bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 132: Clot Radiomics Features From Ct Imaging Predict Treatment Outcomes From Stroke Thrombectomy
Authors: Patel Tatsat , Monteiro Andre , Waqas Muhammad , Siddiqui Adnan H , Tutino Vincent
Published: February 2023

Background:
Radiomics features (RFs) extracted from CT images have the potential to provide valuable biological and structural information about ischemic stroke blood clots, which may inform mechanical thrombectomy (MT) outcome.

Hypothesis:
We aimed to identify RFs that predict MT outcome and interpret these findings using paired histological data.

Methods:
We extracted 293 RFs from co-registered non-contrast CT (nCCT) and CT angiography (CTA) images. RFs predictive of revascularization outcome (defined by first pass effect [FPE], which is near complete removal of occlusive clot in one pass of MT) were selected. We then trained and cross-validated (5-fold) a balanced logistic regression model to assess the RFs’ ability in FPE prediction. In a subset of cases, we performed digital histology on clots retrieved during MT. We computed 227 engineered clot histomic features from whole slide histopathology that represented clot structure and texture.

Results:
Following univariate feature selection and multi-variate feature ranking, we identified 6 RFs significantly associated with FPE (Figure, top rows). Continuity in lower pixel intensities, scattered higher intensities, and intensities with abrupt changes in texture were associated with successful revascularization outcome. The multi-variate model trained using the 6 RFs could predict FPE well, with AUC=0.832±0.031 and accuracy=0.760±0.059 in training and AUC=0.787±0.115 and accuracy=0.787±0.127 in cross-validation. Each of the 6 RFs were related to clot component organization in terms of red blood cell (RBC) and fibrin/platelet (FP) distribution. Clots with more diversity of components and with varying sizes of RBC and FP regions in the clot section were positively associated with RFs predictive of FPE.

Conclusion:
Clot RFs are potential structurally- and biologically-interpretable candidate biomarkers for accurate FPE prediction.
Abstract 135: Adiponectin: Potential Mediator Between Central Obesity And Intracranial Atherosclerosis?
Authors: Logue Makenzie , McCain Caylee , Martin Chylee , Suri Fareed , Wasserman Bruce A , Gottesman Rebecca F , Rosamond Wayne D , Sen Souvik
Published: February 2023

Introduction:
Prior studies have identified a significant association between Waist-to-Hip Ratio (WHR) and intracranial atherosclerosis (ICAS). Adiponectin, a hormone that improves insulin sensitivity, has been hypothesized to have a protective effect against atherosclerosis. We assessed the association between central obesity-ICAS, and its potential mediation by Adiponectin.

Methods:
In the ARIC cohort a stratified subset of subjects were assessed for adiposity, adiponectin level and ICAS during visit 5 (2011-2013). Adiposity was assessed by body mass index (BMI) and waist to hip ratio (WHR). Central obesity was defined as WHR ≥0.90 for men and ≥0.85 for women. Plasma total and total adiponectin were measured by ELISA. ICAS was assessed for by 3D time-of-flight magnetic resonance angiogram (MRA). Subjects were stratified as those with any ICAS and those without. Multivariable analysis was conducted using multiple logistic regression to test the central obesity-ICAS association.

Results:
A total of 1641 subjects underwent evaluations (age 76.3±5.3, 41% Male, 71% white). Of these subjects 506 (31%) had ICAS detected on MRA. Those with ICAS were older (77±5 vs. 76±5, p<0.001), likely to be male (47% vs. 39%, p=0.001), African American (33% vs. 27%, p=0.006) and hypertensive (72% vs. 64%, p=0.004). Those with ICAS had similar BMI (28.5±5.7 vs. 28.1±5.3, p=0.26) although the WHR was higher (0.94±0.08 vs. 0.92±0.08, p<0.001). Adiponectin levels were lower (10.6±6.7 vs. 12.0±7.5, p<0.001) compared with those without ICAS. Those with central obesity had a lower level of Adiponectin (10.6±6.5 vs. 15.3±8.7, p<0.001). Central obesity was significantly (p=0.01) associated with ICAS (Odds Ratio 1.43, 95%) CI 1.08-1.91) adjusted for age, race, gender, and hypertension, however lost its significance (p=0.06) when Adiponectin is added to the model (Odds Ratio 1.33, 95% CI 0.99-1.80).

Conclusion:
We report a significant inverse association between central obesity, as well as ICAS, with Adiponectin levels. We also report a significant association between central obesity with ICAS that loses its significance after adding Adiponectin to the multivariate model. This result suggests that central obesity effect on ICAS may possibly be mediated by Adiponectin.
Abstract 137: Diaschisis Profiles In The Hemodynamic Response To Hemodynamic Stimuli: Implications For Cerebellar Normalization In Patients With Steno-occlusive Disease
Authors: Dogra Siddhant , Wang Xiuyuan , Gee James M , Gupta Alejandro , Veraart Jelle , Ishida Koto , Qiu Deqiang , Dehkharghani Seena
Published: February 2023

Introduction:
Cerebellar hemispheres are commonly used as global references for internal normalization in hemodynamic analysis, including cerebrovascular reactivity (CVR) experiments. We have reported blood oxygen level-dependent (BOLD) MRI coupled acetazolamide for CVR; however, the influence of crossed cerebellar diaschisis (CCD) is understudied in this setting. Importantly, poor signal-to-noise traditionally limits BOLD-CVR to estimation of arbitrary exam conclusions (CVR
end
). We developed a custom computational pipeline for dynamic CVR analysis, permitting unprecedented, dynamic
maximal
CVR (CVR
max
) estimates. We describe CCD in a population of patients with chronic unilateral steno-occlusive disease (uSOD) using CVR
max
.

