bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP308: Reduced Estimated Glomerular Filtration Rate And Outcomes Of Intracerebral Hemorrhage: The SAMURAI-ICH Study
Authors: MIYAGI TETSUYA , Koga Masatoshi , Yamagami Hiroshi , Okuda Satoshi , Okada Yasushi , Kimura Kazumi , Shiokawa Yoshiaki , Nakagawara Jyoji , Furui Eisuke , Hasegawa Yasuhiro , Kario Kazuomi , Arihiro Shoji , Sato Shoichiro , Osaki Masato , Kobayashi Junpei , Okata Takuya , Sakamoto Yuki , Tanaka Eijirou , Minematsu Kazuo , Toyoda Kazunori ,   SAMURAI Study Investigators
Published: July 2021

Background and Purpose:
The association between chronic kidney disease and clinical outcomes in acute intracerebral hemorrhage (ICH) remains uncertain. We aimed to assess associations of renal dysfunction and outcomes in acute ICH patients treated with intensive BP lowering.

Methods:
The SAMURAI-ICH study was a prospective, multicenter, observational study. A total of 211 patients with acute supratentorial ICH were recruited. BP was targeted between 120 mmHg and 160 mmHg during initial 24 h using intravenous nicardipine. Glomerular filtration rate (eGFR) was calculated using admission serum creatinine. After 23 patients on maintenance hemodialysis were excluded, the remaining 188 were divided into 3 groups as follows: Group 1, eGFR of <60; Group 2, 60 to 75; and Group 3, ≥75 mL/min/1.73m
2
. Clinical outcomes were hematoma expansion of ≥33% at 24 h, neurological deterioration within 72 h (GCS decrement ≥2 points or NIHSS increment ≥4 points), and favorable (modified Rankin Scale [mRS] ≤2) and unfavorable (mRS ≥5) outcomes at 3 months.

Results:
Of 188 patients, 35 (18 women) were allocated to Group 1, 58 (20) to Group 2, and 95 (33) to Group 3. Significant differences among 3 groups were found in age (73.1±13.6, 63.3±13.2, 63.8±9.8 yo; p <0.001) and initial systolic BP (208.9±18.1, 201.2±15.6, 200.2±14.8 mmHg; p=0.018). Initial hematoma volume (14.9±11.9, 15.5±14.9, 14.3±12.3 mL) and initial median NIHSS score (14, 11, 13) were similar among 3 groups. For outcomes, significant differences among 3 groups were found in favorable outcome (17.7%, 51.7%, 41.3%; p=0.004) and unfavorable outcome (22.9%, 10.3%, 5.3%; p=0.021), but not in hematoma expansion (17.1%, 10.3%, 22.1%) and neurological deterioration (11.4%, 8.6%, 7.4%). After adjustment with initial hematoma volume, initial systolic BP and initial NIHSS score, eGFR <60 ml/min/1.73m
2
was inversely associated with favorable outcome (OR 0.20, 95% CI 0.07-0.54) and positively associated with unfavorable outcome (4.27, 1.36-13.53).

Conclusions:
Although decreased eGFR on admission was not associated with initial hematoma volume or initial NIHSS score, it was associated with poor outcomes at 3 months of ICH onset.
Abstract TP309: Subarachnoid Extension of Hemorrhage Is Associated with Poor Outcomes in Primary Intracerebral Hemorrhage
Authors: Maas Matthew B , Nemeth Alexander J , Rosenberg Neil F , Kosteva Adam R , Guth James C , Liotta Eric M , Prabhakaran Shyam K , Naidech Andrew M
Published: July 2021

Background:
Extension of hemorrhage into the subarachnoid space is observed in primary intracerebral hemorrhage (ICH), yet the phenomenon has undergone limited study and is of unknown significance. The objective of this study is to evaluate the incidence, characteristics and clinical consequences of subarachnoid hemorrhage extension (SAHE) in ICH.

Methods:
Patients with primary ICH were enrolled into a prospective registry between December 2006 and July 2012. Patients were managed, and serial neuroimaging obtained, per a structured protocol. SAHE was identified on imaging, along with ICH volumes, by expert reviewers blinded to outcomes. Ordinal regression models were developed to test whether the occurrence of SAHE was a predictor of functional outcomes independent of ICH Score, with confirmation of model validity by appropriate tests.

Results:
234 patients were studied, and 93 (39.7%) had SAHE. SAHE was associated with lobar hemorrhage location (65% of SAHE versus 19% of non-SAHE cases, p<0.001), and larger hematoma volumes (median 23.8 versus 6.65, p<0.001). SAHE was a predictor of higher modified Rankin Scale scores (mRS) at discharge (odds ratio 2.22 per mRS point [95% CI 1.29-3.81]) and 28 days (1.80 [1.04-3.11]) after adjustment for ICH Score.

Conclusions:
SAHE is associated with poor outcomes independent of traditional ICH severity measures. Further exploration of this phenomenon to understand the underlying mechanisms of harm is needed.
Abstract TP312: Longitudinal Functional Connectivity Change Associated With Rehabilitation Training In Sub-acute Stroke Patients
Authors: zhang yumei , wang jun
Published: July 2021

Background and aims:
The neural correlate of the motor recovery associated with different rehabilitation therapy is still unknown in stroke patients. In this study, the resting-state fMRI was employed to identify longitudinal functional connectivity changes associated with different rehabilitation training in sub-acute stroke patients.

