bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 3287: Effects Of Serum Uric Acid On Outcomes Following Acute Stroke
Authors: Hara Naoyuki , Ohtsuki Toshiho , Kubo Satoshi , Takamatsu Kazuhiro , Fukushima Tomoko , Ota Taisei , Kuriyama Masaru , Matsumoto Masayasu
Published: March 2022

Objective:
Emerging data show that increased serum uric acid (UA) concentration is an independent risk factor for cardiovascular disease, chronic kidney disease, and stroke. Clinicians and researchers do not regularly monitor serum UA following stroke; therefore, we examined whether serum UA was correlated with neurological outcome after stroke.

Patients and Methods:
Consecutive acute stroke patients (n=1688; 348 hemorrhagic stroke, 1239 ischemic stroke, 101 TIA; median age 70; 1080 males) participated in this study and provided written informed consent to participate. All patients were admitted within 7 days of stroke onset to a regional brain attack center in Japan between January 2005 and December 2010. Patients who showed prehospital modified Rankin scale (mRS) scores of 0-1 were asked about daily lifestyle using the mRS at 3 months after stroke. We measured serum UA, estimated glomerular filtration rate (eGFR) calculated from serum creatinine, and recorded the age and sex of each patient. Patients whose mRS score at 3 months after stroke onset was 2-5 or who died after the stroke were classified into the “poor-outcome” group; patients with a mRS score of 0-1 were classified into the “fair-outcome” group. Logistic regression analysis was used to calculate the odds ratio of poor outcomes; the 95% CI for association between eGFR or UA and poor outcome were examined after adjusting for age greater than 75 years; sex; past history of stroke and/or TIA; current smoking and/or drinking status; hypertension; hypercholesterolemia; and diabetes mellitus.

Results:
The poor-outcome group included 704 patients, and had a higher proportion of females, patients with hypertension and/or hypercholesterolemia, and age over 75 years than did the fair-outcome group (984 patients). No intergroup differences were observed between the poor outcome and fair outcome groups for eGFR (69.4 ± 22.8 vs. 71.0 ± 19.4 ml/min, respectively, p=0.127) or UA (5.49 ± 1.70 vs. 5.44 ± 1.50 mg/dl, p=0.488). However, after adjusting for the above factors, an increase in eGFR of 1 ml/min was not correlated with poor neurological outcomes (odds ratio=1.004, 95% CI: 0.998-1.009), but an increase in serum UA by 1 mg/dl was positively correlated with poor outcome (odds ratio = 1.088, 95% CI: 1.007-1.176, p=0.033).

Conclusion:
After adjusting for confounders and variables, low serum UA upon hospital admission was positively correlated with fair neurological outcome 3 months after acute stroke, indicating that UA may contribute slightly to functional impairment associated with stroke.
Abstract 3289: Novel Biomarkers Add Prognostic Value over Traditional Risk Factors for Nonhemorrhagic Stroke in Patients with Known Coronary Heart Disease: the Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Trial
Authors: West Malcolm J , Kirby Adrienne , White Harvey , Wonders Susan , Simes John , Hunt David , Anderson Neil E , Watson John , Colquhoun David , Hankey Graeme , Tonkin Andrew ,   LIPID Study Investigators
Published: March 2022

Introduction:
The potential for novel biomarkers to identify risk of future nonhemorrhagic stroke in patients with coronary heart disease (CHD) has not been determined. We examined the potential of 8 novel biomarkers, measured at baseline, to predict future nonhemorrhagic stroke in 7863 patients (17% women, median age 62 years) enrolled in the LIPID study, a double-blind, placebo-controlled trial of pravastatin in patients with prior CHD.

Methods and Results:
Over 6 years’ median follow-up, 310 patients had a nonhemorrhagic stroke. In Cox regression analysis for each novel biomarker, BNP, CRP, cystatin-C, D-dimer (each
P
<0.004) and troponin I (
P
<0.02) were significant, but LP(a), midregional pro-adrenomedullin, and Lp-PLA2 activity were not. Treatment with pravastatin was an independent predictor of nonhemorrhagic stroke in each of the models (all
P
≤0.05). There was no evidence that this effect was modified by the baseline level of any of the novel biomarkers. In the multivariable model, BNP, CRP and cystatin-C remained independent predictors for nonhemorrhagic stroke (
Table 1
). The effect of pravastatin also remained significant, as were the traditional risk factors: age, prior stroke, prior hypertension, diabetes mellitus, atrial fibrillation, and systolic blood pressure. This multivariable model was used to create risk groups based on the upper and lower quartiles of the score (
Table 2
).

Conclusion:
BNP, CRP, and cystatin-C levels significantly improve the identification of future nonhemorrhagic stroke in patients with known CHD. Relative treatment effects of pravastatin were similar across all risk levels.
Abstract 3291: Accuracy of Stroke Identification by EMS Dispatch Units: An Analysis of National Emergency Medical Services Information System Data (NEMSIS).
Authors: Pawar Swaroop A , Chaudhry Saqib A , Jadhav Vikram , Rodriguez Gustavo J , Suri Fareed K , Kasner Scott E , Qureshi Adnan I
Published: March 2022

Background:
The accuracy of stroke identification by dispatch units is an important determinant for directing appropriate level of Emergency Medical Services (EMS) and response times.

Objective:
To determine the accuracy of stroke identification by the dispatch center as the first responder and to identify barriers to the accurate diagnosis.

Methods:
We used the 2009 National Emergency Medical Services Information System (NEMSIS) Research Dataset, which is representative of 26 states in the US. We compared the diagnosis for dispatch based on ascertainment by dispatch staff with the diagnosis made by EMS after arrival at scene for identification of stroke/cerebrovascular accident (CVA) and determined the reasons for false diagnosis. We also estimated the sensitivity, specificity, and predictive values of dispatch diagnosis of stroke/CVA.

