bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP312: Developing a Mobile Application for Stroke Informal Caregivers
Authors: Singer Jonathan , Stefanov Dimitre , Gilles Nadege , Weingast Sarah Z , Faysel Mohammad , Girouard Shirley , Fraser-White Marilyn , Burton Dee , Levine Steven R ,   The Mobile Applications for Stroke (MAPPS) Investigators
Published: June 2021

Background:
Following stroke, many survivors require assistance with activities of daily living from untrained individuals. These informal caregivers assume multiple new responsibilities, which can generate stress, especially when their own needs are inadequately addressed during a patient’s recovery.

Methods:
A nationwide survey mailed to 11,720 stroke survivors through the National Stroke Association with a cover letter asking them to give the IRB approved informed consent and survey to their informal caregiver, if applicable. The 17 question survey asked caregivers about demographics, if they own a cell/smart phone, and the caregiver’s opinion about what resources in a mobile app (if any) would be useful – namely: 1) scheduling multiple tasks, 2) finding information about stroke resources, 3) finding local resources, 4) tracking fitness and diet, and 5) communication with their stroke survivor. The survey was developed using focus groups in 2 states. For all questions logistic regression determined if there were racial, gender, or age disparities.

Results:
396 stroke caregivers [(299 (76%) female, 96 (24%) African-American, 42 (11%) Hispanic/Latino, and 210 (53%) Caucasian], aged 20-99 years (mean 59.5 ± 13.3) returned surveys; 96% owned a cell phone; 60% of all caregivers owned a smart phone. Caregivers in this sample reported features of the app to be important including: doctor/rehab appointments (80%, 95% CI, 76-84%), links to trustworthy medical information (84%, 95% CI 80-87%), stroke support groups in my area (81%, 95% CI 77-85%), exercises (76%, 95% CI 71-80%), and a touch screen with useful phrases (76%, 95% CI 71-80%). When examining the utility of the 5 app resources (outlined above), Latino (88%-74%) and African-American (84%-77%) caregivers reported the highest rate of usefulness across the 5 aspects). As age increased, the caregivers’ reporting of mobile app usefulness decreased (
p
< 0.05). However, in the oldest group (63+), 67-79% of caregivers reported that all 5 resources would be useful in a mobile app.

Conclusions:
Implementation of a mobile app unique to stroke caregivers with resources is desired by this diverse, national sample of informal caregivers and holds potential to alleviate stress and improve patient’s recovery.
Abstract TP388: Sharing Best Practices Amongst Stroke Centers in the Chicagoland Region Increases EMS Use and Decreases Door-to-Needle Times
Authors: Masor Minna B , Jennrich Mary Kay , Reilly Ginger , Behrens Dee ,   Midwest Stroke Action Alliance
Published: June 2021

Background:
Research has demonstrated the sooner a patient is treated, the better the outcome. Midwest Stroke Action Alliance (MSAA) began sharing best practices among the Chicago Region area hospital stroke centers in 2007. As MSAA has become a more formal organization, following the ever changing guidelines has been a priority to ensure the outreach in the community matches the current clinical practice guidelines and certification requirements. As the bar has increasingly been raised, this group has consistently met those challenges by sharing barriers and action plans that have been developed across hospitals.

Methods:
This poster will demonstrate retrospective analysis of patients from Q1 2013 through Q1 2016. The patients represent 35 hospitals in the Chicago regions (7, 8, 9, 10 and 11). Key areas of impact include increasing the percentage of patients receiving tPA in 60 minute or less and a brief look at 45 minutes or less and how pre-notification from EMS helps activate the stroke teams to treat quicker.

Results:
In Q1 2013, pre-notification occurred in 64% of patients with resulting DTN times in <60 minutes 33% of the time. In Q12016, pre-notification increased to 73% with subsequent DTN times under 60 minutes occurring 75% of the time. Of note, in Q12013, there was a treatment rate of 6% in DTN <45 minutes, whereas in Q12016, this number rose to 32%.
Abstract 102: Reduced Hemorrhagic Transformation and Neurological Worsening with Neuroprotection (3K3A-APC) During Thrombolysis and Thrombectomy
Authors: Ogami Kyle , Song Shlee , Lyden Patrick , Anderson Ariana ,   on behalf of the NN104 Investigators
Published: June 2021

Background:
Agonism of protease-activated receptor 1 (PAR1) potently protects neurons and vasculature in the central nervous system during stroke. We evaluated the effects of 3K3A-APC, a recombinant variant of activated protein C active at PAR1, in acute ischemic stroke patients during conventional recanalization with thrombolysis or thrombectomy or both. We hypothesized that 3K3A-APC would reduce post-treatment hemorrhage and symptomatic neurologic deterioration.

Methods:
Using the NeuroNEXT trial NN104 (RHAPSODY) database, susceptibility weighted and gradient echo images were graded for intracerebral hemorrhage size according to radiographic criteria described in ECASS (Hemorrhagic infarction type 1 and 2 and parenchymal hematoma type 1 and 2) at four time points (0, 7, 30, and 90 days after treatment). Of 110 participants enrolled, 101 had appropriate imaging for analysis. Images were evaluated and graded by two blinded, independent raters with an expert providing consensus reads. Utilizing NIHSS following drug treatment, neurological worsening was defined as an increase in NIHSS ≥ 4 points. We compared placebo versus drug administration using multi-variate regression.

Results:
Of 101 participants evaluated, those receiving placebo (n=41) were significantly more likely to have hemorrhage at any time compared with those receiving any amount of drug (n=60) (p = 0.04; CI: 1.080 - 7.544; OR = 2.73). Age was found to be the only significant variable leading independently to increased neurological worsening (p = 0.038; CI: 1.015-1.193; OR = 1.086).

