bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W P278: Relationships Between Hospital Volume and Outcomes in Ischemic and Hemorrhagic Patients: J-aspect Study
Authors: Kamitani Satoru , Nishimura Kunihiro , Kada Akiko , Kurogi Ryota , Nishimura Ataru , Sayama Tetsuro , Iihara Koji ,   J-ASPECT
Published: March 2022

Background and Purpose:
Mortality and morbidity can be increased in process of some medical training. We aimed to examine relationship between hospital volumes and outcomes in ischemic and hemorrhage stroke.

Methods:
We analyzed emergency-hospitalized patients in 147 certified training institutions in Japan. Data between April 1, 2010 and May 31, 2013 was obtained from Japanese Diagnosis Procedure Combination database. The outcome measures were in-hospital mortality and proportion of mRS 0-2 at discharge. Hospital volumes were divided by quartile points and compared with that of lower interquartile range (Q1) as control. Effects of hospital volumes were analyzed using logistic regression model, adjusting age, sex, levels of consciousness on admission and comorbidities.

Results:
Of 114,219 emergency-hospitalized patients, 64.1%, 27.9% and 8.2% patients suffered from IS, ICH and SAH, respectively. Table shows proportions of outcomes for each interquartile range of hospital volumes. In-hospital mortality decreased as hospital volumes increased in all subtypes. Proportions of mRS 0-2 at discharge increased as hospital volumes increased in IS and SAH. After adjustment, effects of hospital volumes on mortality were significantly correlated in IS (adjusted OR, 0.89; 95% CI, 0.79-0.99 for upper inter quartile range (Q4) compared with Q1 as control). And effects of hospital volumes on mRS 0-2 at discharge were significantly correlated in SAH (adjusted OR, 1.17; 95% CI, 1.02-1.34 for Q4 compared with Q1 as control) (Figure).

Conclusion:
Increasing hospital volumes were significantly correlated with favorable outcomes in ischemic and hemorrhagic stroke.
Abstract W P284: Frailty Is an Independent Predictor of Functional Status at Hospital Discharge in Acute Ischemic Stroke Patients
Authors: Reeves Mathew J , Sucharew Heidi , Khoury Jane , Alwell Kathleen , Moomaw Charles , Kissela Brett , Woo Daniel , Flaherty Matthew , Adeoye Opeolu , Khatri Pooja , Ferioli Simona , Kleindorfer Dawn
Published: March 2022

Introduction:
Frailty, a state of cumulative decline in multiple systems, is commonly evaluated in geriatrics outcome but rarely for stroke. We sought to determine if frailty is an independent predictor of functional status after accounting for age, pre-stroke function, stroke severity and other factors.

Methods:
Clinical data from ischemic stroke admissions in the Cincinnati/Northern Kentucky Stroke Study during 2005 were obtained. Functional status was measured using the modified Rankin Scale (mRS) with categories ≤1, 2, 3, ≥4. Using established methods, we developed a frailty score using 35 age-related deficits that included comorbidities, symptoms, clinical and lab values (range 0-35 points). We modeled mRS at discharge using an ordinal logistic regression with proportional odds, adjusting for age, race, sex, stroke severity (NIHSS score > 5 vs ≤ 5), pre-stroke functional status (mRS) and EMS (ambulance) arrival. The independent association between the frailty score (expressed as a 1 deficit or point change) and poorer functional status at discharge (higher mRS) was determined.

Results:
A total of 1906 ischemic strokes surviving to discharge were included. The median age was 72 years, 23% black, 55% female, median NIHSS 3 (IQR 2, 6) and median frailty score 6 (IQR 3, 8). The distribution of mRS ≤1, 2, 3, or ≥4 at discharge was 19%, 17%, 27%, and 37%, respectively. The final model (Table) illustrates that frailty score, age, stroke severity, pre-stroke function, and EMS use were all significant predictors. A 1 deficit (point) increase in the frailty score was independently associated with a 10% increase in the odds of a higher discharge mRS.

Conclusions:
Frailty was independently associated with poorer functional status at discharge even after accounting for age, stroke severity and pre-stroke function. These data suggest that a measure of frailty could improve the predictive accuracy and clinical utility of stroke outcome models.
Abstract W P292: Variable Frequencies, Outcomes and Costs Argue for Separate Tracking of Ischemic Strokes (ISs), Subarachnoid Hemorrhages (SAHs) and Other Hemorrhagic Strokes (OHSs)
Authors: Gray Darryl T
Published: March 2022

Introduction:
While cause and treatment vary for ISs, SAHs and OHSs, their results are often combined in reported statistics.

Hypothesis:
ISs, SAHs and OHSs differ in frequency and outcomes.

Methods:
ICD-9-CM principal discharge (D/C) diagnosis codes of 430 (SAH), 431-432 (OHS) and 433-434 (IS) were used to obtain US nationwide estimates of stroke frequency and outcomes for 2006-2012 from HCUPnet, the on-line query system of the Healthcare Cost and Utilization Project (HCUP). HCUP's sampling frame captured ~90% of D/Cs from non-Federal acute care hospitals for 2006, and >95% of such D/Cs as of 2012. Data came from HCUP's Nationwide Inpatient

Sample, which captures 100% of D/Cs from a stratified sample of 20% of HCUP hospitals.

