bluuebunny/crossref_metadata_2025 huggingface dataset:
A 30-Year Follow-Up of the Dallas Bed Rest and Training Study
Authors: McGuire Darren K. , Levine Benjamin D. , Williamson Jon W. , Snell Peter G. , Blomqvist C. Gunnar , Saltin Bengt , Mitchell Jere H.
Published: October 2018

Background
—

Cardiovascular capacity declines with aging, as evidenced by declining maximal oxygen uptake (V̇
o
2
max ), with little known about the specific mechanisms of this decline. Our study objective was to assess the effect of a 30-year interval on body composition and cardiovascular response to acute exercise in 5 healthy subjects originally evaluated in 1966.

Methods and Results
—

Anthropometric parameters and the cardiovascular response to acute maximal exercise were assessed with noninvasive techniques. On average, body weight increased 25% (77 versus 100 kg) and percent body fat increased 100% (14% versus 28%), with little change in fat-free mass (66 versus 72 kg). On average, V̇
o
2
max decreased 11% (3.30 versus 2.90 L/min). Likewise, V̇
o
2
max decreased when indexed to total body mass (43 versus 31 mL · kg
−1
· min
−1
) or fat-free mass (50 versus 43 mL/kg fat-free mass per minute). Maximal heart rate declined 6% (193 versus 181 bpm) and maximal stroke volume increased 16% (104 versus 121 mL), with no difference observed in maximal cardiac output (20.0 versus 21.4 L/min). Maximal AV oxygen difference declined 15% (16.2 versus 13.8 vol%) and accounted for the entire decrease in cardiovascular capacity.

Conclusions
—

Cardiovascular capacity declined over the 30-year study interval in these 5 middle-aged men primarily because of an impaired efficiency of maximal peripheral oxygen extraction. Maximal cardiac output was maintained with a decline in maximal heart rate compensated for by an increased maximal stroke volume. Most notably, 3 weeks of bedrest in these same men at 20 years of age (1966) had a more profound impact on physical work capacity than did 3 decades of aging.
Adventitial Cells Do Not Contribute to Neointimal Mass After Balloon Angioplasty of the Rat Common Carotid Artery
Authors: De Leon Hector , Ollerenshaw Jeremy D. , Griendling Kathy K. , Wilcox Josiah N.
Published: October 2018

Background

Previous studies suggest that the migration of adventitial cells into the neointima after balloon angioplasty might have an important role in vascular lesion formation. The current experiments were designed to study the migration of adventitial cells in response to mechanical injury of the rat carotid artery.

Methods and Results

Adventitial cells were stained in situ with PKH26, a fluorescent dye, after balloon angioplasty of the rat common carotid artery. Animals were killed at different time points, and tissue sections were examined under light and fluorescence microscopy. PKH26-labeled cells were detected exclusively in the adventitia. No labeled cells were present in the media or the neointima at any time point examined. A highly cellular neoadventitial layer composed of myofibroblasts exhibited an extensive proliferative response 3 days after injury over the entire adventitial circumference.

Conclusions

Despite the prominent role that adventitial myofibroblasts seem to have in the postangioplasty remodeling process, they do not migrate to the medial or intimal layers in the rat carotid artery angioplasty model.
Stent Placement to Prevent Restenosis After Angioplasty in Small Coronary Arteries
Authors: Doucet Serge , Schalij Martin J. , Vrolix Mathy C.M. , Hilton David , Chenu Patrick , de Bruyne Bernard , Udayachalerm Wasan , Seth Ashok , Bilodeau Luc , Reiber Johan H.C. , Harel François , Lespérance Jacques ,   for the Stent In Small Arteries(SISA) Trial Investigators
Published: October 2018

Background

Lesions in small-diameter vessels (<3 mm) define a group with distinct clinical and morphological characteristics. There is an inverse relationship between vessel size and angiographic restenosis rate. This study assessed whether stents reduce angiographic restenosis in small coronary arteries compared with standard balloon angioplasty.

Methods and Results

We randomly assigned 351 symptomatic patients needing dilatation of 1 native coronary vessel between 2.3 and 2.9 mm in size to angioplasty alone (n=182) or stent implantation (n=169). The primary end point was angiographic restenosis at 6 months. Secondary end points included death, myocardial infarction, bypass surgery, and target vessel revascularization in hospital and at 6 months. There were no significant differences between groups in terms of major in-hospital complications. There was a trend toward fewer in-hospital events in the stent group (3% versus 7.1% in angioplasty group,
P
=0.076). Crossovers to stent occurred in 37 patients (20.3%). Repeat angiography at 6-month follow-up was performed in 85.3% of patients. Angiographic restenosis occurred in 28% of the stent group and 32.9% of the angioplasty group (
P
=0.36). Target vessel revascularization was required in 17.8% versus 20.3% of patients (
P
=0.54), respectively.

Conclusions

Stenting and standard coronary angioplasty are associated with equal restenosis rate in small coronary arteries. With a lower in-hospital complication rate, stenting may be a superior strategy in small vessels.
Genetic Modifiers for the Long-QT Syndrome
Authors: Crotti Lia , Lahtinen Annukka M. , Spazzolini Carla , Mastantuono Elisa , Monti Maria Cristina , Morassutto Caterina , Parati Gianfranco , Heradien Marshall , Goosen Althea , Lichtner Peter , Meitinger Thomas , Brink Paul A. , Kontula Kimmo , Swan Heikki , Schwartz Peter J.
Published: October 2018

Background—

Long-QT syndrome is an inherited cardiac channelopathy characterized by delayed repolarization, risk of life-threatening arrhythmia, and significant clinical variability even within families. Three single-nucleotide polymorphisms (SNPs) in the 3′ untranslated region of
KCNQ1
were recently suggested to be associated with suppressed gene expression and hence decreased disease severity when located on the same haplotype with a disease-causing
KCNQ1
mutation. We sought to replicate this finding in a larger and a genetically more homogeneous population of
KCNQ1
mutation carriers.