Conclusion:
The neuroprotectant 3K3A-APC showed significant reduction in hemorrhagic transformation when co-administered with conventional recanalization therapy. Further studies are underway for determining the effect of 3K3A-APC on functional outcome.
Abstract 163: Recognizing Sex Disparities Among Invited Speakers at the International Stroke Conference Motivates Change
Authors: Fournier Lauren E , Zhu Liang , Carter Caitlynn , Perez-Pinzon Miguel A , Ovbiagele Bruce , McCullough Louise D , Sharrief Anjail Z
Published: June 2021

Introduction:
Females were significantly underrepresented as invited speakers at the International Stroke Conference (ISC) from 2014-2018. In 2019, there were increased efforts by the ISC program committee to recruit female speakers. Other efforts to increase female participation at the 2019 ISC included a session for women’s issues in stroke and a women’s luncheon.

Methods:
ISC invited speaker data were obtained (years 2014-2019) from the American Heart Association. Variables included sex, degree, race, speaker institution country, session type and category. Data were analyzed by Chi-square test, Fisher’s exact test or logistic regression models.

Results:
From 2014-2018, females represented 28% of ISC invited speakers, and in 2019 the proportion of females rose to 47%. Females represented 38% of physician speakers in 2019 as compared to 18% from 2014-2018. For Black speakers, in 2019 females represented the majority (64%), increased from 2014-2018 (17%). For Hispanic speakers, females remained one of the lowest proportions, but with an increase from 12% to 39%. Females represented the highest and lowest proportion of speakers from South America (100%) and Africa (0%) and the largest in invited symposium (48%), similar to 2014-2018. The odds of being invited for debate as a female increased in 2019 (OR 0.67 vs 0.37, p=0.36), but this did not reach significance. Females represented the largest proportion of speakers in recovery and rehabilitation (52%) in 2019, similar to 2014-2018. Females had higher odds of being invited as a speaker in the acute, in-hospital care category (OR 0.83 vs 0.53, p=0.22), but this did not reach significance. Females were more often invited as speakers more than once in 2019 (OR 0.94 vs 0.61, p=0.29).

Conclusions:
There is potential to increase female participation at major scientific conferences through initiatives by the program committee. Identifying gender disparities at a major conference like the ISC may help to close the gender gap.
Abstract 168: Outcomes of Intra-Arterial Tissue Plasminogen Activator Rescue Therapy During Stroke Thrombectomy-Insights From the STAR Collaboration
Authors: Almallouhi Eyad , Al kasab Sami , Alawieh Ali , Chalhoub Reda M , Anadani Mohammad , Psychogios Marios , Arthur Adam , Kim Joon-Tae , De Leacy Reade , Rai Ansaar , Keyrouz Salah , Fargen Kyle , Dumont Travis , Kan Peter , Starke Robert , Spiotta Alejandro M ,   STAR Collaborators
Published: June 2021

Introduction:
Intra-arterial tissue plasminogen activator (IA-tPA) can be used as rescue therapy during mechanical thrombectomy for stroke patients, mostly in the setting of distal occlusion. The outcomes of IA-tPA has not been assessed in large-scale multi-center studies yet.

Methods:
We used data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which included prospectively maintained databases of 11 thrombectomy-capable stroke centers in the US, Europe, and Asia. We compared the baseline characteristics, procedural metrics, rate of symptomatic intracranial hemorrhage (sICH), and long-term functional outcomes between thrombectomy patients who received rescue IA-tPA and a control group of thrombectomy patients with matched age, National Institute of Health stroke scale (NIHSS) on presentation, location of occlusion and IV-tPA receipt.

Results:
A total of 2827 thrombectomy patients were included in the STAR registry. Out of those, 205 patients received IA-tPA. We matched 191 patients from the IA-tPA group with a control group of 191 patients (table 1). No difference was seen in age, sex, race, vascular risk factors, or Alberta Stroke Program Early CT (ASPECT) score between both groups. In addition, procedural metrics, including onset to groin time, the procedure duration, and rate of successful recanalization (modified Thrombolysis in Cerebral Infarction score≥2b) were similar. Finally, similar outcomes were noted in both groups, including the rate of sICH and good 90-day functional outcome (modified Rankin scale≤2).

Conclusion:
The use of IA-tPA as an adjunctive treatment to mechanical thrombectomy was safe but did not result in a higher rate of successful recanalization or good long-term functional outcomes.
Abstract 169: A Comprehensive Multicenter Evaluation of the Impact of Age on Stroke Thrombectomy Outcomes - Insights From the STAR Collaboration
Authors: Chalhoub Reda M , Alawieh Ali M , Anadani Mohammad , Eid Maya , Arthur Adam , Kim Joon-Tae , De Leacy Reade , Grossberg Jonathan , Psychogios Marios , Maier Ilko , Rai Ansaar , Keyrouz Salah , Fargen Kyle , Dumont Travis , Kan Peter , Starke Robert M , Spiotta Alejandro
Published: June 2021

Introduction:
Elderly patients, octogenarians and nonagenarians, were excluded or under-represented in the majority of stroke endovascular thrombectomy (ET) trials. There is conflicting data on the outcomes of ET in the elderly. We evaluated age-dependent outcomes of ET for stroke in a large dataset from the Stroke Thrombectomy and Aneurysm Registry (STAR).

Methods:
Patients undergoing ET for acute ischemic stroke at 12 comprehensive stroke centers in the US and Europe between 01/2013 and 12/2018 were reviewed. Data was collected retrospectively from patient charts, procedure notes, and patient follow-up in neurology clinics. The primary endpoint was the modified Rankin score (mRS) at 90-days which was dichotomized into good outcome (mRS 0-2) or poor outcome (mRS 3-6).

