bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP286: The Use Of Benzodiazepines In Patients With Acute Ischemic Stroke
Authors: Alves Monique B , Pereira Andrea M , Nogueira Paula S , Miranda Renata C , Coelho Fernando M , Silva Gisele S
Published: July 2021

Background and Purpose:
The effect of benzodiazepines in patients with acute ischemic stroke is controversial. In experimental studies, benzodiazepines can reduce neuronal damage and improve neurological outcome after focal cerebral ischemia. Conversely, patients whose initial stroke syndrome had substantially improved clinically can show transient reemergence of their initial focal syndrome after benzodiazepine use. We assessed the hypothesis that benzodiazepine use can have a negative impact upon functional outcome and increase the risks of complication in patients with acute ischemic stroke.

Patients and methods:
We performed a post-hoc analysis of prospectively collected data of consecutive patients admitted to a Brazilian tertiary hospital with acute ischemic stroke from February 2009 to April 2012. The use of benzodiazepines including drugs, doses, and frequencies were obtained from the electronic pharmacy records. A benzodiazepine equivalence table was used to calculate the equivalent doses to 10mg of diazepam.

Results:
We evaluated 424 patients with acute ischemic stroke (mean age: 72.5 +/-15.2 yo, 58.7% males). Of those, 102 patients (24.1%) received at least one dose of benzodiazepine during hospital admission. The median cumulative dose of benzodiazepine used was 4 [2,11] (1 equivalent=10mg of diazepam). Patients who received benzodiazepines were similar to those who did not receive in age, gender and stroke severity measured by the NIHSS. The cumulative dose of benzodiazepine was an independent predictor of in-hospital pneumonia (OR= 1.03, 95% CI 1.02-1.06, p=0.03 for each unit of diazepam equivalent (1 equivalent=10mg of diazepam) when adjusted for age, gender, stroke severity (NIHSS) and smoking status. The modified Rankin scale at discharge was not different in patients who received or not benzodiazepines.

Conclusions:
In conclusion, exposure to benzodiazepine is associated with in-hospital pneumonia in patients with acute ischemic stroke. Alternative approaches to treat anxiety, insomnia and agitation in such patients are warranted.
Abstract TP292: Thrombin-induced Cerebral Hemorrhage: Role Of Protease-activated Receptor-1
Authors: Cheng Yingying , Xi Guohua , Keep Richard F , Feng Jiachun , Hua Ya
Published: July 2021

Background and Purpose:
Thrombin causes blood-brain barrier disruption and this study examined whether thrombin can cause brain hemorrhage through protease-activated receptor-1 (PAR-1).

Methods:
Male wild type and PAR-1 knockout mice had an intracerebral injection of thrombin or saline. Mice then underwent serial T2 magnetic resonance imaging and were euthanized for brain hemoglobin, iron and interleukin-1β measurements.

Results:
Mortality after intracerebral thrombin injection was not significantly different in WT (11%) and PAR-1 KO mice (9%). Thrombin but not saline resulted in massive T2 lesions in WT mice. MRI studies showed that the T2 lesions induced by thrombin were smaller in PAR-1 KO mice compared to those in WT mice (p<0.05). An examination of brain sections after thrombin injection showed areas of hemorrhage in the ipsilateral hemisphere. This hemorrhage was examined using Perls’ staining for iron and by measuring brain hemoglobin. Perls’ staining showed that thrombin caused significant brain hemorrhage in WT mice and that hemorrhage peaked at day-3. Perls’ positive cells were less in PAR-1 KO mice (p<0.05). Brain hemoglobin content was measured at day-3 after thrombin injection to assess hemorrhage volume. Thrombin-induced marked hemoglobin accumulation in the ipsilateral hemisphere in WT-type mice and this was markedly reduced in PAR-1 KO mice (hemoglobin: 327±134 vs. 913±221 μg in the WT mice, p<0.01). The role of PAR-1 in brain IL-1β levels after thrombin stimulation was also examined. The time course of brain IL-1β levels following thrombin injection in WT mice was examined. Brain IL-1β levels peaked at 12 hours and returned to low levels after 24 hours. We then measured brain IL-1β levels in WT and PAR-1 KO mice and found that thrombin-induced upregulation of brain IL-1β was basically absent in PAR-1 KO mice (p<0.01).

Conclusions:
Thrombin increases interleukin-1β levels and induces intracerebral hemorrhage through PAR-1 activation.
Abstract TP310: Subarachnoid Extension of Intracerebral Hemorrhage and Perihematomal Ischemic Compression Are Related, Harmful Processes
Authors: Maas Matthew B , Nemeth Alexander J , Rosenberg Neil F , Kosteva Adam R , Guth James C , Liotta Eric M , Prabhakaran Shyam K , Naidech Andrew M
Published: July 2021

Background:
Decreased diffusion is associated with poor outcomes in primary intracerebral hemorrhage (ICH), although the mechanism of that phenomenon is uncertain. Two distinct types of decreased diffusion have been observed, perihematomal ischemia (PHI) and distant areas of ischemia. Extension of hemorrhage into the subarachnoid (SAH) and intraventricular (IVH) compartments may be indicators of high perihematomal pressures and diminished brain parenchyma compliance. The objective of this study is to evaluate for an association between PHI and poor outcomes, and to evaluate whether PHI is associated with SAH and IVH as markers of injurious perihematomal pressure.

Methods:
Patients with primary ICH were enrolled into a prospective registry between December 2006 and July 2012. Patients were managed, and serial neuroimaging obtained, per a structured protocol. MRI was performed on all salvageable patients when possible. SAH, IVH and PHI were identified on imaging, along with ICH volumes, by expert reviewers blinded to outcomes. An ordinal regression model was used to evaluate for an association between PHI and modified Rankin Scale (mRS) at 28 days, adjusted for ICH Score. A binary logistic regression models was developed to identify an association between PHI and other potential predictors of malignant peri-hematomal pressures: SAH, IVH, initial hematoma volume, and supra- versus infratentorial location.

