bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 57: Safety of Early and Urgent Carotid Endarterectomy (CEA) in Symptomatic Carotid Artery Stenosis (sCAS): An International, Multicenter Study
Authors: Tsivgoulis Georgios , Krogias Christos , Georgiadis Georgios S , Mikulik Robert , Athanasiadis Dimitrios , Safouris Apostolos , Meves Sakia H , Vadikolias Konstantinos , Voumvourakis Konstantinos , Haršány Michal , Heliopoulos Ioannis , Papageorgiou Sokratis , Georgakarakos Efstratios , Tampaki Ekaterini-Christina , Lazaris Andreas , Piperidou Charitomeni , Stamboulis Elefterios , Stefanis Leonidas , Lazarides Miltos , Vasdekis Spyros N
Published: March 2022

Background&Purpose:
Although the latest AHA recommendations suggest that CEA should be performed within two weeks of the index event in patients with sCAS, only a minority of patients undergoes surgery within the recommended time-frame because of a perceived higher incidence of complications. The aim of this international, multicenter study was to prospectively evaluate the safety of early CEA in patients with SCAS in “everyday clinical practice” settings.

Subjects&Methods:
Consecutive patients with non-disabling (modified Rankin Scale grade<3) acute ischemic stroke (AIS) or TIA due to sCAS (≥70%) underwent early (≤14 days from symptom onset) CEA at five tertiary care stroke centers during a two-year period. Primary outcome events included any stroke, myocardial infarction (MI) or death occurring during the 30-day follow-up period and were defined according to the International Carotid Stenting Study criteria. Secondary outcome events included cranial nerve palsy (CNP) and neck hematoma (NH).

Results:
A total of 165 patients with sCAS (mean age 69±10years; 69% men; 70% acute ischemic stroke, 30% TIA; crescendo TIA 6%; contralateral internal carotid artery occlusion 8%) underwent early CEA during the study period. The median elapsed time from symptom onset to carotid revascularization was 8 days (range 1-14). A total of 20 (12%) patients underwent urgent CEA (within two days from symptom onset). The primary outcomes of stroke and MI were 4.8% (95%CI: 1.5%-8.1%) and 0.6% (0%-1.8%) respectively. All strokes included cerebral infarctions that occurred in the territory of the symptomatic internal carotid artery (ICA). The combined outcome event of non-fatal stroke, non-fatal MI or death was 5.5% (2.0%-9.0%). The rates of CNP and NH were 6.7% and 3.6%. Crescendo TIA, contralateral ICA occlusion and urgent CEA were not associated (p>0.2) with a higher rate of peri-procedural events.

Conclusions:
Our findings indicate that the risk of early CEA in consecutive unselected patients with non-disabling stroke or TIA due to sCAS is acceptable when the procedure is performed within 2 weeks as well as within 2 days from symptom onset.
Abstract 6: Response to Thrombolysis Treatment in Ischemic Stroke Patients With and Without Arterial Occlusion on Computed Tomographic Angiography: The Third International Stroke Trial
Authors: Mair Grant , Wardlaw Joanna M , von Kummer Ruediger , Sandercock Peter A ,   The IST-3 Collaborative Group
Published: March 2022

Background:
The Third International Stroke Trial (IST-3) is a multicenter, randomised open label blinded outcome assessment controlled trial (RCT) testing i.v. thrombolysis (rt-PA) given within 6 hours of ischemic stroke: 3035 patients in whom indications for rt-PA were uncertain were randomised to rt-PA 0.9mg/kg or control after plain brain imaging. We also collected CT angiography (CTA) scans from centers where this was routinely performed. We tested whether the presence or absence of arterial occlusion on CTA influenced the effect of rt-PA on 6-month Oxford Handicap Score (OHS).

Methods:
We included all IST-3 patients with pre-randomisation CTA. One observer analysed all CTAs blind to follow-up imaging and all clinical data. We tested the association between CTA-identified arterial occlusion and 6-month OHS, with and without rt-PA, in an ordinal regression model with age, National Institutes of Health Stroke Scale (NIHSS) and time from onset as covariates. Odds ratios (OR) for the effect of rt-PA on OHS in those with vs without CTA arterial occlusion were compared.

Results:
Pre-randomisation CTA was performed in 272/3035 patients (44.5% male, median age 81 years, IQR 71-86). CTA showed arterial occlusion in 42% (115/272). CTA-demonstrated arterial occlusion at randomisation reduced the odds of good outcome (OR 0.43, 95%CI 0.25-0.76, p=0.003). The effect of rt-PA on good outcome did not differ significantly between patients with (OR 1.60, 0.71-3.63, p=0.260) vs. without (OR 0.89, 0.50-1.57, p=0.684) CTA occlusion (p-value for difference 0.249) although the direction of effect differed.

Conclusion:
Patients with arterial occlusion on CTA had worse 6-month outcome but we did not find a significant rt-PA-occlusion interaction in these patients. However the sample size limits detection of a modest interaction. The suggestion that patients with occlusion might benefit more could be tested in individual meta-analysis to achieve a larger sample size.
Abstract 68: Safety and Effectiveness of Intensive Blood Pressure Management in the Elderly: Findings From the Secondary Prevention of Small Subcortical Strokes Trial
Authors: White Carole L , Szychowski Jeff M , Pergola Pablo P , Lau Helena W , Benavente Oscar R
Published: March 2022

Background:
Despite being at greatest risk for stroke, older adults are less likely to receive the same level of vascular risk factor management as younger adults. Our objective was to examine the safety and effectiveness of intensive systolic blood pressure (SBP) management in the elderly cohort of the Secondary Prevention of Small Subcortical Strokes (SPS3) trial.