Results:
Of 3,850 patients reviewed, 2,827 had 90-day follow-up (mean age 69±14), and were divided into 6 age groups: 20-49 (G1, 10%), 50-59 (G2, 10%), 60-69 (G3, 23%), 70-79 (G4, 27%), 80-89 (G5, 21%), 90 or more (G6, 4%). When adjusted for confounding variables, age was an independent predictor of poor outcome (OR=1.4, p<0.001) and mortality (OR=1.5, p<0.0001). When used as categorical variable, adjusted OR (aOR) for good outcomes were significantly lower in groups G2-G6 compared to G1 (p<0.01, figure), and OR for mortality were significantly higher in G2-G6 compared to G1 (p<0.01, figure). An age increment of 10 years was associated with 23% higher odds of symptomatic hemorrhage, and 50% higher odds of mRS 5-6. The impact of procedure time on good outcome (mRS 0-2) was also age-dependent with aOR=0.84 (p<0.05) in G1,2 compared to aOR=0.65 (p<0.05) in G5,6.

Conclusions:
Age is a major predictor of functional recovery after ET, and this study demonstrates a clear age-dependent increase in rate of mortality and poor outcomes after ET with exponentially worse outcomes above 80 years of age. Complication rates were not age-dependent. Further studies are required to optimize patient selection for ET in the elderly.
Abstract 58: Prediction of Malignant Edema Formation After Endovascular Treatment for Middle Cerebral Artery Infarction: The Added Value of Intracranial Cerebrospinal Fluid Volume
Authors: Kauw Frans , Bernsen Marie Louise E , de Jong Hugo W , Kappelle L. Jaap , Velthuis Birgitta K , van der Worp H. Bart , van der Lugt Aad , Roos Yvo B , Hofmeijer Jeannette , Dankbaar Jan W , Bennink Edwin ,   MR CLEAN Registry investigators
Published: June 2021

Introduction:
Prediction models may guide decisions in the management of patients at risk for malignant middle cerebral artery infarction. The ratio of intracranial cerebrospinal fluid (CSF) volume to intracranial volume (ICV) has been identified as a predictor of malignant edema in ischemic stroke patients treated with intravenous thrombolysis. The added predictive value in stroke patients who received endovascular treatment is unknown.

Methods:
Patients with available thin-slice non-contrast CT data on admission were selected from the MR CLEAN Registry, which is a prospective national multicenter registry of patients with large vessel occlusion who were treated with endovascular treatment between 2014 and 2017. Baseline characteristics and CT imaging data were collected. The CSF/ICV ratio was automatically measured on baseline thin-slice non-contrast CT. The primary outcome was the formation of malignant edema based on clinical and imaging features on follow-up. A previously built logistic regression model was fitted and included the following baseline predictors: age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT score, poor collateral filling and reperfusion. An extended model with the CSF/ICV ratio was compared to the previous model by using the likelihood ratio test. Odds ratios (OR), areas under the receiver operating characteristic curve (AUROC) and 95% confidence intervals (CI) were reported.

Results:
Of the included 683 patients 40 (6%) developed malignant edema. The CSF/ICV ratio of the group with malignant edema (mean 9±5%) was lower than the group without malignant edema (mean 14±6%, P<0.001). In the extended model, the CSF/ICV ratio was associated with the formation of malignant edema (per one percent decrease OR 1.2, 95% CI 1.1-1.3, P<0.001). In addition, the discriminative performance of the model with the CSF/ICV ratio (AUROC 0.87, 95% CI 0.82-0.91) was higher than that of the model without the CSF/ICV ratio (AUROC 0.84, 0.78-0.89, P<0.001).

Conclusions:
The CSF/ICV ratio improves the prediction of malignant edema formation in ischemic stroke patients who received endovascular treatment.
Abstract 68: Impaired Perfusion in Intracranial Atherosclerotic Disease Predicts Cognitive Outcomes
Authors: Liebeskind David S , Romano Jose G , Cotsonis George A , Yaghi Shadi , Honda Tristan , Scalzo Fabien , Cloft Harry J , Fiorella David J , Derdeyn Colin P , Prabhakaran Shyam , Feldmann Edward ,   for the SAMMPRIS Investigators
Published: June 2021

Background:
Poor collateral circulation and hypoperfusion may lead to recurrent stroke in intracranial atherosclerotic disease (ICAD). The role of perfusion in silent strokes and potentially insidious cognitive impairment in ICAD is unknown. We used evidence of impaired perfusion at angiography in SAMMPRIS to predict subsequent cognitive changes.

Methods:
Angiography at enrollment in the SAMMPRIS trial was independently evaluated, blind to clinical data and cognitive testing. Antegrade flow in the symptomatic arterial territory and corresponding collateral flow were scored. Impaired perfusion was defined by poor antegrade and poor collateral flow. Serial testing with the Montreal Cognitive Assessment (MoCA) was done in subjects without aphasia or neglect at baseline, 4 mo, 12 mo and closeout, or until subjects had a clinical stroke endpoint.

Results:
207 subjects (median age 61, range 33-81 years; 37% women) had baseline MoCA scores with angiography data on territorial perfusion. Baseline MoCA scores (mean 24.2±4.1) were similar between categories of antegrade flow and collateral circulation. Impaired perfusion was noted in 33/207 (16%). Serial MoCA revealed that changes in cognition over time were different at 4 mo, 12 mo and closeout based on the presence of impaired perfusion at baseline (p<0.001). After more modest (mean MoCA change = 0.5 increase from baseline, p=0.80) early improved cognitive function at 4 mo, those with impaired perfusion had cognitive decline at 12 mo (mean MoCA change, p<0.01) unlike the continued improvement in other subjects. Cognitive changes in those with impaired perfusion were associated with a higher frequency of subsequent stroke in the territory.

