bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W MP65: Moderate to Severe Left Atrial Enlargement is Associated with Cardioembolic or Cryptogenic Stroke Recurrence in a Multiethnic Cohort: The Northern Manhattan Study
Authors: Yaghi Shadi , Moon Yeseon P , Mora-McLaughlin Consuelo , Willey Joshua Z , Di Tullio Marco R , Sacco Ralph L , Elkind Mitchell S
Published: July 2021

Background:
While left atrial (LA) enlargement increases incident stroke risk, the association with recurrent stroke is unclear. Our aim was to determine the association of LA enlargement (LAE) with stroke recurrence risk and recurrent stroke subtypes likely related to embolism (cryptogenic or cardioembolic).

Methods:
We enrolled 655 first ischemic stroke patients in the Northern Manhattan Stroke Study. LA size was measured by two-dimensional echocardiogram as part of the clinical evaluation and patients were followed annually for up to 5 years. LA size adjusted for sex and body surface area was categorized into three groups: normal (52.7%), mild LAE (31.6%), and moderate to severe LAE (15.7%). The outcomes were total recurrent stroke, and recurrent combined cryptogenic or cardioembolic stroke. Cox proportional hazard models assessed the association between LA size and risk of stroke recurrence.

Results:
Of 655 patients, LA size data was present in 529 (81%). Mean age was 69 ± 13 years; 46% were male and 18% had atrial fibrillation. Over a median of 4 years, recurrent stroke occurred in 83 patients (16%), 29 were cardioembolic or cryptogenic stroke. After adjusting for baseline demographics and risk factors including atrial fibrillation and congestive heart failure, compared to normal LA size, moderate to severe LAE was associated with greater risk of recurrent combined cardioembolic or cryptogenic stroke (adjusted HR 2. 99, 95% CI 1. 10 to 8.13), but not with risk of total stroke recurrence (adjusted HR 1.18, 95% CI 0.60 to 2.32). Mild LAE was not associated with either total stroke recurrence or the combined recurrent cryptogenic or cardioembolic stroke subtypes.

Conclusion:
Moderate to severe LAE is an independent marker of recurrent cardioembolic or cryptogenic stroke in a multiethnic cohort of ischemic stroke patients. Future research is needed to determine if anticoagulant use reduces the risk of recurrence in ischemic stroke patients with moderate to severe LAE.
Abstract W MP69: CHADS2 Score Predicts Stroke Related In-hospital Mortality In Patients With Atrial Fibrillation: An Analysis Of The California State Inpatient Database
Authors: Yaghi Shadi , Pilot Markeith , Sherzai Dean , Sherzai Ayesha
Published: July 2021

Background:
The CHADS2 score predicts stroke risk in patients with atrial fibrillation. Although strokes caused by atrial fibrillation carry the highest mortality when compared to other etiologies, it is unclear whether the CHADS2 score has an impact on stroke related mortality in patients with atrial fibrillation. We hypothesize that higher CHADS2 scores are associated with higher stroke related in-hospital mortality.

Methods:
Data were obtained from the California State Inpatient Database between 2008 and 2011, using appropriate ICD-9 codes. Frequencies and descriptive analysis adjusting for influence of comorbidities and confounders were utilized. Age and ICD-9 codes for hypertension, diabetes, congestive heart failure, and prior stroke were used to calculate the CHADS2 score of patients with atrial fibrillation. A multivariate Cox regression model adjusted for age, gender and race was used to further explore the relationship. The primary outcome was in-hospital stroke mortality. We hypothesized that higher CHADS2 scores increase the risk of stroke related mortality.

Results:
Between 2008-2011, 18,089 patients with atrial fibrillation had stroke as one of the admitting diagnoses; 70% were Caucasians, 5% African Americans, 15% Hispanic, and 10% Asian; 57% were females and 66% of patients were ≥ 75 years. The in-hospital mortality rates of the CHADS2 score were as follows: 0 (18.7%), 1 (18.6%), 2 (21.3%), 3 (26.3%), 4 (23.8%), 5 (22.8%), and 6 (22.2%). After adjusting for baseline demographics, the odds of in-hospital mortality was significantly higher with a CHADS2 score ≥ 2 vs. < 2 (OR 1.15 95% CI 1.08-1.23). Among the individual CHADS2 score items, predictors of increased in-hospital mortality were congestive heart failure (OR 1.61 95% 1.53-1.70), age ≥ 75 years (OR 1.27 95% 1.19-1.35), and diabetes (OR 1.24 95% CI 1.14-1.35).

Conclusion:
CHADS2 ≥ 2 not only increases the risk of stroke but is a predictor of stroke related mortality. Factors driving this association appear to be age, congestive heart failure, and diabetes. This may be useful when deciding on anticoagulation use for stroke prevention especially in patients with elevated bleeding risk.
Abstract W MP8: Stent Retrievers Do Not Encase Clots But Hook Them Within Seconds
Authors: Lamprecht Sophie , Jansen Olav , Riedel Christian H
Published: July 2021

Introduction:
Stent retriever procedures for clot removal in proximal cerebral arteries are often assumed to securely encase a clot for withdrawal.

Hypothesis:
We assessed the hypothesis that the interaction of a stent retriever device with a clot in proximal cerebral arteries typically leads to an encasement of the clot after a steady state of clot-device interaction is reached.

Methods:
We studied how two different stent retrievers (the Trevo and Aperio device) interact with clots made from human blood with a Chandler loop. Therefore, we injected 30 preformed clots of constant length but variable thickness into tapering models of the distal internal carotid artery, the main stem and M2 segments of the middle cerebral artery and filled the remaining lumina with x-ray contrast agent. We then performed stent retrieving procedures with high resolution biplane angiographical imaging to capture all phases of the retrieving procedure without aspiration. We measured penetration depth of the stent struts into the clots, occurrences of clot rupture and the time intervals until a steady state of penetration was achieved.

