bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP364: Impaired Renal Function and Outcome After Intracerebral Haemorrhage: Data From the Ongoing Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage (TICH-2) Trial
Authors: Sprigg Nikola , Robson Katie , Law Zhe K , Appleton Jason , Bath Philip
Published: June 2021

Background:
Trends between renal failure at presentation and poor outcome in intracerebral haemorrhage (ICH) have been investigated; however, few studies have examined this relationship.

Methods:
TICH-2 records estimated glomerular filtration rate (eGFR) at baseline. Renal function was categorised as; normal (>60 mL/min), moderate (30-60) and low (<30). Baseline characteristics were compared across all three groups. Moderate and low eGFR was compared to normal for day 90 outcomes and adjusted for baseline covariates.

Results:
Of 1514 participants in TICH-2 with baseline eGFR recorded, 1277 (84.4%) had a normal eGFR, 214 (14.1%) a moderate eGFR and 23 (1.5%) a low eGFR. Systolic blood pressure was highest in the severe group (normal: 173.4, moderate: 172.0, low: 194.4 mmHg; p-value=0.0078), as was pre-morbid mRS (normal: 0.49, moderate: 0.81, severe: 0.87; p-value=0.0001); however, the moderate group had the highest average age (normal: 68.0, moderate: 75.8, low: 66.9 years; p-value=0.0178) and NIHSS (normal: 12.8, moderate: 14.1, low: 12.4; non-significant) at baseline. Proportionally, the severe group had more previous strokes or TIAs and higher historical rates of heart disease, diabetes and haemorrhagic stroke (see figure); although these differences were not all significant. After accounting for the varied results at baseline; no significant differences were found between the groups when looking at day 90 outcomes, SAEs, deaths, do not attempt resuscitation rates, BP lowering treatment, or length of stay in hospital.

Conclusion:
Patients with renal impairment had more severe strokes and co-morbidities; however, outcomes did not differ once other prognostic factors were accounted for.
Abstract WP370: Cerebral Microbleeds Play an Important Role in Turning Recurrent Stroke Towards Intracranial Hemorrhage in Patients With First-ever Ischemic Stroke/Transient Ischemic Attack
Authors: Nomura Eiichi , Shiga Yuji , Takeshima Shinichi , Takemaru Makoto , Takeshita Jun , Nishigaki Masakazu , Kuriyama Masaru
Published: June 2021

Background and Purpose:
After ischemic stroke (IS) or transient ischemic attack (TIA), use of an antithrombotic agent to prevent recurrence is mandatory. However, antithrombotic agents rarely cause intracranial hemorrhage (ICH), frequently resulting in worse outcomes than recurrent IS. Cerebral microbleeds (CMBs) have been reported as a useful marker for finding ICH-prone patients. This retrospective study aimed to investigate the significance of CMB in the development of ICH in first-ever IS/TIA patients.

Methods:
The data source was our consecutive patient registry between 2005 and 2015. Patients with stroke/TIA admitted to our hospital more than twice (first as first-ever IS/TIA and second or later as recurrent IS/TIA or ICH) and underwent head MRI including T2*-weighted imaging on the first admission were extracted. Clinical characteristics including use of antithrombotic therapy and distribution of CMB on the first and second admissions were compared between recurrent IS/TIA and ICH groups. Distribution of CMB was divided into deep, lobar, or both.

Results:
In total, 708 IS/TIA patients (second stroke: 640 IS/TIA; 68 ICH) were extracted. The ICH group showed a longer period until second stroke (1,062 days vs. 817 days, p=0.022) and higher mean NIHSS score (14.8 vs. 6.1, p<0.001) on second admission than the IS/TIA group. On first admission, the ICH group had a higher frequency of CMB (72.1% vs. 49.5%, p<0.001) and lower frequency of cardioembolism (14.7% vs. 25.8%, p=0.044) than the IS/TIA group. About half of hemorrhages occurred in similar locations of the CMB depicted on first admission. A higher frequency of ICH was observed in patients with deep CMB (11.3% vs. 5.6%, p=0.022) or both deep and lobar CMBs (17.4% vs. 5.6%, p<0.001) than in those without CMB. Use of anticoagulants was a significant risk factor for transition from first IS/TIA to second ICH (odds ratio [95% confidence interval]: 3.75 [1.30-10.8], adjusted by sex, age, type of first stroke, and CMB location).

Conclusions:
This study found IS/TIA patients with CMB are at high risk of ICH compared to patients without CMB. Preventive antithrombotic treatment particularly use of anticoagulants for CI/TIA patients with CMB should be provided under careful monitoring for the risk of hemorrhage.
Abstract WP378: Use of Code Head Bleed to Promote Hemorrhagic Stroke Awareness in the Emergency Department
Authors: McAlpine Candace J , Garcia Rocio , Rojas Pablo
Published: June 2021

Background and Purpose:
Providers recognize the need for quick recognition and allocation of resources when ischemic stroke patients arrive at the emergency department. Hemorrhagic stroke patients have not been always given the same priority. One Comprehensive Stroke Center noticed a deficiency in timely recognition, documentation and mobilization of resources for hemorrhagic stroke patients. The initiation of “code head bleed” in the emergency department was created to correct this deficiency. The purpose of this study was to bring awareness and education to the team initially caring for the hemorrhagic stroke patient.

Methods:
Using Lean methodology, to bring about quality patient care while reducing wasted time, the “code head bleed” was born. Education was provided for all emergency department staff members and physicians regarding “code head bleed.” When a code head bleed notification is paged out it mobilizes all required resources to the patient’s bedside (Faculty physician, Medical Resuscitation team, Patient Care Coordinator, Respiratory Therapy, Stroke Coordinators and Emergency Department leadership).

