bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P190: Are There Differences Between US and UK Adults in Stroke Preparedness? Evidence From Parallel Population-Based Community Surveys
Authors: Dombrowski Stephan , Ford Gary , Morgenstern Lewis , White Martin , Sniehotta Falko F , Mackintosh Joan , Gellert Paul , Skolarus Lesli
Published: July 2021

Background:
Given that pre-hospital delay is the main reason for tPA underutilization, increasing stroke preparedness (i.e. the ability to recognise stroke and contact EMS immediately) is crucial. We sought to determine whether between-country differences exist in stroke preparedness between two different health care systems; US (insurance-based) and UK (universal).

Methods:
A survey was mailed to population-based samples in Ingham County, Michigan, USA (n=2500) and Newcastle upon Tyne, UK (n=2500). Locations were chosen based on their similar population size and rates of unemployment. Newcastle upon Tyne has a higher population density and fewer racial/ethnic minorities than Ingham County. The survey included 12 stroke and 4 non-stroke scenarios followed by a stroke recognition and behavioural intent question and recorded respondent demographics and past stroke history. Descriptive statistics were used to summarize stroke recognition and preparedness. Linear regression models explored the association of country with stroke recognition and behavioural intent after accounting for demographics and stroke history.

Results:
Response rates were 27.4% (n=1369) overall (21.7% US, 33.0% UK). Respondents were on average 55 (SD=17) years old (US 56, UK 54) and 58% were female (US 56%, UK 59%). Compared to UK respondents, US respondents were better in recognizing stroke (70% vs. 63%, t(1355)=-4.9, p<0.001, d=0.27) and stating they would call EMS for witnessed stroke (55% vs. 52%, t(1365)=-2.0, p=0.045, d=0.11). Accounting for demographics and stroke history, US respondents were more likely to correctly recognize stroke (β=0.16, p<0.001) and respond appropriately (β=0.06, p=0.04) than UK respondents.

Conclusions:
US respondents were better at recognising and responding to stroke based scenarios than UK respondents, but response was poor in both groups. Potential reasons for between-country effects will be discussed. Overall, significant gaps in knowledge and behavioural intent remain in both health care systems and suggest the need for aggressive public health based campaigns to improve stroke preparedness.
Abstract T P207: Matrix Metalloproteinase 3 (MMP3) Exacerbates the Hemorrhagic Transformation in Hyperglycemic Stroke
Authors: Hafez Sherif , Abdelsaid Mohammed , Hoda Nasrul , Coucha Maha , Fagan Susan , Ergul Adviye
Published: July 2021

Acute hyperglycemia (HG) worsens stroke outcomes and increases the risk of cerebral hemorrhage especially with the co-administration of tissue plasminogen activator (tPA). MMP3 mediates tPA-induced hemorrhagic transformation (HT) after stroke. However, the role of MMP3 in hyperglycemic stroke is unknown. The working
hypothesis
of the current study is that HG upregulates MMP3 activity and worsens vascular injury after stroke and this response is independent of the method of reperfusion.

Methods:
Control and mildly HG rats (160-200 mg/dl, achieved by 30% glucose injection (i.p.) 15 min prior to surgery, n=7-9/group) were subjected to either 90 min middle cerebral artery (MCA) suture occlusion and 22.5 h reperfusion, or to humanized thromboembolic stroke. At 24 h, neurological deficit, infarct size, edema, HT occurrence rate (HT index) and tissue hemoglobin (Hb) were measured. MMP3 activity in isolated cerebral microvasculature and/or brain homogenates was quantified by FRET assay. In addition, MMP-3 expression was assessed in brain microvascular endothelial cells (BVEC) subjected to 90 min hypoxia followed by 22.5 h reoxygenation.

Results:
While HG did not increase infarct size when compared to control animals, this mild elevation in blood glucose (BG) significantly increased vascular injury indicated by HT index, edema and Hb content in ischemic hemispheres . This was associated with a significant increase in MMP3 activity in both cerebral micro-vasculature and brain homogenates (Table, *p<0.05 vs control). In vitro, the combination of hypoxia and HG has increased MMP3 expression more than each alone (*p<0.05 vs control).

Conclusion:
Even mild elevations in BG increased MMP3 activity and augmented vascular injury following ischemic stroke. Our findings suggest that MMP3 might be playing an important role in worsening the outcomes in hyperglycemic stroke and MMP3 inhibition may be a potential therapeutic target.
Abstract T P213: Post-stroke Administration of Ethanol and Normobaric Oxygen Preserves Oxidative Metabolism by Modulating Pyruvate Dehydrogenase Complex in Transient and Permanent Ischemic Stroke
Authors: Elmadhoun Omar , Peng Changya , Geng Xiaokun , Guthikonda Murali , Ding Yuchuan
Published: July 2021

Background:
Ischemic stroke induces metabolic disarray where the entire framework of cellular metabolism is altered. A central regulatory site, Pyruvate Dehydrogenase Complex (PDHC) sits at the cross-roads of two fundamental metabolic systems: the citric acid cycle and glycolysis. Down regulation of PDHC has been proposed to explain impaired brain catabolism after ischemic injury. In this study, we combined ethanol and normobaric oxygen (NBO) to develop a powerful non-drug treatment to modulate PDHC and its regulatory proteins, namely PDPhosphatase and PDKinase, leading to improved metabolism and reduced oxidative damage.

Methods:
Sprague-Dawley rats were subjected to transient (4h) or permanent (24h) middle cerebral artery occlusion followed by 24 hours reperfusion or no reperfusion. Rats received IP injections of saline, two doses of Ethanol (EtOH, 1.5 at onset of reperfusion followed by 1.0 g/kg in 2 hours) for transient stroke or EtOH+95%NBO (for 6 hours) for permanent stroke. Infract volume and the protein levels of PDHC, PDK, and PDP were all assessed. Oxidative metabolism was determined by ADP/ATP ratios and ROS levels.