Results:
For both stents, we measured stent penetration depth in 60 evenly spaced positions for luminal diameters between 4.2mm and 1.3mm. Above a clot thickness of 2.3mm (Aperio) and 2.1mm (Trevo), a steady state penetration width of 0.5 mm (SD: 0.3 mm) for Trevo and 0.8 mm (SD: 0.4 mm) for Aperio was observed after 2.2s (Trevo) and 5.8 seconds (Aperio) and no encasement was observed. Below a clot thickness of 2 mm, clots were completely encased in 41% (Trevo) and 58% (Aperio), although in both both stents more than 80 % were disrupted. The steady state of penetration was achieved after 3.5s (Trevo, SD: 1.8 s) and 4.8 s (Aperio, SD: 2.1 s).

Conclusions:
Instead of being encased, thick clots are eccentrically attached to the outer surface of stent retrievers within a few seconds until steady state is reached. This results in the risk of stripping off the clots at the entrance of an aspiration catheter. Encasement of clots is only observed in thin clots at the price of clot disruption with a steady state after a few seconds. Both aspects imply that stent-retriever procedures can only be effective with additional close distance aspiration.
Abstract W MP91: Supply-demand Mismatch Transients Trigger Peri-infarct Depolarizations In Ischemic Penumbra
Authors: von Bornstädt Daniel , Seidel Jessica , Houben Mathias Bernard , Dilekoz Ergin , Qin Tao , Sandow Nora , Eikermann-Haerter Katharina , Boas David , Moskowitz Michael , Lo Eng , Dreier Jens , Woitzik Johannes , Sakadzic Sava , Ayata Cenk
Published: July 2021

Background:
Peri-infarct depolarizations (PIDs) worsen the outcome of ischemic stroke. Unlike their impact on metabolism and perfusion, triggering factors are virtually unknown. We hypothesized that transient worsening of O2 supply-demand mismatch precipitates a PID in critically hypoperfused penumbra.

Methods:
We optically imaged cortical blood flow and oxygenation during distal middle cerebral artery occlusion in mice under full systemic physiological monitoring, and tested whether a transient (5 min) drop in O2 supply (hypotension or hypoxia) or increase in O2 demand (somatosensory cortical activation) can trigger PIDs during acute focal cerebral ischemia.

Results:
Transient hypotension (<70 mmHg) or hypoxia (<90 mmHg) triggered a PID 90% of the time (p<0.01). Increasing the O2 demand by functional activation (tactile stimulation) of moderately ischemic cortex (contralesional forepaw or shoulder S1) increased the 5-min incidence of PIDs by approximately five-fold (p=0.001). Cortical oxyhemoglobin levels dropped by 35-40% in the activated S1 immediately before a PID (p=0.004) confirming increased O2 demand. Cortical foci from which PIDs originated during tactile stimulation had 27-32% residual CBF, indicating the presence of a critical range of ischemia vulnerable to PID initiation upon increased demand. Consistently, activation of non-ischemic cortex (hindpaw S1) or severely ischemic cortex (whisker S1) did not significantly increase the PID rate. Both tetrodotoxin (1 μM topical) and normobaric hyperoxia prevented somatosensory triggering of PIDs.

Conclusion:
PIDs are triggered upon O2 supply-demand mismatch transients in metastable peri-infarct hot zones due to increased demand or reduced supply. We propose that minimizing sensory stimulation and hypoxic or hypotensive transients in the early stages of stroke and brain injury would reduce PID incidence and their adverse impact on outcome.
Abstract W MP92: Role of Lipocalin 2 in Acute Ventricular Dilatation After Intraventricular Hemorrhage
Authors: Shishido Hajime , Xi Guohua , Keep Richard F , Hua Ya
Published: July 2021

Background:
Acute hydrocephalus is a common complication following hemorrhagic stroke. Although recent studies demonstrated that intraventricular hemorrhage (IVH) causes hydrocephalus, the exact mechanism by which hydrocephalus develops after IVH are not well understood. Lipocalin 2 (LCN2), a siderophore-binding protein, is an acute phase protein in the brain. In the present study, we examined the role of LCN2 in ventricular dilatation in a mouse model of IVH.

Methods:
First, female wild type C57BL/6 mice (WT, n=8) underwent a right intraventricular injection of hemoglobin (25mg/ml, 20 μl). Control mice (n=6) received saline injection. Ventricular volume was measured at 24 hours using magnetic resonance images. Second, female wild type and LCN2-deficient (LCN2-/-) mice had an intraventricular injection of hemoglobin (25mg/ml, n=5 for each; 50mg/ml, 20 μl, n=7 for WT and n=11 for LCN2-/-). They underwent magnetic resonance images at pre surgery and then 24 hours after surgery. All mice were euthanized at 24 hours after surgery. Brains were used for immunohistochemistry, immunofluorescence and Western blotting. Data are expressed as means±SD. P<0.05 was considered statistically significant.

Results:
In wild type mice, injection of hemoglobin (25 mg/ml) rather than saline resulted in ventricular dilatation at 24 hours (12.5±2.4 vs. 8.6±1.5 mm3 in the control, p<0.01). Western blotting showed that LCN2 was significantly upregulated in the periventricular area after hemoglobin injection (26362±4165 vs. 2780±579 pixels in the control, p<0.01). LCN2 was expressed in astrocytes, whereas its receptor was detected in astrocytes and microglia/macrophages. Hemoglobin-induced ventricle enlargement was less in LCN2-/- mice (p<0.01) as was periventricular microglia activation (p<0.01). At a higher dose (50 mg/ml), hemoglobin resulted in high mortality in WT mice (86%), but much lower mortality in LCN2-/- mice (27%; p<0.05).

