bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 3166: Asymptomatic Internal Carotid Artery Stenosis is Associated with More Cortical Subclinical Brain Infarcts: the Northern Manhattan Study (NOMAS)
Authors: Wright Clinton , Dong Chuanhui , Yoshita Mitsuhiro , Disla Norbelina , Elkind Mitchell S , DeCarli Charles , Sacco Ralph L , Rundek Tatjana
Published: July 2021

Background:
Asymptomatic internal carotid artery (ICA) stenosis is a modifiable risk factor for ischemic stroke but its role in subclinical brain infarction (SBI), also a stroke risk factor, is poorly understood especially in multiethnic populations.

Methods:
In the Northern Manhattan Study community-based cohort, stroke-free participants underwent quantitative assessment of SBI with MRI and of carotid atherosclerosis with Doppler ultrasound. We examined the prevalence and location of SBI in those with and without carotid stenosis (defined as ≥60% or occlusion). We used Fisher Exact Tests to assess group differences.

Results:
The mean age of the sample (N=1217) was 71±9 years and 60% were women. The race-ethnic distribution was 65% Hispanic white, 18% non-Hispanic Black, and 17% non-Hispanic white. There were 21 participants with asymptomatic ICA stenosis or occlusion (1.7%) and 170 participants with SBI (14%). Overall, five of 21 participants with ICA stenosis or occlusion had SBI (24%) compared to 165 of 1196 with less or no stenosis (14%), but this difference was not statistically significant (Fisher Exact Test P=0.19). However, a greater proportion of participants with stenosis or occlusion had cortical SBI (N=3 of 21, 14%) compared to those with less or no stenosis (N=28 of 1196, 2%; Fisher Exact Test P=0.03). Also, of five participants with both SBI and stenosis or occlusion, four were ipsilateral and one was contralateral to the lesion. Race/ethnic differences were not discernible.

Conclusions:
In this stroke free community based sample, participants with asymptomatic ICA stenosis had a greater proportion of cortical SBI than those with less or no stenosis. Further studies with larger race/ethnically diverse samples are needed to confirm these findings, and to assess the risk of stroke associated with having both asymptomatic carotid atherosclerosis and SBI.
Abstract 3192: A Descriptive Study of Interventional Management of Stroke III Trial Investigator Recruitment Enhancement Strategies
Authors: Frasure Jamey , Broderick Joseph , Jauch Edward , Yeatts Sharon , Foster Lydia , Khatri Pooja
Published: July 2021

Purpose:
Randomized control trials (RCT) are the gold standard of clinical research, yet most RCTs do not finish on time or on budget of the original proposal. The literature lacks research relevant to enhancing investigator recruitment strategies. Therefore, we sought to explore the role of these strategies in the ongoing NIH-funded, Interventional Management of Stroke (IMS) Phase III Trial.

Method:
We limited this analysis to November 1, 2007 - July 31, 2011 to exclude the start-up period for the trial. We compiled the dates of all potential recruitment enhancing strategies used in the trial, including investigator meetings, contests to reward recruitment, amendments to broaden eligibility criteria, and the addition of more sites in the US and internationally. We compared mean enrollment in the two months immediately before and after the month of intervention, and prespecified that an enrollment change of ≥ 25% would be considered a potentially effective recruitment strategy. Given the limited variability, only descriptive analyses were performed.

Results:
From November 2007 through July 2011, the mean monthly recruitment in the IMS III Trial was 9.77, (
SD
= 3.2) subjects and the range was 4-20. There was no significant change in recruitment rates over time (
p
= 0.56). We identified a change of ≥ 25% after each investigators’ meeting at the International Stroke Conference in 2008, 2009, 2010, and 2011. Other interventions that exceeded the 25% change were the submission of Amendment 3 (Jan 2009), conduct of an investigators’ conference call (Aug 2010), and initiation of screening at European sites (Mar 2011). See
Table
1.

Discussion:
Investigators’ meetings and/or the International Stroke Conference appeared to increase enrollment significantly in the IMS III Trial. We speculate that these investigators’ meetings convey the commitment of the PI and administrative staff and increase the enthusiasm of investigators to complete the study. Additional efforts may have been beneficial, but our analysis was limited by multiple confounding factors, including the imprecision of the timing for implementation of some strategies as with IRB-approval of new amendments at each institution, and individual site factors such as the probation of underachieving sites. Review of the literature identified online education pertaining to consent methodology as a new avenue for the IMS III Trial to explore to maintain recruitment. Further evidence-based study of methods to improve investigator-initiated recruitment is needed.
Table
1: Recruitment Efforts and Corresponding Monthly Enrollment Rates
Abstract 3197: Hospital Financial Health And Variation In Rates Of IV tPA Adherence In Ma
Authors: D'Amore Katrina , Kulick Erin , Coe Laura , Schwamm Lee H
Published: July 2021

Introduction:
Stroke is the 3
rd
leading cause of death and in MA over 17,000 residents are hospitalized annually for stroke. At 58/69 MA hospitals, The Paul Coverdell National Acute Stroke Registry (PCNASR) has been collecting detailed information about stroke care since 2005. Acute stroke therapy and IV thrombolysis can be resource intensive. We sought to determine if measures of hospital financial health would explain any of the observed variability in IV tPA adherence in MA

Methods:
Hospital PCNASR performance measure data and publicly available financial performance data (
www.mass.gov
) were linked for 58 participating hospitals for FY 2006-2009. Hospitals with missing financial information (n=3), joined the Registry after 2009 (n=3) and those with <20 annual stroke admissions (n=2) were excluded, leaving 50 hospitals in the analysis. Association of 4 yr average adherence rates for the PCNASR IV tPA measure with 5 traditional hospital characteristics (teaching status, urban/rural designation, stroke volume, geographic region, years of participation in the MA stroke QI collaborative) and 4 financial variables (total margin, operating margin, cash flow to total debt ratio, and cash on hand) were assessed in univariate analyses. All variables significant at p< .10 were tested in a multivariable regression model.