Methods:
32 acetazolamide-challenge BOLD MRI exams in 23 patients with uSOD were examined using a custom denoising and preprocessing strategy for CVR time-signal analysis.

BOLD
pre

and

BOLD
post

were defined as the average of the respective first and last one-minute BOLD data. CVR
end
was calculated as %CVR=100*(

BOLD
post

–

BOLD
pre

)/

BOLD
pre

. CVR
max
was the maximal, denoised per-voxel value.

CVR
end
and CVR
max
maps were produced. Cerebellar hemispheres ipsilateral and contralateral to the diseased cerebral hemisphere were visually compared for CCD. Pearson correlations were calculated to study CVR
max
and CVR
end
in cerebral and cerebellar hemispheres.

Results:
CCD could be observed in CVR
end
and CVR
max
maps (Figure 1). Significant correlations were observed between healthy cerebral and contralateral cerebellar hemispheres (r=0.5992, p=0.0011 for CVR
max
, r=0.5034, p=0.0054 for CVR
end
). CVR
max
(r=0.4114, p=0.0215) but not CVR
end
(r=-0.085, p=0.6611) showed correlations between diseased cerebral and contralateral cerebellar hemispheres.

Conclusion:
We present novel CVR
max
estimation from dynamic BOLD-MRI, revealing CCD otherwise unrecognized by conventional BOLD-CVR.
Abstract 142: Higher Risk Of Stroke Recurrence In Elderly With Prediabetes: A Nationwide Analysis Of Over 200,000 Hospitalizations From 2016 To 2019
Authors: Desai Rupak , Meka Gautham Gosh , Ashfaque Mariam , Gowda Supreeth N , BRERETON Brian , Lavu Venkat Srikar , Chauhan Sukhjinder , Puli Srikanth , Samala Venkata Vikramaditya R , Rupareliya Chintan
Published: February 2023

Background:
Prediabetes (preDM) is known to double the risk of strokes and also predicts poor functional outcomes. With rising prevalence of preDM among the elderly population in the US, this study aimed to analyze the risk and trends in secondary stroke in elderly with preDM.

Methods:
We queried the National Inpatient Sample (2016-2019) to identify secondary stroke (with prior stroke/transient ischemic attack, TIA) hospitalizations in elderly population (≥65 years) with vs. without preDM by using ICD-10 codes after excluding patients with diabetes mellitus. Trends and risk of recurrent stroke events, demographics, comorbidities, and outcomes were compared between two cohorts (preDM+ vs. preDM-).

Results:
Overall prevalence of secondary stroke in geriatric preDM population for 2016-2019 was 2.01% (4045/201120, 50.8% female, 68.4% white) with preDM+ cohort often consisting of younger (median 77 vs 81yrs), male vs females (49.2% vs 44.8%), blacks (14.7% vs 10.7%), Hispanics (8.9% vs 5.4%), Asian/Pacific Islanders (7.2% vs 2.6%) (p<0.001). There were declining trends in recurrent any/ischemic strokes among overall/preDM- cohort but nondeclining in preDM+ cohort

Table 1a

. The preDM+ cohort often had higher rates of hypertension, hyperlipidemia, obstructive sleep apnea, obesity and peripheral vascular disease. Multivariate analysis adjusted for confounders showed higher odds of any stroke (aOR:1.74, 95%CI:1.58-1.92) and ischemic strokes (aOR:1.83, 95%CI:1.64-2.03) (p<0.001) in preDM+ cohort vs. preDM- cohort [Table 1b] with prior history of stroke/TIA. The rates of transfer to short term hospitals and home health care requirements were higher among preDM+ cohort (3.2% vs. 2.9% & 18.7% vs. 17%).

Conclusion:
The study shows an increased risk of recurrent/secondary strokes (mainly ischemic) among elderly patients with preDM. Findings emphasize the need for strategies to achieve tighter glycemic control to mitigate risk of future cerebrovascular events.
Abstract 146: Racial Disparities In The Treatment Of Post-stroke Complications Among Acute Stroke Patients
Authors: Simmonds Kent P , Atem Folefac , Welch Babu G , Ifejika Nneka L
Published: February 2023

Introduction:
Racial differences in the treatment of post-stroke sequelae may contribute to known disparities in post-stroke function. Our objective was to quantify the magnitude and timing of racial differences in the treatment of common stroke post-complications to better inform and modify clinical practice.

Methods:
Electronic medical record data from 65 large health care organizations (August 2002-July 2022) were used to identify a cohort of non-Hispanic White (NHW), Black and Hispanic hospitalized acute stroke patients. Baseline differences between populations were adjusted for using a matched propensity score which accounted for 41 demographic and clinical factors. Outcomes included the use of medication(s) for treatment of arousal, spasticity, mood, sleep, bladder incontinence and seizure. Differences were measured at 14-, 90-, and 365-days.

Results:
Prior to matching, the final cohort consisted of 428,155 patients of which n= 309,029 were NHW, n= 82,564 were black, and 28,375 were Hispanic. For the NHW-Black comparison 80,564 pairs were matched, whereas 28,375 pairs were matched for the NHW-Hispanic comparison. All baseline covariates were balanced after matching. Compared to NHW, black patients were significantly less likely to receive treatment for every condition at nearly every timepoint. The largest differences were present for the treatment of arousal (RR: 0.70, 95% CI: 0.66- 0.74), spasticity (RR: 0.73, 95% CI: 0.71-0.76), and mood (RR: 0.83 (0.82, 0.85) at 14-days. Differences for the NHW-Hispanic comparison were similar but with slightly smaller magnitudes.

