bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T MP42: The Use of Voxel-Based Lesion Symptom Mapping to Relate Lesion Location to Motor Performance in Chronic Stroke Survivors
Authors: Shibuya Kimberly , Burke Erin , Dodakian Lucy , See Jill , Cramer Steven C , McKenzie Alison
Published: July 2021

Background and Purpose:
We used voxel-based lesion symptom mapping (VLSM) to determine the relationship between lesion location and performance on upper extremity behavioral outcome measures post-stroke. We hypothesized that a lesion within the upper extremity region of the primary motor cortex would correlate with poorer hand motor outcome measures.

Methods:
Thirty-six chronic stroke survivors with upper extremity motor deficits who underwent 3 weeks of hand/wrist robotic therapy were included in the study. Behavioral motor outcome measures included: Fugl-Meyer Arm (FMA) Test, Action Research Arm Test (ARAT), and Box & Blocks Test (BB). Anatomical imaging included a high-resolution T1-weighted volumetric scan and a T2-weighted scan. Lesioned areas were manually traced using MRIcron; stroke masks were flipped to left and binarized. All of the subjects’ T1-weighted images were transformed to Montreal Neurological Institute (MNI) standardized stereotaxic space. Data were analyzed using the non-parametric mapping (NPM) software package in MRIcron with the Brunner-Munzel test set at 1,000 permutations and a 10% threshold. The threshold for the overlap between low behavioral scores and related brain regions was set at α= 0.01.

Results:
Lesions in the inferior frontal gyrus and underlying white matter and the posterior limb of the internal capsule (PLIC) correlated with poorer motor outcomes on the FMA and ARAT, indicating a degree of anatomical overlap between impairment and activity levels of upper extremity motor performance. Lesions of the premotor area also correlated with poorer ARAT outcomes, whereas lesions of the middle frontal gyrus and underlying white matter correlated with poorer performance on the BB, reflecting the role that motor planning plays in those activities.

Conclusions:
Voxel-Based Symptom Mapping adds a new dimension in clarifying the specific lesion location associated with dexterous motor function post-stroke. Activity vs. impairment deficits relate to lesions in anatomical areas involved in motor planning vs. those involved in movement execution.
Abstract T MP57: Are The Recommendations For The Emergency Management Of Acute Ischemic Stroke Patients On Novel Oral Anticoagulants Sufficient?
Authors: Kepplinger Jessica , Barlinn Kristian , Gehrisch Siegmund , Beyer-Westendorf Jan , Puetz Volker , Bodechtel Ulf
Published: July 2021

Background:
Acute ischemic stroke (AIS) patients receiving novel oral anticoagulants (NOAC) are commonly excluded from thrombolytic therapy as reliable bedside tests for anticoagulation monitoring are lacking. We aimed to prospectively investigate the applicability of our institutional protocol for the management of AIS patients on NOAC that is based on expert recommendations

Methods:
We studied consecutive AIS patients not receiving NOAC and hospitalized general patients receiving NOAC. We performed standard coagulation tests including INR, activated partial thromboplastin time (aPTT), thrombin time (TT) and trough level tests for dabigatran, rivaroxaban and apixaban. In AIS patients, blood samples were taken immediately after admission.

Results:
We enrolled 40 patients: mean age 73±15 yrs, 30% male, median NIHSS 3 (range 0-17), 62.5% AIS. Fifteen patients received NOAC (i.e., 5 dabigatran, 5 rivaroxaban, 5 apixaban). In AIS patients not receiving NOAC, coagulation parameters were within normal limits (INR 0.99±0.07, aPTT 27.4±2.6, TT 16.7±1.2) and significantly lower than in those on dabigatran (INR 1.28±0.15, aPTT 39.6±7.4, TT 111.9±40.8; p<0.001), rivaroxaban (INR 1.42±0.51, aPTT 32.6±4.7, TT 17±1.3; p<0.001) and apixaban (INR 1.2±0.01, p<0.001; except for aPTT 30.2±4.3, p=0.14). In patients not receiving NOAC, dabigatran was not detectable in plasma as opposed to those on dabigatran, where its concentration (79±78 ng/ml; p<0.001) was above the predefined threshold of <31 ng/ml that precludes thrombolysis. According to the predefined threshold of <4 ng/ml, rivaroxaban anti-Xa activity was elevated in 19/25 (76%) patients not receiving NOAC, but lower than in patients prescribed to rivaroxaban (8.4±4.9 vs. 54±33.6 ng/ml, p=0.0004). In patients on apixaban, anti-Xa activity (1.28±0.25 E/ml) was far above currently suggested heparin-equivalent therapeutic trough levels (i.e., 0.1-0.2 E/ml).

Conclusions:
In AIS patients potentially amenable to thrombolytic therapy, altered routine coagulation tests may point to an intake of NOAC. Predefined values for dabigatran, rivaroxaban and apixaban need to be adjusted in a larger validation study and individually validated by local laboratories to be prepared for emergency situations.
Abstract T MP63: Temporal Trends in Stroke Incidence Over the Past Twenty Years: Stroke Incidence Has Stabilized, Racial Disparity is not Improving
Authors: Kleindorfer Dawn , Alwell Kathleen , Khoury Jane , Moomaw Charles J , Woo Daniel , Adeoye Opeolu , Flaherty Matthew L , Khatri Pooja , Ferioli Simona , de los Rios La Rosa Felipe , Martini Sharyl , Mackey Jason , Broderick Joseph P , Kissela Brett M
Published: July 2021

Introduction:
We previously reported that the incidence of stroke was decreasing for whites but stable for blacks from 1993/94 to 2005. We sought to describe recent temporal trends and racial disparities in stroke incidence within our large, bi-racial population, by including a more recent study period.