Results:
There were 50 hospitals analyzed over 4 years with median bed size 194 [IQR 126,292], median stroke admissions 219 [IQR 94,365] and 20% teaching hospitals. Among the 4 candidate financial variables significant in univariate analysis, only total margin remained significant (p=.04) after accounting for interaction terms among the 4 variables (
Table
1). In multivariate analyses, only total margin remained significant (p=0.04) but it accounts for a negligible amount of variability (r-square 0.08) and increasing financial health was if anything inversely associated with tPA use (Beta Coefficient -0.288).

Conclusions:
In our cohort of hospitals representing the majority of tPA administration over 4 years in MA, we found that standard industry measures of hospital financial health or other traditional hospital level factors did not explain the variability in rates of thrombolysis use. These findings suggest that changes in financial health at the global hospital level should not be perceived as a barrier to successful stroke thrombolysis program development at the local level.
Abstract 3229: Criteria for Appropriate Utilization of Helicopter Interfacility Transfer of ICH Patients
Authors: Calhoun Dustin J , Bogenschneider Shana , Iyengar Phaniraj , Asimos Andrew W
Published: July 2021

Background:
Many intracranial hemorrhage (ICH) patients are emergently transferred to tertiary neurosurgical centers by helicopter emergency medical services (HEMS), yet no guidelines exist for HEMS use in acute ICH. The American Stroke Association (ASA) publishes guidelines for neurosurgical intervention in ICH patients. Additionally, high ICH scores have been shown to predict lethal ICHs. We hypothesized that an algorithm including ASA guideline criteria and ICH score would identify patients for whom HEMS transportation might be appropriate.

Objectives:
To determine, in ICH patients transferred by HEMS, (1) the sensitivity of ASA guidelines for predicting emergent neurosurgical intervention, and (2) the ability of an ICH score ≥4 to predict early mortality and failure to receive intervention.

Methods:
We conducted a retrospective chart review of ICH patients transported by HEMS to one tertiary care center between September 2008 and February 2011. We reviewed medical records and brain CTs from the hospital of first presentation to calculate ICH scores and to evaluate for the seven ASA guideline criteria: GCS score ≤8, herniation, intraventricular hemorrhage, hydrocephalus, brainstem compression, lobar clot >30 mL within 1 cm of the paranchymal surface, and cerebellar hemorrhage. We reviewed tertiary center records for neurosurgical interventions and in-hospital mortality.

Results:
Review of 137 patient records identified 86 patients with an ICH and an available initial brain CT. All patients who received an emergent intervention met at least one of the criteria (sensitivity 100%), while 16 (18.6%) patients transferred by HEMS met no ASA criteria. No patient with an ICH score of ≥4 (n=19) received an emergent neurosurgical intervention, and only one such patient survived to hospital discharge. Comparison of this group to all others produced a hazard ratio of 5.86. Thirty-five (40.7%) patients had either no ASA criteria or an ICH score ≥4.

Conclusions:
The ASA guidelines have high sensitivity for detecting those patients who will receive emergent neurosurgical intervention after transfer, while patients with ICH scores of ≥4 almost uniformly have lethal hemorrhages and do not undergo emergent intervention. An algorithm including the presence of at least one of the seven ASA ICH neurosurgical intervention criteria and an ICH score <4 can be used to screen for appropriate use of HEMS transport in acute ICH.
Abstract 3263: Cystatin C is Associated with Early Functional Outcome in Acute Stroke Patients
Authors: Oh Mi-Young , Lee Seung-Hoon , Kim Chi Kyung , Ko Sang-Bae , Kim Beom Joon , Ryu Wi-Sun , Kim Do Houng , Park Hong-Kyun , Yoon Byung-Woo
Published: July 2021

Background:
Cystatin C, a competitive inhibitor of lysosomal cysteine protease, is regarded as a sensitive marker of kidney dysfunction. Lower estimated glomerular filtration rate (eGFR) was associated with poor prognosis and all cause of mortality in stroke patients. Cystatin C was a more sensitive and accurate marker to detect subclinical kidney dysfunction, compared to creatinine, or creatinine based eGFR. We evaluated whether Cystatin C would predict functional outcome, independent of eGFR level in ischemic stroke.

Methods:
We evaluate consecutive patients with acute stroke who were admitted to Seoul National University Hospital between January 2008 and May 2011. We defined the unfavorable outcome group as containing each patient with a discharge mRS score of 1 with admission NIHSS score of 0 to 7, a discharge mRS score of 2 with admission NIHSS score 8 to 14, or a discharge mRS score of ≥3 with admission NIHSS score 15.

