bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP135: Urgent Treatment for Symptomatic Carotid Stenosis: The Pittsburgh Revascularization and Treatment Emergently After Stroke Protocol
Authors: Tonetti Daniel , Jankowitz Brian , Cynthia Kenmuir , Zussman Benjamin , Rao Rahul , Stone Jeremy , Gardner Paul , Friedlander Robert , Gross Bradley , Jadhav Ashutosh , Jovin Tudor
Published: June 2021

Background:
Patients with symptomatic carotid stenosis remain at high risk of early recurrent stroke without revascularization. The aim of this report is to analyze prospectively-recorded data from an institutional protocol that standardized the urgent (<48 hours) treatment of patients presenting with symptomatic carotid stenosis and underwent either carotid stenting (CAS) or carotid endarterectomy (CEA).

Methods:
All patients presenting over 28 months to a comprehensive stroke center with symptomatic carotid stenosis within 48 hours of index event were screened for inclusion. All patients were given dual antiplatelet therapy. If there was clinical equipoise between CEA and CAS, patients underwent angiography and subsequently revascularization if DSA demonstrated ≥50% stenosis. The primary outcome was a composite of stroke or death within 30 days.

Results:
178 patients with a diagnosis of recently symptomatic carotid stenosis were included; 120 patients (67%) met criteria. 59 patients underwent CEA and 61 patients underwent CAS. There were not significant differences in the primary outcome; 3 patients (5.1%) in the CEA arm and 3 patients (4.9%) in the CAS arm met the primary outcome.

Conclusion:
In this prospective analysis, urgent revascularization for symptomatic carotid stenosis can be done with equivalently low rates of stroke or death, regardless of revascularization strategy.
Abstract TP136: A Retrospective Study of Moyamoya in a Unique, Primarily Caucasian Southern US Population
Authors: Noorbhai Ibrahim Z , Fraser Justin F , Lee Jessica D
Published: June 2021

Background:
Moyamoya (MM) is an uncommon cerebrovascular disease characterized by bilateral, progressive stenosis and occlusion at the terminal portion of the internal carotid arteries around the circle of Willis. MM has a higher prevalence in East Asian population; however, an increasing number of cases of MM are being reported in the US and may reflect a different entity often termed moyamoya syndrome (MMS). A study from 2005 to 2008, reported a 4-fold increase in the prevalence of MM in the US. In this study, we sought to describe the clinical features of patients diagnosed with MMS in a unique, primarily Caucasian Southern US population.

Materials and Methods:
We performed a retrospective chart review of patients evaluated at our institution from August 2012 to December 2018. Data collected included age, sex, ethnicity, comorbid medical conditions, and laboratory values.

Results:
Seventy-seven patients with MM were included (52 female and 25 male), average age at time of diagnosis was 42 for females and 48 for males. 81% were Caucasian while 17% were African American, and 3% were Asian. Hypertension was the most common comorbidity affecting these individuals (60%), with hyperlipidemia being the second most common (36%). Autoimmune disorders affected about 22% of this population. The average BMI of females and males was 35 and 29, respectively. Lipid analysis showed similarity in profiles between males and females, and no significant trends were appreciated respective to BMI and age. Interestingly, 85% of individuals had an elevation of sedimentation rate (ESR), Factor VIII, or C - reactive protein (CRP) at the time of diagnosis.

Conclusions:
Women are affected in a 2:1 ratio as compared to men; which is a consistent trend reported in other studies. Hypertension remains the most common comorbidity affecting these individuals. Though the etiology of MMS remains unclear, various autoimmune disorders have been reported in small case series. While ESR, factor VIII activity, and CRP are non-specific markers of inflammation, the high prevalence of these markers in this population further support an autoimmune or immunological component in MM. Additional prospective studies are needed to further elucidate this relationship.
Abstract TP147: Quantitative Measures of Strength and Synergy Differentiate Individuals With Chronic Stroke With and Without Clinically Detectable Elbow Contracture
Authors: Bellinger Grace C , Ellis Michael D
Published: June 2021

Many individuals with chronic stroke demonstrate contracture of the elbow flexors. The development of contracture may be attributable to underlying impairments such as weakness, flexion synergy, and hyperactive reflexes. This study explored differences in motor impairment and function between 17 individuals with clinically detectable elbow flexor contracture and 17 individuals with full passive range of motion. The groups did not differ in age (61.61 ± 7.99, 55.06 ± 12.48, p = 0.078), years post-stroke (12.92 ± 9.34, 10.60 ± 7.16, p = 0.423), or Fugl-Meyer Motor Assessment score (FMA, 26.35 ± 5.86, 26.47 ± 8.70, p = 0.963). The passive range limitation in the contracture group was 3 to 36° (11.65 ± 8.30°). Kinetics, kinematics, and EMG were used to quantify four motor impairments and reaching function. Shoulder abduction and elbow extension strength were measured isometrically and normalized to the unaffected side. Flexion synergy was quantified as a force-based measure assessing independent joint control. Flexor spasticity was quantified while reaching at 50% of maximum shoulder abduction as the change in biceps EMG from reach onset to peak angular velocity, normalized by maximal EMG activity. Reaching function was defined as maximum reaching distance against gravity and normalized by target distance (-10° of full extension). The groups differed in elbow extension strength (Contracture, 0.315 ± 0.129; No contracture, 0.559 ± 0.153; p < 0.001) and flexion synergy (0.146 ± 0.186, 0.397 ± 0.229, p = 0.009). The groups did not differ in shoulder abduction strength (0.500 ± 0.174, 0.615 ± 0.199, p = 0.080), flexor spasticity (0.079 ± 0.090, 0.056 ± 0.115, p = 0.523), or reaching function (0.501 ± 0.391, 0.714 ± 0.296, p = 0.082). The findings of this study suggest a relationship between elbow contracture and the concurrent presence of elbow extension weakness and flexion synergy. The quantitative measure of reaching function will likely differentiate individuals with and without contracture if the assessment is modified so that the standardized reaching target is located at 0° of elbow extension (normal range). Future research should use quantitative metrics to further explore the temporal recovery of impairments in order to prevent the development of contracture.
Abstract TP151: Box Checking for Comprehensive Stroke Care Metrics of Depression Screening: Does It Actually Equate to Better Treatment
Authors: Grewal Parneet , Mirembo Ray , Mathias William , Lee Jessica D
Published: June 2021

