bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP405: Can Discharge Rankin Be Used As A Surrogate For 30-day Functional Outcomes?
Authors: Katzan Irene L , Liskay Alice M , Martin Siobhan , Thomas Charles , Love Thomas E , Konrad Nancy ,   Ohio Coverdell Investigators
Published: March 2022

Functional status after stroke is a critical outcome measurement, although there are significant logistical issues with systematically obtaining this information after hospital discharge.

Objective:
To determine agreement between discharge Rankin (dRankin) and 30-day phone Rankin to explore the feasibility of using dRankin as a surrogate for 30day outcomes after stroke.

Methods:
Prospective cohort study of patients admitted for stroke at 6 hospitals participating in the Ohio Coverdell Outcomes Evaluation Project. dRankin was determined retrospectively and 30d Rankin was assessed prospectively by phone (5 hospitals) or post discharge visit (1 hospital). Patients who died or had hospice care prior to discharge were excluded.

Results:
Discharge and 30d Rankins were available in 368 subjects. Mean age was 68.8 yrs and 78.0% were white. Mean dRankin was 2.75 and 30d Rankin was 2.27. There was perfect agreement between dRankin and 30dRankin in 28.8% cases, which improved to 71.4 % when 30dRankin was dichotomized into non-disabling (0-2), disabling stroke/death (3-6). Differences in scores were due to improvement in 82.9% cases (Figure). For patients with disabling stroke at discharge (dRankin3-5), improvement at least 1 grade occurred more frequently in those discharged home without HHC (84.4%) or to acute rehab (73.8%) compared to other destinations. There was little difference in those with non-disabling or disabling stroke who improved >=1 grade according to multiple variables including sex, age, race, NIHSS, insurance, various comorbid conditions and IV tPA use.

Conclusion:
There was moderate agreement between dRankin and 30d Rankin when dichotomized into non-disabling (0-2) vs disabling stroke/death (3-6). Agreement was marginal at the individual score level, mostly due to improvement postdischarge. More evaluation will be needed to identify factors associated with improved scores if dRankin is used as a surrogate for postdischarge functional status.
Abstract TP408: Availability and Efficacy of Mobile Health Technology Targeting Patients: A Systematic Evidence-based Review
Authors: Pandey Abhishek , Lushbough Catherine , Truong Andrew , Jensen Amy , Bretz Miranda , Henasey Denise , Arnedo Vanessa , Burton Dee , Balucani Clotilde , Fraser-White Marilyn , Browne Ruth , Szarek Michael , Levine Steven R ,   The Mobile Applications for Stroke (MAPPS) Investigators
Published: March 2022

BACKGROUND:
There are approximately 14,000 health/medical iPhone apps with a relative lack of both stroke-specific content and studies on effectiveness, usability, and usefulness.

OBJECTIVE:
Systematic, evidence-based literature search to determine the current availability, usefulness, and efficacy of mobile apps targeting stroke survivors or management of vascular risk factors.

METHODOLOGY:
Repetitive search study in PubMed and EMBASE using pre-specified medical subject headings (MeSH) terms, Boolean logic, and Preferred Reporting items for Systematic Reviews and Meta-analysis (PRISMA) guidelines (last updated 8/12/12). Publications were screened for inclusion using the following criteria: (1) potential usefulness of smartphones in daily patient care, (2) meta-analyses of stroke/vascular risk factor smartphone applications, (3) trials of smartphone-based patient care tools.

RESULTS:
We retrieved 73 articles from 2005-12 from 77 identified; 40/73 were duplicates. The remaining 33 abstracts were reviewed independently by 3 reviewers for relevance. Upon final evaluation/adjudication: 13 articles addressed potential usefulness of smartphones, 3 were on traditional specific stroke risk factors (none for stroke itself), and 8 on the results of trials of smartphone-based patient care tools. Sample sizes ranged from 3 to 3,001. Four articles addressed diabetes, two hypercholesterolemia, three weight loss, three diet/activity, one heart disease, and none addressed hypertension specifically. Of these, 8 were clinical trials on effectiveness or usefulness (3 for patient evaluation/monitoring, 2 for rehabilitation, 1 each for diet/activity, imaging, and drug infusion). Only one study evaluated risk analysis of information security with no studies evaluating strict regulation and critical appraisal.

CONCLUSION:
Despite rapid growth of mobile health applications, there is a paucity of linguistically relevant and culturally sensitive and sustainable stroke-specific apps. There is also a significant lack of studies in general that rigorously test mobile apps for their efficacy, usefulness, and sustainability with specific attention to patient privacy and regulatory compliance.
Abstract TP409: Impact of Surgical Ligation of the Left Atrial Appendage at the Time of Cardiac Surgery: A Propensity-Matched Analysis of Post-Operative Complications, Stroke, and 30-Day Mortality in 1,204 Patients
Authors: Johnson Christopher K , Shaw Richard E , O’Keefe Ryan M , Ferrari Giovanni , Grau Juan B
Published: March 2022

Background:
The left atrial appendage (LAA) is the source of 90% of thrombi in patients with atrial fibrillation. Our technique of doubly ligating the LAA (LLAA) has recently demonstrated a 95% success rate of achieving complete LAA occlusion by follow-up transesophageal echocardiography. However, the outcomes of these patients have yet to be compared to a set of non-ligated patients.

Methods:
From 2005 to 2012, 814 patients received LLAA using our previously published technique of double ligation with both a PDS II endosnare and a running 4-0 Prolene pledgeted suture. Propensity scores were developed based on 22 observed baseline covariates in a logistic regression model with LLAA as the dependent variable. This produced two patient cohorts of 602 patients balanced for baseline factors. These patients were retrospectively analyzed regarding their incidence of 30-day outcomes.