Results:
94 patients were studied. 27 (28.7%) had SAH and 44 (46.8%) had IVH. PHI was associated with mRS at 28 days (odds ratio 2.88 [95% CI 1.23-6.75]), independent of ICH Score. PHI was associated with SAH (3.74 [1.25-11.21]), whereas no significant association was found with IVH, hematoma volume or location.

Conclusions:
PHI is independently associated with poor outcomes in primary ICH. PHI is associated with SAH, but not hemorrhage volume, location or decompression into the ventricular system. These findings suggest that PHI and subarachnoid hemorrhage extension are associated, unique markers for injurious perihematomal pressure.
Abstract TP319: Randomized Pilot Trial of Usual Care versus LIFE (Lifestyle Intervention using Functional Exercise to Reduce Falls) in Those with Mild Stroke
Authors: Korner-Bitensky Nicol , Clemson Lindy
Published: July 2021

Purpose/Objectives:
Falls are a health concern post-stroke with 30% of those who return home reporting loss of balance in the first month. Individuals with “mild” stroke are especially vulnerable as they are often discharged home quickly without exposure to balance improvement/falls prevention programs. It is important to identify effective interventions that can be offered in the naturalistic home setting. We assessed, for individuals with a first mild stroke, the impact of a home-based falls prevention program - LiFE (Lifestyle Intervention using Functional Exercise) vs STRUCTURED vs CONTROL intervention on rate of falls (self-report) and secondary outcomes including static and dynamic balance, etc.. This pilot RCT data is from a larger RCT (n=317) comparing these three interventions in older individuals (>70) at high risk for falls.

Methods:
Three group parallel RCT with all interventions taught at home. The LiFE group received teaching on principles of balance and strength training; applied while the individual performed common daily activities. STRUCTURED received balance and lower limb strength exercises while CONTROLS received gentle exercise. Blind assessments of the main outcomes of interest were performed before randomisation, after intervention (six months) and at one year (follow-up).

Results:
Of 39 participants 14 were randomized to LiFE; 14 to STRUCTURED; and, 11 to CONTROL. There were fewer fallers in the group receiving LiFE (n=6/14) vs the other two groups: (RR = 0.67; LiFE vs CONTROL); but not between STRUCTURED vs CONTROL (RR= 1.01). However, when number of falls was analyzed, LiFE had the greatest number - 26 vs 13 vs 20 - STRUCTURED and CONTROL respectively. Further data exploration revealed that LiFE was the only group with participants (n=3) who had >5 falls.

Conclusion:
Although LiFE was associated with a reduction in fallers; there was a disconcertingly higher rate of frequent falls in a few participants. These findings, while on a small sample, suggest that LiFE, which requires judgment and problem solving, may be suitable for a specified sub-set. The LiFE intervention “how to” and patient selection criteria will be discussed during the presentation.
Abstract TP362: A Team Approach for Improving Door to needle Time for IV t-PA in Acute Stroke
Authors: Steiner Nili E , Wolber Nicole , Robertson Betty , Rosenfield Paula , Paletz Laurie
Published: July 2021

Background:
Brain ischemia kills 2 million nerve cells per minute. As time elapses, the odds of favorable outcome become less likely. By providing treatment rapidly, patient outcome is markedly improved. We recognized an opportunity for improvement by shortening our door-to-needle time. The door-to-needle time is defined by the time the patient arrives in the emergency department to the time the patient receives intravenous tissue plasminogen activator (IV t-PA).

Methods:
We evaluated the system in place to look at opportunities for improvement. We met monthly to assess every acute stroke patient case, particularly to evaluate delays in acute stroke treatment. We analyzed the results of all the acute stroke patient cases from January 2008 to January 2012. We implemented the following interventions: staff education, reducing unnecessary CT angiogram and CT perfusion studies on patients, RN telephone triage for acute stroke patients. pre-hospital activation of the stroke team for patients exhibiting acute stroke symptoms, ED pharmacist at bedside upon patient arrival with t-PA, and placing patients on portable monitors immediately upon ED arrival.

Conclusion:
The average door-to-needle time from January 2008 to October 2011 was 1 hour and 32 minutes. After implementing the changes above, from November 2011 to January 2012, our average door-to-needle time was 38 minutes to 54 minutes, which is within the target of less than 60 minutes. By implementing these changes, we have successfully and safely reduced and improved our door-to-needle time. Monthly quality improvement meetings are on-going to assess continuing quality improvement.
Abstract TP399: Incremental Healthcare Burden Associated with Dyspepsia Among Nonvalvular Atrial Fibrillation Patients: Implications for Anticoagulation Therapy
Authors: Kim Michael H , Bell Kelly F , Makenbaeva Dinara , Daniel Wiederkehr Daniel , Lin Jay , Graham John
Published: July 2021

Background:
Dyspepsia is common among nonvalvular atrial fibrillation (NVAF) patients and may influence stroke preventative medication choice, such as warfarin and dabigatran, especially when bleeding is a concern. This study evaluated the incremental healthcare burden associated with dyspepsia among NVAF patients.

Methods:
NVAF patients ≥18 years of age with continuous insurance coverage were identified (1/1/2007-12/31/2009) from the MarketScan® Commercial and Medicare Research Databases. Patients with at least 1 inpatient or 2 outpatient dyspepsia diagnoses within 12 months following any NVAF diagnosis were categorized as dyspepsia cohort, with patients without any dyspepsia diagnosis during the entire study period categorized as non-dyspepsia cohort. Of the overall dyspepsia/non-dyspepsia cohorts, patients were matched by key patient characteristics. Healthcare usage and costs were measured in a 12-month follow-up period.

