bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP247: Real-time Videomonitoring Markedly Shortens Time Delays For Reperfusion In Acute Stroke
Authors: SANJUAN ESTELA , RUBIERA MARTA , RIBO MARC , KALLAS JULIA A , MELER PILAR , MUCHADA MARIAN , PAGOLA JORGE , RODRIGUEZ-LUNA DAVID , FLORES ALAN A , MOLINA CARLOS A
Published: July 2021

Introduction:
Shortening door-to-needle time is one of the major goals of reperfusion therapy for acute stroke. Real-time videomonitoring provides 24/7 expert support and may potentially accelerate actions taken and improve the decision-making in candidates for reperfusion. We aimed to evaluate the impact of real-time videomonitoring on shortening in-hospital time delays for reperfusion therapy and on the quality of care in acute stroke patients.

Methods:
We evaluated consecutive patients, candidates for reperfusion who underwent stroke code activation. All were admitted to the ER and emergently evaluated by a Stroke Neurologist either in a designated stroke box with videomonitoring (VM) or in a conventional box without VM (NonVM). In all patients, time delays were prospectively collected in specific worksheets. Real-time VM was conducted by experienced stroke researchers who interacted and encouraged speediness of the evaluation process as well as timed and stored images at pre-specified time-points.

Results:
A total of 100 patients were evaluated. 50 on each arm. There were no significant differences between groups in baseline characteristics: Age (VM 70.7 ±16 vs. 71.1±12 in NonVM patients), gender (52% and 50% of men), median time from symptoms onset to admission (76 vs. 73min) and baseline stroke severity NIHSS score (6 vs. 7). In the VM group the median time for blood sampling was 5minutes, and duration of TCD exam 7minutes. Overall median time in box was significantly shorter in VM 13±9min compared to NonVM 20±12 min, p=0.045. VM significantly reduces the time to fist neurological evaluation <5min (VM 98% vs. NonVM 88%), p=0.038. Door-to-CT time was <25minutes in VM (50%) compared to NonVM (42%), p=0,052. 48% of VM and 44% of NonVM patients received reperfusion therapy. The goal of door-to-needle <40min was achieved in 77.8% of VM compared to only 52% of NonVM patients (p=0.034).

Conclusion:
Real-time VM markedly reduces in-hospital delays for reperfusion therapy by shortening time to neurological evaluation, time to CT, and door-to-needle times. Larger studies are needed to evaluate the yield and impact of real-time VM on stroke outcome.
Abstract TP261: Spontaneous Strokes In Sickle Cell Transgenic Mice Captured Ex Vivo With Magnetic Resonance Imaging
Authors: Keegan Philip M , Keifer Orion P , Parker Ivana L , Keilholz Shella D , Platt Manu O
Published: July 2021

With 11% of children with sickle cell disease (SCD) having strokes, many as early as 1 to 5 years old, the underlying mechanisms are still unclear, and it is still unknown why this subpopulation has greater risk. More will suffer from subclinical silent strokes that cause cognitive rather than physical impairments. Sickling of red blood cells due to a point mutation in hemoglobin induces chronic inflammation and vascular remodeling in SCD. We have previously shown that powerful proteases, cathepsins, are activated in SCD to promote vascular remodeling that could lead to stroke. However, a mouse model of detectable sickle cell stroke is required to study mechanism and intervention strategies. Here, we used Townes sickle transgenic mouse, with murine hemoglobin knocked out and replaced with human, sickle hemoglobin, to test the hypothesis that sickle transgenic mice have MRI detectable strokes and increased cathepsin proteolytic activity. Three mice homozygous for sickle mutation (SS) and 6 heterozygous littermate controls (AS) were perfused at 8 weeks. Brains were isolated, embedded in gadolinium-agarose, and scanned using a Bruker 9.4 Tesla magnet with a T2-weighted protocol (TE = 13.4 ms. TR= 10,000, 512 x 512 x 70). Of the 3 SS mice, 2 had abnormalities suggestive of stroke (Figure 1, red arrows), with none noted in the AS controls. Separately, immunohistochemistry with anti-cathepsin K antibody indicated a gene dosing effect of sickle allele on cathepsin K expression (SS>AS>AA), verified in aorta homogenates by multiplex cathepsin zymography assays (n=3, p<.05). To conclude, we have identified strokes in sickle transgenic mice with T2 images. These mouse stroke scans, without occlusive or chemical intervention, will be an improved model to test spontaneous stroke interventions specific to sickle cell disease including targeting upregulated cathepsins.
Abstract TP28: Combining Clinical with Radiographic Criteria to Select Patients for Endovascular Therapy in Acute Stroke
Authors: Grossman Aaron W , Martin ReneéL , Tomsick Thomas A , Khatri Pooja , Broderick Joseph P
Published: July 2021

BACKGROUND:
Patient selection is emerging as an important aspect of interventional treatment of acute ischemic stroke. The baseline CT scan and NIHSS can be performed very quickly to identify those patients who will have proximal arterial occlusions (PAOs) amenable to endovascular therapy. Hyperdense arteries (HDAs) identified on thin-slice reconstruction (0.625 mm slice) CT have been shown to predict PAOs on CT Angiography. We sought to determine whether the combination of clinical (NIHSS strata) and radiographic (standard 5mm slice non-contrast head CT) criteria could better identify ideal candidates for endovascular therapy.

METHODS:
We reviewed IMS I and II subjects who were treated with IV tPA for an anterior circulation stroke, and had a baseline standard head CT followed by a digital subtraction angiogram (DSA; n = 144 of the 161 patients in IMS I and II). Stroke severity (NIHSS 10-19, or ≥20), presence of a HDA on baseline CT (either in the ICA terminus or M1 branch of the MCA), and the location of arterial occlusions (either partial or complete) on DSA were determined. We calculated sensitivity, specificity and the positive predictive value (PPV) of stroke severity and a HDA for the presence of a PAO (ICA, M1 or M2 branches of MCA).