Results:
Overall, the ligated group had a higher rate of comorbidities, shorter ICU and post-surgical length of stay, less post-operative bleeding, lower rate of permanent stroke, and an overall significantly lower in-hospital mortality (0.7% vs. 3.0% p<0.001) and lower 30-day mortality (0.7% vs. 3.4%; p<0.0001). After propensity matching, post-operative myocardial infarction, stroke, atrial fibrillation, re-operation, and complications rates were similar between the two cohorts. There still was a statistically significant difference in mortality, with the ligated group having lower in-hospital (0.8% vs. 2.3% p=0.037) and 30-day mortality (0.8% vs. 2.8% p=0.01)

Conclusions:
Propensity matched analysis demonstrates that LLAA correlates with lower rates of in-hospital and 30-day mortality. This advantage comes without an increase in intraoperative or postoperative complications. This technique can easily be performed off or on pump, is very reproducible, and comes at a very low cost compared to LAA occlusion devices. Stroke has a multifactorial etiology; successful LLAA removes one potential source of thrombi peri-operatively and in the long term.
Abstract TP41: Arterial Spin-Labeled Perfusion MRI with Multi-Delay: Expanding Beyond CBF in Acute Ischemic Stroke
Authors: Liebeskind David S , Qiao Joe X , Günther Matthias , Scalzo Fabien , Johnson Mark S , Starkman Sidney , Ali Latisha K , Kim Doojin , Rao Neal M , Yallapragada Anil , Saver Jeffrey L , Alger Jeffry R , Salamon Noriko , Wang Danny J ,   for the UCLA Stroke Investigators
Published: March 2022

Background:
Arterial spin-labeled (ASL) perfusion MRI can measure cerebral blood flow (CBF), yet the prolonged delays of collateral perfusion in acute ischemic stroke may impose limitations. Multiparametric maps of perfusion, including transit times and cerebral blood volume (CBV), may reveal important hemodynamic features before CBF collapse. We implemented a novel multi-delay ASL sequence to investigate multiparametric perfusion changes in acute stroke.

Methods:
Consecutive acute ischemic stroke patients admitted during an 8-month period were evaluated with pseudo-continuous ASL on Siemens 1.5 T and 3 T scanners within 12 hours of symptom onset. ASL was acquired using a 4-delay pCASL protocol with background suppressed 3D GRASE (postlabeling delay (PLD)=1.5/2/2.5/3s, FOV=22cm, matrix=64x64, 16x8mm slices, rate-2 GRAPPA, TE=22ms, 8 pairs of tag and control for each delay, total scan time 4min). After motion correction, arterial transit time (ATT), CBF, and arterial CBV (aCBV) maps were generated from the 4 PLDs.

Results:
A total of 161 ASL multi-delay perfusion MRI studies were performed in 130 acute ischemic stroke patients (mean age was 71±18 years and 56% were female). Repeated multi-delay ASL or serial studies were acquired in 19 cases, including 11 cases with 2 MRIs, 7 with 3, and 1 with 6 MRIs, depicting multiparametric blood flow changes after treatment. Correlation of multi-delay ASL (4 PLDs) and DSC MRI CBF asymmetry measures in MCA stroke patients (when available) was r=0.785 (p<0.001) and r=0.683 (p=0.003) for CBV measures with limited correlation for ATT.

Conclusions:
Multidelay ASL with 4 PLDs is feasible in the setting of acute stroke, providing multiparametric perfusion measures (CBF, CBV, ATT) of blood flow changes with treatment.
Abstract TP413: Monitoring Of Clopidogrel-related Inhibition In Patients Presenting With Acute Cerebral Ischemia Following Generic Substitution Of Clopidogrel For Cardiovascular Prevention.
Authors: Tsivgoulis Georgios , Christoforidou Anna , Tsakaldimi Soultana , Flamouridou Maria , Mitsoglou Athina , Dalos Pavlos , Charalampopoulos Konstantinos , Boutzoni Soultana , Vadikolias Konstantinos , Heliopoulos Ioannis , Alexandrov Andrei V , Piperidou Charitomeni
Published: March 2022

Background&Purpose:
The European Medicines Agency has recently approved numerous generic versions of clopidogrel for the prevention of cardiovascular diseases. We previously observed a trend in our population based study that patients who switched to generic clopidogrel experienced strokes soon after substitution. We aimed to evaluate platelet function in patients experiencing acute cerebral ischemia (ACI) after generic substitution of clopidogrel (GSOC).

Subjects&Methods:
We prospectively evaluated consecutive patients who presented with symptoms of ACI and were previously treated with brand or generic clopidogrel for cardiovascular protection. Baseline characteristics, vascular risk factors, use of proton-pump inhibitors (PPI) and secondary prevention therapies were documented in all cases. Responsiveness to clopidogrel was assessed within 24 hours from symptom onset using multiple electrode impedance aggregometry (Multiplate analyzer). The validated cut-off of 52U was used to identify clopidogrel non-responders (≥53 U).

Results:
During the first 18-month period we documented 47 patients (mean age 70±10 years; 60%men) presenting with symptoms of ACI (57% acute ischemic stroke, 43% Transient Ischemic Attack). GSOC had occurred within a median of 6 months (range 1-11 months) in 25 cases (53%), while the remaining 22 patients (47%) have been treated only with brand clopidogrel. The clopidogrel groups did not differ (p>0.2) in terms of demographics, vascular risk factors, use of PPIs and secondary prevention therapies. The rate of clopidogrel non-responders tended to be higher in the generic group (44% vs. 23%; p=0.125). After adjusting for demographic characteristics, stroke risk factors, concomitant aspirin or PPI use and secondary prevention therapies, the generic compound tended to be associated with a higher likelihood of clopidogrel non-responsiveness (OR: 6.56; 95%CI: 0.95-45.54; p=0.057)

Conclusions:
Our findings indicate that rate of clopidogrel non-responsiveness tends to be higher in patients presenting with symptoms of ACI following its generic substitution. The observed trend poses a question if clopidogrel generics have the same active ingredient and the same labeled strength as the reference product.
Abstract TP419: Worse Outcome After Intraoperative Re-Rupture In Subarachnoid Hemorrhage Not Due to Increased Vasospasm
Authors: Sheth Sunil A , Lawton Michael T , Josephson Scott A
Published: March 2022

INTRODUCTION:
Intraoperative re-rupture of cerebral aneurysms is a frequent complication of subarachnoid hemorrhage (SAH) treatment. Studies have demonstrated worsened outcomes after re-rupture, particularly in those treated with surgical clipping, for reasons that are unknown. We designed a study to test the hypothesis that worsened outcomes in these patients may be due to increased vasospasm. Detecting a higher incidence of vasospasm in this population would justify aggressive early treatment to prevent subsequent ischemic injury in those with intraoperative re-rupture after SAH.