Results:
There were 2,005 cases (2.7/100,000) seen in 0-17 year-olds (YOs) in both 2006 and 2012. While 33.9 vs 34.2% were ISs, 19.5 vs 17.0% were SAHs, and 46.6 vs 48.9% were OHSs. Analyses focused on 18+ YOs estimated that there were 653,429 such cases (290.1/100,000) in 2006. Among ISs (82.0% of cases), 4.4% died as inpatients, 49.3% were routine D/Cs and the rest (46.3%) were D/Cd to other care settings. Mean length of stay (MLOS) was 4.8 days. Mean hospital costs (not charges) were $10,059/case (in 2012 US $). Among SAHs (4.1%), inpatient mortality was 23.1% and 35.2% were routine D/Cs. MLOS was 12.3 days. Mean costs were $41,941. Among OHSs (13.9%), 24.3% died as inpatients and 24.3% were routine D/Cs. MLOS was 7.8 days. Mean costs were $17,456. Some 680,980 adult cases (283.5/100,000) were seen in 2012. Among ISs (82.5%), 3.7% died as inpatients; 45.7% were routine D/Cs. MLOS was 4.5 days. Mean costs were $11,651. Among SAHs (3.6 %), mortality was 19.6%; 37.2% were routine D/Cs. MLOS was 11.7 days. Mean costs were $50,372. Among OHSs (13.9 %), mortality was 21.7%; 23.3% were routine D/Cs. MLOS was 7.4 days. Mean costs were $19,871.

Discussion:
While pediatric and adult stroke D/C rates were stable from 2006-12, they were much more common in adults. Subtype distributions differed. Adult inpatient mortality fell while LOS varied. Overall adult inflation-adjusted acute care hospital costs rose from $8 to 10
trillion/
year. Lower rates, worse outcomes and higher resource use seen in SAHs and OHSs relative to ISs argue for separate tracking of subtype results.
Abstract W P309: Serum Albumin Predicts Outcome In Primary Intracerebral Hemorrhage
Authors: Shiue Harn , Albright Karen C , Sands Kara A , Hays Angela N , Gadpaille Alissa , Khawaja Ayaz , Sisson April , Alvi Muhammad , Shahripour Reza Bavarsad , Harrigan Mark
Published: March 2022

Background&Purpose:
Low serum albumin is associated with poor outcomes in ischemic stroke. Albumin levels are a marker of nutritional status; albumin also has neuro-protective effects. The role of serum albumin in outcomes in patients with ICH has not been investigated. We examined the association between initial admission albumin and functional outcome at discharge.

Subjects&Methods:
Consecutive patients (2008 - 2013) diagnosed with primary ICH at our academic stroke center in the Southeast US were retrospectively analyzed. Demographics, initial lab values, and ICH scores were recorded. A poor outcome was defined as mRS 4-6 at discharge. Eligible patients were divided into two groups based on ICH score (0-2 and 3-6). Statistical significance was determined using logistic regression.

Results:
A total of 103 patients met inclusion criteria (mean age 63, 45% women, 49% black). In patients with an ICH score of 0-2 (n=85), higher albumin was associated with lower odds of poor functional outcome at discharge (OR=0.40, 0.18 - 0.89; p=0.026). For every 1g/dL increase in albumin, the odds of poor outcome were reduced by 60%. This relationship was not observed in patients with an ICH score of 3-6 (n=18, OR=2.41, 0.06 - 99.5; NS).

Conclusions:
Serum albumin on admission predicts outcome at discharge. Patients with low ICH severity seem to be most sensitive to lower serum albumin levels. Early nutritional support may translate into better clinical outcomes in ICH patients. Future studies incorporating other measures of nutritional status are needed to better delineate optimal serum albumin levels and to understand this effect.
Abstract W P358: Rate of “Non-Go Activation” of a High Volume Stroke Center Neuroendovascular Team during the “After Hours”/On-Call Period: Exploring the Financial Impact to an Acute Stroke Program
Authors: Schindler Kiva M , Faggard Jason , Amerson Leigh , Doppelheuer Shannon , Craft Leah , Anderson Aaron , Belagaje Samir , Nahab Fadi , Gershon Raphael , Frankel Michael , Nogueira Raul
Published: March 2022

Background and Purpose:
Timely reperfusion in large vessel occlusion strokes (LVOS) is crucial to achieving optimal functional outcomes. Acute neurointerventional therapy requires a team of individuals be assembled and ready as soon as the workup is completed and the patient is deemed an eligible and appropriate thrombectomy candidate. On occasion, the endovascular on call team is activated but the patient is subsequently determined ineligible for interventional therapy. We aimed to explore the frequency and financial impact of on-call neuroendovascular team activation when the procedure is a “Non-Go” situation and to determine its impact on the operating budget of an acute endovascular stroke program.

Methods:
From February-July 2014, information was collected on all instances of the neuroendovascular team being activated during the “After Hours”/On-Call period (defined as: weekdays 7PM-7AM and weekends e.g. Fri 7PM-Mon7AM) but a procedure not done due to patient ineligibility. The information collected included patient demographics, date and time of the activation, and reason why the procedure was not performed.

Results:
During the five month data collection period, there were 12 occasions of “Non-Go Activation” of the Neuroendovascular Team during “After Hours”. Three patients (25%) were randomized to IV tPA only in a clinical trial, four patients (33%) had marked improved symptoms and/or no-occlusion on CT angiography, and five patients (42%) had large core on initial imaging. During this same period, a total of 70 thrombectomies were performed for a ratio 5.8 overall thrombectomies for every “Non-Go After Hours” activation which seems to be a financially viable model.

