bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P55: Infarction Patterns Predict Differential Response to Thrombolysis in Acute Middle Cerebral Artery Stroke Patients
Authors: Liu Dezhi , Scalzo Fabien , Johnson Mark S , Starkman Sidney , Rao Neal M , Hinman Jason D , Kim Doojin , Ali Latisha K , Saver Jeffrey L , Noorian Ali R , Ng Kwan L , Liang Conrad , Sheth Sunil A , Yoo Bryan , Liu Xinfeng , Liebeskind David S
Published: March 2022

Introduction:
Thrombolytic treatment within 4.5 hours saves ischemic tissue at risk and is associated with improved clinical outcomes in patients with acute middle cerebral artery (MCA) ischemic stroke. Lesion pattern is one of the most important predictors for acute stroke patients’ outcome. However, the efficacy of thrombolysis in acute MCA stroke patients with different lesion patterns remains unclear. In this study, we aimed to compare response to intravenous tPA in patients with different infarction patterns.

Methods:
We included acute MCA ischemic stroke patients treated with intravenous tPA. All patients had DWI within 24 hours of symptom onset with 6 lesion patterns categorized as territorial, other cortical, small superficial, internal border zone, small deep, and other deep infarcts. We classified territorial infarcts and internal borderzone into Group 1 and the other four lesion patterns as Group 2. We analyzed clinical outcome after tPA based on these distinct DWI lesion patterns.

Results:
A total of 203 patients were included in our study. Mean age was 66.2±18.1.The percent of patients with hypertension at presentation is higher in Group 1 than in Group 2(100% VS 93.8%, p=0.049). The presenting NIHSS of Group 1 is higher than Group 2 (18.0 vs 12.0, p<0.001). After intravenous tPA therapy, the proportion of patients progressing to intra-arterial tPA and/or endovascular thrombectomy in Group 1 was similar to Group 2 (22.0% vs 22.2%, p=0.98). As to the clinical outcome, the percent of patients with discharge mRS≤2 in Group 1 is much higher than that Group 2 (33.9% vs 20.1% p=0.038). Logistic regression demonstrated that infarction patterns were independently associated with discharge outcome of these patients.

Conclusion:
Good response to intravenous tPA was more frequent in patients with territorial infarcts and internal border zone infarcts, indicating that particular DWI infarction patterns can predict good outcome of acute MCA patients after thrombolysis.
Abstract T P58: TPA Contraindications have Little Impact on Thrombolysis Outcomes
Authors: Parker Sarah , Ali Yasmin , Nair Deepak , McNeil Clayton , Mathews Maureen , Jahnel Jan , Swanson-Devlin Teresa , Beck Judith , Wang David
Published: March 2022

Treatment with tPA is effective in patients with acute ischemic stroke but is only given to ~4% of patients. Part of what limits the use of tPA in acute stroke is the list of recognized contraindications (CIs) to tPA. Many of these CIs have little or no evidence describing how they may affect the safety of tPA. At the OSF Saint Francis comprehensive stroke center we have relaxed our definition of who can qualify for tPA.

Aggressively limiting what is considered a contraindication to tPA allows more patients to be treated safely and effectively.

We reviewed 218 patients who received tPA at our center from July 2010 to July 2014 to determine how many had one of 19 recognized CIs. Admission and discharge NIHSS, discharge MRS, discharge disposition and symptomatic ICH rates were compared in patients with CIs and those without.

Ninety (41%) of our patients were found to have one or more contraindication to tPA. There were a total of 157 CIs. The most common contraindication was NIHSS greater than 22 or less than 4 with 37 patients. The mean decrease in NIHSS from admission to discharge was 4 points in patients with CIs and those without CIs. There was no significant difference in the 43% of patients with CIs and the 42% of patients without CIs who had a good outcome on discharge defined as a discharge MRS of 0-2. There was no significant difference between the 64.8% of patients discharged to home or to rehab in the patients with CIs and the 66.1% of patients discharged to home or rehab who did not have CIs. There was also no significant difference between the 1% of patients with CIs who had symptomatic intracerebral hemorrhage and the 2% of patients without CIs with symptomatic intracerebral hemorrhage.

When making the decision to treat acute ischemic stroke with tPA, the risks & benefits of treating vs not treating should be weighed as they apply to each individual patient. Given our findings, we feel there is evidence that many contraindications to tPA should have less weight when making such decisions. This may increase the number of eligible patients who would receive treatment for stroke.
Abstract T P63: Low Creatinine Level Is Associated With Very Early Neurological Improvement After Thrombolysis for Ischemic Stroke
Authors: Guettier Sophie , Apol Marion , Bonnet Anne-Laure , Cohez Julien , Tchoumi Thierry , Dubuc Lydie , Arzur Julien , de la Sayette Vincent , Touzé Emmanuel
Published: March 2022

Introduction:
Early neurological improvement (ENI) within 24 hours after fibrinolysis for ischemic stroke is strongly associated with recanalization and favourable outcome at 3 months. However, it remains unknown why some patients recover within the 1st hour after treatment (very ENI, VENI) whereas others have ENI later within 24 hours. We therefore assessed which factors were associated with timing of ENI.

Methods:
We retrospectively studied consecutive patients treated with intravenous rt-PA for ischemic stroke within 4h30 after onset in 4 regional hospitals. VENI assessed at 1h and ENI assessed at 24h post-treatment was defined by NIHSS improvement by 40% from baseline. We compared patients with VENI to patients with ENI.

Results:
Among 421 patients (mean age 70.8±15.2 years, median NIHSS 15, median onset-to-treatment time 170 minutes) 65 (15%) had VENI, and 110 (26%) ENI. Patients with VENI had significantly lower serum creatinine level than patients with ENI (79±19 vs. 91±35 μmol/L; p=0.01). After adjustment for age, sex, baseline NIHSS, High Blood Pressure and glucose level at admission, patients with low creatinine level were more likely to have VENI (lowest tertile, OR=3.8 CI95%=[1.5-9.7], intermediate tertile, OR=1.8 CI95%=[0.8-4.3]; p for trend=0.006). VENI patients were as likely as ENI patients to have a modified Rankin scale ≤ 2 at 3 months (88% vs. 84%, p=0.46).

