bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP141: Combined Cortical and Peripheral Nerve Stimulation Effects in Patients with Stroke and Moderate to Severe Upper Limb Motor Impairments: A Crossover, Randomized Study
Authors: Menezes Isabella , Cohen Leonardo , Mello Eduardo , Conti Juliana , Machado Andre , Anjos Sarah , Peckham P. Hunter , Plow Ela , Siqueira Inara , Torres Talita , Conforto Adriana
Published: June 2021

Introduction:
Transcranial direct current stimulation (tDCS) and somatosensory stimulation in the form of peripheral sensory stimulation (PSS) have emerged as potential powerful tools to enhance motor performance or increase effects of motor training in stroke victims.

Objectives:
To compare effects of active PSS+tDCS, tDCS alone, PSS alone and sham PSS+tDCS as add-on interventions to motor training in patients with stroke and moderate to severe upper limb impairments.

Methods:
Patients > 6 months post-stroke underwent four different interventions, in a cross-over design: repetitive training of wrist extension of the paretic arm preceded by either active PSS (median, ulnar and radial nerves), active anodal tDCS of the affected hemisphere, sham PSS+tDCS or active PSS+tDCS. Before and after each session, the following outcomes were blindly evaluated in the paretic upper limb: range of movement (ROM) of wrist extension (primary outcome); ROM of wrist flexion, grasp and pinch strength. Measures were compared with analysis of variance with repeated measures (ANOVARM) with factors “session” and “time”.

Results:
After screening 2499 patients, 22 subjects were included in the study (14 men). The mean age (± standard deviation) was 55.2±12.9 years and the mean time from stroke, 5.3±5.6 years. The mean Fugl-Meyer score for the paretic upper limb was 37±7.9. Two patients were excluded (one dropped out and one received botulinum toxin treatment). There was a significant effect of “time” (F=4.6, p=0.046), but no effects of “session” or interaction “session x time” in regard to grasp force. There were no significant effects of “session”, “time” or interaction “session x time” in regard to ROM of wrist extension, wrist flexion, or pinch force.

Conclusions:
Repetitive training of wrist extension specifically improved grasp force and did not influence other outcomes. PSS+tDCS, tDCS alone or PSS alone did not potentiate the effect of training.
Abstract TP144: EEG-Based Brain Computer Interface Therapy for the Restoration of Distal Upper Extremity Motor Function
Authors: Remsik Alexander , Advani Hemali , Rajan Shruti , Dodd Kieth , Jacobson Tyler , Dusek Ali , LaRocque Joshua , Nair Veena , Edwards Dorothy , Prabhakaran Vivek
Published: June 2021

Introduction:
This current study is part of a larger, on-going clinical trial (NCT02098265), which evaluates non-invasive electroencephalographic (EEG) based brain-computer interface(BCI) therapy for restoration of distal upper extremity motor function in stroke survivors. We acquired data for 8 participants (mean age= 64 years) presenting with varying levels of upper-extremity motor deficits and chronicity since stroke. EEG based BCI task-related performance outcomes were compared with distal extremity behavioral testing on the 9-Hole Peg Test - 9HPT) to illustrate the relationship of BCI training performance on behavioral performance.

Methods:
EEG data is acquired with BCI2000, a 16 channel recording system (g.LADYbird-g. GAMMAsys-g. USBamp, Guger Technologies, Graz, Austria) with electrodes positioned according to the standard 10-20 system over the sensorimotor cortex at C3 & C4. Participants performed a hand movement task; randomly cued to move either their affected or unaffected hand depending on the appearance of virtual target and cursor on the screen. 9HPT Data was selected from two BCI conditions: 1) BCI with visual stimulus only, and 2) BCI with visual stimulation plus functional electrical stimulation (FES) of the impaired arm, and tongue stimulation (TS) at four time-points: baseline (prior to BCI therapy), mid-point of BCI therapy, post-therapy, and one month post-therapy.

