bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P307: Return to Driving Following Stroke
Authors: Ozark Shelly , Boan Andrea D , Turan Tanya N , Ellis Charles , Lackland Daniel T , Bachman David L
Published: July 2021

Background:
Stroke frequently causes deficits that may impact a person’s ability to drive. Little has been reported about the frequency with which patients return to driving following a stroke or the use of driver evaluation services to determine a patient’s capacity to drive safely.

Objective:
To examine the frequency of return to driving post-stroke, self-imposed limitations in driving, and the utilization of evaluative services in the decision to return to driving.

Methods:
: The STEP-South Carolina Project surveyed 162 stroke survivors one year after their event, assessing clinical and functional outcomes and patient perceptions of the magnitude of the impact of stroke on their quality of life (“no effect”, “some effect”, or “great effect”). Multivariate analyses (adjusted for NIHSS) were performed to determine the relationship between driving status, the use of evaluative services, self-imposed limitations to driving and the patient’s perceived effect of stroke of the ability to perform valued life activities.

Results:
Multivariate analyses showed that 51.2% (83/162) of survey respondents returned to driving following their stroke, with 59% of these (49/83) returning within one month. Only 5.6% of all respondents (9/162) received any formal driving evaluation, though 11% (9/83) of those who had returned to driving had reported their stroke had a great effect on their ability to performed valued life activities. Among those who reported “no effect” on their ability to perform valued life activities and returned to driving, 45.8% (38/83) limited their driving, though it is unclear whether formal evaluation would have supported such a decision.

Conclusion:
The resumption of driving following stroke is usually a decision made without formal evaluation. Stroke survivors, including those who self-impose restrictions on their driving, may benefit from formal evaluation before returning to the driver’s seat.
Abstract T P309: Cost Effectiveness for Intra-arterial Stroke Therapy Achieved with Image-based Selection and not with Type of Device
Authors: Reese Brenda , Young Scott , Stands Kevin , Hicks William , Mejilla Jenniffer , Gupta Rishi , Davis Tom , Pema Peter , Budzik Ron , Vora Nirav A
Published: July 2021

Background:
Our aim was to determine if stentriever treatment results in cost effectiveness over Merci thrombectomy and to identify a cost-effective imaging threshold for intra-arterial treatment selection.

Methods:
With institutional approval, we retrospectively reviewed patients undergoing intra-arterial stroke therapy from March 2011 to March 2013 at our center. We collected the following data: stroke score, occlusion site, baseline Alberta Stroke Program Early CT Score (ASPECTS), device used, reperfusion, hemorrhage, 90-day modified Rankin Score (mRS), and procedure cost. Using published criteria, a quality-adjusted life year (QUALY) value of 0.74 and 0.4 was ascribed to a mRS outcome 2 respectively. Using the procedural mean cost, we calculated an incremental cost efficiency ratio (ICER) for stentriever versus Merci embolectomy and for interventions done for a baseline ASPECTS above and below the following thresholds: > 6, > 7, > 8, and > 9. Using established criteria, we identified a cost effective patient selection if the ICER was positive and less than $50,000/QUALY.

Results:
Our cohort included 122 patients, 45 treated with Merci in the first year and 78 with stentrievers in year two. Reperfusion occurred in 79% (87% in the stentriever and 64% with Merci groups, p=0.002). The good outcome rate for the entire cohort was 40% (43% good outcomes in the stentriever and 33% in the Merci groups, p=0.21) respectively. Stentriever interventions were not cost effective compared to Merci embolectomy (ICER > $500,000/QUALY). Using baseline ASPECTS > 6 and > 7 as a selection criteria for intervention, the good outcome rate was 42% and 44% respectively but with a negative ICER due to higher costs in treating those with lower scores. For those with an ASPECTS > 8 and > 9, the good outcome rate was 44% and 54% with an ICER of $40,000/QUALY and $24,000/QUALY respectively.

Conclusions:
At our institution, despite better outcome and reperfusion rates, stentriever interventions are yet to show a cost benefit. Optimizing patient selection by using the ASPECTS scoring system has led to improved clinical outcomes and cost effectiveness. Further prospective study may validate this technique for greater value to the individual patient and the health system at large.
Abstract T P315: Intra-Arterial Treatment: Long-Term Mortality and Effect of Hospitals
Authors: Burke James F , Meurer William J , Adelman Eric E , Morgenstern Lewis B
Published: July 2021

Objectives:
To first describe long-term mortality in patients receiving any IA treatment for stroke compared to patients receiving IV thrombolysis. Second, given the wide variability in delivery of IA treatments, to test the hypotheses that long-term mortality after IA treatment would vary at the hospital level and that high volume hospitals would have lower mortality.

Methods:
All Medicare beneficiaries with a principal diagnosis of ischemic stroke (ICD-9 433.x1, 434.x1, 436) admitted via emergency department or transfer were identified using MEDPAR files from 2007-2010. IA procedures were identified using physician billing codes (CPT code 37184-6, 37201, 75896) via linked Medicare Carrier files. Long-term mortality was compared using Kaplan-Meier curves for patients receiving IA, IV or combined therapy.

To estimate hospital variability in mortality after IA or combined therapy we used a multi-level logistic regression model adjusting for demographics, vascular risk factors and comorbidities with a random hospital-level intercept. Hospital effects were characterized with the intraclass correlation coefficient (ICC). Secondary analysis adjusted for hospital characteristics: IA volume, stroke volume, bed size, academic status, rural/urban.

Results:
Median survival after IA was 171 days; after one year-the survival curves for IA and IV treated patients are nearly parallel. (Figure 1) Hospitals had almost no effect on long-term mortality (ICC 0.01) and neither hospital volume nor any other hospital characteristics were associated with mortality.

