bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WMP91: Disparities in Inpatient Mortality from Acute Stroke: Near-national Estimates for Hispanics
Authors: Sauser Zachrison Kori , Lin Mengyun , Hanchate Amresh
Published: June 2021

Background:
Hispanics are the largest minority in the US, yet there is little national data describing stroke outcomes among Hispanic patients.

Objective:
To measure inpatient mortality following admission for ischemic stroke (IS), hemorrhagic stroke (HS), and subarachnoid hemorrhage (SAH) among non-Hispanic blacks, non-Hispanic whites, and Hispanics.

Methods:
We combined discharge data (2010-11) from universe of admissions at all non-federal hospitals from 15 states that account for 85% of the Hispanic population and had near-complete reporting of race/ethnicity (AZ, CA, CO, FL, IL, MA, MD, NJ, NM, NV, NY, OR, PA, TX, VA). We identified all hospitalizations for IS, HS, and SAH, and estimated logistic and hospital-level hierarchical logistic regression models to obtain rates of inpatient mortality by race/ethnicity adjusted for patient characteristics (age, sex, race/ethnicity, comorbidities) and hospital characteristics (annual hospital stroke volume).

Results:
We found 567,498 discharges for acute stroke; Hispanics accounted for 11.7%, blacks for 15.6% and whites for 68.7%. Among all discharges, IS accounted for 83%, HS 12% and SAH 5%. Compared to whites, Hispanics and blacks were younger and had lower observed mortality rate for all stroke subtypes (IS: whites 5.2%, blacks 3.3%, Hispanics 4.3%, p<0.001; HS: whites 25.7%, blacks 20.8%, Hispanics 21.3%, p<0.001; and SAH: whites 20.2%, blacks 17.5%, Hispanics 19.3%, p<0.001). In the fully adjusted model, compared to whites, Hispanic inpatient mortality was lower for HS but nor for IS or SAH (Table); in contrast, blacks had lower inpatient mortality for IS and HS (Table). Individual states’ overall adjusted stroke mortality for all subgroups combined was not significantly different for Hispanics, with the exception of CA (OR 0.90, 95% CI 0.85-0.96).

Conclusion:
In a near-national sample, Hispanic patients had lower adjusted inpatient mortality rates than whites for HS, and similar rates for IS and SAH.
Abstract WMP98: A Nationwide Study of Non-traumatic Intracranial Hemorrhage in Patients Receiving Direct Oral Anticoagulant Therapy: J-Aspect Study
Authors: Kurogi Ryota , Nishimura Kunihiro , Kada Akiko , Kamitani Satoru , Ogasawara Kuniaki , Ono Junichi , Shiokawa Yoshiaki , Aruga Toru , Toyoda Kazunori , Nakagawara Jyoji , Miyachi Shigeru , Yoshimura Shinichi , Okuchi Kazuo , Nagata Izumi , Matsuda Shinya , Nakamura Fumiaki , Onozuka Daisuke , Hagihara Akihito , Suzuki Akifumi , Ido Keisuke , Kurogi Ai , Nishimura Ataru , Arimura Koichi , Sayama Tetsuro , Iihara Koji
Published: June 2021

Background and purpose:
The incidence of non-traumatic intracranial hemorrhage (ICH) during treatment with direct oral anticoagulants (DOACs) is lower than that during warfarin treatment. The characteristics of intracranial hemorrhage during DOAC therapy, however, remain unclear. Therefore, we performed a nationwide survey in Japan to examine the clinical characteristics and outcomes of DOAC-associated ICH using data obtained from the Japanese Diagnosis Procedure Combination (DPC)-based Payment System.

Methods:
We analyzed the data of 1,567 patients with ICH (DOAC-associated ICH, 88; warfarin-associated ICH, 1,479) who were urgently hospitalized at 575 institutions across Japan from April 2010 to March 2013 for whom prescription data before admission were available.

Results:
The annual number of patients with all anticoagulant (DOAC or warfarin)- associated ICH in each year from 2010 to 2013 was 226, 252, 426, and 663, representing 15.7%, 15.4%, 16.1%, and 16.1% of all ICH cases in the same period, respectively. There was an increase in the proportion of patients who presented with DOAC-associated ICH in all anticoagulant-associated ICH in each year from 2010 to 2013 (0%→0.4%→3.8%→10.7%). The proportion of patients with impaired consciousness (three-digit score on Japan Coma Scale) at admission (DOAC, 19.3%; Warfarin, 25.4%; P=0.20), in-hospital mortality within 7 days (DOAC, 11.4%; Warfarin, 19.5%; P=0.06), and mRS score of 5-6 at discharge (DOAC, 27.3%; Warfarin, 37.4%; P=0.06) were lower in the patients with DOAC-associated ICH. The rates of surgery for hematoma removal were significantly lower in the patients with DOAC-associated ICH (NOAC, 2.3%; Warfarin, 9.7%; P=0.019).

Conclusions:
This is the largest nationwide study of DOAC-associated ICH in a real-world situation in Japan, revealing that the patients with DOAC-associated ICH had better clinical outcomes compared with warfarin-associated ICH, probably due to milder hemorrhage at admission.
Abstract WP100: Vitamin D Deficiency Induced Alteration in Blood Brain Barrier Following Stroke in Rats
Authors: Wali Bushra , Sayeed Iqbal , Stein Donald G
Published: June 2021

Background:
Growing evidence suggests that Vitamin D hormone deficiency (VDH
def
) is a risk factor for ischemic stroke and its severity. Blood-brain barrier (BBB) impairment is a marker of secondary cerebral injury following stroke and is associated with an increased propensity for hemorrhage. Our
in vitro
work showed that VDH treatment reduces BBB damage after hypoxia/reperfusion injury via VDR-mediated NF-kB-MMP9 pathways. We explored the role of VDH in maintaining BBB integrity in a rodent model of stroke.

