bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP372: Quality Improvement in Acute Ischemic Stroke Care in Taiwan: the Breakthrough Collaborative in Stroke
Authors: Jeng Jiann-Shing , Lien Li-Ming , Lee Tsong-Hai , Chern Chang-Ming , Chiou Hung-Yi , Liao Hsun-Hsiang , Chang Hang , LaBresh Kenneth A. , Chiu Hou-Chang ,   BTS-Stroke Investigators
Published: July 2021

Background and Purpose:
Guideline adherence for acute ischemic stroke (AIS) management is often suboptimal, particularly in thrombolytic therapy and anticoagulants for atrial fibrillation. We sought to achieve quality improvement of AIS patients via a collaborative learning model, the Breakthrough Series (BTS)-Stroke, in a nationwide, multi-center activity in Taiwan.

Methods:
A BTS Collaborative, a short-term learning system for a large number of multidisciplinary teams from hospitals, was applied to enhance AIS care quality. There were 24 teaching and community hospitals participating in and submitting data for this stroke quality improvement campaign from August 2010 to June 2011. The Get With The Guideline (GWTG)-Stroke measures were adopted to evaluate the performance and outcome of the AIS patients. The results of this study were compared to those of the previous Taiwan Stroke Registry (TSR, 22642 AIS patients from 39 hospitals, 2006-08).

Results:
Data from 24 hospitals with 13181 AIS patients during a 1-year period were analyzed. The BTS-Stroke (2010-11) had better performance as compared to the TSR (2006-08): intravenous thrombolysis frequency for all AIS patients (4.1% vs 1.5%), symptomatic hemorrhage after intravenous thrombolysis (6.0% vs 8.2%), early antithrombotics (96.6% vs 94.1%), anticoagulation for atrial fibrillation (57.1% vs 28.3%), lipid lowering drugs for low-density lipoprotein >100 mg/dL (63.4% vs 38.7%), antithrombotics at discharge (94.0% vs 85.5%), and one-month mortality (3.5% vs 4.0%). Temporal improvement was noted in 7 of 14 performance measures when the fourth BTS-Stroke quarter compared with the first quarter: intravenous thrombolysis frequency for all AIS patients (4.1% vs 3.7%), symptomatic hemorrhage after intravenous thrombolysis (3.4% vs 5.5%), lipid lowering drugs for low-density lipoprotein >100 mg/dL (67.3% vs 60.5%), antithrombotics at discharge (95.5% vs 91.4%), dysphagia screening (81.9% vs 63.4%), early rehabilitation (71.7% vs 63.6%), stroke education before discharge (95.6% vs 83.4%).

Conclusions:
A BTS collaborative learning and campaign model can improve the guideline adherence of stroke. The GWTG-Stroke can be successfully applied to other countries outside the United States.
Abstract WP378: Characteristics and Outcomes of Stroke Patients Transferred to Hospitals Participating in the Michigan Coverdell Acute Stroke Registry 2009-2011
Authors: Roberts Stacey , Nickels Adrienne , Shell Erin , Mitchell Marylou , Hussain Syed , Reeves Mathew
Published: July 2021

Characteristics and Outcomes of Stroke Patients Transferred to Hospitals Participating in the Michigan Coverdell Acute Stroke Registry, 2009-2011

Background:
As stroke systems of care are evolving the number of stroke patients transferred between hospitals is increasing. Our objectives were to describe the characteristics of acute stroke patients who were transferred to hospitals participating in the Michigan Coverdell Acute Stroke Registry, and to determine the independent association between transfer status (TS) and in-hospital mortality (IHM) and in-hospital complications (IHC).

Methods:
From 2009-2011, 30934 acute ischemic (IS) and hemorrhagic stroke (HS) patients were admitted to 35 registry hospitals. Patients with an in-hospital stroke, TIA, or unknown arrival mode were excluded (N= 14,732). Independent factors associated with TS and predictors of IHC (defined as deep vein thrombosis, pneumonia, and/or UTI) were identified using multivariable logistic regression models.

Results:
The mean age of the 16202 admissions was 69.2 years, 51% were female, 68% were white, 83% had an IS, 7.4% died in-hospital, and 13.8% had an IHC. Overall, 19% (N= 3091) were transferred to a registry hospital. The transfer rate increased from 2009-2011 (16.9% -21.1%), and was higher in HS vs. IS patients (37.6% vs. 15.3%).

Significant predictors of TS were year, age, gender, race, stroke type, pre-stroke ambulatory status, nursing home residence, and medical history of diabetes or prior stroke. Length of stay (LOS) was longer for transferred patients vs. non-transferred (7.9 vs. 5.3 days, p<0.0001). Transferred patients were more likely to die in-hospital vs. non-transferred (12.0% vs. 6.4%, P <0.001), and develop IHC (18.4% vs. 12.8%, P < 0.001). After adjusting for confounding variables, TS remained a significant predictor of IHM (adjusted odds ratios [aOR] = 1.46, 95%CI =1.14- 1.88), and IHC (aOR= 1.58, 95%CI =1.34- 1.87).

Conclusions:
The frequency of hospital transfers increased markedly in this registry. Transferred patients experience higher rates of IHM, IHC and longer LOS. Further studies are needed to understand the relationship between TS and outcomes and the implication for improved clinical care and reducing poor outcomes in this higher risk group.
Abstract WP384: Feasibility Of Systematic Assessment Of 30-day Functional Outcomes After Stroke
Authors: Katzan Irene L , Liskay Alice M , Martin Siobhan , Thomas Charles , Love Thomas E , Konrad Nancy ,   Ohio Coverdell Investigators
Published: July 2021

Although functional status after stroke is widely considered important to measure, the feasibility of systematic assessment of functional status after stroke is unknown.

Objective:
To determine the feasibility of obtaining 30 day functional status via phone call follow-up by a central group of nurses spanning multiple hospitals.

