bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP162: The Therapeutic Effects of Peroneal Nerve Functional Electric Stimulation for Lower Extremity in Patients With Sub-Acute Post-Stroke Hemiplegia: A Randomized Controlled Study
Authors: Matsumoto Shuji , Shimodozono Megumi
Published: June 2021

Background and Aims:
The functional electrical stimulation (FES) is the electrical stimulation of a muscle deprived of nervous control for providing muscular contraction and thereby producing a functionally useful movement. FES is particularly effective for treating foot drop caused by stroke. The purpose of this study was to investigate the effect of WalkAide FES system on functional recovery and activities of daily living (ADL) in stroke patients with foot drop.

Methods:
Participants (n=203; 49 females and 154 males; time after stroke 61.6±31.5 days) were randomized to either FES group or the control group. All subjects participated in the same standard rehabilitation program. In addition, FES group participated in FES training for 40 mins per day, five times a week, for 8 weeks, and those in the control group participated in the usual physical therapy including gait re-education, gait training with an orthotic device, and muscle stretching. Functional recovery was assessed using 6-min walk test (6MWT), active range of motion of ankle dorsiflexion (A-ROM), and Timed Up and Go test (TUG). ADL was assessed using 10-m walk test (10MWT), Stroke Impact Scale (SIS), and patient satisfaction.

Results:
After intervention, there were significant improvements in 6MWT, TUG, 10MWT, SIS compared to baseline in both groups (p< 0.0001). The significant improvement in A-ROM was demonstrated only in FES group. At follow-up, AROM showed significant improvements in the FES group compared to the control group (p= 0.0011). However, when comparing average change scores from baseline to end of treatment, significant differences were noted only for the A-ROM scores. Stroke patients preferred the use of an electrical stimulation orthotic substitute device to an orthotic device, according to the questionnaire of patient satisfaction (p< 0.0001).

Conclusions:
The findings of the current study demonstrated the efficacy of FES on the functional recovery and ADL, and also showed the feasibility of applying FES for dropped foot during the convalescent phase of recovery after stroke. These results suggest that long-term FES use may lead to additional improvements in walking endurance and functional ambulation; further research is needed to confirm these findings.
Abstract TP164: Statins for the Prevention of Post-Stroke Seizure and Epilepsy Development: A Systematic Review and Meta-Analysis
Authors: Acton Emily K , Khazaal Ossama , Willis Allison W , Hennessy Sean , Gelfand Michael A , Kasner Scott E
Published: June 2021

Introduction:
Cerebrovascular disease is the leading cause of seizures and incident epilepsy of known etiology in older adults. As prophylactic use of antiepileptic drugs remains controversial, statins have garnered attention as an alternate preventive strategy due to pleiotropic effects, beyond lipid-lowering, which may include neuroprotective and anti-epileptogenic properties. Our objective was to assess the current evidence on statin use for prevention of post-stroke seizure and post-stroke epilepsy (PSE).

Methods:
We conducted a systematic review following PRISMA guidelines. Pubmed and Embase were searched from database inception to May 2019 for English-language, full-text experimental, observational analytic, or systematic reviews/meta-analytic studies examining the association between statin use in adults and development of early-onset seizures (ES; seizures ≤7 days after stroke) or PSE. Pooled analyses were based on random-effects models using the inverse-variance method.

Results:
Of 157 citations, 154 were excluded due to duplication or ineligibility, yielding 3 cohort studies from East Asia. Two studies reported on outcomes of ischemic stroke and 1 on hemorrhagic stroke. Only 1 study reported on ES, finding a significantly reduced risk following post-stroke statin use (OR 0.35, CI 0.20-0.60). Two studies reported on pre-stroke statin use, with findings demonstrating a lack of association with PSE (pooled OR 1.17, CI 0.93-1.48; Figure 1.1). However, post-stroke statin use was associated with less PSE (pooled OR 0.61, CI 0.50-0.74), without evidence of heterogeneity (Figure 1.2).

Conclusions:
Systematic review and meta-analysis of 3 high-quality cohort studies suggests post-stroke, but not pre-stroke, statin use may be associated with reduced risk of PSE. Further research is warranted to verify if these findings are replicable in other populations, as well as to explore the influence of timing and duration of statin use on outcomes.
Abstract TP165: Mortality After Large Artery Occlusion Acute Ischemic Stroke
Authors: Karamchandani Rahul R , Rhoten Jeremy , Strong Edwin , Chang Brenda , Singh Sam , Bernard Joe , Bodle Jeffrey D , Hines Andrew U , Asimos Andrew
Published: June 2021

Introduction:
Despite randomized trials demonstrating the benefit of endovascular therapy (EVT), large artery occlusion (LAO) acute ischemic stroke (AIS) remains associated with high mortality. Identifying factors associated with mortality for patients presenting with LAO AIS can assist in therapeutic decision-making and prognostication.

Hypothesis:
Among patients with LAO AIS, factors associated with 90-day mortality include older age, higher presenting NIHSS score, and lower final Thrombolysis in Cerebral Infarction (TICI) score.

Methods:
From November 2016 to April 2019, we conducted a retrospective analysis from a large healthcare system’s stroke network registry of patients presenting with ICA and/or MCA occlusions. Ninety-day mortality status from registry follow-up was corroborated with the Social Security Death Index. A multivariable logistic regression model was fitted to determine demographic and clinical characteristics associated with 90-day mortality.