Methods:
The Greater Cincinnati/Northern Kentucky region includes two southern Ohio and three Northern Kentucky counties on the Ohio River, a population of 1.3 million. Our study ascertained all hospitalized strokes that occurred in the population between 7/1/93 and 6/30/94 and in calendar years 1999, 2005, and 2010. For 2010, nursing review of medical records is complete but physician review is not; thus, rates for 2010 (calculated using a weighted estimation for events not completely reviewed) are preliminary. The denominator for the calculation of incidence rates (in those aged >20 years) was estimated from the U.S. Census Bureau website (www.census.gov). The 95% confidence intervals (CI) for the incidence rates were calculated assuming a Poisson distribution. Rates are age, gender, and race adjusted, as appropriate, and standardized to the 2000 U.S. population.

Results:
Stroke incidence rates stratified by subtype, race, and study period are presented in the Table. We project that stroke incidence did not significantly change in 2010 vs. 2005 for either blacks or whites, regardless of stroke subtype. Blacks have a substantially higher incidence of stroke compared with whites in all study periods.

Discussion:
In contrast to the trend seen from 1993-94 to 2005, there was no further decline of stroke incidence in whites in 2010, a disappointing finding of great public health significance. Stroke incidence in blacks remains unchanged over all periods. The substantial black > white racial disparity in stroke incidence has not changed over time. Further study is needed to understand and eventually reduce these racial disparities.
Abstract T MP96: Trends and Variation in Inpatient Discharge to Hospice Among High Stroke Volume Hospitals
Authors: George Benjamin P , Kelly Adam G , Schneider Eric B , Holloway Robert G
Published: July 2021

Background:
In recent years, individuals with acute ischemic stroke accounted for approximately 4% of all inpatients discharged to hospice, yet little is known about current practices and trends in discharge to hospice care for stroke admissions within US hospitals.

Methods:
We examined rates of hospice discharge for adult acute ischemic stroke patients admitted to acute care facilities in the top quartile of annual stroke volume between 2001 and 2010 in the Nationwide Inpatient Sample. These high volume hospitals account for nearly 75% of stroke admissions in the dataset. Only those with available information on hospice discharge were considered. Compound annual growth rate was used to examine changes in utilization over time. Hospice trends were evaluated using the Cochran-Armitage test.

Results:
Among 1,935 high volume hospitals there were 455,372 hospitalizations for acute ischemic stroke from 2001 to 2010, 12,036 (2.6%) of which were discharged to hospice (30% to home; 70% to medical facility). The absolute number of discharges to hospice care grew at 29% per year over the ten-year period (P Trend<0.001). Discharge rates to hospice care per 100 stroke admissions increased from an average of 0.5 (SD=1.3) in 2001 to 4.3 (SD=3.0) in 2010 (P Trend<0.001).

Inter-hospital variation in rates of hospice discharge remained large from year to year, and ranged from zero to 15.6 per 100 stroke admissions (Median=3.8; Interquartile Range=3.7) in 2010.

Conclusions:
The average rate of discharge to hospice care for acute ischemic stroke inpatients admitted to high volume hospitals has grown substantially in the past decade; variation in this practice across these hospitals remains large.
Abstract T P10: Hounsfield Unit Value and Clot Length in the Acutely Occlude Vessel and Time Required to Achieve Thrombectomy, Complications and Outcome
Authors: Spiotta Alejandro , Vargas Jan , Hawk Harris , Turner Raymond , Chaudry Imran , Battenhouse Holly , Battenhouse Holly , Turk Aquilla
Published: July 2021

Introduction:
Intra-arterial therapy for acute ischemic stroke (AIS) now has an established role. We investigated if Hounsfield Units (HU) quantification on noncontrast CT is associated with ease and efficacy of mechanical thrombectomy and outcomes.

Methods:
We retrospectively studied a prospectively maintained database of cases of acute ischemic stroke that underwent intra-arterial therapy between May 2008 and August 2012. Functional outcome was assessed by ninety-day follow up modified Rankin Scale (mRS). Patients were dichotomized base on time to recanalization. Hounsfield units were calculated on head CT. Thrombus location and length were determined on CT angiography. Simple linear regression was used to analyze the association between clot length, average HU, and other clinical variables.

Results:
141 patients were included. There was no difference in clot length or average HU among patients with good recanalization achieved within an hour compared to those in which procedures extended beyond an hour. There was no relationship between clot length or density and recanalization. The thrombus length and density were not significantly different between patients with procedural complications and those without. The presence of post procedure intracranial hemorrhage was not associated with thrombus length or density. Ninety day mRS was not associated with thrombus length or density.

Conclusions:
We have not found any significant associations between either thrombus length or density and likelihood of recanalization, time to achieve recanalization, intraprocedural complications, postprocedural hemorrhage or functional outcome at ninety days. These results do not support a predictive value for thrombus quantification in the evaluation of AIS.
Abstract T P109: Discharge Disposition and Functional Status of Patients Suffering a Secondary Stroke Versus First Stroke
Authors: Licon Lisa , Evangelista Lorraine , Mastrolia Deborah , Whitaker Laura
Published: July 2021

Background:
Stroke recurrence is a consistent and independent predictor of disability, institutionalization and death, often resulting in a stepwise decline into dependency in stroke survivors. However, few reliable estimates of the long-term functional outcome after stroke are available.

Objective:
To compare discharge disposition (home with no services, home with home health, acute rehabilitation [ARU], skilled nursing facility [SNF], or hospice) and functional status measured using the Modified Rankin Scale (mRS), at hospital discharge, 30- and 90-day follow-up among patients with secondary vs. first stroke.