Methods and Results—

The 3 SNPs (rs2519184, rs8234, and rs10798) were genotyped in a total of 747
KCNQ1
mutation carriers with A341V, G589D, or IVS7-2A>G mutation. The SNP haplotypes were assigned based on family trees. The SNP allele frequencies and clinical severity differed between the 3 mutation groups. The different SNP haplotypes were neither associated with heart rate–corrected QT interval duration (QTc) nor cardiac events in any of the 3 mutation groups. When the mutation groups were combined, the derived SNP haplotype of rs8234 and rs10798 located on the same haplotype with the mutation was associated with a shorter QTc interval (
P
<0.05) and a reduced occurrence of cardiac events (
P
<0.01), consistent with the previous finding. However, when the population-specific mutation was controlled for, both associations were no longer evident.

Conclusions—

3′ Untranslated region SNPs are not acting as genetic modifiers in a large group of LQT1 patients. The confounding effect of merging a genetically and clinically heterogeneous group of patients needs to be taken into account when studying disease modifiers.
Trajectory of Psychological Risk and Incident Hypertension in Middle-Aged Women
Authors: Räikkönen Katri , Matthews Karen A. , Kuller Lewis H.
Published: October 2018

The aim of the study was to test the hypotheses that the trajectory of psychological risk (ie, persistent or increasing measures of depression and anxiety symptoms, anger, and low social support over time) increases the risk for the development of hypertension and that blood pressure levels fluctuate with psychological changes in women. Initially, healthy normotensive middle-aged women (n=541; 90.6% white, 8.9% African American) were followed across an average of 9.2 years of follow-up. Psychological characteristics were assessed repeatedly via standardized questionnaires, and Cox proportional hazards and random regression models were used to analyze their impact, adjusting for hypertension risk factors (age, race, years of education, parental history of hypertension, baseline blood pressure, body mass index, physical activity, alcohol use, and cigarette smoking). Seventy-five women became hypertensive during the follow-up period. Baseline levels of depression, anxiety, anger, and social support did not predict subsequent hypertension. A high level of anxiety throughout the follow-up, an increase in the level of feelings of anger, and a decrease in the level of social support over the follow-up were significant predictors of hypertension incidence (all
P
<0.05), although covariate adjustment reduced some of the significance levels to nonsignificance. In women, increases in depressive symptoms were significantly associated (
P
=0.003) with concurrent increases in the level of systolic blood pressure, especially among hypertensive patients (
P
=0.0001). Increasing levels of anger, decreasing levels of social support, and high anxiety increase the likelihood of women’s development of hypertension in midlife. These results emphasize the importance of evaluating the trajectory of psychological risk during the period of evolving hypertension.
Pet Ownership, but Not ACE Inhibitor Therapy, Blunts Home Blood Pressure Responses to Mental Stress
Authors: Allen Karen , Shykoff Barbara E. , Izzo Joseph L.
Published: October 2018

In the present study, we evaluated the effect of a nonevaluative social support intervention (pet ownership) on blood pressure response to mental stress before and during ACE inhibitor therapy. Forty-eight hypertensive individuals participated in an experiment at home and in the physician’s office. Participants were randomized to an experimental group with assignment of pet ownership in addition to lisinopril (20 mg/d) or to a control group with only lisinopril (20 mg/d). On each study day, blood pressure, heart rate, and plasma renin activity were recorded at baseline and after each mental stressor (serial subtraction and speech). Before drug therapy, mean responses to mental stress did not differ significantly between experimental and control groups in heart rate (94 [SD 6.8] versus 93 [6.8] bpm), systolic blood pressure (182 [8.0] versus 181 [8.3] mm Hg), diastolic blood pressure (120 [6.6] versus 119 [7.9] mm Hg), or plasma renin activity (9.4 [0.59] versus 9.3 [0.57] ng · mL
−1
· h
−1
). Lisinopril therapy lowered resting blood pressure by ≈35/20 mm Hg in both groups, but responses to mental stress were significantly lower among pet owners relative to those who only received lisinopril (
P
<0.0001; heart rate 81 [6.3] versus 91 [6.5] bpm, systolic blood pressure 131 [6.8] versus 141 [7.8] mm Hg, diastolic blood pressure 92 [6.3] versus 100 [6.8] mm Hg, and plasma renin activity 13.9 [0.92] versus 16.1 [0.58] ng · mL
−1
· h
−1
). We conclude that ACE inhibitor therapy alone lowers resting blood pressure, whereas increased social support through pet ownership lowers blood pressure response to mental stress.
Improved Hypertension Management and Control
Authors: Primatesta Paola , Brookes Marion , Poulter Neil R.
Published: October 2018