Conclusions:
Impaired perfusion in the symptomatic arterial territory of ICAD predicts cognitive outcomes that may precede recurrent ischemia. Future studies may define the role of noninvasive perfusion imaging in ICAD to predict cognitive trajectories and recurrent stroke.
Abstract TMP13: Tenecteplase versus Alteplase Before Endovascular Therapy in Basilar Artery Occlusion
Authors: Alemseged Fana , Puetz Volker , Boulouis Gregoire , Rocco Alessandro , Kleinig Timothy , Wu Teddy , Ng Felix , Shah Darshan , Arba Francesco , Kaiser Daniel , Williams Cameron , Francesca Di Giuliano , Morotti Andrea , Oxley Thomas , Sallustio Fabrizio , Sharma Gagan , Bush Steven , Dowling Richard , Yan Bernard , Mitchell Peter , Diomedi Marina , Donnan Geoffrey A , Parsons Mark , Davis Stephen M , Yassi Nawaf , Campbell Bruce C ,   BATMAN Collaboration
Published: June 2021

Background:
Tenecteplase (TNK) is a genetically modified variant of alteplase with greater fibrin specificity and longer half-life than alteplase. The recent Tenecteplase versus Alteplase before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK) trial demonstrated that increased reperfusion with TNK compared to alteplase prior to endovascular thrombectomy (EVT) in large vessel occlusion ischaemic strokes. However, only 6 patients with basilar artery occlusion (BAO) were included. We aimed to investigate the efficacy of TNK versus alteplase before EVT in patients with basilar artery occlusion (BAO).

Methods:
Clinical and procedural data of consecutive BAO diagnosed on CT Angiography or MR Angiography from the multisite international Basilar Artery Treatment and MANagement (BATMAN) collaboration were retrospectively analysed. The primary outcome was reperfusion of greater than 50% of the involved ischemic territory or absence of retrievable thrombus at the time of the initial angiographic assessment.

Results:
We included 119 BAO patients treated with intravenous thrombolysis prior to EVT; mean age 68 (SD 14), median NIHSS 16 (IQR 7-32). Eleven patients were treated with TNK (0.25mg/kg or 0.4mg/kg) and 108 with alteplase (0.9mg/kg). Overall, 113 patients had catheter angiography or early repeat imaging after thrombolysis. Reperfusion of greater than 50% of the ischemic territory or absence of retrievable thrombus occurred in 4/11 (36%) of patients treated with TNK vs 8/102 (8%) treated with alteplase (p=0.02). Onset-to-needle time did not differ between the two groups (p=0.4). Needle-to-groin-puncture time was 61 (IQR 33-100) mins in patients reperfused with TNK vs 111 (IQR 86-198) mins in patients reperfused with alteplase (p=0.048). Overall, the rate of symptomatic haemorrhage was 3/119 (2.5%). No differences were found in the rate of symptomatic intracranial haemorrhage (p=0.3) between the two thrombolytic agents.

Conclusions:
Despite shorter needle-to-groin-puncture times, tenecteplase was associated with an increased rate of reperfusion in comparison with alteplase before EVT in BAO. Randomized controlled trials to compare tenecteplase with alteplase in BAO patients before endovascular thrombectomy are warranted.
Abstract TMP60: Association Between Pregnancy and Cervical Artery Dissection
Authors: Salehi Omran Setareh , Parikh Neal , Poisson Sharon , Armstrong Jennifer , Merkler Alexander E , Navi Babak , Riley Laura , Fink Matthew E , Kamel Hooman
Published: June 2021

Background and Purpose:
Pregnancy is a risk factor for stroke. The mechanisms of stroke in pregnancy have not been well established. Cervical artery dissection may be one such mechanism, but it is unclear whether pregnancy is a risk factor for cervical artery dissection.

Methods:
We performed a cohort-crossover analysis using administrative claims data from all hospitalizations and emergency department visits involving nonfederal acute care hospitals in NY and FL between 2005-2015. We identified women ≥12 years old who were hospitalized for labor and delivery. Our outcome was cervical artery dissection, defined as carotid or vertebral artery dissection. We defined the period of risk as 6 months antepartum through 3 months postpartum. We compared each patient’s risk of dissection during this time period versus the corresponding 270-day period exactly 1 year later. Conditional Poisson models with robust standard errors were used to calculate incidence risk ratios (IRRs).

Results:
We identified 4,193,417 pregnancies among 3,061,413 women during our study period. There were 52 cases of cervical artery dissection during the peripartum period and 24 cases during the control period 1 year later. The incidence of cervical artery dissection was 12 (95% CI, 10-17) per million pregnancies versus 6 (95% CI, 4-9) per million patients during the control period 1 year later (IRR, 2.2; 95% CI, 1.3-3.5). Our findings were similar when we limited our outcome to cervical artery dissections complicated by ischemic stroke (IRR, 2.3; 95% CI, 1.1-5.1). Secondary analyses suggested that the heightened risk occurred in the peripartum and postpartum period (IRR,5.5; 95% CI, 2.6-11.7), not the antepartum period (IRR, 0.5; 95% CI, 0.2-1.2).

Conclusions:
In a large, population-based sample of women, pregnancy was associated with an increased risk of cervical artery dissection. This increased risk appeared to be limited to the peripartum and postpartum period.
Abstract TP108: Dendritic Cells Mediate the Detrimental Effects of Age-related Gut Dysbiosis After Stroke
Authors: Honarpisheh Pedram , d'Aigle John , Mobley Alexis S. , Won William W. , Bautista Garrido J Jesus , Blixt Frank , Miranda-Sohrabji Darius F. , Blasco Conesa Maria P. , Chauhan Anjali , Lee Juneyoung , Hazen Amy L. , Bryan Robert M. , McCullough Louise D. , Ganesh Bhanu P.
Published: June 2021

