Shenoy Somanath , Ergul Adviye , Fagan Susan
Published: March 2022

Introduction:
Neuroprotection remains an elusive goal for the treatment of stroke patients. Vascular protection is achievable in humans and may result in reduced brain injury. Our recent preclinical studies demonstrated robust protective effects of angiotensin II receptor type-1 blockers (ARBs), leading to improved stroke outcome. These effects were associated with increased VEGF production and an enhanced proangiogenic state.

Purpose:
To remove the possibility of a protective effect with blood pressure lowering alone, we determined whether ARBs exert neuro- and vascular protective effects in isolated brain cells.

Methods:
Human cerebral microvascular endothelial cells (hCMEC) and mouse hippocampal neuronal cells (HT-22) were treated with clinically relevant concentrations of candesartan (0.1 and 1.6 µg/ml) and losartan (0.05 and 0.2 µg/ml). Angiogenic response was assessed using wound healing and Matrigel tube formation assays. Cell proliferation and viability were assessed by BrdU incorporation and MTT assays respectively. Western blotting was used to measure the levels of VEGF isoforms in hCMEC and apoptotic markers in the neurons.

Results:
Treatment with ARBs increased endothelial cell migration (45, 32, 39 and 27% increase in percent migration after 18 hours of treatment with candesartan 0.1, candesartan 1.6, losartan 0.05 and losartan 0.2 µg/ml respectively, p<0.05) and tube formation (4 and 10 fold increase after 48 and 72 hours of treatment with candesartan 1.6 µg/ml respectively, p<0.05). This was accompanied by an increased expression of VEGF-A and B both in the cell lysate and the conditioned media after 24 hours of treatment (90 and 65% increase in VEGF-A and B respectively). Direct application of candesartan did not salvage neurons after 24 hours of serum starvation. However, conditioned media collected from endothelial cells treated with candesartan decreased the expression of apoptotic markers in the neurons by 25%.

Conclusion:
ARBs exert a neuroprotective effect that is mediated through vasculature-secreted VEGF A and B. Translational Impact: This work demonstrates, for the first time, that the neuroprotective effects of ARBs are mediated through effects on the vasculature. Vascular protection represents an exciting new therapeutic avenue for the treatment of ischemic stroke patients.
Abstract 3282: Diagnostic Yield of Repeat CT Angiography in Patients with Subarachnoid Hemorrhage and Negative Initial CT and Catheter Angiograms
Authors: Delgado Almandoz Josser E , Crandall Benjamin M , Fease Jennifer L , Scholz Jill M , Anderson Ruth E , Tubman David E
Published: March 2022

Purpose:
To determine the yield of repeat CT angiography for the detection of causative vascular lesions in patients with subarachnoid hemorrhage (SAH) who have negative initial CT and catheter angiograms.

Methods:
We conducted a retrospective review of patients who presented to our institution between January 1st, 2008 and August 1st, 2011 with SAH and negative initial CT and catheter angiograms who were examined with repeat CT angiography in order to determine the yield of this imaging modality for the detection of causative vascular lesions. Two experienced neuroradiologists evaluated the NCCTs to determine the pattern of SAH (diffuse, perimesencephalic or peripheral) and the CT angiograms (CTA) to assess for the presence of a causative vascular lesion. All differences in reader interpretation were resolved by consensus.

Results:
Twenty-two patients were included in our study, with a mean age of 78 years (median 59 years, range 28-78 years). Sixteen patients were male (72.7%) and 6 female (27.3%). Seventeen patients had diffuse SAH (77.3%), 4 perimesencephalic SAH (18.2%) and 1 peripheral SAH (4.5%). Mean time interval between the initial neurovascular examination and the repeat CTA was 26.5 days (median 20.5 days, range 2-150 days). The repeat CTA demonstrated a causative vascular lesion in 2 patients (9.1%), all of which had diffuse SAH (yield of 11.8%). The vascular lesions identified were 1 small pontine arteriovenous malformation and a 2-mm supraclinoid internal carotid artery aneurysm (
Figure
). The pontine arteriovenous malformation underwent radiosurgery and the internal carotid artery aneurysm underwent surgical clipping. In retrospect, none of these vascular lesions were evident in the initial CT or catheter angiograms.

Conclusion:
Repeat CT angiography is valuable in the evaluation of patients with diffuse SAH who have negative initial CT and catheter angiograms, demonstrating a causative vascular lesion in 11.8% of patients.