bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 2375: Pediatric Stroke Outcome Measure Predicts Cognitive And Functional Deficits After Childhood Ischemic Stroke
Authors: Lo Warren , Gordon Anne , Greenham Mardee , Gomes Alison , Hajek Christine , Mackay Mark , Yeates Keith O , Anderson Vicki
Published: July 2021

BACKGROUND:
The Pediatric Stroke Outcome Measure (PSOM), a 10 point scale based on 5 domains, is one of the few measures of outcome in pediatric stroke. The PSOM has been used to estimate global deficit for studies of stroke outcome and post-stroke quality of life, but its sensitivity to cognitive and functional impairments has received little attention. To address this question, we examined the ability of the PSOM to predict cognitive functioning and behavior after childhood stroke.

METHODS:
Children ages 6-15 years who had neonatal or childhood onset arterial ischemic stroke were identified by chart review at the Nationwide Children’s Hospital (Columbus, OH, USA) and Royal Children’s Hospital (Melbourne, Australia). Subjects were included if they could complete the test battery. Age- and gender-matched children who had asthma were selected as controls. Stroke cases were assessed with the PSOM and had an MRI brain scan after the acute phase of stroke. Cases and controls underwent functional assessments at least 1 year after the incident stroke. The battery of tests and ratings included the Child Behavior Checklist, Adaptive Behavior Assessment System, Child and Adolescent Scales of Participation, the Wechsler Abbreviated Scales of Intelligence (WASI), and the WISC-4 Processing Speed Index. Infarct volumes were measured by manual segmentation.

RESULTS:
The sample included 36 children with perinatal or childhood stroke, and 15 controls. Median age at assessment was 8.7 yrs (IQR 6.9-11.9) and median time after presentation was 5.1 yrs (IQR 2.8-7.4). The total PSOM was significantly and inversely related to all measures of cognitive functioning (p range for WISC and WASI 0.001-0.048), multiple measures of adaptive behavior (p range for ABAS scales 0.000-0.031), and all measures of social participation (p range for CASP scales 0.000-0.007). The cognitive/behavioral (C/B) scale of the PSOM was significantly and inversely related to all measures of social participation (p values for CASP 0.000) and multiple measures of adaptive behavior (p range for ABAS scales 0.001-0.057), and positively related to multiple measures of behavior problems (p range for CBCL scales 0.001-0.037).

Conclusions:
The total PSOM can predict multiple areas of intellectual impairment, and also predicts impairment in adaptive behavior and social participation. In addition the C/B scale can predict behavior problems. The C/B scale depends upon parental report and the clinician's impression, so it is noteworthy that abnormalities on this four-point scale can suggest impairments in a broad range of domains. In addition to a quantitative measure of stroke outcome, the PSOM can serve as a useful screening tool for the identification of intellectual or functional deficits that warrant further investigation for appropriate intervention.
Abstract 2424: Who Bleeds? Predicting Intracranial Bleeding in Patients with Acute Ischemic Stroke and an Indication for Anticoagulation
Authors: Marsh Elisabeth B , Llinas Rafael H , Hillis Argye E , Gottesman Rebecca F
Published: July 2021

Introduction:
Many patients with acute ischemic stroke also have an indication for anticoagulation. A major concern in these patients is whether they are at increased risk for intracranial bleeding, and if so, what factors further increase their risk. We evaluated stroke patients with an indication for anticoagulation to determine what factors are associated with increased risk of intracranial bleeding.

Methods:
Patients presenting with acute ischemic stroke and an indication for anticoagulation were included in analysis. Data were collected in the following categories: demographics (age, race, gender), medical profile (blood pressure, glycemic control, statin use/LDL, renal function [divided into GFR categories- 0: GFR ≥60, 1: GFR 30-59, or 2: GFR <30], antiplatelet use, anticoagulation status), and stroke characteristics (type of stroke, time from onset of symptoms to anticoagulation, NIH Stroke Scale). Stroke volume, gradient echo positivity, and evidence of intracranial bleeding on head CT and MRI were also assessed. Hemorrhages were classified as: hemorrhagic conversion (petechiae) versus intracranial hemorrhage (a space occupying lesion), and symptomatic versus asymptomatic (based on subjective clinical worsening noted by the primary neurology team). Using stepwise regression analysis we determined which factors were associated with increased risk of intracranial bleeding (with any intracranial bleeding as the primary outcome).

Results:
143 patients (mean age 63.5 years) met criteria and were included in analysis. 117 were placed on anticoagulation. The most common indications for anticoagulation were atrial fibrillation (35.6%), deep vein thrombosis (27.3%), presence of a hypercoagulable state (18.2%), and pulmonary embolism (17.5%). The difference in bleeding rates between those placed on anticoagulation and those treated with an antiplatelet agent was not statistically significant (25.6% versus 23.1%, χ2=0.785), but all of the intracranial hemorrhages (n=8) and symptomatic bleeds (n=9) occurred in the anticoagulated group. Age (OR= 1.31 per 10 year increment, 95% CI 0.98-1.74), volume (OR= 1.13 per 10 cc’s, 95% CI 1.05-1.21), and worsening GFR category (OR= 1.81, 95% CI 1.01-3.26) were predictors of intracranial bleeding. Odds of hemorrhage was predicted by exponentiating the equation: -3.823563 + (0.0120706)*(Volume) + (0.5939482)*(GFR Category) + (0.0266442)*(Age). Probability of hemorrhage can then be calculated.