Methods:
SPS3 is an international trial that evaluated SBP targets (< 130 mmHg vs. 130-149 mmHg) for secondary stroke prevention in patients with recent lacunar stroke. Elderly were defined as ≥ 75 years at study entry and compared with patients < 75 years on adherence to SBP targets, presence of side-effects, and risk of recurrent stroke, cardiac events, and death. Interactions between age and SBP targets on outcomes were examined.

Results:
Of the 3020 participants in SPS3, 494 (16%) were ≥ 75 years (mean age 80 years). Mean achieved SBP across all follow-ups was similar (older and younger groups respectively, lower target: 125.2 (15.8) vs. 125.1 (14.4), p=0.62; higher target: 137.1 (14.6) vs. 137.1 (14.4), p=0.95). Adherence to medications and follow-up visits was similar. There was no difference by age group in rates of postural hypotension and serious complications of hypotension. There was no difference in the effect of the SBP intervention by age group on stroke (p=0.39), cardiac events (p=0.62), and all-cause mortality (p=0.29). There was a significant interaction for vascular death (p=0.049). While there was no association with SBP treatment group and vascular death in the younger group (HR: 1.17; 95% CI: 0.68-2.01), there was a significant reduction in vascular death for the elderly in those assigned to the lower target (HR: 0.42; 95% CI: 0.18-0.98).

Conclusions:
These results provide evidence that elderly (≥75 years) can safely tolerate lowering of SBP. In addition to similar benefit as their younger counterparts regarding stroke, cardiac events, and all cause mortality, elderly SPS3 participants had a decreased risk of vascular death. To decrease the growing stroke burden it is critical that age disparities in treatment are eliminated.
Abstract 72: Comparative Effectiveness of Intravenous Thrombolysis in patients with Mild Ischemic Stroke
Authors: Choi Jay Chol , Jang Min Uk , Kang Kyusik , Park Jong-Moo , Ko Youngchai , Lee Soo-Joo , Kim Dae-Hyun , Cha Jae-Kwan , Park Sang Soon , Park Tai Hwan , Lee Kyung Bok , Lee Jun , Kim Joon-Tae , Cho Ki-Hyun , Yu Kyung-Ho , Oh Mi-Sun , Lee Byung-Chul , Cho Yong-Jin , Kim Dong-Eog , Lee Ji Sung , Lee Juneyoung , Bae Hee-Joon
Published: March 2022

Background:
One third of patients with initially mild strokes have unfavorable outcome, and the efficacy of intravenous thrombolysis (IVT) in those patients has not proven. This study aimed to evaluate the comparative effectiveness of IVT over no thrombolysis in patients with mild ischemic stroke presenting within 4.5 hours of onset.

Methods:
From a multicenter prospective stroke registry database, we identified acute ischemic stroke patients (1) who were aged 18 years or more, (2) whose neuroimaging confirmed relevant acute ischemic lesions, (3) who were presented within 4.5 hours of onset, and (4) whose initial NIHSS scores were 5 points or less. Matching and inverse probability of treatment weighting (IPTW) by propensity score (PS) were used to remove baseline imbalance between the IVT and no treatment groups. Further adjustments for potential confounders were made in the IPTW analysis. The adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) of IVT compared to no treatment were calculated for 3-month modified Rankin Scale (mRS) 0-1 (primary efficacy outcome), the full distribution of mRS scores (sedoncary efficacy outcome, by an ordinal logistic regression analysis), and symptomatic hemorrhagic transformation (sHT, safety outcome).

Results:
Between April 2008 and May 2012, 13,117 stroke patients were hospitalized to the 12 participating centers. Among them, 1,386 subjects met the eligibility criteria, and 194 (14.0%) were treated with IVT. The proportions of 3-month mRS 0-1 were not different between the IVT and no treatment groups (71% vs. 75%, p=0.18), but those of sHT were different (4.1% vs. 0.5%, p<0.001).

The adjusted ORs (95% CIs, p values) were 1.46 (0.95-2.25, 0.08) by PS-matching and 1.47 (0.77-2.82, 0.24) by IPTW for 3-month mRS 0-1; 1.05 (0.73-1.49, 0.80) by PS-matching and 1.09 (0.65-1.81, 0.75) for an increment of 3-month mRS score; and 7.47 (1.52-36.64, 0.01) by PS-matching and 3.85 (0.82-18.06, 0.09) by IPTW for sHT.

Conclusion:
This comparative effectiveness analysis based on the large multicenter stroke registry database failed to prove the superiority of intravenous thrombolysis over no treatment in patients with mild ischemic stroke.
Abstract 85: One Size Does Not Fit Fall: Does a Successful Inpatient Fall Reduction Program Benefit Stroke Patients?
Authors: Richardson Alicia M , Reinhardt Kristine M , Leonhardt Ann M
Published: March 2022

Background:
A fall reduction program on an inpatient neurology unit was initiated in 2012 and successfully reduced falls by 51%, but the total percentage of falls among stroke patients increased. In 2011 the percentage of stroke patients who fell was 26%(9/35), in 2012 35%(6/17), and by July 2013 they were up to 50%(6/12).

Purpose:
To identify unique fall risk factors for stroke patients.

Methods:
All falls data from 1/2011-7/2013 was retrieved and within this sample two groups were compared, stroke falls versus non-stroke falls. Significance, p<0.05.

Results:
Within this 36 month period, 64 patient falls occurred; n=21 (33% stroke falls) and n=43 (67% non-stroke falls). Between the stroke falls versus non stroke falls, there were no differences in age or sex but independent patients prior to admission were more likely to be stroke patients with subsequent hospital falls. None of the stroke patients were discharged home, with 81% requiring a higher level of care.