Results:
BCI visual plus stimulus for the unaffected side was found to best relate to 9HPT scores (p= 0.0928) with a trend to significance. BCI visual plus stimulus for the affected side was not shown to correlate with 9HPT scores (p= 0.2655). The results suggest that 9HPT scores better relate with average task accuracy when the TS and FES adjuvants are incorporated (BCI stimulus vs 9H PT unaffected p= 0.09284, BCI stimulus vs 9H PT affected p= 0.26553) compared to the BCI visual only task (BCI visual vs 9HPT unaffected p=0.2702, BCI visual vs 9HPT affected (p= 0.89276).

Conclusion:
Non-invasive EEG-based BCI therapy may be suitable for the restoration of distal upper extremity motor function but average task accuracy does not appear to be a valid indicator of motor improvement. This finding suggests that visual only BCI systems are inadequate for motor rehabilitation.
Abstract TP147: Central Post Stroke Pain: A Systematic Review
Authors: Singer Jonathan , Conigliaro Alyssa , Spina Elizabeth , Law Susan , Levine Steven
Published: June 2021

Background:
Central Post Stroke Pain (CPSP) is reportedly due to strokes in the thalamic region (Dishinbition Theory); however, the Central Imbalance Theory states that CPSP is due to damage to the spinothalamic pathway (STP).

Aims:
1) Clarify the role of thalamic strokes and STP damage in CPSP patients. 2) Gain a current understanding of anatomic substrates, brain imaging, and treatment of CPSP.

Methods:
Two independent reviewers systematically reviewed PUBMED, CINAHL and Web of Science for studies including original, clinical studies and randomized controlled trials (RCTs) using PRISMA guidelines. Studies had to assess CPSP, using a single question or pain scale.

Results:
Search from January – July 2016, identifying 731 publications. We extracted data from 23 studies and categorized the articles’ aims into 4 sections: somatosensory deficits (5 studies), STP (3 studies), brain imaging (7 studies), and RCTs (8 studies). Somatosensory studies showed high rates of CPSP; however, the underlying causes of these deficits were unclear. Most studies did not refer to stroke location as playing a role in CPSP, but that pathways may. STP studies displayed consistent evidence that the STP plays a major role in CPSP, delineating that CPSP can occur even when the stroke is not in the thalamic region but in other regions (e.g. cerebellum, basal ganglia, medulla). Four of the brain imaging studies found CPSP not related and 3 found it was related to thalamic strokes. All 7 studies had major limitations including sample size, no control groups, and selection bias. RCTs were mostly negative, but brain stem and motor cortex stimulation studies showed the most promise.

Conclusions:
While CPSP has been linked to the thalamic region since the early 1900’s, the peer-reviewed literature showed equivocal results when examining location of stroke. Our systematic review suggests damage to the STP is associated with CPSP and this could provide insights into mechanisms and treatment. Moreover, historical connection of strokes in the

thalamic region and CPSP should be reevaluated as many studies noted that strokes in other regions of the brain also produce CPSP.
Abstract TP152: Correlation of NIH Stroke Scale and Fugl-Meyer Motor Scales in a Longitudinal Stroke Recovery Study: Implication for Feasibility Survey for Stroke Rehabilitation Trial
Authors: Chhatbar Pratik , Bayona Hernan , Schlaug Gottfried , Feng Wayne
Published: June 2021

Introduction:
Recruitments of stroke recovery trials have been challenging. NIH stroke scale (NIHSS) has been universally collected in the acute stroke phase, but stroke recovery trials generally use Fugl-Meyer Motor Scale (FMMS) for outcome measure as well as patient selection criteria. The knowledge gap on the relationship between the two scales potentially jeopardize the accuracy of clinical trial recruitment feasibility survey that is based on NIHSS in the acute phase. We aimed to investigate the correlation between the two scales in a longitudinal stroke recovery study.