A survey in 1994 showed that among the 20% of the adult English population who were identified as hypertensive, ≈30% had their blood pressures controlled to <160 mm Hg systolic and <95 mm Hg diastolic. The 1998 Health Survey for England data update the 1994 findings in light of new thresholds and targets for treatment outlined in recent national and international guidelines. This cross-sectional survey is analyzed to describe the prevalence, awareness, treatment, and control of hypertension in a random, nationally representative sample of 11 529 English adults (≥16 years) living in noninstitutional households in 1998 and to compare these rates with those from 1994. In 1998, 20% and 37% of adults were hypertensive according to the old (systolic ≥160 mm Hg or diastolic ≥95 mm Hg) and new (systolic ≥140 mm Hg or diastolic ≥90 mm Hg) definitions, respectively. Corresponding values in 1994 were 20% and 38%. Treatment and control rates among hypertensive adults (new definition) improved from 26% to 32% and from 6% to 9%, respectively, although 60% of those on treatment received only 1 antihypertensive drug in both years. Among persons with controlled hypertension, 59% reported having received nonpharmacological advice from their physicians in 1998 compared with 30% in 1994. Rates of hypertension treatment and control have increased significantly (
P
=0.05 and
P
<0.01, respectively) since 1994 but remain low by international standards. The 1998 data suggest that improved detection, greater use of nonpharmacological measures, and increased use of >1 antihypertensive agent per patient would produce greater success in achieving target levels. This could lead to major reductions in fatal and nonfatal cardiovascular events.
Abstract 100: Comparative Safety and Effectiveness of Dabigatran Versus Rivaroxaban and Apixaban Utilized Among United States Department of Defense Healthcare System Patients
Authors: Villines Todd C , Ahmad Ashar , Evans Amber , Oh Kelly , Petrini Michaela , Rush Toni , Tang Wenbo , Thompson David , Schwartzman Eric
Published: October 2018

Background:
Non-vitamin K oral anticoagulants (NOACs) are guideline-endorsed therapies for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). Information on NOAC comparative effectiveness and safety is limited.

Purpose:
To compare stroke and major bleeding risks in matched NVAF patients initiating treatment of dabigatran versus rivaroxaban and apixaban, using the US Department of Defense Military Health System (MHS).

Methods:
Primary analysis included two standard dose cohorts derived from newly initiated adult MHS patients with NVAF based on the date of clinical approval as follows: 1) dabigatran (150 mg) or rivaroxaban (20 mg) (July 2011-June 2016) and 2) dabigatran (150 mg) or apixaban (5mg) (January 2013-June 2016). To reduce potential channeling bias, propensity score matching (PSM 1:1) was used to account for differences in baseline characteristics. Cox proportional hazard regression was utilized to estimate hazard ratios for primary outcomes of stroke and major bleeding.

Results:
Prior to PSM, there were 12,763 dabigatran and 17,177 rivaroxaban users in cohort 1 and 4,802 dabigatran and 12,594 apixaban users in cohort 2. There were limited dabigatran users available for matching with apixaban. However, PSM resulted in 2 well balanced cohorts. At least 70% of patients were at least 65 years old in both cohorts. Baseline characteristics, follow-up duration, effectiveness and safety outcomes for the PSM cohorts are displayed in the Table.

Conclusions:
In PSM NVAF patients newly initiated on standard doses of NOACs, dabigatran users demonstrated a statistically significant lower risk of major bleeding compared to rivaroxaban users and no difference compared to apixaban users. Neither cohort demonstrated a significant difference in stroke risk. This large-scale, U.S. practice-based comparison may help inform medical decision making in the absence of head-to-head clinical trials of available NOACs.
Abstract 108: Mechanical Thrombectomy in Patients With Milder Strokes and Large Vessel Occlusions - A Multicenter and Matched Analysis
Authors: Nagel Simon , Bouslama Mehdi , Krause Lars , Küpper Clemes , Messer Mirko , Petersen Martina , Lowens Stephan , Herzberg Moritz , Ringleb Peter , Möhlenbruch Markus , Tiedt Steffen , Lima Fabricio , Haussen Diogo , Smith Wade , Lev Michael , Nogueira Raul
Published: October 2018

Background:
In patients with acute ischemic strokes (AIS) and milder symptoms (NIHSS</=5) harboring a large vessel occlusion (LVO) best clinical management is unclear. To describe the safety and efficacy of immediate mechanical thrombectomy (MT) in patients with LVO and milder symptoms versus best medical management, including rescue MT.

Methods:
Retrospective cohort study on consecutive patients for a descriptive analysis regarding clinical and safety outcomes. From local prospectively run databases of six international comprehensive stroke centers data was pooled. 300 Patients with LVO (distal internal carotid artery, MCA-M1 and/or M2 segments, or basilar artery with or without tandem occlusions) and milder symptoms were identified and divided into two groups for analysis: immediate MT (i-MT) or best medical management which included rescue MT after neurological deterioration (n/r-MT). Uni- and multivariate analysis were performed to compare baseline and outcome variables across the two groups. Additional comparisons were performed after patient-level matching for age, baseline NIHSS and occlusion site. The primary outcome was defined as good outcome (modified rankin scale [mRS] 0-2) at day 90. Secondary outcomes were, among others, modified shift analyses at day 90. Safety outcome was symptomatic intracranial hemorrhage (sICH) as defined by the European Cooperative Acute Stroke Study (ECASS) II and mortality at day 90.

Results:
Compared to n/r-MT (n=220), patients with i-MT (n=80) were younger (65.3+/-13.5 vs. 69.5+/-14.1, p=0.021), had more often atrial fibrillation (44.8% vs. 28.2%, p=0.012), higher baseline NIHSS (4, 0-5 vs. 3, 0-5, p=0.005), more MCA-M1 (41.3% vs. 21.9%) and less MCA-M2 (28.8% vs. 49.3%, p=0.016) occlusions. The adjusted odds ratio for good outcome was 3.1 95% CI: 1.4-6.9 favoring i-MT. In the matched analysis, there was a 14.4% absolute difference in good outcome (84.4% vs. 70.1%, p=0.03) and a significant modified mRS shift (OR 2.29, 95% CI: 1.05-4.98) at day 90 favoring i-MT. There were no safety concerns.

