bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 4018: Pretreatment MRI Markers May Predict Hemorrhagic Transformation in Patients Treated with IV tPA
Authors: Luby Marie , Boparai Sundeep , Warach Steven ,   NINDS Natural History of Stroke Investigators
Published: March 2022

Objectives:
Multiple MRI measurements have been investigated as possible markers of post-treatment imaging pathology. The objectives of this study were to understand how well measurements from pre-treatment MRI data including ADC volume, DWI volume, MTT volume, Tmax volume, ADC ratio, and CBV ratio predicted post-treatment hemorrhagic transformation.

Methods:
Patients were selected from the Lesion Evolution of Stroke and Ischemia On Neuroimaging (LESION) database if they: had an acute ischemic stroke, were treated with IV tPA only, had a pre-treatment MRI with evaluable diffusion (DWI) and perfusion (PWI) weighted imaging, and had measurable lesion volumes on both ADC and Tmax images. All ADC and Tmax maps were calculated in Perfscape™ (Olea Medical). A trained rater applied an ADC threshold of 615 mm
2
/seconds and Tmax threshold of >6 seconds using Neuroscape™ (Olea Medical) to produce the ADC and Tmax volumes that included any voxels across affected slices within the visually confirmed area of ischemia. All CBV maps were calculated from the PWI in PMA™ (ASIST-Japan). The regions of interest (ROIs) from the ADC volumes were used in MIPAV™ (National Institutes of Health) to measure the average voxel intensity (AVI) of the ADC and CBV lesions in both the ischemic (AVII) and contralateral hemispheres (AVIC). Logistic regression with covariates of age, baseline NIHSS, DWI volume, MTT volume, ADC volume, Tmax volume, ADC ratio and CBV ratio was performed.

Results:
A total of 74 patients met the study criteria with mean age of 67.9 years (range 32-95), median NIHSS of 12 (range 1-40), median DWI volume of 28.21 ml (IQR 11.05-66.52), and median MTT volume of 147.69 ml (IQR 52.9-250). Fifty patients had hemorrhagic transformation status available at 2 and\or 24 hours post-treatment. Fifty-four percent (n=27) had some degree of hemorrhagic transformation at 2 or 24 hours post treatment. The pre-treatment volumes reported as median (IQR 25-75) for the hemorrhagic transformation cohort (n=27) were 55.22 ml (20.32-70.53), 181.75 ml (65.36-252.88), 4.52 ml (1.07-7.39), 51.19 ml (32.67-118.23) for the DWI, MTT, ADC, Tmax and 0.52 (0.5-0.55) for the ADC ratios. The pre-treatment volumes for the non-hemorrhagic transformation cohort (n=23) were 26.07 ml (6.29-66.96), 133.78 ml (58.7-209.09), 5.27 ml (0.74-8.83), 61.33 ml (26.08-85.86) for the DWI, MTT, ADC, Tmax volumes and 0.53 (0.47-0.63) for the ADC ratios. However the CBV ratios using median (IQR 25-75) for the hemorrhagic transformation cohort versus the non-hemorrhagic transformation cohort were 0.27 (0.14-0.42) versus 0.46 (0.17-0.70). The logistic regression analysis demonstrated that patients with lowered CBV ratio on pre-treatment MRI significantly predicted hemorrhagic transformation (p<0.019).

Conclusions:
Lowered CBV ratio on pre-treatment MRI demonstrates potential as a predictor of hemorrhagic transformation post-treatment.
Abstract 4031: Tissue Plasminogen Activator Exerts Neurotoxic Effects Despite Successful Thrombus Dissolution in Ischemic Stroke
Authors: Houng Aiilyan , Wang Dong , Reed Guy
Published: March 2022

Introduction:
Ischemic stroke, caused by thrombotic arterial occlusion, is a leading cause of death and disability. Tissue plasminogen activator (TPA) reduces neurological disability post-stroke in humans but its therapeutic effect is limited by ischemic time and hemorrhagic risk. Of concern, mechanical occlusion models of stroke suggest that TPA exerts direct neurotoxic effects, but the relevance of these non-thrombotic models to human stroke is controversial.

Methods:
We examined the integrated effects of TPA dose and ischemic time in a thromboembolic model of middle cerebral artery (MCA) stroke with translational relevance to human stroke. In anesthetized mice, blood flow was assessed by laser Doppler, neuronal cell death was quantified by TTC staining and thrombus dissolution was measured with 125I-fibrin.

Results:
MCA thromboembolism reduced ipsilateral hemispheric blood flow by ∼80%. Control, placebo-treated, mice had significant infarcts (27.5±2.8%) and limited thromboembolus dissolution (20.6 ± 2.5%). Standard dose TPA given after 15 min. of ischemia, dissolved the thromboembolus (63.3±3.6 %) and reduced neuronal cell death (1.3± 0.7 %) without increasing hemorrhage (0.02 ± 0.02 %). TPA given after 1 hr. or 2.5 hrs. of ischemia also extensively dissolved the MCA thromboembolus (69.5 ± 8.1% and 64.6 ± 1.5%, respectively, p< 0.001). However, after 1 hr. TPA failed to reduce neuronal cell death and, after 2.5 hrs. of ischemia, TPA significantly increased stroke infarct size (p<0.01). Similarly, after 15 min. or 1 hr. TPA did not cause hemorrhage, but after 2.5 hrs of ischemia TPA caused significant hemorrhage (p<0.01). Lower dose TPA (5-fold) caused less hemorrhage (p<0.01) and less fibrinolysis (21.6 ± 2.2 vs. 64.6 ± 1.5, p<0.001) than standard dose TPA after 2.5 hrs., but it also significantly increased neuronal damage (p<0.01) vs. controls.