Methods:
This is a prospective cohort study (Prediction and Imaging biomarker of Post-stroke Motor Recovery) that enrolled patients with first-ever acute ischemic stroke with various degrees of motor impairment. NIHSS and FMMS were assessed 2-7 days after onset of stroke symptoms as well as at 90 days (± 15 days) post-stroke. Modified Rankin Scale (mRS), Stroke Impact Scale-16 (SIS-16) and Personal Health Questionnaire-9 (PHQ-9) were collected at 90 days (±15 days). Correlation analysis were conducted with Pearson Correlation coefficient.

Results:
119 patients met the inclusion criteria and were included in the analysis. NIH Arm scales of 0, 1, 2, 3 and 4 correspond to FM-UE scales at 3 months of 61.1, 59.8, 58.0, 47.3 and 17.0. NIH leg scales of 1, 2, 3 and 4 correspond to FM_LE scales at 3 months of 32.4, 29.8, 27.8, 21.0 and 17.2. The correlation coefficient between of two leg scales is not as good as the two arm scales. (0.76 vs. 0.83). Similarly, mRS of 0, 1, 2, 3, 4 and 5 correspond to FMMS of 99.0, 91.6, 85.5, 51.6, 41.5, 21.6 and SIS-16 of 73.7, 69.6, 64.7, 55.1, 42.8, 25.3.

Conclusions:
Our data suggest that there is a strong correlation pattern between the NIH arm scale and FM-UE scale, NIH leg scale and FM-LE scale as well as mRS, FMMS, NIHSS and SIS-16. This information is potentially useful to inform the feasibility assessment for future stroke rehabilitation trials done through the NIH Stroke Trials Network.
Abstract TP153: Post Stroke Fatigue and Depression Predict Lower Health Related Quality of Life in Stroke Patients
Authors: Toy Gregory , Singer Jonathan , Balucani Clotilde , Stefanov Dimitre , Huang Alisen , Halket Douglas , Mlabasati Jack , Ahmed Alam , Gilles Nadege , Levine Steven
Published: June 2021

Background and Purpose:
Post stroke fatigue (PSF) is a common and debilitating condition that can last months or even years. Although the relationship between PSF and Health Related Quality of Life (HRQoL) has been studied, the results have been largely inconclusive and not previously reported in a minority cohort.

Hypothesis:
Higher levels of PSF and Post Stroke Depression (PSD), will predict lower levels of HRQoL in African/Caribbean Blacks.

Methods:
Prospective, cross-sectional, observational study approved by the IRB. Patients
≥
18 years old with a stroke in the past 3 years were enrolled. Standardized questionnaires were administered to assess the patients’ levels of PSF [Fatigue Assessment Scale (FAS)], HRQoL [Short Form-36 (SF-36)], and PSD [Beck’s Depression Inventory (BDI)]. Stroke related disability was assessed by modified Rankin Scale (mRS). Responses to the SF-36 were weighted and then averaged in accordance to standard practices. FAS, BDI, and mRS scores were dichotomized and adjusted for gender. A multiple linear regression model was constructed for the HRQoL overall score. The dichotomized FAS, BDI, and mRS scores, age and gender were considered as predictors.

Results:
Of 100 patients enrolled (55% female), mean age = 66.7 years ± 12.8; 93% African or Caribbean American, 86% with hypertension, 53% with diabetes, and 37% with a family history of stroke/TIA. The prevalence of stroke related disability (mRS ≥ 2) was 63%, PSF (FAS≥22) was 51%, PSD (BDI ≥11) was 24%. Both PSF and PSD was seen in 20%. The cohort’s mean SF-36 score was 51.6 ± 21.1. BDI <11 was associated with a score 9.5 units higher on the SF-36 (95% CI: 2.3-16.8,
p
=0.01) than BDI ≥ 11; mRS <2 was associated with 19.8 units higher score on the SF-36 (95%CI: 13.7-25.8, p<0.0001) than mRS≥2. FAS score<22 was associated with 15.0 higher HRQoL score (95%CI: 8.9-21.1,
p
<0.0001) than FAS≥ 22. The analysis was adjusted for gender (
p
=0.10), while age (
p
=0.29) was not included. BDI, mRS, FAS, and gender accounted for 56% of the variability in the HRQoL score.

