bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P126: Cerebral Microbleeds and Functional Outcomes at Discharge and 6 Months after Acute Ischemic Stroke
Authors: Kim Tae-Won , Koo Jaseong , kim Joong-Seok , Choi Hyun Seok , Lee Kwang Soo
Published: March 2022

Introduction:
Whether preexisting cerebral microbleeds (CMB) are associated with poor functional outcome after ischemic stroke has not been reported before. We examined the associations between CMB and functional outcome at discharge and 6 months after ischemic stroke.

Method:
We studied 207 consecutive patients with acute ischemic stroke within 1 week after symptom onset who admitted to our hospital for 1 year. Assessment of stroke severity (by NIHSS) was made at the time of admission, at 24 hours after admission, at discharge and 6 months after admission. Functional outcomes (by modified Rankin scale) were evaluated at discharge and 6 months after admission. Patients’ outcomes were dichotomized into good and poor functional outcome groups with the mRS score cutoff 1 (no significant disability)/2 (slight disability). Microbleeds of each patient were analyzed by an experienced neuroradiologist. Demographic and clinical characteristics, the presence of CMB were compared between two groups. Then, logistic multivariable regression analysis was performed including all variables with a probability value <0.2 in the univariate analysis.

Results:
More patients with poor functional outcome had CMB (45.6% vs. 27.4%; p=0.008) and they had more number of CMB (2.8±5.7 vs. 1.3±4.0; p=0.034) compared with patients with good functional outcome.

After multivariable regression analysis, there were no independent associations between CMB and functional outcome with adjustment for age, sex, history of diabetes, WMH and initial scores on NIHSS at discharge.

At 6 months after ischemic stroke, CMB were significantly associated with poor functional outcomes after adjustment for age, history of previous stroke and hypertension, WMH and initial scores on NIHSS (OR 2.1 95% CI: 1.0-4.5, p= 0.046). When patients were subdivided into those with lobar CMB and those with deep or infratentorial CMB, we found significant association between infratentorial CMB and poor functional outcome (OR 3.8 95% CI: 1.4-10.4, p= 0.009) and an associated trend between lobar CMB and poor outcome (OR 2.1 95% CI: 0.9-4.7, p= 0.067).

Conclusion:
CMB, especially infratentorial area, were significantly associated with worse functional outcomes at 6 months after stroke.
Abstract T P128: Dual Task Walking Reveals Cognitive Dysfunction in Community-Dwelling Elderly Subjects: The Sefuri Brain MRI Study
Authors: Hashimoto Manabu , Takashima Yuki , Uchino Akira , Yuzuriha Takefumi , Yao Hiroshi
Published: March 2022

Introduction:
The aim of our study was to investigate the effects of subclinical brain lesions and cognitive function on gait performance with or without concurrent cognitive task (i.e., dual task) in community-dwelling elderly subjects.

Subjects and Methods:
Between 2010 and 2012, magnetic resonance imaging (MRI) scans were performed for 170 non-demented volunteers (82 men and 88 women with a mean age of 67.5 years). The National Hospital Organization Hizen Psychiatric Center Institutional Review Board approved the study. All participants underwent neuropsychological tests (the Mini Mental State Examination [MMSE], Trail Making Test [TMT] and Rivermead Behavioral Memory Test [RBMT]). Time to complete the Timed Up and Go test was measured under two conditions: 1) Timed Up and Go test, and 2) dual task, walking while adding 3 to a predefined number “1”. Impaired gait velocity was defined as the most prolonged quintile in the time of single (>9.0 sec) and dual (>11.0 sec) tasks. We determined indices for atrophy using Voxcel-based Specific Regional Analysis for Alzheimer’s disease (VSRAD). Multivariate analysis was done using the logistic regression analysis with IBM SPSS Statistics 18 software for Windows.

Results:
Mean education years was 11.3±2.1 (S.D.) years, and mean MMSE score was 27.8±2.1. Silent brain infarction, deep white matter lesions (DWMLs), periventricular hyperintensities and cerebral microbleeds were detected in 19 (11.2%), 50 (29.4%), 24 (14.1%) and 8 (4.7%), respectively. Impaired gait velocity of single task (Timed Up and Go test) was associated with DWMLs (OR 2.57, 95% CI 1.16-5.69) after adjusted for age, sex, education, MMSE, TMT, RBMT, and MRI findings. Impaired gait velocity of the dual task walking was associated with age (OR 3.59/10 years, 95% CI 1.91-6.73) and score of the RBMT (OR 0.88, 95% CI 0.79-0.99), whereas MRI findings including brain atrophy (VSRAD) were not associated with reduced speed of dual task walking.

Conclusions:
Gait disturbance detected by single task was related to DWMLs, while dual task walking revealed an association between reduced gait speed and cognitive dysfunction. The present study showed that gait represents not only physical functioning but also cognitive dysfunction in healthy elderly individuals.
Abstract T P129: Association of Increased Serum Alkaline Phosphatase with Intracranial Atherosclerosis
Authors: Kim Jun Yup , Kim Tae Jung , Kim Chi Kyung , Jung Seunguk , Kim Yerim , Ko Sang-Bae , Lee Seung-Hoon , Yoon Byung-Woo
Published: March 2022

Background:
Vascular calcification is strongly associated with cardiovascular morbidity and mortality by reducing arterial elastance. Recently alkaline phosphatase (ALP) is identified as the critical factor for vascular calcification, but no clinical studies investigating relevance of ALP and cerebral atherosclerosis have been reported. In this study, we assessed the hypothesis that increased levels of serum ALP may be associated with severity of cerebral atherosclerosis.