Aging is a non-modifiable risk factor for stroke. Aging is accompanied by chronic low-grade inflammation and gut dysbiosis (a pathological imbalance of microbial organisms in the gut). Age-related gut dysbiosis exacerbates stroke outcomes and can be reversed by manipulation of the gut microbiota (GM) via fecal microbiota transplants (FMTs) from young animals, or “rejuvenation.” But, the mechanisms that mediate these effects are poorly understood. Dendritic cells (DCs) are potent antigen presenting cells and uniquely equipped to mediate the effects of dysbiosis. DCs constantly sample their environment to regulate the inflammatory response to antigens and tissue injury. In this study we investigated the role of intestinal DCs in mediating the detrimental effects of dysbiosis on stroke outcomes.
We hypothesize
that age-related dysbiosis exacerbates stroke outcomes by inducing an inflammatory and migratory phenotype in intestinal DCs. We studied four cohorts of C57Bl6 mice consisting of (1) naïve young (4mo), (2) naïve aged (22-26mo), (3) middle-aged (14mo) with FMT from aged donors, and (4) naïve young with 60-min middle cerebral artery occlusion (MCAO). Phenotyping of DCs by flow cytometry was performed.

Results:
In our MCAO cohort, we found a significant increase in activated DCs in the gut (1.4% vs. 7.6%, p = 0.051) but a decrease in frequency of activated DCs in the brain (8.4% vs. 3.9%, p = 0.042). In our FMT cohort, frequency of intestinal DCs was altered in a subset-specific manner after FMT from aged donors. Specifically, our data showed that the MHC-II expression by DC subsets with a migratory phenotype (CD11b
+
DCs) and resident DCs (CD103
+
DCs) were significantly increased when middle-aged mice received FMT from aged donors (p < 0.05). In our naïve cohorts, we found a significant decrease of MHC-II surface expression in brain DCs (p = 0.044) and a significant increase in splenic DCs (p = 0.049) with aging.

Conclusion:
Our findings show that frequency and maturity state of DCs significantly differ with aging in a tissue- specific manner and can be influenced by manipulation of the gut microbiota. Our data also support the notion that intestinal DCs are involved in mediating the detrimental effects of age-related gut dysbiosis on stroke outcomes.
Abstract TP429: Arcadia versus Other Esus Trials: Comparison of Patient Characteristics
Authors: Van Sanford Carson , Holden Smita , Tirschwell David , Longstreth W , Kronmal Richard , Meinzer Caitlyn , Chaturvedi Seemant , Broderick Joseph , Kamel Hooman , Elkind Mitchell ,   the ARCADIA Investigators
Published: June 2021

Objective:
We hypothesize that ESUS patients enrolled in the ARCADIA study are broadly representative and similar to those randomized in recent ESUS trials that returned negative results.

Methods:
This study is a qualitative comparison between characteristics of patients in NAVIGATE and RE-SPECT ESUS and those of patients enrolled up to this point in ARCADIA, an ongoing, investigator-initiated, NINDS-funded, multicenter, randomized trial of standard dose apixaban versus aspirin 81 mg daily among consented patients with ESUS and biomarker evidence of atrial cardiopathy. The patients from ARCADIA included all those consented, regardless of biomarker evidence of atrial cardiopathy. Inclusion and exclusion criteria, as well as detailed study protocols, have been previously reported.

Results:
Age and sex were similar in all three trials (see table). All trials had a similar proportion of white patients, but there were more black patients in ARCADIA and more Asian patients in RE-SPECT and NAVIGATE ESUS. More patients smoked (44%) in ARCADIA than in the other trials (17-20%). In all three trials strokes were clinically mild, with mean NIHSS scores and modified Rankin scores of 1. Further comparisons of patient characteristics are seen in the table below.

Conclusions:
Many of the characteristics of patients enrolled thus far in ARCADIA are similar to those of patients enrolled in the RE-SPECT ESUS and NAVIGATE ESUS trials, suggesting that the ARCADIA results will be highly generalizable. If positive, the ARCADIA trial results will highlight the importance of identifying a subgroup of ESUS patients likely to benefit from empiric treatment with anticoagulation, namely those with atrial cardiopathy. Important differences were seen between ARCADIA and the other trials, including proportions of patients who smoked and proportions of Black and Asian patients. These differences may be further analyzed upon completion of the trial.
Abstract TP436: MyRIAD Mechanisms of Recurrent Stroke in Intracranial Atherosclerotic Disease
Authors: Liebeskind David S , Romano Jose G , Nizam Azhar , Feldmann Edward , Sangha Rajbeer S , Campo-Bustillo Iszet , Honda Tristan , Cotsonis George A , Prabhakaran Shyam ,   on behalf of the MyRIAD Investigators
Published: June 2021

Background:
The NINDS-funded Mechanisms of Early Recurrence in Intracranial Atherosclerotic Disease (MyRIAD) study used a battery of MRI and TCD techniques to discern key pathophysiology leading to a relatively high rate of recurrent stroke. Our study objectives aimed to relate imaging abnormalities of limited arterial blood flow, distal tissue perfusion and artery-to-artery emboli with new infarcts on 6-8 week MRI.

Methods:
MyRIAD is a prospective, multicenter, observational study of patients with recent (<21 days) ischemic stroke or TIA due to 50-99% ICAD. Quantitative MRA (QMRA), perfusion MRI and TCD vasomotor reactivity (VMR) with emboli detection (ED) were acquired at enrollment. Central adjudication of each imaging modality, clinical events and 6-8 week MRI were independently ascertained.