Results:
Our therapy enhanced the oxidative metabolism profile of the cell by decreasing ADP/ATP ratios and ROS levels. In transient ischemia, administration of EtOH significantly raised the levels of PDHC and PDP in the ischemic brain issue and simultaneously decreased PDK levels. NBO combined with EtOH synergistically had better outcomes in the permanent ischemic stroke group, as compared to EtOH or NBO alone.

Conclusion:
EtOH and NBO treatment confirms neuroprotection in stroke by affecting brain catabolism. It modulates the damaging cascade of events by bringing the concentration of active PDHC activity back to metabolic levels.
Abstract T P235: Clinical Significance of Continuous Antihypertensive Therapy Throughout the Initial 24 Hours in Hyperacute Intracerebral Hemorrhage: The Samurai-ich Study
Authors: Kobayashi Junpei , Koga Masatoshi , Tanaka Eijiro , Okada Yasushi , Kimura Kazumi , Yamagami Hiroshi , Okuda Satoshi , Hasegawa Yasuhiro , Shiokawa Yoshiaki , Furui Eisuke , Nakagawara Jyoji , Kario Kazuomi , Okata Takuya , Arihiro Shoji , Sato Shoichiro , Nagatsuka Kazuyuki , Minematsu Kazuo , Toyoda Kazunori
Published: July 2021

BACKGROUND and PURPOSE:
Blood pressure (BP) lowering may be beneficial for patients with hyperacute intracerebral hemorrhage (ICH). Although several trials including INTERACT 2 and ATACH II have a design of the strict BP lowering during the initial 24 hours, shorter duration may be enough since active bleeding may not last 24 hours. We aimed to examine the associations between sequential systolic BP levels during antihypertensive treatment (AHT) and clinical outcomes in acute ICH patients.

METHODS:
Hyperacute (180 mmHg were registered in a prospective, multicenter, observational study, the SAMURAI-ICH study (Koga J Hypertens 2012;30:2357). All patients received intravenous AHT, based on a predefined standardized protocol to lower and maintain SBP between 120 and 160 mmHg using intravenous nicardipine. BPs were measured hourly in the initial 24 hours. The mean of 8 SBP levels during 1 to 8, 9 to 16, and 17 to 24 hours after the initiation of AHT were calculated, and referred to as the 1st, 2nd and 3rd mSBPs, respectively. The associations between mSBPs and neurological deterioration (a decrease of ≥2 in GCS or an increase of ≥4 in NIHSS score), hematoma expansion (>33% in volume), and unfavorable outcome (modified Rankin Scale score 4-6 at 3 months) were assessed.

RESULTS:
211 patients (81 women, median age 65 [IQR, 58-74] years, median initial NIHSS score 13 [8-17]) were included. The baseline hematoma volume was 10.2 (5.6-19.2) mL. Neurological deterioration was observed in 17 patients (8%), hematoma expansion in 36 (17%), and unfavorable outcome in 87 (41%). The 1st, 2nd, and 3rd mSBPs were 132 (126-138), 131 (125-140), and 137 (130-144) mmHg, respectively. The 1st (OR 2.41, 95%CI 1.34-4.69 per 10-mmHg) and 2nd mSBPs (2.08; 1.20-3.80) were independently associated with neurological deterioration (17 patients) and the 2nd (1.40; 1.02-2.00) and 3rd mSBPs (1.45; 1.05-2.05) were associated with unfavorable outcome (87 patients), although no mSBPs were associated with hematoma expansion (36 patients).

CONCLUSIONS:
Continuation of AHT throughout the initial 24 hours may ameliorate clinical outcomes.
Abstract T P24: Endovascular Thrombectomy in Non-Intubated Patients for Basilar Artery Occlusive Disease is Associated With Improved Outcomes
Authors: Jadhav Ashutosh P , Starr Matthew , Juuma Mohammad , Syed Zaidi , Hammer Maxim , Reddy Vivek , Jankowitz Brian , Wechsler Lawrence , Jovin Tudor
Published: July 2021

Background and Purpose:
Basilar artery occlusive disease is associated with poor outcomes and high rates of mortality in the absence of recanalization. Intra-arterial thrombectomy can lead to improved outcomes in a subset of patients, but the determinants of these outcomes are poorly understood. Patients are often routinely intubated prior to thrombectomy for concern of poor mental status and potential procedural complication risk in an uncooperative patient, however intubation itself carries an associated complication profile. We sought to understand the outcomes in patients undergoing thrombectomy with intravenous conscious sedation (IVCS) versus general anesthesia (GA).

Methods:
A review of our prospectively maintained endovascular stroke database identified 103 patients presenting with basilar occlusion.

Results:
79 patients underwent GA and 24 patients underwent IVCS. There were no significant differences in age, gender or stroke risk factors between the two groups. The average NIHSS was higher in the GA group versus the IVCS group (21 vs. 14, p=0.006)- this variable was also controlled for as a potential confounder in the multivariate analysis. Rates of TICI 2b/3 recanalization had a trend towards being slightly higher in the IVCS group (92% vs 84%, p=0.26). In the GA group, there was a trend towards higher rates of wire perforation (9% vs 0%, p=0.14) and hemorrhage (11% vs 0%, p=0.08), and there was a significantly higher incidence of in-hospital death (47% vs 17%, p=0.008). In the IVCS group, there was a higher rate of good outcomes (mRS 0-2 at 3 months, 63% vs 23%, p=0.00045). In multivariate analysis, the following variables were significantly associated with good outcomes: lower age (p 0.010), TICI 2b/3 recanalization (p=0.040) and IVCS (p=0.0035).