Conclusions:
Probability of intracranial bleeding in patients with acute ischemic stroke and an indication for anticoagulation can be calculated based on an individual’s age, stroke volume, and GFR. This score can be used to assist with prognosis and clinical management. While anticoagulation does not appear to increase risk of bleeding, it does tend to result in larger, more symptomatic bleeds.
Abstract 2451: Arterial Spin Labelling Provides Usual Clinical Information In Acute Stroke
Authors: Bivard Andrew , Levi Christopher , Parsons Mark
Published: July 2021

Introduction
Arterial Spin Labelling (ASL) is a readily available MR scanning technique and may provide similar information to conventional bolus-tracking dynamic susceptibility MR sequences. However, there is little comparative data in acute stroke. Methods: Patients with an acute ischemic stroke were imaged within 6 hours of ischeamic stroke onset with perfusion CT (CTP) and at 24 hours with MRI, including diffusion weighted MR (DWI),ASL and Perfusion Weighted Magnetic Resonance Imaging (PWI). Patient neurological status was determined using the National institutes of stroke score acutely and at 24 hours, as well as a modified Rankin score at 90 days. The ASL baseline perfusion value was defined as the mean value of the healthy, non ischeamic stroke hemisphere of the patient. Values 20% higher or lower than the mean healthy hemisphere were considered abnormal. A pixel based analysis was also undertaken to compare the perfusion lesion on ASL to the perfusion lesion on the baseline CTP and concurrent PWI maps of CBV, CBF, MTT and Tmax. Results Of the 80 patients in this study there were 32 patients with hyperperfusion in the ischaemic region and 48 with persistent hypoperfusion on follow-up ASL imaging. Hyperperfusion was linked to greater penumbral salvage (defined by the acute CTP and 24 hour DWI) and an improved early clinical outcome (mean improvement in between acute and 24 hour NIHSS = 9) as well as better 3 month outcome (mRS mean = 2, p=0.15). Patients with persistent ASL hypoperfusion showed less improvement in NIHSS (mean improvement 3) and had a poorer 90 day outcome (mean mRS 4). Interestingly, The ASL hypoperfusion lesion was closest to the Tmax PWI map (AUC=0.85) rather than CBF(AUC=0.66) or MTT(AUC=0.73). Discussion. At 24 hours, hyper- or hypo-perfusion on ASL was strongly correlated to clinical outcome. ASL may have clinical utility in the prediction of stroke prognosis based on the difference in clinical outcome (mRS) between the patient groups with hyper- or hypo- perfusion.
Abstract 2532: Improving Motor Recovery after Stroke: Opportunities for FLAME Study Results
Authors: de los Ríos la Rosa Felipe , Khoury Jane , Alwell Kathleen , Moomaw Charles J , Kleindorfer Dawn , Broderick Joseph P , Woo Daniel , Flaherty Matthew L , Khatri Pooja , Adeoye Opeolu , Ferioli Simona , Eilerman Jane , Kissela Brett
Published: July 2021

Introduction:
The Fluoxetine for Motor Recovery after Acute Ischaemic Stroke Study (FLAME, published in 2011) showed that fluoxetine, when administered early to patients suffering from an acute ischemic stroke with moderate to severe hemiplegia, improved motor recovery and reduced the number of dependent patients at 90 days. We sought to estimate the number of cases who might have benefited from this intervention using the population-based Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) database.

Methods:
Stroke cases for calendar year 2005 were ascertained using ICD- 9 discharge codes 430-436. The GCNK region comprises a population of 1.3 million, which is similar to the United States with regard to the proportion of African Americans and socioeconomic status. Data from the hospital record of all potential cases were abstracted by research nurses and then reviewed by study physicians for verification of cases. Based on FLAME study eligibility criteria, patients with a diagnosis of ischemic stroke between 18 and 85 years of age and with hemiparesis or hemiplegia (NIHSS ≥ 1 on both items 5a and 6a or 5b and 6b) were retrospectively considered candidates for therapy with fluoxetine. Patients were not considered candidates if they had a NIHSS > 20, a pre stroke mRS ≥ 3, severe aphasia (NIHSS ≥ 2 on item 9), or dysarthria (NIHSS ≥2 on item 10).

Results:
In 2005, 2234 ischemic strokes were identified. Of these, 427 (19%) would have been candidates for therapy with fluoxetine for motor recovery. Among patients eligible for fluoxetine, 98 (23%) had a diagnosis of depression at discharge, of which 24 (5.6%) were newly diagnosed. At time of discharge, 109 (25.5%) of patients eligible for fluoxetine were prescribed some form of antidepressant, and 66 (15.5%) were prescribed a SSRI. However, only 5 (1.2%) were discharged on fluoxetine (
Table
). The majority of those discharged on antidepressants had this medication prescribed prior to suffering a stroke (71.6%).

Conclusions:
We found that 1 in 5 (19%) of ischemic strokes met criteria for the FLAME study. This represents about 130,000 cases per year in the USA. Meeting this goal would require a significant change of practice as only 15% of eligible cases in our community were prescribed an SSRI and only 1.2% were prescribed fluoxetine upon discharge. It is still unclear how the publication of FLAME will alter SSRI prescription patterns in 2011.
Abstract 2539: Evaluation of Emergency Department Acute Ischemic Stroke Patients With and Without Blockage on Computed Tomography Angiography
Authors: Schrock Jon W , Day Robert , Morris Peter , Reed Steven , Ferguson Robert , Hanna Joseph
Published: July 2021

Background:
CT angiography (CTA) provides early assessment of cerebral vasculature in ED patients presenting with Acute Ischemic Stroke (AIS). Prior studies using 4 row detector CT scanners have suggested that results may be used to determine who receives thrombolytics (tPA). We sought to evaluate the rate of normal CTA and the use of tPA in AIS patients with and without blockages using modern CT technology.

