bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP202: Increased Pulse Pressure is Related to Higher Burden of Microvascular Brain Damage in Ischemic Stroke Patients
Authors: Zurru Maria C , Alonzo Claudia , Brescacín Laura , Balián Natalia , Baroni Maria V , Camera Luis , Cristiano Edgardo , Waisman Gabriel
Published: July 2021

Introduction:
pulse pressure (PP), a marker of arterial stiffness, is a useful tool for measuring vascular aging. White matter hyperintensities (WMH), deep and periventricular, are the expression of subclinical ischemic brain damage.

Hypotesis:
our objective was to evaluate the relationship between pre-stroke blood pressure and the burden of WMH.

Method:
acute ischemic stroke patients, excluding TIA, were prospectively included in a multidisciplinary secondary stroke prevention program. Pre-stroke vascular risk factor profile and control were obtained from electronic medical records and the presence of WMH was evaluated on admission MRI. Periventricular hyperintensities (PVH) and deep white matter hyperintensities (DWMH) were classified according to Fazekas scale (0-3). A correlation analysis between different components of blood pressure and WMH was performed.

Results:
808 patients (59% females, mean age 77±11 years) were included between January 2009 and December 2014. Main vascular risk factors were: hypertension (83%), dyslipemia (64%), obesity (52%), smoking (37%), metabolic syndrome (37%), diabetes (14%), AF (19%), CKD (45%), CHD (14%), stroke (10%), peripheral artery disease (12%). There was a positive correlation between PP values and the severity of PVH (R 0.93) and DWMH (R 0.95), but not with SBP (R 0.48 and R 0.50) and DBP (R 0.52 and 0.47). (figure)

Conclusion:
different blood pressure components may have different deleterious effects on large and small vessels. Pulse pressure, a pulsatile component mainly reflecting large artery stiffness and wave reflections, was the only component of blood pressure with a positive correlation with the burden of WMH in our cohort. As the world is aging, is mandatory to identify predictors of subclinical brain damage, which is related to increased risk of dementia, depression, stroke and gait disorders.
Abstract TP204: Neutrophil-to-lymphocyte Ratio Predicts Short-term Functional Outcome in Acute Ischemic Stroke
Authors: Kim Meyung Kug , Ha Yoon Suk , Yoo Bong Goo
Published: July 2021

Introduction:
As indicators of the systemic inflammatory response, the neutrophil-to-lymphocyte ratio (NLR) have been proposed to predict the clinical outcome in cardiovascular disease, diabetes, and various malignancies. We assessed the significance of NLR as a predictor of the outcome in patients with acute ischemic stroke.

Methods:
We retrospectively analyzed the clinical characteristics, laboratory parameters, and NLR in 356 consecutive patients (62.2% men, mean age 65.8±13.0 years) within 3 days after the onset of acute ischemic stroke between July 2012 and March 2015. The NLR was calculated from the differential counts by dividing the neutrophil number by the lymphocyte number at the time of admission. All subjects were divided into four groups according to quartiles of the NLR. Outcomes were measured as 3-month modified Rankin scale (mRS) score. A good functional outcome was defined as a mRS of 0-2 points, whereas a poor outcome was defined as a mRS of >2 points. Multivariate logistic regression analysis was used to assess association among the clinical, inflammatory and serological parameters including NLR and mRS scores.

Results:
The frequency of atrial fibrillation, heart failure, hypertension, and diabetes, the NIHSS score at admission, and the level of hs-CRP, D-dimer and the NLR were each significantly higher in the poor outcome group (p < 0.05).

The cut-off values of NLR and NIHSS score at admission for prediction of the poor outcome were 2.135 (sensitivity 0.864 and specificity 0.533) and 3.5 (sensitivity 0.862 and specificity 0.787), respectively. In age-adjusted analysis, the NLR were significantly correlated with 3-month mRS score (partial r = 0.329, p < 0.001) and NIHSS score at discharge (partial r = 0.301, p < 0.001). Multivariate logistic regression analysis demonstrated that age of ≥65 (OR, 10.2; 95% CI, 3.31-31.21, p < 0.001), presence of diabetes mellitus (OR, 3.3; 95% CI, 1.36-8.12, p = 0.008), NIHSS score of ≥4 (OR, 26.4 95% CI, 9.81-71.15, p < 0.001), NLR of ≥2.135 (OR, 9.2; 95% CI, 3.18-26.4, p < 0.001) were independently associated with poor functional outcome.

Conclusion:
The NLR is a useful marker for short-term functional outcome in acute ischemic stroke. The NLR may have a role in risk stratification for predicting poor outcome.
Abstract TP208: 1,5-anhydro-d-glucitol as a Predictor of Cerebral Infarction in Patients With Glycated Hemoglobin A1c-based Good Diabetes Control
Authors: Shiga Yuji , Kanaya Yuhei , Takeshima Shinichi , Fujikawa Yasunori , Takamatsu Kazuhiro , Shimoe Yutaka , Nishigaki Masakazu , Ota Taisei , Kuriyama Masaru
Published: July 2021

Introduction:
Current guidelines set the goal of diabetes control to a glycated hemoglobin A1c (HbA1c) level of <7% in order to prevent macrovascular events. However, we often experience diabetes patients with cerebral infarction (CI), even though their HbA1c level is well-controlled. A reason for this disparity between the diabetes control status and CI onset may be the limitation of HbA1c as a diabetes control indicator. HbA1c reflects the mean blood glucose level over the past 2-3 months. Therefore, with HbA1c, we cannot evaluate short-term blood glucose control and glycemic variability, which are reported as risk factors for CI. Measurement of 1,5-anhydro-D-glucitol (1,5AG) allows the evaluation of these factors.