Results:
Among the total patients, 544(76.2%) patients had unfavorable outcome at discharge. Participants with unfavorable outcome tended to be female, older and to have higher Cystatin C, CRP, fibrinogen and Hb A1c concentrations. The proportion of patient with unfavorable outcome was gradually increased according to the cystatin C quartile. Compared to the lowest quartile of Cystatin C (47.2<nmol/L), higher quartiles (47.2 -54.7, 54.7-65.7, 65.7≥nmol/L) were likely to have a higher chance of unfavorable outcome [adjusted OR (95%CI), 1.55(0.73-3.31), 2.66 (1.21-5.87) and 2.84(1.15-7.09)] after adjusting for age, diabetes, Hb A1c, fibrinogen, CRP, NIHSS scale on admission, hemorrhagic transformation, IV thrombolytic treatment. In contrast, eGFR did not show any significant association with unfavorable outcome. Compared to the lowest category of eGFR (≥60 ml/min/1.73m2), higher categories (45.0- 60.0, 15.0-45.0, ≤15.0 ml/min/1.73m2) did not show significant association with unfavorable outcome.

Conclusions:
An increased level of Cystatin C was associated with functional outcome in stroke patients. Cystatin C may be a potent predictor to predictor of functional outcome after ischemic stroke.
Abstract 3286: Persistently Reduced Venous Drainage After Intravenous Thrombolysis is Associated With Poor outcome in Acute Anterior Circulation Ischemic Stroke
Authors: Yeo Leonard L , Wakerley Ben , Shen Liang , Ahmad Aftab , Ng Kay W , Loh Pei K , Paliwal Prakash R , Venketasubramanian N , Teoh Hock L , Chong Vincent F , Ong Benjamin K , Sinha Arvind K , Chan Bernard P , Sharma Vijay K
Published: July 2021

Background-
Significant numbers of acute ischemic stroke (AIS) patients recover with timely-administered intravenous tissue plasminogen activator (IV-TPA). However, rates and extent of recovery remain variable. Considering scarce and costly resources, early identification of reliable predictors for functional outcomes is important for planning rehabilitation strategies. We hypothesized that venous drainage would be impaired on the side of cerebral hypoperfusion due to acute occlusion of internal carotid or middle cerebral artery. The 2 internal cerebral veins (ICV) drain the deep parts of hemispheres and run backward to form great cerebral vein. Since ICVs are consistently seen on CT angiography (CTA), parallel and run very close to each other, even minor asymmetry in their filling can be easily diagnosed. ICV asymmetry in pre-TPA CTA can change in patients achieving arterial recanalization, rendering it less useful for predicting the long-term outcomes. Thus, we aimed at evaluating whether the presence of ICV asymmetry on follow-up CTA can predict the final outcome.

Methods-
Data from consecutive AIS patients treated with IV-TPA, in a standardized protocol, from Jan2007 to March2010 were included in a prospective registry at our tertiary center. In this study, we excluded posterior circulation strokes. Significant proportion AIS patients undergo CTA on day 2 after IV-TPA to assess the status of arterial patency. ICV asymmetry was assessed by 2 independent stroke neurologists/ neuroradiologists, blinded to patient data or outcomes. Functional outcomes were assessed by modified Rankin Scale (mRS) at 3-months, dichotomized as good outcome (mRS 0-1) and poor outcome (mRS 2-6). Data were analyzed for the early predictors of function outcome.

Results-
Of the total of 2238 patients admitted during the study period, 226 (10.1%) with anterior circulation AIS treated with intravenous thrombolysis were included. Median age was 65yrs (range 19-92), 63% males and median National Institute of Health Stroke Scale (NIHSS) 16points (range 4-32). Hypertension was the commonest vascular risk factor in 144 (76%) while 63 (33%) patients suffered from atrial fibrillation (AF). Overall, 108 (47.8%) patients achieved poor functional outcome at 3-months. ICV asymmetry could be assessed only in 103 (45.5%) patients on their follow up CTA films. Admission NIHSS score (OR1.08;95%CI 1.001-1.157,p=0.048) and ICV asymmetry on follow-up CT scan (OR 23.9;95%CI 5.15-63.99,p <0.0001) were associated with poor outcome at 3-months.

Conclusion-
Presence of the asymmetry of internal cerebral veins on the follow up CT angiography in acute ischemic stroke patients treated with IV-TPA can be used as an early predictor of poor functional outcome.
Abstract 3288: Contrast-enhanced Carotid Ultrasound For The Quantitative Evaluation Of Neovascularization In Atheroscrelotic Carotid Artery Plaques
Authors: Saito Kozue , Nagatsuka Kazuyuki , Watanabe Akihiro , Kannki Hideaki , Ishibashi-Ueda Hatsue , Iihara Koji
Published: July 2021

Background and Purpose:
Contrast-enhanced ultrasound(CEUS) enables us to delineate microvessels such as neovascular in the plaques. Plaque vulnerability is associated with neovascularization, especially shoulder regions of the plaques, prone to rupture and cause ischemic events. We aimed to evaluate localization and density of intraplaque neovascularization in carotid atherosclerotic plaques quantitatively with CEUS compared with the pathological findings. Patients and

Methods:
25 consecutive patients (symptomatic:20, asymptomatic:5) undergoing carotid endarterecromy (CEA) for carotid stenoses between July 2010 and March 2011 were enrolled. Using equipment is LOGIQ E9 with a linear probe. CEUS is performed on amplitude modulation mode after a bolus injection of Sonazoid (perflubutane, GE Healthcare, Oslo, Norway). We settled the region of interests (ROIs) in the plaques, and measured the peak intensity (dB). We chose the ROIs in the shoulder and core of the plaques to compare the neovascular density (categorized as absent-sporadic:grade1, extensive:grade2) confirmed by histopathological examination in the CEA specimens that contained the intima and some parts of the media.

