bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP516: Mobile Health mHealth for Secondary Stroke Prevention is Feasible and Effective
Authors: Anderson Jane A , Kimmel Barbara , Tang Xiaohui , Ovalle Anette , Ifeorah Chizoba , Gina Evans , Nwangwa Doris , Kent Thomas A
Published: January 2019

Background:
Evidence indicates inadequate access to secondary stroke prevention (SSP) in rural and poor urban areas. While self-management support (SMS) soon after stroke results in improvements, the best mode of delivery and its use in underserved populations is understudied.

Methods:
A pre/post repeated measures design was applied to determine feasibility and effectiveness of mHealth to deliver SMS to stroke survivors in community based urban clinics and in rural South Texas. Adults with stroke and two or more uncontrolled stroke risk factors were eligible. The telehealth SMS program, Video-teleconference - Self-management TO Prevent stroke (V-STOP) was delivered by trained staff on a video teleconferencing mobile application (see Table 1). Participants received up to 3 stroke follow-up clinic visits and 3 group SMS sessions at home on their mobile device. Primary outcomes were feasibility (attendance and satisfaction); blood pressure, disability, psychosocial measures, and stroke knowledge. Paired t-test was used to determine improvement in outcomes at baseline, 6, 12, 18 weeks.

Results:
V-STOP was delivered using mHealth to 66 participants over 1 year. Mean age: 57, 42% female, 17% Black and 62% Hispanic: annual income of less than $25,000 (54%) and no health insurance (63%). Attendance rate was 40% for all 6 sessions. Satisfaction with the program and mHealth delivery was high, mean score of 4.88 out of 5. Improvements from baseline to 18 weeks were observed in systolic blood pressure, mean reduction 19 mmHg, (
p
=0.015); stroke knowledge, (
p
= 0.001); self-efficacy, (
p
=0.004); exercise (
p
=0.03); activity limitations (
p
=0.001); anxiety (
p
=0.025); disability (
p
=0.024).

Conclusions:
Implementation of SMS using mHealth is feasible for SSP among medically underserved stroke survivors. mHealth increases post stroke follow-up and helps stroke survivors improve risk factors.
Abstract TP517: Characteristics and Outcomes in Patients With Atrial Fibrillation (af) Receiving Direct Oral Anticoagulants (doacs) in off-Label Dose
Authors: Vaughan Sarrazin Mary S , Briasoulis Alexandros , Leira Enrique C
Published: January 2019

Objective:
We evaluated adherence to FDA-approved dosing criteria for patients with AF who initiated dabigatran and rivaroxaban, and the impact of off-label dosing on ischemic stroke and bleeding events.

Methods:
We identified 17,622 and 37,452 Humana Medicare beneficiaries age >=65 years with AF who initiated dabigatran or rivaroxaban, respectively, during 2010-2016. Patients were excluded if they had pulmonary embolism, deep vein thrombosis, or underwent hip surgery within the previous 6 weeks, or were not enrolled in Humana Medicare for at least 1 year prior to initiating the index drug. Stroke, major bleeding, and medication termination in patients who were either ‘potentially over-dosed’ (i.e., receive the standard dose but were eligible for low dose), or ‘potentially under-dosed’ (i.e., received the low dose but were not eligible for low dose) were identified. Multivariable methods controlled for differences in characteristics of patients prescribed low and standard dose within eligibility category.

Results:
Overall, 1734 (9%) and 10,045 (27%) of patients who received dabigatran and rivaroxaban met criteria for low dose, respectively. Of those, 1,161 (67%) and 4,868 (48%) received the standard dose (“potentially over-dosed”). In contrast, 2154 (13%) and 6,480 (23%) of patients eligible for standard dose dabigatran and rivaroxaban received a lower dose, respectively (“potentially under-dosed”). Increased age, female sex, black race, low weight, bleeding history, and heart failure were associated with receipt of lower than recommended dose for patients receiving dabigatran or rivaroxaban. There was modest evidence of increased risk of intracranial hemorrhage in patients overdosed with dabigatran (p=0.07). Among rivaroxaban users, medication termination was significantly higher for rivaroxaban users who were potentially overdosed (Hazard Ratio [HR] = 1.05; p=0.04); and significantly lower among rivaroxaban users who were potentially underdosed (HR = 0.96; p=0.03). No other significant outcomes differences were noted.

Conclusions:
Significant proportions of patients receive off-label dosing of dabigatran and rivaroxaban. Nevertheless, we found little evidence of significant impact on clinical outcomes.
Abstract TP519: The Effect of Different Oral Anticoagulants on Vascular Outcomes in Stroke With Atrial Fibrillation: A Real-world Data
Authors: Seo Woo-Keun , Kim Joon-Tae , Chung Jong-Won , Song Tae-Jin , Kim Yong-Jae , Kim Bum Joon , Heo Sung Hyuk , Jung Jin-Man , Oh Kyungmi , Kim Chi Kyung , Yu Sungwook , Park Kwang Yeol , Kim Jeong-Min , Park Jong-Ho , Choi Jay Chol , Park Man-Seok , Choi Kang-Ho , Hwang Yang-Ha , Bang Oh Young , Kim Geong-Moon
Published: January 2019

Background and Purpose:
Little is known about the different effect of outcomes and factors associated with vascular outcomes in stroke patients with atrial fibrillation in real world practice setting especially in Korea. In this study, we investigated the effect of each oral anticoagulants on vascular outcomes using K-ATTENTION (Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts) study.

Methods:
Consecutive data of acute stroke patients with atrial fibrillation were collected from 11 centers in Korea from January 2013 to December 2015. Eligibility of inclusion was acute stroke within 7 days from the onset of stroke and diagnosis of non-valvular or valvular atrial fibrillation. Vascular outcomes included ischemic stroke, hemorrhagic stroke, death of any cause, and major adverse cerebro/cardiovascular events (MACE). To describe the effect of each oral anticoagulants on vascular outcomes, we performed time-dependent Cox’s regression analyses with the class of oral anticoagulant as a time dependent covariate. For stroke, hemorrhagic stroke, and any stroke, death was considered as competing risk.