Conclusions:
The “stand-by strategy” for the neuroendovascular team for selected stroke transfers and emergency room cases is justifiable based on the need for rapid reperfusion in LVOS. The extra burden on the “on-call” personnel is acceptable and the extra costs represent a relatively small fraction of the treatment expenses.
Abstract W P375: Prior Antithrombotic Therapy, Initial Neurological Severity And 3-month Outcome In Acute Ischemic Stroke Patients With Non-valvular Atrial Fibrillation: The Samurai-nvaf Study
Authors: Tokunaga Keisuke , Koga Masatoshi , Arihiro Shoji , Todo Kenichi , Yamagami Hiroshi , Kimura Kazumi , Furui Eisuke , Terasaki Tadashi , Shiokawa Yoshiaki , Kamiyama Kenji , Okada Yasushi , Takizawa Shunya , Kameda Tomoaki , Mochizuki Hiroshi , Hasegawa Yasuhiro , Nagakane Yoshinari , Ito Yasuhiro , Nakashima Takahiro , Okuda Satoshi , Takamatsu Kazuhiro , Nishiyama Kazutoshi , Kario Kazuomi , Shiozawa Masayuki , Yoshimura Sohei , Toyoda Kazunori
Published: March 2022

Background and Purpose:
We aimed to assess whether prior antithrombotic therapy affects initial neurological severity and functional outcome in acute ischemic stroke patients with non-valvular atrial fibrillation (NVAF).

Methods:
Patients with NVAF who were admitted within 7 days after ischemic stroke onset from 2011 to 2014 were enrolled from the register of a prospective, multicenter, observational study (the SAMURAI-NVAF study). Patients receiving novel oral anticoagulants at onset were excluded from the study. They were classified into 3 groups: the non-WF group, patients without prior warfarin; the iWF group, those on warfarin with initial PT-INR below the target range; the sWF group, those on warfarin with initial PT-INR within or above the target range. They were also divided into patients without prior antiplatelet agents (the non-AP group) and those with (the AP group). Initial neurological severity was measured by NIHSS score. Poor functional outcome was defined by mRS 3-6 at 3 months of onset.

Results:
Of 1000 patients studied, 713, 221 and 66 were assigned to the non-WF group, the iWF group and the sWF group, respectively. Of all, 245 were assigned to the AP group, mainly taking aspirin (202 patients). On multivariate analysis, the sWF group (vs. the non-WF group) (standardized regression coefficient [β], -0.23; p<0.001) was inversely associated with initial NIHSS score, but the iWF group (vs. the non-WF group) (β, -0.03; p=0.327) and the AP group (vs. the non-AP group) (β, 0.02; p=0.580) were not. The sWF group (vs. the non-WF group) (OR, 0.41; 95% CI, 0.21-0.77; p=0.005) was inversely associated with poor functional outcome, but the iWF group (vs. the non-WF group) (OR, 0.81; 95% CI, 0.55-1.18; p=0.267) and the AP group (vs. the non-AP group) (OR, 1.17; 95% CI, 0.80-1.71; p=0.413) were not.

Conclusions:
Prior sufficient warfarinization was associated with mild neurological severity and favorable outcome in acute ischemic stroke patients with NVAF, whereas prior insufficient warfarinization and prior antiplatelet therapy were not.
Abstract W P383: History of Transient Ischemic Attack Affects Outcome from Carotid Artery Stenting
Authors: Macharzina Roland R , Claus Christian , Messé Steven R , Boehme Tanja , Winker Thomas , Rastan Aljoscha , Neumann Franz-Josef , Zeller Thomas
Published: March 2022

Objectives:
Outcomes from carotid artery stenting (CAS) in a real world scenario is of interest to confirm clinical trial findings and to improve selection criteria. This prospective registry study intended to evaluate outcomes and predictors for adverse events of CAS.

Methods:
Patients received neurological and duplex exams before CAS, prior to discharge, and at 30 and 180 day follow-up. Multivariate regression analysis included patient-, lesion- and procedure-related characteristics. The major adverse cerebrovascular and cardiac events (MACCE) endpoint comprised stroke, myocardial infarction and death.

Results:
Three hundred seventy-five consecutive patients underwent CAS between 1998 and 2011. Mean age was 69 ±9.1 years, 53% were symptomatic within the preceding six months (20 minor and 40 major strokes, 140 ipsilateral transient ischemic attacks (TIA)). Mean time to CAS was shorter in patients with TIA compared to stroke, 23 versus 31 days (
P=
0.029). The MACCE rate was 1.6% during intervention and 4.0, 5.6 and 5.9% at discharge, at day 30 and 180. TIA occurred in 31 cases (9.6%) within 30 days. Multivariate regression analysis revealed that history of TIA was independently associated with MACCE (OR: 2.8;
P
=0.04), while prior stroke was not.

Conclusions:
TIA is a common and underappreciated adverse event following CAS. In addition, preprocedural TIA was an independent risk factor for adverse outcomes from CAS, while stroke was not, likely related to the timing of the procedure relative to the index event.
Abstract W P396: Positive Correlation Between Neovascularization Degree of Carotid Atherosclerosis Determined by Contrast-enhanced Ultrasound and Level of Serum C-reactive Protein
Authors: Chang Xiaoni , Feng Jun , Ruan Litao , Shang Jing , Yang Yanqiu , Sun Jian , Dang Ying , Song Yan
Published: March 2022

Objective:
To correlate plaque thickness, artery stenosis and levels of serum C-reactive protein (CRP) with the degree of intraplaque enhancement determined by contrast-enhanced ultrasound (CEUS).

Methods:
CEUS was performed on 72 carotid atherosclerotic plaques in 48 patients. Contrast enhancement within the plaque was categorized as grade 1, 2 or 3. Maximum plaque thickness was measured in short-axis view. Carotid artery stenosis was categorized as mild, moderate or severe. Serum levels of CRP were detected in the fasting state during the same period.

Results:
Patients were divided into three groups according to the degree of contrast enhancement. Plaque contrast enhancement was not associated with the degree of artery stenosis (P>0.05) or with plaque thickness (P>0.05). Serum CRP levels were positively correlated with the number of new vessels in the plaque. CRP levels increased in the three groups(Grade 1: 3.72±1.79mg/L; Grade 2: 7.88±4.24 mg/L; Grade 3: 11.02±3.52 mg/L), with significant differences among them (F=10.14, P<0.01), and significant differences between each two groups (P<0.05). Spearman’s rank correlation analysis showed that serum CRP levels were positively correlated with the degree of carotid plaque enhancement (rs =0.69, P<0.01).