Methods:
Twenty-four sub-acute ischemic stroke patients with right-handed were recruited from Beijing Tiantan Hospital, all of the patients had unilateral upper limb paresis. The subjects were randomly divided into conventional rehabilitation training (CRT) group and functional electrical stimulation (FES) training group. The motor function assessments included FMA, ARAT and MAS. Resting-state fMRI scan were acquired on a Siemens 3.0 T scanner at pre-training and post-training. Ipsilesional primary motor cortex (M1) was selected as the region of interest (ROI), then the functional connectivity (FC) with ipsilesional M1 were analyzed respectively for the two groups.

Results:
Compared with CRT group, the motor function assessments showed that each motor index increased significantly in FES group. For CRT group, compared with pre-training, we found that the FC of ipsilesional M1 increased with the contralesional cerebellum crus I&II, medial and inferior temporal gyrus at post-training . On the contrary, for FES group, compared with pre-training, FC of ipsilesional M1 decreased with the contralesional cerebellum crus I&II, medial and inferior temporal gyrus at post-training .

Conclusion:
The different pattern of the longitudinal changes of functional connectivity might contribute to the motor recovery with different rehabilitation training.
Abstract TP315: Ethnic Differences In Rehabilitation Services During Acute Stroke Hospitalization
Authors: Wheaton Michael W , Morgenstern Lewis B , Cox Melinda , Baek Jonggyu , Sanchez Brisa N , Lisabeth Lynda D
Published: July 2021

Introduction:
Mexican Americans (MAs) have higher stroke incidence compared with non-Hispanic whites (NHWs). Differential use of rehabilitation services could impact stroke outcome. This study was performed to compare the utilization of rehabilitation between MA and NHW in the acute stroke hospital setting.

Hypothesis:
MAs have less access to rehabilitation services during acute stroke hospitalization.

Methods:
Data were obtained from the BASIC (Brain Attack Surveillance in Corpus Christi) Project, a population-based study in Texas. All first strokes identified between July 2009 and June 2011 in patients over the age of 44 were included. Rehabilitation services were abstracted from medical records using the Joint Commission’s definitions. Primary outcome measures were whether the patient was 1) assessed , 2) recommended , and 3) received rehabilitation during the acute hospital stay. Receipt of physical therapy (PT), occupational therapy (OT) and speech pathology (SP) were also specified. Rehabilitation services were compared by ethnicity using Fisher’s Exact tests and/or random effects logistic regression to account for hospital specific effects.

Results:
390 validated strokes met inclusion criteria, 63% were MA. There were no ethnic differences in the rehabilitation services (Table 1). Among those who received rehabilitation services, MAs were more likely to receive OT than NHWs in unadjusted analysis (1.87 [C.I. 1.18-2.94]); however, this association was not apparent after accounting for the hospital in which care was received.

Conclusions:
Encouragingly, availability and receipt of inpatient rehabilitation services after stroke in this community is high and no ethnic differences in access are present. While rehabilitation services during acute stroke hospitalization does not appear to explain ethnic differences in stroke outcome, future work should examine post-discharge rehabilitation services.
Abstract TP323: Does Serum Level Of Sex Hormones Before Rehabilitation Predict Functional Recovery In Elderly Post-stroke Patients?
Authors: Momosaki Ryo , Abo Masahiro , Kakuda Wataru
Published: July 2021

Background:
Sex hormone is recognized as a critical factor affecting physical function in the elderly. However, the influence of these hormones on functional recovery after stroke has not been studied in elderly patients. The objective of the study was to examine whether serum level of sex hormones before rehabilitation can predict clinical outcome in elderly post-stroke patients.

Subjects and Methods:
Seventy-on post-stroke hemiparetic patients who were hospitalized to our rehabilitation ward in their subacute-chronic phase, were subjected (age: 78 ± 6 years, period between onset and admission: 47 ± 31 days). On their admission, serum levels of dehydroepiandrosterone sulfate (DHEA-S) and free testosterone (only in male patients) were measured after an overnight fast. As functional measures, NIHSS and functional Independence Measure (FIM) were evaluated at their admission and discharge. We assessed the correlation between changes in serum levels of measured hormones and functional changes during hospitalization.

Results:
Neither DHEA-S nor free testosterone levels at admission correlated with the severity of stroke at admission. In male patients, significant positive correlation was found between free testosterone level at admission and FIM at discharge (r=0.31, p<0.05), although there was not significant correlation between DHEA-S level at admission and FIM change. Furthermore, the results of multivariate analysis showed that free testosterone level at admission significantly predicted the rate of FIM change during hospitalization in male patients.

Conclusions:
Serum level of free testosterone at the admission to rehabilitation ward can be a predictor of functional recovery in elderly male patients after stroke.
Abstract TP327: Are We Really That Noncompliant? Identifying Barriers to Documenting Patient Education
Authors: Leonhardt Ann M , Finley Heather L , Benesch Curtis G
Published: July 2021

Background/Purpose:
Patient education impacts stroke recovery and prevention. Certification as a Joint Commission Primary Stroke Center (JC PSC) requires consistent performance in patient education. Prior to instituting a new electronic medical record (EMR) in March 2011 our hospital maintained compliance with this measure at or above 93%. We have experienced difficulty returning to this level for unclear reasons. We sought to identify factors contributing to a decrease in performance.

Methods:
The institution’s Get with the Guidelines Stroke database was reviewed from July 2010 to June 2012. Institutional and departmental changes occurring during months of low compliance were explored. A Project RN was hired to focus on data abstraction and patient education.

