bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W P149: Ethnic Disparities In Stroke Related In-Hospital Mortality In Patients With Atrial Fibrillation
Authors: Sherzai Ayesha , Pilot Markeith , Sherzai Dean , Yaghi Shadi
Published: March 2022

Background:
Improved strategies are needed to stratify the risk of stroke in atrial fibrillation. While stroke-related mortality is higher in African Americans, it is unclear whether stroke related mortality in patients with atrial fibrillation differs among different ethnicities. We aim to study race/gender disparities in stroke related in-hospital mortality in patients with atrial fibrillation.

Method:
Data were obtained from the California State Inpatient Database between 2008-2011, using appropriate ICD-9 codes. Frequencies and descriptive analysis adjusting for influence of comorbidities and confounders were utilized. Age and ICD-9 codes for hypertension, diabetes, congestive heart failure and prior stroke were used to calculate the CHADS2 score of patients with atrial fibrillation. A multivariate Cox regression model was used to further explore the relationship. The primary outcome was in-hospital mortality. We hypothesized that higher CHADS2 scores increase the risk of stroke among African Americans due to increased disease burden.

Results:
Between 2008 and 2011, 18,089 patients with atrial fibrillation had a stroke, 70% were Whites, 5% African Americans, 15% Hispanics and 10% Asians. 57% were females, and 66% of the population were 75 years of age and older. After adjusting for baseline demographics, there was no significant difference in the the odds of in-hospital stroke mortality, with Whites taken as reference (African Americans OR 0.93, 95% CI 0.83-1.05; Hispanics OR 1.02, 95% CI 0.94-1.10; Asians OR 1.07, 95% CI 0.98-1.17). There was no significant difference in the odds of in-hospital stroke mortality between males and females (Males OR 0.97, 95% CI 0.92-1.02).

Conclusion:
Our results indicate that in a large, statewide database, the in-hospital stroke mortality among the different races with stroke during hospitalization was not significantly different as compared to Whites.
Abstract W P151: Time is More Brain in Patients with Higher Hemoglobin A1C
Authors: Brar Jaskiran , Korya Daniel , Khan Nile , Galea Bernard , Chaudhry Saqib , Torok Ildiko , Nizam Shayaan , Panezai Spozhmy , Moussavi Mohammad , Kirmani Jawad F
Published: March 2022

Objective:
The aim of our study was to determine if chronic hyperglycemia, demonstrated by elevated hemoglobin A1C (HbA1C), had an effect on outcome after IV tPA infusion for acute ischemic stroke.

Materials:
A comprehensive record review of diabetic patients who received IV tPA with ischemic stroke who presented to a community comprehensive stroke center during a 3-year period (2010-2013) was done. Two groups were made: HbA1C >6% and <6% (Group A & Group B). Each group subdivided into 3 groups based on times from symptom onset to IV tPA: 180 mins. The groups were then compared to establish the number needed to harm (NNH) for IV tPA at different time periods. Harm was considered a worsening in the NIHSS of 3 or more. Mean initial NIH Stroke Scale (INIHSS) and discharge NIHSS (DNIHSS) were determined and 2-tailed t-tests were performed for the outer groups with SPSS V22.

Results:
A total of 1,565 patients with ischemic stroke were evaluated. Of those, 166 patients met study criteria. There were 100 patients with HbA1C over 6% (mean age 73.4, 55% female). Group A had a mean INIHSS/DNIHSS of 24.5/7.8, 13.3/10.6 and 8.65/8.23 at 180 mins, respectively. The mean change in INIHSS to DNIHSS between the 180 group with Group A was Patients with Group B had mean INIHSS/DNIHSS of 16.5/6.5, 13.23/7.6 and 11.6/6.5. The mean differences between INIHSS and DNIHSS in Group A patients in the 180 min time was 13.2 (95% CI 3.8-22.5, p=.01). The NNH for giving IV tPA to patients with HbA1C >6% versus <6% at different times was: 180= 4.8. For every 10 patients with HBA1C >6% treated with IVtPA, one is harmed. This doubled when IVtPA is given after 180 mins.

Conclusion:
Compared with patients with HbA1C <6%, patients with HbA1c >6% have a significantly greater chance of suffering a bad outcome and incurring harm. More data needs to be collected with a larger prospective study to draw better conclusions.
Abstract W P157: Frequency of Occurrence and Predictors of Myocardial Infarction after Incident Ischemic Stroke: A Population-Based Study
Authors: Sedova Petra , Kramer Neha M , Klaas James P , Mandrekar Jay , Brown Robert D
Published: March 2022

Background:
Coronary artery disease (CAD) is a significant cause of morbidity and mortality in ischemic stroke (IS) patients. IS and CAD often coexist and share common risk factors. Absolute risk and predictors of myocardial infarction (MI) in IS and by IS etiology subtype is not well known. We determined the risk of MI and its predictors in patients with incident IS in a population based cohort.

Methods:
Using the Rochester Epidemiology Project (REP) medical records linkage system we identified all residents with incident IS in a 5-year period between January 1, 1990, and December 31, 1994. Comprehensive medical records were reviewed and variables of interest were retrieved and analyzed. Univariate Cox proportional hazard regression models were constructed to assess hazard ratios and 95% CI for predictors of MI occurrence after IS.

Results:
We identified 490 persons with IS, mean age at IS was 76.6 (SD 12.9) years, mean follow up to death or final follow-up was 6.5 (SD 6.3, range 0.0-23.8) years. There were 126 recurrent strokes and 93 MIs during followup. The 1-year actuarial risk of MI was 3.6% (95% CI, 2.2% - 5.9%), and 5-year actuarial risk of MI was 11.4% (95% CI, 8.4% - 15.3%). Univariate predictors of MI included (HR; 95% CI): age (1.02;1.0-1.04), pre-IS history of MI (1.37;1.13-1.65), CHF (1.85;1.06-3.23), CABG (2.11;1.19-3.75), left ventricular dyskinesia (2.14;1.32-3.4), peripheral vascular disease (1.32;1.18-1.49), diabetes mellitus (1.54;1.21-1.96), elevated creatinine (1.93;1.44-2.59), LDL level (1.01;1.00-1.01).