RESULTS:
64 of 144 patients (44%) had a NIHSS ≥20. 74 of 144 patients (51%) had a HDA on CT (39 patients or 49% with NIHSS 10-19; 35 patients or 55% with NIHSS ≥20). After IV tPA, a PAO was seen on DSA in 105 (73%) of patients. DSA showed distal or no occlusion in 39 patients (13 of whom had a HDA on CT). The PPV of a HDA for a PAO was 82% (95%CI = 72-90%; sens = 58%, spec = 67%), whereas the PPV of NIHSS ≥20 for a PAO was 78% (95%CI = 66-87%; sens = 48%, spec = 64%). In patients with a HDA, consideration of stroke severity (NIHSS ≥20) only improved the PPV for a PAO to 86% (95%CI = 70-95%; sens = 60%, spec = 31%). In those with a HDA and a less severe stroke (NIHSS 10-19), PPV was 79% (95%CI = 63-91%; sens = 56%, spec = 68%).

CONCLUSIONS:
In patients with acute anterior circulation ischemic stroke, adding stroke severity does not appear to significantly improve the predictive value of a hyperdense artery on baseline standard CT for the presence of a proximal arterial occlusion after IV t-PA. Further study is needed to identify patients who are candidates for endovascular therapy.
Abstract TP316: When Push Comes to Shove… Pulling is Better: Achieving Better Outcomes by Actively Seeking (Pulling) Stroke Patients for Rehabilitation
Authors: Chan Kien Y , Granger Andrew S , Lee Scott
Published: July 2021

Background:
The length of stay (LOS) of stroke patients in the acute hospital coming to our stroke rehabilitation unit (SRU) has remained largely unchanged despite increasing administrative pressure for earlier discharge in recent years. Reducing this LOS can ease bed pressure and may also improve patient outcome. We explore the effect of changing the model of stroke rehabilitation consultation from patients being referred (or “push”) by the acute team, to the SRU team actively seeking (or “pull”) patients prior to referral.

Methods:
From November 2010 to December 2011, potential stroke rehabilitation patients were sought daily in targeted wards in Sir Charles Gairdner Hospital (our main referring hospital), lead by a consultant geriatrician. Patients were identified by screening the nurses’ hand over sheet, discussing with the treating medical and allied health team, and reviewing the patients and case notes. Patients were reviewed regularly until their rehabilitation/discharge plan is finalised. The patients’ characteristics and rehabilitation outcome over the two periods before and after service initiation were compared.

Results:
Over the 14 months, 89 patients were admitted to our SRU, with an average acute hospital LOS of 12.5 days, a 5 days reduction compared to previous years (1996-October 2010: 17.9 days, n=716). The 89 patients were more disabled (average admission functional independence measure [FIM] 69 compare to 73), but with no worsening of outcome (including discharge FIM, FIM efficacy, FIM efficiency, LOS in SRU, % discharged home and mortality).

Discussion and Conclusion:
The “pull” model in consultation avoids delays from administrative inefficiencies in referring a patient, and allows earlier involvement in discharge planning. This is likely to have contributed to the earlier rehabilitation admission. While this did not change the patients’ outcome, however, the reduction in acute hospital LOS has financial benefit (445 bed days and $800,000 AUD saved over this period). The earlier involvement in patients’ care also facilitates a more seamless transition to rehabilitation. In conclusion, ‘pulling’ patients for stroke rehabilitation is a cost-effective way to reduce LOS in the acute hospital, and may improve rehabilitation outcome.
Abstract TP318: The Circumstances and Consequences of Post-stroke Falls
Authors: Schmid Arlene A , Yaggi H. Klar , Burrus Nicolas , McClain Vincent , Austin Charles , Ferguson Jared , Fragoso Carlos , Sico Jason , Ofner Susan , Miech Edward J , Matthias Marianne S , Williams Linda S , Bravata Dawn M
Published: July 2021

Introduction:
Three-quarters of people with stroke sustain a fall. Fall risk and risk for injury persists into the chronics phases of stroke recovery. Currently, the circumstances surrounding post-stroke falls are not well understood; identifying these circumstances is a key step in the development of fall prevention programs. Likewise, the consequences of falls during the chronic phases of stroke are largely unexplored.

Objectives:
The objectives of the study were to identify the circumstances and consequences of post-stroke fall events.

Methods:
This is a secondary analysis of data derived from a large trial. To be included in the trial and these analyses, participants had to have survived a stroke and had a diagnosis of hypertension or blood pressure >140/90 mmHg. Demographics and stroke characteristics were recorded. Patients were asked about falls prospectively over the one-year study period. Once a fall event was identified, chart review and interviews were used to obtain information regarding circumstances and consequences of the fall. Fall circumstances were separated into intrinsic/personal and environmental categories including: falls with activity; falls with movement; falls due to trips or slips; falls related to a physical or mental state; location of the fall; and the season when the fall occurred. Consequences of falls were classified according to type of injury (laceration, fracture) and medical care received.

Results:
A total of 53 of the 225 (33%) participants reported a fall; 70% of falls occurred at home and 40% of falls were associated with impaired physical or mental state (e.g., falling asleep and falling out of a chair or inattention to tying shoes, or forgetting to use a device). Additionally, 21% of falls were associated with activities, 21% with mobility, and 34% with slips or trips. The majority of people who fell sustained an injury (72%); injuries ranged from bruising to fractures and 55% of those with an injury sought medical care (32% to emergency).