Results:
Among 3213 stroke patients included in K-ATTENTION study, a total 3033 stroke patients (mean age 73.45 ± 9.93 years old, female 48.5%) were included. Mean CHA2DS2-VASc score was 4.89 ± 1.37. During the study period, a total of 161 ischemic strokes, 46 hemorrhagic strokes, 199 any strokes, 556 death and 720 MACE were captured. Time-dependent Cox’s regression analysis revealed that use of oral anticoagulants [vitamin K antagonist (VKA), dabigatran, rivaroxaban, or apixaban] was associated with significantly lower risk of death and MACE compared with no oral anticoagulants use. Although, there was no difference among oral anticoagulants for ischemic stroke, hemorrhagic stroke, or any stroke when compared with no oral anticoagulants, dabigatran showed a trend of reduced risk of any stroke (HR 0.48, 95%CI 0.23 - 1.01, p = 0.0545).

Conclusion:
This real-world data revealed that the use of oral anticoagulants was associated with the reduced risk of MACE and death. However, for ischemic stroke and hemorrhagic stroke, the results were not conclusive. Dabigatran showed a trend of reduced risk of any stroke.
Abstract TP523: A Randomized Controlled Trial Evaluating the Effectiveness of Pretreatment With the Free Radical Scavenger, Edaravone, Before Carotid Artery Stenting
Authors: Kunieda Takenobu , Miyake Kosuke , Sakamoto Hiroki , Nakamura Masataka , Kaneko Satoshi , Kusaka Hirofumi
Published: January 2019

Objective:
Cerebral hyperperfusion syndrome (CHS) is likely to occur after carotid revascularization in patients with severe hemodynamic failure. It is important to control cerebral hyperperfusion phenomenon (CHP) to prevent the development of CHS. To determine whether pretreatment with the free radical scavenger, edaravone, could prevent the onset of CHP after carotid artery stenting (CAS).

Methods:
Patients with severe carotid artery stenosis were randomized to receive either pretreatment with edaravone immediately before CAS or the common CAS procedure. Cerebral blood flow (CBF) was assessed in the affected middle cerebral artery (MCA) region and in the ipsilateral cerebellum using single-photon emission computed tomography (SPECT) of the brain before and immediately after CAS. Cerebrovascular reactivity (CVR) in the MCA region was also evaluated using the stereotactic extraction estimation based on the Japanese extracranial-intracranial bypass trial (SEE-JET) program and classified as reduced when it was <18.4%. The ratio of MCA to cerebellar activity was defined as the CBF in the affected MCA region divided by the CBF in the ipsilateral cerebellar hemisphere. CHP was defined as an increase in the ratio of MCA to cerebellar activity after CAS ≥10%.

Results:
Of the 52 patients recruited in this study, 26 were assigned to the pretreatment with edaravone group and 26 were assigned to the treatment as the usual group. Eleven patients showed reduced CVR. CHP occurred in 0 of 6 patients in the edaravone group and in 4 of 5 patients in the usual group (0% vs. 80%, p=0.0152). However, there was no significant difference in the overall patient population between the two groups.

Conclusion:
Pretreatment with edaravone could reduce the incidence of CHP after CAS in patients with reduced CVR.
Abstract TP526: Can Electronic Alerts Improve Oral Anticoagulant Use in Elderly Atrial Fibrillation Patients?
Authors: Polineni Sai , Kelly Adam , Prabhakaran Shyam , Saposnik Gustavo , Boerman Christine , Lee Lilly , Malik Amer , Chaturvedi Seemant
Published: January 2019

Background:
Oral anticoagulant (OAC) for atrial fibrillation use remains underutilized despite evidence in favor of its utility. In a three-center study examining the efficacy of a technological intervention to improve OAC use, two sites were randomly selected to incorporate an embedded alert in the electronic health record (EHR) while the third site provided usual care. At the intervention sites, the EHR calculated each patient’s CHA
2
DS
2
-VASc score and alerted the clinician when OAC therapy was recommended. We aimed to investigate whether this system increased OAC use in elderly patients.

Methods:
Patient medication was tracked at the time of hospitalization, discharge, and within 30 days of discharge. Patients were categorized by age and study arm to assess medication use at last known follow-up via the Chi Square and Fisher’s Exact tests.

Results:
The control site contained 152 patients, 65 being 75+ years of age, while the two intervention sites contained 164 patients, also with 65 patients who were 75+ years of age. Those aged 75+ show statistically significant proclivity for prior strokes (<0.001), coronary artery disease (0.04), hypertension (0.004), and lower rate of diagnosed obstructive sleep apnea (0.001). Furthermore, they tend to be females (53.9%). The median CHA
2
DS
2
-VASC score was 4 in the elderly group and 2 in the younger group (p<0.001). Use of warfarin or OACs in these two populations did not vary at baseline. At follow-up, use of warfarin was statistically significantly higher in those 75+ (21.9% vs 12.8%, p-value=0.04) but not when partitioned by study arm or when all OAC use was considered. There was no difference in OAC use between the intervention and control sites (43% vs. 54% p=0.22).

Conclusions:
Despite increased CHA
2
DS
2
-VASc scores, we did not demonstrate the benefit of electronic alerts among elderly AF patients. Additional research is needed regarding methods to overcome therapeutic inertia in this area. Study support: Boehringer-Ingelheim
Abstract TP527: Baseline Physical Activity Profiles in CREST-2 Trial Participants
Authors: Chaturvedi Seemant , Turan Tanya , Gordon Neil F , Voeks Jenifer H , Chimowitz Marc I , Howard Virginia J , Howard George , Barrett Kevin M , Brown Robert D , Lazar Ronald , Moore Wesley S , Moy Claudia S , Roubin Gary S , Demaerschalk Bart M , Foster Malcolm , Wechsler Lawrence , Lal Brajesh K , Meschia James F , Brott Thomas G
Published: January 2019

Background:
The importance of physical activity in preventing major vascular events has received increased attention in the past decade. Due to the inclusion of the INTERVENT lifestyle modification program, the CREST2 trial provides a unique opportunity to study physical activity profiles in patients with severe asymptomatic extracranial carotid stenosis.

