bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP26: Existence of Neutrophil Extracellular Traps in Arterial Thrombi from Patients with Acute Ischemic Stroke
Authors: Li Wei , Wang Huan , Feng Wuwei , Zhang Meng
Published: June 2021

Introduction:
Neutrophil extracellular traps (NETs) are composed mainly of strands of filamentous DNA and nuclear proteins, such as chromatin or isoforms of histone and secretable neutrophil granular proteins. Recent studies have shown that NETs existed in the venous thrombi and might function as a scaffold and had implication for thrombolytic treatments.

Hypothesis:
NETs also exists in cerebral arterial thrombus collected from patients with acute ischemic stroke(AIS).

Methods:
Ten arterial thrombi were collected from 10 AIS patients (33-78 years old, 4 females) who were treated by endovascular therapy (eight of them accepted alteplase thrombolysis firstly)within 8 hours after symptoms onset. Hematoxylin-eosin (HE) staining, immunofluorescence staining (including anti-histone H3 and Hoechst 33342 which label DNA) and electron microscopy were performed to identify the existence of fibrin and/or NETs in thrombus.

Results:
There were 4 thrombi from middle cerebral artery, 3 from internal carotid artery and 3 from basilar artery. Cardioembolism were considered as etiology for 5 patients and large artery atherosclerosis was the etiology for another 5 patients. HE staining showed that large amounts of fibrin and white blood cells in all ten cerebral arterial thrombi. NETs structures were also identified in 10/10 cerebral arterial thrombi by immunofluorescence staining. Furthermore, the existence of neutrophil-released DNA network together with fibrin was confirmed using electron microscopy in all 10 thrombi.

Conclusion:
Our results directly demonstrated that NETs do exist in the arterial thrombi from patients with AIS. they may serve as another structural component in addition to fibrin in both cardiogenic and artery atherosclerotic thrombi. NETs can be a new potential target for the recanalization treatment.

Keyword:
Neutrophil extracellular traps (NETs); arterial thrombus; Acute ischemic stroke
Abstract TMP30: Antiangiogenesis as a Predictor of Systemic Atherosclerosis
Authors: Gonzalez Nestor R , Liou Raymond , Kurth Florian , Song Shlee , Alexander Michael J , Schievink Wouter , Schiraldi Michael , Saver Jeffrey
Published: June 2021

Introduction:
Patients with stroke due to intracranial atherosclerosis (ICAS) are more likely to have coronary and peripheral vascular disease abnormalities than patients with other etiologies. We have found in prior studies that in patients with ICAS, an increased antiangiogenic profile was significantly associated with recurrent TIA and stroke. The purpose of this study is to evaluate the hypothesis that the previously identified profile of circulating antiangiogenic factors is associated with atherosclerotic multimorbidity in patients with ICAS.

Methods:
Prospective observational longitudinal study of circulating angiogenic factors in 74 patients with ICAS treated medically. Patients with ICAS greater than 70% had pro and antiangiogenic factors measured in duplicate via ELISA. Angiogenic profiles were defined by principle component analysis. A nominal logistic regression model was fit for the outcome variable atherosclerotic multimorbitdity, defined as the presence of atherosclerosis in more than one vascular bed. The predictor variables were age, gender, smoking history, hypertension, hyperlipedimia, and the profiles of circulating angiogenic factors.

Results:
An angiogenic profile characterized by high levels of HGF and the antiagiogenic factors endostatin, angiostatin, and VEGFR-1 was significantly associated to the presence of atherosclerotic multimorbidity (OR = 1.9; 95% CI = 1.2 - 3.3; p = 0.01). Smoking history, hypertension, and hyperlipidemia were poor predictors of atherosclerotic multimorbidity in this cohort. Commonly related risk factors for atherosclerosis were not associated with the predictive antiangiogenic profile.

Conclusion:
Our results indicate that antiangiogenesis is a stronger predictor of systemic atherosclerosis than classically recognized risk factors, and it may represent a common path for multimorbidity in patients with ICAS.
Abstract TMP41: High-sensitivity C-Reactive Protein and Depression in Patients With Ischemic Stroke
Authors: Katzan Irene , Thompson Nicolas , Itrat Ahmed
Published: June 2021

Background:
Depression is common in patients after stroke and is associated with worse outcomes Recognition of the causal factors contributing to post-stroke depression may lead to new treatment interventions. Ischemic stroke produces inflammatory responses and there is data to suggest that inflammation may promote depression. The objective of this analysis is to determine the association of hsCRP levels with depression in patients with ischemic stroke.

Methods:
We performed a retrospective cohort study of patients with ischemic stroke seen in a cerebrovascular clinic who completed a PHQ-9 depression screen and had a hsCRP level drawn between 28 days before or within 7 days after the PHQ-9 screen. Multivariate linear regression was performed:- the dependent variable was PHQ-9 score, the independent variable was log-transformed hsCRP. Additional covariates included age, sex, race (White vs. Black/Other), time since stroke (≤ 3 months vs. > 3 months), mRS score (0-2 vs. 3-5) and statin use at time of hsCRP draw (yes vs. no).

Results:
Between Feb 3, 2009 and March 14, 2014, 803 patients were seen in the cerebrovascular clinic with a diagnosis of ischemic stroke who had hscrp level. Of these, 220 patients had a hSCRP drawn within the prespecified time interval from PHQ9 screen. Mean age was 60.7 years, 43.2% were female and 78.6% were White. There was a significant independent association between hsCRP value and PHQ-9 score; For each 5-fold increase in hsCRP, the average PHQ-9 score increased by 1.22 points (95% CI 0.38 - 2.06, P = 0.005). Other variables independently associated with PHQ-9 score were: mRS > 2 (OR = 3.39, 95% CI 1.40 - 5.38), female (OR=-1.72 95% CI -3.11 - -0.32), and statin use (OR=-1.91, 95% CI -3.34 - -0.47).