Conclusions:
Stroke patients have unique risk factors that are not fully captured using our current risk assessment tool, which emphasizes prior falls and mental status. This analysis supports assigning higher risk scores to those independent prior to their stroke and in need of higher level of care at discharge.
Abstract 91: Relationship Between Joint Commission Comprehensive Stroke Center Designation and Sparrow Hospital Lansing, Michigan in Conjunction with Michigan State University Department of Neurology
Authors: Shell Erin L , Rose Terry , Bey Julie , Paalman Rebecca , Hussain Syed
Published: March 2022

Background:
Sparrow Hospital, a 600 bed teaching hospital, achieved Comprehensive Stroke Center (CSC) certification in February, 2013. The impact of institutional efforts toward CSC designation on patient satisfaction was unknown.

Objective:
To determine if the continuous quality improvement efforts of the stroke team for Comprehensive Stroke Center certification impacted stroke inpatient satisfaction scores.

Methods:
A total of 600 patients at Sparrow, 18 years and older, who were discharged home following overnight stay with stroke-related DRGs between January 2012 through June 2013 were included. Period A is January 2012-December 2012. Period B is January 2013 -June 2013 after designation of CSC status. Patient satisfaction was assessed and compared via analysis of HCAHPS surveys from January 2012-June 2013 for patients discharged from units that provide the majority of stroke care at this institution.

Results:
The average patient satisfaction percentages for several key drivers were examined. Patient perception of “Nursing Communication” remained stable at 84% for period A and period B. Statistically significant differences between Sparrow’s scores and the benchmarks for each indicator at the 0.5 level are compared. “Satisfaction” improved by 1% in period B. Patient perception of “Pain Management” significantly improved to 82% in period B from 74% in period A. Finally, “Likely to Recommend” increased significantly as well. Period B score was 92% compared to 80% in period A.

Conclusions:
Patients admitted to Sparrow’s Stroke Unit after CSC designation reported higher levels of patient satisfaction in the areas of “Nursing Communication”, overall “Satisfaction”, “Pain Management” and “Likely to Recommend” .

Discussion:
Further studies are needed to understand the complex relationships between improved clinical stroke care and patient satisfaction.

**This publication was supported, in part, by Sparrow Hospital, as well as the Michigan State University Department of Neurology
Abstract 93: Adherence to Mediterranean Diet and Prediction of Incident Stroke
Authors: Tsivgoulis Georgios , Psaltopoulou Theodora , Wadley Virginia , Alexandrov Andrei V , Howard George , Unverzagt Frederick W , Moy Claudia , Howard Virginia J , Kissela Brett , Judd Suzanne
Published: March 2022

Background&Purpose:
There are limited diet regarding the potential association of adherence to Mediterranean Diet (MeD) with incident stroke. We sought to determine longitudinally the relationship between higher adherence to Mediterranean diet and lower likelihood of incident stroke before and after controlling for factors that are independently related to cerebrovascular disease burden by capitalizing on the large, geographically dispersed, race- and gender-balanced sample of REGARDS subjects.

Subjects&Methods:
A prospective, population-based, cohort of individuals enrolled in REGARDS Study was evaluated after excluding participants with history of stroke and missing data with respect to demographic, cognitive or food intake variables. Adherence to a MeD was computed from Food Frequency Questionnaires (FFQ) and was categorized as high, moderate and low using MeD-score tertiles (MeD-score: 6-9, 4-5 & 0-3 respectively). The main outcome of the present analyses was incident stroke that had been diagnosed by a committee of trained clinicians during a mean follow-up period of 5 years. The association of adherence to MeD with incident stroke (ischemic and hemorrhagic) was evaluated using a set of incremental logistic regression models.

Results:
Incident stroke was identified in 565 (1.9%; 497 cases of ischemic and 68 cases of hemorrhagic stroke) out of 30,239 individuals fulfilling the inclusion criteria. After adjusting for age, race, region, gender, income, education, total energy, smoking status, sedentary behavior, body mass index, waist circumference and vascular risk factors, low adherence to MeD was associated with a higher likelihood of incident ischemic stroke (OR versus high adherence: 1.29; 95%CI:0.99-1.67; p=0.057). A similar relationship was documented for moderate adherence to MeD (OR versus high adherence: 1.25; 95%CI:0.98-1.58; p=0.079). We documented no association of adherence to MeD with incident hemorrhagic stroke (p=0.38). There was no interaction of race (p=0.38) on the association of adherence to MeD with incident ischemic stroke.

Conclusions:
Low adherence to MeD was associated with a higher likelihood of incident ischemic stroke independent of numerous potential confounders.
Abstract 98: Stroke Recurrence Rates are Not Changing over Time
Authors: Lee Ikjae , Sucharew Heidi , Alwell Kathleen , Moomaw Charles J , Woo Daniel , Ferioli Simona , Khatri Pooja , Flaherty Matthew , Adeoye Opeulu , Mackey Jason , Martini Sharyl , de los Rios La Rosa Felipe , Broderick Joseph P , Kleindorfer Dawn , Kissela Brett
Published: March 2022

Background:
Previous studies reported that recurrence rates after first ischemic stroke did not change from 1950 to 1989. We hypothesized that advances in secondary stroke prevention since 1990 would lead to a decrease in recurrence rates. We present the first population-based assessment of stroke recurrence rates over time since 1989.

Methods:
We identified all hospitalized strokes during 4 study periods (7/93-6/94 and calendar years 1999, 2005, and 2010) among residents of the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) region (pop. 1.3M) by screening ICD9 codes of all inpatient and emergency department visits. Cases were abstracted by study nurses and verified by study physicians. Results for 2010 are preliminary. Among patients with initial ischemic strokes, we identified recurrent strokes, defined as any stroke (ischemic or hemorrhagic) that occurred after 14 days of the index stroke or that occurred within 14 days in a different vascular territory. Recurrence rates were calculated by Kaplan-Meier life-table analysis.

Results:
We identified 6858 index strokes and 284 recurrent strokes, of which 19 (6.7%) were intracerebral hemorrhages. The table shows the proportion of recurrent strokes in each of the 4 study periods at various times after the index stroke. Mean follow-up times ranged from 147 to 170 days. We found no statistically significant difference in recurrence rates in the GCNKSS population over the 4 study periods.

