bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP315: Acute Myocardial Infarction Associated With Worse Outcomes in Acute Cerebrovascular Disease
Authors: Park Sea mi , Lahiri Shouri , Moheet Asma , Mann Jaspreet , Rosengart Axel
Published: July 2021

Introduction/Hypothesis:
We examined the prevalence and outcomes of patients admitted with acute cerebrovascular disease (ACVD) and concomitant acute myocardial infarction (AMI).

Methods:
We utilized the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database (1998-2009) and identified 1,760,415 adult ACVD patients among 92,848,710 patients enrolled. Using SAS 6.4 and applying SPSS 22 the outcome variables mortality, length of hospital stay (LOS), hospital costs >$20,000, and disposition (home or any care facility) were selected and logistic regression analyses was performed adjusting for the covariates hypertension, diabetes mellitus, age, race, sex, number of comorbidities, and care complexity (numbers of inpatient procedures) among all ACVD with and without AMI.

Results:
Mean age was 71 years (SD 15) with 76% >65 years old; 54% female gender; 55% Whites, 11% Blacks, and 6% Hispanics. Among all ACVD, 66% had HTN, 28% DM, AMI 4.1%, LOS was 7.6 days (SD 9.8), in-patient mortality 12%; disposition home 42% and facility 44%, and mean hospital costs $36,010 (SD $63,331). After covariate adjustment, ACVD patients with AMI compared to those without AMI had a mortality of 30% vs 12% (P<0.000); LOS ≥7 days 53% vs 30% (P<0.000), facility discharge 68% vs 51% (P<0.000), and adjusted hospital costs 71% vs 44% (P<0.000).

Conclusions:
Acute myocardial infarction occurred in 4.1% of patients with acute cerebrovascular disease. It was associated with significantly increased risks of in-patient mortality, length of hospital stay, facility disposition and hospital costs. Considering the poor outcomes of ACVD patients with AMI may indicate more aggressive strategies for early recognition and reduction of myocardial injury.
Abstract WP320: The Management of low Density Lipid Cholesterol and Predictors of Goal Achievement in Stroke Patients in China
Authors: Wang Chunjuan , Wang Yilong , Li Zixiao , Wang Yongjun
Published: July 2021

Background and Purpose:
Modification of low-density lipoprotein cholesterol (LDL-C) has been proved to be an essential component in the primary and secondary prevention of stroke. However, limited data are available on LDL-C goal achievement in patients with ischemic stroke in China. The aim of this study was to assess the management of low-density lipoprotein cholesterol (LDL-C) in patients suffering from ischemic stroke within 6-12 months and to explore the predictors of the achievement of LDL-C target.

Method:
This study was a nation-wide, multicenter, cross-sectional study conducted from July 2013 to August 2013. Patients who had an ischemic stroke within 6-12 months and were more than 18-year old were included into this study. All data referred to personal information, medical history, medication and laboratory tests were collected by face-to-face questionnaires, physical examination and blood tests. The predictors for the achievement of LDL-C target (<1.8mmol/l or <70mg/dl) were analyzed by the multivariate analysis.

Results:
In this study, a total of 3956 cases from 56 centers suffered from ischemic stroke within 6-12 months were finally included into this study. The average serum level of LDL-C in all these patients was 2.42 ± 0.91mmol/l with the median of 2.30 mmol/l and the total LDL-C goal achievement rate is 27.35% (95% CI: 25.97%-28.77%). Lipid-lowering therapy (Odds Ratio [OR]=3.045, 95%CI: 2.456-3.810) was the most significant predictor for LDL-C target achievement and female (OR=0.684, 95% CI: 0.540-0.867), current smoking (OR=0.627, 95% CI: 0.480-0.817), and history of dyslipidemia (OR=0.592, 95% CI: 0.497-0.704) were three other important factors for the LDL-C goal achievement.

Conclusions:
Although the lipid modulation in stroke patients is recommended by the international guidelines, the goal achievement of LDL-C was still very low in this population in China. The modifiable predictors including the use of lipid-lowering drugs and smoking cessation should be improved in dyslipidemia management.
Abstract WP322: Inability to Identify Physician is Associated With Medication and Care Plan Knowledge Gaps Ii Stroke Patients
Authors: Cohen Fred , Katz Jeffrey M , McCarthy Jackie , Lopez Ignacio , Wright Paul
Published: July 2021

Introduction:
Patient dissatisfaction and medication non-compliance correlate with patient misunderstanding of their medications and care plan. We aimed to assess the degree of these gaps and their associations in hospitalized stroke patients.

Methods:
A 5-question survey was administered to patients hospitalized on the neuroscience ward of a comprehensive stroke center. Patient understanding of their condition leading to admission, care plan, medications, primary attending physician, and follow-up plan was assessed. If the patient was unable to communicate, then their health care representative was interviewed.

Results:
A total of 146 patients (55 stroke and 91 general neurology and neurosurgery (non-stroke) patients) or their representatives were interviewed. Stroke patients were less likely to properly identify their primary attending physician (33/55 (60.0%) stroke patients versus 35/91 (38.5%) non-stroke patients; p=0.011). Inability to identify the attending physician was associated with lack of medication and care plan knowledge and was more common in stroke patients, (23/33 (69.7%) stroke patients versus 14/35 (40.0%) non-stroke patients; p=0.014).