Results:
Among the 58013 patients identified by the dispatch center as stroke/CVA, 35118(60.5%) were diagnosed as stroke/CVA by EMS after evaluation at scene. Among the patients with false dispatch diagnosis, the EMS diagnosis was as follows: 8401(14.5%) altered level of consciousness, 4107(7.1%), syncope/fainting, 2391(4.1%) diabetic symptoms-hypoglycemia, 917(1.6%) seizures and 7079(12.2%) other. Identification of stroke by dispatch unit showed a sensitivity of 57%, specificity of 99.03%, positive predictive value of 60.5%, negative predictive value of 98.8%, positive likelihood ratio of 59 (95% CI 58-60) and negative likelihood ratio of 0.43(95% CI 0.43-0.44).

Conclusion:
The complaint of stroke/CVA reported by dispatch unit to EMS seems to have low sensitivity but high specificity. Efforts are required to increase the sensitivity of dispatch unit diagnosis of stroke to ensure appropriate level of EMS care is dispatched and reduce response times.
Abstract 3299: Can The Perfusion Status Predict The Subsequent Ischemic Events Following Acute Symptomatic Steno-occlusion Of Cerebral Arteries?
Authors: Kang Jihoon , Kim Nayoung , Jung Cheolkyu , Choi Byung Se , Lee Ji Sung , Lee Juneyoung , Yang Mi Hwa , Jang Myung Suk , Han Moon-Ku , Bae Hee-Joon
Published: March 2022

Background:
Symptomatic steno-occlusion (SYSO) is associated with stroke progression and recurrence after acute ischemic stroke. And the perfusion status is believed to be an important determinant in this situation. However, the impact of perfusion status on progression or recurrence has not been studied yet in patients with acute SYSO.

Method:
Based on prospective stroke registry, a consecutive series of 1309 patients were identified who were hospitalized due to ischemic stroke within 24 hours of onset. Among them, we selected who had more than 50% of stenosis or occlusion of extracranial internal carotid artery (EICA), intracranial internal carotid artery (IICA), middle cerebral artery (M1 and M2), anterior cerebral artery (ACA), and posterior cerebral artery (PCA) with the corresponding ischemic lesions. Patients who did not undergo perfusion study, who had infratentorial stroke, or the quality of whose perfusion image was poor were excluded. The perfusion status was assessed by perfusion lesion volume (PLV) using geometric method of visually delineated area. Stroke progression and recurrence (subsequent ischemic event, SIE) were defined and captured prospectively up to 1 year as a part of the institution’s quality-of-care monitoring program for hospitalized stroke patients.

Result:
A total 385 patients (age: 69.7 ± 12.6 year-old) were enrolled in this study. The distribution of PLV according to the location of SYSO was presented in the
figure
below. A total 88 patients (22.9%) experienced SIE and 72.7% were ischemic progression. The SIE rates of EICA, IICA, M1, M2, ACA and PCA were 31.8%, 24.1%, 19.9%, 14.1%, 15.4% and 25.0%, respectively. The PLV was dichotomized at median value of each SYSO location and the SIE rate was 26.6% in patients with high PLV and 19.2% in those with low PLV (P=0.084). The SIE rate of patients with occlusion (N=282) was not different from those with stenosis (N=103) (P=0.672). In the multivariable model, the adjusted odds ratio of PLV was 1.64 (95% confidence interval, 0.98-2.74) for the risk of SIE. The adjustments were done for male, time from onset to admission, baseline NIHSS score, and thrombolysis. After additional adjustment for recanalization status, the odds ratio of PLV was 1.81 (1.06 to 3.08).

Conclusion:
This study shows that the initial perfusion status may predict the following stroke progression or recurrence in patients with acute symptomatic steno-occlusion of cerebral arteries.
Abstract 3301: Clinical Outcomes and Rates of Symptomatic ICH May be Better Among Patients Receiving only IA tPA in the 4.5 Hour Window
Authors: Janjua Nazli , Melkumova Emiliya , Akrem Shamrez , Chaudhry Saqib , Hussain Haithem , Ramirez-Abreu Darwin , Poleshuck Rebecca , McIntyre Sherene , Abbas Wajahat , Gropen Toby I , Qureshi Adnan I
Published: March 2022

BACKGROUND:
Intravenous tissue plasminogen activator (IV tPA) has established benefit in the treatment of acute ischemic stroke (AIS) among selected patients. Intra-arterial (IA) thrombolysis, though still of unproven efficacy, is postulated to have greater success in recanalizing large artery occlusion (LAO), and also offers an alternative treatment for patients disqualified from IV tPA. Combination therapy delivers the standard of care with potentially higher recanalization rates, but the safety of this is unknown.

OBJECTIVE:
To evaluate hemorrhage, recanalization, and outcome for different modes of thrombolysis in AIS.

METHODS:
We retrospectively selected consecutive patients with LAO presenting to 2 medical centers within three-4.5 hours between August 2006 and July 2011 and divided them into three groups based on the mode of thrombolysis: group 1) IV-IA, group 2) IA, and group 3) IV. Patients who received IV tPA and underwent mechanical thrombolysis without additional IA tPA were excluded. We compared age, baseline and one week/discharge National Institutes of Health stroke scale scores (NIHSSS), pre/post intervention thrombolysis in myocardial infarction (TIMI) scores, one to three month modified Rankin Scale (mRS) and rates of symptomatic hemorrhage (sICH) using chi-square tests and analysis of variance.