Methods:
From October 2010 to March 2012, we prospectively included total 518 patients (313 men/205 women) aged 25-96 years with acute ischemic stroke. Cardioembolic stroke patients were excluded because of the interference by acute arterial embolic occlusion. The patients were divided by baseline measurements into quantiles of ALP levels (<58, 58-69, 70-89, >90 IU/L). Bilateral middle cerebral arteries, distal internal carotid arteries and basilar artery were selected for the evaluation of intracranial atherosclerosis, bilateral proximal internal carotid arteries and common carotid arteries for the extracranial atherosclerosis. We defined significant arterial stenosis as moderate or more stenosis (50-100%) evaluated by at least one angiographic study using MR angiography, CT angiography or digital subtraction angiography. Statistical analyses were performed using the multivariate logistic regression analysis adjusted for age, gender, hypertension, diabetes, dyslipidemia, smoking, presence of secondary prevention, serum calcium levels.

Results:
In the multivariate logistic regression analysis, compared with the first ALP quantile, adjusted odds ratio of the third and fourth quantiles for significant intracranial atherosclerosis were 2.30 (95% confidence interval 1.06-5.01) and 3.84 (1.78-8.30). There was no significant correlation between ALP levels and significant extracranial atherosclerosis.

Conclusions:
In conclusion, our study demonstrated that increased serum levels of ALP are an independent risk factor for significant intracranial atherosclerosis.
Abstract T P134: Fibroblast Growth Factor 23 and Risk of Incident Stroke in the Regards Study
Authors: Panwar Bhupesh , Jenny Nancy , Howard Virginia , Wadley Virginia , Muntner Paul , Judd Suzanne , Gutierrez Orlando
Published: March 2022

Objective:
Fibroblast growth factor 23 (FGF23) is a hormone that regulates phosphorus and vitamin D metabolism. Elevated levels of FGF23 are strongly associated with heart disease and death, particularly in persons with chronic kidney disease (CKD). Whether FGF23 is also associated with stroke risk is unclear.

Methods:
Using a case cohort design we examined the association of plasma FGF23 with incident stroke in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a cohort of black and white participants from across the United States. Baseline assessment occurred between 2003 and 2007. All physician-adjudicated stroke cases through July 1, 2011 were included in the analysis. Using stored samples, FGF23 was measured on 610 stroke cases and 939 cohort members, all of whom were stroke-free at baseline. The cohort random sample was selected to ensure approximately equal numbers of black and white participants and an equal distribution across ages. We used Cox proportional hazards models weighted back to the original 30,239 participants sampled by the REGARDS study to account for oversampling of stroke cases.

Results:
Participants were followed for a mean of 4.4 years. Higher FGF23 was associated with older age, female sex, lower socioeconomic status, diabetes, and CKD (estimated glomerular filtration rate < 60 ml/min or urinary albumin to creatinine ratio ≥ 30 mg/g). After adjustment for age, race, sex, education, diabetes, hypertension, smoking, atrial fibrillation, heart disease, physical activity, calcium, phosphorus, and serum vitamin D, higher FGF23 levels were associated with greater risk of incident stroke (HR per doubling of FGF23=1.19; 95%CI=1.03, 1.37). After further adjustment for CKD, this association was attenuated and no longer statistically significant (HR per doubling of FGF23=1.06, 95%CI 0.90, 1.25).

Discussion:
Higher FGF23 is associated with greater risk of stroke, but this association is largely explained by CKD.
Abstract T P141: Metabolic Determinants of White Matter Hyperintensity Burden in Patients with Acute Ischemic Stroke
Authors: Cloonan Lisa , Fitzpatrick Kaitlin , Kanakis Allison , Furie Karen , Rosand Jonathan , Rost Natalia
Published: March 2022

Background/Purpose:
Increasing white matter hyperintensity (WMH) burden is linked to risk of stroke and poor post-stroke outcomes. While the biology of WMH remains ill-defined, several lines of evidence implicate endothelial dysfunction. In this study, we sought to assess the association between metabolic markers of endothelial dysfunction and WMH severity in patients with acute ischemic stroke (AIS).

Methods:
Consecutive subjects ≥18 years of age admitted to our ED with AIS, brain MRI, and blood homocysteine (Hcy) and hemoglobin A1c (HgbA1c) measurements were eligible for this analysis. WMH volume (WMHv) was quantified using a validated semi-automated algorithm and log-transformed for linear regression analyses.

Results:
There were 682 AIS subjects included (mean age 65.57±14.7)) median WMHv 6.25cm
3
(IQR 2.83-13.08)). In univariate analysis, age, female gender, race, ethnicity, systolic blood pressure, history of hypertension, atrial fibrillation, coronary artery disease, prior stroke, and current alcohol and tobacco use (all p<0.05), as well as Hcy (p<0.0001) and HgbA1c levels (p<0.005) were associated with WMHv. However, only Hcy (ß=0.11, p<0.003) and HgbA1c levels (ß=0.1, p<0.008) independently predicted WMHv in multivariate model, along with age (ß=0.03, p<0.0001), race (ß=0.4, p=0.013), ethnicity (ß=-0.11, p=0.03), and current alcohol use (ß=0.26, p=0.002).