Conclusions:
Despite several advancements in recurrent stroke prevention, we found no change in stroke recurrence rates over 4 study periods between 1993/94 and 2010 within our large, biracial population. Compared with stroke risk after TIA, the risk of recurrent stroke is relatively low within the first 30 days, but gradually increases over time. Further studies are needed to characterize the utilization of secondary stroke prevention methods within this population.
Abstract NS18: Objective Fall Risk Detection in Stroke Survivors
Authors: Taylor-Piliae Ruth E , Najafi Bijan , Coull Bruce M
Published: March 2022

Background:
Stroke survivors fall up to 7 times more annually than healthy adults. Clinical and laboratory-based measures have failed to accurately predict falls/fall risk. A wearable mobile device for objectively detecting falls/fall risk in stroke survivors has recently been developed.

Purpose:
Determine the feasibility of monitoring falls, fall risk and gait in naturalistic environments using a kinematic motion sensor (PAMSys™) in stroke survivors.

Methods:
Feasibility study using PAMSys™ worn in a comfortable t-shirt to detect falls, identify posture (gait, sitting, standing, lying), postural transitions (fall risk indicators: duration in seconds, and number of unsuccessful attempts) and gait (steps, speed, duration). A questionnaire assessed acceptability of the PAMSys™. Stroke survivors (n=10) wore the PAMSys™ for 48 hours during usual daily activities, and were age-matched with controls (n=10).

Results:
Stroke survivors were on average 70±8 years old and 42±25 months post-stroke. The majority were 60% Caucasian, 70% women, 70% college-educated, and 80% retired; reporting 60% ischemic stroke, 40% hemorrhagic stroke, 70% hemiparesis, and 70% 1st stroke. Stroke survivors (100%) reported that the PAMSys™ was comfortable to wear for the full 48 hours, did not interfere with normal everyday activities and were willing to wear it for another 48 hours. None reported any difficulty with the PAMSys™ while sleeping, removing/putting back on for showering/changing clothes or that it became wet/dirty. Although there were no falls during the study, when compared to age-matched controls, stroke survivors had significantly worse fall risk indicators and decreased gait duration (see Table).

Conclusion:
Since the majority of fall-related events occur at home, the use of wearable mobile technology in stroke survivors may be essential to enhance recovery and prevent injuries. This device could be of use as an outcome measure in certain types of clinical trials.
Abstract NS21: HealtheCongregations: Preventing Stroke Through Stroke Tele-Education
Authors: Schweickert Patty A , Lomboy Andrea C , Solenski Nina
Published: March 2022

Background:
Stroke prevention education is part of the continuum of stroke care. The effectiveness of improving stroke knowledge using a combined academic and community provider based stroke tele-education program specifically targeted to the rural faith community was evaluated.

Objective:
To determine if stroke tele-education increases knowledge about stroke prevention.

Methods:
A quasi-experimental nonequivalent one group pretest/posttest design using a convenience sample of 22 subjects (20% men, 80% women) with mean age of 55 was selected from a southern congregational community. Subjects completed pre-education surveys; received two 30-minute telehealth delivered education sessions weekly for 4 weeks, and completed post-intervention surveys.

Results:
A significant difference between pre-posttest knowledge (p≥0.05) and likelihood of reducing vascular risk factors (p≥0.05) after intervention was found. Satisfaction with delivery method was high as participants appreciated this unique solution to addressing community health needs through direct but remote expert stroke education. This program demonstrated that tele-education is effective in motivating subjects to reduce stroke risk factors. Thus, the stroke tele-education program had a positive impact on knowledge, likelihood of making behavioral changes, and being a satisfactory mode of education in a community congregational health setting.

Conclusions:
This project demonstrates effectiveness and feasibility of providing a high risk population access to telehealth stroke education by using faith-based community network leaders in collaboration with a remote site academia to rural underserved areas. Stroke tele-education was found to be satisfying, improved knowledge of stroke, and increased likelihood of making changes to decrease vascular risk factors. It provides the opportunity to increase community interaction and support among differing faith communities through collaboration with the medical community through use of telehealth.
Abstract NS5: Feasibility of an Electronic Point-of-Discharge Tablet for Collection of Perception of Stroke Care Quality Data
Authors: Cudlip Fern , Swatzell Victoria , Alexandrov Dmitri A , Freier Meghan R , Rowek Tara , Wojner Alexis J , Alexandrov Anne W
Published: March 2022

Background:
Perception of hospital quality is typically collected from mailed surveys distributed to a random sample of discharges. These surveys capture few strokes, and fail to capture data addressing preparedness for transition to home, ability to identify/respond to stroke symptoms, or perceptions tied to acute stroke team performance. We sought to determine the feasibility of using an iPAD™ for collection of stroke perception of care data using the reliable/valid STROKE Perception Report (SPR) instrument.

Methods:
A cloud-based SPR database was established and IRB approval was obtained at 5 U.S. study sites. Consecutive stroke patients were offered an iPAD™ for data entry immediately prior to discharge. Families completed the survey for patients with severe stroke. Data were downloaded for analysis in SPSS.

Results:
A total of 153 surveys were collected with 101 (67%) collected from stroke patients averaging 62+/-14 years (median 62, range 19-94 years). Subjects were 74% White, 14% African American, 6% Asian, 2% Native Hawaiian/Pacific Islander, and 4% Native American/Alaskan Native; 17% were Hispanic. Education was: 37% high school (HS) graduates, 26% some college, 20% college graduates, 12% >college degree, and 5% some HS. The median score for difficulty was 4 (easy to use); only 2% (patients) rated data entry difficult. No users rated their entries as “at risk for confidentiality/privacy loss,” and 77% perceived entries as “more confidential” than paper entries. Of note, 62% indicated that they do not respond to mailed surveys. There was no difference in “ease of use” or “confidentiality protection” by patients, families, or race, however, higher levels of education with associated with perceptions of improved confidentiality (Chi Square 16.3; p=0.039). Interestingly, as patient age increased, perceptions of difficulty of use decreased (r=.29; p=0.029).