RESULTS:
A total of 116 patients were included as follows: group 1, n=71; group 2, n=31; group 3, n=14. The mean age was 67+/-15 years, and initial NIHSSS 16+/-8, with minor inter-group differences. Times to IV tPA were 104+/- 42 (group 1) versus 140 +/-48 minutes (group 2, p=0.012). One week NIHSSS among survivors were 14+/-14 (group 1), 10+/-9 (group 2), and 12+/-12 (group 3). Initial angiographic data was retrievable for 52, among whom 71% had initial TIMI 0 scores in groups 1 and 2 (mean 0+/-1). Final TIMI scores were available in 39 patients with mode scores of 2 in 59% patients in group 1 (mean 2 +/-1) versus 71% in group 2 (mean 2+/-1). Long term outcomes were available for 42 patients, with median mRS of 4 in groups 1 and 3 versus 3 in group 2. There were 2 sICH in groups 1 and 3, and none in group 2.

CONCLUSIONS:
Though there was a trend towards better outcomes with lower rates of hemorrhage in group 2 patients, the above findings did not reach statistical significance in this analysis. As ongoing trials compare outcomes between patients receiving IV versus IV and IA tPA, additional studies evaluating groups receiving only IA tPA are needed.
Abstract 3308: Endovascular Treatment For Distal Middle Cerebral Artery Occlusions In Patients With Acute Ischemic Stroke: A Comparative Analysis.
Authors: Hurliman Lisa E , Chaudhry Saqib A , Rostambeigi Nassir , Hassan Ameer E , Jadhav Vikram , Rodriguez Gustavo J , Qureshi Adnan I
Published: March 2022

Background:
While, endovascular treatment is advocated for proximal arteries including M1 segment of middle cerebral artery (MCA), the role in distal middle cerebral artery (MCA) occlusions which are not always amenable to mechanical thrombectomy remains controversial.

Objective:
To compare outcomes in endovascularly treated patients with distal MCA occlusions (M2 or beyond) with those treated with IV rt-PA or no treatment

Methods:
Consecutive patients with acute ischemic stroke with distal MCA (M2 and beyond) occlusions diagnosed by either computed tomographic angiography (CTA) or catheter angiography over the last seven years were analyzed. We compared the rates of favorable outcome and mortality between the two groups. Favorable outcome was defined by discharge modified Rankin scale (mRS) score of 0-2. Multivariate logistical regression was performed to compare the outcomes after adjusting for potential confounders.

Results:
96 patients were included; mean age of 66.7±16.4, 44 (45.8%) were women. Of these 96 patients, 44 (45.8%) patients underwent endovascular treatment and 52 patients were treated with IV rt-PA or no treatment. There was no statistical difference in age, or cardiovascular risk factors between the two groups. Favorable outcome defined by mRS at discharge was similar 46% vs. 43%, p-value = 0.7. After adjusting for age, gender, cardiovascular risk factors, and National Institute of Health Stroke Scale (NIHSS) score on admission, patients with endovascular treatment had a trend towards higher rates of favorable outcome; odds ratio (OR) 2.912 (confidence interval [CI] 0.807- 10.507) and lower rates of in-hospital mortality; OR 0.416 (CI 0.086 - 2.018).

Conclusion:
Endovascular treatment may improve outcomes in patients with distal MCA occlusions and should be explored in future studies.
Abstract 3326: Reliability Of Hematoma Volume Calculation At Local Sites In The Setting Of A Multicenter Intracerebral Hemorrhage Clinical Trial
Authors: Hussein Haitham M , Tariq Nauman , Qureshi Adnan I
Published: March 2022

Background:
In the clinical trials evaluating new therapies for acute management of intracerebral hemorrhage (ICH), rapid hematoma volume (HV) measurements from computed tomographic (CT) scan using previously described ‘ABC/2’ method at study sites is frequently required for either determining eligibility or stratification. However, the accuracy of this method by multiple observers using variable visual display modes is not known.

Method:
We performed a post hoc analysis of a multicenter clinical trial that recruited ICH patients within 6 hours of symptom onset at ten sites in the United States. HV was measured by local site investigators to determine eligibility for enrollment (<60 cc) into the trial using the ABC/2 method (manual method) on the initial CT scan. CT scan images were subsequently sent to the core imaging laboratory for blinded computer based analysis of HV using ‘Medical Image Processing, Analysis, and Visualization (MIPAV)’ software (computer method). Paired t-test was used to identify any differences between the manual and the computer methods of HV measurements. Spearman’s correlation was used to study the agreement between the two methods.

Results:
HV measurements by both the manual and the computer methods were available in 51 patients enrolled in the trial (mean±standard deviation [SD] age 62±15 years; 26 were women.) The mean±SD HV using as calculated by he computer method (14.6±15.3 mL) was not statistically different from the values calculated by the manual method (16.5±15 mL; p=0.6). Using Spearman’s correlation, there was a significant correlation between the two methods (rho 75%, p<0.01). Manual calculation under estimated the HV by an average of 1.5 mL in the lower 50 percentile of computer-calculated HV (<9.4 ml), while overestimated the HV in the upper 50 percentile by an average of 3.1 mL. None of these differences were statistically significant.

Conclusion:
Rapid measurements at study sites for either determining eligibility or stratification provides reliable HV measurements despite measurements by multiple observers using variable visual CT scan display modes.
Abstract 3332: Common Carotid Intima Media Thickness, Carotid Plaque and Cognitive Performance in Patients with Atherosclerotic Disease
Authors: Molshatzki Noa , Weinstein Galit , Goldbourt Uri , Tanne David
Published: March 2022

Background
- Patients with atherothrombotic disease are prone to cognitive impairment. We tested whether high common carotid intima-media thickness (CC-IMT) and bilateral carotid plaques among patients with long lasting CHD are associated with poorer cognitive scores.