Conclusions:
Short-term mortality is significant in IA treated Medicare beneficiaries. Surprisingly, in spite of wide variation in center experience, patient selection, thrombolytic techniques, peri- and post-procedural management, hospitals have no effect on mortality after IA treatment.
Abstract T P32: Computer Aided Detection of Asymptomatic Cerebral Microbleeds on Magnetic Resonance Images
Authors: Li Yan , Huang Yining , Zhang Jue , Fang Jing
Published: July 2021

Purpose:
Manual rating of Cerebral microbleeds (CMBs) is time-consuming and inconsistent. Since the presence and number of CMBs have become a potential diagnostic and prognostic biomarker of stroke, an automatic identification method is required. We proposed a computer aided diagnosis (CAD) system for the detection of the CMBs on the magnetic resonance (MR) images automatically.

Methods:
Eighty-one patients were recruited in this study. CMBs on the MR T2* weighted images were manually rated according to the Microbleed Anatomic Rating Scale (MARS) criteria. Our automated method consisted of two steps: i) Pre-processing: After skull stripping, isolated islands of points were removed while holes were restored to avoid over segmentation. Local threshold segmentation was applied for the initial candidate selection. ii) Identification model: Seven features were extracted from each candidate: area, roundness, intensity, average of the boundary, contrast, shape-intensity and location-mark (according to the probability density templates calculated from the location information of the CMBs). For further identification of each candidate, Random Forest (RF) model was used to distinguish CMBs from the mimics.

Results:
A total of 337 CMBs in the 81 patients were studied. Comparing with the counting from the experienced doctors, high sensitivity of 92% (310/337) was achieved after pre-processing. The RF model eliminated most of the false-positives while maintaining a reliable sensitivity of 94% (291/310) and specificity of 96% (4272/4450). The area under the Receiver operating characteristic curve was 0.98 ± 0.02 for the detection model. In summary, this CAD system had an overall sensitivity of 86% (291/337) and specificity of 96% (4272/4450), producing only 2.2 false-positives per subject.

Conclusion:
This presented strategy is technically effective. The results indicate that it has the potential to be used for clinical detection of CMBs.
Abstract T P331: Investigating the Association of Traumatic Brain Injury and Ischemic Stroke in a Population-based Study
Authors: Garcia Nelda , Burke James , Lisabeth Lynda D , Sanchez Brisa , Morgenstern Lewis B
Published: July 2021

Background:
Recently, two publications, one from California and one from Taiwan, utilizing administrative data have shown an independent, strong association between traumatic brain injury (TBI) and ischemic stroke (IS). The California analysis suggested TBI was a stronger risk factor for IS than hypertension. To begin the process of assessing whether TBI is really associated with IS with more definitive study types, we assessed the feasibility of obtaining TBI information in a population-based stroke study and characterized the history of TBI among IS patients including the time interval from TBI to stroke.

Methods:
As part of the Brain Attack Surveillance in Corpus Christi Project (BASIC), IS patients (n=439) who completed an interview were asked whether they had ever had a TBI that caused them to lose consciousness. For those IS patients who did have a TBI, we further questioned them as to the number and dates of TBIs and the length of loss of consciousness for the longest event. These questions closely followed the US Department of Defense characterization of TBI. Descriptive statistics were used to summarize history of TBI.

Results:
From 1/2/12 thru 7/7/13, 101 of the 439 (23%) IS stroke patients reported a history of at least one TBI that caused them to lose consciousness. Among patients with TBI, 67% had one TBI, 21% had 2 TBI’s, 10% had 3 or more TBI’s. The median length of time between the last reported TBI and stroke onset was 32 years (Q1: 7 years, Q3: 46 years); 3% had a TBI within 30 days prior to their IS and 9% had TBI within 1 year prior to their IS. The median NIHSS of IS patients with TBI was 3 (Q1: 1, Q3: 8) compared with a median NIHSS of 4 (Q1: 2, Q3: 9) among IS patients without TBI.

Conclusion:
It is feasible to obtain TBI information in this population-based stroke surveillance study where a history of TBI is very common in IS patients. The long interval between TBI to IS suggests a lack of association in most cases. A case-control study would be needed to confirm or refute the striking association of TBI and IS previously seen in administrative data. Further, a population-based study with detailed data collection would allow for discovery of associated mechanisms linking TBI to stroke such as dissection, coagulation disorders and intoxications.
Abstract T P335: Eligibility and Preference of New Oral Anticoagulants in Patients With Atrial Fibrillation: Comparison Between Patients With Versus Without Stroke or TIA
Authors: Yoon Chang Hyo , Park Yoon Kyung , Kim Suk Jae , Lee Miji , Ryoo Sookyung , Kim Gyeong-Moon , Chung Chin-Sang , Lee Kwang Ho , Bang Oh Young
Published: July 2021

BACKGROUNDS:
Recent randomized clinical trials of new oral anticoagulants (NOACs) forms the basis for international guidelines for the management of patients with atrial fibrillation. However, strict enrollment criteria may limit the applicability of results of trials to clinical practice. We estimated the eligibility for participation in landmark trials of NOACs of an unselected group of atrial fibrillation patients with or without stroke/TIA. In addition, we compared the preference for NOACs use between patients with versus without stroke/TIA.

METHODS:
Four hundred patients were prospectively and consecutively enrolled in a database from a university medical center. We applied three large NOAC trials' enrollment criteria (RE-LY, ROCKET-AF, and ARISTOTLE). In addition, INR lability (time in therapeutic window for patients taking warfarin) and bleeding risk schemes (ATRIA) were measured.