Conclusion:
MI is common after first IS. Several factors predicted an increased risk of MI after stroke, and should be taken into account in determining CAD screening strategies at the time of IS. Recurrent stroke was more common than MI during long-term followup.
Abstract W P16: Comparing Outcome Prediction Scoring Systems in the Interventional Management of Stroke (IMS) III Trial: No Clear Winner
Authors: de los Ríos la Rosa Felipe , Seiffge David J , Fan Liqiong , Yeatts Sharon D , Khatri Pooja , Engelter Stefan
Published: March 2022

Introduction:
Several prognostic scores have been developed to predict patient outcome after ischemic stroke. We aimed to compare eight scores in the IMS -III dataset.

Hypothesis:
Prediction of good and poor outcome using different scores is possible in IMS-III.

Methods:
We retrospectively calculated area under the curve (AUC), sensitivity, and specificity for poor (mRS 4-6) and good (mRS 0-2) 90-day outcome in all IMS-III participants with complete data. The scoring systems analyzed were: Houston Intra-arterial Therapy 2 (HIAT2), Ischemic Stroke Predictive Risk Score (iScore), Totaled Health Risks in Vascular Events (THRIVE), DRAGON, Hemorrhage after Thrombolysis (HAT), Alberta Stroke Programme Early CT Score (ASPECTS), Stroke-Thrombolytic Predictive Instrument (TPI), and Simple Variables Model (SVM). Those receiving IV rtPA followed by endovascular therapy (treatment) and those receiving IV rtPA only (control) were analyzed separately.

Results:
Among 656 IMS III subjects, 651 had complete data, including 429 treatment and 222 control subjects. Overall, all scoring systems showed good prediction abilities (AUC range 0.60 to 0.78). AUC comparisons did not clearly favor a single scoring system.

Treatment group: For predicting poor outcome, the TPI score outperformed ASPECTS (AUC 0.73 vs 0.61; P <0.05). For predicting good outcome, the HAT score was significantly better than ASPECTS (0.73 vs. 0.64; P <0.05).

Control group: For poor outcome, the TPI score was significantly better than ASPECTS and THRIVE (0.78 vs. 0.62 and 0.71, respectively; P <0.05). For good outcome, TPI performed better than ASPECTS and THRIVE (0.73 vs. 0.61 and 0.67, respectively; P <0.05).

Conclusions:
Outcome prediction using different scores in IMS III is possible. HIAT2, iSCORE, DRAGON, HAT, TPI, and SVM all performed comparably. Prognostic performances were comparable in both treatment arms.
Abstract W P164: Cerebral Microbleeds and Physical performance: The Framingham Heart Study
Authors: Romero Jose R , Preis Sarah R , Beiser Alexa , Shoamanesh Ashkan , DeCarli Charles , Wolf Philip A , Seshadri Sudha
Published: March 2022

Objective:
To study the association of cerebral microbleeds (CMB) on MRI and physical performance in a community based cohort free of stroke and dementia.

Background:
Impaired mobility and physical function are associated with increased morbidity and mortality. CMB are believed to be subclinical markers of hemorrhage-prone small vessel disease, but CMB-induced neuronal injury may promote physical impairment in individuals free of stroke and dementia by disrupting the complex cerebral pathways involved in gait control and balance.

Methods:
We evaluated 1710 Framingham Offspring Study participants (mean age 64.6 years, 54% women) attending a baseline examination (1998-2008), who had brain MRI allowing for CMB detection and available measurements of physical performance. Walking speed was available in all, while a subset (N≈500) had available standing balance, chair standing and short physical battery scores. Using multivariable logistic regression we related CMB presence overall and stratified by brain location (lobar or deep) to the physical performance measures.

Results:
CMB were observed in 7.7% of subjects. We observed an association of presence of any CMB with lower walking speed score (4 vs. <4) after adjustment for age, sex, time between MRI and study exam, and MRI markers of ischemic small vessel disease (OR 0.53, 95% CI 0.30-0.93, p=0.03). The association was no longer significant after adjusting for vascular risk factors (hypertension, diabetes, smoking, prevalent cardiovascular disease) instead of MRI markers (OR 0.63, 95% CI 0.36-1.11, p=0.11). There were no significant associations by CMB location and CMB were not associated with the remaining physical performance measures in the smaller samples.

Conclusions:
CMB were associated with lower gait speed, a relation that was partly dependent on presence of vascular risk factors. Our findings are limited by the small sample in subgroups of CMB across physical performance measures other than gait speed, but if replicated in other studies, would suggest a negative impact of CMB on physical function in community dwelling persons without stroke or dementia. These findings are significant given longer life expectancy and increasing prevalence of CMB with age.
Abstract W P169: Association Between Serum Leptin Levels and Stroke: Results from Framingham Heart Study
Authors: Saber Hamidreza , Himali Jayandra J , Shoamanesh Ashkan , Beiser Alexa , Pikula Alexandra , Harris Tamara B , Roubenoff Ronenn , Romero Jose Rafael , Kase Carlos S , Wolf Philip A , Vasan Ramachandran S , Seshadri Sudha
Published: March 2022

Background:
Leptin is a major adipokine that regulates weight balance and energy homeostasis. There is some inconsistent evidence linking circulating leptin levels to risk of stroke. We tested the hypothesis that leptin levels are associated with risk of first ever stroke in an elderly community-based population.

Methods:
Serum leptin levels were assayed in 757 stroke-free individuals (mean age 79 [SD, 5 years], 62% women) from the Framingham Original cohort at the 22nd examination cycle (1990-1994). Incidence of all-stroke and ischemic stroke were prospectively ascertained.