Results:
Among 796 patients with 800 encounters, mean age was 68 years, 52% were women, mean presenting NIHSS was 14, and 97% presented within 24 hours of last known well time. Fifty-one percent were treated with EVT. Mortality rate for the entire cohort was 25%. In a univariate analysis, there were significant differences in age, gender, race, blood glucose, presenting NIHSS, hypertension, atrial fibrillation, CTP core volume, CTP delayed perfusion volume, EVT treatment, number of passes for EVT, final TICI score, and discharge mRS, between patients with and without 90-day mortality. In the multivariable model, increasing age (per 10 years, OR 1.54, 95% CI 1.20, 1.97) and higher discharge mRS (per 1 point, OR 4.47, 95% CI 3.05, 6.55) were associated with 90-day mortality. Female gender (OR 0.57, 95% CI 0.27, 1.18) and final TICI score of 2B or better (OR 0.42, 95% CI 0.18, 1.01) were protective against 90-day mortality.

Conclusions:
Increasing age and worse discharge functional outcome are associated with 90-day mortality after LAO AIS. Female gender and better revascularization after EVT are associated with lower mortality. Additional studies are required to refine mortality outcome prediction models for patients presenting with LAO AIS.
Abstract TP166: Age-Associated Transcriptomic Alterations in Patients With Ischemic Stroke
Authors: Sykes Gina , Batool Yusra , Kamtchum Tatuene Joseph , Zehnder Sarah , Jickling Glen C
Published: June 2021

Introduction:
Immune system dysregulation occurs with age. This includes an increase in inflammation, and immunosenescence, the inability to efficiently respond to new immune challenges. These changes are evident in various diseases but have yet to be evaluated in a population with ischemic stroke. Age is an important factor in stroke, contributing to stroke risk, outcome and risk of hemorrhagic transformation. This study aimed to assess the changes that occur with age in the leukocyte gene expression of patients with ischemic stroke.

Methods:
Two cohorts of acute ischemic stroke patients were analyzed; cohort 1 (n=94) and cohort 2 (n=79). RNA was isolated from PAXgene tubes and processed on Affymetrix microarrays. Differentially expressed genes associated with age quartiles were identified by ANCOVA, adjusted for sex and batch. Functional analysis identified age-associated pathways. Differentially expressed genes were compared with previous non-stroke aging studies in whole blood.

Results:
There were 61 and 442 age-associated genes in cohorts 1 and 2 respectively (FDR-corrected p<0.05, partial correlation coefficient ≥ |0.3|). Nineteen genes, including
CR2, CCR6
and
CXCR5
, were found in common and decreased with age among both cohorts (max-log10(p value) = 17). Functional analysis of the 61 and 442 genes revealed with advancing age there is a change in the humoral immune system, including antibody production and B cell proliferation. When compared to aging gene expression studies in controls, 52% of age-associated genes in cohort 1 and 31% of cohort 2 age-associated genes overlapped with those found in controls, and 16 of the 19 common genes to both cohorts overlapped in controls (max-log10(p value) = 15).

Conclusion:
In patients with acute stroke there is a change in leukocyte gene expression with advancing age. Changes included a shift in humoral immune response with a potentially impaired B cell response. While many of the age-associated alterations in gene expression present in stroke are similar to non-stroke controls, these changes warrant further investigation for their impact on stroke outcome and risk.
Abstract TP174: Identifying Predictors for Final Diagnosis of Ischemic Events in an Emergency Department Observation Unit
Authors: Kumar Arooshi , Ishida Koto , Liberman Ava , Zhang Cen , Yaghi Shadi , Torres Jose , Rostanski Sara
Published: June 2021

Introduction:
Transient neurologic events have high rates of diagnostic uncertainty. Emergency department observation units (ED-OU) allow an accelerated diagnostic work up for suspected transient ischemic attacks (TIAs). However, clinical decision support regarding which patients to admit to these units is lacking. This study aimed to identify clinical features that differentiate true ischemic events from nonischemic transient neurological attacks (NI-TNA) among patients admitted to an ED-OU for suspected TIA.

Methods:
A retrospective analysis was performed on consecutive patients admitted to the ED-OU at a single academic center for suspected TIA. Demographics, vascular risk factors, presenting symptoms, and details of the clinical presentation were abstracted from chart review. Final discharge diagnosis was dichotomized to either ischemic event (TIA or minor stroke, TIAMS) or NI-TNA based on the treating vascular neurologist’s final diagnosis. Standard statistical tests were used for comparison testing between the two groups. Significantly different factors with p<0.2 on univariate analysis were carried forward in a multivariable logistic regression model.

Results:
Of 186 consecutive patients, 101 (54%) had a final diagnosis of NI-TNA and 85 (46%) of TIAMS. The median population ABCD2 score was 4 [IQR 3-4]. On univariate analysis, older age (63 vs. 70, p<0.01), history of atrial fibrillation (AF) (12% vs. 26%, p=0.01), and facial weakness (5% vs. 14% p=0.03) were associated with TIAMS. Headache (24% vs. 12%, p=0.04) and symptom duration>60min (57% vs. 40%, p=0.02) were associated with NI-TNA. On multivariable analysis, only symptom duration>60 minutes predicted NI-TNA (OR 0.39, p=0.04) and only history of AF (OR 2.53, p=0.03) predicted TIAMS. Facial weakness was strongly predictive of TIAMS (OR 3.22, p=0.05), but not significant.

Conclusion:
We identified two clinical features that distinguished TIAMS from NI-TNA among patients admitted to an ED-OU for suspected TIA.These may be helpful in emergency room triage of TIAMS. Data from ED-OU can be used to identify factors associated with cerebral ischemia and improve current care pathways for patients with suspected TIA, so diagnostic evaluation is received in the most appropriate setting.
Abstract TP176: Risk Factors and Clinical Significances of the Quantitative CTA Vascular Calcification in Ischemic Stroke Patients
Authors: Shimoyama Takashi , Gaj Sibaji , Nakamura Kunio , Kovi Shivakrishna , Uchino Ken
Published: June 2021

Background and Purpose:
Intracranial arterial calcification is a marker of atherosclerosis burden in the general population. The aim of the study is to investigate risk factor profiles of vascular calcification in ischemic stroke patients.