RESULTS:
The proportions of patients fulfilling the trial enrollment criteria ranged from 20% to 75%, depending on the differences in the indications/contraindications of studies (lower in ROCKET-AF than others) and presence or absence of stroke/TIA (20-60% vs. 75%). The main reasons for ineligible for NOACs are lower CHADS2 score and planned cardioversion for patients without stroke/TIA, whereas low creatinine clearance and bleeding-related complications for those with stroke/TIA. TTR is lower in the former, especially in patients with severe disability. In addition, bleeding tendency as measured by ATRIA is much higher in patients with stroke/TIA, mainly due to concomitant use of antithrombotics.

CONCLUSIONS:
Our data confirm that patients enrolled in randomized clinical trials are representative of most stroke patients with atrial fibrillation, but partly of nonstroke patients, in clinical practice. When INR lability and bleeding tendency with warfarin use were considered, the use of NOACs was preferred in patients with stroke/TIA than in patients without
Abstract T P338: To Evaluate the Efficacy and Safety of Cilostazol in Ischemic Stroke Patients with Peripheral Arterial Disease (SPAD) Study: Methodology and Baseline Data
Authors: Jeng Jiann-Shing , Lien Li-Ming , Chen Sien-Tsong , Hsu Chung Y. ,   the SPAD Investigators
Published: July 2021

Background and Purpose:
Ischemic stroke often co-exists with peripheral arterial disease (PAD). Patients with polyvascular diseases carry higher risks of vascular events and death. We initiated a study to evaluate the safety and efficacy of cilostazol in ischemic Stroke patients with PAD (SPAD) and have been taking aspirin for stroke prevention.

Methods:
The SPAD study is a prospective, multicenter, national, double-blinded, placebo-controlled, randomized trial. Patients with previous ischemic stroke or TIA who have been taking aspirin (100 mg per day), aged 50 years or older, with PAD in the lower limbs based on ankle-brachial index (ABI) <1.0 were randomized to the treatment group with cilostazol (200 mg/day) or the placebo group with a 1:1 basis. Each patient is periodically followed-up for one year. The primary endpoint of the study is the change in the ABI. The secondary endpoints are the change in the common carotid artery intima-media thickness (IMT); major cardiovascular events, including recurrent stroke, myocardial infarction, unstable angina, other vascular events, and all death; and the safety, including major bleeding events, hemorrhagic stroke, and any death.

Results:
From September, 2010 to July, 2012, a total of 800 patients (male, 59.9%; female, 40.1%; average age, 70.4±9.3 years) were enrolled in the SPAD study, including 722 (90.2%) with ischemic stroke or 78 (9.8%) with TIA. Several atherosclerotic risk factors were commonly seen in this study population, including hypertension (88%), diabetes mellitus (48%), hypercholesterolemia (54%), smoking habit (41%), and carotid stenosis (15%). The distribution of baseline ABI were 0.90-0.99 (n=294), 0.70-0.89 (n=371), and <0.70 (n=136). Patients with lower ABI were more frequently associated with old age, lower body mass index, smoking habit, diabetes mellitus, carotid stenosis ≥50%, and higher systolic blood pressure.

Conclusions:
The SPAD trial is the first study to evaluate the safety and efficacy of dual antiplatelets, aspirin plus cilostazol, in ischemic stroke patients with PAD. The trial findings are expected to help in choosing better strategy for prevention of vascular events in this polyvascular disease.
Abstract T P340: Delays in Seeking Medical Attention in Intracerebral Hemorrhage
Authors: Testai Fernando D , Langefeld Carl D , Mukarram Faisal , Castillo Norma K , Hillmann Maureen , Sheth Kevin N , Smith Sharion , Ali Latisha K , Rinek Gilda , Moomaw Charles J , Osborne Jennifer , Woo Daniel
Published: July 2021

Background:
Intracerebral hemorrhage (ICH) is associated with early neurological deterioration and death. Prior studies showed that delays in seeking medical attention may occur among minorities. In this study we investigated the factors affecting time from symptom onset to ER arrival (TOA) in a race/ethnic enriched population.

Methods:
Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) is a prospective study of spontaneous ICH. Baseline characteristics, presenting symptoms, first contact (911 vs. ER vs. primary physician), ICH volume, location and intraventricular extension, insurance status, GCS at presentation, and TOA were collected. Data was analyzed using generalized linear models and Spearman’s rank correlations. TOA was natural log transformed and a multivariate model was developed using backward elimination (P-value=0.05).

Results:
A total of 1158 subjects were enrolled; 28 were excluded due to lack of TOA. Of the 1,030 included 59% were men with 24% whites, 41% blacks, and 35% Hispanics. Mean age was 61±15 years, mean Glasgow Coma Scale (GCS) at presentation was 12.4±3.7 (median=15), and median TOA was 431 min (interquartile range 106-820). Location of ICH was 56% deep, 28% lobar, 8% cerebellum, and 5% brainstem. Approximately 29% of subjects had no medical insurance, 36% had medicare, 18% medicaid, 36% private insurance, and 1% VA insurance. In univariate analysis women, use of 911, EMS run, different presenting symptoms, lobar and deep location, and low GCS were associated with shorter TOA. In multivariate model only women (p=0.05), GCS (p=0.04), use of 911 (p<0.001), EMS run (p<0.001), and weakness and dysarthria as presenting symptoms remained significant. Ethnicity was not a significant predictor (p=0.79). These variables explain 23.3% of the variation in TOA.