Hypothesis:
Based on data from a trial of intracranial stenosis patients, we aimed to evaluate the hypothesis that <40% of carotid stenosis subjects will have optimal physical activity levels. We also assessed key subgroups to determine patterns of physical activity.

Methods:
We analyzed 1087 CREST2 participants with baseline data on physical activity. The Physician-based Assessment and Counseling for Exercise (PACE) score is recorded for each patient and dichotomized as “in target” (4-8 points) or “out of target” (<4 points). A PACE score of <4 indicates a subject who does not engage in regular exercise. Results are analyzed for the entire trial. Chi square testing and t-tests were performed for evaluation of subgroup differences.

Results:
The mean age of the study population is 69.5±7.8 years (60% male). The median PACE score at baseline is 4.0 (mean 3.8±2.1; IQR 2 to 6). The Table shows baseline characteristics of patients by mean PACE score. Being male, not having diabetes mellitus, having a body mass index <30kg/m2, being a non-smoker, and not having a history of peripheral arterial disease were associated with significantly higher mean PACE scores (P<0.01).

Conclusions:
We have defined several patient groups with asymptomatic carotid stenosis that have suboptimal physical activity. These results provide opportunities for targeted efforts to improve primary stroke prevention. These baseline data will also allow investigators to determine if trial involvement and the INTERVENT program leads to improvement in the level of physical activity.
Abstract TP53: Intravenous Thrombolysis Preceding Mechanical Thrombectomy is Associated With Reduced Procedure Time and Lower Proportion of Fibrin in Retrieved Thrombus
Authors: Maekawa Kota , Shibata Masunari , Kobayashi Kazuto , Sano Takanori , Naito Yutaka , Yabana Tadashi , Miya Fumitaka
Published: January 2019

Introduction:
Previous studies showed that recombinant tissue plasminogen activator (rt-PA) administration preceding mechanical thrombectomy reduced puncture to recanalization times. Fibrin rich thrombus was associated with extended puncture to recanalization times.

Hypothesis:
rt-PA administration preceding mechanical thrombectomy is associated with reduced procedure time and low proportion of fibrin in retrieved thrombus

Methods:
All retrieved thrombus was stained with hematoxylin-eosin. Embolic debris underwent quantitative analysis to quantify three main components: red blood cells, white blood cells and fibrin, by color based segmentation. Patients were assingned to receive either mechanical thrombectomy with rt-PA (IVTMT group) or mechanical thrombectomy alone (MT group). Considering influence by stroke etiology, patients with non-cardioembolism were excluded.

Results:
From August 2015 to March 2018, 173 consecutive patients were treated in our hospital by MT for acute large vessel occlusion. Histopathologic analysis of retrieved thrombus from 90 patients with acute stroke. 70 patients with cardioembolism were included. Patients were assigned to IVTMT group (n=29) or MT group (n=41). Onset to recanalization time was significantly shorter in IVTMT group than in MT group (median 167 vs 455 minutes; p < 0.01). The other clinical backgrounds were not significantly different. IVTMT group had shorter puncture to recanalization time (median 45 vs 63 minutes; p=0.02), shorter door to recanalization time (median 91 vs 120 minutes; p=0.02). IVTMT group had lower proportion of fibrin in retrieved thrombus (59.6% vs 77.5%, p=0.03).

Conclusion:
Intravenous thrombolysis preceding mechanical thrombectomy is significantly associated with reduced procedure time and lower proportion of fibrin in retrieved thrombus.
Abstract TP537: Jugular Bulb Microdialysis in Subarachnoid Hemorrhage
Authors: Forsse Axel , Nielsen Troels H , Nordström Carl-Henrik , Poulsen Frantz R
Published: January 2019

Introduction:
Metabolic perturbations are common in patients with subarachnoid hemorrhage (SAH) and contribute to patient outcome. Cerebral microdialysis (CMD), used for monitoring of poor grade SAH patients, is intracranial invasive and highly regional, depending on proximity to lesions. Microdialysis of jugular bulb venous drainage has not been attempted in this patient group and it may give a measure of global cerebral metabolism detecting critical events potentially missed by regional monitoring.

Methods:
Adult SAH patients were included at admission when local clinical guidelines prompted extended multimodal neuromonitoring (impaired consciousness and poor grade SAH). Patients were monitored using non-dominant frontal CMD combined with an intracranial pressure (ICP) and brain oxygen tension (PbtO
2
) probe in a double lumen bolt (Raumedic®) as well as dominant jugular bulb microdialysis for a mean period of 5 days. Jugular bulb lactate/pyruvate ratio (LPR) and intracranial derived measurements were analysed for correlation. 6 month modified Rankin scale (mRs) was assessed.

Results:
Twelve patients were included (mean age 62 years, mean mRs 3.7). There were no complications related to jugular bulb access. Of 1218 monitoring hours, 131 displayed elevated jugular bulb LPR (>20), 133 elevated ICP (>20 mmHg) and 287 reduced PbtO
2
(<20 mmHg). Periods of co-variation were seen in selected patients, but no significant correlations between jugular bulb LPR vs. cerebral LPR (r=-0.07, p=0.014), jugular bulb LPR vs. ICP (r=-0.03, p=0.72) or jugular bulb LPR vs. PbtO
2
(r=0.08, p=0.16) were found in Spearman analysis of critical periods. Concerning jugular LPR vs. mRs the study was underpowered (r=-0.36, p=0.27).