Conclusions:
The degree of plaque enhancement on CEUS was not significantly correlated with plaque thickness or vascular stenosis. However, CEUS could semi-quantitatively evaluate new vessels in plaques, and there was a positive correlation between the degree of intraplaque neovascularization and serum CRP levels. The combination of serum CRP levels and intraplaque neovascularization detected by CEUS may allow more accurate evaluation of plaque stability.
Abstract W P404: Magnetic Particle Surface Characteristics Associated with Bradykinin Upregulation: Cause of Hypotension in the Magnetically-Enhanced Diffusion (MED) of Intravenous tPA in Acute Ischemic Stroke Feasibility Trial
Authors: Derdeyn Colin , Campbell Bruce , Bladin Christopher , Levi Chistopher , Parsons Mark , Panagos Peter , Creighton Francis M
Published: March 2022

Background:
Hypotension during treatment was observed in some subjects in a first in man study of MED. The MED system uses an external magnet and magnetic particles to enhance diffusion of intravenous tPA and speed lysis. While free iron and dextran have been associated with hypotension for commercial iron products, the MED magnetic particles use a PEG coating and possesses nearly no free iron. One potential cause for the hypotension was surface charge, similar to acute hypotension reported with dialysis blood filters and liposomes.

Methods:
Several preclinical experiments were conducted to investigate IgE and complement mediated allergic responses, dose rate vs. dose, baroreflex, and bradykinin upregualtion. Two particle lots were evaluated: Lot A (negatively charged, used in pilot clinical study) and lot B (50% smaller, neutral behavior). For the bradykinin investigation, particle boluses were administered in the presence of a bradykinin blocker (HOE-140) or ACE-I. Mean arterial pressure (MAP) and heart rate (HR) were monitored with acute hypotension defined as a significant drop in MAP over 30s.

Results:
Studies show a dose-rate relationship to hypotension, not total dose, for lot A only. Baroreflex, IgE, and complement mediated allergic mechanisms were deemed unlikely. While rabbits appeared immune to the response, pigs reliably showed a ~30% MAP decline using the lot A particles, and not for lot B. ACE-I premedication resulted in a stronger response whereas HOE-140 premedication prevented hypotension (Figure). HR appeared to be largely unaffected in the study.

Conclusion:
It is believed this study represents the first published relationship between bradykinin upregulation and surface characteristics (charge and/or area). Modification of the magnetic particle surface appears to prevent hypotension. The results may provide a new understanding of hypotension reported with other IV iron compounds.
Abstract W P424: Poor Functional Outcome And Intracerebral Hemorrhage: What Are The Main Factors?
Authors: Terceño Mikel , Silva Yolanda , Serena Joaquín , van Eendenburg Cecile , Blasco Gerard , Puig Josep , Castellanos Mar
Published: March 2022

Background:
Although variables associated with mortality in patients with intracerebral hemorrhage (ICH) are well known, there are few data about which factors are related to functional prognosis in these patients. Therefore, the aim of our study was to study the factors that determine poor functional outcome at three months in patients with ICH.

Material and methods:
We prospectively studied 241 patients consecutively admitted to our stroke unit due to a primary ICH within 12 hours of symptom onset. Clinical, radiological, and analytical data during hospitalisation were collected. Patients were also evaluated at three months. We defined as good outcome if modified Rankin scale (mRS) at three months was ≤2 and bad outcome if mRS was between 3 and 5.

Results:
At three months, 36.1% of patients presented good outcome (group A), 38.2% of patients poor outcome (group B) and 25.7% had died (85.5% of them during hospitalization). Patients of group B were significantly older (67 years vs 63), had a higher NIHSS at admission (15 vs 6), greater basal hematoma volume (23.8 cc vs 6.2 cc) and basal edema volume (10.9 cc vs 3.2 cc), a higher proportion of women (31.4% vs 14.9%), early neurological deterioration (END) (19.8% vs 3.4%), lobar localization of the hematoma (18.6% vs 11.4%), frontal lobe impairment (34.9% vs 9.1%) and insular ribbon (30.2% vs 6.8%), higher mass effect (26.9% vs 16.9%), relevant hematoma growth at 24 hours (78.4% vs 50%) and a greater frequency of more than 2 spot sings on neuroimage (47.8% vs 12.9%).

In the logistic regression analysis, baseline NIHSS, END, lobar localization of the hematoma, frontal lobe and insular ribbon impairment, the presence of mass effect, hematoma and edema volume on baseline CT and a number of spot signs > 2 were significantly associated with poor outcome of patients.

Conclusions:
New radiological variables have to be considered for predicting poor outcome in patients with intracerebral hemorrhage in addition to classical factors.
Abstract W P50: FLAIR Vessel Hyperintensity In TIA and Minor Stroke Predicts Early Recurrent Stroke
Authors: Coleman Elisheva R , Corado Carlos , Bergman Deborah L , Bernstein Richard A , Curran Yvonne , Ruff Ilana M , Ansari Sameer A , Prabhakaran Shyam
Published: March 2022

Objectives:
FLAIR vessel hyperintensity (FVH) is frequently seen in patients with major acute ischemic stroke, but its significance in patients with transient ischemic attack (TIA) and minor stroke is not known. We sought to establish the prevalence of FVH in TIA and minor stroke and assess whether FVH predicts recurrent TIA or ischemic stroke.