Results:
Among NVAF patients, 10.2% had dyspepsia. For the dyspepsia cohort (n=14,556) vs. unmatched non-dyspepsia cohort (n= 127,766), mean CCI (2.4 vs. 1.6, p<0.0001), CHADS2 score (1.8 vs. 1.6, p<0.0001), hospitalizations (dyspepsia-related, GI-related, GI-bleed related, any cause), associated inpatient costs, outpatient usage and costs, as well as pharmacy usage and costs were greater. After matching, a lesser proportion of patients in the dyspepsia cohort used warfarin (49% vs. 57%, p<0.0001) and had significantly higher healthcare resource usage and costs vs. the non-dyspepsia cohort during the follow-up period (Table).

Conclusions:
The incremental healthcare burden associated with dyspepsia among NVAF patients is significant and appears associated with less warfarin usage. Further data on dyspepsia as a barrier to anticoagulation in NVAF are needed.
Abstract TP411: Preoperative Anemia a Significant Risk Factor for Postoperative Intracranial Hemorrhage in Active Infective Endocarditis
Authors: Yoshioka Daisuke , Toda Koichi , Okazaki Shuhei , Miyagawa Shigeru , Yamauchi Takashi , Nishi Hiroyuki , Yoshikawa Yasushi , Fukushima Satsuki , Saito Tetsuya , Sawa Yoshiki
Published: July 2021

Background:
Patients with infective endocarditis (IE) are often associated with cerebrovascular lesions which may cause critical postoperative intracranial hemorrhage (ICH). Although it has been known that postoperative ICH is not related to operative timing, prevalence or predictors is not fully understood. We thereby hypothesized that postoperative ICH in active IE may be predictable by thorough preoperative investigations including brain imaging modalities.

Methods:
A series of 102 patients who were diagnosed and surgically treated for active IE according to the AHA/ACC guideline was studied. All patients were preoperatively and postoperatively examined by brain magnetic resonance imaging and/or computed tomography scan regardless of the neurological symptom. Of them, 48 patients (47%) had cerebral complications preoperatively.

Results:
Surgery was performed at 19 ± 27 days after the diagnosis. In-hospital mortality occurred in 12 patients (11.7%), 2 of which were related to postoperative ICH. New neurological symptoms postoperatively appeared in 3 patients (2.9%), while postoperative ICH was identified in 11 patients (10.8%), presenting with ectopic cerebral bleeding in 3 patients, subdural hematoma in 3 patients, acute subarachnoid hemorrhage in 4 patients and, postinfarct hemorrhagic transformation in 1 patient. Logistic regression analysis identified preoperative anemia as sole independent risk factor for postoperative ICH with cutoff value being preoperative hemoglobin level of 8.5 g/dl (odds ratio; 2.37,
P
<0.01). Early surgery, preoperative presence of cerebral infarction/hemorrhage or bacterial species was not an independent risk factor of postoperative ICH.

Conclusions:
ICH occurred in 10.8% after the surgery for active IE. Preoperative anemia is the sole predictor of postoperative ICH, whereas preoperative cerebral complications or surgical timing was not a significant predictor, suggesting that preoperative management may be important in preventing postoperative ICH in active IE.
Abstract TP436: Dysfunctional Cerebral Neovascularization And Remodeling Patterns In Obese And Lean Models Of Type 2 Diabetes
Authors: Prakash Roshini , Johnson Maribeth , Fagan Susan C , Ergul Adviye
Published: July 2021

We previously reported intense pial cerebral collateralization and arteriogenesis in a mild and lean model of type 2 diabetes, Goto-Kakizaki (GK) rats. Further 3-dimensional fluroscein (FITC) imaging studies revealed regional differences in increased cerebral neovascularization which was associated with poor vessel wall maturity. Building upon these findings, the goals of this study were a) to compare and contrast this pathological neovascularization pattern in db/db mice and GK models of diabetes, and b) determine the effect of glycemic control on erratic cerebral neovascularization. Total vascular volume, density and surface area as well as structural parameters including microvessel/macrovessel ratio, non-FITC perfusing vessel abundance, penetrating arteriole (PA) branching density and diameter, and tortuosity were measured by 3 dimensional reconstruction of FITC stained vasculature using Z-stacked images obtained with confocal microscopy. Lean GK rats exhibited an increase in both micro and macrovessel density, non-perfusing vessel abundance, branch density, diameter and tortuosity. Glycemic control with metformin prevented these changes. Obese db/db mice, on the other hand, showed an increase in only microvascular density but this was not associated with an increase in non-FITC perfusing vessels. PA branch density was higher than controls but branch diameter was reduced. Diabetes also promoted astrogliosis. These results suggests that type 2 diabetes leads to cerebral neovascularization and remodeling but structural characteristics of newly formed vessels differ between lean and obese models that have mild or severe hyperglycemia, respectively. The prevention of dysfunctional cerebral neovascularization by early glucose control suggests that hyperglycemia is a mediator of this response. N=4-8 * p≤ 0.05, ** p≤ 0.005 *** 0.0005
Abstract TP75: Natural History of Incidental Small Paraclinoid Unruptured Aneurysm
Authors: Kim Jeong Eun , Jeon Jin Sue , Ahn Jun Hyong , Son Young-Je , Bang Jae Seung , Sheen Seung Hun , Kang Hyun-Seung , Oh Chang Wan , Han Moon Hee
Published: July 2021

Objective:
The optimal consensus over treatment of incidental small paraclinoid unruptured intracranial aneurysm (UIA) remains controversial. The aim of this study was to reveal the natural history of small paraclinoid UIA with the goal of informing a treatment plan.

Methods:
A total of 344 patients harboring 364 paraclinoid UIA (≤5 mm) were retrospectively evaluated during the mean follow-up of 32±17.3 months from September 2001 to May 2011. Barami’s classification was used for categorizing aneurysm location. Univariate and multivariate analyses were used to determine the risk factors of aneurysm growth. The Kaplan-Meier product-limit estimator and generalized Wilcoxon tests were performed to assess the cumulative survival without aneurysm growth.