Methods:
We conducted a retrospective cohort study of all code stroke patients presenting to our ED over a 3 year period ending in February 2011. Inclusion criteria included an ED and neurology diagnosis of AIS with a CTA performed at presentation. All patients had a NIHSS score recorded at presentation and underwent imaging using a 64 row detector scanner (Phillips) with 50cc of non-ionic contrast. Demographic, imaging, and clinical data were collected. Modified Rankin Scores (mRS) were assigned at presentation and hospital discharge. Good clinical outcome was defined as a mRS of 0-2. Data are reported as frequencies and medians with interquartile ranges (IQR) as appropriate. Rates of tPA use were evaluated using χ
2
testing. Changes in mRS were evaluated with the paired t-test.

Results:
A total of 209 subjects met inclusion for analysis of which 104 (50%) were male and 116 (55%) had no blockage on CTA. The median NIHSS score and mortality rates were 14 (IQR 8-19), 14 (15%) with CTA blockage, and 4 (IQR 2-7), 3 (3%) for those without. The use of tPA occurred in 46(50%) with 29 patients receiving intra-arterial therapy, and 14 (12%) patients with and without blockage respectively. Post tPA bleeding occurred in 12 (13%) patients with blockage on CTA and in 0 patients without blockage. Use of tPA was significantly more frequent in patients with a blockage on CTA, P <0.001. As a group, patients without a blockage had a significant decrease in mRS at discharge, however the overall difference was greater in the tPA group, difference = 0.4 (0.2-0.7) P<0.0002 and 1.9 (1.2-2.6) P<0.0001 respectively. Only AIS patients with a blockage and given tPA had a significant reduction of mRS, difference = 0.6 (0.2-1.0) P<0.005 compared with no tPA, difference = -0.1 (-0.4-0.3) P<0.7.

Conclusion:
More than half of our AIS patients presenting through our ED have no blockage on CTA. Patients with AIS and no blockage on CTA have less severe strokes and are less likely to receive tPA. Both AIS patients with and without a blockage on CTA appear to derive benefit from tPA.
Abstract 2550: Early 3 Hour Imaging Demonstrates Substantial Diffusion Reversal with Lower Infarction Risk Compared to Tissue without Diffusion Reversal
Authors: Ford Andria L , An Hongyu , Kumar Gyanendra , Vo Katie D , Powers William J , Lin Weili , Lee Jin-Moo
Published: July 2021

Background:
Literature suggests that diffusion reversal--determined by visually inspecting diffusion-weighted images which reverse on subsequent imaging--is uncommon. However, these studies performed the initial scan 3 to 6 hrs from onset which may miss lesions that have already undergone reversal. We measured apparent diffusion coefficient (ADC) reversal between 2 scans obtained at 3 and 6 hrs from onset comparing infarct probability in reversed regions to brain regions with persistent ADC lesions.

Methods:
Ischemic stroke patients underwent 3 MRI’s: <4.5 hrs (tp1), at 6 hrs (tp2), and at 1 mo (tp3) after onset. Co-registered maps measured ADC lesions (tp1, tp2) and FLAIR infarct (tp3). Diffusion lesions were manually outlined as hypointense regions on ADC. A population-derived ADC threshold to distinguish abnormal from normal ADC was calculated based on the maximum ADC value capturing >90% of voxels within the outlined lesions. ADC values less than or greater than this threshold were defined as abnormal and normal, respectively. ADC “reversal” was defined as voxels with abnormal tp1 ADC and normal tp2 ADC, whereas ADC “non-reversal” was defined as abnormal ADC on both tp1 and tp2. Final infarcts were outlined as hyperintense regions on tp3 FLAIR. Infarct probability (% of the tp1 ADC lesion which infarcted on tp3) was compared between reversed and non-reversed tissue using a Mann-Whitney test. Leukoariosis or CSF voxels due to infarct atrophy were excluded from the infarct analysis.

Results:
39 patients were prospectively scanned at 2.8hr (tp1), 6.4hr (tp2), and 1mo (tp3) after stroke onset (NIHSS=14, 74% received tPA). The population-derived ADC threshold to distinguish between abnormal and normal was 71 × 10
-5
mm
2
/s. Median ADC lesion volume at tp1 was 34ml [15, 70] and at tp2 was 34ml [14, 65]. Median ADC reversal volume was 6.6ml [5, 17], accounting for 34% [11, 44] of the tp1 ADC lesion volume (ADC non-reversal volume was 21ml [6, 50]). 31 of 39 (79%) and 20 of 39 (51%) patients had reversal volumes >10% and >33% of their initial ADC lesion, respectively. Infarct probability was lower (57%) in ADC reversal tissue compared to tissue with non-reversal (82%, p<0.0001) (
Figure
). To confirm that the derived ADC threshold distinguished abnormal tissue on tp1 from normal tissue on tp2, ADC tp1 and tp2 values were compared and differed (66 vs. 77, p<0.0001).

Conclusion:
While ADC closely approximates infarct core, during early ischemia, a substantial proportion of the initial ADC lesion may reverse. Brain tissue with this MR signature carries a significantly lower risk of infarction than tissue without ADC reversal.
Abstract 2562: Neighborhood Poverty, Personal Income and Incident Stroke in Black and White Participants in the REGARDS Study
Authors: Howard Virginia J , Letter Abraham J , McClure Leslie A , Howard George , Cunningham Solveig , Kleindorfer Dawn O , Thrift Amanda G , Diez Rouz Ana V
Published: July 2021

Background.
Neighborhood poverty has been identified as an important risk factor for coronary heart disease, with an association that is independent of individual income. Associations of poverty with stroke outcomes have been mixed, and not all studies have included adjustment for risk factors.