Conclusion:
Ethnicity and insurance status did not affect time to presentation. Women, use of 911, EMS run, weakness and lower GCS were associated with shorter TOA in ICH. Increased education in target populations with higher incidence of ICH such as minorities on stroke signs/symptoms and use of 911 may expedite access to medical care. Further studies are needed to determine the impact of TOA on outcome.
Abstract T P345: Cardiovascular Health Metrics and All-cause and Cardiovascular Disease Mortality among Middle Aged Men in Korea: The Seoul Male Cohort Study
Authors: Kim Ji Young , Rhee Chul Woo , Ko Young-Jin , Park Byung-Joo , Kim Dong-Hyun , Bae Jong-Myon , Shin Myung-Hee , Lee Moo-Song , Li Zhong Min , Ahn Yoon-Ok
Published: July 2021

Background:
In Korea, Cerebrovascular and cardiovascular diseases (CVD) were the second leading cause of deaths in 2011. In 2010, the American Heart Association (AHA) published cardiovascular health metrics (CVHM) aimed at reducing deaths from all CVDs and stroke, and improving the cardiovascular health of the population as a whole. Despite their implications, the AHA’s metrics have not been broadly studied or previously applied to an Asian population.

Objectives:
This study estimated the combined association of cardiovascular health behaviors on the risk of all-cause and CVD mortality in middle-aged men in Korea.

Methods:
In total, 14,533 men aged 40-59 years were enrolled in 1993 and followed-up through 2011. CVHM defined the following lifestyles proposed by the AHA: smoking, physical activity, BMI, healthy diet score, total cholesterol, blood pressure, and fasting blood glucose. The CVHMs score was calculated as a single categorical variable, by assigning 1 point to each ideal healthy behavior vs. 0 points otherwise. All subjects were classified as meeting 0-7 CVHM. The principal outcome variables were all-cause and CVD mortality. The Cox proportional hazard regression model was used to estimate the hazard ratio (HR) of cardiovascular health behavior, and CVHMs score. PARs were calculated from significant CVHMs.

Results:
During 266,482.8 person-years of follow-up, there were 1,314 deaths in total. Current smoking, blood pressure, and fasting blood glucose were significantly associated with all-cause and CVD mortality. The adjusted PARs for the 3 significant metrics combined were 81% (95% CI, 50-94%) and 96% (66-99%) for all-cause and CVD mortality, respectively. More ideal CVHM was significantly associated with lower risks of all-cause and CVD mortality (
p-trend<.0001
). The adjusted HRs of the groups with 6-7 vs. 0-2 ideal CVHM were 0.49 (0.35-0.70) and 0.23 (0.10-0.57) for all-cause and CVD mortality, respectively.

Conclusions:
Among ideal cardiovascular health behaviors, non-smoking, normal blood pressure, and recommended fasting blood glucose levels associated with reduced risks of all-cause and total CVD mortality. There was a strong trend towards decreased all-cause and CVD mortality risk with increasing the number of ideal CVHMs.
Abstract T P352: Dantrolene for the Prevention and Treatment of Cerebral Vasospasm after Subarachnoid Hemorrhage - A Randomized Placebo-Controlled Trial to Assess Safety, Tolerability and Feasibility
Authors: Muehlschlegel Susanne , Carandang Raphael , Hall Wiley , Nisha Kini , Izzy Saef , Van der Bom I. Martijn , Flood Thomas , Gounis Matt , Weaver John , Barton Bruce , Wakhloo Ajay
Published: July 2021

Introduction:
Dantrolene is neuroprotective in animal models and may attenuate cerebral vasospasm (cVSP) after aneurysmal subarachnoid hemorrhage (aSAH) in humans. We evaluated safety/tolerability and feasibility of intravenous dantrolene (IV-D) after aSAH.

Methods:
In this single-center, randomized, double-blind, placebo-controlled trial, 31 patients with acute aSAH were randomized to IV-D 1.25 mg IV every 6 hours x 7 days (n=16) or placebo (n=15). Primary endpoint was incidence of hyponatremia (sNa ≤ 134 mmol/L) and liver toxicity (% patients with ALT, AST and AlkPhos >5x upper limit of normal). Secondary safety endpoints included tolerability, systemic hypotension and intracranial hypertension. Efficacy was explored by clinical, transcranial Doppler (TCD) or angiographic cVSP occurrence, delayed cerebral ischemia (DCI) and 3-month modified-Rankin-Scale, Glasgow Outcome Scale and Barthel Index. Statistical analysis was performed using non-parametric tests, generalized estimating equations and mixed models.

Results:
Between IV-D vs. placebo, no differences were observed in the primary outcome (hyponatremia: 44% vs. 67% [p=0.29]; liver toxicity 6% vs. 0% [p=1.0]). Numerically more AEs and SAEs were seen in the IV-D group, but did not reach statistical significance (16 vs. 5 AEs, of which 5 vs. 2 were severe; RR 2.2; 95% CI 0.7-6.7; p=0.16). Three IV-D vs. two placebo patients reached stop criteria: one IV-D patient developed liver toxicity; two patients in each group developed brain edema requiring osmotherapy. No differences in angiographic, TCD, clinical cVSP, DCI, or 3-month functional outcomes were seen. Quantitative angiogram analysis revealed a trend towards increased vessel diameters in the IV-D group after the 7-day infusion-period (p=0.05).

Conclusion:
In this small trial, IV-Dantrolene after aSAH was feasible, tolerable and safe, but was underpowered to show efficacy or outcome differences.
Abstract T P355: Dobutamine versus Mirlinone for Intensive Hemodynamic Augmentation to Relieve Clinical Delayed Cerebral Ischemia after Subarachnoid Hemorrhage
Authors: Mutoh Tatsushi , Ishikawa Tatsuya , Kazumata Ken , Matsumoto Keigo , Taki Yasuyuki , Suzuki Akifumi
Published: July 2021