Conclusions:
Our results indicate that LCN2 has a critical role in hemoglobin-induced ventricular dilatation.
Abstract W MP94: Neuroprotective Effect of Isosteviol Sodium on Focal Cerebral Ischemia in Rats
Authors: Hu Hui , Liu Qing , Tian Fang , Zhang Hao , Qu DaiXin , Gao Bing , Tan Wen
Published: July 2021

Background & Objective:
Isosteviol is a molecule derived from Steviaside which has been used as sweetener worldwide. In this study, sodium salt of isosteviol (STVNA) was given i.v. in rats hours after the transient or permanent middle cerebral artery occlusion (tMCAO or pMCAO) to investigate its therapeutic neuroprotective effects.

Methods:
In male Sprague-Dawley rats 2 hours tMCAO with reperfusion or pMCAO was induced and ischemia were confirmed by a laser doppler flowmetry simultaneously. In dosage study, animals were divided into 6 groups: sham, vehicle, or treatment with STVNA at dosage of 1, 5, 10mg•kg-1 or Edaravone 1 hour before the onset of reperfusion. In therapeutic time window study, animals were divided into 5 groups: sham, vehicle, STVNA (10mg•kg-1) at 0, 2 or 4 hours after reperfusion. In pMCAO study, animals were divided into 5 groups: sham, vehicle or STVNA (10mg•kg-1) at 1, 2 or 4 hours after ischemia. Rats were assessed for neurobehavioral deficits after 24 hours and sacrificed for infarct volume quantitation and histology evaluation. Proteomic analysis of the penumbra area in some rats used a Snaps G2x MS-TOF system.

Results:
In dosage study, the infarct volume of STVNA 10mg•kg-1 group was significantly less compared either with the vehicle group (22±2% vs 41±5%, p< 0.01) or with the Edaravone group (22±2% vs 30±3%, p< 0.05 ). The therapeutic window study shows that STVNA treated at 4h after reperfusion still has significant effects than vehicle group (32±4% vs 41±5%, p<0.05). In pMCAO study, the infarct volume of STVNA at 4h still decreased comparing the vehicle group(29±5% vs 50±6%, p< 0.05).In all STVNA treated groups the neurobehavioral deficits were significantly improved, and there are more restored NeuN-labeled neurons and alleviated TUNEL positive cells in penumbra in comparing with the vehicle group. Proteomic analysis indicates that proteins involved in various inflammations associated signal pathways were dramatically increased by tMCAO, and then were greatly reduced after treated with STVNA.

Conclusions:
STVNA exhibited remarkable neuroprotective effects when administered 4 hours after pMCAO or 4 hours after reperfusion of tMCAO. Since STVNA has low systemic toxicity, it may be a better alternative for the treatment of stroke.
Abstract W MP96: Low Dose Tissue Plasminogen Activator Amplifies Vascular Injury and Worsens Functional Outcomes in Acute Hyperglycemic Stroke Independent of the Model of Reperfusion
Authors: Hafez Sherif , Hoda Md Nasrul , Guo Xinyue , Fagan Susan , Ergul Adviye
Published: July 2021

Clinically, hyperglycemia (HG) exacerbates reperfusion injury and aggravates tPA-induced hemorrhagic transformation (HT). Yet, most of the experimental hyperglycemic stroke studies exclusively employed suture occlusion model. Only few studies involved tPA in hyperglycemic setting and employed a 10-fold higher dose of tPA than that is used in patients. Thus, in this translational study using suture and thromboembolic occlusion of middle cerebral artery (MCA), with and without human tPA dose, we tested the hypothesis that even acute mild HG worsens the neurovascular injury and functional outcomes irrespective of the method of reperfusion, and that the use of low dose tPA amplifies this injury.

Methods:
Control and mildly HG rats (140-200 mg/dl, achieved by 30% glucose ip injection 15 min prior to surgery, n=7-9/group) were subjected to MCA occlusion by either suture (90 min) or humanized clot and 24 h reperfusion. tPA (1mg/kg) was injected IV 2 h after induction of ischemia. At 24 h, neurological deficit, infarct size, edema, HT occurrence rate (HT index) and tissue hemoglobin (Hb) were measured.

Results:
Cerebral blood flow monitoring indicated that % drop at occlusion were similar across the groups and that low dose tPA effectively resolved the clot in the embolic model. tPA did not increase the infarct size in either control or hyperglycemic animals when compared to no tPA groups (Table). HG increased vascular injury (HT index and Hb content) in both suture and embolic occlusion models. The combination of HG and tPA exacerbated the vascular injury and worsened functional outcomes more than each alone.

Conclusion:
The interaction between HG and even low dose tPA has a significant deleterious effect on cerebrovasculature and functional outcomes independent of the method of reperfusion.
Abstract W P113: Prolonged Use of Clopidogrel and Aspirin and Stroke Risk in Intracranial Stenosis in SAMMPRIS
Authors: Holmstedt Christine , Lynn Michael J , Turan Tanya N , Derdeyn Colin P , Fiorella David , Lane Bethany F , Montgomery Jean , Janis L S , Nahab Fadi , Chimowitz Marc I ,   for the SAMMPRIS Investigators
Published: July 2021

Background:
In the SAMMPRIS trial, the use of combination aspirin and clopidogrel for 90 days after enrollment could be one reason that the outcome of patients in the medical arm was better than expected. The SAMMPRIS protocol required stopping clopidogrel after 90 days unless the patient had a non-neurological indication for continued use. We sought to compare outcomes in patients on vs. off clopidogrel beyond 90 days.

