bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract MP25: Inequities in Interhospital Transfer for Acute Ischemic Stroke in the United States: Lower Odds for Women and the Underinsured
Authors: Oh Daniel M , Markovic Daniela , Towfighi Amytis
Published: March 2021

Background:
Patients with acute ischemic stroke (AIS) may undergo interhospital transfer (IHT) for higher level of care. Although the Emergency Medical Treatment and Active Labor Act stipulates that patients should be transferred to and accepted by referral hospitals if indicated, it offers few concrete guidelines, making it vulnerable to bias. We hypothesized that (1) IHT for AIS has increased over recent years and (2) minorities, women, and those without insurance had lower odds of IHT.

Methods:
Using the National Inpatient Sample, adults (>18 yrs) with a primary diagnosis of AIS from 2010 to 2017 (n=770,970) were identified, corresponding to a weighted sample size of 3,798,440. Those transferred to another acute hospital were labeled IHT. Yearly rates of IHT were assessed. Adjusted odds ratio (AOR) of IHT (vs. not transferred) were compared in 2014-2017 vs. 2010-2013 using a multinomial logistic model, adjusting for socioeconomic, medical, and hospital characteristics. Multinomial logistic regression was used to determine odds of IHT by race/ethnicity, sex, and insurance status, adjusting for the above characteristics.

Results:
From 2010 to 2017, the proportion of IHT declined from 3.2% (SE 0.2) to 2.9% (SE 0.1). Comparing IHT in 2014-2017 to 2010-2013 showed lower odds of IHT (OR 0.93, 95% CI 0.88-0.99), but this difference did not remain significant in the fully adjusted model. Fully adjusted OR showed that black patients were more likely than white patients to undergo IHT (AOR 1.13, 1.07-1.20). Women were less likely than men to be transferred (AOR 0.89, 0.86-0.92). Compared to those with private insurance, those with Medicaid (AOR 0.86, 0.80-0.91), self-pay (0.64, 0.59-0.70), and no charge (0.64, 0.46-0.88) were less likely to undergo IHT.

Conclusions:
Adjusted odds of IHT for AIS did not change significantly. Blacks were more likely than whites to be transferred; however, women and the uninsured/underinsured were less likely to be transferred. Further studies are needed to further understand these inequities and develop interventions and policies to ensure that
all
individuals have equitable access to stroke care, regardless of their race, sex, or ability to pay.
Abstract MP28: Nationwide Racial Disparities in Smoking Cessation After Stroke in the United States
Authors: Parikh Neal S , Parasram Melvin , Zhang Yongkang , Mir Saad , White Halina , Navi Babak B , Kamel Hooman
Published: March 2021

Introduction:
Black Americans face a higher risk of recurrent stroke than White Americans, and the reasons are unclear. Smoking after stroke is associated with a higher risk of recurrence. We investigated whether there are racial disparities in smoking cessation among stroke survivors in the United States.

Methods:
We performed a cross-sectional analysis of data from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System, an annual, nationally representative health survey. Respondents are asked about medical conditions and health-related behaviors. We pooled data from 2013-2018, during which race and ethnicity were uniformly reported. We included respondents with prior stroke and any smoking history. The exposure was self-reported race, and the outcome was smoking cessation. We calculated the quit ratio, defined as the proportion of former smokers among ever smokers; this is a standard measure in population-based studies of smoking cessation. Survey procedures were used to estimate frequencies and summarize quit ratios by race. Multiple logistic regression was used to assess the association of Black race with smoking cessation, as compared to White race, while adjusting for age, gender, Hispanic ethnicity, education, income, health insurance, and the number of smoking-related health conditions (heart disease, lung disease, cancer) that may prompt cessation.

Results:
Among 4,374,011 Americans with a history of stroke and any smoking, the median age was 67 years (IQR, 58-76), and 45.7% were women; 15.4% were Black, 74.8% were White, and 9.8% reported other race. The crude quit ratio was 51.4% (95% CI, 49.0-53.7) in Black and 63.2% (95% CI, 62.4-64.1) in White stroke survivors. In unadjusted analyses, Black stroke survivors were less likely to have quit smoking than White stroke survivors (OR, 0.61; 95% CI, 0.55-0.68). This remained the case after accounting for differences in demographics and smoking-related comorbidities (OR, 0.85; 95% CI, 0.74-0.98).

Conclusion:
In this nationwide study, Black stroke survivors had lower smoking quit rates than White stroke survivors, even after accounting for group differences. Expanding access to smoking-cessation interventions may reduce disparities in recurrent stroke.
Abstract MP29: Effects of System-Level Factors on Race/Ethnic Differences in In-Hospital Mortality After Acute Ischemic Stroke
Authors: Ibish Abdullah , Sun Philip , Markovic Daniela , Faigle Roland , Gottesman Rebecca F , Towfighi Amytis
Published: March 2021

Introduction:
Stroke mortality has declined, with differential changes by race; stroke is now the 5
th
leading cause of death overall, but 2
nd
leading cause of death in blacks. Little is known about recent race/ethnic trends in
in-hospital mortality
after acute ischemic stroke (AIS) and whether system-level factors contribute to possible differences.

Methods:
Using the National Inpatient Sample, adults (>18 yrs) with a primary diagnosis of AIS from 2006 to 2017 (n=763,808) were identified. We assessed
in-hospital mortality
by race/ethnicity (white, black, Hispanic, Asian/Pacific Islander [API], other), sex, and age. Hospitals were categorized by proportion of minority patients served: <25% minority (white hospitals); 25-50% (mixed hospitals), and >50% (minority hospitals). Using survey adjusted logistic regression, the association between race/ethnicity and odds of mortality was assessed, adjusting for key sociodemographic, clinical, and hospital characteristics (e.g. age, comorbidities, stroke severity, DNR status, and palliative care).