Intensive hemodynamic augmentation by increasing cardiac output (CO) is a valuable method of elevating cerebral blood flow and oxygenation in the dysautoregulated vascular territories after subarachnoid hemorrhage (SAH). We prospectively assessed the effect of hyperdynamic therapy with dobutamine (DOB) or milrinone (MIL) on regional cerebral oxygenation (rSO
2
) for reversing clinical deterioration induced by delayed cerebral ischemia, using an integrative monitoring with uncalibrated pulse contour CO analysis and multi-channel near-infrared spectroscopy. One-hundred ten SAH patients diagnosed to have clinical deterioration due to delayed cerebral ischemia were assigned to receive hemodynamic augmentation with DOB or MIL (n=56 per each group). For hyperdynamic therapy, each inotrope was initiated at low dose (DOB: 3μg/kg/min; MIL 0.15μg/kg/min) and then increased in each dose increment until resolution of the symptoms unless any adverse effects occur during the therapy, based on our predefined hemodynamic regimen to induce similar dose-related increase in CO. Real-time CO and rSO
2
changes in conjunction with the assessment of neurological improvements were compared. A total of 425 dose increment challenges (DOB, n=197; MIL, n=228) were performed. In spasm-affected territories, decreased and/or fluctuating rSO
2
was detected compared with recordings in other brain region. Patients who exhibited rapid elevation of CO by each challenge had subsequent uptake and stabilization of rSO
2
. The responses (total number and degree of neurological improvements) were more significant in patients treated with DOB than those treated with MIL (
P <
0.05), although tachycardia that may affect stroke volume depression during the DOB therapy was more evident (DOB 28% vs. MIL 9%). Area under the ROC curve to predict rSO
2
elevation or neurological improvement for both drug groups were significant (
P <
0.0001) and the values were significantly greater in DOB than in MIL (
P <
0.05). In conclusion, DOB can provide more effective hemodynamic augmentation in relieving focal cerebral ischemia in patients after SAH. MIL is also effective in the hyperdynamic therapy but may be used as a second line in a patient subgroup when DOB was contraindicated.
Abstract T P362: Prevalence and Clinicoradiological Profile of Japanese Patients with Alzheimer Disease Coexisting Multiple Microbleeds
Authors: Ikeda Ken , Hirayama Takehisa , Takazawa Takanori , Kiyozuka Testuhito , Yanagihashi Masaru , Ishikawa Yuchi , Murata Kiyoko , Kawabe Kiyokazu , Kano Osamu , Iwasaki Yasuo
Published: July 2021

Background:
Pathological findings of cerebral amyloid angiopathy (CAA) and Alzheimer’s disease (AD) coexist frequently. Both diseases are associated with β-amyloid deposition and dementia. We aimed to evaluate frequency and clinicoradiological profile of AD patients with multiple microbleeds (MBs)

Methods:
We reviewed clinical charts and magnetic resonance imaging (MRI) findings in patients with probable AD from 2009 to 2012, according to the DSM-IV. Brain MRI was performed at 1.5 T using protocols, including T2*-weighted gradient-echo or susceptibility-weighted imaging. MBs were defined as rounded, hypointense foci ≤ 10 mm in size in the brain parenchyma. MBs topography was divided into the lobar (L) and the deep/infratentorial (D/I) region. Multiple MBs were defined as the number ≥ 8 in the L or the D/I territory. White matter hyperintensities (WMH) were assessed using the age-related white matter changes scale. Clinicoradiological findings were examined for ≥ 1 year. Prevalence and clinicoradiological profiles were studied in patients with multiple L MBs or multiple D/I MBs.

Results:
Five hundred fifty patients (238 men and 312 women) were participated in the present study. Mean age (SD) was 78.4 (7.7) years, 78.3 (8.1) in men and 78.6 (7.5) in woman. A total of 132 patients (55 men and 78 women) had at least MB. Prevalence of total MBs was 24.0%, 23.1 in men and 25.0 in women. Multiple L MBs existed in 49 patients (8.9%), 15 men (6.3) and 34 women (10.9). Multiple D/I MBs were found in 44 patients (8.0%), 23 men (9.7) and 21 women (6.7). Clinical profiles of multiple L MBs revealed sudden deterioration, rapid progression, non-hypertension, higher rates of symptomatic subcortical hemorrhage and onset of CAA-associated leukoencephalopathy. Radiological hallmarks exhibited increased number and size of MBs, high score of WMH and asymptomatic subcortical hemorrhage. Clinicoradiological features of multiple D/I MBs exhibited higher rates of hypertension and variable degrees of WMH.

Conclusions:
The present study indicated that prevalence of multiple MBs was 16.9% in Japanese patients with AD. The clinicoradiological profile suggested severe degree of CAA in patients with multiple L MBs (8.9%) and hypertensive changes in patients with multiple D/I MBs (8.0%).
Abstract T P368: Subcortical Calcification on CT as Diagnostic Sign of Transverse-Sigmoid Dural Arteriovenous Fistula With Cortical Venous Reflux
Authors: Mugikura Shunji , Metoki Takahiro , Murata Takaki , Kurihara Noriko , Matsumoto Yasushi , Ezura Masayuki , Takahashi Shoki
Published: July 2021

Background:
and purpose The annual mortality rate of the patients who had dural arteriovenous fistula (dAVF) with cortical venous reflux (CVR) is high without treatment and early diagnosis is considered desirable. However, diagnostic symptoms of dAVF with CVR are varied and sometimes non specific or chronic one such as tinnitus, headache, dizziness, dementia and so on, which causes of delay in diagnosis. We sought to determine the subcortical calcifications on computed tomography (CT) scans as the diagnostic sign of dAVF with CVR.

Material and methods:
In 119 consecutive patients diagnosed with dAVF by the cerebral angiographic findings, we reviewed for the prevalence of subcortical calcifications on CT, shunting sites and side of shunting and the presence of cortical venous reflux (CVR) on angiograms and clinical symptoms leading to the diagnosis (diagnostic symptoms).