Results:
21 patients (4 were excluded because of calcification and ulcer) were analyzed. The contrast effect was higher in the shoulders by 6.9dB than in the cores of the plaques (p<0.05). Contrast effect had no significant difference between symptomatic and asymptomatic plaques. Histopathological examination revealed that the all plaques contained necrotic core, intraplaque hemorrhage and neovascularization in the shoulder with thinning or ruptured fibrous cap, which showed vulnerable plaques. Plaque with greater neovascularization showed higher contrast effect (grade1 vs grade 2: 4.8 dB vs. 7.4 dB, respectively, p<0.05).

Conclusion:
Quantitative evaluation of the contrast effect in the plaque, especially plaque shoulder, correlated with the density of neovascular proliferation. While only neovascularization does not destabilize the atheroscrelotic plaques, quantitative evaluation using CEUS may help us to stratify plaque vulnerability .
Abstract 33: Seasonal Patterns in Risk-Standardized Mortality after Ischemic Stroke: A Winter and July Effect
Authors: Lichtman Judith H , Jones Sara B , Leifheit-Limson Erica C , Wang Yun , Goldstein Larry B
Published: July 2021

Background:
A recent systematic review found that mortality rates were higher and efficiency of care lower in hospitals coincident with the introduction of new trainees in July, but there was significant heterogeneity in study quality, and none of the included studies focused on stroke care.

Purpose:
To assess seasonal variation in 30-day risk-standardized mortality rates (RSMRs) for elderly ischemic stroke patients from 1999 to 2006 and determine whether patterns differ for patients discharged from teaching versus non-teaching hospitals.

Methods:
The study cohort included all fee-for-service Medicare beneficiaries aged 65 years and older discharged with an ischemic stroke (ICD-9 primary codes 433, 434, 436) from 1999 to 2006 in the United States. A hierarchical logistic regression model fitted annual data to estimate the 30-day RSMR, adjusted for demographic and clinical characteristics. The annual datasets were combined and reconstructed to time series analyses, with month as a unit. The time series analysis included 96 months; RSMRs were calculated for each month. The unobserved components modeling approach was used to fit the time series data with risk-adjusted mortality as an outcome to compare seasonal patterns by month for teaching and non-teaching hospitals.

Results:
Of 2,824,694 ischemic stroke discharges, 51.7% were from teaching hospitals. The 30-day RSMR decreased steadily from 1999 to 2006 in teaching hospitals (
Figure 1
A). Seasonal patterns were present within each calendar year, with the highest 30-day RSMR occurring in the winter (January) and the lowest RSMR in the summer, with a secondary peak in July (p=0.004;
Figure 1
B). The same patterns were also seen for non-teaching hospitals (not shown).

Conclusions:
Thirty-day risk-standardized mortality rates after ischemic stroke in the elderly have decreased between 1999 to 2006. Seasonal patterns are evident, with the highest RSMR in January, and a secondary peak in July. Because these patterns were similar for teaching and non-teaching hospitals, the July peak can not be explained based on the introduction of new trainees. The reasons for these seasonal patterns, including higher mortality rates in July, are unclear.
Abstract 3372: The Ratio Of Apolipoprotein B-100 And A-i And Risk Of Intracranial Artery Stenosis In Acute Ischemic Stroke
Authors: Cho Hyun-Ji , Kim Yong Jae
Published: July 2021

Background and Object:
Intracranial artery stenosis (ICAS) is a common cause of acute ischemic stroke and has characteristics of poor prognosis and high recurrence. The role of plasma lipid level as risk factors for ICAS, still has controversy. So we investigated the relationship between the levels of the major lipids, apolipoproteins (Apo), lipoprotein (LP) and ICAS in acute ischemic stroke patients.

Method:
We assessed the clinical data of 881 consecutive patients from the stroke registry who were admitted due to TIA or acute ischemic stroke between November 2007 and January 2011. The major lipid levels [total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C)], the levels of Apo B100, Apo A-I and lipoprotein A [Lp (a)] and the level of high sensitivity C reactive protein (Hs-CRP) and were measured within three days after admission. The arterial segments were classified as normal, < 50 % stenosis or ≥ 50% stenosis on magnetic resonance angiography. ICAS was defined when at least one artery had ≥ 50% stenosis.

Results:
Of the total 881 patients, ICAS was found in 422 patients (31.0%, mean age: 66.17 ± 11.79 year old, males: 307), and 460 (55.7%) patients without ICAS were analyzed as a reference group. Compared with the reference group, the patients with ICAS were older (P < 0.001) and they had a greater prevalence of hyperlipidemia (p=0.002), a previous history of stroke (P =0.004) and no statin medication history (P < 0.001). The serum concentration of Hs-CRP was significantly higher in the patients with ICAS. (P < 0.001) The level of TC, LDL-C, HDL-C, Apo B100, Apo A-I, ratio of Apo B100/A-I and Lp (a) showed no significant difference between the two groups. But with adjustment of age, hypertension, diabetes mellitus, smoking, a previous history of stroke and statin medication, the ratio of Apo B100/ Apo A-I was significant for ICAS, (p=0.010) and was also the level of Hs- CRP (P=0.023). The odds ratios (ORs) for the presence of ICAS for those patients in the top, second, third quartiles were 2.054 (95% CI, 1.218-3.464), 1.721(95% CI, 1.033-2.868), and 1.667(95% CI, 1.008-2.757) sequentially for the ratio of Apo B100/ Apo A-I .