Results:
None of the aneurysm ruptures and 12 (3.3%) cases of aneurysm growth were observed during the follow up of 969.7 aneurysm-years. Aneurysm ≥ 4mm (hazard ratio [HR], 6.73; p=0.001) and hypertension (HR, 4.92; p=0.02) were associated with aneurysm growth. Other variables including female (p=0.18), age (p=0.24), arterial branch related location (p=0.47), multiplicity (p=0.11), and smoking (p=0.36) did not differ significantly. The multivariate analysis disclosed that aneurysm ≥4mm (HR, 4.78; p=0.01) and hypertension (HR, 4.20; p=0.03) were significant predictable factors for aneurysm growth. The cumulative survival without aneurysm growth reached a significant difference in aneurysms ≥4mm (p<0.001) and with hypertension (p=0.01). No statistical difference was observed between arterial branch related and unrelated groups (p=0.16).

Conclusions:
Incidental small paraclinoid UIA can be primarily treated conservatively. Patients with high risk factors including aneurysm ≥4 mm and hypertension must be monitored closely.
Abstract TP9: Solitaire FR Thrombectomy For Acute Stroke: Real-world Experience After FDA Approval
Authors: Mokin Maxim , Dumont Travis , Veznedaroglu Erol , Binning Mandy , Fessler Richard , To Chiu Yuen , Turner Raymond D , Turk Aquilla S , Chaudry Imran , Arthur Adam S , Fox Benjamin D , Hanel Ricardo A , Tawk Rabih G , Kan Peter , Gaughen John , Lanzino Giuseppe , Lopes Demetrius , Chen Michael , Moftakhar Roham , Billingsley Joshua T , Snyder Kenneth , Siddiqui Adnan , Hopkins Nelson , Levy Elad
Published: July 2021

Background and Purpose:
Based on promising results of the Solitaire FR With the Intention for Thrombectomy (SWIFT) trial, Solitaire FR stent retriever device recently received the Food and Drug Administration (FDA) approval for recanalization of cerebral vessels in patients with acute ischemic stroke. Real world experience with this device since its FDA approval in the United States has not been previously described.

Methods:
We conducted retrospective analysis of consecutive acute ischemic strokes cases from March 2012 to July 2012 in 10 centers within the United States, where Solitaire FR was used as a single device or in conjunction with other intra-arterial endovascular approaches.

Results:
A total of 107 patients were identified (mean age, 64 years; male gender, 51%; mean admission NIHSS score 17). Mean time from symptom onset to angiogram (groin puncture) was 4 hrs 47 min. Intravenous thrombolysis with tissue plasminogen activator (tPA) was administered in 37% of cases. Other endovascular techniques utilized in conjunction with Solitaire FR included intra-arterial thrombolysis with tPA (12% of patients), aspiration thrombectomy with Penumbra system (29%) and stenting (17%). Complete recanalization (TIMI 2-3) was achieved in 88% of patients. The rate of sICH within the first 24 hours was 15%. In-hospital mortality was 24%. 30-day clinical follow up data was available on 82 (77%) patients. Of those, 28 patients (34%) had favorable functional outcome (defined as modified Ranking Scale,mRS≤2) and 22 patients (27%) had excellent functional outcome (mRS≤1) at 30 days. Three or more passes with the Solitaire device was associated with a higher incidence of mortality compared with patients requiring 1 or 2 passes only (43% and 18% respectively, p = 0.011). No statistically significant correlation between clot location or length and outcome was evident. Use of other devices with the Solitaire FR was correlated with worsened outcome (p=0.037).

Conclusions:
This is the first study describing real-world experience with Solitaire FR device outside the SWIFT trial in the United States. Out study shows that variety of other endovascular approaches are used in conjunction with Solitaire FR.
Abstract WMP10: Single-center Experience In The Off Label Use Of FDA Approved Drugs And Devices For Endovascular Treatment Of Cerebrovascular Diseases
Authors: Abdihalim Muhamed , Hassan Ameer E , Qureshi Adnan I
Published: July 2021

Background:
The off label use of FDA approved drugs and devices in neuroendovascular procedures is common. However, the frequency and characteristics of such use in the endovascular treatment of cerebrovascular diseases is not well defined.

Methods:
We reviewed 100 consecutive endovascular procedures and ascertained off label use with either drugs or devices. The off label uses were categorized as I or II if the drug or device had been evaluated as primary or ancillary intervention in prospective trial/registry of neuro-endovascular procedures and III if evaluated in case series. Category IV use was based on evaluation as primary or ancillary intervention in prospective trial/registry of non neuro-endovascular procedures.

Results:
Of the 100 consecutive endovascular procedures reviewed, all the procedures were performed under heparin infusion (category II off label use); intra-arterial (IA) nicardipine or verapamil (category III) in 31 cases; dual anti platelet therapy (category II) in 24 cases; IA thrombolytics (category I) in 13 cases; stent assisted embolization of intracranial aneurysms (category I) in 3 cases; stent placement of intracranial stenosis (category I) in 4 cases; angioplasty alone of intracranial stenosis (category III) in 3 cases; 5 cases had stent placement of carotid or vertebral dissections (category III); the intravascular ultrasound (IVUS) catheter system were used in 3 cases (category III); and PVA embolization of the internal maxillary artery (category III) in 2 cases.

