bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP344: Seizure is an Independent Predictor of Poor Outcome in Ischemic Stroke
Authors: Gadpaille Alissa , Boehme Amelia , Shiue Harn , Sisson April , Lyerly Michael , Gropen Toby
Published: July 2021

Background and purpose:
Occasionally, seizures can be an early complication of ischemic stroke. Recent studies have shown that hemorrhagic transformation is a predictive factor for early seizures as a complication of AIS (acute ischemic stroke). Our research looked as early seizures as a complication of AIS (either seizures on presentation in the emergency department or seizures while admitted for acute stroke), correlation with hemorrhagic transformation (HT), and the implication with poor functional discharge outcomes.

Methods:
We evaluated consecutive AIS patients from March 2014-April 2015 admitted to our comprehensive stroke center. The primary endpoint was the modified rankin scale (mRS) on discharge (“poor outcome” defined as a score of 3-6), and association with hemorrhagic transformation (defined as hemorrhagic transformation seen on repeat imaging - either CT or MRI). Seizures were defined as clinical seizures - we did not require EEG data for diagnosis of seizure.

Results:
A total of 773 patients met inclusion criteria with a mean age 64, 49.3% female, and 36.6% black. Of these patients, 29 (3.7%) presented with seizures at onset or as an early complication of stroke while in the hospital. In our population, 15.5% of all AIS patients had HT, and 47.5% of all AIS patients had poor functional outcomes. In our patient population, seizures were not an independent risk factor for HT as a complication of AIS (after adjusting for SBP on presentation, age and NIHSS, OR 0.64, 95% CI: 0.18-2.28, P 0.493). We found that early seizures as a complication of AIS was an independent risk factor for poor functional outcome on discharge (after adjusting for SBP on presentation, age and NIHSS, OR 13.3, 95% CI 2.69-65.9, P 0.0015).

Conclusion:
In our patient population, we did not find that seizure was an independent risk factor for HT as a complication for AIS. We did find that early seizures as a complication of AIS was an independent risk factor for poor functional outcome.
Abstract TP366: National Institutes of Health Stroke Scale (NIHSS) is a Potent Predictor of Outcome in Acute Intracerebral Hemorrhage
Authors: Kazaryan Suzie , Sanossian Nerses , Liebeskind David S , Starkman Sidney , Eckstein Marc , Stratton Samuel , Pratt Franklin D , Gausche-Hill Marianne , Conwit Robin , Hamilton Scott , Saver Jeffrey L ,   FAST-MAG Investigators and Coordinators
Published: July 2021

Background:
Although the NIHSS is a well-validated tool in assessing neurological deficit and predicting long-term outcome in acute cerebral ischemia, its utility in ICH has not been extensively studied. As NIHSS is routinely obtained in cases of stroke prior to imaging, it is often available in ICH patients to potentially assist physicians in triage, prognostication, and risk-adjustment.

Methods:
We analyzed consecutive patients enrolled in the NIH Field Administration of Stroke Therapy-Magnesium (FAST-MAG) phase 3 trial whose final diagnosis was ICH. Trained study nurses performed the NIHSS in the Emergency Department (ED) shortly after arrival and the modified Rankin Scale (mRS) at 90 days. Primary outcomes were disability or death (mRS 3-6) and mortality. Candidate potential predictor variables, including NIHSS, ICH Score, and GCS, those with threshold of p<0.10 were candidate parameters for backward selection logistic regression to determine independent predictors of disability or death and of mortality.

Results:
Among the 384 ICH patients, age was mean 65 (±13); female 34%; race white 78%, black 10%, Asian 10%; Hispanic ethnicity 33%; and history of hypertension 78%. The ED NIHSS and GCS was performed a median 148 minutes (IQR 121-180) after last known well. Initial NIHSS was median 16 (IQR 9-16), GCS 15 (IQR 10-15), and ICH Score 1(IQR 0-2). NIHSS correlated with ICH Score (r=0.780) and GCS (r=0.860). At 90 days, median mRS was 4 (IQR 2-6), disability or death (mRS 3-6) was present in 70%, and mortality occurred in 26%. In predicting disability or death at 90 days, c statistics were: NIHSS 0.81, ICH Score 0.81, and GCS 0.72. NIHSS≥14 showed 72% sensitivity and 75% specificity. For mortality by 90 days, c statistics were: NIHSS 0.78, ICH Score 0.80, and GCS 0.73. NIHSS≥19 had 80% sensitivity and 70% specificity. On multivariate analysis age (OR 1.07, 95%CI 1.04-2.0) and NIHSS (OR 1.18, 95%CI 1.13-1.23) were independent predictors of disability and death.

Conclusions:
The initial NIHSS is a strong predictor of disability and death and good predictor of mortality after intracerebral hemorrhage, performing as well as the ICH Score and better than the GCS. Consideration should be given to routine performance and documentation of the NIHSS in ICH patients.
Abstract TP367: Impacts of Supratentorial Intracerebral Hemorrhage Locations on the Complexity of Heart Rate Variability
Authors: Chen Chih-Hao , Huang Pei-Wen , Tang Sung-Chun , Hsieh Jiann-Shing , Lai Dar-Ming , Wu An-Yu , Jeng Jiann-Shing
Published: July 2021

Introduction:
Acute stroke commonly affects cardiac autonomic responses. Our recent study showed that lower complexity of heart rate variability (HRV), assessed by multiscale entropy (MSE), is associated with worse outcome in acute stroke patients.