Objective:
One in three stroke patients develop depression following the event. The exact cause of post stroke depression has been debated but may be due to brain injury resulting from stroke and psychological factors. We aimed to 1) Discover frequency of patients suffering from depressive symptoms post-stroke 2) Ascertain whether occurrence of post-stroke depression plays a role in adherence to follow up appointment 3) Determine the frequency of antidepressant treatment post-stroke and 4) Identify location of stroke most commonly associated with depression.

Methods:
We conducted a single institution, retrospective chart review of patients ≥18 years, discharged with ischemic stroke from October2017 - March2018. Variables such as age, sex, location of stroke, discharge PHQ9 score, depression treatment and follow up appointment adherence were determined.

Results:
In our cohort of 200 patients (48.5% M, 51.5% F), 28 (14.0%) had pre-existing diagnosis of depression. The mean PHQ9 on discharge was 5.32±5.16 (n=145, deficits too severe to obtain PHQ9 in 55 subjects), with 66 (45.5%) of patients having PHQ9 ≥5 at discharge, indicating at least mild depressive symptoms. While there was no difference in discharge NIHSS or modified Rankin scores, females were twice as likely to experience at least mild depressive symptoms post-stroke as compared to males (66.7% vs 33.3%, p=0.002). Only 19 patients with PHQ9≥5 at discharge were started or continued on antidepressants. On subgroup analysis of patients with PHQ9 ≥5 (n=66), the three most common locations of stroke, in descending order were right parietal (20, 30.3%), left subcortical (14, 21.2%) and right frontal (13, 19.6%). No association was found between discharge PHQ9 score and follow up appointment adherence.

Conclusion:
Discharge PHQ9 scores irrespective of treatment do not play a predictive role in follow up appointment adherence. Females were more likely than males to experience post stroke depression; and while depressive symptoms are common, patients were unlikely to be prescribed antidepressant therapy. The most common location of stroke associated with depression was right parietal lobe. Such patients should be assessed closely for symptoms of depression with standardized screening tools.
Abstract TP153: Differences in Detection of Late Complications After Stroke in Young Stroke Survivors With Active Surveillance versus Usual Care
Authors: Gans Sarah , Michaels Elena , Leung Lester Y
Published: June 2021

Background:
Many stroke survivors develop late medical complications that impair function and return to pre-stroke responsibilities. Optimal strategies for detection of late complications after stroke (LCAS) have not been established.

Methods:
This retrospective cohort study included patients age 18-50 with acute ischemic stroke, transient ischemic attack, or non-traumatic intracerebral hemorrhage with outpatient evaluations in the Stroke Clinic at a tertiary care center within the first year after stroke between 1/2016-12/2017. Demographics, comorbidities, stroke subtype, and presence of LCAS were obtained from the EHR. “Active surveillance” was defined as use of a structured questionnaire (by one neurologist) to elicit symptoms suggesting the presence of LCAS including headache, seizures, lethargy, mood disorders, cognitive impairment, central pain, insomnia, spasticity, dystonia, and orthostasis. Patients were assigned to outpatient visits with neurologists based on prior inpatient encounters while the neurologists were on-call for stroke. Differences between detection of LCAS in patients with active surveillance or usual care were compared at two time points (0-3 months, 3-12 months).

Results:
One hundred twenty-one young stroke survivors were included in this study, of which 37% (45) underwent active surveillance. There were no differences in baseline characteristics between the two groups. Participants undergoing active surveillance were more likely to have at least one LCAS detected (77% vs 49% at 0-3 months, p=0.02; 81% vs. 54% at 3-12 months, p=0.008). Active surveillance was significantly more likely to detect symptoms suggesting headache, seizures, lethargy, mood disorders, cognitive impairment, insomnia, and orthostasis.

Conclusion:
Active surveillance leads to higher rates of early detection of LCAS in young stroke survivors. Validation of screening tools for LCAS and assessment of an active surveillance approach in a prospective cohort are needed to improve the management of these conditions among stroke survivors.
Abstract TP160: What Matters Most? Predictors of Poststroke Functional Outcomes From Inpatient Rehabilitation Facilities Across the United States
Authors: García James J , Warren Karlita L , Gong Fengmei , Wang Honggang
Published: June 2021

Introduction:
Stroke is one of the leading cause of disability and death in the United States (Benjamin et al., 2018). Inpatient rehabilitation is the gold standard treatment for post-acute care (Weinstein et al., 2016). Data indicate a discharge to inpatient rehabilitation facilities (IRFs) following the acute stroke phase has increased (Buntin, Colla, & Escarce, 2009). The inpatient milieu provides a unique opportunity to examine predictors of functional outcomes using a captive sample. Thus, the current study aim is to identify factors associated with poststroke functional outcomes throughout inpatient rehabilitation.