Conclusions:
The off label use of FDA approved drugs and devices for endovascular treatment of cerebrovascular diseases is highly prevalent. However, physicians have the responsibility to be well informed about the product, in order to base its use on firm scientific rationale and to maintain awareness of the product’s use and effects.
Abstract WMP102: Development and Testing of a Web-Based Decision Aid to Improve Decision Making for Asymptomatic Carotid Disease
Authors: Halm Ethan , Nelson Colin , Tiro Jasmin , Sepucha Karen , Batchelor Kim , Xuan Lei , Fowler Jack , Stilwell Diana , Witteman Holly , Dickson Mark , Zikmund-Fisher Brian
Published: July 2021

Introduction:
Patients (Pts) with asymptomatic (ASX) carotid stenosis have 3 treatment (Rx) options (surgery[CEA], stenting[CAS], and medical therapy alone[Med],) each with its own risks and benefits (R/Bs). In prior work, many ASX Pts who had CEA did not understand the disease (Dz), their Rx options, and associated R/Bs. Decision aids (DAs) have been shown in other conditions to foster more informed Rx choices.

Objective:
To develop and assess the impact of a DA on knowledge of Dz, Rx options, and DA satisfaction.

Methods:
We created a multimedia, web-based DA to explain ASX carotid Dz, Rx options, and associated R/Bs. The DA was refined and vetted by experts in neurology, vascular/neuro-surgery, internal medicine, decision making, and patient education. The DA included: text, anatomic graphics, pictographs of short term and long R/Bs of CEA v. Med, and Pt and MD video testimonials. We tested it in an online Pt panel in those: 55+ yrs with ≥ 1 risk factor for carotid Dz (HTN, DM, CHOL, CAD, PVD). Post-viewing knowledge of key educational messages incl. Rx options, associated R/Bs, and DA satisfaction were assessed with validated instruments.

Results:
Overall, 1778 of 1843 completed viewing the 40 minute DA (96%). Mean age was 67 yrs, 51% female, 91% White, and 24% ≤high school degree. Pts correctly answered 68% of the 19 knowledge items. The DA was well-liked with mean score of 4.4 (out of 5) on a 10 item DA satisfaction score and 4.3 (out of 5) on a 7 item DA helpfulness score. Pts correctly grasped most gist messages including that: not everyone needed CEA (99%), there was no best Rx it depends on the Pt (92%), they had time to make a decision (86%), CEA can cause stroke (92%), CEA can cause death (91%), and carotid Dz can cause stroke (83%). They had trouble understanding the time trade of CEA v. Med-only 55% correctly said CEA was riskier in the short term, and 50% that Med was riskier in the long term. Overall, 74% said they would choose Med. Pts who were younger, female, White, higher education, or with family/friends with stroke or CAD had higher knowledge scores.

Conclusions:
A web-based DA was effective in conveying most gist messages regarding making an informed decision in ASX carotid Dz. The next step is testing the impact of the DA in Pts facing a real decision about revascularization.
Abstract WMP106: Increased Carotid Stenting For Nonspecific Symptoms In The Post-crest Era
Authors: Rayes Mahmoud , Bhattacharya Pratik , Damani Rahul , Chaturvedi Seemant
Published: July 2021

Background:
Nonspecific symptoms such as dizziness and syncope may prompt evaluation of the carotid circulation and detection of carotid stenosis. The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) demonstrated equivalent outcomes from Endarterectomy (CEA) and Stenting (CAS) in asymptomatic stenosis. We reviewed the trends in selection and outcomes from revascularization procedures for nonspecific symptoms in the light of CREST results.

Methods:
We performed a retrospective review of carotid revascularization procedures at a large volume urban medical center, between June 2009 (8 months pre-CREST) and April 2012. Demographics, surgical risk features and in-hospital outcomes of stroke/death/MI were reviewed. Patients were labeled as having nonspecific symptoms when they presented with posterior circulation symptoms or with non-focal symptoms i.e. Dizziness, syncope, etc. To evaluate the effect of CREST, we compared pre CREST (up to Jan 2010) and post CREST cases (Feb 2010 to Apr 2012).

Results:
701 procedures (36.1% CEA, 63.9% CAS) were performed and mean age was 70 ±10 years. Non-specific indications accounted for 13% of CEA and 15.9% of CAS. Procedures for nonspecific symptoms did not increase post CREST in the CEA group (12.1% VS 13.3%). They increased significantly in the CAS group (6.3% pre and 18.5% post CREST). Among CAS, the rise was insignificant in the first 8 months (Feb 2010-Sep 2010) post CREST: 7.5%. This rose to 21.2% from Oct 2010 to May 2011: p=0.0017; and 23.8% from June 2011 to April 2012: p=0.0004. The rise in CAS was noted among elderly patients (>70 years), a group in which CREST demonstrated higher complication rates. The rise was noted among both men and women and they did not have surgical high-risk criteria. In-hospital complication rates of stroke/death/MI were 5.6% in this group. Most complications occurred in patients >70 years.

Conclusion:
CAS for nonspecific symptoms has increased following CREST, and the complication rates associated with these procedures is significant. This raises concern about the value of this procedure. Primary care physicians evaluating non-specific symptoms should obtain neurological expertise prior to revascularization procedures, to allow appropriate patient selection.
Abstract WMP28: Follow-up of Large Intracranial Aneurysms Indicates Growth Frequency Varies According to Location and Size
Authors: Chien Aichi , Liang Feng , Salamon Noriko , Villablanca Pablo , Vinuela Fernando
Published: July 2021

Background:
Although treatment is recommended for unruptured large aneurysms (≥7mm), which have higher rupture risk, in practice some aneurysms remain under observation due to a patient’s medical history or age. Detailed data about aneurysm growth during follow-up is limited. In this study, we aim to investigate growth in large aneurysms by reviewing the unruptured aneurysms cases which were followed in our center.

Hypothesis:
The growth of large unruptured aneurysms varies according to aneurysm characteristics and patient medical history.

Method:
A retrospective review of patient records based on unruptured aneurysms diagnosed in our center from 2005 to 2011 was performed. Large unruptured aneurysms which had more than one CTA examination separated by at least 3 months were included. Aneurysm characteristics, patient information, and medical history were recorded. Univariate and multivariate logistic regression were used to analyze aneurysm growth.