Conclusions:
Intracranial regional monitoring events were not mirrored in jugular bulb LPR and periods of metabolic perturbations seen in jugular bulb LPR passed without consistent indication from regional modalities. Metabolic disturbances are potentially missed by regional monitoring in SAH.
Abstract TP538: Dynamic of Microglial Polarization in Experimental Subarachnoid Hemorrhage
Authors: Wong George K , Zheng Vera , Poon Wai Sang , Lam Ping Kuen , He Zhigang
Published: January 2019

Introduction:
Subarachnoid hemorrhage (SAH) is a devastating stroke type. Microglia/Macrophage, in neuroinflammation response, are capable of classic M1 and alternative M2 polarization after activation. However, the profile of microglial activation was not well studied in SAH. In this study, we aimed to unravel the polarization-specific dynamic of microglia after SAH.

Methods:
Wild-type C57BL/6 mice and

Cx3cr1
GFP/GFP
Ccr2
RFP/RFP

mice were used and SAH was induced by endovascular perforation. The Immunohistochemistry and Immunofluorescence were employed to characterize the profile of microglia activation on day 1, day 3, day 5, day 10 (n=6-8).

Results:
Iba1-positive microglia accumulated significantly in the cortex adjacent to the bleeding site (CAPS) on day 1 and sustained to increase till the delayed phase in SAH. Microglial accumulation was also observed on motor cortex and hippocampus on the early phase. Immunofluorescence showed the CD16/32-positive M1-predominant phenotype appeared in 3 days, then gradually transformed into the CD206-positive M2 phenotype. The functionally microglial polarization advanced along with the morphological changes through ramified to amoeboid shape. The bipolar microglia appeared through the morphological transformation with the colocalization of M1/M2 markers. In addition, Ccr2 low expressed and Cx3Cr1 highly expressed (CCR2
-
/Cx3Cr1
+
) cells are observed on CAPS with a co-existing of a small group of CCR2
+
/Cx3Cr1
+
cell. The results suggested the preponderant microglial activation rather than the infiltrated macrophage.

Conclusions:
Microglia demonstrated a preponderant and early accumulation and this accumulation showed a centrifugal spreading through CAPS to remote motor cortex. Pro-inflammatory response occurred early and transform to the anti-inflammation on the delayed phase. The dynamic of microglial morphological changes and polarization implied the function-related neuroinflammatory response and pathophysiologic process of restoration upon the hemorrhage attack.
Abstract TP539: The Complement Protein C1q is Elevated Early in Cerebrospinal Fluid After Subarachnoid Hemorrhage but Decreased in Patients With Symptomatic Vasospasm
Authors: Geraghty Joseph R , Katz Eitan , Oparowski Matthew , Tate Alexander , Testai Fernando D
Published: January 2019

Introduction:
Neuroinflammation is common after subarachnoid hemorrhage (SAH). The complement protein C1q is a well-known inflammatory mediator that has emerged as a key player in neuroimmune synaptic alterations. In this study, we sought to evaluate changes in cerebrospinal fluid (CSF) C1q after SAH and its association with outcome and symptomatic vasospasm (sVS).

Methods:
Subjects with SAH were recruited from a regional referral center. Cases were eligible to participate if they had nontraumatic aneurysmal SAH and an external ventricular drain. Samples were obtained within 72 hours of symptom onset. Control subjects were those undergoing lumbar puncture with normal CSF and normal brain MRI. C1q levels were determined using commercially available ELISA, normalized by total CSF protein, and divided into tertiles. SAH subjects were prospectively followed through hospitalization and categorized into those with good outcome (Glasgow Outcome Scale, GOS, of 5) or poor outcome (GOS of 2-4). Patients were also further categorized into those with and without sVS, defined by the presence of arterial narrowing on angiography and neurological deterioration. The rates of patients with poor outcome and sVS in each C1q tertile were compared.

Results:
We analyzed the CSF of 29 SAH and 11 control patients. Mean age of SAH patients was higher than controls (53.2 vs. 42.0, p=0.03) while there were no sex differences across groups. Levels of C1q were elevated in SAH patients compared to controls (p=0.02). Within the SAH group, 7 (24%) were defined as good outcome while 22 (76%) were defined as poor outcome. Mean C1q levels were comparable between these two groups (p=0.61). Symptomatic vasospasm occurred in 18 (62%) SAH patients - 16 (89%) with poor outcome and 2 (11%) with good outcome. Patients with sVS had decreased levels of C1q compared to those without (p=0.03). The rate of poor outcome per tertile of C1q was 100%, 60%, and 70%, while the rate of sVS per tertile was 88%, 70%, and 40% of patients.

Conclusions:
The complement protein C1q is elevated in CSF of SAH patients and may contribute to early neuroinflammation. C1q levels also appear to be lower in patients who experience sVS, suggesting that elevated C1q may have a protective role in early SAH.
Abstract TP540: Effects of Stimulant Use on the Temporal Course of Vasospasm in Aneurysmal Subarachnoid Hemorrhage
Authors: Cheng Roger , Meisel Karl , Ko Nerissa
Published: January 2019

Background:
Comorbid use of stimulants (cocaine and amphetamines) has been associated with worse outcomes in aneurysmal SAH (aSAH), however its effect on the course of cerebral vasospasm (CV) and delayed cerebral ischemia (DCI) has not been consistently established. If stimulant use changes the temporal course of CV, an inexpensive toxicology screen could help to inform decisions on length of ICU stay or timing of more resource intensive monitoring tools such as conventional angiography (DSA).