Conclusions:
In addition to age and TICI 2b/3 quality recanalization, the use of IVCS is associated with improved outcomes in patients with basilar artery occlusive disease undergoing thrombectomy. These data also suggest the safety and efficacy of endovascular thrombectomy in non-intubated patients. Routine and elective intubation of patients undergoing IA therapy should be avoided if possible as it may be associated with higher complication rates and poor outcomes.
Abstract T P251: Factors for Delayed Medical Care Seeking among Elderly Stroke Patients in Korea
Authors: sim Jeongha , Ahn Dongchoon , shin cha-nam
Published: July 2021

Background:
Stroke is the second leading cause of death in Korea and the prevalence of acute ischemic stroke among older adults continues to grow, which is known to be related to delayed hospital arrival after the onset of symptoms. Thus, decreasing the incidence of elderly stroke is a major health promotion objective in Korea, yet little is reported about the factors associated with the delayed medical care seeking behavior among elderly stroke patients in Korea.

Purpose:
The purpose of this study was to understand factors of delayed medical care seeking among elderly stroke patients in order to develop intervention strategies to improve the health of this population.

Methods:
A cross-sectional, descriptive study was conducted in a convenience sample of 233 hospitalized elderly patients with acute ischemic stroke using a self-administered survey. Descriptive statistics and chi-square test were used for data analysis.

Results:
More than half of them were male (60.5%) with age of 61 and older (76.9%), and relied on the opinion of their children or friends when deciding medical care for stroke (58.3%). Regarding the reasons of seeking medical care, there was no statistical significance between individuals who arrived at a hospital within three hours of the onset of symptoms and who arrived after three hours. Reasons for delayed hospital arrival were significantly different between groups (individuals of hospital arrival within three hours vs. individuals with hospital arrival after three hours), which include lack of knowledge about the severity of stroke and unawareness of symptoms (χ2 = 24.1), or inconvenience of a hospital visit, waiting for the effects of alternative medications, and stroke during sleep (χ2 = 55.1) with p <0.001.

Conclusions:
In conclusion, this study helped identify factors delaying hospital arrival after the onset of symptoms among Korean elderly stroke patients. Interventions should include stroke education focusing on the severity of stroke and related symptoms. The stroke education should target not only elderly stroke patients but their family members and friends. It may result in overall national health by decreasing prevalence of stroke among Korean elderly population.
Abstract T P256: Effective Strategy for Implementation of Swallowing Assessment in the Acute Stage of Stroke
Authors: Schaarup Susanne Z , Christensen Hanne
Published: July 2021

Background and Purpose:
Dysphagia affects between one and two thirds of patients with acute stroke. According to the Danish national guideline, the standardized instrument “Gugging Swallowing Screen (GUSS)” including an indirect and a direct test of swallowing is the optimal method for swallowing assessment. The instrument has been translated to Danish form the original developed and validated. A strategy for implementation GUSS was started in January 2012. The aim of this report is to document the strategy and the results of this strategy.

Methods:
Guided by the conceptual model for implementing improvements “Plan-Do-Study-Act” the strategy included following steps in the study period from January 2012- December 2012: 1. A steering committee representing nursing staff and occupational therapist was created. All nurses were educated in the use of GUSS theoretically and practical with bedside following up. A “screening package” including all instruments needed for the assessment and a registration form was made. 2. The implementations process was monitored.3. Monthly and early reports from the Danish Stroke Register on goal achievements in % of patients tested indirectly and directly on the admission day, respectively were studied. Depending on the results a plan for improvement e.g. a gatekeeper function was organized

Results:
Data in The National Stroke register for the year 2012 showed that 599 patients were admitted with stroke within the study period. Indirect swallowing test: % patients assessed on the day of admission: 87% (95%CI 69-80%) (359 in 416 relevant patients) - an improvement from the year 2011 75% (69-80) 95 %CI (200 in 268 relevant patients).Direct swallowing test: % patients assessed on the day of admission: 86% (95%CI 83 - 89%) (359 patients in 416 patients) an improvement from the results in 2011: 71% (95%CI 66-75) (241 in 339 relevant patients); 525 patients were admitted with symptoms of stroke in 2011.

Conclusions:
The instrument “Gugging Swallowing Screen GUSS” has effectively been implemented in the acute stroke unit in our institution, and had improved the goal achievement. The standard of 80% defined by the national steering group for both indicators has been achieved in 2012.
Abstract T P264: Start the Clock- Stop the Clot- Decreasing Door to tPA Times
Authors: Deitch Cheryl , Cummins Jennifer
Published: July 2021

Background and Purpose:
A process improvement project was identified in 2012 by our hospital stroke committee surrounding timeliness of administering tPA to eligible patients. Stroke committee members came together to identify these barriers and develop a more efficient process of administering tPA. The purpose of this project was to decrease our door to needle times. Our average door to needle times for the previous two years was 77 minutes. Opportunities for improvement that were identified prior to implementation included decreasing turn around times for laboratory studies, delayed decision making by patient and/or family, and time needed to perform additional clinical tasks.

Methods:
A door to needle performance improvement team was formed. They first reviewed past cases to determine reasons for delays and used performance improvement techniques to determine current and ideal states and gaps in the process. The team discovered that staff needed a single resource with all of the necessary policies and procedures they would need to administer tPA. A reference folder was created that included job cards for all members of the care team identifying their roles and duties; checklists with procedural steps; patient education materials; tPA precaution signs, and inclusion/exclusion criteria checklist. Several other strategies implemented included purchasing timers to remind staff of target times, having designated IV pumps for tPA use only, and partnering with the Laboratory to expedite results. The final step in our process was to educate the staff on this process change and provide feedback on successes and opportunities for improvement.