Methods:
Male Wistar rats (n=48) were assigned to one of two diet cohorts, VDH-sufficient (VDH
suf
) and VDH
def
. The VDH
suf
group was fed standard chow and the VDH
def
group was fed a VDH-null version of the same diet for 8 weeks. Animals from both cohorts received either sham or transient middle cerebral artery occlusion (tMCAO) surgeries and were assigned to one of 4 groups (n=12/group): sham VDH
suf
, MCAO+VDH
suf
, Sham+VDH
def
, or MCAO+VDH
def
. Rats were killed at 72h and one group of animals (n=6) was used for immunohistological assays and other group (n=6) used for western blot assays. Their brains were evaluated for BBB permeability, MMP-9 activity, alteration of TJ proteins and VDR expression.

Results:
VDH
def
induced a significant increase in BBB permeability as measured by IgG extravasation in sham VDH
def
control rats. Following MCAO, expression of MMP-9 and the TJ proteins occludin and claudin-5 increased significantly in the MCAO+VDH
def
group compared to the MCAO+VDH
suf
group. IgG extravasation after MCAO was observed to be significantly higher in the MCAO+VDH
def
than the MCAO+VDH
suf
group, indicating more severe BBB injury in the VDH
def
group.

Conclusion:
Our result showed greater BBB dysfunction in the sham and MCAO groups in the VDH
def
diet than in the control cohort, indicating more severe BBB injury in rats fed a VDH
def
diet. This finding that VDH status modulates BBB integrity may help explain the clinical correlations between low serum VDH levels and stroke.
Abstract WP102: Retrograde Neurodegeneration of Substantia Nigra Projections to the Striatum Following Long Term Survival After Ischemic Stroke
Authors: Panta Aditya , Sohrabji Farida
Published: June 2021

Introduction:
Stroke survivors suffer from long-term physical, cognitive and affective disabilities. These disabilities lower the quality of life, contribute to social isolation and anhedonia, and clinical disorders such as post-stroke depression (PSD), which disproportionately affects women. Preclinical studies show that lesions of the substantia nigra (pars compacta) impair both motor performance and reward seeking behavior. Neurons from the SNc project to the striatum, a region that is significantly infarcted by middle cerebral artery occlusion (MCAo).

Hypothesis:
Ischemia induced by MCAo leads to retrograde degeneration of the SNc pathway projecting to the striatum.

Methods:
Middle-aged Sprague-Dawley female rats (12 months old) were subjected to ischemic stroke using a silicon-coated nylon filament suture to occlude the middle cerebral artery (MCA) which was removed 75min after to allow for reperfusion. After 14 weeks of survival, rats were again anesthetized and Fluorogold (Flg) was injected into the left and right striatum. Four days later, animals were overdosed with anesthetic, perfused with saline and formaldehyde and the brain removed for cryosectioning. In three sections per animal, Flg-labeled cells in the SNc were counted on both hemispheres, using fluorescent illumination.

Results:
Flg-injections into the striatum retrogradely labeled neurons in the midbrain. There was a 35% decrease (p<0.009) in the number of Flg labeled SNc cells in the ischemic hemisphere (85.5+18.2) as compared to the non-ischemic hemisphere (132.4+22.7). The reduced number of projection neurons in the ischemic hemisphere is consistent with the loss of trophic support from the striatum.

Conclusions:
SNc neurons are a critical component of reward pathway and motor function, hence degeneration of these neurons could lead to long term motor deficits and depressive symptoms including anhedonia that are common after stroke.
Abstract WP11: Tiered Triage Approach Improves Stroke Treatment Times and Reduces Activation Fatigue in Stroke Centers
Authors: Hawkins Angela , Olds Karin , Larsen Marc , Martin Coleman , Akhtar Naveed , Holloway William
Published: June 2021

Background:
Time critical care in the Emergency Department is important for a patient’s survival and recovery. Reductions in disability are attributed to rapid triage and treatment for patients with both small and large vessel strokes. Current guidelines provide recommendations in clinical practice but do not delineate which type of stroke patients should receive heightened levels of triage when they arrive in the ED simultaneously.

Purpose:
To decrease unintentional care delays by classifying patients who are in need of intravenous tPA, endovascular therapy, or patients receiving no therapy in the initial assessment. Additionally, the number of activations of over 4,000 since 2014 was leading to stroke fatigue and we sought to decrease this fatigue with a tiered triage approach.

Methods:
Performance improvement initiatives were used to eliminate under used resources while also accounting for overburden of multiple patients in a very busy stroke center. The project prioritized code stroke activations based on acuity into RED, YELLOW and GREEN stroke alerts. RED signified a patient as a possible candidate for IV tPA, YELLOW prioritized the patient as possible endovascular candidate, and GREEN prioritized the patient as having a longer symptom onset initially.

Results:
The ultimate goal was to improve stroke treatment times while also decreasing activation fatigue. In the RED activations, the door to needle (DTN) time decreased from a mean of 46 minutes in 2014 to a mean of 34 minutes in 2016. In the YELLOW activations, the door to groin puncture mean decreased from 155 minutes to 72 minutes in the same time period. Prioritizing stroke based on acuity has demonstrated efficiency in team members’ time and improved stroke treatment times and treatment rates.