Results:
During a mean follow-up of 10 years, 119 individuals developed stroke, 99 of whom had ischemic stroke. In multivariable Cox regression models, log-leptin levels were not associated with incidence of all-stroke or ischemic stroke (hazard ratios [HR] per SD increment in log-leptin 0.9 [0.73-1.09] and 0.89 [0.72-1.11], respectively). The results were highly suggestive for effect modification by WHR for the association between leptin and ischemic stroke. Analysis in sub-groups stratified by waist-to-hip ratio (WHR) and adjusting for age, sex and established stroke risk factors revealed a lower incidence of first-ever all-stroke and ischemic stroke associated with higher leptin levels among subjects in the top WHR quartile but not in others (HR, 0.64 [0.43, 0.95] versus 0.98 [0.77, 1.25] for incident all-stroke and 0.61 [0.39, 0.95] versus 0.96 [0.74, 1.26] for ischemic stroke).

Conclusions:
Our data suggests that leptin may exert protective effects against first ever stroke in obese individuals. Further investigations are required to confirm these findings and explore possible mechanisms for this protective effect.
Abstract W P172: Baseline Quality of Life and Risk of Stroke in the Antihypertensive and Lipid Lowering to Prevent Heart Attack (ALLHAT) Trial
Authors: Shams Tanzila , Auchus Alexander P , Oparil Suzanne , Wright Clinton , Wright Jackson , Furlan Anthony J , Sila Cathy A , Davis Barry , Pressel Sara , Yamal Jose-Miguel , Einhorn Paula , Cutler Jeff , Lerner Alan J
Published: March 2022

Background:
Quality of Life (QoL) is an integrative health status measure that may predict medical outcomes. No prospective study assessed relationship between QoL, subsequent stroke risk, and post-stroke outcome.

Objective:
Determine how baseline QoL predicted non-fatal stroke, as well as the impact of stroke risk factors on QoL in ALLHAT using visual analogue scale (VAS) – a validated QoL tool.

Methods:
ALLHAT randomized hypertensive patients to Chlorthalidone (C), Amlodipine (A) or Lisinopril (L), and used VAS to measure global QoL (0.00 -1.00) at baseline, 2, 4, and 6 yrs. QoL values underwent statistical Torrance transformation (TQoL). Mean QoL and TQoL pre (baseline) and post non-fatal stroke were analyzed. Hazard ratios (HR) and Kaplan-Meier curves for each quartile of baseline QoL were calculated. Baseline QOL, TQoL, and stroke risk factors were used in a multiple linear regression model to predict post-stroke QoL. QoL changes were examined by study arm, age, gender, and race.

Results:
28,534 (86%) participants completed at least one VAS. Of the 1,517 strokes; 22% (n=322) were fatal. QoL and TQoL results were similar. Patients who experienced in-trial stroke in C and A arms had lower baseline QoL than those who did not (HR =.71 vs .74, p<0.001and .71 vs .74, p=0.004, respectively), but not in L (HR=.73 vs .74, p=0.24). A 10% increment in baseline QoL or TQoL was associated with 5% and 7% reduction in the risk of stroke respectively (adjusted HR; 95% CI = .95; .91 -.99) and .93; .89 –.98). In risk factor adjusted models, lowest baseline QoL quartile had a 20% higher stroke risk (HR =1.20; 95% CI: 1.00-1.44) than highest quartile. QoL worsened post stroke, dropping most in elderly >75 yrs (-.08 units, p<0.0001), compared to groups 55-64 (-.04, p<0.05) and 65-75 yrs, (-.07, p <0.0001), and in A arm (-.09 units, p<0.0001) compared with C (-.05, p=0.0006) and L (-.07, p< 0.0001), but did not differ by gender or race. In a multiple linear regression model, baseline QoL predicted post-stroke QoL.

Conclusions:
Lower baseline QoL was associated with higher stroke risk. Qol was lower post stroke. Baseline QoL was the only factor predicting post stroke QoL, and QoL change increased with age. Investigation of factors determining QoL may be fertile ground for stroke risk reduction.
Abstract W P174: Risk of Intracranial Hemorrhage after Acute Ischemic Stroke in Patients with Systemic Rheumatologic Conditions: A Nationwide Analysis
Authors: Mehta Tapan , Sheth Khushboo , Soni Ronak , Mehta Kathan
Published: March 2022

Introduction:
Rheumatologic conditions like Systemic Lupus Erythematosus (SLE), Antiphospholipid antibody (ApL) syndrome, Rheumatoid Arthritis (RA) and scleroderma are known risk factors of CVA. The data on impact of these conditions on risk of intracranial hemorrhage (ICH) in patients of acute ischemic stroke is limited.

Methods:
We queried the Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample (NIS) data between 2004 and 2010 with ICD 9 diagnostic codes for acute ischemic stroke published by HCUP. Severity of co-morbidities was determined using Deyo modification of Charlson co-morbidity index (CCI). Primary outcome of the study was development of ICH. Multivariate predictors for ICH were identified by logistic regression model. Using SAS 9.2, Survey procedures were used to accommodate for hierarchical two stage cluster design of NIS.

Results:
A total of 791,015 (weighted N= 3,900,707) patients hospitalized with acute ischemic stroke were available for analysis. After controlling for confounders (thrombolytic therapy, age, sex, atrial fibrillation, chronic kidney disease, diabetes mellitus, rheumatic heart disease, diseases of endocardium, CCI, hospital region, and hospital teaching status ), presence of SLE (OR=0.775, 95% CI=0.575-1.044), and scleroderma (OR=1.060, 95% CI= 0.545-2.063) were not associated with risk of ICH; whereas, presence of ApL syndrome was associated with significantly increased risk of ICH (OR= 1.889, 95% CI=1.672-2.156). In subgroup analysis, patients with ApL syndrome, had higher risk of ICH with thrombolytics (OR=2.464, 95% CI=1.722-3.528), as well as without thrombolytics (OR=1.860, 95%CI= 1.626-2.127). In contrast, patients with RA had lower risk (OR=0.793, 95%CI=0.658-0.955) of ICH; but in patients who received thrombolytics, RA had no impact on risk of ICH (OR=0.716, 95%CI=0.086-5.923).