Conclusions:
There are significant racial disparities in the treatment of common post-stroke sequelae. Differences were greatest at 14-days indicating the acute hospitalization and rehabilitation are crucial to identify and treat complications to reduce disparities in post-stroke function.
Abstract 154: Resource Considerations For Acute Ischemic Stroke Intervention In Nonagenarians
Authors: Gandhi Sani , Hollender Kimberly , Chukwuneke Florence , Cheng Roger
Published: February 2023

Background:
While there is evidence to support the viability of intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) as treatments for acute ischemic stroke (AIS) even in the very elderly, there are practical considerations to be made regarding triage and resource allocation, particularly in a hub-and-spoke system of stroke intervention.

Methods:
This is a retrospective review of the stroke registry (GWTG) quality data from 2017-2021 at a comprehensive stroke center serving as the primary hub for an associated health care system. We identified patients aged 90 or above who received acute stroke treatment with IVT and/or MT. NIHSS, modified Rankin Score (mRS), transfer status, length of stay (LOS), and discharge disposition were examined; Fisher exact, Wilcoxon Rank Sum, and T test were used for comparison as appropriate.

Results:
Out of 268 total nonagenarians admitted for AIS, 60 received an acute intervention (37 IVT, 14 MT, 9 both). All MT attempts resulted in successful reperfusion (>TICI 2b). Median initial and discharge mRS were 2 and 5 respectively; only 3.3% were discharged home, with 46.7% of patients either deceased or discharged to hospice. Median LOS was 5 days (range 0-77), but prolonged LOS was common, with 11 patients having LOS >14 days. Comparing the groups who received MT vs. IVT alone, median initial NIHSS was 17 vs. 15 (p=0.23); the MT group had better baseline mRS (1 vs 3, p=0.005), but despite this, there were no significant differences in mortality (56% vs 40%) or discharge mRS (5 vs. 5). Median LOS was not significantly different (6 vs. 5 days). Mortality in MT was 75% for transfers vs. 53% for local arrivals (p=0.36).

Conclusion:
Outcomes were poor overall in the nonagenarian population, with very high morbidity and mortality. In particular, MT did not appear to improve outcome over IVT alone despite patients having better initial functional status and successful reperfusion. Though blanket withholding of treatment from this population is not the correct (nor a viable) course, when considering transfers away from a “home” hospital for MT or deployment of intensive resources such as air transport, extra care should be taken such that families/surrogates have a realistic picture of expected outcomes for informed decision making.
Abstract 155: NORAHOME. A Virtual Multimodal Stroke Remote Monitoring Hospitalization Program
Authors: Muchada Marian , Rubiera Marta , Juega Jesús , PAGOLA JORGE , Olive-Gadea Marta , Garcia-Tornel Garcia Alvaro , boned sandra , Rodriguez Noelia , Lozano Prudencio , Rodriguez-Luna David , Montiel Estefania , Sanchez Ester , Ribo Marc , Molina Carlos A
Published: February 2023

Background and Aims:
The rising pressure on medical services, highlighted throughout the pandemic, has revealed a need for alternative methods of hospital care. Our objective is to evaluate a home hospitalization virtual multimodal monitoring program (NORAHOME) for patients who have had a previous transient ischemic attack (TIA) or minor stroke, as an efficient strategy compared to Routine Clinical Practice (RCP).

Methods:
A prospective cohort study of consecutive patients with a suspected TIA or minor stroke evaluated at the emergency room of a tertiary hospital by a neurologist between 1st December 2020 and 1st June 2022, had completed NORAHOME and was compared with a historic control group of patients with a suspected TIA or minor stroke who had completed a conventional hospitalization (RCP) between 1st June and 30th November 2020.

Results:
430 patient cases were analyzed, 215 patients in the prospective group were compared with a retrospective cohort of the same number of patients. Mean age 75.21 ± 12.6 years; 54.9% women. In the NORAHOME group we observed a recurrence rate of 2.3% (5 patients) and mortality of 2.8% (6 patients) during the follow up. In the RCP group 6.5% (14 patients) presented recurrence and 7% (15 patients) died. No significant differences were found in the risk of early recurrence, emergency room readmission or functional outcome between the groups.

Conclusions:
In our series of TIA and minor stroke patients, NORAHOME is a safe strategy compared to RCP. The development and implementation of digital home-hospitalization programs may reduce direct hospital costs by shortening length of stay and reducing hospital readmission. Moreover, the program improves self-assessed health outcomes reported by patients and their experience with the healthcare system compared to the RCP.
Abstract 158: An Evaluation Of Stroke Survivors' Self-efficacy In Self-management Using A Stroke Telehealth Service
Authors: Chau Janita Pak Chun , Lo Suzanne Hoi Shan , Lau Alexander Yuk Lun , Lee Vivian Wing Yan , Choi Kai Chow , Shum Edward Wai Ching , Hung Sheung Sheung , Mok Vincent C , Siow Kee Chen Elaine , Ching Jessica Yuet Ling , Lam Simon Kwun Yu
Published: February 2023

Background:
Previous studies indicate that stroke survivors encounter difficulties in participating in self-management programs because of lack of transportation to rehabilitation centres and unsuitable scheduling. A virtual multidisciplinary stroke care clinic (VMSCC) that builds on the advantages of self-management programs to promote survivors’ recovery and improve caregivers’ outcomes was developed.

Methods:
A VMSCC was set up to facilitate the interactions between the participants and the healthcare professionals. Participants received a device kit containing a tablet and a clinically validated wireless home blood pressure monitoring device. It was encouraged that survivors monitor their blood pressure daily to take an active role in managing their health. Registered nurses conducted Skype-based video calls with stroke survivors on issues relating to stroke self-management. A nurse reviewed blood pressure data before video calls and used online tools to reinforce self-management knowledge and skills during the video calls. A hotline for psychological and non-urgent health concerns was also maintained by the nurse in the call centre. To determine its effectiveness on stroke survivors' self-efficacy in self-management, a two-arm randomised controlled trial was conducted. We measured self-efficacy outcome using the Stroke Self-Efficacy Questionnaire at baseline (shortly before discharge) and 3 and 6 months after study initiation.