Methods:
After IRB approval, data from an academic center encompassing 6/2012 and 10/2017 were retrospectively reviewed to identify adult patients who had 1) diagnosis of aSAH with known ictus, 2) vascular imaging and tox screen within 72 hours of ictus, and 3) imaging or transcranial Doppler (TCD) documentation of CV. Clinical trial enrollment or early transition to comfort care were exclusions. Standard clinical care for SAH was provided by a multidisciplinary team in a dedicated neuroscience ICU. By institutional protocol, patients receive at least one post-aneurysm exclusion DSA study and typically, surveillance for CV by TCD every weekday independent of clinical symptoms. This is supplemented by symptom triggered DSA/CTA/MRA. These reports were reviewed to establish the day of onset, duration, and peak severity (mild, moderate, severe) of CV. Baseline factors known to affect CV such as age, gender, and SAH grade were also collected. Statistical comparisons were done using Wilcoxon rank-sum and Student’s t-test.

Results:
40 patients met inclusion criteria, of which 8 (20%) were positive for stimulant use. There were no statistically significant differences between stimulant positive and negative groups with respect to age, gender, Hunt-Hess grade, modified Fisher score, or EVD placement. The stimulant positive group had an earlier onset of CV (day 3.4 vs 5.4, p=0.019) and higher severity (p=0.044), but non-significant difference in duration (5.2 vs 6.3 days, p=0.565). Rate of confirmed DCI by infarct on CT/MRI was the same (25%) in both groups.

Conclusion:
Stimulant use was associated with earlier onset and severity of vasospasm in this sample of aSAH patients. Further exploration with a larger population is warranted to better establish this relationship.
Abstract TP544: Differences in Ascending Reticular Activating Systems Between Persistent Vegetative and Minimally Conscious States Following Putaminal Hemorrhage
Authors: Chang Chul Hoon
Published: January 2019

Object:
Investigated differences in ascending reticular activating systems(ARAS) of persistent vegetative state(PVS) and minimally conscious states(MCS) following putaminal hemorrhage(PH)

Method:
17 patients with PH and classified them into PVS(7patients) and MCS(10patoents) groups. Eight parst of the ARAS were reconstructed: dorsal lower, ventral lower, whole upper, prefrontal cortex(PFC)-upper, premotor cortex-upper, primary motor cortex-upper, primary somatosensory cortex-upper, posterior parietal cortex-upper, ARAS. For each ARAS part, diffusion tensor tractography(DTT) paremeters(fractional anisotrophy(FA) and tract volume(TV)) were estimated.

Result:
The FA valvue did’t differ significantly among eight parts between the PVS and MCS groups (
p
> 0.05). The TV value of PFC-upper ARAS was significantly lower in PVS group. There were no other significant TV differences in other parts of the ARAS(
p
< 0.05).

Conclusion:
The sole difference between PVS and MCS patients following PH was decrement in neural fibers in PFC-upper ARAS in PVS patients group. Based on result, it appears that the prefrontal portion of the upper ARAS is critical area when discerning PVS nad MCS in patients with PH.

Key words:
ascending reticular activating systems, prefrontal cortex, diffusion tensor tractography, putaminal hemorrhage
Abstract TP545: Continuous Intravenous Tirofiban in Patient With Aneurysmal Subarachnoid Hemorrhage Requiring External Ventricular Drain and Ventriculoperitoneal Shunts
Authors: Dandapat Sudeepta , Zanaty Mario , Nakagawa Daichi , Guerrero Waldo , Asi Khaled , Limaye Kaustubh S , Al Kasab Sami , Ortega-Gutierrez Santiago , Samaniego Edgar , Hasan David M
Published: January 2019

Introduction:
Due to advancements in the field of endovascular neurosurgery, use of intracranial stenting and flow diversion (ISFD) in the treatment of acute aneurysmal subarachnoid hemorrhage (aSAH) is on the rise. ISFD requires dual antiplatelet therapy (DAPT), which poses a challenge when patients undergo placement of an external ventricular drain (EVD) or ventriculo-peritoneal-shunt (VPS). We describe our experience with the use of intravenous tirofiban in similar settings.

Methods:
Patients with aSAH between July 2017 and June 2018 requiring intravenous tirofiban for ISFD after EVD placement and subsequent VPS were included in our retrospective study. Patients were started on intravenous tirofiban at maintenance dose prior to IFSD and continued until transitioned to DAPT after removal of EVD with or without VPS. Intravenous tirofiban was held 4 hours prior to EVD removal/VPS placement and resumed 2 hours later followed by loading dose of DAPT. Patients were monitored in ICU and CT head obtained 24-hours after the procedure.

Results:
15 patients (mean age 55 years, 14 females and 1 male) with aSAH who required ISFD and were placed on intravenous tirofiban for 3-18 days. In total, 21 procedures were performed with placement of 16 EVDs (one patient had bilateral EVDs) and 5 VPS. Two patients had clinically asymptomatic small track hemorrhages and 1 patient had a retroperitoneal hemorrhage and thrombocytopenia. No thromboembolic complications were reported. We encountered an 18% risk of hemorrhages, which compares favorably to our previously published 22% risk of all hemorrhages with DAPT.

Conclusions:
The continuous infusion of tirofiban in patients with aSAH who require ISFD is feasible and has hemorrhagic complication rate similar to the use of DAPT.
Abstract TP548: Stent Retrievers as a Novel Treatment Tool for Refractory Cerebral Vasospasm
Authors: Su Sophie , Zanaty Mario , Sedora-Roman Neda , Pukenas Bryan , Favilla Christopher , Hasan David , Kung David
Published: January 2019

Introduction:
Cerebral vasospasm commonly contributes to morbidity in patients who survive aneurysmal subarachnoid hemorrhage. When vasospasm becomes refractory to medical management, endovascular treatment options include intraarterial (IA) vasodilator injections and/or balloon angioplasty. However, IA vasodilators often provide limited angiographic improvements and can cause secondary systemic hypotension. Limitations of balloon angioplasty include restricted use to proximal vessels, risk of rupture with balloon inflation, and temporary vessel occlusion.