Results:
Overall, mortality decreased from 5.0% in 2006 to 2.9% in 2017, p<0.001. Comparing 2006-2011 to 2012-2017, there was a 66% reduction in mortality after adjustment for covariates, most prominent in whites (68%) and smallest in blacks (58%). Compared to whites, blacks and Hispanics had
lower
adjusted odds of mortality (AOR 0.82, 95% CI 0.78-0.86 and AOR 0.92, CI 0.86-0.98), primarily driven by those >65 yrs (age x ethnicity interaction p = 0.003). Compared to white men, black, Hispanic, and API men and black women had lower odds of mortality. Adjusted mortality was lower in minorities vs. whites and most pronounced in white hospitals (white: AOR 0.78, 0.73-0.85; mixed: 0.85, 0.80-0.91; minority: 0.89, 0.82-0.95; interaction effect: p=0.018). These differences were present for both minority men and women in white and mixed hospitals, but not women in minority hospitals.

Discussion:
AIS mortality decreased dramatically in recent years. Overall, black and Hispanic AIS patients have
lower
mortality than whites, a difference that is most striking in white hospitals. Further study is needed to understand these differences and to what extent biological, sociocultural, and system-level factors play a role.
Abstract MP34: Retrospective Analysis on Predictive Factors and Timeline for Early Neurologic Decline and Symptomatic Intracranial Hemorrhage Following Administration of Intravenous Recombinant Tissue Plasminogen Activator for Ischemic Stroke
Authors: Clark Alexander , Shah Kavit , Desai Shashvat , Jadhav Ashutosh
Published: March 2021

Introduction:
Current guidelines recommend that patients given intravenous tPA (IV tPA) for acute ischemic stroke (AIS) receive comprehensive stroke care for 24 hours post-treatment to monitor key physiologic variables.
1,2,3
Early de-escalation of monitoring is likely feasible in a particular subset of patients, which may have implications in the post-COVID era.
4
In this study, we examined when patients with AIS are susceptible to early neurologic decline (END) and symptomatic intracranial hemorrhage (sICH) after IV tPA and whether those at low clinical risk of neurologic deterioration may be suitable for earlier transition to lower level of care.

Methods:
We performed a retrospective analysis of AIS receiving IV tPA based on AHA/ASA guidelines. We included those that presented within 4.5 hours of last seen well (LSW) without large vessel occlusion (LVO) or flow-limiting stenosis (FLS) on non-invasive angiographic imaging. Outcomes included END (≥4-point worsening of NIHSS at 24 hours) from any cause, parenchymal hemorrhage (PH1 or PH2), and/ or symptomatic intracranial hemorrhage (sICH; ≥4-point NIHSS worsening with presence of hemorrhage).

Results:
1238 patients were included from 1/2013 - 6/2019. END and ICH occurred in 7.4% (91) and 9.4% (116), respectively. 63.7% of patients with END did not have ICH within 24 hours. In those with NIHSS <12, 82% had END within 12 hours and most occurred within 5 hours. Predictive factors included older patients (72.6 ±16.1 vs 69.1 ±14.8, p=0.03), history of tobacco use (OR-2.1 [1.1-4.3], p = 0.04) and hyperlipidemia (OR-1.7 [1.1-2.8] p = 0.02). ICH occurred within 12 hours in 30% of patients, predictors included older age (74.6 ± 12.4 vs 68.8 ± 15.1, p ≤ 0.01), higher NIHSS (14.6 ± 7.3 vs 10.8 ± 7.9, p ≤ 0.01), and higher presentation serum glucose levels (155.1 ± 87.5 vs 140.4 ± 70.5, p = 0.04). Overall, only 2.7% (33) of patients developed sICH. There were no independent predictive factors for delayed ICH (≥ 12 hours).

Conclusion:
In our selected post-IV tPA patients, a relatively small proportion suffered sICH and END; most often within 12 hours of tPA administration. These findings may support earlier de-escalation of higher acuity monitoring for clinically stable post-IV tPA patients.
Abstract MP35: Blood Pressure Reductions Before Arrival at a Thrombectomy-Capable Hospital Are Associated With Neurologic Worsening in Patients With Large-Vessel Occlusion
Authors: Kobsa Jessica , Prasad Ayush , Soto Alexandria , Kodali Sreeja , Nguyen Cindy Khanh , Peshwe Krithika , Quispe-Orozco Darko , Farooqui Mudassir , Zeballos Cynthia , Sansing Lauren H , Schindler Joseph L , Matouk Charles , Sheth Kevin N , Ortega-Gutierrez Santiago , Petersen Nils H
Published: March 2021

Introduction:
Decreases in blood pressure (BP) during thrombectomy are associated with infarct progression and worse outcomes. Many patients present first to a primary stroke center (PSC) and are later transferred to a comprehensive stroke center (CSC) to undergo thrombectomy. During this period, important BP variations might occur. We evaluated the association of BP reductions with neurological worsening and functional outcomes.

Methods:
We prospectively collected hemodynamic, clinical, and radiographic data on consecutive patients with LVO ischemic stroke who were transferred from a PSC for possible thrombectomy between 2018 and 2020. We assessed systolic BP (SBP) and mean arterial pressure (MAP) at five time points: earliest recorded, average pre-PSC, PSC admission, average PSC, and CSC admission. We measured neurologic worsening as a change in NIHSS (ΔNIHSS) from PSC to CSC >3 and functional outcome using the modified Rankin Scale (mRS) at discharge and 90 days. Relationships between variables of interest were evaluated using linear regression.