Hypothesis:
The study aimed to further investigate the impact of stroke locations on various HRV parameters in patients with non-surgical supratentorial intracerebral hemorrhage (ICH), and their correlations with stroke severity, and outcome.

Methods:
Continuous one-hour ECG signals were obtained from ICH patients within 48 hours after admission and controls. The complexity index was defined as the area under the MSE curve from scale 1 to 20. Stroke severity was assessed by NIHSS. A favorable outcome was defined as modified Rankin scale ≤2 at 3 months after stroke.

Results:
A total of 93 supratentorial ICH patients (male 59.1%, mean age 61.1 years), including basal ganglia (n=40), thalamic (n=35), and lobar ICH (n=18), were recruited during 2012 and 2014. The HRV complexity index was lower in ICH patients than that in controls (26.9 ± 7.4 vs 33.6 ± 3.7, P<0.001). Lobar ICH had significantly lower complexity index than basal ganglia and thalamic ICH (21.6 ± 7.9 vs. 27.9 ± 6.4 & 28.5 ± 7.2, P<0.01, Figure). Complexity index was negatively associated with NIHSS score (= -0.25, P=0.02). Forty patients (43%) had a favorable outcome. Complexity index independently predicted outcome (OR 1.09, 95%CI 1.00 - 1.19, P=0.039), though the effects did not exist in ICH location.

Conclusions:
The HRV complexity was related to stroke severity and function outcome in patients with supratentorial ICH, and lobar ICH had the lowest complexity of HRV.
Abstract TP369: Comparison of Hematoma Volume Estimates in Intracerebral Hemorrhage
Authors: Khan Muhib A , Rodriguez-Srednicki Joshua , Baird Grayson , Elias Roderick , Yan Sandra , Shadi Yaghi Shadi Yaghi , Silver Brian , Collins Scott
Published: July 2021

Background:
Intracerebral hemorrhage (ICH) volumes are frequently used for prognostication and inclusion of patients in clinical trials. There are three commonly used methods for volume estimation: the original ABC/2 method a simplified version (sABC/2), and the planimetric method. We sought to compare the ABC/2 and sABC/2 methods with the planimetric method.

Methods:
We retrospectively reviewed admission CT scans of consecutive ICH patients admitted to a single academic center from July 2012 to April 2013. Only patients with spontaneous ICH were included. We assessed ICH volume on the admission CT. In the ABC/2 method, C is the number of approximate cuts the hemorrhage is seen on (weighted by area as 75%), while in the sABC/2 method, C is the total number of cuts in which the ICH is seen. Planimetric analysis was performed with the Analyze software. Band-Altman plots were generated for both the ABC/2 and sABC/2 methods in comparison to the planimetric method; all units were log transformed.

Results:
135 patients with spontaneous ICH were included in the final analysis. Band-Altman analysis illustrated that both ABC/2 and sABC/2 were concordant with the planimetric method. ABC/2 had more bias than sABC/2 (47% vs 5%, respectively) with no evidence of a linear trend. At a lower volume threshold of 30 mL, ABC/2 was less sensitive but more specific than sABC/2 (sensitivity 77.9% and specificity 98.9% vs sensitivity 93.3% and specificity 91.1%, respectively, p<.0001). Overall, sABC/2 performed better than ABC/2 (c-stat 0.92 vs 0.88, respectively).

Conclusion:
Simplified ABC/2 (sABC/2) method performs better than ABC/2 in differentiating volumes greater than 30 ml. Both ABC/2 and sABC/2 methods accurately measure hematoma volumes in spontaneous ICH patients, in comparison with the planimetric method. These findings may have implications for outcomes prediction and clinical trials inclusion.
Abstract TP380: Change in the Medication Behavior During One Year After Stroke in Patients With Initial Mild Ischemic Stroke
Authors: Kobayashi Akie , Ichihara Takako , Tamura Ayako
Published: July 2021

Background and Purpose:
Patients with stroke often stop medication for the prevention. Medication behavior is mainly composed the medication compliance and understanding of the medication. The purpose of this study was to assess change in the medication behavior during one year after initial stroke, and to identify the correlation between medication compliance and understanding of the medication in patients with mild ischemic stroke.

Methods:
Thirty-one patients with initial mild ischemic stroke were prospectively recruited. Two types of self-reported questionnaires (Medication compliance questionnaires, Understanding of medication questionnaires) were applied at admission (baseline) and 1 year after stroke respectively. Understanding of medication questionnaires contained 4 factors; “motivation”, “capacity”, “understanding” and “drug cost” for the medication. Change in the medication was analyzed by Wilcoxon signed rank test. The correlation between the medication compliance and understanding of medication were analyzed by Spearman’s rank correlation. The p-values<0.05 were considered statistically significant.

Results:
Among the patients who agreed to participate in this study, 71% were males and 29% were females, with the average age of 66.0±8.4. Lacunar was the most common type of stroke among those patients. Their scores of medication compliance at 1 year after stroke were significantly increased (p<0.01) compared to those in the baseline. Their scores of understanding of medication“the drug cost burden” were also significantly increased (p<0.05).At baseline, there was significant correlation between medication compliance and understanding of medication“hassle for taking medicine”(ρ=0.464,p<0.01 ),“simple medication ” (ρ=0.528,p<0.01 ).At 1 year after stroke, there was significant correlation between medication compliance and understanding of medication“hassle for taking medicine” (ρ=0.381,p<0.05).