Results:
We recruited 274 participants from 10 Hong Kong's public hospitals. At 3 months (T1) and 6 months (T2), survivors in the control group demonstrated no significant difference in the change of self-efficacy with respect to T0 (baseline). The generalized estimating equations analysis showed a significant change and estimated additional improvement in self-efficacy in the intervention group at T2.

Discussion:
VMSCC's intervention was based on self-efficacy theory, which identified perceptions of personal capability as a significant variable associated with stroke outcomes. The development of a self-management program based on the self-efficacy theory was further supported by significant improvements in self-efficacy in the intervention group in this study.
Abstract 16: Retinoid X Receptors (RXR) Play Essential Roles In Improving Post-ischemic Stroke Recovery In Aged Brain By Restoring Age-associated Dysfunctions Of Microglia/macrophages
Authors: Ting Shun-Ming , Sun Guanghua , Obertas Lidiya , Aronowski Jaroslaw A
Published: February 2023

After stroke, microglia and blood macrophages (MΦ) clear dead cells and cellular debris in the infarcted brain through phagocytosis. However, the phagocytic capability of MΦ declines with age. Age-related dysfunctions in MΦ also include reduced secretion of trophic factors, resulting in poor recovery after stroke. Retinoid-X-receptor (RXR) is a pleiotropic transcription factor. Our earlier studies suggest that RXR enhances MΦ phagocytic functions and improves post-stroke recovery in young mice. To assess MΦ dysfunctions with age, microglia were FACS-sorted from the brains of young adults (2-4 mo old) and aged (18-20 mo old) mice for gene expression profiling with qPCR. RXR agonist bexarotene (BEX; 5 mg/kg) or vehicle were IP injected daily for 3d prior to harvest (n=3/group). We found that compared to young adults, aged microglia have reduced expression of trophic factors (
Vegf
) and scavenger receptors (
Cd206
and
Cd36
) and that BEX treatment restored this deficit. Also, in agreement with gene expression profiles, using erythrocytes as targets for phagocytosis, we showed that BEX enhanced the phagocytic ability of MΦ in aged brain. This suggests that RXR activations restore the age-associated dysfunctions in MΦ.To further investigate the role of MΦ RXR activations in recovery after stroke, aged (18-20 months old) myeloid-specific RXRα knockout mice (Mac-RXRα-KO) and littermate control (RXRα-LoxP) of both sexes were subject to 60 min MCA occlusion. To activate RXR, BEX (5 mg/kg) or vehicle control was IP injected 24h after stroke onset and then daily for 7d (n=22/group). Sensorimotor functions were assessed using foot-fault and corner turn tests (d3, 7, 14, 28). The cognitive functions were evaluated via novel object recognition test (d30). We found that BEX significantly improved sensorimotor and cognitive functions in RXRα-LoxP mice. The beneficial effect of BEX was diminished in Mac-RXRα-KO mice, suggesting RXR signaling in MΦ plays essential role in recovery after stroke. Brain histology and serological cytokine profiles will also be discussed. In conclusion, our data show that activating RXR restores age-related dysfunctions in MΦ. More importantly, RXR in MΦ may be a potential target to improve post-stroke recovery in aged brain.
Abstract 163: Cerebral Amyloid Deposition Predicts Long-term Cognitive Decline In Intracerebral Hemorrhage Survivors
Authors: Tsai Hsin-Hsi C , Tsai Ya-Chin , Liu Chia-Ju , Lin Sheng-Sian , Chuang Yu-Chen , Chen Ya-Fang , Jeng Jiann-Shing , Tsai Li-Kai , Yen Ruoh-Fang
Published: February 2023

Background:
To investigate the role of cerebral amyloid deposition for long-term cognitive outcomes in spontaneous intracerebral hemorrhage (ICH) survivors.

Methods:
Patients experiencing an ICH without over dementia were included (n = 68). Each patient received the brain MRI and Pittsburgh Compound B (PiB) PET at baseline, and the cognitive function was followed up using Mini-mental Status Examination (MMSE) and clinical dementia rating (CDR) with an overall median of 3.8 years. The association between follow-up cognitive outcomes and neuroimaging markers was explored using multivariable Cox regression models. Positive amyloid scan was defined as global PiB standardized uptake value ratio > 1.2.

Results:
Patients with PiB(+) were older (72.1 ± 7.8 vs. 59.9 ± 11.7,
p
= 0.002) and were more frequently associated with probable CAA (54.5% vs. 8.8%, p=0.001) than patients with PiB(-). PiB(+) was associated with a higher risk of dementia conversion (32.9 vs. 4.0 per 100-person-years, HR=16.4 [3.5-75.5],
p
<0.001) and cognitive decline (defined as MMSE decline≥ 2, 58.8 vs.9.9 per 100-person-years, HR=6.1 [2.0-18.8], p=0.002) compared to PiB(-). Higher lobar microbleed number and the presence of lacune were also associated with cognitive worsening (both p<0.005). In the cox models, PiB(+) was an independent predictor of dementia conversion (HR=12.3 [2.9-52.6], p=0.001) or cognitive decline (HR=7.9 [2.4-26.0], p=0.001) after adjustment for age, sex, educational years, lobar microbleeds and lacune. In the subgroup of patients who were non-CAA (n=57), PiB(+) remained an independent predictor of cognitive worsening (both p<0.005).