Conclusion:
Elevated levels of Hcy and HgbA1c have been previously linked to endothelial dysfunction related to oxidative stress. The association between Hcy and HgbA1c and WMH burden in AIS suggests that endothelial dysfunction may be more severe in patients with increased WMHv and underlie the relationship between WMHv and poor outcome from stroke.
Abstract T P147: Vitamin D Deficiency is Associated With Stroke in ethnic Chinese but Not South Asians in a Case-Control Study
Authors: De Silva Deidre , Tan Melissa , Woon Fung-Peng , Ikram Kamran , Wong Tien-Yin , Tan Eng-King , Lee Wei-Ling
Published: March 2022

Vitamin D deficiency is associated with risk of stroke and coronary artery disease in whites but not in blacks. There are no such data comparing Asian ethnicities with differing skin pigmentation. Compared to ethnic Chinese, ethnic South Asians are comparatively of darker pigmentation and are have lower vitamin D levels. We aimed to determine any ethnic interaction between vitamin D and ischemic stroke in a case-control study of ethnic Chinese and South Asians. We recruited 271 ischemic stroke patients of Chinese (87%) and South Asian (13%) ethnicity with blood samples taken within 2 weeks of onset to reflect pre-stroke levels. They were matched for age, gender and ethnicity to 271 stroke-free controls from a population-based study. Serum 25 hydroxyvitamin D [25(OH)D] levels were measured using competitive electroluminescence immunoassay in an accredited laboratory, blinded to clinical data. Among the cases and controls, the ethnic distribution was 87% Chinese and 13% South Asian. Mean 25(OH)D levels were lower in South Asians than Chinese among stroke cases (19.1 ± 8.4 vs 24.6 ± 9.3μg/L; p=0.001), and among controls (16.7 ± 6.6 vs 29.3 ± 9.7μg/L; p<0.001). Among Chinese, 25(OH)D levels were lower in stroke cases than controls (p<0.001), however this was not observed among South Asians (p=0.188). There was an interaction between ethnicity with the association of 25(OH)D levels and stroke (p <0.001), which remained even after adjusting for covariates of diabetes, hypertension, hyperlipidemia, previous myocardial infarction and smoking status as well as calcium, phosphate, and PTH levels (p=0.003). The relationship between vitamin D and stroke risk differed between Chinese and South Asians, consistent with studies of ethnic groups with differing skin pigmentation. This adds to evidence of a possible adaptive mechanism towards the consequences of vitamin D deficiency in ethnicities with darker pigmentation. Furthermore, ethnicity should be an important consideration in vitamin D-related epidemiology and treatment studies.
Abstract T P149: Prevalence of Atrial Fibrillation in Stroke Patients: an Observational Study in the Very Old
Authors: Mieiro Luis , Miranda Ana , Alves Mariana , Narciso Marco , Lopes Francisca , Fonseca Teresa
Published: March 2022

Background:
Atrial fibrillation (AF) is the most common arrhythmia in older adults, increases with age and it is a well-established risk factor for stroke. Recent studies showed that up to 15% of stroke admissions present with AF. Furthermore, the number of patients with AF is expected to increase 2.5-fold in the next 50 years. Therefore, stroke prevention must constitute a priority in current health policies. Nonetheless, little is known about the prevalence of paroxysmal AF (PAF) in older adults. We aim to assess the prevalence of AF in stroke patients and to identify further paroxysmal events in patients with reported normal rhythm on admission.

Methods:
Observational study of routinely collected data over a 26-month period in a Stroke Unit within an Internal Medicine Department. All types of stroke were analyzed. AF diagnosis based on medical records, admission 12-lead electrocardiogram (ECG) or 24-hour Holter monitoring. Descriptive statistics were used.

Results:
A total of 332 consecutive patients were identified. Median age (IQR) was 77 (68-83) years; 53.0% women; 2.4% hemorrhagic stroke; 59.5% aged 75 years or older. Overall prevalence of AF on admission was 23.2%, of which 10.4% were newly diagnosed. 34.8% of the patients with known AF were on anticoagulation. Amongst the patients with reported normal rhythm on admission, a 1.9% of PAF was demonstrated on 24-hour Holter monitoring recorded during acute phase. In the 75 years or older cohort, we found higher prevalence of AF (31.3% vs 11.2%, p<.001) but no difference of that of PAF (2.2% vs 1.7%, p=NS). Cardioembolism was much more prevalent in the very old (33.0% vs 17.9%, p=.03).

Conclusion:
We report a higher prevalence of AF in patients presenting with stroke than published literature. Some patients were unaware of this condition. Surprisingly, only a third of patients with known AF were on anticoagulation. We were able to detect a high prevalence of PAF on 24-hour Holter monitoring during acute phase. However, PAF is as prevalent in the very old as it is in younger patients. Cardioembolic stroke is more frequent in the very old; therefore exhaustive investigation to detect AF in this cohort should be sought, so an effective secondary prophylaxis can be offered.
Abstract T P157: The Impact of Estimated Glomerular Filtration Rate on a Recurrence of Ischemic Stroke: The Fukuoka Stroke Registry
Authors: Kuwashiro Takahiro , Kamouchi Masahiro , Kumai Yasuhiko , Maeda Koichiro , Uwatoko Takeshi , Wakugawa Yoshiyuki , Ago Tetsuro , Yasaka Masahiro , Okada Yasushi , Kitazono Takanari
Published: March 2022

Introduction:
Although chronic kidney disease has been shown as a risk factor for stroke recurrence in several studies, there are few reports about the impact of the degree of estimated glomerular filtration rate (eGFR) on recurrence.

Hypothesis:
There is a trend that hazard ratio of stroke recurrence was lower in the higher group of eGFR while higher in the lower group. We aimed to determine the influence of eGFR grade on stroke recurrence.

Methods:
We enrolled 5101 consecutive patients who were hospitalized in stroke centers within seven days of onset from June 2007 to May 2012. The clinical characteristics of patients were assessed on admission, and the clinical course of all patients was followed subsequently. Patients were divided into three groups based on the level of eGFR; E1 (eGFR < 30 ml/min/1.73 m
2
), E2 (30 ≤ eGFR < 60), E3 (60 ≤ eGFR). In these groups, we performed Multivariate Cox proportional hazards analyses to determine the influence of eGFR grade on stroke recurrence.