Methods:
We identified ischemic stroke patients who underwent complete CTA from a prospective single-hospital stroke registry in 2018. Automatic artery and calcification segmentation method measured calcification volumes in the intracranial, extracranial, and aortic arteries using deep-learning U-net model and region-grow algorithms. Severe vascular calcification was defined as patients in the upper quartile calcification volume. The prevalence of severe vascular calcification and mean calcification volume were investigated by age category (<60 years, 60-70 years, 70-80 years, 80 years ≥). The relation between each potential risk factors and severe vascular calcification was assessed using the multivariate logistic regression analysis adjusted for age, sex, NIHSS score, and TOAST stroke subtypes.

Results:
Of the 558 consecutive acute ischemic stroke patients, 388 patients (212 males; mean age 66.6±14.2 years) met inclusion and with quantitative CTA calcification. The prevalence of severe vascular calcification (CTA calcification volume> 812 mm
3
) increased with increasing age category (<60 years: 6.8% (7/103), 60-70 years: 15.7% (18/115), 70-80 years: 39.6% (38/105), 80 years ≥: 45.9% (34/74), P<0.001 for χ
2
test). Over age 80 years subsets had significantly higher mean calcification volume with 1213 mm
3
than other age category (<60 years: 225 mm
3
, P<0.001; 60-70 years: 462 mm
3
, P<0.001; 70-79 years: 817 mm
3
, P=0.020 for t-test). In the multivariate logistic regression analysis, age (OR 1.096, 95% CI 1.066-1.128, P<0.001), smoking (OR 3.430, 95% CI 1.833-6.419, P<0.001), and large artery atherosclerosis (LAA) (OR 4.260, 95% CI 1.963-9.247, P<0.001) were independently associated with severe vascular calcification.

Conclusion:
In the quantitative CTA analysis of calcification volume, older age and smoking were high risk for severe atherosclerotic calcium burden in ischemic stroke patients. Moreover, severe vascular calcification may differentiate LAA from other stroke etiology.
Abstract TP18: First-Pass Effect May Reduce the Impact of Delays to Treatment in Endovascular Thrombectomy: Analysis of the STRATIS Registry
Authors: Manning Nathan W , Hassan Ameer , Liebeskind David , Mueller Nils , Jadhav Ashutosh , Nogueira Raul , Yavagal Dileep , Wenderoth Jason , Cheung Andrew , Zaidat Osama
Published: June 2021

Introduction:
First-pass reperfusion effect (FPE) appears superior to multiple device passes in achieving good functional recovery in endovascular thrombectomy (EVT). It is unclear if this represents an epiphenomenon or a true independent effect. Historically, earlier treatment has been associated with improved functional recovery. We analyzed how these two variables interact using the STRATIS registry data.

Methods:
The STRATIS registry prospectively enrolled large vessel occlusion, stroke patients, treated with Solitaire and/or Mindframe Capture low profile revascularization devices within 8 hours of symptom onset. Reperfusion was assessed by an independent core lab.

Results:
A total of 984 patients were enrolled (mean age 67.8 +/- 14.7 years, 54.2% male, median NIHSS 17). Mean time from stroke onset to groin puncture was 226.4+/- 100.0 minutes. At 90 days, functional recovery (mRS 0-2) was achieved in 56.5%. Core lab assessment was performed in 824 cases with a mTICI2b/3 rate of 87.9%. Every 60-minute delay to treatment was associated with less functional recovery cOR 0.79 (95% CI, 0.68 - 0.93). In patients with first-pass effect reperfusion (FPE), delay to treatment did not affect functional recovery FPE-mTICI 2b cOR 1.03 (95% CI, 0.83 - 1.28) or FPE-mTICI 2c/3 cOR 0.96 (95% CI, 0.84 - 1.11). Poor reperfusion (FPE-mTICI <2b) maintained a negative relationship between functional recovery and delay to treatment cOR 0.76 (95% CI, 0.66 - 0.88).

Conclusion:
First pass effect may reduce the impact of delays to treatment compared to historical data. Further studies to determine the mechanism of this effect are required.
Abstract TP183: Characteristics of Stroke in the Young in a Diverse Urban County
Authors: Dardick Joseph M , Labovitz Daniel , Liberman Ava , Cheng Natalie , Esenwa Charles
Published: June 2021

Introduction:
The incidence of acute ischemic stroke (AIS) among the young in the United States has increased by as much as 35% over the past 15 years. To curb this trend, more information is needed on the subtypes and risk factors for AIS in the young. We sought to characterize AIS subtypes in patients aged 19 to 49 in a racially and ethnically diverse urban county.

Hypothesis:
We hypothesized that race/ethnic minorities would have a younger median age of AIS and more small vessel disease given known disparities in cardiovascular health.

Methods:
We performed a retrospective cohort study of AIS patients aged 19-49 discharged from two Bronx-based academic teaching hospitals from 2013 to 2018. Strokes were subtyped using TOAST criteria. ANOVA and Mann-Whitney U-tests were used to determine age differences and chi-squared analysis was used to determine differences in subtype.

Results:
In the 451 patients that met inclusion criteria, mean age was 41.1 (median = 44) and 48.2% were women. We found no differences in subtype by race or ethnicity. In addition, though the median age of AIS was similar by race, it was significantly lower in Hispanic patients compared to non-Hispanic patients (median
Hispanic
= 42; median
non-Hispanic
= 45;
p
= 0.024; table 1). Finally, the median ages of patients with cardioembolic (CE), cryptogenic and other subtypes were significantly lower than the median ages of patients with lacunar and large artery atherosclerosis (LAA) subtypes (median
CE
= 41yrs; median
cryptogenic
= 43 yrs; median
other
= 40 yrs; median
lacunar
= 47 yrs; median
LAA
= 47 yrs; figure 1).