Conclusion:
Post-stroke falls are associated with an alarming rate of injury and healthcare utilization. Targeting mental and physical states may be key to fall prevention programming for people with chronic stroke.
Abstract TP321: Testing a Neural Activity Triggered Device for Stroke Rehabilitation
Authors: Song Jie , Walton Leo , Pizarro Ricardo , Vergun Svyatoslav , Nair Veena , Tyler Mitch , Sattin Justin , Farrar-Edwards Dorothy , Williams Justin , Prabhakaran Vivek
Published: July 2021

Background:
In this ongoing study we are testing a closed-loop neurological feedback device that can facilitate functional recovery in stroke patients with upper extremity motor deficits.

Methods:
This device combines Brain Computer Interface (BCI) and functional electrical muscle stimulation (FES), together with tongue stimulation (TS) in order to utilize the subject’s intention-to-move with the stimulated output. FMRI is used to examine the brain plasticity changes secondary to the rehabilitation. Subjects, wearing a 16-channel EEG cap, are first trained to voluntarily modulate beta and mu rhythms as they use motor imagery or execution of left and right hand squeezing task and then trained to use this imagery or execution to control the movement of a cursor, either to the right or the left depending on the presentation of a target rectangle shown on the screen. Once subjects achieve consistent accuracy in doing this task, FES in conjunction with TS is used. The subject is then asked to perform the task with the stimulation of FES and TS linked to their task performance.

Results:
Two chronic stroke patients (mean age=57, 1 male, more than 1 year postonset) were able to complete the entire 3-week BCI training course and to perform the tasks at a > 70% success rate. Cortical activation recorded by EEG in response to attempted paretic arm movement became concentrated over the contralateral motor areas. Similar changes were confirmed by fMRI measures (Figure 1). Although neither subject showed any improvement on the Action Research Arm Test (ARAT), subjects self-reported increased strength, less spasticity and a greater range of movement in their paretic arm.

Conclusion:
Our preliminary results indicate that training with the device may lead to brain plasticity changes toward normalization of cortical activation patterns and promote behavioral improvements for stroke patients even in their chronic stage.
Abstract TP322: Towards better screening for Post Stroke Depression
Authors: Herzig Alyssa J , Mayo Nancy , Miller Syd
Published: July 2021

Post stroke depression (PSD), occurring in 33% of stroke survivors, is considered the most critical obstacle to rehabilitation after stroke. PSD is consistently linked with increased length of hospital stay, motivation to undergo rehabilitation, poorer rehabilitation outcomes, decreased engagement in recreational and social pursuits, decreased quality of life, and mortality. Although addressing PSD should be considered a critical factor in stroke recovery, the condition remains largely under-diagnosed. A challenge to diagnosis of PSD is a lack of appropriate screening tools. Existing screening tools were not designed for stroke populations or are too time consuming and complex to be utilized routinely. The goal of the present study was to identify a quick, two item screening tool for PSD that requires no training or scoring. Specifically, we examined what brief combination of dichotomized self-report questions can be used as indicators for a DSM-IV-TR classification of depression in stroke survivors In this prospective natural history study, a consecutive sample of 121 stroke survivors completed comprehensive interviews at 10 days post stroke. Contender questions assessing mood, cognition, physical functioning, social support, and relationship profiles were selected based on previous findings. At 10 days, 7 of 121 participants were classified as depressed in accordance with the SCID-I, the gold standard diagnostic tool for clinical depression. Results of logistic regression indicated that patients who met threshold on two MHI item, are you a happy person and have you been so down in the dumps, were 25 times more likely to be depressed than patients who did not (C Statistic > 0.90). As well, these brief questions better predicted PSD at 10 days than did the total MHI score. In the present paper, screening models are considered with regard to practical and theoretical issues in the assessment of PSD. The present study indicates that quick and simple screening tools designed for PSD can be used to select patients for diagnostic assessments and facilitate timely diagnoses of PSD. The present study contributes to our understanding of the clinical presentation of depression in the context of stroke and to our goal of facilitating recovery from stroke.
Abstract TP339: Stroke Severity Scoring: A Bi-variate Analysis of Clinical Outcomes Post Intravenous t-PA as a Guide to Influence Potential Change in Clinical Practice
Authors: Rehman Zia u , Mazer Mark A , Freeman Susan D , Small Cristine W , Butt Abid
Published: July 2021

Background:
Care of the acute stroke patient in a dedicated stroke unit or ICU has been associated with improved outcomes. Not all post tPA patients require ICU level care, however general practice is admission to the ICU for 24 hours following tPA administration. In a Certified Primary Stroke Center nestled in the buckle of the stroke belt, 800+ patients with a primary diagnosis of stroke are admitted annually. There is a dedicated stroke unit with continuous multichannel telemetry. All post tPA patients are admitted to the medical ICU for the first 24 hours.

Purpose:
Hospitals administering intravenous tPA should continuously evaluate the impact of patient selection, unit placement and overall outcomes to include clinical efficiency, cost effectiveness, quality, safety, complications and deaths. Partnering with critical care physicians to evaluate stroke severity scores is essential for empirical consideration.

Methods:
Data analysis of clinical elements that may predict patient outcomes and serve as a guide to influence change in clinical practice was reviewed.

Bi-variate analysis of stroke severity scores, whereby the first National Institute of Health Stroke Scale (NIHSS), < 15 and > 15

Review of comorbities

Blood pressure control

Complications to include symptomatic bleeding

Discharge disposition

Death

Results:
Clinical outcomes of 171 patients post tPA administration were reviewed over a two year period.