Conclusion:
Our results suggest that both PSF and PSD are significantly correlated with a lower HRQoL. In this minority cohort, over half of post-stroke HRQoL is attributed to depression, disability, fatigue, and female gender.
Abstract TP154: Infarct Volume and Prolonged Intubation are Critical Determinants of Inpatient Rehabilitation Cost in Anterior Circulation Large Vessel Occlusion Stroke Patients
Authors: Streib Christopher , Rangaraju Srikant , Jadhav Ashutosh , Jovin Tudor
Published: June 2021

Introduction:
Anterior circulation large vessel occlusion (ACLVO) stroke is one of the most devastating stroke subtypes. Significant recent advances, including endovascular thrombectomy, have markedly improved ACLVO stroke outcomes. The economic burden of ACLVO stroke treatment is now an important consideration. Our study investigates the critical determinants of acute inpatient rehabilitation (AIR) cost in ACLVO stroke.

Methods:
We utilized comprehensive patient-level cost-tracking software to calculate AIR costs for ACLVO stroke patients at our institution between July 2012-October 2014. Cost was calculated from the hospital perspective. Patient demographics, clinical course, neurologic exam, and imaging findings were analyzed. Variables with p-value <0.20 in univariate analysis were included in multivariable analysis to determine significant predictors of AIR cost (p<0.05).

Results:
65 patients were included in our analysis (median age 61 [IQR 54-73], median AIR admit NIHSS 12 [6-16]). Univariate analysis results are shown (Figure). In our multivariable analysis the only statistically significant predictors of AIR cost were the patient’s final infarct volume (p<0.001) and intubation >48 hours during the hospitalization (p=0.044). AIR costs increased by $66.46 for every 1 cubic centimeter increase in infarct volume.

Conclusion:
Infarct volume and intubation >48 hours were significant predictors of AIR cost in ACLVO stroke patients at our institution. ACLVO stroke interventions that limit infarct volume may decrease AIR costs, in addition to avoidance of intubation and aggressive pursuit of extubation when feasible.
Abstract TP163: The Relationship Between PAP Adherence and Optimal Cardiovascular Disease Protective Regimen Prescription Depends on Race Among Veterans With Obstructive Sleep Apnea
Authors: Marulanda-Londoño Erika T , Wallace Douglas M , Ziayee Habibullah , Chaturvedi Seemant , Wohlgemuth William K
Published: June 2021

Introduction:
Obstructive sleep apnea (OSA) severity is an independent predictor of cardiovascular disease (CVD) including stroke. Black race has been associated with higher likelihood of CVD morbidity and lower PAP adherence, an unhealthy patient behavior. Data are equivocal for “healthy user” effect: whether a patient’s regular PAP use is associated with physician behavior of optimal CVD prescription regimen. It is unknown if this relationship varies by patient race. We aim to describe whether the association of PAP use with optimal CVD treatment regimen prescription depended on race in veterans with OSA.

Methods:
We conducted a cross-sectional study of existing PAP users at a VA Medical Center. Data on demographics, medications, comorbidities, and OSA were collected. Optimal CVD medication regimen required prescription of antiplatelet, antihypertensive, and statin.

Objective:
PAP use was measured by % of days with use ≥ 4 hours. Using logistic regression, we examined whether the association of patient PAP use with physician optimal medication prescription varied by race. The model included race, PAP use, PAP use by race interaction term, and pertinent covariates.

Results:
A total of 499 veterans (95% male, 38% Black) were included. Two hundred seventy-three veterans (55%) were prescribed an optimal CVD prevention regimen, while 226 (45%) were prescribed a suboptimal regimen. In logistic regression analyses, older age (OR 1.06, 95% CI 1.0-1.1), Black race (OR 1.8, 95% CI 1.1-2.9), higher BMI (OR 1.1, CI 1.1-1.2), and higher Charlson Index (OR 1.3, 95% CI 1.2-1.5), and PAP use by race interaction term were significantly associated with optimal medication regimen prescription. Among white veterans, level of PAP use was not associated to likelihood of optimal CVD prescriptions regimen; However, among Black veterans, those with high levels of PAP use were significantly more likely to be prescribed optimal medication regimen than individuals with low levels of PAP use.

