bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 89: Accuracy and Clinical Implications of Cincinnati Pre-hospital Stroke Scale and Los Angeles Pre-hospital Stroke Scale use by Emergency Medical Services
Authors: Trivedi Tushar , Heidari Khosrow , Merchant Anwar , Jauch Ed , Venkatesh Swamy , Sen Souvik
Published: July 2021

Background:
Cincinnati Pre-hospital Stroke Scale (CPSS) and Los Angeles Pre-hospital Stroke Scale (LAPSS) are widely used by emergency medical services (EMS) to screen potential ischemic stroke patients. We performed a population based state-wide study to evaluate the accuracy of CPSS and LAPSS in identifying stroke cases and investigate their impact on ischemic stroke treatment.

Methods:
A statewide EMS database was created by linking South Carolina’s statewide Emergency Department (ED) and hospital discharge records for the calendar years 2010-2012. The EMS data were obtained from the Division of EMS and Trauma at Department of Health Environmental Control and linked to hospitalization records at Office of Research and Statistics. Results from the EMS use of CPSS and LAPSS were compared with hospital discharge diagnoses for stroke. For both scales, we calculated Sensitivity, Specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV). Additionally we evaluated the impact of identification of stroke during EMS transportation by CPSS/LAPSS on treatment of ischemic stroke with intravenous tissue plasminogen activator (IV-tPA).

Results:
Of all the EMS transported cases between January 2010 and December 2012, use of CPSS or LAPSS was recorded for 101,442 cases. Among the cases where the use of CPSS/LAPSS stroke scale was recorded, 6,757 cases had a diagnosis of ischemic stroke on hospital discharge records. CPSS demonstrated sensitivity of 59%, and specificity of 96%. Sensitivity and specificity for LAPSS were 26% and 84%, respectively. PPV and NPV for CPSS were 45% and 98%, and for LAPSS were 27% and 83%, respectively. Rates of IV-tPA administration were approximately five times higher for those correctly identified by CPSS (18.3% for true positive vs. 3.5% for false negative, P<0.01), and about two higher for those correctly identified by LAPSS (33.3% for true positive vs. 14.9% for false negative, P<0.01).

Conclusion:
Early identification of potential stroke cases using CPSS/LAPSS can have a significant impact on treatment of ischemic stroke with IV-tPA. We report a modest accuracy of CPSS and LAPSS in correctly identifying stroke cases in the field, with CPSS leading to a better rate of IV-tPA use compared with LAPSS.
Abstract 92: Demographic, Regional and Social Predictors of Do Not Resuscitate Order Utilization in Intracerebral Hemorrhage: A National Perspective
Authors: Jani Vishal B , Patel Achint , Nadkarni Girish , Benjo Alexandre , Annapureddy Narender , Yacoub Rabi , Mahajan Abhimanyu , Malik Ahmed , Chaudhary Saqib , Hussain Syed , Qureshi Adnan
Published: July 2021

Background:
Non-traumatic Intracerebral hemorrhage (ICH) is a life-threatening condition associated with substantial morbidity and mortality. Do-not-resuscitate (DNR) orders have recently linked to poor outcomes in ICH patients probably due to the inactive management associated with these orders.

Hypothesis:
We tested the hypothesis that demographic, regional and social factors not related to ICH severity are significant predictors of DNR utilization.

Methods:
We reviewed the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database from 2011-2012 for ICH admissions in patients >18 years using the ICD 9-CM code 431. We defined DNR status with ICD code - V49.86 entered during the same admission as a secondary diagnosis and estimated severity of illness by the 3M™ All Patient Refined DRG (APR DRG) classification System. A hierarchical two level multivariate regression model were generated to estimate odds ratios (OR) for predictors of DNR utilization and discrimination power of models was assessed using C statistics. We considered a two tailed p value of <0.01 to be significant.

Results:
We analyzed 25768 pts (weighted estimate 126254) with ICH out of which 4620 (18%) pts (weighted estimate 22668) had DNR orders placed. In multivariable regression analysis, female gender (OR 1.2, 95% CI 1.2-1.3), Ethnicity [White(OR 1.6, 95% CI 1.5-1.7) and Hispanic(OR 1.2, 95% CI 1.1-1.3) compared to Black], Insurance [Medicare (OR 1.1, 95% CI 1.1-1.2) and self or no pay (OR 1.1, 95% CI 1.0-1.2) compared to private insurance], Hospital location [West (OR 1.6, 95% CI 1.2-2.1) compared to North-East ] were significantly associated with high DNR utilization rates after adjusting for patient level, hospital level characteristics, APR DRG severity scale and other clinical characteristics.

Conclusions:
In conclusion, demographic (female gender/ethnicity), social (insurance status) and regional (hospital location) are significantly associated with increased DNR utilization. The reasons for this are likely multifactorial, qualitative, linked to both patient and provider practices and need to be explored in more detail.
Abstract 96: What Critical Volume of Intraventricular Hemorrhage is Important in Intracerebral Haemorrhage? Interact2 Results
Authors: Anderson Craig , Chan Edward , Wang Xia , Arima Hisatomi , Heeley Emma , Stapf Christian , Robinson Thompson , Huang Yining
Published: July 2021

Background and purpose:
Intraventricular haemorrhage (IVH) predicts outcome in acute intracerebral haemorrhage (ICH), but there is uncertainty over the strength of association and what clinically relevant threshold volume is relevant to prognosis. We aimed to elucidate risk associations of IVH and outcome in participants of the INTERACT2 study.

Methods:
INTERACT2 was an international, multicenter, prospective, open, blinded endpoint, randomized controlled trial of 2839 patients with ICH (<6 hr) and elevated systolic BP (SBP) who were randomly assigned to intensive (target SBP <140mmHg) or guideline-based (SBP <180mmHg) BP management in 2008-2012. Associations of 740 (26%) patients with IVH on poor outcome (mRS >3) at 90 days, were determined in logistic regression models.