Results:
For the most recent year 7/1/2012-6/30/2013- 10 out of 11 (90.9%) patients receiving tPA did so within 60 minutes.

Conclusions:
By implementing this targeted approach to administering tPA in less than 60 minutes, we have achieved for the third time in a row, the Target Stroke Award through Get with the Guidelines/American Heart Association. Within our health system, we are the only facility that has achieved this goal.
Abstract T P278: HASTe: A Team Approach to Improving Pre-Hospital and ED Delays in Stroke Care
Authors: Dofredo Melissa , West Angela
Published: July 2021

Background:
Despite an array of available guidelines and research, many organizations continue to seek innovative ways to decrease time delays and enhance their stroke care delivery systems. After dissecting the case of an acute ischemic stroke (AIS) patient cared for in our facility, many delays were noted from onset of symptoms until admission to ED.

Purpose:
The purpose of the HASTe (Hyper Acute Stroke Team) initiative is to utilize a case-study approach to discover pre-hospital and ED delays, and offer quality improvement project ideas that can be used to enhance stroke-care delivery systems.

Methods:
With leadership from the Stroke Program Director, 15 neuro-critical care nurses formed the HASTe to ameliorate delays noted in AIS care. A case-study review of an AIS patient led to a schematic timeline map which demonstrated minutes lost at each area of delay. Identified areas of delay included lack of community knowledge on stroke, preventative delays in Emergency Medical System (EMS) on-scene time, lack of updated AHA/ASA guideline knowledge at an outside facility ED, inefficient transfer processes to our facility for endovascular intervention, and technical delays in electronic medical record entry. All of these factors contributed to time lost for reperfusion therapy.

Results:
Pre-hospital and ED delays contributed to approximately 120 minutes lost. After analyzing these delays, the HASTe initiated several performance improvement projects to address the delays. Community and EMS presentations covering the urgency of stroke were created. Connections were made with outside facility ED educators to offer in-services on AHA/ASA updates. Improved transfer processes were coordinated with local EMS administration and private ambulances. A pre-admitted “John Doe-Stroke” medical record was created for potential stroke patients coming in to our ED.

Conclusions:
A team approach such as the HASTe is an innovative way to integrate knowledge gleaned from individual case studies to induce coordinated performance improvement projects that affect the community, EMS, and ED. Further case study reviews can reveal other areas in which the HASTe can positively affect change in the continuum of stroke care.
Abstract T P279: Recognizing Depression in the Stroke Patient
Authors: Donnelly Rose M , Burns Jo-Ann
Published: July 2021

Depression is a frequent sequela of stroke that has been associated with poor recovery and rehabilitation response. Clinical depression may occur within 3 months post stroke and can last for several years if left untreated.

Utilization of a depression screen helps identify patients at risk for post-stroke depression.

It is important to recognize and treat depression symptoms early to improve patient outcomes.

In performing a gap analysis in preparation for our survey for Comprehensive Stroke Center Certification, it became apparent this psychological aspect of patients was not being met. A systemic literature review was performed in search of a depression screening tool that was easy to use and addressed the needs of the patient. The tool chosen is the validated 2-item Patient Health Questionnaire depression module (PHQ-2). This depression screen is also utilized in our rehabilitation center which enhances the communication between our facilities.

After educating all the neuroscience nursing staff and stroke physicians, the tool became part of the patient assessment. The nurse screens each stroke patient on admission to the division or transfer from the intensive care unit. If the patient scores 3 or greater, the physician is notified so appropriate follow-up and treatment can occur. If a patient is unable to be assessed, the physician is notified so other depression assessment measures can be considered.

The utilization of a depression screening tool along with staff education has increased our staff’s awareness of the potential devastating effects depression can have on stroke recovery.
Abstract T P305: Fragmented Care Among Stroke Patients at 4 Chicago Hospitals
Authors: Corado Carlos , Cashy John , Kho Abel , Prabhakaran Shyam
Published: July 2021

Background/Objective:
Stroke patients may be unable to provide medical history. Given the urgency of decision-making in acute stroke and importance of medication compliance post-stroke, prompt access to prior health records could reduce delays and errors. We hypothesized that stroke patients often have fragmented care in the Chicago Health Atlas.

Methods:
The Chicago Health Atlas encompasses clinical data on over 1 million unique patients within the 606xx ZIP codes of Chicago. A unique ID is created for each patient through the use of a secure one-way hash function. The creation of a unique ID enables longitudinal tracking of a patient’s care across participating sites. We identified all acute stroke admissions to any of 4 Chicago Health Atlas hospitals using ICD-9 codes (430-436) and searched for prior inpatient or outpatient encounters at any of those sites. Fragmented care was defined as having prior encounters at a site different from the site of stroke hospitalization. In the same cohort, we assessed post-hospitalization outpatient encounters within the Health Atlas.

Results:
There were 5,980 stroke patients with emergency department or inpatient visits between 2006 and 2010. Of these, 3,732 (62.4%, mean age 61.1 years, 47% black) had non-fragmented care prior to stroke while 2,066 (34.5%, mean age 58.1 years, 31% black) were completely new encounters (first-ever) in the Health Atlas and only 182 (3.0%, mean age 57.5 years, 59% black) had fragmented care. The percent with fragmented care increased from 1.3% in 2006 to 3.3% in 2010 (p<0.001 for trend). Rates of follow-up within following 12 months varied across the 3 groups (non-fragmented: 75% and fragmented: 64% vs. new: 51.4%; p<0.001).