Results:
Prior to March 2011 compliance was 93-100%, at which time it dropped to 68%. April 2011 to June 2012 the range was 76-100% with 9 months less than 90%. Only three months during that time were 93% or better. The initial decrease in compliance was clearly attributable to the EMR which lacks previously available “hard stops” for education. Continued compliance of less than 90% was multifactorial. An average census increase of 16.8% per month from 2010 to 2012 was identified. In addition, there were staffing changes within the stroke center during months of low performance. Absence of a nurse practitioner on the inpatient unit had a negative impact. Patients in the stroke unit had better documentation of education than those on other units. Improved compliance coincided with preparation for a JC PSC site visit and completion of the Project RN’s orientation.

Conclusions:
Consistent achievement of stroke education at 93% or better can be reached, but is challenging in a frequently changing environment. We believe our patients are getting stroke-specific education, but documentation has declined due to the EMR, changes in staff, and growing census. Identifying these barriers has allowed the development of a PI plan with a goal of consistent compliance of 93% or better. This plan includes revision of the Project RN responsibilities and scheduling patient education sessions more frequently. Another NP is being recruited, and investigation into better use of the available features of the EMR is underway.
Abstract TP34: Is there an Added Value for Vascular Imaging Prior to Administration of Intravenous tPA in Patients with Acute Middle Cerebral Artery Occlusion
Authors: Leker Ronen R , Eichel Roni , Gomori John M , Ben Hur Tamir , Cohen Jose E
Published: July 2021

Background and objectives:
Advanced neurovascular imaging with CT or MR angiography (CTA/MRA) adds information regarding the vascular pathology and prognosis but may delay treatment with intravenous tissue plasminogen activator (tPA) in patients with proximal middle cerebral artery occlusions (pMCAO).

Methods:
Patients with pMCAO included in our prospective stroke registry were identified. Stroke severity was measured with the National Institutes of Health Stroke Scale (NIHSS) and only patients presenting with NIHSS>10 were included. Patients underwent multi-parametric imaging studies whenever possible. Patients that underwent CTA/MRA were compared to those that only had a non-contrast CT prior to tPA. Disability was measured with the modified Ranking Scale (mRS) and shifts towards favorable outcomes (mRS≤2) were analyzed. Logistic regression was used to determine outcome modifiers.

Results:
We included 73 patients (median age 73, 52% men) with moderate-severe stroke (median admission NIHSS 14). Forty four patients had a neurovascular imaging study and 29 did not have such a study. There were no differences between the groups in risk factor profile or baseline characteristics including stroke severity and door to needle, door to imaging or imaging to treatment times. At 90 days post stroke there were no statistically significant differences in mortality or favorable outcomes between the groups. On multivariate analysis performance of CTA/MRA had no impact on the chances of obtaining favorable outcome at day 90 after stroke.

Conclusions:
Advanced neurovascular imaging studies do not delay treatment with tPA but do not impact the outcome of patients with pMCAO treated with tPA and may therefore be unnecessary in the acute stage prior to administration of tPA.
Abstract TP343: In-hospital Stroke: Patterns Of Care, Clinical Characteristics And Outcomes
Authors: Alves Monique B , Jaures Michele , Nogueira Paula S , Miranda Renata C , Laselva Claudia R , Coelho Fernando M , Silva Gisele S
Published: July 2021

Epidemiological and clinical features of patients with in-hospital stroke are not well described in the literature. Our aim was to compare clinical characteristics and outcomes of patients who experienced a stroke during hospital admission with those who were admitted by the emergency department (ED)

Retrospective analysis of prospectively collected data from medical records. Clinical and demographic findings were analyzed. Modified Rankin Scale (mRs) was performed at discharge. We included patients who were admitted to a tertiary hospital with any disease and suffered an ischemic stroke (IS), intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH) during admission and those that were admitted by the ED from Feb-09 to Jun-12.

We evaluated 501 patients. A total of 11.1% had in-hospital stroke (IHS). In patients with IHS, IS was more frequent 75,8%, followed by ICH 16.0% and SAH 8.9%. Patients who had IHS were similar to those who were admitted by the ED in age, type of stroke, gender and in the use of CT scan for diagnosis. Stroke was more severe in patients with IHS, NIHSS [7.0 (1-9) x 3.0 (3-15), p=0.007]. The median time between admission and stroke was 2.5 days [0,25-6]. When symptoms onset were noticed, 37.7% of the patients were on a regular ward, 32.1% in the ICU, 21.1% in a step down unit (21.1%) and 17.8% in the OR or interventional suite. A total of 39.3% of the patients were admitted for elective surgery, 23.2% for treatment of an infectious, 19.6% for cardiac diseases, 3.6% for cancer treatment and 10.7% for neurological diseases. Patients with IHS and those admitted by the ED were similar in the prevalence of stroke risk factors and in the frequency of complications rates. Thrombolysis rate was similar between the two groups. The mean length of stay was higher in IHS group [20 days 9-47 x 8 days 4-16, p<0.01]. Functional outcome measured by the mRs ≤ 2 at discharge was worse in patients with IHS [37.5% x 68.8%, p<0.005]. Patients with IHS had a higher chance of dying (OR3.52 [95% CI 1,85-6,69]).

In conclusion, patients with IHS had a worse prognosis and higher in-hospital mortality when compared to patients admitted because of an incident stroke. This is probably explained by more severe strokes in the IHS group in association with the presence of previous comorbidities
Abstract TP350: Protecting Stroke Patients from Aspiration and Mortality through a Bedside Aspiration Screen
Authors: Matesic Edith
Published: July 2021

Background:
Stroke patients initially experience dysphagia approximately 42-76% of the time, putting them at high risk for developing aspiration pneumonia and increasing the risk of death threefold in the first 30 days following onset of the condition. Interventions to identify risk for aspiration pneumonia are key to reducing mortality in hospitalized patients. However, no generally recognized bedside aspiration screen exists, and few have been rigorously tested. The Edith-Huhn-Matesic Bedside Aspiration Screen (EHMBAS)
TM
was developed as an evidence-based RN bedside aspiration screening protocol.