Results:
Patients with ICH-IVH were significantly older, had greater clinical severity, and more with prior ischemic stroke and deep and large hematoma volume, after adjustment for other variables. Poor outcome occurred in 67% of ICH-IVH patients compared with 49% of ICH-alone patients (odds ratio [OR] 0.5, 95% confidence interval [CI] 0.42-0.60; p<0.01). There was a strong linear relation between ICH volume and poor outcome. Compared to lowest quartile (Q1) IVH volume (0-2.07mL), OR for poor outcomes increased in Q2 (2.08-5.84 mL) 0.74 (95%CI 0.46-1.18 mL), Q3 (5.97-13-74 ml) 1.27 (95%CI 0.78-2.06), and Q4 (13.82-117.55) 1.56 (95%CI 0.94-2.58), p trend 0.03. Associations were stronger for death, where a baseline IVH volume of 5-10mL emerging as a statistically (and clinically) significant threshold for risk.

Conclusion:
While a linear relation exists between IVH and outcome in ICH, a 5-10mL volume appears an appropriate cut-point for clinical-decisions over use of interventions with risk.
Abstract 98: Blood Pressure Control and Risk of Recurrent Lobar Intracerebral Hemorrhage
Authors: Biffi Alessandro , Anderson Christopher D , Battey Thomas W , Ayres Alison M , Schwab Kristin , Viswanathan Anand , Greenberg Steven M , Rosand Jonathan
Published: July 2021

Introduction:
Elevated blood pressure (BP) is a potent risk factor for risk and recurrence of Intracerebral Hemorrhage (ICH) in non-lobar regions, but its role in lobar ICH remains unclear.

Hypothesis:
We tested whether: elevated BP after index lobar ICH is associated with lobar ICH recurrence and whether the role of elevated BP is influenced by APOE genotype and microbleeds on MRI.

Methods:
Eligible subjects were survivors of primary lobar ICH enrolled in a single-center prospective cohort study. The number of MRI-defined lobar microbleeds (MB) and APOE genotype (ε2/ε3/ε4 alleles) were determined at time of index ICH. Survivors were followed prospectively for recurrent ICH. BP measurements were captured at 3, 6, 9, 12 months, and every 6 months thereafter. BP was treated as a time-varying variable, and analyzed in two ways: 1) a dichotomous variable based on AHA/ASA ICH secondary prevention guidelines goal; 2) a categorical variable for JNC7 hypertension stages.

Results:
Among 505 lobar ICH survivors, there were 102 recurrences during median follow-up of 30 months. Inadequate BP control (based on AHA/ASA guidelines) was associated with increased recurrence risk (Hazard Ratio [HR] 3.53, p=0.001). Effect size correlated with JNC7 stage: pre-hypertension (HR 2.76, p=0.007), hypertension stage 1 (HR 3.90, p=0.012); hypertension stage 2 (HR 5.21, p 2 MB, interaction p = 0.037) to increase risk of lobar ICH recurrence.

Conclusions:
Elevated BP is associated with increased risk of recurrent lobar ICH, with effect size rising with JNC7 stage. Presence of APOE ε2 / ε4 and > 2 MB on MRI interacts with BP, further increasing risk of recurrence. Further studies are required to determine the clinical implications of these findings.
Abstract 99: A Magnetic Resonance Spectroscopy [1H-MRS] Study of Peri-infarct Neuro-glial Interactions in Recovering Stroke Patients
Authors: Mazibuko Ndaba , O'Gorman Ruth , O’Daly Owen , Zelaya Fernando , Williams Steven , O'Sullivan Mike , Kalra Lalit
Published: July 2021

Background:
The adult brain has the capacity to reorganize after acute stroke and the ability to follow neuroplastic processes can be useful in predicting and monitoring recovery after stroke. This study investigates the ability of 1H-MRS to measure metabolic events in the structurally intact peri-infarct region between 2-12 weeks after stroke and their relationship to motor recovery.

Method:
The study included 15 first-ever stroke patients aged 18-75 years and age/sex matched controls. Structural, perfusion and 1H-MRS imaging was undertaken to measure regional cerebral blood flow (rCBF), N-acetylaspartate (NAA), choline (Cho), myoinositol (mI), creatine (cr) and lactate in the ipsilesional and contralesional hemisphere of stroke patients at 2 weeks, 6±1 and 12±3 weeks after stroke onset. Simultaneous clinical assessments were undertaken to measure motor impairments using the Fugl-Meyer [F-M]) scale. Patients were compared with controls at all time-points and the relationships between metabolites and with motor outcome were assessed.

Results:
Stroke patients were aged 51.4 (SD 13.3) years and all improved significantly between 2 and 12 weeks. Ipsilesional rCBF was decreased (22.7 v 36.8 mL/100 g/min, p=0.0036) at 2 weeks but increased to normal values by 12 weeks. Cr concentration (energy balance) were decreased in parallel and increased to normal concentration by 12 weeks. Ipsilesional NAA (neuronal integrity) was similar to healthy controls at 2 weeks it decreased significantly by 6 weeks. Cho (membrane turnover) significantly higher compared with controls at all time points; mI (glial cells) did not differ at 2 weeks but increased significantly between 2 and 12 weeks and there was a significant rise in lactate (inflammation) concentration at 12 weeks. There were strong positive correlations of rCBF with NAA at 12 weeks (r=0.42, p <0.002), NAA at 2 and 12 weeks with FM scores at 12 weeks (r = 0.79, p= 0.004, r = 0.799, p = 0.006) and rCBF with change in F-M score between 2-12 weeks (r = 0.44, p=0.01).

Conclusions:
Ipsilesional CBF and metabolite estimation may be a sensitive tool to quantify vascular and neuro-glial interactions in the spared cortex after stroke that can be used to predict and monitor recovery.
Abstract NS18: Prevalence and Predictors of Depression among Elderly Stroke Patients in Korea
Authors: Sim Jeongha , Shin Cha-Nam , Ahn Dongchoon
Published: July 2021

Background:
Depression after stroke not only affects rehabilitation and recovery, but increases caregiver burden. With rapidly increasing aged population, stroke burden substantially increases in Korea, which makes depression after stroke an important concept to assess.