Methods:
Consecutive patients from a prospective registry with high-risk TIA or minor stroke between 8/2012-7/2013 were analyzed based on these inclusion criteria: symptoms of unilateral weakness and/or speech deficit, NIHSS score ≤5, and completion of MRI within 48 hours of symptom onset. We excluded patients with isolated brainstem or cerebellar syndromes. MRI scans were reviewed by a single rater who was blinded to clinical data and used examples from published literature to score the presence of FVH and classify its location as proximal MCA, distal MCA, or PCA. After FVH rating, DWI and head and neck MRA were rated for presence of restricted diffusion and stenosis or occlusion. We employed univariable and multivariable statistics to identify independent predictors of FVH, and to examine the association between FVH and stroke recurrence.

Results:
Among 136 patients (mean age 69.5 ± 13.5 years; 43.4% female; 69.1% white; median NIHSS 1), 29 (21.3%) had FVH. The most common location was MCA (distal only 23; proximal only 1; distal/proximal: 3) with only 2 in the PCA. In multivariable analysis, the following variables were strongly associated with FVH: ipsilateral intracranial occlusion/stenosis (OR 13.7, 95% CI 4.8-39.2, p<0.001) and cardioembolic TOAST subtype (OR 7.4, CI 2.3-23.4, p=0.001). Neither DWI lesion nor ABCD2 score was associated with FVH. Patients with FVH were more likely to experience recurrent stroke or TIA within 90 days (17.2% vs. 1.9%; p=0.005).

Conclusions:
FVH is common in high-risk TIA and minor stroke patients, is associated with ipsilateral intracranial stenosis or occlusion, and strongly predicts recurrent TIA or stroke within 90 days. Since FVH did not correlate with DWI or ABCD2 scores, it should be considered in larger studies of clinical-imaging prediction tools of stroke risk after TIA and minor stroke.
Abstract W P59: Safety and Efficacy of Acute Clopidogrel Load in Patients with Moderate and Severe Ischemic Strokes
Authors: Shaban Amir , Rincon Natalia , Tiu Jonathan , Valmoria Melisa , Monlezun Dominique , Martin-Schild Sheryl
Published: March 2022

Objective:
To study the safety and efficacy of clopidogrel loading in patients with moderate and severe strokes.

Background:
The safety of clopidogrel loading has been extensively investigated in patients with minor strokes and transient ischemic attacks.

Methods:
AIS patients presenting consecutively to our center from 06/07/07-07/31/13 were screened. Clopidogrel loading was defined as at least 300 mg dose (with or without aspirin) given within 6 hours of admission. We compared outcomes in patients with baseline NIHSS >3 with and without clopidogrel loading.

Results:
Inclusion criteria were met for 1011 patients (43.6% females, 69.1% black, median age 63). Patients with clopidogrel loading had lower baseline NIHSS than patients not loaded (8 vs 9, p=0.005). The two groups had similar risk of hemorrhagic transformation (p=0.918) and symptomatic hemorrhage (p=0.599). Patients who were loaded had a lower rate of neuroworsening (defined as an increase in NIHSS score by 2 points within 24 hours, 38.9% vs 48.3%, p=0.031) and less in-hospital mortality (4.3% vs 13.4%, p=0.001) compared to those who were not loaded. The likelihood of having a poor functional outcome (defined as mRS > 2 on discharge) did not differ between the two groups after adjusting for NIHSS on admission (OR=0.71, 95% CI 0.4633-1.0906, p=0.118).

Conclusion:
Clopidogrel loading dose is safe and was associated with reduced rates of neuroworsening and mortality following AIS in patients with more than minor stroke. A prospective study of safety and efficacy at preventing stroke progression more than minor strokes is warranted.
Abstract W P62: Symptomatic Intracerebral Hemorrhage after Thrombolysis in MRI Selected Patients is Rare and Unpredictable
Authors: Simonsen Claus Z , Schmitz Marie L , Madsen Mette H , Mikkelsen Irene K , Andersen Grethe
Published: March 2022

Background:
Symptomatic intracerebral hemorrhage (sICH) is the most feared complication following intravenous tissue plasminogen activator (IV-tPA) in ischemic stroke with a mortality rate of 50%. The strictest definition of a sICH is a parenchymal hemorrhage type 2 (defined as a hemorrhage of more than 30% of the infarct with a mass effect or hemorrhage in an unrelated area) and associated with an increase in NIHSS of 4 points or more. The incidence of sICH in a stroke cohort selected by CT was nearly 3% in a recent study.

Objectives:
We examined the incidence of sICH in acute MRI-evaluated stroke patients treated with IV-tPA in a Danish stroke center between 2004 and 2010. We also sought to identify clinical and imaging factors related to an increased risk of sICH.

Methods:
MRI is the preferred imaging modality for patients presenting with symptoms of acute stroke at our hospital. Treatment with IV tPA was guided by MRI findings and patients with DWI lesions >1/3 of MCA was excluded from therapy. No higher or lower NIHSS cut off was applied and treatment was initiated within 4.5 hours from symptom onset.

Results:
Overall, 519 patients received IV tPA on the basis of an acute MRI scan. (Forty-six patients who received both IV tPA and intraarterial treatment were excluded.) Six patients (1.2%) had a sICH as defined above. Age, acute DWI lesion size, stroke severity and time to treatment did not differ significantly among patients with and without a sICH. The patients with sICH did not differ from the patients not suffering sICH regarding vascular risk factors (sex, hypertension, diabetes, hyperlipidemia, smokingor atrial fibrillation). However, five patients suffering an sICH (83%) were taking antiplatelet drugs prior to treatment, while only 33% of the “non-bleeders” were (p=0.03).