Conclusions:
Use of an electronic tablet to collect important perception of care data in stroke patients or family at discharge is feasible, and may constitute an improved method for obtaining sample sizes sufficient to draw conclusions about stroke service quality. Our findings support use of a discharge data collection model that can be widely disseminated regardless of age and education.
Abstract NS9: Retention of Stroke Education Provided During Hospitalization: Increasing Stroke Knowledge or Wasting Resources?
Authors: Handler Diane , Alexandrov Anne W
Published: March 2022

Background:
Provision of stroke education for patients and/or family members is an accreditation and CMS requirement for Stroke Centers. However, little is known of the retention of educational content after hospital discharge. We sought to determine retention of stroke education content at 4-6 weeks post-hospital in a Midwest community hospital sample.

Methods:
From September 2010 to May 2013, patients or primary caregivers returning to our Stroke Clinic at 4-6 weeks post-discharge from 2 Joint Commission Primary Stroke Centers were tested to determine retention of stroke education presented during hospitalization. Test questions covered 4 stroke education components: Recognition of signs and symptoms; personal risk factors; 911 utilization; and, understanding prescribed medications to prevent stroke. Each test was tailored to contain content personalized to individual patient risk factors and medications.

Results:
A total of 198 patients completed testing, of which 49 (25%) scored 100% correct; 69 (35%) patients scored 75% correct, 49 (25%) patients scored 50% correct, 24 (12%) patients scored 25% correct, and 7 (3%) patients got all test questions wrong. Interestingly, the question most commonly graded as incorrect (n=117) related to understanding personal risk factors for stroke. Stroke signs and symptoms were incorrectly identified by 74 patients, and 52 patients did not correctly understand their medications; only 19 patients failed to identify use of the 911 system for new onset symptoms.

Discussion:
While stroke education is required during hospitalization, its value to retention of important information remains poorly understood. Given that retention of simple education (calling 911) was most successful during hospitalization, stroke patients and caregivers may be best supported by provision of simple sound-bytes of information, and then followed post-discharge with more advanced teaching.
Abstract T MP109: Tocotrienol Induces TIMP1 Expression and Pro-arteriogenic Remodeling of Cerebrovascular Collaterals
Authors: Khanna Savita , Heigel Mallory , Gnyawali Surya , Sen Chandan K , Rink Cameron
Published: March 2022

Introduction:
Tocotrienols (TCT), lesser-known vitamin E family members, improve perfusion to brain tissue and attenuate stroke injury. Mechanisms underlying TCT improvement of collateral perfusion during ischemic stroke, however, remain unclear. Arteriogenesis is defined by the growth of functional collaterals in brain tissue where tissue inhibitor of metalloproteinase-1 (TIMP1) is believed to play a key role in extracellular matrix remodeling.

Objective/Hypothesis:
We tested the effect of prophylactic TCT on arteriogenesis by measuring collateral diameter and quantity in stroke-affected brain. Gene and protein expression of TIMP1 was queried in isolated collaterals as a key regulator of arteriogenesis. We hypothesize that TCT increases collateral size and number, and induces TIMP1 expression in collaterals of stroke-affected brain.

Methods:
C57/BL6 mice (male, 5 wks) were orally gavaged daily with 50mg/kg body weight of TCT or volume matched placebo (n=12) for 10 wks prior to middle cerebral artery occlusion (MCAO). During MCAO, cerebral perfusion was monitored using laser speckle flowmetry. While ischemia persisted, mice were perfused with FITC-conjugated lectin to identify patent collaterals in the MCA territory of the stroke-affected hemisphere. Collaterals size (diameter) and number were quantified as CD31+/FITC-lectin+ arterioles in stroke-affected S1 cortex and collected by laser capture microdissection. TIMP1 gene and protein expression in laser-captured collaterals was determined by RT-PCR and Western blot.

Results:
Compared to placebo, TCT treatment significantly increased perfusion (38.7%, p<0.05), collateral size (21.2%, p<0.05), and collateral number (5.7-fold, p<0.05) during MCAO. Prophylactic TCT supplementation significantly induced TIMP1 expression 9.6-fold (p<0.05) in laser-captured collaterals as compared to placebo controls.

Conclusions:
TCT induced expression of TIMP1 in brain collaterals and enabled arteriogenic remodeling for functional collateral growth and protection against ischemic stroke. As TCT is a safe, natural nutrient, proposal outcomes may quickly translate toward clinical applications for high-risk stroke patients, such as those who suffer a transient ischemic attack (TIA).
Abstract T MP14: Clinical Outcomes Following Thrombolysis for Acute Ischemic Stroke in Patients with Primary Brain Tumors: A Nationwide Population Study
Authors: Murthy Santosh B , Shah Shreyansh , Karanth Siddharth , Shastri Aditi , Bershad Eric , Suarez Jose I
Published: March 2022

Background:
There are no large studies evaluating the safety of thrombolysis for acute stroke in patients with brain tumors and hence, these patients are often excluded from thrombolytic therapy. Our aim is to study stroke outcomes following thrombolysis in patients with primary brain tumors.

Methods:
Acute ischemic stroke (AIS) patients who received thrombolysis were identified from the 2005-2010 Nationwide Inpatient Sample using ICD-9 codes. Patients with primary brain tumor-associated strokes (BTS) including both benign and malignant tumors, and non-brain tumor associated strokes (NBTS) were compared based on demographics, comorbidities, hospital characteristics, and outcomes. Intracranial metastases and spinal tumors were excluded. The main outcomes were in-hospital mortality and intracerebral hemorrhage (ICH).