Conclusions:
Two-thirds of stroke patients have previously accessed the health care system, with a majority having records at the same site of stroke hospitalization. However, 3% of patients have fragmented care, a rate that is increasing over time. Our estimate of fragmentation may be an underestimate since only 4 sites were included in this analysis. Having health information exchange may be valuable in reducing fragmentation of care for stroke patients.
Abstract T P332: Despite Differences in Device Design, Anticoagulation, and Duration of Use, Pulsatile- and Continuous-Flow Left Ventricular Assist Devices Share Similar Stroke Rates and Outcomes
Authors: Burton Tina M , Davis Erin S , Tanana Michael J , DeWitt L Dana , Wold Jana J , Selzman Craig H , Majersik Jennifer J
Published: July 2021

Background:
Stroke is the primary adverse outcome in Left Ventricular Assist Devices (LVADs), not well-described in current literature. We hypothesized that pulsatile-flow devices would have worse stroke rates and outcomes than continuous devices.

Methods:
This is a single-center retrospective study of all adult LVADs from 1999-2013 at the University of Utah utilizing the internal LVAD and Stroke Center databases. Complete chart review included review of all relevant outside records with no case loss. Categorical variables were computed using a χ
2
test; ordinal variables via the Mann-Whitney U test.

Results:
Among 52 pulsatile (47 patients) and 91 continuous (81 patients) devices, 17.3% of pulsatile and 18.7% of continuous devices had at least one stroke/TIA (p=0.84). Stroke subtypes and LVAD-specific outcomes did not vary by device. Stroke severity was higher at first stroke/TIA with a median (IQR) NIHSS of 4 (2, 11) vs. 1 (1, 2) in continuous vs. pulsatile devices (p=0.03). Despite continuous devices having nearly twice the number of overall days on device (DOD), there was no difference in median DOD until first stroke/TIA: 170 in pulsatile; 165 in continuous; p=0.56. Stroke outcomes by device were good with mRS≤2 in 71% of pulsatile and 53% of continuous devices (p=0.42). All-cause 1-year mortality was high but with only the minority due to stroke (Table 1). Neither sepsis nor pump thrombus were associated with stroke/TIA.

Conclusions:
Continuous devices provide longer DOD without increased stroke risk or significantly worse outcomes. First AIS/TIA events were more severe in continuous devices, with non-significantly worse mRS scores. In this study, we did not replicate previous findings of infection predisposing to stroke.
Abstract T P337: Asymmetric Dimethylarginine Is Related to the Predicted Stroke Risk in Middle-aged Japanese Men
Authors: nishiyama yasuhiro , Ueda Masayuki , Katayama Yasuo , Otsuka Toshiaki
Published: July 2021

Background:
Asymmetric dimethylarginine (ADMA) has recently been investigated as a risk marker for cardio- and cerebrovascular diseases. However, it remains unclear whether ADMA levels are related to the risk of stroke in the general Japanese population.

Methods and Results:
In this cross-sectional study, we examined 769 Japanese men (mean, 47 ± 5 years) who underwent health examinations. Each patient’s ADMA level and various vascular risk factors were assessed, and the predicted 10-year risk of stroke was calculated using the point-based prediction model for incident total stroke for Japanese from the Japan Public Health Center Study. In a multiple linear regression analysis, age, body mass index, estimated glomerular filtration rate, and current smoking status were significant independent determinants of the ADMA level. A significant odds ratio (OR) for high predicted stroke risk (10-year risk ≥ 5%) was noted in the highest quartile of ADMA level (OR, 2.47; 95% CI, 1.00-6.07) as compared to the lowest quartile, even after adjusting for potential confounding factors. A significant OR for high predicted stroke risk was also found for each standard-deviation increment in ADMA level (adjusted OR, 1.46; 95% CI, 1.10-1.92).

Conclusions:
An elevated ADMA level was significantly associated with an increase in predicted stroke risk, suggesting that the measurement of ADMA level may be useful for identifying middle-aged Japanese men at high risk for stroke.
Abstract T P350: Phase I Clinical Feasibility &Safety Trial of Remote Ischemic Conditioning After Aneurysmal Subarachnoid Hemorrhage
Authors: Connolly Mark , Dusick Joshua , Vespa Paul , Gonzalez Nestor
Published: July 2021

Objective:
Remote ischemic conditioning (RIC) is a phenomenon by which brief periods of sublethal ischemia in one tissue confers protection from ischemia to distant tissues. The safety and feasibility of RIC must be assessed before testing it in efficacy trials. We report a phase I feasibility and safety trial of RIC in aneurysmal subarachnoid hemorrhage (aSAH) patients.

Methods:
Patients with aSAH received 2-4 RIC sessions on non-consecutive days. A complete session was defined as four rounds of 5 minutes of one sided lower limb ischemia with a thigh blood pressure cuff followed by 5 minutes of reperfusion (verified by pedal Doppler). Primary end-points were tolerance to the procedure and any complication attributable to RIC. Secondary end-points included cerebral infarction or hemorrhage.

Results:
Twenty-one patients (67% female, mean age 52, Fisher 3.5, H&H 3.3) were enrolled. Seventeen had evidence of vasospasm during hospitalization. Of 76 RIC sessions performed, 75 (98.7%) were completed and tolerated. One session was incomplete due to poor cooperation secondary to delirium. No patients developed DVTs or other local complications within 2 weeks of their final RIC session. No patients suffered cerebral infarction or hemorrhage throughout the duration of RIC sessions and through 72 hours after their last complete session. Three had infarction confirmed on MRI at 3 and 5 days following the final RIC session. In conscious patients, there was a small increase in the analog pain scale upon inflation of the cuff (deflated: 0.5 inflated: 1.2, p<0.0005), but none requested to stop the session. There was no significant change in other vitals.