Conclusions:
The proportion of AIS subtypes in a diverse urban cohort aged 19-49 did not vary by race or ethnicity. Patients with CE and cryptogenic stroke types were significantly younger than those with lacunar and LAA subtypes. More exploration of subtype-specific risk factors is needed to understand drivers of stroke in the young.

Error bars indicate median and 95% CI. **
p
<0.01; ***
p
<0.001; ****
p
<0.0001
Abstract TP197: Countries With an Inverse Ratio of Ischemic Stroke and Ischemic Heart Disease- Analysis of Global Burden of Disease Data
Authors: Jilani Talha , Lobanova Iryna , French Brandi R , Siddiq Farhan , Gomez Camilo R , Qureshi Adnan I
Published: June 2021

Background:
Ischemic heart disease is more prevalent than ischemic stroke in most countries, including the United States; however, recent data suggests that ischemic stroke may be more prevalent in some countries. We performed this study to identify the countries with an inverse ratio of ischemic stroke and ischemic heart disease and associated attributes.

Methods:
We analyzed the data using the Global Burden of Disease (GBD) website; GBD Compare tool published by the Institute for Health Metrics and Evaluation (IHME), Seattle, Washington for the year 2017. We categorized individual 195 countries based on the ratio of ischemic stroke/ischemic heart disease and divided them into ≥1.0, 0,5-99, and <0.5. Gross domestic product (GDP) per capita for each country was calculated using data from Worldometers.

Results:
There were 51, 125, and 19 countries with the ratio of ischemic stroke/ischemic heart disease and divided them into ≤0.5, 0.5-0.99, and ≥1.0 respectively (see Table). The range of ratio was between 0.24 and 1.86. Countries with inverse ratio included China (1.86), North Korea (1.31), Guam (1.28), Taiwan (1.20), Marshall Islands (1.15), Timor-Leste (1.16), South Korea (1.13), Seychelles (1.11), Northern Mariana Islands (1.10), Cambodia (1.09), Federated States of Micronesia (1.08), American Samoa (1.07), Samoa (1.06), Kiribati (1.04), Solomon Islands (1.03), Fiji (1.02), Indonesia (1.02), Mauritius (1.01), and Vanuatu (1.00).

Conclusions:
Approximately 1 out of 10 countries have an inverse ratio of ischemic stroke / ischemic heart disease incidences. The inverse ratio is predominantly driven by a lower incidence of ischemic heart disease.
Abstract TP2: Impact of Neglect on Outcomes After Right Hemisphere Stroke Thrombectomy
Authors: Desai Shashvat M , Ramaiah Guru , Haq Waqas , Atchaneeyasakul Kunakorn , Starr Matthew , Rocha Marcelo , Molyneaux Bradley J , Jovin Tudor G , Jadhav Ashutosh P
Published: June 2021

Introduction:
Right Hemisphere Strokes (RHS) are characterized by severe motor and sensory deficits and signs of neglect including extinction and inattention. National Institutes of Health Stroke Scale (NIHSS) score provides an objective measurement of presence or absence of neglect. Data regarding the impact of neglect on outcomes after RHS thrombectomy are lacking. We hypothesize that the presence of neglect in RHS is associated with worse outcomes after thrombectomy in RHS.

Methods:
Retrospective analysis of prospectively collected database of right sided anterior circulation large vessel occlusion [internal carotid and/or middle cerebral artery M1] strokes at a comprehensive stroke center. Patients with successful recanalization (TICI≥ 2B) and complete follow-up data were included in the study. Two group of RHS were identified- with and without neglect by itemized NIHSS. Baseline characteristics and outcomes were compared.

Results:
A total of 172 patients were included in the study. Median NIHSS score was 15 (11-18) and median ASPECTS was 9 (8-10). Signs of neglect were observed in 63% (108) of patients. In multivariate analyses, younger age [0.9 (0.8-0.95) p=<0.01] and higher ASPECTS [1.8 (1.1-3.1) p=0.015] were independent predictors of mRS 0-2 at 90 days. Absence of neglect [0.39 (0.13-1.1) p=0.07] may predict good outcome. Independent predictors of mortality on multivariate analyses included older age [1.1 (1.03-1.15) p =0.001], presence of atrial fibrillation [0.3 (0.1-1) p=0.05] and diabetes mellitus [0.16 (0.05-0.53) p=0.003]. Presence of neglect [2.5 (0.9-6.6) p=0.06] and lower ASPECTS [0.7 (0.4-1) p=0.06] may predict mortality.

Conclusion:
Signs of neglect were observed in approximately 63% of right hemisphere LVO strokes. Presence of neglect may predict poor functional outcome and mortality at 90 days after thrombectomy for right hemisphere strokes. Further studies are required to evaluate the impact of thrombectomy on recovery of neglect.
Abstract TP201: Effect of Documentation Patterns on Prevalence of Comorbid Conditions in Ischemic Stroke
Authors: Amin Moein , Jillella Dinesh , Man Shumei , Uchino Ken
Published: June 2021

Introduction:
Studies over the past decade indicate increasing prevalence of comorbid conditions of diabetes, obesity, smoking, and hypertension among those hospitalized with ischemic stroke. While this might indicate true increase in disease prevalence, changing documentation patterns, use of electronic health records or coding might account for an apparent increase in the prevalence of these comorbid conditions.

Hypothesis:
True disease prevalence has not changed and increase in documentation and billing has led to an apparent increase in the comorbid conditions.

Methods:
We randomly selected medical records from the years 2011 through February 2012 (90 patients) and 2017 (90 patients) with acute ischemic stroke aged 18 or older who were hospitalized at a large urban hospital. Medical records of the patients were reviewed for documentation of comorbid conditions in admission history narrative, discharge diagnoses, problem list, discharge summary, or records up to 1 year prior (true prevalence - TP). Billing data were extracted for billed diagnoses of respective comorbid conditions (apparent prevalence - AP). Chi-square test was used to compare the two study periods and billing and documented data.