Conclusion:
Low serum creatinine levels are associated with VENI, suggesting that quickness of efficacy of rt-PA, of reperfusion, or of neurological recovery may depend on renal function.
Abstract T P67: Similar Outcomes With tPA Protocol Violations as with Protocol Adherence
Authors: Schlick Konrad H , Le Duy , Song Shlee S , Raman Rema , Ernstrom Karin , Ali Maysun , Ramani Hami , Meyer Dawn , Modir Royya , Meyer Brett C , Hemmen Thomas
Published: March 2022

Background:
Nearly twenty years after demonstrating the efficacy of IV tPA in clinical trials, it continues to be widely underused. Fibrinolytic therapy is heavily restricted by a long list of laboratory, radiographic, and clinical inclusion/exclusion criteria. We sought to evaluate whether patients who received IV-tPA in violation of these criteria had different outcomes.

Methods:
We included all ischemic stroke patients who received IV tPA (no intra-arterial therapy) and were followed to 90 -days. Group A: IV-tPA use despite contraindication (protocol violation), Group B: IV-tPA protocol-adherent. We compared baseline variables and demographics (age, sex, race, ethnicity, diabetes, hypertension, atrial fibrillation, cerebrovascular disease, baseline NIHSS, and smoking). We analyzed the frequency of symptomatic intracranial hemorrhage (sICH) and gastrointestinal bleeding (GIB). Measures of good clinical outcome included modified Rankin Scale (mRS) 0-1 and discharge home.

Results:
A total of 660 tPA-treated patients were included from October 2003 to August 2014, Group A included 22 patients; group B included 638. Group A had 2 patients under 18 years of age, 4 with bleeding risks (low platelets, elevated PTT, or known bleeding diathesis), 4 with recent surgery, trauma, or clinical bleeding, 2 with recent stroke or past ICH, one patient with abnormal glucose accounting for the deficit, and 11 patients outside the time window, rapidly improving, or no disabling deficit.

Baseline demographics and stroke severity were similar, except for diabetes, which was more common in Group A (45.5% vs. 24.3%, p=0.04). There was no difference in sICH (4.55 vs. 3.46%, p=0.55) or GIB (0 vs. 0.6%, p>0.99). Good clinical outcomes were similar (mRS 0-1 38.5% vs. 33.2%, p=0.77; discharge home 65.0 vs 61.8%, p=0.82).

Conclusions:
Clinical outcomes and bleeding risks were similar between patients who received IV tPA despite contraindications. Our analysis is limited by small numbers in Group A. Larger patient samples are needed to better understand the role of individual contraindications.
Abstract T P73: Overcoming Framing Bias in Stroke Neurologists’ Assessments of the Minimally Clinically Important Difference for Novel Acute Ischemic Stroke Therapies
Authors: Cranston Jessica , Kaplan Brett D , Saver Jeffrey L
Published: March 2022

Background:
The determination of the minimally clinically important difference (MCID) worth detecting is an essential prerequisite for clinical trial sample size calculation, funding decisions by NIH and other sponsors, and drug or device approval by regulatory agency. However, prior surveys to establish expert judgment of MCID have had a cognitive framing bias by offering response options with midpoints in the 5-15% range, well above the treatment effect actually accepted in practice and national guidelines as worthwhile (1% for acute aspirin).

Methods:
A 5 item internet-based survey was administered to US academic stroke neurologists. Respondents were asked to indicate, for an acute neuroprotective drug free of side effects, how many patients, per 1000 treated, would need to benefit by achieving freedom from disability at 90 days (mRS 0-2) for the agent to be worthwhile to use in clinical practice?

Results:
Survey responses were received from 122 of 332 academic stroke neurologists. Among the participants, 38.0% were professors, 24.0% associate professors, 33.1% assistant professors, and 5.0% neurology residents or fellows. All respondents were engaged in stroke clinical care, with cerebrovascular disease accounting for more than half of practice time in over 75%. Categorized responses to the value of the MCID were: 1 per 1000 by 3.3% of respondents, 2-5 in 7.4%, 6-10 by 19.7%, 11-15 by 22.1%, 16-20 by 15.6%, and greater than 20 by 32.0%. The median MCID was 13 (IQR 8 to > 20). Converted to natural base 100 values, the MCID was 1.3% (IQR 0.8% - >2%).

Conclusion:
When assessed with framing based on clinical practice rather than convenience, vascular neurologists indicated the minimally clinical important difference for a safe agent to be worthwhile to use in acute ischemic stroke is about 1%. Drug and device agencies should consider this value to be the expert opinion MCID for acute ischemic stroke treatments when making regulatory decisions.
Abstract T P77: Long-term Neuroprotection with Pharmacological Hypothermia by TRPV1 Agonism in Ischemic Stroke
Authors: Cao Zhijuan , Balasubramanian Adithya , Marrelli Sean P
Published: March 2022

Background:
Therapeutic hypothermia is a promising strategy for neuroprotection following stroke. However, current widely available methods are not compatible with conscious patients and produce unwanted physiological stress. We have recently demonstrated that pharmacological hypothermia (PH) through transient receptor potential vanilloid 1 (TRPV1) channel agonism is effective and safe in the conscious mouse and provides significant neuroprotection following ischemic stroke at 24 hours reperfusion. We now evaluate whether this method of PH provides sustained neuroprotection through one month reperfusion.