Conclusions:
TPA dissolved MCA thromboemboli independent of duration of ischemia. However, TPA only reduced stroke size within a narrow time window (15 min.); after 2.5 hrs., TPA markedly enhanced neuronal cell death and brain hemorrhage. Thus, in a model of thromboembolic stroke with translational relevance, despite successful dissolution of thromboemboli, TPA exerts neurotoxic effects related to dose and duration of ischemia.
Abstract 4033: Structural Integrity of the Corticospinal Tract Correlated with the Degree of Hand Recovery in Pediatric Patients Following Stroke
Authors: Domi Trish , Mikulis David , McAndrews Mary Pat , deVeber Gabrielle
Published: March 2022

Introduction:
The objective was to investigate association of the corticospinal tract (CST) and the association with neurological outcome using Diffusion Tensor Imaging (DTI) to measure the structural integrity of the CST at the level of the cerebral peduncles and the descending CST (DCST) using a tractography based approach (Diffusion Tensor Tractography - DTT) in children with a range of recovery in hand function following arterial ischemic stroke.

Methods:
Structural integrity of the CST supplying the hand (DTI) and neurological outcome was evaluated in 11 patients and 8 controls.
DTI:
sequences were performed with 2 dimensional DW EPI, 25 directions, 1000 0b value, TR 8300 msec, TE ∼ 79msc, scan time: 5 minutes. CST integrity at the level of the peduncles was measured by drawing a region-of-interest (ROI) on the anterior cerebral peduncles (Kirton, 2007) and calculating Fractional Anisotropy ([FA], range 0=isotropic, 1=anisotropic) (FSL v4.1). Tract-based spatial statistics (TBSS) were used for CST reconstruction by drawing an ROI on single axial T1-weighted image in which the hand knob region was most noticeable as the initial seed point, and the second ROI on the single axial T1 weighted image in which the cerebral peduncle was most prominent. T-tests with Welch correction (for unequal variance) were used to compare the difference in the mean FA values of the ROIs between peduncles and the DCST in normal controls, and the stroke and non-stroke affected peduncles in patients. The correlation of the mean FA of the DCST and neurological outcome assessed with the sensori-motor subscale of the Pediatric Stroke Outcome Measure.

Results:
Patients and controls did not differ in age at acquisition (mean=9.61 vs 12.29).
DTI:
The mean FA values of the peduncles between patients and controls were found to differ between hemispheres (p= .006). The mean FA of the stroke affected (ipsilesional) (mean=.3912) peduncles were significantly lower than the non-affected peduncle (contralesional) (mean =.4336, p=.001).
DTT:
The tract based analyses also showed FA values (mean=.3197) in the stroke affected DCST were significantly lower than the unaffected (contralesional) DCST (mean=.4441). Correlation analysis a revealed a significant negative correlation between motor outcome and mean FA of the stroke affected DCST (P < 0.05) and the unaffected DCST (P < 0.05).

Conclusions:
Integrity of the fibers in the DCST shows an association with motor outcome of the hand in pediatric stroke patients. Greater damage to the DCST was associated with a greater motor deficit. The results of this study suggest that the level of motor skill recovery achieved in pediatric stroke patients relates to microstructural status of the DCST.
Abstract 44: Influence of Antithrombotics on Outcome Following Subarachnoid Hemorrhage
Authors: Tawk Rabih G , Cameron Briana C , Edmonston Drucilla Y , Darwish Ribal , Heckman Michael G , Diehl Nancy N , Owens Stephanie B , Freeman William D , Hanel Ricardo A
Published: March 2022

Objective:
This study seeks to investigate the impact of antithrombotics, including Aspirin, Clopidogrel, and Warfarin, on the severity of bleeding and outcomes in patients with subarachnoid hemorrhage (SAH). We hypothesize that patients with a history of antithrombotic use have a more severe injury from SAH.

Methods:
Two hundred twenty-eight patients admitted to the Mayo Clinic Florida consecutively between July 2008 and July 2011 were studied retrospectively. Of this group, 77 patients had a known history of antithrombotic use while 151 did not. Both aneurysmal and non-aneurysmal cases were included in the study. Each patient’s Hunt and Hess Score, Fisher Grade, modified Rankin Scale (mRS) and Glasgow Coma Scale (GCS) were evaluated. Associations between history of antithrombotic use and severity of SAH were assessed using Spearman’s test of correlation and Mann-Whitney tests.

Results:
There was strong evidence of higher mRS grades in patients with a history of antithrombotic use compared to other patients (Median: 3 vs. 2, P=0.001). There was no significant difference between patients with and without a history of antithrombotic use regarding SAH Fisher grade (Median: 3 vs. 3, P=0.31) and Hunt and Hess score (Median: 2 vs. 2, P=0.93). The difference in GCS score was not statistically significant (Median: 14 vs. 15, P=0.20).

Conclusion:
This analysis found a significant effect of previous use of antithrombotics on overall outcome following SAH. Further analysis is needed to correlate the outcomes with specific medications and investigate the role of aggressive reversal of coagulopathy on overall outcomes.
Abstract 48: High Risk of Symptomatic Vasospasm in Unaffected Arteries in Subarachnoid Hemorrhage Patients Receiving Targeted Endovascular Treatment for Focal Symptomatic Vasospasm
Authors: Tekle Wondwossen A , Qaiser Habib , Chaudry Saqib A , Hassan Ameer , Suri M. Fareed K , Qureshi Adnan I
Published: March 2022

Background:
Targeted treatment (angioplasty and/or vasodilators) limited to symptomatic artery offers effective and sustained clinical benefit in patients with cerebral vasospasm and cerebral ischemia. However, there is controversy whether arteries that are not symptomatic within the same patients should be treated in the same session (global treatment).

Objective:
To determine the rates of occurrence of symptomatic vasospasm on previously asymptomatic arterial distributions among patients with subarachnoid hemorrhage who underwent targeted endovascular treatment for symptomatic focal vasospasm.