Results:
Since its inception in May, the “code head bleed” is the most used code notification in the hospital (n=163 ), surpassing ischemic stroke alerts (n= 89 ) in the same period. An increase of traumatic hemorrhages has been noticed since they are also included in the notification; which has led to an increased awareness in this population of patients as well. Code head bleed has improved neuro-check documentation by 21 % and documentation of vasoactive drip titration by 15% in the hemorrhagic stroke population.

Conclusions:
In conclusion, having all essential staff, services and resources lends to optimizing the hemorrhagic stroke patient’s care. The “code head bleed” initiative has been attributed to an increased awareness of the needs of the hemorrhagic stroke patient in the emergency department and an improvement in the documentation of care provided.
Abstract WP381: The Culture Influence on Coping and Adaptation to Stroke Caregiving: the Chinese Family Caregivers’ Experience
Authors: Qiu Xichenhui , SIT Janet W , Feng Haixia
Published: June 2021

Introduction:
In China, the estimated number of stroke survivors is 22.5 million, of which 78% need home care. It has been indicated that culture could play a major role on the stroke caregiving experiences. Understanding stroke caregivers’ coping and adaptation within Chinese culture is needed.

Objective:
To explore how Chinese culture influences the coping and adaptation to stroke caregiving among stroke caregivers.

Methods:
In this qualitative descriptive study, 25 stroke caregivers (age 52±15.6, 60% female, 58% children-caregivers, 40% spouse-caregivers) were recruited from an 1800-bed regional hospital in China. Data were collected through individual, semi-structured interviews. Qualitative content analysis was performed. Member checking, triangulation of the data and peer debriefing were used to achieve trustworthiness.

Results:
Three themes emerged from the interviews reflecting the influence of Chinese culture on stroke caregiving: (1)
Caregiving role adaptation.
Confucianism, which emphasizes duties and responsibilities profoundly influences Chinese world views. Chinese caregivers accepted caregiving for the sick family member as an expected part of life and caregiving is a culturally prescribed obligation. (2)
Emotional coping strategies.
The emotional coping strategies adopted by caregivers including relying on religion and discussing their feeling with families. Fatalistic appraisal has been described as an emotional coping strategy and Chinese caregivers reported cognitive appraisal of belief system involving ‘
Ming
’ (fate) to help them adapt the caregiving reality. (3)
Passive help seeking attitude and behaviors.
Chinese caregivers identified self-tolerance and traditional belief of ‘
Ren
’(tolerance)as a negative coping. Chinese caregivers did not actively seek professional/ community help and reluctant to turn to their families and friends for support even though they felt very helpless and isolated.

Conclusions:
An underlying coping and adaptation of undertaking stroke caregiving within Chinese culture is highlighted in our findings. Researchers and health care professionals who plan to develop a support intervention for Chinese stroke caregivers need to put culture in context.
Abstract WP382: Primary Stroke Centers - What Should We Measure?
Authors: Thompson Jackie T , Aucoin Julia , Johnson Anna , Richesson Rachel , Huang David , Short Nancy
Published: June 2021

Background and Issues:
Primary stroke centers are struggling to find their voice in the spectrum of stroke care. It is not feasible for all of us grow into Comprehensive Stroke Centers or even offer endovascular intervention. Victims of our own success, 7 of the 8 stroke Core Measures are discontinued by CMS. Meanwhile we must find other measures to continue to improve the effectiveness of stroke care and our value to our local population, EMS providers, internal stakeholders and the Joint Commission.

Purpose:
The purpose of this project at our 433-bed community hospital was to shift the focus from micro-management of outdated metrics to a macro-view of our program and demonstrate an effective method for internal evaluation.

Methods:
We followed the CDC guidelines for public health program evaluation. We reviewed the evidence for all aspects of our program, and developed a program logic model (Figure 1) and theory-based evaluation questions. We used a mixed-methods approach to analyze data for each question. We engaged our leaders in focus groups to review the findings.

Results:
Table 1 shows examples of our findings. Eleven program leaders, including the hospital medical director, the ED medical director, and nursing directors, identified four priorities: expanding our community outreach, improving ED stroke processes, increasing the use of stroke order sets, and improving post-discharge follow-up recommendations.

Conclusions:
Structured program evaluation is a means for primary stroke centers to continue to improve outcomes for stroke patients and justify their valuable role in the continuum of stroke care.
Abstract WP384: The Impact of a Clinical Pharmacist on Door to Needle Time
Authors: Brackman Jennifer M , Coss Brianna , Perry Scott , Prewett Rebecca
Published: June 2021

Background and Issues:
Decreasing thrombolytic door-to-needle (DTN) time has been shown to improve neurological outcomes of ischemic stroke patients as well as decrease incidence of bleeding. At Aultman, a dedicated pharmacist responds to all stroke alerts between 0700 and 1700 Monday through Friday. In September of 2014, a clinical pharmacist was added to the stroke team to attend stroke alerts and focus solely on facilitating the TPA ordering, dispensing, and delivery, with the goal of decreasing DTN times. The mixing of the tPA was done in the central pharmacy during all alerts. At the same time of hiring a clinical pharmacist, Aultman changed the stroke alert procedure to immediately send patients straight to CT after an alert was called.

Purpose:
To compare DTN times with and without the presence of a pharmacist on emergency department stroke alerts.