• 80% of patients with NIHSS < 15 were discharged to home or rehab

• 42% of patients with NIHSS > 15 were discharged to home or rehab

• Four deaths occurred in patients with NIHSS < 15. Three deaths unrelated to tPA administration included one cardiac arrest and two respiratory failure. The fourth death, a regional transfer with advanced age, complex comorbities and uncontrolled blood pressure, resulting in a symptomatic bleed.

• 16 deaths occurred in the patients with NIHSS > 15

Conclusions:
Analytical review of outcome data, specifically stroke severity scores, should serve to influence ICU admission criteria and processes. Engagement of board certified neurocritical physicians or intensivists supports empirical evidence for improved utilization of resources and critical care beds using NIHSS < 15 as a reference.
Abstract TP342: Utilization of Minimally Invasive Hemodynamic Monitoring Via Arterial Line Provides Accurate Data in Which to Treat Cerebral Vasospasm in the Subarachnoid Hemorrhage Population
Authors: Hawk Melissa D , O’Day Kimberly
Published: July 2021

Background and Purpose:
In the subarachnoid hemorrhage (SAH) patient intravascular volume status is one of three important components in the treatment of cerebral vasospasm. Traditionally, pulmonary artery occlusion pressure (PAOP) coupled with central venous pressure (CVP) were values obtained to help determine the intra-vascular volume status in these patients and were used to help guide the treatment of cerebral vasospasm. However, pulmonary artery (PA) catheter derived values are unreliable, and have poor sensitivity and specificity. The use of minimally invasive hemodynamic monitoring via an arterial line has been shown to be more reliable than the PA catheter in determining the state of a patient’s fluid volume status. The goal is to demonstrate that minimally invasive hemodynamic monitoring is a more reliable source of data and therefore a better guide for the treatment of cerebral vasospasm compared to the PA catheter.

Methods:
Our institution’s method of utilizing the minimally invasive hemodynamic monitoring device to aide in determining a patient’s fluid volume status and consequently treating cerebral vasospasm is unconventional from its originally intended use. It was through trial, error, and extensive research that our institution implemented and developed a protocol, therefore eventually replacing the PA catheter. The desired data to be collected is stroke volume variation (SVV) and stroke volume index (SVI). This data is also coupled with CVP obtained via a central venous catheter (CVC). The protocol states that if two out of three of the SVV, SVI, or CVP values are out of desired range, then a fluid bolus should be given. These numbers are adjusted as needed to correlate with both the clinical and pulmonary status of the patient.

Results:
As a result of the initiation of this protocol, coupled with the other two pieces of “Triple H” therapy, there has seemingly been a less incidence of both vasospasm and pulmonary edema compared to the utilization of the PA catheter.

Conclusions:
In conclusion, given that there are no formal studies comparing minimally invasive hemodynamic monitoring directly to the PA catheter in the same patient, formal studies need to be conducted in order to obtain data to confirm observations noted in our institution.
Abstract TP369: Blood Pressure Dynamics During Long Sitting Position In Acute Ischemic Stroke Patients: Prevalence Of Orthostatic Hypotension.
Authors: Sasaki Kaori , Kaneyuki Mika , Fujii Miho , Ota Akiko , Ota Taisei , Nishigaki Masakazu
Published: July 2021

Background and Purpose:
Long sitting positioning (LSP) using head of bed elevation is an important part of early rehabilitation and mobilization for patients with acute ischemic stroke. However, little is known about orthostatic hypotension (OH) during LSP, which is potential risk factor for ischemic stroke recurrence. This study aimed to investigate the prevalence of OH during LSP and its related factors.

Methods:
Patients with acute ischemic stroke were enrolled in this study (n=246, male: 68.1%, mean age 74.7y). Ten-minutes LSP by 70-degree head of bead elevation with successive blood pressure (BP) measurement was conducted a week after their stroke. BP was measured for three times on un-affected arm: pre-measurement in supine position, 1 and 10 minutes after beginning of LSP. OH was defined as ≥20 mmHg fall in systolic BP (SBP) and/ or ≥10 mmHg fall in diastolic BP (DBP) from pre-measurement in supine position. Potential related factors such as demographics, comorbidities, stroke severity, baseline BP were investigated by multivariate logistic analysis.

Results:
The overall prevalence of OH were 15.0% (n=37) at 1 minute and 20.3% (n=50) at 10 minutes after beginning of LSP. Patients with OH at 1 minute were more likely to have higher supine DBP (p=0.034), and patients with OH at 10 minutes were more likely to have higher supine SBP (p=0.004) and DBP (p<0.001). In multivariate logistic analysis showed that older age (OR [95%CI], 1.05[1.01-1.09]), male gender (3.15[1.19-8.33]) and higher supine DBP (1.03[1.00-1.06]) were independently associated with the OH at 1 minute after LSP. Similarly, older age (1.05[1.01-1.08]) and higher supine DBP (1.05[1.03-1.08]) were independently associated with OH at 10minutes after LSP.

Conclusions:
The OH prevalence at 1 minute after beginning of LSP was similar to previous studies which defined OH as hypotension in upright position. However, the prevalence rose remarkably at 10 minutes after LSP, while temporary hemodynamic instability would recover within one minute in healthy adults. These results implicated that impaired activity of the autonomic nervous system in acute ischemic stroke patients was associated with defect in hemodynamics regulation, especially in the patients with older age and/or higher supine BP.
Abstract TP377: Advance Care Planning in Stroke
Authors: Arneson Francine V , Lee Christopher , Kirshner Howard
Published: July 2021

Introduction:
Stroke is a leading cause of death and disability in the United States. In acute stroke, patients are often unable to communicate goals of care. Many survivors of stroke have high morbidity. Communication deficits resulting from stroke often complicate the assessment of patient wishes, particularly in severely disabling strokes. Many advance care documents are vague and not helpful in stroke settings, and many patients have not communicated their wishes.