Methods:
We retrospectively identified all patients with aneurysmal subarachnoid hemorrhage and selected those who had developed focal symptomatic vasospasm and received targeted treatment with either angioplasty with or without intra-arterial (IA) vasodilators or IA vasodilators alone, in two academic institutions from June 2006- April 2010. We ascertained any new occurrence of ischemic symptoms requiring endovascular treatment in previously unaffected (and untreated) arterial distributions within the duration of hospitalization. Blinded reviewer quantitatively graded cerebral vasospasm (50%) in all major arteries on the angiogram acquired for each patient at the time of targeted treatment.

Results:
Out of the total of 127 patients with aneurysmal subarachnoid hemorrhage, 48 patients developed focal symptomatic vasospasm. Of the 48 patients, 43 received endovascular treatment and 5 patients were treated with medical management for mild angiographic changes. Of the 43 who received targeted endovascular treatment for vasospasm, 17 (40 %) were treated with angioplasty with or without IA vasodilators, and 26 (60%) were treated with IA vasodilators alone. In subsequent days, 13 out of the 43 patients (30%) developed vasospasm associated ischemic symptoms in previously asymptomatic vascular distributions requiring treatment with angioplasty and/ or IA vasodilators. Severity of angiographic vasospasm in asymptomatic arteries at the time of targeted treatment did not predict the new occurrence of ischemic symptoms requiring endovascular treatment.

Conclusions:
The high risk of new occurrence of ischemic symptoms in previously asymptomatic (and untreated) arterial distributions among patients receiving targeted treatment should be recognized. Further studies should evaluate the benefit of performing global treatment during the initial treatment session for symptomatic vasospasm treatment in preventing subsequent occurrence of ischemic symptoms in previously asymptomatic arteries.
Abstract 51: Degree of Clot Enhancement on Admission CT Predicts Revascularization Efficacy in Acute Ischemic Stroke
Authors: Moftakhar Parham , English Joey , Dowd Christopher , Higashida Randall , Halbach Van , Hetts Steve
Published: March 2022

Background:
Thrombi in the setting of acute ischemic stroke have been classified in pathology studies as “red clots” (erythrocyte rich) versus “white clots” (platelet/fibrin rich). Current strategies in lysing these clots include pharmacological agents and mechanical devices. Despite these treatment options, thrombolysis fails in a significant portion of patients and may lead to hemorrhagic complications. Having insight into the clot composition may provide clinicians with a way to triage patients to the appropriate treatment. The purpose of the study was to investigate whether the lysability of thrombi in acute ischemic stroke can be predicted by measuring the Hounsfield (HU) on the admission non-contrast CT (NCT), post-contrast enhanced CT (CECT) and CTA.

Methods:
We studied 53 patients with acute anterior and posterior circulation large vessel ischemic strokes treated at our institution with IV tPA, IA tPA, and/or mechanical thrombectomy devices (Merci). The HU of the clot was measured on NCT, CECT and CTA. The HU of the homologous contralateral cerebral artery was also measured for standardization purposes. The obtained HU was corrected for hematocrit by using an accepted correction formula HUclot/HUcontralateral. The volume of the clot was calculated using the formula for a cylinder with an elliptical base (π x R x r xH). Recanalization was assessed by TICI grade (0-3).

Results:
There is a strong correlation between the HU of the thrombus on preintervention NCT and postintervention TICI grade among all patients regardless of pharmacological or mechanical treatment (
Table 1
). Patients with TICI≥2 demonstrated higher HU on NCT compared to patients with TICI<2 among all treatment modalities. On CECT and CTA, patients with higher TICI scores tended to have a lower HU, however, this did not reach statistical significance. There was no correlation between clot volume and lysability.

Conclusion:
Thrombi with lower HU on NCT appear to be more resistant to pharmacological and mechanical thrombectomy and likely represent “white clots.” While thrombi with higher HU are less resistant to acute stroke therapies and likely represent “red clots.” Measuring the HU of the thrombus on the admission NCT provides the stroke team with a rapid method to analyze the clot composition, a potentially useful discriminator in selecting the most appropriate reperfusion strategy for an individual patient.
Abstract 53: The Malignant MRI profile: Implications for Endovascular Therapy
Authors: Mlynash Michael , Lansberg Maarten G , Straka Matus , Kemp Stephanie , Wechsler Lawrence R , Jovin Tudor G , Wilder Michael J , Lutsep Helmi L , Czartoski Todd , Bernstein Richard A , Chang Cherylee W , Warach Steven , Fazekas Franz , Thai Demi , Inoue Manabu , Tipirneni Aaryani , Hamilton Scott A , Zaharchuk Greg , Marks Michael P , Bammer Roland , Albers Gregory W ,   The DEFUSE 2 Investigators
Published: March 2022

Background:
The Malignant MRI profile identifies stroke patients with poor outcomes and an increased incidence of parenchymal hematoma following iv thrombolysis; outcomes following endovascular reperfusion therapy have not been described.

Methods:
The NIH funded DEFUSE 2 trial enrolled consecutive acute stroke patients in whom endovascular therapy was anticipated. An MRI scan was obtained immediately prior to intra-arterial reperfusion therapy, then repeated following the procedure and on day 5. Perfusion-weighted (PWI) and diffusion-weighted imaging (DWI) maps were created and lesion volumes estimated with an automated software program (RAPID). In the DEFUSE 2, the Malignant profile was pre-specified as a DWI lesion ≥70mL and/or a PWI lesion based on Tmax>10sec threshold (Tmax>10s) ≥100mL. A receiver operating characteristic (ROC) curve analysis was performed to identify Tmax>10s and DWI volumes that predicted poor outcome (defined as a mRS 5-6 at 30 days) with a high specificity. Patients with an M1 or ICA occlusion who did not undergo endovascular therapy based on local site criteria were also included in the ROC analysis.