Methods.
The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study is a national, population-based, longitudinal study of 30,239 black and white adults > 45 years, enrolled 2003-2007. Baseline data collection included a centralized telephone interview for demographics and medical history and an in-home evaluation for physical measures. Participants are subsequently telephoned bi-annually for self- or proxy-reported stroke; then medical records are retrieved and adjudicated by physicians. Baseline home addresses were geocoded and linked to census tract, and percentage of census tract living below federal poverty level was determined from the 2000 US Census. Neighborhoods were stratified as wealthier (poverty levels below 15%) and poorer (15% and above). Participants reporting a physician-diagnosed stroke at baseline, missing income, < 80% reliability on geocoding, or no follow-up were excluded, leaving n=20,596. These participants resided across 10,471 census tracts. Proportional hazard models were fit to establish the association of incident stroke with neighborhood poverty within strata of personal income by race, adjusting for age, sex, and region (Stroke Belt, Buckle, or other) and further adjustment for education and Framingham stroke risk factors.

Results.
There were 460 strokes in the analysis cohort of 8,637 blacks and 11,959 whites; mean age was 64.5 years; 54% were women. After controlling for age, sex, region, and personal income, neighborhood poverty was not associated with increased stroke risk. However, there was a trend for blacks with low incomes and whites with high incomes to have increased risk if they lived in a poor neighborhood (see
figure
). Further adjustment for education and stroke risk factors did not substantially alter results.

Conclusions.
We observed that within most levels of personal income, neighborhood poverty was not associated with stroke risk; however, there was an intriguing suggestion that residence in poor neighborhoods increases the risk for low income blacks and high income whites. Additional work using other measures of neighborhood socioeconomic status may be warranted.
Abstract 2579: tPA Contributes To Aggravation of Endothelin and Thromboxane Induced Cerebrovasoconstriction After Hypoxia/Ischemia Through Upregulation of ERK MAPK
Authors: Armstead William , Kaczynski Heather , Riley John , Cines Douglas , Higazi Abd Al-Roof
Published: July 2021

Introduction:
The sole FDA approved treatment for acute stroke is tissue type plasminogen activator (tPA). However, endogenous tPA is upregulated and potentiates impairment of pial artery dilation in response to hypotension after hypoxia/ischemia (H/I) in pigs. Mitogen activated protein kinase (MAPK), a family of at least 3 kinases, ERK, p38 and JNK, is also upregulated after H/I, with ERK contributing to vasodilator impairment. Impairment of stimulus induced vasodilation may result from tonic withdrawal and/or impairment of a vasodilator influence or upregulation of a vasoconstrictor. This study examined the effect of H/I on the vascular response to two important spasmogens released during CNS ischemic disorders, endothelin-1 (ET-1) and thromboxane, and the influence of tPA and ERK MAPK in such responses.

Methods:
Cerebral ischemia (20 min) was induced via global increase in intracranial pressure via saline infusion into a hollow bolt placed in the cranium (dura intact) while hypoxia (10 min, pO2 35 mm Hg) was produced by decreasing the inspired O2 via inhalation of N2. Vascular responses to topical ET-1 (10-10, 10-8 M) and U 46619 (1, 10 ng/ml) were obtained at 1h post insult. Phosphorylated and total ERK MAPK were measured by ELISA in the CSF of piglets equipped with a closed cranial window. Data (n=5) were analyzed by ANOVA, with significance at p less than 0.05.

Results:
H/I aggravated pial artery vasconstriction induced by ET-1 and the thromboxane mimic U 46619, which was blocked by EEIIMD, an inhibitor of PAI-1’s vascular activity and signaling of tPA, but not its fibrinolytic action, but unchanged by its inactive analogue EEIIMR. CSF ERK MAPK was increased by H/I and potentiated by tPA. The ERK MAPK antagonist U 0126 blocked H/I induced aggravation of ET-1 and U 46619 vasoconstriction.

Discussion:
These data indicate that H/I aggravates ET-1 and thromboxane mediated cerebral vasoconstriction through upregulation of tPA and ERK MAPK. These data suggest that thrombolytic therapy for treatment of CNS ischemic disorders can dysregulate cerebrohemodynamics by augmenting vasoconstriction induced by spasmogens co-released during CNS pathology.
Abstract 2619: Autoregulation of Cerebral Blood Flow is Preserved in Primary Intracerebral Hemorrhage
Authors: Gould E B , McCourt Rebecca , Vahidy Sana , Asdaghi Negar , Hill Michael D , Coutts Shelagh B , Demchuk Andrew M , Jeerakathil Thomas , Emery Derek , Butcher Kenneth S
Published: July 2021

Background:
Treatment of hypertension during acute intracerebral hemorrhage (ICH) is controversial. There are concerns that in the context of disrupted cerebral autoregulation, blood pressure (BP) reduction may cause decreased cerebral blood flow (CBF), particularly in the perihematoma region. CBF was assessed using serial CT perfusion (CTP) studies. We hypothesized that CBF would remain stable following BP reduction.

Methods:
Acute primary ICH patients were imaged pre and post BP treatment. Perfusion maps were calculated from CTP source images. Mean CBF was measured in a 1cm perihematoma region, contralateral homologous regions and in both hemispheres. Mean cerebral blood volume (CBV), mean transit time (MTT), and time to drain (TTD) were calculated in the same manner. Relative measures (i.e. rCBF) were calculated as ratios/differences between ipsilateral and contralateral regions.