Results:
Among the 180 patient records, the true prevalence of obesity, smoking, hypertension, atrial fibrillation, hyperlipidemia, ischemic heart disease, and diabetes mellitus showed no significant difference between 2011/2012 and 2017. Billed comorbidities as the ratio of AP/TP increased in diabetes (0.82 vs 0.96 p = 0.003) over the two periods, but decreased in atrial fibrillation (0.91 vs 0.67 p < 0.001), and remained unchanged for obesity (0.40 vs 0.42 p = 0.786), hyperlipidemia (0.78 vs 0.88 p = 0.075), ischemic heart disease (0.84 vs 0.89 p = 0.328), smoking (0.87 vs 0.83 p = 0.454), and hypertension (0.67 vs 0.64 p = 0.673).

Conclusions:
Consistent increase in billing does not appear to account for the changing prevalence in vascular comorbidities seen in administrative data.
Abstract TP203: Factors Associated With Temporal Window Failure in Transcranial Doppler Sonography
Authors: Lee Chan-Hyuk , Jeon Seung-Ho , Wang Su-Jung , Shin Byoung-Soo , Kang Hyun Goo
Published: June 2021

Background and purpose:
Temporal window failure (TWF) is found in 8-20% of subjects. Although it has been reported that, it is more common for the elderly and females, there are not enough studies on this topic. This study aimed to identify new factors affecting TWF.

Methods:
This study analyzed 376 patients who underwent both transcranial Doppler sonography (TCD) and cerebral angiographic imaging among patients visited the neurology department of Chonbuk National University Hospital from January to December 2018. They were divided into two groups depending on the presence of TWF. Afterward, demographics and cardiovascular factors, degree of stenosis from proximal intracranial artery (ICA) to the middle cerebral artery (MCA), and MCA diameter and skull features were examined.

Results:
The mean age of the patients was 68.4±12.1 years old and 241 of them (64.1%) were male. The study subjects were composed of 314 TWF negative patients (83.5%) and 62 TWF positive patients (16.5%). The stenosis from the proximal ICA to the 2/3 segment of the MCA proximal was not different between the two groups. Factors affecting TWF were analyzed using multivariate logistic regression analysis and the results showed that age (odds ratio [OR], 1.05;
p
=0.019), female (OR, 4.64;
p
=0.002), temporal bone thickness (OR, 6.03;
p
<0.001), temporal bone density (OR, 0.996;
p
=0.002), and soft tissue thickness (OR, 1.31;
p
=0.004) significantly affected TWF.

Conclusions:
We confirmed that the soft tissue thickness of the temporal area was a new associated factor of TWF in addition to the previously reported age, sex, temporal bone thickness, and temporal bone density. The results implied that measuring the soft tissue thickness of the temporal area for patients with suspected TWF would be useful to clinically identify the measurement error due to a technical problem.
Abstract TP204: Intima-Media Thickness in the Carotid Bifurcation, But Not Cardio-Ankle Vascular Index or Ankle-Brachial Index, is Related to Silent Brain Infarct on Magnetic Resonance Imaging in Healthy, Middle-Aged Japanese Individuals
Authors: Nishiyama Yasuhiro , Otsuka Toshiaki , Muraga Kanako , Kimura Kazumi
Published: June 2021

Background:
Carotid ultrasonography is currently the principal noninvasive tool for evaluating subclinical atherosclerosis and carotid artery disease. Increased carotid intima-media thickness (IMT) may precede the development of atherosclerotic plaques. Several studies have shown that increased IMT is associated with increased incidence of stroke. Silent brain infarct (SBI) has been proposed as a strong subclinical risk marker for future symptomatic stroke onset. However, the relationship between SBI and elevated IMT in healthy, middle-aged Japanese individuals has not been adequately examined.

Methods:
We examined 280 Japanese adults (92 women; mean age, 52.9 ± 5 years) with no history of cardiocerebrovascular disease. We assessed all participants’ periventricular hyperintensities, deep subcortical white matter hyperintensities, SBI on magnetic resonance imaging, cardio-ankle vascular index (CAVI)/ankle-brachial index (ABI), and various vascular risk factors. In addition, we measured intima-media thickness at the common carotid artery (CCA), carotid bifurcation (CB), and internal carotid artery (ICA).

Results:
Participants were categorized into two groups according to the presence or absence of SBIs, and we then compared the clinical characteristics of the two groups. Age, hypertension, increased HbA1c level, and decreased estimated glomerular filtration rate were found to be significantly associated with the SBI group. The odds ratio (OR) of the maximum IMT at the CB for the presence of SBI was 4.016 (95% confidence interval [CI], 1.565-10.304), even after adjusting for potential confounding factors. In contrast, the ORs of maximum IMT at the ICA and CCA as well as CAVI and ABI were not significant. Participants with IMTs ≥2 mm at the CB had a higher probability of the presence of SBI (OR, 26.451; 95% CI, 2.404-291.00).

Conclusion:
The maximum IMT at the CB was significantly correlated with the presence of SBI on MRI, but ABI or CAVI did not show significant correlation. Thus, compared to CAVI or ABI, carotid ultrasonography appears to be a very useful tool for noninvasively detecting SBI. In particular, IMTs ≥2 mm at the CB on carotid ultrasonography may be practical for identifying SBIs among middle-aged Japanese individuals.
Abstract TP207: Clinicoradiologic Discordance in Methamphetamine Vasculopathy-Associated Rhombencephalitis: Three New Cases of Temporal and Geographical Similarity
Authors: Flannery Michael P , Bennett Alicia
Published: June 2021

Introduction:
Structural and functional imaging techniques have demonstrated CNS abnormalities due to methamphetamine use, however there are no prior reports of rhombencephalon involvement. Furthermore, clinicoradiologic discordance is unique to this case series.