Methods:
Three experimental groups were evaluated: sham operated (Sham), stroke with normothermia (Stroke/NT), and stroke with PH (Stroke/PH) (n=8, 10, 7). Stroke was induced by transient occlusion of left distal middle cerebral artery (MCA) plus left common carotid artery for two hours. For the Stroke/PH group, hypothermia (32-34°C) was induced by infusion of TRPV1 agonist (dihydrocapsaicin) for 8 hours; beginning 90 minutes after reperfusion. We evaluated several behavioral tests from pre-stroke up to 28 days reperfusion. Total cerebral infarct was then evaluated in Nissl-stained brain sections at 30 days reperfusion.

Results:
The foot fault test was the most sensitive in demonstrating extended functional deficit after stroke. With this test, Stroke/NT demonstrated prolonged deficiency (through 21 days reperfusion) compared to Sham. PH treatment (Stroke/PH) demonstrated significant improvement in function compared to Stroke/NT. Other tests demonstrated non-statistically significant performance reduction of Stroke/NT in swimming time, grip side preference, turning and climbing time. Histological analysis demonstrated significant ipsilateral necrosis and hemisphere shrinkage in Stroke/NT brains compared to Stroke/PH brains.

Conclusions:
In summary, we demonstrate long-term neuroprotection with TRPV1-mediated PH following stroke. These studies support the therapeutic potential of TRPV1 agonism for promoting hypothermia in the conscious stroke subject.
Abstract T P79: Rapamycin Improves Outcome Post Stroke Injury by Enhancing Autophagy in Neuronal Cells
Authors: Buckley Kathleen M , Hoda Md. N , Kondrikova Galina , Sazonova Irina Y , Hess David C , Schoenlein Patricia V , Hill William D
Published: March 2022

Background and Purpose:
Previous literature and studies from our laboratory indicate that pharmacological inhibition and enhancement of autophagy are both effective in reducing infarct volume after stroke injury.

Methods:
Mice were treated with rapamycin to enhance, and chloroquine to suppress autophagy in mice immediately after stroke injury and again 24 hours post stroke injury in a murine stroke model. Survival data and neurological score were taken before sacrifice at 48 hours and lesion size was determined by TTC. HT22 neuronal mouse hippocampal cells were treated for one hour with H2O2 to mimic an oxidative stress injury and treated concurrently with rapamycin to enhance autophagy, chloroquine to inhibit autophagy or ZVAD to inhibit apoptosis. The treatment with pharmacological agents continued for 24 hours. Cells were counted with trypan blue on a hemocytometer. Western blot analysis was used to monitor protein changes. shRNA to Atg5 was used to genetically inhibit autophagy.

Results:
Both pharmacological agents showed decreased lesion size, though enhancement of autophagy with rapamycin exhibited a greater reduction in lesion size as well as increased survival and an improved neurological score. Rapamycin improved survival of neurons after oxidative injury and genetic inhibition of autophagy abrogated rapamycin's positive effect.

Conclusions:
Rapamycin improves stroke outcome by enhancing autophagy in neuronal cells.
Abstract T P82: The Role of the A2B Receptor in a Mouse Model Of Stroke
Authors: Weitzel Lindsay B , Grewal Himmat , Herson Paco S , Traystman Richard J
Published: March 2022

Introduction:
Every 40 seconds someone in the United States has a stroke, and we currently spend $73.3 billion on stroke-related disability. A2B receptor agonists are strongly protective against ischemia in many organ systems including liver, lung, and kidney. Very little work has been carried out to uncover the role, if any, for A2B in brain ischemia. The objective of this study was to elucidate the role of the A2B receptor through the use of the middle cerebral artery occlusion mouse model (MCAO), the A2B receptor antagonist PSB1115, and A2B KO animals.

Hypothesis:
We hypothesized that the A2B receptor antagonist PSB1115 would be detrimental in stroke.

Methods:
Transient focal ischemia was induced for 60 min of middle cerebral artery occlusion (MCAo) using the intraluminal filament model in male C57Bl/6 wild-type and A2B KO mice. PSB1115 at a dose of 5mg/kg and a vehicle of DMSO in saline were blinded and animals were randomized to treatment. Drug was delivered to C57BL/6 mice immediately post-reperfusion in the 60 minute MCAO model. Mice were sacrificed after 24 or 72 hours and infarct volume was measured using 2,3,5-triphenyltetrazolium chloride (TTC). Infarct volumes were compared between drug and vehicle groups and WT and A2B KO mice. Statistical analysis was performed using Student’s t-test with P<0.05 considered significant.

Results:
Analysis of histological damage 24 hours after MCAo revealed that the A2B antagonist PSB1115 decreased infarct size from 49±8.0% (n=7) to 37±4.3% (n=10;p<0.005). Similarly, we observed that the same dose of PSB1115 provided prolonged protection (analyzed 72 hours after MCAo), infarct volume decreased from 44±6.4% (n=7) in vehicle treated animals to 22±2.9% (n=4;p<0.05) in PSB115 treated animals. To extend this remarkable observation, we took advantage of A2B KO mice. We observed that A2B KO mice had significantly smaller infarct size at 24h compared to WT littermates, reducing from 55±6.4% (n=4) in WT mice to 19±4.3% (n=6;p<0.05) in A2B KO mice.

Conclusion:
Contrary to our hypothesis and its role in other organ systems, blocking or genetic deletion (KO mice) of the A2B receptor conveys protection following experimental stroke.
Abstract W MP102: Development and Validation of a Short Form for the Stroke Impact Scale
Authors: Fulton Rachael L , Ali Myzoon , Peters Michele , English Coralie , Rodgers Helen , Lees Kennedy R , Quinn Terence J ,   The Virtual International Stroke Trials Atchive (VISTA) Collaborators
Published: March 2022

Introduction:
The Stroke Impact Scale (SIS) is an eight domain (59 item) stroke specific quality of life measure. A short form of SIS (SF-SIS) has been proposed but requires independent validation.