Methods:
A survey was developed and distributed in hypertension, diabetes, and stroke clinics to test the hypothesis that patients generally desire fewer heroic measures in a severely disabling stroke compared to a milder stroke. The survey included demographics, perceptions of stroke risk, and posed three stroke scenarios to assess care measures preferred in each setting.

Results:
We collected 101 surveys; 59% from patients with stroke; 50% were male. Strong majorities had not had discussions with doctors about advance care plans. Nearly a third had not had these discussions with family. Eighty-nine percent indicated good quality was more valued than duration of life. Generally, respondents would accept invasive therapies in mild stroke scenarios compared to severe stroke scenarios, consistent across all clinics. Tracheostomy was the least desired intervention; although about 40% indicated they would opt for any measure of heroic treatment, regardless of stroke severity.

Conclusions:
Stroke causes significant morbidity, and many individuals have not communicated or even considered their wishes should they face difficult decisions in stroke. We found a wide range of desires in our severe stroke scenario, with no reliable factors to predict those who would opt for heroic measures. We assert that advance care planning specific to stroke among patients at highest risk for stroke would define each individual’s preferences and guide clinicians to provide appropriate care consistent with the patient’s values.
Abstract TP380: Increasing the Sample Size in the Secondary Prevention of Small Subcortical Strokes (SPS3) Trial: What Did We Gain?
Authors: McClure Leslie A , Szychowksi Jeff M , Benavente Oscar , Hart Robert G , Coffey Christopher S
Published: July 2021

Introduction:
The NIH-funded SPS3 study assessed whether combination antiplatelet therapy (AC) was superior to aspirin alone (AP) in preventing recurrent stroke among patients with a lacunar stroke at baseline. Due to lower than expected overall rates of recurrent stroke, the sample size was increased from 2500 to 3000 to ensure adequate power to detect a 25% reduction in recurrent stroke. The antiplatelet trial was terminated early due to lack of efficacy, coupled with safety concerns. We conducted a retrospective analysis to assess the gains achieved by the sample size re-estimation.

Methods:
We assessed the difference in stroke recurrence among the first 2500 patients recruited, assuming follow-up ended when the antiplatlet arm terminated, and compared the results to those obtained with the complete 3020 patients.

Results:
Among the first 2500 patients, we observed 248 events, over an average of 3.9 years follow-up. The recurrent stroke rate for the AC and AP groups was 2.5% and 2.7% per year, respectively. The hazard ratio for AC vs. AP was 0.92 (95% CI: 0.72-1.18). Including the additional 520, only 15 more patients had primary events, and recurrent stroke rates (2.7%, and 2.5% year), and the HR of 0.92 (95% CI: 0.72-1.16) were similar.

Conclusions:
Despite an increase in sample size in SPS3, there was no appreciable difference in the results obtained for the antiplatelet trial had the study adjustment not been made. While sample size re-estimation is an important tool for ensuring adequate power for detecting treatment effects of interest, there is a potential to add unnecessary cost and complexity when no effect exists. More post-hoc examinations of studies using adaptive designs are warranted to understand their strengths and weaknesses.
Abstract TP384: Recovery Trajectories in Acute Non-fatal Stroke
Authors: Busija Lucy , Liew Danny , Yan Bernard , Weir Louise , Hand Peter , Davis Stephen M
Published: July 2021

Introduction:
Traditional approaches to the study of post stroke recovery assume that recovery follows a homogenous path, with deviations from the average explained in terms of socio-demographic and clinical differences. Latent class analysis (LCA) provides a powerful tool to investigate potential heterogeneity in post-stroke recovery pathways.

Aims:
We aimed to 1) explore recovery trajectories in acute stroke over 3 months using LCA and 2) identify predictors of poor recovery.

Methods:
Data from 202 patients admitted to Stroke Care Unit at the Royal Melbourne Hospital (Australia) between January and June 2011 were analyzed. The main outcome was disability (modified Rankin Score) pre-stroke, at discharge, and 3 months post stroke. Predictors of poor recovery were assessed using logistic regression analysis.

Results:
Patients’ mean (SD) age was 68.6 (14.1), 58% were males and 82% had ischemic strokes. LCA identified 6 mutually exclusive recovery trajectories (see Figure 1), including: 1) No disability at onset, no impact from stroke (n=43); 2) Substantial disability, no impact from stroke (n=20); 3) Some disability, mild impact, full recovery (n=36); 4) No disability, mild impact, partial recovery (n=26); 5) No disability, high impact, partial recovery (n=50); 6) No disability, high impact, no recovery (n=27). Compared with those who made at least partial recovery (trajectories 1-5), those who made no recovery at 3 months were significantly younger (OR 0.97 95%CI 0.95,0.99) and more likely to be smokers (OR 2.48 95%CI 1.04,5.90). History of atrial fibrillation, ischemic heart disease, previous stroke, and stroke type were not associated with poor recovery (p≥0.103).

Conclusions:
This study identifies stroke recovery pathways, providing a potentially useful tool for identifying individuals at risk of poor recovery and in need of targeted intervention.
Abstract TP401: Inflated Expectations about Stem Cell Therapy in Patients With Chronic Stroke
Authors: Lee Jinho , Lee Kyu-Yong , Kim Young-Seo , Kim Hyun Young , Kwon Hyuk Sung , Park Hyun-Hee , Choi Na-Young , Lee Eunhye , Son Jeongu , Yu Hyun-Jeung , Lee Yeong Bae , Koh Seong-Ho
Published: July 2021

Introduction:
Stem cell therapy (SCT) has been proposed for the treatment of neurological disorders. Although there isinsufficient clinical evidence to support its efficacy, unproven SCTs are being performed worldwide.