Conclusions:
These data suggest that the estimation of drug cost and hassle for medication primarily affects the medication compliance. Nurses need to focus on not only the medication compliance but also the motion and cognitive function.
Abstract TP383: Creating Educational Modules for Family Caregivers to Reduce Potentially Preventable Hospitalizations in Stroke Survivors
Authors: Pierce Linda L , Steiner Victoria
Published: July 2021

Background and Issues:
Preventable hospitalization utilization among stroke survivors is common. Although about 1/3 of potentially preventable hospitalizations are attributed to recurrent ischemic stroke, other comorbidities that lead to hospitalization are prevalent and need to be monitored. Timely and appropriate care for community-dwelling stroke survivors is critical. Since family caregivers provide the majority of care in the home, support and education of caregivers is essential to monitoring comorbid conditions.

Purpose:
This project’s aim was to develop brief educational modules on common comorbid conditions (e.g. chronic obstructive pulmonary disease, congestive heart failure, gastroenteritis); have family caregivers and nurse practitioners (NPs) review the content for validity; and then construct 8-10 minute voice-over PowerPoint presentations for each module.

Methods:
Based on evidence from randomized controlled trials, these modules were developed to provide caregivers with needed information to competently care for stroke survivors. Each module was concisely written at an 8th grade reading level and consists of: 1) a short introduction to the topic and key points; 2) what caregivers can do to alleviate the condition, should watch for, and should report to healthcare providers; 3) linked websites for more information and references; and 4) a four-question assessment about what they learned.

Results:
Once developed, these modules were evaluated by family caregiver (n=10) and NP (n=5) reviewers. The caregivers thought that the modules were appropriate in length to facilitate easy reading and understanding. The NPs noted that some content needed to be added, such as additional websites and drug information, but overall believed the modules contained supportive resources for caregivers. To provide an alternate learning modality, audio-presentations that highlight pertinent information for each module were then constructed.

Conclusions:
Registered nurses are well-suited to assess, teach, and support family caregivers. These modules are appropriate for inclusion in web-based or in-person education/support for these caregivers.
Abstract TP395: Objective Identification of Endovascular Candidates
Authors: Peters Lindsey
Published: July 2021

Background:
Patient selection for endovascular treatment in a 325 bed PSC located near two CSCs was based on subjective findings only.

Purpose:
The project scope was to streamline evaluation and treatment of acute ischemic stroke patients. The goals were to improve identification of large vessel strokes, transfer patients who could benefit from endovascular intervention, and minimize unnecessary transfers.

Method:
A flow diagram was created using objective selection criteria and advanced imaging. The criteria consisted of assessment findings, symptom onset time, and renal function to guide vascular imaging. Completed images were electronically sent to the CSC. The algorithm was implemented in June 2015, and the stroke team was educated on the new process. After algorithm implementation, data on utilization, endovascular candidates, and patient outcomes were presented monthly at the multidisciplinary Neuro QI meetings.

Results:
Five months prior to algorithm implementation, 16% (34/213) met the screening criteria for having advanced imaging. Of those, only four were transferred for possible endovascular treatment with two receiving interventions. Patient discharge dispositions were 26% home, 15% rehab, 29% SNF, 26% hospice, and 3% expired. After algorithm implementation, in the initial two months 19% (13/68) met screening criteria for advanced imaging. Of the 13 patients, six transferred for endovascular treatment with two receiving intervention. Three had advanced imaging and avoided unnecessary transfer. The remaining four received only IV tPA, family chose no treatment, or not identified in ED. Patient discharge dispositions were 38% home, 46% rehab, 0% SNF, 8% hospice, and 8% expired.

Conclusions:
By using objective criteria to aid identification of potential large vessel occlusions and incorporating vascular imaging, appropriate transfers are occurring more consistently and patient outcomes are improving. The defined criteria has increased awareness and identification of potential large vessel occlusions. However the implementation of vascular imaging has been slow to put into practice, requiring educational reinforcement. When utilized at the facility, candidates are selected more appropriately for higher levels of care.
Abstract TP414: Support from a Comprehensive Stroke Center Improves Door to tPA Times at Primary Stroke Centers
Authors: Fussner Julie M , Montgomery Kelly , Gumberidze Tinatin , Supan Erin
Published: July 2021

Target Stroke, a national quality improvement initiative of the American Heart Association /American Stroke Association (AHA/ASA) to improve the timeliness of administration of intravenous (IV) tissue plasminogen activator (tPA) to eligible stroke patients, was launched in 2010. The door-to-needle time goal is 60 minutes (mins) from hospital arrival. Earlier administration of IV t-PA is associated with greater functional recovery. Since 2009 University Hospitals Comprehensive Stroke and Cerebrovascular Center (UHCSCC) has meet quarterly with its 7 system community hospitals to share stroke core measure data, review clinical practice guidelines and address new system initiatives for the care of the stroke patient. The purpose of this project is to demonstrate how a comprehensive stroke center (CSC) can assist a primary stroke center (PSC) to improve their door to tPA treatment times. In 2010 to support the primary stroke centers, the UHCSCC developed standardized stroke education for nurses including an online course for tPA. In 2014 an additional online interactive module was created to assist nurses in programing the Alaris IV pump to improve their speed. In 2013 the quarterly system meetings started to include door to CT and door to tPA data with discussions about best practices and challenges. The AHA Target Stroke campaign recommendations and evidenced-based strategies were reviewed and a gap analysis at each hospital was completed to identify opportunities. Throughout 2012-2013 the stroke coordinator at UHCSCC led monthly conference calls with the community stroke coordinators. Since 2014 the stroke operations manager visits each community hospital monthly to work with the stroke coordinator and their teams reviewing TPA cases. Finally, a formal feedback took was developed and is sent to the PSC to provide patient outcomes and opportunities on all TPA cases that are transferred to the CSC. The AHA Get With The Guidelines stroke registry is used to monitor compliance. In 2012 the University Hospitals Health System average door to tPA in 60 mins was only 41%. January - June 2015, the system average has improved 86%. Community primary stroke centers benefit from the comprehensive stroke center interventions and support to improve door to tPA in 60 mins.
Abstract TP419: Shared Medical Appointments: Supporting Stroke Care Transitions Through Improved Knowledge and Peer Support
Authors: Burns Kathleen , Theodore Karen S
Published: July 2021