Purpose:
The purposes of this study were to (1) assess the prevalence of depression and (2) identify predictors of depression among elderly stroke patients in Korea.

Methods:
A cross-sectional, descriptive study was conducted in a convenience sample of 233 hospitalized elderly patients with acute ischemic stroke using a self-administered survey. We assessed depression using the Hospital Anxiety and Depression Scale (HADS) and collected demographic data and stroke severity (e.g., hemiparesis, dysphagia, cognitive impairment). Descriptive statistics, chi-square test, and logistic regression analyses were used for data analysis.

Results:
Of the total participants, 60.5% were men, 76.8% were aged ≥ 61 years, 70% were married, 80.3% lived with family, and 71.7% were depressed (HADS depression scale ≥ 8). Individuals who were women (χ
2
=10.32), lived alone (χ
2
=3.38), had symptoms of dysphagia (χ
2
=6.14), dysphasia (χ
2
=8.14), hemiparesis (χ
2
=5.61), cognitive impairment (χ
2
=4.86), or anxiety (χ
2
=54.53) were more likely to be depressed than those who were men, lived with family, had no symptoms of dysphagia, dysphasia, hemiparesis, cognitive impairment (
p
< .05), or anxiety. The likelihood of being depressed was higher in individuals who had anxiety (OR=18.93, 95% CI=[6.88, 52.08]) or lived alone (OR=0.28, 95% CI=[0.06, 0.77]) than individuals who did not have anxiety or lived with family.

Conclusions:
In conclusion, the study findings suggest that clinicians who handle elderly stroke patients should pay attention to the individuals who have anxiety or live alone as the risk of depression after stroke seems to be higher in these groups. Further research focus should be given to (1) identifying underlying factors of anxiety, (2) developing preventive interventions for depression after stroke, including strategies to decrease anxiety and ensure social support, and (3) exploring the association of depression with other health outcomes, such as quality of life and mortality.
Abstract NS22: Palliative Care in the Stroke Patient
Authors: Hamm Theresa
Published: July 2021

Background and Purpose:
Palliative and end of life care are gaining importance in the healthcare environment. Palliative care and hospice may be underutilized in this population. Evaluation of current process will determine opportunities for improvement.

Methods and Results:
Retrospective review of patients admitted over one year with the diagnosis of acute ischemic stroke (AIS) and hemorrhagic stroke was completed, assessing 575 records. This population included 491 AIS and 84 hemorrhages. Eighty-one AIS patients received t-PA. Discharge status distribution included: 269 to home; 114 to acute rehabilitation; 123 to skilled nursing facilities (SNF); 29 to hospice; and 42 died. Fifty-five patients had comfort care orders prior to discharge: 32 by hospital day two, 23 by hospital day three or later. AIS patients with comfort care orders had an average NIHSS of 17; hemorrhagic stroke patients had an average GCS of 5. Patients with comfort care orders were an average age of 72 years with equal distribution (AIS = 27; hemorrhage = 28) and gender (25 male, 30 female); majority were Caucasian (3 African American, 1 Latino, 1 Asian). Twenty patients with similar characteristics were discharged to SNF with no discussion of palliative care or hospice. A review of records revealed provider disagreement for long-term prognosis as a significant barrier to patient/family decisions regarding end of life choices, or supporting choices made by patients/family opting for palliative care.

Conclusions:
Based on these data, a palliative care nurse joined the stroke team, and the stroke coordinator joined the palliative care committee to assist in these conversations. Palliative care training for providers is on-going in the acute care setting, while outpatient providers are being engaged in utilizing The Iowa Physician Order for Scope of Treatment (IPOST).This document was designed to promote community care coordination and advanced care planning, in order to provide seamless communication and execution of individual care choices across the healthcare continuum. As these strategies are implemented, an increase in end of life planning is anticipated.
Abstract T MP26: Progression Of Asymptomatic Carotid Stenosis: Incidence Of Symptoms And Predictive Factors
Authors: Singh Tarun , Kramer Christopher L , Lanzino Giuseppe , Rabinstein Alejandro A
Published: July 2021

Background:
Given the uncertainty regarding clinical applicability of early treatment trials and lack of data on long-term disease progression, we evaluated the progression of stenosis and development of symptoms on patients with asymptomatic carotid artery stenosis (ACAS) treated with contemporary medical therapy over a prolonged follow up.

Methods:
Retrospective review of bilateral carotid arteries from consecutive patients diagnosed with moderate or severe ACAS, at our institution between 2000 and 2001. Patient vascular risk factors and treatments, cerebrovascular imaging, ipsilateral symptoms, and revascularization were recorded. Progression of stenosis was defined by change category of stenosis. Factors associated with symptomatic carotid disease were sought using univariate and multivariate logistic regression analysis.

Results:
We identified 214 patients (58.8% men; median age 70 years) and collected data on 349 vessels. Severe stenosis (>70%) upon diagnosis was present in 92(26.4%) vessels. All patients were on antithrombotics, 97% on antihypertensives, and 95% on statins. Median length of follow up was 13 years (range 5-14) and the mean number of time points with follow-up imaging was 8.1±3.9. Progression of stenosis was observed in 237(67.9%) vessels. 72(20.6%) patients developed symptomatic carotid stenosis (TIA in 14.4%, non-disabling stroke in 4%, and disabling stroke in 2.2%). Median time to appearance of first symptom was 6 years (range 1-13). Revascularization procedures were performed in 118(33.8%) vessels, including 73(61.9%) vessels which had become symptomatic. On multivariate analysis, baseline stenosis (OR 1.65, 95%CI 1.12-2.44), intracranial stenosis > 50% (OR 2.87, 95%CI 1.46-5.62), plaque ulceration (OR 3.41, 95%CI 1.34-8.69), silent infarction (OR 4.25, 95%CI 2.30-7.83), and previous history of TIA/stroke (OR 2.73, 95%CI 1.14-6.54) were associated with development of TIA/stroke ipsilateral to the carotid stenosis.