Conclusion:
Despite sharing a common pool of providers, the inability to identify the primary attending physician was significantly more common in stroke patients and was associated with patient knowledge deficits regarding their medication regimen and care plan. This correlation was significantly higher in stroke patients and suggests that stroke patients may require different, extra or more robust communication and education than the general neurology and neurosurgery population. Additionally, emphasis on attending physician identification may improve patient satisfaction and medication compliance.
Abstract WP326: Improving Follow-up Visits for Patients from the Stroke Service
Authors: Gannon Kimberly P , Kasner Scott
Published: July 2021

Background:
Follow-up services after stroke may improve functional outcome and decrease readmissions. We aimed to improve discharge of patients from the stroke service by ensuring that they have a follow up appointment with Neurology scheduled at the time of discharge, to evaluate factors impacting appointment scheduling, and to evaluate factors impacting appointment attendance.

Hypothesis:
We hypothesized that access to an online scheduler would increase appointments scheduled at the time of discharge.

Methods:
This retrospective analysis included patients diagnosed with ischemic stroke, TIA, intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (1/2013 - 9/2014 time) discharged from the stroke service, but excluded patients who were deceased, transferred to another inpatient facility, clinical trial patients, and those with outside providers. The following metrics were collected from 975 patient discharges: diagnosis, date of hospitalization, length of hospitalization, discharge location, time from discharge to clinic appointment, if appointment was made at the time of discharge, and if the clinic appointment was attended.

Results:
Access to an online scheduling tool did not increase the number of patients who were discharged with an appointment (35% v. 41%; p=0.087). However, appointments were scheduled significantly more frequently for patients hospitalized for > 5 days, ICH and Ischemic stroke patients, and those discharged to a facility (Figure 1). Patients for whom an appointment was made prior to discharge did not follow up more frequently than those who were asked to call to make an appointment (45% v. 43%, p=0.64); however, follow up was influenced by length of stay, diagnosis, discharge location and time to appointment (Figure 2).

Conclusion:
Scheduling an appointment prior to discharge did not improve post-discharge follow-up. Future directions will work to elucidate the reason for poor clinic attendance and increase follow-up.
Abstract WP328: Seizure in Patients With Co-morbid Stroke in the United States: Frequency and Characteristics
Authors: Akinboro Oladimeji , Olorunfemi Odunayo , Jesmajian Stephen , Ovbiagele Bruce
Published: July 2021

Background:
The commonest cause of epilepsy in the elderly is symptomatic vascular brain injury. As the population ages, the prevalence of stroke is projected to rise, and so conceivably the incidence of seizures will increase as well. However, the extent to which individuals presenting with a seizure have a co-morbid diagnosis of stroke and precisely how this relationship varies by age, gender, and race is unclear.

Objective:
To assess the relation of admission for an epileptic event with a co-morbid diagnosis of stroke.

Methods:
Using the National Inpatient Sample, a nationally representative data set of US hospital admissions, we assessed patients aged 18 years or older hospitalized with seizures who had a comorbid diagnosis of stroke from 2004-2009. We define seizure or epilepsy hospitalizations using primary ICD-9 discharge diagnosis codes 345.0-345.5, 345.7-345.9, and 780.39. Secondary discharge codes for stroke used were 433-437.10, 437.3, and 437.5-438. The sample was stratified into age-categories (75 years), and racial categories. Frequencies and descriptive analysis of comorbidities and confounders were utilized. A logistic regression model was used to further explore the relationship. All analysis were survey-weighted.

Results:
During the study period, 253,778 adults (0.64%) of the sample were hospitalized for seizures. On survey-weighted analysis, 11.1% of those hospitalized for seizures had a co-morbid diagnosis of stroke. Among patients with seizures and co-morbid stroke, 23.6% were aged 75 years, 51.6% were women, and 60.7% were of White race. Greater odds of hospitalization for seizures were seen with those with co-morbid stroke vs. no stroke (OR 3.68; 95% CI 3.49-3.89, p<0.01), and blacks (OR 1.45; 95% CI 1.38, 1.52), relative to whites. Females were less likely to be hospitalized for seizure than males (OR 0.63; 95% CI 0.62, 0.65) significant interaction between comorbid stroke, and gender (p<0.01 ).

Conclusions:
One out of eleven patients hospitalized with seizures in the United States has a co-morbid diagnosis of stroke. Patients with co-morbid stroke are almost 4 times more likely to hospitalized with seizures than those without known stroke, with gender modifying this relationship.
Abstract WP329: Video Conferencing is the Preferred Method for Follow-up Communication for Post-hospital Stroke Patients
Authors: Cohen Fred , McCarthy Jackie , Gribko Michelle , Katz Jeffrey M , Wright Paul
Published: July 2021

Introduction:
Close communication with a stroke patient after discharge from a comprehensive stroke center has been shown to be crucial for medication compliance, follow up care and improving patient satisfaction. We aimed to improve post-hospitalization compliance and patient satisfaction by assessing if a video call as a routine follow-up communication modality would be the preferred method of communication.

Methods:
Admitted stroke patients were asked for their preference in post-hospitalization communications with their attending physician.

Results:
A total of 52 stroke patients were interviewed, 30 (57.7%) requested a video call, 22 (42.3%) requested a phone call. 100% (14/14) ages 55 and younger requested a video call. 70.3% (19/27) of patients 65 years old and younger requested a video call.