Results:
Subcortical calcifications on CT scans were seen in 10 patients (8.4% of 119 patients with dAVF). All of them had dAVF of transverse-sigmoid sinus (TS-dAVF) with CVR. Prevalence of subcortical calcifications was significantly higher in patients with TS-dAVF (P<0.001) (21%, 10 of 48 patients) than in patients with other than TS-dAVF (0 of 71 patients), and significantly higher in patients with CVR (P<0.001) (19 %, 10 of 52 patients) than in patients without CVR (0%, 0 of 67 patients). Subcortical calcifications tended to limited in the posterior part of the same hemisphere as hemisphere with shunting and appeared to be curvilinear ones predominantly involving the cortico-medullary junction at the bottom of cerebral gyri. Prevalence of subcortical calcifications was significantly higher in patients with chronic or non specific symptom (P<0.001, 26 %, 8 of 31 patients) than those with acute or ophthalmic symptom (2%, 2 of 88 patients).

Conclusion:
Subcortical calcification on CT is a sign of TS-dAVF with CVR, specifically in patients who present chronic or non specific symptoms. Subcortical calcifications found in TS-dAVF could be caused by venous congestion due to long-lasting CVR without being noticed or diagnosed.
Abstract T P37: Cerebral Blood Volume Does Not Differentiate Regions With Persistent Cerebral Hypoperfusion That Infarct From Those That Survive: A DEFUSE 2 Substudy
Authors: Mann Sharan K , Christensen Soren , Mlynash Michael , Kemp Stephanie , Lansberg Maarten G , Albers Gregory W ,   The DEFUSE 2 Investigators
Published: July 2021

Background:
The optimal Tmax threshold for predicting critically hypoperfused tissue is a delay of >6 seconds. However, persistent Tmax >6s lesions do not invariably progress to infarction. Differences in cerebral blood volume (CBV) may explain why some regions of persistent cerebral hypoperfusion (PCHP) infarct whereas others survive. We hypothesized that CBV is higher in areas of PCHP that survive versus those that infarct.

Methods:
We included patients that had: 1) a Tmax >6s lesion on baseline and early follow-up MRI perfusion scans, and 2) a FLAIR lesion on the day 5 MRI scan. Regions of PCHP had to meet two criteria: 1) Tmax >6s positive on both baseline and co-registered early follow-up MRI perfusion scans, and 2) DWI negative on the baseline MRI scan. PCHP regions were classified as PCHP-infarct if there was a corresponding lesion on the co-registered 5 day FLAIR and as PCHP-survival if there was no corresponding lesion. Patients with no region of either PCHP-infarct or PCHP-survival were excluded. The study had two parts. In part 1, the paired t-test was used to compare lesion volume, CBV, cerebral blood flow (CBF), mean transit time (MTT), and Tmax between PCHP-infarct and PCHP-survival regions within each patient. In part 2, the 2-sample t-test was used to compare mean volume, CBV, CBF, MTT, and Tmax in PCHP-infarct and PCHP-survival regions for all patients together as a group.

Results:
61 patients were included in the analysis. Mean total PCHP volume was 26cc (16cc infarct, 10cc survival) and median total PCHP volume was 15cc (9cc infarct, 6cc survival). For part 1, CBV was not different in PCHP-infarct versus PCHP-survival (P=0.16). CBF was higher (P=0.05) in regions of PCHP-survival, and MTT and Tmax were less prolonged (P=0.03 and P < 0.01). For part 2, mean CBV and MTT did not differ between PCHP-infarct and PCHP-survival (P=0.23 and P=0.40). Mean CBF trended higher (P=0.07) and mean Tmax delays were milder (P= 0.04) in PCHP-survival.

Conclusion:
CBV does not differ between regions of PCHP-infarct versus PCHP-survival and does not explain why some areas of persistent, severe hypoperfusion survive. Tmax was less severely delayed and CBF values were higher in regions of PCHP-survival, which warrant further study.
Abstract T P57: Length of Stay and Hospital Charges in Japanese NVAF Inpatients with Acute Stroke/TIA: The SAMURAI-NVAF Study
Authors: Toyoda Kazunori , Arihiro Shoji , Todo Kenichi , Yamagami Hiroshi , Kimura Kazumi , Shiokawa Yoshiaki , Kamiyama Kenji , Terasaki Tadashi , Okada Yasushi , Nagakane Yoshinari , Mochizuki Hiroshi , Takizawa Shunya , Hasegawa Yasuhiro , Okuda Satoshi , Furui Eisuke , Ito Yasuhiro , Nakashima Takahiro , Kario Kazuomi , Kameda Tomoaki , Takamatsu Kazuhiro , Nishiyama Kazutoshi , Sato Shoichiro , Koga Masatoshi ,   The SAMURAI Study Investigators
Published: July 2021

Purpose:
Warfarin needs several days to reach the steady anticoagulative state, however novel oral anticoagulants (NOACs) does not. It may cause differences in acute hospital stay for stroke and hospital charges between NVAF patients taking warfarin and those taking NOACs. We aimed to determine the association of OAC choice after stroke with length of hospital stay and hospital charges from a multicenter prospective registry (the SAMURAI-NVAF, NCT01581502) involving 18 hospitals.

Methods:
634 acute ischemic stroke/TIA survivors with NVAF (277 women, 77±10 years old) who was taking OACs at discharge between Sep 2011 and Jun 2013 were studied; three NOACs were approved for clinical use in NVAF patients in Japan just before or during the periods (dabigatran in Jan 2011, rivaroxaban in Jan 2012, apixaban in Dec 2012). Hospital charges were analyzed using 217 patients in the first author’s hospital where the Diagnosis Procedure Combination, a Japanese diagnosis-dominant case-mix system was used for charges.