Conclusions:
hsCRP level was independently associated with depressive symptoms. Understanding the association between inflammatory markers and depression following ischemic stroke may lead to the development of improved methods to predict post-stroke depression and new treatment interventions
Abstract TMP63: Large Vessel Occlusion Triage Scales Struggle With Atypical Presentations but Misclassifications Are Rarely Detrimental
Authors: Zhao Henry , Coote Skye , Dewey Helen M , Davis Stephen M , Campbell Bruce C
Published: June 2021

Introduction:
Large vessel occlusion (LVO) triage scales aim to identify LVO on clinical grounds and direct ambulances to endovascular centers, but current tools are reported to have poor performance in independent datasets. We investigated situations where these tools were performing poorly and examined the possible impacts of misclassification.

Methodology:
Patient data were collected prospectively from consecutive ambulance initiated stroke codes at two major stroke centers. Patients with symptom onset >6 hours and pre-existing deficits were excluded. LVO was defined as ICA, M1 or proximal M2 occlusion on CT angiography. National Institutes of Health Stroke Scale (NIHSS) scores assessed by stroke clinicians were used to derive five published triage tools (RACE, LAMS, CPSSS, PASS, FAST-ED). Patients were classified as 1) Typical presentations where LVO presented with severe symptoms (weakness and cortical sign) and non-LVO did not, or 2) Atypical presentations where non-LVO had severe symptoms and LVO did not.

Results:
A total of 391 patients were included, of whom 59 were atypical presentations which included 25 ICH and 5 mimics. Most triage tools were able to correctly identify >95% of typical presentations but only 10-25% of atypical presentations. Within the atypical cases, bypassing the nearest stroke center would have delayed tPA for 6 patients (3.5% of all infarcts) with non-LVO infarcts. Conversely, of the missed LVO cases 10 patients (19.6% of all LVO) would have been immediately eligible for endovascular therapy. A further 6 M2 occlusions with NIHSS <6 would have been missed but were unlikely to have received intervention due to mild severity.

Conclusion:
Misclassification by LVO triage tools is largely due to ICH and the uncommon situations where presence of LVO does not correspond to a severe clinical syndrome (and vice versa). Inaccuracies however, would have resulted in relatively few potential tPA patients bypassing the nearest center. Whilst a small proportion of LVO will be missed, overall delivery of LVO to endovascular centers will still be dramatically increased. LVO triage tools therefore have excellent potential to expedite endovascular treatment, but efforts are needed to improve prehospital paramedic accuracy to achieve this goal.
Abstract TMP7: Endovascular Stroke Therapy Abrogates Sex-Related Differences in Recanalization in Acute Ischemic Stroke
Authors: Sheth Sunil A , Warach Steven , Gralla Jan , Jahan Reza , Goyal Mayank , Nogueira Raul , Zaidat Osama , Pereira Vitor , Siddiqui Adnan , Lutsep Helmi , Liebeskind David , McCullough Louise , Saver Jeffrey L
Published: June 2021

Background:
Ischemic stroke affects women differently than men. Prior studies evaluating recanalization treatment with IV tpA showed that while women are more likely to achieve recanalization, there are strong sex disparities with respect to clinical outcome. We evaluated the effect of endovascular stroke therapy (ET) on recanalization and outcomes in women versus men.

Methods:
In the combined databases of the SWIFT, STAR, and SWIFT-PRIME trials, we identified patients treated with the Solitaire stent retriever to determine the effects of sex on recanalization and clinical outcome.

Results:
Among 389 patients treated with ET, mean age was 67±13, 55% were female, and median National Institutes of Health Stroke Scale (NIHSS) score was 17 [8-28]. There were no differences between females vs. males in presentation NIHSS (17 vs. 17, p=0.21), occlusion location (69% vs. 64% M1, p=0.62), or ASPECTS score (9 vs. 8, p=0.24). Rates of successful TICI 2b/3 recanalization were nearly identical (87% vs. 83%, p=0.374). There were no differences in onset to recanalization time (OTR) (277 vs. 306, p=0.46), procedural time (44 vs. 48 minutes, p=0.23), number of stent-retriever passes (1.7 vs. 1.8, p=0.17), rate of PH2 hemorrhage (1.9% vs. 1.1%, p=0.70), or functional independence at 90 days (53% vs. 56%, p=0.54). In ordinal multivariate analysis, collateral grade (OR 1.4, p=0.007) but not sex, age, or history of atrial fibrillation predicted improved TICI recanalization. In logistic (Figure) and ordinal regression analysis, the impact of delayed OTR was no different between men and women (1% versus 1.2% likelihood of worsened mRS outcome per 5 minute delay, p=0.27).

Conclusions:
In our prospective multicenter randomized cohort of nearly 400 patients undergoing ET, presentation and treatment characteristics of women were similar to men. Women were equally likely to achieve successful recanalization and good clinical outcomes.
Abstract TMP74: Evaluation of NIHSS-Onset to Groin Time and Prehospital Acute Stroke Severity Scale-onset to Groin Time Scores in Prediction of Outcomes After Endovascular Treatment in Acute Ischemic Stroke Patients: A Retrospective Single-center Study
Authors: Niazi Muhammad H , El-Ghanem Mohammad , Cockroft Kevin , Morrison Kathy , Richardson Alicia , Raymond Reichwein , Ermak David
Published: June 2021

Background:
Prehospital triage tools are essential to identify large vessel occlusion (LVO) in order to triage patients to a comprehensive stroke center for timely endovascular treatment (ET). Prehospital Acute Stroke Severity Scale (PASS) (score range 0-3) was recently identified as a valuable tool to predict LVO. Several studies have shown that in patients treated with IV tPA, a score calculated by multiplying admission NIHSS by the time from symptom onset to tPA treatment (in hours) can predict outcome. In our study, we applied similar concept for patients with LVO who underwent successful ET.