Results:
Of all patients, 5028 (2998 males, 74 ± 12 years of age) cases with ischemic stroke were investigated in the present study. Six hundred twenty-nine patients (13%) suffered a recurrence of ischemic stroke during the follow-up period (680 ± 387 days). The Kaplan-Meier method revealed the cumulative recurrence rates of ischemic stroke in three groups of patients were significantly different, as shown in figure (E1 vs. E2, E1 vs. E3, p < 0.0001 by the log-rank test). On Cox proportional analysis with adjustments for multiple confounding factors, E2 (hazard ratio [HR] 1.27, 95% confidence interval [CI] 1.06 to 1.52, p = 0.0115) and E3 ([HR] 1.95, 95% [CI] 1.48 to 2.52, p < 0.0001) groups were at greater risk of stroke recurrence compared with the E1 group.

Conclusions:
There is the significant relationship between a level of eGFR and a recurrence of ischemic stroke. In the stroke patients who have lower eGFR, the risk of a recurrence more increases.
Abstract T P162: Cardio-Ankle Vascular Index (CAVI) predicts Cardioembolic Stroke in Patients with Atrial Fibrillation
Authors: Yamaura Gensai , Nishiyama Satoshi , Watanabe Tetsu , Wanezaki Masahiro , Sasaki Shintaro , Takahashi Hiroki , Arimoto Takanori , Shishido Tetsuro , Miyashita Takehiko , Miyamoto Takuya , Kubota Isao
Published: March 2022

Arteriosclerosis has shown to be a definite risk factor of atrial fibrillation, which is an important cause of cardioembolic stroke. The cardio-ankle vascular index (CAVI) has been reported as a novel parameter for arterial stiffness, and high CAVI implies progression of carotid and coronary arteriosclerosis. However, it remains to be determined whether CAVI is associated with cardioembolic stroke.

We performed CAVI and transesophageal echocardiography in 219 patients with paroxysmal or chronic atrial fibrillation (165 males, 64 ± 12 years), including 53 patients with the history of cardioembolic stroke.

CAVI was higher in patients with hypertension, diabetes mellitus, chronic atrial fibrillation and the history of heart failure compared with those without them. CAVI showed a good correlation with age, systolic blood pressure, pulse pressure, fasting blood glucose, high-sensitivity CRP, fibrinogen and von Willebrand factor. CAVI was also associated with left atrial dimension, left atrial volume index, left atrial emptying fraction, left ventricular diastolic function and left atrial appendage emptying flow velocity. CAVI was significantly increased with advancing grade of spontaneous echo contrast and increasing CHADS
2
score and CHA
2
DS
2
VASc score. Furthermore, CAVI was significantly different between patients with score 0 and score 1 in CHADS
2
and CHA
2
DS
2
VASc. CAVI was significantly higher in patients with left atrial appendage thrombus than in those without (10.3 ± 2.4 vs. 8.5 ± 1.6, P<0.0001). CAVI was also significantly higher in patients with cardioembolic stroke than in those without (10.6 ± 2.2 vs. 8.3 ± 1.2, P<0.0001). Logistic regression analysis revealed that CAVI was an important risk factor for cardioembolic stroke after adjustment of age and heart rhythm (odds ratio 2.16, 95% confidence interval 1.55-3.01). The patients with CAVI ≥ 9 had 12 times higher risk for cardioembolic stroke compared with those with CAVI < 9 after adjustment of age and heart rhythm.

In conclusion, CAVI is a novel parameter to predict cardioembolic stroke in patients with atrial fibrillation.
Abstract T P172: Putative Blood Biomarkers for Reversible Cerebral Vasoconstriction Syndrome
Authors: John Seby , Willard Belinda , Calabrese Leonard , Hammad Tariq , Uchino Ken , Tepper Stewart , Stillman Mark , Hajj-Ali Rula
Published: March 2022

Background:
The pathophysiology and molecular mechanisms of Reversible Cerebral Vasoconstriction Syndrome (RCVS) are unknown. Objective of the study was to identify putative biomarker proteins for RCVS.

Methods:
Patients were recruited from our institution’s prospective RCVS registry. Plasma samples were collected from 6 patients with RCVS during the acute cerebral vasoconstrictive phase, 2 patients at 6-month follow-up after resolution of vasoconstriction, and 4 patients with CNS vasculitis.

After appropriate processing, plasma samples were analyzed by liquid chromatography tandem mass spectrometry (LC-MS/MS) on a high resolution Orbitrap-Elite FT-MS system. The quantitation was performed by searching the data with the programs Mascot and Sequest. These search results were then uploaded into the program Scaffold. Quantitation was performed by comparing normalized spectral counts (nSC) for the samples. The data was filtered based on several parameters including 2 matching peptides, a FDR of 1.0%, a protein threshold of 95%, and identification of at least 3 peptides in the samples. In order for a protein to be considered as a putative biomarker, the relative abundance needed to be at least two fold different with the T-test derived p-value < 0.05.

Results:
A total of 228 proteins were identified. Three, 5 and 4 proteins were found to be of higher abundance in a) follow-up samples of RCVS compared to baseline RCVS, b) CNS vasculitis samples compared to baseline RCVS, and c) baseline RCVS samples compared to CNS vasculitis respectively.(Table 1)

Conclusion:
This is a preliminary study looking at proteomic analysis of RCVS plasma samples. Results of this study show proteins that might be potential biomarkers for RCVS and which could help differentiate RCVS from its mimic CNS vasculitis. Further studies with larger number of patients are needed to assess reproducibility. The function and the pathways of these differentially expressed proteins should be further explored.
Abstract T P173: Accuracy of Transcranial Doppler for the Diagnosis of Intracardiac Right-to-Left Shunts: A Meta-Analysis of Prospective Studies
Authors: Mojadidi M. Khalid , Zaman Muhammad O , Roberts Scott , Winoker Jared , Romero Jorge , Goodman David , Gevorgyan Rubine , Tobis Jonathan M
Published: March 2022

Background:
Right-to-left shunting (RLS), usually through a patent foramen ovale (PFO), has been associated with cryptogenic stroke, migraine with aura, and hypoxemia. With emerging observational studies and clinical trials on the subject of PFO and its association with these clinical syndromes, there is a need for accurate diagnosis of PFO in patients being considered for transcatheter closure. While transesophageal echo (TEE) bubble study is the current standard reference for diagnosing PFO, transcranial Doppler (TCD) bubble study may be a preferable screening test for RLS due to its high sensitivity, non-invasiveness and low cost. The aim of this meta-analysis was to determine the accuracy of TCD compared to TEE as the reference.