Results:
Sixteen patients (median age 75 (54-91)) were imaged with CTP (median time from onset 19.4 (2.0-72.2) h) and re-imaged 2.0 (1.1-3.3) h later. Median NIHSS at baseline was 9 (2-24); this remained stable at the time of the second CTP (10 (2-24), P=0.14). Baseline hematoma volume was 24.8±19.9 ml and there was no change at the time of the second CTP (26.3±22.1 ml, P=0.16). Patients were recruited from an ongoing trial, in which they were randomly treated to a target systolic BP of <150mmHg (n=9) or <180mmHg (n=7). Four patients received no antihypertensives as BP was below target at the time of randomization. Mean systolic BP in treated patients (n=12) decreased significantly between the first (165±23 mmHg) and second (143±18 mmHg, P<0.0001) CTP scans. Mean perihematoma CBF in treated patients was stable with BP reduction (pre=35.1±7.1 vs. post=35.4±6.2 ml/100g/min, P=0.87). Ipsilateral hemispheric CBF was also stable (pre=47.3±7.2 vs. post=46.4±7.1 ml/100g/min, P=0.66). Although perihematoma CBF was lower than in contralateral homologous regions (rCBF=0.72±0.11), BP reduction did not decrease this further (0.74±0.14 post-treatment, P=0.58). Ipsilateral hemispheric rCBF (0.96±0.06) was also unaffected by BP treatment (0.95±0.08, P=0.64). Perihematoma rCBF decreased in 5 treated patients, but never by >12%. Linear regression showed no relationship between changes in systolic BP and perihematoma rCBF (R=-0.002, [-0.005, 0.001], P=0.18). Perihematoma rCBV (pre=0.77±0.11 vs. post=0.79±0.10, P=0.20), rMTT (pre=0.51±0.54s vs. post=0.70±0.65s, P=0.26) and rTTD (pre=0.71±1.01s vs. post=0.89±0.84s, P=0.42) also remained stable following BP treatment.

Conclusions:
Acute BP reduction does not appear to exacerbate perihematoma oligaemia. Stability of CBF following acute BP treatment suggests preservation of cerebral autoregulation in ICH, within the range of arterial pressures studied. These findings support the safety of early BP treatment in ICH.
Abstract 2629: The Effectiveness Of A Stroke Educational Activity Performed By A Schoolteacher For Junior High School Students
Authors: Miyashita Fumio , Yokota Chiaki , Amano Tatsuo , Inoue Yasuteru , Shigehatake Yuya , Sakamoto Yuki , Tani Syoko , Narazaki Hiroshi , Toyoda Kazunori , Nakazawa Kazuo , Minematsu Kazuo
Published: July 2021

Background and Purpose:
School-based programs of stroke enlightenment would be promising means to improve prevention of stroke as well as to spread the knowledge of stroke. Junior high school education is compulsory in Japan. We developed an educational system of stroke for junior high school students and teachers. Our purpose is to verify the effectiveness of this educational system to acquire knowledge of stroke for junior high school educations.

Methods:
Subjects were 100 students in the 3
rd
grade of a public junior high school (40 girls, 14-15 years old). A stroke neurologist gave 45 minutes’ lesson in stroke to 25 students (S group) and 1 schoolteacher of health education by use of our educational system. A stroke neurologist also performed instructions to the schoolteacher how to use our stroke educational system to the students. The system includes stroke signs, symptoms, the FAST massage (Facial droop, Arm weakness, Speech disturbance, Time to call 119) and risk factors. After instructions by the stroke neurologist, the schoolteacher performed the lesson using the same educational system to the other 75 students (T group). Questionnaires on stroke knowledge (total 12 items for stroke signs and 10 items for risk factors) were examined for all students at the baseline and immediately after the lesson.

Results:
The total scores were not significantly different between the 2 groups either at the baseline or immediately after the lesson. In the S group, the items of correct answers on stroke signs[median 11(IQR 8-11) vs. 6(6-8.5) , P<0.001 ]and stroke risk factors [9(8-9) vs. 7(5-7.5), P<0.001] significantly increased after the lesson than at baseline. In the T group, the items of correct answers on stroke signs [10(8-11) vs. 7(6-9), P<0.001 ]and stroke risk factors [8(7-10) vs. 7(6-8); P<0.001]also significantly increased. On the FAST massage, there is no significant difference between 2 groups (73% vs. 92%; P=0.056).

Conclusions:
The stroke education program using our educational system would be promising means for junior high school educations.
Abstract 2713: Functional Recovery Associated with Connectivity Changes in Contralesional Hemisphere after Severe Transient Stroke.
Authors: SHIM WOO HYUN , Rosen Bruce , Jeong Jaeseung , Kim Young
Published: July 2021

Stroke impairs connections in the brain system, commonly resulting in significant sensorimotor deficits. Some degree of functional recovery typically occurs even after a severe stroke, yet changes in the brain connectivity that underlie such recovery are poorly understood. In this study, using rat stroke models, we monitored functional connectivity when the sensorimotor deficit recovered after a severe ischemic stroke (defined DWI by more than 15% of the entire brain volume). We used seven Sprague-Dawley rats (∼350g), which showed nearly full recovery of both motor and sensory functions approximately 180 days after 90 min occlusion of the right middle cerebral artery. Six healthy age controlled rats were used for the control group. BOLD MRI time courses during rest (10min, TR=1s, 9 slices) were collected. Both the seed-voxel analysis and the ROI-based analysis were performed, in which seed voxels were selected in the left S1FL, and multiple ROIs were placed over the somatosensory regions. Stroke rats showed the markedly decreased functional connectivity in the ipsilesional side (right) for both voxelwise and ROI-based methods. Interestingly, in contralesional (non-stroke) side (left), the voxelwise connectivity spatially expanded into the entire cortical area. The cross-correlation coefficient values between ROI’s slightly increased in the contralesional hemisphere compared to the control rats. In conclusion, we demonstrated that the restoration of sensorimotor function is associated more with the increase and spatial expansion of functional connectivity within the contralesional than the ipsilesional hemisphere.
Abstract 2721: Probabilistic Matching of Computerized Emergency Medical Services (EMS) records and Emergency Department and Patient Discharge Data: a Novel Approach to Evaluation of Prehospital Stroke Care
Authors: Govindarajan Prasanthi , Cook Larry , Ghilarducci David , Johnston S C
Published: July 2021

Background and Purpose:
Emergency Medical Services is an important element of acute stroke care. However, evaluation of prehospital stroke care is limited by lack of exchange of patient outcome data between hospitals and emergency medical services (EMS) agencies. In this study, we describe and demonstrate the feasibility of linking county wide patient level ambulance data with emergency department (EDD) and patient discharge data (PDD) using a probabilistic matching algorithm.

