bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WMP49: Temporal Trends in the Burden of Atrial Fibrillation in Acute Ischemic Stroke and Transient Ischemic Attack in the United States
Authors: Otite Fadar O , Khandelwal Priyank , Chaturvedi Seemant , Romano Jose G , Sacco Ralph L , Malik Amer M
Published: July 2021

Background:
Large scale data on atrial fibrillation (AF) prevalence in acute ischemic stroke (AIS) is sparse since approval of dabigatran for non-valvular AF in 2010. We studied recent trends in prevalence of AF in AIS and transient ischemic attack (TIA) in the United States (US) and association of AF with in-hospital mortality, cost and length of stay (LOS) in AIS.

Methods:
Adults admitted to US hospitals from 2007-2012 with diagnosis of AIS (n=3,427,806) and TIA (n=502,820) were identified from the Nationwide Inpatient Sample. Weighted prevalence of AF in AIS and TIA by demographics and region was computed. Multivariate logistic regression was used to evaluate association of AF with other clinical factors and mortality in AIS. Association of AF with LOS and cost was assessed using generalized linear models.

Results:
AF prevalence increased by 11.5% in AIS (22%-24.5%, p<0.001) and by 29% in TIA (13.5%-17.4%, p<0.001) from 2007-2012. AF prevalence varied by age (AIS: 7% in 50-59yo vs 38% in >80yo; TIA: 5% in 50-59yo vs 27% in >80yo), sex (AIS: 20% in M vs 25% in F); TIA: 16% in M vs 15% in F), race (AIS: whites 26% vs blacks 12%) and region (AIS: Northeast 25% vs South 21%). AF prevalence increased in all subgroups over time (p<0.001) except AIS <40yo and TIA<50yo (Figure 1). Advancing age, female sex, white race, high income, Medicare insurance, CHA
2
DS
2
-VASc score and large hospital size were associated with increased odds of AF in AIS. AF was positively associated with death (OR=1.60, 95%CI 1.56-1.64) but mortality in AIS with AF decreased from 13.2% in 2007 to 10.7% in 2012 (p<0.001). AF was associated with increased cost of $2,631 and LOS 1.1 days in AIS.

Conclusion:
Prevalence of AF in AIS and TIA has continued to increase. Disparity in AF prevalence in AIS and TIA exists by patient and hospital factors. AF is associated with increased mortality, LOS and hospital cost in AIS but mortality in AIS with AF is decreasing. More AIS preventive efforts are needed in AF patients especially in the elderly.
Abstract WMP59: Multiple Scattered Tiny Cerebral Infarctions Are Unlikely Cardiogenic
Authors: Dong Yi , Gao Yuan , Nair Deepak S , Parker Sarah , Jahnel Jan L , Swanson-Devlin Terasa G , Beck Judith M , Maureen Mathews , Mcneil Clayton J , Dong Qiang , Upadhyaya Manas , Wang David Z
Published: July 2021

Background:
Embolic ischemic strokes are commonly considered to be cardiogenic. In clinical practice, however,patients with a pattern of multiple tiny ischemic foci on MRI often have no cardiac source. To identifying its etiology may help selecting the right therapy to treat or prevent recurrent strokes.

Methods:
From 1/2010 to 12/2013, records and MRI imaging of 2984 consecutive stroke patients were reviewed. Patients with the following DWI MRI findings were included: 1) ≥3 high intensity lesions in three different arterial territories, 2) each ≤15mm in size and ≤2 sections in thickness. Other data reviewed include general demographics, clinical features and lab results. Patients with known cardiac embolism, aortic arch plaques or aneurysms and recent surgery were excluded. Images of follow-up MRI were reviewed.

Results:
Among 2984 cases reviewed, 71 patients had multiple tiny DWI lesions. In order to rule out artery to artery emboli, patients with lesions from the same artery territory or watershed region were excluded. Only 43 met all criteria. Their median age was 65 and 23(53.5%) were male. Extremity weakness and slurred speech were the most common presenting symptoms. The median number of DWI lesions in each brain was 13. Common disorders identified include: infection (81.4%), hyperlipidemia(58.1%), moderate chronic kidney disease(39.5%), previous history of stroke (48.8%). Four (9.3%) had large B cell lymphoma and 2 had lung cancer. The quantity of DWI lesions was related to hyperglycemia, hyperlipidemia and impaired GFR. Patients with primary hypercoagulable state more likely had multiple lesions (median 39). On discharge, 5 (11.6%) patients were prescribed dual antiplatelet therapy and 11 (25.6%) were given oral anticoagulants.

Conclusions:
To our knowledge, this was the first review of this type of specific DWI findings with clinical correlation. Multiple tiny or ‘Star-like’ type of lesions on DWI MRI were likely caused by infection, hyperlipidemia CKD and leukemia. They are unlikely cardiogenic and its recurrent rate was high. Recognizing the pattern of these tiny lesions will help clinicians refocus on the work up of stroke, strategies of treatment and stroke prevention strategy.
Abstract WMP6: Earlier Treatment is Associated with Higher Reperfusion Rates and Better Outcomes in the SWIFT PRIME Trial
Authors: Yavagal Dileep R , Saver Jeffery , Goyal Mayanak , Jahan Reza , Nogueira Raul , Jovin Tudor , cognard christophe , Diener Chris , levy elad , Bonafe Alain , Periera vitor , Albers Greg
Published: July 2021

Background:
Previous randomized trials of endovascular therapy for stroke have shown better rates of functional independent outcome (mRS 0-2 at 90 days) with earlier initiation of endovascular therapy. In these trials no information was available to assess the volume of salvageable brain tissue prior to intervention or tissue reperfusion post- intervention. We sought to determine the associations between times to treatment, mismatch volume, reperfusion rates and functional independent outcome (FIO) in patients with the Target mismatch (TMM) profile in SWIFT PRIME.