Background:
Stroke patients have complex needs and are at high risk for complications, making transitional care critical to achieving improved outcomes. Although shared medical appointments (SMAs) are known to improve outcomes for other patient populations, evidence supporting SMA benefit for stroke patient transition from hospital to home is lacking. This study’s purpose was to examine feasibility of participation, patient satisfaction and understanding of key stroke topics following a transitional stroke SMA.

Methods:
Inclusion criteria for this study included: age 18 years or older, hospitalized for stroke/TIA, and planned discharge to home. Individuals with deficits impairing group participation were excluded. Eligible patients were educated on and invited to attend a SMA occurring 1-2weeks after hospital discharge. The SMA included a private exam and interactive group session to address key stroke topics: 1) medication compliance 2) individual risk factors, 3) secondary prevention, 4) signs of stroke and 5) actions for signs of stroke. Following the SMA, participants completed a two-part survey seeking a) a yes/no response to assess increased understanding of stroke topics, and b) level of agreement on satisfaction with the SMA format. Responses were analyzed using descriptive statistics.

Results:
While 15 patients agreed to participate prior to discharge, only eight attended the SMA. Attendees were primarily male (75%) with an ischemic stroke diagnosis (63%). The majority who did not attend were female (71%) and without family present during in-hospital education and invitation (86%). Age, stroke severity and stroke risk factors for both groups were otherwise similar. All participants reported an increased understanding of all stroke topics and 95% were satisfied with the SMA.

Conclusion:
Findings support use of SMAs for stroke patients transitioning from hospital to home. Reinforcing key stroke topics in a peer supported environment may increase understanding and compliance, leading to improved outcomes. Additional research is warranted to explore barriers to SMA participation.
Abstract TP434: The Effect of Therapeutic Modalities on Outcomes in Patients With Subarachnoid Hemorrhage: a Nationwide Study Using the Japanese Diagnosis Procedure Combination Database From The J-aspect Study
Authors: Kurogi Ryota , Kada Akiko , Nishimura Kunihiro , Kamitani Satoru , Nishimura Ataru , Sayama Tetsuro , Nakagawara Jyoji , Ogasawara Kuniaki , Ono Junichi , Shiokawa Yoshiaki , Aruga Toru , Miyachi Shigeru , Toyoda Kazunori , Matsuda Shinya , Yoshimura Shinichi , Okuchi Kazuo , Nakamura Fumiaki , Iihara Koji ,   J-ASPECT investigators
Published: July 2021

Background and Purpose:
The effects of the clipping or coiling treatment on patients with subarachnoid hemorrhage (SAH) remain elusive. We performed a nationwide study to compare the effects of clipping with those of coiling in patients with SAH by using the Japanese Diagnosis Procedure Combination (DPC) database.

Materials and methods:
We analyzed data obtained from patients who were hospitalized for SAH in 427 certified training institutions of the Japan Neurosurgical Society between April 2012 and March 2013. Outcomes regarding in-hospital mortality, modified Rankin Scale (mRS) scores, cerebral infarction, and complications were compared between clipping and coiling groups using mixed model analysis and propensity score matching analysis. In addition, we conducted a questionnaire-based survey regarding comprehensive stroke center (CSC) capabilities. The questionnaire elicited data regarding the availability of personnel, diagnostic techniques, specific expertise, infrastructure, and educational components recommended for CSCs in 749 professional training institutions on February 2011.

Results:
Data obtained from a total of 5214 patients with SAH (3624 clipping, 1590 coiling) were analyzed. Mixed model analysis (OR=1.30, P=0.013) and propensity score matching analysis (OR=1.35, P=0.022) revealed that the in-hospital mortality was significantly higher in the coiling group, while both analyses revealed that the discharge mRS was not significantly different between groups. Clipping of intracranial aneurysms (IAs) and operating rooms staffed 24/7 were available in 91.5% and 60.4% of 749 hospitals, respectively. Coiling of IAs and interventional services coverage 24/7 were available in 48.1% and 37.3% of 749 hospitals, respectively.

Conclusions:
This study demonstrated that clipping is superior to coiling for SAH patients. In Japan, the number of hospitals where coiling is available is still considerably lower than the number of hospitals where of clipping is available. The differences among hospitals may be associated with the increased in-hospital mortality in the patients undergoing coiling. This nationwide database study can complement the findings of prospective clinical trials, and reflect real-world practice.
Abstract TP445: Angiotensin Receptor Type 1 Deficiency Attenuates Brain Damage and Improves Outcome After Experimental Traumatic Brain Injury
Authors: Kim Jong Youl , Kim Nuri , Johnson Meshell , Yenari Midoir A.
Published: July 2021