Methods:
We used patient-level data contained in the Virtual International Stroke Trial Archive (VISTA). SIS was available for rehabilitation settings, a modified scale SIS-16 was predominantly used in acute settings. For both groups we extracted and standardised clinical and demographic data. We derived a short form index (SIS-VISTA) by selecting 8 items, one per domain; choosing those items most highly correlated with total domain score. Validation compared short forms with SIS/SIS-16 (Cronbach’s alpha) and other outcomes as available:Barthel Index; EQ-5D; visual analogue scale (VAS); mRS; NIHSS (correlation).

Results:
Acute data comprised n=5549 (603 intracerebral haemorrhage [ICH]) mean age:68.5 (SD:13); mean SIS:64 (SD:32). SIS-VISTA items agreed with SF-SIS for all available domains other than communication. Results did not differ in analyses restricted to ICH. Rehabilitation data, n=332 (mean age 65.7 [SD:11]; mean SIS:61 [SD:11]) preferred SIS-VISTA items agreed with SF-SIS for all domains except communication, ADL and mobility. Where items did not match differences in correlation were minimal. Short forms demonstrated good agreement with SIS and correlation with other metrics of interest (table).

Conclusions:
Using multiple approaches we have validated SIS short forms. There was no significant difference between existing SF-SIS and SIS-VISTA and we would encourage researchers to use SF-SIS to allow collection of robust quality of life data with less associated test burden.
Abstract W MP103: Describing Clinimetric Properties of the Stroke Impact Scale
Authors: Fulton Rachael L , Ali Myzoon , English Coralie , Rodgers Helen , Lees Kennedy R , Quinn Terence J ,   The Virtual International Stroke Trials Archive (VISTA) collaborators
Published: March 2022

Background and purpose:
The Stroke Impact Scale (SIS) is an eight domain (59 item) quality of life scale prevalent in the literature, a short form with physical function focus (SIS-16) is also described. These stroke specific scales may have utility but we should not assume favorable properties. We examined clinimetrics of SIS and SIS-16.

Methods:
We used patient-level data contained in the Virtual International Stroke Trial Archive (VISTA). For all patients with SIS/SIS-16 we extracted and standardised corresponding clinical and demographic data. We described internal consistency (Cronbach’s alpha) of scales and component sub-domains. We compared SIS to SIS-16 and described correlations with other outcomes. We compared individual SIS domains to scales measuring similar constructs.

Results:
Using SIS data, n=332 (mean age 65.7 [SD:11]; mean SIS:61 [SD:11]). Internal consistency of SIS was excellent α:0.93. SIS domains agreed with total SIS, poorest agreement was for emotion α:0.63. SIS correlated with BI (r=0.72, p<0.0001); EQ-5D (r=0.69, p<0.0001) and a visual analogue scale (r=0.58, p<0.0001); agreement with SIS-16: α:0.918. SIS domains correlated with some equivalent scales.(table, *data measured at 4 month post ictus) For SIS-16, n=4310, mean age:68.5 (SD:13); mean SIS-16:64 (SD:32); α:0.98; emotion domain had poorest agreement with total SIS-16 α:0.66. SIS-16 correlated with mRS (-0.87 (p<0.0001) and BI (0.89 (p<0.0001)).

Conclusions:
SIS and SIS-16 show reasonable, but not perfect, construct and congruent validity. Internal consistency of emotion domain is problematic. High internal consistency, even for SIS-16, suggests redundancy and scope to further shorten SIS while maintaining clinimetric properties.
Abstract W MP109: Variation In Utilization Of Do-not-resuscitate Orders Between Hospitals In Patients With Intracerebral Hemorrhage: A National Perspective
Authors: Jani Vishal B , Patel Achint , Lahewala Sopan , Arora Shilpkumar , Nadkarni Girish , Benjo Alexandre , Hussain Syed , Majid Arshad , Malik Ahmed , Qureshi Mushtaq , Razak Anmar , Suri Fareed , Qureshi Adnan
Published: March 2022

Background:
An unfavorable clinical course and limited treatment for intracerebral hemorrhage (ICH) leads to frequent do not resuscitate (DNR) orders. Data on inter-hospital variability of DNR utilization in patients (pts) with ICH is limited.

Hypothesis:
To analyze the between hospital variation in the utilization of DNR in ICH among low volume and high volume hospitals.

Methods:
We reviewed the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database from 2011-2012 for ICH admissions in patients >18 years using the ICD 9-CM code 431. We defined DNR status with ICD9CM code V49.86 entered during the same admission as a secondary diagnosis and estimated severity of illness by the 3M™ All Patient Refined DRG (APR DRG) classification System. We calculated ICH annual hospital volume and ranked them into four quartiles. 1st quartile hospitals were defined as low volume and rest as high volume. We generated hierarchical two level multivariate models and calculated Inter class correlation (ICC) and Median Odds Ratio (MOR).

Results:
We analyzed 25768 patients (weighted estimate126254) with ICH out of which 4620 (18%) patients (weighted estimate 22668) had DNR orders placed. Low volume hospitals accounted for total of 6575 pts (weighted: 32849), out of which 1504 pts (weighted: 7508) had DNR orders. Of the variation in DNR utilization between low volume hospitals, 63.0 % (ICC of 0.63; C statistics: 0.9) was attributable to individual hospital behavior of as compared to 29% in high volume (ICC=0.29; C statistics: 0.8), Also, the MOR was 9.3 for low volume hospitals indicating that a randomly selected patient at a particular hospital would have approximately nine times the chance of having a DNR order placed than an identically matched patient at another. This was three times as high as that for high volume hospitals (MOR=3). All models were adjusted for patient level, hospital level characteristics, APR DRG severity scale and other clinical characteristics.