Methods:
Patients with TMM on CT or MR perfusion, as determined by an automated software package (RAPID), were included in the analysis. We compared the rate of FIO and factors associated with FIO in patients randomized early (<3h) vs. late (>3h) from stroke symptom onset (SSO). Age, NIHSS, core volume, mismatch volume and successful reperfusion at 27 h (>90% reduction in perfusion lesion volume on CT or MR Perfusion) were included in univariate and a multivariate logistic regression analysis.

Results:
A total of 131/195 patients had TMM. FIO was 62.3% (33/53) in the early vs. 43.6% (34/78) in the late group, p=0.0498. In the Solitaire arm, FIO was 72.4% (21/29) in early group vs. 55.0% (22/40) in the late group. In the tPA arm FIO was 50.0% (12/24) in the early group vs. 31.6% (12/38) in the late group. There was no significant difference in age, baseline NIHSS, core volume, or mismatch volume among the overall early vs late groups but successful reperfusion at 27h occurred in 76% of the early vs. 55% of the late group (p<0.05). The rate of successful reperfusion at 27h was 92% (early) vs. 81% (late) for Solitaire; p=0.28 and 61% (early) vs. 27% (late) for tPA; p=0.032). The 27 hour CTA or MRA TICI 2b-3 rates were 92% (early) vs. 84% (late) for Solitaire group and 71% (early) vs. 38% (late) for tPA group.

Conclusions:
Earlier lytic and stent-retriever thrombectomy interventions are associated with higher rate of FIO in patients with Target mismatch profiles in SWIFT Prime trial. This improved outcome is likely due to higher reperfusion rates that are achieved with earlier intervention, suggesting greater responsiveness of less organized and less compacted thrombi to fibrinolysis and potentially stent retrieval.
Abstract WMP63: Outcomes After Regionalization of Acute Stroke Care: Time Trend Analysis From Multiple Counties in the State of California
Authors: Govindarajan Prasanthi , Shiboski Steve , Grimes Barbara , Cook Larry , Ghilarducci David , Johnston S.Claiborne
Published: July 2021

Objective:
To determine if regionalization of acute stroke care is associated with IV t-PA use over a five year period.

Methods:
This is a before-after observational study of all ambulance transported patients with a discharge diagnosis of acute ischemic stroke (AIS). We excluded inter-facility transports and direct admissions. Our data sources were the patient discharge abstract file from the Office of Statewide Health Planning and Development and prehospital records. Probabilistic matching was used to link the records. Relative risk regression was performed to study the independent association of regionalization with IV t-PA use after controlling for patient, hospital demographics and stroke center status. Data analysis was performed using SAS 9.2

Results:
Number of ambulance transported AIS patients to 13 hospitals in both counties were 4282 in the “before-phase” and 15571 in the “after-phase” (County 1 “after-phase” n=11368 (73%), County 2 “after-phase” n= 4203 (27%). In the “after-phase”, 10189 (65.4%) were transported to primary stroke centers and 14981 (96.2%) were treated at community hospitals. In the “before-phase” IV t-PA was given to 79 patients (1.9%) and in the “after-phase” IV t-PA was given to 514 patients (3.3%). In the model, regionalization was independently associated with higher use of IV t-PA (Overall RR: 2.4 95% CI 1.4, 4.1)

aRR for County 1 - 1.2 95% CI 0.82, 1.65

aRR for County 2 - 2.4 95% CI 1.4, 4.1

Conclusions:
Regionalization was associated with higher rates of thrombolysis in AIS patients.

Figure 1:
IV t-PA rates before and after regionalization (County 1/County 2)

Table 1:
Independent association of regionalization with IV t-PA use
Abstract WMP80: Stroke Mimic Treatment Rates and Physician-patient Language Discordance
Authors: Rostanski Sara K , Williams Olajide , Stillman Joshua , Boehme Amelia K , Marshall Randolph S , Willey Joshua Z
Published: July 2021

Intro:
While thrombolysis in stroke mimics (SM) is considered safe, recent data highlights the excess cost associated with treatment of these patients. Several studies have identified common demographic features of SM, however less is known about whether language barriers between patient and physician influence SM treatment rates. We sought to evaluate the role of physician-patient language discordance on the rate of SM treatment at a single center serving a large Spanish-speaking population.

Hypothesis:
Stroke mimic treatment rates are higher when there are language barriers between physician and patient due to greater diagnostic uncertainty

Methods:
We reviewed the electronic medical record (EMR) for all patients who received tPA in the ED from 7/2011 to 7/2015. Patient’s primary language was obtained from the EMR; language fluency of treating neurologists was obtained via questionnaire; final diagnosis (SM, imaging negative, imaging confirmed) was the attending physician’s impression at discharge. We compared baseline characteristics and SM rates between encounters where the treating neurologist and patient spoke the same language (concordant group) versus those where they did not (discordant group). Means were compared via t test, medians via Mann Whitney U test and dichotomized variables via chi square test.

Results:
During this period 311 patients received tPA. English was the primary language for 158 (51%), Spanish for 144 (46%), and other languages for 9 (3%); 183 (59%) encounters were classified as concordant and 128 (41%) as discordant. Final diagnosis was SM for 37 (12%); among those with a final diagnosis of stroke, 65 (24%) were imaging negative. There were no significant differences in mean age (67 vs. 70, p=0.1), male sex (38% vs. 32%, p=0.3), and median NIHSS (7 vs. 7, p=0.4) between concordant and discordant groups. We found higher rates of SM in the concordant group (16% vs. 6%, p=0.01). When imaging negative strokes were included with SM, these differences were no longer significant (33% vs. 32%, p=0.9).