Results:
We identified 2,964,733 patients with AIS from 2005-2010. Thrombolysis was administered to 272 out of 18,441(1.5%) BTS patients, and 89,680 out of 2,856,612 (3%) NBTS patients. BTS correlated with higher age quartiles (p<0.001) and female sex (69.5% vs. 49.7%, p<0.001). While vascular risk factors such as hypertension and hyperlipidemia were similar in the two groups, atrial fibrillation was more common in BTS (42.3% vs. 23.2%, p<0.001). In the univariate analysis, ICH rate after thrombolysis was significantly higher in the BTS cohort (OR: 2.19, CI: 1.57-3.76, p<0.001), while mortality was similar. In the multivariate analysis, there was no difference in hospital mortality between the two groups following thrombolysis; however, ICH remained significantly higher among BTS (OR: 2.16, CI: 1.53- 3.03, p<0.001) after adjusting for confounders. In the regression model on brain tumor patients with AIS, the main predictors of ICH were malignant pathology of tumors (OR: 1.27, CI: 1.05-1.55, p<0.001) and administration of thrombolytic therapy (OR: 5.10, CI: 3.55-7.35, p<0.001).

Conclusions:
Thrombolytic therapy for acute stroke in patients with primary brain tumors is associated with increased risk of ICH. Cardioembolic strokes appear to be more common in BTS. Stroke outcomes following thrombolysis are less favorable in malignant brain tumors compared to benign tumors. Prospective confirmation is warranted.
Abstract T MP18: Physical Activity Prior to Stroke May Exert Neurorestorative Effects by Increasing Vascular Endothelial Growth Factor Expression after Acute Ischemic Stroke
Authors: Lopez-Cancio Elena , Sobrino Tomas , Campos Francisco , Ricciardi Ana Clara , Pérez de la Ossa Natalia , Hernández-Pérez Maria , Gomis Meritxell , Dorado Laura , Arenillas Juan F , Dávalos Antonio
Published: March 2022

Objective:
Previous studies by our group have found an independent association between pre-stroke physical activity (PhA) and good functional outcome in a cohort of patients with a cerebral large vessel occlusion. In this study our aim was to evaluate the possible molecular mechanisms by which PhA exerts its neurorestorative effect by studying angiogenic and neurogenic growth factors at different timepoints after stroke onset.

Methods:
We included 159 consecutive previously independent patients with an acute stroke due to MCA or TICA occlusion within the first 8 hours from stroke onset. Pre-stroke PhA was evaluated with the international physical activity questionnaire (IPAQ) and subjects were classified into 2 groups: low and high level of pre-stroke PhA. We measured serum levels of Vascular Endothelial Grow Factor (VEGF), Granulocyte Colony-Stimulating Factor (G-CSF) and Brain-Derived Neurotrophic Factor (BDNF) at admission, day 7, and 3 months. We considered good functional outcome at 3 months (mRS ≤ 2) as primary endpoint.

Results:
Mean age was 68 and median NIHSS 17. Serum levels of VEGF, G-CSF and BDNF at admission were similar among patients with good (46.5%) and poor (53.5%) functional outcome, However, VEGF and G-CSF serum levels were significantly higher at 7 days and 3 months (p<0.05) in those patients who showed good functional outcome, emerging as independent predictors of good outcome in adjusted logistic regression analyses. When we studied the temporal profile of biomarkers in the different groups of pre-stroke PhA, we observed that those more physically active before stroke had a significantly higher increment of VEGF at day 7 compared to those with low PhA level. In a logistic regression model adjusted for age, sex, baseline NIHSS, reperfusion therapies administered, VEGF increment at day 7 and level of PhA previous to stroke, both VEGF increment and high level of pre-stroke PhA emerged as independent predictors of good functional outcome with and OR 7.7 and 33 respectively, p<0.05.

Conclusion:
Beneficial effect of pre-stroke PhA in stroke outcomes may be mediated by increasing the expression of VEGF in the first days after stroke, triggering angiogenesis processes.
Abstract T MP2: Efficacy of Endovascular Therapy in Acute Ischemic Stroke with Major Artery Occlusion of Anterior Circulation -RESCUE-Japan Registry-
Authors: Yamagami Hiroshi , Yoshimura Shinichi , Enomoto Yukiko , Egashira Yusuke , Sakai Nobuyuki , Okada Yasushi , Kitagawa Kazuo , Kimura Kazumi , Tanahashi Norio , Hyogo Toshio ,   RESCUE-Japan Investigators
Published: March 2022

Background and Purpose:
Efficacy of endovascular therapy (EVT) for acute ischemic stroke (AIS) has not been established. In the Japanese nationwide registry study, we aimed to clarify the impact of EVT on outcomes in AIS patients with major artery occlusion of anterior circulations.

Methods:
In the Recovery by Endovascular Salvage for Cerebral Ultra acute Embolism (RESCUE)-Japan registry, 1442 AIS patients with major artery occlusion within 24 hours after the onset were recruited between July 2010 and Jun 2011. Among them, patients with occlusion of anterior circulation were categorized into 2 groups according to site of occluded arteries: internal carotid artery (ICA) or middle cerebral artery (MCA) M1 proximal occlusion as Group P, and MCA M1 distal, M2 or M3 occlusion as Group D. In each group, we examined the relations between EVT and favorable outcome defined as modified Rankin Scale≦2 at 90days.