Hypothesis:
1,5AG can be used to evaluate the risk of CI in patients with well-controlled diabetes.

Methods:
We retrospectively reviewed the medical records of 1169 patients with diabetes who received treatment for CI at our hospital between 2009 and 2014. These patients were divided into the following two groups according to their HbA1c-based diabetes control status: a CI-low group (HbA1c <7%, n=549) and a CI-high group (HbA1c ≧7%, n=620). We also included a non-CI group of 394 diabetes patients without CI (control group), and these patients were further divided into the following two groups in the same manner: a nonCI-low group (n=199) and a nonCI-high group (n=195). The 1,5AG levels were compared between the CI-low and nonCI-low groups, and the CI-high and nonCI-high groups.

Results:
There was no difference in the 1,5AG level between the CI-high and nonCI-high groups (8.8±7.3% vs. 8.9±7.1%, p=0.83). However, the 1,5AG level was significantly lower in the CI-low group than in the nonCI-low group (12.5±8.1% vs. 15.2±8.8%, p<0.001). This difference remained significant after adjusting for age and sex.

Conclusion:
The results of this study show that short-term glycemic control and glycemic variability have a significant relationship with existing CI especially in patients with good diabetes control. The 1,5AG level may be a surrogate measure of the risk of CI in patients with HbA1c levels that indicate good diabetes control.
Abstract TP209: Decreased Heart Rate Variability in Patients With Minor Stroke
Authors: Yu Sungwook , Kim YooHwan , Cho Kyung-Hee , Kim Byung-Jo
Published: July 2021

Introduction:
Minor stroke or transient ischemic attack (TIA) is considered to have little effect on autonomic functions. However, it is unclear whether autonomic dysfunction in patients with minor stroke develops during acute stroke phase.

Hypothesis:
We evaluated whether patients with minor stroke had autonomic dysfunction during acute stroke phase.

Methods:
Patients with ischemic stroke or TIA were included. Those with diabetes and urological problems were excluded. Quantitative sudomotor axon reflex test (QSART), head-up tilt test (HUTT), sympathetic skin response (SSR), and heart rate variability (HRV) were performed during admission after acute stroke onset. HRV frequency measurements included time-domain and frequency-domain parameters. We analyzed the difference of autonomic function among patients with minor stroke (NIHSS score ≤ 3), major stroke (NIHSS score≥3) and TIA.

Results:
Total of 81 patients was included. There were 55 with minor ischemic stroke, 15 with major ischemic stroke, and 11 with TIA. RR interval of HRV was significantly different among three groups (938.8 ± 99.1 ms in TIA, 871.4 ± 104.9 ms in minor stroke, and 832.7 ± 107.8 ms in major stroke, P = 0.042). Parameters of HRV in patients with stroke had significantly lower compared to those with TIA [high frequency (HF) 8.9 ± 3.6 ms2 vs 12.2 ± 5.0 ms2, respectively, P = 0.013; the square root of the mean of the sum of the squares of differences between adjacent NN intervals (RMSSD), 23.5 ± 9.3 ms vs 30.7 ± 11.6 ms, respectively, P = 0.023]. Moreover, HF and RMSSD significantly decreased in patients with minor stroke compared to those with TIA (HF, 8.9 ± 3.6 ms2 vs 12.2 ± 5.0 ms2, respectively, P = 0.038; RMSSD, 23.2 ± 9.4 ms vs 30.7 ± 11.6 ms, respectively, P = 0.05). Results of QSART, HUTT and SSR were not different among three groups.

Conclusion:
Patients with minor stroke had decreased HRV compared to those with TIA, indicating that even minor stroke could be associated with decreased parasympathetic activity at early stroke phase. Further studies will be needed to evaluate effects of autonomic dysfunction on clinical outcome in patients with minor stroke.
Abstract TP210: The Genetic Polymorphisms in Oxidative Stress Genes, Superoxide Dismutase and Glutathione Peroxidase, Correlated With Ischemic Stroke
Authors: Yadav Binod Kumar , Yadav Renu , Shin Byoung-Soo
Published: July 2021

Background:
Reactive oxygen species (ROS) are controlled by endogenous antioxidant systems that include superoxide dismutase (SOD), glutathione peroxidase (GPx), catalase and antioxidant vitamins. Defect in these systems may develop oxidative stress, and different studies have shown the profound effect of oxidative stress in the stroke because of high susceptibility of the brain to ROS-induced damage. Superoxide is dismutated to H
2
O
2
by SOD which is further converted to H
2
O and O
2
by GPx or catalase in the mitochondria and the lysosomes. The present study was aimed to investigate the association of SOD and GPx polymorphisms in the development of stroke.

Methods:
A total 982 subjects ( 674 patients, 308 controls) were recruited in this study. Genotyping of SOD1 (
rs1041740
), SOD2 (
rs4880
), GPx1 (
rs1050450
) were performed by LightCycler real-time PCR using LightSNiPreagents and FastStartDNAMasterHybProbe while genotyping of GPx4 (
rs713041
) were done by PCR-RFLP were done by PCR-RFLP. All biochemical parameter were measured in automated clinical chemistry analyzer, at department of laboratory medicine.