Methods:
We report our initial experience on the use of stent retrievers for five cases of refractory vasospasm. After injecting IA nicardipine and noting minimal angiographic improvement, we deployed the stent retriever for two minutes before the stent was re-sheathed.

Results:
We show safe and successful angiographic resolution of vasospasm in all cases, with a representative angiography shown in Figure 1. Injection of the left vertebral artery shows vasospasm along the basilar (BA) and posterior cerebral arteries (PCA) (Fig 1A). Narrowing improves significantly after stent deployment in the left PCA and BA (Fig 1B). There were no procedural complications.

Conclusion:
Stent retrievers have several benefits over balloon angioplasty for treatment of vasospasm. Stent retrievers are non-occlusive, conform easily to the curvature of the vessel, and have a known, safe opening force that prevents vessel rupture. In contrast to balloon angioplasty, stent retrievers have limited surface interface with the lumen, theoretically resulting in less endothelial injury. Lastly, most endovascular surgeons have more technical experience with stent retrievers given its widespread use in mechanical thrombectomy. In summary, stent retrievers can be used as a facile, safe, and effective endovascular treatment and should be considered as one of the emerging therapies for refractory cerebral vasospasm.
Abstract TP551: The Safety and Utility of Steroids in Aneurysmal Subarachnoid Hemorrhage
Authors: Miller Malgorzata M , Mahta Ali , Mayasi Yunis , Yakhkind Aleksandra , Dakay Katarina B , Azher Idrees , Hannoun Anas , Barton Bruce , Wendell Linda C , Carandang Raphael A
Published: January 2019

Background:
Hydrocephalus is a common complication in patients with aneurysmal subarachnoid hemorrhage (aSAH) and is one of the predictors of poor outcome. Currently the only treatment modality for hydrocephalus is shunting; there is no known prophylactic therapy. Limited pre-clinical data suggest that anti-inflammatory effect of steroids could be used to prevent arachnoiditis and subarachnoid fibrosis after aSAH, which in turn may reduce the rate of hydrocephalus that requires shunting.

Methods:
A retrospective study of patients with aSAH admitted to two tertiary care centers from 2009 to 2017 was performed. Age, sex, hypertension, Glasgow coma scale [GCS], Hunt Hess [HH] grade, administration of steroids (dexamethasone [DXM], methylprednisolone [MTP] or none), presence of hydrocephalus and ventriculoperitoneal shunt (VPS) as well as occurrence of adverse events such as hyperglycemia, delirium and infection were recorded for each patient.

Results:
A total number of 288 patients were included. Mean age was 56.9±13.9 years, 186 (64.6%) patients were female and 145 (50.5%) patients had hypertension. Median GCS score was 14 (IQR 7-15) and median HH grade was 3 (IQR 2-4). 204 (71%) patients received DXM, 23 (8%) patients received MTP and 61 (21%) patients were not administered any steroids during hospital stay. Hydrocephalus was present in 114 (56.4%) patients who received DXM, 13 (56.5%) who received MTP and 37 (61.6%) who did not receive steroids (p>0.05; χ
2
-test). The incidence of VPS placement did not differ between the groups (p>0.05; χ
2
-test). Patients who received steroids were more likely to develop pneumonia (63 [31%] vs. 7 [31.8%] vs. 5 [8.2%] in DMX, MTP and no steroids group, respectively; p=0.008; χ
2
-test). Patients who received DXM (but not MTP) more frequently were treated for a urinary tract infection (48 [23.5%] vs. 6 [9.8%]; p=0.019; χ
2
-test). There was no difference in the ratio of hyperglycemia or delirium between the groups.

Conclusion:
Our results support the evidence that, although commonly used in clinical practice, steroids administered in patients with aSAH do not decrease the risk of developing hydrocephalus and subsequent VPS. In addition, steroids may increase the risk of infections such as pneumonia and urinary tract infection.
Abstract TP552: Race and Gender Differences in Mortality Due to Spontaneous Subarachnoid Hemorrhage
Authors: Rushworth David , Mathews Amber , Mandava Pitchaiah
Published: January 2019

Background and Aims:
Spontaneous subarachnoid hemorrhage (sSAH) is a rare stroke event with a relatively high rate of mortality. There are a number of risk factors, including gender and race, for sSAH. However, it is unclear whether these risk factors are associated with the age of mortality due to sSAH.

Methods:
We utilized the CDC Wonder dataset (wonder.cdc.gov) “Underlying Cause of Mortality 1999-2016” to query for sSAH mortality in named arterial distributions. Age, race and other demographic data from the entire United States was available. Statistical differences between populations of different races including Caucasian African American, Asian, or Native American or between genders were assessed using a Chi-squared test of independence and unpaired Student’s
t
tests.

Results:
Our analysis detected an association between race and age range of mortality due to sSAH (χ
2
= 414.00, df = 51,
p
-value = 1.6E-58). Further analyses revealed a younger age of mortality due to sSAH in males as compared to females, with an average age of mortality at 53.3 and 60.0 years old respectively (
p
< 0.0001). Notably, race differences were greater in females than in males, whereby black females exhibited the youngest age of mortality due to sSAH with an average age of mortality at 51.8 years as compared to 61.6 for non-black females (
p
< 0.0001).

Conclusion:
These findings suggest that underlying differences in race and gender have an effect on age of mortality due to sSAH.
Abstract TP553: Early Elevation of MicroRNA-15a is Associated With Development of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage
Authors: Kikkawa Yuichiro , Kamide Tomoya , Tabata Shinya , Takeda Junichi , Shibata Aoto , Kayahara Tomomichi , Matsuzawa Ryo , Kimura Tatsuki , Suzuki Kaima , Ikeda Toshiki , Kurita Hiroki
Published: January 2019

Backgrounds:
Delayed cerebral ischemia (DCI) is a major determinant of prognosis in patients with subarachnoid hemorrhage (SAH). However, little is known about the role of microRNAs (miRNAs) in the development of DCI after SAH. We investigated the expression profile of miRNAs and the chronological changes in the expression of microRNA-15a (miR-15a) in the plasma and cerebrospinal fluid (CSF) of SAH patients.