Results:
MyRIAD enrolled 105 (mean age 63.7 years, SD 11.8 years; 43% women) patients. Primary outcomes of recurrent stroke in the territory occurred in 9/105 (9%) with secondary outcomes of territorial TIA in 7/105 (7%) and new infarcts on 6-8 week MRI in 22/87 (25%). The limited number of clinical stroke and TIA endpoints precluded definitive analysis of mechanism. Pre-specified Tmax>4s 10 cc lesions on perfusion MRI were noted in 40/92 (43%) but did not predict new infarcts at 6-8 week MRI. New infarcts were noted in 12/44 (27%) of those with Tmax>4s 5 cc lesions at baseline compared to 3/26 (12%) when absent. Abnormal volume flow ratio (VFR) on QMRA was noted in 25/98 (26%), abnormal TCD VMR in 25/76 (33%) and ED in 30/74 (41%). Other pre-specified analyses revealed both abnormal VMR and ED in 21/77 (27%) and both abnormal Tmax>4s perfusion and VFR in 16/99 (16%). Two or more imaging abnormalities were noted at baseline in 49/105 (47%) and stenosis ≥ 70% in 76/91 (84%). New infarcts on 6-8 week MRI were more frequent with ≥ 2 abnormalities (33 vs 18%, p=0.1) and ≥ 70% stenosis (29 vs 7%, p=0.2).

Conclusions:
Early, recurrent infarction on MRI is common in ICAD. Imaging abnormalities of limited arterial blood flow or distal tissue perfusion and artery-to-artery emboli are frequent and the presence of multiple abnormalities may increase risk. Larger ICAD studies are needed to link routinely acquired imaging with covert infarcts and cognitive impairment.
Abstract TP495: Symptom Onset To Arrival Time And Outcomes Among Acute Ischemic Stroke Patients, Paul Coverdell National Acute Stroke Program (PCNASP) 2016-2018
Authors: Abbas Amena Y , Odom Erika C , Coleman King Sallyann , Tong Xin ,   PCNASP Team
Published: June 2021

Introduction:
Early use of intravenous (IV) alteplase among those with Acute Ischemic Stroke (AIS) has been associated with better outcomes. However, many patients are ineligible for treatment due to late arrival or contraindications. We used PCNASP data to examine the descriptive characteristics and clinical outcomes associated with arrival time.

Methods:
A total of 233,794 patients were identified with an AIS in PCNASP data from 2016-2018. A total of 131,195 (56%) patients had documented last known well time (LKW). Symptom onset to arrival times (OAT) were categorized into the following using LKW and ED arrival times: 0-2, >2 and ≤3, >3 and ≤4.5, >4.5 hours. We assessed associations between OAT and two outcomes - discharge to home and independent ambulation at discharge using generalized estimating equations (GEE) modeling.

Results:
Patients with documented LKW time had the following OAT: 39,694 (30.3%) 0-2 hours, 11,573 (8.8%) >2 and ≤3 hours, 13,582 (10.3%) >3 and ≤4.5 hours, and 66,346 (50.6%) >4.5 hours. Overall, 51% were male, 75% were Whites, and 51% of patients arrived by ambulance. Only 17% of patients received IV alteplase. After adjusting for age, sex, race, arrival by ambulance, stroke severity score, and IV alteplase use, compared to those arriving >4.5 hours of symptom onset, patients arriving ≤4.5 hours were more likely to be discharged to home (0-2, 1.85 [1.79, 1.92]; >2 and ≤3, 1.38 [1.32, 1.45]; >3 and ≤4.5, 1.13 [1.08, 1.18]; referent >4.5), and independently ambulate at discharge (0-2, 1.89 [1.82, 1.96]; >2 and ≤3, 1.41 [1.34, 1.48]; >3 and ≤4.5, 1.15 [1.10, 1.21], referent >4.5) (Table).

Conclusion:
In this study, shorter OAT were associated with better outcomes for AIS patients. Although significant progress has been made in the early management and treatment of stroke, continued efforts are needed to emphasize the significance of early hospital arrival and promote implementation of treatment guidelines to improve clinical outcomes for all stroke patients.
Abstract WP24: Arterial Tortuosity is a Potent Determinant of Safety in Endovascular Therapy for Ischemic Stroke
Authors: Liebeskind David S , Colby Geoffrey P , Mueller-Kronast Nils H , Aziz-Sultan M A , Klucznik Richard P , Saver Jeffrey L , Sanossian Nerses , Hellinger Frank R , Yavagal Dileep R , Yao Tom L , Jahan Reza , Haussen Diogo C , Nogueira Raul G , Froehler Michael T , Zaidat Osama O ,   for the STRATIS Investigators
Published: June 2021

Background:
Subarachnoid hemorrhage (SAH) associated with vessel injury during endovascular therapy for acute ischemic stroke is a known complication. Arterial anatomy may predispose to increased risk of SAH and technical safety, yet factors such as clot location, arterial size and tortuosity have not been explored. We examined these anatomical factors with respect to SAH during thrombectomy.

Methods:
Arterial anatomy at the site of occlusion and mechanical thrombectomy during device deployment was detailed by the STRATIS core lab. Luminal diameters, arterial branching and segmental tortuosity were measured. Arterial tortuosity was quantified using the distance factor metric (DFM). Statistical analyses included descriptives of arterial anatomy, with univariate and multivariate modeling to predict SAH.

Results:
Arterial tortuosity in each segment from the proximal cerebral arteries to the site of occlusion was quantified in 790 subjects treated with mechanical thrombectomy in STRATIS. Cumulative arterial tortuosity to the site of vessel occlusion was greater in distal lesions (Table 1). SAH was clearly linked with more distal thrombectomy (p=0.017), with 19.0% of distal M2, 16.7% of M3, 7.3% of distal M1, 5.8% of proximal M2, 2.4% of distal ICA and 2.1% of proximal M1. Multivariate prediction of SAH revealed that arterial diameter was unrelated to SAH (p=0.30) when accounting for tortuosity, whereas the presence of tortuosity tripled the risk of SAH (OR 3, p<0.05).