Methods:
For all stroke cases where tPA was administered from January 1 2014 to July 31 2016, the DTN was grouped based on pharmacist presence - before a pharmacist was present on any stroke alerts (January 1 2014 to September 30 2014), when a pharmacist was present, and when a pharmacist was not present after September 30 2014. A Shapiro-Wilk analysis was run to assess normality, and the Mann-Whitney U test was used to compare the means.

Results:
From January 2014 to the placement of a pharmacist on the stroke team, the mean DTN time was 80.68 minutes (95% CI: 62.23-99.14 min, n=19). After hiring a pharmacist (September 2014 to July 2016), the mean DTN time was significantly different (p=0.001) when a pharmacist responded to stroke alerts (48.26 minutes, 95% CI: 38.11-58.40 min, n=27) compared to when a pharmacist was not present (68.63 minutes, 95% CI: 59.57-80.69 min, n=31).

Conclusion:
Having a pharmacist who can focus solely on the tPA portion of a stroke alert can significantly decrease DTN times. The pharmacist knows the computer ordering system more fluently than the provider increasing ordering speed and can allow other members of the stroke team to focus on their responsibilities during the alert. The decrease in DTN time from early 2014 to post-September 2014 when a pharmacist was not present could be attributed to implementation of new policies routing stroke alerts directly to CT.
Abstract WP407: Role of the Stroke Response Nurse to Improve Compliance with Key Stroke Performance Indicators
Authors: Broadway Katie
Published: June 2021

Background and Issues:
Comprehensive Stroke Centers are in high demand and bed availability can be limited. Oftentimes, patients are admitted to non-neuro intensive care units while waiting for a Neuro ICU bed to become available. Key stroke performance indicators, such as an initial NIH Stroke Scale assessment and bedside nursing dysphagia screen, are often missed in these instances.

Purpose:
The purpose of this performance improvement project was to improve compliance of the key stroke performance indicators on patients admitted with stroke in the facility, specifically those who were admitted to non-neuro units.

Methods:
A Stroke Response Nurse project was developed by the Neuro ICU to help improve the compliance of these key stroke performance indicators when patients were admitted to one of the other four intensive care units in the hospital. This performance improvement project involved a pilot period of three months, which was compared to the three months prior to implementing the Stroke Response Nurse project. The project was established using the Plan, Do, Check, Act model.

Results:
The Stroke Response Nurse responded to 22% of the stroke patients that were admitted to non-Neuro ICUs. Out of these patients, all showed 100% compliance with the indictors of an initial NIH Stroke Scale assessment and bedside nursing dysphagia screen. The pilot period was repeated for another 51 days, in which the Stroke Response Nurse responded to 75% of these stroke patients.

Conclusions:
The Stroke Response Nurse project improved the compliance of key stroke performance indicators for the patients that were seen. More training is needed among the non- Neuro intensive care units in this facility to increase the number of patients that are seen to 100%.
Abstract WP412: Low Concordance Rates of Dysphagia Screening in Stroke Patients Evaluated by Neuroscience Nurses and Speech-Language Pathologists
Authors: Durm Laura Beth , Bonner Julie , Meyer Ellen , Brasher Cyndy , Schleuse Stuart , Stewart Ellen , Sinsley Debbie , Humphrey Jan , Reif Lisa , Omess Sarah , Danaie Elham , Nahab Fadi
Published: June 2021

Background:
While there is recognition about the importance of dysphagia screens in stroke patients, there is limited data on the concordance rates of dysphagia screens performed by neuroscience-trained nurses and speech language pathologist (SLPs).

Hypothesis:
Neuroscience nurses and SLPs will have high concordance rates when assessing stroke patients with dysphagia screens.

Methods:
From March 1, 2016 through May 31, 2016 a random sample of stroke patients underwent a dysphagia screening by neuroscience nurses and subsequently by SLPs within 24 hours using the same tool, a 2-part screen assessing for contraindications and using the 3-ounse water swallow test. Results of the dysphagia screens were retrospectively collected to identify concordance rates.

Results:
During the study period, 98% of stroke patients underwent dysphagia screening prior to oral intake. Of 50 stroke patients evaluated by neuroscience nurses and SLPs, only 26 patients (52%) demonstrated concordance with pass or fail results. Of 33 patients who were administered the water test and passed the dysphagia screen based on the neuroscience nursing assessment, 20 patients (61%) were determined by SLPs evaluation to have dysphagia and 11 (33%) of these patients had had overt aspiration.

Conclusions:
Current metrics on dysphagia screening do not identify the efficacy of dysphagia screening among stroke patients. Stroke centers who utilize bedside nurses to perform initial dysphagia screens should evaluate concordance rates with SLPs. A multidisciplinary team including Clinical Nurse Specialists, SLPs, and Nursing IT specialists have implemented measures (hospital wide re-education of nursing staff and optimizing the electronic dysphagia screening form) to improve concordance rates among nurses and SLPs. A post-intervention follow-up study of concordance rates among neurosciences and SLPs is underway.
Abstract WP427: Examining the Role of Gut Dysbiosis in Cerebral Small Vessel Disease
Authors: Nelson James W , Durgan David , Ajami Nadim , Petrosino Joseph , Bryan Robert
Published: June 2021