Conclusion:
At our institution, language discordancy does not contribute to higher rates of SM treatment. Careful observation of how language discordant pairs communicate is needed to understand the role of interpreters in these findings
Abstract WMP83: Rivaroxaban Therapy Is Not Associated with Hemorrhagic Transformation After Acute Cardioembolic Stroke: A Prospective MRI Study
Authors: Gioia Laura C , Kate Mahesh , Sivakumar Leka , Kalashyan Hayrapet , Hussain Dulara , Buck Brian , Bussiere Miguel , Shuaib Ashfaq , Jeerakathil Thomas , Emery Derek , Butcher Ken
Published: July 2021

Introduction:
Early anticoagulation after cardioembolic stroke remains controversial, due to the potential for symptomatic hemorrhagic transformation (HT). The safety profile of rivaroxaban within 14 days of cardioembolic stroke onset has not been assessed prospectively.

Methods:
We conducted a prospective, open label study of patients with atrial fibrillation treated with rivaroxaban ≤14 days of mild/moderate ischemic stroke/TIA (NIHSS score≤8) onset. Informed consent was obtained after the decision to treat with rivaroxaban was made by the treating physician. All patients underwent MRI, including susceptibility-weighted sequences, within 24 hours of rivaroxaban initiation and at day 7, with clinical assessment at 90 days. HT was classified using ECASS criteria (hemorrhagic infarct (HI) 1/2, or parenchymal hemorrhage (PH) 1/2). The primary endpoint was symptomatic HT (defined as PH2 associated with an NIHSS increase ≥4 within the study period). Secondary outcomes included any PH at day 7 and recurrent stroke within 90 days of enrolment.

Results:
Sixty patients were enrolled (mean±SD age 71±19 years, 82% stroke/18% TIA). Median (IQR) time from onset to first rivaroxaban dose was 3(5) days. At treatment initiation, median NIHSS was 2(4) and median DWI volume was 7.9(13.7) ml (range 0-175 ml). Baseline DWI volume was correlated with time to first dose (r=0.58, p<0.001). On baseline MRI, HT was present in 25 patients (42%) (HI1=19, HI2=6). Fifty patients had follow-up MRI at a median 7(4) days after rivaroxaban initiation (4 patients withdrew consent and 6 were lost to follow-up). No patients developed symptomatic HT or PH at any point. New asymptomatic HI1 developed in 3 patients. There was asymptomatic progression from HI1 to HI2 in 5 patients. In the remaining 18 patients with baseline HI and follow-up MRI, there was no change at day 7. Two recurrent ischemic strokes occurred (day 5 and day 28). Two additional patients had new asymptomatic DWI lesions at day 7. Two patients died within 90 days (one recurrent stroke and one pneumonia).

Conclusion:
These data support the safety of rivaroxaban initiation within 14 days of mild/moderate cardioembolic stroke/TIA. MRI evidence of petechial HT, which is common, does not appear to increase the risk of symptomatic HT.
Abstract WMP86: Evaluation of Cerebrospinal Fluid Dynamics and External Ventricular Drain Management in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage trial (CLEAR III)
Authors: Ziai Wendy , Bhuiyan Mariam , McBee Nichol , Dlugash Rachel , Sheth Kevin , Ram Malathi , Mayo Steven , Thompson Carol , Lane Karen , Awad Issam , Hanley Daniel F
Published: July 2021

Background:
Acute obstructive hydrocephalus secondary to spontaneous intracerebral/intraventricular hemorrhage (ICH/IVH) requires early cerebrospinal fluid (CSF) drainage to reduce intracranial pressure (ICP). Extensive CSF drainage may reduce IVH clot burden. We characterize CSF dynamics, strategies and impact on end of treatment (EOT) IVH volume (72 hours post randomization [Rand]) in the CLEAR III trial.

Methods:
Prospective analysis of CSF output in all 500 patients enrolled in the CLEAR III trial, a multicenter, double-blind, randomized study comparing EVD + intraventricular recombinant tissue plasminogen activator (rtPA) vs. EVD + placebo for treatment of obstructive IVH and intracerebral hemorrhage (ICH) volume <30cc. CSF output was recorded every 4 hours until 7 days post Rand, and compared by clinical and radiological variables.

Results:
Daily median CSF output in the first week was 188cc (IQR: 125, 252). Maximum daily EVD drip settings were <10mmHg in 27.8%, =10 in 44.1% and >10 in 28.1%. Independent predictors of higher daily CSF output after adjustment for initial IVH volume (p=0.04) were lower drip setting (p<0.001), lower age (p<0.001), male sex (p=0.03), dual EVD (p=0.005), CSF protein (p<0.001) and ICP>20mmHg (P=0.007). Both EOT IVH volume and change in IVH volume (ChgIVH) (over 1
st
week) were independently associated with total CSF output (P=0.004/<0.001, respectively), and initial IVH volume (P<0.001/<0.001)). Early opening of 3
rd
and 4
th
ventricle (P=0.03) was associated with lower EOT volumes, while CSF protein (P=0.02), and side of EVD ipsilateral to largest IVH (P=0.04) were associated with ChgIVH. Shunting for hydrocephalus was performed in 18.6% over 1 year follow-up and was associated with higher total CSF output over first week (P<0.001).

Conclusions:
CSF circulation in severe IVH can be assessed by CSF output which is associated with EVD drip management and other clinical variables. EOT IVH volume and IVH volume reduction are important surrogate endpoints which are related to CSF dynamics. VP shunt requirement in spontaneous IVH is associated with early CSF output levels. These results permit future correlation of CSF output with treatment rendered (thrombolysis versus placebo) with upcoming unblinding of the trial.
Abstract WMP9: National Trends in the Use of Endovascular Stroke Treatment at Academic Medical Centers (2009-15)
Authors: Guterman Elan , Threlkeld Zachary D , Smith Wade S , Choi Jay Chol , Kim Anthony S
Published: July 2021

Objective:
To characterize temporal trends in the use of endovascular treatment (EVT) for acute ischemic stroke at academic medical centers in response to recent clinical trials.