Methods:
We report a case series of patients with a diagnosis of vasculopathy-associated rhombencephalitis out of proportion to clinical examination in the setting of methamphetamine use at our tertiary stroke center.

Results:
Three patients were evaluated within 3 months of each other for focal neurologic deficits with normal mental status at our tertiary stroke center. All admitted to recent methamphetamine use. MRI of the brain with and without contrast demonstrated T2 hyperintensity without enhancement or diffusion restriction involving primarily the pons, consistent with vasogenic edema or demyelination (Figure 1). Workup for infectious and inflammatory etiologies including CSF analysis was unremarkable. All patients had vessel imaging demonstrating extracranial vasculopathy; all had dissections of the vertebral arteries, one of which had an associated pseudoaneurysm (Figure 1). All of the patients had GCS of 15 and minimal to no improvement with various treatment.

Conclusion:
Vasculopathy-associated rhombencephalitis in the setting of acute methamphetamine use has not been reported previously. The temporal and geographic relationship among these cases is key to the suspected diagnosis that a methamphetamine adulterant has a leukotoxinogenic predilection for the rhombencephalon. The cause of significant clinicoradiologic discordance remains unclear. Further investigation into this association is needed.
Abstract TP221: Cerebellar Infarction Presentations: A Population-Based Study From the Greater Cincinnati/Northern Kentucky Stroke Study
Authors: Kerber Kevin A , Khoury Jane , Burke James , Meurer William , Alwell Kathleen , Moomaw Charles , Flaherty Matthew , Woo Daniel , De Los Rios La Rosa Felipe , Mackey Jason , Martini Sharyl , Ferioli Simona , Adeoye Opeolu , Khatri Pooja , Kissela Brett , Kleindorfer Dawn
Published: June 2021

Background:
Cerebellar lesions reportedly account for 2-7% of acute infarct visits, but this may be an underestimate since prior studies were not population-based or from the modern imaging era. Cerebellar symptoms are also often nonspecific such that increased MRI use might lead to a higher proportion of stroke due to cerebellar lesions. Details about presenting features of cerebellar infarcts and baseline medication use are also not well known.

Methods:
We used the 2010 Greater Cincinnati/Northern Kentucky Stroke Study. Strokes were identified by screening ICD9 codes 430-436 and physician verification. Infarct location was categorized as isolated cerebellar, mixed cerebellar (cerebellar plus ≥1 other location), or non-cerebellar. Isolated dizziness was defined as dizziness/vertigo without other focal symptoms. Atherosclerotic cardiovascular disease (ASCVD) 10-year risk scores were calculated. Descriptive statistics and multivariable logistic regression were used to compare infarct categories.

Results:
Isolated cerebellar lesions occurred in 4.6% (90/1940; 95% CI, 3.7%-5.7%) of infarct events. An additional 4% (77/1940; 95%CI, 3.1%-4.9%) were mixed cerebellar infarcts. Mixed cerebellar infarcts had clinical characteristics more similar to non-cerebellar events than to cerebellar events. The multivariable model found an association of isolated cerebellar infarct with low NIHSS (odds ratio [OR] 2.3, 95% CI 1.1-4.8) and any dizziness/vertigo (OR 5.1, 95% CI, 2.4-10.6), but not with isolated dizziness/vertigo, age, or sex. Median ASCVD scores were high in all infarct categories (21, interquartile range [IQR] 9-35 for isolated cerebellar; 32, IQR 15-42 for mixed cerebellar; 31, IQR 16-52 for all others). Both cerebellar and non-cerebellar strokes had a high frequency of baseline antiplatelet or anticoagulant use (52.1% vs 56.2%), whereas baseline statin therapy was less common in isolated cerebellar infarcts (34.1% vs 43.8%).

Conclusions:
This population-based study during the modern imaging era found that about 5% of stroke cases have isolated cerebellar infarcts and nearly 9% have any cerebellar infarct. Both cerebellar and non-cerebellar presentations have high baseline vascular risk and antiplatelet/anticoagulant use.
Abstract TP229: Cerebral Venous Thrombosis Caused by Congenital Thrombophilia in Japan
Authors: Shindo Akihiro , Wada Hideo , Ishikawa Hidehiro , Ii Yuichiro , Ikejiri Makoto , Matsumoto Takeshi , Tomimoto Hidekazu
Published: June 2021

Background:
Cerebral venous thrombosis is an uncommon type of stroke that sometimes affects young to middle-aged patients. Various conditions can cause CVT, including drugs, infection, dehydration, pregnancy, malignancies, and acquired and congenital thrombophilia. Hereditary thrombophilia caused by genetic mutation, such as antithrombin, protein C (PC) and protein S (PS), requires warning about the risk and signs of thrombosis recurring. Because CVT itself is a rare disease, it’s sometimes difficult to diagnosis the hereditary thrombophilia in each case. This study describes the clinical features and causes related to CVT in Japan, and elucidates the characteristics of CVT caused by hereditary thrombophilia.

Methods:
We enrolled 40 patients (24 males, 16 females, age: 18-81 years) diagnosed CVT confirmed by either magnetic resonance venography, enhanced computed tomography, or angiography. Demographic data and clinical features were recorded and compared.

Results:
Eleven patients (6 males, 5 females, age: 27-71 years) were diagnosed CVT due to congenital thrombophilia, and the other twenty-nine patients (18 males, 11 females, age: 18-81 years) were not. Congenital thrombophilia included five patients with PS gene mutation, three with PC gene mutation, two with antithrombin gene mutation, and one alpha fibrinogen gene mutation. Although we failed to detect a significant statistical difference between congenital thrombophilia patients and others with regards to age, sex, symptoms, vein of occlusion, d-dimer levels, activity levels of PS and PC were significantly decreased in congenital thrombophilia patients.