Inflammation which accompanies traumatic brain injury (TBI) can exacerbate neurological deficits. Thus, anti-inflammatory treatments have the potential to improve outcome. Angiotensin II receptor type 1 (ART1) mediates vasoconstriction, and its inhibition has been widely used to treat hypertension. However, recent work has suggested that it may also modulate apoptosis, and neuroinflammation. Thus, treatment with already available ART1 blockers may have additional neuroprotective value. We explore the contribution of ART1 to neuroprotection and brain hemorrhage in a model of TBI. Male, wildtype (Wt) and ART1 knockout (Ko) mice were subjected to TBI using controlled cortical impact (CCI). This model leads to reproducible traumatic brain injury with disruption of motor function and hemorrhage into the area of injury. Sensorimotor function (adhesive removal & elevated body swing tests), brain hemorrhage and lesion size were assessed at 3, 7 and 14 days. To explore the clinical relevance of ART1 in brain injury, we also gave Wt mice an ATR1 inhibitor (candesartan, 0.1mg/kg IP). We found that ATR1 deficient mice were protected from CCI as evidenced by decreased lesion and hemorrhage volumes (decreases of ∼40% in lesion size amongst Ko mice, n=6/group, p<0.05), improved neurobehavioral outcomes (n=6/group, p<0.05) and fewer activated microglia in Ko mice (p<0.05). This was also associated with decreased cytokine expression relative to Wt. Candesartan similarly protected against brain injury and improved neurological outcome out to 14 days post CCI (n=6/group, p<0.05). These data are consistent with the notion that ART1 contributes negatively to traumatic brain injury, and its inhibition or deficiency leads to improved outcomes and decreased immune responses. Considering the clinical availability of ART1 inhibitors, this approach may be a promising novel therapeutic target against TBI and related conditions including stroke.
Abstract TP59: Rapid MR in Suspected Acute Stroke: Identifying Mimics That Can Avoid Admission
Authors: Bykowski Julie , Gaines Nathan , Meyer Brett , Meyer Dawn , Hemmen Thomas , Bradley William G , Modir Royya
Published: July 2021

Introduction:
Diffusion weighted MR imaging (DWI) is the most accurate method to confirm or exclude acute ischemic stroke, however due to logistics is not widely used in the emergent setting. While many patients with stroke symptoms will get an MRI during their hospitalization, it may occur only after hours of care in the ER or after admission.

Hypothesis:
Providing emergent MR imaging in Stroke Code patients avoids unnecessary admission and associated costs for work-up of stroke mimics which otherwise would not be rapidly identified.

Methods:
IRB-approved retrospective review of the first year of expedited acute stroke MR imaging availability at a TJC Comprehensive Stroke Center. Imaging included immediate non-contrast head CT on arrival with CT Angiography at discretion of Stroke Code Leader. Emergent MR was then performed in patients without MRI contraindications who had unclear diagnosis, or to clarify extent of infarct. Demographic, clinical and imaging data were analyzed with time from triage to imaging, tPA decision, and discharge.

Results:
MRI was performed prospectively in 68/456 patients presenting with possible acute stroke symptoms from 7/1/2014-7/1/2015 (44 male, 26 female, age 60+/-15 years). Symptom onset was within 3 hours in 34 (49%), 3-6 hours in 12 (17%) and >6 hours or awoke with symptoms in 22 (31%); NIHSS of 4 or less in 40 (59%). Median time from arrival to completion of non-contrast head CT was 16 minutes; median time from CT imaging to completion of DWI was 39 minutes. Twenty-nine patients were discharged directly from the ER after MRI, with median ER stay of 5 hours, 15 minutes.

Conclusions:
Through multi-departmental collaboration, expediting MR imaging in the setting of acute stroke evaluation can avoid unnecessarily prolonged ER observation and admission in patients with stroke mimics.
Abstract TP64: Negative-FLAIR Vascular Hyperintensities Serves as a Marker of Chronic Major Arterial Occlusion in Acute Stroke
Authors: Aoki Junya , Suzuki Kentaro , Sakamoto Yuki , Abe Arata , Suda Satoshi , Okubo Seiji , Kimura Kazumi
Published: July 2021

Introduction:
Because acute fluid-attenuated inversion recovery vascular hyperintensities (FVH) represent disordered blood flow, FVH has been considered as a marker of major arterial occlusions. Contrary, the role of absence of FVH (negative-FVH) is unknown.

Hypothesis:
We hypothesized that negative-FVH may indicate chronic occlusion. Thus, we investigated the clinical characteristics and neuroimaging findings in patients with negative-FVH and major arterial occlusion.

Methods:
Consecutive acute stroke patients within 24 hours of onset and major arterial occlusion on magnetic resonance angiography (MRA) were studied. All patients were examined using serial angiography to evaluate the presence of recanalization. Patients were classified into two groups (NF: group without FVH, F: group with FVH).

Results:
Seventy-two patients (49 [68%] males, 76 [66-83] years) were enrolled. Thirty-six (50%) patients were treated with acute recanalization therapy, including the intravenous thrombolysis or endovascular therapy. On admission, 10 patients were NF group and 62 were F group. Initial National Institutes of Health Stroke Scale (NIHSS) score was 4 (2-8) in NF group and 10 (4-21) in F group (p=0.012). The rate of internal carotid artery occlusion was similar between NF and F group (20% vs. 29%, p=0.716). Serial angiography studies revealed that recanalization was achieved in only 1 (10%) of the 10 patients with NF group and 49 (79%) of the 62 patients with F group during hospitalization (p<0.001). When all patients divided into 2 groups based on the presence or absence of recanalization, patients with recanalization were younger (p=0.023), had higher NIHSS (p=0.008), earlier admission (p=0.014), higher prevalence of atrial fibrillation (p=0.010), and frequently treated with acute recanalization therapy (p=0.040). When multivariate regression analysis was conducted, that Negative-FVH (odds ratio 0.061, 95% CI 0.06-0.620, p=0.018) was a negative independent factor associated with recanalization during hospitalization.