Results:
We report a preliminary analysis of the DEFUSE 2 database (full data will be presented at the meeting). One hundred and one patients were triaged to the cath lab for endovascular therapy. Of the 83 patients who had adequate data available for this analysis, 9 (11%) met the predefined criteria for the Malignant profile. 56% of the Malignant patients had poor outcome compared with 30% of the non-Malignant cases (p=0.14). Malignant patients had an increased risk of parenchymal hematoma (PH1 or PH2): 44% vs. 14% (p=0.04). Only 1 of the Malignant patients achieved a mRS of 0-2 at 30 days. Early reperfusion was obtained in 6 of the 9 Malignant patients but was not associated with an increase in favorable clinical outcome or a decrease in the risk of poor outcome. Fifteen patients with an M1 or ICA occlusion did not undergo endovascular therapy based on local site criteria. Ten of these patients had the Malignant profile and 8 of these 10 had a poor outcome. ROC curve analysis identified a DWI lesion of 112 mL and a Tmax>10s lesion of 116 mL as optimal thresholds to predict poor outcome; both achieved a specificity of 98% and sensitivities of 27% and 24% respectively. 81% (13/16) of the Malignant patients identified by the DWI and/or Tmax>10s optimal thresholds had poor outcome.

Conclusion:
Patients with large baseline DWI and/or large severe PWI lesions are likely to have poor outcomes with or without endovascular reperfusion therapy. Automated imaging software can identify these patients rapidly.
Abstract 56: Thrombolysis in Selected Patients with Wake Up Stroke is Feasible with Similar Safety as Thrombolysis in 0-4.5 Hours
Authors: Manawadu Dulka , Bodla Shankaranand , Jarosz Jozef , Kalra Lalit
Published: March 2022

Introduction
Thrombolysis with alteplase is effective within 4.5 hours of ischaemic stroke onset in patients with no or early ischaemic changes (EIC) on CT. Patients with wake up strokes (WUS) make up to 25' of all strokes but are excluded on the basis of time alone. Emerging data suggest that imaging appearances in many WUS patients are similar to those treated within 4.5 h and recanalisation therapies may be beneficial.

Hypothesis
Treatment with alteplase in WUS patients selected on CT imaging findings showing no or limited EIC who would otherwise be eligible for thrombolysis will have functional outcome and bleeding risks similar to those thrombolysed within 4.5 hours of stroke onset.

Methods
We analysed registry data between January 2009 and December 2010 for WUS patients thrombolysed on compassionate grounds with consent and compared their outcomes with those thrombolysed within 4.5 hours of stroke onset. Standard guidelines were followed but there was no upper age limit for thrombolysis. WUS patients were thrombolysed if they met all eligibility criteria apart from time and the non-enhanced CT scan showed an Alberta Stroke Program Early CT Score (ASPECTS) of ≥7. CT Perfusion (CTP) mismatch was used as an additional modality for assessing eligibility for thrombolysis in a proportion of WUS patients but was not obligatory. Inclusion criteria for the analysis were defined a priori and were masked to outcomes.

Results
The analysis included 356 patients thrombolysed within 4.5 hours of stroke onset and 68 thrombolysed WUS patients. The two groups were comparable for mean age (72.6 v 74.8, years, p=0.28) and vascular risks profile but there were more women in the WUS group (66% v 52%, p=0.034). There were fewer WUS patients with premorbid Rankin Score (mRS) of 0-2 (69% v 84% p=0.01). There were no differences in mean baseline BP (151/85 v 153/84 mm Hg, p=0.55), mean blood glucose (6.5 v 6.5 mmols/L, p=0.99) and mean National Institute of Health Stroke Scale (NIHSS) score (13.2 v 12.6, p=0.44). CTP was undertaken in 26% patients within 4.5 h and in 67% of WUS patients (p<0.0001). The door to needle time was 59 minutes and 73 minutes respectively (p=0.11). There were no differences in mean NIHSS score at 24 hours (9.2 v 8.1, p=0.32), any intracranial haemorrhage (ICH) (17% v 22%, p=0.21), symptomatic ICH (2.5% v 2.9%, p=0.55) and mRS 0-2 at 3 months (49% v 37%, p=0.10) between patients within 4.5 h and WUS patients. Mortality at 3 months was lower in thrombolysed WUS patients (15% v 24%, p=0.063) and became significant after adjusting for co-variates in multiple regression (p=0.024).

Conclusion
Functional and safety outcomes after thrombolysis in WUS patients selected using CT imaging based protocols is comparable to that of patients treated within 4.5 h of stroke onset. Our experience suggests that randomization of patients with WUS on the basis of defined imaging criteria in thrombolysis trials is appropriate.
Abstract 62: Thrombolysis with Intravenous Recombinant Tissue Plasminogen Activator 3 to 4.5 h After Acute Ischemic Stroke In China
Authors: liao xiaoling , wang yilong , wang chunjuan , zhao xingquan , wang chunxue , wang yongjun
Published: March 2022

Background and Purpose_
Extending the time window is an important strategy in maximizing thrombolytic therapy in stroke patients. ECASS III had examined a 3 to 4.5h time window and showed a benefit to treated patients. However, little is known about safety and efficacy of intravenous recombinant tissue plasminogen activator(rtPA) treatment in the 3 to 4.5 h time window of acute ischemic stroke in chinese people.

Methods_
We analyzed data from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China(TIMS-China)- a prospective, multicentric cohort study of intravenous alteplase treatment with patient enrollment from 67 centres across China. Patients who were fully compliant with Chinese product characteristics criteria of alteplase except for the time window and within 4.5 h after symptom onset were included. The symptomatic intracranial hemorrhage, mortality and 90-day outcome of patients treated between 3 and 4.5 h and within 3 h of symptom onset were compared.