Purpose:
This study analyzed the sensitivity and inter-rater reliability of EHMBAS
TM
, assessed the efficacy of training methods, evaluated patient feedback, and looked at the impact of organizational learning.

Methods:
RNs were trained to apply the EHMBAS
TM
. An evaluation study assessed the sensitivity, specificity and predictability of the screen to detect aspiration in the stroke population study group. Cohen’s Kappa statistics was applied to test inter-rater reliability. Pre- and post-implementation Likert surveys examined patient and staff satisfaction on the education plan and screening process, respectively. Lastly, an analysis of organizational learning examined whether changes enhanced adherence to screening requirements.

Results:
Results showed that the EHMBAS
TM
demonstrated strong validity (94% sensitivity) and high inter-rater reliability (Kappa = .92, p<.001). Pre- and post- staff training survey results demonstrated a significant positive change in knowledge gained, feelings of preparedness, and satisfaction with teaching methods. Further, 92.3% of patients surveyed had positive screening experiences. The hospital received Silver recognition from The American Heart Association for following stroke treatment guidelines 85% of the time for at least 12 months, demonstrating the positive impact of the protocol on organizational change.

Conclusions:
This study contributes to the body of work aimed at establishing a reliable evidence-based, bedside aspiration screen. Patient safety is enhanced, because screen results help determine when patients can safely receive medication and nutrition by mouth.
Abstract TP357: Top Reasons Why IV r-TPA Not Given in Wisconsin Rural and Primary Stroke Center Hospitals
Authors: Fuhrman Sue , Pittenger Jeannie , Hansen Anne , Polum Kathy , Miller Kathryn , Watkins Katie , Gardner Michelle
Published: July 2021

Background and Issues—
Stroke continues to be a significant cause of morbidity and mortality. Research has shown improved outcomes when IV tPA is started as close as possible to the time the patient was last known well. Although the use of IV tPA has increased over time, there still an opportunity to increase the use of IV tPA so more patients may benefit from this acute intervention.

Purpose—
To explore the top reasons documented for not giving IV tPA in WI Rural and WI PSC Hospitals.

Methods—
Two groups (Rural and WI PSC) were established in Wisconsin through the Get With The Guidelines-Stroke database. The Rural hospital group includes an average of 13 hospitals with 282 total documented reasons for no IV tPA being given. The WI PSC Hospital group includes 26 hospitals with 2552 documented reasons for not giving IV tPA. The time period in which these reasons were tracked was January 1, 2008 through December 31, 2011. Reasons were ranked as a percentage of the whole for each group, and the top five are listed in the Results section.

Results—

Conclusions—
Advanced age and rapid improvement of symptoms are commonly documented reasons for not giving IV tPA in both Rural and PSC Hospitals in WI. Rural hospitals also note some facility reasons; whereas the PSC hospitals noted delay in presentation to their facility or that tPA was started elsewhere as common reasons for not administering this acute intervention. Of all the reasons listed above, the patient that already received tPA at another institution is the only absolute contraindication for more tPA. An opportunity exists to increase education to providers on weighing the relative risk for tPA criteria versus the potential benefit of the patient, as well as community education of early treatment necessity. Further research is also needed to determine other factors (i.e. salvageable penumbra) in deciding on treatment options.
Abstract TP364: Importance of Collaboration of Hospital Leaders in Implementing Stroke Best Practice Across 17 Organizations
Authors: Linkewich Elizabeth , Willems Jacqueline , Sharp Shelley , Levy Charissa , Bayley Mark
Published: July 2021

Background:
Literature indicates that organized acute stroke care and early access to intense rehabilitation improves patient outcomes. Toronto-wide system data demonstrated 1) Institutional variation in acute and rehabilitation stroke care performance 2) Specialized acute stroke centres perform better for mortality, readmission rates, time to rehab referral, and length of stay 3) Patients could be better streamed to appropriate rehab settings (18% of inpatient referrals were mild stroke; 3% of strokes referred to outpatient) 4) Need for higher intensity rehab post severe stroke to improve outcomes.

Purpose:
To re-organize the stroke system in a large city (Toronto) to increase access to acute stroke units and timely, appropriate rehabilitation while reducing variability in care.

Methods:
Recommendations generated from the above needs were endorsed by regional funders and organization CEOs. Key system decision-makers were engaged in planning and implementation through regional task groups. Organization-specific gap analyses and implementation plans were developed based on best practice and system needs. An evaluation framework, including targets, was created.

Results:
All 17 Toronto acute and rehab organizations committed in writing to a common vision of stroke care: o Reorganization of acute care to hospitals with geographical stroke units and dedicated interprofessional teams supporting evidence-based processes. o Early access to high intensity inpatient (3 hours therapy/patient/day within 5-7 days of stroke onset) and outpatient rehab (within 2 weeks of acute discharge). Organizational implementation plans are in progress. Working groups were established to address emerging system issues (e.g. Emergency walk-in patients).