Hypothesis:
In this study, we investigated the perspectives and expectations of chronic ischemic stroke patients and physicians about SCTs.

Methods:
A total of 250 chronic ischemic stroke patients were interviewed at 4 hospitals. Structured open and closed questions about SCT for chronic stroke were asked by trained interviewers using the conventional in-person method. In addition, 250 stroke-related physicians were randomly interviewed via an e-mail questionnaire.

Results:
Of the 250 patients (mean 63 years, 70% male), 121 (46%) responded that they wanted to receive SCT in spite of its unknown side effects. Around 60% of the patients anticipated physical, emotional, and psychological improvement after SCT, and 158 (63%) believed that SCT might prevent strokes. However, physicians had much lower expectations about the effectiveness of SCTs, which was not in line with patient expectations. Multivariate analysis revealed that male gender (OR: 2.00, 95% CI: 1.10-3.64), longer disease duration (OR: 1.01, 95% CI:1.00-1.02), higher modified Rankin Scale score (OR: 1.30, 95% CI 1.06-1.60), and familiarity with stem cells (OR: 1.86, 95% CI: 1.10-3.15) were independently associated with wanting SCT. The major source of information about SCT was television (68%), and the most reliable source was physicians (49%).

Conclusion:
Patients have unfounded expectations that SCT will improve their functioning. Considering our finding that the major source of information on stem cells is media channels but not the physician, to decrease patients’ inappropriate exposure, doctors should make more effort to educate patients using mass media with accurate information.
Abstract TP414: Cerebral Infarction After Antithrombotics Withdrawal and Its Impact on Clinical Outcome
Authors: Lee Keonjoo , Kim Jeong Min , Jung Keun-Hwa , Han Jee-young , Roh Jae-Kyu
Published: July 2021

Background:
The cessation of antithrombotic agent is related with increased thromboembolic events. However, the clinical characteristics of stroke after antithrombotics withdrawal and its impact on stroke outcome have not been studied. In this study we tried to evaluate clinical significance of antithrombotics withdrawal in stroke occurrence and outcome.

Methods:
Between January 1
st
2009, and March 1
st
2012, the acute stroke patients who admitted in Seoul National University Hospital within seven days after symptom onset were eligible in the study. We defined stroke after antithrombotics withdrawal (SAW) as those stroke patients who had maintained antiplatelet agent or anticoagulant regularly but ceased their medication before stroke onset. We reviewed their clinical characteristics as well as the reason of medication cessation, type of medication, and duration between medication hold and stroke onset. To evaluate the effect of antithrombotics withdrawal in stroke outcome, we compared SAW with stroke patients which occurred on regular medication.

Results:
Among 1635 acute stroke patients, 84 patients (5.2%) were identified as SAW during the inclusion period, with a mean age of 68.0±13.2 years including 49 male patients. The most common cause of medication cessation is poor compliance in 32 patients (37.7%), followed by pre-operation/procedure hold in 24, antithrombotics complication in 16, and doctor’s decision in 13. The 42 patients with SAW who had stroke within one month after medication cessation were compared with 261 patients who experienced cerebral infarction during regular medication. Stroke progression defined as 3 or more NIHSS worsening during admission was more prevalent in SAW patients than in patients with regular medication (14.3% vs. 5.0%, p=0.042). The patients with poor functional outcome defined as mRS of 5 and 6 at discharge were more common in SAW than in patients with regular medication (16.7% vs. 6.5%, p=0.043).

Conclusion:
This study shows that 5.2% of total stroke is due to medication withdrawal, and poor compliance is the most common cause of antithrombotics hold. Stroke after antithrombotics hold is associated with higher rate of stroke progression and poor outcome, implying exacerbated thromboembolic state.
Abstract TP416: Effects Of Pioglitazone In Patients With Abnormal Glucose Metabolism After Stroke The J-SPIRIT Study
Authors: Tanaka Ryota , Yamashiro Kazuo , Tanaka Yasutaka , Miyamoto Nobukazu , Ueno Yuji , Watanabe Masao , Okuma Yasuyuki , Nakamura Shinichiro , Furukawa Yoshiaki , Watada Hirotaka , Kawamori Ryuzo , Hattori Nobutaka , Urabe Takao
Published: July 2021

Background and aims:
The stroke patients with abnormal glucose metabolism are increasing in Japan. The J-SPIRIT study (Juntendo the Stroke Prevention study in Insulin Resistance and Impaired glucose Tolerance) was planned to investigate the effect of pioglitazone on the reduction of recurrent stroke in the patients with abnormal glucose metabolism and insulin resistance after ischemic stroke.

Methods:
The study is a multicenter, randomized controlled trial performed in the four hospitals in Tokyo or neighboring cities in Japan. We enrolled the patients who ; (1) were 35 to 85 years old ; (2) had symptomatic ischemic stroke; (3) had no history of diabetes and no evidence of diabetes by initial blood test. Among those patients, a standard OGTT with 75g of glucose was performed at least 2 weeks after admission. We enrolled the patients of newly diagnosed diabetes and IGT by OGTT, and randomized these patients to receive either pioglitazone or matching placebo.