Conclusions:
A “healthy user” effect was detected for the relationship between patient PAP adherence and physician optimal CVD regimen prescription in Black, but not white, veterans. Longitudinal studies are needed to determine the temporal order of these health behavior associations.
Abstract TP171: Differences Between Men and Women in Long-term Participation Restriction After Stroke: The International Stroke Outcomes Study (INSTRUCT)
Authors: Phan Hoang T , Blizzard Leigh , Reeves Mathew J , Thrift Amanda G , Cadilhac Dominique , Sturm Jonathan , Heeley Emma , Feigin Valery , Parmar Priya , Krishnamurthi Rita , Barker-Collo Suzanne , Parag Varsha , Konstantinos Vemmos , Anderson Craig , Bejot Yannick , Cabral Norberto , Carolei Antonio , Sacco Simona , Chausson Nicolas , Olindo Stephane , Silva Carolina , Correia Manuel , Magalhães Rui , Appelros Peter , Korv Janika , Vibo Riina , Minelli Cesar , Otahal Petr , Gall Seana
Published: June 2021

Introduction:
As women suffer worse functional outcomes of stroke than men, they may also face more challenges with community reintegration but data are scarce. We examined sex differences in participation after stroke and which factors might account for these disparities.

Methods:
INSTRUCT is an individual participant data pooling study of incident strokes obtained from 13 population-based cohorts worldwide. Two of the cohorts (Melbourne ’96-‘99 and Auckland ’02-‘03) included assessment of participation at 5 years after stroke using the London Handicap Scale (LHS). The LHS is used to assess the individual’s perspective of their involvement in life situations including orientation (person’s awareness of surroundings), physical independence, mobility, occupation, social interaction and economic self-efficiency. The total score ranges from 0 (worst disadvantage) to 100 (no disadvantage). Linear regression was used to compare LHS total scores and sub-domains for women compared to men. Study-specific multivariable models incorporated adjustment for socio-demographics, stroke-related factors, pre-stroke health and post-stroke factors were combined using random-effects meta-analysis.

Results:
At 5 years after stroke, there were data on participation for 351/592 (59%) of survivors in Melbourne and 266/881 (30%) of survivors in Auckland. Women suffered greater participation restriction than men (total LHS, pooled mean difference, MD -5.55 [95% CI -8.47, -2.63]). The magnitude of the difference attenuated after adjusting for covariates (pooled MD -2.48 [-4.99, 0.03]). Significant confounders in study-specific models included age, stroke severity, pre-stroke dependency and pre-stroke dementia for Melbourne; and age, stroke severity and pre-stroke dependency for Auckland. In sub-dimensions, women had greater restriction than men in mobility, physical independence and occupation. Additionally, women in Melbourne experienced poorer social integration and orientation than men.

Conclusion:
Greater restriction in participation after stroke among women than men was mostly attributable to their advanced age and greater pre-stroke dependency. Interventions targeting participation could reduce the impact of stroke in women.
Abstract TP18: Endovascular Treatment in the Elderly with Acute Ischemic Stroke - Is it Safe in Clinical Practice?
Authors: Leslie-Mazwi Thabele M , Ali Syed F , Onteddu Sanjeeva R , Amole Adewumi D , Akdol Mehmet S , Schwamm Lee H
Published: June 2021

Introduction:
An overwhelming benefit from endovascular treatment (EVT) of acute ischemic stroke (AIS) has been shown in recent trials, making it the new evidence-based standard of care for ischemic stroke due to anterior circulation large vessel occlusion. We sought to determine usage, safety and efficacy of EVT in patients ≥80 years of age.

Methods:
Using GWTG stroke registry data from MGH and UAMS, we analyzed 7,505 consecutive stroke admissions from 01/2009 - 06/2016. Univariate analysis was carried out to compare AIS patients < 80 vs. those ≥ 80yr.