Methods:
Prospective cohort study of patients admitted for stroke at 6 hospitals participating in the Ohio Coverdell Outcomes Evaluation Project. At 5 of these sites, patients were contacted by a central nurse 30-51days post discharge using a standardized protocol. In the remaining hospital, outpatient appointments were arranged for 30 days postdischarge. Patients who died inhouse or had hospice care were excluded from the follow-up protocol.

Results:
Of the 699 patients in this cohort, 53.1% were female and 76.4% were white. Mean age was 68.5 yrs and mean admission NIHSS was 6.0. Phonecalls were successfully completed in 65.8% of the 486 eligible patients. There was no significant difference in completion rates among the 5 hospitals. Most common reasons for unsuccessful phone followup were: patient/family never reached 22.8% (111/486) and patient opted-out 6.4% (31/486). Factors associated with unsuccessful phone call included: DNR order (15.7% vs 8.7%, p=0.021), longer lengths of stay (median days 4 vs 3, p=0.015), higher discharge Rankin (2.9 vs 2.6, p=0.06), and IV tPA use (6.6 vs 2.8, p=0.05). There was no association between completed phone calls and discharge destination. In multivariable analysis, only age (OR 1.02, 95% CI 1.00 - 1.04) and no DNR (OR 1.96, 95% CI 1.00 - 3.83) were independently associated with successful phone follow-up. Post discharge clinic visits were completed in 52.9% (46/87) patients at the remaining site, and there were similar clinical associations with a completed visit.

Conclusion:
Success of obtaining 30day phone follow-up is modest, occurring in 65.8% in 5 hospitals of varied types and patient populations. This has important policy implications for measuring stroke outcomes; systematic assessment of functional status post-discharge may require a combination of different methods to achieve high assessment rates.
Abstract WP385: Seasonal, Circaseptan and Diurnal Variations in Stroke Onset, Severity and Costs: Findings from the Royal Melbourne Hospital Stroke Registry 2004-2011
Authors: Busija Lucy , Liew Danny , Yan Bernard , Weir Louise , Hand Peter , Davis Stephen M
Published: July 2021

Introduction:
Information on regular variations in the volume and severity of strokes has important implications for planning of emergency services and resource allocation. A number of studies have investigated seasonal, circaseptan and diurnal variations in stroke incidence but little is known about corresponding variations in stroke severity and costs.

Hypotheses:
Following results of previous studies, we hypothesized an increase in strokes in winter months, on Mondays, and between 09:00 and 12:00 hours. We also explored associations between stroke onset and stroke severity and in-patient costs.

Methods:
Data were analyzed for 4484 consecutive admissions to the Stroke Care Unit at the Royal Melbourne Hospital (Australia) from January 2005 to September 2011. Temporal variations in stroke frequency, severity and costs were assessed using generalized linear modelling. Stroke severity was measured using NIH Stroke Severity (NIHSS) scores.

Results:
The mean (SD) age of patients was 70.6 (14.3) years and 56% were males. Ischemic strokes accounted for 62% of admissions, 19% were haemorrhages, and 19% were TIAs. Stroke frequency varied significantly during the day (p<0.001). Contrary to expectation, strokes peaked between 06:00 and 21:00. The daily incidence of strokes differed significantly during the year (p<0.001), being highest in August (2.8/day, 95%CI 2.6,3.1) and lowest in January (2.1/day, 95% CI 1.8,2.3). Weekday was not associated with variations in stroke frequency (p=0.130). NIHSS scores were not associated with weekday (p=0.465) but varied significantly during the year (p=0.012) and day (p=0.011). Most severe strokes occurred in July and at 12:00-15:00, and least severe strokes occurred in December and at 09:00-12:00. Admission costs differed significantly during the year (p=0.039) but not during the week (p=0.469) or day (p=0.099). The highest admission costs were in August ($16053, 95%CI $12586,$19521) and lowest in October ($11256, 95% $9131,$13380).

Conclusions:
The frequency of stroke peaks between late morning and early afternoon and is highest in winter. The severity and costs of stroke admissions are also highest during winter. This information can be used in the planning of emergency services and resource allocation.
Abstract WP396: Effects of the Accessibility to Emergency Medical Systems on Stroke Mortality: A Nationwide Survey (J-ASPECT study)
Authors: Kada Akiko , Nishimura Kunihiro , Nakagawara Jyoji , Ogasawara Kuniaki , Ono Junichi , Shiokawa Yoshiaki , Aruga Toru , Miyachi Shigeru , Nagata Izumi , Toyoda Kazunori , Matsuda Shinya , Iihara Koji ,   J-ASPECT Investigators
Published: July 2021

Objective:
Rapid emergency medical care for patients with acute stroke is necessary for better prognoses. To decrease the time to medical care, emergency medical systems (EMSs) and stroke centers are distributed extensively in Japan, with universal coverage of medical insurance. We examined the influence of the accessibility to EMSs on stroke mortality in Japan.

Methods:
We approached 1381 certified training institutions of the Japan Neurosurgical Society and/or the Japan Stroke Society with a question survey regarding acute stroke care capacity. In institutions that responded, the data of the stroke patients hospitalized were obtained from Japanese Diagnosis Procedure Combination database of 2011. The transfer time was measured by an electronic mapping system as the time taken from the postal address of the patient to the transferred hospital. Geographical location by urban employment area (UMA) was classified into 5 categories: metropolitan employment areas (MEA) - central, MEA - outlying, micropolitan employment areas (McEA) - central, McEA - outlying, and unclassified. We examined the effects of UMA and transfer time as measures of accessibility by using a hierarchical linear regression model adjusted by age, gender, and characteristics of institutions.