Methods:
We retrospectively reviewed all LVO patients between January 2015 and June 2016 who received ET. We analyzed the association of time of symptom onset to groin time (OGT), NIHSS, PASS, NIHSS-OGT, and PASS-OGT with modified Rankin scale (mRS) at the time of discharge.

Results:
Fifty-four patients underwent ET during the study period. Patients with posterior circulation LVO and those treated after 6 hours from last known normal were excluded. A total of 34 patients were left for final analysis. Patients with a good outcome (mRS ≤2) had an average NIHSS-OGT score of 43.2 (95% CI: 29.7-56.8) and PASS-OGT score of 5.52 (95% CI: 4.48-6.56). Patient’s with poor to miserable outcomes (mRS 3-6) average NIHSS-OGT 84.7 (95% CI: 72.8-96.6) and PASS-OGT average 9.8 (95% CI: 8.3-11.2).

For NIHSS-OGT cut off of 55 the sensitivity and specificity was 0.75 and 0.85 respectively; diagnostic odds ratio 16.5 (96% CI: 2.41-112.83). For PASS-OGT cut off of 6.5 the sensitivity and specificity were 0.88 and 0.76 respectively; diagnostic odds ratio 23.33 (95% CI: 2.37-229.33). The wide confidence intervals can be attributed to small sample size.

Conclusion:
Our study indicates NIHSS–OGT and PASS-OGT scores have a linear relationship with discharge mRS and can reliably predict early clinical outcomes after ET. Further confirmation with randomized control trials is needed.
Abstract TMP87: Early Surgery for Infective Endocarditis with Stroke Does Not Increase Post-operative Neurological Complications: What are We Waiting For?
Authors: Zhang Lucy Q , Cho Sung , Marquardt Robert , Thatikunta Prateek , Hussain M. Shazam , Uchino Ken , Wisco Dolora
Published: June 2021

Introduction:
Ischemic and hemorrhagic stroke often complicate infective endocarditis (IE). Optimal timing of surgical intervention for IE with stroke remains controversial. We compared neurological outcomes of early and delayed valve surgery for IE complicated by stroke.

Methods:
We reviewed 73 patients with acute IE by Duke Criteria who underwent brain imaging (CT, MRI, or cerebral angiogram) before valve operations between December 2014 and August 2016. Date of IE diagnosis was defined as date of antibiotic initiation. Early surgery was defined as valve replacement ≤14 days from date of IE diagnosis and delayed surgery as >14 days. Neurological complication is defined as delirium >72 hours after extubation and cessation of sedation, new ischemic or hemorrhagic stroke.

Results:
Among 73 patients who underwent valve replacement surgery, 71 had evidence of stroke on imaging: 54 patients with acute or subacute ischemic infarct, 9 patients with evidence of intracerebral hemorrhage, and 8 patients with subarachnoid hemorrhage. The median time from IE diagnosis to surgery was 9 days. Forty patients had early surgery, and 33 patients had late surgery. Early surgery group had fewer patients with history of ischemic stroke (55% vs 79%, p=0.033), fewer acute or subacute infarcts on imaging (63% vs 88% p=0.016), but more native valve infections (73% vs 45%, p=0.018). The incidence of post-operative stroke was similar between both groups (2.5% vs 9%, p=0.32). In the delayed group, ischemic strokes occurred in 4 patients awaiting surgery. Hypertension and diabetes mellitus were associated with post-operative neurological complications (p<0.05), but pre-operative stroke on imaging was not.

Conclusion:
In IE patients with acute stroke, early surgery does not appear to increase post-operative neurological complications.
Abstract TMP88: Male Gender Predicts Ultrafast Administration of Intravenous Tissue Plasminogen Activator in a Twenty-Six Hospital Network
Authors: Bhatt Archit , Lucas Lindsay , Baraban Elizabeth
Published: June 2021

Background:
The benefits of intravenous tissue-type plasminogen activator (IV-Alteplase) in acute ischemic stroke (AIS) are time dependent. Current guidelines recommend a 60-minute door-to-needle (DTN) time for IV-Alteplase. Moreover, for every 15-minute reduction in treatment time, clinical outcomes are improved by an estimated 4%. In this study, we identified characteristics of patients with DTN times less than 30 minutes (i.e. “ultrafast DTN”).

Methods:
Data obtained from the 26-hospital Providence Health and Services Get With the Guidelines stroke registry were used to identify patients with ultrafast DTN. IV-Alteplase-treated AIS patients over age 18 who were discharged from the hospital between 2009 and 2015 were included. A mixed effects logistic regression model with backwards elimination was used to identify which of the following variables were significant in predicting ultrafast DTN: year of discharge, age, gender, NIHSS score, weekend or evening admission, telestroke usage, hospital arrival time, mode of arrival (EMS vs private car), medical history of dyslipidemia, diabetes, atrial fibrillation, or hypertension, consult with a stroke neurologist, and the certification of the hospital. Parametric bootstrapped p-values, mean estimates and percentile confidence intervals were calculated.

Results:
We identified 2,695 AIS patients who received IV-Alteplase between 2009 and 2015. Of those, only 108 (3.9%) had ultrafast DTN times. In the final bootstrap analysis, ultrafast DTN patients were more likely to be male (adjusted odds ratio (AOR) = 2.23; p<.001), ambulance arrivals (AOR = 4.76; p<.001), weekday arrivals (AOR = 1.89; p<.001), more severe cases (AOR per NIHSS point = 1.03; p=0.04), and more recently discharged (AOR per year = 1.34; p<.001).