Methods and Results:
A retrospective analysis was conducted of 236 acute stroke patients- average age 75.9±13.7, male (49.6%), married (52%), Caucasian (82%), secondary stroke survivors (25.4%) admitted our hospital between June-December, 2012. A greater number of patients with first stroke were discharged home with no services (48.9% vs. 28.3%,
p
= .001) or to an ARU (21% vs. 15%,
p
= 0.001) whereas a greater number of patients with secondary stroke (38.3% vs. 14%,
p
= 0.002) were discharged to a SNF; there were no significant differences in the number of patients discharged home with home healthcare or hospice. The average number of comorbities (1.2 ± 1.7 vs. 3.5 ± 1.9,
p < 0.001)
and length of stay (3.7±3.4 vs. 6.0±8.4,
p = 0.005)
were higher for secondary vs. first stroke survivors. The mRS scores at discharge and follow-up were higher for secondary vs. first stroke patients (all
p’s
< 0.050, Figure).

Conclusion:
Secondary stroke was associated with lower mRS scores at discharge and follow-up and confirms previous reports that secondary stroke survivors have higher disability and worse outcomes than first stroke survivors. Our findings support the need to implement strategies to promote self-care behaviors and prevent recurrent stroke in all stroke survivors to reduce the burden associated with this condition.
Abstract T P120: Clinical Demographic Effects on Functional Outcome in Patients Following Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction
Authors: AbdeleRahman Kader , Pineda Maria Carissa , Rincon Fred , Young William , Vibbert Matthew , Bell Rodney , Moussouttas Michael
Published: July 2021

Background:
Malignant MCA infarction is a devastating disease representing 1-10% of strokes. Evidence from recent randomized controlled trials show improved survival and functional outcomes following decompressive hemicraniectomy (DHC) compared with optimal medical. Ideal patient selection remains somewhat controversial. The current study examines the effects of demographic and clinical variables on functional outcomes in patients surviving one or more years following DHC.

Methods:
We retrospectively reviewed patients who underwent DHC for malignant MCA infarction at our institution from 03/2006 to 04/2012. We collected and compared demographic and clinical variables including age, gender, race, timing of DHC, side of infarction, IV TPA administration, and additional cerebral territorial involvement (ACA or PCA). The mean mRs was calculated for each group and the Wilcoxon-Mann-Whitney two tailed test was used to calculate statistical significance.

Results:
A total of 32 patients met inclusion/exclusion criteria. There was no statistical difference in functional outcomes between patients ≤60 years of age and those >60 years (p=0.51). No statistical difference was observed between males and females (p=0.84)). Patients who received their DHC within 48 hours of their stroke were more likely to have a better outcome than patients who received DHC after 48 hours (p=0.024). Other variables including race, cerebral dominance involvement, IV TPA administration, or additional cerebral territory involvement did not show statistical significance with respect to functional outcomes (p=0.22, p=0.462, p=0.597, and p=0.614 respectively).

Conclusion:
In this retrospective study, early DHC done within 48 hours of stroke was the only clinical variable shown to improve functional outcomes 1 year or more later among survivors of patients receiving DHC for malignant MCA infarction. No difference in functional outcome was seen based on age, gender, race, IV TPA administration, dominant MCA involvement, and additional cerebral territorial co infarction. Patient selection should be individualized and larger studies are needed to better assess this patient population, especially in the elderly.
Abstract T P138: Time Trends over Five Decades in Rates of Hospital Admission for Any Stroke and Stroke Subtypes in England
Authors: Seminog Olena O , Hall Nick , Goldacre Michael J
Published: July 2021

Aim:
To study 43 year trends in England in the rates of hospital admission for any stroke, and for stroke subtypes divided into stroke that was coded as haemorrhagic, ischaemic or of undefined etiology.

Methods:
We analysed routine hospital statistics from the Hospital In-Patient Enquiry and Hospital Episode Statistics to estimate trends in hospital admissions for any stroke and the three stroke subtypes in England from 1968 to 2011. The rates were age-standardised and expressed per 100 000 population.

Results:
The study included 2 555 180 admissions for stroke. Annual admission rates for any stroke increased from 169.79 (95% CI 165.61-173.97) in 1968 to 272.4 (270.86-273.93) in 1993; and then started to decline to reach 196.58 (195.38-197.79) in 2011. Admission rates for haemorrhagic stroke declined from 30.40 (28.61-32.19) in 1968 to 15.07 (13.80-16. 34) in 1982, and then steadily increased to 44.65 (44.07-45.24) in 2011. Admission rates for ischaemic stroke halved between 1968 and 1982 from 60.3 (57.81-62.80) to 32.32 (30.53-34.11). This was followed by a steep rise to 128.10 (127.13-129.07) in 2011. Admission rates for stroke of undefined cause increased from 75.54 (72.75-78.33) in 1968 to 178.35 (174.35-182.34) in 1984. This was followed by a sharp decline to 27.66 (27.22-28.11) in 2011.