Results:
Total 134 patients were enrolled. 58 patients were received pioglitazone, 61 were placebo control. Mean HbA1c were not different among both groups (5.6±0.38 pioglitazone vs 5.5±0.38 control) and mean observation period were 25±19.9 months in piolgitazone group and 30±16 months in control group. The data showed a trend of benefit with pioglitazone for the primary end point of recurrence of ischemic stroke compared to placebo control. (event rate=3.4% pioglitazone vs 11.6% control)

Conclusions:
Our data indicated pioglitazone might be able reduce the risk of recurrent stroke in the patients of ischemic stroke with newly diagnosed abnormal glucose metabolism and insulin resistance.
Abstract TP42: Brain Plasticity Changes in Default Mode Network after Stroke
Authors: SONG JIE , NAIR VEENA A , LA CHRISTIAN , JENSEN MATHEW , CHACON MARCUS , SATTIN JUSTIN , PRABHAKARAN VIVEK
Published: July 2021

Background:
Resting-state fMRI (rs-fMRI) has been used for assessing task-free brain activity changes after stroke. One prominent resting-state neural network is the default mode network (DMN) that has been suggested to be suppressed during cognitive tasks. Older adults often show difficulties in suppressing DMN compared to younger adults during cognitive task performance. Moreover, dysfunction of DMN appears to be linked with the severity of post-stroke depression. Here we explored brain plasticity changes in DMN in stroke subjects.

Methods:
9 stroke subjects (mean age=60.3, 5 Male) and 5 normal healthy subjects (mean age=48, 4 Male) underwent two rs-fMRI scans. Patients participated in the 1st scan within 7 days after onset and within 6 months (mean ~3 months) postonset in the 2nd scan. Brain plasticity changes were examined by functional connectivity measures that were computed using region-of-interest analysis. Rs-fMRI data were pre-processed in AFNI. The resulting time-series from 6 common seeds in DMN were averaged over each seed and correlated with that from every other seed to generate the Pearson correlation coefficients. These correlations were then z-transformed representing the 15 unique functional connections (fconn) in DMN. Fconn changes were determined with intraclass correlation (ICC), which measures reproducibility of fconn between scans. A reliable connection, as suggested to be an ICC ≥ 0.5, requires a small within-subject plasticity change compared to the between-subject variance.

Results:
Shown in Table 1.

Conclusion:
As seen from Table 1, fconn between RtLatPar and PC may undergo plasticity changes after stroke (ICC < 0.5) as would be reliable in the normal group. Fconn between LtLatPar and PC, mPFC and PC, right and left LatPar were found to be significant and reliable, which could be due to less suppression in DMN and higher between-subject variability after stroke.
Abstract TP430: Plasma Proteomic Changes Persist in Long Term Follow-up of Patent Foramen Ovale Related Stroke Patients after PFO Closure
Authors: Ning MingMing , Lopez Mary , Sarracino David A , Feeney Kathleen , Thayer Molly , Elia Mikaela , Koop Hailey , McMullin David , Demirjian Zareh , Inglessis-Azuaje Ignacio , Silverman Scott , Dec G W , Palacios Igor , Lo Eng H , Buonanno Ferdinando S
Published: July 2021

Introduction:
Paradoxical embolism from patent foramen ovale (PFO), a heterogeneous multi-organ condition involving brain, lung, heart and blood, lacks consensus for treatment options due to variability among individual patients. Clinical proteomic approaches may be promising for such complex diseases, where the disease process can be monitored in clinically accessible fluid such as blood. Here, we apply a pharmaco-proteomic approach to study PFO endovascular closure, an intervention that requires better risk stratification and monitoring of therapeutic efficacy to individualize treatment. Previously, we found that plasma small molecule signals such as serotonin, TSP-1 and microparticles -- which may avoid pulmonary filtration via PFO -- decrease immediately in the systemic circulation after effective PFO closure. Now we study the long-term effect of PFO endovascular closure.

Methods/Results:
To reduce confounders in an inherently complex system, the most robust clinical proteomic comparisons are those of profiles taken over time from the same individual. Accordingly, in consecutively recruited patients who underwent PFO closure (n=37), we analyze venous blood obtained prior to closure and in long-term followup (1-3 yrs) post closure. None of the subjects experienced recurrent TIA or strokes. More than 1 year post closure, plasma protein profiles -- in addition to the persistent decrease in small molecules such as serotonin -- continue to show a statistically significant (p<0.05) decrease of coagulation markers such as fibrinogen, fibrinogen fragments, D-dimer and others. Moreover, markers of inflammatory changes such as hsCRP, apolipoproteins and various immunoglobulins also remain decreased.

Conclusion:
A pharmaco-proteomic approach is clinically feasible and may help to monitor therapeutic efficacy, improve patient selection, and ensure more precise clinical phenotyping for clinical trials in PFO-related stroke. More than 1 year post PFO closure, relevant inflammatory and coagulation factors remain lowered after adjusting for other confounders such as medication changes. Further studies are needed to explore the utility of proteomic profiling to help individualize treatment in PFO-related strokes.
Abstract TP438: Reaction Time In Acute Stroke Predicts Long-Term Quality Of Life
Authors: Cumming Toby , Linden Thomas , Brodtmann Amy , Darby David , Bernhardt Julie
Published: July 2021

Introduction—
Post-stroke cognitive impairment has a negative impact on quality of life. Little is known, however, about the relative importance of different cognitive domains, or whether cognitive markers in acute stroke can be prognostic for longer term outcomes.

Hypothesis—
We hypothesised that processing speed and attention would be the strongest predictors of long-term quality of life.

Methods—
Patients with confirmed stroke were followed up at 3 months with a full neuropsychological battery and at 12 months with the Assessment of Quality of Life (AQoL) and the modified Rankin Scale (mRS). A subgroup of these patients was assessed over the year (acute stage, 3 months, 12 months) on 2 computerised cognitive tasks: simple and choice reaction time.