Conclusions:
There is a substantial rate of progression of stenosis in patients with asymptomatic carotid atherosclerosis over time despite adequate medical therapy. Over long-term follow up, one in five patients with ACAS developed ipsilateral TIA/stroke.
Abstract T MP39: Could Difficult-to-treat Hypertension Be a Predictor of Bad Outcome in Ischemic Stroke?
Authors: Colla Machado Pedro , Zurru Maria C , Luzzi Ariel , Brescacin Laura , Alonzo Claudia , Camera Luis , Waisman Gabriel , Cristiano Edgardo
Published: July 2021

Background and purpose:
hypertension is the vascular risk factor most commonly related to stroke, making antihypertensive treatment a cornerstone of stroke prevention. Achieving targets of clinical practice guidelines could be difficult in some patients, requiring combination of drugs to maintain these goals. We aimed to evaluate the relationship between difficult-to-treat hypertension (DTTH) and stroke outcomes.

Methods:
acute ischemic stroke patients were prospectively included in PROTEGE-ACV, a multidisciplinary secondary stroke prevention program. Demographic data, vascular risk factors (VRF) profile and control, and stroke outcome (disability, mortality and stroke recurrence) were evaluated 30 days after stroke. Difficult-to-treat hypertension was defined as those requiring more than two drugs in hypertension management.

Results:
we analyzed data of the 1194 stroke patients included between December 2006 and December 2013. We found 186 DTTH patients, who had higher burden of VRF and poorer pre-stroke control (table); they had higher admission blood pressure (0 drugs 146/82 mmHg, 1 drug 151/84, 2 drugs 154/83, 3 drugs 153/83, 4 drugs 169/88; p 0.001 for SBP, 0.26 for DBP) and pulse pressure (63 mmHg, 66 mmHg, 70 mmHg, 67 mmHg, 81 mmHg respectively; p 0.0006). These patients had also worst 30-day outcome: m-Rankin >1 (24% in no-DTTH vs 54% in DTTH, 0.0001), mortality (1% vs 16%, p 0.001), composite disability + all cause death (44% vs 73%, p 0.001). We found no difference in early stroke recurrence.

Conclusion:
the number of drugs necessary to treat hypertension could be useful to identify barriers to achieve blood pressure targets for vascular disease prevention, as vascular aging, hemodynamic changes, adherence to medication and healthy lifestyle. This indicator is easy to collect and could help to decision making in daily clinical practice.
Abstract T MP4: Quality of CT Perfusion Imaging Thresholds for Infarct and Penumbra in the Acute Ischemic Stroke Setting: An Updated Systematic Review
Authors: d'Esterre Christopher , Dykeman Jonathan , Al-mekhlafi Mohamed , Cimflova Petra , Patil Shivanand , Singh Dilip , Choi Philip , Menon Bijoy , Goyal Mayank
Published: July 2021

Background:
CT Perfusion (CTP) may inform treatment decisions in acute ischemic stroke (AIS). We sought to determine extent of variability with CTP thresholds for infarct core and penumbra and reasons for such variability using an up-to-date systematic review.

Methods:
Search strategy combined the themes of AIS, perfusion imaging, and CT/MRI. Two independent reviewers screened at all levels; disagreements were settled through consensus. Inclusion criteria were CTP within 24hrs of stroke onset and reported perfusion thresholds for infarct core, penumbra, and/or normal/not at risk tissue for mixed grey/white matter. Study demographics, QUADAS assessment of quality, and mean thresholds of cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), relative CBV (rCBV), relative CBF (rCBF), and relative MTT (rMTT) were collected. Thresholds were reported as median mean threshold (interquartile range).

Results:
The search resulted in a total of 11919 abstracts from EMBASE and MEDLINE. Of these, 711 studies were identified for full-text review, 134 met all eligibility criteria. 29 studies provided thresholds for CTP and were included in the review. For CBF, median mean threshold was 8.64 (7.94-13.92) ml/min/100g for core, 19.1 (17.1-31.9) ml/min/100g for penumbra and 47.4 (35.6-59.1) ml/min/100g for normal/not at risk tissue. For CBV, median mean threshold was 1.0 (0.68-1.88) ml/100g for core, 2.45 (2.0-3.0) ml/100g for penumbra, and 2.65 (2.0-3.3) ml/100g for normal/not at risk tissue. For MTT median mean threshold was 15.6 (15.3-17.7) seconds for core, 10.5 (7.1-46.2) seconds for penumbra, and 3.9 (3.65-4.15) seconds for normal/not at risk tissue. Median mean threshold for rCBF was 29% (22.5%-35.5%) for core. Sufficient TTP and Tmax data were not reported. Overall, quality was highly variable according QUADAS ranging from 20.7% to 93.1% across the 14 variables.

Conclusions:
Due to heterogeneity of vendor CTP algorithms, follow-up imaging to define infarct core (NCCT, DWI), unknown recanalization times/reperfusion status and differing onset to CT times, CTP thresholds for infarct core and penumbra are highly variable. As such, a single best threshold for core could not be derived from literature.
Abstract T MP48: Androgen Suppression in Patients with Prostate Cancer Increases Incidence of Combined Cardiovascular Outcomes
Authors: Ali Zuber S , Greere Danielle M , Shearer Robyn L , Gardezi Syed Ali , Jahangir Arshad
Published: July 2021

Introduction:
Androgen suppression therapy for prostate cancer is controversial due to adverse fatal and non-fatal cardiovascular outcomes reported in some studies. However, effects of androgen suppression on stroke have not been fully assessed in the elderly.