Results_
A total of 574 patients were included. 165 patients received alteplase between 3 and 4.5 h of symptom onset and 409 patients received altepase within 3 h. In the 3-4.5h cohort, treatment was started at a median of 80 min later after symptom onset (220 min versus 140 min, p<0.0001). After adjustment for the baseline variables including age, sex, past history, aspirin treatment at stroke onset, baseline NIHSS, et al, there were no significant differences between the 3-4.5h cohort and the within 3h cohort for any outcome measure-rate of symptomatic intracranial haemorrhage(2.42% versus 1.47%, p=0.70); mortality(5.70% versus 6.33%, p=0.52); and independence(70.25% versus 64.56%, p=0.15).

Conclusion_
Our study suggests that intravenous rtPA treatment also remains safe and effective for chinese people between 3 and 4.5 h of symptom onset after acute ischemic stroke.
Abstract 71: Inpatient Complications, Outcomes and Predictors of Mortality in 80 Years or Older Patients Undergoing Mechanical Embolectomy for Acute Ischemic Stroke
Authors: Moradiya Yogesh , Modi Sneha , Bharodiya Pareshbhai , Panichpisal Kessarin
Published: March 2022

Background and Purpose:
Though utilization of mechanical embolectomy has increased in recent years, the procedure is still associated with significant morbidity and mortality in all age groups. We aimed to compare complications and outcomes after mechanical embolectomy between age groups ≥80 years and <80 years and to identify the predictors of mortality among ≥80 years.

Methods:
We identified patients with acute ischemic stroke who underwent mechanical embolectomy in 2006-2009 from Nationwide Inpatient Sample (NIS) of Healthcare Cost and Utilization Project (HCUP). We compared co-morbidities and inpatient complications between age ≥80 and <80 years after sample weighting to get estimates of population. Multivariate logistic regression model was constructed to identify predictors of inpatient mortality in age ≥80 years.

Results:
Of the 6723 adults who underwent mechanical embolectomy, 1298 (19%) were ≥80 years. Compared to younger, octogenerians were more likely (p<0.05) to be of female gender (68% vs. 46%) and white race (83% vs. 74%). They also had higher Elixhauser co-morbidity index (mean ± SD: 3.4 ± 1.6 vs. 3.0 ± 1.7). Unadjusted mortality rate was higher (31% vs. 22%) and rate of functional independence at discharge was lower (4% vs. 16%) for age ≥80 years. Age ≥80 years had significantly higher incidence of acute myocardial infarction (7% vs. 5%), acute kidney injury (9% vs. 6%), GI bleeding (3% vs. 2%), need for blood products transfusion (10% vs. 8%), and urinary infections (22% vs. 15%). Use of concomitant thrombolytic treatment (intravenous or intra-arterial) was higher (58% vs. 53%) in age ≥80 years. Incidence of intracranial hemorrhage (11% vs. 10%) was similar (p>0.05) between the two cohorts, as were the rates of mechanical ventilation (29% vs. 30%), gastrostomy tube placement (17% vs. 15%) and permanent tracheostomy (0.8% vs. 0.7%). After adjusting for gender, race, inter-facility transfer status, and length of hospitalization, significant predictors of in-hospital mortality for age ≥80 years were intracranial hemorrhage, sepsis, mechanical ventilation, acute myocardial infarction, acute kidney injury, and chronic pulmonary disease. Use of thrombolytic treatment did not change inpatient mortality (
Table
).

Conclusions:
Morbidity and mortality in mechanical embolectomy for ischemic stroke in age ≥80 years are significantly higher compared with younger. Inpatient medical complications independently predict mortality in age ≥80 years.
Abstract 81: Rapid Microbleed Formation in the First Year Following Primary Intracerebral Hemorrhage
Authors: Mackey Jason , Wing Jeffrey J , Sobotka Ian , Menon Ravi S , Burgess Richard E , Gibbons M. C , Shara Nawar M , Fernandez Stephen , Jayam-Trouth Annapurni , German Laura , Edwards Dorothy F , Kidwell Chelsea S
Published: March 2022

Introduction:
Cerebral microbleeds (MBs) have emerged as a marker for a hemorrhage-prone vasculopathy. Few studies have evaluated MBs prospectively following intracerebral hemorrhage (ICH). We sought to investigate the frequency of rapid MB development in a predominantly African-American hypertensive ICH population.

Methods:
The Differences in the Imaging of Primary Hemorrhage Based on Ethnicity or Race (DECIPHER) study is an ongoing prospective, longitudinal, MR-based cohort study designed to evaluate racial/ethnic differences in risk factors for MBs and to prospectively evaluate the prognostic impact of MBs in underserved patients with ICH. We evaluated new MB formation in 2 time periods: from baseline to 30-day and from 30-day to 1-year. All 30-day images were coregistered to the baseline images in the first analysis; 1-year images were coregistered to 30-day images in the second. MB presence and location were determined by consensus review. Only subjects with 3T GRE sequences were included in this analysis. Univariate analyses were performed for both time intervals and subsequent logistic regression analysis was performed on the 30-day to 1-year analysis with new MB formation as the outcome variable.

Results:
Of the 35 subjects in the baseline to 30-day analysis, 7 (20%) had new MBs, compared to 20 of 55 (36%) in the 30-day to 1-year analysis. Univariate analyses are shown in the
Table
. Primary ICH location was deep in 32/35 (91%) in the first analysis and in 35/47 (74%) in the second. ApoE status, CAD, smoking status, and atrial fibrillation were not significantly different in either analysis. Logistic regression analysis demonstrated that MAP was significantly associated with new MB formation (OR 1.04 [95% CI 1.0, 1.07], p=0.038); a protective effect of hyperlipidemia was non-significant (OR 0.256, p=0.116).