Methods:
For patients who did not have a primary endpoint within 90 days after enrollment (n = 397), we compared baseline features (t and Fisher’s exact tests), survival curves for the primary endpoint beyond 90 days after enrollment (the logrank test), and major hemorrhages (Fisher’s exact test) in patients on vs. off clopidogrel in the medical arm and stenting arms.

Results:
In the medical and stenting groups combined, baseline factors that were significantly (p<0.05) different between those on vs. off clopidogrel beyond 90 days (all higher in on clopidogrel group) were: age, diabetes, lipid disorder, coronary disease, SBP, and on antithrombotic agent at qualifying event. The table shows the primary endpoints and major hemorrhages in patients on vs. off clopidogrel in both treatment groups.

Conclusion:
This analysis, which was underpowered to detect even very large differences in event rates, suggests that prolonged use of clopidogrel plus aspirin may lower the risk of stroke in medically treated patients with intracranial stenosis, but increase the risk of major hemorrhage. Further studies with higher statistical power are needed to test this hypothesis.
Abstract W P117: Risk of Carotid Revascularization During the Acute Period According to Neurological Instability
Authors: De Rango Paola , Farchioni Luca , Lenti Massimo , Cieri Enrico , Verzini Fabio , Parlani Giovanbattista , Pelliccia Selena , Caso Valeria
Published: July 2021

Background:
Neurological instability may increase operative risks and decrease the benefit of early carotid revascularization in patients with carotid stenosis.

This study aims to define the risks after carotid revascularization performed during the acute period stratified for the presenting neurological event.

Methods:
Consecutive patients undergoing carotid revascularization in 2009-2014 during the acute period (within 15 days from the last neurological event) were reviewed. Thirty-day and 4-year stroke/death rates were analyzed in patients presenting with Transient Ischemic attack (TIA), recurrent TIA (more than one in the last 2 weeks before treatment) and stable stroke.

Results:
There were 227 patients (71% males; mean age 73.6y): 104 (45.8%) were treated after stable stroke. In 46 (20.3%) recurrent TIA were recorded before treatment. According to timing, 123 interventions were performed within the first 7 days and 36 within the first 48hours from index symptom. At 30-day there were 2 deaths, 1 fatal cerebral hemorrhage and 4 recurrent ischemic strokes. 30-day stroke/death rate was 1.6% in patients with TIA, 4.9% in patients with stroke, 4.5% in those with recurrent TIA. Multivariable analysis (backward stepwise) for 30-day stroke/death risk identified recurrent TIA presentation as the strongest independent predictor (Odds ratio,OR, 16.8; 95% Confidence Interval, CI, 1.47-191.7; P=.023), while stroke presentation was retained as a borderline statistical predictor (OR 14.8; 95%CI 0.96-228.6; P= 0.05). At 4-year, survival (86% vs. 94.9% P=.034) and freedom from stroke recurrence (90.4% vs. 97%; P=.055) rates were lower for patients with stroke presentation compared to other patients. Patients with recurrent TIA a showed comparable 4-year outcomes than other TIA patients (survival 94% vs 95% P=. 93; Stroke freedom rates 97% vs 97%; P=.86)

Conclusions:
For symptomatic patients undergoing carotid intervention during the acute period, presentation with recurrent TIA may expose to increased periprocedural 30-day stroke/death risk. Nevertheless, stroke remains a major marker of poorer late outcomes while recurrent TIA does not impact long-term survival and stroke recurrence.
Abstract W P120: Patterns of Vessel Involvement of Intracranial Stenosis in the Young
Authors: Mathew Jason , Strohm Tamara , Cerejo Russell , Katzan Irene , Uchino Ken
Published: July 2021

Introduction:
Intracranial stenosis in the young has various etiologies. We sought to identify patterns of vessel involvement of intracranial stenosis.

Methods:
This is a retrospective cohort study of young patients (≤50 years old) with intracranial stenosis seen in the stroke clinic of a tertiary center from 2008-2013. Patients were grouped by clinical diagnosis of 1. atherosclerosis (≥ 3 traditional risk factors ) 2. vasculitis ; 3. RCVS; 4. unknown etiology. Stenosis location and severity were compared among these groups based on cerebral angiography, CTA, or MRA.

Results:
A total of 128 patients were identified in this cohort. Of this cohort, presumed atherosclerosis (56%) was the most common etiology followed by unknown etiology (21%). Distinct patterns of stenosis were noted among these categories (see table). Atherosclerosis was more commonly identified in the anterior circulation (68.1%, p=.036). Moyamoya disease and the vasculitides had high predilection for MCA stenosis. RCVS showed a more diffuse vessel involvement which includes posterior circulation.

Conclusion:
Distinct of patterns of vessel involvement are seen among different etiologies of intracranial stenosis in the young. These patterns may help in determining the etiology of intracranial stenosis in this population.
Abstract W P126: Accurate Outcome Predictions for Intracerebral Hemorrhage Patients Are More Likely Than Inaccurate Predictions to Be Influenced by Co-morbidities Not Included in Clinical Scales
Authors: Hwang David Y , Dell Cameron A , Sparks Mary J , Watson Tiffany D , Langefeld Carl D , Comeau Mary E , Rosand Jonathan , Battey Thomas W , Koch Sebastian , Perez Mario L , James Michael L , McFarlin Jessica M , Osborne Jennifer L , Woo Daniel , Kittner Steven J , Sheth Kevin N
Published: July 2021

Introduction:
Clinical scales for intracerebral hemorrhage (ICH), such as the ICH and FUNC Scores, utilize a limited number of variables for outcome prediction. The variables that physicians incorporate into subjective predictions of ICH outcome and how they relate to predictive accuracy are unknown.

Hypothesis:
Accurate physician predictions of functional outcome for ICH patients are more likely than inaccurate predictions to incorporate decision-making factors outside of the variables comprising the ICH and FUNC Scores.