Conclusions:
Despite the increased influx of stroke patients into comprehensive stroke for endovascular consideration, the patients who were candidates for tPA could be prioritized to minimize delays in tPA treatment. Furthermore, patients with potential treatment for endovascular could be further prioritized and treatment times could also improve. Decreasing activation fatigue and fine tuning flow process helped manage multiple stroke patients at one time and favored improved patient outcomes.
Abstract WP117: High-dimensional Analysis of Inflammatory Cells in Ischemic Stroke Mice
Authors: Li Yaning , Tao Tao , Zhao Heng
Published: June 2021

Background:
Inflammatory leukocytes in the ischemic brain modulate brain injury, but their functions are not fully understood. The purpose of this study is to establish a novel technique of mass cytometry (CyTOF) to identify the functions and roles of inflammatory cells in ischemic stroke mice, an alternative method to flow cytometry, without fluorescence cross contaminations.

Methods:
Leukocytes were isolated from the spleen, bone marrow, and ischemic brain of ischemic stroke mice. These cell samples were simultaneously stained with 16 metal-labeled immune cell phenotype markers, and then detected by CyTOF. Data were analyzed by Cytobank program.

Results:
By using the manual gating strategy, the results showed that stroke resulted in significant increases of microglia-derived macrophages (MiMΦs), monocyte-derived macrophages (MoMΦs), natural killer (NK), plasmacytoid dendritic cells (pDCs), conventional DCs (cDCs), B cells, CD4
+
T, CD8
+
T cells, γδ T, and regulatory T (Treg) cells (
p
<0.05). For the first time, we discovered that the number of Eff/mem CD4, and Eff/mem CD8 T cells was significantly increased in the ischemic brain (
p
<0.05), suggesting that these effector/memory T cells are important for brain injury. In addition, SAPDE analysis showed that individual leukocytes in the ischemic brain on day 3 after stroke had higher protein expressions of CD45, CD11b, CD11c, B220, CD3, CD4, CD8, CD44, and NK1.1 than those from sham brains, suggesting that these proteins may be actively involved in brain injury. As expected, the number of leukocytes was significantly reduced (
p
<0.05) in the spleen, an indicator of immunosuppression after stroke. Nevertheless, in the bone marrow, Treg were increased at day 1, neutrophils and CD8 T cells increased at day 3 after ischemia (
p
<0.05), while the number of the remaining subtypes was reduced.

Conclusions:
The novel technique of CyTOF is a powerful tool to quantify leukocyte cell types and protein expressions in individual cells. Our results suggest that effector/memory T cells are involved in brain injury, and upregulation of cell surface receptors in individual leukocytes may be important for their effects on brain injury.
Abstract WP135: Is Hyperintense Carotid Plaque on T1-weighted Images an Independent Risk Factor for Symptomatic Carotid Stenosis?
Authors: Narumi Shinsuke , Sasaki Makoto , Natori Tatsunori , Ogasawara Kuniaki , Kobayashi Masakazu , Terayama Yasuo
Published: June 2021

Introduction:
Carotid plaque showing hyperintensity on T1-weighted magnetic resonance imaging reflects unstable plaque consisting of lipid/necrosis and/or hemorrhage and has been reported as a risk factor for embolic complications during carotid endarterectomy (CEA) or stenting. However, it remains unclear whether hyperintense plaque is related to stroke events. Thus, we evaluated the difference in the intraplaque signal between asymptomatic and symptomatic patients with carotid stenosis.

Methods:
We prospectively collected and retrospectively analyzed 68 patients who underwent CEA (age, 53-79 years; 61 men and 7 women; 52 symptomatic and 16 asymptomatic). Using a fast spin-echo technique at 1.5 T, the contrast ratio (CR) of carotid plaque to adjacent muscle was calculated on axial images based on maximum plaque size. Differences in patient characteristics (age, sex, hypertension, dyslipidemia, diabetic mellitus, and degree of stenosis) as well as CRs between symptomatic and asymptomatic patients were examined using Fisher’s exact test, the Mann-Whitney test, and multivariable logistic regression analysis.

Results:
The CRs of the carotid plaque were significantly higher in the symptomatic group than in the asymptomatic group (0.97-2.32 [median, 1.55] and 0.95-2.01 [1.32], respectively; p = 0.026). In addition, age, hypertension, and stenosis degree were significantly higher in the former than in the latter (p = 0.013- 0.003). Multivariate logistic regression analysis revealed that only hypertension and CRs of the plaque were independent risks of symptomatic stenosis (odds ratio, 11.0 and 2.7; 95% confidence interval, 2.0-62.0 and 1.1-6.6; p = 0.007 and 0.025; respectively).

Conclusion:
CRs of the carotid plaque as well as hypertension were significantly and independently related with symptomatic patients, suggesting that hyperintense plaque can be a risk factor of stroke events in patients with carotid stenosis.
Abstract WP14: Outcomes after Endovascular Therapy in a Population with Mild Acute Ischemic Stroke and Large Vessel Occlusion: Does Treatment Help?
Authors: Frei Donald , Orlando Alessandro , Bellon Richard , Wagner Jeffrey , Fanale Christopher V , Jensen Judd , Bartt Russell , van Vliet Rebecca , McCarthy Kathryn , Bar-Or David
Published: June 2021

Introduction:
Patients with mild acute ischemic strokes (NIHSS ≤7, AISs) have been excluded from intra-arterial therapy (IAT) trials, limiting our understanding of their outcomes after IAT. Mild AIS with large vessel occlusions (LVOs) represent a fragile subset of mild AISs. Despite a low NIHSS, these patients can have a sudden failure of collateral circulation and deteriorate rapidly, resulting in significant disability. The objective of this study was to compare patient outcomes between those with mild AIS and LVO who did and did not received IAT.