Results:
From a total of 410 unruptured aneurysms followed in our center, 50 large aneurysms (41 females, 9 males; age 67.3±12.6 years) were included: 42 aneurysms with initial size 7-12.9 mm, 7 aneurysms 13-23.9 mm, and 1 aneurysm ≥24 mm. During the average 25.6 month follow-up, 15 (30%) aneurysms enlarged and 35 (70%) were unchanged. The growth frequency of aneurysms located in ICA, MCA, ACA, BA was 40%, 22%, 20% and 17%, respectively. The growth frequency of aneurysms of sizes 7-12.9 mm, 13-23.9 mm and ≥24 mm was 23.8%, 71.4% and 0, respectively. Using univariate logistic regression analysis, duration of follow-up (P=0.023), and history of ischemic stroke (P=0.027) were associated with growth. Multivariate logistic regression showed only duration of follow-up as a risk factor for growth (OR, 1.056 per month; 95% CI 1010 to 1.104; P=0.016). Only one aneurysm (ICA) ruptured in the follow-up (70 months), resulting in a rupture rate of 6.7% (1/15) enlarged aneurysms (0/35 unchanged aneurysms).

Conclusion:
A large percentage of aneurysms selected for observation grew, and growth frequency varied according to aneurysm location and size. A larger, future study may identify additional factors associated with growth, including ones specific to aneurysm characteristics like location and initial size.
Abstract WMP32: Immunomodulation and Neuroprotection by Progesterone in Infections following Ischemic Brain Injury in Middle-Aged Rats
Authors: Yousuf Seema , Atif Fahim , Sayeed Iqbal , Stein Donald G
Published: July 2021

Infection is one of the major complications during the acute phase following stroke, accounting for in-hospital deaths and worsening outcomes. We investigated the effect of delayed systemic inflammation on stroke outcomes and neuroprotection by progesterone (P4). Middle-aged rats underwent transient middle cerebral artery occlusion (MCAO) and received P4 (8 or 16 mg/kg) or vehicle until day 7 post-MCAO. Beginning 24h post-MCAO systemic inflammation was induced by 3 doses of lipopolysaccharide (LPS; 50 mg/kg, i.p.) to model post-stroke infections. We evaluated serum brain-derived neurotrophic factor (BDNF), pro-inflammatory cytokines, brain infarctions, and conducted behavioral testing at multiple time points. Data were analyzed using repeated measures (RM)-ANOVA followed by LSD and Tukey’s tests. RM-ANOVA revealed a significant group effect (

F
(4,25)

=153.60;
P
<0.001) for IL-1β, IL-6 (

F
(4,25)

= 179.56;
P
<0.001), and TNFα (

F
(4,25)

= 58.94;
P
<0.001). Vehicle-alone showed a significant increase in all cytokine levels at different times following stroke which were further elevated after LPS injections in the vehicle+LPS group. P4 at both doses produced a significant decline (
P
<0.05) in cytokine levels compared to vehicle and vehicle+LPS. BDNF levels showed a significant group effect (
F
(4,25)
= 24.838;
P
<0.001) and greater (
P
<0.05) decrease in the vehicle+LPS group compared to vehicle-alone at 3 and 7 days post-injury. P4 significantly (
P
<0.001) restored BDNF levels post-injury. At 3, 5 and 7 days, a significant group effect was observed in rotarod (
F
(4, 26)
= 33.059,
P
<0.001), grip strength (
F
(4, 26)
= 42.263,
P
<0.001), sensory neglect (
F
(4, 26)
= 150.712,
P
<0.001), and locomotor activity (
F
(4,25)
= 63.423,
P
<0.001). The vehicle group had significant (
P
<0.05) deficits in all tests, and performance was worse in the vehicle+LPS group. P4 produced significant (
P
<0.05) improvement in the animals’ performance on all tests. Systemic inflammation did not show an additive effect on infarct volume but P4 at both doses showed significant infarct reduction. Ourb data suggest that post-stroke infection exacerbates stroke outcomes and P4 exerts neuroprotective/modulatory effects through its anti-inflammatory and BDNF regulatory action.
Abstract WMP38: Neurorestorative Therapy of Stroke in Type One Diabetes Rats with Human Umbilical Cord Blood Cell
Authors: Chen Jieli , Yan Tao , Ye Xinchun , Kuzmin-Nichols Nicole , Zacharek Alex , Cui Yisheng , NIng Ruizhou , Roberts Cynthia , Sanberg Cyndy Davis , Chopp Michael
Published: July 2021

Diabetes mellitus (DM) instigates a cascade of events leading to vascular damage and poor recovery after ischemic stroke. Our previous studies have found that treatment of stroke with bone-marrow-stromal cells initiated at 24h after stroke improves functional recovery in non-DM rats, but not in DM rats. Effective therapy for stroke in the non-DM population may not necessarily transfer to the DM population, prompting the need to develop therapeutic approaches specifically designed to reduce neurological deficits after stroke in the DM population. In this study, we hypothesize that treatment of stroke with human umbilical cord blood cells (HUCBCs) promotes neurorestorative effect in DM rats.

Methods:
Type one DM (T1DM) was induced with a single injection of streptozotocin (60 mg/kg, ip) to adult male Wistar rats. These rats were subjected to 2h MCAo and were randomized to intravenous injection via tail-vein with: 1) phosphate-buffered saline control; 2) HUCBCs (5x10
6
) at 24 hours after MCAo. A battery of functional tests were performed.