METHODS:
All patients with aneurysmal SAH treated with open surgical clipping between 2006-2008 were examined at a single institution. Angiographic vasospasm was defined as narrowing of vessels seen on catheter angiography. Symptomatic vasospasm was defined as clinical deterioration after other causes had been excluded or radiographic evidence of infarction attributable to vasospasm.

RESULTS:
We identified 241 consecutive patients that included 41 with intraoperative re-rupture (17%). Average age was 54 ± 13 years and 69% of the patients were female. Hunt Hess scores between the group with intraoperative re-rupture and without were similar (2.1 ±1.3 vs. 2.4 ± 1.3, p = 0.09). Modified Fischer scores were also similar between the two groups (2.8 ±1.2 vs. 2.8 ± 1.2, p = 0.66). Time from rupture to definitive treatment was not significantly different (3.5 days ± 3.2 vs. 3.5 days ± 3.2, p=0.9). Patients in both groups had similar histories of smoking (58% vs. 50%, p=0.47) and HTN (49% vs. 53%, p=0.72). Angiographic vasospasm was seen in 61% of the group without re-rupture and 63% in the group with re-rupture (p=0.83). Symptomatic vasospasm was seen in 38% of patients without re-rupture and 49% of patients with re-rupture (p=0.26). In-hospital mortality was higher in the group with intraoperative re-rupture (20% vs. 9%, p<0.05).

DISCUSSION:
Our results corroborated previous findings of worsened outcomes after intraoperative re-rupture in SAH patients treated with surgical clipping, but did not show a significant difference in rates of vasospasm. These findings indicate that the worsened outcome of these patients is likely secondary to other, as yet known, causes.
Abstract TP420: Sphingolipid Profile Changes In The Cerebrospinal Fluid Of Subarachnoid Hemorrhage Patients
Authors: Testai Fernando D , Hillmann Maureen , Castillo Norma , Amin-Hanjani Sepideh , Gorshkova Irina , Berdyshev Evgeny , Dawson Glyn
Published: March 2022

Background:
The pathogenesis of brain injury after subarachnoid hemorrhage (SAH) is multifactorial and not completely understood. We recently described that profound changes in the ceramide (Cer) profile occur after SAH. Cer is an endogenous sphingolipid associated with brain-cell death. Dihydroceramide (DH-Cer) is an inactive sphingolipid that is metabolized into Cer by desaturases. In this study we sought to investigate if a differential metabolism of Cer into DH-Cer occurs in SAH and if this is related to vasospasm (VS) and outcome.

Methods:
Cerebrospinal fluid (CSF) Cer and DH-Cer levels were determined by mass spectrometry in control subjects and patients with Fisher 3 grade SAH within 48 hours of the bleed. Patients were prospectively followed and subcategorized based on the presence or absence of symptomatic VS (sVS versus no-sVS) and modified Rankin Scale (mRS) at discharge.

Results:
A total of 8 controls and 23 SAH patients were enrolled in the study. Compared to controls, patients with SAH had higher CSF levels of total Cer (12.41±8.84 versus 54.65±49.30 pmol/mL, p=0.001) and DH-Cer (1.44±1.05 versus 4.73±3.43 pmol/mL, p<0.0001). Cer/DH-Cer ratios in both groups were comparable (p>0.05). Within the SAH group, sVS had higher Cer and DH-Cer levels than no-sVS (104.23±56.97 versus 28.60±16.91 pmol/mL, p=0.001 for Cer; 7.87±4.03 versus 3.12±1.88 pmol/mL, p=0.005 for DH-Cer). In addition, the sVS group had lower Cer/DH-Cer ratios than no-sVS (0.11±0.03 versus 0.08±0.02; p=0.009). Compared to individuals with good outcome (mRS≤3), SAH patients with poor outcome (mRS≥4) had lower Cer/DH-Cer ratios (0.12±0.04 versus 0.09±0.02; p=0.04)

Conclusions:
CSF levels of Cer and DH-Cer increase after SAH, particularly in individuals with sVS and poor neurological outcome at discharge. The distinctive Cer/DH-Cer ratios observed in sVS and no-sVS groups suggest that differences in sphingolipid metabolism exist in these subgroups.
Abstract TP425: Clinical and Radiological Spectrum of Nontraumatic Cortical Subarachnoid Hemorrhages : A Consecutive Series of 62 Patients
Authors: Viguier Alain , Calviere Lionel , Cuvinciuc Victor , Bonneville Fabrice , Larrue Vincent
Published: March 2022

Non-traumatic cortical subarachnoid hemorrhage (cSAH) is an unusual location of SAH not related to aneurysmal rupture. Several causes have been described in small cohorts. We report the characteristics and the follow-up of a large cohort of such patients.

Methods:
During 4 years, consecutive patients admitted in our institution with a cSAH revealed by neurological symptoms were included in a registry. Retrospective review of medical records, neuroimaging studies, and follow-up data was performed.