The importance of a healthy gut microbiota on host physiology is becoming increasingly evident. Recent studies suggest that alterations to the microbiota can have adverse effects beyond the GI tract, and has been linked to hypertension and stroke. Thus we hypothesized that gut dysbiosis could contribute to the development of cerebral small vessel disease (CSVD). Giving merit to this hypothesis, we found that the microbiota of the spontaneously hypertensive stroke prone rat (SHRSP) is significantly different than that of WKY controls. Using 16s rRNA sequencing of bacterial DNA we found that SHRSP animals had decreases in measures of bacterial richness (p=.005) and diversity (p=.028), indicative of gut dysbiosis. Phenotypically, CSVD includes vessel remodeling, BBB breakdown and neuroinflammation. Gut dysbiosis is often associated with a leaky gut barrier that allows bacteria to enter the systemic circulation. We observed significantly greater permeability of the SHRSP colon barrier when compared to WKY (p=.026). We next sought to determine if impaired colon barrier function in SHRSP could lead to increased bacterial translocation to the periphery and ultimately to the brain. Brains were harvested from 24 week old SHRSP and WKY animals and qRT-PCR of the 16s rRNA gene was performed to detect the presence of bacteria in the brain. We discovered that SHRSP animals displayed a 50% increase in bacterial 16S rRNA load in the brain compared to WKY animals (p=.0063) confirming that bacteria are not only present in CSVD rats, but also in greater abundance than WKYs. Similarly, we found that SHRSP animals displayed a near 2-fold increase of the bacterial endotoxin LPS in the brain, as compared to WKY brain LPS levels (p=.01). Finally, to further confirm the presence of bacterial components in the brain we used immunofluorescence imaging to visualize peptidoglycan (PG), a molecule found solely in bacterial cell walls. We discovered that we could visualize the presence of PG in the brains of SHRSP animals, and note that PG was commonly observed inside microglia. We conclude from this study that SHRSP rats exhibit gut dysbiosis, gut barrier breakdown, and bacterial products in the brain. Further studies will examine how this bacterial presence contributes to the CSVD phenotypes.
Abstract WP438: The Role of Transforming Growth Factor-beta in Post-Stroke Glymphatic Impairment
Authors: Howe Matthew D , Spiegel Gabriel S , McCullough Louise D , Urayama Akihiko
Published: June 2021

Introduction:
The recently discovered glymphatic system may protect the brain from dementia by clearing toxic amyloid-β (Aβ) along the basement membrane (BM) via bulk flow of cerebrospinal fluid (CSF). It is not known whether stroke impairs glymphatic flow, or how this might occur. Previous work has shown that stroke enhances astrocytic transforming growth factor-β (TGF-β) signaling, which could increase the expression of pro-fibrotic BM proteins such as fibronectin. BM fibrosis may obstruct glymphatic flow after stroke, driving Aβ accumulation and neurodegenerative disease in stroke survivors.

Hypothesis:
I hypothesize that stroke induces BM fibrosis via enhanced TGFβ-Smad2 signaling in perivascular astrocytes, impairing glymphatic flow.

Methods:
To test this hypothesis, the glymphatic influx of CSF tracer in mice following stroke or TGF-β treatment (ICV, 500 ng) was assessed. TGF-β signaling was measured as Smad2 phosphorylation. Brain expression of fibronectin and GFAP (astrocytes) were assessed by western blot and immunohistochemistry.

Results:
Stroke impaired the glymphatic distribution of FITC-dextran and FITC-Aβ bilaterally (
Fig. 1
). TGF-β treatment also inhibited glymphatic distribution, measured by reduced
14
C-Inulin uptake
(38 fold-reduction, p < .05).
Increased fibronectin
(5.5 ± 0.7 fold-increase)
and GFAP
(2.3 ± .2 fold-increase)
expression was found after stroke
(p < .05
), localized to the glial scar and around vessels bilaterally
.
Finally, Smad2 phosphorylation was increased in cortex contralateral to injury
(2.5 ± 0.2 fold, p < .01).

Conclusion:
The present study shows that stroke impairs glymphatic flow, which may be mediated through increased TGF-β signaling and global BM fibrosis. This could impair the clearance of Aβ, leading to dementia in stroke survivors. TGF-β inhibition can rescue post-stroke fibrosis, glymphatic flow and Aβ clearance, presenting a novel therapeutic target for post-stroke dementia.
Abstract WP444: Postoperative Cognitive Dysfunction is Associated with Large Acute Cerebral Infarcts in Older Adults Following Aortic Valve Replacement for Aortic Stenosis
Authors: Giovannetti Tania , Price Catherine C , Fanning Molly , Messé Steven , Ratcliffe Sarah J , Lyon Abigail , Kasner Scott E , Seidel Gregory , Bilello Michel , Bavaria Joseph E , Szeto Wilson Y , Hargrove W. Clarke , Acker Michael A , Floyd Thomas F
Published: June 2021

Introduction:
Aortic valve replacement (AVR) for calcific aortic stenosis (AS) is associated with high rates of perioperative clinical stroke and “silent” acute cerebral infarcts (SACI) in older adults. The goal of this study was to determine the impact of clinical stroke and acute infarcts on cognitive outcomes.

Methods:
129 elderly surgical AVR (age=74.7±6y) participants underwent perioperative evaluations by neurologists and post-surgical diffusion-weighted MRI during the first week post-op. Clinical assessments and MRI’s were reviewed by vascular neurologists, and participants were classified as having clinical stroke, SACI, or no stroke. Trained coders quantified all acute lesions on MRI (lesion number, lesion volume). Participants also completed cognitive testing at baseline, 4-6 weeks, and 1 year. The incidence of post-operative cognitive disorder (POCD) was identified using reliable change index scores calculated in reference to a comparison group of 154 nonsurgical participants with vascular disease.