Conclusions:
Considering any stroke in England, in the 1970s and1980s there was an increase in admission rates, followed by a decline in the 1990s, and a plateau in the first decade of the 21st century. Changes in stroke rates for haemorrhagic and particularly for ischaemic stroke tended to go in opposite directions from rates in stroke of unspecified type. Specifically, the observed declines in haemorrhagic and ischaemic stroke rates between 1968-1983 coincided with a rise in stroke of undefined cause. These trends reflect shifts in diagnostic preferences towards the latter at that time. The recent dramatic increase in ischaemic stroke rates is mirrored by a sharp fall in stroke of unspecified type. These changes are likely to result from the increasingly wide use of brain imaging. Trends in admission rates for a particular subtype of stroke should not be considered on its own, as changes in diagnostics, and preferences for diagnostic terminology, are likely to affect the rates.
Abstract T P146: Vitamin D Deficiency is Associated With Stroke in Black and White Participants of the REGARDS Study
Authors: Judd Suzanne E , Howard Virginia J , Muntner Paul , Kissela Brett M , Panwar Bhupesh , Jenny Nancy , Gutierriez Orlando M
Published: July 2021

Objective:
Black Americans are at greater risk of both stroke and vitamin D deficiency than white Americans. We have previously shown that both higher dietary vitamin D and sunlight exposure are associated with decreased risk of stroke; however, serum 25(OH) is thought to be a better marker of vitamin D status.

Methods:
Using a case cohort design, we examined the association of plasma 25(OH)D with incident stroke in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a cohort of black and white participants from across the United States enrolled between 2003 and 2007. Medical records were reviewed by physicians and strokes were classified on the basis of symptoms and neuroimaging. Strokes through July 1, 2011 were included. A stratified cohort sample was selected to ensure approximately equal numbers of black and white participants and an equal distribution across ages. We used Cox proportional hazards models weighted back to the original 30,239 participants, excluding those with history of stroke. Serum 25(OH)D was measured by Immunodetection Systems ELISA.

Results:
Over mean follow-up of 4.4 years, there were 539 ischemic and 71 hemorrhagic strokes. The stroke-free sub-cohort included 939 participants. After adjustment for age, race, sex, education, diabetes, hypertension, smoking, atrial fibrillation, heart disease, physical activity, kidney function, calcium and phosphorous, 25(OH)D level 30 ng/mL. The direction of association was similar for hemorrhagic stroke though not statistically significant (HR=1.59; 95%CI=0.78, 3.24). Vitamin D deficiency was associated with an increased risk of all stroke (HR=1.54; 95%CI=1.05, 2.23). This effect was greater in blacks (HR=2.09; 95%CI=1.09, 3.99) than whites (HR=1.38; 95%CI=0.78, 2.42). Results were not as strong when we modeled 25(OH)D as a continuous variable (HR=0.99 per 1 ng/ml change in 25(OH)D; 95%CI=0.98, 1.01).

Discussion:
Similar to low vitamin D intake, vitamin D deficiency is a risk factor for incident stroke. These findings support evidence from cardiovascular and cancer epidemiology that treating low 25(OH)D may prevent strokes.
Abstract T P152: Correlates of Dolichoectasia in an Urban, Stroke-free Cohort: Results From the Northern Manhattan Study
Authors: Gutierrez Jose , Bagci Ahmet , Del Brutto Victor , Gervasi-Franklin Palma , Rundek Tatjana , Elkind Mitchell S , Alperin Noam , Sacco Ralph L , Wright Clinton B
Published: July 2021

Introduction:
Dolichoectasia (DE) is an arteriopathy characterized by tortuosity and/or dilatation of an artery. Some risk factors for atherosclerosis, such as male sex, age and hypertension are shared with DE, but the association of DE with subclinical measures, such as carotid plaque, is not clear. The objective of this study is to evaluate the frequency and determinants of DE in an unselected population.

Methods:
Surviving stroke-free participants from the Northern Manhattan Study cohort were invited to undergo brain MRI and MRA. Demographic, clinical and radiological data were collected in consented subjects. Arterial diameters were measured with semi-automated software in the proximal segments of 14 large brain arteries. Dolichoectasia was defined as an arterial diameter 2 SD above the head-size adjusted mean. Logistic and linear regressions were used to determine statistical significance between DE and baseline factors with a P value < 0.05.

Results:
A total of 718 NOMAS participants had MRA data available (mean age± SD, 71.6± 8.0 years), 40% were men, 61% Hispanic, 20% black, 19% white, 68% had hypertension, 19% had diabetes mellitus, and 16% had a history of cardiac disease. Arterial diameters were available in 6,863 intracranial arteries. Dolichoectasia of at least one artery was classified in 19% of the sample and a third of these had two or more affected arteries. Adjusting for demographic and vascular risk factors, the odds of DE were greater in older participants (OR 1.31, per 10 years, 95% CI 1.0-1.7) and in women (OR 3.1, 95% CI 1.8-5.3) but lower in those with ultrasound defined extracranial carotid plaque (OR 0.5, 0.3-0.8). Stratified analyses by anterior or posterior circulation DE did not alter our findings; with the exception that hypertension was associated with posterior circulation DE, although this was not significant (OR 1.9, 95% CI 0.9-4.2).

Conclusions:
Intracranial DE was found in a fifth of this urban, multicultural cohort. The prevalence of DE increases with age and is more common in women. Our data suggest carotid plaque may be linked in some way to DE as measured by intracranial arterial diameters. Understanding the mechanisms leading to arterial dilatation might open new ways for potential treatments in patients with DE.
Abstract T P156: Chronic Kidney Disease as a Risk Factor for Carotid Atherosclerosis : A Case Control Study
Authors: Kim Tae Jung , Kim Jun Yup , Kim Chi Kyung , Kim Yerim , Jung Seunguk , Ko Sang-Bae , Lee Seung-Hoon , Yoon Byung-Woo
Published: July 2021

Background:
Chronic kidney disease (CKD) increases risk of cardiovascular diseases, which might be mediated by facilitation of atherosclerosis. However, impact of CKD on progression of atherosclerosis has not been fully evaluated, and we sought to investigate associations between CKD and extent of carotid atherosclerosis.