Conclusion:
In our large hospital network, we found that only a small proportion of AIS patients received ultrafast Alteplase administration, with males twice as likely as females to receive treatment in less than 30 minutes. This study highlights the necessity to further understand the role gender plays in treatment-related decisions.
Abstract TMP90: Trends in Tracheostomy after Stroke: Analysis of the 1993-2013 Nationwide Inpatient Sample
Authors: Chatterjee Abhinaba , Gialdini Gino , Murthy Santosh , Kamel Hooman , Merkler Alexander E
Published: June 2021

Background:
Tracheostomy is a potentially life-sustaining procedure for patients with severe stroke, yet trends in its use are not well known.

Methods:
Patients presenting with ischemic stroke (IS), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH) were identified from the 1993 to 2013 Nationwide Inpatient Sample using previously validated ICD-9-CM codes. Our outcome was tracheostomy, also defined using previously validated procedure codes. Survey weights and descriptive statistics with exact confidence intervals [CI] were used to report rates of tracheostomy, stratified by stroke type. In a secondary analysis, we used multivariate logistic regression to assess rates of tracheostomy stratified by age, race, and sex.

Results:
From 1993-2013, 13,729,365 patients (95% CI, 13,103,569-14,355,160) were hospitalized in the U.S. with IS, ICH, or SAH. Among these patients, 230,555 (1.7%; 95% CI, 1.6-1.8%) received a tracheostomy. The mean age of patients undergoing tracheostomy was 58.9 (±19.8) years. Rates of tracheostomy use were 1.1% (95% CI, 1.0-1.5%) after IS, 3.8% (95% CI, 3.6-4.0%) after ICH, and 6.2% (95% CI, 5.8-6.6%) after SAH. Tracheostomy was more common in men (OR, 1.32; 95% CI, 1.30-1.35), non-whites (OR, 2.04; 95% CI, 2.00-2.09), and those ≤60 years of age (OR, 2.33; 95% CI, 2.30-2.37). The overall rate of tracheostomy use after any type of stroke increased from 1.2% in 1993 to 2.0% in 2013 (p <0.001). This trend was more pronounced in patients with ICH and SAH than in patients with IS (Figure 1). Tracheostomy use increased annually by 0.9% (p <0.001) among patients ≤60 years of age versus 1.7% (p <0.001) among patients >60 years of age, and by 2.7% (p <0.001) among men versus 0.02% (p <0.05) among women.

Conclusion:
Over the past two decades, the use of tracheostomy appears to be increasing among patients admitted with stroke.
Abstract TMP93: Hypertension is Associated with Disruption of White Matter Tracts in Healthy Middle-aged Persons at Risk for Vascular Disease
Authors: Hannawi Yousef , Yanek Lisa R , Kral Brian G , Vaidya Dhananjay , Becker Lewis C , Becker Diane M , Nyquist Paul A
Published: June 2021

Background:
Fractional anisotropy (FA) measured by Diffusion Tensor Imaging (DTI) is a sensitive biomarker of white matter (WM) integrity and offers a means to detect early axonal disruption and attendant cognitive impairment secondary to vascular disease.

Hypothesis:
We hypothesized that hypertension (HTN), of all known risk factors, is most closely linked to early WM tract injury in apparently healthy high risk relatives of patients with early-onset coronary artery disease (CAD).

Methods:
DTI was acquired on a Phillips 3T MRI scanner (slice thickness 2.2 mm, field of view 212X212 mm and b-value 700 mm
2
/s) for relatives of CAD patients. The brain was segmented into 181 regions using the Eve Atlas, Large Deformation Diffeomorphic Metric Mapping paradigm, and 48 regions representing the deep WM were selected for analysis. Mean regional FA (rFA) was assessed using t-tests in persons with and without smoking, HTN, diabetes. Continuous variable association with rFA was tested using Spearman correlations. Covariate-adjusted GEE linear regression (corrected for nonindependence of families) was performed for regions meeting the Bonferroni threshold of 0.001 (0.05/48).

Results:
116 subjects had DTI data (mean age 49.5±11, 57% males, 40.5% African Americans, 23% smokers, 36% hypertensives, 12% diabetics). rFA was not significantly associated with diabetes or current smoking. Moreover, rFA was not significantly correlated with glucose level, LDL, total cholesterol or body mass index. However, patients with HTN showed a significantly lower rFA compared to normotensives in the left (L) genu of corpus callosum, L external capsule, right (R) cingulum, L fornix/ stria terminalis, L and R column and body of fornix, and R sagittal stratum. After adjusting for age, sex and race, this relation remained significant in the R sagittal stratum (P=0.012) and R cingulum (P=0.001). Systolic blood pressure (SBP) correlated with rFA after adjustment in the L superior longitudinal fasciculus as well (unadjusted rho=-0.309, p=0.00073, adjusted beta =-1.08+-0.47, P=0.02).

Conclusions:
Of all of the risk factors, as hypothesized, HTN and SBP were significantly associated with early WM tract injury in areas related to cognition in middle-aged persons at risk for vascular disease.
Abstract TMP96: Neuroinflammatory Mechanism of Vascular Cognitive Impairment
Authors: Davis Catherine M , Benedek Gil , Weber Sydney , Roese Natalie , Zhang Wenri , Raber Jacob , Offner Halina , Alkayed Nabil J
Published: June 2021

Introduction:
The mechanisms of vascular cognitive impairment (VCI) are poorly understood. We previously demonstrated increased expression and activity of soluble epoxide hydrolase (sEH) in microvascular endothelium of human brain tissue from deceased patients with pre-mortem VCI. sEH is a key enzyme in the inactivation of endogenous lipid signaling mediators, epoxyeicosatrienoic acids (EETs), known to have vasodilator and anti-inflammatory properties.

Hypothesis:
Upregulation of endothelial sEH impairs cognition, by mechanisms involving reduced cerebral blood flow (CBF) and enhanced inflammation.