Conclusions:
Our study showed that the ratio of Apo B100/ Apo A-I was independently associated with presence of ICAS.
Abstract 3388: Awareness and Risk for Stroke among Community Living Middle-Aged Adults in Korea
Authors: Nam Kyoung , Song Hee-Young
Published: July 2021

Background
Control of stroke risk factors, in particular, hypertension and unhealthy life styles such as high fat diet, and inactivity which are modifiable have been focused for primary prevention of stroke. Greater awareness for stroke may promote individual to involve preventive activities. In Korea, relatively little research has been done on the awareness and risk for stroke among community living adults. We investigated awareness for stroke, calculated stroke risk score using the Framingham stroke risk score profile, and examined the relationship among awareness for stroke, blood pressure(BP), body weight, blood sugar, cholesterol and stroke risk score among middle-aged adults in Korea.

Methods
A total of 99 participants (
3
9 men, 60 women) aged 47.0 years old were recruited in an urban area and were interviewed by researchers using a structured questionnaire including stroke risk factors. Awareness for stroke was assessed with baseline knowledge on stroke risk factors, symptoms, and treatment; and recognition on important indicators such as BP, body weight, blood sugar and cholesterol. Stroke risk was determined by applying the Framingham stroke risk profile. Data were analyzed by descriptive statistics, t-test, and Pearson’s correlation using PASW statistics 18.0.

Results
Participants answered more than 3 stroke warning signs out of 5, although most participants did not know if their BP, body weight, blood sugar, and cholesterol were within normal limits. Scores of stroke risk determined by Framingham stroke risk profile showed significant difference between men and women (3.85±2.35 vs. 2.52±.06) (t=2.968, p=.004). Only systolic blood pressure was related with stroke risk in men(r=.537, p=.002), while blood sugar(r=.497, p=.005), systolic(r=.705, p <.001) and diastolic blood pressure(r=.557, p<.001) were related with stroke risk in women. The negative correlation between awareness for stroke and stroke risk was found in women(r=-.303, p=.021).

Conclusions
There is need to improve the awareness of stroke among community living middle-aged adults by providing more targeted information on stroke risk factors and their contribution to stroke prevention.Further studies are warranted to refine predictive factors for the risk of stroke, regarding gender difference in relationship between stroke risk score and BP, body weight, blood sugar and cholesterol which are important indicators for major illness related to stroke.
Abstract 3391: FAST Stroke Educational Program for Middle School Students
Authors: Miller Elaine T , King Keith , Miller Rosemary , Lee Roberta
Published: July 2021

Significance and Purpose:
Given the continuing escalation of obesity and other major modifable stroke risk factors in American children, now more than ever the testing of the efficacy of stroke educational programs remains a priority. The specific aim of this study was to determine if the 9 month FAST Stroke Prevention Educational Program for Middle School Students leads to a significantly greater increase in stroke knowledge (signs/symptoms, risk factors), self-efficacy, treatment seeking behaviors (calling 911), and stroke risk reduction behavior when compared to a control school. A secondary purpose was to obtain comparison data (intervention and control school) regarding blood pressure, waist circumference, and body mass index.

Methodology:
The study design is quasi-experimental with an intervention and control middle school that each receives the initial program pretest and long-term posttest. Both schools are in the same city and serve primarily African American students ages 10-14. Instruments to measure the key study variables have established reliability, Chronbach alpha of .85 or higher, and content validity. The FAST Program framed within Social Cognitive Theory, spanned 9 months consisting of 6 modules that included active learning experiences, involvement of multiple stakeholders (school, parents, and community), and senior nursing students in the program implementation.

Findings:
Seventy-seven students (54% male, 46% female) received the FAST Program and 101 students were in the control school (45% male, 55% female). Students who received the FAST Program knew significantly more of the warning signs of stroke than students not receiving the program. No significant difference between the control and intervention school occurred pertaining to knowledge of stroke risk factors at pretest or long-term posttest at 9 months. Compared to pretest scores, students receiving FAST scored significantly higher at posttest and long-term posttest on self-efficacy. Of those in the intervention group who had identified a modifiable stroke risk reduction objective (e.g., increase exercise, eat a more healthy diet, stop smoking), 42% reported achieving their objective; while another 19% reported making progress. Although BMIs and blood pressures improved in students receiving FAST, there were not any significant improvements between the two schools.

Conclusions and Practice Implications:
The FAST Program improved the convenient sample of African American students’ knowledge of stroke warning signs and self-efficacy. Plus, many students were able to achieve their predetermined modifiable stroke risk factors in the FAST Program. Further program improvements are recommended, but it is clear that active involvement of parents, school and community stakeholders are essential.
Abstract 3472: Neurofluctuations in Patients with Subcortical Ischemic Stroke (NISS)
Authors: Hicks William J , Acosta Indrani , Alderman Susan , Peng Hui , Pandurengan Renganayaki , Martin-Schild Sheryl , Barreto Andrew , Grotta James C , Savitz Sean I
Published: July 2021

Objective:
Patients with progressive strokes during hospitalization have increased morbidity and mortality as well as worsened functional outcome compared with those who remain stable. While the reported rate of fluctuations in subcortical stroke patients has ranged between 20 to 70%, there are no prospective “natural history” data regarding in-hospital deterioration, neurofluctuation, and reversion back to baseline. The purpose of this prospective study was to capture the incidence of fluctuations and their outcome in subcortical stroke patients receiving standard of care (antiplatelet drugs, intravenous fluids, and bed rest).

Methods:
We conducted a prospective study of all patients with subcortical strokes identified based on their clinical exam and routine imaging studies. Informed consent was obtained and demographics collected. An NIH stroke scale (NIHSS) was performed daily and whenever symptoms worsened (defined as a motor score increase of at least 1 on the NIHSS). Modified Rankin scales (mRS) were obtained at 90 days.