Conclusion:
In conclusion, there is significant individual variation between hospitals in DNR utilization. Variation is three times higher in low volume hospitals as compared to high volume hospitals. Further attempts should be made to understand this inter-hospital difference.
Abstract W MP113: Type and Timing of Venous Thromboembolism Prophylaxis after Intracerebral Hemorrhage
Authors: Cherian Laurel J , Smith Eric , Schwamm Lee , Fonarow Gregg , Xian Ying , Wu Jingjing , Prabhakaran Shyam
Published: March 2022

INTRODUCTION:
Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality after intracerebral hemorrhage (ICH). Guidelines encourage the early use of mechanical and chemo prophylaxis (CP; i.e., low-dose heparin or low-molecular weight heparin) after ICH. We sought to determine the type and timing, temporal trends, and patient and hospital characteristics associated with VTE prophylaxis after ICH in the Get With the Guidelines-Stroke registry.

METHODS:
We identified patients with ICH between January 1, 2009 and September 30, 2013 who: 1) were not ambulatory and/or comfort care measures only by hospital day 2; 2) were not transferred to another acute care facility; and 3) had known VTE prophylaxis status at end of hospital day 2. Categories for VTE prophylaxis were 1) no prophylaxis, 2) mechanical prophylaxis alone or unknown/other prophylaxis, or 3) CP with or without mechanical prophylaxis. Early VTE prophylaxis was defined as occurring by hospital day 2. Using multivariable logistic regression, we assessed patient, hospital, and geographic factors associated with early CP use.

RESULTS:
Among 81,828 patients with ICH from 1,450 hospitals, 5929 (7.2%) received early CP; 68,205 (83.4%) received early mechanical prophylaxis only or other/unknown type; and 7,694 (9.4%) had no early prophylaxis. There was no increase in CP use over the study period. In multivariable analysis, several patient, hospital, and geographic factors were independently associated with early versus no early CP use (Table).

CONCLUSIONS:
Nationwide, the large majority of ICH patients receive early VTE prophylaxis with mechanical devices only, without prophylactic anticoagulants. Hospital characteristics such as size and geographic location are strong determinants of increased early prophylactic anticoagulant use. Further study of practice variation is needed.
Abstract W MP114: Impact of Blood Removal on Perihematomal Apparent Diffusion Coefficients in Patients Treated with Minimally Invasive Surgery Plus rt-PA
Authors: Mould W. Andrew , Lovett Braeden L , Muschelli John , Hanley Daniel F , Carhuapoma J. Ricardo
Published: March 2022

Introduction:
Novel procedures such as minimally invasive surgery (MIS) and rt-PA administration can effectively reduce not only blood volume, but also perihematomal edema (PHE) formation in stroke patients. In order to quantify the amount of blood brain barrier (BBB) disruption within this perihematomal region, apparent diffusion coefficient (ADC) maps can be used. We hypothesized that hematoma removal in MIS treated patients would result in lower ADC values when compared to patients receiving standard medical care.

Methods:
The impact of hematoma removal on ADC elevation was evaluated in patients from MISTIE II using MRI. FLAIR and GRE sequences were used at baseline (D1) and one-week (D7) post ictus, to delineate total lesion (hematoma plus PHE) and hematoma regions. The ROIs of the two sequences were subtracted leaving the PHE region to be transferred to the ADC map and averaged for each patient at both time points.

Results:
Fourteen surgical and 10 medical patients were analyzed. Time between D1 and D7 was similar between MIS, 7.28(1.68) days, and medical patients, 6.91(0.84) days (p=0.49); as was baseline hematoma volume, 41.9(17.9) cc and 35.2 (14.3) cc, respectively (p=0.32). Successful clot removal was demonstrated with a group difference in end of treatment ICH volume, MIS 15.2(8.9), medical 32.3(10.3) (p<0.001). Finally, the median change in average ADC for the MIS cohort, a decrease of 30.5 mm2/sec, was significantly lower when compared to the median change for the medical cohort, an increase of 75.7 mm2/sec (p=0.004).

Conclusion:
Hematoma removal has been previously reported to significantly reduce both ICH and PHE volume. Here, we report the effect of clot removal on ADC elevation. A decrease in ADC between D1 and D7 in the MIS cohort when compared to the increase in the medical cohort suggests that MIS plus rt-PA mitigates BBB disruption, and in turn, provides an explanation for the difference in formation of perihematomal edema.
Abstract W MP116: Goals of Care Impact Early Outcome Estimates in Intracerebral Hemorrhage
Authors: Kalani Rizwan , deHavenon Adam , Creutzfeldt Claire , Longstreth William T , Sultan-Qurraie Ali , Huffer Andrew , Becker Kyra , Tirschwell David
Published: March 2022

Background/Objective:
Prior reports of ICH score-based early mortality rates included patients declared comfort measures only (CMO). We aimed to describe more clinical relevant mortality and functional outcomes restricted to patients in whom all care was continued (non-CMO).

Methods:
Using a single-center retrospective study design, admission ICH score, goals of care, hospital death (HD), and modified Rankin scale (mRS) at discharge were collected in patients with spontaneous ICH from June 2005 to September 2008. Use of CMO and proportions of outcome measures, stratified by admission ICH score, were compared using Pearson’s chi-square test statistics.

Results:
Of 657 patients with ICH, 56.5% were male, 74.7% Caucasian, with mean (SD) age of 66.6 (14.6) years. CMO was pursued in 30.6% of all patients, with a significant increase in use associated with increasing age (p=0.021) and increasing ICH score (p<0.001). HD occurred in 33.8% of all patients, but only 7.2% of non-CMO. In the non-CMO patients, the association between HD and ICH score remained significant (p<0.001), though values were substantially lower than those including CMO patients. An improved distribution of mRS at discharge, in non-CMO patients, was significantly associated with lower ICH score, (p<0.001).