Background:
Although endovascular devices for stroke were first cleared for marketing in 2004, initial clinical trials in 2013 failed to demonstrate efficacy and subsequent clinical trials beginning in 2014 were strongly positive. The impact of these data on practice patterns at academic medical centers, which perform most EVTs, is unknown.

Methods:
We identified all acute ischemic stroke hospitalizations at academic medical centers that were members in the University HealthSystem Consortium from October 2009 to July 2015 using International Classification of Disease, 9th revision codes 433.x1, 434.x1, and 436 for stroke and procedure code 39.74 for EVT. We compiled quarterly data on the number and proportion of stroke hospitalizations using EVT and we used segmented log-linear regression to identify temporal trends and to evaluate changes in trends at prespecified time points corresponding to the quarter in which pivotal trials were first reported.

Results:
From 2009-15, we identified 357,973 acute ischemic stroke hospitalizations at 161 medical centers. The proportion of stroke hospitalizations using EVT was 1.5% in 2009 and grew by 25% a year (95% CI 21% to 29%) to reach 3.1% in 2013. After negative results from the initial trials were reported in 2013, EVT use hovered between 2.5% and 2.7% (1% relative change per year; 95% CI -9% to +8%; p=0.004 for change in trend) until 2014 when the first positive trials were reported and EVT use jumped at a growth rate of 151% per year (95% CI 101% to 212%; p<0.001 for change in trend) to reach fully 4.7% of all stroke hospitalizations by 2015.

Conclusion:
The previously steady growth in EVT flattened in 2013, coincident with the initially negative results from clinical trials, but has dramatically increased since positive trials were first reported in 2014.
Abstract WP122: Asymptomatic Moderate Carotid Artery Stenosis With Intraplaque Hemorrhage ∼ Progression of Degree of Stenosis and New Ischemic Stroke
Authors: Yamada Kiyofumi , Kawasaki Masanori , Yoshimura Shinichi , Nakahara Shigehiro , Sato Yoshikazu
Published: July 2021

Background:
Carotid artery stenosis is one of the major causes of ischemic stroke. Carotid intraplaque hemorrhage (IPH) plays a critical role in the progression of carotid atherosclerotic disease. Previous studies showed that IPH was associated with high intensity signal (HIS) on maximum intensity projection (MIP) images from routine three dimensional magnetic resonance imaging (3D-TOF MRA). The aim of this study was to evaluate the relationships among HIS, new ipsilateral ischemic stroke and a progression rate in carotid plaques with moderate stenosis.

Materials and Methods:
We included 45 carotid plaques with moderate stenosis (50% to 69%) in 45 patients who could be followed more than 12 months. Carotid IPH was defined as the presence of HIS in carotid plaque on MIP image from routine 3DTOF MRA using the criteria previously we published. We analyzed the relation between the presence of HIS in the plaques and new ischemic strokes and annual progression rate of carotid stenosis.

Results:
HIS in carotid plaque was present in 21 (47%) carotid arteries. Over a follow-up period of 24 ± 9 months, six ischemic strokes occurred ipsilateral to the index carotid artery. New ipsilateral ischemic stroke occurred more frequently in HIS positive group (6 of 21, 29%) than HIS negative group (0 of 24, 0%) (p=0.017). Annual progression rate of carotid stenosis is significantly higher in HIS positive group (+3.35%/year) than HIS negative group (-0.02%/year) (p= 0.0026). In multivariate regression analysis, HIS positive was an independent predictor for annual progression rate of carotid stenosis (p=0.003).

Conclusions:
HIS in carotid plaques on 3DTOF-MRA MIP images are associated with new ischemic stroke and higher annual progression rate of stenosis. Evaluation of HIS in asymptomatic moderate carotid stenosis can potentially provide risk stratification of new ipsilateral ischemic strokes.
Abstract WP129: Nationwide Questionnaire Survey of Carotid Artery Stenting for Patients at High Risk for Cerebral Hyperperfusion Syndrome
Authors: Hayakawa Mikito , Matsumaru Yuji , Sakai Nobuyuki , Yamagami Hiroshi , Iihara Koji , Ogasawara Kuniaki , Oishi Hidenori , Ito Yasushi , Sugiu Kenji , Yoshimura Shinichi ,   STOP CHS study group
Published: July 2021

Background and purpose:
Cerebral hyperperfusion syndrome (CHS) including intracranial hemorrhage (ICH) is a serious complication after carotid artery stenting (CAS). Therefore, in Japan, neuroendovascular physicians commonly evaluate the CHS risk of the CAS candidates using various pre-procedural imaging tests and sometimes perform preventive procedures against CHS, such as staged angioplasty (SAP; balloon angioplasty with an undersized balloon followed by delayed CAS) reported by Yoshimura et al. We conducted a nationwide questionnaire survey to clarify the current status of pre-procedural evaluation of the CHS risk and outcomes of high-risk patients of CHS who underwent CAS (including SAP) in Japan.

Methods:
Questionnaires were mailed to neuroendovascular therapy experts certified by the Japanese society in June 2014, regarding imaging tests to evaluate the CHS risk and the total number of the patients who underwent CAS with or without 30-day adverse event (CHS, ICH, stroke or death) between October 2007 and March 2014.