Conclusion:
There is evidently a strong demand for video conferencing as a method of follow-up communication among the post hospitalized stroke population. Although age appears to influence the demand, the majority of patients expressed greater enthusiasm with the concept of video conferencing. Follow-up video communication could improve patient medication, treatment compliance, risk factor reduction and ultimately improve patient care and satisfaction. Video calls will also provide additional visual information that a routine phone call would miss, potentially reducing readmissions. Therefore, with advancing technology and the strong desire for video conferencing, one should begin to think of ways to provide this service.
Abstract WP330: Unreliable Long-term Cost Data Introduces Substantial Uncertainty Into Stroke Cost-Effectiveness Models
Authors: Leppert Michelle , Burke James , Simpson Jennifer , Campbell Jonathan
Published: July 2021

Background:
Cost effectiveness analysis (CEA) models evaluate the value of stroke care methods. Estimates of long-term costs of stroke, a key input, vary substantially. We explored the effect of long-term cost variation on the interpretation of stroke CEA models.

Methods:
We estimated the lifetime costs and outcomes associated with intravenous tissue-type plasminogen treatment in acute ischemic stroke within the 0-3 hr and 3-4.5 hr windows. Decision analytic model inputs were from previously published literature, and clinical trials. We varied annual long term care costs, using cost groupings (i.e. cost per year at a given level of function) from published CEA models. Low estimates were from the Stroke Treatment Economic Model based on cost in the United Kingdom. High estimates were from the Rochester Stroke Registry from 1987 to1989. Split estimate took cost of minor disability from the low estimate and cost of major disability from the high estimate. We estimated incremental cost effectiveness ratio (ICER) for the base-case and conducted probabilistic sensitivity analyses.

Results:
The split estimate resulted in the lowest ICERs and was the dominant strategy (improved efficacy, cost savings) in all three conditions (0-3hr, 3-4.5hr, ECASS III) with ICERS -$67,530, -$223,294, and -$39,517 respectively. The low estimate, while still cost effective, increased ICERS substantially to $809, $144, and $18,549 respectively. When low cost estimates were substituted for split cost estimates, the percentage of dominant stimulations dropped by more than half (figure 1).

Conclusion:
Varying cost estimates led to considerably different conclusions regarding the cost effectiveness of tPA . For a highly cost-effective therapy, these differences do not affect the overall judgement of cost-effectiveness. However, this uncertainty could alter the cost effectiveness of more marginally effective or costly treatments. More reliable long term stroke cost estimates are needed.
Abstract WP336: Patient Characteristics and in Hospital Complications Associated With High Cost Ischemic Stroke Admissions
Authors: Siddiqui Khawja A , Liu Xiu , Lynch Karen E , Mahmood Sadiqa B , Zheng Hui , Shahian David M , Schwamm Lee H
Published: July 2021

Introduction:
Stroke poses a major public health burden. We sought to determine the clinical and demographic variables associated with high cost among hospitalized ischemic stroke (IS) patients.

Methods:
Using our local Get with the Guidelines Stroke database, we identified 1,578 IS patients admitted from 2010- 2013 and linked them to administrative claims data (EPSI, inc). Patients in the highest cost quartile (n=394) were compared to all others (n=1184) using descriptive statistics and multilevel logistic regression models. All financial data are relative costs, reported as medians [IQR] multiplied by a constant.

Results:
The median relative cost in the top quartile was 4 times higher than that for all other patients. In univariate analyses, the groups differed substantially (Table 1). In multivariable models, high cost patients were more likely to have discharge ICD 9 codes of 433.11 or 434.91 (IS patients with carotid or cerebral artery occlusion), higher serum creatinine, fasting blood glucose and NIHSSS. They were more likely to receive IV or IA reperfusion, remain NPO during their stay or develop hospital acquired pneumonia, and less likely to transition to comfort care. The C statistic for a model with NIH stroke scale only performed well (c= 0.77) even when compared to a model with all variables present on admission (c= 0.83) or the fully adjusted model (c= 0.86).

Conclusion:
Many patient level demographic and clinical characteristics available on admission predict high cost, even after adjustment for stroke severity. Cost management opportunities may exist for targeted interventions, perhaps through geographic co-location or specialized stroke units.
Abstract WP341: Difference in Acute Ischemic Post Thrombolytic Stroke Outcomes in Pre Comprehensive and Post Comprehensive Status: Single Center Experience
Authors: Jani Vishal B , Patel Achint , Schurr Jillian , Shell Erin , Bey Julie , Mitchell Marylou , Shippey Ray , Kassab Mounzer , Razak Anmar , Safdar Adnan , Majid Arshad , Hussain Syed
Published: July 2021

Background:
In last decade there is a significant change in stroke care especialy with newer data for ischemic stroke treatment there is a movement to obtain comprehensive stroke center certification (CSCC) to provide enhanced complex care for stroke. This study aims to assess the single center quality matrix assessment pre and post CSC status

Methods:
We reviewed single center cohort of IV tPA (tissue plasminogen activator) in-between year 2010 to 2014 at sparrow health system in mid Michigan region. This cohort was dichotomized in pre CSCC and post CSCC era. Stroke quality matrics data was collected for these patients. Severity of stroke was categorized in mild-moderate vs moderate-severe based on NIH stroke scale (NIHSS) scale. Primary out come for this study was any complication, which is composite end point of in-hospital mortality, and hemorrhage and secondary outcome was hospital stay. Chi square, student’s t test and wilcoxon sum rank test was used to compare both groups. Multivariable regression models were utilized to calculate odd ratios after adjusting with stroke severity.