Conclusions and Relevance:
The observed benefit-safety profile favors immediate MT in patients with milder symptoms and LVO.
Abstract 11: Patters and Predictors of Persistent Use of a Post-Discharge Mobile Application to Improve Care and Outcomes Among Stroke Patients
Authors: Chang Hong , Zhao Jie , Yao Hui , Wang Xiao J , Qiao Yu C , Ruan Zheng , Song Hai Q
Published: October 2018

Introduction:
There are relatively few published data on the use of mobile technology to enhance post-stroke care and outcomes. Information on the utility and key characteristics of mobile health applications (APPS) in the post-discharge care of stroke patients could inform their successful implementation into routine clinical practice.

Objective:
To identify the patterns and predictors of high usage of a mobile care APP among recently discharged stroke patients.

Methods:
Of 1817 patients consecutively encountered at a single academic medical center from August 2016 to April 2017, 471 (25.9%) stroke patients discharged from the hospital were given use of a mobile medical application for a period of 3 months. The status of the usage and the preferences setting of APP were recorded. Demographic characteristics, medical history, stroke related information were summarized. Persistent/high usage was defined as 80% of time for usage. Relevant factors associated with the usage of APP were analyzed with a multiple regression.

Results:
176 out of 471 (37.4%) patients persistently used the APP during the study period. Health education (91.3%), self-monitoring comprising blood pressure and blood glucose modules (77.1%) and nurse consultation (60.1%) were the top three commonly used modules. Multivariate analysis showed that younger age (p=0.010), higher education (p=0.000), history of hypertension (p=0.011), diabetes (p=0.000), and stroke (p=0.026), and non-drinker (p=0.023) were significantly associated with persistent use of the APP.

Conclusion:
We found that only one out of 3 stroke patients in this cohort persistently utilized our post-discharge mobile APP. Our data suggest that either such apps should focus primarily on patient groups most likely to persistently use them or specific interventions may need to be developed to facilitate greater use among low users.
Abstract 110: Thrombectomy With Longer Stent Retrievers Increases Rates of First-pass Reperfusion
Authors: Haussen Diogo C , Al-Bayati Alhamza , Grossberg Jonathan , Bouslama Mehdi , Barreira Clara , Bianchi Nicolas , Frankel Michael , Nogueira Raul G
Published: October 2018

Background:
Longer stent retrievers have become recently available and may enhance device purchase distal to the clot (increasing chances of rolling clot out) and prevent misplacement. We aim to evaluate if the device length impacts reperfusion rates in stroke thrombectomy.

Methods:
Retrospective analysis of a prospectively collected databank. Inclusion: thrombectomies in which 4mm stent-retrievers were used as the first-line strategy from Sep2010-Mar2017. Population was dichotomized into Long (Trevo4x30mm/Solitaire4x40mm) or Short (Trevo4x20mm/ Solitaire4x20mm) retrievers. Primary outcome was first-pass reperfusion (modified TICI2b-3 with first pass).

Results:
Of 1204 thrombectomies within the study period, 594 were included. Age, gender, NIHSS, ASPECTS, and IV-tPA use (41vs41%;p=1.00) were comparable between groups. Long device arm included more MCA M1 [72vs60%;p<0.01], less M2 [10vs17%;p=0.02] and basilar artery [4vs11%;p<0.01] occlusions. Occlusion site was comparable for intracranial carotid and Tandem occlusions. Time from last-known-normal to puncture was longer in the Long retriever group (6.3[4.2-11.9]hours 5.3[3.6-8.5];p<0.01). Percentage use of Long and Short Trevo (total n=334) and Solitaire (total n=260) and of newer generation local thromboaspiration (19vs20%;p=0.75) were comparable. First-pass reperfusion was more common in the Long retriever group (63vs49%;p=0.001) as well as first-pass complete reperfusion (42vs28%;p<0.001). This effect remained when only MCA-M1 and intracranial carotids were analyzed. Parenchymal hematomas type-II were similar (3vs3%;p=1.00) as well as subarachnoid hemorrhage (6vs5%;p=0.72). 90-day mRS0-2-good outcome (46vs46%;p=0.96) and mortality (24vs25%;p=0.83) were comparable. Multivariable analysis indicated Long retriever (OR1.8;95%CI 1.2-2.7;p=0.002), IV-tPA (OR1.5;95%CI 1.1-2.2;p=0.02), local aspiration (OR1.6;95%CI 1.0-2.5;p=0.04) and good outcome (OR1.6;95%CI 1.1-2.5;p=0.01) independently associated with first pass reperfusion.

Conclusions:
The use of longer stent retrievers is an independent predictor of first pass reperfusion. First pass reperfusion predicted good clinical outcome at 90 days.
Abstract 112: Identifying Patients Who May Benefit From Thrombectomy in the Late Time Window: Predictors of Good Outcome Beyond Advanced Imaging
Authors: Sarraj Amrou , Nogueira Raul , Liebeskind David S , Budzik Ronald , Farrell Christine M , English Joey , Baxter Blaise , Bartolini Bruno , Krajina Antonin , Hassan Ameer , Veznedaroglu Erol , Shields Ryan , Zhang Yanchang , Savitz Sean , McCullough Louise , Malek Ali ,   Trevo Retriever Registry Investigators, Vora Nirav A , Chen Michael , Gupta Rishi
Published: October 2018

Background:
The DAWN trial showed EVT effectiveness in the late time window (6-24 hrs), however, DAWN patients were carefully selected based on advanced perfusion imaging, CTP and MRI. Similar to the early window (0-6 hrs), simple imaging (CT) and other clinical variables may select patients for thrombectomy beyond 6 hours. We evaluated a largescale, real world practice for predictors that could identify patients who may benefit from EVT in the late time window.