Results:
Responses were obtained from 154 institutes enrolling 363 experts (35.3% of all the certified experts). Pre-procedural imaging tests to evaluate the CHS risk were introduced in 144 institutes (93.5%) and single photon emission CT (SPECT) was mostly used in 88.2% of the institutes. A total of 7114 patients (7470 lesions) who underwent CAS with pre-procedural imaging tests was registered, including 1269 high-risk patients of CHS (1305 lesions, 17.5%). The rates of CHS and ICH in the high-risk patients were significantly higher than those of the non-high-risk patients (6.0% vs 0.4% [p<0.01] and 3.1% vs 0.3% [p<0.01], respectively). SAP was performed in 184 high-risk patients (189 lesions, 14.5%). SAP tended to reduce CHS (6.5% to 3.2%, p=0.08) of high-risk patients although modestly increase ischemic stroke (3.2 to 4.2%, p=0.51). The composite stroke or death rate of the SAP group was not different from that of the single-stage CAS group (6.1% vs 5.8%, p=0.88).

Conclusion:
Most of the CAS candidates were stratified according to the CHS risk by SPECT in Japan, and CHS was developed in 6.5% of the high-risk patients who underwent single-stage CAS and in 3.2% of those who underwent SAP. To prove the efficacy of SAP, further study is needed.
Abstract WP131: Effects Of EDAS Surgery On The Circulating Angiogenic Factors Of Patients With Moyamoya And Intracranial Atherosclerosis.
Authors: Gonzalez Nestor R , Toscano Juan F , Liou Raymond , Rao Neal , Hinman Jason D , Restrepo Lucas , Laiwalla Azim , Ooi Yinn , Liebeskind David S , Martin Neil , Ali Latisha , Saver Jeffrey
Published: July 2021

Objective:
To evaluate the levels of circulating angiogenic factors in patients with moyamoya disease (MMD), intracranial atherosclerosis (ICAS), and controls, and the effects of EDAS in their levels.

Methods:
Prospective longitudinal study of angiogenic factors in 22 patients with MMD, ICAS, and controls. Patients with MMD and ICAS underwent EDAS surgery. Control cases had cranial surgery for non-vascular or tumor pathology. Angiogenic factors were measured at baseline and 7 days after surgery. Log-corrected levels were compared between groups. Multivariate analysis of variance (MANOVA) was used to examine differences within pairs and between groups. Regression mixed models were built to account for intrasubject correlation and evaluate the association of angiogenic levels with group and treatment.

Results:
Mean age was 41 ± 11 in MMD, 65 ± 16 in ICAS, and 51 ± 19 in controls. There were 83% females in the MMD group, 44% in ICAS, and 43% in controls. Patients with MMD had significantly higher levels of PDGFAA (568.8 pg/ml), vs ICAS (165.9pg/mL), and controls (38.4 pg/mL) p=0.007; PDGFBB (1449.7 pg/mL), vs. ICAS (141.2 pg/mL), and controls (65.2 pg/mL) p=0.03; TGFB1 (24.5 ng/mL), vs. ICAS (13.8 ng/mL), and controls (6.2 ng/mL) p=0.006; TSP1 (128.5 ng/mL), vs. ICAS (91.7 ng/mL), and controls (9 ng/mL) p=0.0007. After surgery (EDAS for MMD and ICAS vs. cranial surgery for controls) levels of PDGFAA, PDGFBB, and TGFB1 increased on the ICAS and control groups eliminating the baseline differences. EDAS, independently from etiology, affected the levels of pro-angiogenic TGFB2 (EDAS: 290 pg/mL, controls: 161 pg/mL), and BMP2 (EDAS: 153 pg/mL, controls: 109 pg/mL) p<0.02. EDAS also increased the levels of the anti-angiogenic TSP2 (EDAS: 54.5 ng/mL, controls: 29 ng/mL) p=0.02.

Conclusion:
Patients with MMD have baseline higher levels of pro-angiogenic factors PDGFAA, PDGFBB, and TGFB1, involved in vessel maturation. EDAS, independent from etiology, affected the levels of TGFB2, BMP2 and TSP2, cytokines involved in vessel maturation, increased vascular permeability, and modulation of cell migration, respectively.
Abstract WP133: Long-term Outcomes of Carotid Endarterectomy and Carotid Artery Stenting: Real-World Status of Single Institute in Japan
Authors: Hosoda Kohkichi , Imahori Taichiro , Fujita Atsushi , Yamamoto Yusuke , Kimura Hidehito , Kohta Masaaki , Kohmura Eiji
Published: July 2021

Introduction:
We investigated long-term outcomes of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in our hospital to assess the outcomes of real-world practice in single institute of Japan.

Methods:
Between August 2006 and July 2014, 236 consecutive carotid revascularizations with either CEA or CAS were performed in our institute. The initial treatment was regarded as the starting point in the cases of the patients who received treatment by bilateral carotid artery stenosis or retreatment. We assessed the long-term outcomes with survival analyses.

Results:
A total of 210 patients (CEA 128, CAS 82), including 94 symptomatic patients, were enrolled in the current study with mean follow-up period of 45.8 months. The periprocedural stroke/death/myocardial infarction (MI) rate was 3.1% for CEA and 4.9% for CAS groups (p=0.71). Estimates of the 4-year event-free rate from the primary end point (the composite of any stroke, death, or MI within 30 days and any ipsilateral stroke thereafter) using competing risk analysis were 3.1% for CEA and 8.6% for CAS (P=0.041). Kaplan-Meier estimates of the 4-year event-free rate from the secondary end point (the composite of any stroke, death, or MI within 30 days and any stroke or death thereafter) were 12.8% for CEA and 20.1% for CAS (P=0.051). Age (Hazard ratio [HR], 1.14/year [95%CI, 1.03-1.26]; p = 0.012) and CAS (HR, 3.5 [95%CI, 1.05-11.5]; p = 0.04 ) were significant predictors for the primary end point in multivariate analysis. For the secondary end point, age (HR, 2.1/10year [95%CI, 1.27-3.47]; p = 0.004) and CAS (HR, 2.0 [95%CI, 1.04-3.83], p = 0.037) were significant predictors. The inclusion of higher risk patients in the CAS group may have been the reason for CAS being a risk factor.