Results:
Of the total 7,505 AIS patients, 3,722 presented within 12 hr of last known well and of these 334 (334/3722, 9%) underwent EVT. The majority of AIS patients undergoing EVT were younger than 80yr of age (264/334, 79%). Of the patients who underwent EVT, younger patients were more often male, Caucasian, and had stroke risk factors of atrial fibrillation, CAD, hypertension and smokers. The two groups were similar in NIHSS, initial clinical presentation, modified pre-stroke Rankin scale of ≤ 3, and initiation of tPA as a drip and ship or stroke center front-door administration. Higher rates of pneumonia were observed in younger patients while rates of sICH were similar. Younger patients were more often discharged to home/inpatient rehabilitation facility. On univariate analysis, in-hospital mortality was significantly higher in patients ≥ 80yr [Unadj. OR 2.50 (1.24, 5.03), p=0.01], however the strength of the association attenuated substantially after adjusting for significant covariates [Adj. OR 2.34 (0.99, 5.47), p=0.05] (Table).

Conclusion:
Elderly stroke patients are largely excluded from clinical trials and data are limited on the effectiveness of EVT in this cohort. Our results showed that rate of sICH and adjusted in-hospital mortality was not statistically different between those < 80yr vs. ≥ 80yr. Further studies are needed to explore the functional outcome of the elderly stroke patients undergoing EVT.
Abstract TP183: Food Insecurity Screening in Stroke Patients
Authors: Warrior Lakshmi , Kelly Michael , Chan Kathy
Published: June 2021

Introduction:
Food insecurity refers to a state of being without reliable access to sufficient quantity of affordable, nutritious food. Food insecurity is gaining recognition as a risk factor for uncontrolled hypertension and diabetes and possibly for stroke. Our hospital serves a population of uninsured and underinsured patients. We sought to determine the prevalence of food insecurity in our population of patients recently discharged from the hospital with stroke.

Methods:
Patients recently discharged from the hospital with stroke were screened for food insecurity in the neurology stroke clinic from March 23, 2016 to July 28, 2016. Food insecurity screening consisted of validated, two question screening tool. Electronic medical records were reviewed of patients who were screened. Information regarding insurance, zip code, reason for neurology consult, history of hypertension, history of diabetes, history of stroke and BMI were abstracted.

Results:
A total of 216 neurology patients were screened. Forty-nine patients (22.7%) were identified as food insecure. Sixty-four patients presented to the neurology clinic for diagnosis of stroke. Twelve of these (18.8%) were found to be food insecure. In this food insecure stroke group, 11/12 (84.6%) were diagnosed with hypertension, 7/12 (58.3%) had diabetes, and 2/12 (16.7%) had previous diagnosis of stroke. In the food secure stroke group, 35/52 (67.3%) had diagnosis of hypertension, 15/52 (28.8%) had diagnosis of diabetes, and 11/52 (21.2%) had previous diagnosis of stroke.

Conclusions:
Food insecurity is a prevalent issue in our patient population. Food insecurity may lead to an increased risk of stroke risk factors such as diabetes and hypertension and complicate their management. Understanding the magnitude of the problem may allow considered interventions.
Abstract TP19: Role of Pial Collateral Flow in Acute Ischemic Stroke Outcomes
Authors: Modi Sumul , Marin Horia , Varelas Panayiotis , Mitsias Panayiotis
Published: June 2021

Background and Purpose:
Collateral flow can influence the pace and extent of evolution to irreversible tissue damage and thus have a significant impact on the clinical outcome of patients with acute ischemic stroke (AIS), including those treated with endovascular treatment (ET). Using prospectively collected data of a Stroke Registry, we explored the relationship between digital subtraction angiography (DSA) collateral status and clinical outcome of AIS patients with middle cerebral artery (MCA) occlusion treated with ET.