Conclusion:
MRI-based IV tPA, with exclusion of large infarct sizes from treatment, is associated with low rates of sICH. No pretreatment clinical or imaging characteristics, but antiplatelet drugs, could identify patients with an increased risk of sICH.
Abstract W P78: Gene Expression Comparison of Flow Diversion and Coiling in an Experimental Aneurysm Model
Authors: Puffer Cole , Ding Yong-Hong , Dai Daying , Cebral Juan , Kallmes David , Kadirvel Ram
Published: March 2022

Backgound and Purpose:
Mechanisms of both healing and complications, including spontaneous aneurysm rupture, remain unclear following flow diverter treatment. The aim of the current study was to compare the gene expression of various key molecules involved in the healing of aneurysms between aneurysms treated with microcoils and flow diverters.

Methods:
Saccular aneurysms were created in rabbits (n=12). Aneurysms were either treated with coils (n=6) or with flow diverters (n=6). Aneurysm tissue was harvested at four weeks following treatment and used for gene expression and zymography experiments. Genes with a fold change of 1.2 or greater were considered up regulated, whereas those with a fold change of 0.8 or less were considered down regulated.

Results:
All coil embolized aneurysms were completely occluded at follow up. Two aneurysms were occluded and the remaining four samples were incompletely occluded in the flow diverter treated group. The following genes were expressed at lower levels in the flow diverter group as compared to the coiled aneurysm group: genes encoding proteinases (matrix metalloproteinases -2 and -9), cellular markers (endothelial nitric oxide synthase and smooth muscle actin), and structural proteins (collagens and fibronectin). Genes related to inflammation (tumor necrosis factor-α and monocyte chemoattractant protein -1) were up regulated in flow diverter treated aneurysms compared to coil embolized aneurysms. Notably, the enzymatic activity of active MMP-9 was high in aneurysms treated with flow diverters.

Conclusion:
As compared to coiled aneurysms, the molecular milieu surrounding aneurysms treated with flow diverters is characterized by higher levels of activated proteases, elevated expression of genes encoding inflammatory proteins, and diminished expression of genes encoding structural proteins. These data may provide improved understanding of rupture risk and healing following aneurysm treatment, and inform development of therapies aimed at lowering rupture risk and accelerating healing.
Abstract W P90: Valproic Acid Ameliorates Ischemic Brain Injury in Hyperglycemic Rats with Permanent Middle Cerebral Occlusion
Authors: Suda Satoshi , Saito Moeko , Inaba Toshiki , Nishiyama Yasuhiro , Nito Chikako , Ueda Masayuki , Katayama Yasuo , Kimura Kazumi
Published: March 2022

Background:
Valproic acid (VPA) is widely used for the treatment of epilepsy in clinic. Some previous studies demonstrated that VPA ameliorated brain injury following experimental stroke. However, the effect of VPA in stroke model with comorbid conditions has not been fully studied. In this study, we investigated the effects of VPA in permanent ischemic stroke with hyperglycemia.

Methods:
Male Sprague-Dawley rats were subjected to permanent middle cerebral artery occlusion according to a modification of the Tamura method. Hyperglycemia was induced by streptozotocin (STZ) injection 3 days before ischemia induction. The animals received a single injection of VPA immediately after the induction of ischemia. Vehicle-treated animals underwent the same procedure with physiological saline. Infarct volume, neurological deficits and immunohistological assessments were performed 3 days after ischemia.

Results:
Hyperglycemia significantly enhanced the number of myeloperoxidase-positive cells, ionized calcium binding adapter molecule 1-positive cells, inducible nitric oxide synthase-positive cells, von Willebrand factor-positive cells, and Fluoro-Jade C-positive cells in the ischemic boundary zone, which was accompanied by increased infarct volume and neurological deficit compared with normoglycemia (p < 0.05; Figure). VPA significantly alleviated the aggravation of neurological deficit by suppressing these inflammation, endothelial injury, and neuronal degeneration compared with saline-treated group (p < 0.05; Figure).

Conclusions:
Our results showed that VPA ameliorated neurological deficits through modulating the inflammatory responses and protecting endothelial damage, leading to reduced neuronal cell death following ischemia in STZ-induced hyperglycemic rats.
Abstract 103: Infarct Patterns in the Anterior Circulation as Predictors of Recurrent Stroke in the Medical Arm of SAMMPRIS
Authors: Wabnitz Ashley M , Derdeyn Colin P , Fiorella David J , Lynn Michael J , Cotsonis George A , Liebeskind David S , Waters Michael F , Lutsep Helmi , Lopez-Cancio Elena , Turan Tanya N , Lane Bethany F , Montgomery Jean , Janis L. S , Chimowitz Marc I ,   for the SAMMPRIS Investigators
Published: March 2022

Introduction:
A previous SAMMPRIS analysis showed that stroke as the qualifying event and old infarct in the territory of the stenosis were independently associated with recurrent stroke in the medical arm. We sought to refine these findings by characterizing the relationships between the patterns of infarcts on baseline brain imaging, collateral flow, and risk of stroke.

Methods:
In the medical arm of SAMMPRIS, 101 patients had acute infarcts in the territory of a stenotic MCA or ICA stenosis on baseline imaging. Blinded to patient outcome, infarcts were characterized as involving primarily the core MCA, internal or cortical borderzone (BZN), or perforator territories. Among these 3 subgroups, the time to primary endpoint (logrank test) and collateral blood flow on baseline angiography (Chi-square tests) were compared. Old infarcts in the same territory were also characterized according to infarct patterns and correlated with acute infarct patterns and outcome.

Results:
The table shows rates of stroke in the territory during follow-up in the 3 groups of patients (n = 101) with different acute infarct patterns. Data on collaterals were available in 82/101 patients. Among those, no or partial collaterals were seen in 30/43 patients (70%) with acute BDZ, 7/19 (37%) with core MCA, and 11/20 (55%) with perforator patterns (p = 0.049). Old infarcts in the territory on baseline imaging were also seen in 30/101 patients. Among those, recurrent stroke in the territory occurred in 12/30 (40%), all of whom had either an acute or old BDZ infarct on baseline imaging. Of 14 patients with both acute and old BDZ infarcts on baseline imaging, 50% had a recurrent stroke in the territory during follow-up.