Results:
90 patients were prospectively enrolled. Analysis is shown in the corresponding tables. Thirty eight percent (34/90) of patients deteriorated; 41% of those patients fully recovered back to their admission NIHSS and 32% experienced partial recovery. There were no differences in age, gender, admission NIHSS, or ethnicity between those who deteriorated and those who remained stable. Deteriorating patients were more likely to have received tPA, have a higher discharge NIHSS, and a higher 90 day mRS. Three quarters of the patients had deterioration within 24 hours of symptom onset. Of the deteriorating patients who initially received tPA, all worsened within 24 hours. Patients who deteriorated had a significantly higher incidence of mRS 3-6 compared to patients who remained stable. There were no associations between age, gender, or ethnicity with neurological recovery back to admission NIHSS in those patients who initially deteriorated.

Conclusion:
This is the first prospective study to characterize the natural history of subcortical stroke fluctuation during hospitalization. Nearly 40% of all subcortical strokes patients deteriorated neurologically, but nearly 40% of those patients who deteriorated returned to their pre-deterioration status. Deterioration was associated with worse functional outcome at 90 days. Our study establishes a natural history template for designing future studies and identifies a subpopulation of patients for which new in-hospital therapies are needed to treat neurological deterioration in subcortical stroke.
Abstract 3499: Novel Nitric Oxide-Containing Echogenic Liposome for the Treatment of Vasospasm Following Subarachnoid Hemorrhage
Authors: Britton George L , Peng Tao , Aronowski Jaroslaw , McPherson David D , Huang Shao-Ling , Kim Hyunggun
Published: July 2021

Background:
Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is a major cause of high morbidity and mortality. The reduced availability of nitric oxide (NO) in blood and cerebrospinal fluid (CSF) is suggested an important mechanism underlying cerebral vasospasm, a complication of SAH. NO or NO donors are known to have potent effects on cerebral vascular relaxation. We have developed NO-containing echogenic liposomes (NO-ELIP) for NO delivery to assess the role of NO in SAH-induced vasospasm. We hypothesized that NO-ELIP can produce vasodilation and provide an effective therapeutic approach to treat vasospasm following SAH.

Methods:
NO-ELIP was created by a freeze-under-pressure method. Male Sprague- Dawley rats (n=9) underwent SAH by puncturing the right middle cerebral artery with a sharp tip nylon monofilament. In the treatment groups, NO-ELIP were administered through the right femoral vein at 24 hours after SAH onset. The brain tissue was obtained for H&E staining at 30 min after NO-ELIP administration. Measurement of the posterior communicating artery was performed to evaluate the effects of NO-ELIP treatment on vasospasm following SAH.

Results:
After SAH, the normalized lumenal and wall thickness areas decreased from 1.02 ± 0.08 to 0.40 ± 0.15 (p<0.001). NO-ELIP inhibited SAH-induced vasospasm by 67% (normalized area decreased to 0.82 ± 0.10 (p=0.004).

Conclusion:
This study demonstrates that NO-ELIP have the potential to deliver NO for therapeutic treatment of vasospasm. Enhancing the release of NO from circulating NO-ELIP by combining ultrasound exposure over the carotid artery may further provide an improved treatment strategy. This suggests that targeted therapeutic gas can be delivered to the cerebral circulation for the treatment of vasospasm following SAH
Abstract 3500: Implementing Best Practice Recommendations to Address Urinary Incontinence after Stroke
Authors: Donaldson Sarah , Leci Erik , Meyer Matthew , Janzen Shannon , Foley Norine , Salter Katherine , Teasell Robert
Published: July 2021

Background and Purpose:
Urinary incontinence following stroke is known to have a detrimental effect on rehabilitation progress, resulting in a slower rate of recovery and less functional independence at discharge. Canadian Best Practice Recommendations for Stroke Care (2010) and the American Stroke Association Clinical Practice Guidelines (2005) recommend that a bladder training program, including timed and prompted toileting on a consistent schedule, be implemented in patients who are incontinent of urine following a stroke. Canadian Best Practice Recommendations for Stroke Care (2010) further recommend intermittent catheterization as an intervention to address urinary incontinence. The aim of the present study was to assess the extent to which the Canadian guidelines are being incorporated into clinical practice.

Methods:
A retrospective chart review was conducted for consecutive stroke admissions to a neuro-rehabilitation unit in Ontario, Canada over a period of six months. Charts were reviewed for the occurrence of urinary incontinence, whether intermittent catheterization was performed, any mention of bladder training and the documentation of a bladder training protocol.

Results:
One hundred and four charts were reviewed, after excluding four patients that could not be assessed for urinary incontinence due to other medical conditions. Thirty-three patients were reported to be incontinent of urine during their stay in the rehabilitation unit. Intermittent catheterization was performed for 11 patients (33.3%) with urinary incontinence. Bladder training was indicated as a therapy that was used in the rehabilitation of 16 patients (48.5%). However, a formal bladder training protocol followed by the nursing staff was only documented in 5 patients (15.2%).

Conclusions:
The rehabilitation of urinary incontinence following stroke is an important issue, with a substantial number of patients failing to receive the recommended therapy. There is a need to develop strategies to promote the application of best-practice recommendations to address urinary incontinence.
Abstract 3520: Major Neurological Improvement is Predicted by Recanalisation and Absence of Acute Tissue Damage: An Analysis of 2'006 Consecutive Acute Ischemic Strokes
Authors: Cuendet David , Ntaios George , Lambrou Dimitris , Michel Patrik
Published: July 2021

Introduction:
Major neurological improvement (MNI) in acute ischemic stroke (AIS) is related to better outcome. We aimed to evaluate predictors of MNI in a large cohort of consecutive AIS patients.