Conclusion:
There is increased risk of ICH after ischemic stroke, in patients with ApL Syndrome. The risk of ICH further increases when they receive thrombolytic therapy. The risk of ICH after ischemic stroke is low in RA population; however there is no difference in risk of ICH if they receive thrombolytics. SLE and scleroderma are not associated with ICH in patients of ischemic stroke.
Abstract W P178: Temporal Trends of Emergency Department Arrival Times after Acute Ischemic Stroke: a Population-Based Study
Authors: Katz Brian S , Khoury Jane , Alwell Kathleen , Moomaw Charles J , Kissela Brett M , Flaherty Matthew L , Woo Daniel , Adeoye Opeolu , Khatri Pooja , Ferioli Simona , Mackey Jason , Martini Sharyl , De Los Rios la Rosa Felipe , Kleindorfer Dawn
Published: March 2022

Introduction:
The largest exclusion criterion for thrombolysis in ischemic stroke (IS) continues to be delayed time of presentation to the ED. We hypothesized that public education regarding IS would lead to improved ED arrival times over two decades within our large biracial population.

Methods:
We identified all IS patients > 20 years old that presented to an ED by screening ICD-9 codes 430-436 among residents of the Greater Cincinnati/Northern Kentucky Stroke Study region, a biracial population of ~ 1.3 million. Study periods were 7/1/93-6/30/94 and calendar years of 1999, 2005, and 2010. Study nurses abstracted relevant information from the medical record, including symptom onset and ED arrival times, and all potential cases were physician reviewed.

Results:
There were 1,749 total IS in 1993/94; 1,959 in 1999; 1830 in 2005; and 1912 in 2010. See Figure that displays the distribution of IS patients with known symptom onset time progressively arriving later in each study period. Arrival times stratified by race and gender showed whites arriving later in 2010 than prior study periods (p=0.02). Similarly, males arrived later in more recent periods (p=0.04). Mild IS (NIHSS <5) were less likely to arrive within 3 hrs p <0.001). Additionally, the percentage of mild IS within our population increased over time (55.8% in 1993/94 vs 62.9% in 2010, p<0.0001). After accounting for the increase in mild IS over time, temporal trends in overall arrival times were no longer significant.

Discussion:
We found that IS patients arrived at progressively later times from 1993/4-2010, and this was driven by an increasing proportion of mild IS patients. It is unknown if this increase in prevalence of mild IS patients is due to improved public awareness of mild stroke symptoms, better detection with MRI, or better management of comorbities. More research is needed to determine the reasons for delayed arrival to medical attention, since time from onset dominates the exclusion of patients from rt-PA.
Abstract W P18: Evaluating Clot Burden and the Vascular Basis of Pial Collaterals with a Bimodal Angiographic Score
Authors: Gerber Johannes , Kuhn Matthias , Petrova Marketa , Puetz Volker , von Kummer Ruediger
Published: March 2022

Treatment decision for endovascular recanalization in acute ischemic stroke is based on validated outcome predictors such as age, initial infarct size, collaterals and clot burden. The CTA-based Clot Burden Score (CBS) only considers occlusions of the A1-segment of the anterior cerebral artery (ACA), but patency of the ipsilateral A2-segment is mandatory for collateral formation in a typical middle cerebral artery (MCA) occlusion. Secondly, CTA often cannot differentiate between an extra- or intra-cranial internal carotid artery (ICA) occlusion due to non-contrasting of the whole ICA in both. Thirdly, a 4-vessel angiogram, necessary to grasp the vascular basis of all pial collaterals, is often not done during acute recanalization therapy for reasons of time. To bypass these inadequacies, we propose a combined CTA/DSA score (ALITA) to assess pre-therapeutic thrombus load. We hypothesized a good outcome prediction of this score. We evaluated the ALITA score in a retrospective study including consecutive patients of the years 2010-12, who received endovascular therapy for acute stroke in the ICA-territory. Final outcome was measured with the modified Rankin Scale score (mRS) at 90 days. Reperfusion (mTICI), collaterals (CT-CS), clot burden (CBS), and the ALITA score were independently assessed. ALITA evaluates patency of the ACA and MCA in CTA and of the ICA in DSA. Data-driven ordinal regression analysis modeled outcome prediction of all scores. Of 99 patients 60% had a good reperfusion (mTICI 2b/3) and 29% had a good outcome (mRS 0-2), mortality was 23%. Age and reperfusion were independent predictors of good outcome (p<.001). CT-CS (p<.01), CBS (p<.01) and ALITA (p<.05) were significant predictors, but showed interaction regarding outcome. In the considered model CBS was a stronger predictor than ALITA. Although ALITA assesses all vessels of the anterior circulation contributing to collaterals the score was statistically different from CT-CS. This is consistent with results that describe pial collaterals as genetically determined. In conclusion, the combined CTA/DSA clot burden score better depicts the vascular basis of pial collaterals and predicts outcome in acute stroke patients.
Abstract W P182: Left Atrial Volume as a Clinical Predictor for Atrial Fibrillation Detection in Cryptogenic Stroke: A Retrospective Analysis
Authors: Martinez Raisa C , Paoli Albit , Iwuchukwu Ifeanyi
Published: March 2022

Background:
Detection of paroxysmal atrial fibrillation (PAF) after cryptogenic stroke has a major impact on secondary stroke prevention. Identifying clinical predictors to obtain a higher detection rate is necessary. There is an unclear association between left atrial enlargement (LAE) and PAF. Our goal was to determine the yield of 30-day Holter monitoring in patients with left atrial enlargement following acute ischemic stroke.