Methods:
Between January 2009 and February 2013, we enrolled a consecutive series of 147 CKD patients and compared the same number of age, sex and vascular risk factor-matched 147 control subjects who visited our hospital during the same period. Carotid atherosclerosis was examined with MR angiography of internal carotid artery (ICA). The degree of stenosis of the internal carotid artery (ICA) in each patient was classified into 5 grades; (1) normal; (2) mild (<50%); (3) moderate (50-69%) ;(4) severe (70-99%); (5) occlusion.

Results:
Mean age of the subjects was 72.2±8.7 years, and 208 were male (70.7%) among the total of 294 subjects. Significant stenosis of ICA (stenosis more than 50%) was more prevalent in CKD patients [odds ratio (OR) 6.7; 95% confidence interval (CI) 2.2-20.4, p=0.001). The presence of CKD was an independently risk factor for increasing the severity of stenosis of ICA (mild, OR 4.5, 95% CI 2.0-10.2; moderate, OR 3.9, 95% CI 1.3-22.4; severe, OR 12.0, 95% CI 4.3-34.6; occlusion, 14.1, 95% CI 2.1-92.2).

Conclusion:
In the current case-control study, we found that CKD is associated with incidence of significant carotid stenosis and increases the severity of carotid stenosis. Our results indicate that CKD should be treated as a new risk factor for carotid atherosclerosis.
Abstract T P16: Availability of Endovascular Services at Primary Stroke Centers
Authors: Alberts Mark J , Range Jean , Spencer Bill , Cantwell Vicki , Hampel M J
Published: July 2021

Background:
Endovascular treatments (EVTs) are useful for treating various types of cerebrovascular disease. There is little data about the availability of such services at stroke centers and how outcomes are tracked. Our hypothesis was that some of these services may be available at Primary Stroke Centers (PSCs), but that outcome tracking may be sub-optimal.

Methods:
We conducted an Internet-based survey of hospitals certified by The Joint Commission (TJC) as PSCs in the U.S. The survey inquired about EVTs such as IA lytics, IA mechanical clot removal, coiling of aneurysms, and cervical arterial stenting; physician training, coverage models, hospital type, and outcomes. We used chi-square analysis to detect differences between academic and community PSCs.

Results:
Data were available from 352 certified PSCs, of which 75% were community hospitals, 23% academic centers, and 80% were non-profit; almost half (48%) see 300 or more patients with acute ischemic stroke annually. A majority (60%) provided some or all EVTs on-site, while 29% had none on-site and no plans to add them. Among the respondents offering EVTs, 95% offered stenting of neck vessels, 86% IA lytics, 80% IA mechanical, and 74% aneurysm coiling. The majority (>55%) who did offer such services provided them 24/7/365. There were no significant differences in EVT service availability between academic and community PSCs. Most facilities (75%) would transfer a patient to a site with endovascular capability if a patient treated with IV TPA did not show a clinical response. Most endovascular coverage was provided by interventional neuroradiologists (60%), fellowship trained endovascular neurosurgeons (42%), and interventional radiologists (41%). More than half of treating physicians (53%) cover just one facility, while 22% cover 2 and 7% cover 3. The majority of hospitals (81%) did not participate in an audited national registry for EVTs, but 91% did track outcomes locally.

Conclusions:
EVT services are offered in both academic and community-based PSC hospitals. These services are typically available 24/7/365. Increasing participation in a national registry may be an opportunity to track and validate outcomes. How EVT availability at PSCs will impact the formation and number of CSCs remains unknown.
Abstract T P167: Emergent Identification of Type A Aortic Dissection as a Cause of Acute Ischemic Stroke
Authors: Ohara Tomoyuki , Toyoda Kazunori , Yokoyama Hiroyuki , Minatoya Kenji , Tanaka Eijiro , Nagatsuka Kazuyuki , Minematsu Kazuo
Published: July 2021

Background:
Acute aortic dissection (AAD) sometimes presents with predominant neurological symptoms of acute cerebral ischemia. Fatal AAD patients after thrombolysis for stroke without noticing AAD were reported. The purpose of this study was to clarify the characteristics of AAD patients with acute cerebral ischemia and develop a score to emergently identify AAD for such patients.

Methods:
From the database of Stanford type A-AAD patients admitted in our hospital between 2007 and 2012, we selected those presenting with acute focal neurological deficits due to ischemic stroke/TIA. Patients presenting with shock state or cardiopulmonary arrest were excluded. Physiological, radiological, and blood examinations were assessed for AAD identification.

Results:
Of 187 AAD patients, 19 patients (10%) with focal neurological deficits as an initial presentation were studied. Involvement of one or more main branches of the aortic arch was observed in all of 19 patients. Stroke experts, not cardiovascular experts, were primarily called to ER in 18 patients, and 12 were potential candidates for intravenous thrombolysis. Left hemiparesis (14 patients, 74%) was the most common neurological symptom. Nine patients (47%) complained of chest or back pain. As components of the score, (1) systolic BP differential >20mmHg between upper extremities was present in 11 of 17 patients (65%), (2) mediastinal widening on chest radiography in 13/16 (81%), (3) occlusion or the intimal flap of the proximal common carotid artery on carotid ultrasonography in 14/16 (88%), (4) pericardial effusion on echocardiography in 10/19 (47%), and (5) abnormal elevation of D-dimer levels in all 19 (median 24.8 [range 4.2-406.2] μg/ml). Two components were positive in 4 patients, three in 6, four in 5, and all the five in 4.