Discussion:
Cerebral venous thrombosis in Japanese patients is frequently associated PS or PC gene mutations. This study showed CVT caused by congenital thrombophilia had low activity of PS and PC. Clinicians should aware the presence of PS or PC gene mutations during the treatment of CVT and check the PS and PC activity.
Abstract TP235: No
Off-Hours
or
Weekend Effect
on Door-In to Door-Out Time in Patients Transferred for Thrombectomy
Authors: Cierny Marek , Fuhrman Susan , Lazzaro Marc A
Published: June 2021

Introduction:
Time-sensitive therapies can be delayed during weekends or off-hours. Regional systems of care require interfacility transfers from
Primary Stroke Centers
(PSC) to
Comprehensive Stroke Centers
(CSC).
Door-in to door-out
(DIDO) time, an emerging performance measure, is a modifiable factor in time to thrombectomy. Off-hours presentation has been associated with longer
Door-To-Needle
(DTN) time, however its effect on DIDO time is unknown.

Hypothesis:
Presentation during off-hours (before 8 AM, after 5 PM or on weekends) prolongs DIDO time.

Methods:
Retrospective review of transfers for CT perfusion or thrombectomy from 4 PSC to a CSC between 1/2017 and 6/2019. We used Mann-Whitney for hypothesis testing and Spearman’s correlation.

Results:
Sixty-seven persons were included, of which 36 were male, 31 received IV tPA, 40 presented during off-hours. Median (upper and lower quartile) for age, NIHSS, DTN and DIDO were 74 (61-83) years, 17 (12-23) points, 37 (31-54) and 98 (77-127) minutes, respectively. Off-hours presentation did not prolong DIDO time (p=0.32, image) nor affect any interval in the sequence door-in,
non-contrast CT
(nCT), IV tPA,
CT Angiogram
(CTA) initiation, CTA interpretation, door-out; or
door-in at PSC to groin puncture
(DTGP) time. Transport from PSC to CSC was slower off-hours (p=0.04). On post-hoc analyses, DIDO correlated with door-in to nCT interpretation time (r
s
=0.27, p=0.02), nCT interpretation to consulting neurointerventionalist (r
s
=0.59, p<0.01) and their acceptance of a transfer (r
s
=0.37, p=0.01); door-in to CTA initiation (r
s
=0.77, p<0.01), CTA initiation to interpretation (r
s
=0.61, p<0.01), and DTGP time (r
s
=0.85, p<0.01).

Conclusions:
Off-hours presentation is not associated with prolonged DIDO time in patients transferred for possible thrombectomy. Time to calling neurointerventionalist and initiation and interpretation of CTA contributes to DIDO, and may be targets for improvement to expedite transfers.
Abstract TP240: Dizziness Triage in Acute Posterior Circulation Stroke Identification
Authors: Fawcett Michael , Tran Deborah S
Published: June 2021

Background:
Posterior circulation strokes (PCS) is a challenge in Emergency Medicine. Incorrect diagnosis can lead to missed treatment with acute stroke therapy. FAST has not been shown to evaluate PCS symptoms: dizziness, ataxia & vision. The inclusion of balance to the BE-FAST has helped increase the capture rate of patients suspected with PCS, yet how this is assessed needs clarification. Defining disability for consideration of acute stroke therapy in the dizzy patient can be aided by gait assessment.

Purpose:
The purpose of this study is to identify any patterns of co-morbid conditions or assessment elements that would make identification of PCS easier by completing a retrospective chart review. The team also attempted to identify any trends in the patient’s physiologic response to stroke.

Methods/Methodology:
An IRB-approved retrospective, observational chart review was completed on patients that presented with PCS symptoms to the target hospital’s ED from January 2016 to May of 2017. Patients with the presence of a chief complaint OR reported symptom during physician initial interview of dizziness, vision loss, ataxia, or syncope AND completion of one imaging study were included in the study. The charts were abstracted for demographic information, symptoms reported/observed, vital signs, labs, imaging and final diagnosis.

Results:
Seventy-nine patients were coded as a stroke on discharge diagnosis from 378 patients with PCS symptoms. The mean SBP & DBP was greater in stroke patients (
p< .01
) and the mean blood glucose measured higher in stroke patients (
p=0.01
). The mean heart rate did not have a statistically significant difference. Dizzy/vertigo (
p=.022
), gait disturbance/ataxia (
p=.017
) correlated to stroke diagnosis and a BP over 200/100 trended towards significance (
p=.054
), with 95% CI.

Findings/Conclusion:
A report of dizziness or vertigo, ataxia, and a higher measurement of blood glucose or blood pressure was correlated in those with a stroke diagnosis. In the setting of PCS symptoms, these triggers should raise awareness for increased likelihood of acute PCS. When attempting to identify PCS, walking the patient is a subtle addition to balance assessment that can provide important information to distinguish PCS.
Abstract TP25: Outcomes of Endovascular Thrombectomy in Late-presenting Patients: Findings From the Florida Stroke Registry
Authors: Asdaghi Negar , Wang Kefeng , Mueller-Kronast Nils , Gardener Hannah E , Gutierrez Carolina M , Lau H. Lee , Saini Vasu , Marulanda-Londoño Erika , Koch Sebastian , Krementz Nastajja , Dong Chuanhui , Hanel Ricardo , Mehta Brijesh , Nobo Ulises , Zevallos Juan C , Rundek Tatjana , Yavagal Dileep R , Sacco Ralph L , Romano Jose G
Published: June 2021

Introduction:
It is unclear whether the outcomes of late presenting patients (6-24 hrs from symptom onset) receiving endovascular thrombectomy (EVT) in routine clinical practice parallels the favorable results of recently completed randomized trials. We evaluated characteristics and outcomes of EVT utilization, over the past decade, for late and early presenting (≤ 6 hrs from onset) patients.