Method:
This is a cross-sectional and retrospective analysis of data extracted from an administrative database during years 2005-2016 from 244,286 stroke patients across 30% of IRFs in the U.S. Inclusion criteria were patients at or above the age 18 with stroke as an admitting diagnosis using ICD 9/10 codes 430-438/I60-I69. Dependent variables were: admission Total FIM, Total FIM efficiency, discharge Total FIM, and length of stay (LOS).

Results:
Using separate regression analyses, marital status, admit year, type of admission, race/ethnicity, insurance type, sex, age, number of complications, number of comorbidities, and stroke type, emerged as significant predictors of functional outcomes throughout inpatient rehabilitation. Moreover, those with greater comorbidities and complications were associated with lower admission FIM total score, less total FIM efficiency, lower discharge FIM total score, and a longer LOS. Compared to NHWs, racial/ethnic people were associated with lower FIM scores throughout inpatient rehabilitation and a longer length of stay.

Discussion:
In this robust national dataset, data indicate clinical and sociodemographic factors are significantly associated with poststroke functional outcomes throughout inpatient rehabilitation. Implications are discussed within a framework of social determinants of health.
Abstract TP169: Migraine Phenotypic Spectrum in a CADASIL Cohort: Mayo Clinic Florida
Authors: Glover Patrick , Gopal Neethu , Badi Mohammed , Goldstein Eric , Huang Josephine F , Meschia James
Published: June 2021

Objective:
To characterize migraine in patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL).

Background:
CADASIL serves as a key model of a monoallelic stroke disease. A portion of patients have coexistent migraine with aura, yet the relationship between migraine and the pathophysiology of CADASIL is poorly understood.

Design/Methods:
We performed a prospective study of adults with a confirmed genetic diagnosis of CADASIL, age-matched controls with migraine with aura (MA), and headache-free controls. The Migraine Disability Assessment Questionnaire (MIDAS) and Headache Impact Test (HIT-6) were used to quantify migraine-related disability. Subjects were followed for one year after enrollment.

Results:
We enrolled 88 subjects, which included 33 subjects with CADASIL, 32 subjects without CADASIL but with MA, and 23 control subjects without CADASIL or MA. Mean age was 53.6 (range, 22-86), 64.8% (57/88) were females, and 83% (73/88) were white. Of the CADASIL subjects, 61% (20/33) suffered from MA (CAD/+MA). Aura semiology amongst the CAD/+MA and MA patients were as follows: visual (80% vs 81%), sensory (75% vs 81%), speech (75% vs 50%), motor (30% vs 50%), brain stem (60% vs 81%) and retinal (30% vs 25%). Mean MIDAS scores at enrollment were comparable between the CAD/+MA and MA populations (32.3 vs 33.5), as were mean HIT-6 scores (56.3 vs 56.9).

Discussion:
These preliminary results do not show a significant difference in migraine disability between CADASIL migraineurs and chronic migraineurs. Minor differences were observed in aura distribution between the two groups, although further investigations are needed to better understand the underlying pathology of CADASIL and migraine.
Abstract TP233: Clinical Predictors of Endovascular Stroke Treatment Among Emergency Department Patients Screened With Multimodal Computed Tomography
Authors: Smythe Ken , Oostema John A
Published: June 2021

Background:
Endovascular therapy (EVT) offers dramatic benefit to selected patients with large vessel occlusion (LVO) ischemic stroke. However, identification of EVT candidates requires advanced imaging and often interfacility transfer. We sought to quantify the yield of such testing as well as identify clinical predictors of EVT candidacy.

Methods:
This retrospective cohort study identified consecutive Emergency Department (ED) patients with stroke symptoms who underwent CT angiogram and brain perfusion (CTA/P) imaging to assess for EVT candidacy. Demographics, medical history, clinical characteristics, final diagnosis, and outcomes were abstracted. We compared clinical characteristics among those who did and did not undergo EVT. Multivariable logistic regression was used to identify independent clinical predictors of EVT and derive a clinical prediction rule to quantify the probability of EVT.

Results:
Over a 12-month period, 835 patients underwent CTA/P imaging in the ED. EVT was undertaken for 116 (13.9%) patients; 321 (38.4%) ultimately received a non-stroke diagnosis. Patients who received EVT were older and had higher stroke scores (Table). Patients with an unknown last known well (LKW) time were less likely to receive EVT, however increasing time form LKW to door did not predict EVT (test for trend p=0.976). Multivariable analysis results are presented in the Table. A clinical decision rule based on the regression coefficients demonstrated moderately high discrimination for predicting EVT with an AUC of 0.79 (0.74 to 0.83). Among 102 patients transferred for CTA/P, 24 (24%) had and a score <1, none of whom received EVT.

Conclusions:
EVT Candidates are common among ED patients screened with CTA/P. Clinical factors can predict the likelihood of EVT candidacy. If validated in other populations, a simple clinical prediction rule may assist in triaging patients in need of urgent transfer to a thrombectomy-capable facility.
Abstract TP238: Encephalopathy Only Stroke Codes (EoSC) Do Not Result in rt-PA Treatments
Authors: Chen Patrick , Meyer Dawn , Meyer Brett
Published: June 2021

Background:
Isolated mental status changes as presenting sign (EoSC+), are not uncommon stroke code triggers. As stroke alerts, they still require the same intensive resources be applied. We previously showed that EoSC+ strokes (EoSC+CVA+) account for 8-9% of EoSC+ codes but only 0.1-0.2% of all codes. Whether these result in thrombolytic treatment (rt-PA), and the characteristics/ risk factor profiles of EoSC+CVA+ patients, have not been reported.