Conclusions:
Negative-FVH was independently associated with no recanalization during hospitalization. Negative-FLAIR may present not acute occlusion but chronic occlusion.
Abstract TP72: The PRISMS Trial: Baseline Characteristics of the First 100 Subjects
Authors: Khatri Pooja , Devlin Thomas , Sapkota Biggya , Sethi Pramod , Mejilla Jennifer , Lopez J I , Jauch Edward C , Broderick Joseph , Chatterjee Anjan , Levine Steven , Romano Jose G , Saver Jeffrey I , Yeatts Sharon , Mu Yunming , Tayama Darren ,   the PRISMS Collaborators
Published: July 2021

Introduction:
Ischemic stroke patients with mild deficits were largely excluded from pivotal trials of IV rt-PA. The balance of benefit versus risk of intravenous thrombolysis for this large, understudied patient cohort is uncertain. The PRISMS trial is underway to test the benefit of IV rt-PA for treatment of mild stroke.

Objective:
To characterize baseline features of the first 100 patients enrolled in this prospective cohort of exclusively mild stroke.

Methods:
The PRISMS trial is a Phase 3b, double-blind, 75-center, 948-subject study evaluating IV rt-PA administered within three hours of mild stroke onset to improve 90-day functional outcome (modified Rankin Scale 0 or 1). Mild stroke is defined as NIHSS ≤5 and not “clearly disabling” (i.e., inability to return to work or perform basic activities of daily living based on current deficits). Patients are randomized 1:1 to IV rt-PA 0.9 mg/kg with aspirin placebo or IV rt-PA placebo with aspirin 325 mg. Here we describe baseline characteristics, including clinical presentations by NIHSS item, of the first 100 enrolled patients. The study team remains fully blinded to patient treatment assignment and outcomes.

Results:
The 100th subject was enrolled on June 15, 2015. Baseline characteristics are presented in the Table. Median NIHSS was 2 (IQR 1-3). Clinical presentations of each patient by abnormal NIHSS items are shown in the Figure. Dysarthria, facial palsy, and sensory loss were the most common deficits.

Conclusions:
This initial 100-patient PRISMS cohort is consistent with expectations. Upon completion, the PRISMS trial will determine the benefit of IV rt-PA for mild stroke.
Abstract TP75: Safety and Outcome of Thrombolysis in Acute Stroke with Prolonged Onset-to-Treatment Times and Low National Institute of Health Stroke Scale Scores. Report on Experience in China, First 1000 Patients of 3300 Treated
Authors: Zhang Pei-Lan , Wang Jin-Huan , Wang Yu-Xin , Chen Yan , Zhang Chen-Hao , Li Chen-Hua , Dong Zhong , Liang Jing , Wang Zuo , Oliverio Patrick J , Greenberg Edward D , Vyas Nilesh , Eberly Lewis B , Cochran John W
Published: July 2021

Introduction:
Stroke in China is the leading cause of death. We report on a collaboration between a large metropolitan hospital in China, Tianjin Huanhu Hospital, and Inova Fairfax and Inova Alexandria Stroke Programs presenting data on the first 1000 (of more than 3300 treated since 2012) patients treated with IV-rtPA. The safety and efficacy of treatment with rtPA between 4.5-6 hours after onset is unclear. Similarly there is little data on outcome of patients treated with rtPA with normal or low NIHSS.

Methods:
Patients were treated with thrombolysis between late 2012 and fall of 2014. Patients had MRI scans at 24 hours. Patients had NIHSS scores before and after treatment, and modified Rankin Scores (mRS) at 90 days after treatment.

Results:
See Chart.

Conclusions:

1) IV-rtPA can be given safely between 4.5-6 hours without significant risk of sICH and worsening outcomes.

2) Higher NIHSS before thrombolysis was correlated with poorer outcomes.

3) There was no significant correlation between onset to treatment time up to 6 hours and outcome.

4) Outcome was excellent (mRS 0-1) in 72% treated 0-3 hours, 74% 3-4.5 hours and remarkably 85% 4.5-6 hours.

The data set includes many patients who were asymptomatic or nearly so prior to treatment. This will need to be more fully evaluated in the remainder (2300) of this cohort of more than 3300 treated patients.

Comment:
This cohort represents one of the largest series of acute stroke patients treated with IV-rtPA > 4.5 hours after onset. It also reveals outcome of treatment in patients with low NIHSS treated at various intervals after last know well.
Abstract TP85: Impact of Periodontal Disease and -Bacteria on Intracranial Aneurysms
Authors: Yoshioka Shotaro
Published: July 2021

Introduction:
Periodontal Gram-negative bacteria and their products can initiate inflammatory responses in periodontal tissues with systemic consequences. They are associated with the pathogenesis of atherosclerosis and ischemic stroke. Local inflammation and oxidative stress play a crucial role in the pathophysiology of intracranial aneurysms (IAs). Under the hypothesis that the severity of periodontal disease is associated with the formation and rupture of IAs we assessed which periodontal pathogens contribute to the pathogenesis of IAs.