Results:
Our study demonstrated that the CC+CT/TT genotype of
rs4880
significantly increased the risk of stroke (AOR=1.57, 95%CI=1.10-2.24) and SAD-stroke (AOR=1.64, 95%CI=1.17-2.41) compared with CC genotype. In GPx polymorphsims,
rs1050450
showed no association with stoke, while
rs713041
and the combination analysis of
rs1050450
with
rs713041
demonstrated the significant association for the stroke development. Interestingly, the inter-combined effect of genetic polymorphism of SOD/GPx showed the significant association for the stroke. Most of the genotypes of these SNPs demonstrated significant difference between control and stroke cases on different biochemical parameters.

Conclusion:
This study suggests a possible role for oxidative stress in the risk of stroke and clearly states that genetic component of stroke is polygenic as altered SOD and GPx genes interaction showed increased risk for stroke development
Abstract TP216: Atrial Fibrillation Detection in Patients With an Implantable Loop Recorder After Acute Embolic Stroke of Unknown Source (ESUS)
Authors: Kitsiou Alkisti , Kalyani Malik , Ekosso Ejangue Lucy , Hagemeister Christoph , Manegold Johannes , Israel Carsten , Schäbitz Wolf-Ruediger
Published: July 2021

Introduction:
The embolic stroke of unknown source concept was introduced as a more rigid analysis of patients with cryptogenic stroke representing a superselection of patients with cardioembolic stroke. These patients are particularly candidates for intermittent AF. As long as AF has not been documented, current concepts do not recommend oral anticoagulation.Implantable loop recorders (ILR) in patients with ESUS may detect AF and establish the indication for oral anticoagulation. The aim of this study was to prospectively assess and predict AF occurrence in patients with ILR after ESUS.

Methods:
In patients with ESUS (MR imaging based cardioembolic stroke, exclusion of structural cardiac stroke source by TEE, no AF detectable by 72h Stroke Unit monitoring and 24h holter ECG, exclusion of other stroke causes such as symptomatic carotid stenosis) an ILR was implanted and AF detection assessed by daily remote monitoring. The ILR was implanted on average 20 days after stroke. We analyzed the predictive value of different clinical and imaging characteristics for AF detection.

Results:
By daily remote monitoring of 124 Patients over a period of 12.7±5.5 months, AF was documented and manually confirmed in 29 of 124 patients (23.4%). First AF detection occurred on average after 3.6±3.4 months of monitoring. Characteristics of patients with and without AF detection are shown in the table.

Conclusions:
Patients with ESUS and asymptomatic AF detected only by long-term continuous monitoring with an ILR were on average older, had a higher CHA2DS2-VASc score and had more often microangiopathy. Other clinical parameters and features of cerebral imaging in ESUS did not increase the probability of AF detection in these preselected patients with ESUS. Importantly, ESUS selection almost doubled AF detection rate compared to recent studies such as the ILR group of the Crystal-AF trial (23.4% in 12.7±5.5 months compared to 12.4% in 12 months).
Abstract TP24: Should the Decision for Mechanical Thrombectomy be Based on Pre-procedure CT Head Showing Early Changes in Specific Regions of the Brain?
Authors: Korya Daniel , Moussavi Mohammad , Mehta Siddhart , Brar Jaskiran , Samaan Mena , Kondapali Swathi , DeCarvalho Briana , Kirmani Jawad
Published: July 2021

Background:
The treatment of acute ischemic stroke has evolved over the past several years to utilize neuroimaging in guiding therapy. With regard to IV tPA and thrombectomy, recent endovascular therapy trials have utilized the ASPECT score in determining if intervention should be attempted. We sought to evaluate different regions of interest on the ASPECT score to determine if specific areas of injury should be weighed more heavily during decision making.

Methods:
We evaluated the pre-intervention CT scans of the head on all patients who received IV tPA and mechanical thrombectomy during the last two years at a community based, university affiliated comprehensive stroke center. All 20 regions of interest (ROIs) of the ASPECT score were compared with each other with regard to initial NIH stroke score, discharge NIHSS, delta NIHSS and modified Rankin Score to determine if one or more regions were associated with worse outcome. SPSS version 22 was used to determine Spearman rho values and paired samples t-test.

Results:
A total of 864 patients presented with acute ischemic stroke, of which 70 patients received IV tPA followed by mechanical thrombectomy and were included in the study. The 4 ROIs with the greatest correlation with worse outcome as rated by discharge mRS were the right and left M5-M6 [4.2 (p=.001, 95%CI 3.5-4.8); 4.3 (p=.001, 95%CI 3.4-5.1); 4.3 (p=.001, 95%CI 3.4-5.2); 4.2 (p=.001, 95%CI 3.6-4.8), respectively].

Conclusion:
Early changes defined as hypodensity in the M5 and M6 ROIs on either side of the pre-intervention head CT were associated with significantly worse outcomes. A modified ASPECT score should be considered to better prognosticate patients and guide the appropriateness of endovascular therapy in select patients. These findings should be validated in a larger population and a longer follow-up period.
Abstract TP244: A Successful Statewide Initiative to Designate Hospital as Remote Treatment Stroke Centers
Authors: Nichols Shelley , Camp Debbie , Smith McCord , Threlkeld Chris , Lugtu James , Krompf Kerrie , Peters Doretha , Long Julie , Watkins Beth , Briscoe David , Reid Joyce , Johnson Kay , Kiser Danita , Caudill Nita , Frankel Michael
Published: July 2021

Background:
As treatment of acute ischemic stroke (AIS) with IV tPA has become standard of care, smaller hospitals with limited resources have struggled to conform to consensus guidelines. To fill this practice gap, stroke systems of care were developed to support smaller, often rural, hospitals in providing standard stroke care to the patients they serve.