Results:
The data of 256 institutions and 53,170 emergency hospitalized patients were analyzed. Mortalities were as follows: 7.8% in cerebral infarction (n = 32,671); 16.8% in intracerebral hemorrhage (n = 15,699); and 28.1% in subarachnoid hemorrhage (n = 4,934). The mortality was lower in MEA - central and higher in unclassified areas for mortality in cerebral infarction (MEA - central, 7.3%; unclassified, 12.0%; OR = 1.55, 95%CI = 1.01-2.39) and subarachnoid hemorrhage (MEA - central, 26.7%; unclassified, 42.9%; OR = 1.95, 95%CI = 1.03-3.70). In areas in cerebral infarction, longer transfer time affected mortality (P = 0.027, MEA - central; P = 0.038, unclassified).

Conclusion:
Stroke mortality increased according to the inaccessibility to EMS combined with UMA and transfer time. These factors should be taken into account to resolve inappropriate EMS disparities.
Abstract WP40: “Good” Angiographic Collateral Circulation Correlates With Lower Dwi Infarct Volumes In Acute Ischemic Stroke
Authors: Cheng-Ching Esteban , Wisco Dolora , Man Shumei , Hui Ferdinand , Toth Gabor , Uchino Ken , Hussain Muhammad S
Published: July 2021

Background and purpose
Large artery occlusion leads to ischemic stroke which volume is influenced by time from symptom onset. This effect is modulated by several factors, including the presence and degree of collateral circulation. We analyze the correlation between a standard angiographic collateral grading system and DWI infarct volumes.

Methods
We reviewed a prospectively collected retrospective database of ischemic stroke patients admitted between august of 2006 and december of 2011. We included patients with anterior circulation acute ischemic stroke presenting within 8 hours from symptom onset with large vessel occlusion, who underwent pre-treatment MRI and endovascular therapy. DWI infarct volumes were measured by region of interest. ASITN collateral grading system was used and grouped into “good collaterals” for grades 3 and 4, and “poor collaterals” for grades 0, 1 and 2. JMP statistical software was utilized.

Results
152 patients (71 (46.7%) male, mean age: 68±15 years;) were included in the initial analysis. We identified 49 patients who had angiographic collateral circulation grading. Seven patients had ASITN collateral grade 0 with mean infarct volume of 27.6 cc, 25 had collateral grade of 1 with mean infarct volume of 27.9 cc, 10 had collateral grade of 2 with mean infarct volume of 23.4 cc, 5 had collateral grade of 3 with mean infarct volume of 6.3 cc, and 2 had collateral grade of 4 with mean infarct volume of 14.6 cc. Forty two patients had “poor collaterals” with a mean infarct volume of 26.8 cc. Seven patients had “good collaterals” with mean infarct volume of 8.7 cc. When comparing the infarct volumes between these two groups, the difference was statistically significant (p=0.017).

Conclusions
In anterior circulation acute ischemic stroke, “good” angiographic collateral circulation defined as ASITN grading system of 3 or 4, correlates with lower infarct volumes on presentation.
Abstract WP411: Missed Opportunities for Transcranial Doppler Screening Among Children with Sickle Cell Disease
Authors: Reeves Sarah L , Dombkowski Kevin J , Fullerton Heather J , Cohn Lisa M , Lisabeth Lynda D
Published: July 2021

Background:
With high healthcare utilization among children with sickle cell disease (SCD) but low rates of Transcranial Doppler (TCD) screening, missed opportunities for TCD screening may be numerous. We sought to quantify missed opportunities among children with SCD and to identify characteristics associated with missed opportunities to help target future interventions.

Methods:
All children ages 2-16 with SC-SS or SC-Beta Thalessemia were identified in Michigan Medicaid (2007-2010) through newborn screening records. SCD healthcare encounters were assessed for each child during a 2-year interval of continuous enrollment. Healthcare utilization (inpatient, outpatient, ED and hematologist visits) was classified during year one. During year two, we assessed outcomes including receipt of TCD screening and presence of a missed opportunity for TCD screening. A missed opportunity was defined as having at least one SCD healthcare encounter during the outcome interval, but no TCD screening. Each child could have multiple eligible intervals for assessment. Age, gender and SC type were also considered. Logistic regression with generalized estimating equations was used to model the association between a missed opportunity and each individual-level factor. Factors associated with the outcome in bivariable analysis were included in a multivariable model.

Results:
Overall, there were 240 children with SCD during the study period (50% female, 99% black, 83% SC-SS) in which a total of 551 two-year intervals were eligible for assessment. At least one TCD screening was identified in 21% of eligible time intervals and 18% of children received at least one TCD screening. Missed opportunities occurred in 64% (n=352) of the eligible time intervals. Only age was associated with missed opportunities (OR=1.06, CI:1.01,1.11). The proportions of intervals with missed opportunities among children ages 2-6, 7-11 and 12-16 were 49%, 63% and 71% respectively.

Conclusion:
In the Michigan Medicaid population, missed opportunities for TCD screening are common among children with SCD and associated with increasing age. Reduction of missed opportunities through physician intervention is a potential strategy to increase TCD screening rates.
Abstract WP414: Comparative Analysis of Clinicoradiological Factors between Asymptomatic Subjects and Stroke Patients with Vertebrobasilar Dolichoectasia in Japan
Authors: Ikeda Ken , Hirayama Takehisa , Nakamura Yoshikazu , Kano Osamu , Kawabe Kiyokazu , Iwasaki Yasuo
Published: July 2021

Background:
Vertebrobasilar dolichoectasia (VBD) is a distinct arteriopathy known as stroke risk. We aimed to elucidate etiologic factors for developing stroke in VBD patients.