Conclusions:
We demonstrate the strong association between positive amyloid scan and long-term cognitive change in ICH survivors, suggesting cerebral amyloid deposition as an important driving factor for cognitive impairment in hemorrhagic small vessel disease.
Abstract 164: Cerebral Amyloid Angiopathy Is Associated With A Higher Risk Of Subdural Hemorrhage: Combined Analysis Of The Uk Biobank And All Of Us
Authors: Rivier Cyprien , Kamel Hooman , Sheth Kevin N , Iadecola Costantino , Gupta Ajay , de Leon Mony , Ross Margaret E , Falcone Guido J , Murthy Santosh
Published: February 2023

Background:
Cerebral amyloid angiopathy (CAA) is a condition characterized by amyloid deposition in the brain’s blood vessels. CAA is a common cause of spontaneous intracerebral hemorrhage (ICH) in older patients. Although other types of intracranial hemorrhages can occur in conjunction with CAA-related ICH, it is unknown whether CAA is a risk factor for other types of intracranial hemorrhage in the absence of ICH.

Hypothesis:
CAA is an independent risk factor for isolated non-traumatic subdural hemorrhage (SDH).

Methods:
We conducted a 2-stage (discovery and replication) observational study that retrospectively analyzed data from the UK Biobank (discovery phase) and the All of Us (replication phase) study. We included participants over 55 years of age to meet the age threshold for the modified Boston Criteria. The exposure was a diagnosis of CAA and the outcome was non-traumatic SDH, both identified using ICD-9 and ICD-10 codes. We used survival analyses with log-rank tests and multivariable Cox proportional hazards models adjusted for demographic characteristics and vascular risk factors.

Results:
The discovery phase included 283,452 UK Biobank participants comprising 123 CAA cases and 504 SDH cases. SDH subsequently occurred in 2.4% of participants with CAA versus 0.2% of those without CAA. In a multivariable Cox model, CAA was associated with a significantly increased risk of SDH (hazard ratio [HR], 7.3; 95% CI, 2.3-22.7). This finding was replicated among 168,370 study participants in All of US, where 66 had CAA and 443 had a SDH (HR, 11.66; 95% CI, 5.2-26.2).

Conclusion:
In two large heterogeneous cohorts conducted in different countries, CAA was independently associated with a higher risk of isolated non-traumatic SDH. Further research is needed to further determine causality and identify biological pathways that may mediate this association.
Abstract 166: Sex Differences In Perihematomal Edema Volume And Outcome After Intracerebral Hemorrhage
Authors: Witsch Jens , Luo Yunshi , Sloane Kelly L , Rothstein Aaron , Song Jae W , Favilla Christopher G , Cucchiara Brett L , Kasner Scott E , Messe Steven R , Choi Huimahn A , Mayer Stephan A , Cao Quy , Gusdon Aaron M
Published: February 2023

Introduction:
Hematoma volume predicts poor outcome after intracerebral hemorrhage (ICH), while outcome associations with perihematomal edema (PHE) remain controversial. Prior studies using non-standardized timing of serial CT imaging reported larger ICH and PHE volumes in men than women, but worse outcome in women. Leveraging data from a cohort with early admission and time-locked follow-up imaging, we investigated the role of sex on PHE and outcomes.

Methods:
We conducted a post hoc analysis of the randomized FAST (Factor VII for Acute-Hemorrhagic Stroke Treatment) trial. Participants underwent CT imaging within 3 hours of symptom onset, and at 24 and 72 hours. Lesion volumes were calculated using computerized planimetric techniques (AnalyzeDirect). Outcomes (modified Rankin Scale, mRS) were assessed at 90 days. Two-way repeated measures ANOVA tested whether changes in lesion volumes were driven by an interaction between sex and time. Multivariable logistic regression tested for associations between PHE and poor outcome (mRS 4-6).

Results:
Of 842 subjects, 781 with supratentorial ICH (mean age 65 years, 38% women) were included. Men (n=485) compared to women (n=296) had similar mean ICH and PHE volumes at baseline (p=0.063 and p=0.98) but larger ICH and PHE at 24 hours (p=0.002 and p=0.017) and 72 hours (p=0.002 and p=0.003). All volumes varied over CT time points according to sex (Figure 1 A-C, all three ANOVA: p<0.001). Unlike ICH, PHE expanded between 24 and 72 hours (men: 1.5 ml/h, women: 1.6 ml/h). There was no interaction between PHE changes and FAST-treatment-arm (p=0.85). PHE volume, but not sex, was associated with poor outcome at all CT time points (Figure 1D).

Conclusions:
Men had greater early lesion expansion than women. In both sexes, PHE expanded beyond 24 hours and was associated with poor outcome. While mechanisms explaining sex differences need further investigation, future ICH studies should be carefully adjusted for sex.
Abstract 30: Association Between Hospital-ascertained Atrial Fibrillation And Central Retinal Artery Occlusion: A Study Of 12 Million Patients
Authors: Lusk Jay B , Song Ailin , Unnithan Shakthi , Al-Khalidi Hussein R , Piccini Jonathan P , Xian Ying , O'Brien Emily C , Mac Grory Brian C
Published: February 2023

Introduction:
Atrial fibrillation (AF) is a major risk factor for cerebral ischemic stroke. However, it is not known whether AF predicts the development of central retinal artery occlusion (CRAO), a form of ischemic stroke affecting the retina.

Methods:
A retrospective cohort study was undertaken using data from the California Healthcare Cost and Utilization Project (HCUP) State Inpatient and State Emergency Department Datasets (SID/SEDDs). Patients 18 years and older discharged from non-federal hospitals between 2005 and 2011 who did not have a history of CRAO were analyzed. The exposure variable was AF and the endpoint was CRAO, each identified using validated ICD-9-CM diagnosis codes. Association between AF and CRAO was modeled using a Fine-Gray method with death as a competing risk with adjustment for age, biological sex, race, and vascular co-morbidities.