Methods:
As a result of legislative support from the Coverdell-Murphy Act, the Georgia Coverdell Acute Stroke Registry (GCASR) in collaboration with the Georgia Office of EMS (GA OEMS), the Georgia Hospital Association (GHA), and other state partners, developed a method for designating hospitals as Remote Treatment Stroke Centers (RTSC). The primary focus of performance improvement was treatment with IV tPA in eligible patients. Data collection and process change were used to improve the following quality indicators: percentage of eligible AIS patients treated with IV tPA and number of stroke alert notifications. Hospitals were required to partner with an accredited stroke center and use telemedicine to support the decision for administering IV tPA. GA OEMS was charged with reviewing and surveying individual hospitals applying for RTSC status. The GCASR served as the central repository to facilitate data sharing and benchmarking across hospitals. An inter-hospital transfer tool was created for EMS providers, adopted by GA OEMS, and disseminated throughout the state to guide management of patients receiving IV tPA who required transfer from a RTSC to an accredited stroke center.

Results:
Starting in 2014, pertinent information was distributed and assistance provided to the 24 RTSC eligible GCASR hospitals. At present, 4 hospitals have achieved designation; 1 hospital is pending survey; and several are considering application. In 2012-13 the now 4 RTSC hospitals gave IV tPA to 8 patients. In 2014-15 as these hospitals sought and achieved designation, this number rose to 24. During this same period, stroke alerts increased from 76 to 308.

Conclusion:
A state-based public health stroke initiative is effective in facilitating the designation of RTSC and thereby improving the delivery of acute stroke care in underserved areas.
Abstract TP254: The Use of Prehospital Telemedicine to Aid in the Decision to Airlift Patients to a Comprehensive Stroke Center From a Rural Area
Authors: Brotons Angel , Motola Ivette , Romano Jose , Schwemmer Sandra , Issenberg Barry
Published: July 2021

Introduction:
In patients with acute ischemic stroke, significant time can elapse from symptom onset until initiation of thrombolytic therapy. Prehospital diagnosis can reduce time delays, and remote evaluation using telemedicine may help; especially in the context of rural areas where a decision to airlift the patient to a stroke center must be made. The Florida Keys is a stretch of 126 miles with no stroke center. In order to combat delays to therapy, a system was implemented to airlift patients directly from the field to a comprehensive stroke center. Air transport costs can range $10,000-$50,000 per patient, whereas the cost to place the telemedicine unit inside the ambulance was $2,250.

Hypothesis:
The purpose of the study was to determine the feasibility of using prehospital telemedicine as a triage tool to air transport stroke patients.

Methods:
Fire Rescue units in three departments were equipped with a smartphone programmed with encrypted software. Noise cancelling headsets were provided, together with a hard mount antenna. Stroke physicians were given a tablet with the same software. Prehospital providers conducted the CPSS initially, then the MEND exam, and if abnormal, contacted the stroke physician for a telemedicine consult. Crews were stationed on a designated landing zone, in an effort to reduce time to air transport after the exam was performed. Upon the patient’s arrival at the receiving facility, the physician performed the NIHSS again and recorded his/her findings.

Results:
From January 2013 to July 2015, physicians utilized telemedicine to evaluate 45 stroke patients. The initial pilot phase led to software and hardware upgrades to enhance patient examinations. The average NIHSS was 10. Initial analysis revealed a high correlation between the NIHSS done over telemedicine and the arrival NIHSS performed by the same physician. EMS providers and stroke physicians found the system easy to use and extremely valuable in making the triage determination.

Conclusion:
The use of prehospital telemedicine to conduct a neurological exam by a stroke physician has proven to be a valuable tool. Prehospital telemedicine for stroke air transport determination is feasible and cost-effective.
Abstract TP268: Combination Therapy of Normobaric Oxygen With Hypothermia or Ethanol Modulates Pyruvate Dehydrogenase Complex in Thromboembolic Cerebral Ischemia
Authors: Thibodeau Alexa , Cai Lipeng , Peng Changya , Geng Xiaokun , Diaz Vicki , Ji Xunming , Ding Yuchuan
Published: July 2021

Background and Hypothesis:
Pyruvate Dehydrogenase Complex (PDH) is a brain mitochondrial matrix enzyme that is inactivated during stroke injury. PDH impairment after stroke can be particularly devastating given PDH’s critical role in the conversion from anaerobic to aerobic energy metabolism. In this study, we evaluated the restoration of oxidative metabolism by measuring reactive oxygen species (ROS) levels and energy regulation by characterizing modulation of PDH and its inhibitor, pyruvate dehydrogenase kinase (PDK), with therapeutic combination of normobaric oxygen (NBO) plus either hypothermia (Hypo) or ethanol (EtOH).

Methods:
Sprague-Dawley rats were subjected to middle cerebral artery (MCA) occlusion induced with an autologous embolus, the more clinically relevant stroke model. One hour after occlusion, tissue-type plasminogen activator (t-PA) was administered alone or with NBO (60%), EtOH (1.0g/kg) or Hypo (33°C), either singly or in combination. PDH activity and ROS levels were measured at 3 and 24 hours after t-PA administration. Western blotting was used to detect PDH and PDK protein expression levels.

Results:
Administration of 60% NBO alone after reperfusion by t-PA treatment did not affect PDH activity. Under t-PA, compared to EtOH or Hypo alone, combined administration of NBO plus either EtOH or Hypo produced the greatest increases in PDH activity and protein expression levels, as well as the greatest decrease in PDK expression. Combination therapy also provided the most significant decline in ROS generation compared to any monotherapeutic approach.