Methods:
We enrolled patients with ruptured- (n=5, age 60±11.9) and unruptured IAs (n=13, age 67±6.1) and controls without IAs (n=7, age 58±8.5); their prior informed consent was obtained. The severity of periodontitis was recorded using the community periodontal index (CPI) of the Treatment Needs code. Subgingival plaques (n=23) were evaluated with the quantitative real-time PCR assay to check for the Gram-negative bacteria Aggregatibacter actinomycetemcomitans (Aa), Fusobacterium nucleatum, Treponema denticola, Prevotella intermedia (Pi), Tannerella forsythia, and Porphyromonas gingivalis (Pg). Plasma IgG titers of antibody against Pg, Pi, Aa, and Eikenella corrodens were evaluated by ELISA.

Results:
The CPI was significantly higher in patients with IAs than the controls (2.7 vs 1.9, p<0.05) and their DNA level of subgingival plaques and their plasma IgG titers of Pg were also higher. Periodontal disease was more severe and the plasma IgG titers of Pg were higher in patients with ruptured- than unruptured IAs, suggesting that Pg is associated not only with the formation but also the rupture of IAs.

Conclusions:
We present evidence that severe periodontal disease and Pg infection may be involved in the pathophysiology of IAs. The management of periodontal diseases may help to prevent the formation and rupture of IAs.
Abstract TP9: Safety of Endovascular Treatment in Acute Stroke Patients Taking Oral Anticoagulants
Authors: Uphaus Timo , Singer Oliver C , Berkefeld Joachim , Nolte Christian H , Bohner Georg , Niederkorn Kurt , Deutschmann Hannes , Haring Hans-Peter , Trenkler Johannes , Neumann-Haefelin Tobias , Hofmann Erich , Stoll Anett , Bormann Albrecht , Bussmeyer Matthias , Mpotsaris Anastasios , Reich Arno , Wiesmann Martin , Petzold Gabor C , Urbach Horst , Jander Sebastian , Turowski Bernd , Weimar Christian , Schlamann Marc U , Groeschel Klaus , Boor Stephan , Groeschel Sonja
Published: July 2021

Introduction:
The endovascular treatment (EVT) of cerebral ischemia in the case of large vessel occlusion has been established over recent years. Randomized trials showed a positive impact on the clinical outcome of endovascular treatment in addition to thrombolysis with respect to clinical outcome and safety, so that this therapeutic option will be implemented in future guidelines. The role of EVT in patients treated with oral anticoagulants remains uncertain.

Hypothesis:
We assessed the hypothesis that application of EVT is safe with regard to the occurrence of intracranial bleeding and clinical outcome in patients taking anticoagulants.

Methods:
The ENDOSTROKE-Registry is a commercially independent, prospective observational study in 12 stroke centers in Germany and Austria launched in January 2011. An online tool served for data acquisition of pre-specified variables concerning endovascular stroke therapy.

Results:
Data from 815 patients (median age 70, 57% male) undergoing EVT and known anticoagulation status were analyzed. A total of 85 (median age 76, 52% male) patients (10.4%) took oral anticoagulants prior to EVT. Anticoagulation status as measured with INR was 2.0-3.0 in 24 patients (29%), <2.0 in 52 patients (63%) and above 3.0 in 7 patients (8%) of 83 patients with valid INR data prior to EVT. Patients taking anticoagulants were significantly older (median age 76 vs. 69, p < 0.001). Comparing those patients taking anticoagulants and those not, there were no differences concerning NIHSS at admission (with anticoagulants Median-NIHSS 17 vs. without Median-NIHSS 15, p = 0.492, Mann Whitney Test) and the rate of intracranial hemorrhage after intervention (with anticoagulants 11.8% vs. without 12.2%, p = 0.538). After adjustment for age and NIHSS at admission there were no significant differences between the two groups with regard to good clinical outcome, as measured with the modified ranking scale (mRS, 90d-mRS 0-2, 39.2% of patients not receiving anticoagulants; 25.9% of those receiving anticoagulants).

Conclusion:
The application of endovascular treatment in patients taking oral anticoagulants is safe and should be considered in acute stroke treatment as an important alternative to contraindicated intravenous thrombolysis.
Abstract TP91: Vessel Wall Imaging Demonstrates Aneurysm Wall Enhancement in Unruptured Posterior Communicating Artery Aneurysms With Oculomotor Nerve Palsy
Authors: Liang Feng , Qi Tiewei , Li Fanying , Ou Siqi , Chien Aichi
Published: July 2021

Background:
In ruptured aneurysms, vessel wall imaging (VWI) shows aneurysm wall enhancement, which may be caused by inflammation of the aneurysm wall. However, whether this inflammation is the cause or the result of aneurysm rupture remains unknown. In this study, we analyzed high-resolution VWI on posterior communicating artery (PComA) aneurysms, seeking to better understand aneurysm wall inflammation.

Hypothesis:
Oculomotor nerve palsy (ONP) is a warning sign of PComA aneurysm rupture. ONP results from compression of the oculomotor nerve and indicates aneurysm enlargement. Thus, PComA aneurysms with ONP are about to rupture, which makes them perfect cases to research aneurysm wall inflammation. If the inflammation of the aneurysm wall is the cause of aneurysm rupture, VWI may capture images of aneurysm wall enhancement before it ruptures.

Methods:
PComA aneurysm patients with ONP were examined using a Verio 3.0T scanner with a 12-channel head coil (Siemens Healthcare, Erlangen, Germany). Time-of-flight MRI angiography was performed to localize the aneurysm site. Then, a high-resolution T1-weighted black blood vessel wall sequence was obtained before and after intravenous administration of gadolinium. Each sequence was performed in the axial planes. Additional coronal planes or other planes were obtained if necessary. Patients with ruptured PComA aneurysms were also examined as a positive control, and patients with unruptured PComA aneurysms without ONP were examined as a negative control.