Methods:
Patients diagnosed with prostate cancer during 2007-2013 in a large community-based healthcare system were identified from the Cancer Registry, electronic records, and billing codes. Those who underwent androgen suppression therapy with Gonadotropin-releasing hormone agonist (GnRH) were propensity-matched to patients treated without androgen suppression therapy by age at cancer diagnosis, race/ethnicity, disease stage and outcome, body mass index and use of surgery, radiation, and chemotherapy. Tests of independence and Cox proportional hazards models were used to examine effects of hormone therapy on acute myocardial infarction (AMI), stroke, and mortality outcomes. Models also adjusted for patient comorbidities.

Results:
A total of 1282 patients and 641 matched-pairs were identified, with mean diagnosis age of 69 yr and follow-up period of 3.05 yr. Effects of androgen suppression therapy on AMI (P=0.051) and stroke (P=0.062) were of marginal to non-significance, but adjusted-odds of death and combined AMI, stroke, and death were 1.61 times (P=0.002; odds ratio [OR] 95% CI: 1.19-2.18) and 1.70 times (P<0.001; OR 95% CI: 1.26-2.28) greater, respectively, for men with than without androgen suppression. An interaction of androgen suppression and age-group (<65 yr, 65-74 yr, >74 yr) was discovered for combined outcomes, suggesting increased probability of AMI, stroke, and/or death with age (8.6-20.0%; P=0.003) for patients without androgen suppression but elevated risk of outcomes across all age groups (18.3-22.4%; P=0.546) for men treated with androgen suppression therapy.

Conclusion:
Endogenous androgen suppression presents elevated risk of combined cardiovascular and death outcomes, especially for men <65 yr.
Abstract T MP49: Should Transesophageal Echocardiography (TEE) be the Initial Diagnostic Modality of Choice in Young Ischemic Stroke (IS) Patients?
Authors: Bhole Rohini , Goyal Nitin , Gilbert Robert W , Tsivgoulis Georgios , Malkoff Marc D , Alexandrov Andrei V
Published: July 2021

Background&Purpose:
Current data is limited regarding the comparative utility of Transthoracic echocardiography (TTE) vs. TEE in diagnosing potential sources of cardioembolism (PSOC) in patients with cryptogenic stroke, particularly in young stroke patients. We sought to evaluate the comparative diagnostic yield of these two echocardiographic modalities in young IS patients.

Methods:
We conducted a retrospective chart review of consecutive young (18-45 yrs) IS patients admitted to a tertiary care stroke center over a study period of 42 months. All patients underwent both TTE and TEE during their standard diagnostic work-up. Stroke classification at discharge was performed according to TOAST criteria by treating physicians.

Results:
The study population consisted of 83 IS patients (mean age 38±5years, 40% men, 86% blacks, median admission NIHSS-score 3 points, IQR 1-8) who underwent both echocardiographic examinations. Cardioembolic stroke (CS) was the discharge diagnosis in 22 cases (27%). EF calculated by TEE strongly correlated to EF calculated by TTE (r=0.846; p<0.001). Left atrial enlargement was detected more frequently by TEE than TTE (27% vs. 11%; p<0.001). The overall yield of TEE for detecting PSOC was higher than TTE (23% vs 4%; p=0.011). TTE diagnosis of a PSOC was not associated with CS discharge diagnosis in univariate analyses (OR: 6.0, 95%CI: 0.5-69.8; p=0.152). TEE diagnosis of PSOC was associated with CS in univariate analyses (OR: 13.2, 95%CI: 4.0-43.8; p<0.0001). After adjustment for demographics, vascular risk factors, admission NIHSS-score, admission SBP and DBP levels, admission blood glucose and abnormal TTE, TEE diagnosis of a PSOC was independently associated with a higher likelihood of CS diagnosis at hospital discharge (OR: 24.3, 95%CI: 5.9-100.0; p<0.0001).

Conclusions:
Our study showed that the yield of TEE for detecting PSOC was higher than that of TTE, while abnormal TEE findings were independently associated with a higher likelihood of CS diagnosis. TEE should be considered as the initial echocardiographic modality for evaluating young IS patients, since it may expedite workup and early detection of stroke etiopathogenic mechanism.
Abstract T MP62: Acute Infarct Volume in Perinatal Stroke Can Be Accurately Estimated by Measuring Residual Uninfarcted Tissue on Follow-up MRI
Authors: Stence Nicholas V , Mirsky David M , Weitzenkamp David , Poisson Sharon , Herson Paco S , Hollatz Amanda , Traystman Richard J , Armstrong-Wells Jennifer , Bernard Timothy J
Published: July 2021

Introduction:
Developing accurate measurements of infarct volume is vital to studying outcomes in Perinatal Arterial Ischemic Stroke (PAS). Methods for measuring Acute Infarct Volumes (aIV) are well established in PAS. However, techniques for measuring chronic infarct volume (cIV) in order to estimate aIV have not been validated and must account for changes in Total Brain Volume (TBV) over time, as well as contraction of the infarct. We compared two methods of measuring cIV, hypothesizing that cIV extrapolated from residual uninfarcted brain tissue volume would better estimate aIV than direct measurement of cIV.

Methods:
Using modified manual segmentation techniques, two pediatric neuroradiologists independently measured the brain and infarct volumes of 10 PAS patients both on the acute (0-7 days old) and chronic (>3 months) MRIs. Volume measurements were averaged after high inter-rater reliability was established (ICC>0.9). We evaluated acute and chronic scans for changes in infarct anatomy, and excluded patients with bilateral infarctions. Method 1 for estimating cIV used a direct measurement of the infarct (figure). Method 2 extrapolated infarct volume from residual uninfarcted brain tissue (figure). The cIV for each method was then compared to the aIV.