Methods:
We reviewed the data of all patients with acute MCA occlusion treated with ET within the past 5 years. Baseline DSA collaterals were classified as - no (0), poor (1), intermediate (2) and good (3). Clinical outcomes were assessed using the National Institute of Health Stroke Scale (NIHSS) at 24-48 hours and at the time of discharge. Multivariable regression analysis was done to evaluate association of DSA collateral score with the outcome. The regression model was adjusted for the age, baseline NIHSS, infusion of intravenous (IV) thrombolytic (tPA) and symptom-onset to angiographic recanalization time.

Results:
50 patients with the MCA occlusion were treated with ET and 25 (50%) patients received IV tPA prior to ET. Median baseline NIHSS score was 19.5. Median time from the onset to IV tPA was 122 minutes and onset to angiographic recanalization was 277 minutes, respectively. Patients with DSA collateral score of 0, 1, 2 and 3 were 7 (15%), 21 (44%), 15 (31%) and 5 (10%), respectively. Every 1-point increase in the DSA collateral score was associated with 4.5-point reduction in NIHSS at 24-48 hours and 4.9-point reduction in NIHSS at discharge (Standard Error 1.4, p<0.01 for both).

Conclusions:
In the patients with AIS due to MCA occlusion, better collaterals on the DSA are independently associated with improved NIHSS at 24-48 hours after ET and at the time of discharge. This concept needs to be explored further in a larger dataset that will also include additional imaging parameters.
Abstract TP197: Risk of Stroke in Women with use of Testosterone-Containing Hormone Replacement Therapy
Authors: Rahman Haseeb A , Malik Ahmed , Rahman Aesha , Chaudhry Saqib , Adil Malik M , Imran Rajeel , Qureshi Adnan , Shahid Muhammad H , Rahman Daoud T , Shafi Rabiah , Thomas Abraham P
Published: June 2021

Background:
There has been debate in the role of exogenous testosterone as a risk factor for stroke. Hormone replacement therapy (HRT) is considered a risk factor for stroke. The risk of ischemic stroke may increase when using testosterone-containing HRT.

Methods:
Using data from the observational component of the Women’s Health Initiative (WHI) [WHI Observational Study (OS)], we analyzed the 93,676 women aged 50-79 years, who participated in the OS over a period of 12±1 years. We compared the outcome of stroke in participants with reported use of a combination of testosterone and estrogen, estrogen alone, progesterone alone, and a combination of estrogen and progesterone, as recorded at the baseline visit. A logistic regression analysis was run to determine the odds of developing stroke.

Results:
Of the 93, 676 participants, 1772 used a combination of testosterone and estrogen (Estratest) HRT, 11,282 used progesterone alone, 10,808 used a combination of estrogen and progesterone, and 31,673 used estrogen alone. A smaller proportion of participants who developed an outcome of stroke had used Estratest as compared to estrogen alone or a combination of estrogen and progesterone (1.9% vs. 96.3% p=0.62). In the logistic regression, participants who had used Estratest were 1.2 times as likely to develop stroke as users of other hormone replacement therapy (OR 1.2 95%CI (0.96-1.6)), while women who had used progesterone only were 0.87 times less likely to develop stroke than users of other hormone replacement therapy (OR 0.874 95%CI (0.77-0.99)). After adjusting for confounders, the risk of developing stroke increased in users of Estratest (OR 1.25 95%CI (0.96-1.6) p=0.04), and decreased in users of progesterone only (OR 0.873 95%CI (0.77-0.99) p=0.038).

Conclusion:
Use of testosterone-containing HRT slightly increased the risk of stroke in women when compared to progesterone alone HRT, although this was not found to be significant. Stroke risk with Estratest may be considered to be similar to estrogen only and combination of estrogen plus progesterone HRT. Future studies are required to investigate these correlations.
Abstract TP207: Sex Differences in Cardiovascular Risk Profiles of Patients with Diabetes in the Greater Cincinnati/ Northern Kentucky Stroke Study
Authors: Madsen Tracy E , Khoury Jane C , Alwell Kathleen , Moomaw Charles J , Demel Stacie L , Flaherty Matthew , Woo Daniel , Mackey Jason , De Los Rios La Rosa Felipe , Martini Sharyl , Ferioli Simona , Adeoye Opeolu , Khatri Pooja , Kissela Brett M , Kleindorfer Dawn O
Published: June 2021

Introduction:
Diabetes mellitus (DM) carries a greater stroke risk for females than males, possibly because of a difference in cardiovascular risk profiles between females and males with DM. Our aim was to compare the sex-specific risk factor profiles for patients with DM with those without DM among patients with acute ischemic stroke (AIS) in the Greater Cincinnati/ Northern Kentucky Stroke Study (GCNKSS).