Methods:
Patients with LVO in the anterior circulation (M1, M2, ICA) from a prospective, single arm, multicenter, international registry (Trevo Retriever Registry) treated in the late window LSN to groin puncture (GP) (6-24 hrs) were included. Univariate and multivariate analyses assessed factors independently correlating with good outcome (90 day mRS 0-2). Furthermore, patients outcomes were compared based on their baseline imaging selection CT vs CTP and MRI.

Results:
549 patients were treated beyond 6 hours. The average age was 67, median/IQR ASPECTS 8(6-9), median/IQR NIHSS was 15 (9-20), median/IQR time LSN to GP (hr) was 9.7 (7.3-13.6) and IV-tPA rate were 22.8%. CT was the only imaging selection method in 15.9%, while additional advanced imaging was utilized in the remaining patients; CTP (70%), and MRI(14.1%). Good outcomes were observed in 51.4% of late window patients. Age (aOR 0.96, 95% CI 0.94-0.98, p<0.001), stroke severity by NIHSS (aOR 0.9, 95% CI 0.86-0.95, p<0.001) and ASPECTS (for each point increment in ASPECTS aOR 1.24, 95% CI 1.05-1.47, p=0.012) were independent pre-intervention predictors of good outcome in the late window. The addition of advanced imaging beyond CT, including CTP or MRI, did not confer higher correlation with good outcome (aOR 1.45, 95% CI 0.77-2.73, p=0.25). Good outcome was achieved in 56% of CT selected patients as compared to 53% patients selected by CTP or MRI.

Conclusion:
Simple imaging and clinical variables can identify patients that could benefit from thrombectomy in the late window. Importantly, ASPECTS reliably predicted good outcome beyond 6 hours without adjunctive benefit from adding advanced perfusion imaging, a finding that may simplify patients selection to facilitate and generalize the intervention in the late window to wide, real world practice.
Abstract 115: CT Perfusion Identifies Patients with Poor Outcomes in The Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times (ESCAPE) Trial
Authors: Wannamaker Robert , Rempel Jeremy , Goyal Mayank , Menon Bijoy , Demchuk Andrew , Hill Michael , Shuai Ashfaq , Butcher Kenneth
Published: October 2018

Background:
In the ESCAPE trial, patients with large vessel occlusions and small infarct cores identified with CT/CT angiography were randomized to endovascular therapy or standard of care. CT Perfusion (CTP) was obtained in some cases, but was not utilized to select patients. We tested the hypothesis that patients with penumbral CTP patterns have higher rates of good clinical outcome.

Methods:
All CTP data acquired in ESCAPE patients was analyzed centrally using a semi-automated perfusion threshold based approach. A penumbral pattern was defined as an infarct core<70 mL, penumbral volume >15 mL, and a total hypoperfused volume:core volume ratio of >1.8. The primary outcome was a good functional outcome at 90 days (mRS 0-2).

Results:
CTP was acquired in 138 of 316 ESCAPE patients. Motion degraded CTP images from 9 patients were excluded. Penumbral patterns were present in 110/129 (85.3%) of patients. The rate of good functional outcome in penumbral pattern patients (53/108; 49.1%) was higher than that in non-penumbral patients (3/19; 15.8%, p=0.011). In penumbral patients, endovascular therapy increased the likelihood of good outcome (35/58; 60.3%) over those in the control group (18/50; 36%, OR=2.71, p=0.013). Only 4 of 19 non-penumbral patients were randomized to the endovascular group, preventing an analysis of treatment effect.

Conclusion:
The majority of patients with CTP imaging in the ESCAPE trial had penumbral patterns, which were associated with better outcomes overall. Patients with penumbra treated with endovascular therapy had the greatest odds of good functional outcome. Non-penumbral patients were much less likely to achieve good outcomes.
Abstract 116: Conventional and Automated Aspects vs. Ct Perfusion Core Volume to Predict Functional Outcome in Reperfused Acute Ischemic Stroke Patients Undergoing Endovascular Therapy
Authors: DEMEESTERE Jelle , Scheldeman Lauranne , Cornelissen Sandra , Heye Sam , Christensen Soren , Mlynash Michael , Lansberg Maarten G , Lemmens Robin
Published: October 2018

Objective:
To compare conventional and automated Alberta Stroke Program Early CT score (ASPECTS) to CT perfusion core volumes to predict functional outcome in acute ischemic stroke patients with successful reperfusion after thrombectomy.

Materials and methods:
Patients from the Computed Tomography Perfusion to Predict Response to Recanalization in ischemic Stroke Project (CRISP) study who achieved mTICI 2b or 3 reperfusion were included. Four independent physicians rated and reached consensus on the conventional ASPECT scores of the baseline CT. Automated ASPECT scores were determined with e-ASPECTS software (Brainomix, Oxford, UK). We used RAPID software (iSchemaView, Stanford, USA) to analyze CT perfusion core volumes. Good and poor functional outcome (GFO and PFO) was defined as a score of 0-2 and 4-6 on the modified Rankin Scale (mRS). Predictors of GFO and PFO were obtained by multivariate logistic regression.

Results:
We included 156 patients from the CRISP study. Interrater reliability for conventional ASPECTS was excellent (intra-class correlation coefficient 0.77). Median values for conventional ASPECTS, automated ASPECTS, and CT perfusion core volume were 7 (IQR 5-8), 9 (IQR 7-10) and 6.2 ml (IQR 0-17.7). Patients with GFO (59%) had lower baseline NIHSSS, lower rates of diabetes and smaller CTP infarct cores (p < 0.01 for all). Patients with PFO (25%) were older (p < 0.0001), had higher NIHSSS (p = 0.001), higher rates of diabetes (p < 0.0001) and larger CTP infarct cores (p < 0.05). In multivariate analysis CT perfusion core volume was associated with both GFO (OR 0.98; 95%CI 0.96-1.00) and PFO (OR 1.02; 95%CI 1.01-1.04)). Automated ASPECTS was a predictor for GFO (OR 1.26; 95%CI 1.04-1.53) but not PFO. Conventional ASPECTS was not associated with functional outcomes.