Conclusions:
A significant association exists between ICH score on admission and decision for CMO. Although hospital discharge outcomes (death and mRS) worsen with increasing ICH score even in non-CMO patients, they are substantially improved compared to estimates which include CMO patients, including the original ICH cohorts in the literature. These findings have important implications for early discussions with families related to prognostication and decisions regarding goals of care, especially given a new mandate from The Joint Commission for reporting ICH scores at Comprehensive Stroke Centers.
Abstract W MP119: Sensitivity and Reliability of MRI SWI Compared With GRE Sequences for Detecting Microbleeds in a Community Population
Authors: Batool Saima , Patil Shivanand , Noseworthy Michael D , O'Donnell Martin , Sharma Mukul , Islam Shofiqul , Teo Koon , Black Sandra , Lauzon M L , McCreary Cheryl R , Frayne Richard , DeJesus Jane , Rangarajan Sumathy , Yusuf Salim , Smith Eric E
Published: March 2022

Background:
MRI susceptibility-weighted imaging (SWI) provides better contrast and is typically done at higher spatial resolution than MRI T2*-weighted gradient-recalled echo (GRE), increasing the sensitivity for cerebral microbleed (CMB) detection. However, few studies have implemented SWI and GRE in the same scan session, and there is uncertainty regarding whether findings on SWI are comparable to findings on GRE. We compared the sensitivity and reliability of SWI vs. GRE sequences for detecting CMBs in a community population.

Methods:
Using a standardized case report form, two radiologists independently identified CMBs on SWI and GRE in 247 participants age 40 to 75 in the community-based Prospective Urban Rural (PURE) MIND substudy. MRI was performed on the same GE 3T MRI scanner using typical clinical sequence parameters. SWI and GRE were read >2 weeks apart. After the independent readings, the two raters met to determine CMB presence by consensus.

Results:
Mean age was 58.0±7.6 years, 65% were women, 23% had hypertension and 8.6% had diabetes. By consensus, CMBs were seen in 30 participants (12.2%) on SWI but in only 13 (5.2%) on GRE (p<0.001). Inter-rater reliability was moderately good on SWI (kappa 0.52, 95% CI 0.34-0.71) and GRE (kappa 0.51, 95% CI 0.30-0.73). A pattern of lobar CMBs, with or without cerebellar CMBs but without other non-lobar CMBs, was seen in 8/13 (62%) with GRE CMBs and 19/30 with SWI CMBs (63%). Increased age and diabetes were associated with CMBs on both SWI and GRE.

Conclusions:
More than twice as many CMBs were detected on MRI SWI compared to GRE, with the same inter-rater reliability. SWI may be the preferred sequence for detecting CMBs, given its greater sensitivity. However, CMB distribution patterns and risk factors were similar regardless of sequence type, suggesting that the findings of studies using either sequence are comparable.
Abstract W MP12: Sequential NIHSS Change is a Better Predictor of Good Functional Outcome than Pre-Treatment Neurological Status after Mechanical Thrombectomy in Acute Stroke
Authors: Mocco J , Yoo Albert J , Zaidat Osama O , Buell Hope , Kuo Sophia S , Bose Arani , Sit Siu Po ,   for the Penumbra Pivotal, POST, PICS, START and RetroSTART Trialists
Published: March 2022

Purpose:
Pre-treatment NIHSS has been shown to be the strongest predictor of outcome after endovascular therapy in acute ischemic stroke. However, it is not clear if sequential changes in NIHSS scores have any predictive value after mechanical thrombectomy cases.

Methods:
Prospective (Pivotal N=119, PICS N=219, START N=124) and retrospective/registry (POST N=95, RetroSTART N=168) cases using the Penumbra System were pooled. All were IV tPA-ineligible or refractory with treatment at <8 h. The association of NIHSS pre- and post-treatment and good clinical outcome (mRS 0-2 at 90 days) was tested.

Results:
Among 725 patients, mean age was 66 ± 15 and median admission NIHSS score was 17 (IQR 13-21). Median NIHSS improved to 11 at 7 days. NIHSS scores at 7 days showed a stronger relationship with good outcome (correlation 0.84; p<0.001) than baseline (correlation 0.37; p<0.001). Furthermore, serial NIHSS scores (baseline minus 7 day) also predicted good outcome (correlation -0.69; p<0.001). Age (correlation 0.39, p < 0.001), pre-treatment ASPECTS score (correlation -0.19; p < 0.001) but not reperfusion to TIMI 2-3/TICI 2b-3 also demonstrated associations with good outcome.

Conclusion:
In this pooled Penumbra cohort, post treatment improvement in neurological status significantly predicted good clinical and functional outcomes, independent of reperfusion status.
Abstract W MP120: Minimally Invasive Subcortical Parafascicular Access for Clot Evacuation. A Paradigm Shift
Authors: Britz Gavin W , Kassam Amin , Labib Mohamed , Young Ronald , Zucker Lloyd , Maioriello Anthony , Day jd , Gallia Gary , Kerr Robert
Published: March 2022

Introduction:
Spontaneous intracerebral hemorrhage (ICH) is common and causes significant mortality and morbidity. To date, intervention remains uncertain. Neurosurgical therapies for subcortical lesions have been limited by procedure-related injury to the cerebral cortex and adjacent subcortical brain regions. This is particularly relevant for eloquent cortex, therefore surgical therapy is often not performed.

Hypothesis:
We hypothesized that using an integrated systems approach for Minimally invasive Subcortical Parafascicular Access for Clot Evacuation (MiSPACE) consistently, could result in improved clinical outcomes and protection of eloquent tissue, especially if we focus on minimizing trauma to normal tissue.

Methods:
We report on this standardized technique incorporating 5 cores of MiSPACE 1) image interpretation and trajectory planning, 2) dynamic navigation, 3) a traumatic access (BrainPath, NICO Corp), 4) optics (Storz), and 5) resection (Myriad, NICO, Corp), wherein all surgeons have been trained through a CME course and have applied the surgical technique and approach in all 25 cases. Pathology, pre- and post-operative clinical and radiographic characteristics and clinical outcome at last follow-up were collected.