Conclusion:
Key enablers crucial to the success of this transformational system change include: engagement of key stakeholders/leaders, grounding in best practices, based on a system perspective, supported by data, and funder endorsement. Regular monitoring and status reporting provides a foundation for ongoing continuous quality improvement and accountability. A knowledge translation strategy is being developed to support implementation.
Abstract TP407: Participant Satisfaction With a Lifestyle Management Program in the SAMMPRIS Clinical Trial
Authors: Turan Tanya N , Caskey Michele F , Helwig Stephanie , Steiner Megan R , Wright Brenda S , Montgomery Jean , Lane Bethany , Lynn Michael J , Derdeyn Colin P , Fiorella David , Janis Scott , Chimowitz Marc I ,   SAMMPRIS Investigators
Published: July 2021

Background:
SAMMPRIS was the first secondary prevention stroke trial to provide a lifestyle modification program to all clinical trial participants. We sought to determine if SAMMPRIS participants would have a high level of satisfaction with the compulsory lifestyle program.

Methods:
Patients enrolled in SAMMPRIS who were actively participating in the lifestyle modification program for > 12 weeks were mailed anonymous surveys. The survey was conducted by the company that administered the lifestyle program and the data was provided to the authors. The survey measured 6 constructs: consistency of program delivery, quality of materials, confidentiality, coach-participant relationship, individualization, and time efficiency, with 2 statements addressing each construct. Participants were asked to respond to 2 variables, “importance” and “satisfaction”, for each statement using five-point Likert-type scales (5 = high; 1 = low). An adjusted needs index (ANI) was computed for each statement: [(mean importance - mean satisfaction) x (mean importance)]. Participants were also asked to respond (“strongly agree” or “strongly disagree”) to 2 statements related to their overall evaluation of the program and if they would recommend the program to others.

Results:
Surveys were completed by 199/327 (61%) participants. For the 6 constructs, mean scores for “importance” ranged from 4.36 - 4.73 and mean scores for “satisfaction” ranged from 4.38 - 4.69. The coach-participant relationship rated highest for both “importance” and “satisfaction”. ANIs for 8 of 12 statements were either 0 or negative values, indicating that expectations were met or exceeded. Individualization of the program had the highest ANI at 0.45. Statements regarding overall evaluation received high ratings (means 4.65, 4.66).

Conclusion:
SAMMPRIS clinical trial participants had a high level of satisfaction with the study’s lifestyle management program. These data, coupled with final data from SAMMPRIS showing that compliance with the program resulted in improved control of risk factors, would strongly support the use of lifestyle programs in future stroke prevention clinical trials and in clinical practice.
Abstract TP410: Race/ethnicity Modifies Increased Recurrent Event Risk For Female Stroke Survivors
Authors: Benn Emma K , Fei Kezhen , Roberts Eric T , Quarles Leigh , Boden-Albala Bernadette
Published: July 2021

INTRODUCTION:
Demographic disparities in recurrent events among stroke survivors have received some attention, but little is known about the impact of gender. We explored whether gender was associated with having a recurrent event, after accounting for health status and SES, in a multi-ethnic stroke cohort.

METHODS:
The Stroke Warning Information and Faster Treatment study (SWIFT) was a randomized stroke preparedness educational intervention, which prospectively enrolled mild and moderate stroke/TIA patients able to sign informed consent and identified at the NY Presbyterian Medical Center from 2005 to 2010. We defined a recurrent event as having ≥1 of the following post-enrollment: a stroke, TIA, MI, death, migraine, or significant stroke mimic. Gender was dichotomous. Health status included age, race/ethnicity, comorbidities, and CVD history. SES included education, employment, and insurance. We conducted chi-squared tests and t-tests. We used multiple logistic regression to assess the impact of gender, after adjustment for health status and SES, on having a recurrent event. Effect modification of the adjusted gender difference by race/ethnicity was also examined.

RESULTS:
The cohort included 1203 patients, of which 31% (n=375) had 580 recurrent events. Intervention was not associated with gender (p=0.35) nor having a recurrent event (p=0.07). Females (n=596, 49.5%) were older (p=0.002), had a higher proportion of comorbid hypertension (p=0.019), had less non-Hispanic Whites (p=0.028), were less educated (p=0.022), and had more Medicaid recipients (p<0.001), than males. About 35% of females and 28% of males had a recurrent event (p=0.006). The adjusted odds of a recurrent event were 1.35-fold (95% CI=1.04-1.75) higher for females than for males. Race/ethnicity modified the association. Females, compared to males, were similar for Blacks (OR=1.26, 95% CI=0.68-2.33) and Latinos (OR=0.87, 95% CI=0.60-1.24), yet the difference was substantial among Whites (OR=3.16, 95% CI=1.84-5.41).

CONCLUSION:
While age has historically been suggested as an explanation for poorer functional scores post stroke, the nature of these recurrent events among women with milder stroke/TIA and its intersection with race/ethnicity needs further exploration.
Abstract TP43: Transient Global Brain Ischemia Induces Striatal Neuronal Death of T1-Hyperintensity without Hemorrhage: Susceptibility-Weighted Imaging Study on Cardiac Arrest Survivors
Authors: Fujioka Masayuki , Watanabe Tomoo , Taoka Toshiaki , Okuchi Kazuo
Published: July 2021

Background:
Global brain ischemia-reperfusion leads to selective neuronal death in the hippocampal CA1 area, cerebellar cortex, dorsolateral striatum, and/or neocortical layers 3, 5, and 6 in animal models and in humans. We have reported a delayed neurodegeneration of late-onset neuroimaging change in such brain areas vulnerable to ischemia (Stroke.1994;25:2091-95., Stroke.1999;30:1038-42., Stroke.1999;30:1043-46., Cerebrovasc Dis.2000;10:2-7., Ann Neurol.2003;54:732-7.). The magnetic resonance imaging (MRI) studies on patients after cardiac arrest showed 1) bilateral neurodegeneration with hyperintensity on T1-weighted MRI in the striatum, thalamus, and/or substantia nigra (Stroke.1994;25:2091-5., Neuroradiology.1994;36:605-7.), and 2) specific hippocampal atrophy in the chronic stage (MRI volumetry) (Cerebrovascular Dis.2000;10:2-7.). In the current study with susceptibility-weighted MRI (SWI), we investigated if the delayed T1-hyperintensity in the dorsolateral striatum consistently observed in cardiac arrest survivors represents minor hemorrhage (methemoglobin) or signifies selective neuronal death without bleeding reported as a specific type of ischemic neurodegeneration (Ann Neurol.2003;54:732-47.).