Conclusion:
In the setting of successful thrombectomy, CTP core volume is a better predictor of functional outcome than either conventional or automated ASPECTS.
Abstract 12: Oregon Region Standard Stroke Neurological Assessment Utilizing AACN Synergy Model
Authors: Swearingen Natalie , Cox Kailey , Clark Diane
Published: October 2018

Background:
Best practice guidelines recommend using standardized valid assessment tools to trend neurological assessment of acute stroke patients. The Oregon region and nationally recognized accrediting bodies for stroke certifications have identified Glasgow Coma Scale (GCS) as inadequate for quickly trending a patient’s neuro status after IV alteplase (t-PA) and/or thrombectomy.

Purpose:
Develop a stroke neurological check that is quick to perform, more complete than a GCS, and provides a snapshot of patient status including original neuro symptoms.

Methods:
Stroke program coordinator nurses and clinical experts from the Oregon region collaborated, conducted literature review, and developed a recommendation for a new standard stroke neuro check. The new stroke neuro check or SNAP (Stroke Neuro Assessment by Providence) entails 4 major parts: Level of consciousness as defined by NIH Stroke Scale (NIHSS) 1a, 1b, 1c or GCS; Pupil reactivity to light; movement of extremities as defined by NIHSS 5a, 5b, 6a, 6b, and finally trending patient’s original stroke symptoms. Throughout development of this standard stroke neuro check, we applied the Synergy Model combining stroke patient characteristics, health care environment, and nurse competencies. As a professional model of care, we incorporated the AACN Synergy Model to standardize RN education tools for implementation throughout ED, critical care, and stroke units.

Results:
One certified comprehensive stroke center and three certified primary stroke centers implemented SNAP in various stages throughout their hospitals within a 9 month time period. Multiple education methods were used including, 1:1 staff education, laminated tip sheets, computer sticker reminders, safety huddles, staff meetings, stroke classes, SNAP pen lights, continuous quality improvement feedback aimed at improving nurse competency, and electronic medical record enhancements to harmonize environment of documentation with RN workflow.

Conclusion:
The definition of a stroke neuro check continues to be controversial. Successful Oregon region development and implementation of SNAP through AACN Synergy Model, meets regulatory and practice requirements as a standard stroke neuro check.
Abstract 120: Measures of Coagulation and Hemostatic Activation Outperform Left Atrial Structural Parameters in Identifying Embolic Stroke of Undetermined Source (ESUS) Patients Who May Benefit From Early Anticoagulation
Authors: Ellis Deandrea , Rangaraju Srikant , Duncan Alexander , Hoskins Michael H , Raza S. A , Rahman Haseeb , Winningham Melanie , Belagaje Samir , Bianchi Nicolas , Belair Trina , Henriquez Laura , Nahab Fadi
Published: October 2018

Introduction:
The objective of this study was to evaluate left atrial (LA) echocardiographic parameters and a novel panel of serum biomarkers to identify ESUS patients who may benefit from early anticoagulation.

Methods:
We prospectively identified ESUS patients seen in the Emory Clinic from January 1, 2015 to June 30, 2017 who underwent prolonged cardiac monitoring with mobile cardiac outpatient telemetry (MCOT) and/or implantable loop recorder (ILR). In a subset of consecutive patients, 4 measures of coagulation and hemostatic activation (MOCHA) including d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer were obtained ≥ 2 weeks after the index stroke and repeated if abnormal. We evaluated the ability of LA structural parameters to identify patients with atrial fibrillation (AF) on monitoring and the ability of abnormal MOCHA levels to identify patients who had the composite outcome of newly diagnosed AF, malignancy, or recurrent stroke.

Results:
During the study period, 92 ESUS patients (mean age 64 +/- 15 years, 54% female, 62% non-white, mean follow-up 1.4 +/- 0.8 years) underwent prolonged cardiac monitoring (65% MCOT, 62% ILR, 38% MCOT+ILR); 16 (17%) were found to have AF. Severe LA enlargement (vs normal) was associated with subsequent detection of AF (p=0.09) however LA diameter and LA volume index were not. Baseline characteristics of ESUS patients who underwent MOCHA testing (n=44) were similar to patients who did not except that those tested were younger (60 vs 67 years, p=0.04); over mean follow-up of 1.2 +/- 0.8 years, 18 (41%) patients had newly diagnosed AF, malignancy or recurrent stroke. ESUS patients with persistently abnormal (vs normal) MOCHA levels were significantly more likely to have newly diagnosed AF, malignancy or recurrent stroke (OR 11.3, 95% CI 2.5-50.1, p=0.001); elevated levels of ≥ 3 MOCHA markers had a 67% sensitivity and 81% specificity for identifying patients with the composite outcome.

Conclusion:
Abnormal MOCHA levels identified ESUS patients who were more likely to have newly diagnosed AF, malignancy or recurrent stroke over follow-up and may be more effective than LA structural abnormalities in identifying patients who could benefit from early anticoagulation.
Abstract 122: Elevated Pulse Wave Velocity is Associated With Regional Aortic Flow Reversal as an Embolic Mechanism in Patients With Cryptogenic Stroke
Authors: Jarvis Kelly , Vali Alireza , Shen Xin , Prabhakaran Shyam , Collins Jeremy D , Markl Michael
Published: October 2018

Introduction:
There is recent evidence that diastolic flow reversal in the descending thoracic aorta (DAo) is prevalent in patients with atherosclerosis, enabling a mechanism for cerebral embolism. Specifically,
aortic stiffness
(assessed by

pulse wave velocity, PWV

) is a precursor of plaque formation and

reverse aortic flow

. The aim of this study was to 1) employ aortic 4D flow MRI for quantification of both PWV and regional flow reversal and 2) evaluate relationships between PWV, reverse flow and age in a cohort of cryptogenic stroke patients with plaques in the DAo and age-matched controls.