Results and Conclusions:
The cases presented illustrate successful application of the MiSPACE standardized systems approach. Mean pre-operative ICH volume was 47.2 and mean percentage of clot removal was 89%. Most importantly, significant recovery was observed in 89% of patients with no new deficits reported. MRI tractography obtained pre operatively illustrates how collateral tissue preservation can be achieved by trajectory planning. Using the same technique, the same equipment, in a standardized approach in dominant, eloquent cortex and subcortical regions (Table 1) this may lead to improved outcomes. Safety and feasibility studies are required to further assess this promising new therapeutic paradigm.
Abstract W MP13: Stroke Thrombolysis: Comparing CTA, CTP and NCCT Imaging Criteria for Thrombolysis
Authors: Bivard Andrew , Levi Christopher , Parsons Mark
Published: March 2022

Background:
We examined the important and controversial issue of the value of various advanced imaging methods in a large, prospective cohort of acute stroke patients at a university hospital stroke centre that routinely uses multimodal CT imaging to assist thrombolytic treatment decisions. Methods: We prospectively collected baseline, 24 hour, and day 90 clinical and imaging data from acute ischemic stroke patients being assessed for acute thrombolytic therapy at a centre where multimodal CT (NCCT, perfusion CT, and CT angiography) is used routinely as part of the decision-making process for thrombolysis. NCCT was assessed with the ASPECTS scoring system, CTA was graded for collateral flow and occlusion status and on CTP patients were classified according to the DEFUSE2 ‘target mismatch’ criteria. Patients treated with thrombolysis were compared to those who were untreated to generate odd ratios for mRS 0-1 and 5-6 and regression statistics were used to compare the imaging profiles to mRS. Results: 368 rtPA treated patients with hemispheric ischaemic stroke and complete follow-up were analysed. Treated patients ASPECTS >7 had mRS 0-1 OR 0.6 compared to untreated, and mRS 5-6 OR 1.98. Patients Treated patients with an ASPECTS score <7 had mRS 0-1 OR 0.18, mRS 5-6 OR 3.30, with an ASPECTS score >7 and occlusion on CTA had mRS 0-1 OR 2, mRS 5-6 OR 0.76. Patients with an ASPECTS score >7 and occlusion and good distal collateral flow on CTA had mRS 0-1 OR 2.91, mRS 5-6 OR 0.94. Patients with CTP DEFUSE2 mismatch had mRS 0-1 OR 11.93, mRS 5-6 OR 0.52. Patients with CTP DEFUSE2 mismatch and occlusion on CTA mRS 0-1 OR 19.71, mRS 5-6 OR 0.36. Conclusions: Acute CTP selection criteria was the strongest predictor of outcome compared to either NCCT ASPECTS or combined NCCT and CTA criteria.
Abstract W MP16: Introducing the Imaging the Collaterals in Acute Stroke (iCAS) Multicenter MRI Trial
Authors: Zaharchuk Greg , Marks Michael P , Do Huy M , Bammer Roland , Lansberg Maarten , Kemp Stephanie , Albers Gregory W ,   iCAS Investigators
Published: March 2022

Introduction:
imaging Collaterals in Acute Stroke (iCAS)
is an NIH-funded, multicenter study to determine if non-contrast arterial spin label (ASL) MRI can characterize collateral flow in patients presenting with acute large vessel stroke and whether it can identify patients who benefit from endovascular therapy. It also enables direct comparison with current state-of-the-art clinical perfusion imaging, bolus perfusion-weighted imaging (PWI).

Hypotheses:
(1) ASL identifies collaterals with high sensitivity and specificity compared to digital subtraction angiography (DSA). (2) Increasing collateral grade determined by either ASL or DSA is associated with higher CBF. (3) ASL collateral grade independently predicts reduced infarct growth. (4) Patients with a “target mismatch” based on PWI(Tmax>6) can be identified using ASL. (5) Only patients with intermediate grade collaterals will benefit from early reperfusion.

Methods:
180 patients will be recruited from up to 6 sites over 5 yrs. Current sites include Stanford, Swedish Hospital Seattle, and UPMC. Inclusion criteria: >18 yrs; NIHSS >=5; planned endovascular therapy (primary or adjuvant therapy following IV tPA); planned MR imaging with ASL & PWI; IA therapy <60 min from MR completion and <12 hrs of symptom onset. Exclusion criteria: mRS>=2 prior to the qualifying stroke; Cr clearance <40 ml/min; contrast allergy; pregnancy; MRI contraindications. MRI will be obtained at 3 time points (<12 hrs, 18-36 hrs later, 5 d), with clinical data at 30 & 90 days.

Results:
7 patients have been recruited. While formal image analysis has not been performed, initial review suggests that ASL has similar performance to PWI in this patient population (Fig).

Conclusion:
It is feasible to acquire ASL during an acute stroke MRI workup, enabling comparison of both collateral measures with DSA and perfusion metrics with PWI. It will provide a framework to account for the crucial role of collaterals in endovascular triage strategy.
Abstract W MP2: Unchanged Utilization of Endovascular Treatment in Acute Ischemic Stroke Patients in the post IMS-III era
Authors: Hassan Ameer E , Bezzina Cara , Malik Ahmed A , Jones-Fullingim Lisa , Sanchez Christina , Tekle Wondwoosen G , Qureshi Adnan I
Published: March 2022

Background:
The results of Interventional Management of Stroke (IMS) III, MR RESCUE, and SYNTHESIS EXPANSION trials are expected to affect the utilization of endovascular treatment for acute ischemic stroke.

Objective:
To evaluate trends in utilization of endovascular treatment among acute ischemic stroke patients after the publication of IMS III, MR RESCUE, and SYNTHESIS EXPANSION trials.