Results:
Of 91 patients (mean age 70±16 years, mean NIHSS 12) included, 13 (14%) experienced early neurologic deterioration (ΔNIHSS>3), and 34 (37%) achieved a good outcome at discharge (mRS<3). We found that patients with good outcome had significantly lower SBP at all five assessed time points compared to patients with poor outcome (Figure 1, p<0.05). Percent change in MAP from initial presentation to CSC arrival was independently associated with ΔNIHSS after adjusting for age, sex, and transfer time (p=0.03, β=0.27).

Conclusions:
Patients with poor outcomes have higher BP throughout the pre-CSC period, possibly reflecting an augmented hypertensive response. Reductions in SBP and MAP before arrival at the CSC are associated with neurologic worsening. These results suggest that BP management strategies in the pre-CSC period to avoid large reductions in BP may improve outcomes in patients affected by LVO stroke.
Abstract MP45: Racial Differences in Adult Moyamoya Disease: Clinical Presentation, Angiographic Characteristics, and Outcomes After Revascularization
Authors: Wang Allan R , Li Yiping , STEINBERG Gary K
Published: March 2021

Introduction:
Racial differences in the clinical presentation, angiographic characteristics, and treatment outcomes of adult moyamoya disease (AMMD) are not well-characterized.

Methods:
Consecutive patients with AMMD prospectively treated at our institution from 2015-2018 were reviewed.

Results:
261 patients with AMMD were enrolled (91 Asian/Pacific Islander, 128 Caucasian, 21 Hispanic, 21 Black). Asian patients were older at first clinic visit (43.6±10.8 vs. white 38.0±10.8, Hispanic 41.0±10.3, black 39.1±9.4; p=0.003). There were no differences in rates of hypertension (p=0.23) or smoking (p=0.36), but Hispanic patients had higher rates of diabetes (38% vs. Asian 16%, Caucasian 11.7%, Black 28.5%; p=0.05). All 7 patients with known familial MMD were Asian (p=0.002). There were no differences between races in terms of ischemic or hemorrhagic presentation; however, Asian patients were less likely to present with sentinel events such as headache (50.5% vs. Caucasian 71%, Hispanic 71.4%, Black 52.4%; p=0.03). On pre-operative angiography, Asians were more likely to have anterior choroidal or posterior communicating artery moyamoya collaterals (44% vs. Caucasian 30%, Hispanic 17%, Black 28.6%; p=0.004) and more extensive external carotid artery supply (4.9±10.6% vs. Caucasian 2.2±6.3%, Hispanic 1.3±4.5%, Black 1.1±3.0%; p=0.05). There were no differences in rates of peri-operative symptomatic infarct (p=0.94) or hemorrhage (p=1.0). After revascularization, moyamoya collaterals were more likely to regress/improve in Asians (59% vs. Caucasian 39.5%, Hispanic 28.6%, Black 33%; p=0.005), remain stable in Caucasians (58.6% vs. Asian 36%, Hispanic 52.4%, Black 56%; p=0.03), and increase/worsen in Hispanics (19% vs. Asian 5%, Caucasian 1.9%, Black 11%; p=0.01). At last follow-up with a mean of 1.91±1.5 years, there were no differences in functional outcomes between races (p=0.94).

Conclusions:
AMMD patients of Asian descent may present later in the disease course, potentially due to experiencing fewer milder symptoms such as headache that may serve as early warning signs. The effect of revascularization on regression of moyamoya collaterals may differ based on race. The clinical impact of these differences requires further investigation.
Abstract MP46: Internal Carotid Artery Web and Acute Ischemic Stroke - A Systematic Review and Meta-Analysis
Authors: Mac Grory Brian C , Boyanpally Anusha , Stretz Christoph , El-Jamal Sleiman , Shah Shreyansh , El-Husseini Nada , Chhatbar Pratik Y , Chilukuri Vani , Ehrlich Matthew , Guhwe Mary , Kam Wayneho , Le Scott , Xian Ying , Graffagnino Carmelo , Schrag Matthew , Yaghi Shadi , Nossek Erez , Feng Wuwei
Published: March 2021

Introduction:
The carotid web is a compelling potential mechanism of embolic ischemic stroke. In this study, we perform a systematic review and meta-analysis to determine the prevalence of ipsilesional carotid webs in patients with acute ischemic stroke.

Methods:
We performed a systematic review of prospective and retrospective observational studies enrolling consecutive patients with acute ischemic stroke. We included only studies in which high quality imaging of the cervical vessels was performed and in which the presence or absence of carotid web was adjudicated based on established criteria. The prevalence of carotid web was calculated in each study and pooled prevalence calculated via a random effects model. We also calculated relative risks of carotid web ipsilateral versus contralateral to stroke in the same pool of patients and performed sensitivity analyses including patients with cryptogenic stroke, patients less than 60 and patients with cryptogenic stroke <60.

Results:
A systematic review yielded 3,814 patients from 11 studies of whom 1,127 had cryptogenic stroke. We identified 4 studies in which we could derive data on patients <60 with cryptogenic stroke, a total of 332 patients. The relative risk of carotid web ipsilateral versus contralateral to ischemic stroke was 2.6 (95%: 1.6-4.3, p<0.01) in all patients with acute ischemic stroke and 3.0 (95% CI: 1.6-5.8, p<0.01) in patient less than 60 with cryptogenic stroke (
Figure A-C
). The pooled prevalence of ipsilateral carotid web in patients <60 with cryptogenic stroke was 13% (95% CI: 7%-22%; I
2
= 66.1%) (
Figure D
).