Results:
HUCBC treatment did not decrease lesion volume and blood glucose level, but significantly improved functional outcome (p<0.05) after stroke in T1DM rats compared to T1DM-MCAo control. To test the mechanisms of HUCBC induced neurorestorative effects, vascular and white matter changes were measured. HUCBC treatment significantly increased percent areas of Bielschowsky silver (axon, control:30.96%±1.2; HUCBC:43.64%±5.7), Lucifer fast blue (myelin, control:37%±1.3; HUCBC:53.2%±3.3) and Synaptophysin (control: 34.6%±0.9; HUCBC: 45.5%±2.4) expression as well as increased vascular diameter (control:16.4um±0.65; HUCBC:20.9um±1.7) compared to T1DM-MCAo control. HUCBC treatment of stroke also significantly increased percent area of Angiopoietin-1 (Ang-1, control:6.1%±1.1; HUCBC:10.2±1.4) and decreased Angiogenin (control:10.8%±1.6; HUCBC: 4.8%±0.5) and MMP9 (control:4.7%±0.6; HUCBC:2.3%±0.4) expression in the ischemic border compared to T1DM-MCAo control.

Conclusion:
HUCBC is an effective neurorestorative therapy for stroke in T1DM rats. Increasing Ang1 and decreasing Angiogenin and MMP9 may contribute to HUCBC induced brain plasticity and functional recovery after stroke in T1DM rats.
Abstract WMP64: Prehospital Triage To Comprehensive Stroke Centers: GCS Identifies Patients At Increased Risk For Death, ICH, Or SAH
Authors: Kwok Heemun , Schubert Glenn B , Longstreth W T , Becker Kyra J , Tirschwell David
Published: July 2021

INTRODUCTION:
Regionalization of stroke care is occurring nationwide, but evidence-based criteria for prehospital triage to comprehensive stroke centers are lacking. We assessed the hypothesis that a prehospital clinical decision rule can identify a group of patients more likely to require comprehensive stroke services--those with an increased risk of in-hospital mortality, ICH, or SAH.

METHODS:
This study represents a retrospective cohort of patients seen by an urban EMS system from 2000-2003. Subjects were included if they had either a prehospital diagnosis of “stroke/TIA” or a prehospital diagnosis of “decreased level of consciousness” or “headache” and signs and symptoms suggestive of a cerebrovascular event. The primary outcome was a composite of in-hospital mortality, ICH, or SAH. Multivariate logistic regression was used to derive a clinical prediction rule.

RESULTS:
In 1682 subjects, the discharge diagnoses included TIA (n = 282, 17%), ischemic stroke (n = 433, 26%), ICH (n = 102, 6%), and SAH (n = 30, 2%). There were 221 patients (13%) who experienced the primary outcome: 67 (4%) with non-fatal ICH or SAH and 154 (9%) who died. Using GCS score alone, the area under ROC curve was 0.72, and GCS ≤ 10 resulted in a sensitivity of 0.48 (95%CI 0.42, 0.55) and specificity of 0.88 (95%CI 0.87, 0.90). A six-point prehospital stroke triage score (PSTS) was also derived: nausea/vomiting (1 point), systolic BP ≥ 175 (1 point), GCS 7-10 (2 points) and GCS 3-6 (4 points). The area under ROC curve for the PSTS was 0.74. Test characteristics for PSTS and GCS were similar (Table).

CONCLUSION:
GCS alone performed similarly to a six-point clinical decision rule for the prehospital identification of patients at increased risk of death, ICH or SAH. GCS has potential utility as a criterion for the prehospital triage to comprehensive stroke centers.
Abstract WP12: Downstream Clot Fragment Migration During Endovascular Clot Extraction Adversely Affects Clinical Outcome
Authors: Frey James L , Darbonne Carol , Chapple Kristina M , Saldivar Christina , Saha Kamala , Clark Joni , Taylor Heather
Published: July 2021

Background and Purpose:
FDA approval of endovascular clot extraction devices that are used in stroke is based on efficacy for opening target arteries safely. Favorable clinical outcomes using devices currently available, however, is limited. Time to treat and stroke severity are obvious contributors, but a factor that receives little attention is intraoperative downstream migration of clot fragments. We assessed the effect of migrated clot fragments on clinical outcome in patients treated at our institution.

Methods:
With IRB approval, we retrospectively reviewed charts, procedure reports, and images of all patients with M1 occlusions treated with endovascular clot extraction within the past 5 years to compare relevant variables and discharge outcomes in patients whose arteries were ultimately “open” (OP) versus “open with fragments” (OF).

Results:
Thirty four patients were treated (21 Penumbra, 7 Merci retriever, 6 Solitaire), all under general anesthesia. Numbers of patients in each category of final vessel patency were: OP=15, OF=19.

No significant intergroup differences were found (means) for age (60), gender (male 55%), time from onset to treatment (4.71 hours), admission BP (141/82), duration of anesthesia (2.1 hrs), mean blood pressure during anesthesia (132/70), admission NIHSS (13.8), pretreatment with IV-rtPA (70%).

OP patients were more likely to have had an atheroembolic than cardiac source of stroke (p<0.03), as well as treatment with Solitaire stent (all 6 Solitaire patients were OP).

OF were more likely to have had IV-rtPA (p<0.15), treatment with Penumbra (p<0.03), and adjunctive use of IA-rtPA and abciximab for target clot (p<0.09).

OP had lower discharge NIHSS (6.79 v 13.22; p<.03); greater change in NIHSS

(-6.21 v -1.89; p<0.03); discharge mRS=0-2 (47% v 21%; p<0.15); discharge mRS=0-3 (53% v 79%; p<0.005); discharged home (33% v 11%; p<0.2).

There was one death in each group (NS), one sICH in OF, and length of stay was 8 days in both.

Conclusion:
Although our numbers are small, they strongly suggest an adverse effect of downstream clot fragments on outcomes. Awareness of this phenomenon should be useful in the approval process for future devices, as well as in the evaluation of post-marketing device use.
Abstract WP125: Comparison Of Carotid Intraplaque Hemorrhage With Other Markers Of Plaque Vulnerability.
Authors: McNally Joseph S , Kim Seong-Eun , Yoon Hyo-Chun , Roberts John , Narra Krishna , Parker Dennis , Treiman Gerald
Published: July 2021

Background:
MR detected carotid intraplaque hemorrhage (IPH) has been associated with acute ischemic events. Other markers of plaque vulnerability can also be imaged by MRI/MRA and include >70% carotid stenosis, plaque ulceration, and intraluminal thrombus. Atherosclerosis is a systemic disease, and many of these markers are found bilaterally in patients.