Methods:
Mice constitutively expressing human sEH in endothelium (Tie2-hsEH) and wild-type (WT) underwent unilateral common carotid artery occlusion (UCCAO) or sham surgery, then analyzed 4 months later for cognitive performance using the Morris water maze (MWM), CBF by perfusion MRI, immune cell profiling in brain, blood and spleen using fluorescence-activated cell sorting (FACS) and immunohistochemistry (IHC). Additionally, immune profiling was performed on WT mice 28 days following surgery, with and without pretreatment with immune modulator DRa1-hMOG-35-55 (HLA-DR a1 moiety linked to human MOG-35-55 peptide).

Results:
Tie2-hsEH mice showed impaired spatial memory retention in the MWM. No differences were observed in CBF between genotypes. IHC demonstrated a higher density of CD45-positive cells in Tie2-hsEH brain compared to WT. FACS analysis revealed a higher frequency of CD11b
+
CD45
hi
cells in Tie2-hsEH vs. WT mice. Furthermore, these cells express higher levels of CD74, the receptor for macrophage migration inhibitory factor (MIF). Similarly, following UCCAO, the frequency of antigen-presenting dendritic cells and CD74 expression on CD11b
+
CD45
hi
cells were increased in brain, but reduced in spleen and blood compared to naïve mice; both changes were reversed by treatment with DRa1-MOG-35-55, resulting in a decreased frequency and activation state of these cells.

Conclusions:
Our data suggest that infiltration of monocyte-derived macrophages may contribute to cognitive impairment in VCI. Our findings suggest that CD74 expression could serve as a biomarker for VCI, and that DRa1-MOG-35-55 may be effective in treating VCI.
Abstract TMP98: Could Mobile Health be an Effective Strategy for Enhancing Stroke Prevention?
Authors: Liu Shimeng , Feng Wuwei , Chhatbar Pratik Y , Ovbiagele Bruce I
Published: June 2021

Background:
The overwhelming majority of strokes can be prevented via optimal vascular risk factor control. However, there remains an evidence practice gap with regard to treatment of vascular risk factors. With the rapid growth worldwide in cell-phone use, Internet connectivity, and digital health technology, mobile health (mHealth) technology may offer a promising approach to bridge these treatment gaps and reduce the global burden of stroke.

Objective:
To evaluate the effectiveness of mHealth in vascular risk factor control through a systemic review and meta-analysis.

Methods:
We searched PubMed from January 1, 2000 to May 17, 2016 using keywords: mobile health, mhealth, short message, cellular phone, mobile phone, stroke prevention and control, diabetes mellitus, hypertension, hyperlipidemia and smoking cessation. We performed a meta-analysis of all eligible randomized control clinical trials that assessed the long-term (at 6 months) effect of mHealth.

Results:
Of 79 articles identified, 13 of them met eligibility criteria (6 for glycemic control and 7 for smoking cessation) and were included for the final meta-analysis. There were no eligible studies for dyslipidemia or hypertension. mHealth resulted in greater HbA1c reduction at 6 months (6 studies; 663 subjects; SMD: -0.44; 95% CI: [-0.82, -0.06],
P
=0.02; Mean difference of decrease in HbA1c: -0.39%; 95% CI: [-0.74,-0.04],
P
=0.03). mHealth also led to relatively higher smoking abstinence rates at 6 months (7 studies; 9,514 subjects; OR: 1.54; 95% CI: [1.24, 1.90],
P
<0.0001).

Conclusion:
Use of mHealth improves glycemic control and smoking abstinence rates, two factors that may lead to better stroke outcomes. Future mHealth studies should focus on modifying premier vascular risk factors like hypertension, specifically in people with or at risk of stroke.
Abstract TP108: Association Between Intracranial Atherosclerotic Calcium Burden and Angiographic Luminal Stenosis Measurements
Authors: Baradaran Hediyeh , Patel Praneil , Gialdini Gino , Giambrone Ashley , Lerario Michael , Navi Babak , Min James , Iadecola Costantino , Kamel Hooman , Gupta Ajay
Published: June 2021

Background:
Recent data have shown that atherosclerotic calcification of the intracranial vasculature is an independent risk factor for ischemic stroke. The relationship between the most commonly used marker of high risk intracranial atherosclerosis, the percent degree of luminal stenosis, and calcium burden in the intracranial circulation has not been investigated.

Materials and Methods:
We evaluated the relationship between atherosclerotic calcification and luminal stenosis in the intracranial internal carotid arteries (ICAs). Using a prospective stroke registry, we identified patients who had non-contrast computed tomography (NCHCT) and either CT angiography (CTA) or magnetic resonance angiography (MRA) examinations as part of a diagnostic evaluation for ischemic stroke. We used NCHCTs to qualitatively (Modified Woodcock Visual Score) and quantitatively (Agatston-Janowitz calcium score) evaluate ICA calcium burden and angiography to measure arterial stenosis (Figure). We calculated correlation coefficients between the degree of narrowing and calcium burden measures.

Results:
In 470 unique carotid arteries (235 patients), 372 (79.1%) had atherosclerotic calcification detectable on CT while only 160 (34%) had measurable arterial stenosis (p < 0.001). We found a weak linear correlation between qualitative (R = 0.48) and quantitative (R = 0.42) measures of calcium burden and the degree of luminal stenosis (p < 0.001 for both). Of 310 ICAs with 0% luminal stenosis, 216 (69.7%) had measureable calcium scores.