Results:
Surgical participants who had a perioperative clinical stroke (n=34) had the largest infarct volume and performed worse than participants with SACI (n=59) and those without stroke on cognitive testing at baseline and at 4-6 weeks post-surgery (p < .05 for all). Among participants who showed an acute infarct on postop MRI (i.e., clinical stroke + silent stroke, n = 93), total acute infarct volume but not infarct number was significantly correlated with cognitive outcomes at 4-6 weeks and 1 year (r > .27 for all). Surgical participants with POCD (12.2% at 4-6 weeks; 9.2% at 1 year) were older, more likely to have had a perioperative clinical stroke, and had more and larger acute infarcts on MRI than surgical participants without POCD (p <.05 for all).

Conclusions:
Cognitive outcomes and POCD are significantly associated with perioperative clinical stroke and volume of acute infarct on MRI. However, surgical participants who demonstrate small, SACI show good cognitive outcomes that are comparable to participants without perioperative infarct. Low baseline cognitive function may be a risk marker for perioperative stroke and poor cognitive outcomes in the elderly.
Abstract WP446: Increased Nighttime Blood Pressure and Small Vessel Diseases Are Strongly Associated With Cognitive Impairment Increased Nighttime Blood Pressure and Small Vessel Diseases Are Strongly Associated With Cognitive Impairment Ischemic Stroke Patients
Authors: Yamamoto Yasumasa , Nagakane Yoshinari , Toimii Yasuhiro , Tanaka Eijiro , Toda Shintaro
Published: June 2021

Purpose:
To explore the relationship between diurnal blood pressure (BP) pattern and small vessel diseases, and cognitive impairment in stroke patients.

Methods:
Twenty-four hour blood pressure monitoring for every 30 minutes was performed for 415 patients with ischemic stroke in chronic stage. Patients with modified Rankin Scale >2 were excluded. Patients whose Mini Mental State Examination <24 points were diagnosed as having cognitive impairment (CI). Silent lacunae and white matter lesions (WML) on MRI were identified and multiple lacunae and/or confluent WML were estimated as extensive small vessel disease (eSVD). When the nocturnal BP decline, calculated as (daytime BP -nighttime BP) / daytime BP, was more than 1.0, patients were classified as dipper, when 0-1.0 as non-dipper and when less than 0 as riser. Patients were classified into 7 groups. A: single lacuna without CI (n=110), B: multiple lacunae without CI (n=103), C: lacunar infarct with CI (n=70), D: atherothrombotic infarction (ATB) (n=71), E: ATB with CI (n=13), F: cardio embolic infarction (CE) (n=41), G: CE with CI (n=7).

Results:
Average 24-hour BP values (mmHg) and nocturnal BP decline were calculated. Nocturnal BP decline in the Groups with C, E and G showed significantly lower than group A. The prevalence of riser (%) in the Groups with C, E and G showed significantly higher than group A. The prevalence of eSVD in the Groups with E showed significantly higher than group D (p=0.0011) and groups G showed significantly higher than group F (p= 0.0026). Logistic regression analysis in all patients showed that more than 75 years old (versus less than 65 years old) (OR: 4.0, p=0.0006), eSVD (OR: 23.5, p<0.0001), and non-dipper and riser (versus dipper) (OR: 5.5, p=0.0003 and OR: 16.5, p<0.0001, respectively) were independently associated with CI after adjustment 24-hour averaged systolic blood pressure.

Conclusions:
Extensive small vessel disease and increased night time blood pressure, especially riser, were strong predictors for cognitive impairment in ischemic stroke patient. In patients with ATB and CE, eSVD was the determinant for cognitive impairment. Nighttime blood pressure, not just daytime blood pressure, should be focused on to prevent post-stroke cognitive impairment.
Abstract WP65: Low-Versus Standard-Dose Alteplase for AcuteIschemic Strokes Within 4.5 Hours: An updated Meta Analysis
Authors: Zheng Huaguang , Tong Xu , Liu Liping , Li Zixiao , Liao Xiaoling , Du Wanliang , Dong Kehui , Lu Jingjing , Ju Yi , Zhao Xingquan , Yang Zhonghua , Wang Yilong , Wang Yongjun
Published: June 2021

Background and Purpose:
We performed a meta-analysis to compare the outcomes between lower dose
and
standard dose intravenous tissue-type plasminogen activator (tPA) for acute ischemic stroke in randomized and non- randomized controlled trials.

Methods:
We searched PubMed for relevant studies and calculated pooled odds ratios (ORs) using random effects models.The primary endpoint was good functional outcome[modified Rankin Scale (mRS) of 0-1] at 3 month after stroke onset. Other major end points were all-cause mortality and symptomatic intracerebral haemorrhage (sICH).

Results:
From 2010 to 2016, 7 Cohort studies and 1 randomized controlled trial (ENCHANTED trial) were pooled in meta-analysis. The lower tPA strategy was likely to be less effective than the standard dose treatment (OR=0.87; 95% confidence interval [CI], 0.73-1.04, P=0.136; I
2
=47.9%, P=0.044 in random effects models and OR=0.88; 95% CI 0.88-0.98,P=0.016 ;I
2
=0.0%, P=0.693 in non- random effects models after 2 cohort studies were excluded due to heterogeneity). No difference was found for mortality at 90 days (OR=0.87; 95% CI 0.74-1.03, P=0.102 ;I
2
=0.0%, P=0.635 in non-random effects models)and sICH (OR=1.12; 95% CI 0.68-1.83,P=0.659; I
2
=57.6%, P=0.016 in random effects models and OR=1.23; 95% CI 0.92-1.65, P=0.168; I
2
=0.0%, P=0.547 in non-random effects models after 2 cohort studies were excluded due to heterogeneity ) between lower tPA group and standard dose .