Methods:
We studied 11 patients in a vegetative state after unexpected out-of-hospital cardiac arrest who were able to undergo multiple brain MRI. We performed SWI to evaluate if the late-onset striatal T1-hyperintensity represents iron accumulation derived from hemoglobin degradation products or not.

Results:
In the 11 patients, serial MR images demonstrated delayed T1-hyperintesity in the bilateral striatum from one to two weeks after the onset. The SWI study showed no hypointense change in the striatal T1-hyperintensity.

Conclusion:
The striatal T1-hyperintensity after cardiac arrest seems to correspond to selective neuronal death and glial proliferation with paramagnetic effects but not hemoglobin degradation due to erythrocyte-extravasation.
Abstract TP431: Role of Aromatase in Cerebrovascular Endothelial Function in Female Mice
Authors: Zuloaga Kristen L , Zhang Wenri , Alkayed Nabil J
Published: July 2021

Women are at lower risk for stroke than age-matched men even after menopause when ovarian estrogen is lost and the major source of estrogen becomes local (extra-gonadal) synthesis by the enzyme aromatase. Aromatase gene deletion in ovariectomized female mice exacerbates ischemic brain damage after stroke. It is not clear however which cell type is responsible for this effect, since aromatase is expressed in multiple cell types in brain, including cerebrovascular endothelium. Therefore, we tested the hypothesis that endothelial aromatase plays an important role in endothelium-dependent cerebrovascular function in females, which in part contributes to the sex difference in endothelial function in the cerebral microcirculation. Cerebrocortical microvascular responses to the endothelium-dependent vasodilator acetylcholine (ACh; 1-100 μM) were compared between male and female wild-type (WT) and aromatase knockout (ArKO) mice using an in-vivo closed cranial window preparation combined with laser Doppler perfusion monitoring. WT female mice had significantly greater response to ACh at doses between 10-100 μM (10 μM = 267 +/- 41%, 100 μM= 273 +/- 51%) compared to both WT male (10 μM = 144 +/- 19%, 100 μM= 156 +/- 19%) and ArKO female mice (10 μM= 158 +/- 21%, 100μM = 165 +/- 22%) (mean +/- SEM, *p<0.01, ANOVA). We conclude that aromatase plays an important role in endothelium-dependent vascular responses in female cerebral vessels, which may contribute to the observed sex differences in cerebrovascular function and response to ischemic injury.
Abstract TP44: Brain Areas Affected by Severity of Vascular Disease as Characterized by fMRI Measures
Authors: La Christian , Nair Veena A , Sattin Justin A , Jensen Matt , Chacon Marcus , Meyerand Mary E , Prabhakaran Vivek
Published: July 2021

Background:
Vascular disease has the potential of imposing varying degrees of structural, as well as functional changes onto the brain. In this study, we examined the effect of three levels of vascular disease: mild (normal aging), moderate (patient with risk factors for stroke), and severe (stroke patient), and explored the functional activity differences in these three groups using resting state fMRI. While many have reviewed rsfMRI with functional connectivity, we examined the fALFF (fractional amplitude of low frequency fluctuation), reflecting the intensity of the region’s spontaneous brain activity.

Methods:
14 stroke patients (avg. age = 64.3, 5F), 8 patients with risk factors for stroke (avg. age=67.3, 3F) were recruited and imaged within 7 days of their hospital admissions for clinical symptoms. 15 aging normals or mild vascular disease subjects (avg. age = 59.6, 9F) were also recruited. A ten minute eyes-closed resting-state fMRI scans were collected with a 3T GE scanner. fALFF quantification were computed using the REST toolkit. Identified clusters are significant at p<0.05, trending at p<0.10, corrected for multiple comparisons.

Results:
Compared to aging normals, moderate vascular disease patients demonstrated a trending decrease in fALFF activity over the medial prefrontal cortex, rostral right superior frontal gyrus and left middle temporal cortex, and a significant increase in the cerebellum. With more severe vascular disease, those trending regions became significant. The activity over the cerebellum amplified and three additional cortical regions became disrupted or showed a decrease in fALff: left middle frontal gyrus, precuneus and right insula. The left precentral gyrus demonstrated an increase in fALff activity.

Conclusions:
Though the sample size is limited, this study suggests a consistent pattern of cortical fALFF activity changes as a result of increasing vascular disease. The left middle temporal, medial prefrontal cortex and right superior frontal gyrus are areas most susceptible for disruption. With a more severe vascular disease, the left middle frontal gyrus, precuneus and right insula become disrupted additionally. Moreover, the cerebellum becomes markedly more active with increasing vascular disease.
Abstract TP441: Neurovascular Coupling is Impaired in Cerebral Amyloid Angiopathy
Authors: Peca Stefano , McCreary Cheryl R , Donaldson Emily , Sanchez Karla , Charlton Anna , Pillay Neelan , Poulin Marc , Frayne Richard , Goodyear Brad , Smith Eric E
Published: July 2021

Introduction:
Cerebral amyloid angiopathy (CAA) is marked by accumulation of vascular beta-amyloid which is toxic to smooth muscle cells. An animal study and a pilot study in humans suggest decreased vasodilation in CAA. We studied patients with CAA and matched controls to determine whether neurovascular coupling is impaired in CAA.