Conclusion:
The current study on real-world practices demonstrated perioperative and long-term outcomes that were comparable to previous major studies of large numbers of patients.
Abstract WP141: Identifying Modifiable Predictors of Long-term Functional Outcome After Stroke
Authors: Kapoor Arunima , Swartz Richard , Lanctot Krista , Bayley Mark , Kiss Alex
Published: July 2021

Introduction:
Disability is often an assumed and accepted consequence of stroke. Post-stroke disability is frequently attributed to demographic risk factors such as age and stroke severity. These factors cannot explain all the variability in stroke outcomes. Other factors, such as post-stroke depression, sleep apnea and cognitive impairment can impact function, and yet their relationships to long-term outcomes are rarely assessed. The primary purpose of our research is to understand the role of these potentially modifiable factors in predicting long-term post-stroke functional outcomes.

Hypothesis:
Stroke patients who screen positive for depression, sleep apnea or cognitive impairment at baseline will have significantly worse long-term functional outcome.

Methods:
A follow up outcome assessment of stroke patients is being conducted by telephone 2-3 years after an initial baseline visit where their risk of depression, sleep apnea and cognitive impairment was assessed. Baseline predictors such as age and stroke severity are also abstracted from their baseline visit. Assessment measures were selected to evaluate numerous levels of human functioning and include the following: modified Rankin Scale, MoCA, Barthel Index, Frenchay Activites Index and Reintegration to Normal Living Index. The primary outcome is mRS Score, with a score ≥ 2 indicating poor outcome.

Results:
Seventy six patients have been enrolled in our study and projected enrolled of another 100 patients should be complete by December 2015. Based on preliminary data, our prognostic logistic regression model including only stroke severity and age is statistically significant, χ2(2)= 29.06, p < 0.001. This model explains 42.7% (Nagelkerke R2) of the variance in long-term outcomes and correctly classifies outcome in 78.9% of patients. Future analyses with the full sample size and addition of potentially modifiable factors will verify whether these factors increase the predictive value of our prognostic model.

Conclusion:
By identifying modifiable factors related to poor functional outcomes, this study may allow the development of novel interventions to alter the trajectory of this vulnerable population to help optimize long-term function after stroke.
Abstract WP146: Intravenous Bone Marrow Derived Mononuclear Stem Cells in Chronic Ischemic Stroke-Paracrine Mechanisms of Recovery
Authors: Bhasin Ashu , Srivastava Padma , mohanty Sujata , Subramaniyam Vivekanandhan , kumaran Senthil , Bhatia Rohit
Published: July 2021

Background:
The emerging role of Stem cell technology and transplantation has helped scientists to study its potential role in neural repair and regeneration. The fate of stem cells is determined by its niche, consisting of surrounding cells and the secreted trophic growth factors. This present study evaluates the safety, feasibility and efficacy of bone marrow derived mononuclear stem cells (BM-MNC) in chronic ischemic stroke by studying the release of serum vascular endothelial growth factor (VEGF) and brain derived neurotrophic growth factor (BDNF).

Methods:
Twenty (n=20) stroke patients recruited with the inclusion criteria as: 3 months to 1.5 years of index event, power of hand muscles atleast 2; Brunnstrom stage: 2-5; conscious and comprehendible, were randomized to study and control groups receiving autologous mean 60-70 million BM-MNC and controls receiving neuromotor rehabilitation regime only for 8 weeks. Clinical assessment (FM, mBI, MRC, Ashworth) and serum VEGF & BDNF were done at baseline and 8 weeks (2 months).

Results:
No patients exhibited any complication or adverse events during the whole procedure. There was no statistical significant clinical improvement between study and control groups (FM: 95%CI; 15.2 to 5.35, p=0.25; mBI : 95% CI;14.3 to 4.5, p=0.31). VEGF and BDNF were increased after stem cell infusion and exercise training in both the groups (VEGF: 442.1 pg/ml vs 400.3pg/ml; p=0.67; BDNF:95% CI∼15.09 to 4.09, p=0.57), without any statistical significant result.

Conclusion:
Autologous mononuclear stem cell infusion is safe and tolerable by chronic ischemic stroke. The paracrine hypothesis extends the traditional concept of stem cell niche to study the influence of stem cell released growth factors (VEGF and BDNF) on the microenvironment.
Abstract WP159: The Association Between Cerebral Artery Calcification and Homocysteine Among Stroke Patients
Authors: Park Kwang-Yeol , Kim Jeong-Min , Shin Dong-Woo , Park Moo-Seok
Published: July 2021

Introduction:
Elevated serum homocysteine level is known to be associated with increased risk of atherosclerosis and cardiovascular event possibly through endothelial senescence. Also, homocysteine was reported to be a potential regulator of vascular calcification in animal study.

Hypothesis:
We hypothesized that elevated homocysteine level is associated with cerebral artery calcification.

Methods:
We identified 708 consecutive patients (mean age 66.3+/-12.9, 297 female patients) who were admitted with acute ischemic stroke or transient ischemic attack. Cerebral artery calcification was assessed from brain CT angiography, and advanced calcification was determined when calcification involved long (more than 1 cm) or thick (50% or more of vessel diameter) segment of distal cavernous internal carotid artery. Hyperhomocyseinemia was defined as serum homocysteine level exceeding 15 umol/L on admission.

Results:
Cerebral artery calcification from brain CT angiography was present in 546 patients (77.2%). Advanced cerebral artery calcification was detected in 156 patients (22.1%), and hyperhomocysteienemia was detected in 171 patients (24.2%). On bivariate analysis, advanced cerebral artery calcification was associated with hypertension, diabetes mellitus, smoking, atrial fibrillation, previous stroke history, high-sensitivity C-reactive protein (hs-CRP) and elevated homocysteine level. Multivariate logistic regression analysis including hyperhomocysteinemia, vascular risk factors, age>70 years and hsCRP>2.0mg/dL showed that hyperhomocysteinemia is independently associated with advanced cerebral artery calcification (odds ratio 1.8, confidence interval 1.1-2.8, p=0.011).