Results:
3 patients with bilateral infarcts were excluded. Infarct anatomy between acute and chronic scans did not change for the 7 unilateral infarcts evaluated. In these 7 cases, the ICC comparing aIV and cIV from Method 1 was 0.507 (CI -0.120, 0.891), while the ICC comparing aIV and cIV from Method 2 was 0.964 (CI 0.821, 0.994). cIV’s from Method 1 were smaller than the aIV’s in all cases, despite stability of infarct anatomy.

Conclusions:
In this pilot study measuring cIV in PAS, direct measurement of cIV likely underestimates volume because of contraction of infarcted tissue. In conclusion, extrapolation of cIV from measurement of residual uninfarcted tissue appears to accurately estimate aIV.
Abstract T MP90: Relationship Between Daily Blood Glucose Variability and Neurological Outcome in Acute Ischemic Stroke Patients With Diabetes Mellitus
Authors: Kubo Satoshi , Hosomi Naohisa , Yoshimoto Takeshi , Neshige Syuichiro , Himeno Takahiro , Kono Ryuuhei , Takeshima Shinnichi , Shimoe Yutaka , Takamatsu Kazuhiro , Ota Taisei , Kuriyama Masaru , Matsumoto Masayasu
Published: July 2021

BACKGROUND:
Although hyperglycemia in acute stroke is associated with poor stroke outcomes, it remains unclear whether blood glucose variability are also associated with stroke outcomes. In this study, we examined the relationships between daily blood glucose variability and early neurological outcome in acute ischemic stroke patients with diabetes mellitus.

METHODS:
Subjects were a total of 329 acute ischemic stroke patients (216 male, 70.9 ± 9.6 years) who were either already undergoing treatment for diabetes or had a hemoglobin A1c level of >5.8% at admission from July 2006 to June 2009. The consecutive morning fasting blood glucose (BG) levels were evaluated during 7 days from admission and described as mean and successive variation (SV). The unfavorable outcome was defined by a modified Rankin Scale score of 4 to 6 at discharge.

RESULTS:
The patients with unfavorable outcome (n=86) were older (75.7 ± 10.5 vs. 69.2 ± 8.6 years, p<0.001), more frequently female (47.7% vs. 29.6%, p=0.003), less commonly had dyslipidemia (40.7% vs. 60.9%, p=0.001), less commonly took oral hypoglycemic agents (30.2% vs. 53.5%, p<0.001), and had higher NIHSS scores (median 9 vs. 3, p<0.001) than those without. The mean BG levels and SV levels in patients with unfavorable outcome were higher than those in patients without (163.3 ± 39.0 vs. 147.9 ± 34.0 mg/dl; p<0.001 and 33.7 ± 24.9 vs. 23.2 ± 15.3 mg/dl; p<0.001, respectively).

SV levels was independently associated with unfavorable outcome (OR 1.023, 95%CI 1.004-1.042, p=0.015) using logistic regression analysis controlling age, sex hypertension systolic blood pressure, NIHSS score at admission and insulin use during hospitalization, which are selected using stepwise method.

However mean BG levels did not remained as factor, which associated with unfavorable outcome with step wise method.

CONCLUSION:
Increased blood glucose variability, but not mean BG, was independently related to unfavorable outcome at discharge in acute ischemic stroke patients with diabetes mellitus.
Abstract T P1: Predictive Factors of Intracranial Hemorrhage in Patients With Acute Large Vessel Occlusion
Authors: Enomoto Yukiko , Yoshimura Shinichi , Egashira Yusuke , Yamagami Hiroshi , Sakai Nobuyuki ,   RESCUE-Japan Investigators
Published: July 2021

Objective:
Recanalization therapy, such as intravenous tissue plasminogen activator (IVT) or endovascular treatment (EVT), is known to improve outcomes in acute ischemic stroke; however, such maneuver carries the risk of intracranial hemorrhage (ICH). The present study assessed the predictive factors of ICH in the patients with acute large vessel occlusion.

Methods:
The Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism (RESCUE)-Japan registry prospectively registered 1,442 stroke patients with major vessel occlusion who were admitted to 84 Japanese stroke centers within 24 hours after onset from July 2010 to June 2011. We analyzed the incidence and predictive factor of ICH within 24 hours after onset among the 1,436 patients except 6 patients who underwent bypass surgery.

Results:
Any ICH was observed in 283 (19.7%) patients, and symptomatic (with neurological deterioration defined as National Institute of Health Stroke Scale score ≥4) ICH was observed in 47 (3.3%) patients. Comparing patients without ICH, we find statistical significance in the rate of favorable outcome (any ICH; 18.3% vs. 35.0%, p<0.001, symptomatic ICH; 4.3% vs. 32.6%, p<0.001). On multivariate analyses, any recanalization therapy (IVT and/or EVT)(OR, 1.94; 95% CI, 1.09-3.44)and reperfusion of the affected artery on MR angiography at 24 hours after onset (OR, 1.90; 95% CI, 1.31-2.75) significantly related to any ICH. Significant related factor of symptomatic ICH was only recanalization therapy (OR, 2.45; 95% CI; 1.30-4.16), but not EVT (OR; 1.26; 95% CI, 0.50-3.16). Moreover, warfarin-, antiplatelet-, heparin- or thrombolytic agents-use was not an independent predictor of ICH risk.

Conclusions:
Among the patients with acute large vessel occlusion, ICH was associated with recanalization therapy (IVT or EVT), but not the use of antithrombotic agents.
Abstract T P102: Recurrent Stroke Risk in Patients With ICAD Treated With Aggressive Medical Management: A Comparison With The Sammpris Trial
Authors: Sangha Rajbeer S , Corado Carlos , Bernstein Richard A , Ruff Ilana , Curran Yvonne , Ansari Sameer A , Prabhakaran Shyam
Published: July 2021

Background:
Since the SAMMPRIS trial, aggressive medical management (AMM) with the use of dual antiplatelets (aspirin, clopidogrel) and high dose statin therapy has been standard of care for patients with symptomatic intracranial atherosclerotic disease (ICAD). However, there is limited data on the “real-world” application of this regimen. We hypothesized that 30-day recurrent stroke risk among patients treated with AMM would be similar to that in SAMMPRIS medically-treated patients.