Methods:
Retrospective analysis of stroke codes from an IRB approved registry, from 2004 to 2018, was performed. EoSC+ definition used was consistent with prior publications (NIHSS>0 for Q1a, 1b, or 1c with remaining elements scored 0). Other definitions were also assessed. Characteristics and risk factors were compared for EoSC+, EoSC+CVA+, and rt-PA (EoSC+ CVA+TPA+) patients.

Results:
EoSC+ occurred in 59/2982 (1.98%) of all stroke codes. EoSC+CVA+ occurred in 8/59 (13.56%) of EoSC+ codes and 8/2982 (0.27%) of all stroke codes. 6/8 (75%) of EoSC+CVA+ scored NIHSS=1. Hispanic ethnicity (p=0.009), HTN (p=0.02), and history of stroke/TIA (p=0.002) were less common in EoSC+. No demographic/ risk factor differences were noted for [EoSC+CVA+ vs. EoSC+CVA-]. No cases of rt-PA eligibility/ treatment were noted. In EoSC+CVA+ analysis, imaging positive stroke/intracranial hemorrhage was noted on only 3 cases (3/2982=0.10% of all stroke codes) and none were posterior stroke.

Conclusions:
EoSC+ is not an uncommon reason to activate stroke codes, but rarely results in stroke/TIA (0.27%) or stroke (0.10%), and in our analysis never (0%) resulted in rt-PA. Sub-analysis did not show missed rt-PA or posterior strokes. This adds information for application of limited acute stroke code resources. Though stroke codes must still to be activated, understanding characteristics, and knowing that EoSC+CVA+ patients are unlikely to receive rt-PA, may help triage stroke resources. Further investigation is warranted.
Abstract TP242: The Los Angeles Motor Scale Outperforms the Vision, Aphasia, Neglect Test as a Prehospital Stroke Scale
Authors: Stead Tej G , Ganti Latha , Mangal Rohan , Banerjee Paul
Published: June 2021

Introduction:
In the prehospital setting, it is important to identify which patients need to be sent to a comprehensive stroke center.

Methods:
This IRB-approved prospective study included all patients transported for stroke by our EMS system from December 2018-May 2019. Patients were administered the Los Angeles Motor Scale (LAMS) and vision, aphasia, neglect (VAN) test by paramedics prior to hospital arrival. LAMS 4 or 5 was considered high for the purposes of our study. Patients were considered VAN positive if they were deficient in any of the three areas it tests.

Results:
Our cohort (n=480) was 50% male. Median age was 72, IQR 62-81 and range 13-108 years. The LAMS/VAN breakdown (n=378 patients who received both) was as follows:

Low LAMS/Negative VAN: 32%

High LAMS/Negative VAN: 10%

Low LAMS/Positive VAN: 38%

High LAMS/Positive VAN: 20%

68% of patients had either high LAMS or positive VAN.

26% received CTA perfusion imaging, 14% received tPA, and 7% received mechanical intervention. 9% were hemorrhagic strokes, 43% ischemic, and 11% TIAs. The median National Institutes of Stroke Score (NIHSS) at hospital arrival was 6, with IQR 2-13 and range 0-36. 50% of patients were discharged home and 5% expired. Table 1: relative risk (if applicable) and p-values associated with certain outcome-scale combinations, calculated using Fisher’s exact test or Wilcoxon’s rank-sum test (NS = not significant).

In predicting mechanical intervention, LAMS had sensitivity 87% and specificity 72%, VAN had sensitivity 73% and specificity 41%, LAMS or VAN had sensitivity 96% and specificity 31%, LAMS and VAN had sensitivity 62% and specificity 82%.

Conclusions:
The LAMS is more effective than the VAN for general prehospital usage. Combining the two scales results in higher sensitivity at the cost of specificity in predicting mechanical intervention, which may be useful so that all potentially eligible patients for mechanical intervention can be sent to a comprehensive stroke center.
Abstract TP244: Predictive Scoring System to Differentiate Acute Ischemic Stroke From Stroke Mimic During Code Stroke Evaluation
Authors: Hathidara Mausaminben , Ray Bappaditya , Xu Chao , Marulanda-Londono Erika , Sidorov Evgeny
Published: June 2021

Background:
Migraine, seizure and toxic metabolic encephalopathy are common stroke mimics (SM) during code stroke (CS) evaluation and up to 30% of patients treated with IV tPA are found to have SM. An ideal way to differentiate SM from acute ischemic stroke (AIS) is through history and clinical examination in conjunction with MRI brain. Quick identification of a set of clinical characteristics predictive of SM may be helpful to prevent unnecessary IV thrombolysis. This study aimed to develop and evaluate effectiveness of a predictive scoring system to differentiate AIS from SM.

Methods:
The study population included 508 patients who received IV tPA from Jan 2013-Dec 2016 at a large comprehensive stroke center. Sixty clinical characteristics were reviewed and 27 were chosen for prediction analysis based on univariate ANOVA F-test. A prediction model is proposed by multivariate logistic regression with step wise selection of variables with the variable entry and stay threshold of p value 0.2 and 0.05 respectively to develop a predictive score.