Conclusions:
Reperfusion with t-PA followed by 60% NBO improves the efficacy of EtOH or Hypo in neuroprotection by ameliorating oxidative injury and improving metabolic regulation with PDH. Comparable neuroprotective effects were found when treating with either EtOH or Hypo, suggesting a similar mechanism and the possibility of substituting EtOH for Hypo in the clinical setting.
Abstract TP270: Ischemic Preconditioning-afforded Neuroprotection Against Ischemic Stroke is Associated With Altered Peripheral Immune Responses
Authors: Liu Zongjian , chen Chen , Luo Mei , Du Huishan , Ji Xunming , Hu Xiaoming
Published: July 2021

The limb remote ischemic preconditioning (RIPC) is considered a clinical feasible protective strategy against ischemia-reperfusion injury after stroke. However, its mechanisms of protection remain elusive. Here, we used a rat model of non-invasive RIPC by tourniquet to study the impact of RIPC on the immune cell and cytokine profiles after transient middle cerebral artery occlusion. Our data indicates that RIPC protects against focal ischemia and preserves neurological functions 3 days after stroke. Meanwhile, RIPC results in dramatic changes in several immune cell populations after stroke. Specifically, the RIPC ameliorated the post-MCAO reduction of blood CD3+CD8+ T cells and abolished the reduction of CD3+/CD161a+ NKT cells. Another striking change is that RIPC significantly elevated the B cell percentage in peripheral blood, which reversed the otherwise reduced B cell population after stroke. RIPC also markedly elevated the percentage of CD43+/CD172a+ non-inflammatory residential monocytes, while showing no effect on the percentage CD43-/CD172a+ inflammatory monocytes. In addition, we found that RIPC induced IL-6 expression and enhanced the elevation of TNFα after stroke. Collectively, our results reveal potential immune mechanisms of RIPC-afforded neuroprotection against cerebral ischemia. Further exploration about these immune elements in RIPC-afforded ischemic tolerance may lead to the development of systemically administered immune therapies for stroke patients.
Abstract TP29: Endovascular Thrombectomy and Medical Therapy Versus Medical Therapy Alone in Acute Stroke (EASI): a Randomized Care Trial
Authors: Khoury Naim N , Darsaut Tim E , Ghostine Jimmy , Deschaintre Yan , Daneault Nicole , Durocher André , Lanthier Sylvain , Poppe Alexandre , Odier Céline , Lebrun Louise-Hélène , Guilbert François , Gentric Jean-Christophe , Batista André , Weill Alain , Roy Daniel , Bracard Serge
Published: July 2021

Background:
Until recently, clinical benefits of endovascular stroke treatment remained unproven. Care trials can be used to simultaneously offer yet-to-be validated interventions and verify treatment outcomes. Our aim was to implement care trial methodology for patients with severe acute ischemic stroke.

Methods:
The study was offered to all patients considered for endovascular management of acute ischemic stroke in one Canadian hospital. Inclusion criteria were broad: onset of symptoms ≤ 5h or at any time in the presence of clinical-imaging mismatch; suspected anterior or posterior circulation large vessel occlusion; patients eligible or ineligible for intravenous thrombolysis. Exclusion criteria were few: established infarction or hemorrhagic transformation of the target symptomatic territory; poor 3-month prognosis from comorbidities. The primary outcome was mRS ≤ 2 at three months. Patients were randomly allocated to standard care (control) or standard care plus endovascular treatment (intervention group). Analyses were by intention-to-treat. (Identifier NCT02157532)

Findings:
Seventy-seven patients were recruited in 19 months (March 2013 - October 2014) at a single center. Randomized allocation was interrupted when other trials showed the benefits of endovascular therapy. At three months, 20 of 40 patients (50·0 %; 95% C.I.: 35%-65%) in the intervention group had reached the primary outcome, compared to 14 of 37 patients (37·8%; 95% C.I.: 24%-54%) in the control group arm (P=0·36). Eleven patients in the intervention arm died within 3 months compared to 9 patients in the standard care arm.

Interpretation:
EASI met all the characteristics of a care trial: inclusion of all eligible patients, no extra risk, no extra test, no extra cost, simple case report forms filled by care personnel, normal follow-up, involvement of all regular practitioners, and flexible care. The trial was prematurely interrupted, but this approach offers a promising means to manage clinical dilemmas and guide uncertain practices in the care of patients.

Funding:
There was no funding source for this study.
Abstract TP290: Decreased Recognition of Minor Stroke Patients Leads to Longer Door-to-Needle Time
Authors: Rostanski Sara K , Williams Olajide , Stillman Joshua , Marshall Randolph S , Merkler Alexander , Yaghi Shadi , Willey Joshua Z
Published: July 2021

Intro:
Shorter door-to-needle time (DTN) is associated with better outcomes for ischemic stroke. National increases in tPA volumes are partially driven by treatment of larger numbers of minor strokes. However, it is not known whether treatment times differ in these patients. We sought to evaluate DTN and component times in minor strokes.

Hypothesis:
In minor strokes DTN is longer due to more diagnostic uncertainty

Methods:
We reviewed the record of all patients who received tPA in our ED from 7/2011-7/2015. Minor stroke was defined as NIHSS≤5. We compared demographics, EMS usage, pre-notification rates and DTN between minor strokes and all others. We also compared DTN component times, specifically neurologist-dependent times where diagnostic uncertainty may be apparent (stroke activation (SA)-to-tPA and imaging-to-tPA) and ED-dependent times which capture initial stroke recognition (door-to-SA and door-to-imaging). Means were compared via t test, medians via Mann Whitney U test, and dichotomous variables via chi square test.