Methods:
In the Acute STroke Registry and Analysis of Lausanne (ASTRAL), MNI was defined as ≥ 8 point improvement of NIHSS or a NIHSS of 0-1 after 24 hours. Patients with initial NIHSS of 0-1 were excluded and missing data were imputed. For comparison of patients with and without MNI, logistic regression analysis of a large number of demographical, clinical, radiological and metabolic data was performed. The influence of MNI on length of hospital stay (LOS), favorable outcome defined as modified Rankin score 0-2 at three and 12 months, and recurrence was also assessed in univariate analysis.

Results:
203 patients were excluded because of initial NIHSS of 0-1. Before imputing 50 missing NIHSS values to obtain a sample of 2’006 patients, MNI occurred in 333 (17.0%). MNI was predicted by spontaneous or therapeutic intracranial recanalization (OR= 0.49, CI 0.31-0.76, p<0.01) especially in the presence of eye deviation, absence of early ischemic lesions on neuroimaging (OR= 0.62, CI 0.47-0.82, p<0.01), earlier onset to arrival delay (OR= 0.95/60 minutes, CI 0.93 - 0.97, p<0.01) and lower systolic blood pressure at 24h (OR=0.92/10 mmHg, CI 0.86 - 0.98, p=0.01). Patients with MNI had significantly shorter LOS (median 8 vs. 10 days, p<0.01), more frequent favorable three months (73.6% vs. 47.6%, p<0.01) and 12 months outcome (66.1 vs. 43.5, p < 0.01). They also had less three (3.9% vs. 17.3%, p<0.01) and 12 months fatality (6.0% vs. 21.8% p < 0.01). Recurrence rates at three months were similar (9.0% vs. 9.2%, p=0.86).

Conclusion:
Absence of radiological signs of irreversible tissue damage and arterial recanalisation are strong predictors of MNI. Earlier arrival to hospital delay and lower subacute SBP also contributed to MNI. We confirm that radiological markers are strong predictors of MNI in thrombolysed and untreated patients.
Abstract 3541: Do Periodic Assessments Of Bleeding Risks Identify More Patients With Major Bleeding Events? A Population-based Cohort Study Among Warfarin-treated Stroke Patients.
Authors: Seet Raymond C , Rabinstein Alejandro A , Christianson Teresa J , Petty George W , Brown Robert D
Published: July 2021

Background
We sought to determine the occurrence of major bleeding events in a population-based cohort of stroke patients with atrial fibrillation in a population-based cohort who were risk-stratified at baseline, one and five years, following initiation of warfarin treatment.

Methods
The resources of the Rochester Epidemiology Project Medical Linkage System were used to identify acute ischemic stroke patients with atrial fibrillation undergoing warfarin treatment for secondary stroke prevention from 1980 to 1995. These patients were risk-stratified according to the HAS-BLED and HEMORRHAGES scores prior to warfarin initiation following stroke onset; these scores were reassessed one and five years later. Major bleeding was considered in patients with fatal or clinically overt bleeding associated with either transfusion of >2 units of blood or >2 g/dl decrease in hemoglobin.

Results
One hundred patients (mean age, 79.3 years; 68% women) were studied. Median duration of warfarin treatment was 2.4 years (interquartile range, 0.4-6.6) and duration from stroke onset to death was 3.7 years (1.1-8.8). Major bleeding events occurred in 41 patients at a median duration of 19 months (5-58) following warfarin initiation. Sixteen events occurred within a year of treatment, 25 events from years 1-5, and 14 events in patients treated for >5 years. Patients with baseline HAS-BLED scores ≥2 had higher life-time risks of major bleeding events compared with those ≤1 (95% vs 5%, p=0.002), while those with HEMORRHAGES score ≥2 had higher life-time risks of major bleeding events compared with those ≤1 (90% vs 10%, p=0.030). Periodic reassessments of these risks were associated with a higher detection of major bleeding events. Patients with an increase in the HAS-BLED scores had a higher subsequent risk of major bleeding events compared with those with no change (year one, 64% vs 34%, p=0.043; year five, 75% vs 29%, p=0.018). Similarly, patients with an increase in the HEMORRHAGES scores had a higher risks of major bleeding events compared to those with no change (year one, 57% vs 33%, p=0.063; year five, 71% vs 10%, p<0.001).

Conclusions
Periodic assessments of bleeding risks using prognostic scales are associated with a higher detection of major bleeding events. These scales should be periodically reassessed in the years following warfarin initiation to determine if the benefit of ongoing use outweighs the bleeding risk.
Abstract 3573: Successful Regeneration After Experimental Stroke by G-CSF is not Further Enhanced by Constraint-Induced Movement Therapy
Authors: Diederich Kai , Quennet Verena , Bauer Henrike , Schäbitz Wolf-Rüdiger , Sommer Clemens , Minnerup Jens
Published: July 2021

Background and Purpose
Both application of granulocyte-colony stimulating factor (G-CSF) and constraint-induced movement therapy (CIMT) have been shown to improve recovery after experimental stroke. The aim of the present study was to determine whether concurrent or sequential combination of both therapies will further enhance the therapeutic benefit and whether specific modifications in the abundance of various neurotransmitter receptors do occur.