Methods:
We retrospectively identified patients with acute ischemic stroke from November 2012 to June 2014 who had an echocardiogram done and a 30-day holter monitor on discharge. Demographics, medical history, clinical/laboratory data, echocardiographic features and holter monitor detected events were collected. Moderate to severe LAE was defined as left atrial volume index (LAVI) >35 cc/m2 on trans-thoracic echocardiogram. Patients were divided into two groups based on LAVI >35 cc/m2; thirty day holter monitoring results were retrieved in each group. Along with paroxysmal atrial fibrillation, detection of other supraventricular arrhythmias associated with subsequent development of PAF (i.e., supraventricular tachycardia (SVT) and atrial ectopy) was compared between the groups. Categorical variables were analyzed with Fischer’s exact test and continuous variables using independent sample T-test.

Results:
136 patients met our inclusion criteria, of which 76 (55.9%) completed 30 days of monitoring. Moderate to severe LAE was identified in 30 of 76 patients (39.5%). PAF was detected in 4 patients (5.3%). However, PAF was more likely in patients with LAE (13.3% vs 0%, p= 0.21). Detection of any PAF, SVT and atrial ectopy was more likely in patients with LAE (30% vs 6.5%, p= 0.009). Demographics, medical history, clinical and laboratory variables did not differ between patients with and without LAE.

Conclusions:
In our cohort, the presence of LAE increased the yield of PAF on 30-day holter monitoring. Supraventricular arrhythmias historically associated with subsequent development of atrial fibrillation were more likely in ischemic stroke patients with LAE.
Abstract W P187: Pathological Differences of Ischemic Stroke Caused by Cholesterol versus Clot Embolization
Authors: Yang Shu , Dong Honglin , Yao Luyu , Gu Xin , Zhao Cynthia , Zhang Wayne
Published: March 2022

Objectives:
The nature and shapes of cholesterol and blood emboli are significantly different. The objective of this study was to investigate if any significant pathological differences between the embolic ischemic strokes resulted from cholesterol versus blood clot embolization.
Methods:
Embolic stroke model was created using Sprague-Dawley rats. They were randomly divided into three groups: control, cholesterol emboli, and blood clot emboli groups. After written consents were obtained, we collected cholesterol plaque specimens and blood samples from the patients who underwent carotid endarterectomy. Plaques were rinsed and heated at 100
o
C for 60 minutes to denature protein in the plaques and minimize immunoreaction in animal models. Plaques and blood clots were broken into 0.30 - 0.35 mm and diluted into a final concentration of 1,000 fragments per 100 μL. Normal saline, the suspensions of cholesterol emboli and blood clot emboli (300μL) were separately injected into rat brains through the left internal carotid artery, based on different groups. Rats were sacrificed at 3, 6 and 24 hours post injection and brain ischemia was assessed using pathological H/E staining.
Results:
Shrunken eosinophilic changes, which are the characteristics of moderate hypoxia/ischemia injury, were identified in hippocampus in both cholesterol and blood clot embolic groups. However, the severe neuron damage with cell necrosis was only visualized in the cholesterol embolic group at 24 hours (Figure 1)
Conclusions:
The findings suggest that cholesterol and blood clot embolization may result in different degrees of damage in brain tissue. It may affect the treatment choice and the outcome of embolic strokes.
Abstract W P189: Cryptogenic Strokes and Second Ischemic Stroke Rates in Relation to the CHADS
2
and CHA
2
DS
2
-VASc Risk Scores
Authors: Hunter Tina D , Lip Gregory Y , Quiroz Maria E , Mollenkopf Sarah A , Turakhia Mintu P
Published: March 2022

Objective:
A significant proportion of cryptogenic strokes may be due to undetected atrial fibrillation (AF) and this may be associated with an increased risk of stroke recurrence. Our goal was to determine the rate of AF detection and recurrent strokes in a large cohort of US patients with a probable diagnosis of cryptogenic stroke.

Methods:
Patients with a first diagnosis of stroke or TIA between 01/2008 and 12/2011 were extracted from the Truven Health MarketScan® Commercial and Medicare Supplemental Databases. Patients were included if they had data available ±12 mo. around the index event. The stroke/TIA events, including “probable cryptogenic” status, along with CHADS
2
and CHA
2
DS
2
-VASc risk scores, were derived from diagnosis codes, procedure codes, and prescription drug usage. The 12-mo. incidence of new AF diagnoses, new oral anticoagulation (OAC) prescriptions, and recurrent stroke, stratified by risk scores, were determined in patients with cryptogenic stroke and non-cryptogenic stroke.

Results:
A total of 174,318 stroke/TIA patients were included, of whom 120,246 were likely to have cryptogenic diagnoses (age 64.5±15.6 years, 55.9% female). Due to the definition of cryptogenic stroke utilized, none of the patients had a diagnosis of AF or a prescription for OAC within the 12 months prior to their index stroke. Within 12 months after their index stroke, 4.1% had a new AF diagnosis and 4.4% had a new OAC prescription. The rate of recurrent stroke in the year after the index stroke was 31.7% (range: 27.4% to 36.2% and 27.7% to 38.5% with increasing CHADS
2
and CHA
2
DS
2
-VASc scores, respectively). Of the recurrent strokes, 86.5% occurred less than 6 months after the index event.

Conclusion:
One-third of all surviving cryptogenic stroke patients experienced second strokes in the year following their first stroke. Given the low rate of newly diagnosed AF, this suggests that undiagnosed AF may be an important contributor to the high recurrent stroke rate. Further study is required to determine if more rigorous post-stroke arrhythmia monitoring can lead to increased AF detection and OAC utilization, thus resulting in a reduction in recurrent stroke.
Abstract W P196: Utility of Echocardiography in the Evaluation of Transient Ischemic Attack Patients
Authors: Harmouche Elie , Ross Michael , Hockenberry Jason , Dharia Robin , Greene James , MacDonald Paul , Nahab Fadi
Published: March 2022

Background:
Current guidelines recommend that patients presenting with transient ischemic attack (TIA) undergo echocardiography to evaluate for a cardiac source. The aim of this study was to determine the utility of transthoracic echocardiography (TTE) in TIA patients evaluated as part of an emergency department observation unit (EDOU) protocol.