Methods:
From Jan 2010 to Jan 2019, 84,346 ischemic stroke patients presenting within 24 hrs of symptoms were enrolled in the Florida Stroke Registry. Differences in clinical characteristics, utilization trends and outcomes at discharge were compared between late vs. early presenting EVT patients using multivariable regression analysis.

Results:
Among 5,702 EVT patients (mean age 71±15, 48% women), 1,580 (28%) were late presenting. Late presenting EVT patients had higher rates of private insurance (39% vs 35%), dyslipidemia (39% vs 35%) and smoking (16% vs.13% ) but lower rates of Hispanic patients (19% vs 24%) and atrial fibrillation (34% vs 37%.). Late presenting patients had lower National Institute of Health Stroke Scores [median 14 (IQR=12) vs 17 (IQR=11)] and rates of thrombolysis (6% vs 58%). Short term discharge outcomes and treatment complications are shown in Table. In multivariable analysis adjusting for age, sex, stroke severity and intravenous thrombolysis, late presenting EVT patients had similar symptomatic intracerebral hemorrhage rates [OR 1.02 (0.72-1.45)] and outcomes but were less likely to ambulate independently at discharge (OR 0.80, 95% CI 0.70-0.92) compared to early presenting EVT patients.

Discussion:
Over the past decade, nearly a third of EVT patients were treated after 6 hours from onset. In clinical practice late EVT carries comparable safety and favorable outcome profiles to early EVT.
Abstract TP250: Reducing Treatment Time in Acute Ischemic Stroke by Utilizing a Kaizen Model
Authors: Fayad Mohamad , Lima Jussie` , Beland Dawn , Staff Ilene , Abbott Lincoln , Ollenschleger Martin , Nouh Amre
Published: June 2021

Introduction:
Treating patients suspect of acute stroke requires efficient multidisciplinary teamwork in order to provide appropriate care. Several “Lean Management” methods have been applied in a variety of healthcare settings. Kaizen, meaning “improvement” in Japanese is a tool which emphasizes empowerment of employees on creating value streams to identify and reduce wastes, synchronize work flow processes, manage variability, and devise communication and sustainability plans. We report on the use of this methodology to improve our acute stroke care metrics.

Objective:
To optimize the management of the acute stroke patient flow process from the emergency department ED to destination therapy by applying the Kaizen methods.

Methodes:
This is a quality improvement project designed to evaluate the efficiency of the new workflow model for acute stroke that was put into place June 2018 at Hartford Hospital. A 5 day event spent involving all stakeholders from patient registration to destination treatment (IV or mechanical thrombolytic therapy) were conducted. During this event, a time work flow process for the management of suspected stroke patients was identified and an appropriate plan was formulated to reduce times. The following parameters were utilized: Door to CT scanner time (DTCT), Door to drug (IV-tPA) (DTD), and Door to mechanical thrombectomy puncture time (DTP). We included all stroke patients presenting to the ED and treated at our institution 6 months prior and post implementation. A non-parametric analysis was utilized.

Results:
A total of 135 patients were included in this analysis, 60 prior and 75 post Kaizen. Improvement across all parameters was observed post Kaizen with an average reduction time of DTCT 5 min, DTD 5min, and DTP 22min. The median times pre-Kaizen were; DCT 14min IQR 6-27, DTD 55min IQR 43.5-77.5, and DTP 128min IQR 88-151. The median times post-Kaizen were; DTCT 9min IQR 6-23, DTD 50.5min IQR 37-64, and DTP 106 min IQR 83.5-141.5.

Conclusion:
By utilizing the Kaizen, we identified numerous opportunities to reduce variability, standardize workflow processes, and ultimately reduce all parameter times. As time is brain, reducing pretreatment times favorably impacts patients’ outcomes and reduces morbidity in stroke.
Abstract TP259: Mission: Lifeline Stroke Education Campaign Drives Systems of Care Improvement in North Dakota
Authors: Pietrzak Janna , Drofa Alexander , Alexander Jerilyn , Carlblom Megan , Henderson Mandy , Quirk Lynde , Richter Samantha , Wiseman JuLann , Cook Mindy
Published: June 2021

Introduction:
The AHA Mission: Lifeline Stroke program is a 3-year initiative in North Dakota which aims to improve statewide stroke systems of care. Due to complexities in recognizing and treating stroke patients, effectively educating prehospital and hospital health care providers on guideline-based assessments and treatment methods was identified as an interventional opportunity.

Purpose:
The purpose of the education campaign was to increase early recognition of stroke symptoms and expand application of guideline-based triage and treatment protocols thereby improving early recognition, treatment times and outcomes.

Methods:
The planning group considered individual learning style preferences by using the Visual, Auditory, Read/Write, and Kinesthetic (VARK) model which divides learners into these four categories. Beginning in January 2017, the following education offerings were deployed to address each style: in person lectures, conferences, workshops, stroke simulation trainings, online courses, webinars and a stroke certification course. Topics included: stroke symptom screening, severity scoring, LVO criteria, transport protocols, statewide stroke treatment guidelines and IV alteplase administration. Systems improvement data was correlated from the GWTG-Stroke registry in which all 6 ND tertiary hospitals and 32 of 36 critical access hospitals participate.

Results:
In the ND critical access hospital cohort the percentage of stroke patients who received brain imaging within 25 minutes of arrival increased from 57.1% in 2016 to 72% in 2018, and those who arrived at the hospital within 2 hours of LKW and received IV alteplase within 3 hours increased from 56.0% in 2016 to 64.3% in 2018. While in the all ND hospital cohort the percentage of acute ischemic stroke patients receiving IV alteplase within 60 minutes of arrival increased from 66.2% in 2016 to 78.2% in 2018.

Conclusions:
A multifaceted stroke education campaign can be an effective way to improve statewide stroke triage and treatment times. Continuing educational efforts are needed to maintain these gains and elicit further advancements. Additional studies are needed to determine if an improvement in triage and treatment times corresponds with reduced mortality and morbidity.