Conclusion:
Infarct patterns in patients with intracranial stenosis presenting with stroke help refine risk stratification. BDZ infarcts are usually associated with impaired collateral flow and are predictive of a particularly high risk of recurrent stroke during follow-up.
Abstract 133: Donor Age Drastically Affects Structural and Functional Recovery After Cell Therapy Following Ischemic Stroke
Authors: Yamaguchi Susumu , Horie Nobtaka , Satoh Katsuya , Matsuo Takayuki
Published: March 2022

Background and purpose:
Cell transplantation therapy hold great potential to improve impairments after cerebral ischemia. However, it is still unclear whether donor age affects structural and functional recovery after cell therapy. Here, we investigate the hypothesis that donor age (Young vs. Old) drastically affects the repair mechanism after cell transplantation for ischemic stroke.

Methods:
Male Sprague Dawley rats were subjected to transient middle cerebral artery occlusion. At 24 hours after stroke, rats were randomly assigned to receive PBS (Control), human mesenchymal stem cells derived from 24 years old man (Young) and MSC derived from 64 years old man (Old) via internal carotid artery. Behavioral recovery was assessed with modified Neurological severity score (mNSS) until 21 days (D21) after stroke. Animals were euthanized at D21, and histological analysis was performed regarding neovascularization and neurogenesis.

Results:
Young showed a significant recovery in mNSS (3.7±0.6) compared with Control (6.1±0.5) or Old (5.2±0.7) at D21 (P<0.01). Immunohistological analysis revealed that the number of RECA-1 and PDGFR-1β double positive vessels much increased in Young (113±48.6/mm2) compared with that in Control (61.5±35.9/mm2) or Old (76.9±36.9/mm2) suggesting vessel maturation (P <0.01). Interestingly, direction of the astrocyte process, defined as direction index, significantly correlated with the number of Msi-1 positive neural stem cells (P<0.01, r=0.27; Spearman), and direction index with many neural stem cells was significantly higher in Young compared with Old (P <0.05).

Conclusions:
Donor age drastically affects the host environment and functional recovery after cell transplantation for ischemic stroke. This study revealed that direction of the astrocyte contributed to neural stem cell migration into the periinfarct area. Young hMSC was superior to old hMSC in structural and functional recovery after ischemic stroke.
Abstract 14: Size Ratio can be a Strong Predictor for Future Rupture of the Unruptured Cerebral Aneurysms
Authors: Morita Akio , Tominari Shinjiro ,   UCAS Japan Investigators
Published: March 2022

Introduction:
Various factors have been nominated for the rupture of unruptured cerebral aneurysms including size, shape and specific locations of aneurysms. Size ratio, which is the quotient of maximum size of the aneurysm divided by the diameter of the adjacent parent artery, has also been nominated as a strong indicator to discriminate ruptured versus unruptured cerebral aneurysms. However, this has never been tested as a risk in the prospective cohort. In this paper, we have assimilated size ratio in cases of UCAS Japan using reported average parent arterial size and evaluated its value.

Methods:
We used average main intracranial artery diameter reported in anatomical studies as follows: AComA: 1.5mm, MCA: 3.9mm, ICA: 4.3mm, PComA: 1.3mm, BA: 4.1mm and VA: 3.9mm. UCAS Japan cohort, which is a Japanese prospective cohort of unruptured cerebral aneurysms in Japan, were utilized (6,312 aneurysms with 11,011 aneurysm*year follow-up).

Result:
Rupture risks according to this assimilated size ratio (aSR) were as follows: aSR<1.0: 0.13%/yr, aSR:1∼1.5: 0.24%/yr, aSR 1.5∼2: 1.17%/yr, aSR: 2∼3: 1.03%/yr, aSR 3-; 2.62%/yr. With multivariate logistic regression model, aSR >1.5 was significant factor along with presence of daughter sac, symptomatic presentation and age >=70. Hazard ratio for the aSR>1.5 was 6.01 and the highest among these factors. Aneurysm locations lost its significance as the influencing factor.

Conclusions:
While our outcome was limited because the parent artery size was not measured in individual cases, our aSR showed clear demarcation of the future rupture risk. Rather than considering specific location as the risk factor, size ratio might be more important rupture predictor in assessing natural course of unruptured cerebral aneurysms.
Abstract 149: Association of Ischemic Stroke Location and Demographic Variables with Percutaneous Endoscopic Gastrostomy Placement
Authors: Star Michael , Sucharew Heidi , Ruland Sean , Moomaw Charles J , Alwell Kathleen , Kissela Brett M , Flaherty Matthew , Woo Daniel , Mackey Jason , Martini Sharyl , Adeoye Opeolu , Ferioli Simona , De Los Rios La Rosa Felipe , Kleindorfer Dawn O
Published: March 2022

Introduction:
PEG is often necessary in patients with dysphagia after ischemic strokes (IS) to prevent aspiration. As cranial nerve nuclei responsible for swallowing are in the brainstem; it seems intuitive that IS in the posterior circulation (PC) would cause dysphagia requiring PEG. We describe current clinical practice patterns within a large, biracial population.

Methods:
Within the Greater Cincinnati/Northern Kentucky region (population ∼1.3 million) we screened all 15 local hospitals’ admissions in 2010 using ICD-9 discharge codes 430-436. All cases were study physician confirmed. IS location was determined by brain imaging or study physician clinical impression. Demographic and clinical variables included age, race, sex, insurance status, baseline rNIHSS, atrial fibrillation (AF), dysphagia, thrombolysis, bi-hemispheric stroke, community or academic hospital, and volume of stroke admission. Logistic regression was used to evaluate associations between PEG and clinical/demographic characteristics.