Results:
Cohort of IV tPA was identified in-between year 2010 to 2014 (332 hospitalizations off which 241 were pre CSCC and 91 were Post CSCC ). In- hospital complication was lower after receiving CSCC (9.89% vs. 21.99%; p:0.011). In multivariable regression analysis the trend for in hospital complication persisted [Adjusted Odds ratio (OR):0.43–95%confidence-Interval(CI):0.20-0.93–p:0.032] but there was no significant difference in hospital stay (Median days 5 vs. 5; P:673)

Conclusion:
There is a clear and persistent trend of low in-hospital complication rates after acquiring CSCC quality matrics.
Abstract WP360: Outcomes After Intracerebral Hemorrhage in Patients With Systemic Cancer: A Population-Based Study
Authors: Murthy Santosh , Moradiya Yogesh , Hanley Daniel , Ziai Wendy , Kamel Hooman , Navi Babak B
Published: July 2021

Background:
Single-center studies suggest that patients with cancer have similar outcomes after intracerebral hemorrhage as compared to patients without cancer. However, these studies were limited by small sample sizes and inclusion of patients with intratumoral hemorrhage. We hypothesized that systemic cancer patients without known brain involvement fare worse after ICH than patients without cancer.

Methods:
We used the ICD-9 code 431 to identify all patients diagnosed with spontaneous ICH from 2002 to 2011 in the Nationwide Inpatient Sample. Our predictor variable was systemic cancer; patients with primary brain tumors and known brain metastases were excluded. Our primary outcome was discharge disposition, which was dichotomized into favorable discharge (home/self-care or rehabilitation) or unfavorable discharge (nursing facility, hospice, or death). We used logistic regression to compare the demographics, comorbidities, and outcomes of patients with cancer versus those without cancer. We performed secondary analyses by cancer subtype (i.e., non-metastatic solid tumors, non-metastatic hematologic tumors, and metastatic solid or hematologic tumors).

Results:
Our cohort comprised 597,046 ICH patients, among whom 22,394 (3.8%) had systemic cancer. Stroke risk factors such as hypertension and diabetes mellitus were significantly more common in patients without cancer, while anticoagulant use and higher Charlson comorbidity scores were more common amongst cancer patients. In multivariate logistic regression adjusting for demographics, comorbidities, and hospital-level characteristics, patients with cancer had higher odds of death (OR 1.62, 95% CI 1.56-1.69) and lower odds of favorable discharge (OR 0.59, 95% CI 0.56-0.63) than patients without cancer. Our primary results were substantiated in our secondary analysis as patients with cancer did worse than patients without cancer regardless of cancer subtype. Amongst the cancer groups, patients with non-metastatic hematologic tumors and those with metastatic disease fared the worst.

Conclusions:
Patients with systemic cancer have higher mortality and less favorable discharge outcomes after ICH than patients without cancer. Cancer subtype may influence outcomes after ICH.
Abstract WP405: Improving Adherence to Secondary Stroke Prevention Strategies Through Motivational Interviewing: a Randomised Controlled Trial
Authors: Barker-Collo Suzanne , Barber Peter A , Witt Emma , Feigin Valery L , Jones Amy , McPherson Kathryn ,   for the MIST Study Investigators
Published: July 2021

Background:
Stroke recurrence rates are relatively high (20-25%), and have not declined significantly over past three decades. This study tested the effectiveness of Motivational Interviewing(MI) for reducing stroke recurrence as measured by improving adherence to evidence-based medication and recommended lifestyle changes compared to usual care (UC).

Hypothesis:
That MI will improve medication adherence in stroke patients.

Methods:
A single-blind, prospective Phase III randomised controlled trial of 386 people with stroke assigned to receive either MI Treatment (4 sessions at 28-days, 3-, 6-, and 9-months post-stroke) or UC; with outcomes assessed at 28-days, 3-, 6-, 9-, and 12-months post-stroke. Primary outcomes were change in systolic blood pressure (BP) and low-density lipoprotein (LDL) cholesterol levels as indicators of adherence at 12-months. Secondary outcomes included self-reported adherence, new stroke or coronary heart disease events (both fatal and non-fatal); quality of life (Short Form-36), and mood (Hospital Anxiety and Depression Scale, HADS).

Results:
Motivational Interviewing did not significantly change measures of blood pressure [mean difference in change -.2.35 (95% CI -6.16, 1.47)] or cholesterol (mean difference in change -.0.12(95% CI -0.30, 0.06). However, MI had positive effects on self-reported medication adherence at 6- (1.979, 95% CI 0.98, 3.98, p=0.0557) and 9-months (4.295, 95% CI 1.56, 11.84, p=0.0049) post-stroke. Improvement across other measures were also observed, but the differences between MI and UC groups was not statistically significant.

Conclusion:
Motivational Interviewing improved self-reported medication adherence. All other effects were non-significant, though in the direction of a treatment effect. Further study is required to determine if MI leads to improvement in other important areas of functioning, for example, care giver burden.
Abstract WP408: Temporal Trends in Pediatric Stroke Hospitalization From 2000 - 2009: Analysis of the KID Inpatient Database
Authors: Taylor John M , Horn Paul , Yeramaneni Samrat , Sucharew Heidi , Khoury Jane
Published: July 2021

Background/Hypothesis:
Stroke in children ≤18 years is an important public health problem. The incidence of stroke in adults has been falling over several decades, likely attributable to better management of vascular risk factors. Children have different risk factors for cerebrovascular disease, however we wanted to see if similar trends were observed in pediatric stroke. We examined pediatric hospital discharges for stroke over the last decade.

Methods:
We used the Kids’ Inpatient Database (KID) for 2000, 2003, 2006, and 2009 using the published weighting guidelines to estimate the number of overall discharges and number of discharges due to stroke. To identify stroke we queried primary position discharge ICD-9 stroke codes 430, 431, 432.9, 434.X1, 434.9, and 435.9; previously identified to have high PPV for detection of stroke in children in a physician-verified epidemiology stroke study. We calculated incidence for stroke among hospitalized children as number of stroke discharges / total number of discharges, and expressed the ratio per 100,000 discharges. We compared trends in stroke type, age, race and sex over the decade.