Methods:
Peripheral blood and CSF samples were collected from eight aneurysmal SAH patients and three controls without SAH. Exosomal miRNAs were isolated and subjected to microarray analysis with the 3D-gene miRNA microarray kit. The time course of the expression of miR-15a was analyzed using quantitative real-time PCR. Then, blood sample collected at day 1 and 5 from 17 SAH patients with DCI and 15 without DCI were analyzed using quantitative real-time PCR.

Results:
Microarray analysis demonstrated that 12 miRNAs including miR-15a were up- or down-regulated both in the CSF and plasma after SAH within three days. Quantitative real-time PCR revealed that miR-15a expression was significantly increased in both the CSF and plasma, with a peak around 3 to 5 days after SAH. Furthermore, the plasma level of miR-15a in patients with DCI was significantly elevated on day 5, while it remained unchanged in those without DCI.

Conclusions:
Our results suggest that an early increase in miR-15a may contribute to development of DCI after SAH.
Abstract TP56: Is Reperfusion Therapy Safe and Effective in Minor Stroke?
Authors: Suzuki Kentaro , Aoki Junya , Numao Shinichiro , Nishi Yuji , Takeshi Yuho , Kutsuna Akihito , Kanamaru Takuya , Suda Satoshi , Nishiyama Yasuhiro , Kimura Kazumi
Published: January 2019

Objective:
The efficacy and safety of intravenous thrombolysis (IVT) and endovascular therapy (EVT) in minor acute ischemic stroke patients is unclear. We investigated whether reperfusion therapy in minor stroke patients is effective and safe compared with patients treated with aspirin.

Methods:
We performed a retrospective, single center analysis in patients with NIHSS scores of 0 to 5 from September 1, 2014 to April 30, 2018. Patients within 4.5 hours from onset and pre modified rankin scale (mRS) 0-2 were enrolled into this study and divided into two groups; reperfusion therapy group and medical treatment group. Favorable outcomes were defined as mRS 0-2 at 3 month.

Results:
Of the 2405 ischemic stroke cases, 216 cases with minor neurological deficits were enrolled (age; 72 [62-80] and 144 [67%] men). Seventy six (36%) cases were performed reperfusion therapy. Neurological severity (NIHSS scores at admission) was higher (3.0±1.5 vs. 2.0±1.4, p<0.01) in reperfusion group. Age (71±12 vs 69±14, p=0.25), Men (51[65%] vs. 93[67%], p=0.77), onset to door time (2.0±1.5 vs 2.4±1.4, p=0.23), intracranial hemorrhage (7[9%] vs. 10[7%], p=0.79), symptomatic intracranial hemorrhage after therapy (1[1%] vs. 1[1%], p=1.00) were not different between 2 groups. At 90 days, Favorable outcomes (66[85%] vs. 114[83%], p=0.85) were not different. On multivariate analysis, reperfusion therapy was not associated with favorable outcome after adjustment by age and NIHSS score at admission (OR 1.63, CI 0.72-3.90, P=0.25).

Conclusions:
Reperfusion therapy in minor stroke might be safety, but not be more effective compared with aspirin therapy.
Abstract TP560: Cognitive Impairment Should Be an Independent Predictor of Poor Functional Outcome in Acute Minor Stroke
Authors: Nishimura Takuya
Published: January 2019

Objective:
The evaluation of cognitive status is not routine in the acute stroke setting. The aim of the study was to elucidate the association between cognitive function and functional outcome in acute minor ischemic stroke patients.

Methods:
From December 2016 to November 2017, patients with acute minor ischemic stroke (prehospital modified Rankin Scale (mRS) ≤1 and National Institute of Health Stroke Scale (NIHSS) score ≤3) who were admitted to our department were prospectively analyzed. Prestroke cognitive state was estimated by Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) which was completed by the patient’s relative at the time of admission. Cognitive performance was measured using the Japanese version of Montreal Cognitive Assessment (MoCA-J) within the first 7 days of admission. Cognitive impairment was defined as MoCA-J <23. Functional outcomes were assessed using the mRS at the time of discharge. A poor discharge outcome was defined as an mRS score of 3-5 or death (mRS score of 6). The impacts of cognitive function on outcome were assessed by multivariate logistic regression analyses.

Results:
Overall, 581 consecutive patients with acute ischemic stroke admitted to our department during the study period. Finally, 128 patients with minor ischemic stroke (median age 72years) were enrolled. In total, 74 (58%) patients had impaired cognitive impairment in the acute phase. Age (
P
= 0.0161), NIHSS score on admission (
P
<0.0001), IQCODE (
P
=0.0167), Moca-J (
P
<0.0001), dyslipidemia (
P
=0.0101), and sex (
P
=0.0222) were different between good and poor outcome. Multivariate analysis showed that high NIHSS score (odds ratio [OR], 7.30; 95% confidence interval [CI], 2.33-39.95,
P
< 0.0001) upon admission as well as low Moca-J score (OR, 1.32; 95% CI, 1.11-1.61,
P
= 0.0006) was independently associated with poor functional outcome.

Conclusion:
Cognitive impairment in acute minor ischemic stroke was common and independently associated with poor functional outcome after adjusting for the effects of stroke severity, prestroke cognitive status, and various risk factors.
Abstract TP561: The Effects of Recanalization of Chronically Occluded Internal Carotid Artery on Patients' Neurocognition
Authors: Ali Muhammad S , Zanaty Mario , Teferi Nahom , Kung David , Limaye Kaustubh , Al Kasab Sami , Nakagawa Daichi , Jabbour Pascal , Samaniego Edgar A , Hasan David M
Published: January 2019

Objective:
To evaluate pre and postop cerebral hemodynamics and the effects it has on neurocognitive outcomes in patients with chronically occluded internal carotid artery (COICA) who have undergone successful recanalization.