Methods:
A total of 10345 adults (7034 men and 3311 women) underwent healthy check-up and brain magnetic resonance (MR) studies. Seven hundred eighty-one consecutive patients (452 men and 329 women) with acute brain infarct (524 patients) or brain hemorrhage (257 patients) were recruited. We reviewed medical records and MR data in both groups. VBD was defined as the diameter of the basilar artery (BA) ≥ 4.5 mm and the diameter of the intracranial vertebral artery ≥ 4.0 mm on MR angiography. The height and lateral displacement of BA were graded according to scale of Smoker et al (AJNR 1986). Asymptomatic VBD was confirmed by neurological examination. Cardiovascular disease (CVD) risk and radiological variables were analyzed statistically in asymptomatic subjects and stroke patients with VBD.

Results:
One hundred thirty-four subjects (118 men and 16 women) had asymptomatic VBD. Mean age (SD) was 60.3 (11.6) years. VBD existed in 60 stroke patients (54 men and 6 women). Mean age (SD) was 65.4 (13.2) years. Prevalence of VBD was 1.3% in physical check-up adults and 7.7% in stroke patients. On univariate analysis, age and the frequency of atrial fibrillation (AF), past CVD history or chronic kidney disease (CKD) defined as proteinuria or estimated glomerular filtration rate < 60 mL/min/m
2
were significantly higher in stroke patients than in asymptomatic subjects. Other CVD risk profiles, the score of the BA height and displacement did not differ statistically between both groups. The BA diameter, the frequency of brainstem compression and the number of silent infarct lesions were increased significantly in stroke patients compared to asymptomatic subjects. Multiple logistic regression analysis showed that stroke onset was significantly associated with AF [odds ratio (OR)=1.4], CKD (OR=2.0), past CVD history (OR=1.8), silent infarcts ≥ 3 lesions (OR=2.2) and BA diameter ≥ 4.9 mm (OR=1.3).

Conclusion:
The present study clarified independent factors for developing stroke in VBD patients. Intensive management of these clinicoradiological factors could prevent a stroke event in VBD patients.
Abstract WP417: Ideal Cardiovascular Health Metrics on Risk of Ischemic and Intracerebral Hemorrhagic Stroke: A Result from Kailuan Study
Authors: Zhang Qian , Zhang Shufeng , Bian Liheng , Zhao Xingquan
Published: July 2021

Objectives
To investigate the relationship between ideal cardiovascular health metrics (including smoking, body mass index, dietary intake, physical activity, blood pressure, total cholesterol and fasting blood glucose) and risk of stroke.

Background
Previous studies showed a strong relationship between the number of ideal cardiovascular health metrics and lower risk of cardiovascular diseases and stroke. However, little is known regarding its relationship with ischemic and hemorrhagic stroke risk respectively.

Methods
We collected information on the ideal cardiovascular health metrics among 91,698 participants (18-98 years old; 72826 men and 18872 women) free of myocardial infarction and stroke at baseline (2006-07) in the Kailuan cohort study, China. We then prospectively investigated the association between ideal cardiovascular health metrics and risk of stroke.

Results
During four years of follow-up, we identified 1443 incident strokes (1057 ischemic and 386 intracerebral hemorrhagic). The multivariate-adjusted hazard ratios for total stroke with adherence to 0 (reference), 1, 2, 3, 4, 5, and 6 or 7 ideal health metrics were 1, 0.91, 0.69, 0.51, 0.37, 0.28, and 0.25 (95% confidence interval: 0.11-0.55; p-trend <0.0001) respectively after adjusting for age, sex, and other covariates. Similar inverse associations were observed for both ischemic and intracerebral hemorrhagic stroke (p-trend < 0.0005 for both).

Conclusions
We observed a clear inverse dose-response relationship between the number of ideal cardiovascular health metrics and risk of stroke in a Chinese population, which supports the importance of ideal health behaviors and factors in the prevention of stroke.
Abstract WP419: Secondary Prevention Of Cardiovascular Events With Lifestyle Intervention In Patients With Mild Ischemic Stroke - A Randomized Controlled Trial -
Authors: Yamada Sumio , Kono Yuji , Iwatsu Kotaro , Okumura Hisako , Yamaguchi Junko , Hattori Makoto , Araki Amane , Yasui Keizo , Hasegawa Yasuhiro , Koike Yasuo
Published: July 2021

Introduction:
Lifestyle modification is associated with a substantially decreased risk of cardiovascular events. However, the role of lifestyle intervention for the secondary prevention in patients with ischemic stroke (IS) is inadequately defined. We assessed the hypothesis that lifestyle intervention which comprised exercise, salt reduction and nutrition advice could reduce new onset of vascular events in patients with mild IS.

Methods:
We conducted a single-blind randomized controlled trial that enrolled 66 patients (45 men, 21 women; mean age, 63.5 yo) with acute mild ischemic stroke. The patients were randomly allocated to a lifestyle intervention group (n = 33) or control group (n = 33). We performed lifestyle interventions, which comprised exercise training, salt restriction and nutrition advice for 24 weeks. The primary endpoint was ospitalization due to stroke recurrence and new onset of coronary heart disease. We also evaluated blood pressure, serum lipid profile and hemoglobin A1c to compare the efficacy of the lifestyle modification intervention.

Results:
This trial was terminated earlier than expected because the prespecified early stopping rule for efficacy had been met. After 24 weeks intervention period, the intervention group showed a significant decrease in the clinic and home blood pressure and significant increase in the high density lipoprotein cholesterol (HDL-C) levels from the baseline to the 6-month assessment (clinic and home SBP,
P
<0.001; HDL-C,
P
=0.018), with significant differences between the randomized groups (clinic and home SBP,
P
<0.001; HDL-C,
P
=0.022). Median duration of follow-up was 2.9 years, 12 patients allocated the control group and 1 patient allocated the lifestyle intervention group had at least one major vascular event. A sequential plans analysis indicated that lifestyle intervention superior to control in interim analysis. Kaplan-Meier survival curves after log-rank test showed significant prognostic difference between randomized groups (
P
=0.005).