Results:
Sixty two patients (37 women; mean age ± SD : 66 ± 14 years) were included. The main clinical presentation was a transient deficit in 50 % of cases. Headache was present in only 39 % of cases. Cerebral amyloid angiopathy (CAA) accounted for 50 % of cases. The main other etiologies were reversible vasoconstriction syndrome (13 %), endocarditis (11 %), severe intracranial or cervical arterial stenoses (8 %) and cerebral venous thrombosis (5 %). Patients with CAA were older (p < 0.001) and suffered essentially from transient deficit (80 vs 18 %; p < 0.001) without headache (18 % vs 58 %; p = 0.002). Cortical hemosiderosis on MRI was strongly associated with CAA (77 % vs 0 %; p < 0.001). Follow up data were available in 55 patients (28 with CAA). Forty eight patients underwent an imaging follow up (25 with CAA). Recurrent hemorrhages (cSAH or hematoma) occurred in 52 % of CAA cases against 12 % in other origins (p = 0.01).

Conclusions:
Our data show that CCA is clearly the main etiology of cSAH with a specific pattern associating transient neurological deficit without headache and cortical hemosiderosis on MRI. Many origins can be found in younger patients to whom the diagnosis is guided by imaging findings and clinical background. The risk of recurrence is high in CAA contrary to other etiologies.
Abstract TP432: Glyco-proteomic Study of Therapeutic Hypothermia in Global Ischemic Brain Injury Post Cardiac Arrest
Authors: Ning MingMing , Cao Jing , Buonanno Ferdinando S , Feeney Kathleen , Elia Mikaela G , McMullin David , Guo Shu-Zhen , Arai Ken , Lo Eng H
Published: March 2022

Background:
Global ischemic brain injury post cardiac arrest is prevalent with dismal prognosis -- less than 10% survive to hospital discharge. Therapeutic hypothermia (TH) is an efficacious neuroprotective treatment, protects against multi-organ damage, doubles the chance of good neurologic outcome and decreases mortality by 25%, but is grossly underutilized (<5%). We use a glyco-proteomic approach to better understand and predict TH response, because: 1) glycosylation is one of the most important and common extracellular post-translational modifications in immunity and coagulation, and is crucial in TH-related side effects such as sepsis and bleeding; 2) it occurs rapidly over the time window of treatment; and 3) it can be used to focus proteomic profiling by targeting specific plasma signals.

Methods:
Lectin array and various lectin immunoblots were used to study plasma glycosylation patterns of TH patients (n=30; 24 hrs post cardiac arrest) with good vs poor clinical outcome (evaluated at 3 months post event). To identify and enrich candidate plasma proteins with potential clinical utility, specific lectin affinity chromatography and LC-MS/MS were performed.

Results:
Plasma glycosylation patterns differ dramatically with respect to clinical outcome in TH-treated patients. On screening lectin blots (figure), whereas SBA showed little change, RCA (decreased around 35-100kD - in box) and ConA (increased around 40-150kD - in box) were different in a wide range of MW, and WGA identified unique banding around 100kD (in box) in TH responders. In lectin affinity pull-down, more than 400 specific glycoproteins were identified showing significant changes with respect to TH outcome.

Conclusion:
A glyco-proteomic approach is promising to help predict neurologic outcome, select TH responders, and triage hypothermic therapy in global ischemic brain injury patients post cardiac arrest. Further studies are under way to investigate these exploratory findings.
Abstract TP443: Clinical Features, Surgical Treatment, And Long-term Outcome In Adult Patients With Moyamoya Disease In China
Authors: Duan Lian
Published: March 2022

Background:
Moyamoya disease develops mostly in Asian countries including Japan, Korea, mainland China and Taiwan. However, there was few detailed demographic and clinical data about Chinese patients with moyamoya disease. Here we describe the clinical features, surgical treatment, and long-term outcome of adults with moyamoya disease treated at a single institution in China.

Methods:
Our cohort included 470 adult patients with moyamoya disease. The demographic and clinical characteristics were obtained by retrospective chart review and long-term outcome was evaluated using the stroke status. Univariate and multivariate logistic regression analyses were performed to determine risk factors for postoperative morbidity and functional outcome. Risk of subsequent stroke was determined using the Kaplan-Meier method and Cox regression was used to determine risk factors for postoperative or subsequent strokes.

Results:
The median (range) age for the onset of symptoms was 36.8 (18 to 59) years. The ratio of female to male patients was 1:1(231/239). Familial occurrence of moyamoya disease was 2.3%. The most common initial symptom was a cerebral ischemic event. The incidence of postoperative ischemic events or hemorrhage was 5.9% (9.8% of patients). Older age of symptom onset, PCA involvement and present of TIA were identified as predictors of adverse postoperative events. The Kaplan-Meier estimate stroke risk was 10.1% in the first 2 years, and the 5-year-Kaplan-Meier risk of stroke was 13% after surgery for all patients treated with surgical revascularization. Older age of symptom onset, PCA involvement, and present of TIA were identified as predictors of postoperative or subsequent strokes. Overall, 73.2% of patients had an independent life with no significant disability and the strongest predictor being the preoperative mRS score.

Conclusion:
Clinical characteristics of adult moyamoya disease in China are different from that in other Asian countries. EDAS in adult patients with moyamoya disease carries a low risk, is effective at preventing future ischemic events, and improves quality of life.
Abstract TP49: Association Between Low CBV and ICH in Acute Stroke Patients Undergoing Intra-Arterial Therapy
Authors: Nolte Justin , Gupta Purbasha , Davis Melanie , Matheus Maria , Cianfoni Alessandro , Chaudry Imran , Yeatts Sharon , Rumboldt Zoran , Turan Tanya
Published: March 2022

Background:
Acute stroke patients with middle cerebral artery (MCA) or intracranial internal carotid artery (ICA) occlusion who have decreased cerebral blood volume (CBV) in the basal ganglia (BG) on CT perfusion (CTP) imaging are thought to be at high risk of intracerebral hemorrhage (ICH) following recanalization with intra-arterial therapy (IAT). We sought to determine if low BG CBV in patients with MCA or ICA occlusion is associated with post-IAT ICH.