Methods
- Patients with CHD previously included in a secondary prevention trial were assessed after a period of 15±3 years for cognitive performance (Mindstream Computerized Cognitive Battery), for CC-IMT (M’Ath®-Std, Metris) and for carotid plaque using ultrasound (HDI 5000 SonoCT, Philips). We compared cognitive scores in patients with and without high CC-IMT values (top quartile of CC- IMT; >1.06 mm) and in patients with and without high CC-IMT and bilateral carotid plaques.

Results
- Among 448 non-demented patients (mean age 71.8±6.1 yrs, 96% men) mean±SD CC-IMT was 0.97±0.17 and 54.7% had bilateral carotid plaques. Linear regression models (
Table
) adjusted for age, sex, education, BMI, smoking, diabetes and hypertension (Model 1) demonstrated that high CC-IMT and presence of high CC-IMT and carotid plaques were associated with lower cognitive scores. Additional adjustment for history of stroke and impaired cerebrovascular reactivity (Model 2) resulted in similar effects. Associations were only slightly altered after exclusion of patients with history of stroke.

Conclusion
- Among non-demented patients with long lasting CHD, high CC- IMT and presence of high CC-IMT and carotid plaques are associated with lower cognitive performance particularly in the executive function domain.
Abstract 3337: Stem Cells As Regenerative Therapy In Stroke: A Case Control Study.
Authors: Bhatia Rohit , Bhasin Ashu , Mohanty Sujata , Kumaran Senthil , Padma Srivastava M V
Published: March 2022

Background:
The alarming disability burden and a high prevalence rate of Stroke in India has encouraged the researchers to develop new therapies to reduce clinical deficits. Stem cell therapy promises to restore function after stroke evidenced by experimental model studies and clinical trials. These cells are feasibile, multipotent and have homing-in characteristics to the lesioned cortex. The present study evaluates safety, feasibility and efficacy of autologous mononuclear and mesenchymal stem cell therapy in stroke patients evaluated on clinical scores and functional imaging including functional MRI (fMRI) and diffusion tensor imaging (DTI).

Methods:
Forty (n=40) stroke patients were recruited with the following inclusion criteria: 3 months to one year of index event; power in hand muscles of at least MRC grade 2; NIHSS between 4 and 15; conscious and able to comprehend. Fugl Meyer (FM), modified Barthel Index (mBI), MRC, Ashworth tone scale and functional imaging were used for assessments at baseline, 8 weeks and 24 weeks. Fourteen (n=14) patients were administered mononuclear stem cells and six (n=6) patients cultured expanded mesenchymal stem cells. 50 to 60 million cells were dissolved in 250 ml saline and infused intravenously over 2-3 hours. Twenty patients served as controls.

Results:
The clinical, laboratory and radiological tests were normal for patients with stem cell therapy. There was no mortality or therapy related adverse reactions. mBI showed statistical significant improvement (p0.05) in the stem cell group as compared to controls. There was an increased number of cluster activation in Brodmann areas BA 4 and BA 6 post stem cell infusion compared to controls.

Conclusion:
Autologous intravenous stem cell (mononuclear and mesenchymal) therapy is safe and feasible and likely facilitates behavioral recovery after stroke. Stem cells act as “scaffolds” / cellular mediators for neural transplantation and may aid in repair mechanisms in stroke.
Abstract 3345: Does Acute Stroke Critical Pathway For Recanalization Therapy In Acute Ischemic Stroke Improve Short-term Clinical Outcome?
Authors: Ko Youngchai , Kim HyoJeong , Lee SooJoo , Lee JiSung
Published: March 2022

Background & Objectives:
The benefit of intravenous thrombolytic therapy in acute brain ischemia is strongly time dependent. However, in-hospital time delay is the most serious obstacle to achieve a goal for timely administration of intravenous tPA. Previous studies have been reported that critical pathway (CP) for acute stroke would reduce door-to-needle time, but there are few studies about the clinical efficiency. We aimed to elucidate the roll of CP for improving clinical outcomes among patients who underwent thrombolytic therapy.

Method:
Acute stroke CP has been implemented in our hospital since November 2010 for the purpose of reducing in-hospital delay, and applicated to the patients who were presented with focal neurologic signs within 24 hours after onset. To evaluate effectiveness of CP, we predefined time indicators as follows; arrival to consultation time by neurologist (door-to-doctor) time, arrival to tPA administration (door-to-needle) time, and arrival to intra-arterial thrombolysis (door-to-IA) time. We compared the performance of time indicators during 6 months with that of before implementation for the same months. The difference of NIH stroke scale (NIHSS) between administration and discharge was selected for comparing short-term clinical outcome between two groups.

Results:
A consecutive series of 282 patients with acute ischemic stroke were collected during the study period. Among them, 125 patients were assigned to ‘before CP ’ group and 157 to ‘after CP’ group. Median of Door-to-doctor time was significantly reduced after implementation of CP; 45 min (IQR, 25 to 69) vs. 17 (12 to 27) (P<0.001). Median of door-to-needle time was also significantly reduced; 58 (49 to 99) vs. 47 (40 to 59) (P=0.003). However, median of door-to-IA time was failed to reduce; 2.0 h (1.4 to 3.1) vs. 1.9 (1.6 to 2.2) (P = 0.445). The number of patients who were treated with thrombolytic therapy slightly increased from 24.8% (31/125) to 25.4% (40/157) and especially, rate of intra-arterial thrombolytic therapy significantly increase from 8.8%(11/125) to 15.2%(24/157). The analyses about the difference of clinical outcome between two groups by generalized estimating equation (GEE) showed that there was no significant improvement (P = 0.09) in terms of short-term clinical outcome which was assessed by initial and discharge NIHSS.