Methods:
We included all adults (≥18) with a mild AIS due to an LVO admitted over 6.5 years to a high-volume comprehensive stroke center. Patients were excluded for any contraindication to IAT (n=240). Comparison groups were IAT vs. no therapy. Outcomes were sICH, in-hospital mortality, discharge mRS ≤2, and an improvement in NIHSS at discharge (>2 vs ≤2). Fisher’s, chi-squared, and logistic regression compared outcomes between groups.

Results:
There were 75 patients included in the study (Table 1). Overall 21% received treatment, and a majority of patients were 55-79 years, presented with hypertension and hyperlipidemia, and arrived within 4.5h from symptom onset. 7 patients also received IV-tPA. The IAT group had a significantly larger proportion of males, and hypo-mild strokes (NIHSS 4-7). There was one sICH in the no therapy group, and overall few deaths (Table 1). There was no significant difference between groups in improvement in NIHSS, and after adjusting for admission NIHSS, there was no significant difference in favorable discharge mRS. There were no IAT procedure complications.

Conclusions:
It remains to be seen whether IAT is beneficial in patients with mild AIS and LVO. Future, interventional, multi-center studies are needed to definitively determine the efficacy of IAT. Though these data come from a small patient population, they offer an insight into the potential safety of IAT in a fragile stroke population.
Abstract WP143: Intensive Lipid-Lowering Therapy Ameliorating Asymptomatic Intracranial Atherosclerosis
Authors: Guo Xiu-Hai , Yang Qi , Yang Yu-Jiao , Ren Ming , Ji Xun-Ming
Published: June 2021

Background:
Intracranial atherosclerotic stenosis(ICAS) is an independent risk factor for ischemic stroke, especially in Asians and Africans. Studies showed that statins stabilized or ameliorated atherosclerotic coronary artery and symptomatic ICAS. Effect of intensive lipid-lowering therapy (ILLT) for asymptomatic ICAS (AICAS) has not been reported.

Objective
To explore whether ILLT can ameliorate the atherosclerosis of AICAS.

Method:
Single-center, prospective cohort study was performed in AICAS patients, who were evaluated with transcranial doppler sonography before and after statin therapy. With target level of low density lipoprotein (LDL-C ≤ 1.8mmol/l or LDL-C decreased over 50%), patients were divided into intensive statin treatment group (IST) and standard statin treatment group (SST).

Results:
(1) No statistical differences were detected in age, gender, BMI, history of HT, DM or CHD, ICAS degree between two groups. (2) 50 cases with 105 branches of AICAS in IST and 20 cases with 47 branches of AICAS in SST were followed up for 12 months. LDL-C level significantly decreased in IST (1.48 ± 0.23 vs 2.39 ± 0.65, P=0.000). In IST, 36 (36/105) AICAS regressed, 59 (59/105) was stable and 10 (10/105) progressed. In SST, 9 (9/47) ICAS regressed, 36 (36/47) ICAS was stable, and 2 (2/47) ICAS progressed. The ratio of regressed ICAS in IST was not statistically higher than that in SST (34.3% vs 19.1% P=0.059). (3) 23 cases with 48 branches of AICAS in IST and 10 cases with 22 branches of AICAS in SST were followed up for 24 months. In IST, 21 (21/48) AICAS regressed, 20 (20/48) was stable and 7 (7/48) ICAS progressed. In SST, 2 (2/22) ICAS regressed, 17(17/22) ICAS were stable and 3 (3/22) ICAS progressed. The ratio of regressed ICAS in IST was significantly higher than that in SST (43.8% vs 9.1% P=0.006).

Conclusions:
(1) Degree of atherosclerosis in AICAS is further reduced with ILLT; (2) LDL-C ≤1.8mmol/l or LDL-C decreased over 50% can be reached by moderate-intensity statin for Chinese.
Abstract WP146: Outcomes of Carotid Endarterectomy Following the CMS Reimbursement Guidelines
Authors: Alawi Aws , Al Shakarchi Firas , Alshekhlee Amer
Published: June 2021

Background:
In 2005, the Center for Medicare Services (CMS) approved the reimbursement for carotid artery stenting for high-risk carotid stenosis; leaving carotid endarterectomy (CEA) to be performed primarily for a low-risk population. In this study, we assess trends of outcomes associated with CEA over the period of CMS regulation.

Methods:
A cohort of patients with CEA was identified from the National Inpatient Sample database using the procedure codes (38.12) for the years 2001 through 2009. Patients under age 18, missing information on the death status, transfer between hospitals, and urgent or emergent admissions were eliminated. Trend analysis for the following outcomes (post procedure stroke, myocardial infarction ‘MI’, and death) was performed over the year included in the study. Two periods encompass the implementation of the guideline (first period: 2001 through 2004 and second period: 2006 through 2009) were compared.

Results:
Over 9 years, 152 051 CEA procedures were performed; 63375 performed during the first period and 70886 in the second period. The mean age (71.02 ± 9.2) and male preponderance (57.4%) were similar in both treatment periods (P > 0.05). Ninety six percent of this population was asymptomatic by the time CEA was performed. Overall poor outcome risk of post-procedure stroke, MI and death was 1.97%; being lower in the second compared to the first period (2.05% versus 1.88%; P =0.02; unadjusted odds ratio “OR’ 0.91; 95% CI, 0.84, 0.98; and adjusted OR 0.88; 95% CI, 0.82, 0.96). The risk of post-procedure stroke was similar in both periods (0.94% versus 0.97%; P = 0.56); however, the risks of MI (0.91% versus 0.76%; P = 0.002) and death (0.46% versus 0.33%; P < 0.0001) declined over time.