Results:
482 patients were categorized into Group P (men, 257; mean age,74.6±12.1 years; median baseline National Institute of Health Stroke Scale [NIHSS] score, 18 [IQR 13-22]), and 373 patients were into Group D (men, 204; mean age, 74.2±10.6 years; median baseline NIHSS score, 13 [IQR 7-19]). EVT were performed in 158 patients (32.8%) in Group P and 92 (24.7%) in Group D. In Group P, patients treated with EVT had similar NIHSS score (17.3 vs 17.7) and higher the Alberta Stroke Program Early CT Score on diffusion-weighted imaging (DWI-ASPECTS) on admission (7.4 vs 5.9 P<0.001), and achieved higher rate of favorable outcome (33.5% vs 13.9%, P < 0.001) compared to those without EVT. Whereas in Group D, patients treated with EVT had higher NIHSS (15.0 vs 12.7, P=0.01) and similar DWI-ASPECTS (7.9 vs 7.9), and achieved similar rate of favorable outcome (40.2% vs 45.6%, P=0.40) compared to those without EVT. In a multivariate logistic regression analysis, EVT was related to favorable outcome in Group P (Odds ratio [OR] 2.54, 95% confidence interval [CI] 1.42 - 4.52), but not in Group D (OR 0.74, 95% CI 0.39-1.41).

Conclusions:
Endovascular therapy can improve the clinical outcome in AIS patients with ICA or M1 proximal occlusion.
Abstract T MP24: Are There Disparities in Thrombolytic Treatment and Mortality in Acute Ischemic Stroke in the Hispanic Population Living in Border States versus Non-Border States?
Authors: Hassan Ameer E , Adil Malik M , Zafar Taqi T , Umair Muhammad , Tekle Wondwossen G , Sanchez Olive , Qureshi Adnan I
Published: March 2022

Background:
Recent studies have found an underutilization of hospital in-patient care for coronary artery disease in Hispanics living in Border States.

Objective:
To identify acute treatment disparities in acute ischemic stroke Hispanic patients and determine the effect of such disparity on patient outcomes.

Methods:
We identified Hispanic and non-Hispanic acute ischemic stroke patients from the Nationwide Inpatient Sample-2011 data files. We determined the rate of utilization of thrombolytics and outcomes according to patient’s demographic and clinical characteristics and whether or not they lived in a Border state (defined as California, Arizona, New Mexico and Texas).

Results:
A total of 34,904 Hispanic patients were admitted with ischemic stroke; of those 21,130 were admitted in Border states and 13,774 in non-Border states. Patient demographics, risk factors, complications and discharge disposition are included in the Tables below. There was a significantly lower rate of thrombolytic use in Hispanic patients (1013 (4.8%) and non-Hispanics (5326 (5.7%, p=0.05). After adjusting for age, gender, and other confounding risk factors, Hispanics were 30% more likely to suffer in-hospital mortality versus there non-Hispanic counter-parts in Border states [OR 1.3 (1.1-1.6) p=0.009], which was not apparent in the non-Border states [OR 1.0 (0.8-1.2) p=0.9].

Conclusions:
There was an underutilization of thrombolytics and higher mortality in the Hispanic population admitted in Border States but not in non-Border States. Further studies are warranted to better understand the associated factors.
Abstract T MP28: High Rate of Symptomatic Intracranial Stenosis (sICS) in Patients Treated with Systemic Thrombolysis at a United States Stroke Belt Tertiary Care Center
Authors: Sands Kara A , Bavarsad Shahripour Reza , Tsivgoulis Georgios , Lyerly Michael J , Kumar Gyanendra , Sisson April , Rawal Pawan V , Alvi Muhammad , Kapoor Niren , Houston J. T , Alexandrov Andrei V
Published: March 2022

Background & Purpose:
sICS is a common mechanism for acute ischemic stroke (AIS), believed to preferentially affect Asians and Blacks compared to Whites. In the U.S., the reported rates of sICS for regions other than the Stroke Belt are 17% among hospitalized Blacks and 9% among Whites with AIS. We aimed to determine the rate of sICS among stroke patients treated at our Southeastern U.S. center.

Subjects & Methods:
Consecutive AIS patients receiving IV tPA admitted to our tertiary center were routinely evaluated for the presence of intracranial stenosis (≥50% diameter reduction in the intracranial vessel supplying the affected territory) using either CT-angiography, catheter angiography, contrasted MRA or standardized transcranial Doppler (TCD). All imaging studies were performed following reperfusion therapy within 48 hours from symptom onset. Our published TCD criteria were previously validated against WASID measurements. Persisting arterial occlusions (TIMI 0-1 flow) and patients with cardioembolism as the only suspected stroke mechanism were not considered as having sICS.

Results:
We examined 318 patients who received IV tPA at our center in 2010-12 (52% men, mean age 62±16 years, median NIHSS 5, IQR 8, 36% Blacks, 63% Whites, 1% Other) who underwent multi-modal vascular imaging with at least 2 of the 4 abovementioned modalities post treatment. Symptomatic ICS was found in 84 (26%) patients (63% men, 65±17 years, 37% Blacks, 62% Whites, 1% Other). Multiple intracranial stenoses were identified in 26% of patients with sICS (95% CI, adjusted Wald method:17.9%-36.5%). The most common locations of sICS included MCA (34.5%), intracranial ICA (15.5%), and vertebral artery (12%). Only basilar artery stenosis was more common in Blacks (16.1%) than Whites (1.9%; p=0.024).

Conclusions:
Our study showed that approximately 1 out of every 4 AIS patients treated with tPA had sICS as the underlying mechanism of acute cerebral ischemia. Whether the persisting lesions represent partial recanalization of a thrombus or an underlying atheromatous stenosis deserve further investigation in a prospective multicenter study. Furthermore, this is the first report showing that sICS may be more common among Whites in the Stroke Belt of the U.S. than previously thought.
Abstract T MP30: Cerebral Arteriogenesis and Angiogenesis: Distinct Angioarchitecture of Innate and EDAS Collaterals in Intracranial Arterial Steno-Occlusive Disease
Authors: Gonzalez Nestor R , Ooi Yinn , Connolly Mark , Vinuela Fernando , Liebeskind David S , Saver Jeffrey
Published: March 2022

Introduction:
Patients with ICASD form various degrees of collateralization. However, those collaterals fail over time contributing to symptom progression. Indirect revascularization via encephaloduroarteriosynangiosis (EDAS) establishes collateral flow through new vessels formed from external carotid branches in both moyamoya disease (MMD) and non-moyamoya (NM) ICASD. We hypothesize that the EDAS neovascularization differs in terms of angioarchitecture when compared to spontaneously formed collaterals in ICASD.