Results:
Stroke incidence in 2000 was 26.4 (95% CI 23.2-29.6). In the 2009 sample, incidence was 30.9 (27.7-34.1) showing a non-significant increasing trend over time. Ischemic stroke was increasingly diagnosed over the same interval with a statistically significantly higher incidence in 2006 and 2009 compared to 2000 (Figure 1). Groups with highest stroke incidence in hospitalized children were 10-14 year olds, males, and children identifying with the racial group “black.”

Conclusion:
In the KID database, we identified a rising incidence of ischemic stroke diagnosis over the past decade, however the overall rate of pediatric stroke has not increased significantly. The increasing rate of an ischemic stroke discharge diagnosis may be the result of increased awareness of childhood stroke.
Abstract WP414: Ultrasonographic Changes after Indirect Bypass Surgery in Pediatric Patients with Moyamoya Disease
Authors: Yeh Shin-Joe , Tang Sung-Chun , Tsai Li-Kai , Chen Ya-Fang , Liu Hon-Man , Chen Ying-An , Hsieh Yu-Lin , Yang Shih-Hung , Kuo Meng-Fai , Jeng Jiann-Shing
Published: July 2021

Background:
The marked cerebral hypoperfusion caused by moyamoya disease (MMD) usually manifests as ischemic stroke or transient ischemic attack. The treatment of choice for MMD is extracranial-intracranial bypass surgery; however, the changes of ultrasonographic features following indirect bypass surgery are unknown. This study sought to characterize the ultrasonographic changes that result from indirect bypass surgery in pediatric patients with MMD.

Methods:
We prospectively recruited 15 pediatric MMD patients who had undergone a total of 19 indirect bypass surgeries (encephaloduroarteriosynangiosis, EDAS) and obtained the relevant clinical and radiological characteristics. Neurovascular ultrasonography of extracranial and intracranial arteries was performed pre-operatively and post-operatively at 1, 3, and 6 months.

Results:
Among the 15 patients (11 males, 4 females), the mean age was 10.4 ± 4.6 years. Among the extracranial arteries, the superficial temporal artery presented the most pronounced increase in flow velocity and decrease in flow resistance, beginning at 1 month post-op (all p<0.01). Among the large intracranial arteries, a significant increase in mean flow velocity was observed in the anterior cerebral artery since 3 months post-op (p<0.05).

Conclusion:
Significant hemodynamic changes were observed in pediatric MMD patients after EDAS surgery, as evidenced by periodic ultrasonographic assessment.
Abstract WP415: What Factors Determine Choice of Anticoagulant?
Authors: Zimmerman Eli E , Ayres Alison , Gurol M. E , Greenberg Steven M
Published: July 2021

Introduction:
Non-vitamin K antagonist Oral Anticoagulation (NOAC) agents are approved for prevention of ischemic stroke in atrial fibrillation (Afib). NOACs offer both advantages (ease of use, reduced rate of intracranial hemorrhage) and disadvantages (cost, absence of reversal agent, less clinical experience) relative to warfarin. We tested the hypothesis that the decision to prescribe a NOAC might be influenced by non-medical factors such as prescriber subspecialty or patient demographics.

Methods:
We performed an IRB-approved search of the Research Patient Data Registry at our major tertiary referral hospital for all Afib patients prescribed warfarin, dabigatran, rivaroxaban or apixaban between January 2013 and June 2014. We encoded data related to prescriber clinic, patient demographics (including home ZIP code as a marker of family income), intracerebral hemorrhage (ICH) and medical comorbidities.

Results:
Of 4,261 individuals with Afib prescribed oral anticoagulants during the specified interval, 3450 (81%) received warfarin, 442 (10.4%) rivaroxaban, 304 (7.1%) dabigatran, and 65 (1.5%) apixaban per their last prescription during the period. In univariate analyses patients prescribed NOACs were younger (71.5 ± 11.4 vs. 76.6 ± 10.5 years, p < 0.001), more likely male (64.4% vs. 35.6%, p < 0.005), had lower CHADS2 scores (2.17 ± 1.43 vs. 2.68 ± 1.40, p<0.001) and resided in areas with higher median income ($86,384 ± 33,410 vs. $80,470 ± 30,390, p<0.001). Race and prior ICH did not differ. Among 2,013 prescriptions from a defined subset of cardiology, primary care and neurology clinics, NOACs were more commonly used by cardiologists (37.1%) than neurologists (18.9%) or primary care providers (17.1%, p<0.001). Multivariable analysis of this subset found that physician specialty, residential area income, age and CHADS2 score but not gender were independently associated with receiving a NOAC.

Conclusions:
Younger, more affluent individuals treated by a cardiologist were likeliest to receive NOACs for prevention of Afib-related stroke. The data suggest that factors other than medical characteristics might influence the decision to use NOACs.
Abstract WP416: African Americans are Less Likely to be Adherent to Statins After Ischemic Stroke: an Analysis of Medicare Beneficiaries Following Hospital Discharge
Authors: Albright Karen C , Blackburn Justin , Howard Virginia , Beasley T. Mark , Limdi Nita , Zhao Hong , Muntner Paul
Published: July 2021

Introduction:
Statins have been shown to decrease cardiovascular disease morbidity and mortality. Although statins have proven efficacious in reducing the risk of recurrent stroke, little is known about adherence among older adults following ischemic stroke.