Conclusions:
Our study suggests that the acute stroke CP might be effective in reducing door-to-doctor and door-to-needle time although it could not lead to improvement of clinical outcome. The study about relationship between CP and long-term outcome should be needed for the future direction.
Abstract 3347: Derivation and Double External Validation of an Integer-based Prognostic Score (ASTRAL Score) to Predict Functional Outcome in Acute Ischemic Stroke: a Collaborative Analysis from the ASTRAL, Athens and Vienna Stroke Registries
Authors: Ntaios George , Faouzi Mohamed , Ferrari Julia , Lang Wilfried , Vemmos Konstantinos , Michel Patrik
Published: March 2022

Introduction:
We aimed to develop and externally validate a simple, integer-based prognostic score to predict functional outcome at three months in patients with acute ischemic stroke (AIS) using variables readily available at hospital admission.

Methods:
Using emergently available demographic, clinical and laboratory variables of consecutive AIS patients in a single university hospital, logistic regression analysis was performed in the derivation cohort (ASTRAL registry) to identify independent predictors of unfavorable outcome, defined as modified Rankin Scale score >2. The β-coefficient of each covariate of the fitted multivariate model was used to generate an integer-based point scoring system for each one; the overall score was calculated as the sum of weighted scores of the covariates. The model was validated externally in two AIS cohorts from the Athens and Vienna Stroke Registries. Two indices of accuracy were assessed: discrimination (Area Under the Curve, AUC) and calibration (Hosmer-Lemeshow test).

Results:
Six covariates were identified as independent predictors of unfavorable outcome in 1968 patients in ASTRAL: age (A), severity of stroke (S) measured by admission NIHSS, time from stroke onset-to-admission (T), range of visual fields on clinical exam (R), acute serum glucose (A) and level of consciousness (L). AUC in the ASTRAL cohort was 0.850. β-coefficients were multiplied by 4 and rounded to the closest integer. The score was well calibrated in the derivation (p=0.43) and validation cohorts [0.22 and 0.49 in the Athens (n=1659) and Vienna cohorts (n=653) respectively, 0.82 in their combination]. AUCs were 0.937 and 0.771 in the Athens and Vienna cohorts respectively, and 0.902 in their combination. An ASTRAL score of 28 indicates a 50% likelihood of unfavorable outcome.

Conclusions:
The ASTRAL score is a simple integer-based score to predict 3 months functional outcome using 6 readily available items at hospital admission. It performed well in double external validation and may be a useful tool for clinical practice and stroke research.
Abstract 3352: Sulcal Effacement On Flair MRI In Hyperacute Stroke: Association With Collateral Flow And Clinical Outcomes
Authors: Kim Suk Jae , Ha Yeon Soo , Ryoo Sookyung , Noh Hyun Jin , Ha Sam-Yeol , Bang Oh Young , Kim Gyeong-Moon , Chung Chin-Sang , Lee Kwang Ho
Published: March 2022

Background:
The clinical significance of sulcal effacement has been widely investigated in CT studies, but the results are controversial. In this study, we evaluated the presence of perisylvian sulcal effacement (PSE) on fluid attenuation inversion recovery (FLAIR) MRI and hypothesized that PSE may be related to collateral flow status together with hyperintense vessels (HVs) on FLAIR in hyperacute stroke. In addition, we investigated whether an association between PSE and clinical outcome could be found in these patients.

Methods:
Consecutive patients with acute middle cerebral artery (MCA) infarcts within six hours of symptom onset were included. All patients had internal carotid artery (ICA) or MCA occlusion and underwent MRI including FLAIR. The presence of PSE and HVs on FLAIR (
figure
) and the collateral status and occurrence of early recanalization (ER) on conventional angiography were evaluated.

Results:
Of 139 patients, 79 (56.8%) had PSE. Multivariate testing revealed PSE was independently associated with collateral status. The association between HVs and collaterals was different depending on PSE. Compared to PSE (+) and ER (-) patients, PSE (-) and ER (-) patients (OR 4.11, 95% CI, 1.12-15.17) and PSE (-) and ER (+) patients (OR 34.62, 95% CI, 5.75-208.60), but not PSE (+) and ER (+) patients were more likely to experience favorable clinical outcomes (mRS≤2 at three months).

Conclusion:
PSE is independently associated with collateral status in patients with acute MCA stroke. Moreover, PSE in conjunction with recanalization status can predict clinical outcomes in these patients.
Figure
. Typical examples of perisylvian sulcal effacement (PSE; dotted circle) and distal hyperintense vessels (HVs; arrow head) on FLAIR MRI. (a) PSE (+) with subtle distal HVs (b) PSE (+) with prominent distal HVs (c) PSE (-) without distal HVs (d) PSE (+) with prominent distal HVs
Abstract 3353: Primary Transluminal Balloon Angioplasty for Symptomatic Cerebral Vasospasm in Subarachnoid Hemorrhage without Triple H Therapy.
Authors: Sheen Seung , Jeon Jin Sue
Published: March 2022

Background and Purpose-
Triple H therapy has been used to treat symptomatic cerebral vasospasm as a first line therapy, but its clinical validity of improving cerebral blood flow (CBF) is still controversial. This study was started to confirm clinical validity of early transluminal balloon angioplasty (TBA) as a primary treatment measure for specific symptomatic cerebral vasospasm without triple H therapy.

Methods-
This retrospective analysis was performed in 17 patients with SAH who had TBA for symptomatic vasospasm after subarachnoid hemorrhage (SAH). Only the patients whose conscious levels were alert or drowsy after operation were included.