Results:
Our sample included 2168 patients with IS; 118 underwent PEG placement. The overall population was 55% women and 22% black. Of the PEG patients,62% were women and 32% were black. Median (range) age was 74 (66-83) yrs in PEG patients and 71 (58-82) in those without PEG. In patients with PC only stroke, 16/457 (3.5%) had a PEG, while 83/1365 (6.0%) of anterior circulation only stroke required PEG and 19/346 (5.5%) of patients with both anterior and PC stroke required PEG. Findings were not explained by differences in hospice/mortality rates. In multivariable analysis, black race, rNIHSS, AF, and dysphagia were strongly associated with PEG (table).

Conclusions:
PC strokes were not more likely to undergo PEG placement compared to anterior circulation IS within our population. Further investigation is needed to understand the associations of PEG with black race and AF, including possible racial differences in approach to end-of-life care.
Abstract 150: Complications and Outcomes of Thrombolysis in Stroke Patients Aged 90 and Over: UK National Registry Data
Authors: Paley Lizz , Bray Benjamin , James Martin , Tyrrell Pippa , Behrouz Reza , Smith Craig J , Di Napoli Mario , Cloud Geoffrey , Rudd Anthony ,   On behalf of the SSNAP Collaboration
Published: March 2022

Introduction:
National clinical guidelines in England and Wales recommend that intravenous thrombolysis is provided without restriction based on age. However, thrombolysis trials have included very few patients aged 90 and over. We therefore analysed data from the national stroke register of England and Wales to describe the safety and outcomes of thrombolysis in patients aged 90 and over.

Methods:
Data were extracted from the national stroke register (Sentinel Stroke National Audit Programme (SSNAP)) of adults with acute ischemic stroke treated in all hospitals in England and Wales from April 2013-March 2015.

Results:
Of 128826 adults with acute ischemic stroke admitted to 202 hospitals, 14854 (11.5%) were aged 90 or over. Of these, 1262 (8.5%) were treated with intravenous alteplase (iv-tPA).

Females comprised 70.0% of treated patients aged 90 or over, 6.3% had stroke onset whilst already an inpatient, 65.0% were independent prior to stroke (mRS of 2 or less), 71.2% were fully conscious upon arrival at hospital and 37.2% had a diagnosis of atrial fibrillation prior to stroke. The median age of the thrombolysed patients was 92 (IQR 91-94), similar to patients aged 90 or over who were not treated. Median NIHSS score was 14 (IQR 9-20).

Following tPA, 12.5% of patients had complications; 4.8% had symptomatic intracranial hemorrhage, 0.7% had angioedema, 0.6% had extracranial bleeds and 6.6% had some other type of tPA complication.

The median NIHSS 24h after tPA was 10 (IQR 4-18). Of the 871 patients (69.0%) who had a fully completed NIHSS at arrival and at 24h after thrombolysis, the median improvement was 3 points on the scale (IQR 0-7).

Inpatient case fatality rate was 32.8%, 20.9% were independent upon discharge from inpatient care (Rankin 2 or below), 14.1% were newly institutionalised into a care home (21.0% of those discharged alive).

Conclusions:
Patients aged 90 and over treated with iv-tPA have a similar rate of complications as reported for younger patients in national registries and clinical trials. However stroke in this age group carries a high risk of mortality and a high proportion of survivors are discharged to long term care for the first time.
Abstract 153: Shorter, More Frequent Out of Bed Activity Very Early After Stroke (AVERT) is Associated With a Favorable Outcome at 3 Months
Authors: Bernhardt Julie , Churilov Leonid , Ellery Fiona , Collier Janice , Langhorne Peter , Lindley Richard I , Moodie Marjorie , Dewey Helen , Thrift Amanda G , Donnan Geoffrey A ,   on behalf of the AVERT Trialists' Collaboration
Published: March 2022

Introduction:
A Very Early Rehabilitation Trial (AVERT) is a randomized controlled trial to test the efficacy and safety of early and frequent mobilization after stroke (The Lancet, 2015, 386, p46-55). Our pre-specified dose response analyses of the AVERT trial aims to provide practical guidance for clinicians on the timing, frequency and dose of mobilization following acute stroke.

Methods:
Eligible patients were aged ≥18 years, had confirmed first (or recurrent) stroke, and were admitted to a stroke unit within 24 hours of stroke onset. Patients were randomized to receive very early and frequent mobilization, commencing within 24 hours, or usual care. The timing, frequency and amount (minutes) of all out of bed mobilization was recorded online. We used regression analyses and Classification and Regression Trees (CART®)
2
to investigate the effect of timing and dose of mobilization on efficacy and safety outcomes, irrespective of assigned treatment group.

Results:
2104 patients were enrolled between 18 July 2006 and 16 October 2014, of whom 2083 (99.0%) were followed up at 3 months. No patients withdrew due to adverse events. We found a consistent pattern of improved odds of favorable outcome in efficacy and safety with increased daily frequency of out of bed sessions (OR 1.13, 95% CI 1.09 to 1.18, p<0.001) keeping time to first mobilization and amount of mobilization constant. Increased amount of mobilization reduced the odds of a good outcome (OR 0.94, 95% CI 0.91 to 0.97, p<0.001). Session frequency was the most important variable in the CART® analysis, after prognostic variables age and baseline stroke severity.

Conclusions:
These data suggest that shorter, more frequent mobilization early after acute stroke is associated with a greater odds of favorable outcome at 3 months when controlling for age and stroke severity. This study provides class III evidence that shorter, more frequent early mobilization improves the chance of regaining independence after stroke.