Conclusion:
Following the CMS reimbursement guideline, CEA is associated with lesser risks of poor outcomes (MI and death).
Abstract WP147: Carotid Endarterectomy and Concurrent Clopidogrel Use: U.S. National Practice Patterns
Authors: Mistry Eva A , Khoury Jane , Kleindorfer Dawn
Published: June 2021

Background:
Patients diagnosed with high-grade carotid stenosis often receive a carotid endarterectomy (CEA) during their hospital stay and most receive antiplatelet medication. There is inter-surgeon variability in performing CEA in patients receiving clopidogrel due to its potent antiplatelet effect.

Methods:
Utilizing the PREMIER database (a representative sample of 15% of US hospital discharges with procedure codes and medications); adults with principal discharge diagnosis coded as stroke, transient ischemic attack (TIA) or carotid artery stenosis or occlusion without stroke/TIA(CAS) (ICD-9: 434, 435, 433.10, and 433.11 respectively), who had a CEA (ICD-9 38.12) during the same hospital stay, in 2014 were analyzed. Clopidogrel use was defined as receiving any dose within the 3 days prior to the CEA. Univariate and multivariable analyses; T-test, Chi-square and multiple logistic regression, were used to examine the association of age, race, gender, principal diagnosis of stroke/TIA vs. CAO, academic vs non-academic center, and region of the US, with CEA following clopidogrel use.

Results:
There were 15,381 patients with stroke, TIA, or CAS who had a CEA during the same hospital stay in 2014. Patients were median age 71 years, (IQR 65-78), 86% were Caucasians, 4% Black, and 10% other race; 42% were female. 2570 patients (17 %) received a dose of clopidogrel within 3 days prior to their procedures. In univariate analysis, male sex, having a stroke/TIA vs CAS, not being at a teaching hospital, being in the Northeast or South were associated with CEA after clopidogrel. Results for the multivariable analysis are presented in the Table.

Conclusions:
Our study found that across the US, about 1 in 6 patients who undergo CEA have clopidogrel in their system. Younger age, having a stroke/TIA vs CAS, non-teaching hospitals, and areas other than the West are found to convey higher odds of CEA while on clopidogrel. Future analysis of differences in outcomes and safety events are needed.
Abstract WP157: Sympathetic and Cerebrovascular Responses to Blood Flow Restriction Resistance Exercise: A Potential Parallel to Remote Ischemic Preconditioning?
Authors: Sprick Justin D , Colby Hannah B , Rickards Caroline A
Published: June 2021

Introduction:
Remote ischemic preconditioning (RIPC) is characterized by the cyclic application of limb blood flow restriction and reperfusion, and has been shown to protect the brain during a subsequent ischemic insult. Blood flow restriction exercise (BFRE) is a novel training modality that similarly combines bouts of blood flow restriction and reperfusion with low-intensity exercise and thus could potentially emulate the protection demonstrated by RIPC. One concern with clinical application of BFRE is the potential for an augmented exercise pressor reflex, resulting in an unsafe rise in sympathetic outflow. Due to the use of lower workloads, however, we hypothesized that BFRE would exhibit an attenuated increase in sympathetic outflow, mean arterial pressure (MAP), and brain blood flow.

Methods:
11 subjects (6M/5F; age 28±2 yrs) underwent 2 leg press exercise interventions separated by ≥1 month: 1. BFRE - 220 mmHg thigh occlusion during 4 cycles x 5-min of exercise, consisting of 3 x 10 reps at 20% of 1 rep-max (1RM), and; 2. Conventional exercise (CE) - 4 cycles x 5-min of exercise, consisting of 3 x 10 reps at 65% 1RM without occlusion. 5-min of rest and reperfusion (for BFRE) followed each cycle. MAP, mean middle cerebral artery velocity (MCAv), cerebral oxygen saturation (ScO
2
), and plasma norepinephrine concentrations ([NE]) were compared between trials.

Results:
MAP increased with exercise under both conditions (P<0.001) and was higher (P≤0.03) with CE vs. BFRE for each cycle (1. 107±3 vs. 103±2 mmHg, 2. 107±2 vs. 103±2 mmHg, 3. 107±2 vs. 103±2 mmHg, 4. 107±2 vs. 104±2 mmHg). MCAv and ScO
2
(N=10) increased over time (P<0.001) with no difference between conditions for MCAv (P=0.83), while ScO
2
was higher for CE vs. BFRE (65±1 vs. 62±1%, P=0.05). Plasma [NE] (N=7) increased over time for both conditions (P=0.08) and was higher for CE vs. BFRE (757±103 vs. 524±71 pg/ml, P=0.09).

Conclusions:
BFRE elicited an attenuated sympathetic response compared to CE as evidenced by lower MAP and plasma [NE]. The lower ScO
2
(i.e., increased oxygen extraction) and no difference in MCAv responses suggests greater cerebral metabolic demand with BFRE. These findings indicate that BFRE could be explored as an alternative to CE in the clinical setting such as stroke-rehabilitation.
Abstract WP16: Acute Stroke Treatment and Hemorrhagic Complication in Infective Endocarditis
Authors: Thatikunta Prateek , Marquardt Robert J , Cho Sung-Min , Zhang Lucy , Uchino Ken , Wisco Dolora
Published: June 2021

Introduction:
Acute ischemic stroke (AIS) is common in patients with infective endocarditis (IE). Use of IV thrombolytic therapy (IV-tPA) has been reported and appears to carry greater risk of hemorrhage, while reports of endovascular therapy are rare. We present two cases where these interventions were utilized.