Methods:
Probabilistic linkage was used to match county-wide ambulance data from 2005-2007 to hospital (EDD and PDD) records with a final ICD -9 diagnosis of stroke (430-436). The linkage model was based on the patient’s transport/admission date, date of birth, race, sex, county of residence, and destination hospital. Probabilistic linkage was performed using LinkSolv version 8.29746 which calculates the probability that a pair of records is a true match based on agreement/disagreement patterns of the linkage variables. Pairs of records with a match probability of 0.8 or higher were considered true matches. All other pairs were false matches and rejected.

Results:
During 2005 - 2007 there were 310,731 patients transported to a facility in county and 34,785 hospital records with a diagnosis of stroke. Using the linkage algorithm we identified 11,473 (33%) matches with EMS records. Linkage rates increased each year with 30%, 34%, and 36% of hospital patients matching EMS record for 2005, 2006, and 2007 respectively. The median match probability was 0.993 and the IQR was 0.974 to 0.9996. By taking the compliment of the match probability we estimate our linked sample to include 255 (2%) false matches. Date of treatment/admission and the patient’s sex were observed to be the most reliable, disagreeing on less than one percent (1%) of all matched pairs. Patient’s zip code was the least reliable, disagreeing on one third of matched pairs.

Conclusions:
Our study demonstrates that probabilistic matching can be used to create a comprehensive patient care record which in turn can provide opportunities for researchers to study different phases of stroke care.
Abstract 2763: Total Plaque Area Measurement Is A Reliable Indicator Of Vascular Risk Factor Treatment Effect
Authors: Estol Conrado , Armando Luis J , Perez Hernan A , Spence J. David , Garcia Nestor H
Published: July 2021

Background:
Ultrasound measurement of carotid plaque area (TPA) is a noninvasive method for identifying patients at higher risk of cardiovascular events. Previous studies demonstrated that intensive medical therapy reduces TPA. In this study we examined effects of less intensive therapy on TPA, and the usefulness of TPA in risk stratification.

Methods.
Baseline Framingham Risk Score (FRS), TPA, blood pressure (BP), body mass index and the post test probability using TPA (PtP TPA) were determined from patients at the primary care unit. TPA measurements were reported to primary physicians to encourage them to follow preventive guidelines. After 10±1 months patients were reevaluated to investigate changes from baseline.

Results:
among 140 patients enrolled between July 2009, and July 2011, 52% were male, BP was 142±1/81±1 mmHg, BMI 29±1 kg/m2, FRS 24±1, PtP TPA 50±2, and TPA 97±7 mm2. After 10±1 months of treatment, three groups were identified. Group 1 had a reduction of TPA (127±13 to 99±12 mm2, p<0.002), BP (142±3/80±2 to 137±2/75±2mmHg, p<0.002) and PtP TPA score (55±3 to 47±3, p<0.007). Group 2 patients had progression of TPA (from 90±8 to 138±12mm2, p<0.001) and reached a poorer PtP TPA score (51±2 to 58±2, p<0.001). Group 3 patients with stable TPA only decreased the BMI (from 28.5±0.9 to 27.8±1.0 kg/m2, p<0.05). TPA identified high-risk patients; 27% of these patients achieved regression of TPA, associated with a decrease of BP and PtP TPA. The rest of the patients only decreased the BMI, and the TPA remained stable. FRS did not change in any group in spite of changes on blood pressure or body weight. These data suggest that reduction in BP as well as reduction of BMI is required to prevent TPA progression.

Conclusions:
Plaque measurement may be useful for targeting preventive therapy and evaluating new treatments and response to therapy, and may improve cost-effectiveness of secondary preventive treatment.
Abstract 2769: A Simple Clinical Index Based On Nihss Score During 1-h Tpa Infusion To Predict Unfavorable Outcome
Authors: Osaki Masato , Miyashita Fumio , Koga Masatoshi , Fukuda Mayumi , Shigehatake Yuya , Nagatsuka Kazuyuki , Minematsu Kazuo , Toyoda Kazunori
Published: July 2021

Background:
When intravenous tissue-type plasminogen activator therapy (IV-tPA) does not work, additional endovascular thrombectomy is a promising choice. However, there is no clear standard of timing to add thrombectomy after IV-tPA. We sought to create a handy clinical index to judge insufficient effects of IV-tPA immediately after the therapy based on posttreatment NIH Stroke Scale (NIHSS) score.

Methods:
Consecutive ischemic stroke patients with the baseline NIHSS score ≥8 and occlusion at the ICA or MCA on the initial MRA, who received IV-tPA within 3 h of onset, were retrospectively studied. NIHSS was assessed 30 min and 1 h after the initiation of IV-tPA and change from the baseline score was calculated (ΔNIHSS). The subjects were divided into 2 groups according to the arterial occlusion sites; ICA or proximal M1 with the residual length <5 mm (Group P) and distal M1 or M2 (Group D). Optimal cutoff scores of NIHSS and ΔNIHSS for predicting unfavorable outcome at 3 months, corresponding to the modified Rankin Scale of 3 to 6, were determined using receiver operating characteristic curves. The predictive accuracy of unfavorable outcome by NIHSS score and its combination with ΔNIHSS score was assessed.