Methods:
We analyze pre and post-operative digital subtraction angiograms (DSA) of patients enrolled in a prospective trial of EDAS surgery using ImageJ software (http://imagej.nih.gov/ij). Angioarchitectural differences between innate and post-EDAS collaterals were evaluated by comparing their branching angioscore (BA) and artery tortuosity index (ATI).

Results:
Images from 26 patients, ages 4 to 84 (mean: 37 SD+/-19.5) were evaluated. Patients included 13 MMD and 13 NM-ICASD. Postoperative mean DSA time was 14 months. Post-EDAS collaterals had significantly higher BA and lower ATI than innate collaterals (BA: 9.8 vs. 5.5 and ATI 110 vs. 167 [p<0.001] respectively). Subgroup analyses for patients with MMD and NM-MMD demonstrated the same pattern with higher BA for post-EDAS collaterals and lower ATI for innate collaterals (MMD: BA: 9.6 vs. 5.2, and ATI 107.7 vs.176.5, NM-ICASD: BA: 9.9 vs. 5.8, and ATI: 153.7 vs.115.4 p≤0.01). Type of ICASD, age, or time after angiography did not affect the indexes.

Conclusions:
Collaterals formed after EDAS differ in angioarchitecture to innate collaterals in MMD and NM-ICASD. Morphological differences are consistent with two distinct mechanisms of vessel formation: innate collaterals formed by arteriogenesis display high tortuosity and low branching as expected by a shear stress process acting on pre-existing conduits. Conversely, post-EDAS collaterals have higher branching and lower tortuosity as expected in a process of angiogenesis in which collaterals form through sprouting and splitting from the donor vessels.
Abstract T MP31: 3D Computational Flow Model of Intracranial Arterial Stenosis With Physiologic Boundary Conditions
Authors: Connolly Mark , Scalzo Fabien , Liebeskind David , Gonzalez Nestor R
Published: March 2022

Introduction:
Intracranial arterial stenosis (IAS) is a significant cause of ischemic stroke worldwide. Prior studies have identified degree-of-stenosis, time from symptom onset, and gender as predictors of recurrent stroke. However, the role of wall shear stress (WSS), turbulent kinetic energy (TKE), flow velocity (FV), and pressure gradients have not been studied. We present a computational fluid dynamics (CFD) model of IAS extracted from diagnostic imaging with added anatomical details to further investigate these factors.

Methods:
The vascular anatomy was reconstructed from a semi-automatically delineated biplane angiogram to obtain the geometry of the internal carotid artery bifurcation, middle cerebral artery (MCA) and anterior cerebral artery (ACA). Lenticulostriate arteries (LSAs) and 0%, 70% and 90% stenoses were added. A volumetric mesh was generated with more than 2 million tetrahedral cells and used to evaluate the hemodynamic parameters of the models using the ANSYS: Simulation Technology package. The boundary conditions of the MCA and ACA outlets were adjusted based on an autoregulatory model of the distal vasculature.

Results:
In the 0% stenosis model, flow throughout the MCA was laminar observed through the LSAs. Pressure drop, FV, WSS, and TKE were unremarkable. At 70% stenosis, there was an elevated FV through the stenosis (5.4m/s), pressure drop across the stenosis (8.04kPa), distal TKE (0.39m^2/s^2), and WSS distal to the stenosis (25.3Pa) (Figure 1). The 90% stenosis model had high FV and pressure drop (4.2m/s, 10.3kPa), elevated WSS (32.2Pa), but a negligible TKE.

Conclusions:
A CFD model of the IAS based on patient images with added anatomical details can reproduce hemodynamic parameters associated with IAS. The addition of patient-specific flow patterns and arterial wall elasticity could provide further insight into IAS progression and patient outcomes.
Abstract T MP35: Difference in Long-Term Survival After Carotid Endarterectomy Between Standard and High Risk Patients
Authors: Heo Sung Hyuk , Nam Hyojung , Chang Dae-Il , Bu Seon Hee
Published: March 2022

Background:
Large randomized controlled trials have shown that carotid endarterectomy (CEA) in carefully selected patients reduced the risk of stroke and death compared to existing medical therapy alone. Early and long-term mortality after CEA and the predictive factors of major adverse events (MAEs) should be considered when deciding on this procedure.

Methods:
We enrolled the patients who underwent consecutive CEA procedures. Perioperative (≤30 days) and long-term outcome in standard-risk (SR) and high-risk (HR) procedures was obtained. MAE was defined as the occurrence of stroke, death, or myocardial infarction out to 174 months.

Results:
A total of 247 patients underwent 271 CEA procedures. Of these, 157 patients had SR and 90 patients had HR. The 30-day rate of death, myocardial infarction, or stroke was 4.5% among all patients (3.2% for SR vs. 6.7% for HR). Kaplan-Meier analysis showed significant lower survival rate in HR patients (p=0.002). At 5 year, survival rate was 68.1% in SR patients and 28.6% in HR patients, respectively. The most single significant predictor of MAE was coronary artery disease (HR, 3.1; 95% CI, 1.8-5.5).

Conclusion:
In this study of patients underwent CEA, a substantial reduction in long-term survival was observed in high risk patients compared with standard risk patients. Therefore, evaluation and treatment for coronary disease is strongly recommended before and after CEA.