Discussion:
Carotid webs are more common in young patients with ESUS than in other stroke subtypes. Future studies concerning the diagnosis and secondary prevention of stroke associated with carotid web should focus on this population.
Abstract MP48: Intracranial Dolichoectasia in Patients With Symptomatic Intracranial Atherosclerotic Disease: The Myriad Study
Authors: Del Brutto Victor J , Nizam Azhar , cotsonis george , Campo-Bustillo Iszet , Liebeskind David S , Prabhakaran Shyam , Romano Jose G
Published: March 2021

Background:
It is unknown whether intracranial atherosclerotic disease (IAD), in addition to vessel narrowing, also contributes to the abnormal dilation and increased tortuosity of intracranial vessels, a condition known as intracranial dolichoectasia (IDE). We aim to determine the degree to which these two arteriopathies coexist and whether IDE correlates with subsequent ischemic events in patients with recently symptomatic moderate-to-severe IAD.

Methods:
The study included 99 patients (mean age 6311 years; 57% men) enrolled in the Mechanisms of Early Recurrence in Intracranial Atherosclerotic Disease (MyRIAD) study. Intracranial vessels diameter, length, and tortuosity were determined by semiautomatic vessel segmentation and were considered abnormal if ≥2 standard deviations from the study population mean. Either ectasia (increased diameter) or dolichosis (increased tortuosity) defined IDE. We assessed the correlation of IDE in the symptomatic vessel with the composite outcome of either new infarcts in the territory of the affected vessel on brain MRI performed at 6-8 weeks from the index event or stroke recurrence during 12-month follow up.

Results:
IDE prevalence was 34% (isolated ectasia 8%, isolated dolichosis 18%, and both ectasia and dolichosis 8%) and 14% of symptomatic vessels. Patients with and without IDE had similar demographics and vascular risk factors prevalence (Table). I Twenty-two out of 85 (26%) patients with brain MRI at 6-8 weeks had new infarct(s) in the territory and 9% of the entire cohort had stroke recurrence during follow-up. Coexistence of IAD and IDE in the target vessel was not associated to subsequent ischemic events (21.4% versus 29.4%; P=0.54).

Conclusion:
IDE is a common finding in patients with moderate-to-severe IAD. Superimposed IDE did not increase the already heightened risk of subsequent ischemic events in patients with symptomatic IAD.
ClinicalTrials.gov Identifier:
NCT02121028
Abstract MP49: Subgroup Analysis of Icosapent Ethyl for Hypertriglyceridemia in Prevention of Non-Fatal Stroke and Overall Mortality
Authors: Assad Salman , Zahid Mehar , Assad Malik Shuja
Published: March 2021

Background and Purpose:
Often in clinical practice, stroke patients with elevated triglycerides more than 150 mg/dl are seen despite being treated with moderate to high-intensity statins and with even in settings of low-density lipoprotein (LDL) <70 mg per deciliter (mg/dl). This analysis aims to understand the role of icosapent ethyl (IPE) for controlling the elevated triglycerides in cardiovascular and cerebrovascular high-risk populations.

Methods:
We performed the subgroup analysis of the REDUCE-IT double-blinded controlled study. The patient population included had either established cardiovascular disease or diabetes and other risk factors, who had been receiving statin therapy and who had a fasting triglyceride level of 135 to 499 mg/dl and a low-density lipoprotein cholesterol level of 41 to 100 mg/dl. The patients were randomly assigned to receive 2 g of IPE twice daily (total daily dose, 4 g) or placebo. The primary outcomes assessed as nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or unstable angina. The secondary outcomes were death from any cause, cardiovascular, or cerebrovascular related mortality.

Results:
Almost 8179 patients were studied (70.7%) for secondary prevention of cardiovascular and cerebrovascular events and were followed for a median of 4.9 years. The rate of death from any cause was 6.7% in the IPE group and 7.6% in the placebo group (hazard ratio [HR], 0.87; 95% confidence interval [CI] 0.74 to 1.02). The time to event analysis over 4.5 years follow up showed better primary outcomes by 17.2% in the IPE group than 22% in placebo, HR 0.75; 95% CI, 0.68 to 0.83; p<0.001). The secondary outcomes in terms of overall mortality from cerebrovascular or cardiovascular accidents were reduced by 25% in IPE compared to placebo (HR: 0.74; 95% CI 0.65-0.83; p<0.001).

Conclusion:
The combination therapy of IPE with moderate to high dose statins reduces the overall risk of cardiovascular and cerebrovascular accidents and mortality. The better primary and secondary outcomes were achieved irrespective of triglyceride levels at one year and it does explain the other metabolic effects of IPE.
Abstract MP7: Multicenter Study of Intracranial Hemorrhage and Death Risk and Predictors in the Untreated Course of Brain Arteriovenous Malformation Patients
Authors: Kim Helen , Nelson Jeffrey , McCulloch Charles , Hetts Steven , Hess Christopher , Zaroff Jonathan , Moayeri Nicole , Flemming Kelly , Lanzino Giuseppe S , Krings Timo , Zhao Yuanli , Morgan Michael , Mohr J P , Lawton Michael , Al-Shahi Salman Rustam
Published: March 2021

Background:
Accurate and reliable models of intracranial hemorrhage (ICH) risk in the untreated course of brain arteriovenous malformation (BAVM) patients are needed to help weigh the risk-benefit of treatment. We present preliminary estimates of rates and risk factors for ICH or death in the Multicenter AVM Research Study (MARS), which is the largest individual patient data meta-analysis (IPDMA) of cohort studies of unruptured BAVM.