Methods:
A retrospective review was done of 116 consecutive patients with IE who were seen by stroke neurology in a tertiary care center from January 2015 to July 2016. Two cases were identified in which acute stroke therapy was utilized, one case with IV-tPA and one case with endovascular thrombectomy. We searched PubMed from inception to August 2016 and systematic review was performed to evaluate acute stroke therapy in IE.

Results:
In case 1, an 82 year old female with prosthetic aortic valve endocarditis and atrial fibrillation presented with slurred speech and right hemiplegia. IV-tPA was given within 2.5 hours, and NIHSS improved from 11 to 1 over 24 hours. CT Brain done 24 hours post-tPA revealed a small L thalamic hemorrhage. In case 2, a 49 year old IV drug-using male with prior IE and current prosthetic aortic valve endocarditis developed right middle cerebral artery occlusion with an NIHSS 17. Endovascular thrombectomy was performed with successful TICI 3 recanalization. CT Brain done 24 hours post-thrombectomy showed evolving right middle cerebral artery infarct with hemorrhagic conversion. Systematic review revealed 7 reports of IV thrombolysis, 5 reports of mechanical thrombectomy, and 3 reports with intra-arterial thrombolysis plus endovascular thrombectomy. Including our cases, IV thrombolysis alone had a hemorrhagic complication rate of 82% (9 out of 11 patients). Endovascular thrombectomy alone, all reporting at least TICI IIb recanalization, had a hemorrhagic complication rate of 17% (1 out of 6 patients). Intra-arterial thrombolysis and endovascular thrombectomy together had a hemorrhagic complication rate of 0% (0 out of 3 patients).

Conclusion:
Endovascular thrombectomy alone appears to be safer than IV-tPA alone in the management of AIS in patients with IE.
Abstract WP161: Early Short Physical Performance Battery (SPPB) Score Can Predict Functional Independence and Death for Acute Stroke
Authors: Kumagae Ken-ichi , Yamauchi Kohta , Hagiwara Risa , Koyanagi Yasuhiro , Arakawa Shuji , Fujimoto Shigeru , Suzuki Satoshi
Published: June 2021

Background and Purpose:
Lower extremity function is a strong predictor for functional outcome and death in a variety of pathological status. National Institute of Health Stroke Scale (NIHSS) is a world-wide standard scoring system for stroke patients; however, it is not sufficient to evaluate lower extremity function. Short Physical Performance Battery (SPPB) is a simple assessment tool for lower extremity function, consists of standing balance, walking speed, and repetitive standing (range: 0-12, 12: high function). SPPB can predict adverse events, such as disability and mortality in elderly population, but its disease specific utility for stroke patients is still unknown. The purpose of this study was to determine whether SPPB score predicts functional independence and death for acute stroke.

Methods:
Between April 2013 and November 2014, 410 consecutive stroke patients admitted within 7 days after the onset. Patients with premorbid modified Rankin Scale (mRS) of 0-2, and evaluated SPPB at 7
th
days after the admission were enrolled in this study. Clinical data were analyzed using univariate and multivariate model to assess functional independence (defined as mRS of 0-2) at 3 months and 1 year mortality adjusting covariates to investigate the association between SPPB and functional independence or death. Receiver operating characteristics (ROC) curve analysis was performed for detecting optimal cut-off value.

Results:
A total of 243 patients (mean age 73.8 years, male 58.4%) were included in this study. Of them, 132 (54.3%) patients were independent at 3 months follow up, and 14 (5.8%) patients have died. Median SPPB score at 7
th
days after the admission was 6 (IQR: 1-11). After adjusting age, sex, BMI, NIHSS score on admission, SPPB score at 7
th
days after the admission was significantly associated with 3-month functional independence (odds ratio, 1.48; 95%CI, 1.29-1.69; p<0.001) and 1-year death (hazard ratio, 0.36; 95% CI, 0.17-0.74; p=0.005). ROC curve analysis revealed the cut-off point of SPPB for functional independence was 6 (AUC:0.88, 95%CI, 0.83-0.93, p<0.001, sensitivity: 0.83, specificity:0.84).

Conclusions:
Early SPPB score is a useful assessment tool in predicting functional independence and death for acute stroke patients.
Abstract WP162: Work Performance Questionnaire After Returning to Work in Ischemic Stroke Survivors: The Work Performance Survey
Authors: Barboza Miguel A , Becerra Luis C , Serrano Fabiola E , Arauz Antonio
Published: June 2021

Introduction:
return to work is a challenging task among work-active stroke survivors, which has been widely analyzed, but few data has been collected regarding the performance quality compared to previous state before stroke.

Hypothesis:
work performance after stroke is not only determined by the probability of being active in daily job activities, but also in the ability to recover different cognitive and motor areas to perform tasks as previous.

Methods:
we developed a 15-item survey (work performance questionnaire [WPQ]) for stroke survivors who returned to work, and applied the instrument on those who had more than 3 months in their work activity; patients were selected from the INNN-stroke database, with demographic and epidemiological characteristics collected on each patient. The survey evaluated 11-different domains (language, memory, attention, planning, calculus, writing, motor skills, gait, visual, mood and self-perception). Points were assigned according to 4 categories: high (0-5 points), good (6-15 points), moderate (16-29 points) and low performance (30-45 points). Internal consistency, test-retest reliability, item-scale correlation and factor analysis were conducted.

Results:
A total of 100 ischemic stroke survivors were recruited (51% female patients, median age 42 years [IQR 34.5-54.5 years]); median time after returning to work was 4 months (IQR 2-7 months), with 39 patients decreasing the work-schedule to part time job, and 100% of subjects keeping the same work activity than previous to the index stroke. Work performance after stroke was high in 16% cases, good in 58% cases, moderate in 24% cases, and low in 2 cases. Chronbach’s alpha coefficient was 0.75 for the scale. Kaiser-Meyer-Olkin measure of sampling adequacy was 0.72 (p<0.001). The test-retest reliability, as estimated by the intraclass correlation coefficients was good. Memory, Language and Attention explained 59.7% of the variance of the questionnaire at the extraction analysis.