Methods:
Patients with symptomatic COICA who underwent revascularization technique using either angioplasty and stenting (AS) or a hybrid of carotid endarterectomy and AS are included in this analysis.

Results:
From January 2016 to June of 2018, 31 subjects underwent revascularization. Only 5 subjects (6 COICA) had CTP and MoCA scores pre and post revascularization. All 5 subjects had very large penumbra involving the ipsilateral hemisphere, which has resolved postop. No permanent complications were associated with the procedure. All patients have objective improvement in their neurocognitive outcomes (pre MoCA: 19.8±2.4, post MoCA: 27±1.6; p-0.0038).

Conclusions:
CTP can guide in patient selections for recanalization. Successful recanalization lead to improvement in CTP parameters and neurocognitive functions.
Abstract TP562: Clinical and Brain-regional Characteristics Associated With Delirium Occurred After Acute Ischemic Stroke
Authors: Shin Jong Wook , Jeong Hye Seon , Yang Hee Won , Lee Miji , Kim Jeong Lan , Kim Jei
Published: January 2019

Background:
Post-stroke delirium is not uncommon in acute ischemic stroke patients. We evaluated the clinical and brain-regional characteristics associated with the development of delirium in acute ischemic stroke patients.

Method:
We prospectively included 444 consecutive patients, who were diagnosed as acute ischemic stroke from August 2017 to March 2018. All patients daily screened for delirium using the Confusion Assessment Method during the entire admission period. After the screen, the delirium was diagnosed using the criteria of the Diagnostic and Statistical Manual of Mental Disorders (fifth edition). Motor subtypes (hyperactive, hypoactive, and mixed) of individual delirium was measured by the Korean Version of Delirium Motor Subtype Scale. Clinical characteristics and subtypes of delirium were compared by the location of the initial stroke lesion (total anterior [TACI], partial anterior [PACI], posterior circulation infarctions [POCI] and lacunes) and by the involvement of cognition-related brain regions (angular gyrus, medial temporal or frontal lobe, anterior and medial thalamus, and/or caudate nucleus).

Results:
Post-stroke delirium occurred in 43 (9.7%) of the total patients. Hyperactive subtype (27 patients, 62.8%) of delirium were more frequent than hypoactive (2, 4.7%) and mixed ones (12, 27.9%). The post-stroke delirium more frequently occurred in PACI (19, 44.2%) and POCI (17, 39%) rather than TACI (4, 9.3%) and lacunes (3, 7%,
p
<0.001). Cognition-related brain regions was involved in 48 (10.8%) of the total patients, but, showed significantly higher delirium occurrence (22 of 48 patients, 51.2%) than the other region involvement (26 of 401, 6.5%,
p
<0.001). Delirium started within a mean of 1.6±1.6 (SD) days after onset of stroke, and continued for a mean of 7.2±6.7 days after treatment began. By the delirium subtypes, hyperactive (4.9±5.3 days) had shorter duration of delirium than hypoactive (12.5±6.4) and mixed subtype (11.4±7.4,
p
<0.001).

Conclusion:
The present study shows the clinical and brain-regional characteristics of post-stroke delirium patients. The regional and delirium subtype characteristics could be useful to expect the occurrence and duration of delirium for acute ischemic stroke patients.
Abstract TP563: White Matter Hyperintensities are Associated With Intracranial Internal Carotid Artery Calcifications in a Cohort of Patients With Acute Ischemic Stroke or Transient Ischemic Attack
Authors: Nath Nikitaa , Sarkar Monica , Le Roux Melissa , Powell Kimerly A , Torbey Michel T , Hannawi Yousef
Published: January 2019

Introduction:
Previous studies of the relationship between cerebral small vessel disease (CSVD) lesions and carotid artery (CA) calcifications have yielded conflicting results.

Hypothesis:
We hypothesized that intracranial ICA (ICICA) calcifications are most closely associated with CSVD in comparison to extracranial ICA (ECICA) and common CA (CCA) calcifications.

Methods:
Acute ischemic stroke and transient ischemic attack patients were recruited into a hospital-based prospective stroke registry. Total CSVD burden score including white matter hyperintensity (WMH), lacunes, microbleeds (MBs) and enlarged perivascular spaces (PVS) was measured according to Staals et al. Fazekas scale was used to rate the periventricular and deep WMH (PVMH and DWMH respectively). ICICA calcifications were measured on plain head CT scan according to Subedi et al. ECICA and CCA calcifications were measured according to Yamada et al on the neck CT angiography. Univariate analyses were used to test the relationship between CSVD lesions and CA calcifications. Binary and ordered logistic regression analyses were performed to adjust for the effect of age, sex, race, history of hypertension, diabetes and current smoking for the variables that showed significance in the univariate analyses.

Results:
141 patients (age 64.5±15.3, 49% females, total CSVD score 1.6±1.4, ICICA, ECICA and CCA calcification scores were 7.8±9.9, 10.3±13.4 and 2.1±6.9, respectively). In Univariate analyses, ICICA calcification score showed significant relationships with PVMH, DWMH, lacunes, MBs and total CSVD scores ( P values: <0.0001, 0.0005, 0.0078, 0.049 and 0.0026 respectively). ECICA calcification score showed significant relationships with PVWMH and DWMH (P values: 0.0062 and 0.0332, respectively) while CC calcification score showed significant relationships with PVMWH, DWMH, MBs and PVS (P values: 0.0008, 0.034, 0.045 and 0.013). Multivariate analyses showed significant relationships only for PVWMH and DWMH with ICICA calcification (P values: 0.008 and 0.05, respectively).

Conclusions:
ICICA calcifications are most closely linked to PVMW and DWMH. Further studies are required to investigate the pathophysiological mechanisms behind this relationship.