Methods:
For each consecutive adult patient admitted with primary ICH at 5 centers, one physician on the treatment team was surveyed for a prediction of modified Rankin Scale (mRS) at 3 months. All predictions were prospectively collected within 24 hours of admission. Physicians were also asked to indicate up to 10 factors influencing their prediction. Accuracy was defined as an exact prediction of the mRS obtained for each patient at 3 months. The frequency of recurring factors listed by physicians were calculated for both the accurate and inaccurate predictions and compared using Fisher’s exact test.

Results:
We collected 38 accurate and 86 inaccurate predictions for 124 ICH patients. There was no difference between groups with regards to the proportion of respondents listing age, ICH volume, or general clinical exam on admission as factors. However, 16 (42.1%) of the accurate surveys listed the patient’s general co-morbidities as a factor in prediction, compared to 20 (23.3%) of inaccurate surveys (p = 0.05). Listing of pre-morbid functional status as a factor also trended towards a higher percentage in the accurate survey group (n = 7, 18.4%, versus n = 6, 7.0%; p = 0.11). Of note, all surveys that cited the etiology of the bleed (n = 5), the initial blood pressure (n= 4), and the presence or absence of an extraventricular drain (n = 7) as influencing factors contained either overly optimistic or pessimistic predictions.

Conclusions:
Accurate predictions of ICH outcome are more likely than inaccurate predictions to factor in general patient co-morbidities, which are not included in ICH or FUNC Score calculation.
Abstract W P130: Recovery of "Cortical Deficits" after Thalamic Stroke Related to Changes in Functional Connectivity in Cortex
Authors: Hillis Argye E , Faria Andreia
Published: July 2021

Background:
Thalamic stroke can cause various “higher cortical” deficits, including impaired naming after left thalamic stroke and impaired emotional empathy after right thalamic stroke. Impaired naming is also associated with left inferior temporal gyrus (ITG) lesions, and impaired empathy with right ITG lesions. Deficits after thalamic stroke may be due to diaschisis, or dysfunction of cortex due to impaired input from thalamus. Changes in cortical function can be explored using resting state functional connectivity MRI (rsfcMRI). We tested the hypotheses that in patients with acute ischemic stroke restricted to left or right thalamus with naming/empathy impairment but no motor impairment, connectivity between left and right ITG (but not between left and right precentral gyrus; PrG) is (1) significantly different from that of controls within 3 days of stroke, and (2) normalizes over time with recovery of the naming/empathy impairment.

Methods:
We evaluated 7 patients with ischemic strokes restricted to the thalamus within 3 days of onset and 7 age-matched controls with rsfcMRI, structural and perfusion MRI, and testing of naming and empathy. Three patients had repeat imaging and cognitive testing.

Results:
Stroke patients showed significantly higher connectivity between left and right ITG at onset compared to controls (z score= 2.21 vs. 1.42; p=0.04), but showed no difference in connectivity between left and right PrG (z score= 1.87 vs. 1.70; p=0.53). Three patients who showed recovery of naming/empathy showed change in homologous connectivity toward more normal values in ITG, but less change (or change toward less normal values) in PrG from Time 1 to Time 2 (see Figure).

Conclusion:
In patients with thalamic infarcts, recovery of naming or empathy is associated with “normalization” of homologous connectivity in cortical regions thought to be critical for those cortical functions (e.g. ITG), consistent with recovery from diaschisis.
Abstract W P133: Combined Malignant MCA Plus ACA or PCA Infarcts Do Not Have a Worse Outcome Than Isolated Malignant MCA Infarcts in Patients One Year Following Decompressive Hemicraniectomy
Authors: Maali Laith , Abdelerahaman Khader
Published: July 2021

Background:
Malignant MCA infarction is a devastating disease associated with up to 80% mortality due to edema and herniation. Evidence from three European randomized trials show that decompressive hemicraniectomy (DHC) may improve functional outcomes in select patients. Adjacent cerebral territorial infarction often coincides with malignant MCA infarcts. This study compares the effects of isolated malignant MCA infarcts versus combined malignant MCA plus ipsilateral (ACA or PCA) infarcts on functional outcomes in patients surviving one or more years following DHC. We hypothesized that patients with no additional territorial involvement would have a better functional outcome.

Methods:
Retrospective analysis was performed on patients who underwent DHC for malignant MCA infarction from 03/2006 to 03/2012. Inclusion criteria include: Age 18-60, clinical and radiographical diagnosis of acute unilateral MCA stroke involving at least 50% of MCA territory, and DHC performed primarily to treat space occupying edema . Exclusion criteria include: Prestroke mRs of >2, life expectancy < 3 years, and death < 1 year after DHC. Patients were divided into two groups: (a) those with isolated MCA infarcts and (b) those with MCA combined with significant adjacent ipsilateral ACA or PCA involvement. Functional outcomes were calculated using the modified Rankin scale (mRs). The mean mRs was calculated for each group and the Wilcoxon-Mann-Whitney two tailed test was used to calculate statistical significance. Alpha level was set at p< 0.05.

Results:
A total of 26 patients met criteria. 20 patients had isolated MCA infarcts while 6 had combined MCA plus ACA or PCA infarcts. No statistical difference in functional outcome was observed between the isolated MCA group (x
-
=3.6) and the combined MCA group (x
-
=3.83) (p value=0.614).