Results:
Over this period 311 patients received tPA; 126 (41%) were minor strokes. There were no significant differences in language (48 vs 52% English-speaking, p=0.6) or sex (39 vs 34% male, p=0.3) for minor strokes compared to all others. Minor strokes were younger (62 vs 73 years, p<0.01), less likely to use EMS (55 vs 80%, p<0.01), and less likely to receive pre-notification by EMS (43 vs 71%, p<0.01).

We found longer DTN (61 vs 55 min, p=0.01) in minor strokes compared to all others. For DTN components, door-to-SA (5 vs 2 min, p<0.01) and door-to-imaging (27 vs 21 min, p<0.01) were longer in minor strokes while imaging-to-tPA (33 vs 32 min, p=1.0) and SA-to-tPA (50 vs 51 min, p=0.5) were not. In the subgroup arriving by EMS, these differences persisted although they were no longer significant (DTN 59 vs 54 min, p=0.4; door-to-SA 4 vs 1 min, p=0.05; door-to-imaging 25 vs 20 min, p=0.05).

Conclusion:
We found longer DTN in minor strokes. The difference in door-to-stroke activation and door-to-imaging but not other component times suggests delayed recognition of minor strokes at ED presentation. Similarly, less frequent pre-notification points to poor recognition by EMS. Efforts are needed to improve minor stroke recognition by EMS and ED providers
Abstract TP298: Code Stroke Simulation Training Benefits Junior Neurology Residents
Authors: Wendell Linda C , Thompson Bradford B , Jayaraman Mahesh , Khan Muhib , Lindquist David , Silver Brian , Furie Karen L
Published: July 2021

Introduction:
Junior neurology residents frequently receive the first call for emergency neurological conditions, including acute ischemic stroke and intracerebral hemorrhage (ICH) (Code Stroke). Code Stroke simulations allow residents to gain experience in the evaluation and treatment of a potential stroke patient without compromising patient care. Simulations also give residents the opportunity to improve their skills through direct observation and feedback. We hypothesized that simulation training would increase junior neurology residents’ confidence, comfort level and preparedness in leading a Code Stroke.

Methodology:
Ten neurology residents in their first months of training each took turns leading a Code Stroke simulation – either assessment of an ischemic stroke patient for intravenous thrombolytics, coordination of an ischemic stroke patient for embolectomy, or management of an ICH patient. Standardized patients were used in each case. Emergency medicine, vascular neurology and neurointerventional radiology attendings were active participants in the cases and gave feedback. Residents completed a survey before and after the simulation.

Results:
On a 5-point Likert scale (1 – least true and 5 – most true), confidence in leading a Code Stroke significantly increased from 2.80 to 3.95 (p=0.01) and perceived preparedness for the next Code Stroke significantly improved from 2.80 to 4.30 (p<0.01). Residents reported significantly improved comfort levels in rapidly assessing the National Institutes of Health Stroke Scale score (3.35 vs. 4.25, p=0.03) and rapidly assessing a Code Stroke patient for thrombolytics (3.15 vs. 4.25, p=0.02), making the decision to give thrombolytics (2.80 vs. 4.00, p=0.02) and assessing a patient for embolectomy (3.33 vs. 4.67, p=0.03). There was a perception of enhanced mutli-disciplinary collaboration with emergency medicine providers (3.55 vs. 4.40, p=0.04) and neurointerventional radiologists (3.00 vs. 4.50, p=0.07).

Conclusion:
Simulation training is a beneficial part of medical education for junior neurology residents and should be considered in addition to traditional didactics and clinical training.
Abstract TP311: Multidisciplinary Stroke Simulation: Novel Team Based Approach to Decrease Door-to-Needle Times
Authors: Mutch Christopher A , Threlkeld Zachary , Cole Sara , Martin Christine , Kozak Benjamin , Cooke Daniel L , Singh Vineeta , Rehani Bhavya
Published: July 2021

Introduction:
In acute stroke, time equals brain. Minimizing time to treatment maximizes eligibility and effectiveness of fibrinolytics. Timely treatment of acute stroke requires precise coordination of a multidisciplinary team ranging from first responders to neurointerventionalists. Simulation-based learning allows participants to hone their skills and make mistakes in a controlled environment. To our knowledge, the impact of multidisciplinary stroke simulation has not been reported in literature. Here we describe our initial experience implementing such a simulation.

Hypothesis:
Participation in stroke simulation will improve knowledge of acute stroke care guidelines and decrease door-to-needle time.

Methods:
Neurology, emergency medicine and radiology trainees, EMTs, nurses, medical students, technologists, and pharmacists took part in the evaluation and treatment of simulated patients with stroke symptoms in actual clinical settings from ambulance to ED to CT scanner to IR suite. Neurology and neuroradiology faculty debriefed participants following simulations. Questions on stroke care (derived from the 2013 AHA/ASA guideline and 2015 update) were sent to likely participants before and after the simulation; those who completed pre/post quizzes and the simulation were included in analysis.

Results:
Survey response rate was 86%. All participants had improved scores on the post-simulation quiz, scoring an average of 19% higher, 95% CI [8%, 29%]. For example, correct responses that IV tPA is not contraindicated prior to endovascular therapy improved from 64 to 100% after the simulation; responses correctly identifying the appearance of ischemic penumbra on CT perfusion imaging increased from 27 to 73%. Nearly all (92%) respondents would recommend the simulation to their peers.