Methods:
Longitudinal data from 9 cohorts comprising 2,839 unruptured BAVM at time of diagnosis were included: UCSF (n=557), Macquarie (n=462), Kaiser Permanente Northern California (n=354), Columbia (n=335), Barrow Neurological Institute (n=324), Tiantan Hospital (n=303), Mayo Clinic-Rochester (n=244), Scottish Intracranial Vascular Malformation Study (n=194), and Toronto Western Hospital (n=66). Clinical and angiographic data were collected using standardized definitions across cohorts. Cox proportional hazards analysis of time-to-event (ICH or death) in the untreated course after diagnosis was performed, censoring at first treatment or last visit. Baseline hazard rates were stratified by cohort to account for different rates and follow-up times.

Results:
The combined cohort was 49% female, 72% white race, and 17% Hispanic ethnicity; mean age at diagnosis was 37±17 years and mean follow-up was 3.4±7.0 years. The most common presenting symptom was seizures (43%). Mean AVM size was 3.5±1.9 cm and 46% were Spetzler-Martin grade I-II. Overall, 123 ICH and 131 deaths occurred over 9,608 person-years (PY) for an event rate of 2.64 per 100 PY [95% CI: 2.34-2.99]. Cox regression analyses adjusting for age at diagnosis (HR=1.67 [1.54, 1.82], P<0.001) identified cerebellar location (HR=1.73 [1.03-2.93], P=0.040) and exclusively deep venous drainage (HR=1.83 [1.09-3.09], P=0.022) as predictors.

Conclusion:
Our current model identified increasing age, exclusively deep venous drainage, and cerebellar location as risk factors for ICH or death in the untreated course of unruptured bAVM patients. Review of imaging data, multiple imputation of missing angioarchitectural data, and additional data from pending cohorts will provide greater power to search for additional risk factors in this ongoing IPDMA.
Abstract P10: Posterior Circulation Strokes Are Less Likely to Receive Alteplase or Mechanical Thrombectomy: Analysis From the IAC Study
Authors: Kala Narendra S , Yaghi Shadi , De Havenon Adam H , Liberman Ava L , Mistry Eva , Henninger Nils , Leon Guerrero Christopher , Liu Angela , Pasupuleti Hemanth , Scher Erica , Asad Syed Daniyal , Keyrouz Salah G , Azher Aidan I , Moeini-Naghani Iman , Moncrieffe Khadean , Furie Karen L , Giles James A , Nouh Amre , Fakhri Hiba , Lord Aaron , Mac Grory Brian C , Tan Jose T , Espaillat Kiersten , Martin Heather , Siddu Mithilesh , Nagy Muhammad , Veerasamy Manivannan , Trivedi Tushar , Khan Muhib , esenwa charles , Kaushal Ashutosh , Cheng Natalie , Cutting Shawna M
Published: March 2021

Background:
Emergent treatment with intravenous thrombolysis and mechanical thrombectomy improved outcomes in patients with acute ischemic stroke. We aim to identify differences in acute stroke treatment trends between strokes occurring in the anterior versus posterior circulation.

Methods:
The IAC (Initiation of Anticoagulation after Cardioembolic stroke) study represents pooled data registry of 8 comprehensive stroke centers across the United States and included patients with cardioembolic stroke in the setting of AFib. In a post hoc analysis, we identified and separated patients into posterior circulation stroke (PCS) and anterior circulation stroke (ACS) groups based on imaging. Patients without infarct locations or those with multi-circulation infarcts were excluded. We compared baseline characteristics, stroke severity and the treatment trends with alteplase (tPA) and mechanical thrombectomy (MT) in PCS vs ACS using Fisher exact test, t-test and non-parametric tests. We then performed multivariable logistic regression adjusted for baseline differences to determine the associations between PCS and tPA or MT.

Results:
Of the 2084 patients in IAC cohort, 1589 met inclusion criteria for this study, in which 294 (22.7%) had PCS. Mean age was 76.8 years, 29.3% received tPA and 26.9% had MT. When compared to ACS, patients with PCS were more likely to be men (55.4% vs 45.6%, p=0.003), have diabetes (42.8% vs 29.8, p< 0.001) and lower median NIHSS score on admission (4 vs 8, p<0.001). Patients with PCS were less likely to receive tPA (16.3% vs 32.3%, p<0.001) or MT (10.9% vs 30.6%, p<0.001). Other variables were not significantly different. When adjusted for baseline differences, patients with PCS remained less likely to be treated with tPA (adjusted OR 0.49, 95%CI 0.35-0.70, p<0.001) or MT (adjusted OR 0.38, 95%CI 0.25-0.58, p<0.001).

Conclusion:
Posterior circulation strokes are half as likely to receive thrombolytic therapy and almost a third as likely to have thrombectomy, even after adjusting for baseline stroke severity scores. This is possibly due to difficulty in timely identification and diagnostic delays. There is need for better tools incorporating posterior circulation stroke signs and symptoms to allow for early detection and treatment.
Abstract P102: Elevated Von Willebrand Factor in Patients Presenting With Large-Vessel Occlusion Stroke as First Symptom of COVID-19 Mirrors Levels in Patients With COVID-19 Requiring ICU-Level Care
Authors: Olson Lyra B , Naqvi Ibtehaj A , CHEN LINGYE , Que Loretta G , KRAFT BRYAN D , Nair Smita K , Nimjee Shahid M , Sullenger Bruce A
Published: March 2021

Introduction:
COVID-19 is a coagulopathic disease marked by elevated d-dimers, fibrinogen, and von Willebrand factor (vWF) levels accompanying arterial and venous thrombosis. While the majority of thrombotic events associated with COVID-19 occur in hospitalized patients, a subset of patients with minimal risk factors for CVA but with positive SARS-CoV-2 testing present with stroke as presumed first manifestation of infection. It is unclear if the pro-coagulant milieu present in patients requiring hospitalization for the respiratory complications of COVID-19 is the same as that of patients who present with stroke as first symptom of disease.