Conclusion:
There is only a weak correlation between intracranial atherosclerotic calcium scores and luminal narrowing, which may be explained by the greater sensitivity of NCHCT compared to angiography in detecting the presence of measurable atherosclerotic disease. Future studies are warranted to evaluate the relationship between stenosis and calcium burden in predicting stroke risk.
Abstract TP110: Helicobacter Pylori Infection and Genetic Factors as Determinants of Carotid Plaque Stability
Authors: Arias Eugenia , Arakaki Naomi , Martinetto Horacio , Sevlever Gustavo E , Ameriso Sebastian F
Published: June 2021

Introduction:
Little is known about the role of
H pylori
in human atherosclerosis. We have previously demonstrated its presence in carotid plaques, especially among asymptomatic patients, with prevalence of
cag
A-positive strains. Polymorphisms of genes of angiotensin-converting enzyme (ACE), lipoprotein APOE (APOE), IL1 receptor antagonist (IL1Ra) and myeloperoxidase (MPO) are associated with atherosclerosis. We evaluated the role of
H pylori
in certain features of carotid plaques and assessed allelic and genotypic frequencies and their association with
H pylori
infection and plaque characteristics.

Methods:
We studied 137 carotid plaques of patients undergoing endarterectomy. We categorized as stable those predominantly fibrous plaques with scarce inflammatory cells, intact cap and no hemorrhage and unstable those plaques with inflammation, thin cap, ruptured lipid core, thrombi and hemorrhage. We extracted genomic DNA and identified and typified
H Pylori
DNA. DNA was also obtained from peripheral blood and we identified allelic and genotypic frequencies and susceptibility variants of ACE, APOE, IL1Ra, and MPO genes. Fisher’s exact test (two-tailed) and good fit test were used.

Results:
There were 72 asymptomatic patients with 47 stable and 25 unstable plaques and 65 symptomatic patients with 13 stable and 52 unstable plaques (p<0.0001).
H pylori
infection was present in 48 of 60 stable plaques and 31 of 77 unstable plaques (p<0.0001). In addition, stable infected plaques more often carried the more virulent
cag
A strain.
H pylori cag
A-negative plaques had larger intima media complex thickness than
cag
A-positive and
H pylori
-negative plaques. Stable infected plaques were associated to alleles APOE-33 and IL1RN-11. Unstable noninfected plaques were associated to proatherogenic alleles ACE-DD, APOE*4, APOE*2, IL1RN*2, and MPO-GG.

Conclusions:
Histopathological features of plaque instability are associated to the presence of recent symptoms.
H pylor
i infection with the virulent
cag
A strain is highly prevalent in stable carotid plaques of asymptomatic subjects. Noninflammatory genotypes are present in stable infected plaques whereas proatherogenic polymorphisms are predominant in unstable noninfected plaques.
Abstract TP117: Outcomes of Elective Carotid Stenting in the Octogenarians
Authors: Alawi Aws , Al Shakarchi Firas , Edgell Randall , Alshekhlee Amer
Published: June 2021

Background:
The CREST trial showed that risk of stroke, MI, death, and composite of the any of the 3 adverse events during the periprocedural period of carotid artery stent (CAS) is 4.1%, 1.1%. 0.7%, and 7.2% respectively. We aim to assess trends of periprocedural outcomes after CAS based on different age strata.

Methods:
A cohort of patients with CAS is identified from the National In patient Sample database using the procedure codes (00.63) for the years 2001 through 2009. We only included elective admissions for CAS. Missing observations on the death status are eliminated. Age was stratified as follows: < 60, 61-70, 71-80, and > 80. Trend analysis for the following periprocedural outcomes: peri-procedure stroke, myocardial infarction ‘MI’, and death; was performed across different age strata. The Cochrane-Armitage test was used for trend analysis.

Results:
Over 9 years, 10,655 CAS procedures were performed; 1818 (17.1%) were performed in the octogenarians. Race and gender distribution was similar across the age strata; men and Whites were predominant. In addition to age, co-morbid high risk factors were documented in 91% of the octogenarians compared to 83.2% of those < 60. The overall periprocedural outcome of stroke, MI and death across all ages is 2.37%, (stroke 1.6%, MI 0.66% and death 0.37%). Unfavorable periprocedural outcomes in different age strata are as follows: < 60 (1.1%), 61-70 (1.9%), 71-80 (3%), and > 80 (2.75%); trend P value < 0.0001. The risk of stroke is as follows: < 60 (0.72%), 61-70 (1.3%), 71-80 (2.0%), and > 80 (1.9%), P value < 0.0003; and MI < 60 (0.33%), 61-70 (0.52%), 71-80 (0.85%), and > 80 (0.77%), P value < 0.03. Mortality remained between 0.27 and 0.44 in different age strata; P = 0.54.

Conclusion:
In this study, periprocedural risks of stroke and MI are lower than what was reported in the CREST trial. A slight increase in these risks is noted with age, though appeared to plateau after age of 70 years.
Abstract TP124: Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke: South Asian Experience
Authors: Kamran Saadat , Akhtar Naveed , Bhutta Zain A , Salam Abdul , Alboudi Aymen , Rashid Hiba , Kamran Kainat , Ahmed Arsalan , Own Ahmed M , Rukun Sohail A , Inshasi Jihad , Deleu Dirk , Sulaiti Ghanim A , Shuaib Ashfaq
Published: June 2021

Objective:
The randomized trials and pooled analysis showed improved outcome and reduced mortality in malignant middle cerebral artery [MMCA] undergoing decompressive hemicraniectomy (DHC) within 48 hours of stroke onset. This could be due to highly selective patient population in trials, not reflecting real world practice. Furthermore, with ischemic stroke being so common in the South Asian and Middle Eastern population, there still exists very little published data on DHC in MMCA stroke patients.

Methods:
Retrospective, multicenter cross-sectional study to measure outcome following DHC using the modified Rankin Scale [mRS] and dichotomized as favorable ≤4 or unfavorable >4, at three months.