Methods:
We compiled a retrospective cohort of Caucasian and African-American Medicare beneficiaries in the 5% sample to estimate statin adherence among older adults initiating therapy following hospitalization for ischemic stroke in 2007 - 2011. To be included, beneficiaries were required to have 365 days of Medicare fee-for-service coverage with no claims for stroke-related events or statins prior to the index stroke event. The cohort was limited to beneficiaries with an initial Part D claim for a statin within 30 days plus at least 1 additional claim during follow-up. Adherence was determined by percent of days covered (PDC) for the 365 days following discharge home (time spent in rehabilitation or skilled nursing was excluded); non-adherence was defined as a PDC <80%. Relative risk of statin non-adherence was determined using modified Poisson regression.

Results:
Among 6,251 statin-naïve beneficiaries with stroke, 2,070 (33.1%) initiated statin therapy and were included in the analysis. Among them, 13.1% (n=271) were African American. African Americans were more likely than Caucasians to have a PDC <80%, 15.4% vs. 11.7%, respectively (crude RR 1.21, 95% CI 1.04-1.40). The racial disparity remained after adjusting for demographics, dual Medicare-Medicaid eligibility, and baseline comorbidities (adjusted RR 1.17, 95% CI 0.99-1.37).

Conclusions:
African Americans may not be obtaining the recurrent stroke prevention therapy provided by statins, possibly contributing to the higher rate of recurrent stroke in this population.
Abstract WP429: The Cognitive Impairment in Stroke Screener (CISS) Tool: an Improved Screening Tool to Detect Cognitive Impairment Early Among Stroke Patients
Authors: Bonner Julie , Rangaraju Srikant , Schleuse Stuart , Lampert Sarah , Sinsley Debbie , Javalkar Vijay , Gebru Minas W , Brasher Cynthia , Dunn Joshua , Bryant Katja , Hales Chadwick M , Nahab Fadi
Published: July 2021

Background:
Early cognitive screening of stroke patients may identify unmet rehabilitative needs during stroke recovery but validated tools are lacking. We report our experience with the Six Item Screener (SIS) compared to the Montreal Cognitive Assessment (MOCA) and attempt to improve upon its shortcomings in stroke patients.

Hypothesis:
Low sensitivity of the SIS for cognitive impairment (CI) in stroke patients can be improved by incorporating visuoexecutive dimensions.

Methods:
Patients admitted with ischemic stroke (IS), transient ischemic attack (TIA), intracerebral (ICH) or subarachnoid hemorrhage (SAH) between December 2014 and June 2015 underwent inpatient screening for CI using SIS and MOCA, administered by speech-pathologists if they were alert and not aphasic. Predictive value and sensitivity/specificity cut-offs of SIS for CI (MOCA≤23) were determined. A screening tool, created by adding a clock-drawing task and dropping least important SIS components was developed.

Results:
Of 110 (IS/TIA: 56, ICH: 17, SAH: 26) patients who had MOCA and SIS performed at the same visit, 79 patients had CI; other patient characteristics including stroke severity, are described (Fig 1A). The AUC of SIS for CI was 0.78 and comparable across stroke types (AUC for IS: 0.81 ICH: 0.79 SAH: 0.95). SIS≤4 had 46.6% sensitivity for CI while SIS≤5 had 72.6% sensitivity and 80.6% specificity for CI. Excluding ‘year’ and ‘month’ questions of the SIS had no effect on the performance of the screening test (AUC=0.78 without). A 7-item tool (CISS) that included the clock drawing task (3 points) and omitted “year/month” SIS questions had excellent predictive power for CI (AUC=0.89) and comparable across stroke types (AUC 0.89-0.93) (Fig 1B,C). CISS≤6 had 94.5% sensitivity and 49.4% specificity for CI.

Conclusions:
The CISS improves upon the low sensitivity of the SIS for CI in stroke patients. A validation study using 3-month neuropsychological testing as the gold-standard is underway.
Abstract WP431: Acute Stroke in Right Anterior Insula and Frontal Operculum Impair Empathy
Authors: Chien Jui-Hong , Kim Eun-Hye , Liu Chang-Chia , Oishi Kumiko , Oishi Kenichi , Lenz Frederick , Hillis Argye E
Published: July 2021

Introduction:
Emotional empathy includes emotional contagion (sharing another’s feelings) and perspective-taking (inferring another’s feelings). Earlier studies show that right hemisphere stroke (RHS) can cause impaired perspective-taking. However, studies have not identified stroke lesions associated with impaired emotional contagion.

Hypothesis:
Acute infarcts in specific frontal, temporal, or limbic regions disrupt emotional contagion, measured with skin conductance response (SCR; a sensitive measure of emotional response), as well as perspective-taking.

Methods:
Participants (9 acute RHS, 9 age-matched controls) played a “roulette” game and watched a partner play. We measured SCR to winning and losing. They rated the emotions (happy to sad) of themselves and their partner when they won and lost money. A neurologist blind to behavioral responses measured percent damage to 10 frontal, temporal, and limbic regions of interest (ROI) on DWI after registration to an atlas. We evaluated differences in group means with unpaired t-tests and differences between ratings of emotions for wins versus losses with paired t-tests. We evaluated associations between SCR magnitude and percent damage to ROI with Spearman correlations.