Methods:
A systematic review of Medline, Cochrane and Embase was done to look for all the prospective studies assessing for intracardiac RLS using TCD compared to TEE as the reference; both TCD and TEE were performed with a contrast agent and a maneuver to provoke RLS in all studies.

Results:
A total of twenty-seven studies with 1910 patients (mean age 48 ± 5.6, 58% male) fulfilled the inclusion criteria. The weighted mean sensitivity and specificity for TCD were 96% (95% CI 90-100) and 88% (95% CI 82-94) respectively. The PPV and NPV were 87% (95% CI 81-93) and NPV: 96% (95% CI 92-100) respectively. Overall diagnostic accuracy was 91% (95% CI 87-94).

Conclusion:
TCD is a reliable, non-invasive alternative diagnostic modality to TEE with an excellent sensitivity and NPV, making it a reliable screening tool for detecting RLS. TEE is limited by patient tolerance. If the precise anatomy is required, then TEE can be obtained before scheduling a patient for transcatheter PFO closure.
Abstract T P175: Symptoms and Signs of Cerebrovascular Ischemia in the New England Medical Center Patent Foramen Ovale Registry
Authors: Toma Hassanain , Thaler David E
Published: March 2022

Objective:
To evaluate the frequencies of symptoms and signs in patients with cryptogenic strokes in the setting of patent foramen ovale (PFO).

Methods:
We conducted a retrospective case series of cryptogenic stroke patients at the NEW England Medical Center, with proven PFO. The patients' records were reviewed for: 1) Activity at time of symptoms, 2) symptoms, 3) physical exam finding.

Results:
The study included 148 men (58%) and 109 women (42%). The average age was 52 years. The most frequent activity at the time of symptoms onset were lifting weights (30%), bending (34%), coughing/ sneezing/ nose blowing (16%), intercourse (7%), vomiting (5%). A history of prolonged immobility was present in 31% of patients. The most frequent presenting symptoms were unilateral weakness (46%), dysarthria (17%), unilateral numbness (11%), unsteady gait (10%), visual field defect (9%), diplopia (8%), vomiting (6%). The most frequent signs were normal exam (52%), unilateral weakness (14%), visual field deficits (13%), ataxia (4%), neglect/ inattention (2%), Babinski (3%), nystagmus (2%), unsteady gait (1%).

Conclusion:
We report our experience with cryptogenic stroke in patients with proven PFO. The disparity in frequencies of the signs and symptoms at the time of presentation raises the possibility of including these variables in an algorithm for predicting PFO in the setting of cryptogenic stroke.
Abstract T P176: Readmission for Infective Endocarditis after Ischemic Stroke or Transient Ischemic Attack
Authors: Chu Stacy Y , Merkler Alexander E , Cheng Natalie T , Kamel Hooman
Published: March 2022

Background:
Guidelines recommend blood cultures for the evaluation of cerebral ischemia when infective endocarditis (IE) is the suspected cause, but given the absence of more specific guidance, providers likely have significantly varying thresholds for obtaining blood cultures in patients with cerebral ischemia. To explore the utility of blood cultures in these patients, we assessed rates of missed diagnoses of IE in patients discharged after stroke or TIA before blood culture results could have been available.

Methods:
Using administrative claims data, we retrospectively identified consecutive patients discharged from all nonfederal emergency departments (ED) or hospitals in California from 2005 through 2011 with a diagnosis of ischemic stroke (defined as ICD-9-CM codes 433.x1, 434.x1, or 436 in any diagnosis code position) or TIA (ICD-9-CM code 435 in the primary diagnosis position). Our primary outcome was a subsequent hospitalization within 14 days with any diagnosis of IE (ICD-9-CM code 391.1 or 421.x in any position). Patients with a diagnosis of IE before or at the time of their first stroke or TIA were excluded. To target patients discharged without conclusive blood culture results, only patients discharged directly from the ED or within 2 days of admission were included. A subgroup analysis was performed in patients diagnosed with TIA and discharged home from the ED.

Results:
Among 172,666 patients discharged with stroke or TIA, 24 were subsequently hospitalized for IE, equating to a readmission rate of 1.4 per 10,000 (95% CI, 0.8-2.0 per 10,000). Subgroup analysis of 39,019 patients diagnosed with TIA and discharged home from the ED revealed a readmission rate of 0.8 per 10,000 (95% CI, 0.1-1.6 per 10,000). Multiple logistic regression identified valvular disease (OR, 7.0; 95% CI, 2.9-17.2), chronic kidney disease (OR, 3.7; 95% CI, 1.3-10.4), and possibly drug abuse (OR, 5.0; 95% CI, 0.7-38.3) as risk factors for readmission with IE after discharge for stroke or TIA.

Conclusions:
In a cohort of patients with acute cerebral ischemia discharged before blood culture results could have been available, the rate of subsequent IE was negligible. These findings argue against the liberal use of blood cultures in the routine evaluation of ischemic stroke or TIA.
Abstract T P18: Development of A SPECT-Based Objective Evaluating System for Therapeutic Effect of Acute Endovascular Therapy
Authors: Hirano Teruyuki , Watanabe Masaki , Kai Yutaka , Kawano Hiroyuki , Yonehara Toshiro
Published: March 2022

Background:
and purpose Endovascular therapies (EVT) are increasingly preformed among patients with acute ischemic stroke in whom alteplase failed to recanalize or contraindicated. However, it is difficult to prove its efficacy by a randomized controlled study. Thus, we developed a SPECT-based objective evaluating system using a relative threshold value of cerebral blood flow (CBF) measured within the first 6 hours of onset.