Results-
Fifteen patients (88.2%) with 61 stenotic segments of vessels were conducted with TBA and IA-Nimo infusion together and two patients (11.8%) with 7 segments of vessels were conducted with TBA only. The recurrence cases were found in 2 patients (11.8%) with 4 segments (6.6%) after first endovascular treatment. TBA was conducted on 26 segments on distal artery such as A2, M2 and P2 in 12 patients and only 2 (7.7%) segment vessels were retreated. The excellent outcome in neurologically are found in 16 patients (94%) and 15 (88.2%) in angiographically.

Conclusion-
Patients in SAH whose conscious level is alert or drowsy after operation, TBA can be considered first as a therapeutic option for treating symptomatic cerebral vasospasm without 3H therapy due to its instant effect and impact on improving CBF. Keywords: subarachnoid hemorrhage; cerebral vasospasm; transluminal Balloon Angioplasty
Abstract 3354: Effect of Homocysteine-Lowering on Recurrent Vascular Risk in Middle-Aged Stroke Patients
Authors: Towfighi Amytis , Markovic Daniela , Ovbiagele Bruce
Published: March 2022

Background:
Cross-sectional studies suggest that the association between elevated homocysteine (HCY) and stroke is strongest in young adults and decreases with age. Furthermore, individuals with coexisting hypertension and elevated HCY have a substantially higher risk of stroke. Although clinical trials have failed to demonstrate a benefit of vitamin therapy for secondary stroke prevention in individuals with high HCY, the trials enrolled subjects in their late 60s and did not specifically assess the effect of HCY lowering in hypertensive subjects. Additional data in support of the aforementioned cross-sectional data may make the case for considering future HCY-lowering trials targeting younger individuals with hypertension.

Methods:
Post-hoc analysis of individuals aged 45-64 years enrolled in the Vitamin Intervention for Stroke Prevention trial, a multicenter, double-blind, randomized controlled trial of high vs. low dose folic acid, pyridoxine, and cobalamin in ischemic stroke patients with elevated HCY. Time to primary (stroke, myocardial infarction or death from any cause) and secondary (stroke) outcomes were assessed after adjusting for demographic and vascular risk factors. Interaction effects of age vs. treatment category on outcome and baseline hypertension or blood pressure > 140/90 mm Hg vs. treatment category on outcome were assessed.

Results:
Among 1425 individuals aged 45-64 years, the treatment groups were similar with respect to stroke severity, demographic and vascular risk factors. The only differences between the treatment groups were among individuals aged 45-54 years; those treated with high dose vitamins were more likely to smoke and have a history of prior stroke compared to those treated with low dose vitamins. Among individuals aged 45-54 years, high dose vitamin therapy trended towards a reduced risk of the primary outcome (HR 0.62, 95% CI 0.36-1.06, p=0.08)(
Figure
) after adjustment for covariates, but this benefit was not seen in those aged 55-64 years (HR 1.08, 95% CI 0.72-1.63). High dose vitamin therapy did not have an effect on the secondary outcome. Also, subjects with concomitant hypertension did not have different outcomes compared to those without hypertension.

Conclusions:
Among younger individuals with a history of stroke and elevated HCY, high dose vitamin therapy is linked to a lower trend in risk of subsequent major vascular events. Future randomized clinical trials with adequate power will be necessary to prospectively determine if high dose vitamin therapy reduces the risk of vascular events in individuals <55 years with elevated HCY and stroke.
Abstract 3355: Combination Therapy With Magnesium Sulfate And Nimodipine For The Prevention Of Symptomatic Cerebral Vasospasm In Aneurysmal Subarachnoid Hemorrhage
Authors: Sheen Seung , Jeon Jin Sue
Published: March 2022

Background and Purpose-
Magnesium treatment can cause dose-dependent vasodilatation and improve cerebral blood flow. This investigation was conducted to evaluate efficacy of the combination therapy with magnesium and nimodipine in patients with aneurysmal subarachnoid hemorrhages (SAH).

Methods-
This retrospective analysis was performed in 143 patients who presented with ruptured aneurysms from January 2007 to April 2011 at a single center. Nimodipine alone was infused in 89 patients until October 2009, and the combination of magnesium with nimodipine was infused in 54 patients after November 2009. The combination therapy and nimodipine-only treatment was started 13.1 ± 7.7 h (median ± SD) and 13.8 ± 11.2 h, respectively, after SAH symptom development. Magnesium treatment was maintained at a dose of 64 mmol/L per day for fourteen days.

Results-
Symptomatic vasospasm developed in 6 patients (11.1%) in the combination-treatment group and 26 (29.2%) in the nimodipine-only group. Thus, treatment with magnesium significantly reduced the incidence of symptomatic vasospasms (Odds Ratio, 0.285; 95% Confidence Interval, 0.102-0.794; p = .016). Duration of the vasospasm was shorter in the combination-treatment group (2.7 ± 0.8 days vs 6.4 ± 4.3 days;
p
= .000). No complications associated with magnesium treatment were observed.

Conclusion-
Early treatment with magnesium and nimodipine reduced the incidence of symptomatic cerebral vasospasms in patients with aneurysmal SAH, and 64 mmol/L per day without the supplementation of magnesium to attain a specific concentration of high serum magnesium, was sufficient to prevent vasospasms.
Abstract 3357: Women Have Higher Odds of Dying within 3 Months of a Stroke than Men
Authors: Towfighi Amytis , Lee Meng , Valle Natalie , Ovbiagele Bruce
Published: March 2022

Background:
In recent years, the public health burden of stroke in women has become apparent. Due to their greater longevity, more women than men have strokes each year. Numerous studies have shown that women fare worse than men with regards to in-hospital treatment, vascular risk factor control, and disability after stroke; however, data regarding sex differences in stroke mortality are conflicting.