Conclusions:
In conclusion, the results of this study indicate that lifestyle intervention is beneficial for preventing stroke recurrence and other vascular events.
Abstract WP426: Subarachnoid Hemorrhage in patients infected with Human Immunodeficiency Virus
Authors: Zacharatos Haralabos , Adil Malik M , Hassan Ameer E , Gilani Sarwat I , Qureshi Adnan I
Published: July 2021

Background:
There is limited data regarding the unique attributes of ischemic stroke among patients infected with human immunodeficiency virus (HIV). There is no published data regarding the occurrence and outcomes of subarachnoid hemorrhage (SAH) among HIV infected persons.

Methods:
The largest all-payer Nationwide Inpatient Sample (NIS 2002-2010) data was used to identify and analyze all patients presenting with the primary diagnosis of SAH in the United States. Among this cohort, we identified the patients who were not HIV positive and those who were HIV positive. Patient demographics, medical co-morbidities, in-hospital complications, in-hospital procedures, and discharge disposition were compared between the two groups. The association between HIV infection and outcomes was evaluated in multivariate analysis after adjusting for potential confounders.

Results:
Of the 351,491 patients admitted with SAH, 1367 (0.39%) were infected with HIV. HIV infected patients were younger, mean age [±SD] of 45 ±14.2 years versus those who were not 58±19 years, (p<0.0001). The rate of blood transfusion [27,286 (7.8%) versus 245.6 (18%), p=0.0003], mechanical ventilation [51,199 (14.6%) versus 316.1(23.1%), p=0.008], and sepsis [14,644 (4.2%) versus 236.1 (17.3%), p<0.0001] was significantly higher among HIV infected patients. After adjusting for age, gender, hypertension, coagulopathy, atrial fibrillation, renal failure, and dyslipidemia, HIV negative patients had a significantly higher rate of discharge to home (odds ratio [OR] 1.9, 95% CI: 1.4-2.6, p<0.0001) and lower in-patient mortality (OR 0.4, 95% CI: 0.3-0.5, p<0.001). Further adjustment for blood transfusion and sepsis reduced the odds of discharge to home for the HIV negative patients, from 1.9 to 1.7 but did not affect in-hospital mortality.

Conclusion:
The in-hospital mortality in HIV infected patients with SAH is higher despite these patients being younger than non-HIV infected patients. We believe that this study provides a nationwide perspective which may have some important implications for early recognition and diagnosis of HIV-infection in SAH patients.
Abstract WP439: Hiv-associated Brain Arterial Remodeling Is Correlated With Increased Mmp-2 Expression: A Pilot Study.
Authors: Gutierrez Jose , Murray Jacinta , Jackson Todd , Larkin Tony , Dwork Andrew J , Elkind Mitchell S , Morgello Susan , Marshall Randolph S
Published: July 2021

Introduction:
The pathophysiology of stroke in HIV involves alterations in vessel wall structure, both inward (stenosis) and outward remodeling (dilatation). Metalloproteinase-2 (MMP-2) has been implicated in the remodeling of large arteries, but it has not been studied in the cerebral arteries.

Objectives:
To assess the potential role of MMP-2 in brain arterial remodeling in HIV infection.

Methods:
Circle of Willis arteries were obtained from 38 brain donors with and without HIV infection, autopsied by the Manhattan HIV Brain Bank. The lumen-to-wall-ratio (LWR) was obtained from transversal Van Gieson stains and used to assess remodeling with larger ratios indicating outward remodeling. Immunohistochemistry was used to assess MMP-2 expression in the arterial wall, scored as average pixel intensity and expressed as arbitrary units (AU). Demographic and clinical variables were used as covariates of remodeling in linear regression models.

Results:
The sample included 38 middle cerebral arteries from 28 individuals with HIV and 10 without. Compared to non-HIV controls, the HIV group was younger (57 vs. 45 years, P=0.001), more frequently male (40 vs. 70 %, P=0.08) and African American (43 vs. 20%, P=0.18), but reported less hypertension (50 vs. 25%, P=0.14) and diabetes (66 vs. 33%, P=0.03). The expression of MMP-2 was higher in the HIV group (171 vs. 186 AU, P=0.14). After adjusting for age, sex, ethnicity, hypertension and diabetes, subjects with HIV had higher LWR (β=4.7, P=0.03, R
2
=0.22), although adjusting for MMP-2 reduced the strength of the association (β= 3.7, P=0.20, R
2
=0.52). Stratifying by HIV status, MMP-2 was the only significant predictor of outward remodeling in the HIV group (P=0.02). In this group, age >45 years (P=0.005), CD4 count <200 (P=0.005) and hypertension (P=0.07) were predictors of greater MMP-2 expression. The numbers were too small to assess the role of MMP-2 in individuals without HIV.

Conclusion:
MMP-2 may be associated with outward remodeling of cerebral arteries in HIV-infected individuals, particularly in the context of hypertension and immunosuppression. More studies are needed to better understand this arterial physiopathology given the increased cerebrovascular disease seen in the HIV-infected population.
Abstract WP46: Blood Pressure, Clinical Improvement And Recanalization Following Acute MCA Occlusion
Authors: Nagaraja Nandakumar , Warach Steven , Hsia Amie W , Auh Sungyoung , Latour Lawrence L , Merino José ,   For the LESION Investigators
Published: July 2021

Background:
Blood pressure (BP) drop in the first 24 hours after stroke onset may occur in response to vessel recanalization. Clinical improvement could be due to recanalization or better collateral flow with persistent occlusion. We hypothesize that patients with combination of significant improvement on the NIHSS and a drop in BP at 24hr post tPA is associated with recanalization.