Methods:
Non-contrast free-breathing 4D flow MRI (spatial resolution = 3-3.5 x 2.2-2.6 x 2.6-3 mm
3
, temporal resolution=19.6 ms, venc = 150 cm/s, 1.5T Area, Siemens Germany) was performed in n=10 (age=66±7 [53-80]) patients with cryptogenic stroke and n=12 (age=68±7 [56-78]) controls. Methods were developed for the automatic quantification of global aortic PWV (by cross-correlation) and regional (voxel-wise) reverse flow based on a 3D centerline (Figure 1a-c). Reverse flow during one cardiac cycle was averaged among voxels in user-defined ROIs in the ascending aorta (AAo), aortic arch (AArch) and DAo.

Results:
Elevated PWV was associated with increased age in all subjects (patients: R
2
=0.52, p=0.02; controls: R
2
=0.58, p=0.004) and increased reverse flow in patients (AAo: R
2
=0.60, p=0.009; AArch: R
2
=0.73, p=0.002; DAo: R
2
=0.44, p=0.04) but not controls (AAo: R
2
=0.04, p=0.52; AArch: R
2
=0.25, p=0.10; DAo: R
2
=0.06, p=0.42) (Figure 1d).

Conclusions:
Evaluation by 4D flow MRI shows aortic stiffness, as measured by PWV, increases with age and is associated with pronounced reverse aortic flow in cryptogenic stroke patients with DAo plaque compared to controls, providing further evidence retrograde embolism may be a mechanism of stroke in otherwise cryptogenic stroke patients.
Abstract 124: Clot Composition of Embolic Strokes of Undetermined Source
Authors: Nouh Amre M , Mehta Tapan , Hussain Mohammed , Song Xianyuan , Ollenschleger Martin
Published: October 2018

Background:
A number of emerging studies have evaluated clot composition in acute ischemic stroke. Studies of clot composition of embolic strokes of undetermined strokes are lacking.

Objectives:
We sought to analyze the RBC to platelet ratios in mechanically retrieved clots and correlate our findings with stroke etiology.

Methods:
This is a prospective study analyzing clots retrieved by mechanical thrombectomy in acute ischemic stroke patients at our institution. Retrieved clot material was fixed and cut at 4-m thickness. All clots were stained with hematoxylin-eosin to identify red blood cells (RBC’s), and antibodies for platelet glycoprotein IIIa with CD61 (LifeSpan Biosciences, Seattle, Washington) for platelets. Stained slides were scanned at 200x magnification by using a Scanscope XT digital scanner (Apergio, Vista, California). Image-J software (National Institutes of Health, Bethesda, Maryland) was used for semi quantitative analysis of percentage RBC’s and platelets. Unpaired t-test was used to compare means of RBC to Platelet ratios. Statistical significance was set at 0.05. Correlation of RBC to Platelet ratios with stroke etiology was performed.

Results:
A total of 33 clots from 33 patients were analyzed. Stroke etiology was undetermined in 6 patients, cardioembolic in 14, Large vessel atherosclerosis (LVA) in 9, and carotid dissection in 4. The mean RBC to platelet ratio was 0.78:1 (+/- 0.65) in cardioembolic clots, 1.73:1 (+/-2.38) in LVA and 1.4:1(+/-0.70) in carotid dissections. Although patients with undetermined etiology had a similar clot composition to cardioembolic stroke (0.36:1+/-0.33), (p=0.19), it differed significantly from LVA and dissections respectively (p=0.047, p=0.01).

Conclusion:
In our study, a low RBC to Platelet ratio was found among patients with embolic strokes of undetermined source, however shared similar characteristics with cardioembolic thrombi. Ongoing collection and analysis is needed to confirm these findings and its significance in evaluating stroke etiology.
Abstract 128: Intensive Blood Pressure Lowering in Patients with Moderate to Severe Grade Acute Cerebral Hemorrhage: Post Hoc Subgroup Analysis of Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH)-2 Trial
Authors: Qureshi Adnan , Palesch Yuko , Foster Lydia , Qureshi Mushtaq , Suarez Jose
Published: October 2018

Background:
The intent to treat analysis of ATACH-2 trial did not demonstrate any difference in rates of death or disability with intensive systolic blood pressure (SBP) reduction compared with standard SBP reduction in patients with intracerebral hemorrhage (ICH). The benefit may have been obscured due to relatively high proportion of good grade patients (ceiling effect) in both treatment groups.

Methods:
We evaluated the effect of intensive (goal 110-139 mmHg) over standard (goal 140-179 mmHg) SBP reduction using intravenous nicardipine within 4.5 hours of symptom onset in a subgroup of moderate to severe grade subjects with ICH. Moderate to severe grade was defined by Glasgow coma scale score <13 or baseline National Institutes of Health Stroke Scale score ≥10 or baseline intraparenchymal hemorrhage volume ≥30cm
3
or presence of intraventricular hemorrhage. The primary outcome was death or disability (score 4-6 on modified Rankin scale) at 3-months post-randomization ascertained by a blinded investigator.