Methods:
Patients with CAA and controls underwent task-related fMRI with a visual task (viewing a flashing alternating checkerboard pattern) or a motor task (tapping the fingers of the dominant hand) using a block design, and visual evoked potentials (VEPs). CAA patients were diagnosed by Boston criteria and had normal corrected visual acuity, no visual field deficits and no paresis of the dominant arm. Controls were recruited by community advertising and were matched by gender and age (±5 years) to CAA cases.

Results:
Eighteen CAA patients (12 M, 6F; 72±7 yrs) and eighteen controls (12 M, 6F; 70±7 yrs) were studied. For the visual task, CAA patients had reduced activity in the occipital lobe (Figure) and lower amplitude of the BOLD response vs. controls (28% reduced, p=0.005). By contrast, for the motor task CAA patients had a similar response of the primary motor cortex vs. controls (9.6% reduced BOLD response, p=0.53). VEP P100 latencies and amplitudes did not differ between CAA and controls (p=0.49 and p=0.74). Lower visual cortex BOLD amplitudes were correlated with greater white matter lesion volumes in CAA (r=-0.66, p=0.003).

Conclusions:
Neurovascular coupling is impaired in the occipital lobe in CAA. BOLD signal amplitudes are reduced despite normal evoked potentials, suggesting impaired vasodilation. The association with white matter lesion volume raises the possibility that impaired vasodilation may be involved in the pathogenesis of these lesions. BOLD responses in the primary motor cortex in CAA were not reduced, likely reflecting the known posterior predominance of CAA with lesser involvement of the frontal lobe.
Abstract TP50: Functional Recovery In Stroke: Performance On Verbal Fluency Task
Authors: NAIR VEENA A , LA CHRISTIAN , NADKARNI TANVI , REITER PETER , CHACON MARCUS , JENSEN MATHEW , SATTIN JUSTIN , PRABHAKARAN VIVEK
Published: July 2021

BACKGROUND:
The objective of this study is to investigate the brain activation patterns and relationship with verbal fluency performance in stroke recovery.

METHODS:
Patients with ischemic stroke (N=19, mean age =64, 7F) and 17 healthy age-matched controls, participated in the study. Measures on a verbal fluency task were collected outside the scanner. Functional MR images were collected as subjects performed the same task(3T GE scanner). Task included alternating 20 second blocks of rest and word retrieval given a letter. Results from 19 acute patients(< 7 days from stroke onset - V1), of which 9 were also tested in the sub-acute stage(between 7 days and 6 months from stroke onset - V2), are reported here.

RESULTS:
Acute patients showed significantly greater activation in several regions, including the right middle and inferior frontal gyrus, and de-activations in regions including left middle temporal and frontal gyri(p<.05, corrected for multiple comparisons). Beta values representing the intensity of BOLD signal were extracted from these significant activation clusters. There were significant differences in beta values in acute(p<.001 corrected) and sub-acute(p<.01 uncorrected) stages compared with healthy controls(Figure). Pearson r correlations computed between the beta values and normed verbal fluency scores did not show significant group difference in correlation between these measures.

CONCLUSIONS:
Results suggest increased activation in acute stroke in right hemisphere language regions; healthy controls conversely show less activation in these regions. Additionally, activity in brain areas significantly correlated with behavior. Activation pattern in acute stroke however changes over time with patients in the sub-acute stage showing pattern similar to healthy controls. This is consistent with studies suggesting that activations in the acute stage tend to normalize over time likely due to areas prior to the stroke re-gaining function.
Abstract TP60: Intravenous Thrombolysis For Patients With Reverse MRA-DWI Mismatch: SAMURAI And NCVC Rt-PA Registries
Authors: Sakamoto Yuki , Koga Masatoshi , Kimura Kazumi , Nagatsuka Kazuyuki , Okuda Satoshi , Kario Kazuomi , Hasegawa Yasuhiro , Okada Yasushi , Yamagami Hiroshi , Furui Eisuke , Nakagawara Jyoji , Shiokawa Yoshiaki , Okata Takuya , Kobayashi Junpei , Tanaka Eijirou , Minematsu Kazuo , Toyoda Kazunori
Published: July 2021

Background and purpose:
Characteristics of reverse MRA-DWI mismatch, defined as large DWI lesion despite absence of the major artery occlusion (MAO), remain unknown, especially in patients treated with IV rt-PA. This study aimed to clarify the frequency, associated factors, and outcomes of patients showing reverse MRA-DWI mismatch prior to IV rt-PA therapy.

Methods:
From the multicenter (SAMURAI) and additional single-center (NCVC) rt-PA registries, patients with the MCA territorial stroke were included. Early ischemic changes (EIC) were assessed with the Alberta Stroke Program Early CT score (ASPECTS) on pretreatment DWI. MAO was defined as ICA or M1 occlusion on MRA. Patients were divided into 4 groups: the large-EIC match (LM) group (MAO, ASPECTS <7); the reverse mismatch (RMM) group (no MAO, ASPECTS <7); the conventional mismatch (CMM) group (MAO, ASPECTS ≧7); and the small-EIC match (SM) group (no MAO, ASPECTS ≧7). Outcomes included sICH per ECASS II criteria, and mRS 0-2 and death at 90 days. Multivariate backward stepwise logistic regression analysis was performed to identify independent clinical characteristics (demographic factors, risk factors, stroke subtypes by TOAST classification, and blood tests) associated with the reverse MRA-DWI mismatch and to compare the outcomes among the 4 groups.