Conclusions:
This novel systematic analysis of arterial tortuosity and angiographic anatomy during mechanical thrombectomy establishes tortuosity as a determinant of SAH, providing insight for future techniques and innovative device designs.
Abstract WP276: Variation in Treatment Times for Patients With LVO - The Massachusetts Statewide Experience
Authors: Curiale Gioacchino G , Zachrison Kori , Magdon Ismail Zainab , Bemben Lisa A , Egan Abigail , Silver Brian , Leung Lester Y , Feske Steven K , Lerner David P , Feldmann Edward , Selim Magdy H , Leslie-Mazwi Thabele M , Schwamm Lee H ,   Massachusetts Stroke Systems of Care Workgroup
Published: June 2021

Introduction:
Acute ischemic stroke guidelines recommend endovascular therapy (EVT) for select patients with large vessel occlusion (LVO). A committee of stroke care providers from across MA pooled data to evaluate LVO related care and improve stroke systems of care. We sought to determine variation in care and factors associated with timeliness of Door To Start of Revascularization (first pass)(DTR).

Methods:
We analyzed 2018 patient-level Get with the Guidelines-Stroke data from 7 of 8 MA EVT-capable centers who provided consent for us to pool the data. Factors affecting DTR times were compared with univariate analysis (Kruskal-Wallis and t-tests as appropriate) and in linear regression models to identify those independently associated with DTR times, adjusted for patient characteristics and clustering by hospital. Variables included age, stroke severity, arrival on (M-F 7a-7p) vs. off hours, mode of arrival (EMS from scene
vs
interhospital transfer), and hospital EVT volume.

Results:
Median DTR for 317 patients from 7 centers was 89 (IQR 59-128) min. Site-specific median DTR times varied from 58 (IQR 30-93) to 137.5 (IQR 80.5-171.5) min. In univariate comparisons, median DTR times were shorter after interhospital transfer than EMS from scene (74 (IQR 45-108) vs. 114 (IQR 89-151) min, p<0.001). After controlling for other characteristics, stroke severity, mode of arrival, and off-hours arrival were significantly associated with DTR times, but hospital EVT volume was not (Table).

Conclusion:
Analysis of GWTG-Stroke data for MA demonstrates variability in hospital-level DTR times, with LVO patients presenting during off hours/holidays experiencing delays in DTR. Reassuringly, patients with more severe strokes were more likely to have shorter DTR times. While hospital EVT volume was not significant, this may be due to small sample size. This variability in performance suggests opportunities for improvement in the MA stroke systems of care.
Abstract WP3: Predictors and Outcomes of Successful First Pass in Neurothrombectomy- Insights From the STAR Collaboration
Authors: Almallouhi Eyad , Al Kasab Sami , Alawieh Ali , Chalhoub Reda M , Anadani Mohammad , Arthur Adam , Kim Joon-Tae , De Leacy Reade , Psychogios Marios , Rai Ansaar , Keyrouz Salah , Fargen Kyle , Dumont Travis , Kan Peter , Starke Robert M , Spiotta Alejandro M ,   STAR collaborators
Published: June 2021

Introduction:
Shorter procedure time during neurothrombectomy is a strong predictor for good outcomes in stroke patients with large vessel occlusion. We sought to assess the predictors and outcomes of successful first pass (SFP) using multi-center investigator-initiated database.

Methods:
Prospectively collected neurothrombectomy data from 11 thrombectomy-capable stroke centers was combined in the Stroke Thrombectomy and Aneurysm Registry (STAR). SFP was defined by achieving modified Thrombolysis in Cerebral Infarction (mTICI) score≥2b with a single thrombectomy device pass. We compared the baseline characteristics, procedural metrics, rate of symptomatic intracranial hemorrhage (sICH), and long-term functional outcomes between SFP and non-SFP patients. A multivariate logistic regression analysis was used to assess the predictors of SFP and evaluate whether SFP was an independent predictor for good long-term functional outcomes (90-day mRS≤2).

Results:
A total of 733 SFP patients and 1134 non-SFP patients were included in this analysis. SFP patients were older (73 vs. 70, P=0.001), had higher Alberta Stroke Program Early CT (ASPECT) score on presentation (9 vs. 8, P=0.002). The use of Solumbra technique was an independent predictor of SFP (OR 1.2, 95% CI 1.1-1.4, P=0.004) after controlling for age, sex, location of occlusion, National Institute of Health stroke scale (NIHSS) on presentation, intravenous alteplase (IV-tPA), and onset to groin (OTG) time. SFP was an independent predictor for good long-term functional outcomes (OR1.6, 95% CI 1.1-2.3, P=0.008) after controlling for age, sex, location of occlusion, NIHSS on presentation, OTG time, IV-tPA, procedure technique, and procedure duration.

Conclusion:
SFP lead to higher rates of functional independence in stroke patients with large vessel occlusion. These records reiterate the importance of SFP as a benchmark measure for stroke thrombectomy devices.
Abstract WP32: Introducing STAR: A Multicenter International Collaborative Registry of Real-World Outcomes After Mechanical Thrombectomy for Ischemic Stroke
Authors: Alawieh Ali M , Chowdhry Shakeel , Linfante Italo , Grossberg Jonathan , Gory Benjamin , Shaban Amir , Crosa Roberto , Shah Shreyansh , Crowley Richard , Knopman Jared , Fox Christopher , Levitt Michael , Ducruet Andrew , Park Min , Ogilvy Christopher S , Jabbour Pascal , Arthur Adam , Arthur Adam , Kim Joon-Tae , De Leacy Reade , Psychogios Marios , Maier Ilko , Rai Ansaar , Keyrouz Salah , Fargen Kyle , Dumont Travis , Kan Peter , Starke Robert M , Spiotta Alejandro
Published: June 2021

Introduction:
Mechanical thrombectomy (MT) for acute stroke is the current standard of care treatment. Level 1 evidence for efficacy of thrombectomy has been established in multiple randomized controlled trials on selective patient populations; however, the high effect size of MT had led multiple centers in the US and globally to expand their patient selection to include populations that were not studied in major trials. To provide ongoing data on MT outcomes in different patient populations from the real-world, we have initiated an international multicenter initiative, STAR (Stroke Thrombectomy and Aneurysm Registry).