Conclusion:
Hyperhomocysteinemia was associated with advanced cerebral artery calcification. Our study suggests that homocysteine may be used as a biomarker for cerebral artery calcification.
Abstract WP181: Incidence of Transient Ischemic Attack in Auckland, New Zealand, in 2011-2012
Authors: Barber Peter A , Krishnamurthi Rita , Parmar Priya , Parag Varsha , Feigin Valery L ,   for the ARCOS Study Investigators
Published: July 2021

Introduction:
There have been few recent population studies reporting the burden of TIA. We aimed to determine the incidence (first ever in a lifetime) of TIA in an ethnically diverse population.

Hypothesis:
The incidence of TIA may vary by different ethnic group.

Methods:
The fourth Auckland Regional Community Stroke study (ARCOS IV) used multiple overlapping ascertainment methods to identify all hospitalized and non-hospitalized cases of definite TIA in people ≥16 years of age usually resident in Auckland (population ≥16 years was 1.12 million), over 12 months from March 2011. TIA was defined as an acute loss of focal cerebral or ocular function with symptoms lasting <24 hours, of presumed vascular cause. Patients with isolated vertigo, diplopia and non-focal symptoms were excluded.

Results:
There were 785 people with TIA [402 (51.2%) women, mean (SD) age 71.5 (13.8) years]. Of these, 614 (78%) were European, 32 (4.1%) Maori (indigenous people of New Zealand), 62 (8%) Pasifika (originating from the Pacific Islands) and 75 (10%) Asian/Others. Most (82%) TIA patients were seen in a hospital setting (emergency room, outpatient clinic or admitted). The annual age-standardized incidence of TIA was 40 (95% CI 36-43) per 100,000 people. The annual age-standardized incidence per 100,000 people of TIA was less in Maori (27; 95% CI 8-40) and Asian/Others (21; 95% CI 16-27) than in Europeans (45; 95% CI 41-50). Vascular risk factor profiles and treatment at presentation varied between the different ethnic groups. For example, non-Europeans were more likely to be diabetic (p<0.01), and Maori and Pasifika were less likely to be taking lipid-lowering therapy (p<0.01), than other groups.

Conclusions:
This study has demonstrated ethnic differences in the burden of TIA in an era of aggressive primary and secondary vascular risk factor management. We speculate that that the lower incidence of TIA seen in ethnic minorities may reflect a failure to seek medical attention as opposed to a true difference in incidence. If confirmed, programs targeting different ethnic groups, particularly those of lower socioeconomic status, and aimed at improving health literacy around vascular disease and reducing barriers to accessing health care, will be required.
Abstract WP185: The Risk of Pregnancy-associated Stroke Does not Increase With Age: an Analysis of Claims Data From New York State
Authors: Gatollari Hajere J , Miller Eliza C , Too Gloria , Boehme Amelia K , Colello Anna , Elkind Mitchell S , Willey Joshua Z
Published: July 2021

Introduction:
Stroke is a rare but feared complication of pregnancy and the postpartum period. Prior studies have found that older age is associated with increased risk of pregnancy-associated stroke (PAS). It is unclear to what extent pregnancy contributes to this increased risk of PAS. There is limited information on age-specific incidence ratios to assess whether the risk of PAS is comparable to stroke in similarly aged non-pregnant women.

Hypothesis:
Increased incidence of PAS in older women is attributable to the increasing risk of stroke with age.

Methods:
We used the 2008-2012 New York State Department of Health (NYS DOH) Statewide Planning and Research Cooperative System (SPARCS) inpatient database to identify women aged 12-50 with ischemic (ICD-9 433, 434, 436), ICH (ICD-9 431), SAH (ICD-9 430), and non-specified PAS, including post-partum stroke (ICD-9 671.7, 674). Population data were obtained from NYS DOH Vital Statistics. Age-specific incidence ratios were calculated for strokes in pregnant or postpartum women compared to non-pregnant women. We used standard age groups considered by obstetricians to be at low, moderate, or high risk for pregnancy complications, including stroke.

Results:
Of 7099 stroke hospitalizations occurring in women, 386 were in pregnant women. The table shows the incidence of stroke in women stratified by pregnancy status and age group, and age-specific incidence risk ratios associated with pregnancy.

Conclusions:
Compared to non-pregnant women of the same age, pregnant women appeared to be at similarly increased risk of stroke at all ages, except for those over age 40. These results suggest that pregnancy itself does not further increase the risk of stroke in older women, though they could also reflect a tendency for healthier women to have pregnancies at later ages. More research is needed to investigate the characteristics that may put younger women at increased risk of stroke, compared to their non-pregnant contemporaries.
Abstract WP187: Predictors of Medication Adherence Prior to Hospitalization in a Multi-ethnic Cohort of First Stroke Survivors
Authors: Goldmann Emily , Nelson Bryan S , Parikh Nina S , Boden-Albala Bernadette
Published: July 2021