Methods:
We included intravenous t-PA patients from the Lesion Evolution of Stroke Ischemia On Neuroimaging (LESION) registry who had pre-treatment and 24 hour MRA scan, NIHSS scores at those times and an M1 MCA occlusion at baseline, but excluded those on pressors, pre tPA SBP<120 and tandem ICA occlusion. We classified recanalization status on the 24 hour MRA as none, partial or complete. We abstracted all BP measurements for the first 24 hours from the chart and calculated BP drop as the difference of the triage pre-tPA BP and the average of the last 3 hour readings preceding the 24 hour MRI. NIHSS improvement was defined as ≥4points improvement on NIHSS or NIHSS of 0 at 24hour. Patients with combination of drop in BP and NIHSS improvement were compared with others for recanalization status on 24hr MRA by Kendall Tau-b test.

Results:
Seventeen patients met the study criteria. There were 13 women, the mean age was 76 years and the median baseline NIHSS was 15. On the 24 hour MRA, 3, 8 and 6 patients had none, partial and complete recanalization, respectively. Patients with NIHSS improvement and a SBP drop ≥20 mmHg were more like to have recanalization at 24 hrs (57% Vs 0%, p=0.03). Similar patterns were seen for patients with NIHSS improvement and DBP drop ≥5mmHg (50% Vs 0%, p=0.04) or MAP drop ≥20mmHg (50% Vs 0%, p=0.04). Complete recanalization was only associated with the combination of NIHSS improvement with SBP drop ≥ 20mmHg (66% Vs 0%, p=0.04). A significant association was not found for recanalization with NIHSS improvement alone or drop in BP alone.

Conclusion:
There is an association of clinical improvement and BP drop in patients who recanalize. Bedside clinical information may be useful in the management of stroke patients.
Abstract WP53: Can Attenuation Characteristics On Non Contrast CT Be Used In Place Of Diffusion FLAIR Mismatch In The Imaging Triage Of Acute Ischemic Stroke Patients?
Authors: Menon Bijoy K , Mahajan Aakash , Nambiar Vivek K , Qazi Abdul , Qazi Emmad , Kosior Jayme , Hill Michael D , Goyal Mayank , Demchuk Andrew , Sohn Sung I
Published: July 2021

Purpose:
We aimed to determine if attenuation characteristics on NCCT can be used in place of DWI FLAIR“mismatch”as an imaging paradigmto detect patients within a recommended time window for thrombolysis.

Methods:
Data is from consecutive acute stroke patients (2005-2009) from Keimyung University, South Korea analyzed at the University of Calgary. Only patients with visible anterior circulation occlusions on baseline CT-angio, known stroke symptom onset time and MRI within 60 minutes of baseline CT were included. All patients received revascularization therapy (IV tPA and/or IA). DWI FLAIR mismatch and CT changes at baseline were diagnosed by consensus. Ratio of ipsilateral vs. contralateral CT HU (rCT) within baseline DWI lesion was calculated. CT attenuation within DWI lesion was qualitatively graded into a) equal or more (subtle)or b) less than contralateral white matter (obvious). ROC analyses was used to compare the ability of models using DWI FLAIR mismatch vs. rCT in predicting onset to imaging time< 4.5 hrs and ICH at 24 hours.

Results:
Of 136 patients included [mean age 67.6 yrs (SD 11.2 yrs), 55.1% male, median onset to MR time was 159.5 minutes (IQR 128-226 mins)], 131/136 (96.3%) had DWI changes on baseline MRI. DWI FLAIR mismatch was seen in 88/136 (64.7%) andNCCT hypo-attenuation in 93/136 (68.9%). A rCT>=0.85predicted DWI FLAIR mismatch with a sensitivity of 72.5%, specificity of 75.6% and PPV of 85.3%. No patient without baseline CT changes had rCT<0.9. DWI FLAIR mismatch was not better than rCT>=0.85 in predicting onset to MRtime<4.5 hrs (AUC 0.66 95% CI 0.57-0.75 vs. 0.61 95% CI 0.51-0.70, p=0.23). Subtle or no CT hypo-attenuation within DWI lesion measured qualitatively predicted presence of DWI FLAIR mismatch. (p=0.002)

Conclusion:
CT hypo-attenuation is as good as DWI FLAIR mismatch in identifying patients who are good candidates for thrombolytic therapy.
Abstract WP61: Pre-hospital Remote Ischemic Perconditioning - A Promising Neuroprotective Therapy.
Authors: Hougaard Kristina D , Hjort Niels , Bø Hans-Erik , Søen Leif H , Nørd Anne , Øtergaard Leif , Mouridsen Kim , Andersen Grethe
Published: July 2021

Pre-hospital remote ischemic perconditioning (rPerC) is a potential neuroprotective therapy to patients with suspected acute stroke. We tested the effect of pre-hospital rPerC as an adjunct treatment to intravenous alteplase (rtPA) in patients suspected of acute stroke. The study was conducted as a single-blinded randomized study of rPerC in a 1:1 ratio in 298 consecutive patients with acute ischemic stroke or TIA of whom 184 were subsequently treated with rtPA and 149 had a 1 month MRI follow-up (81 rPerC, 68 controls). TIA was more frequent (p=0.006) in the intervention group (n=42) than in the control group (n=16). NIHSS on admission was significantly lower (p=0.016) in the intervention group (median 4, IQR 2-7) than in the control group (5, IQR 3-11). Accordingly there was a trend towards smaller volumes of tissue hypoperfusion (PWI 17.35 (1.01-87.18) vs. 16.55 (1.71-170.16), p=0.26) at the time of the initial MRI. Tissue voxels in the volume difference between PWI and DWI at baseline which did
not
proceed to infarction on follow-up T2-FLAIR MRI were identified and adjusted for baseline values of PWI and DWI. This voxel based logistic regression analysis takes any imbalance in baseline severity of DWI and PWI and any patient-specific effects into account to determine tissue-level infarct risks. The results were analysed according to baseline vessel status and recanalisation at 24 h. The likelihood ratio test for effect of rPerC in the whole group was p=0.0003. In the subgroups not changing vessel status (occlusion without recanalization and the group without observed occlusion) the tests for effect of rPerC yielded p<0.0001. For the recanalizer subgroup p=0.0002. . The neuroprotective effect of rPerC may have worked already prior to admission.
Abstract WP62: Enhanced Neuroprotection of Normobaric Oxygenation with Ethanol Conferred by Apoptosis Reduction in Acute Ischemic Stroke
Authors: Parmar Sweena , Geng Xiaokun , Peng Changya , Guthikonda Murali , Ding Yuchuan
Published: July 2021