Conclusions:
The low-dose alteplase strategy was less effective comparable to the standard-dose treatment .The safety was similar between the two strategies.
Abstract WP76: Baseline Characteristics of the 3,096 Patients Recruited Into the ‘Triple Antiplatelets for Reducing Dependency After Ischaemic Stroke’ (TARDIS) Trial
Authors: Bath Philip M , Appleton Jason P , Beridze Maia , Christensen Hanne , Dineen Robert A , Duley Lelia , England Timothy J , Heptinstall Stan , James Marilyn , Krishnan Kailash , Markus Hugh S , Pocock Stuart , Ranta Annemarei , Robinson Thompson , Flaherty Katie , Scutt Polly , Venables Graham S , Woodhouse Lisa , Sprigg Nikola
Published: June 2021

Background:
The risk of recurrence following ischaemic stroke (IS) or transient ischaemic attack (TIA) is highest immediately after the event. Antiplatelet agents are effective in reducing the risk of recurrence and two agents are superior to one in the early phase after ictus.

Design:
The Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial was an international multicentre prospective randomised open-label blinded-endpoint trial that assessed the safety and efficacy of short-term intensive antiplatelet therapy with three agents (combined aspirin, clopidogrel and dipyridamole) as compared with guideline treatment in acute IS or TIA. The primary outcome was stroke recurrence and its severity, measured using the modified Rankin Scale at 90 days. Secondary outcomes included recurrent vascular events, functional measures (cognition, disability, mood, quality of life) and safety (bleeding, death, serious adverse events). Data are number (%) or mean (standard deviation, SD).

Results:
Recruitment ran from April 2009 to March 2016. 3,096 patients were recruited from 106 sites in 4 countries (Denmark 1.6%, Georgia 2.7%, New Zealand 0.2%, UK 95.4%). Randomisation characteristics included: age 69.0 (10.1) years; male 1945 (62.8%); time onset to randomisation 29.4 (11.9) hours; stroke severity (National Institutes for Health Stroke Scale) 2.8 (3.6); blood pressure 143.5 (18.2)/79.5 (11.4) mmHg; IS 2143 (69.2%), TIA 953 (30.8%).

Conclusion:
TARDIS was a large international trial of intensive/triple antiplatelet therapy in acute IS and TIA, and included participants representative of patients in many western stroke services.

Funders:
National Institute of Health Research Health Technology Assessment Programme and British Heart Foundation.
Trial registration:
ISRCTN47823388
Abstract WP81: Prediction of Cerebral Aneurysm Growth Using Original Magnetic Resonance Imaging-based Computational Fluid Dynamics Tool
Authors: Kimura Hidehito , Hayashi Kohsuke , Hosoda Kohkichi , Fijita Atsushi , Taniguchi Masaaki , Tomiyama Akio , Kohmura Eiji
Published: June 2021

Background:
Cerebral aneurysm growth is supposed to often precede aneurysm rupture. To predict aneurysm growth for unruptured aneurysms is still difficult by means of recently well-developed commercially available computational fluid dynamic (CFD) software.

Purpose:
To detect the possible factor contributing to for the aneurysm growth with our originally developed CFD tool.

Methods:
We retrospectively reviewed the aneurysms that were treated between April 2013 and March 2016 at our institute by surgical clipping or endovascular coiling with the reason of its growth (growth group). In contrast, we extracted unruptured aneurysms that had experienced no growth for at least five years (non- growth group). Time of flight (TOF) - magnetic resonance (MR) imaging data of them were converted to the three- dimenstional (3D) vessel geometric data and three hemodynamic indices: stream line (SL), wall shear stress (WSS), oscillatory shear index (OSI), were calculated with lattice Boltzmann method and compared between the two groups.

Results:
Six growth aneurysms and 5 non-growth aneurysms were analyzed in this study. In the growth group, mean initial aneurysms size was 4.7mm and increased to 6.2mm after mean follow up of 33.4 months. In the non-growth group, mean aneurysm size was 5.8mm. Analyses of flow dynamics were successfully done in all cases. In all six enlarged aneurysms, WSS was increased temporally at the early diastolic phase on the focal aneurysmal sac where the aneurysms would enlarge in the future (Fig. A,B). Furthermore, in four of them, focal increase in WSS formed crescent-like shape surrounding low WSS (Inset in Fig. A). In contrast, WSS was not increased even at the early diastolic phase in three of five non-enlarged aneurysms. The SL or OSI showed no specific differences between the two groups.

Conclusion:
Focal increase of WSS, some of them formed crescent-like shape, at the early diastolic phase may be the possible factor for the aneurysm enlargement in future.
Abstract WP82: Transcranial Doppler Detection of Microembolic Signals During the Advancement and Deployment of Pipeline Embolization Devices in Unruptured Intracranial Aneurysm Repair
Authors: Hughes Andres , Dannenbaum Mark J , Chen Peng R , Day Arthur L , Choi Huimahn A , Kim Dong H , Blackburn Spiros L
Published: June 2021

Introduction:
Pipeline embolization devices (PED) have become an essential tool in the endovascular treatment of complex intracranial aneurysms. A high-density stent like device, the PED functions to redirect blood flow and facilitate the growth and remodeling of the artery. Postoperative ischemic stroke proves to be the most common neurological complication associated with treatment, ranging from about 3-6% with most occurring within 30 days. Transcranial Doppler (TCD) monitoring has been used in the past to evaluate similar procedures by measuring the occurrence of microembolic signals (MES). Due to the delivery and manipulation of the PED and its thrombotic nature, microembolic events have been postulated to form during device placement and contribute to thromboembolism. Our initial study is the first to detect and measure MES during a PED procedure.