Methods:
This is a single-center retrospective chart review of consecutive stroke patients seen in the emergency room from 6/07 - 12/10. All acute stroke patients with an MCA (M1) or intracranial ICA occlusion on CT angiogram, who underwent CTP imaging and were treated with IAT (IA tpa and/or thrombectomy) were included. The primary outcome was the presence of ICH on CT 24 hours post-IAT. Good clinical outcome was defined as a modified Rankin score ≤ 3 at discharge. Clinical variables, CBV, and ICH were each assessed by investigators who were blinded to the other abstracted data. CBV and ICH were agreed upon by at least 2 readers. Univariate analyses were performed using chi-square tests. Multivariate analyses of other potential predictors of ICH were done using logistic regression.

Results:
Sixty-two patients were included in these analyses. The mean age was 65.8 years, 44% were male, and 34% were non-white. The mean time to artery recanalization was 717 minutes. In univariate analysis, there was a trend toward higher rates of post-IAT ICH in patients with low BG CBV compared to those with preserved CBV (64.3% vs. 47.1%, p=0.175). Patients with post-IAT ICH had higher rates of a poor outcome than those without ICH (94.1% vs 64.3%, p=0.0031). Multivariate analyses did not demonstrate any independent predictors of ICH.

Conclusion:
Acute stroke patients with proximal MCA or ICA occlusion and low BG CBV on CTP imaging had a trend toward a higher risk of post-IAT ICH, but this association was not statistically significant, possibly due to the small sample size. Given that ICH is associated with poor outcome, future studies are needed to determine if patients with low BG CBV should be excluded from IAT due to increased risk of ICH. .
Abstract TP55: Comparison of Arterial Spin Labeling and Dynamic Susceptibility Contrast Perfusion for Quantitative Evaluation of Mismatch in Successfully Recanalized Acute Stroke Patients
Authors: Nael Kambiz , Meshksar Arash , Liebeskind David S , Ellingson Benjamine , Salamon Noriko , Villablanca Pablo J ,   UCLA Stroke Investigators
Published: March 2022

Purpose:
Arterial spin labeling (ASL) has gained attention in evaluation of acute stroke as an alternative perfusion method that does not require contrast. We evaluate the agreement of ASL and dynamic susceptibility contrast (DSC) mismatch classification using a quantitative method in successfully recanalized patients.

Methods:
This retrospective study was performed using MR examinations acquired between 2010-2012. Inclusion criteria were: patients with acute stroke who underwent successful recanalization and acquisition of both ASL and DSC before and after revascularization. The volumes of DWI and hypoperfused (Tmax > 6 seconds) lesions were calculated on DSC using an automated software. The hypoperfusion volumes on ASL were calculated using a region of interest-based analysis. The ratios of volume of the hypoperfusion region to DWI lesion were calculated and used to classify the patients into 3 categories: 1) mismatch: ratio >2; 2) matched: 0.7 < ratio < 2; and 3) reperfused: ratio < 0.7. Intermodality agreement for mismatch categories was evaluated with Kappa test.

Results:
Seventeen patients met the inclusion criteria, resulting in 34 pair of ASL-DSC for comparison. The mean ± SD of the volumes of the DWI lesions was 14.2± 8 ml and 18.2 ± 13 ml before and after revascularization respectively. ASL overestimated the hypoperfusion volume in both pre and post-treatment groups (p<0.01) in comparison to DSC-Tmax lesion volume. In pre-treatment group, ASL-DWI and DSC-DWI mismatch categories agreed in 15 of 17 cases (88%) with high agreement (k=0.82; 95% CI, 0.3 -0.87). In post-treatment group, ASL-DWI and DSC-DWI mismatch categories agreed in 11 of 17 cases (64%) with moderate agreement (k=0.46; 95% CI,0.25-0.82). Out of 6 discrepant cases, three reperfused patients on DSC were categorized matched on ASL and 3 matched cases on DSC were classified as mismatch on ASL.

Conclusion:
ASL overestimates the DSC time to maximum lesion volume. There is only moderate agreement between ASL and DSC in mismatch classification of revascularized patients, suggestive of less sensitivity of ASL in detection of reperfusion. Improvement in ASL methods with varying degree post-labeling delay may be needed for evaluation of revascularized patients.
Abstract TP58: NIH Stroke Scale as Predictor of Prognosis in Posterior Circulation Stroke
Authors: Inoa Violiza , Aron Abraham W , Staff Ilene , Fortunato Gilbert , Sansing Lauren H
Published: March 2022

BACKGROUND:
The NIHSS is an indispensable tool that aids in the decision-making of acute stroke management. Posterior circulation strokes often have lower NIHSS scores. This may result in withholding treatment with IV tPA and poor outcome in this population. We aimed to assess the predictive value of the NIHSS on poor functional outcome in anterior circulation (AC) versus posterior circulation (PC) strokes.

METHODS:
This was a retrospective analysis of a prospectively collected database from a single center. Adult patients admitted to the stroke service with acute ischemic stroke from January 2000 through December 2011 were included. Data collected included demographics, initial NIHSS, vascular distribution of infarct, complications, and outcome at 3 months. Since this study focused on minor strokes, death or disability was defined as death or a score of < 18 on the modified Barthel Index (BI) scale.

RESULTS:
The analysis included 1,197 patients with AC stroke and 372 with PC stroke. Table 1 lists the characteristics of the two groups. The NIHSS score on admission was lower in PC stroke and the majority (63%) of PC stroke patients had baseline NIHSS scores < 4. AC stroke patients were more likely to be treated with IV tPA or endovascular treatment. Surprisingly, 15% of patients with posterior circulation strokes and admission NIHSS score < 4 had death or disability at 3 months. On multivariable analyses, higher NIHSS score was an independent predictor of death or disability at 3 months in both AC (OR 1.20, 95% CI 1.17-1.23, p <0.001) and PC (1.15, 1.08-1.21, p <0.001) stroke. In PC stroke, treatment with IV tPA was a strong predictor of excellent outcome at 3 months (OR 5.62, 95% CI 1.06-29.9, p < 0.05).