Results—
Sixty patients participated in the study [mean age 72.1 years (SD=13.9), mean education 10.5 years (SD=3.9), mean NIHSS 5.8 (SD=4.0)]; a subgroup of 33 received the computerised tasks. Cognitive domains at 3 months that were significant predictors of 12-month AQoL were attention (p = 0.002), executive function (p = 0.005) and visuospatial ability (p = 0.009), but not memory or language. Subgroup data indicated that choice reaction time in the acute stage was a significant independent predictor of 12-month AQoL (p = 0.01). Acute reaction times were significantly correlated with mRS at 12 months (r > 0.50), and were not simply a proxy for stroke severity (they were not correlated with acute NIHSS and did not improve significantly across time).

Conclusions—
Attention, executive and visuospatial function are important contributors to quality of life after stroke. Speed of processing within a week of stroke is predictive of long-term quality of life, raising the possibility that straightforward reaction time tasks can reveal the extent of disruption to the brain’s network.
Abstract TP439: Temporary Cognitive Impairment in Transient Ischemic Attack and Minor Stroke Patients is Predicted by Chronic White Matter Hyperintensity Volume
Authors: Sivakumar Leka , Jeerakathil Thomas , Asdaghi Negar , Camicioli Richard , Beaulieu Christian , Emery Derek , Butcher Ken
Published: July 2021

Background:
Cognitive changes have been described in subacute TIA/minor stroke (TIA/MIS), but the temporal profile is unknown. We tested the hypothesis that TIA/MIS patients experience transient cognitive impairment, and that this can be predicted by Diffusion-Weighted Imaging (DWI) lesion volume.

Methods:
Acute TIA/MIS stroke (NIH stroke scale score ≤3) patients with no history of cognitive impairment were prospectively recruited within 72 h of onset. Patients underwent Montreal Cognitive Assessment (MoCA), Mini-Mental Status Examination (MMSE) and MRI, including DWI and Fluid-Attenuated Inverse Recovery (FLAIR) sequences, at baseline, days 7 and 30. DWI lesion and FLAIR chronic white matter hyperintensity (WMH) volumes were measured planimetrically.

Results:
Fifty patients (mean age 68 ±15.1 years) were imaged at a median (IQR) of 26.5 (28.5) h after onset. Cognitive impairment (scores ≤26) was detected more frequently with MoCA (31/50, 62%) than MMSE (13/50, 26%, p=0.009). Acute ischemic lesions (DWI) were present in 33 (66%) patients. Mean DWI volume at baseline was 4.5 ± 11.1ml. Patients with DWI lesions (22/33, 67%) had similar impairment rates as those without (9/17, 53%; p=0.34). Linear regression indicated no relationship between acute DWI lesion volume (log transformed) and baseline MoCA scores (β=0.028, 95% CI [-2.09, 2.44]). Impaired patients had larger WMH volumes (13.6 ± 21.9 ml) than unaffected patients (2.6 ± 3.2 ml, p=0.01). Log transformed WMH volumes were inversely predictive of baseline MoCA scores (β=-0.54, 95% CI [-7.84, -2.28]). Median MoCA scores improved over time (27(5) at day 7 and 28(5) at day 30). Patients with baseline impairment and an increase of ≥2 points on MoCA by day 30 were defined as reverters (N=20). DWI lesion frequency was similar in reverters and those with persisting impairment (75% vs 64%, p= 0.50), as was DWI (6.9 ±14.3 ml vs 1.2 ±1.9 ml; p= 0.113) and WMH lesion volume (17.0 ± 26.2 ml vs 8.1 ± 8.1 ml; p= 0.18).

Conclusions:
Most TIA/MIS patients have evidence of temporary acute cognitive impairment when assessed with MoCA. Deficits are correlated with chronic WMH, suggesting an unmasking of subclinical cognitive impairment. Temporary cognitive deficits should be considered in the management of TIA/MIS patients.
Abstract TP445: Combined Treatment of Brain Arteriovenous Malformations with Onyx Embolization followed by Radiosurgery
Authors: Pierot Laurent , Kadziolka Krzysztof , Lanoix Olivier , Rousseaux Pascal
Published: July 2021

Purpose:
The treatment of cerebral arteriovenous malformations (AVMs) is complex, based on embolization, surgery, and radiosurgery, or a combination of modalities. Treatment by Onyx embolization followed by radiosurgery was not previously evaluated. The goal of our study is to evaluate in an homogeneous, monocentric series the long-term clinical and anatomical outcome of patients treated by this combination.

Materials and Methods:
From April 2003 to June 2008, 20 patients (11 females and 9 males, aged 10 to 55 years) were treated for a brain AVM by Onyx embolization followed by radiosurgery. AVM size was < 3cm in 7 cases and ≥ 3 cm in 13 cases. Modalities and complications of the procedure were analyzed as well as long term clinical and anatomical outcome (2-4 years after treatment).

Results:
Out of 17 patients evaluated by DSA after radiosurgery, 10 had a complete occlusion of AVM nidus (58.8%). Complete occlusion was observed in 5/7 Spetzler-Martin grade 1-2 AVMs (71.4%) and in 5/10 Spetzler-Martin grade 3-4 AVM (50.0%). Complete occlusion was observed in 4/5 AVM with size < 3cm (80.0%) and 6/12 AVM with size > 3cm (50.0%). One out of 20 patients had significant worsening of their clinical status (mRS ≥ 2) at long term follow-up.

Conclusions:
In this series of patients with AVMs treated with Onyx embolization followed by radiosurgery, the safety and efficacy of this treatment combination is quite satisfactory with a 58.8% rate of complete obliteration and a low rate of clinical complications (5.0%).