Conclusions:
Simulation of acute stroke scenarios improves participants’ knowledge of acute stroke management guidelines and may improve door-to-needle time. We present a novel framework for multidisciplinary simulation, which could be implemented at other institutions. Further evaluation of simulation effect on door-to-needle time is ongoing.
Abstract TP327: Predictors of Surgical Feeding Tube Placement in Intracerebral Hemorrhage.
Authors: Saeed Umair , Brown Kristin , Sharrief Anjail , Indupuru Hari , Jacobs Amber , Deguzman Maria , Shoemake Paige , Clayton Alana , Cooper Stephanie , Xavier Andreea , Cai Chunyan , Vu Kim , Barreto Andrew
Published: July 2021

Introduction:
Decisions to pursue enteral feeding with percutaneous endoscopic gastrostomy tube (PEG) may lead to prolong hospitalization in stroke patients. Prediction models in intracerebral hemorrhage (ICH) have shown conflicting data, lacked objective speech pathology findings, and have included race predictor without biological basis. We hypothesized that stroke severity and findings from instrumental swallowing assessments would predict PEG placement and race would not be a significant predictor after controlling for other variables.

Methods:
Using our prospectively obtained stroke registry, we analyzed consecutive ICH cases at our comprehensive stroke center. Patients transferred to hospice or died within 3 days were excluded. Backward stepwise elimination using logistic regression evaluated potential predictors of PEG placement. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and Modified Barium Swallow (MBSS) studies utilized the validated Penetration-Aspiration (PEN-ASP) scale; an 8-item scale: 1-2, normal; 3-5, penetration; 6-8 aspiration.

Results:
Between June-14 and April-15, 290 ICH patients were treated by our stroke service (65.5% hospital transfers). Overall, 64 (21.4%) patients received PEG tubes with higher rates in non-whites (table). Ten variables with p<0.1 were identified (see table). In the final model, race was not significantly associated with PEG (p=0.092), but total NIHSS, sub-item 1a of the NIHSS, presentation to our ED and GCS remained independent predictors of PEG placement (p<.05). PEG patients had significantly worse PEN-ASP scores for both thin and nectar-thick liquids.

Conclusions:
Our work represents the largest cohort of ICH patients that underwent surgical feeding tube placement. We did not find an independent association with race as previously reported. Future research regarding dysphagia and stroke should include objective assessments of swallow function such as the PEN-ASP score.
Abstract TP33: Ischemic Stroke Outcomes in Medical vs Endovascular Treatment of Proximal Carotid Artery Occlusion
Authors: Shwe Yamin , Cai Chunyan , Sharrief Anjail Z , Sarrraj Amrou
Published: July 2021

Background:
Acute ischemic stroke (AIS) due to proximal carotid artery occlusion (pCAO) can be associated with significant neurological deficits and poor outcome without timely intervention and successful reperfusion. Intravenous thrombolytics (IT) have low recanalization rates in pCAO and these patients were excluded from recent randomized controlled trials which showed superiority of endovascular therapy (EVT) over IT.

Purpose:
The purpose of this study is to investigate clinical outcomes in AIS due to pCAO treated with medical vs. endovascular treatment.

Methods:
We conducted a retrospective chart review of patients who underwent IT or EVT±IT for all types of pCAO from January 2008 to June 2015. Our primary outcome was the functional outcome at discharge measured by modified Rankin score (mRS) 0-3. The secondary outcomes were hemorrhagic transformation (HT), neurological worsening (NW), symptomatic hemorrhage (sICH) and death. Logistic regression analysis was used to compare outcomes between the two groups.

Results:
A total of 133 patients were included in the study. Baseline characteristics are depicted in table 1. There were no significant differences between the two groups. IV tPA was given in 56% IT vs. 72% EVT (p=0.14). While there was a shift towards better outcomes in the mRS distribution in EVT group (22% vs. 16%) as shown in Figure 1, the treatment effect did not reach significance (OR 1.71, 95% CI (0.55, 5.34), p=0.35). There was also no difference in HT (26% vs. 14%, p=0.14), or NW (26% vs. 21%, p=0.6). However, sICH was higher in EVT (3.7% vs. 0%, p=0.2).

Conclusion:
Our study did not show difference in discharge functional outcomes between EVT and IT in AIS with pCAO. Our results are limited by small sample size and retrospective nature. Future prospective studies randomizing patients to medical vs. endovascular treatments are warranted to guide management.
Abstract TP332: Neuro-QOL Measures Have Improved Statistical Power versus the Dichotomized Modified Rankin Scale in Stroke Thrombolysis
Authors: Sangha Rajbeer S , Bernstein Richard , Cella David , Corado Carlos , Curran Yvonne , Naidech Andrew , Ruff Ilana , Prabhakaran Shyam
Published: July 2021

Introduction:
The modified Rankin scale (mRS) is a reliable objective measure of disability and is widely applied in clinical trials. Health-related quality of life (QOL) measurements using Neuro-QOL provide validated measures of patient-reported outcomes. In a matched case-control study, we hypothesized that differences in QOL in favor of tPA would be readily detectable compared to the dichotomous mRS outcome traditionally applied in acute stroke research.

Methods:
From a single-center prospective cohort study, we identified ischemic stroke patients who received intravenous tPA, admitted between August 1, 2012 and July 31, 2014, and who had 3-month QOL and mRS outcomes. Using a propensity score matching algorithm based on age and stroke severity, ischemic stroke patients who did not receive tPA were selected as controls. The mRS was assessed by structured telephone interviews and Neuro-QOL using short forms analyzing domains of upper extremity (UE), lower extremity (LE), executive function (EF), and general cognition (GC). T-scores for Neuro-QOL domains are referenced to the general population (mean 50, SD 10). We assessed differences in mRS (dichotomized 0-1 vs. 2-5) and QOL T-scores (continuous) in each domain using appropriate tests.