Results:
A total of 682 subjects (336 in intensive and 346 in standard groups) met the definition of moderate to severe grade. The primary endpoint of death or disability was observed in 52.5% of subjects receiving intensive treatment and 48.9% subjects receiving standard treatment (relative risk: 1.07; 95% confidence interval: 0.86 to 1.33). Serious adverse events were significantly higher (relative risk: 1.38; 95% confidence interval: 1.04 to 1.84), among patients randomized to intensive treatment (32.7% and 23.7% for intensive and standard treatment groups, respectively).

Conclusions:
Similar to the conclusion from the overall ATACH-2 Trial sample, the rate of death or disability in the moderate to severe ICH subjects was similar, but significantly higher rate of serious adverse events were observed in subjects randomized to intensive SBP reduction.
Abstract 131: Impact of Concomitant Use of Antiplatelet and Anticoagulation Therapies on Outcomes in Patients With Intracerebral Hemorrhage
Authors: Inohara Taku , Xian Ying , Liang Li , Matsouaka Roland , Saver Jeffrey L , Smith Eric E , Schwamm Lee H , Reeves Mathew J , Hernandez Adrian F , Bhatt Deepak L , Peterson Eric D , Fonarow Gregg C
Published: October 2018

Background:
The impact of the preceding use of concomitant use of antiplatelet and anticoagulation therapies on outcomes of intracerebral hemorrhage (ICH) has not been thoroughly investigated.

Methods:
We analyzed 138,834 patients presenting with ICH between October 2013 and December 2016 from 1661 hospitals participating in the Get With The Guidelines-Stroke program. Multivariable logistic regression was used to evaluate the impact of concomitant antiplatelet therapy on in-hospital mortality in anticoagulation-related ICH.

Results:
Of 138,834 patients (mean [SD] age 68.4 [15.3] years; 48.0% women), 118,219 (85.2%) patients were not receiving any oral anticoagulant (OAC), 15,777 (11.4%) were receiving warfarin and 4,838 (3.5%) were receiving non-vitamin K oral anticoagulants (NOACs) prior to ICH. Stroke severity as measured by NIHSS was similar across three groups. Patients receiving warfarin or NOACs were more likely to have single antiplatelet therapy (SAPT) than those receiving no OAC (33.0% for warfarin, 30.7% for NOACs, and 27.3% for no OAC), whereas patients receiving no OAC were more likely to have dual antiplatelet therapy (DAPT) (2.5% for warfarin, 2.3% for NOACs, and 4.4% for no OAC). After adjustment for confounders, SAPT was associated with a slightly higher rate of mortality (33.8% vs. 32.1%, adjusted odds ratio [AOR] = 1.20, 95% CI [1.11-1.30]) than no antiplatelet in patients receiving warfarin, whereas there were no statistically significant differences between SAPT vs. no antiplatelet in patients with no OAC (22.4% vs. 22.9%, AOR = 0.99 [0.95-1.03]) or NOACs (26.8% vs. 26.9%, AOR = 1.09 [0.94-1.26]). DAPT was associated with increased risk of death in patients taking warfarin (46.5% vs. 32.1%, AOR = 2.08 [95% CI, 1.68-2.57]) and no OAC (30.4% vs. 22.9%, AOR = 1.51 [95% CI, 1.40-1.63]). By contrast, in patients taking NOACs, the association of DAPT was not significant but the confidence intervals were wider (32.7% vs. 26.9%, AOR = 1.37 [95% CI, 0.90-2.08]) likely due to small sample size.

Conclusions:
In patients experienced an ICH, prior concomitant use of antiplatelet therapy (either SAPT or DAPT) significantly increased odds of mortality in patients taking warfarin, but such a difference was not apparent in NOAC-treated ICH patients.
Abstract 134: Cost-Related Nonadherence to Medication Among US Stroke Survivors After Affordable Care Act Implementation
Authors: Levine Deborah A , Shannon Colman F , Burke James F , Reale Bailey K , Chen Lena M
Published: October 2018

Background and Objectives:
Medication nonadherence is associated with increased risk of cardiovascular disease (CVD) events among patients with CVD. In 2014, many Americans gained the option of purchasing health insurance coverage and states gained the option of expanding Medicaid eligibility under the Affordable Care Act (ACA). Little is known regarding cost-related nonadherence (CRN) to medication among US stroke survivors after implementation of the ACA. We assessed CRN to medication by age, insurance, and time in a national sample of stroke survivors.

Methods:
Among 5,011 stroke survivors 45 or older responding to the National Health Interview Survey years 2011 to 2015, we examined CRN to medication within the last 12 months by age and insurance because Medicare eligibility begins at 65. We used logistic regression to adjust for socio-demographic and clinical factors. We compared results from 2014 to 2015 to those from 2011 to 2013 as well as to our previous investigation of age-related differences in CRN to medication from 2006 to 2010.

Results:
In 2015, 13% of US stroke survivors reported CRN to medication. From 2010 to 2015, the percentage of stroke survivors who were uninsured decreased from 7% to 3% overall (57% decrease) (P<0.001) and from 15% to 7% among survivors aged 45-64 (53% decrease) (P<0.001). From 2011-2013 to 2014-2015, the percentage of stroke survivors aged 45-64 with Medicaid coverage increased from 24% to 31% (P<0.01). From 2006 to 2015, CRN to medication remained stable among younger stroke survivors (Ptrend=0.19) and increased slightly among older stroke survivors (Ptrend=0.01)(Figure).

Conclusions:
Among stroke survivors who are aged 45-64 years, insurance coverage, namely Medicaid, has increased substantially while CRN to medication has remained stable. Federal programs to improve insurance availability and access to care may not be reducing CRN as intended, and a resulting large number of stroke survivors are at risk for subsequent events.