Results:
Our scoring system consists of 7 clinical characteristics which are easily assessable during “CS” with yes and no answers. Each clinical variable has score weightage based on strength of statistical association with final diagnosis AIS Vs SM. Score is composed of : seizure at onset (score yes: -1.8, no:0), headache (yes: -2.3, no:0), history of migraine (yes: -1.7, no:0) , encephalopathy (yes: -1.2, no:0), atrial-fibrillation (yes: 1.3, no:0), NIHSS (0.1 per unit) and localizable symptoms (yes : 3.3, no: 0). Area under receiver operative characteristic (ROC) curve was 0.91 and a score >3.4 identified AIS with a sensitivity of 88.3% and specificity of 82.1%.

Conclusion:
Our study found that clinical characteristics of acute presentation were more helpful than conventional vascular risk factors history to differentiate AIS from SM. Our predictive score is reliable to differentiate AIS from SM and is intended to help clinicians identify SM using quick and simple clinical characteristics. Prospective validation of the score is needed.
Abstract TP272: Selective Inhibition of Histone Deacetylase 3 Decreases Cerebral Edema and Blood-Brain Barrier Leakage
Authors: Shehadah Amjad , Lu Hui , Clendaniel Victoria , Matheson Rudy , Fisher Marc , Selim Magdy , Lo Eng
Published: June 2021

Introduction:
Histone deacetylase 3 (HDAC3) has been implicated as neurotoxic in several neurodegenerative conditions. However, its role in ischemic stroke has not been thoroughly explored. In this study, we examined HDAC3 expression after stroke and tested whether selective inhibition of HDAC3 decreases cerebral edema and blood-brain barrier (BBB) leakage after ischemia.

Methods:
To examine HDAC3 expression over time, adult male Wistar rats (n=6/group) were subjected to middle cerebral artery occlusion (MCAO) and sacrificed at different time points after stroke. Another set of adult male Wistar rats was subjected to 2-h MCAO, and randomly selected animals were treated i.p. with either vehicle (1% Tween 80) or a selective HDAC3 inhibitor (RGFP966, 10 mg/kg) at 2 and 24 h after MCAO. Behavioral tests were performed, and infarct volumes and cerebral edema were measured. Evans blue dye (EBD) assay was employed to assess BBB leakage. Immunostaining for HDAC3, CD31, claudin-5, occludin, and ZO-1; and Western Blot for TNF-alpha and matrix metalloproteinase-9 (MMP9) were performed.

Results:
Total and neuronal HDAC3 significantly increased in the peri-infarct cortex as early as 3 hours after ischemia. HDAC3 levels continued to be significantly elevated at 3 days and returned to baseline at 7 days. Selective HDAC3 inhibition improved functional outcome (p=0.01) and reduced infarct volumes (p<0.001). Compared to vehicle control, RGFP966 treatment significantly decreased cerebral edema (p<0.001) as well as BBB leakage, as measured by EBD assay. Immunostaining showed that RGFP966 significantly increased the expression of tight junction proteins (claudin-5, occludin, and ZO-1) in the peri-infarct area compared to vehicle control group. Western Blot showed that RGFP966 treatment significantly decreased the expression of TNF-alpha and MMP9 in the ischemic brain.

Conclusions:
HDAC3 is upregulated in the ischemic brain as early as 3 hours after stroke. Early administration of a selective HDAC3 inhibitor improves neurological functional outcome and decreases infarct volume, cerebral edema, and BBB leakage. BBB protection by selective inhibition of HDAC3 is mediated in part by upregulation of tight junction proteins and attenuation of TNF-alpha and MMP9.
Abstract TP287: Validation of a Mice Model of Synangiosis to Quantify Neovascularization After Ischemic Stroke
Authors: Toscano Juan F , Jiang Hao , Quintero-Consuegra Miguel , Gonzalez Nestor R
Published: June 2021

Introduction:
Some publications have shown encephalomyosinangiosis (EMAS) as a potential model for surgical indirect revascularizations (SIR). Despite these reports, the validity of this model for neovascularization has not been addressed, in particular the observed variability in vessel proliferation response to ischemia and spontaneous neovascularization. Therefore, we present a systematic quantitative approach to evaluate the validity and variability of EMAS as a SIR model.

Methods:
We induced precise cerebral ischemia by ligation of the distal MCA via a 3mm temporal craniotomy on C57/BL6J mice. Subjects were randomly allocated to EMAS (placement of temporalis muscle in direct apposition to the brain) or controls (placement of an inert barrier-Teflon). After surgery, animals received BrdU in drinking water to mark newly formed cells. Brain tissue was harvested 14 days after surgery and stained with CD31, NeuN, anti-BrdU-Ab, and DAPI. New-vessels were defined as BrdU/CD31 co-staining, neuronal survival was quantified with NeuN density percentage. Groups were compared using regression mixed models and variability was evaluated using the heterogeneity of variance (HOV) test.

Results:
New-vessels were seen in the control and EMAS groups. The mean number of new vessels was 8 (SD 4.4) in controls vs. 15.8 (SD 5.1) in EMAS. The effect of treatment (EMAS vs. control) was a significant predictor of new-vessel formation (p<0.01, OR = 1.5 (95% CI: 1.1 - 1.9). The HOV between groups was non-significant. However, CD31 staining alone was not different (controls = 0.58 vs EMAS = 0.59). In terms of neuronal survival, the median NeuN density percentage distribution was 0.9% (IQR=1.2) for controls and 1.6% (IQR= 0.8) for EMAS (p = 0.2). The HOV was also non-significant.