Conclusions:
The WPQ-INNN is a reliable and valid tool for assessment of performance quality in stroke survivors who returned to work, with the highest prediction ability based on memory, language and attention. This instrument should be validated in prospective studies.
Abstract WP164: Paging Dr. Lasagna: Why Early Inpatient Rehab Trial Recruitment Rate is in Single Digits
Authors: Geed Shashwati , Giannetti Margot L , Barth Jessica , Brady Kathaleen P , Wilson Claire P , Edwards Dorothy F , Dromerick Alexander W
Published: June 2021

Introduction:
Lasagna’s Law, that the
prevalence of a disease falls to 10% of your estimate the day you start recruitment
, is relevant for stroke rehab trials. Data describing the problem are limited for very early trials (within 30 days) since most trials focus on more chronic survivors and moderate upper-extremity (UE) impairment (NIHSS motor arm > 0). Very early trials are important for rehab because animal data suggest very early intervention may improve recovery. We thus provide estimates on barriers to recruitment for very early rehabilitation trials in the US.

Methods:
We used screening data for the Phase II Critical Periods After Stroke Study RCT, designed to identify when after stroke patients are most responsive to motor training. Starting Aug 2014, 893 patients eventually admitted to inpatient rehab were screened (5 ±2 days post stroke).

Results:
We enrolled 4.3% of those screened, at 15.5 ±4.9 days post stroke. Participants had ischemic/hemorrhagic stroke within 28d, and moderate UE impairment (NIHSS motor arm > 0 and manual muscle test score >2- on shoulder flexion/abduction). The largest % were excluded for being “too mild” (35.7%, NIHSS motor arm = 0), or “too late” (18%, unable to receive first study-related treatment < 30 days of stroke). A smaller percentage were “too severe” (3.6%, UE motor assessment scale <3, or dense sensory loss). Another subset were excluded for medical reasons (19.7%, prior/non-motor stroke, cognition, neglect, ataxia), and a smaller subset for other reasons (17.8%, non-English speakers, early discharge, age < 21). Additional UE motor assessment in a subset of the “too mild” group revealed motor deficit (Action Research Arm Test score = 47.7 ±12, max = 57, MCID = 5.7) in spite of their NIHSS motor arm score = 0. Thus, some individuals are excluded from trials because the NIHSS misses UE motor impairment.

Conclusion:
Frequent barriers to recruitment for inpatient rehab trials include persistent but too mild UE motor impairment and delayed admission to inpatient rehab. For early intervention studies, screening and treatment must begin in the acute hospital setting. Further, there is a patient subset whose motor impairment persists, but is too mild for most trials. These mildly affected individuals warrant more investigation.
Abstract WP170: Identifying the "New Norm" of Cardiac Rehabilitation after Stroke
Authors: Miller Elaine T , Dunning Kari , Whitesel Dustyn , Deinlein Amber , Kissela Brett , Boyne Pierce , Savicki Tony , Gerson Myron , Couch Sarah , Tsevat Joel , Ittenbach Richard , Ballman Kathleen , Faulkner Theresa , McCormack Thomas
Published: June 2021

Background and Purpose:
Physical inactivity after stroke stymies motor recovery, perpetuates further deconditioning, and contributes to a high long-term risk of cardiac events and recurrent stroke. This study used stakeholder input to develop a cardiac rehabilitation program specific to stroke.

Methods:
An exploratory qualitative study was performed consisting of separate focus groups of stroke survivors, caregivers, rehabilitation clinicians, nurse practitioners along with individual physician interviews. Two experienced researchers in qualitative research methodology independently identified themes, patterns, and issues prioritized by participants.

Results:
Four major themes emerged: safety, individualization of the cardiac rehabilitation program, return to function and living at highest potential, and need to maintain prolonged activity. Major components identified in developing the cardiac rehabilitation program included: Individualized stroke survivor education pertaining to fall prevention, safe aerobic exercise and learning how to live well after stroke (e.g., fitness, nutrition, chronic disease management, etc.); Exercise/stress testing prior to aerobic exercise; Determine when to begin cardiac rehabilitation post stroke (e.g., readiness, needs, resources, benefit, etc.), individualize approach and timing after holistic assessment; Education/training of cardiac rehabilitation professionals regarding best care practices for stroke survivors; Interdisciplinary approach to assure safety and continuum of care; Referral programs for IADLs, driving, sexual function, etc.; Motivational interviewing to overcome barriers with inclusion of peer mentoring/coaching; Discharge to cost effective community programs or a sustainable home program.

Conclusions:
Addressing safety concerns along with the creation of an individualized cardiac rehabilitation program that enables stroke survivors to achieve and maintain their highest level of function long-term are fundamental components. Partnering with the major stakeholders and incorporating a coordinated interdisciplinary approach are crucial to the creation of a feasible and cost effective cardiac rehabilitation program for stroke survivors.
Abstract WP171: Female Sex Hormones and Post Acute Stroke Outcome
Authors: Ashley Jessica , Singh Charan , Griesbach Grace S
Published: June 2021

Introduction:
The protective effects of estrogen are widely known following brain injury and waning female sex hormones such as estrogen and prolactin with age are associated with decline in cognitive performance. In this study, we focus on the relationship between female sex hormones and outcome following stroke, specifically how these hormones affect level of disability and responsiveness to rehabilitation following stroke.