Methods:
Prospectively identified TIA patients presenting to the Emory University Hospital EDOU from January 1, 2011 to July 31, 2013 were eligible for this analysis if they had a final discharge diagnosis of TIA. Baseline patient characteristics, diagnostic test results, and clinical outcome at 3 months were retrospectively collected. An abnormal TTE was defined as an ejection fraction (EF) ≤ 45%, significant regional wall motion (RWM) abnormality, significant diastolic dysfunction (DD), valvular mass, presence of clot, or positive bubble study.

Results:
Of 236 patients discharged with a diagnosis of TIA during the study period, mean age was 62 ±15 years, 68% were female, 57% were African American, 17% had a history of prior stroke, 27% had history of cardiac disease, and mean ABCD2 score was 3.8 ±1.5. Overall, 19 (8%) patients had an abnormal bedside cardiac exam, 44 (19%) patients had an abnormal ECG, and 51 (22%) patients had an abnormal TTE including 18 with EF ≤ 45%, 6 with significant RWM abnormality, 9 with significant DD, 2 with clot, and 32 with positive bubble study; no valvular masses were seen. At 3 months, there was no significant difference in outcomes among patients with and without abnormalities on TTE (stroke 1.5% vs 1.8%, p=1.0; myocardial infarction 0 vs 1.2%, p=1.0). Among the 125 patients with no history of stroke or coronary artery disease and normal cardiac exam and ECG, TTE identified 5 (4%) patients with EF ≤ 45%, 17 (14%) patients with positive bubble study and no patients with significant RWM abnormalities, diastolic dysfunction, valvular mass, or clot; at 3 months, 2 (1.6%) of these patients had a stroke and no patients had a myocardial infarction.

Conclusion:
Among TIA patients with no history of stroke or coronary artery disease, normal cardiac exam, and normal ECG, TTE has a low yield.
Abstract W P197: Temporal Association between Infective Endocarditis and Stroke
Authors: Merkler Alexander E , Chu Stacy , Lerario Michael P , Navi Babak B , Kamel Hooman
Published: March 2022

Introduction:
Stroke is a frequent complication of infective endocarditis (IE). However, there is uncertainty regarding the temporal association between IE and stroke.

Methods:
Using claims data from nonfederal acute care hospitals in California, we identified patients hospitalized for IE between July 1, 2007 and June 30, 2011. We used validated diagnosis codes to identify a primary composite outcome of ischemic or hemorrhagic stroke during discrete 1-month periods in the 6 months before and 6 months after the diagnosis of IE. We then compared the likelihood of stroke in these 1-month periods to the corresponding 1-month periods 2 years prior, which was considered each patient’s baseline risk of stroke. In a secondary analysis, ischemic and hemorrhagic stroke were evaluated separately. Absolute risks and odds ratios (ORs) were calculated using a Mantel-Haenszel estimator for matched data.

Results:
Among 17,926 patients with IE, 2,275 strokes occurred within the 12-month period surrounding the diagnosis of IE, compared to 174 strokes during the corresponding period 2 years prior. The risk of stroke was the highest in the one month after diagnosis of IE as compared to the 1-month period 2 years prior (1640 versus 17 strokes). This equaled an absolute risk increase of 9.1% (95% CI 8.6-9.5) and an odds ratio of 96.5 (95% CI 59.6-155.6). Stroke risk was significantly increased from 4 months before to 5 months after the diagnosis of IE. Similarly, there was an increase in ischemic stroke risk from 4 months before to 3 months after IE, and an increase in hemorrhagic stroke risk from 4 months before to 5 months after IE. In all analyses, the increase in risk was highest in the 1 month after IE diagnosis.

Conclusions:
Patients with IE have a dramatically increased risk of ischemic and hemorrhagic stroke. The risk of stroke was highest in the one month after IE diagnosis and persisted for several months afterward. Furthermore, stroke risk was elevated beginning 4 months prior to the diagnosis of IE, which may reflect risk factors that can lead to both stroke and IE (e.g., heart valve surgery) or post-stroke factors that may predispose to IE (e.g., post-stroke immunosuppression or use of central venous catheters after stroke).
Abstract W P202: Comparison of Stroke in India versus USA: The Indo-US Stroke Project
Authors: Singhal Aneesh B , Schwamm Lee H , PN Sylaja , Khurana Dheeraj , Kaul Subhash , Padma MV , Arora Deepti , Thankachan Tijy , Ayres Alison , Mills Brittany , Kaur Paramdeep , Pandian Jeyaraj D
Published: March 2022

BACKGROUND:
There is little knowledge about differences in ischemic stroke risk factors, mechanisms, and outcomes between geographically diverse countries such as India and USA.

METHODS:
The Indo-US Stroke Registry/Infrastructure Development Project, jointly funded by NINDS and Indian Dept of Biotechnology, has 5 Indian centers (AIIMS Delhi; PGI Chandigarh; CMC Ludhiana; Nizam’s Hyderabad; SCTMS Kerala) and one in Boston, USA. Trained MDs and research coordinators prospectively collect data on consecutive adult patients with imaging-confirmed ischemic stroke <2wks after onset. Data is entered into a central web-based electronic database. We compared stroke demographics, risk factors, mechanisms, and outcome between the 5 Indian centers (1944 patients, Nov-2012 to July-2014) and the US center (2167 patients, Jan-2007 to Mar-2011).