Methods
Adult male Wistar rats were subjected to photothrombotic ischemia and assigned to the following treatment groups (n=20 each): (1) ischemic control (saline); (2) CIMT (CIMT between post-stroke day 2 and 11; (3) G-CSF (10μg/kg G-CSF daily between post-stroke day 2 and 11 (4), combined concurrent group (CIMT plus 10μg/kg G-CSF daily between post- stroke day 2 and 11; (5) combined sequential group (CIMT between post-stroke day 2 and 11 and 10μg/kg G-CSF daily between post-stroke day 12 and 21, respectively). Rats were functionally tested before and up to 4 weeks after ischemia. Quantitative receptor autography was performed for NMDA, AMPA and GABAA receptors.

Results
Significant improvement of functional outcome was seen in all groups treated with G-CSF alone and in either combination with CIMT, while CIMT alone failed to enhance recovery. Infarct sizes and remaining cortical tissue did not differ in the various treatment groups. Failure of significant benefit in the CIMT group was associated with a shift towards inhibition in perilesional and remote cortical regions.

Conclusions
Our findings unveil G-CSF as the key player for enhanced recovery after experimental stroke, preventing a shift towards inhibition as seen in the solitary CIMT group.
Abstract 36: Association of Parental Stroke with Cognitive and Brain MRI Measures in Offspring - The Framingham Heart Study
Authors: WEINSTEIN GALIT , Beiser Alexa , Au Rhoda , DeCarli Charles , Wolf Philip A , Seshadri Sudha
Published: July 2021

Objectives-
Parental stroke is related to an increased risk of stroke among the offspring. Vascular related brain changes, however, often occur before clinical stroke and the association of parental history of stroke and structural brain measures and cognition has not been fully explored. We hypothesized that prospectively verified parental stroke will be associated with increased vascular brain injury and poorer cognitive performance.

Methods-
A total of 1,297 Framingham offspring (mean age: 61 ± 9 years, 54% women) were studied. Of these, 9.9% had prospectively identified stroke in one or both parents before age 65. Volumetric brain MRI measures of total cerebral brain volume (TCBV), regional brain volumes, white matter hyperintensity volume (WMHV), and covert brain infarcts (CBI) and performance on tests of verbal memory, abstract reasoning, verbal learning and visuospatial memory (VRd) were compared for offspring with and without parental history of stroke. All measures were assessed cross-sectionally and longitudinally (mean duration of follow-up was 6.1±1.2 years). We used models adjusted only for age, sex, education and also additionally adjusted for vascular risk factors and for WMHV as an index of subclinical vascular brain injury. GEE models were used to adjust for sibling relationships among offspring.

Results-
Higher WMHV (β±SE=0.17±0.08;p=0.027) and lower VRd scores (β±SE=-0.80±0.34; p=0.017) at baseline were found in offspring with parental history of stroke. In addition, participants with parental stroke by age 65 years were more likely to be in the highest quintile of increase in WMHV (OR=1.87;p=0.04) as well as worsening executive function (Trails B-A) (OR:1.81;p=0.03). Parental stroke was not associated with total and regional brain volumes or with memory, abstract reasoning and verbal learning.

Conclusions-
In our community-based sample of middle-aged asymptomatic subjects, the occurrence of parental stroke by age 65 years is associated with higher baseline WMHV and with a more rapid increase in WMHV. Further, parental stroke is also associated with poorer performance on VRd and a decline in executive function. The effects on baseline WMH and VRd were substantial equivalent to 2.8 and 7 years of brain aging, respectively.
Abstract 3621: Predicting 90 Day Outcome in Acute Ischemic Stroke Patients
Authors: Meyer Dawn M , Raman Rema , Ernstrom Karin , Obviagele Bruce , Hemmen Thomas , Meyer Brett C
Published: July 2021

Background and Purpose-
Predictive scales for outcome in intracerebral hemorrhage patients have been used to provide prognostic information on mortality. Valid and reliable scales do not exist for acute ischemic stroke patients. The purpose of this study was to create a statistically valid model on which to predict 90 day functional outcome in acute ischemic stroke patients.

Methods-
This was a retrospective analysis of prospectively collected data on acute ischemic stroke patients. A univariate logistic regression analysis was done to assess for independent predictor variables. Any variable with a p<0.15 at the univariate level was included in a stepwise logistic regression model and appropriate interaction effects were tested. A model was constructed to predict 90 day stroke outcome. Good outcome was defined as mRS 0-2 and bad outcome was defined as mRS 3-6 at 90 days.

Results-
569 patients were included in the analysis. Age ranged from 21-98 (mean 70), baseline NIHSS 0-40 (median 6), 48% of patients were treated with rt-PA (n=277), 10% were black (n=57), and 15% were Hispanic (n=89). In univariate analysis, independent predictors of outcome were age (p<0.0001), weight (p=0.0003), baseline NIHSS (p<0.0001), diastolic blood pressure (p=0.02), treatment with rt-PA (p<0.0001), history of hypertension (p=0.0009), history of CAD/MI (p=0.002), history of stroke (p=0.02), current smoker (p=0.02), and history of atrial fibrillation (p=0.0001). Ethnicity (p=0.09) was included in the model. On stepwise linear regression, age (p<0.001, β-0.03), baseline NIHSS (p<0.001, β -0.15), Hispanic ethnicity (p=0.02, β -0.66) remained as independent predictors of 90 day outcome.

Conclusions-
A prognostic scale for acute ischemic stroke patient outcome would be clinically useful. This analysis based on sound statistical procedures can serve as a basis for the creation of a valid and reliable scale for predicting 90 day outcome in acute ischemic stroke patients. A scoring system is currently being developed for testing.