Methods:
STAR is a multicenter and international platform to curate patient outcome data after MT for acute ischemic stroke at comprehensive stroke centers. STAR includes all patients who underwent MT for acute ischemic stroke irrespective of age, time from onset, ASPECT score, and NIHSS. Patients were curated from 01/2015 to date and is prospectively maintained. Patient charts are reviewed for demographics, baseline functioning, and admission deficits. Procedure notes are reviewed for technical variables and technical outcomes. Clinical outcomes were collected at 90-day follow-up by stroke neurologist.

Results:
A total of 24 centers globally have enrolled in STAR. By December 2018, the total number of enrolled and verified patients in STAR was 3,850 (mean age 69±14, 51% females). Anterior circulation strokes were treated in 89% of cases, average NIHSS on admission was 15.5±7, and 73% had pre-stroke mRS below 2. Around 51% of patients received IV-tPA. Mechanical thrombectomy was performed using aspiration (45%), stent retriever (28%), primary combined approach (24%) or intracranial stenting (3%). Successful recanalization was achieved in 84% of cases, the rate of favorable outcome (mRS 0-2) was 41%, and mortality was 25%. Complication rate was 6% and rate of symptomatic post-procedural hemorrhage was 6%.

Conclusions:
STAR represent a large real-world international registry for outcomes after MT, and constitutes a statistically robust platform to study real-world practice outcome in patient sub-populations that are under-represented in randomized trials.

Link:
https://medicine.musc.edu/departments/neurosurgery/star
Abstract WP348: Difference Risk Factors in Sex Difference Between Patients With First-Ever and Recurrent Strokes in Shanghai
Authors: Dong Yi , Fang Kun , Wang Xin , Zhuang Jianhua , Liu Xueyuan , Guan Taiyang , Yu Xiaofei , Li Gang , Liu Jianren , Fu Yi , Dong Qiang ,   On the behalf of Shanghai Stroke Service System
Published: June 2021

Objective:
The underlying mechanisms of high recurrence of ischemic stroke in Chinese population are unclear. Our study is to determine sex differences in recurrent stroke and hospital mortality after a recurrent stroke in Chinese population.

Methods:
Shanghai Stroke Service System is a quality improvement project based on the EHR system. All stroke population who were hospitalized in 2018 for acute ischemic stroke within 7 days were prospectively extracted. The ORs for recurrent ischemic stroke were calculated with adjustment for demographics and risk factors.

Results:
Among 21,805 acute ischemic stroke patients in Shanghai Stroke Service System, having an ischemic stroke (mean age 69 years [SD 12 years], 63.7% male). About 21.8% of patients had a recurrent stroke (95%CI 21.3-22.4%). The multivariable logistic regression suggested that recurrent stroke population have more vascular risk factors, compared to first-ever stroke population. Furthermore, the sex differences in risk factors were gradually increasing, but reduction in smoking (35% vs. 28% in male; 2% vs 1.8% in female) and alcoholic status (22% vs. 18% in male; 1.9% vs 1.4% in female). The ORs of recurrent rate in male stroke population compared with in female was 0.74 (95% CI 0.62-0.79) after multivariable adjusted. The hospital mortality after recurrent stroke for male and female was 2.1% (95% CI 1.6%-2.6%) and 3.1% (95% CI 2.3%-4.1%), respectively. The multivariable-adjusted relative risk for hospitalization mortality of a recurrent stroke was 1.19 (95% CI 0.94-1.50). There is no significant difference impact on mortality between sex (aOR 1.08, 95% 0.72-1.63).

Conclusion:
The vascular risk factors in recurrent stroke population were mostly increasing, compared to those with first-ever stroke. However, the rates of smoking and alcoholism were reduced in male but not in female. The hospitalization mortality rate in recurrent stroke was similar to those with first-ever stroke population.
Abstract WP450: Stroke Support Group Partnership With Community Wellness Program Provides Education and Interventions Improving Self-Care Outcomes
Authors: Stoll Nancy M ,   Heart Smart For Life Wellness Team
Published: June 2021

Background and Purpose:
The purpose of this program is to offer education and support with attention to post acute transitions. The multidisciplinary team: social worker, dietician, and registered nurse encourage the development of attainable behaviors and activities.

Methods:
The participants, (311), enrolled in the free three month program of 12 sessions. Upon enrollment blood chemistry, weight, Body Mass Index, and blood pressure are measured and recorded. Subsequent visits include weight and blood pressure measurements. The program is designed to promote a one to one relationship to foster lifestyle behaviors. These consults assist with goal identification and promote self-management. Nutritional education includes healthy eating guidelines. The social worker leads sessions on navigation of social services, financial wellness, accepting change, awareness of emotions, and stress triggers. Stroke prevention, personal risk factors, living with disabilities, importance of care coordination and transition of care are discussed with emphasis on following up with primary care providers and specialists.

Results:
Participants share results such as increase in physical activity, and feelings of well-being. In 2017 and 2018, outcomes include: 266 of the participants (86% of 311 totals) began the program with a BMI > 25. 145 participants lost a total of 792 pounds with small changes in diet and exercise. 134 participants began the program with a BP > 140/90 mmHg or a diagnosis of hypertension. Of these, 118 or 88% achieved a BP reading of ≤ 140/90 mmHg by their post program evaluation. In the first year of the program, 73 participants (46% of 158) began exercising regularly for the first time. In addition, class evaluations and narratives reveal positive lifestyle and behavioral changes for participants and their families

Conclusions:
In conclusion, partnering a stroke support group with a wellness program provides an effective collaboration pooling resources and knowledge supporting the patient and caregiver.