Results:
A total of 12,181,778 patients were included, among these 806,397 with AF and 11,375,381 without AF. In total, 309 patients had CRAO. In an unadjusted analysis, there was a higher risk of CRAO in patients with versus without AF (HR 2.24 (95% CI: 1.51 to 3.32)). After adjustment for pre-specified covariates, there appeared to be a lower hazard of CRAO in patients with AF (aHR 0.61 (95% CI: 0.45 to 0.98)). Further analyses including cerebral ischemic stroke (aHR 1.16 (95% CI: 1.14 to 1.18)) and specifically embolic stroke (aHR 4.29 (95% CI 4.10-4.48)) as positive controls argued against overadjustment bias. We present sensitivity analyses including CRAO identified in any position of the discharge ICD list, using different ascertainment windows for AF and using broader categories of retinal ischemia.

Conclusion:
The incidence of CRAO was higher in patients with AF than those without AF, but the hazard of CRAO was not higher for patients with AF after adjustment for measured covariates. Endpoint and exposure ascertainment may have been limited by inclusion only of inpatient and emergency department encounters.
Abstract 45: Geographic Distribution Of Social Service Resources For Stroke Survivors In Ohio Varies By Rurality
Authors: Wing Jeffrey J , Rajczyk Jenna I , Burke James F
Published: February 2023

Introduction:
The availability of social services resources and stroke prevalence vary by geography. We assessed whether distributions of resources relevant to stroke survivors were clustered around areas of highest stroke prevalence in Ohio and if this varied by rurality.

Methods:
Census tract (CT) level self-reported stroke prevalence estimates (CDC PLACES-2019 Behavioral Risk Factor Surveillance System) was linked with sociodemographic and rurality data (2019 American Community Survey) and geographic density of resources in Ohio (2020 findhelp—search engine connecting individuals to a network of area social services). Resources were grouped into categories: housing, in-home, financial, transportation, education, and therapy. Negative binomial regression models estimated mean number of resources within 25 miles of a CT centroid and quartiles of stroke prevalence for each resource group and stratified by rurality status (rural, urban, and suburban). Models were sequentially adjusted for total population and CT level demographics.

Results:
The highest stroke prevalence quartile was associated with fewer resources within 25 miles compared to the lowest quartile overall (Prevalence Ratios (PR): 0.57-0.98), but this varied by rurality with the most pronounced disparity in rural CT (
p
<0.05 for all resource categories). Rural CTs with the highest quartile stroke prevalence had fewer housing PR: 0.49 (95% CI: 0.32, 0.75), in-home PR: 0.31 (0.20, 0.49), and therapy PR: 0.23 (0.13, 0.43) resources compared to those with the lowest quartile stroke prevalence. Rural disparities became null after adjustment for federal poverty limit (FPL), supporting FPL as a mediator of this association.

Conclusions:
The inverse link between stroke prevalence and resource availability in rural Ohio is likely explained by geographic differences in poverty. Stroke-specific resource-related interventions are likely needed and should consider the role poverty.
Abstract 49: Association Of Intravenous Thrombolysis And Pre-interventional Reperfusion: A Post-hoc Analysis Of The Swift Direct Trial
Authors: Mujanovic Adnan , EKER Omer , Marnat Gaultier , Strbian Daniel , Ijas Petra , Preterre Cécile , Triquenot Aude , Albucher Jean-Francois , Gauberti Maxime , Weisenburger-Lile David , Sophie Marielle , NIkoubashman Omid , Mpotsaris Anastasios , Gory Benjamin , Tuan Hua Vi , Ribo Marc , Liebeskind David S , Dobrocky Tomas , Meinel Thomas , Bütikofer Lukas , Gralla Jan , Fischer Urs , Kaesmacher Johannes
Published: February 2023

Background:
One potential benefit of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) is pre-interventional reperfusion. Currently, there is a paucity of data regarding the occurrence of pre-interventional reperfusion in patients randomized to IVT or no-IVT before MT.

Methods:
SWIFT DIRECT was a randomized controlled trial including acute ischemic stroke IVT-eligible patients being directly admitted to a comprehensive stroke center, with allocation to either MT alone or IVT + MT. Primary endpoint of this analysis was the occurrence of pre-interventional reperfusion defined as pre-interventional expanded Thrombolysis in Cerebral Infarction score ≥2a. The effect of IVT and potential treatment effect heterogeneity were analyzed using logistic regression analyses.

Results:
Out of the 396 patients analyzed, pre-interventional reperfusion occurred in 20 (10.0%) of patients randomized to IVT+MT, and 7 (3.6%) of patients randomized to MT alone. Receiving IVT favored the occurrence of pre-interventional reperfusion (aOR 2.91 [95% CI 1.23 - 6.87]). There was no IVT treatment effect heterogeneity on the occurrence of pre-interventional reperfusion with different strata of Randomization-to-Groin-Puncture (p for interaction=0.33), although the effect tended to be stronger in patients with Randomization-to-Groin-Puncture >28 minutes (aOR 4.65 [95% CI 1.16 - 18.68]). There were no significant difference in rates of functional outcomes between patients with and without pre-interventional reperfusion.

Conclusion:
Even for patients with proximal large vessel occlusions and direct access to MT, IVT leads towards an absolute increase of 6.9% (95% CI 1.7-12.2%) in the rates of pre-interventional reperfusion. The effect of IVT tended to be more pronounced when Randomization-to-Groin-Puncture intervals were longer, but this heterogeneity did not reach statistical significance.
Abstract 60: Patient Engagement With Stroke Nurse Navigator Reduces Readmissions
Authors: Pope Leslie , Hackett Chris , Dellostretto Nicole , Noah Patty , Cerejo Russell
Published: February 2023

Objective:
We aimed to evaluate whether the level of engagement with stroke nurse navigators affected readmission rates and outcomes in acute ischemic stroke (AIS). Engagement is defined as a phone or virtual encounter between the patient and the navigator. We further defined the level of engagement as: low engagement < 5 encounters or high engagement ≥ 5 encounters in 90 days.