Conclusions:
In aSAH patients, RIC was successfully applied and well tolerated with no procedure-related complications. No patient suffered ischemic stroke within 72 hours of RIC, consistent with our previous studies showing protective cerebral metabolic changes up to 48 hours after sessions. These results demonstrate that application of RIC is safe and feasible and suggest that RIC may be associated with transient tolerance to ischemia during the treatment period. The efficacy of RIC for neuroprotection should be investigated in larger controlled trials.
Abstract T P351: Unbound Iron and Ceruloplasmin Levels in Cerebrospinal Fluid Are Associated with Development of Deep Cerebral Infarcts Following Subarachnoid Hemorrhage
Authors: Koffman Lauren , Toth Gabor , Hussain M. Shazam , Selim Magdy , Rasmussen Peter , Provencio J. Javier , Gomes Joao A
Published: July 2021

Introduction:
Iron-dependent formation of reactive oxygen species has been implicated in the development of vasospasm (VSP) and neuronal injury following experimental subarachnoid hemorrhage (SAH). We report the association between unbound (“free”) iron in CSF of SAH patients and the risk of angiographic vasospasm and cerebral infarcts (CI) on neuroimaging from a recently completed pilot study.

Methods:
Samples of cerebrospinal fluid (CSF) were obtained on days 1, 3, and 5. A fluorometric assay that relies on an oxidation sensitive probe was used to measure redox active iron (REDOX-Fe). Ceruloplasmin (Cp) concentration and levels of malondialdehyde (MDA), a marker of lipid peroxidation were also measured. We prospectively collected and recorded demographic, clinical, and radiological data. Logistic regression and Wilcoxon Rank Sum test were used.

Results:
Five of 12 patients developed angiographic VSP (41.6%) and eight developed CI (66.6%). Mean REDOX-Fe was higher in patients with CI (3.96 ± 0.97 Vs. 2.77 ± 0.87 mcg/dl,
p
0.07), particularly in patients with deep-seated strokes (4.56 ± 0.67 Vs. 3.35 ± 0.89,
p
0.03). Levels of Cp at day 3 were lower in patients with deep strokes (34,092 ± 23,780 Vs. 86,045 ± 34,752 ng/ml,
p
0.03). A trend towards higher REDOX-Fe on day 3 in patients who developed VSP (4.52 ± 1.16 Vs. 2.96 ± 0.71,
p
0.07), and lower Cp levels on day 5 (45,033 ± 29,079 Vs. 63,044 ± 24,821,
p
0.1) was found. Levels of MDA were higher in patients who developed CI (10.36 ± 4.36 Vs. 5.9 ± 4.2 nmol,
p
0.08).

Conclusions:
In this preliminary study we found higher concentrations of redox active iron in CSF of SAH patients who develop deep-seated CI on neuroimaging. Evidence of increased oxidative damage correlated with development of CI. A possible association between non-protein bound iron and angiographic VSP is suggested as well. Ceruloplasmin may exert a protective effect in this setting. Further studies are needed to validate these findings.
Abstract T P354: The Role of Lindegaard Ratio on TCD for Predicting Angiographic Vasospasm Following Aneurysmal Subarachnoid Haemorrhage
Authors: Ahmad Aftab , Khan Khurshid , Basir Ghazala , Derksen Carol , Shuaib Ashfaq , Siddiqui Muzaffar , Rizvi Nasir , Saqqur Maher
Published: July 2021

Background and objective:
Middle cerebral artery (MCA) Lindegaard ratio (LR) has been used as indicator of moderate to severe vasospasm (VSP) following subarachnoid hemorrhage (SAH). However there have been many criticisms about the ability to detect impending vasospasm using Transcranial Doppler (TCD). The purpose of this study was to determine the correlation between TCD Mean Flow Velocities (MFV) and angiographic VSP after aneurysmal SAH using LR of several anterior circulation vessels.

Methods:
The study population included prospective collected data of 134 patients with aneurysmal SAH admitted to University of Alberta hospital from January 2006 to December 2008. Complete TCD was performed daily from day 2 to 14 from symptoms onset. All patients underwent cerebral angiography on admission and within 7 days following onset of symptoms. The M1, M2 MCA, ACA and intracranial ICA/ipsilateral extra cranial ICA velocity ratios (LR) were calculated and correlation was made with the presence of angiographic vasospasm (defined as more than one-third luminal narrowing). Then, anterior circulation LR was defined as the highest LR in the ipsilateral anterior circulation arteries. Moderate to severe VSP was defined as LR > 3.

Results:
Results are shown in table.

The probability of VSP in the presence of one anterior circulation vessel LR > 3 is 14 % (2/14), 2 vessels LR >3 (4/16. 16 %), 3 vessels LR > 3 (3/6, 50 %) and 4 vessels LR >3 (5/5 = 100 %). (P< 0.001)

Conclusion:
LR of M2 MCA has higher sensitivity compared to other vessels and ACA LR has less sensitivity but more specificity whereas the rest of anterior circulation LR had modest predictive value. The likelihood of VSP increases as more number of vessels in anterior circulation shows LR>3. LR should not be interpreted in a blind fashion to the rest of TCD MFV numbers.
Abstract T P47: Response to Thrombolysis in Ischemic Stroke Depends on the Presence of Initial Arterial Occlusion
Authors: Medlin Freidrich , Amiguet Michael , Vanacker Peter , Michel Patrik
Published: July 2021

Objective:
We aimed to assess effectiveness of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) depending on the presence or absence of cervical or intracranial arterial occlusion on acute CT angiography (CTA).