Conclusions:
Despite a relatively small sample size, we found that more than one-third of ICH patients surviving one year developed new MBs, which suggests a dynamic and rapidly progressive vasculopathy at work. Future studies will examine the impact of new MB formation on patient outcomes.
Abstract 85: A Pilot Population-Based Outcomes Study using a Health Information Exchange: Preliminary Feasibility Results
Authors: Kissela Brett M , Rademacher Eric , Alwell Kathleen , Moomaw Charles , Lindsell Christopher , Embi Peter , Woo Daniel , Flaherty Matthew , Khatri Pooja , Adeoye Opeolu , Khoury Jane , Ferioli Simona , Kleindorfer Dawn
Published: March 2022

Introduction:
Post-stroke outcomes are traditionally determined by direct, follow-up interview of stroke victims. This approach is expensive, time consuming and can lead to a biased cohort, all of which limit the ability to conduct population-based outcomes studies. We evaluated the feasibility of facilitating outcomes assessment using a Health Information Exchange (HIE), a regional network for sharing healthcare data among providers. We hypothesized that HIE-facilitated cohort identification with phone-call follow-up would enable more efficient population-based outcomes determination compared to traditional approaches.

Methods:
We identified all regional ischemic strokes during 2010 by screening ER/hospital admissions for stroke cases, first using a computerized algorithm that filtered by selected key words and zipcodes for potential strokes, then using human-screening of those records to identify actual stroke cases. Cases were then enrolled into one of two cohorts in a non-random fashion. First, 500 cases were assigned for “hot pursuit” and in-person interview (traditional cohort). Those cases not enrolled in the traditional cohort for logistical reasons were assigned to have outcomes assessment by HIE-data review and phone call interview (HIE cohort) at 3 months only. The feasibility of contacting patients and assessing outcomes were the primary endpoints of interest for the HIE cohort; time spent and cost were also assessed but will not be discussed herein.

Results:
There were 17,671,258 HIE messages about 1,967,415 unique patients seeking care at hospitals within the study region in 2010. The computerized algorithm identified 5,082 potential strokes for human review. In-person interviews were attempted on 793 subjects; 104 died or entered hospice; 173 refused and 516 agreed to participate in the traditional cohort. Immediate cooperation rate was 75%. Of 516 participants, 408 completed a 3-month follow-up interview. For the HIE cohort, 581 subjects were identified for potential phone interviews. 491 calls were placed, and 320 were reached; 204 completed the interview while 116 refused. For 3 month phone calls, the cooperation rate was 52% and the completion rate was 64%. Data sufficient to determine outcomes were similar using both approaches.

Conclusions:
These results suggest that using HIE-data and phone-call follow-up for outcomes determination is feasible and comparable to hot-pursuit and in-person interviewing. The use of the HIE greatly facilitated both processes. While basic data collected appear similar, further study is needed to: 1.) fully assess for any differences in the quality of outcomes determination, and 2.) determine the feasibility of performing a truly population-based outcomes study using either approach or a combination of the two.
Abstract 89: Fatigue and Anxiety in Patients Following Stroke and TIA.
Authors: Mulroy Martin , Kavanagh Helen , Walsh Suzanne , Harbison Joseph
Published: March 2022

Introduction.
Up to 60% of patients report fatigue in the 6 months following acute stroke but the cause of this is poorly understood. Previous studies have reported a correlation with depression however the majority of fatigued subjects are not depressed and the majority of depressed subjects are not fatigued. We hypothesised that the association between fatigue and depression may not be direct and that it may be due to the enhanced level of arousal associated with anxiety disorder.

Methods:
Data was reviewed from four previous studies performed to identify associations of fatigue in stroke patients. All studies were performed in cognitively intact, independent (Modified Rankin Score <3) stroke patients by trained clinicians. Assessments of fatigue (Fatigue Severity Score), Anxiety and Depression (Hospital Anxiety and Depression Scale) were performed on all or subgroups of patients in all 4 studies. The FSS is a 9 item scale predominantly evaluating physical manifestations of fatigue. A score>4 is indicative of severe fatigue. The Hospital Anxiety and Depression Scale is a simple fourteen item questionnaire (seven questions on symptoms of anxiety (HADS-A) and seven depression (HADS-D) based). Each question may be scored between 0 and 3. A score in either subset <8 is considered normal, between 8 and 10 borderline abnormal and >10 definitely abnormal.

Results:
Data on 94 patients were included in the assessment. 57 (61%) were male and median age was 68 years (range 44-90 years). Mean FSS was 3.6 and 38 subjects (40.4%) had an FSS >4. Mean HADS-A score was 6.4, 14 (14.9%) subjects had a HADS-A >10 and 21 (22.3%) had a score 8-10. Mean HADS-D score was 4.4, 6 (6.4%) subjects had a score >10 and 10 (10.6%) had a HADS-D between 8 and 10. FSS correlated strongly with both HADS-A (r=0.57 (95% ci 0.42-0.69) p<0.0001 and HADS-D (r=0.51 (95% ci 0.34-0.64) p<0.0001). Positive predictive value (PPV) for an FSS>4 for possible anxiety (HADS-A >7) was 0.61. (PPV) for an FSS>5 for possible anxiety was 0.73. Negative predictive value for a FSS</=4 for HADS-A <8 was 0.79. PPV for an FSS>4 for possible depression (HADS-D <7) was 0.32 and NPV was 0.93. PPV for an FSS of >6 for both HADS-A and HADS-D was 0.87.