Methods:
Using the prospective Northwestern University Brain Attack Registry, we identified all patients admitted between 8/1/12 and 1/31/14 with 1) confirmed ischemic stroke or transient ischemic attack (TIA); 2) independently adjudicated symptomatic ICAD; and 3) discharged on AMM. At 30 days (28-35 day window) post-stroke, patients or proxies were contacted by telephone to review events and outcomes. We also utilized an electronic surveillance system of hospital records at any of 3 health system hospitals with confirmation by manual review of the medical record in all instances of reported recurrent stroke or TIA. Ischemic stroke in the territory of the symptomatic stenotic artery was the primary outcome. We calculated 30-day rate of stroke in the territory of the stenotic artery and 95% confidence intervals using the Wald method and compared it with that reported in the SAMMPRIS trial.

Results:
Among 36 patients who met study criteria, 13 (36.1%) were female and mean age was 65.4 (± 9.7) years. Median initial NIHSS score was 4 (interquartile range 0-17). Symptomatic ICAD was localized to the anterior circulation in 21 (58%) patients and posterior circulation in 15 (41.7%). At 30 days, 3 of the 36 patients (8.3%, 95% CI 2.1-22.6%) had recurrent stroke compared to 5.8% in the medical arm of SAMMPRIS (p=0.47). An additional 3 patients (8.3%) experienced TIA within 30 days.

Conclusions:
In a single-center observational cohort study, we found that AMM in patients with symptomatic ICAD yielded similar rates of recurrent stroke at 30-days as observed in the SAMMPRIS trial. Our study provides “real-world” confirmation of the potential benefits of AMM in this high-risk stroke subtype.
Abstract T P105: Decrease in Noninvasive Fractional Flow on MRA Is a Useful Marker of Misery Perfusion on SPECT
Authors: Miura Masatomo , Nakajima Makoto , Watanabe Masaki , Shiraishi Shinya , Ando Yukio
Published: July 2021

Background:
Cerebrovascular reactivity to acetazolamide on 123I-IMP SPECT is used to detect misery perfusion due to intracranial atherosclerosis. Noninvasive fractional flow reserve (FFR) on time-of-flight magnetic resonance angiography (TOF-MRA) can provide a feasible alternative to identify high-risk intracranial atherosclerosis. We here demonstrate the association between FFR on TOF-MRA and cerebral blood flow pattern on 123I-IMP SPECT. Methods: Patients with a unilateral middle cerebral artery (MCA) stenosis who underwent both TOF-MRA and 123I-IMP SPECT with acetazolamide administration were retrospectively recruited from our radiology database. Signal intensity (SI) was measured in the background, proximal and distal to the stenotic lesion in the MCA on TOF-MRA. Adjusted FFR was calculated: FFR = [distal SI - background SI] / [proximal SI - background SI]. Mean cerebral blood flow (CBF) at rest, CBF after acetazolamide administration, and cerebrovascular reactivity (CVR) were measured in the target MCA territory. CBF patterns of MCA were divided into three: Stage II, CBF at rest of < 80% in that of normal subject and CVR below 10%; Stage 0, CVR over 30% regardless of CBF at rest, and Stage I, any other CBF patterns. We sought the optimum cut-off point for FFR to identify MCA territories with Stage II CBF on 123I-IMP SPECT. Results: A total of 41 sets of diagnostic imaging in 23 patients (mean age 57 y; 14 men, 9 women) was assessed. Four (9.8%) MCA territories demonstrated Stage II, 21 (51.2%) stage I, and 16 (39.0%) stage 0. Mean FFR of MCA with Stage II pattern was 0.59 (IQR 0.38 - 0.69), Stage I was 0.78 (IQR 0.70- 0.92), and Stage 0 was 0.90 (IQR 0.81 - 0.93). The optimal cut-off point for FFR to predict Stage II was ≤ 0.7 (sensitivity 100%; specificity 86%). Conclusion: In patients with unilateral MCA lesions, an FFR decrease was correlated with misery perfusion on 123I-IMP SPECT with acetazolamide, which may be a more feasible predictor of high-risk intracranial stenosis.
Abstract T P11: What Clinical Factors Predict An Intracranial Arterial Stenosis Responsible For An Intracranial Larger Artery Occlusion Treated By Endovascular Therapy?
Authors: Lee Jin Soo , Hong Ji Man , Lee Kyu Sun , Suh Hong Il , Demchuk Andrew M
Published: July 2021

Objectives:
In Asian countries where intracranial arterial stenosis (ICAS) is a common etiology regarding large artery intracranial occlusions in stroke. We sought to identify any clinical, laboratory and baseline imaging variables that may predict ICAS prior to endovascular treatment compared with angiographically-defined embolism (ADE).

Methods:
Patients were included if they had large cerebral artery occlusion in stroke on CT angiography and undertook transfemoral cerebral angiography, and if their onset to puncture time was within 8 hours. We defined ICAS and ADE by transfemoral cerebral angiography. ICAS was defined as fixed significant (> 50%) focal stenosis in the occlusion site, which could be seen in the final angiography or during the procedure of endovascular treatment. ADE was defined by no focal stenosis was evident after some recanalization achieved. Patients were excluded if their cause of stroke was associated or combined with other etiologies.

Results:
Finally, a total of 157 patients were included for this study. Table shows comparisons of clinical laboratory and imaging characteristics between ICAS and ADE groups. Patients in ICAS group were younger and male-predominant than in those in ADE group. Dyslipidemia and smokers were more frequent in ICAS group. Total cholesterol level was higher in ICAS group than in ADE group. Compared to ADE an ICAS was much more common in the posterior circulation 11/30 versus only 12/127 in the anterior circulation (p<0.001). Independent predictors of ICAS on multivariable analysis were male gender (odds ratio 6.34 [95% CI, 1.23-32.85], p=0.028), posterior circulation involvement (5.37 [1.62-17.82], p=0.006) and total cholesterol level (1.02 [1.004-1.033], p=0.012).