Conclusion:
In this retrospective study, patients surviving one year after their DHC did not demonstrate a worse functional outcome due to additional cerebral territorial co-infarction. These findings argue against a major negative influence of combined infarctions on functional outcome compared to previous limited studies. Larger studies are needed to verify these results and to better assess criteria for ideal patient selection for DHC.
Abstract W P143: Ankle-brachial Index Predicts Extracranial Vascular Events After Transient Ischemic Attacks. Data From The Promapa Study
Authors: Purroy Francisco , Porta Sara , Jiménez-Caballero Pedro E , Jirón Juan María , Gorospe Arantxa , Torres María José , Jiménez-Caballero Carmen , Martínez-Sánchez Patricia , Martí-Fábregas Joan , García-Pastor Antonio , Casado-Naranjo Ignacio , Ramírez-Moreno José María , Segura Tomás , Masjuan Jaime
Published: July 2021

The ankle brachial index (ABI) is a known measure of lower-limb peripheral artery disease (PAD), as well as an independent predictor of vascular events. Various methods of ABI calculation have been described. The traditional method (ABI-TM) uses the higher ankle pressure as a numerator and it results in higher specificity. The alternative method (ABI-AM) takes the lower ankle pressure as numerator. It is associated with better sensitivity. Our goal was to compare the prognostic value of abnormal ABI (ABI <=0.9), determined by the two methods, in order to predict subsequent stroke and extracranial vascular events (EVE) in transient ischemic attack (TIA) patients from a multicenter study.

Methods:
We analyzed data from consecutive 1137 patients with TIA from the multicenter PROMAPA study in which ABI was determined. We determined risk of stroke recurrence (SR) and EVE (ischemic cardiopathy or peripheral arterial disease) at one year of follow up.

Results:
A total of 616 (54.2%) subjects fulfilled all inclusion criteria. The risk of SR and EVE was 4.7% and 2.1%, respectively. The proportion of abnormal ABI differed according to the method used: 11.5% ABI-TM versus 38.0 ABI-AM (p=0.001). In both situations, abnormal ABI was related to the association of >1 risk factors and large artery atherosclerosis. SR was not predicted by abnormal ABI. However, only abnormal ABI-AM was significantly associated with EVE (p=0.003). Cox proportional-hazards multivariate analyses identify the association of > 1 risk factors (Hazard Ratio [HR] 4.7, 95% CI 1.1-21.2. p=0.045) and abnormal ABI-AM (HR 4.0, 95% CI 1.1-14.6, p=0.035) as independent predictors of EVE.

Conclusion:
ABI using the lower ankle pressure as numerator is associated with EVE after TIA. The measurement of ABI using the lower ankle pressure as numerator among TIA patients appeared to be useful to identify patients with risk of EVE and to plan adequate prevention therapies or specific diagnostic protocols.
Abstract W P146: Clinical Characteristics of PFO Stroke in Pregnancy
Authors: Chen Lei , Deng Wenjun , Wickham Thomas R , McMullin D David , Eng H Lo , Buonanno Ferdinando S , Ning Mingming
Published: July 2021

Background:
Stroke can be a devastating complication of pregnancy. Patent foramen ovale (PFO), an incomplete closure of antenatal interatrial communication, may cause maternal stroke by allowing venous clots to travel directly to the brain. PFO is common in the general population (approximately 25%) and poses unique challenges during pregnancy. Clinically PFO is thought to increase the risk of stroke during pregnancy due to increased venous hypercoagulability in the peripartum period. However, data on PFO related stroke during pregnancy is lacking. We prospectively study the clinical characteristics of stroke in pregnant patients with and without PFO.

Method:
Following IRB-approved protocol, we prospectively collected and compared clinical characteristics of pregnant stroke patients with and without PFO over a 25 year period at our medical center.

Results:
Of 8134 PFO related stroke patients at our center, 24 patients had PFO related stroke during pregnancy. Compared to 46 age-matched pregnant stroke patients without PFO, PFO stroke patients had higher NIHSS scores at presentation (6.1 vs 3.8; P<0.05). While the two groups were similar in conventional risks such as hyperlipidemia, gestational diabetes, smoking, EtOH/drug use (Table), PFO patients had a trend toward lower incidence of hypertension (p=0.054), but statistically significantly higher incidence of hypercoagulable state (p=0.0004), migraine with aura (p=0.006), and May-Thurners Syndrome (p=0.001). (Table).

Conclusion:
PFO may pose unique risks compared to non-PFO related stroke in pregnancy. Novel risk factors such as May-Thurner’s anatomy, which promote venous clotting with the increase in abdominal girth are important during pregnancy. For high risk individuals (such as those with known hypercoagulable state), screening for PFO may be of clinical utility in preventing strokes. Further studies are ongoing to validate these preliminary findings.
Abstract W P148: Elevated Fibroblast Growth Factor 23 Associates with Greater White Matter Lesion Load and MRI-Defined Infarction: The Northern Manhattan Study (NOMAS)
Authors: Shah Nirav H , Dong Chuanhui , Santiago Maria , Elkind Mitchell S , Rundek Tatjana , Sacco Ralph L , DeCarli Charles , Wolf Myles , Wright Clinton B
Published: July 2021

INTRODUCTION:
Elevated fibroblast growth factor 23 (FGF23) regulates phosphate homeostasis and has been linked with mortality, cardiovascular events, and stroke. However, the role of FGF23 as a risk factor for subclinical cerebrovascular damage (SCVD) is not known.

METHODS:
We used multivariable linear and logistic regression to evaluate associations between FGF23, continuously and by quartiles, with white matter hyperintensity volume (WMHV), expressed as percent intracranial volume (%ICV), and subclinical brain infarction (SBI) in a race/ethnically diverse communitybased sample.