Results:
In total 137 patients underwent DHC. At 90 days, mortality was 16.8%, 61.3% of patients survived with an mRS ≤4 and 38.7% had an mRS of >4. Age (55 years), diabetes [p=0.004], hypertension [p=0.021], pupillary abnormality [p=0.048], uncal herniation [p=0.007], temporal lobe involvement [p=0.016], additional infarction [MCA + ACA, PCA] [P=0.001], and infarction growth rates [P=0.025] was significantly higher in patients with unfavorable prognosis in univariate analysis. Multivariate analysis showed age, additional infarction, septum pellucidum deviation >1cm and uncal herniation to be associated with a significantly poor prognosis. Time to surgery had no impact on outcome [p=0.109].

Conclusions:
Similar to the effects observed in the studies from the West, DHC improves functional outcome in predominantly South Asian patients with MMCA stroke. Increasing age, MCA with additional infarctions, septum pellucidum deviation 1cm and uncal herniation were significant predictors of disability and poor functional outcomes. Time to surgery had no impact on functional outcome.
Abstract TP126: Ocular Circulation in Carotid Artery Stenosis Treated by CEA or CAS
Authors: Kawaguchi Shoichiro , Kurioka Hisanobu
Published: June 2021

Background:
The authors evaluated the effect of carotid artery revascularization surgery for ocular circulation and chronic ocular ischemic syndrome (OIS).

Methods:
The authors examined ninety-3 patients with carotid artery stenosis (more than 50% stenosis) at its origin treated by carotid endarterectomy (N=58) or carotid artery stenting (N=34). Twenty-six patients (28%) complained of chronic OIS evaluated by the ophthalmic examination. Ocular circulation was examined before and after revascularization surgery using ophthalmic artery (OphAr) and central retinal artery (CRA) color Doppler flow imaging.

Results:
1) Ocular circulation: Preoperatively, the average OphAr peak systolic flow velocity (Vs) was 0.05 m/sec, and the average CRA Vs was 0.07 m/sec. At 1 week after surgery, the average OphAr Vs significantly increased to 0.32 (
p
< 0.05), and the average CRA Vs significantly increased to 0.11 m/sec (
p
< 0.05). These significant improvements were sustained throughout the three months of the follow up.2) OIS: During the follow-up period (mean: 3.6 years), 16 patients (62%) showed visual acuity improvement, and no patients complained of amaurosis fugax or worsening of the chronic OIS.

Conclusion:
Carotid revascularization surgery was effective in improving the ocular circulation, and it was also useful for the chronic OIS due to the carotid artery stenosis.
Abstract TP127: Mortality and Recurrence in Atherosclerotic Ischemic Stroke: Long-term Follow-up
Authors: Barboza Miguel A , Uribe Rodrigo , Serrano Fabiola , Becerra-Pedraza Luis C , Mantilla-Barbosa D. K , Arauz Antonio
Published: June 2021

Background and purpose:
Atherosclerotic ischemic stroke is the second most frequent etiology of stroke in the adult population. Functional outcome, mortality and recurrence of stroke rates on the long-term follow-up are poorly studied. This study investigates long-term outcome among patients with ischemic stroke secondary to atherosclerotic causality, and identifies the main factors associated with poor outcome, recurrence, and death.

Methods:
We analyzed data from our consecutive acute ischemic stroke database, over a period of 25 years (1990-2015). The endpoints were: bad outcome (Modified Rankin Score ≥3), recurrence and mortality at discharge, and final follow-up. Multivariate Cox and Kaplan-Meier analysis were used to estimate the probability of death and recurrence.

Results:
A total of 946 consecutive atherosclerotic stroke patients were included (571 [60.4%] males, median age 65 years [interquartile range 57-73 years] for the entire population); dyslipidemia (64.2%), hypertension (63.3%), diabetes (35.0%), and active smoking history (31.8%) were the most prevalent risk factors.After a median follow-up of 38 months (IQR 12-75 months), 59.3% patients had a bad outcome at discharge. A result of 26.1% had stroke recurrence (median time until recurrence: 9 months [IQR 12-84 months], with 12.9% cases presenting ≥2 recurrences), and 24.1% were dead (median time to death: 18.5 months [IQR 11-74 months]) at the final follow-up period. After multivariate adjustment, hypertension (HR 4.2, CI 95% 2.8-6.1; p<0.001) was the strongest predictor of recurrence. Additionally, diabetes (HR 2.6, CI 95% 2.0-3.5; p<0.001), bad functional outcome after recurrence (HR 2.3, CI 95% 1.9-2.9; p<0.001), age ≥65 years (HR 2.2, CI 95% 1.7-2.9; p<0.001), and active smoking (HR 1.8, CI 95% 1.3-2.3; p<0.001) were the strongest predictors of mortality.

Conclusions:
Atherosclerotic ischemic stroke has a high rate of recurrence, associated mainly with hypertension. Mortality is predicted by diabetes, bad functional outcome at recurrence, and older age.
Abstract TP132: Selection and Activation of Sites in a Large Multi-Center Randomized Clinical Trial
Authors: Demaerschalk Bart M , Brown Robert D , Howard Virginia J , Tom MeeLee , Longbottom Mary E , Voeks Jenifer H , Kadiric Eldina , Lal Brajesh K , Meschia James F , Brott Thomas G
Published: June 2021

Introduction:
Careful selection and timely activation of clinical sites in multicenter clinical trials is critical for successful enrollment, subject safety, and generalizability of results.

Methods:
In the Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2), a multidisciplinary Site Selection Committee evaluated applicants referred via participation in CREST, CREST principal investigators (PIs) and other investigators, StrokeNet and industry partners. Data for consideration included performance metrics in CREST and other carotid trials and a site selection questionnaire containing information on the investigators as well as quantitative data on carotid procedures performed. Any FDA warning letters were reviewed.