Methods:
Patients from the Acute STroke Registry and Analysis of Lausanne (ASTRAL) were included in the analysis if they had an onset-to-door-time ≤ 4hours, CTA within 24 hours of onset, premorbid modified Rankin scale (mRS) ≤ 2, and a National Institute of Health Stroke Scale score (NIHSS) >4. Patients having significant intracranial stenosis (50-99%) or receiving endovascular treatment were excluded. The primary outcome was a 3 month handicap of mRS >2. We used an interaction analysis of IVT and initial arterial occlusion after adjusting for potential confounders for the primary outcome.

Results:
Of 655 included patients, 382 patients (58%) showed arterial occlusion, of whom 263 (69%) received IVT. Of the 273 patients without arterial occlusion, 139 (51%) received IVT.

In patients with initial arterial occlusion and after multiple adjustments, IVT was associated with lower likelihood of unfavourable outcome (adjusted OR 0.33, 95% CI 0.12-0.91, p=0.03) whereas it had no significant effect in non-occluded patients (OR 1.32, 95% CI 0.36-4.76, p=0.67). Similarly, the presence of arterial occlusion did not significantly worsen the outcome in thrombolysed patients (OR 1.99, 95% CI 0.68-5.81, p=0.21), whereas it did so in non-thrombolysed patients (OR 7.89, 95% CI 2.29-27.25, p<0.01).

Conclusions:
IVT for AIS is more effective in the setting of visible arterial occlusions on acute imaging. If confirmed in other studies, this information may influence thrombolysis decisions and planning of further randomized trials.

Classification of evidence:
This retrospective analysis provides class III evidence that IVT has less benefit in patients without visible occlusion on acute CTA.
Abstract T P48: Intravenous Thrombolysis Using Low-Dose Alteplase for Nonagenarians with Acute Ischemic Stroke: The SAMURAI rtPA Registry
Authors: Hayakawa Mikito , Koga Masatoshi , Sato Shoichiro , Arihiro Shoji , Shiokawa Yoshiaki , Nakagawara Jyoji , Furui Eisuke , Kimura Kazumi , Hasegawa Yasuhiro , Yamagami Hiroshi , Okada Yasushi , Okuda Satoshi , Kario Kazuomi , Minematsu Kazuo , Toyoda Kazunori
Published: July 2021

Objective:
Although intravenous thrombolysis (IVT) using alteplase for octogenarians with acute ischemic stroke becomes relatively familiar, it is unclear whether IVT for nonagenarians is a futile intervention. The purpose of this study is to clarify the efficacy and safety of IVT using low-dose alteplase (0.6 mg/kg) for nonagenarians compared with octogenarians.

Methods:
Stroke Acute Management with Urgent Risk-factor Assessment and Improvement (SAMURAI) rtPA registry retrospectively collected 600 consecutive acute stroke patients receiving IVT from 10 Japanese stroke centers between October 2005 and July 2008. We extracted all octogenarians (O group) and nonagenarians (N group) from the registry. We compared baseline characteristics, symptomatic intracranial hemorrhage (SICH), and 3-month outcomes between the groups. 3-month outcomes include; functional independence (FI) defined as a mRS score 0-2, good outcome (GO) as a mRS score 0-2 or same as the premorbid mRS, poor outcome (PO) defined as a mRS score 5-6, and death.

Results:
Twenty-five nonagenarians (mean age, 93 years) and 124 octogenarians (mean age, 84 years) were included. N group was more female-predominant (76% versus 56%, p=0.06) and premorbidly dependent (44% versus 14%, p<0.001) than O group. There were no significant differences of median baseline NIHSS score (16 versus 14, p=0.95) and Alberta Stroke Program Early CT Score (9 versus 9, p=0.36) between the groups. The rate of FI tended to be lower in N group than O group (16% versus 36%, p=0.06), otherwise, the differences of the rates of GO (28% versus 37%, p=0.39), PO (40% versus 36%, p=0.73), death (20% versus 11%, p=0.23) and SICH (0% versus 2.4%, p=1.00) were not significant between the groups. In comparison with O group, N group was not associated with 3-month clinical outcomes (FI; OR 0.61; 95% CI, 0.15-2.42, GO; 0.98; 0.31-3.07, PO; 0.63; 0.15-2.70, death; 3.18; 0.62-16.3) and SICH (0.68; 0.17-2.69) after multivariate adjustment.

Conclusions:
IVT using low-dose alteplase for N group resulted in less frequent achievement of FI mainly because of more premorbid dependency than O group, however, showed at least a similar safety and a potential efficacy.
Abstract T P50: ASTRAL-R score Predicts absence of Recanalization after Intravenous Thrombolysis in Acute Ischemic Stroke
Authors: Vanacker Peter , Lambrou Dimitris , Heldner Mirjam , Seiffge David , Mueller Hubertus , Eskandari Ashraf , Ntaios George , Mosimann Pascal J , Sztajzel Roman , Mendes Pereira Vitor , Cras Patrick , Engelter Stefan , Lyrer Philippe , Fischer Urs , Arnold Marcel , Michel Patrik
Published: July 2021

Background:
Intravenous thrombolysis (IVT) is the best proven recanalization treatment in acute ischemic stroke (AIS), but may be insufficient or of little value in certain patients. By predicting the probability of absence of recanalization after IVT, the decision for more aggressive revascularization treatment can be individualized with the goal to improve clinical outcome.

Aim:
To derive and internally validate a predictive scoring system for absence of recanalization with IVT, using readily available variables in the prehospital and emergency room phase.

Methods:
Data from prospective thrombolysis registries of four academic stroke centers were examined. Patients with arterial occlusion on acute imaging and repeat arterial assessment at 24hours were selected. Based on a logistic regression analysis, an integer-based score for each covariate of the fitted multivariate model was generated. The overall score was calculated as the sum of the weighted scores. In a patient with an ASTRAL-R score > 3, the likelihood of absence of recanalization was > 50%. The area under the receiver-operator curve was 0.65 in the derivation cohort.