Results:
SCR magnitude was significantly lower in response to both wins and losses in patients with right anterior insula (AI) or inferior frontal gyrus opercularis (IFGop) lesions, compared to those without these lesions, when they played or watched partner play (p=0.0001 to 0.008). SCR to partner winning or losing negatively correlated percent damage to insula (rho=-.64;p=0.005) and IFGop (rho=-.47; p=0.045). Controls and patients without AI or IFGop lesions rated partners and themselves as significantly happier when they won versus lost (p<0.0001); but patients with AI or IFGop lesions showed no difference in ratings for wins vs. losses. The difference between ratings for wins vs. losses negatively correlated with percent damage to AI (rho=-.75; p=0.0005) and IFGop (rho=-.80; p=0.0001) but not total infarct volume (rho=-.46; ns).

Conclusions:
Acute right AI and IFGop infarcts are associated with impaired emotional contagion measured with SCR and perspective-taking.
Abstract WP46: FLAIR Vascular Hyperintensity ASPECTS (FVH-ASPECTS) Pattern Predicts Outcome in Endovascular Therapy in Acute M1-MCA Occlusion
Authors: Liu Dezhi , Scalzo Fabien , Starkman Sidney , Rao Neal M , Hinman Jason D , Kim Doojin , Ali Latisha K , Saver Jeffrey L , Noorian AliReza , Ng Kwan , Liang Conrad W , Sheth Sunil A , Yoo Bryan , Liu Xinfeng , Liebeskind David S
Published: July 2021

Introduction:
In acute arterial occlusion, the FLAIR vascular hyperintensity (FVH) sign have been linked to slow flow in leptomeningeal collaterals and cerebral hypoperfusion, but the impact on clinical outcome is still controversial. In this study, we aimed to investigate the association between FVH-ASPECTS pattern and outcome in acute M1-MCA occlusion patients with endovascular treatment.

Methods:
We included acute M1-MCA occlusion patients treated with endovascular therapy. All patients had DWI and FLAIR before endovascular therapy. Distal FVH ASPECT score was evaluated according to distal MCA-ASPECT area (M1-M6) and acute DWI lesion was also reviewed. Presence of FVH inside DWI positive lesion and outside DWI positive lesion was separately analyzed. We analyzed clinical outcome after endovascular therapy based on these different FVH-ASPECTS patterns.

Results:
Among 101 patients that met inclusion criteria for the study, mean age was 66.2±17.8 and median NIHSS was 17.0 (IQR 12.0-21.0). FVH-ASPECTS measured outside of the DWI lesion was significantly higher in patients with good outcome (mRS 0-2), (8.0 vs 4.0, p<0.001). Logistic regression demonstrated that FVH-ASPECTS outside of the DWI lesion was independently associated with clinical outcome of these patients (OR 1.3, p=0.013). FVH-ASPECTS inside the DWI lesion was associated with hemorrhage transformation (OR 1.3, p=0.019).

Conclusion:
Higher FVH-ASPECTS measured outside the DWI lesion is associated with good clinical outcomes in patients undergoing endovascular therapy. FVH-ASPECTS measured inside the DWI lesion was predictive of hemorrhage transformation. FVH pattern, not number, can predict outcome of acute M1-MCA occlusion patients after endovascular therapy.
Abstract WP52: Impact of Baseline DWI ASPECTS Lesion Topology on Functional Outcome after Endovascular Treatment
Authors: Guenego Adrien , Mazighi Mikael , Sissani Leïla , Inoue Manabu , Meseguer Elena , Labreuche Julien , Mlynash Michael , Amarenco Pierre , Olivot Jean Marc
Published: July 2021

Introduction:
Acute brain infarction (BI) topology determined by diffusion weighted imaging - Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) on post-treatment magnetic resonance imaging (MRI) has been associated with clinical outcome in internal carotid artery (ICA) or proximal middle cerebral artery (MCA) occlusion treated by endovascular reperfusion therapy (EVRT).

Hypothesis:
We hypothesize that among the same type of patients, the topology of acute BI captured by DWI ASPECTS on baseline MRI may be associated with 3 months functional outcome after EVRT.

Methods:
Consecutive patients with an acute BI complicating ICA or proximal MCA occlusion treated by EVRT after a baseline MRI before treatment at a single center between April 2007 and March 2013 were enrolled. Poor functional outcome was defined by modified Rankin Scale (mRS) of 3 to 6 at 3 months. We used penalized logistic regression due to the multicollinearity between DWI-ASPECTS sites to assess the relationship between each DWI-ASPECTS sites and functional outcome after adjustment for age, sex, blood pressure, DWI lesion volume and infarct side. We estimated this relationship in the full cohort of patients and according to the achievement of a complete recanalization.

Results:
We enrolled 206 patients [mean age 71 ± 16.5, median NIHSS 16 (IQR 10-21)]. Among them 58 (28%) had an ICA occlusion, 115 (56%) a MCA M1 occlusion and 33 (16%) a MCA M2 occlusion. Median DWI lesion volume was 13 mL (IQR 4-43), and median DWI ASPECTS score was 6 (IQR 4-8). A complete recanalization was achieved among 96 patients (47%), after a median time from onset of 237 min (IQR:185-282). The involvement of the lentiform nucleus was associated with poor functional outcome in the full cohort of patients [OR : 10; 95% CI (5-23); p<0.0001]. This relationship was observed in the subgroup of patients who did experience a complete recanalization [OR : 4; 95% CI (1.5-12); p=0.007] and among those who did not [OR : 21; 95% CI (5-92); p<0.0001].