Objective:
To conduct a systematic review and meta-analysis investigating the relation of sex with short-term and long-term mortality after stroke.

Methods:
We performed a systematic search of Pubmed, Cochrane Library, MEDLINE, LILACS, review articles, and reference lists with the terms “ischemic stroke” or “cerebral ischemia” or “brain ischemia” crossed with “sex differences” or “gender differences” or “sex-specific” crossed with “case fatality” or “mortality” or “in-hospital mortality” or “outcome” or “survival” or “death.” We restricted our search to humans. There were no language restrictions. Entry criteria were as follows: (1) sex-specific rates of 1 of the following assessed: in-hospital, 1-month, or 90-day mortality; (2) ischemic stroke, and (3) adults (>18 years). All data from eligible studies were abstracted by 3 independent investigators according to a standard protocol. Discrepancies were resolved by discussion with a 4
th
investigator and by referencing the original report. Heterogeneity was assessed by the probability value of chi square statistics and I
2
. The primary endpoint was short-term mortality (at 0-3 months) and the secondary endpoint was long-term mortality (at 12-18 months).

Results:
The literature review yielded 21 studies which met entry criteria. Of these, 6 provided female to male odds ratios of short-term mortality (n=3,183,110) and 3 provided female to male odds ratios of long-term mortality (n=104,141). Overall, women had higher short-term (OR 1.11, 95% CI 1.03-1.19)(
Figure1
) and long-term (OR 1.12, 95% CI 0.97-1.28)(
Figure 2
) mortality compared to men, although the latter was not significant.

Conclusion:
Women are more likely than men to die within the first 3 months of an index stroke. Intensified efforts at mitigating post-stroke complications and improving vascular risk factor control among female stroke survivors may aid in reducing this disparity.

Figure 1

Figure 2
Abstract 3369: Intravenous Autologous Bone Marrow Derived Stem Cell Therapy for Patients with Subacute Ischemic Stroke (InVeST): A Multi-Centric Randomized Controlled Trial
Authors: Prasad Kameshwar , Johari S. , Gorthi S. P , Sarkar R. S , Prabhakar Sudesh , Mishra U K , Bhatnagar Shinjini
Published: March 2022

Background & Objective
We have completed a randomized controlled clinical trial (CTRI-PROVCTRI/2008/091/00046) to evaluate the safety and efficacy of administering bone marrow mononuclear cells intravenously to patients with subacute ischemic stroke.

Methods
A total 120 consecutive, eligible and consenting patients, aged 18 to 75 years with ischemic stroke involving MCA or ACA territory infarct between 7 to <30 days of onset of stroke with moderate severity in stable condition were recruited from 31 January 2009 to 16 June 2010. Patients were randomly allocated by central telephone/fax/email. For stem cell arm, bone marrow has been aspirated from iliac crest and the harvested mononuclear cells infused into antecubital vein. Outcome measures for safety are immediate reactions after cell infusion and evidence of tumor formation at one year in whole body FDG-PET scan. Efficacy measurement time points are 7 (±2 days), 90(-7 to +14 days), 180 (-7 to +28 days) and 365 (-7 to +28 days) NIHSS, BI, mRS, MRI, PET scan and EEG. BI and mRS were measured by blinded assessors centrally on telephone. Primary outcome is modified BI score at six months post-randomisation.

Results
Stem cell arm has been administered bone marrow mononuclear cells (mean 280.73 million with CD34+ mean 2.85 million). Central telephonic follow up has been completed in 117 patients. Data on SAEs, clinical outcome (mRS, BI, NIHSS), cerebral infarct volume, whole body FDG-PET scan and EEG will be presented.

Conclusion
Intravenous bone marrow MNC therapy is safe in patients of subacute stroke. Further results will be presented.
Abstract 3373: Fibrinolytic Therapy in a Community Hospital: the Same Old Protocol with a New Perspective
Authors: Heckler Deborah L , Cimino Nancy J
Published: March 2022

Background:
In 2007 Union Memorial Hospital, a 300 bed urban community hospital began the journey to Primary Stroke Center certification including the challenge of administering rtPA to qualified candidates within the golden hour of arrival. Our 50 bed Emergency Department worked with the hospital Stroke Committee to improve our processes. It proved difficult to get the head CT and lab work completed within the hour much less administer the rtPA. While these processes improved, our door to needle times did not decrease. We worked to standardize, bundle and electronically post our forms and order sets. With each rtPA patient we identified a new area for improvement and continued staff education, promoted early recognition and obtained interdisciplinary feedback.

Purpose:
To decrease our door to needle time.

Methods:
Based on literature review and stakeholder feedback, the Nurse Manager, Quality Coordinator and Medical Directors decided to model the Acute Stroke response off of our Hazmat response as both of these are low volume, critical incidents requiring every staff member to be knowledgeable and prepared to respond. We developed job action sheets, clearly identifying the required duties, for each member of the ED team. Acute Stroke response was divided into four phases: 1) Notification/Arrival of Potential BAT, 2) CT completion to Decision to administer rtPA, 3) Decision to Administer rtPA, and 4) rtPA administration to CCU. Overhead page of Code Stroke notified all staff of the time intensive emergent process allowing work loads to be temporarily re-assigned minimizing interruptions, the rtPA protocol was now available in red folders with instructions for proper action or completion, and a timekeeper/facilitator was assigned. The new protocol was disseminated to staff in early March 2011. Lab and CT staffs were also re-educated with emphasis on the critical nature of their roles.