RESULTS:
There were 1,170 strokefree NOMAS participants with FGF23 levels and quantitative MRI data on WMHV and SBI. Participants with FGF23 levels in the top quartile (range=84.98 to1424.59 RU/mL) had greater WMHV (β=0.19 %ICV, 95% CI=0.04 to 0.33 %ICV, p=0.01) compared to those in the lowest quartile (range=15.41 to 48.96 RU/mL), adjusted for demographics, vascularrisk factors, and estimated glomerular filtration rate (eGFR). These findings remained significant in those without evidence of chronic kidney disease (CKD). The highest quartile of FGF23 also associated with greater odds of SBI, but this effect was not significant after adjusting for demographic factors and eGFR. However, sex was an effect modifier ofFGF23 in relation to odds of SBI (p for interaction=0.03). Stratified by sex, FGF23 was associated with greater odds of SBI in men (OR=1.7, 95% CI=1.0 to 2.6, p=0.03) after adjusting for demographics, vascular risk factors, and eGFR, but not among women.

CONCLUSIONS:
These crosssectional communitybased data from a diverse urban sample suggest elevated FGF23 may be a risk factor for small vessel disease, as well as MRIdefined brain infarction in men, independent of CKD. Prospective data on elevated FGF23 and SCVD are needed.
Abstract W P160: Elevated Lipoprotein A Levels Predict Worse Short-term Outcomes in Acute Ischemic Stroke
Authors: Samai Alyana A , Monlezun Dominique J , Shaban Amir , George Alexander , Cyprich Janelle , El Khoury Ramy , Martin-Schild Sheryl
Published: July 2021

Background:
Lipoprotein A (Lp(a)) is a risk factor for vascular disease; however, few studies have examined the relationship between serum levels of Lp(a) and patient outcomes in acute ischemic stroke (AIS). In this study, we sought to assess whether AIS patients with elevated Lp(a) levels exhibit characteristic differences in stroke severity, in-hospital complications, and short-term outcomes as compared to patients with normal Lp(a) levels.

Methods:
From our prospective stroke registry, patients consecutively admitted and diagnosed with AIS 07/2008-10/2013 were included if Lp(a) levels were measured during admission. Regressions, adjusting for key covariates, analyzed outcomes in patients with elevated (+) and severely elevated (++) Lp(a) with respect to normal (-) Lp(a). The primary outcome was poor functional outcome (modified Rankin Scale > 2) on discharge.

Results:
Among the 1,453 patients in our stroke registry, 159 patients met our inclusion criteria; 24 patients (15.1%) were in the +Lp(a) group and 37 patients (23.3%) in the ++Lp(a) group. After adjustment for total cholesterol, LDL, HDL, and triglycerides, patients with ++Lp(a) were more than twice as likely to experience poor functional outcome (OR=2.48, 95% CI 1.0781-5.7231, p=0.033) as those with -Lp(a). Adjusting for age, NIHSS baseline, history of diabetes, admission glucose level, and tPA administration, patients with ++Lp(a) were more than 2.5 times more likely to experience poor functional outcome (OR=2.59, 95% CI 1.0129-6.6282, p=0.047) as compared to those with -Lp(a).

Conclusions:
Lp(a) elevation predicts higher odds of poor functional outcomes for patients with AIS compared to patients with normal levels. Our findings support the utility of Lp(a) level as a clinically useful biomarker in the development of patient risk profiles.
Abstract W P166: Transient Ischemic Attacks In Post-menopausal Women With History Of Migraines Have Lower Risk For Subsequent Ischemic Strokes
Authors: Rahman Haseeb A , Thomas Abraham P , Malik Ahmed A , Qureshi Adnan I
Published: July 2021

Background:
TIAs and migraines have both been found to increase the risk of ischemic strokes. The risk for ischemic strokes may be further increased in patients with both of these risk factors.

Objective:
To compare the risk of ischemic strokes in women with and without a history of migraine following a TIA.

Methods:
The Observational Study (OS) of the Women’s Health Initiative (WHI) was the observational component of the WHI Study. We analyzed the 93,676 women aged 50-79 years, who participated in the OS over a period of 12±1 years. We determined the risk of incident ischemic stroke following TIAs in women with and without history of migraine. A logistic regression analysis was used to determine the differential risk of ischemic stroke in women with and without history of migraine after adjusting for potential confounders.

Results:
A total of 133 of the 93676 women without history of migraine and 20 women with history of migraine from the same population developed ischemic strokes. Logistic regression analysis demonstrated that women without history of migraine had a higher odds of developing ischemic stroke [OR 1.9 (95%CI 1.5-2.5) p<.0001] compared with women without TIA after adjustments were made for age, systolic blood pressure, alcohol intake, carotid endarterectomy, DVT, pulmonary embolism, bleeding problems, oral contraceptive use, and hormone replacement therapy. There was not a higher risk of subsequent ischemic stroke among women with migraine history after TIA [OR 1.5 (95%CI 0.7-3.3); p =0.3]

Conclusions:
The risk of ischemic stroke is lower following TIA in women with migraine history (compared with those without migraine) suggesting potentially different pathophysiology in such women.
Abstract W P191: Patient Compliance High with Long-Term Continuous ECG Monitor
Authors: Lenane Judith C , Fought Angela J , Alexander Jay H
Published: July 2021

Introduction:
Long term ECG monitoring to detect atrial fibrillation in a cryptogenic stroke is now the emerging standard of care. The advent of patch based ECG monitors raises the question of patient compliance with this new modality.

Hypothesis:
We assessed the hypothesis that patient compliance, as measured by Leads-On detection for patch based ECG monitoring, is constant over time.

Methods:
We performed a retrospective analysis from ZIO® Patch (Patch) devices (iRhythm, San Francisco, CA). The Patch is a continuous recording single lead ECG monitor that can be worn for up to 14 days. The primary endpoint of Leads-On is the percentage of time the device is applied to the patient during the wear period, which was derived from a second channel in the device. The data are gathered by ZEUS software and exported in a CSV file. The compliance data were analyzed overall and in categories at days: 0-1, 1-2, 2 to 7, >7 to 10 and >10 to 14. A secondary endpoint, percent Analyzable Time (percentage of ECG record that was available for detection by the algorithm during the wear period and signifies signal quality), was assessed for the same time increments.