Methods:
Between 2010 and 2012, 27 patients with supratentorial embolic stroke presented within 6 hours and contraindicated for intravenous rt-PA (16 men, 11 women, 74+/-12 years old, NIHSS median 19) were enrolled. After obtaining informed consent, all patients’ pre-treatment CBF was measured by 99mTc-HMPAO SPECT (tracer injection: median 361 min). All SPECT images were co-registered to individual FLAIR images and analyzed using the software developed for exclusive use (FusionViewer, Nihon Medi-Physics Co., Ltd, Japan). A predicted infarct size (x) was obtained 3-dimensionally as the sum of voxel sizes exhibiting <64% CBF of symmetrical voxel. Final infarct volume (y) was calculated on CT at 24 hours. A significant infarct size reduction was defined if final infarct volume was smaller than the lower 95% C.I. of the regression line [Y=0.8914X+3.742]. This study was approved by each IRB.

Results:
EVT was performed in 3 patients: 1 with localized intra-arterial thrombolysis (LIT), 1 with mechanical clot disruption (MCD) and 1 with LIT+MCD. A complete recanalization of M1/ M2 was obtained in 2 patients, while the other patient’s M1 recanalized partially. Median recanalization time was 5.1 (range 2.8~5.7) hours. All EVT patients had achieved significant infarct size reduction (predicted size: 121.9+/-47.1 cm3, final infarct size: 51.8+/-58.8 cm3). On the other hand, none of 24 patients without EVT showed significant infarct size reduction (predicted size: 97.2+/-74.6 cm3, final infarct size: 118.3+/-115.1 cm3).

Conclusion:
We confirmed the significant infarct size reduction obtained by EVT. This CBF based surrogate measure could be applied to the evaluation of various interventional therapies.
Abstract T P182: Post-tPA ICH: INSTINCT Community Hospitals vs Pooled Analysis Data
Authors: Hume Benjamin D , Zahuranec Darin B , Morgenstern Lewis B , Sozener Cemal B , Meurer William J , Scott Phillip A
Published: March 2022

Background:
The threat of ICH limits community physician use of tPA in stroke. Only the PH2 subtype, however, independently causes clinical deterioration. We explored ICH characteristics in the community-based INSTINCT trial and compared PH2 incidence rates in INSTINCT to the pooled analysis (PA) of the ECASS, ATLANTIS, NINDS and EPITHET trials.

Methods:
Secondary analysis of tPA-treated patients in the INSTINCT trial, a prospective, cluster-randomized, controlled trial conducted at 24 randomly selected Michigan community hospitals. Medical records of all tPA-treated strokes from 2007 to 2010 were initially reviewed by an independent physician panel to identify any evidence of possible ICH. In a second stage, 2 vascular neurologists, blinded to clinical data, independently categorized each possible ICH using ECASS criteria. Disagreements resolved by consensus. All images within 72h post-tPA were reviewed, with classification based on the most severe category. Data from pooled subjects with OTT of ≤180 minutes served as a historical control in the comparison. IRB approved.

Results:
Neuroimaging was obtained from 23 of 24 INSTINCT sites, with 462 tPA-treated subjects. 85 (18.4%) were identified at initial review as a possible ICH. 82/85 (96%) had post-treatment neuroimaging available. At second-stage review, 19 had no identified hemorrhage, leaving 63/462 (13.6%) with an ICH. ICH subtype is presented in Table 1. In the PA cohort, 464 tPA-treated subjects had OTT ≤ 180 minutes. 161 (34.7%; 95% CI 30.5, 39.1) had an ICH, with 22 (4.7%; 95% CI 3.1%, 7.1%) identified as PH2. In the comparison, the difference did not reach significance (1.1%; 95% CI -1.6%, 3.8%; p = 0.42).

Conclusions:
The overall INSTINCT ICH rate was low. Incidence of PH2 was not different from rates reported by investigators in large clinical research trials. This supports the safety of community treatment of stroke.
Abstract T P183: Transient Neurological Symptoms with MRI Evidence of Infarction in an Emergency Department Observation Unit
Authors: Siket Matthew S , Silver Brian , Seigel Todd A , Paolucci Gino , Pezzullo John A , Rogg Jeffrey , Gibbs Frantz J , Merck Lisa H
Published: March 2022

Background:
Transient symptoms with infarction (TSI) is distinguished from transient ischemic attack (TIA) by the presence of diffusion-weighted imaging (DWI) lesions on MRI. We report a series of patients with DWI lesions identified in an emergency department observation unit (EDOU) TIA protocol.

Methods:
Patients were treated in the ED of a tertiary care center (annual census=100,000 visits). In the first 3 months of operation of an EDOU for TIA, 50 patients met inclusion criteria of sudden/transient neurological deficit in the absence of known metabolic or cardiac source. Patients were excluded from the study if they demonstrated: persistent or stuttering deficits; fever >100.4F, heart rate <60 or >100 bpm; SBP >180 or <100mmHg; pulse ox <93%; or positive CT. Evaluation included: laboratory analyses; CT/MRI/MRA of the head/neck; EKG; echocardiogram, and neurology consult. MR data (ED 1.5T MR unit) include: DWI, ADC, GRE, and T2FLAIR images. Patients with TSI, were identified by the presence of 1 or more DWI bright and ADC dark lesions on ED MRI. All patients completed CT and MR imaging within < 24 hours of admission. This study was approved by the hospital IRB.