Methods:
Following emergent revascularization, clinical vWF levels were measured in patients presenting with stroke who tested positive for COVID-19. In parallel, plasma vWF levels from 28 patients with COVID-19 requiring ICU-level care and 8 healthy volunteers were measured via ELISA.

Results:
Three otherwise healthy patients between the ages of 45-55 years with positive test for SARS-CoV-2 presented with large-vessel stroke. By comparison, the average age of non-COVID stroke patients was 66 years. The consistency of the clots extracted through the aspirating catheter was dark, gelatinous throughout, without evidence of calcification, and distal thrombosis was noted minutes after revascularization. The vWF level for one patient was 345%, while the other two patients had vWF levels >400% of normal, exceeding the upper limit of detection of clinical assays. In the ICU cohort, 12 of 28 had thrombotic events during hospitalization. vWF levels were elevated by a mean of 800% over healthy controls with a range of 230-1670%.

Conclusions:
vWF levels were markedly elevated in both ICU patients and stroke patients with COVID-19 with an overlapping range of elevation over healthy controls. This suggests that widespread endothelial inflammation accompanies infection with SARS-CoV-2 even in the absence of respiratory symptoms.
Abstract P104: Incidence, Characteristics and Outcomes of Large Vessel Stroke in Covid-19: An International Multicenter Study
Authors: Khandelwal Priyank , Al-Mufti Fawaz , Tiwari Ambooj , Singla Amit , Dmytriw Adam A , Piano Mariangela , Quilici Luca , Pero Guglielmo , Renieri Leonardo , Limbucci Nicola , Martinez-Galdamez Mario , Arenillas-Lara Juan F , Schuller Miguel , Galvan Jorge , Hashim Zafar , Nayak Sanjeev , DeSousa Keith , Sun Hai , Agarwalla Pankaj K , Nanda Anil , Roychowdhury Sudipta , Nourollahzadeh Emad , Prakash Tannavi , Efendizade Aslan , Gandhi Chirag D , Xavier Andrew R , Gupta Gaurav , Yavagal Dileep R
Published: March 2021

Background:
While there are reports of acute ischemic stroke (AIS) in COVID-19 patients, the overall incidence of acute ischemic stroke and clinical characteristics of large vessel occlusion in such patient remains to be established.

Methods:
A retrospective, international multicenter study of large vessel occlusion (LVO) was undertaken from March 1 to May 1, 2020 at 12 stroke centers from 4 countries. Detailed data were collected on consecutive LVOs in hospitalized patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the incidence of AIS/LVO was measured. Among patients who underwent mechanical thrombectomy, stroke outcomes along with COVID-19 symptoms were reported.

Results:
Out of a total of 6698 COVID-19 patients admitted to 10 stroke centers, the incidence of stroke was found to be 1.3% (range 0.6-2.6%). The median age of patients who presented with LVO was 51 years (range 27-87) and in the US centers, African Americans comprised 28% of all patients. Ten patients (16 %) were less than 50 years of age with no significant risk factors for LVOs the vast majority. Among the LVOs eligible for MT, the average time to presentation from symptom onset to presentation was 9.3 hours. Successful revascularization was achieved in 81% of patients and the intracranial hemorrhage rate was 14% with no symptomatic hemorrhages. Twenty-one (50%) patients were either discharged to home or to acute rehabilitation facilities.

Conclusion:
LVOs was predominant in patients with AIS and COVID-19, occurring at a significantly younger age and affecting African Americans disproportionately.
Abstract P108: Impact of the Covid-19 Pandemic on Hyperacute Stroke Treatment: Experience From a Comprehensive Stroke Centre in Singapore
Authors: Paliwal Prakash R , Tan Benjamin Y , Leow Aloysius , Sibi Sunny , Chor Daniel , Chin Amanda , Yau Ying-Wei , Cross Gail , Wong Lily , Chia Magdalene , Quak Zhixuan , Chua Christopher , Tang David , Zune Ei T , Hung Jennifer , Goh Yihui , Jing Mingxue , Gopinathan Anil , Yang Cunli , Ahmad Aftab , Khoo Deborah , Lee Chang-Chuan , Seet Raymond C , Sharma Vijay K , Teoh Hock-Luen , Yeo Leonard L , Chan Bernard P
Published: March 2021

Background:
The Coronavirus disease 2019 (COVID-19) pandemic is rapidly evolving and affecting healthcare systems across the world. Singapore has escalated its alert level to Disease Outbreak Response System Condition (DORSCON) Orange, signifying severe disease with community spread.

Objectives:
We aimed to study the overall volume of AIS cases and the delivery of hyperacute stroke services during DORSCON Orange.

Methods:
This was a single-centre, observational cohort study performed at a comprehensive stroke centre responsible for AIS cases in the western region of Singapore, as well as providing care for COVID-19 patients. All AIS patients reviewed as an acute stroke activation in the Emergency Department (ED) from November 2019 to April 2020 were included. System processes timings, treatment and clinical outcome variables were collected.

Results:
We studied 350 AIS activation patients admitted through the ED, 206 (58.9%) pre- and 144 during DORSCON Orange. Across the study period, number of stroke activations showed significant decline (p =0.004, 95% CI 6.513 - -2.287), as the number of COVID-19 cases increased exponentially, whilst proportion of activations receiving acute recanalization therapy remained stable (
p
= 0.519, 95% CI -1.605 - 2.702). Amongst AIS patients that received acute recanalization therapy, early neurological outcomes in terms of change in median NIHSS at 24 hours (-4 versus -4,
p
= 0.685) were largely similar between the pre- and during DORSCON orange periods.