Conclusions:
Only half of AAD patients with stroke/TIA complained of chest or back pain. All the AAD patients with stroke/TIA showed high D-dimer levels and one or more additional abnormal findings in physiological and radiological examinations. Combination of such handy diagnostic tools is helpful to identify AAD without long time delay and to avoid unnecessary thrombolysis for AAD patients.
Abstract T P174: Stroke Severity in Patients With Different Durations of Atrial Fibrillation
Authors: Wachter Rolf , Weber-Krueger Mark , Stahrenberg Raoul , Seegers Joachim , Gröschel Klaus ,   Find-AF study group
Published: July 2021

Background:
Persistent atrial fibrillation (AF) is a common risk factor for stroke. Strokes caused by AF are usually more severe as compared to stroke in patients without AF. Recent evidence suggests that stroke risk in paroxysmal AF is similar to persistent AF, but which minimal duration of AF already increases stroke risk, is unknown. We aimed to compare stroke severity in stroke patients with different durations of AF.

Methods:
272 stroke patients were prospectively included. 43 had AF on admission (persistent AF). During 7-day-Holter-ECG, an additional 29 patients were diagnosed with AF of at least 30 seconds (paroxysmal AF). 200 patients had no AF > 30 seconds. Of these, 72 had supraventricular runs of at least 10 beats during 24h-Holter ECG. Stroke severity was characterised by NIH stroke scale (NIHSS) and modified Rankin scale (mRS). All values are given as median (25%/75%) and compared by Mann-Whitney-U-Test.

Results:
NIHSS and mRS values were similar in patients with persistent and paroxysmal AF (see table: p=0.239 (NIHSS), p=0.623 (mRS), respectively. In patients with no AF, NIHSS: 2 (1-4) and mRS: 2 (1-3) were significantly lower as compared to patients with paroxysmal AF (NIHSS: p <0.001; mRS: p=0.034).

NIHSS and mRS did not differ in patients with short episodes of paroxysmal AF (6 minutes or shorter) as compared to patients with medium duration of episodes (6 minutes to 6 hours) or long episodes > 6 hours.

In patients with no AF, the presence of supraventricular runs of at least 10 beats was not associated with higher NIHSS or mRS as compared to patients without supraventricular runs (p=0.239 and p=0.621, respectively).

Conclusion:
Our results suggests that patients with paroxysmal AF of at least 30 seconds during 7-day-Holter have strokes similar to patients with persistent AF. Whether these patients benefit similarly to persistent AF patients from anticoagulation for secondary stroke prevention, should be investigated in further prospective randomised trials.
Abstract T P189: Time Trends in Transient Ischemic Attack Admission From the Emergency Department
Authors: Albright Karen , Donnelly John , Mullen Michael , Cucchiara Brett , Blackburn Justin , Lo Alexander
Published: July 2021

Background:
Prior studies suggest transient ischemic attack (TIA) admission from the Emergency Department (ED) increased over time. We investigated how TIA admission trends may have changed with publication of TIA risk stratification rules involving the ABCD /ABCD2 scores.

Methods:
We used ED data on TIA from the National Hospital Ambulatory Medical Care Survey. We defined three time periods to account for the initial publication by Johnston et al., highlighting the risk of ischemic stroke following TIA (2000) and related reports on the ABCD (2005) and ABCD2 (2007) scores. We defined 2005 through 2007 as a washout period to allow for any practice change that occurred with the evolution of ABCD/ABCD2 scores. Admission trends were stratified across younger (18-64y) and older (65y+) patients.

Results:
There were 327,339 TIA visits yearly from 1994 to 2010 in adults 18+ years. We compared three distinct time periods (1994-1999; 2001-2004 and 2008-2010 to reflect the timing of publications above. We observed interaction between time and age with regard to TIA admission (Figure). TIA patients 18-64y showed a decreasing admission trend overall (p = 0.047). Patients 65y+ showed a similar decreasing trend up to 2005-2007, but after 2007 had a marked increase in TIA admissions (p = 0.021). A comparison of stroke admissions during the same time period did not show an increasing trend in the 65+ group.

Conclusion:
Contrary to prior reports, TIA admissions decreased over time among persons 18-64y. Among older persons 65+, there was a sharp increase in TIA admission after 2007 that was not due to an increase in admissions for stroke or stroke-related diagnosis. The increase in TIA admissions could be related to new tools for the risk-stratification of TIA patients, but a large percentage of TIA patients are discharged from the ED. More research is needed to ensure that all high risk TIA patients receive a rapid evaluation.
Abstract T P20: Correlation Between Whole Brain Ct Perfusion Maps And Non-contrast Ct Alberta Stroke Program Early Ct Score (aspects) In Patients Undergoing Acute Endovascular Stroke Interventions
Authors: Morr Simon , Mokin Maxim , Sonig Ashish , Snyder Kenneth , Siddiqui Adnan , Levy Elad
Published: July 2021

Introduction:
Tools for evaluating risk of post-intervention risk hemorrhage in the setting of acute stroke include a noncontrast head CT based Alberta Stroke Program Early CT score (ASPECTS) and contrasted CT based perfusion plots. The correlation between these parameters is unknown.

Methods:
We performed a retrospective analysis of a prospectively collected endovascular stroke database of patients with M1 middle cerebral artery occlusion who underwent endovascular recanalization. We reviewed admission preintervention noncontrast CT for Alberta Stroke Program Early CT score (ASPECTS) and 320-detector row whole brain CT perfusion parameters (Cerebral blood volume and time to peak). Pearson correlation was determined between cerebral blood volume on the side of the stroke and ASPECTS.

Results:
ASPECTS and CT perfusion map were identified in 45 and 43 patients respectively. Statistically significant correlation was found between ASPECTS and cerebral blood volume data on CT perfusion MAP. (p=0.034, r=-0.28). The correlation coefficient is very weak. No correlation could be found between time to peak and ASPECTS.