Objective:
To determine the relative risk acute ischemic events with carotid IPH compared to other markers of plaque vulnerability, and to determine whether IPH is associated with these markers and contralateral IPH.

Methods:
Over 2 years, 159 patients with suspected acute stroke were evaluated with brain DTI and MRA neck workup. Carotid MRA included lumen evaluation as well as carotid plaque imaging with the MPRAGE sequence. This provided 318 carotid artery and ipsilateral brain images for analysis. 48 arteries were excluded due to extracarotid sources of brain ischemia and 4 were excluded due to carotid occlusion. 266 arteries were eligible for data analysis.

Results:
Acute territorial ischemic events were associated with carotid IPH, >70% stenosis, ulceration and intraluminal thrombus (relative risk=6.4 (4.3-8.7), 4.4 (2.8-5.9), 3.8 (2.4-5.6), and 5.7 (3.6-5.7) respectively, p<0.001). Within the same carotid plaque, IPH was associated with ulceration and >70% stenosis (relative risk=7.8 (4.4-13.1) and 6.0 (2.6-13.8) respectively, p<0.001). There was a trend toward association with intraluminal thrombus, but this did not reach significance (relative risk=3.4 (0.9-12.4), p=0.056). Carotid IPH also increased the relative risk of contralateral carotid IPH (relative risk=6.3, (3.4-10.9), p<0.001).

Conclusions:
Carotid IPH is associated with acute stroke, with a relative risk on par with other markers of plaque vulnerability. Carotid IPH is highly associated with ulceration or >70% stenosis. Carotid IPH is also associated with contralateral IPH, suggesting that systemic factors result in plaque hemorrhage elsewhere in the body.
Abstract WP244: The Stroke Interventional Radiology (SIR) Process for Rapid Transport of the Acute Stroke Patient
Authors: Baumann JJ , Barch Carol , Dodd Robert , Marcellus Mary , Lansberg Maarten
Published: July 2021

Background:
Expedient transfer of acute stroke patients is imperative for optimizing stroke treatment. Our aim was to develop and evaluate a new process that would provide rapid accessibility to expert advice, multi modality imaging, and interventional stroke treatments.

Methods:
In October 2008, members from Interventional Neuroradiology and Stroke neurology identified obstacles that led to delays in acceptance and transfer of patients. the Stroke Interventional Radiology (SIR) processwas developed to streamline the transfer of acute stroke patients.

Results:
Before implementation of the SIR process, numerous calls were made to arrange for coordination of care. Communication between the referring physician, stroke neurologist and neuro-interventionalist occurred sequentially. Once a decision was made to accept the patient for transfer, checking for bed availability before approval of the transfer created additional delays. In May 2009, the SIR process was developed to improve rapid access. The process involves coordinated care among the neuro-interventionalist, stroke neurologist, transfer center, hospital administration, radiologist, radiology techs, and crisis nurses and has three main components: 1)the neurologist and interventional neuroradiologist are jointly connected via conference call with the referring physician within five minutes, 2) bed availability for acute stroke transfers is guaranteed, and 3) a paging system provides communication to physicians, nurses, radiology technologists, transport team, and respiratory therapist on patient condition and estimated time of arrival. Since implementation, total time to transfer approval has decreased by 75%. Simultaneously, we have increased the volume of patients transferred (38 in 2010, 59 in 2011 and 21 for first quarter of 2012), the number of acute stroke patients treated with intervention (10, 13, 16, 17 for consecutive years from 2008), and, via phone consultation, the number of patients treated with IV tPA at referring hospitals (3, 2, 19, 28, for consecutive years since 2008 and 12 already for first quarter of 2012).

Conclusion:
A system of coordinated care can markedly reduce acute stroke transfer times.
Abstract WP247: Use and Importance of Emergency Medical Services in Rural Delivery of tPA in Acute Ischemic Stroke
Authors: Scott Phillip A , Sozener Cemal B , Hume Benjamin D , Meurer William J
Published: July 2021

Introduction:
Data indicate approximately 60% of stroke patients use Emergency Medical Systems (EMS) to access medical care. EMS use is associated with improved door to physician and CT times in stroke treatment. Rural areas, however, may have limited EMS access and its use and impact on tPA delivery in this setting is unknown.

Hypothesis:
We assessed the hypothesis that EMS use in tPA treated stroke patients would be lower in rural areas compared to urban areas. We also examined important time intervals between groups.

Methods:
Prospective, observational study using previously collected data from 24 randomly selected Michigan community hospitals in the INSTINCT stroke trial. Hospitals were identified a priori as urban or rural using two models to account for varying rural definitions. Model 1 defined rural hospitals as those outside a Metropolitan Statistical Area (MSA). Model 2 used hospitals outside a major Urban Area (UA > 150 square miles). Descriptive statistics presented; Student’s t and X
2
tests used in the comparisons.

Results:
All 557 patients treated with tPA for AIS from 2007 - 2010 were included in the analysis. 82% [95% CI: 79%-85%] used EMS to access stroke care. Patients in both urban and rural groups had similar demographics. EMS transport times were significantly longer for rural patients in both models. Model 2, with a more restrictive geographic definition of a rural hospital, identified a significant reduction in EMS use in rural patients compared to the urban group. See Table.

Conclusions:
Overall EMS use among stroke patients receiving tPA was substantially higher than previously reported in the general stroke population. Lower EMS use in rural settings, however, was confirmed in the restrictive model. EMS transport times were longer in the rural setting, likely reflecting greater travel distances. EMS level interventions to improve tPA delivery would reach a large majority of treated patients in both urban and rural settings.