Objectives:
Normobaric oxygenation (NBO) has been shown to provide neuroprotection
in vivo
and
in vitro
. Yet, a recent Phase 2 clinical trial investigating NBO therapy in acute ischemic stroke was terminated due to questionable therapeutic benefit. NBO therapy alone may be insufficient to produce improved outcomes. In our recent study, we demonstrated a strong neuroprotective effect of ethanol at a dose of 1.5 g/kg (equivalent to the human legal driving limit). In this study, we sought to identify whether low-dose ethanol administration enhances the neuroprotection offered by NBO and whether combined administration of NBO with ethanol is associated with reduced apoptosis.

Methods:
Sprague-Dawley rats were subjected to right middle cerebral artery occlusion (MCAO) for 2 h, followed by reperfusion. Ischemic animals received either an intraperitoneal injection of 1.0 g/kg ethanol, 2 h of 100% NBO, or both ethanol and NBO. The Cell Death Detection ELISA Assay (Roche) was performed to determine apoptotic cell death at 24 h after reperfusion. Levels of pro-apoptotic (Caspase-3, Bcl-2-associated X-BAX, and Apoptosis-Inducing Factor-AIF) and anti-apoptotic proteins (Bcl-2 and Bcl-xL) were determined by Western blot analysis at 3 and 24 h after reperfusion.

Results:
As expected, untreated ischemic rats had the highest apoptotic cell death. Combined NBO/ethanol therapy decreased cell death by 48%, as compared to 29% with ethanol and 22% with NBO. Similarly, combined NBO/ethanol therapy promoted the greatest expression of anti-apoptotic factors and the lowest expression of pro-apoptotic proteins at 3 h after reperfusion. This effect was maintained at 24 h and even more pronounced for AIF and Caspase-3.

Conclusions:
Given singularly, NBO and ethanol improved the degree of cell death, decreased the expression of pro-apoptotic proteins, and increased the expression of anti-apoptotic proteins. Yet, when administered together, their effects largely compounded. These results suggest a synergistic neuroprotection offered by NBO with ethanol, which may be attributed at least in part to their shared role in modulating neuronal apoptosis.
Abstract WP81: Outcomes Following X- and Y-Configuration Stent-Assisted Coil Embolization of 52 Complex Bifurcation Cerebral Aneurysms
Authors: Lazzaro Marc A , Asif Kaiz S , Fitzsimmons Brial-Fred , Lynch John R , Zaidat Osama O
Published: July 2021

Background:
Wide-neck bifurcation cerebral aneurysms pose technical challenges in endovascular therapy. Intersecting stents are used with increasing frequency. Periprocedural, clinical, and mid-term angiographic outcomes of this approach are not well known. We report clinical and angiographic outcomes in our use of the X- and Y-configuration techniques.

Methods:
We reviewed a retrospectively collected database to identify all aneurysm cases in which an X- or Y-configuration stent technique was used. Demographic, periprocedural and mid-term clinical and imaging data were collected. Outcomes included rate of thromboembolic events (TEE), intraoperative perforations (IOP), mortality, aneurysm residual at the time of the procedure and recurrence observed at follow-up.

Results:
Among 807 cerebral aneurysms, we identified 52 aneurysms in 50 patients treated with X- or Y-configuration stent implantation. Mean age was 58 years (SD = 10) with 34 (65%) women. Aneurysm locations were basilar artery (n = 20), MCA (n = 13), ACA (n = 16), and ICA (n = 3). Mean aneurysm maximum diameter was 7.0 mm (SD 2.9) and the mean neck size was 4.5 mm (SD = 1.7). Fifty cases (96%) involved “Y” configuration, and two cases (4%) used an “X” configuration. Aneurysm catheterization technique was trans-stent in all cases (vs jailing). Interstices catheterization required a wire or catheter change in 13 (25%) cases. Immediate results revealed complete occlusion in 45 (86.5%), residual aneurysm in 3 (5.7%), and residual neck in 4 (7.7%). There were no mortalities, and 7 (13.5%) TEEs, of which 2 (4%) were symptomatic. There were 2 (4%) asymptomatic IOPs. Imaging follow-up was available for 40 (77%) cases, with mean interval from index procedure of 5.7 months. This mid-term outcome showed complete obliteration in 28 (70%) cases, residual neck in 8 (20%), and residual aneurysm in 4 (10%).

Conclusions:
These results suggest that placement of intersecting stents in X- and Y-configurations for coil embolization of wide-neck bifurcation cerebral aneurysms is feasible and can be performed with acceptable procedural safety and good rates of aneurysm occlusion.
Abstract WP85: Risk factors for Stenosis of Stents Utilized for Stent Assisted Coiling of Unruptured Intracranial Aneurysms
Authors: Beadell Noah , Bozorgchami Hormozd , Fields Jeremy
Published: July 2021

Introduction:
Stent-assisted coil embolization facilitates the treatment of wide-necked aneurysms. In-stent stenosis, although rare, may lead to stroke by occlusion of the parent artery or by thromboembolism. To our knowledge, the risk factors for in-stent stenosis in this context have not yet been investigated.

Hypothesis:
We hypothesized that cardiovascular risk factors and vessel size would be associated with in-stent stenosis.