CONCLUSION:
There is a potential risk for death or disability in patients with PC stroke even with low NIHSS scores. These data suggest that treatment with IV tPA should not be withheld from patients with PC stroke syndromes based on the NIHSS score.
Abstract TP64: Optimal Minor Stroke Definition For Thrombolysis Decision-making
Authors: Park Tai Hwan , Hong Keun-Sik , Choi Jay-Chul , Song Pamela , Lee Ji Sung , Lee Juneyoung , Park Jong-Moo , Lee Kyung Bok , Cho Yong-Jin , Han Moon-Ku , Bae Hee-Joon
Published: March 2022

Background and purpose:
Patients with a low National Institutes of Health Stroke Scale (NIHSS) score are frequently excluded from thrombolysis, but >25% of those patients remain disabled. We sought to define a minor stroke definition that helps guide treatment decision-making.

Methods:
From a stroke outcome database, untreated patients with NIHSS ≤5 presenting within a 4.5-hour window were identified. The validity of the following minor stroke definitions were assessed: 1) the National Institute of Neurological Disorders and Stroke Tissue Plasminogen Activator (NINDS-TPA) trials’ definition; 2) the total NIHSS score, varying a threshold from 0 to 4; 3) our proposed definition which included NIHSS=0 or NIHSS=1 in the items of level of consciousness, gaze, facial palsy, sensory, or dysarthria.

Results:
Of 647 included patients, 172 (26.6%) had a 3-month unfavorable outcome (modified Rankin Scale 2-6). When the NINDS-TPA trials’ definition, our proposed definition, or NIHSS ≤1 definition was applied, >75% of patients with an unfavorable outcome were defined as a non-minor stroke and >85% of those defined as a minor stroke had a favorable outcome. For a hypothetical population of 1000 patients with NIHSS ≤5, as compared to the NINDS-TPA trials’ definition, our definition would treat additional 23 patients and increase 17-18 favorable outcomes at the expense of 1-2 symptomatic hemorrhagic transformations (SHTs), whereas the NIHSS ≤1 definition would further exclude 54 patients from treatment and the benefit of avoiding 1-4 SHTs would be negated by the increase of three unfavorable outcomes among untreated patients.

Conclusion:
A validated criterion should be applied to thrombolysis decision-making for patients with a mild deficit. Our definition would further increase the treatment rate and favorable outcomes.
Abstract TP65: Fas Ligand Induced Brain Inflammation After Ischemic Stroke And Attenuates By Human Urinary Kallidinogenase
Authors: xu yun , Zhang Xin
Published: March 2022

Inflammation is an important contributing mechanism in ischemic stroke. Fas ligand plays a critical role in post-stroke inflammatory responses. However, little progress has been made in clinical therapy, especial the treatment of inflammation after ischemic stroke. From 2010-2012, acute brain infarction patients within 72 hours of onset in the territory of anterior circulation artery have been enrolled in this study. All the patients were randomized to the HUK treated group (HP) and non HUK treated group (control group, CP). Both two groups received the same foundation treatment. In HP group, the patients received an intravenous transfusion of HUK once a day, for 10 days. The NIHSS index were used to evaluate neurological deficit at both day 0, days 10 and day 90. All patients were imaged with 3.0T MRI at both day 0 and day 10. The ischemic lesion area was measured by both DWI, PWI and FLAIR. The brain edema extent were compared. The blood samples were taken by all the patients for sFAL and inflammation factors detection at day 0, day 10 and day 90. We found: 1) 206 patients were enrolled in this study, 117 patients were in HP group and 89 patients were in CP group. The NIHSS index and brain edema extent show no significant difference between the HP group and CP group at day 2) sFAL could be detected in peripheral blood, and the level of sFAL had an significant increase at day 10 compared to day 0. Both inflammation cells and inflammation factors were increased at day 10 as compared to day 0. 3) As patients which received the HUK treatment, we observed the obvious improvement of NIHSS score, brain edema as well as inflammatory mediators. sFAL induced inflammation might contribute to the brain injury after ischemic stroke, and HUK protects against ischemic brain injury by inhibiting inflammatory response.
Abstract TP71: Efficacy Of Intravenous Thrombolysis With Tissue Plasminogen Activator In Elderly Patients- Fukuoka Stroke Registry (FSR)
Authors: Matsuo Ryu , Kamouchi Masahiro , Ago Tetsuro , Kuroda Junya , Kuwashiro Takahiro , Sugimori Hiroshi , Kitazono Takanari
Published: March 2022

Background and purposes:
Intravenous thrombolysis with tissue plasminogen activator (tPA) is efficacious to improve clinical outcomes in patients with acute ischemic stroke. However, the benefit of its use for elderly patients remains unclear. The aim of this study is to elucidate the clinical outcomes before and after tPA era and the efficacy of tPA in Japanese elderly patients with acute ischemic stroke.

Methods:
The Fukuoka Stroke Registry (FSR) is a multicenter, stroke registry in Japan. As of May 2012, 13,761 patients within 7 days after onset were registered in the database. Among them, the elderly patients (≥75 years old, n=1,645) within 3 hours after onset were categorized into two groups according to the era: from Jun 1999 to Sep 2005 before approval of usage of tPA in Japan (pre-tPA group, n=910) and after that from Oct 2005 to May 2012 (post-tPA group, n=735). Neurological severity was assessed by NIH stroke scale score (NIHSS). Clinical outcomes were assessed as follows: neurological improvement (decrease in NIHSS more than 4 during hospitalization or NIHSS 0 at discharge), favorable functional outcome (modified Rankin Scale 0-1 at discharge), and in-hospital mortality.