Results:
In 534 thrombolyzed AIS patients, five variables were identified as independent predictors of absence of recanalization: Acute glucose >7mmol/L (A), significant extracranial vessel STenosis (ST), decreased Range of visual fields (R), proximal Arterial occlusion (A) and altered Level of consciousness (L). An altered level of consciousness was weighted 2 and all other variables 1 point based on β-coefficients. In a patient with an ASTRAL-R score > 3, the likelihood of absence of recanalization was >50%. The score was highly predictive (OR 0.65, 95%CI 0.55-0.76) in the derivation cohort.

Conclusions:
A simple 5-item ASTRAL-R score shows high prediction for absence of recanalization at 24hours in thrombolyzed AIS patients. If confirmed by external validation, planning for more aggressive revascularization strategies may facilitate through this tool.
Abstract T P58: Early Anticoagulant Therapy for Secondary Stroke Prevention in Japanese NVAF Patients With TIA/minor Stroke: The SAMURAI-NVAF Study
Authors: Kinoshita Naoto , Yamagami Hiroshi , Arihiro Shoji , Koga Masatoshi , Sato Shoichiro , Todo Kenichi , Kimura Kazumi , Shiokawa Yoshiaki , Kamiyama Kenji , Terasaki Tadashi , Okada Yasushi , Nagakane Yoshinari , Furui Eisuke , Ito Yasuhiro , Nakashima Takahiro , Kario Kazuomi , Kameda Tomoaki , Takamatsu Kazuhiro , Takamatsu Kazuhiro , Takamatsu Kazuhiro , Takamatsu Kazuhiro , Nagatsuka Kazuyuki , Toyoda Kazunori
Published: July 2021

Objective:
Early anticoagulant therapy is commonly used for acute cardioembolic stroke in Japan, although its usefulness remains undetected. The purpose of this study was to estimate the efficacy and safety of early anticoagulation for the treatment of acute stroke/TIA patients with nonvalvular atrial fibrillation (NVAF).

Methods:
From September 2011 through June 2013, 697 acute ischemic stroke/TIA patients with NVAF were registered from a multicenter prospective registry (the SAMURAI-NVAF study including 18 Japanese stroke centers, NCT01581502). Of those, the patients who started anticoagulant therapy within 48 hours after the onset were assessed for the incidence of ischemic and hemorrhagic events during the first 30 days.

Results:
A total of 438 patients (62.8%; 247 men, 77.4±9.8 years old) was evaluated. Of these, 292 patients (66.7%) started anticoagulation with intravenous unfractionated heparin (UFH) mono-therapy, 87 patients (19.9%) with UFH and warfarin, and 2 patients (0.5%) with UFH switched to novel oral anticoagulants (NOACs). As oral anticoagulants mono-therapy, 34 patients (7.8%) started with warfarin, and 23 (5.3%) with NOAC. Ischemic events were developed in 11 patients (2.5%: 11 recurrent ischemic strokes), and hemorrhagic events in 11 patients (2.5%: 6 symptomatic intracranial hemorrhages during the first 7days and 5 extracranial hemorrhages). Patients with major artery occlusion had higher incidence of hemorrhagic events than those without (4.0% versus 0.6%, p=0.02), whereas ischemic events were similar in both groups (2.4% versus 2.7%, p=0.82). In multivariable analysis, major artery occlusion was independently associated with higher rate of major hemorrhagic events (OR 6.19; 95% CI 1.01-119.75) adjusted for age, sex, BMI, HAS-BLED score before index TIA/stroke, and NIHSS on admission.

Conclusion:
In our cohort, early initiation of anticoagulant therapy is often performed in patients with acute stroke/TIA with NVAF patient, and the frequency of ischemic and hemorrhagic events seems to be low compared with previous reports. Early anticoagulant therapy can be safe for patients without major artery occlusion.
Abstract T P65: Prior Stroke but Not Diabetes Mellitus Is Associated with Symptomatic Intracranial Hemorrhage after Rt-PA Administration
Authors: van Eendenburg Cecile , Serena Joaquín , Silva Yolanda , Terceño Mikel , Puig Josep , Blasco Gerard , Pedraza Salvador , Kazimierczak Martha , Castellanos Mar
Published: July 2021

Introduction:
The European drug license for rt-PA considers diabetes plus previous stroke as an exclusion criterion for the administration of the treatment due to an increased risk of symptomatic intracranial hemorrhage (SICH). However, given that data from different studies have not confirmed this association, we were interested in analyzing whether the presence of these pathologies was associated with the development of SICH in our population of rt-PA-treated patients.

Patients and methods:
For the purpose of this study, we evaluated 667 patients treated with rt-PA at our center between October 1999 and December 2012. The existence of bleeding was assessed in the cranial CT performed at 24±12 h after rt-PA administration and was considered to be symptomatic when it was associated with neurological deterioration, which was defined as an increase ≥4 points in the NIHSS. Previous history of diabetes and stroke was collected from all patients.

Results:
176 (26.4%) had hemorrhagic transformation (HT), which was symptomatic in 30 cases (4.5%). In the univariate analysis, neither diabetes and previous stroke together, nor alone, were associated with HT. However, previous stroke (10% vs. 4%, p=0.028) but not diabetes or both, was associated with SICH. After adjustment for the rest of the variables associated with the development of SICH, only the history of prior stroke remained as an independent predictor of this complication (OR 4.3;CI 95%, 1.12-16.19; p=0.03).

Conclusions:
In our large cohort of patients treated with rt-PA, only a prior history of stroke predicted the development of SICH. No association was found with diabetes.