Methods:
Consecutive patients undergoing stent-assisted coil embolization at our institution using the Neuroform stent (Stryker, Kalamazoo, MI, USA) were identified by billing records. Medical comorbidities were extracted retrospectively from patient charts. In-stent stenosis on last angiogram and vessel size (dichotomized into <2 mm or ≥2 mm) were estimated by direct review of angiography. Patients were grouped into those with and without ≥50% in-stent stenosis and the characteristics of the two groups were compared using a t-test for continuous variables and Fisher’s exact test for categorical variables.

Results:
A total of 224 unruptured aneurysms were treated with stent assisted-coil embolization between 2003 and 2010 utilizing the Neuroform stent. Follow-up catheter angiography was available in 196/224 (87.5%) at mean of 19 mos in those with in-stent stenosis and 24 mos in those without. In-stent stenosis occurred in 8/196 (4.1%). Mean age was 59 in those with in-stent stenosis and 62 in those without. The prevalence of cardiovascular risk factors in the groups with and without stenosis were as follows: diabetes 25% (2/8) vs. 6.9% (13/188), hypertension 42.6% (80/188) vs. 50% (4/8), hyperlipidemia 13% (1/8) vs. 5.9% (11/188), coronary artery disease 13% (1/8) vs. 3.7% (7), and smoking 38% (3/8) vs. 39% (75/188). Vessel size was <2 mm in 25% (2/8) in those with in-stent stenosis and 9.6% (18/188) in those without. None of these results were statistically significant.

Conclusions:
The overall risk of in-stent stenosis in patients undergoing stent-assisted coil embolization was relatively low. Although cardiovascular comorbidities were numerically more common in patients with in-stent stenosis, the differences between the two groups were not statistically significant.
Abstract WP93: CD4+ T Helper Cell Mediated Regulation Of Cerebral Ischemia In Vitamin D Deficient Rats
Authors: Balden Robyn , Alaniz Robert C , Sohrabji Farida
Published: July 2021

Stroke is the third leading cause of death worldwide, and Vitamin D deficiency is associated with increased stroke risk, severity, and mortality. Vitamin D potently regulates the immune system and the post-stroke inflammatory response plays a critical role in ischemia-induced CNS pathogenesis; and neuroimmune interactions in the CNS and periphery regulate the nature, extent, and duration of inflammation. Previous studies from this lab indicate that Vitamin D deficiency (VDD) exacerbates ischemic cell loss and sensory motor behavioral deficits in adult rats subject to middle cerebral artery occlusion, an experimental stroke model. Changes in inflammatory cytokines post-ischemia included increased TGF-β expression in both groups but significantly higher IL-6 expression in VDD ischemic cortical tissues than control levels. Increased IL-6 levels in the presence of TGF-β is known to induce pathogenic CD4+ Th17 cell development and suppress neuroprotective Treg generation. In the present studies we used flow cytometry to examine Th17 and Treg subsets in ischemic cortical and splenic tissues. Flow cytometry indicated that VDD rats had significantly less activated Treg cells in ischemic cortical and splenic tissue, while Th17 activation was significantly increased in VDD ischemic cortical tissue. Due to the dysregulation of Treg:Th17 subsets in VDD animals post-stroke and the recently recognized role of the spleen and peripheral nervous system in ischemia-associated neurodegeneration we hypothesized that adoptive transfer of CD4+ T cells harvested from the spleen of control animals 2d post-stroke to the VDD group acutely following middle cerebral artery occlusion (4h) may provide key neuroimmune regulatory elements and/or neuroprotective immune cells and secretions. We found that splenic CD4+ adoptive transfer to VDD rats 4h post-stroke markedly improved infarct volume, survival, and behavioral performance as compared with VDD animals injected with vehicle alone. Together, these results suggest that peripheral immune status significantly influences stroke severity and that acute manipulation of the peripheral immune system post-stroke can prevent or ameliorate inflammation-associated neurodegeneration.
Abstract 102: Use of Emergency Medical Services by Stroke Patients
Authors: Anderson Aaron M , Sucharew Heidi , Alwell Kathleen , Moomaw Charles J , Adeoye Opeolu , Woo Daniel , Ferioli Simona , Flaherty Matthew , Khatri Pooja , Mackey Jason , De Los Rios La Rosa Felipe , Martini Sharyl , Kissela Brett M , Kleindorfer Dawn O
Published: July 2021

Introduction:
Rapid evaluation and treatment with rt-PA is the hallmark of acute stroke care, yet only a fraction of ischemic stroke patients arrive within the time window for treatment. National stroke awareness campaigns have attempted to increase community awareness of stroke with action plans to call 911. We sought to compare the use of emergency medical services (EMS) by stroke patients between 2005 and 2010.

Methods:
Stroke and TIA patients were identified in a population of 1.3 million in the Greater Cincinnati area in 2005 and 2010. Patient charts were abstracted by research nurses and reviewed by study physicians. For this analysis, patients must have resided at home and presented to a local ED. Proportion of EMS users was computed. Logistic regression was used to test for associations of EMS use with age, race, sex, prior stroke, stroke type and severity, and setting (home, work, other) where stroke occurred.

Results:
There were 2546 stroke cases identified in 2005 and 2704 in 2010 which met criteria for analysis. The mean age was 68 years (SD 15), 54% female, and 20% black in both study periods. EMS use did not change between study periods, 52.7% in 2005 and 52.0% in 2010 (p=.64). In both study years, increasing age, increasing stroke severity, and hemorrhagic stroke were associated with EMS use. History of prior stroke was associated with increased EMS use in 2005, but this association was not seen in 2010. Sex, race, and the setting where stroke occurred were not associated with EMS use. Discussion: Rates of EMS use in our population-based study are still only about 52% and did not increase between 2005 and 2010. Community stroke awareness campaigns should include an action plan containing the urgency of calling 911 as soon as any stroke symptoms occur.