Results:
Thirty % of the patients in post-tPA group were treated by t-PA. Neurological improvement (pre-tPA group 44% vs post-tPA group 52%, P<0.001) and favorable functional outcome at discharge (pre-tPA group 21% vs post-tPA group 26%, P<0.001) were significantly more prevalent in post-tPA group than in pre-tPA group. The prevalence of in-hospital mortality (pre-tPA group 13% vs post-tPA group 8%, P=0.005) was significantly higher in pre-tPA group. In multivariable logistic analysis adjusted for confounding variables, intravenous thrombolysis was independently associated with good outcomes: neurological improvement (OR 1.94, 95% CI 1.46-2.59, P<0.001), favorable outcome at discharge (OR 2.88, 95%CI 1.89-4.38, P<0.001), and in-hospital mortality (OR 0.44, 95% CI 0.27-0.69, P<0.001). There was no significant difference in hemorrhage complications between both groups.

Conclusions:
Intravenous thrombolysis improves clinical outcomes in elderly patients with acute ischemic stroke. Elderly patients can be treated efficiently and safely with intravenous thrombolysis.
Abstract TP79: Imbalance Between Activation Of Matrix Metalloprotease And Its Inhibition May Facilitate The Growth Of Cerebral Aneurysm In Female Rats
Authors: Kohrai Masaaki
Published: March 2022

Introduction:
Cerebral aneurysms are a major cause of subarachnoid hemorrhage . Despite the catastrophic consequences of their rupture, not all mechanisms underlying the formation, progression, and rupture of cerebral aneurysms are fully understood. Using our model of reproducible cerebral aneurysms in oophorectomized rats we have documented the pathogenesis of cerebral aneurysms. Methionine-induced hyperhomocysteinemia which participates in coronary disease or stroke, is also associated with cerebral aneurysm formation. Whether it facilitates the growth and rupture of cerebral aneurysms remains obscure. We explored the role of methionine in the growth and rupture of cerebral aneurysms.

Methods:
We subject 13 week-old female Sprague-Dawley rats fed an 8% high-salt diet to bilateral oophorectomy and ligation of the right common carotid artery. Four weeks later they underwent ligation of the bilateral posterior renal artery divided into 2 groups; one group did and the other did not receive 1g/kg/day methionine in the drinking water. The aneurysmal rupture rate and morphologic- and genomic changes in the 2 groups were compared at 12 weeks.

Results:
The incidence of cerebral aneurysm formation was the same in both groups. While the rate of rupture was not higher in the methionine group, their aneurysms were larger and oxidative stress-related NOX4, Rac1, and apoptosis-related Rac1 were up-regulated. Interestingly, the expression of MMP-9 was increased as was the ratio of MMP-9 to TIMP2 but not of MMP-9 to TIMP1, suggesting vascular degradation due to an imbalance between the activation and inhibition of extracellular matrix metalloprotease.

Conclusion:
Our findings suggest that excessive vascular degradation due to oxidative stress and apoptosis induced by methionine contribute to the progression of cerebral aneurysms in oophorectomized rats.
Abstract TP88: Tailored Periprocedural Antiplatelet Therapy for Coil Embolization of Unruptured Intracranial Aneurysms using Neck Size
Authors: Satow Tetsu , Morita Ken-ichi , Ishii Daizo , Takada Shigeki , Ito Koichi , Yamauchi Keita , Hamano Eika , Kataoka Hiroharu , Iihara Koji
Published: March 2022

Introduction and Hypothesis:
Although periprocedural antiplatelet therapy (APT) for coil embolization of unruptured aneurysms (UAs) has been prevailing, its detailed regimens such as mode (single or dual), dose, and duration, are not yet well established. Recently, we have reported our retrospective data that dual APT better prevented ischemic complications from coiling in wide-necked aneurysms compared with single APT. The aim of this prospective study is to assess the efficacy of using the aneurysmal neck width to determine the mode of APT (single or dual) for coiling of UAs, especially focusing on the safety of single APT for narrow-necked aneurysms in prevention of ischemic complications.

Methods:
A total of 78 consecutive patients harboring UAs treated by endosaccular coil embolization at our institute between September 2009 and July 2012 were included. Stent-assisted cases were excluded. APT was started 4 days prior to the procedure, and UAs with narrow neck (<4mm, 24 cases) received single APT (aspirin 100mg; group 1) while wide-necked cases (≥4mm, 54 cases) received dual APT (aspirin 100mg and clopidogrel 75mg ) were administered for one month. The incidence of both ischemic and hemorrhagic complications, and abnormality in postprocedural diffusion weighted imaging (DWI) in each group was assessed.

Results:
Symptomatic ischemic complications occurred in 3 (5.5%) cases in group 2 and none in group 1. DWI abnormalities were observed in 5 (20.8 %) in group 1 and 20 (37.0%) in group 2. In cases with adjunctive technique, there was no significant difference in the incidence of DWI positive cases between group 1 (3/13, 23.1%) and 2 (19/49, 38.8%) (P=0.16). Hemorrhagic complicationoccurred in only one case in group 2 (1.9%).

Conclusions:
In this series, single APT for coiling of narrow-necked aneurysms well prevented both periprocedural ischemic events and DWI positive lesions. In conclusion, this protocol, which determines the mode of APT by neck size, seems easy to use and could be beneficial in prevention of ischemic/hemorrhagic complications and from medico-financial aspect.
Abstract TP93: Increased Contralesional Activation during Reach is Associated with Recovery of Chronic Arm Motor Deficits
Authors: Pundik Svetlana , Litinas Krisanne , McCabe Jessica , Tatsuoka Curtis , Feng I-Jung , Daly Janis J
Published: March 2022

Background:
In chronic stroke, recovery of coordinated reaching is critical to arm function and quality of life. Improvement of motor function can be achieved with intensive rehabilitation even years after stroke, but current methods fall short of restoring normal movement for many stroke survivors. Little is known regarding the change in brain function that is required to improve shoulder/elbow reach function. Therefore, the aim of this study was to characterize the change in brain activity of bilateral motor-sensory brain regions, which may drive recovery of functional reach.