Conclusions:
The number of stroke activations decreased while the proportion receiving acute recanalization therapy remained stable in the current COVID-19 pandemic in Singapore.
Abstract P109: Geography Not a Factor in 2020 Stroke Consults; A Telestroke Experience During the Covid19 Pandemic
Authors: Brown Aliza T , Backus Marzella L , Culp William C , Joiner Renee , Nalleballe krishna , Onteddu Sanjeeva
Published: March 2021

Introduction:
The COVID19 pandemic causes strokes in younger patient populations with higher deficits. We examined recent numbers of stroke consults, their age and deficits in a large telestroke program and compared them to 2019

Hypothesis:
Increased younger stroke consults in 2020 would involve higher deficits associated with COVID19.

Methods:
The Institute for Digital Health & Innovation-Stroke Program provides neurology support to 54 spoke hospitals across Arkansas. Stroke consults who received Alteplase during 01/01/20 to 07/31/20 were compared to the same months in 2019. Retrospective analysis included consult age, geographical region, mechanical thrombectomy (MT), deficits (initial and post NIHSS) and outcomes. Age was listed as < 65 or >/=65 yrs. The state was blocked into seven geographical regions. MT was noted and deficits as improved, worsened, same (no improvement) or unknown. COVID19 positivity was unknown.

Results:
Consult numbers declined in 2020 vs. 2019, 285 vs. 370, respectively. Both years saw MT in approximately 10%; however, 27% went to hospice or expired in 2020 vs. 7.7% in 2019. In 2020 and 2019, those < 65 consults who received MT were similar at 37 and 41% of total procedures, respectively. Pre-pandemic, there were significant differences in consult numbers among the seven regions (X2=30.1,n=370,p=0.037) in 2020, there were none (p=NS). The number of consults < 65 or >/= 65 years were not different between years(p=0.61); however, age had a similar significant effect on the initial NIHSS in both 2019 and 2020 (X2=13.5,n=370,p=0.0037 and X2=10.8,n=285,p=0.012, respectively). Improvement in initial deficit scores did not change (X2=6.9,n=655,p=0.074). No geographical differences were seen (p=0.66). Monthly initial deficits indicated a significant peak rise in the younger consults (< 65) in April 2020.

Conclusion:
Stroke consult numbers declined by 13% in 2020 but the proportion of young and old were unchanged. In April 2020, younger consults (< 65) experienced a spike in deficits. Further evaluation throughout 2020 is warranted as COVID19 cases spread.
Abstract P111: Ischemic Stroke Associated With Covid-19 and Racial Outcome Disparity in North America
Authors: Dmytriw Adam A , Phan Kevin , Schirmer Clemens , Settecase Fabio , Heran Manraj K , Efendizade Aslan , Kuhn Anna L , Puri Ajit S , Menon Bijoy K , Dibas Mahmoud , Sivakumar Sanjeev , Mowla Ashkan , Leung Lester , Malek Adel , Voetsch Barbara , Sehgal Siddharth , Wakhloo Ajay , Cohen Jake , Wu Hannah , Xavier Andrew R , Tiwari Ambooj
Published: March 2021

Introduction:
Underlying biological, genetic, or epigenetic characteristics may predispose to health differences and outcomes with COVID-19 associated stroke. Social determinants of health, access and geographical differences pertaining both to population density and other location-based factors may also be important.

Methods:
We report 69 cases of acute stroke in patients positive for SARS-CoV-2, in a dichotomized analysis of ischemic stroke outcomes between patients of African American background versus all other backgrounds. All patients presented to 14 major hospitals in the United States and Canada, from March 14-April 14, 2020. All patients had nasopharyngeal swab samples that were positive for SARS-CoV-2 on qualitative RT-PCR assays.

Results:
We found no significant difference in age (64.4 versus 62.9 years) or the proportion of females (51.9% versus 38.1%) (table 1). Diabetes mellitus was present significantly less in African American cases versus others (37% vs. 66.7%). The African American cohort had a similar mean NIHSS score of 16.3 compared with 14.9 in other races (p=0.63). The door-to-CT time was also similar (23 versus 19 minutes). The proportion of patients presenting with a large vessel occlusion was not significantly different (40.7% versus 47%). We noted 14.8% of African American cases received intravenous tPA compared to 31% in other races but was not significantly different. The proportion of thrombectomy cases mirrored this (14.8% versus 31%). Regarding stroke functional outcomes, there was no difference between African Americans and other races with respect to discharge mRS or proportion of favorable outcome (mRS 0-2). Symptomatic intracranial hemorrhage (sICH) was significantly higher for African Americans (11.1% versus 3%, p<0.001). Mortality was significantly higher in African Americans compared to other races (51.9% vs. 28.6%, p=0.03).

Discussion:
The reasons for increased mortality in African Americans with COVID-19-associated stroke are unknown. The finding in this study that mortality rate of COVID-19 positive stroke patients is greater than that previously reported in either COVID-19 respiratory infection alone or acute ischemic stroke alone, suggests an interaction that also warrants further study.
Abstract P112: Markers of Coagulation and Hemostatic Activation Identify Covid-19 Patients at High Risk for Thrombotic Events
Authors: Alabyad Darwish , RANGARAJU Srikant , Liu Michael , Imran Rajeel , Kempton Christine L , Sharifpour Milad , Auld Sara C , Gaddh Manila , Sniecinski Roman , Maier Cheryl L , Guarner Jeannette , Duncan Alexander , NAHAB Fadi B
Published: March 2021

Introduction:
COVID-19 has been associated with venous and arterial thrombotic complications. The objective of our study was to determine whether markers of coagulation and hemostatic activation (MOCHA) on admission could identify COVID-19 patients at risk for thrombotic events.