Conclusions:
In conclusion, the involvement of the DWI ASPECTS lentiform region on baseline MRI in patients experiencing an acute BI complicating an ICA or MCA occlusion treated by EVRT was associated with poor functional outcome, overall and despite a complete recanalization.
Abstract WP68: Tissue Type Plasminogen Activator (t-PA) and Edaravone Combination Therapy Study (YAMATO Study)
Authors: Aoki Junya , Kimura Kazumi , Metoki Norifumi , Tateishi Yohei , Todo Kenichi , Morita Naomi , Harada Masafumi , Hayashi Koji , Yamamoto Nobuaki , Tanahashi Norio , Inoue Takeshi , Iwanaga Takeshi , Kaneko Nobuyuki , Iguchi Yasuyuki , Ueno Yasushi , Ogata Toshiyasu , Fujimoto Shigeru , Yokoyama Mutsumi , Nagahiro Shinji ,   YAMATO Study Group
Published: July 2021

Introduction&Hypothesis:
The aim of the present study was to investigate whether administration of edaravone, a free radical scavenger, before or during t-PA administration can increase the rate of early recanalization and improve the clinical outcome in stroke patients with major arterial occlusion.

Methods:
YAMATO study is an investigator initiated, multicenter (17 hospitals in Japan), prospective, randomized, open labeled study. Acute stroke patients with horizontal (M1) or vertical (M2) portion of the middle cerebral artery occlusion within 4.5 h of onset were studied. The subjects were randomly allocated to the early edaravone (early-E) group (intravenous edaravone [30 mg] was started before or during t-PA administration) and the late edaravone (late-E) group (edaravone was started after t-PA administration). Primary outcome, defined as any early recanalization 1h after t-PA therapy. Secondary outcomes included the rate of the significant recanalization, defined as ≥50% of the territory of the occluded artery on magnetic resonance angiography, or the thrombolysis in cerebral infarction score ≥2b on digital subtraction angiography as well as the incidence of symptomatic intracerebral hemorrhage (sICH), and the favorable clinical outcome (modified Rankin scale [mRS] of 0-2) at 3 months after onset.

Results:
One-hundred and sixty-six patients (96 men; median age [interquartile range], 78 [69-85] years) were randomized 1:1 to either the early-E group or the late-E group. Twenty-three (13.9%) had proximal M1 occlusion; 60 (36.1%), distal M1 occlusion; 83 (50%), M2 occlusion. Early recanalization was similarly observed in the early-E group and in the late-E group (53.1% vs. 53.0%, P=1.000). The rate of significant recanalization was also similar between the 2 groups (27.2% vs. 33.7%, p=0.399). sICH was occurred in 4 (4.8%) patients in the early-E group and in 2 (2.4%) in the late-E group (p=0.682). Among the 144 patients who were pre-morbid mRS of 0-2 and eligible for 3 months assessment, favorable outcome was seen in 53.9% in the early-E group and 57.4% in the late-E group (p=0.738)

Conclusions:
The timing of the edaravone infusion should not affect the rate of early recanalization, sICH, or favorable outcome after t-PA therapy.
Abstract WP8: Minor Stroke With Large Vessel Occlusion
Authors: Shoirah Hazem , Al-Bayati Alhamza R , Kenmuir Cynthia L , Aghaebrahim Amin , Jovin Tudor G , Jadhav Ashutosh P
Published: July 2021

Background and Rationale:
Minor stroke symptoms (NIHSS </= 8) with large vessel occlusion (LVO) comprise an important population that has not been thoroughly studied in the recent intra-arterial therapy (IAT) trials. A subset of patients with mild symptoms may benefit from IAT. We attempt to characterize those patients.

Methods:
We retrospectively reviewed patients who presented with minor stroke symptoms and LVO between the years of 2002 and 2015. In our primary analysis, we divided patients who underwent IAT based on 90 day modified Rankin Scale (mRS) into favorable (mRS 0-2) vs unfavorable outcome (mRS >2). Using unpaired t-test, we compared demographics, comorbidities, NIHSS at presentation, use of IV tPA, stent retrievers, IAT within 8 hours from last known well and location of LVO. In our secondary analysis, we compared the two cohorts with matched patients who received tPA only without IAT.

Results:
Risk of complication of patients undergoing IAT was low (4%). The overall good outcome in patients undergoing IAT was 62.5%. Patients with favorable outcome tended to have anterior circulation occlusion (70% vs 41.6%, p = 0.03) and tandem occlusions (32.5% vs 8.3%, p = 0.03) with higher rates of TICI 2b/3 recanalization (90% vs 62.5%, p = 0.008). There was no difference in favorable outcome between patients who received IV tPA only vs IAT +/- IV tPA (68.5% vs 62.5%, p = 0.5). However, the medical therapy group had higher rates of distal occlusions (46% vs 17.2%, p = 0.001) and the IAT group had higher rates of vertebrobasilar occlusion (20.4% vs 40.6%, p = 0.02).

Conclusion:
This study highlights good safety profile in patients undergoing IAT for strokes with minor symptoms. Favorable outcomes were observed in patients with successful recanalization, anterior circulation occlusions and tandem lesions. A randomized clinical trial is warranted to investigate the benefit of IAT in patients with low NIHSS over medical therapy alone and our findings can assist in patient selection.
Strict Liability and Necessity in Grotius, Pufendorf, Smith, Kant, and Beyond
Authors: Wauters Bart
Published: July 2021

This article compares the views of Grotius and subsequent authors on the doctrines of necessity and strict liability. This comparison takes place at two levels. On the one hand, there is a comparison of the views of Grotius with those of Pufendorf, Smith, Kant and recent Kantian authors. On the other hand, there is a comparison between the doctrines of necessity and strict liability. This exercise leads to the conclusion that strict liability does not have to be a mere matter of choice opted for by positive law, but in some instances can also be thought of as a requirement of a private law framework expressing the fundamental moral equal freedom of man.