Methods:
22 stroke subjects (>6 months post-stroke) with arm motor deficits were enrolled and treated with intensive arm rehabilitation (5 hours/day, 5 days/week for 12 weeks). Outcome measures were: 1) functional magnetic resonance imaging (fMRI) during a shoulder/elbow reach task (paretic arm), 2) skilled motor function (Arm Motor Assessment Test (AMAT)). fMRI activation (voxel count) was calculated for bilateral sensory-motor control regions. Multiple linear regression analysis was conducted to determine the relationship between the change in brain function and recovery of functional reach. Co-variates included pre-treatment AMAT, age and time-since-stroke.

Results:
Subject characteristics were: age, 56.3 (±12.8years); 41%, female; and 1.8 (±1.1) years post-stroke. AMAT improved from 1636.63 (±668.41) to 1213.67 (±6643.79) seconds (p<.0001). Regression analyses demonstrated that greater improvement of AMAT score was associated with increase in activation in the ipsilesional primary motor(p=.02), and in the contralesional regions as follows: primary motor(p=0.02), primary sensory(p=0.03), secondary sensory(p=0.03), premotor(p=0.009), supplementary motor(p=0.05), thalamus(p=0.02), putamen(p=0.03) and cerebellum( p=0.009).

Conclusions:
In chronic stroke, important gain in functional reach is associated with increased activation, not only in the ipsilesional primary motor region, but also in the contralesional motor-sensory regions, which occurred in response to intensive neurorehabilitation. Arm neurorehabilitation methods should be based on principles that engage this brain plasticity, which may drive recovery of arm function.
Abstract WMP103: Late Adverse Events of Patent Foramen Ovale Closure: A Systematic Review
Authors: Nelson Sarah , Green Amanda , Rhodes John , Thaler David
Published: March 2022

Background:
Optimal secondary stroke prevention for patients with cryptogenic stroke (CS) or transient ischemic attack (TIA) and patent foramen ovale (PFO) is not established. Observational studies imply a benefit for PFO closure over conventional medical management. Data from randomized trials are more equivocal or pending. Most studies report short term follow-up that will miss late adverse events (AEs).

Methods:
A systematic review was conducted of the Manufacturer and User Facility Device Experience (MAUDE) database for all septal closure device reports of late (>30 days) AEs between 1/1/00-9/10/11. Search terms were brand names of closure devices used in PFOs. To exclude patients not treated for a PFO, cases were those for whom 1) the narrative clearly described PFO as the target lesion, or 2) the device was designed only for PFO closure. Data extracted were device type, indication for closure, time from implantation to AE, and explantation. We collected clinical (e.g. stroke) and device-related (e.g. thrombus on device) AEs.

Results:
We reviewed 1250 reports - 50 (4%) met inclusion criteria. Devices were CardioSEAL (n=28), Gore Helex (n=11) and Amplatzer PFO or ASD Occluders (n=11). Clinical AEs were stroke/TIA or systemic embolism (n=20), arrhythmia/palpitations (n=6), pericardial effusion (n=3), visual symptoms (n=3), chest pain (n=2), asymptomatic (n=7), and unknown/other (n=18). Device AEs were thrombus (n=24), residual shunt (n=8), embolization (n=7), erosion (n=3), infection (n=2), fracture (n=1), and unknown/other (n=8). AEs led to device explantation in 28 patients. The range of time between device placement and AE was 30 days to 6 years; 23 reports (46%) were >1 year.

Conclusion:
The most common late clinical AE for device PFO closure was embolization and most common device event was thrombus. Nearly half of reported devices were explanted. These data cannot produce AE incidence rates because the number of implanted devices is unknown. We are also unable to determine the comparative safety of devices. However, the data emphasize that late AEs should be included when calculating the overall risk with the possible benefits of PFO closure.
Abstract WMP104: Effect Of Addition Of Clopidogrel To Aspirin On Stroke Incidence: Meta-analysis Of Randomized Trials
Authors: Palacio Santiago , Hart Robert G , Pearce Lesly A , Anderson David C , Sharma Mukul , Birnbaum Lee A , Benavente Oscar R
Published: March 2022

Introduction:
Current guidelines do not support the use of aspirin and clopidogrel for secondary stroke prevention due to a nonsignificant reduction in stroke and a significant increase in life-threatening bleeding.

Hypothesis:
We assessed the hypothesis that the effect of dual antiplatelet therapy on stroke prevention would be different depending on the trial cohort.

Methods:
We conducted a meta-analysis of published randomized trials comparing the combination of clopidogrel and aspirin versus aspirin alone that reported stroke incidence. Statistical heterogeneity across trials was evaluated using the I2 index and the Chi-square test for heterogeneity.

Results:
Thirteen randomized trials were included with a total of 90,433 participants (mean age 63 years; 63% male) with a mean follow up of 1.0 years and 2011 strokes. Stroke was reduced 19% by dual antiplatelet therapy (OR=0.81; 95% CI 0.74-0.89) with no evidence of heterogeneity of effect across different trial populations (I2 index = 5%, p = 0.4 for heterogeneity). Dual antiplatelet therapy reduced ischemic stroke by 23% (OR=0.77; 95% CI 0.70-0.85). The risk of major bleeding was increased by 40% (OR 1.40, 95% CI 1.26-1.55) by dual antiplatelet therapy; there was a nonsignificant 2% increase in intracerebral hemorrhage (OR=1.12, 95% CI 0.86-1.46).

Conclusions:
Contrary to our hypothesis, this meta-analysis demonstrates a substantial relative risk reduction in stroke by clopidogrel plus aspirin vs. aspirin alone that is consistent across different trial cohorts. Given this findings the strong proscription against the use of clopidogrel plus aspirin for secondary stroke prevention advocated by most current guidelines may warrant reconsideration.