Poor medication adherence is associated with poor health outcomes and elevated health care costs. Although studies have examined predictors of medication adherence after stroke, few have assessed factors associated with medication adherence prior to the stroke. We hypothesized that socioeconomic vulnerability and poor health behaviors would be important risk factors for low medication adherence prior to stroke hospitalization. Data for this study came from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) trial, a behavioral intervention to reduce vascular risk in a multi-ethnic group of mild/moderate stroke/TIA patients. Medication adherence was assessed using the 8-item Morisky Medication Adherence Scale and categorized as “low” (scores 3-8) or “medium/high” (scores 0-2). Chi-square tests were used to identify factors significantly associated with low adherence, which were then included in multivariable logistic regression models to examine their independent association with adherence, among those with no stroke/TIA history. Of the 309 patients with no stroke/TIA history who were taking medication prior to hospitalization (66.6% of the sample), 47.6% reported low medication adherence. Factors independently associated with increased odds of low adherence were being non-Hispanic black vs. non-Hispanic white (OR=2.8, 95% CI: 1.4-5.9), living with others vs. living alone (OR=3.1, 95% CI: 1.3-7.3 among those living with one non-spouse; OR=2.2, 95% CI: 1.2-4.3 among those living with more than one person), meeting criteria for depression (Center for Epidemiologic Studies - Depression score ≥ 16) (OR=2.0, 95% CI: 1.0-4.2), and drinking a greater number of drinks on one occasion in the past month (OR=1.4, 95% CI: 1.1-1.6). Older age was protective against low adherence (OR=0.5, 95% CI: 0.3-0.9 among those 65 years or older vs. less than 65). Targeted interventions to improve medication adherence among those at risk of stroke with other poor health behaviors, particularly among non-Hispanic black and younger individuals, may help reduce the risk of stroke in the first place.
Abstract WP189: Trends in Comorbidities Among Stroke-related Hospitalizations in California, 2000-2013
Authors: Ratnasiri Anura W , Ratnasiri Buddhika M , DiLibero Ralph
Published: July 2021

Background:
Preventive care for adults with hypertension and diabetes has improved over the recent decade. This study aims to identify trends of these and other comorbidities for patients with stroke-related hospitalizations in California from 2000 to 2013.

Methods:
This retrospective study is based on patient discharge information compiled by the California Office of Statewide Health and Planning Development from 2000 to 2013. The study population is comprised of residents, and represents over 31.68 million hospital events. Stroke hospitalizations were identified using the first listed diagnoses in the hospital records, ICD-9-CM codes 430 to 436.

Comorbidities were identified using ICD-9-CM codes in 24 other diagnostic fields in each stroke hospitalization, aided by AHRQ’s Clinical Classification Software.

Cochran Armitage trend test was employed to identify comorbidity trends from 2000 to 2013. Stroke hospitalizations were adjusted for sex, age, race/ethnicity and insurance type using multivariable logistic regression for each of the comorbidities analyzed.

Results:
Over 1 million hospitalizations and 77,908 in-hospital mortalities for stroke were identified from 2000 to 2013. Disorders of lipid metabolism among stroke-related hospitalizations rose by 230.5% from 16.7% in 2000 to 55.1% in 2013. Diabetes mellitus increased by 45.1% from 27.0% in 2000 to 39.2% in 2013. Cardiac dysrhythmia rose by 36.6% from 21.0% in 2000 to 28.7% in 2013 while hypertension rose by 22.0% from 67.7% in 2000 to 82.6% in 2013. The trend test showed significant upward trends (p <0.001) for these four comorbidities during the study period.

After adjusting for patient demographics and insurance type, all four comorbidities had a positive association with stroke-related hospitalizations: diabetes mellitus (AOR 1.247; 95% CI=1.228-1.267), hypertension (AOR 2.685;[95% CI=2.631-2.740), disorders of lipid metabolism (AOR 2.095; 95% CI=2.063-2.127) and cardiac dysrhythmias (AOR 1.193; 95% CI=1.172-1.213).

Conclusion:
Diabetes mellitus, hypertension, disorders of lipid metabolism and cardiac dysrhythmia are positively associated with stoke-related hospitalizations.
Abstract WP205: C-reactive Protein Levels Are Associated With Cerebral Small Vessel-related Lesions
Authors: Mitaki Shingo , Nagai Atsushi , Oguro Hiroaki , Yamaguchi Shuhei
Published: July 2021

Introduction:
Arteriosclerosis is characterized by the loss of smooth muscle cells and a hyalinized thickened wall, and concentric narrowing of the lumen in penetrating arteries causes cerebral small vessel disease, including lacunar infarcts, deep white matter lesions, and cerebral microbleeds mainly in the basal ganglia. Although infrequently fatal, lacunar infarcts and deep white matter lesions, which account for 30% of ischemic strokes in Japan, are associated with a high risk of recurrence and cognitive impairment. Basic studies have reported on the importance of inflammation in the pathogenesis of arteriosclerosis.

Hypothesis:
We investigated the hypothesis that serum high sensitive C-reactive protein (hs-CRP) levels have some effect on cerebral small vessel (CSV)-related lesions.

Methods:
From January 2008 to March 2013, a total of 1,362 Japanese subjects voluntarily participated in the health checkup system. We selected 519 neurologically normal subjects (284 males and 235 females) aged 29-90 years (mean, 63.5 ± 10.3 years) from these participants for inclusion. All the participants underwent MRI, and their CSV-related lesions (i.e., lacunar infarcts, cerebral microbleeds, deep white matter hyperintensity, and periventricular hyperintensity) were evaluated. The serum levels of hs-CRP were evaluated as common inflammatory markers.

Results:
Subjects with higher hs-CRP levels had more lacunar infarcts (p = 0.02). After adjusting for the traditional cardiovascular risk factors, higher hs-CRP levels were still associated with the presence of lacunar infarcts (odds ratio for the highest vs. the lowest tertile of hs-CRP, 3.57 [95% confidence interval: 1.30-9.80]). These associations did not change when the logarithmically transformed values for hs-CRP were included. Furthermore, subjects with higher CRP levels had more cerebral microbleeds (p = 0.03), more severe deep white matter hyperintensity (p = 0.04), and periventricular hyperintensity (p = 0.04); however, these associations were not observed after adjusting for the cardiovascular risk factors.

Conclusions:
Higher levels of hs-CRP were associated with lacunar infarcts. Thus, inflammatory processes may be involved in the pathogenesis of small vessel disease.