RESULTS:
As compared to patients in India, patients in Boston, USA were older (69±15y vs 58.5±15y, p<0.001); more women (47% vs. 33%, p<0.001), and had lower admission NIHSS scores (median, IQR: 4 (2-12) v. 10 (5-15); p<001). Risk factors and stroke mechanisms, showed impressive differences (Table). The Indian patients had higher in-hospital complications (pneumonia, 13% vs. 6%, p<0.001; UTI, 10% vs. 8.5%, p=0.1), and worse 90-day outcomes (mRS score 0-3, 50% vs. 57%, p=0.001).

CONCLUSION:
These data provide insights into the differences in stroke between India and USA. Our results have implications concerning the limited generalizability of the results of stroke prevention trials, and suggest opportunities to reduce stroke burden in both countries.
Abstract W P204: Diagnostic Ability of a Novel Probe Attached to the Cervix for the Detection of Right-to-left Shunt Is Similar to Transesophageal Echocardiography
Authors: Mitsumura Hidetaka , Arai Ayumi , Komatsu Teppei , Sakuta Kenichi , Terasawa Yuka , Kubota Jun , Iguchi Yasuyuki
Published: March 2022

Introduction:
Although transcranial Doppler (TCD) plays an important role of detecting right-to-left shunt (RLS) in order to diagnose patients as a paradoxical brain embolism, insufficient temporal bone window interrupts the precise examination. So, we developed the novel probe (PSUP) attached to the cervix for the detection of RLS. Our hypothesis is that diagnostic accuracy of RLS by PSUP is comparable to those of transesophageal echocardiography (TEE) as a gold standard. .

Methods:
Subjects were patients with ischemic stroke and transient ischemic attack who underwent TEE. PSUP was a 2.0-MHz center frequency and had an equal property with TCD transducer. The shape was thin, soft, and square modified for adequate attachment to the neck. At first, we performed TEE with the echoscope at the level of the fossa ovalis after injection of saline agitated with air in the right antecubital vein. The procedure was performed with and without Valsalva maneuver. Visualization of microembolic signals (MES) induced contrast agent within the right atrium and crossing the interatrial septum was considered positive for RLS. Then, monitoring using PSUP was performed at unilateral common carotid artery (CCA) using similar preparation and procedure to TEE. RLS by PSUP was diagnosed as having 1and more MES in CCA. After compared RLS detectable rate between TEE and PSUP, accuracy parameters for RLS detection of PSUP against TEE were calculated.

Results:
From May to August 2014, 21 patients were included in this study. RLS was 5 (24%) of 21 on TEE, and 5 (24%) on PSUP, respectively (table). As a reference of TEE findings, diagnostic power of PSUP was 84% of sensitivity, 94% of specificity, 84% of positive predictive value, 94% of negative predictive value, and 91% of accuracy.

Conclusion:
RLS detection by PSUP is substantially correct. PSUP may be useful for patients with insufficient temporal bone window, such as elder Asian women.
Abstract W P210: Stroke Alert Notification by Emergency Department or Emergency Medical Service Which One Shortened Door to Needle Time?
Authors: Dong Yi , Nair Deepak. S , Sarah Parker , Jan Jahnel L , Swanson-devlin Teresa G , Beck Judith M , Mathews Maureen , Mcneil Clayton J , Dong Qiang , Wang David Z
Published: March 2022

Background and Aim:
Timely evaluation of patient with acute ischeamic stroke and administering tPA is the first step to ensure a good outcome. Emergency Medicine Service (EMS) prenotification and Emergency Department (ED) triage were two pathways to notify stroke team. However, which one faster is unclear.

Method:
We retrospectively reviewed the medical records of all patients who received IV tPA at our institution from 2007 to 2013. Clinical features at baseline and clinical quality measurements were recorded. Patients were classified into two groups, EMS prenotification group and ED triage group. Primary outcome was to compare the accuracy in stroke diagnosis between two groups. Secondary outcome was to explore the difference between the two processes on achieving clinical quality measurements.

Result:
During 2007 to 2013, stroke team was activated 1244 times by either EMS or ED for suspected stroke patient. Among them, 845 patients (70.3%) had a final diagnosis of stroke. More patients were ruled out of stroke in the ED group (34.2% vs 29.0%, p=0.039). After stroke team consultation, 288 patients receiving tPA. EMS prenotification significantly shorten the time of onset to treatment (OTT), door to needle (DTN) and OTST(onset to stroke team) in logistic regression analysis.

Conclusion:
EMS prenotification had less misdiagnosis of stroke than the stroke alert from ED. Moreover, EMS shortened the tPA treatment time significantly compared to ED notification. Our study confirmed that EMS was a more effective and accurate way to prenotify stroke team of patient with acute stroke than the ED.
Abstract W P213: ,,Door-to-needle-,, Or ,,Onset-to-treatment-time”? What Is The Key Marker To Assess Telestroke Care?
Authors: Zerna Charlotte , Kepplinger Jessica , Barlinn Kristian , Pallesen Lars-Peder , Siepmann Timo , Puetz Volker , Reichmann Heinz , von Kummer Ruediger , Bodechtel Ulf
Published: March 2022

Background:
Telestroke networks apply specialized stroke care in rural areas. A short “onset-to-treatment-time” (OTT) reduces the risk of disability and death after thrombolysis. To minimize OTT the “door-to-needle-time” (DNT) should be less than 60 minutes. However, this is not achieved in many telestroke networks. We postulate that telestroke networks can accomplish adequate OTT′s despite of extended DNT′s.

Methods:
We retrospectively analyzed data of consecutive stroke patients treated with thrombolytics within the Stroke-East-Saxony-Network (SOS-NET) from 07/2007 to 07/2012. Time of symptom onset, hospital admission, CT scan, teleconsultation and thrombolysis were derived from in-patient records. DTN and OTT time were calculated. We report median values and interquartile range (IQR) as well as symptomatic intracranial hemorrhage (sICH) by ECASS-2-criteria.