Conclusion:
A statistically significant, but weak correlation exists between ASPECTS and CBV. Further research is needed to assess the physiological meaning of diverse imaging modalities utilized in the acute stroke setting.
Abstract T P210: Splenectomy Attenuates Sex Differences in Infarct Volume Following Experimental Stroke in Mice
Authors: Wang Jianming , Bodhankar Sheetal , Offner Halina , Murphy Stephanie J
Published: July 2021

It is now increasingly clear that human stroke can have other serious consequences besides brain damage that can impact on patient survival and recovery. For example, many stroke patients succumb to CNS injury-induced immunodepression and fatal infections. Our prior work suggests that evolving cerebral ischemic injury elicits a cycle of injury from brain-to-spleen-to-brain that is strongly influenced by sex. We determined if splenic immunocytes are important in contributing to sex differences in post-ischemic brain injury. Male and female C57BL/6J mice were splenectomized 14 days before experimental stroke. Male and female mice with or without splenectomy (n=9-10 per group) then underwent 60 min of middle cerebral artery occlusion (MCAO) via intraluminal filament. Laser-Doppler flowmetry (LDF) was used to monitor cortical perfusion. All mice were euthanized and brains collected at 96 hours of reperfusion. Infarct volume (% corrected contralateral structure) was determined by image analysis of coronal brain slices stained with 2,3,5-triphenyltetrazolium chloride. Mean arterial blood pressure (MABP), blood gases (pH, P
a
O
2
, P
a
CO
2
), and blood glucose were measured at 30 min MCAO and at 15 min of reperfusion in separate groups of male and female mice with or without splenectomy (n=5 per group). Relative LDF changes (% baseline), MABP, blood gases, and blood glucose during and after MCAO were comparable among the experimental groups. We observed that infarct volume in females (cortex, 41±4%; striatum, 55±6%) was smaller (
P
<0.05) compared to males (cortex, 52±3%; striatum, 75±3%) at 96 hours of reperfusion. However, no differences (cortex,
P
=0.313; striatum,
P
=0.601) in infarct volume were seen between splenectomized male (cortex, 43±4%; striatum, 51±7%) and female (cortex, 38±4%; striatum, 46±5%) mice. Our data suggest that removal of all splenocyte lineages via splenectomy attenuates sex differences in post-ischemic brain injury. Future studies will evaluate the role of different splenic immunocyte subsets, such as T or B lymphocytes, on male vs. female ischemic brain outcomes. This study was supported by National Institutes of Health grant NS076013.
Abstract T P237: Alpha-4 Integrin Mediates Inflammatory Monocyte Trafficking to the Brain After Intracerebral Hemorrhage
Authors: Ambler William , Hammond Matthew , Taylor Rosyln , Sansing Lauren , Ai Youxi
Published: July 2021

Background:
Intracerebral hemorrhage (ICH) triggers an immune response leading to leukocyte recruitment to the brain and secondary injury. Inflammatory monocytes traffic to the brain over the first 3 days after ICH in murine models, and genetic knock-outs that lack these cells have improved functional outcomes. The aim of this study was to determine the adhesion molecules used by monocytes to enter the brain, and whether antagonism of candidate adhesion molecules could be a new therapeutic target.

Methods:
ICH was modeled via injection of collagenase into the right striatum of wild type mice. Mice were sacrificed 1 and 3 days post-ICH. Brain and blood were harvested for leukocyte quantification by flow cytometry. Cells were stained with antibodies for CD45, CD3, Ly6G, Ly6C, CD11b, CD49d (alpha-4 integrin), CD11a/CD18 (LFA-1), and CD31 (PECAM). Inflammatory monocytes were identified as CD45high+CD3-Ly6G-CD11b+Ly6C+. Adhesion molecule expression on inflammatory monocytes in brain and blood were compared by t-test. To block leukocyte trafficking, anti-mouse alpha-4 integrin blocking antibody (or IgG control) was administered intraperitoneally 4 hours prior to ICH. Blinded behavioral testing using the cylinder and beam walking tests were used to quantify neurological deficit.

Results:
Alpha-4 integrin is significantly increased on inflammatory monocytes in the brain after ICH compared to blood on days 1 and 3 (Day 1: 22.7 ±3.4% vs 0.9±0.5%, p<0.001, n=3/group, Day 3: 19.1±4.9% vs 2.9±0.5%, p<0.001, n=5/group). On days 1 and 3 after ICH, the majority of mice could not perform behavioral testing. However, on day 3 mice treated with anti-alpha-4 integrin antibody were more likely to be able to complete 20 rears in the cylinder within 15 minutes compared to controls (50% vs. 0%, p<0.05, n=6/group).

Conclusions:
Alpha-4 integrin appears to be important for inflammatory monocyte trafficking into the brain after ICH and may be a new potential therapeutic target to prevent the early phase of immune-mediated injury. Importantly, there is a monoclonal antibody therapy approved for use in humans, which could be studied for ICH if further experimental work supports a benefit.
Abstract T P243: Mortality Among Transferred Hemorrhagic Stroke Patients in United States: An Analysis From National Database
Authors: Adil Malik M , Prabhakaran Shyam
Published: July 2021

Background:
Hemorrhagic stroke patients may require inter-facility transfer for higher level of care. Limited data are available on outcome of transferred patients.

Objective:
To determine in-hospital mortality and discharge outcomes among transferred hemorrhagic stroke patients.