Methods:
Multicenter retrospective analysis of AIS patients with admission from January 2021 to April 2022. Patients were excluded if: died during index hospitalization, discharged to hospice or had incomplete data. Our primary outcome was readmission within 90 days analyzed with a binomial logistic regression. Secondary outcomes were: attendance of neurology appointments, recurrent neurologic symptoms, both assessed with a binomial logistic regression, and functional outcome as defined by utility weighted modified Rankin Scale (UWmRS) at 90 days post discharge which we used a hierarchical multiple regression analysis. Sensitivity analysis examined outcomes in patients who were discharged to home.

Results:
Stroke nurse navigators enrolled 2,584 patients. 2,035 patients were analyzed. Of the 2,035 patients, 1195 (58.7%) were highly engaged and 840 (41.3%) were less engaged. Highly engaged patients were less likely to be readmitted within 90 days compared to less engaged patients (20.9% vs. 33.3%), adjusted odds ratio (aOR)= 0.57 [95%CI, 0.46 - 0.72], p< 0.001. Additionally highly engaged patients compared to less engaged patients were: more likely to attend neurology follow-up appointments (64.6% vs. 43.3%), aOR= 1.94 [95%CI 1.59 - 2.37], p<0.001; less likely to have a recurrent neurologic event (6.5% vs. 9.3%), aOR=0.56 [95%CI 0.39 - 0.81], p = 0.002 and had greater functional ability at 90 days (7.9±2.6 vs. 5.4±4.0), b=0.98 [95%CI, 0.71, 1.25], p<0.001. Sensitivity analyses suggested that trends found in primary and secondary analyses were similar when examining only patients discharged to home, all p<0.05.

Conclusion:
Patients with AIS actively engaged with a stroke nurse navigator were found to have better outcomes and less readmissions through 90-days of post-discharge care irrespective of discharge location.
Abstract 61: Retrospective Safety Study Of Low Intensity Monitoring In Cases Of Acute Ischemic Stroke That Received Thrombolytic Therapy
Authors: Clark Diane K , Bello Yarexy , Cox Kailey L , Lesko Alexandra C , Swearingen Natalie R
Published: February 2023

Introduction:
It is standard to observe acute ischemic stroke (AIS) patients under high intensity monitoring (HIM) for the first 24 hours after intravenous thrombolysis (IVT). However, HIM is resource intensive and may not be necessary for every AIS patient. This study evaluates the safety and efficacy of low-intensity monitoring (LIM) for a subset of low-risk AIS patients who received IVT.

Methods:
Data from patients discharged from 2 hospitals between April 2020-April 2022 admitted to LIM post-IVT were retrospectively abstracted from patient records. Patients under age 18, arrival NIHSS ≥17, presence of large vessel occlusion, need for endovascular therapy, uncontrolled high blood pressure or unstable neuro exam (change in NIHSS of 4 or more within the 1st hour) were excluded. Primary outcomes were transfer back to HIM, instances and treatment of high blood pressure (HBP), in-hospital stroke mortality, discharge disposition and 90-day mRS. Population characteristics of age, sex, race, medical history, transfers to hub prior to LIM admission, discharge mRS and door-to-needle times were also examined.

Results:
Among 173 patients who met inclusion criteria, 1 (.6%) patient was transferred back to HIM and no patients died from in-patient stroke-related causes. Most patients were discharged home (80.9%) with a median 90-day mRS score of 1 (IQR: 0, 2, Table 1).

Conclusion:
LIM can reduce resource intensity of stroke care and free up critical care beds, which can result in less cost for the hospital and the patient. We conclude that LIM is safe and effective and could be the standard of care for low-risk AIS patients treated with IVT.
Abstract 62: Stroke Busters High School Stroke Education Initiative
Authors: Parker Ranisha L , Allen Kris , Salas Samantha , Nystrom Karin , Forman Rachel
Published: February 2023

Background:
It is estimated that 91% of stroke risk can be attributed to modifiable risk factors; however, on a population level, these risk factors are not well controlled. One recent response to reducing the burden of stroke has been to improve childhood knowledge about stroke. The purpose of our initiative was to educate high school students about stroke and careers in neuroscience.

Methods:
Thirteen students in Yale University Pathways to Science Summer Scholars participated in a 5-day program called
Stroke Busters.
Summer Scholars is a free summer science day program for rising 10th- 12th grade students. The demographic breakdown is 32% Asian, 30.1% Black, 20.4% Latinx, 15.5% White, and 1.9% Middle Eastern.
Stroke Busters
is a program within Pathways that includes an interactive stroke lecture, mock stroke code simulation, interactive mechanical thrombectomy demonstration, and a workshop where students created their own stroke learning materials. Students completed an 8 question pre and post-test that assessed stroke knowledge.

Results:
Between 7/11-7/15/22 thirteen students participated in
Stroke Busters
. The average test scores increased from 38% to 73%. Prior to the program, eight students (62%) listed that a stroke occurred in the brain and four students (31%) correctly identified the acronym “FAST”; 100% of students got these items correct in the post-test. The score for identifying 4/4 stroke symptoms improved from 56% to 92%. Twelve students provided feedback; the overall satisfaction rating for the program was 4.44/5. Students commented on the stroke simulation as the most enjoyable part of the program.