Results:
Warfarin was chosen for 420 patients (66%), dabigatran for 143 (23%), and rivaroxaban for 71 (11%) at hospital discharge. Warfarin users were older (warfarin 79±10, dabigatran 73±9, rivaroxaban 74±10 years old, p<0.001) and more female (47%, 34%, 41%, p=0.021), and had higher scores of admission NIHSS (median 10, 3, 6, p<0.001) and discharge mRS (3.5, 1, 2, p<0.001) than the others. Median hospital stay was longer in warfarin users (28 [IQR 18-36] days) than dabigatran users (15 [12-22] days) and rivaroxaban users (18 [13-26] days, p<0.001). As compared to NOAC use, warfarin use was independently associated with longer stay both after adjustment for sex, age, and initial NIHSS score (p<0.001) and after adjustment for sex, age, and discharge mRS (p<0.001). Median hospital charges were 1,623*10
3
[IQR 980-2141] JPY for warfarin users (n=137), 967*10
3
[IQR 716-1240] JPY for dabigatran users (n=43), and 1,354*10
3
[IQR 944-2063] JPY for rivaroxaban users (n=137, p<0.001). There was no independent association of OAC choice with hospital charges after multivariate adjustment.

Conclusion:
Use of NOACs for secondary prevention shortened acute hospital stay after stroke/TIA independently from stroke severity.
Abstract T P59: Inflammatory Mediators and Metalloproteinase Profile Predict Poor Outcome in Ischemic Stroke Patients Treated with Thrombolysis: Results from the MAGIC Study
Authors: Nencini Patrizia , Gori Anna M , Giusti Betti , Piccardi Benedetta , Palumbo Vanessa , Nesi Mascia , Armillis Alessandra , Pracucci Giovanni , Abbate Rosanna , Inzitari Domenico
Published: July 2021

Background:
Experimentally inflammatory mediators and metalloproteinases (MMPs) play a detrimental role related to severity of an ischemic brain lesion. MMPs activity is also induced by the inflammatory response after an ischemic attack. This study aimed to evaluate the role of a large panel of circulating molecules in the setting of tPA treated stroke patients

Methods:
Blood was taken before and 24-hours after tPA from 327 patients (mean age 68 years, median NIHSS 11) with acute ischemic stroke. Baseline values and delta median values [(post tPA-baseline)/baseline] of each parameters were analyzed related to 3-month death and 3-month Rankin scale (mRs) score 3-6. The net effect of each biomarker was estimated by a logistic regression model including the major clinical determinants.

Results:
1) Death vs survival: significant for baseline alpha 2-macroglobulin (A2M), deltaMMP9, and deltaTIMP1 [OR (95%CI): A2M 2.52(1.14-5.55); MMP9 1.58(1.11-2.26), TIMP1 2.59(1.44 - 4.66)]. 2) mRs 3-6 vs 0-2: significant for deltaMMP9, deltaIL6, and deltaCRP [OR (95%CI): MMP9 1.35(1.01 - 1.81); IL6 1.07(1.01-1.13); CRP 1.03(1.01-1.06)]. ROC analysis demonstrated that the addition of baseline A2M and deltaMMP9 (model 2) to a model including factors known to affect the outcome (model 1) significantly improved the area under the curve for mortality [model 1: AUC=0.82 (95%CI 0.75-0.90); model 2: AUC=0.88 (95%CI 0.83-0.93), p<0.05]. Discussion: Our data add substantial clinical evidence about the detrimental role of inflammatory mediators and MMPs profile, in particular A2M and MMP9, in tPA treated stroke patients.
Abstract T P64: Cerebral Ischemic Events Associated with Intravenous Thrombolytic Administration in International Joint Efficacy Comparison of Thrombolytics (INJECT) Trial.
Authors: Tasneem Nudrat , Adil Malik M , Suri M Fareed K , Qureshi Adnan I
Published: July 2021

Background:
Platelet activation can be seen subsequent to thrombolytic administration leading to re-occlusion within coronary arteries. However, the occurrence of cerebral ischemic events secondary to thrombolytic administration is not well studied.

Objective:
To study the rate and outcome of patients with acute myocardial infarction [MI] who develop cerebral ischemic events within 48 hours of thrombolytic administration.

Methods:
A post-hoc analysis of the INJECT trial data was performed. Patients from 208 centers in nine countries (n = 6010) with acute myocardial infarction (<12 hr after symptom onset) were randomized to receive double-blind either streptokinase 1.5 MU intravenously over 60 min or reteplase two boluses of 10 MU given 30 min apart. All patients received intravenous heparin for at least 24 h. Ascertainment of ischemic stroke during hospitalization was performed throughout the study.

Results:
A total of 81 in-hospital strokes were observed in 6010 acute MI patients of which 47 were classified as ischemic events. A total of 29 (62%) suffered ischemic events within 48 hours of thrombolytic administration; 23 were ischemic stroke and 06 were transient ischemic attacks. The mean age (±SD) of the 29 patients was 70± (10) ; 20 were men. None of the patients had pre-existing or new onset atrial fibrillation. Underlying cardiac shock and heart failure was seen in 2 and 5 patients, respectively. IV heparin was continued for 24-72 hours in 11 patients. Survival was 66% (n=19) at 35 days and 55% (n=16) at 6 months.

Conclusions:
Most cerebral ischemic events occur in the immediate post-thrombolytic period and result in disproportionately low survival over 6 months.
Abstract T P82: Long-Term Neurorestorative Effect of α-lipoic Acid Treatment in Focal Cerebral Ischemia Model
Authors: Choi Kangho , Kim Joon-Tae , Park Man-Seok , Cho Ki-Hyun
Published: July 2021

Introduction:
A considerable body of evidence suggests that oxidative stress is a fundamental mechanism of brain damage in stroke. A recent study suggests that the antioxidant properties of alpha-lipoic acid (aLA) correlate with its ability to promote neuroproliferation. However, there have been no reports of comprehensive studies examining the neurorestorative effects of aLA administered after the onset of ischemia.