Methods:
Patients undergoing endovascular PED treatment were simultaneously monitored with TCD. MES were detected, separated from artifacts, and counted for each step.

Results:
Embolic signals were detected in all patients and were highest during deployment. With 3 PED deployments in the paraophthalmic ICA of 2 patients, the mean MES during PED deployment was 515 +/- 46. Average emboli per second during deployment was 1.62 +/- 0.59 verses 0.30 +/- 0.12 emboli per second observed prior to microcatheter insertion and manipulation.

Conclusion:
A very high incidence of MES was observed during the procedure and PED deployment. The little success thus far in elucidating a possible mechanism to account for PED’s associated complications warrants more investigation. Determining the occurrence of MES might reveal insight into the relative safety of each step and on the formation of distal thromboembolisms.
Abstract WP84: Obstructive Sleep Apnea May Worsen the Overall Outcome of Intracranial Aneurysms
Authors: Bir Shyamal , Nanda Anil , Cuellar Hugo , Sun Hai , Liendo Cesar , Minagar Alireza , Chernyshev Oleg
Published: June 2021

Introduction:
Obstructive sleep apnea (OSA) is associated with the progression of abdominal and thoracic aortic aneurysms. However, the role of OSA in the overall outcome of intracranial aneurysms (IAs) has not yet been established. We have investigated the role of OSA in the progression and outcome of intracranial aneurysms.

Methods:
Radiological and clinical data of 283 patients (from 2010 through 2015) were retrospectively reviewed. Significant differences between the OSA and non-OSA groups were determined by a chi-square test. Logistic regression analysis was performed to identify the predictors of unfavorable outcome.

Results:
Among the 283 patients with IAs, 45 (16%) patients were positively screened for OSA, a proportion that was significantly higher than the prevalence of OSA in the general population (4%), p=0.008. Number of patients with hypertension (p=0.018), BMI ≥ 30 (p<0.0001), hyperlipidemia (p=0.034), diabetes mellitus (DM, p=0.005), chronic heart disease (CHD, p=0.024), cerebrovascular accident (CVA, p=0.03) was significantly higher in the OSA group compared to the non-OSA group. Similarly, the number of wide neck aneurysms (p=0.00001) and poor Hunt and Hess grade 4-5 (p=0.01) was significantly higher in the OSA group compared to the non-OSA group. In addition, the number of ruptured aneurysms (p=0.03) and vasospasms (p=0.02) was significantly higher in the OSA group. The number of the patients with poor modified Rankin scale (mRS) scores (3-6) was significantly higher in the OSA group (p=0.03). Both in univariate (p=0.01) and multivariate (p=0.04) regression analysis, OSA was identified as an individual predictor of unfavorable outcome. In addition, hypertension, smoking, CHD and CVA were revealed as positive predictors of poor outcome of IAs.

Conclusions:
The complications of IAs such as rupture and vasospasms are influenced by presence of OSA. Overall outcome (mRS) of IAs is also affected by the concurrence of OSA. Therefore, coexistence of OSA in patients with IAs affects progression as well as outcome of IAs. Lastly, OSA serves as an individual risk factor for poor outcome in these patients.
Abstract WP86: Early Detection of Aneurysm Growth by Volume and Surface Area Analysis Using 3D Modeling From CT Angiography
Authors: Yokota Hajime , Chien Aichi , Morimoto Emiko , Villablanca Pablo , Salamon Noriko
Published: June 2021

Introduction:
Enlargement of unruptured aneurysms indicates an increased risk of rupture. Assessment of aneurysm growth is typically based on aneurysm max diameter. However, this method is often unreliable due to factors such as the degree of contrast enhancement, tilting among studies and artifacts.

Hypothesis:
Three-dimensional modeling can help to judge aneurysm growth.

Methods:
All aneurysm patients who underwent CTA (1.0-mm slice thickness) with at least one follow-up in 2015, were reviewed. Intracranial saccular aneurysms were selected and fusiform, dissecting and mycotic aneurysms were excluded. Growth was defined as more than a 0.5 mm increase in size compared with the first study. 3D models were created from the source data using 3D-slicer (http://www.slicer.org). Aneurysm extraction from the parent artery was performed semi-automatically and volume and surface area were calculated using vascular toolkit (http://www.vmtk.org). The Mann-Whitney test and ROC curve analysis were applied to compare cases which increased in size with no-change cases.

Results:
This research included 59 aneurysms in 51 patients that underwent 250 CTA, with follow-up duration of 50.0 ± 50.5 months. Nine aneurysms increased in size. In 5 of 9 cases, follow-up studies prior to growth detection were available. In these cases, maximum diameter change from the first study was not significant (P = 0.169). By contrast, volume and area were significantly different (P = 0.046 and 0.046, respectively). On ROC analysis, AUCs of maximum diameter, volume, and area changes were 0.7, 0.772 and 0.772.

Conclusions:
Calculating volume and area changes was useful to judge aneurysm growth earlier than size measurement.
Abstract WP9: Primary Aspiration Thrombectomy in Acute Ischemic Stroke: A Single-Center Experience
Authors: Asaithambi Ganesh , Castle Amy L , Stein Lana J , Hanson Sandra K , Lassig Jeffrey P
Published: June 2021

Background:
Recent endovascular stroke studies utilizing primarily stent retrievers have proven clinical benefit among eligible patients. It remains unclear if this benefit is exclusive to stent retrievers. We present the results of a single-center experience for patients undergoing primary aspiration thrombectomy for acute ischemic stroke (AIS).