Conclusion:
EMAS is a suitable model for evaluation of neovascularization after ischemic stroke. However, isolated quantifications of endothelial markers, such as CD31, are insufficient. The use of BrdU, which incorporates in newly synthesized DNA, in combination with endothelial markers is essential to quantify neovascularization. Neovascularization requires time and, as shown in this model, have little impact in neuronal survival in acute stroke.
Abstract TP293: Prognostication in Neurological Emergencies
Authors: Sloane Kelly L , Miller Julie , Piquet Amand , Rosenthal Eric , Singhal Aneesh
Published: June 2021

Background:
Neurologic prognosis is often estimated acutely based on clinical experience, scoring systems and patient co-morbidities. We investigated the consistency of prognostication among trainees, junior and senior neurologists.

Methods:
Five cases (2 large hemispheric infarcts; 1 brainstem infarct, 1 lobar hemorrhage, 1 hypoxic-ischemic encephalopathy) were chosen for a simulation exercise. All cases involved patients presenting to our hospital’s ED where poor outcome predictions were documented within 24 hours, yet care was not withdrawn. Relevant clinical data were presented through a web-based platform to respondents who remained blinded to actual outcome. The trainee/faculty was requested to rank-order, from most to least likely, predicted 90-day modified Rankin Scale (mRS) scores and possible management options (intensive comfort measures now; defer prognostication for 48-72 hours; treat aggressively). The average highest ranks were compared to actual patient outcomes. Responses were compared between pre-defined groups: trainees vs. faculty; junior vs. senior faculty; non-vascular vs. vascular (‘expert’) faculty.

Results:
We received 106-113 responses per case. The mean predicted 90-day mRS matched the actual outcome in only 3 of 5 cases (60%). Individual responses were more variable, with predicted mRS matching actual mRS only 20% across the 5 cases. With dichotomous cutoffs of mRS 0-3 vs. 4-6, predicted outcomes were accurate in 4 of 5 cases. In the one case that the group predicted inaccurately, the respondents prognosticated a severely disabled state (mRS 5) while the actual 90-day was mRS 2. Only 2/106 respondents (1.8%) predicted mRS 0-2 and 67/106 (63%) predicted mRS 5-6. Across all cases there were no significant differences between sub-groups.

Conclusion:
In acute neurological conditions, estimates of clinical prognosis can be highly variable. We acknowledge possible selection bias in case selection and the limitations of a simulation exercise. Further analysis is ongoing to determine consistency of responses against validated outcome prediction scoring systems. Our results have led to new department guidelines regarding the timing of acute prognostication.
Abstract TP299: Association Between Rates of Dysphagia Screening Failure and Short-Term Outcomes in Patients With Mild Stroke
Authors: Ali Syed F , Schwamm Lee H , Onteddu Sanjeeva , Nalleballe Krishna , Patrice Kelly-Ann , Hemmen Thomas
Published: June 2021

Intro:
Guidelines advocate screening all acute stroke patients for dysphagia. However, limited data are available regarding how many patients with mild presentation fail initial screening. We sought to evaluate the rates and predictors of dysphagia screening failure in mild acute ischemic stroke patients (NIHSS < 5).

Methods:
Using GWTG stroke registry data from three large comprehensive stroke centers in the Northeast, South and West, we analyzed 8,687 stroke admissions from 06/2008 - 12/2018. Patients with mild stroke (NIHSS<5) were identified and dysphagia failure rate was evaluated. Using univariate and multivariable regression (MV) analysis (using factors with p<0.1, in bold), we evaluated factors associated with dysphagia screen failure in mild stroke patients.

Results:
Of the 8,687 patients, 3,614 (41%) had NIHSS < 5. Dysphagia screening failure was seen in 30.2% in the entire cohort while only 10.3% (373/3,614) in patients with NIHSS < 5. Mild stroke patients who failed dysphagia screening were older, more often had stroke risk factors of hypertension, hyperlipidemia, CAD/MI. They had higher median NIHSS and more often had language disturbance on presentation. Patients who failed dysphagia screening were less likely to be discharged home. On MV analysis, age (1.01, 95% 1.00, 1.02), hypertension (1.45, 95% 1.10, 1.91), NIHSS (1.62 95% 1.48, 1.77) and language disturbance at presentation (1.89 95% 1.13, 2.32) were significantly associated with initial dysphagia.

Conclusion:
Dysphagia screen failure rates are significantly less frequent in patients with mild symptoms and even lower for those with NIHSS of 0-1 at presentation. Factors associated with failure - older age, higher NIHSS and language disturbance at presentation may help focus efforts to avoid complications in these patients who might otherwise do well. This focused approach of screening patients all patients but targeting mild patients with dysphagia may hold potential for improved outcomes.
Abstract TP3: Early Reocclusion After Mechanical Thrombectomy for Acute Stroke Due to Intracranial Atherosclerotic Stenosis-Related Occlusions
Authors: Miura Masatomo , Nagao Yoichiro , Nakajima Makoto , Shindo Seigo , Wada Kuniyasu , Terasaki Tadashi , Uchida Kazutaka , Shirakawa Manabu , Yoshimura Shinichi
Published: June 2021

Background:
In acute ischemic stroke (AIS) patients due to intracranial atherosclerosis-related occlusions (ICAS-O), despite successful reperfusion with mechanical thrombectomy (MT), unexpected early reocclusion sometimes occurs and worsens clinical outcome. We investigated prevalence, outcomes, and predictors of early reocclusion within 48 hours of MT in AIS due to ICAS-O.

Methods:
In 557 consecutive AIS patients who underwent MT from January, 2016 to March, 2019 in two stroke centers, 71 patients due to ICAS-O were retrospectively evaluated. We divided them into two groups: patients with early reocclusion and those without. Clinical and angiographical findings and outcomes were compared between the 2 groups. Multivariable logistic regression analysis was used to investigate predictors of early reocclusion after MT.