Results:
Forty two patients (16 women, 75±9 years old, 27 ICA, 15 M1) were enrolled as Group P and 78 patients (22 women, 77±12 years old, 50 M1, 28 M2) as Group D. In Group P, 35 patients (83%) had unfavorable outcome; cutoff NIHSS scores predicting unfavorable outcome were ≥14 at both 30 min (AUC 0.855) and 1 h (0.916), and cutoff ΔNIHSS scores were ≤1 at both 30 min (0.829) and 1 h (0.888). In Group D, 42 patients (54%) had unfavorable outcome; cutoff NIHSS scores were ≥11 at 30 min (AUC 0.684) and ≥12 at 1 h (0.723), and cutoff ΔNIHSS scores were ≤6 at 30 min (0.615) and ≤7 at 1 h (0.631). In each time-point of both groups, cutoff NIHSS scores themselves were good predictors of unfavorable outcome, and the combination with cutoff ΔNIHSS scores strengthen the predictive accuracy more. In Group P, ‘NIHSS
30min
≥14 plus ΔNIHSS
30min
≤1’ showed the sensitivity (SEN) of 67%, specificity (SPEC) of 100%, positive predictive value (PPV) of 100%, and negative predictive value (NPV) of 39% in predicting the outcome, and ‘NIHSS
1h
≥14 plus ΔNIHSS
1h
≤1’ showed SEN 66%, SPEC 100%, PPV 100%, and NPV 37%. In Group D, ‘NIHSS
30min
≥11 plus ΔNIHSS
30min
≤6’ showed SEN 71%, SPEC 67%, PPV 71%, and NPV 67%, and ‘NIHSS
1h
≥12 plus ΔNIHSS
1h
≤7’ showed SEN 62%, SPEC 78%, PPV 77%, and NPV 64%.

Conclusion:
Combination of the NIHSS score and its change from the baseline score during 1-h tPA infusion seems to be a good predictor of unfavorable outcome at 3 months and helpful to decide the timing of adding endovascular thrombectomy. In particular, the combination showed high specificity and PPV of the outcomes in patients with occlusion at the proximal carotid axis.
Abstract 2792: Bone Marrow Mononuclear Cells Improve Blood-Brain Barrier Permeability And Decrease Hemorrhagic Transformation After Treatment With Tissue Plasminogen Activator In An Embolic Stroke Model
Authors: Yang Bing , Xi Xiaopei , Savitz Sean.I
Published: July 2021

Background:
Tissue plasminogen activator (t-PA) is the only treatment approved in the US for acute ischemic stroke. Cell-based therapies are being studied as a new investigational treatment approach for stroke but few studies have assessed the interaction of cell therapies with IV t-PA in an embolic model. Our laboratory has been investigating the therapeutic potential of bone marrow mononuclear cells (MNCs), which have been shown to enhance recovery after acute ischemic stroke and are currently being studied in safety clinical trials.

Methods:
An embolic ischemic stroke model was established by deposition of an autologous blood clot into the internal carotid artery in adult Long Evans rats. IV t-PA (10 mg/kg) was administered at 1 hour after occlusion. Two hours later, 10 million allogeneic MNCs per kilogram or saline were given intravenously (N=12 per group). Hemorrhagic transformation (HT) and blood-brain barrier permeability using Evans Blue were quantified at 3 days after stroke. In an
in vitro
study, astrocytes were isolated from postnatal P1 rats, pre-conditioned by oxygen-glucose deprivation (OGD) for 45 min, and then cultured with MNCs derived from the mother’s bone marrow. MMP-3 was assayed in the media.

Results:
Over 40% (42%) of animals treated with t-PA had HT at 3 days after stroke. The incidence of HT did not differ in the MNC and saline treated groups. However, the ICH scores were significantly reduced in the MNC group (2±1.2) compared to saline controls (3.8±0.8) (
Fig
A,
p
=0.027). BBB permeability was also reduced in the MNC group (0.28±0.07) compared to saline controls (0.6±0.12) (
Fig
B,
p
=0.033). In the
in vitro
study, MMP-3 levels in the medium of cultured pre-conditioned astrocytes (30.6±3.7 ng/ml) were reduced when co-cultured directly with MNCs (23.1±2.0 ng/ml,
p
=0.047) but MMP-3 levels were unchanged when astrocytes and MNCs were co-cultured in transwell (32.8±3.2 ng/ml) (
Fig
C&D).

Conclusion:
We have found for the first time that bone marrow derived MNCs reduce hemorrhagic transformation and blood brain barrier permeability after treatment with IV t-PA for acute ischemic stroke. Our results suggest a novel mechanism in which MNCs may attenuate hemorrhagic risk from t-PA by reducing the release of MMP-3 from astrocytes.
Abstract 2801: Improved Outcomes among Patients with Decompressive Hemicraniectomy over the Last Decade: Insights from the Nationwide Inpatient Sample
Authors: Bhattacharya Pratik , Kansara Amit , Chaturvedi Seemant , Coplin William
Published: July 2021

Background:
Hemicraniectomy provides a substantial survival benefit for patients with malignant middle cerebral artery infarcts. Over the last few years, our understanding of patient selection criteria for this potentially life-saving procedure has increased. Little is known about whether hemicraniectomy performance has improved outcomes following the procedure outside of clinical trials. Our objective was to evaluate trends in survival and discharge outcomes of ischemic stroke patients receiving hemicraniectomy in the United States over the last decade.

Methods:
Data from the Nationwide Inpatient Sample for the years 2001 through 2009 were reviewed. Hospitalizations with a discharge diagnosis of an acute ischemic stroke (ICD-9 codes: 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 424.01, 434.11, 434.91 and 436) were included. Hemicraniectomy utilization was determined using procedure codes 01.2, 01.25 and 02.01. Nationwide estimates of deaths and discharge destination were calculated for each year within the hemicraniectomy subset. The Cochrane Armitage test was used to assess trend across the years.