Methods:
A retrospective analysis of all AIS patients receiving primary aspiration thrombectomy from January 2014 to March 2016 was performed. We assessed stroke severity at admission and discharge as defined by the National Institutes of Health Stroke Scale score (NIHSSS), median onset to puncture and onset to recanalization times, location of target vessel treated, rate of concurrent intravenous (IV) alteplase use, and rate of TICI 2b/3 reperfusion. Outcomes adjudicated included rates of symptomatic intracerebral hemorrhage (sICH), favorable discharge disposition to home, and 90-day modified Rankin Scale (mRS) score ≤2.

Results:
During the study period, 121 patients (mean age 68.7±16.5 years, 53.7% women) received primary aspiration thrombectomy for 124 occlusions (26% terminal internal carotid artery, 45% M1, 15% M2, 11% basilar artery, 3% other). Median admission NIHSSS was 19 [11, 22] and improved to 6 [1, 15] upon discharge. Median onset to puncture and onset to recanalization times were 258 [148, 371] and 300 [180, 409] minutes, respectively. The rate of TICI 2b/3 reperfusion was 84.7%, and 52% received adjunctive IV alteplase. Rates of favorable discharge to home was 28.9% and 90-day mRS ≤2 was 39.8%. Only one patient developed sICH.

Conclusion:
Our single-center experience shows that primary aspiration thrombectomy can yield both favorable angiographic and clinical outcomes with minimal adverse effect.
Abstract 104: Disability After Minor Stroke and TIA in the POINT Trial
Authors: Cucchiara Brett L , Elm Jordan , Easton J Donald , Coutts Shelagh , Willey Joshua , Biros Michelle , Ross Michael , Johnston S. Claiborne
Published: June 2021

Background and Purpose:
To assess the effect of combination antiplatelet therapy with aspirin and clopidogrel versus aspirin alone on disability following TIA or minor stroke and to identify factors associated with disability.

Methods:
The POINT trial randomized patients with TIA or minor stroke (NIHSS≤3) within 12 hours of onset to dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel versus aspirin alone. The primary outcome measure was a composite of stroke, MI, or vascular death. We performed a post-hoc exploratory analysis to examine the effect of treatment on overall disability (defined as mRS>1) at 90 days as well as disability ascribed by the local investigator to index or recurrent stroke. We also evaluated predictors of disability.

Results:
At 90 days, 188/1964 (9.6%) of patients enrolled with TIA and 471/2586 (18.2%) of those enrolled with stroke were disabled. Overall disability was similar between patients assigned DAPT versus aspirin alone (14.7% vs. 14.3%, OR 0.97, 95%CI 0.82-1.14, p=0.69). However, there were numerically fewer patients with disability in conjunction with a primary outcome event in the DAPT arm (3.0% vs. 4.0%, OR 0.73, 95%CI 0.53-1.01, p=0.06), and significantly fewer patients in the DAPT arm with disability attributed by the investigators to either the index event or recurrent stroke (5.9% vs. 7.4%, OR 0.78, 95% CI 0.62-0.99, p=0.04). Notably, disability attributed to the index event accounted for the majority of this difference (4.5% vs. 6.0%, OR 0.74 95% CI 0.57-0.96, p=0.02). In multivariate analysis of patients enrolled with TIA, disability was significantly associated with age, subsequent ischemic stroke, serious adverse events, and major bleeding. In patients enrolled with stroke, disability was associated with female sex, hypertension, diabetes, NIHSS score, recurrent ischemic stroke, subsequent myocardial infarction, and serious adverse events.

Conclusions:
In addition to reducing recurrent stroke in patients with acute minor stroke and TIA, dual antiplatelet therapy might reduce stroke-related disability.
Abstract 105: Impact of the Extended Window Mechanical Thrombectomy on Tele Stroke Call Volume in the Post-DAWN and DEFUSE -3 Era
Authors: Al Kasab Sami , Almallouhi Eyad , Abdul Rahman Line , Nahhas Michael , Harvey Jillian , Debenham Ellen , Turner Nancy , Spiotta Alejandro M , Holmstedt Christine A
Published: June 2021

Introduction:
Recently, two randomized controlled trials proved the safety and efficacy of mechanical thrombectomy in patients presenting up to 24 hours from symptom onset. While the number of patients receiving mechanical thrombectomy has increased following the publication of the extended time window trials, the literature on acute stroke calls over telestroke is relatively scant. In this study we evaluate the volume of telestroke calls, rate of transfers to the thrombectomy center and MT receipt before and after the extended window MT trials publication.

Methods:
We interrogated the prospectively collected data from a major telestroke network in Southeast the United States to include patients who received a telestroke consult between January 2015 and July 2019. We compared the demographical and clinical characteristics and the outcomes between patients who presented before and after the publication of the extended window mechanical thrombectomy trials.

Results:
Total of 7,438 patients were evaluated during the study period. Of those, 3392 were after February 2018. There was no difference in age, race, or sex between the two groups (table 1). Patients in the post extended window group had lower National Institute of Health stroke scale (NIHSS) on presentation (3 vs. 4, P<0.001), had longer symptom-onset to door time (123 vs. 85 min, P<0.001), and were more likely to present with stroke mimics (41% vs. 35.3%, P<0.001).Despite this increase in the number of consults per month (190 vs. 103, P<0.001) in the post-DAWN era, there was similar rates of patients eventually receiving MT (3.9% vs. 3.8%, p=0.849)

Conclusion:
The number of telestroke consults almost doubled since the publication of the extended thrombectomy trials without increase in the rate of MT receipt. These findings have important operational implications for hospitals implementing telestroke call coverage.