Methods:
COVID-19 patients admitted to a tertiary academic healthcare system from April 3, 2020 to July 31, 2020 underwent admission testing of MOCHA profile parameters (plasma d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, and fibrin monomer). For this analysis we excluded patients on outpatient anticoagulation therapy preceding admission. Prespecified endpoints monitored during hospitalization included deep vein thrombosis, pulmonary embolism, myocardial infarction, ischemic stroke and access line thrombosis.

Results:
During the study period, 276 patients were included in the analysis cohort (mean age 59 ± 6.3 years, 47% female, 83% non-white race). Arterial and venous thrombotic events occurred in 43 (16%) patients (see Table). Each coagulation marker was independently associated with the composite endpoint (p<0.05). Admission MOCHA with ≥ 2 abnormalities was associated with the composite endpoint (OR 3.1, 95% CI 1.2-8.3), ICU admission (OR 3.2, 95% CI 1.8-5.5) and intubation (OR 2.8, 95% CI 1.5-5.5). Admission MOCHA with < 2 abnormalities (26% of the cohort) had sensitivity of 88% and a negative predictive value of 93% for an in-hospital endpoint.

Conclusion:
Admission MOCHA with ≥ 2 abnormalities identified COVID-19 patients at risk for a thrombotic event, ICU admission and intubation while < 2 abnormalities identified a subgroup of patients who were at low risk for thrombotic events. Our results suggest that an admission MOCHA profile can be useful to risk stratify COVID-19 patients. Further studies are needed to determine whether an admission MOCHA profile can guide anticoagulation therapy and improve overall clinical outcomes.
Abstract P115: Fatigue Adaptation Among Stroke Survivors: A Sc
oping Review
Authors: Teng Chiao-Hsin , Phonyiam Ratchanok , Davis Leslie L , Anderson Ruth A
Published: March 2021

Introduction:
No study has systematically examined stroke survivors’ challenges with fatigue. We use the Adaptive Leadership Framework for Chronic Illness (ALFCI) to synthesize what survivors’ challenges are with fatigue and how they respond or collaborate with others to achieve poststroke fatigue adaptation.

Methods:
We searched PubMed, CINAHL, Embase, and PsycInfo using PRISMA-ScR guidelines, gathering studies between 2012 and 2020. Qualitative studies or qualitative findings in mixed-method studies were included if they described stroke survivors’ (cerebral infarction, TIA, and brain hemorrhage) experiences with fatigue and/or care partners’ experiences to help survivors adapt to fatigue. We excluded studies which were not full-text English and did not report empirical data (e.g., literature review or editorial). We used interpretive synthesis to analyze the published qualitative data.

Results:
Of 714 papers identified, we retained 25 papers (22 qualitative and 3 mixed-method studies). Using ALFCI to synthesize data, we found that survivors with fatigue had many types of adaptive challenges. Fatigue made them less productive and it affected their cognitive, language, and physical functions, as well as sleeping patterns and social activities. To respond to these challenges, survivors did adaptive work such as changing mindset, using energy-conservation strategies, restructuring routines, and exercising. Care partners, health professionals, and others showed leadership by helping survivors adapt to fatigue by giving information about fatigue, assessing survivors’ fatigue levels, reducing survivors’ workload, and collaboratively negotiating for new daily routines. However, some studies indicated survivors needed fatigue education from professionals. No study interviewed care partners to examine their experiences helping survivors adapt to fatigue.

Conclusions:
Survivors had many types of challenges and responses towards fatigue. Care partners and others showed leadership by facilitating survivors with fatigue adaptation. Future studies can identify targets for interventions to address poor adaptation to fatigue and also explore care partners’ perspectives.
Abstract P117: Stroke-Nurse Triage: Effects on Time Metrics at a Regional Stroke Center
Authors: Kazi Stephanie , Fanta John , DeHaan Katerina , Tej Mehta , Wolf Jessie , Sandhu Divyajot
Published: March 2021

Introduction:
Optimization of time metrics in the management of acute stroke is a priority. Nurses with special training in stroke management may contribute to enhanced delivery of care. This study analyzes the effects of initiating a nurse-led stroke triage program at a regional stroke center on time metrics of acute stroke.

Methods:
Registered nurses (RNs) who received specialized stroke training including NIHSS certification were designated to each presenting stroke code at our institution. The stroke RN was responsible for initial assessment, obtaining NIHSS, continued monitoring of the patient, and maintaining timely progression of care. Metrics including time from arrival to assessment by emergency department (ED) physician, assessment by a neurologist, head CT scan, the start of tissue plasminogen activator (tPA) administration, and puncture for mechanical thrombectomy were recorded. In retrospective review, stroke metrics 25 months prior to the start of the triage program (controls) and 23 months after the start of the program (cases) were analyzed.

Results:
1,019 patients presented with symptoms of acute stroke during the study duration, with 293 presenting pre-program initiation and 796 presenting post-program initiation. No significant differences during this period were seen for primary outcomes of time from arrival to assessment by ED physician, CT scan, start of tPA administration, or groin puncture. A significant increase in time to assessment by a neurologist was observed (pre-program: 12.24 minutes, post-program: 17.42 minutes, p<0.001). There was no difference before or after the program in Modified Rankin Scale (mRS) scores at discharge.

Conclusions:
Implementation of the stroke-nurse triage program involved the delegation of tasks previously under the responsibility of ED physicians to the stroke nurses. This delegation did not negatively impact care as determined by the lack of significant difference pre- and post-program for the primary metrics of arrival to CT, arrival to tPA, and arrival to groin puncture. Incorporating specially trained stroke-nurses in acute stroke management may be an appropriate use of personnel without negatively impacting stroke care.