Conclusion:
In this high school stroke educational program students improved their knowledge about stroke significantly. This is the first stroke education program to our knowledge that focuses on high school students using a multi-day curriculum led by a diverse group of healthcare professionals.
Abstract 65: Cerebrovascular Reactivity Imaging Is Well Tolerated In Children With And Without Sickle Cell Disease
Authors: Giourgas Barbra , Binkley Michael , Lewis Joben , Streb Madison , Beshears Jade , Hulbert Monica , Fields Melanie , Shimony Joshua , Guilliams Kristin
Published: February 2023

Background:
Cerebrovascular reactivity (CVR) refers to a stimulus-induced change in blood flow, reflecting hemodynamic reserve. Carbon dioxide (CO
2
) stimulus increases cerebral blood flow (CBF), and exogenous noninvasive CO
2
with concurrent MRI is an established CVR method in adults. However, children with and without sickle cell disease (SCD) have increased resting CBF compared to adults, and few studies have examined CVR in children. Our objective was to determine tolerability of CO
2
CVR MRI in children with and without SCD.

Methods:
Children undergoing CO
2
CVR MRI had post-scan assessments of their experience and comfort during CVR testing. This included a preference rating ranking 8 experiences, including CVR MRI, in order from most to least enjoyable, a 6-point comfort scale, and a yes/maybe/no question asking if they would do CVR MRI again. The 8 preference items were grouped into quartiles for analysis. The Wilcoxon test was used to compare comfort rating based on SCD status and quartile preference rankings. Spearman’s correlation was used to compare peak end-tidal CO
2
with comfort rating.

Results:
Nine children with SCD and 22 controls ages 8-21 years old completed CVR MRI, with a median peak end-tidal CO
2
of 50 mmHg [IQR 47, 51]. No child had a serious adverse event. On a 6-point scale, the median comfort rating was 4 (slightly uncomfortable) [IQR 2,4]. There was no difference in comfort based on SCD status (p=0.70) or peak end-tidal CO
2
(p=0.65). Across all participants, CVR fell in the 3rd preference quartile. CVR rated similarly to visiting the dentist (p=0.95), but was better than throwing up (p=0.03). Despite ranking the scan in the 3
rd
quartile, the majority reported willingness to repeat CVR MRI, and only one participant (control) said they would not.

Conclusion:
Noninvasive CO
2
CVR imaging is safe and tolerable in children with and without SCD. After completing the session, most children would be willing to undergo similar testing again.
Abstract 75: History Of Covid-19 And Mortality Among Medicare Beneficiaries Hospitalized With Acute Ischemic Stroke, Medicare Cohort April 2020 - April 2022
Authors: Tong Xin , Yang Quanhe , Gillespie Cathleen , Merritt Robert K
Published: February 2023

Introduction:
Although COVID-19 is associated with increased risk of acute ischemic stroke (AIS), limited evidence exists about the impact of prior COVID-19 on overall survival among older AIS patients.

Methods:
We analyzed data on Medicare fee-for-service beneficiaries ≥65 years of age hospitalized with AIS from 04/01/2020 to 04/30/2022. Overall survival was defined as time from date of AIS to date of death, or through end of follow-up on 05/31/2022. We used a Cox proportional hazard model to examine the association between history of COVID-19 and all-cause mortality among AIS patients, and obtained age, sex, race/ethnicity, National Institutes of Health Stroke Scale (NIHSS) score, and comorbidity-adjusted survival estimates.

Results:
Among 294,226 AIS patients, 92,893 died (31.6%) during a median of 268 days (IQR, 81—502 days) and 245,262 person-years of follow-up through 05/31/2022. The crude mortality rates were 792 (95% CI, 770—815), 557 (95% CI, 540—575), and 362 (95% CI, 360—365) per 1000 person-years among AIS patients with history of hospitalized COVID-19, history of non-hospitalized COVID-19, and without COVID-19, respectively. As compared to AIS without history of COVID-19, the adjusted hazard ratios for all-cause mortality were 1.28 (95% CI, 1.25—1.32) for those with history of hospitalized COVID-19, and 1.05 (95% CI, 1.01—1.08) for those with non-hospitalized COVID-19. The pattern of associations between history of COVID-19 and all-cause mortality were largely consistent across age groups, sex, and race/ethnicity.

Conclusion:
Having a history of COVID-19 was associated with significantly higher risk of all-cause mortality among Medicare beneficiaries hospitalized with AIS, especially among those with a history of severe COVID-19.
Abstract 77: Comparison Of Adverse Reactions Following Intravenous Alteplase Versus Intravenous Tenecteplase For Acute Ischemic Stroke In Real World Clinical Practice
Authors: Lugonjic Sara , Erdenizmenli Mert , Andrews Sarah ,   Dell Med Sch Ascension Texas Stroke Service, Warach Steven J
Published: February 2023

Introduction:
Tenecteplase (TNK) has been increasingly used in clinical practice for acute stroke thrombolysis. Comparisons with alteplase (ALT) for major adverse effects (AEs) in randomized trials have shown no differences between the thrombolytics. The relative rates of acute AEs of interest in real world clinical practice have not been fully investigated.

Methods:
We performed a retrospective comparison of acute AEs (see Table), including those not reliably reported in clinical trials, between the two drugs as used in real world clinical practice. Objective definitions of AEs were used for chart abstraction, to minimize user interpretation. For example, the criteria for hypotension included mean arterial pressure less than 65 mmHg sustained for at least 20 minute occurring within 6 hours of thrombolytic administration. Logistic regression analyses were performed adjusted for age, sex, NIHSS, thrombectomy, time from last known well to thrombolytic bolus, and pre-stroke history of antithrombotic medicines.

Results:
Sequential samples of 354 ALT and 472 TNK patients were analyzed. No differences in the adjusted logistic regression of acute AEs were seen between the two groups using a p<0.05 criterion (Table). Nominal trends for fewer hypotensive and symptomatic intracranial hemorrhage (sICH) events and more orolingual angioedema events for TNK were observed.

Conclusion:
In this retrospective quality improvement analysis, no significant differences in rates of acute AEs were observed between TNK-treated and ALT-treated patients. Larger samples may be needed to determine whether the nominal differences we observed in angioedema, hypotension, and sICH will prove to be significant.