Results:
Two weeks later the new protocol was put to the test with rtPA door to needle time of 50 minutes! In July 2011, the mean door to needle time was 49 minutes.

Conclusion:
Looking at the same process or problem from a different perspective can change the approach of a whole team. Changing the protocol format, informing all staff, reassigning work load, designating a time keeper and creating job action sheets made a Code Stroke successful!
Abstract 3397: Do Patients Enrolled by Family Members in an Acute Stroke Trial Continue to Participate When They Regain Competency?
Authors: Yallapragada Anil , Sanossian Nerses , Starkman Sidney , Liebeskind David , Ali Latisha , Restrepo Lucas , Kim-Tenser May A , Valdes-Sueiras Miguel , Hamilton Scott , Eckstein Marc , Pratt Franklin D , Stratton Samuel , Conwit Robin , Saver Jeffrey L
Published: March 2022

Background:
Stroke renders many patients aphasic or cognitively impaired, requiring their initial research consent for acute stroke trials be obtained from a proxy - a family member or other legally authorized representative (LAR). Federal law requires that proxy-enrolled patients who regain competency be approached for explicit self-consent to continue or discontinue trial participation. The frequency of competency recovery and the delayed decisions made have not been well studied.

Methods:
We analyzed patients enrolled in the NIH Field Administration of Stroke Therapy-Magnesium (FAST-MAG) testing prehospital initiation of magnesium sulfate within 2h of stroke onset. In FAST-MAG, a physician obtains consent by cellphone from: 1) the patient, 2) an on-scene LAR, if patient noncompetent. Per California law, LARs are: spouse, adult child, sibling, parent, registered domestic partner, and individual identified in an advanced health care directive /guardian.

Results:
Among the first 1008 explicitly consented patients, 397 (39.4%) were enrolled by proxy consent. Providers of proxy consent were: spouse (49.8%), daughter (24.9%), son (18.7%), sister (3.0%), brother (2.0%), mother (0.8%), and registered/domestic partner (0.3%). Among proxy consent patients, mean age was 74.0 (SD 12), 46.1% were female, and initial NIHSS was median 16 (IQR 2-14). Over the three month course of trial follow-up, 99/397 (24.9%) of these patients regained competency. The rate of consent to continue participation after competency recovery was 99/99 (100%, 95CI 96.4%-100%). Among the 298 patients who did not regain competency, 295 (99.0%) continued to final study visit under LAR consent and 3 had family consent withdrawn (1.0%). The all-source (self or LAR) rate of continued consent was 394/397 (99.2%). Among patients providing explicit self-reconsent, the median interval to reconsent was 1 day (IQR 0-2, range 0-118) and final 3 month MMSE scores were median 27.5 (IQR 25-29).

Conclusions:
In this prehospital stroke trial, 4 of every 10 patients were noncompetent and enrolled by proxy. Among these patients, 1 of every 4 later regained competency. All consented to continue. The high rate of delayed self-consent suggests LARs understand patient wishes well and proxy consent is an acceptable method for enrolling cognitively impaired patients in acute stroke trials.
Abstract 3421: Delayed Diagnosis of Cerebellar Infarctions
Authors: Sangha Navdeep S , Vahidy Farhaan , Chen Zhongxue , Peng Hui , Savitz Sean I
Published: March 2022

Background:
An acute ischemic cerebellar stroke presents a clinical and radiological diagnostic challenge, which may be due in part to the difficulty in recognizing its symptoms and signs and to an over-reliance on CT. This retrospective study addresses for the first time the differences in clinical features and outcomes between those individuals with a cerebellar infarct who were correctly diagnosed (CD) on initial presentation compared to those who were initially misdiagnosed (MD), and consequently had a delay in correct diagnosis.

Methods:
A retrospective review was conducted of our stroke registry from 09/2003 to 07/2010. Forty three patients had an isolated cerebellar infarction confirmed by MRI. Common neurological signs and symptoms were chosen to analyze their association with correct diagnosis or misdiagnosis. Misdiagnosis was defined as the diagnosis given by the first physician who saw the patient in the outpatient or inpatient setting. Onset to door time is defined from onset of the patient’s symptoms to our ED. The primary outcome was mRS at discharge. Data was analyzed using the chi square test, Fischer exact test, Wilcoxon-rank sum test and logistic regression.

Results:
Sixteen (37%) patients were MD; among these patients, the median duration of delay to being CD was 24 hours (IQR 9-48h). The median onset to our ED was 11.1 hrs in the MD versus 5.5 hrs in the CD group (p=0.02). The median age in the MD group was 49 y/o versus 65 y/o in the CD group (p< 0.001). More patients with hypertension were CD (71.4%, p<0.05). Weakness was associated with a decreased likelihood of MD (OR 0.18; 95% CI 0.034-0.94). The presence of nausea increased the tendency of MD (OR 5.6; 95% CI 1.06-29.6), and a trend toward MD was present if a patient had vertigo (OR 3.3; 95% CI 0.92-12.1). Five (18.5%) patients who were CD received tPA compared to none in the MD group (p=0.14). Ten (37%) MD patients presented within the time window for tpa, and subsequently were no longer candidates for thrombolysis. There was a trend toward a good outcome at discharge (mRS 0-1) in the CD group (OR 3.5; 95% CI 0.9-13.8). There were no deaths before discharge in either group.

Conclusion:
Timely identification of an acute cerebellar infarction requires the recognition that stroke may occur in younger individuals and that symptoms of cerebellar stroke are commonly associated with more benign processes such as gastroenteritis. Although limited by sample size, our data suggests that timely diagnosis of cerebellar infarction might increase thrombolysis rates and may impact functional outcome.