Conclusion:
Post stroke fatigue is strongly correlated with both anxiety and depression in patients with stroke but the prevalence of symptoms of anxiety is higher. It is worthwhile assessing stroke patients complaining of fatigue for evidence of anxiety disorder.
Abstract 97: Multiparametric T2*-Permeability MRI Accurately Predicts Hemorrhagic Transformation: STIR/VISTA Imaging Multicenter Observational Study
Authors: Liebeskind David S , Alger Jeffry R , Scalzo Fabien , Hao Qing , Fong Albert K , Saver Jeffrey L , Dani Krishna A , Muir Keith W , Demchuk Andrew M , Coutts Shelagh B , Luby Marie , Warach Steven ,   on behalf of the STIR/VISTA Imaging Investigators
Published: March 2022

Background:
Perfusion MRI may be used to reveal permeability changes reflective of blood-brain barrier derangements that predate hemorrhagic transformation (HT) in acute ischemic stroke. We conducted a multicenter observational study to compare and validate these novel T2*-permeability MRI measures as predictors of hemorrhage, deriving a predictive model for use with acute stroke therapies.

Methods:
Dynamic T2*-weighted perfusion MRI source images routinely obtained in the setting of acute ischemic stroke were collected from four academic medical centers. Post-processing was used to generate six previously described permeability parameters including contrast slope (CS), final contrast (FC), maximum peak bolus concentration (MPB), peak bolus area (PB), relative recirculation (rR), and %Recovery (%R). Clinical data including baseline demographics, medical history, lab values and treatment details were utilized to develop a predictive model for HT, combined with these novel permeability measures. The multivariate predictive model was evaluated using a 10-fold cross-validation to measure its generalization power on new patients.

Results:
Among 263 acute ischemic stroke patients analyzed in this large, multicenter collaborative imaging study, mean age was 69±15 years, 58.2% were women and baseline median NIHSS was 10 (range, 0-40). T2*-MRI sequences were acquired as part of routine imaging evaluation at a median of 214 minutes (range, 33-1440) from symptom onset. Treatments included IV tPA alone in 49%, endovascular recanalization therapies alone in 21.2%, and both in 10.4%. Overall, HT on GRE at 24 hours was observed in 84 (31.9%), including 34 HI1, 30 HI2, 9 PH1 and 11 PH2. More severe baseline NIHSS (r= 0.25, p<0.01) predicted HT at 24 hours. Individual T2*-permeability parameters exhibited positive predictive values (PPV) for HT ranging from 79-82% with negative predictive values (NPV) ranging from 70-78%. An automated predictive model integrating clinical data and all 6 multiparametric permeability measures exhibited PPV of 80% and NPV of 73% for HT at 24 hours.

Conclusions:
Permeability indices on

dynamic T2*-weighted MRI routinely acquired for perfusion imaging in acute ischemic stroke can accurately predict HT using an automated predictive model. This novel automated predictive model may be used to refine treatment decisions in acute stroke.
Abstract NS 11: Reshaping Exercise Habits And Beliefs (REHAB): A Randomized Trial Of Home-based Exercise In Sub-acute Stroke
Authors: Shaughnessy Marianne , Stookey Alyssa
Published: March 2022

Background:
Following conventional rehabilitation, many stroke survivors adopt sedentary activity patterns that contribute to a cycle for “learned non-use” and cardiovascular deconditioning that compounds disability. These patterns become established in the sub-acute recovery period, when opportunities to alter behavior patterns may be most timely. This randomized study investigated the hypothesis that the 12-week REHAB behavior modification intervention would increase ambulatory function, falls efficacy and quality of life compared to matched attention controls.

Methods:
Subjects were recruited following discharge from acute rehabilitation, screened for hemiparetic gait deficit and randomized to intervention or control groups. Intervention subjects received education on the benefits of exercise and a home-based exercise prescription that included a progressive walking program, and “homework” tasks to perform daily that were tailored to their stroke deficit and personal goals. This group also received telephone contacts each week for 12 weeks to assess compliance with exercise program, address barriers to exercise and receive positive reinforcement for exercise. Control subjects received education regarding risk factors for stroke, warning signs and symptoms and surveillance for weekly activity and exercise patterns. Measures were taken at baseline, 12 and 24 weeks (to assess sustained effects), and included visual analog quality of life scale, step activity profiles and self efficacy for falls.

Results:
Thirty-seven stroke survivors enrolled and 35 completed the entire protocol. The average age was 60.4 years (SD+10.9), and there were 21 males, 15 African Americans, 16 Caucasians and 1 Hispanic participants, with 3 not selecting a racial/ethnic background. Seventeen were randomized to the intervention. Repeated measures ANOVA revealed a significant time effect on step activity between 0, 12 and 24 weeks F(2.34, 77.23)= 2.972, p<.05, but no group by time interaction (p=.195). Similarly, in quality of life, a significant time effect was noted, F(2,62)=6.425, p<.05, but no treatment by time interaction (p=.363). Finally, a significant group by time interaction was noted for falls efficacy, indicating that the intervention group had a significant increase in confidence they could keep from falling, F(2,32)=5.012, p<.05.

Conclusion:
The improvement of both groups in these measures was not unexpected due to spontaneous recovery, but the program did not provide sufficient stimulus to effect significant changes in the outcomes measured. The intervention subjects reported relatively high levels of compliance with the intervention protocol. Additional study using a more rigorous home program post discharge may yield significant improvements in community ambulation.
Abstract NS 12: Caregiver-Provider Interactions Impact Preparedness of Family Caregivers of Stroke Survivors
Authors: Creasy Kerry R , Lutz Barbara J , Ford Ariel , Young Mary Ellen , Martz Crystal
Published: March 2022

Background and Purpose:
Research illuminates the importance of integrating family caregivers of stroke survivors into the rehabilitation phase of the stroke trajectory. Despite this, caregivers continue to express insufficient preparation for post-discharge care duties, resulting in poor caregiver and survivor mental and physical health. The purpose of this study was to identify how caregivers experienced their interactions with healthcare providers during rehabilitation and how these interactions impacted their perceived preparedness for caregiving.