Methods:
Data from all patients admitted to US hospitals between 2008 and 2011 with a primary discharge diagnosis of hemorrhagic stroke [intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH)] were identified by ICD-9 codes (ICH: 431; SAH: 430). In separate models for ICH and SAH using logistic regression, the odds ratio (OR) and 95% confidence intervals (CI) for in-hospital mortality and good outcome (discharge home or inpatient rehabilitation) among transfer vs. non-transfers were estimated, after adjusting for potential confounders.

Results:
Of 290,395 patients with ICH, 48,749 (16.8%) arrived by inter-hospital transfer; for SAH, 25,726 (33%) of 78,156 were transfers. In-hospital mortality was lower among ICH transfers (21.2% vs. 23.2%; p=0.004). In adjusted analyses, in-hospital mortality was not significantly different (p=0.20) while discharge to home or inpatient rehabilitation was more likely among transferred ICH patients (OR 1.1, 95% CI 1.0-1.2, p=0.05). In-hospital mortality was lower for SAH transfers (17.4% vs. 22.9%, p<0.001) and remained significant in adjusted analyses (OR 0.7, 95% CI 0.6-0.8). Transferred SAH patients were also more likely to be discharged to home or inpatient rehabilitation (OR 1.2, 95% CI 1.1-1.4, p<0.001). Coiling and clipping procedures were significantly more common in SAH transferred patients while cerebral angiography, mechanical ventilation and gastrostomy were significantly higher in both ICH and SAH transfer patients.

Conclusion:
While ICH patients arriving by transfer have similar mortality as non-transfers, they are more likely to be discharged to home or acute rehabilitation. For SAH, transfer confers both mortality and outcome benefit. Definitive surgical treatments and aggressive medical supportive care at receiving hospitals may mediate the benefits of inter-hospital transfer in hemorrhagic stroke patients.
Abstract T P269: Validation of Telephone Assessment for a Portuguese Version of the Modified Rankin Scale With Brazilian Stroke Patients
Authors: Baggio Jussara A , Santos-Pontelli Taiza E , Cougo-Pinto Pedro T , Silva Nathalia F , Machado Laura , Antunes Paula E , Leite João P , Pontes-Neto Octávio M
Published: July 2021

Background:
The modified Rankin Scale (mRS) is the most commonly used scale to asses functional outcome after stroke. Several studies on mRS have shown good reliability, feasibility and interrater agreement of this scale using a face-to-face assessment and by telephone assessment in developed countries. Nevertheless, it is still uncertain with the culture-adapted and translated version of the scale to Portuguese could also be reliably applied by telephone assessment in Brazil. The aim of this study was to validate the telephone assessment of a Portuguese version of the mRS using a structured interview in a sample of Brazilian stroke patients.

Methods:
We evaluated 50 stroke outpatients twice. The first interview was face-to-face and the second was made by telephone and the time between the two assessments was at most 14 days. Four web-certified raters evaluated the patients using a structured interview as reported in the literature. Raters were blinded for the mRS score given by the other rater. For both assessments, the rater could also interview a caregiver if necessary.

Results:
The patients’s mean age was 62.8±14.7; mean duration of education was 5.2±3.4 years; 52% were males and 55.2% needed caregiver assistance to answer the questions. The majority of caregivers were female (85%), mean age 49.1±15 years old, and mean number of years of study 8.3±3.4. Perfect agreement between the telephone and face-to-face assessments was obtained for 27 (54%) patients, corresponding to an unweighted Kappa of 0.44 (95% CI 0.27 - 0.61) and a Kappa with quadratic weighting of 0.89. A difference of 1 level occurred in 21 (42%) patients. The median of telephone assessment mRS was 3.5 (interquartile range= 2-4) and of face-to-face assessment was 4 (interquartile range= 2-5). There was no difference between the two assessments (Wilcoxon test, p=0.35).

Conclusion:
Despite the low education level of our sample, telephone assessment of using a translated and culturally adapted Portuguese version of the mRS showed good validity, reliability and reproducibility in Brazil. The use of a structured interview is recommended for this purpose.
Abstract T P274: Stroke Mimics in Telestroke
Authors: Johnson Rayetta K
Published: July 2021

Background and Issues:
Wake Forest Baptist Medical Center in Winston-Salem, N.C. deployed a telestroke network system in January of 2010 to provide 24/7 access to a stroke specialist for rural communities. There are twelve hospitals in the network at the present time with tPA administration rate currently at 43%.

The potential advantage of face-to-face examination is that it is potentially easier to identify stroke mimics. The frequency of false-positive diagnosis of ischemic stroke has been estimated at approximately 1-14%. It has been demonstrated that patients with mimics have a low tPA related complication rate but it is relevant that these patients have received an unnecessary and potentially harmful treatment.

Methods:
We reviewed the data on 436 patients who received telestroke consultations between 1/2010 and 9/2012. We retrieved information on the following: number of mimics, presenting complaints and clinical characteristics of patients and outcomes.

Results:
There were 49 drip and ship patients, with 14% of patients being diagnosed as stroke mimics. The percentage of stroke mimics given thrombolytic therapy via the telestroke network was low and is similar to what has been reported elsewhere. Our results concur with previous studies, proving the feasibility and safety of treating acute ischemic stroke via telemedicine.
Even though the administration of tPA in the mimic patient has a low complication rate it provides an unnecessary (medically and financially) intervention and is a potentially harmful treatment. Our stroke team set forth a goal to decrease
the rate of treating stroke mimic patients via our telestroke network. Two strategies were developed: first, an educational program was provided for each network hospital regarding neurological assessment and differential findings of ischemic stroke and a stroke mimic, and second, case studies of stroke mimic patients were presented and discussed at our quarterly telestroke conferences. These educational endeavors have decreased the number of stroke mimics that are treated with tPA via our telestroke network from 14% to 9%.