Results:
A total of 90 patients were analyzed (45 tPA and 45 controls; median NIHSS score 7). There was no statistical difference between the two groups by age (p=0.967) and NIHSS score (p=0.855). When comparing Neuro-QOL T-scores, higher scores were reported for domains of EF (tPA: 52 vs. controls: 46; p=0.032) and LE function (tPA: 46 vs. controls: 41; p=0.008) among tPA patients compared to controls. No differences were noted for UE or GC QOL T-scores. Using the mRS, the results were not statistically significant (dichotomous: 0-1, tPA: 75.6% vs. controls: 57.8%, p=0.117).

Conclusion:
Neuro-QOL offers a complementary tool for assessment of neurological function and may help identify finer grades of functional change and outcomes for stroke patients undergoing a specific therapy. The mRS requires a greater number of patients to show statistical significance while utilization of a continuous measurement of function from the patient perspective may improve statistical power in future clinical trials.
Abstract TP334: The Cultural Appropriateness of the National Institute of Health Stroke Scale (NIHSS) in Singapore: a Survey on Healthcare Workers’ Opinions
Authors: Woon Fung Peng , Queck Kian Kheng , Fabiaña Natasha L , Oh Daniel C , Tay Deirdre D , Ng Wai May , De Silva Deidre A
Published: July 2021

Introduction:
The National Institute of Health Stroke Scale (NIHSS) is the most utilized scale for neurological deficits of stroke, assessing various components including dysphasia and dysarthria. However, some non-Western countries have found certain components in the NIHSS to be inappropriate due to cultural differences, but no studies have been conducted in Singapore. We sought the opinions of healthcare workers in Singapore who are involved in stroke care on the cultural appropriateness of the NIHSS.

Hypothesis:
The NIHSS contains components which are considered culturally inappropriate by healthcare workers in Singapore.

Methods:
We surveyed 79 healthcare workers who care for stroke patients (24 doctors, 40 nurses, 15 speech therapists), on cultural appropriateness of the dysphasia and dysarthria components of the NIHSS in Singapore, using a standardized questionnaire.

Results:
The majority of respondents (84%) found ≥1 objects tested for dysphasia culturally inappropriate, with 33% substituting with another picture, 29% skipping the object and 32% using a physical object. Most (86%) opined that ≥1 dysphasia objects should be changed, specifically the hammock (67%) and cactus (51%). The dysphasia phrases and kitchen scene were reported as culturally inappropriate by 49% and 29% of the respondents respectively. For the dysarthria component, 58% found ≥1 word culturally inappropriate and 75% reported adjusting the acceptability of responses by patient demographics.

Conclusions:
The dysphasia objects, dysphasia phrases and dysarthria phrases of the NIHSS are culturally inappropriate in Singapore. There are inconsistencies in handling these issues and responses are commonly being adjusted to patient’s demographics. Thus we aim to modify the standard NIHSS based on response to this survey and to develop a NIHSS version that is culturally suitable in Singapore.
Abstract TP336: Influence of Aversion to Uncertainty in STROKE Care
Authors: Li Yue , Crump Lauren , Sharma Mike , Sacco Ralph , Smith Eric , Saposnik Gustavo ,   on behalf of the Stroke Outcomes Rsch Canada Working Group (SORCan-www.sorcan.ca)
Published: July 2021

Introduction:
Physicians caring for patients with silent cerebral infarction (SCI) face several diagnostic and therapeutic challenges. In situations with limited information or lack of guidelines, clinical decisions may be influenced by aversion to uncertainty (AU) defined as a tendency to prefer known over unknown risks.

Hypothesis:
We hypothesize that physicians’ AU is associated with overutilization of diagnostic tests and influences therapeutic choices for patients with covert cerebrovascular disease.

Methods:
Participating physicians were practicing neurologists with expertise in stroke care identified from WSO, CSC, VasCog and SORCan. Those who agreed to participate were sent an online questionnaire.

Participants randomly received 10 cases from a pool of 20 assessing perception of risk for later stroke and treatment preferences, with additional validated questions to quantitatively determine AU, and overconfidence. The questionnaire was completed online. A multivariable analysis was completed adjusting for age, years of experience, and annual volume of stroke patients.

Results:
Of 252 initial participants, 35 (13.9%) were excluded for incomplete responses. Of 217 remaining participants for the analysis, 50% of participants expressed that uncertainty was troublesome with their diagnosis. AU was associated with greater recommendation of oral anticoagulants for a case-scenario with atrial fibrillation, CHADS 4 and microbleeds (OR 3.26; 95%CI 1.30-8.19), and with ordering more investigations for an asymptomatic cortical infarction (OR 2.61; 95%CI 1.17-5.83). AU was also associated with recommending tPA or endovascular treatment for a 72 year old woman presented within 4 hours with an NIHSS 6-7 and asymptomatic microbleeds, but otherwise no other contraindication (OR 3.32; 95%CI 1.19-9.27).

Conclusion:
Aversion to uncertainty is common among practicing stroke neurologists. AU was associated with ordering more investigations and more appropriate recommendations for oral anticoagulation or revascularization when indicated. The present study has practical implications, as aversion to uncertainty may be associated with a more vigilant practice.