Methods:
We used grounded theory with a symbolic interactionist lens in a secondary analysis of pre-discharge and one-month follow-up interviews of 14 patient/family caregiver dyads from two inpatient rehabilitation facilities. Data were analyzed using card sort, axial coding, and constant comparative methods, focusing primarily on identifying and understanding how caregivers described their interactions with providers.

Results:
Caregivers described a circular process of both direct and indirect interactions with providers, each resulting in a level of awareness of preparedness which in turn impacted caregivers’ later interactions with providers. Interactions focused primarily on one of two outcomes - to improve survivor status/functional ability or to improve caregiver preparedness. Caregivers described providers as focused more on immediate survivor-specific outcomes while interactions to improve caregiver preparedness were often initiated by active caregivers. Caregivers who were more passive in their interactions with providers described a lower level of awareness of preparation for caregiving.

Conclusions:
Current interactions between family caregivers and healthcare providers in rehabilitation settings focus primarily on immediate stroke survivor outcomes. Although some caregivers are more active in advocating for more preparation of their new role, others are not being assessed or prepared for the care they are expected to provide post-discharge. Further research is warranted on the current state of caregiver assessment for caregiving tasks and level of preparation for care, with inclusion of data from both caregivers and healthcare providers.
Abstract 1: Patient and Hospital Factors Associated with Lack of IV tPA Use among Eligible Patients with Acute Ischemic Stroke: Findings from Get with the Guidelines-Stroke
Authors: Khatri Pooja , Reeves Mathew J , Smith Eric E , Saver Jeffrey L , Ghatt Deepak L , Grau-Sepulveda Maria V , Peterson Eric D , Fonarow Gregg C , Schwamm Lee H
Published: March 2022

BACKGROUND:
Nationally representative studies suggest that many eligible patients are not treated with IV tPA. Even among hospitals participating in the Get With The Guidelines (GWTG)-Stroke, treatment rates remain suboptimal. We sought to determine patient and hospital characteristics independently associated with lack of tPA treatment among eligible patients in the GWTG registry.

METHODS:
We studied patients with ischemic stroke who arrived ≤2 hours of onset, were tPA-eligible, and had complete data at 1,839 GWTG hospitals from 4/1/03-12/31/11. Eligibility was determined by the lack of documented contraindications/warnings to tPA. Unadjusted and adjusted ORs (computed with GEE logistic regression models to account for hospital clustering of patients) are reported. Due to 28.4% missing NIHSS, GEE models were built with and without NIHSS.

RESULTS:
Of 75,115 tPA-eligible patients during the 9-year period, 50,798 (68%) were tPA-treated with median age of 73 years (IQR 60-82), 51% female, 74% non-Hispanic white, and median NIHSS 11. In multivariable models, lack of treatment was associated with older age, females, African-American race, prior diabetes, stroke, or prosthetic heart valve and not arriving by EMS (Table). Treatment was also less likely at hospitals that were rural, non-teaching, in the Midwest and South, and non-stroke centers, earlier in the study period, and at hospitals that did not routinely perform NIHSS (Table). Adding NIHSS to the model (c=0.77 vs. c=0.78) did not change model results substantially but did show reduced tPA use in patients with mild strokes (NIHSS 0-4 vs 5-9, OR 3.4; vs 10-14, OR 4.6; vs 15-20, OR 5.4; vs 21+, OR 4.5).

CONCLUSIONS:
One-third of eligible patients at GWTG hospitals did not receive IV tPA treatment. Several patient and hospitals factors were independently associated with this lack of treatment. These findings can inform system interventions to improve tPA treatment among eligible patients.
Abstract 100: Cellular Therapy for Acute Stroke: Assessing a Potential Treatment Effect
Authors: Vahidy Farhaan S , Rahbar Mohammad H , Hicks William J , Alderman Susan , Kasam Mallikarjunarao , Juneja Vaibhav , Bambhroliya Arvind B , Savitz Sean I
Published: March 2022

Introduction
Cell therapy is an investigational modality to enhance recovery after stroke. We completed a Phase I clinical trial of 25 patients assessing the safety and feasibility of autologous bone marrow derived mononuclear cells (MNCs). Study participants underwent a bone marrow harvest and were intravenously administered autologous MNCs 24-72 hours after stroke onset. We report an ordinal analysis that compares 90-day outcomes of study patients with retrospectively generated controls.

Methods
We compared the study patients to a group of patients derived from our stroke registry who presented to our center during the same time period as the clinical trial. The control group was initially matched for age and NIHSS and was further refined based on other inclusion / exclusion criteria of the trial, generating a final set of 185 patients. Between the two groups, we compared demographics, clinical characteristics, baseline lab values, co-morbidities and adverse events. An ordinal logistic regression model, utilizing the full range of outcome scores, was fitted to compare 90-day mRS scores.

Results:
The bone marrow harvest and infusion of MNCs was completed successfully in all study patients without any definitive study related severe adverse event. Table 1 shows the balance of tested co-variates between the stem cell and control groups. After controlling for 24-48 hour NIHSS, t-PA, rehab, length of stay, cardiac disease, and PTT, the final model estimated a greater odds of having a higher mRS at 90 days in the control group compared with the study patients (OR: 3.25, 95% CI: 1.48 - 7.14). Our model did not violate the proportionality of odds assumption (likelihood-ratio, p=0.1). Figure 1 shows the proportion of patients for each level of discharge and day 90 mRS score.

Conclusion:
Intravenous infusion of autologous MNCs is safe in the setting of acute stroke. This analysis suggests that patients receiving MNCs may also be exhibiting a signal of enhanced functional recovery.