Results:
The study included information from 4,917,217 stroke discharges over 9 years. Of these, an estimated 3,447 (0.07%) patients received a hemicraniectomy. There was a progressive decrease in mortality among hemi-craniectomy patients, from 50.1% in 2001 to 26.2% in 2009; trend p=0.016. This survival benefit over the years was primarily seen amongst males (trend p=0.04) and in the younger age group (age <45 years trend p=0.06). Discharges to home (independent or with home care) showed a small decrease in trend over the 9 years. However discharges to rehabilitation facilities and nursing homes have increased over the years (
Figure
).

Conclusions:
Over the last decade, deaths from hemicraniectomy have decreased. A considerable proportion of survivors are being discharged to rehabilitation facilities and nursing homes. Appropriate patient selection and timing for hemicraniectomy has improved survival outcomes for these patients over the last decade. Data on long term neurologic recovery and patient satisfaction are needed.
Abstract 2806: Does Motor Cortex Activity Predict Motor Recovery? An fMRI Study of Subacute Lacunar Stroke
Authors: Jaillard Assia , Delon martin Chantal , Carey Leeanne , Lalamalle Laurent , Hommel Marc J , LeBas Jean Franois , Zeffiro Thomas A
Published: July 2021

Background:
While primary motor cortex (M1) has been demonstrated to be crucial for motor recovery in a recent meta-analysis including fMRI and TMS studies, other functional neuroimaging studies have found that activity in a broader sensorimotor cortical network correlate with motor recovery. The heterogeneity of stroke lesions and the small sample size characterizing many studies could account for these discrepancies.

Hypothesis :
The strength of task-related activity in primary motor cortex predicts motor recovery in a clinically homogenous population of acute lacunar stroke patients.

Methods:
We used fMRI to investigate the neural mechanisms of stroke recovery. We studied 18 stroke patient (4 females, 14 males) after their first single lacunar stroke (7 right , 11 left hemisphere). The lesions caused pure hemiparesia one week after stroke onset (mean 7.2 days; range 2 -15). Lesions were limited to the deep territory of the anterior choroid artery, involving the corticospinal tract at the level of the internal capsule or the corona radiata (
Figure 1
). Patients were matched to 18 healthy controls for age and sex. Motor impairment was assessed using the NIH Stroke Scale (NIHSS), the Fugl-Meyer Scale (FMS), Finger Tapping Score (FTS), Purdue Pegboard and simple reaction times 7 days and 6 months after stroke. At 6 months, a global motor recovery score was computed using the FMS and the FTS to assess motor recovery. Functional MRI scans were obtained using a self-paced finger tapping (FT) task implemented as a block design alternating right FT, left FT and rest. Data were processed using SPM8. In the first level analysis “FT minus fixation” contrasts were computed for the impaired hand. At the second level, multiple regression was used to assess the effect of the motor recovery score on the FT-related motor activity (threshold p<0.05 FWE; extent threshold k=5). Age and FT rate recorded during the experiment were included as covariates in the second level model.

Results:
As a group, the patients showed good recovery at 6 months. Both patients and controls exhibited a typical pattern of FT task-related activity. Activity in primary motor cortex predicted motor recovery at 6 months, after adjustment for age and FT rate. MNI coordinates = [-34,-14,48] See
Figure 1
.

Conclusions:
Primary motor cortex activity, measured soon after stroke onset, predicts motor recovery assessed at 6 months post-stroke. fMRI measurements made in the early phase of stroke recovery could be useful to derive prognostic biomarkers in both clinical practice and clinical trials investigating novel treatments, such as stem cell administration.
Abstract 2841: Intravenous Thrombolysis For Minor Strokes: Outcome In A Cohort Of Patients Treated Through Telemedicine
Authors: Yaghi Shadi , Keyrouz Salah G , Hinduja Archana
Published: July 2021

Objective:
to determine the outcome of patients with minor strokes who receive intravenous thrombolysis in a telestroke network.

Background:
The Arkansas SAVES (Stroke Assistance through Virtual Emergency Support) telestroke network provided emergency evaluation and therapy for acute stroke to 22 spoke sites statewide between November 2008 and May 2011. While there is little question regarding safety of IV thrombolysis in minor strokes, its impact on long-term outcome is equivocal. Few studies, yet with methodological problems attempted to answer this question.

Methods:
Institutional IRB approval was obtained to review the prospective database of the Arkansas SAVES program. We included patients with admission NIHSS ≤ 4. They were divided into two groups based on whether or not they received IV thrombolysis. Baseline characteristics, risk factors, laboratory data and outcomes were compared between the two groups. Good outcome was defined as mRS < 2 and excellent outcome as mRS < 1, at 90 days. For statistical analysis, we used independent T, and fisher’s exact tests.

Results:
The cohort included 562 patients receiving a teleconsultation between November 2008 and May 2011, of whom 116 underwent IV thrombolysis. Sixty patients with admission NIHSS ≤ 4 were included in this analysis. Patients who received IV thrombolysis had a trend towards a higher mean admission NIHSS (3.5 ± 0.7 vs. 3.9 ± 1.0, p = 0.085). There was no statistically significant difference in the percentage of good (76.7% vs. 73.3%, p = NS) or excellent outcome (60.0% vs. 56.7%, p = NS) between the two groups. The mean admission NIHSS was similar in patients with mRS<1 and mRS>1 (3.6 ± 0.9 vs. 3.7 ± 0.9, p = NS), possibly indicating a disconnect between stroke severity, when mild, and overall outcome.

Conclusion:
Intravenous thrombolysis did not improve outcomes in patients with minimal deficits. The use of IV thrombolytics in patients with minor strokes should be individualized depending on the type of deficits and potential disability. A larger randomized trial is needed to confirm those results.