Hypothesis:
The neuroprotective effects of acute treatment with ALA on neuroproliferation and long-term functional recovery following cerebral ischemic injury were examined using an animal model of clinical stroke with middle cerebral artery occlusion (MCAO).

Methods:
The middle cerebral artery (MCA) of adult male Sprague-Dawley rats was occluded for 2 h and then reperfused. To examine the effect of ALA on brain infarction, ALA (20 mg/kg body weight) was administered after the induction of anesthesia in 71 animals (ALA group) through the left external jugular vein immediately after reperfusion of the left MCAO. An equivalent volume of vehicle was administrated to 71 animals (control group) using the same procedure. A neurologic examination was performed at defined points after MCAO and a neurological deficit score (NDS) was obtained. Motor impairment was assessed by the accelerating rotarod test. Levels of endogenous neural precursor and glial cell were analyzed by immunohistochemistry.

Results:
Immediate aLA administration group after reperfusion significantly reduced the mortality, infarct size, and NDS than control group (n=71, P=0.005, P=0.002, and P=0.001, respectively). Long-term functional outcomes by Rotarod test were also markedly improved by aLA treatment (P=0.013). After 7 and 14 days of treatment, significantly more cells were labeled with BrdU, nestin, and GFAP in the aLA-treated rats along the infarct and infarct core regions. Significantly more BrdU/GFAP double-labeled cells were observed in the subventricular zone of the aLA group on days 7 and 14.

Conclusions:
These results indicate that urgent treatment with aLA after ischemic injury may have significant neurorestorative effects through enhanced neuroproliferation. aLA may be a useful intervention for the treatment of acute ischemic stroke.
Abstract T P95: Coronary Artery Disease in Moyamoya Disease
Authors: Jo Kyung Il , Kim Jong Soo , Hong Seung-Chyul , Yeon Je Young
Published: July 2021

Background and Purpose:
Coronary artery disease in moyamoya disease (MMD) have been described sporadically in several case reports. The purpose of this study is to determine the prevalence and characteristics of coronary artery disease in patients with MMD.

Methods:
From August 1991 to December 2012, 446 patients diagnosed with adult MMD at our hospital. Baseline characteristics and prevalence of coronary artery disease were reviewed based on medical records and laboratory findings. The findings of conventional coronary angiography and/or coronary computed tomography were also reviewed for the presence and appearance of coronary artery lesion.

Results:
- Of 446 patients with adult MMD, 21 patients were found to have coronary artery disease. Ten patients were treated with coronary artery bypass graft (n=4) or percutaneous coronary intervention (n=6) for unstable angina or myocardial infarction. Eleven were treated with medication for stable angina (n=6) and variant angina with mild degree of stenosis (n=5). Median age at diagnosed with coronary artery disease of these patients were 44 (range, 27-59). Two patients showed calcification on coronary artery lesion. Comorbid stroke risk factor rate were 19%, 38%, 9.5% and 19 % in diabetes, hypertension, dyslipidemia and smoking. Six of 21 patients had more than 2 risk factor.

Conclusion:
- Twenty one (4.7%) of our adult MMD registry patients showed coronary artery disease. And only 2 (9.5%) showed calcification which might means that atherosclerosis burden is low in coronary artery disease with MMD. Coronary artery disease might be a clinically relevant systemic manifestation in patients with MMD, considering early onset coronary diseaes and low prevalence of stroke risk factor.
Abstract W MP106: Temporal Trends in Stroke Investigations and Their Effect on Management
Authors: Ng Vivian T , Bayoumi Ahmed M , Fang Jiming , Burton Kirsteen R , Stamplecoski Melissa , Kapral Moira K
Published: July 2021

Background:
Current guidelines recommend that patients with suspected stroke undergo neuroimaging to confirm the diagnosis and that those with ischemic stroke or TIA receive carotid imaging and cardiac investigations to determine stroke etiology. It is not known how rates of investigations have changed over time, and if those trends have led to changes in medical or surgical management. We used a clinical stroke registry to evaluate temporal trends in stroke investigations in Ontario, Canada.

Methods:
We used the Ontario Stroke Registry to identify patients who presented with stroke and TIA to 11 stroke centers between 2003 and 2012. The primary outcome was the proportion of patients who received CT, MRI, CTA, MRA, carotid doppler, and echocardiography in each year. Secondary outcomes were (1) the total number of neuroimaging procedures per patient; (2) the proportion of patients with ischemic stroke/TIA prescribed antithrombotics at discharge; and (3) the proportion who had carotid revascularization. The characteristics of study participants, rates of investigations and interventions, and test for trends over one year intervals were completed using a Cochran-Armitage trend test.

Results:
The study sample included 42,738 patients. From 2003 to 2012, the proportion receiving any type of neuroimaging increased from 96% to 99%, those receiving an MRI increased from 10% to 49%, those receiving carotid imaging increased from 62% to 88% and those receiving echocardiography increased from 52% to 70% (P<0.0001 for all comparisons). The total number of neuroimaging procedures per patient also increased, from a median of 1 in 2003 to 3 in 2011 (P<0.0001), and with almost 40% undergoing three or more neuroimaging procedures in 2011. In those with ischemic stroke or TIA, rates of antithrombotic therapy increased from 83% to 91%, as did the rate of carotid endarterectomy, from 0.7% to 0.8%. (P< 0.009).

Conclusions:
Rates of neuroimaging, carotid imaging and cardiac investigations after stroke have markedly increased over time. It is uncertain whether the increased rates of MRI and neuroimaging per patient are associated with improved outcomes. Further research is needed to evaluate the cost-effectiveness of current patterns of investigations following stroke.