Results:
Of 71 patients (aged 72 ± 10 years; 23 women; median NIHSS score, 15), early reocclusion was observed in 11 (15%). The first procedure for recanalization was stent retriever in 25 patients (35%), Penumbra system in 25 patients (35%), and balloon angioplasty in 21 patients (30%). Of these, 63 patients (88%) received rescue therapy (balloon angioplasty, 50; intracranial stenting, 13). In the early reocclusion group, more number of intraprocedural reocclusion (median [IQR], 3 [2-3] vs. 1 [0-1], p < 0.001), a higher rate of remaining stenosis on the final angiography (67.6 ± 5.9% vs 57.3 ± 15.9%, p = 0.044), and a higher rate of procedure-related adverse events (27% vs 5%, p = 0.043) were observed compared to the other group. On logistic regression analysis, a total number of intraprocedural reocclusion was independently associated with early reocclusion (odds ratio, 31.4; 95% confidence interval, 2.6-375.2). Early reocclusion was related to a low rate of favorable outcome at 90 days (modified Rankin Scale ≤ 2, 9% vs 54%, p = 0.007).

Conclusions:
In AIS patients due to ICAS-O, early reocclusion within 48 hours was not rare and associated with unfavorable outcome. Patients with repeated intraprocedural reocclusion are at high risk for early reocclusion; they might need follow-up angiographical assessment and intensive antithrombotic treatment.
Abstract TP301: Gender Differences in Short- and Long-Term Outcome of Patients With Suspected Acute Stroke
Authors: Akhtar Naveed , Kamran Saadat , Singh Rajvir , Bhutta Zain , Morgan Debby , Joseph Sujatha , Bourke Paula , Saqqur Maher , Imam Yahia , Amir Numan , Babu Blessy , Ojha Laxmi , Jose Namitha , Shuaib Ashfaq
Published: June 2021

Background:
There are gender differences in the short-term prognosis following acute stroke suggesting that outcome is less favorable in women. Factors contributing to this poor outcome include preexisting morbidity, stroke severity and higher age. Most previous studies have looked at short-term prognosis. PURPOSE: We investigated whether gender differences have a differential impact on incidence of short-term outcome and long-term major adverse cardiovascular events (MACE) including stroke, myocardial infarction, unstable angina, coronary revascularization procedure, and death in patients with suspected acute stroke.

Methods:
The study used a prospective cohort of Qatari patients with suspected acute stroke between January 2014 and February 2019. We calculated the modified Rankin score (mRS) at discharge and 90-days (short-term) and MACE (long-term) outcomes in both genders. To determine the independent predictor for MACE, the Cox proportional hazards regression analysis was used and summarized as hazard ratio and 95% confidential interval.

Results:
A total of 1372 patients identified. At 90-days, women found to have significantly poorer outcome (34.0% vs 23.4%, p<0.001) mortality (8.5% vs 5.2%, p<0.03) overall. MACE was present in 30.5% (418/1372) during follow-up (57.2% males and 54.3% females, p=0.32). Median follow-up was 44.6 months for females and 47.2 months for males. Mean age in MACE group was significantly higher (65.5±15.3 vs 60.1±15.9, p< 0.001). Hypertension, diabetes, prior history of stroke, coronary artery disease, and atrial fibrillation on admission was more significant in MACE group, while obesity (BMI ≥ 30 kg/m2) was more common in non-MACE group. Patients with MACE had higher NIHSS on admission (6.1±7.4 vs 3.5±5.3, p<0.001), HbA1c (7.7±2.3 vs 7.4±2.3, p=0.02) and poorer prognosis (44.5% vs 18.6%, p<0.001) and higher mortality at 90-days. Once corrected, the hazard regression analysis showed that no difference in MACE between the two genders.

Conclusion:
Our results show that despite higher mortality and poor outcome at 90-days, the long-term outcome in women did not show any significant difference from men in this cohort. This may be related to older age and presence of cardiovascular risk factors.
Abstract TP311: Organizational Culture Drives Confidence in Implementing Telestroke Care
Authors: Miao Christopher E , Martin Holly , Graham Glenn , Martini Sharyl , Anderson Jane , Damush Teresa , LaPradd Michelle , Ofner Susan , Williams Linda
Published: June 2021

Background:
In its first 18 months, the VA National Telestroke Program (NTSP) conducted 800 consults at 30 sites. Data from staff at participating sites are collected in anonymous surveys. We aimed to determine factors associated with confidence in providing stroke care at these sites, and whether confidence is associated with performance on NTSP quality indicators.

Methods:
Surveys were sent to providers at participating sites at baseline (BL) and 6 - 12 months post-NTSP implementation (post-I). Survey questions included items about confidence providing stroke care and items from the Organizational Readiness to Change Assessment (ORCA). Confidence (0-10) was dichotomized into fully confident (mean score of 10) and not fully confident sites (mean <10). ORCA score was averaged by site. Covariates included site performance, volume, and time in the NTSP. We used a Kruskal Wallis analysis to examine the association of BL variables with post-I confidence, and a Pearson correlation test to examine the association between performance indicators and confidence.

Results:
16 sites, with 54 staff members total responding (57% nurses, 26% providers, 17% administrators/other), had BL and post-I data. Five sites were fully confident at the post-I assessment, the remaining 11 had mean confidence scores 8.32 - 9.5. Site confidence improved over time (mean 7.97 at BL vs. 9.44 post-I, p = 0.004), but confidence was not associated with site performance on any NTSP indicator. Higher ORCA scores were significantly associated with post-I confidence (mean ORCA 4.46 vs. 4.01, p=0.04). Fully confident sites also had shorter NTSP participation times (mean 5.40 months in the fully confident sites vs. 13.45, P=0.01). BL confidence, rurality, and consultation volume were not associated with post-I confidence. Periodic retraining was the most commonly suggested program addition.