Methods:
Sex hormone levels were evaluated in 54 female stroke survivors with a mean latency of 98.8 days (SEM ± 23.06). Age differences in hormone levels and disability were evaluated according to younger (Y; M=39.3, SEM ± 1.5) and older (O; M=58.4, SEM ± 1.2) age categories. Functional ability was assessed with the Disability Rating Scale (DRS), Independent Living Scale (ILS) and the Mayo-Portland Adaptability Inventory 4 (MPAI). All patients underwent post acute rehabilitation.

Results:
The Y group had higher levels of estradiol (p<0.05) and prolactin (p<0.05) compared to the O group. Correspondingly, follicle stimulating (FSH) and luteinizing hormones (LH) were higher in the O group (p<0.05). The Y group had lower disability according DRS, ILS activities of daily living (ADL) subscale and MPAII (p<0.05). High levels of prolactin were correlated with better performance in ADL’s (p<0.005). Estradiol correlated with lower disability as measured by MPAI (p<0.005). High values of FSH were associated with lower initiation as assessed by a subscale of the ILS. Analysis of changes in outcome measures before and after rehabilitation showed that both groups benefited equally.

Conclusions:
Hormones are predictive of levels of disability and independence in ADL’s. Sex hormone levels in post-stroke patients should be considered for prognostication. In spite of hormonal differences both groups benefit from rehabilitation.
Abstract WP177: Retinal Nerve Fiber Layer Thickness and Risk Factors of Stroke
Authors: Wang Dandan , Li Yang , Zhou Yong , Wu Shouling , Wei Wenbin , Zhao Xingquan
Published: June 2021

Background and Purpose:
We aimed to find the relationship between retinal nerve fiber layer (RNFL) thickness and the relevant risk factors of different stroke subtypes of TOAST classification, in order to make a better primary prevention of stroke.

Method:
The study population came from the first follow- up of the Asymptomatic Polyvascular Abnormalities Community study (APAC) population. We finished the questionnaire of epidemiological information and medical history during the baseline time, and finished the physical and laboratory examination, transcranial doppler, carotid ultrasound, cognitive functional scale and ophthalmological optical coherence tomography (OCT) examination to measure the thickness of RNFL and whether there exists intracranial artery stenosis (ICAS), extracranial artery stenosis (ECAS) or cognitive impairment. Then we discuss the association between RNFL thickness and the risk factors of stroke mentioned above.

Results:
We included 5440 participants at baseline and 3376 finished the follow- up eventually. The average thickness of RNFL was 101.89± 10.53 μm. As RNFL became thinner, the percentage of older age, male sex and hypertension became higher (P<0.001). We also found out that ICAS and ECAS, especially ECAS increased as RNFL become thinner (OR:0.982,95% CI:0.969- 0.996,P= 0.011), and the severity of ECAS became worse when RNFL was thinner (P=0.001), and retinal central arteriolar was narrower (P=0.003). What is more, RNFL thickness is associated with cognitive impairment as well (P< 0.05).

Conclusion:
The thickness of RNFL is associated with stroke risk factors, such as older age, male sex and hypertension. As RNFL became thinner, the prevalence of ICAS and ECAS, which are the main cause of LAA stroke, became higher, and the severity of ECAS became worse. The thinner RNFL was also relevant with cognitive impairment, which is common in the SAO stroke. The results provide a new point of view on stroke classification and prevention.
Abstract WP185: Stroke Pre And Post Cardiac Events; A Predictive Or A Prognostic Factor!
Authors: AlHejily Wesam A , Almekhlafi Mohammed
Published: June 2021

Background:
Cerebral and cardiovascular events can occur simultaneously in a given patient or in differential timing. There are no comparative studies on the impact of stroke timing difference on the risk and outcome of coronary events.

Objective:
To describe the association of cerebrovascular and cardiac events and the impact of the order of occurrence of these events on patients’ outcomes.

Design:
Retrospective longitudinal cohort study

Setting:
Single tertiary center from 2010 through 2015

Patients:
All patients with who underwent coronary angiogram or had a primary admitting diagnosis of stroke.

Methods:
The two separate databases were crossed matched to identify patients with both diagnoses, and then temporal relationships were identified on both directions (stroke before or after cardiac event). Cardiac events include any suspected acute coronary events that triggered referral for coronary angiogram.

Outcome Measures:
A composite of death, recurrent stroke and re-hospitalization within 30 days.

Results:
Among 6300 cardiac patients and 500 stroke patients, 16 patients were identified with both diagnoses. The mean age was 56.9±18.5 years, and 37.5% were females. The most common vascular risk factors were hypertension (94%) diabetes (81%), atrial fibrillation (25%), and renal impairment (6%). When classified based on stroke timing, a quarter (n=4) of patients had stroke pre cardiac event and 75% (n=12) had stroke post cardiac event. The composite endpoint of death, recurrent stroke and re-hospitalization within 30 days was higher in the stroke pre cardiac event group (
p=0.0001)
This was primarily driven by increased risk of recurrent stroke in the stroke pre vs. post cardiac event: odds ratio 2.4 (1.2-4.7) vs. 0.4 (0.2-0.8), respectively. The mean time from stroke to cardiac event was 89.5 days compared to 40.5 months from cardiac event to stroke.

Conclusions:
In this cohort, we observed low co-incidence of stroke with symptomatic coronary disease. Stroke preceding cardiac events carried worse prognosis than its occurrence after a cardiac event. This could imply different vulnerability of the cerebral and coronary vascular beds. Optimization of medical treatment after stroke will reduce future cerebrovascular and coronary events.