Results:
Of the 486 patients (167 women, median age 74 years) enrolled, reverse MRA-DWI mismatch was observed in 24 (5%, RMM group); 108 belonged to LM, 161 to CMM, and 193 to SM groups. Among clinical characteristics, cardioembolism (RMM 92%, LM 76%, CM 69%, SM 49%) was only independently associated with the RMM group (OR 5.49, 95%CI 1.25-24.1). Median initial NIHSS score was 18 in RMM, 18 in LM, 13 in CMM, and 8 in SM (p<0.001). MRS 0-2 (RMM 54%, LM 19%, CMM 46%, SM 69%) was more common in the RMM than the LM group (OR 4.02, 95% CI 1.28-12.7). SICH (RMM 13%, LM 6%, CMM 2%, SM 2%) and death (RMM 8%, LM 12%, CMM 9%, SM 2%) were not different between the RMM and LM groups after multivariate analysis.

Conclusion:
Reverse MRA-DWI mismatch was observed in 5% of patients eligible for rt-PA. Cardioembolism was independently associated with reverse mismatch. Patients with reverse mismatch may benefit from thrombolysis, compared to those with extensive EIC with MAO.
Abstract TP66: Quantitative Proteomic Profile of Tissue Plasminogen Activator (tPA) Responders
Authors: Ning MingMing , Cao Jing , Lopez Mary , Sarracino David A , McMullin David , Buonanno Ferdinando S , Wang Xiaoying , Lo Eng H
Published: July 2021

Background:
The utilization of IV tPA continues to be low after more than a decade of FDA approval. We aim to widen the therapeutic window for tPA by understanding clinical thrombolysis response. Besides its intended role in clot lysis, tPA is also a pleiotrophic signaling protease in the blood, whose efficacy may potentially be monitored by proteomic profiles directly in stroke patients.

Method/Results:
To study thrombolysis response, we mapped quantitative profiles of all proteins pre and post IV tPA administration in plasma of stroke patients with good clinical outcome at 3 months. Plasma was sampled from stroke patients immediately before and 6-12hrs after tPA administration (n=28). Quantitative changes of proteins pre and post tPA were mapped by isotopic methods and analyzed on LC-MS. While both intra- and extracellular proteins were found, most were known plasma proteins, as seen on IPA analysis (Figure). Of 191 proteins found, 48 changed significantly post tPA (fold ratio in parenthesis). Compared to pre-tPA levels, we found significantly increased post-tPA levels of thrombolysis-related proteins such as fibrinogen gamma chain (↑11x), α-2-antiplasmin (↑4x), and a decrease in factor X (↓7x) etc. Changes were also found in factors outside of standard thrombolytic pathways, such as α-2-macroglobulin (↑2.3x); CD14 (↓2x) and GPX3 glutathione peroxidase 3 (↓2x) etc.

Conclusion:
In order to study thrombolysis response and monitor thrombolysis efficacy at the bedside, we mapped quantitative protein fold changes of IV tPA responders and found a coordinated change not only in reported thrombolysis pathways, but also in other enzymatic pathways in patient plasma. These early results are a step toward attempts to monitor clinical thrombolysis response in acute stroke patients in real time. Further studies are under way to compare plasma profiles of tPA-treated stroke patients with respect to different clinical outcome and imaging findings of reperfusion.
Abstract TP73: Transition of ECASS III Results to Clinical Practice: 90 Day Outcomes in a US Cohort
Authors: Cronin Carolyn A , Langenberg Patricia , Dutta Tara M , Kittner Steven J
Published: July 2021

Introduction:
ECASS III showed benefit of IV tPA for acute ischemic stroke (AIS) 3-4.5 hr from onset in a select group of patients from Europe, with this extended treatment subsequently recommended by the AHA/ASA. We prospectively enrolled AIS patients treated with IV tPA as this recommendation was being applied in clinical practice, to determine safety and efficacy in a representative cohort from the USA.

Methods:
Consecutive AIS patients treated with IV tPA at 18 primary stroke centers throughout Maryland were approached and informed consent obtained during hospitalization. Sites ranged from small community hospitals to large academic medical centers. In-hospital and demographic data were obtained from each site’s GWTG database or directly from the medical record. Study personnel blinded to the treatment time window obtained 90 day modified Rankin Scale (mRS) by structured phone interview. Patients were grouped by time to treatment (≤ 3hr vs. 3-4.5hr) and compared for presence of additional exclusion criteria from ECASS III that are not standard practice in the USA for ≤ 3hr (age >80, history of stroke and diabetes, oral anticoagulant treatment, and NIHSS>25). Good functional outcome (mRS 0-1 and 0-2), mortality, and symptomatic intracerebral hemorrhage (sICH) were analyzed.

Results:
Patients treated 3-4.5hr were somewhat younger (mean age 62.6 vs. 66.6, p=0.06), and had smaller infarcts (median NIHSS 5 vs. 8, p=0.04). There was only partial adherence to the additional ECASS exclusions (Table 1). There were no significant differences by time to treatment in sICH, mortality, or 90 day functional outcome (Table 2).

Conclusion:
For US patients treated with IV tPA 3-4.5 hr from onset in every day practice, there is no evidence for increased risk or worse outcomes compared to standard treatment up to 3 hr.