Conclusions:
Organizational culture, but not performance or consult volume, is significantly associated with staff confidence in providing stroke care via telestroke. The finding that less confident sites have longer participation times suggests that planned retraining should be a part of telestroke programs to help sustain site confidence in providing stroke care.
Abstract TP336: The Intestinal Barrier Dysfunction Induced by Intracerebral Hemorrhage Contributes to the Brain Edema
Authors: Wang Tian , Han Bing , Han Yingjie , Li Ting , Fu Fenghua
Published: June 2021

Background and Purpose:
This study aims to investigate whether intracerebral hemorrhage (ICH) can lead to intestinal barrier dysfunction, and whether ICH-induced intestinal injury plays a role in brain edema.

Methods:
ICH mice model was prepared by an intrastriatal injection of bacterial collagenase. The following parameters were investigated at 3 h, 6 h, 12 h, 1 d, 2 d, 3 d, or 7 d after ICH preparation. Mice were given intragastrically with FITC-dextran and the intestinal permeability was evaluated by serum fluorescence measurement. Serum lipopolysaccharide (LPS) level was assayed with ELISA kits. Ileum and jejunum were stained with hematoxylin and eosin. Intestinal mucosal injuries were graded according to the scoring method (grade 0 to grade 4). Brain water content was evaluated via a wet/dry weight method. Correlations of intestinal injury, intestine permeability, LPS, and brain edema were analyzed using Pearson’s correlation analysis.

Results:
Compared with the Sham group, Ileum and jejunum damage occurred at 6 h after ICH, and the ICH-induced intestinal injury continued until 7 d. In line with the histopathological findings, the degree of ileum and jejunum injury was significantly increased at 6 h after ICH, showing mostly scores in Grade 1 to Grade 3 (
P
< 0.05 or
P
< 0.01). After 6-h ICH, the intestinal permeability to FITC-dextran was higher compared to the Sham group, and the increase of intestinal permeability lasted 7 d (
P
< 0.01). From 6 h to 7 d, serum LPS was significantly augmented (
P
< 0.01). The brain content of the ipsilateral hemispheres was increased at 12 h, 1 d, 2 d, and 3 d after ICH (
P
< 0.05 or
P
< 0.01), and the brain content of the contralateral hemispheres was also enhanced at 1 d, 2 d, and 3 d after ICH (
P
< 0.01). The ileum and jejunum injury were positively associated with intestine permeability (r = 0.625,
P
< 0.01, r = 0.465,
P
< 0.01, respectively). The intestine permeability was positively associated with the serum level of LPS (r =0.585,
P
< 0.01). The LPS levels were positively associated with brain water content (r = 0.338,
P
< 0.01).

Conclusion:
ICH can cause intestinal mucosal injury. Consequently, the increase of intestinal permeability results in the translocation of endotoxins, which contributes to ICH-induced brain edema.
Abstract TP339: Elevated Admission Troponin Predicts Unfavorable Outcomes After Intracerebral Hemorrhage in Patients With Atrial Fibrillation
Authors: Kalagara Roshini , Moody Scott , Mac Grory Brian , Burton Tina M , Cutting Shawna , Stretz Christoph , Madsen Tracy E , Mahta Ali , Wendell Linda C , Thompson Bradford B , Rao Shyam S , Yaghi Shadi , Furie Karen L , Reznik Michael E
Published: June 2021

Background:
Intracerebral hemorrhage (ICH) often carries cardiac implications, and serum troponin has been suggested as a predictive biomarker for patients with ICH and other stroke subtypes. We aimed to determine whether previously described associations between troponin and worse outcomes in ICH patients varied based on the presence of atrial fibrillation (AF).

Methods:
We performed a single-center cohort study using data from consecutive ICH patients admitted over 12 months. ICH characteristics and 3-month outcomes were prospectively collected, while admission troponin levels were retrospectively abstracted. We performed ordinal and binary logistic regression to determine associations between elevated troponins (>0.05 ng/mL) and 3-month outcomes (using the modified Rankin Scale [mRS]), with multivariable models adjusted for relevant demographics, ICH severity, and comorbidities including AF, anticoagulation use, coronary artery disease (CAD), and chronic kidney disease (CKD). An interaction variable combining elevated troponin and AF was also included in our models.

Results:
Of 261 ICH patients with troponin measured on admission, 17% (n=44) had elevated troponins. Patients with elevated troponins were not significantly older than patients with normal troponin levels (mean age 74.8±13.6 vs. 70.4±15.4, p=0.08), but were more likely to have AF (36% vs. 21%, p=0.03), CAD (32% vs. 15%, p=0.007), and CKD (16% vs. 5%, p=0.006); ICH size, location, and other predictors were not significantly different between groups. In adjusted models, neither elevated troponin nor AF were independently associated with worse outcomes. However, the interaction between the two was significant (p=0.003), and the presence of elevated admission troponin in the context of AF was significantly associated with worse outcomes (ordinal: common OR 9.8 [95% CI 2.0-47.8]; binary (mRS 4-6): OR 14.4 [95% CI 1.9-106.4]).

Conclusions:
Troponin may be a useful predictive biomarker in ICH patients with underlying AF, potentially signaling higher levels of cardiac and systemic stress in patients with lower cardiac reserve.