Results:
The Committee met bi-weekly for 36 months (n=64 meetings). Applications from 176 sites between March 2014 and July 2016 were evaluated: 153 were approved, 7 are under Committee review, 5 were approved but withdrew, 5 were placed on a waiting list, and 6 were rejected. One-hundred-four sites have completed the regulatory and training requirements to randomize: 51 (49%) academic medical centers, 31 (30%) private hospital-based centers, 16 (15%) private office-based practices, and 6 (6%) Veterans Administration medical centers. The mean times from application-to- approval was 5.2 weeks (interquartile range, 1.9, 6.2), and from approval-to-randomization status was 46.7 weeks (interquartile range, 35.4, 51.7). Specialties of the 104 site PIs are vascular surgery for 35 (33.7%), cardiology for 30 (28.8%), neurology for 25 (24%), neurosurgery for 8 (7.7%), interventional radiology for 4 (3.8%), and interventional neuroradiology for 2 (1.9%).

Conclusions:
Careful site selection is time-consuming for prospective sites and for trial leadership. Times from application-to-site-approval were modest (mean = 5.2 weeks), in contrast to the times for completing regulatory and training requirements (mean = 46.7 weeks). However, subject enrollment by teams from a wide range of medical centers led by a multi-disciplinary cohort of PIs will promote the generalizability of trial results.
Abstract TP136: The Effect of Caregivers on Motivation to Improve Daily Physical Activity After Stroke
Authors: Sheehan Orla C , Weinstein Matthew G , Ahuja Alka , Urrutia Victor C , Marsh Elisabeth B , Roth David L , Schrack Jennifer A
Published: June 2021

Introduction:
Physical activity (PA) levels in stroke survivors are typically lower than those observed in the general older population. Higher PA after stroke has been associated with improved mobility, balance and quality of life. A greater understanding of ways to increase daily PA in stroke survivors is paramount to long-term recovery. The purpose of this study was to compare and contrast daily PA quantities, patterns, and trends in stroke survivors with and without a caregiver, and with and without clinical motivation to engage in regular walking activity.

Methods:
PA was objectively assessed using an Actigraph wrist worn accelerometer over a 7-day period in 40 stroke survivors within one year of stroke. All had modified Rankin scores of
<
3. Half were randomized to receive clinical motivation with instructions to take three 10-minute daily walks that were timed to target the late afternoon, a period associated with low PA in older adults. The other half were told to maintain their normal activity levels.

Results:
39 patients returned their accelerometer within a week of wear time. Mean age was 63.3 (± 11.5) years, 53.8% were female and 48.7% were African American. In linear regression models, unadjusted and adjusted for age, BMI, and sex, total daily PA was lower with increasing age in the afternoon and evening hours (P < 0.05). This effect was attenuated in those who were currently employed in the unadjusted (p=0.02) but not the adjusted model (p=0.10). There were no differences by race (p=0.73) or gender (p=0.27). Although clinical motivation did not contribute to higher PA levels at any time of day, the presence of a caregiver increased PA in the late afternoon in the adjusted model (P = 0.04). Interestingly, among all participants, as time since stroke increased, daily PA tended to decrease (p = 0.08).

Conclusions:
Effective and sustainable interventions are needed to increase and maintain PA after stroke. Involving caregivers appears to contribute to higher PA, although a brief motivational intervention did not further augment that effect. The negative association between time since stroke and daily PA suggests the challenges stroke survivors face to preserve daily PA. Future research is needed to expand these findings across a greater age and mobility range.
Abstract TP138: Repeated Bilateral Multifocal Cortical Magnetic Stimulation with a New Wearable Transcranial Stimulator in Chronic Ischemic Stroke
Authors: Helekar Santosh , John Blessy , Laredo Rafferty , Card Cynthia , McCane Charles , Clearman Rebecca , Chiu David
Published: June 2021

Introduction:
Repetitive transcranial magnetic stimulation (rTMS) treatment of ipsilesional (IL) or contralesional (CL) cortex combined with occupational/physical therapy (OT/PT) shows significant promise in chronic ischemic stroke (CIS). Here we describe a multifocal cortical magnetic stimulation protocol with a new wearable device called transcranial rotating permanent magnet stimulator (TRPMS) for a pilot clinical trial in CIS, and present preliminary results in one patient.

Hypothesis:
Simultaneous repeated excitatory and inhibitory stimulations of IL and CL cortical sites, respectively cause perilesional functional cortical reorganization with recovery of motor function in CIS.

Methods:
After informed consent, we treated a 58-year old male patient with a right middle cerebral artery thromboembolic infarct causing left sided hemiparesis. At the start of TRPMS treatment 19 months after the stroke he had a stable baseline on motor function tests. The treatment consisted of 4 two-week sessions (with intervening one-week rest periods) of daily (on week days) 40 min TRPMS stimulation (5 Hz, 25 ms pulse duration at 4 perilesional cortical sites, and 0.2 Hz, 100 ms pulse duration at 2 CL primary motor cortical sites) accompanied by OT/PT. Pretreatment, posttreatment and follow-up assessments were functional magnetic resonance imaging (fMRI) during attempted gripping movements, and grip strength, gait speed and Fugl-Meyer (FM) scale testing.

Results:
After the 2
nd
treatment session movement-related fMRI showed increasing levels of neural activation of the stimulated intact cortex surrounding the lesion. Grip strength of the affected hand increased ~2.5 fold. Gait speed increased by ~15%. Left lower extremity motor function and sensation measures on the FM scale showed sustained increase by ~17% and ~30%, respectively. These changes persisted above the pretreatment levels at the 3-month follow-up. There were no adverse effects.

Conclusions:
These findings suggest that the new TRPMS protocol might bring about some degree of functional cortical reorganization and motor recovery in CIS. We have therefore launched a randomized double-blind sham treatment-controlled clinical trial involving a four-week TRPMS treatment in 30 CIS patients.