Conclusion:
The neurointerventionalist should prepare for the possibility of ICAS when performing endovascular treatment especially with posterior circulation occlusions in a Korean population.
Abstract T P121: Combinations of Fast and Slow Eye Movement Strategies Improve Clinical Outcomes and EEG Activity in Stroke Patients, a Randomized Controlled Trial
Authors: Carrick Frederick R , Machado Calixto , Estrada Genco , Pando Alejandro , Cossio Otto , Beltrán Carlos
Published: July 2021

Introduction:
The majority of our patients with middle cerebral artery (MCA) infarcts have impaired latency of visual saccades, saccadic dysmetria and saccadic intrusions of pursuits. We wanted to see if the utilization of eye movement rehabilitation in cases of middle cerebral artery infarction would result in changes of brain function and patient clinical outcomes.

Hypothesis:
We assessed the hypothesis that visual training of fast and slow eye movements to novel targets will result in changes in EEG activity, decrease physical and cognitive impairment and increase clinical outcomes in stroke patients.

Methods:
A sample size of 60 subjects (80% power, alpha of 0.05 at 95% CI) with acute MCA ischemic stroke within the first 48 hours of clinical evolution were randomized to an active treatment (n=30) group that performed eye movement strategies and a matched control group (n= 30) that did not. All subjects underwent CT and MRI and received standard therapies and NIH Stroke Scales and QEEG.

Results:
A significant reduction of the NIHSS scale was found after a week of practicing our eye movement strategies, indicating a clinical improvement. There was a significant reduction of the DAR index after eye movement exercises. QEEG brain mapping demonstrated a significant reduction of the spectral power in the Delta and an increment in the Alpha bands also demonstrated with the reduction of the DAR index. The brain symmetry index significantly increased after eye movement exercises indicating an augmentation of balance of the absolute mean value of the hemispheric power difference in the frequency range from 1 to 30 Hz. There was a significant reduction of the PRI index after eye movement exercises, indicating an increment of the fast (alpha +beta), compared with the slow (delta + theta) activities. A significant correlation was found between NIHSS (before) and DAR (after).

Conclusions:
The stroke patients undergoing eyes exercises had a significant neurological recovery with decreased impairment and improvement of electrical brain activity both reflected in the modifications of the NIHSS scale, and the DAR and BSI QEEG indices and strong correlations of DAR post-exercise with NIHSS scores before eye movement training strategies.
Abstract T P131: Racial Disparities in Post-Stroke Activity Limitations are not due to Pre-Stroke Activity Limitation Differences
Authors: Burke James F , Skolarus Lesli E , Freedman Vicki A
Published: July 2021

Introduction:
African Americans have higher stroke incidence and more long-term disability than whites, in spite of similar stroke severity. We sought to explore whether these differences may be due to differences in pre-stroke functioning.

Methods:
Initiated in 1968, the Panel Study of Income Dynamics (PSID) is a nationally representative US panel survey of approximately 5,000 families and their descendants, including an oversample of African-American families. We studied all PSID household heads and spouses (about 12,000 individuals per year) who reported they had an incident stroke in the prior two-year period (directly or by proxy response) between 2001-2011. PSID queries difficulty with seven different self-care and mobility activities. Our primary outcome was an index representing the sum of total activity limitations (0-7). Racial differences in activity limitations were estimated using survey-weighted descriptive statistics for study waves before, with and after the wave when incident stroke was reported.

Results:
A total of 534 incident strokes were identified, 198 (37%) in African-Americans who were younger (52.2 vs. 60.1, p < 0.001) and had more hypertension (57% vs. 42%, p < 0.01) and diabetes (23% vs. 14%, p < 0.01) than whites. In the wave prior to the stroke there was no racial difference in activity limitations. In the wave of the incident stroke (between 0-2 years from incident stroke), African Americans had considerably more activity limitations than whites, a difference that decreased over subsequent waves. (Figure) These changes persisted after adjusting for age, sex and comorbidities.

Conclusion:
Racial disparities in stroke functional outcomes are not due to pre-stroke functional differences and most likely arise after stroke.
Abstract T P132: Risk Factors for Spinal Cord Infarct Compared to Those for Stroke and Transverse Myelitis
Authors: Prabhu Divya , Kamel Hooman , Willey Joshua Z
Published: July 2021

Background:
Although spinal cord infarction (SCI) is a rare form of CNS injury, the long-term disability can be substantial. There are limited epidemiological data on the incidence and risk factors of SCI and most prior data were based on small case series of surgical patients.

Objectives:
To evaluate risk factors for SCI in a contemporary population-based sample, and compare the profiles of those with SCI to those with ischemic stroke and transverse myelitis.

Methods:
Using California state data on all patients discharged from nonfederal emergency departments or acute care hospitals between 2005 and 2011, we identified all patients with a discharge diagnosis of SCI (ICD9 code = 336.1), ischemic stroke (433.x1, 434.x1, or 436) and transverse myelitis (341.2, 341.3, or 323.82). Age, sex, race, and vascular risk factors were compared among these diagnoses subsets using the Chi square test.

Results:
The annual incidence of SCI (7 per million) was significantly less than that of stroke (1136 per million). The age of patients with SCI (60.8±18.8) was less than that for patients with stroke (72 ±14.4) but more than that for transverse myelitis (50.6 ±18.5). In general, patients with SCI had vascular risk factors more often than transverse myelitis patients but less often than stroke patients, with the exception of peripheral vascular disease, aortic dissection or rupture, and aortic surgery_all of which were more prevalent among SCI patients than stroke patients.

Conclusion:
In a large population-based sample of patients, we found that traditional vascular risk were less common with SCI than with ischemic stroke, while peripheral vascular disease and aortic disease or surgeries were more common.