Results:
1659 patients of 3172 teleconsultations had an acute ischemic stroke. Thrombolysis was recommended in 688 and performed in 657 patients. Complete data were available for 368 patients (median age 77 [IQR) 12] years, NIHSS score 12 [IQR 10]). Twenty-three patients (6.3%) suffered sICH. Time from symptom onset to hospital admission was 63 minutes (IQR 47) and hospital admission to CT scan 16 minutes (IQR 15). The teleconsultation took 20 minutes (IQR 13) and time from teleconsultation to treatment was 40 minutes (IQR 22). DNT was 70 (IQR 33), OTT 143 minutes (IQR 72).

Discussion:
Compared to a primary stroke center DNT was longer in the SOS-NET (70 minutes [IQR 33] vs. 20 minutes [IQR 18]) which could be explained with less expertise of the affiliated hospitals and duration of teleconsultation. However, OTT was 143 minutes [IQR 72] and not different to OTT in this single center (120 [IQR 90]) or in a large regional registry (144 minutes [IQR 115-170]), respectively. This is probably because telestroke care prevents transportation of patients.

Conclusion:
OTT is more important in the assessment of stroke care in rural areas than DNT alone. Telestroke care can implement adequate OTT despite delayed DNT. Nevertheless, DNT still got room for improvement.
Abstract W P232: High Sodium Diet Did Not Increase Peripheral Blood Pressure in a Transgenic Mouse Model of Alzheimer's Disease
Authors: Taheri Saeid
Published: March 2022

Introduction:
The impairment of Ca2+ homeostasis has been connected to the deleterious effect of abnormal beta-amyloid (Ab) on the calcium sensing receptors (CaSR) in Alzheimer’s disease (AD). Elevated extracellular Ca2+ can also induce relaxation of arteries and prevent the development of hypertension. Change in ionic strength reduces the effect of CaSR agonists, such as Ab, and regulates Ca2+ homeostasis. Na+ gradient also increase ionic strength and may regulate Ca2+ homeostasis through CaSR and Na+/Ca2+ antiporter exchange to affect blood pressure. In non-pathological conditions, the elevation of Na+ gradient through high-sodium diet is considered as a reason for imbalance of Na+/Ca2+, and one of the several causes of hypertension and cardiovascular complications. However, the effect of Na+ gradient on AD patients is unclear. The purpose of this study was to test the hypothesis that in AD the increase of Na+ gradient diminishes the Ab ability on activation of CaSR and does not induce the hypertension.

Method:
We examined the effect of Na+ load on the arterial blood pressure in double transgenic mice harboring Ab precursor protein (APPswe), and presenilin-1 (PSEN1) as mouse model of AD (10-20 weeks, 25-30g). Wild type littermates were used as controls. Four groups: Control + low sodium diet (n=6); Control + high sodium diet (n=12); APP + low sodium diet (n=12); APP + high sodium diet (n=12) were tested for both systolic arterial blood pressure (SAP) and diastolic arterial blood pressure (DAP). Mice were fed a low- (0.08% NaCl) or a high-sodium (4% NaCl) diet for 3 months. Heart rate and SAP and DAP were measured noninvasively using tail blood pressure measurement device after 3 months.

Results:
Compared with mice fed standard diet (0.08% NaCl), mice fed high sodium diet showed markedly elevated SAP and DAP (134±4.8 compared with 162±2.8 mmHg, and 114±5.0 compared with 137±20 mmHg) (p<0.0001). There was no significant difference in both SAP and DAP between APP mice fed standard (0.08% NaCl) and high-sodium (4% NaCl) diet. SAP and DAP in elevated Aβ mouse were not affected by high dietary levels of sodium.

Conclusion:
Data from this AD model suggest that APP transgenic mice is resistant to high sodium-induced increase in systolic and diastolic blood pressure.
Abstract W P233: FTY720 Preserves Arteriolar Vasodilating Function after Subarachnoid Hemorrhage
Authors: Testai Fernando D , Pelligrino Dale A , Reddy Amit B , Xu Hao-Liang
Published: March 2022

Background:
Inflammation is increasingly recognized as a key mediator of brain injury in subarachnoid hemorrhage (SAH). In this study we investigated the protective effect of the immunomodulatory agent, FTY720, on SAH.

Methods:
We utilized the endovascular perforation rat model of SAH. The animals were divided into three groups: (1) sham surgical control; (2) vehicle-treated SAH; and (3) FTY720-treated SAH. In group (2) and (3) rats received either vehicle solution or FTY720 (0.5 mg/kg) intraperitoneally 3h post-SAH. A close cranial window system was established at 48h post-SAH and intravital microscopy was used to assess (1) inflammation, which was represented by rhodamine-6G-labeled leukocyte trafficking in the pial venules, and (2) pial arteriolar dilating function to a variety of vasodilators including hypercapnia, acetylcholine (Ach), adenosine (ADA), and S-nitroso-N-acetyl penicillamine (SNAP). In addition, neurological function was evaluated at 48h using motor-sensory tests.

Results:
Compared to sham controls, the vehicle treated SAH animals had a 4-fold increase in pial venular leukocyte adhesion (2.90±0.6% vs. 14.4±2.7%; p<0.001). Treatment with FTY720 decreased leukocyte adhesion to 8.78±4.4% (p<0.05). Vehicle-treated SAH animals displayed a significant decrease in pial arteriolar responses to all the vasodilators tested and these were partially preserved in the presence of FTY720 (p<0.05; Table). In addition, neurological scores obtained at 48h post-SAH showed significant neurological deficits in the vehicle-treated group (10.8±2.1 vs. 20.5±0.4, vehicle vs. sham control) which was partially preserved by FTY720 (15.5±1.9; p<0.0001 compared to vehicle group).

Conclusions:
The use of FTY720 decreases the adhesion of leukocytes to pial vessels, preserves pial arteriolar FTY720 function, and improves the neurological outcome in rats subjected to SAH.