Results:
TSI was identified in 10/50 EDOU patients (Mdn age 72.5, ABCD2 score 5). Two patients demonstrated infarcts in multiple vascular territories. Table 1 illustrates patient demographics, comorbidities, presentations, and outcome. Fifty percent of TSI patients were admitted from EDOU, 3 patients returned to the ED within 30 days , and no 30 day distinct recurrent events, such as recurrent stroke were identified.

Conclusions:
EDOU for TIA including DW-MRI resulted in TSI diagnosis in 20% of patients. In the TSI cases identified, infarct locations were heterogeneous; vascular and/or cardiac etiology must be considered. Longitudinal analysis is recommended to further assess the relationship between presentation, TSI risk, risk of recurrent stroke, and need for hospital admission.
Abstract T P185: Effectiveness Of A Telestroke System In A Metropolitan Area: A Prospective Cohort Study. The Madrid Telestroke Project
Authors: Martinez-Sanchez Patricia , Alonso de Leciñana María , Miralles-Martínez Ambrosio , Huertas-Gonzalez Nuria , Martín-Martínez Alfonso , Correas-Callero Elisa , Sanz de Barros Rosa , Domingo-García Julio , Serrano-López Soledad , Fuentes Blanca , Masjuan Jaime , Ruiz-Ares Gerardo , Martinez-Martinez Marta , Sanz-Cuesta Borja E , Cruz-Herranz Andrés , Díez-Tejedor Exuperio
Published: March 2022

Introduction:
our objective was to evaluate the efficacy of a Telestroke system, in terms of an increase in the number of patients treated with intravenous (IV) thrombolysis and a shorter door-to-needle time, in the metropolitan area of Madrid, Spain.

Methods:
prospective observational cohort study: 1) cohort exposed to Telestroke: acute ischemic stroke patients attended at Infanta Sofia University Hospital (community hospital) connected by Telestroke with the Stroke Center at La Paz University Hospital; 2) Non-exposed cohort: acute stroke patients who are attended at Severo Ochoa University Hospital (community hospital) connected by phone with the Stroke Center at Ramon y Cajal University Hospital. The number of patient attended, number of IV thrombolysis, times used (min), and the number of unnecessary transfers were recorded. We analyzed the first two years of the Telestroke (March 2010-March 2013).

Results:
in the Telestroke cohort the system was activated in 44 patients, being stroke code in 30 cases. In the non-exposed cohort 29 phone calls were made, being stroke code in 27 cases. In the Telestroke cohort, IV thrombolysis were administrated in 66.43% (19/30) of patients whereas in the non-exposed only 37% (10/27) received this treatment (p = 0,047). The door-to-needle time was shorter in Telestroke cohort than in the non-exposed cohort (mean (SD), 76.9 (33.3) vs. 132.7 (62.5), p = 0,022). In addition, there were fewer unnecessary secondary transfers in the Telestroke cohort (4% vs. 22.2%, P NS).

Conclusion:
the implementation of a Telestroke system in a metropolitan area is effective, increasing the number of IV thrombolysis and reducing the door-to-needle times.
Abstract T P186: "I Think It's a Stroke" - An Analysis of 9-1-1 Calls
Authors: Mathew Subin , Corado Carlos , Masor Minna , Song Sarah , Markul Eddie , Stein-Spencer Leslee , Richards Christopher , Albarran Frank , O'Neill Kathleen , Aggarwal Neelum , Prabhakaran Shyam
Published: March 2022

Background and objective:
Immediate access to emergency medical services (EMS) is critical in stroke. Correct dispatcher diagnosis may be influenced by caller recognition of stroke symptoms. In a study of 9-1-1 calls, we hypothesized that the word "stroke" is infrequently used by EMS callers when reporting strokes.

Methods:
From 3 hospitals, we identified 62 patients with confirmed stroke who arrived by EMS during the period of January - June 2013 and analyzed the 9-1-1 audio recordings. We used an evaluation form to identify words used to describe stroke symptoms by the callers. We compared the association between dispatcher diagnosis and caller use of “stroke” and call duration between those that used “stroke” versus to those that did not.

Results:
Of the 62 patients in the study, "stroke" was mentioned by 20 (32.3%) callers. The average duration of 9-1-1 calls was 55 seconds (IQR 40-78 seconds) and did not differ in calls that used “stroke” vs. those that did not (56 vs. 54 seconds; p=0.47). The dispatcher suspected stroke in 20 cases (32.3%) of which 18 were instances where the caller used the word “stroke” (p<0.001); in 2 cases, the caller used “stroke” and dispatcher did not while in 2 others the dispatcher suspected stroke but the caller did not. Other symptoms reported were altered consciousness/confusion (24.2%), sudden weakness (22.6%), fall (17.7%), speech disturbance (16.2%), difficulty in balance or dizziness (16.2%), and numbness (11.3%). Atypical symptoms like chest pain, backache, depression, erratic heartbeat, and abdominal pain were noted by 27.4% of callers. Weakness (p=0.048) was significantly associated with use of “stroke” while altered consciousness/confusion (p=0.006) and atypical symptoms (p=0.047) were more common in calls that did not mention “stroke”.

Conclusion:
The word "stroke" was used by only one-third of the EMS callers. The most common reported symptom that correlated with use of the word “stroke” was weakness. Use of the word “stroke” by callers was strongly associated with dispatcher diagnosis of stroke. Effective educational intervention with emphasis on communicating stroke symptoms and indicating stroke may help facilitate immediate and correct action by the EMS.
Abstract T P191: Emergent Management of Acute Retinal Ischemia
Authors: Schlick Konrad H , Hemmen Thomas M , Meyer Brett C
Published: March 2022

Background:
Retinal artery occlusion (RAO) is characterized by acute monocular visual loss (AMVL). It is unclear how intravenous tissue-type plasminogen activator (IV tPA) affects this stroke subset. Other interventions have been explored, but clear benefit of these has yet to be demonstrated. Given the emergent nature of RAO, and absent uniform guidelines, we investigated the incidence of and approach to management of RAO at our institution.