Results:
Ten patients with PComA aneurysm were examined. VWI of 3 patients with ONP showed aneurysm wall enhancement. Of these 3 patients, 2 were with post-orbital pain, and VWI showed complete enhancement of the aneurysm wall. VWI showed partial enhancement of the aneurysm wall in the other one patient without post-orbital pain. In the positive control group, complete wall enhancement was seen in all 3 ruptured PComA aneurysms (2 with ONP, 1 without ONP). In the negative control group of 4 cases, no aneurysm wall enhancement was seen.

Conclusion:
VWI demonstrated aneurysm wall enhancement in PComA aneurysms with ONP, which indicates that wall inflammation may occur before aneurysm rupture.
Abstract TP96: Functional Recovery and White Matter Repair After Exosomes Administration in Different Experimental Animal Models of Stroke
Authors: Otero Ortega Laura , Gutiérrez Fernández María , Rodríguez Frutos Berta , Ramos Cejudo Jaime , Lorenzo Llorente Irene , Fuentes Blanca , Medina Esperanza , Carmichael S. Thomas , Díez Tejedor Exuperio
Published: July 2021

Introduction:
Extracellular vesicles such as exosomes has opened a new field of research. Exosomes are able to transfer DNAs, mRNAs, microRNAs, non-coding RNAs, proteins, trophic factors and lipids associated with brain plasticity enhancement after stroke.

Aim:
To investigate white matter repair after exosomes administration in two experimental models of subcortical stroke: ischemic and hemorrhage.

Material/Methods:
Subcortical ischemic stroke was induced by Endothelin-1 and Collagenase IV was used to induce subcortical hemorrhagic stroke into striatum. Intravenous exosomes or saline only were administrated at 24h after cerebral infarct as treatment. Exosomes were isolated from culture of adipose mesenchymal stem cell and they were characterized by Nanoshight, Electronic microscope, Western blot and Immunofluorescence. Proteins contained into exosomes were analyzed by Orbitrab. We analyzed functional recovery by Rotarod, beam walking and Rogers tests. Lesion volume and tract connectivity were studied by magnetic resonance image. Anterograde and retrograde tracers were used to analyze axonal sprouting. Myelin formation was analyzed by cryomielin.

Results:
Proteomics analysis of exosomes identified more than 1400 proteins, many of them involved in intercellular communication. DiI labeled-Exosomes were detected in brain and peripheral organs (liver, lung and spleen). After 28 days, treated groups showed smaller functional deficit compared to control groups in both hemorrhagic and ischemic models. Moreover, treated group showed an increase in tract connectivity at 7 and 28 days compared to control groups. Also, animals which received exosomes showed an increase axonal sprouting and myelin formation at 28 days after stroke in both hemorrhagic and ischemic stroke. The treated groups also showed higher levels of white matter-associated markers in the injured area than the control groups.

Conclusion:
White matter integrity in different subcortical strokes is in part restored by exosomes treatment, probably mediated by repair molecular factors implicated in axonal sprouting, remyelination and oligodendrogenesis. These findings are associated with improved functional recovery in both kinds of strokes.
Abstract WMP105: Quantitative Assessment of Cerebrovascular Reactivity in Paediatric Moyamoya
Authors: Dlamini Nomazulu , Armstrong Derek , Dirks Peter , Moharir Mahendranath , Askalan Rand , Kirkham Fenella , deVeber Gabrielle , Logan William
Published: July 2021

Background:
Moyamoya disease is a progressive steno-occlusive arteriopathy that causes recurrent ischaemic events and neurological decline. Cerebrovascular reactivity (CVR) is an indicator of tissue level perfusion impairment and stroke risk. Quantitative BOLD MRI using carbon dioxide as a vasoactive stimulus has been validated in adults and region of CVR abnormality shown to be concordant with angiographic region of abnormality. However the evidence in paediatric literature remains scarce and mainly refers to the use of targeted-controlled delivery of CO2 which has limited utility in the paediatric population.

Objective:
To examine whether hypercapnic challenge BOLD CVR using endogenous CO2 in the awake (breath-hold [BH]) and sleep (general anaesthetic [GA]) state in children is reliable and repeatable. We also sought to explore whether regional abnormalities of CVR using these techniques were concordant with angiographic regions of abnormality.

Method:
Consecutive children with angiographic confirmation of MM had BH or GA CVR studies. All repeat studies - conducted on the same day in the same MRI session - were assessed for reliability and repeatability of qualitative measures of CVR.

Results:
Thirty seven children (16 male; median age MM diagnosis 8.61 years, range 0.6 - 16.7; median age at CVR 10.7 years, range 1.08-17.7) had CVR studies. Children who had a CVR study under GA were significantly younger at diagnosis of MM (mean age 7.4 years, range .67-16.58) compared to those studied using BH (mean age 10.47 years, range .83-15.58). CVR region of abnormality was concordant with region of angiographic abnormality. Twenty nine had repeat studies (14 GA, 15 BH). Intraclass correlation was fair (0.783, 95% confidence interval .534-.899) to excellent (.910, 95% confidence interval .577-.908) and agreement between repeat measures good.

Conclusion:
Qualitative measures of CVR using general anaesthetic and breath-hold techniques are reliable, repeatable and interpretable for use in clinical practice. However standardization of protocols would allow more reliable application of these tools for assessment of ischaemic risk in childhood cerebrovascular disease.