Methods:
We obtained data for patients admitted to hospitals with a primary diagnosis of ischemic stroke using data from Minnesota Hospital Association. We determined the rate of utilization of endovascular treatment for acute ischemic stroke from March 2012 to December 2012 and March 2013 to December 2013. Outcomes were classified based on discharge disposition.

Results:
Of the 13,408 patients with ischemic stroke, 6765 (50.5%) were admitted with ischemic stroke prior to, and 6643 (49.5%) after the publication of trials’ results. The proportion of patients who underwent endovascular treatment was unchanged: 2.3% of ischemic stroke patients in the pre-IMS III group vs 2.4% in the post-IMS III group (p=0.6). The estimated number of patients undergoing any thrombolytic treatment increased (7.1% versus 7.8%,p=0.1). There was a significant reduction in length of stay in the post IMS III group, 3.8 ± 4.1 vs 3.6 ± 3.5 (p=0.02). The rates of discharge to home remained unchanged in the pre- and post- IMS III groups (3646 (53.9%) vs 3585 (54.0%), p=0.9).

Conclusion:
Contrary to expectations, there has been no reduction in the utilization of endovascular treatment among acute ischemic stroke patients after IMS-III, MR RESCUE and SYNTHESIS EXPANSION results were published.
Abstract W MP32: Is Acute Reperfusion Therapy Safe in Acute Ischemic Stroke Patients Who Harbor Unruptured Intracranial Aneurysm?
Authors: Mowla Ashkan , Singh Karanbir , Mehla Sandhya , Ahmed Mohammad K. , Shirani Peyman , Krishna Chandan , Kamal Haris , Sawyer Robert N. , Ching Marilou , Siddiqui Adnan H. , Levy Elad I. , Snyder Kenneth V. , Crumlish Annmarie , Hopkins L.N.
Published: March 2022

BACKGROUND:
Intracranial aneurysm was considered an exclusion criteria for intravenous(IV) thrombolysis in acute ischemic stroke in both NINDS and ECASS III studies, possibly due to a hypothetical increase in the risk of bleeding from the aneurysm rupture; however, there is limited data available on whether IV thrombolysis is unsafe for acute ischemic stroke patients with incidental brain aneurysms and to the best of our knowledge, no data is available on the safety of combination of IV and intra-arterial (IA) thrombolysis in those patients.

AIM:
To find out the safety of acute reperfusion therapy in acute ischemic stroke patients who harbor intracranial aneurysm.

METHODS:
We retrospectively reviewed the medical records and cerebrovascular images of all the patients treated with IV thrombolysis for acute ischemic stroke in our center from the beginning of 2006 till the end of April 2014. Those with evidence of unruptured intracranial aneurysm on cerebrovascular images prior to acute reperfusion therapy were identified. Post thrombolysis brain imaging were reviewed to evaluate for any symptomatic intraparenchymal or subarachnoid hemorrhage related or unrelated to the aneurysms.

RESULTS:
A total of 637 patients received IV thrombolysis in our center during a 9.3 years period. 33 (5.1%) were found to have at least one intracranial aneurysm. 24(72.7%) of those received only IV thrombolysis and 9 patients received combination of IV and IA thrombolysis. The size of the largest aneurysm was 9 mm (Range: 2 mm to 9 mm). No symptomatic intracranial hemorrhage occurred among the 24 patients receiving only IV thrombolysis. Out of those who received a combination of IV and IA thrombolysis, 1 developed symptomatic intraparenchymal hemorrhage with intraventricular extension in the location of acute infarct, distant to the aneurysm location.

CONCLUSION:
Our findings suggest that neither IV thrombolysis nor combination IV and IA thrombolysis increase the risk of aneurysmal hemorrhage in acute ischemic stroke patients who harbor unruptured intracranial aneurysms less than 10 mm in diameter. Their listing in exclusion criteria for IV thrombolysis should be reconsidered to assure appropriate use of acute reperfusion therapy in this group of patients.
Abstract W MP41: Co-prevalence of Intracranial and Aortic Aneurysms: A Retrospective Study
Authors: Koskey Gloria , Chee Christina Y , Surakiatchanukul Thamolwan , Grider Ronald , Thomas Matthew J , Southerland Andrew M , Worrall Bradford B
Published: March 2022

Introduction:
Intracranial aneurysm (IA), abdominal aortic aneurysms, thoracic aortic aneurysms and dissection share genetic and environmental risks. In a retrospective clinical record review, we characterized a population presenting with aortic aneurysm (AA) and subsequently had intracranial vascular imaging (magnetic resonance (MRA), computerized tomography (CTA), or digital subtraction (DSA) angiography).

Method:
Using the University of Virginia Clinical Data Repository, we searched for patients with a diagnosis of any AA by ICD-9 codes for 2004-2014. We used 3 search strategies to identify individuals with intracranial vascular imaging: 1) CPT codes for MRA, CTA or DSA, 2) their billing codes, and 3) presence of vascular anatomic terms in radiology reports. We then undertook a chart review to confirm intracranial imaging and identify those with a IA. We readjudicated 10% of cases.

Results:
We identified 5500 cases of AA and 550 cases with evidence of potential intracranial vascular imaging. We report data on 338 of these 550 cases. The available demographic data of the 5500 AA cases and the subset reported were similar (Table).

Of the 338 potential cases reviewed, 163 did not actually have intracranial imaging and we could not verify a diagnosis of in 56 case. A total of 212 remain to be reviewed. Of the 119 cases with a CTA, MRA or DSA performed, 23/119 (19.3%) had an IA identified. The descriptive statistics of the demographics and co-morbidities are presented in the table.

Conclusion:
We found a co-prevalence of 19.3% for IA in a clinical population presenting with AA and undergoing intracranial vascular imaging. These data, though limited, support a potential shared risk for aneurismal disease in the aorta and the brain and warrant further investigation with prospective screening and investigation of the mechanisms of shared risk.