Results:
The dataset consisted of 18,885 records. The total wear time ranged from 0.10 up to 14.01 days, with a median of 12.51. The medians and interquartile ranges for the percent Leads On and percent of Analyzable Time were 100% (99.99-100%) and 97.99% (94.64-99.26%). In Table 1, the interquartile ranges for percent Leads On and Analyzable Time was wider when the Patch was worn less than a day, but remains above 74%.

Total wear time in days n Percent Leads On Percent Analyzable Time

Median Interquartile Range Median Interquartile Range

0.10-<1 105 99.65 86.52-100 92.86 74.19-96.97

1-<2 407 100 99.88-100 97.37 90.96-99.02

2-<7 4124 100 100-100 97.96 94.3-99.26

7-<10 2963 100 99.98-100 97.79 94.33-99.19

10+ 11286 100 100-100 98.07 95.00-99.29

Conclusion:
Patient compliance with long term ECG patch monitors is high as measured by Leads-On detection. High patient compliance results in a large volume of quality ECG. Further study is needed to compare patient compliance with ECG patch based monitors with other monitoring modalities, particularly in the cryptogenic stroke population.
Abstract W P193: Clinical Usefulness of Contrast-Enhancement Cardiac Magnetic Resonance on Detecting Left Ventricular Thrombus in Acute Ischemic Stroke
Authors: Takasugi Junji , Yamagami Hiroshi , Noguchi Teruo , Morita Yoshiaki , Tanaka Tomotaka , Yasuda Satoshi , Toyoda Kazunori , Nagatsuka Kazuyuki
Published: July 2021

Objective:
Although anticoagulants are recommended in patients with left ventricular (LV) thrombi following myocardial infarction (MI) or LV dysfunction for preventing ischemic stroke, it remains unknown what imaging modality is useful. We sought to detect LV thrombi in acute ischemic stroke patients using contrast-enhancement cardiac magnetic resonance (CE-CMR).

Methods:
Between February and July 2014, 232 consecutive patients with acute ischemic stroke were admitted to our stroke center within 48 hours after the onset. Among them, patients with a prior MI or systolic LV dysfunction (LV ejection fraction [LVEF] <50%) were prospectively enrolled. CE-CMR and conventional transthoracic echocardiography (TTE) were performed within 7 days from admission. Clinical characteristics and parameters of CE-CMR were analyzed to predict LV thrombus.

Results:
Twenty-two patients (18 men, 74±12 years old) were enrolled. They consisted of 14 (64%) patients with a prior MI and 8 (36%) patients with LV dysfunction. Two (9%) patients had been treated with anticoagulants before the onset of stroke. The stroke subtypes were classified as follows; cardioembolism in 16 (73%), large-artery atherosclerosis in 3 (14%), small-vessel occlusion in 1 (4%), and others in 2 (9%). LV thrombus was identified in 4 patients (18%) by CE-CMR, whereas only 1 patient was detected by TTE. The locations of LV thrombi were apex (n=2), inferior wall (n=1), and lateral wall (n=1), respectively. Patients with LV thrombus had significantly larger LV end-diastolic (275±89 vs. 182±55ml, p = 0.011) and end-systolic volumes (229±88 vs. 114± 52ml, p = 0.009), and lower LVEF (18±6 vs. 40±11%, p = 0.006) than those without.

Conclusion:
In acute ischemic stroke patients with prior MI or LV dysfunction, CE-CMR was a useful tool for detecting LV thrombus in comparison with TTE. CE-CMR could identify the patients who need anticoagulant therapy.
Abstract W P201: New Echocardiographic Indicator for Cardioembolic Stroke
Authors: Kim Yerim , Kim Chi Kyung , Jung Seunguk , Kim Tae Jung , Ko Sang-Bae , Yoon Byung-Woo , Lee Seung-Hoon
Published: July 2021

Background:
In many cardioembolic (CE) strokes, the specific embolic source might be uncertain. Despite the high mortality of CE stroke, we do not pay attention enough for the potential CE sources. Although atrial fibrillation (Af) is the most common cause of embolic sources, more complex and dynamic multiplicity of the cardiac sources may influence CE stroke. The aim of this study was to evaluate the new echocardiographic indicators which have been underestimated as low-risk CE sources.

Methods:
One thousand eight hundred twelve patients with acute ischemic stroke who had a transthoracic echocardiogram during admission were identified. We classified patients into 2 groups of potential CE and non-CE. In patients with undetermined etiology, we excluded patients who had definite non-CE sources such as vasculopathy, hypercoagulable state, hematologic disorder and patients with incomplete evaluation. Thereafter, a stroke neurologist reviewed all of the magnetic resonance images.

Results:
Among a total of 1812 patients, 575 (31.7%) had potential CE infarctions. About half of the patients with CE etiology had Af. Patients with potential CE etiology were more likely to have larger left ventricular end-diastolic diameter, left ventricular end-systolic diameter, left atrial size, mitral ratio of peak early to late diastolic filling velocity (E/A) and smaller ejection fraction. After adjusting for multiple echocardiographic variables including Af, binary logistic regression demonstrated that E/A >2.0 had a significant predictive value for CE stroke (OR 3.45, 95% CI: 1.43-8.36, p<0.01). After dichotomizing by gender, the statistical significance remained only in female group. (OR 9.71, 95% CI: 1.96-48.04, p<0.01)

Conclusion:
Diastolic dysfunction might be a predominant embolic source. The E/A>2.0 is a significant predictor of CE stroke and provides prognostic information incremental to left ventricular systolic function.