Methods:
We retrospectively reviewed medical records at the University of California, San Diego from 1992 through December 2012. Charts were retrieved via the ICD-9 codes 362.30-362.37 (retinal vascular occlusion). We excluded patients with monocular visual loss for more than 24 hours before presentation, spontaneous symptom resolution, traumatic visual loss, and patients with other associated acute neurologic symptoms. We captured time from presentation to initial physician encounter, time to consultant evaluation, consultant specialty, and whether time was <4.5 hours since last known well.

Results:
Of 132 patient charts reviewed, 111 were excluded as per criteria above (>24 hours = 55, spontaneous resolution = 50, trauma = 2, other symptoms = 4). We identified 16 patients with AMVL: 11 with central RAO, 2 with branch RAO, 1 with temporal arteritis, and 1 with nonarteritic anterior ischemic optic neuropathy. Ophthalmology was consulted first in 12, Neurology and Interventional Radiology (IR) in 2 patients each. Mean time from presentation to consultant evaluation was 282 minutes; for Ophthalmology 308 minutes, for Neurology 90 minutes and for IR 315 minutes. Five patients presented within 4.5 hours from their last known well time; one received IV tPA.

Conclusion:
Acute central RAO is uncommon. Ophthalmology is most frequently consulted for RAO, but without a designated acute treatment plan, most patients are seen relatively late. Future studies must include predefined treatment and faster assessment algorithms and include multiple study centers to recruit patients.
Abstract T P193: Impact of Observing TIA Patients in a Clinical Decision Unit
Authors: Nair Deepak , Gardner Joanna , MacGregor Scott , McNeil Clayton , Gonia Linda , Beck Judi , Swanson-Devlin Teresa , Jahnel Jan , Parker Sarah , Talkad Arun , Wang David
Published: March 2022

Background:
TIA carries a high risk of early stroke. National guidelines recommend that TIA cases should have rapid work up, ideally within 24 hours. Hospitalization is recommended when rapid outpatient work-up is not possible. As a result, most TIA patients are managed in the hospital. However, recent literature supports the use of observation in the Emergency Department for testing and monitoring of TIA patients. Here, we review the effects of our protocol for the observation of TIA cases in a Clinical Decision Unit (CDU) at our Comprehensive Stroke Center (CSC).

Methods:
Retrospectively, we reviewed the charts of all TIA cases, from one year prior to the use of a CDU protocol, to one year after its use. Patients were identified by billing codes, using our informatics system. Data on location of care, final diagnosis, cost of care, contribution margin, admission rate, and imaging test was collected and analyzed. Descriptive and analytical statistics were used to compare groups.

Results:
From May 2011 to May 2013, 400 suspected TIA cases were seen. Prior to the initiation of our protocol, 209 TIA patients were hospitalized. After the protocol, 191 patients were seen, with 85 patients seen in the CDU and 106 patients being admitted. The inpatients were mostly cases transferred to our CSC from regional facilities. Of the 85 CDU cases, 51 had a final diagnosis of TIA, 7 had confirmed strokes, 25 were non-cerebrovascular, and 2 were transient global amnesia. From the CDU, 20 patients were admitted, due to confirmation of stroke, recurrence of symptoms, or need for urgent intervention. Over two thirds of all patients underwent MRI/MRA for neuroimaging; the rest had non-contrast CT and carotid ultrasound. Since the start of the TIA protocol, the direct cost of care per case was $453.65 less (p=0.02) in the CDU cases. During the same time period, there was no significant difference in the contribution margin between the CDU and inpatient groups.

Conclusion:
Given the high risk for early stroke after TIA, early evaluation and monitoring remains imperative. Our results are similar to recent literature, showing that similar management can be provided for less cost and similar clinical outcomes. Larger studies are necessary to determine the overall financial impact of such programs.
Abstract T P194: Clinical Use of Telemedicine for Acute Stroke Care in a Regional Area: Findings From the Victorian Stroke Telemedicine (VST) Project
Authors: Bladin Christopher , Moloczij Natasha , Dewey Helen , Hand Peter , Gerraty Richard , Denisenko Sonia , Ermel Sharan , Cadilhac Dominique
Published: March 2022

Background:
Telemedicine systems can facilitate evidence-based care for patients with stroke, but are rarely used in rural Australia.

Objective:
We assessed the hypothesis that a stroke telemedicine program could increase stroke thrombolysis and improve the timeliness of diagnosis and investigation of stroke.

Methods:
The finalised Victorian Stroke Telemedicine (VST) protocol was implemented at one site in regional Australia from October 2011 to October 2012. All patients who present to the Emergency Department (ED) within 4.5 hours of stroke onset, who were aged 18 years or older, and had suspected stroke symptoms, were eligible for a telemedicine consultation. Clinical data was collected for stroke patients who presented within 4.5 hours of symptom onset one year prior to implementation (baseline) and during the one year VST implementation phase.

Results:
For all admitted strokes during VST (October 2011 - October 2012), stroke thrombolysis increased from 8% to 13% compared to pre-VST data. For those patients who arrive to the ED within 4.5 hours, analysis was based on small groups (baseline n=58; VST n=62), which limited ability to detect statistically significant results. However, there was evidence of clinically important trends, such as a 29 minute reduction in door-to-CT scan from baseline [median 63, IQR 29-103] to VST [34, IQR 20-58, p=.006]. Stroke onset-to-needle time was quicker by 45 minutes after VST implementation [173, IQR 148-234, p=.108]. There was a 21% reduction in hospital transfers (p<0.005). Overall, it was estimated that there was a reduction in three years of disability adjusted life years (DALY’s) for thrombolysed patients.

Conclusion:
The VST program has enhanced thrombolysis delivery and timeliness of associated clinical investigations and decisions in a regional emergency department.