Methods:
The GCNKSS ascertained cases of AIS in 2005 and 2010 among adult (age ≥20 years) residents of a biracial population of 1.3 million. Past and current stroke risk factors, obtained via chart review, were compared between those with and without DM using chi-square to examine bivariate differences and multiple logistic regression to examine sex-specific profiles. P < 0.05 was considered statistically significant.

Results:
There were 3515 patients with incident AIS; 1919 (55%) were female, 697 (20%) were black, and 1146 (33%) had DM. A lower proportion of females with DM were over 65 years old compared with those without DM. The proportion of males >65 with DM was not significantly different from that of males without DM. Among both females and males with DM, significantly more were Black, obese, and had histories of hypertension, high cholesterol, CAD and myocardial infarction compared to those without DM. In sex-specific adjusted analyses, women with DM were significantly less likely to be over 65 and more likely to have CAD than women without DM, whereas age and CAD were not significant factors in differentiating the profiles of men with and without DM.

Conclusions:
The result that females had their strokes at a younger age if they had a history of DM, and that no such age difference existed in males, suggests that DM is more severe and has a greater negative impact on females than males. As opposed to males, females with DM were also more likely to have CAD compared to those without DM, consistent with a possible sex difference in the association between DM and vascular disease.
Abstract TP210: Histopathological Evaluation of Thrombus in Acute Stroke and Correlation with Stroke Etiology
Authors: Nouh Amre , Mehta Tapan , Hussain Mohammed , Song Xianyuan , Ollenschleger Martin
Published: June 2021

Background:
While more endovascular treatments for acute stroke are being performed, few studies evaluate clot composition with variable results. We sought to evaluate the feasibility of collecting and analyzing the RBC to platelet ratios in clots, and correlated our findings with stroke etiology.

Methods:
This is an ongoing prospective study analyzing clots retrieved by mechanical thrombectomy in acute stroke patients at our institution. Retrieved clot material was fixed and cut at 4-m thickness. All clots were stained with hematoxylin-eosin to identify red blood cells (RBC’s), and antibodies for platelet glycoprotein IIIa with CD61 (LifeSpan Biosciences, Seattle, Washington) for platelets. Stained slides were scanned at 200x magnification by using a Scanscope XT digital scanner (Apergio, Vista, California). Image-J software (National Institutes of Health, Bethesda, Maryland) was used for semiquantitative analysis of percentage RBC’s and platelets. Correlation of RBC to Platelet ratios with stroke etiology was performed.

Results:
A total of 18 clots from 18 patients were analyzed. Stroke etiology was cardioembolic in 8, Large vessel atherosclerosis (LVA) in 5, undetermined in 3 and carotid dissection in 2. The mean RBC to platelet ratio was 0.51:1 in cardioembolic and 0.64:1 in LVA strokes. Patients with undetermined etiology had similar clot composition (0.53:1) to cardioembolic stroke. The highest RBC content was found in carotid dissection thrombus with a ratio of 1.73:1 as compared to other etiologies (p=0.01 cardioembolic, p=0.04 undetermined, p=0.02 LVA).

Conclusion:
In our study’s first phase, clot processing and analysis was found to be feasible. Although a high mean RBC content was found in carotid dissections and strokes of undetermined etiology had similar clot composition to cardioembolic stroke, ongoing collection and analysis will help support these findings.
Abstract TP211: Plasma Cytokine Levels Differ Between Primary and Syndromic Moyamoya and Pediatric and Adult Moyamoya Disease
Authors: Elbers Jorina , Ding Victoria , Han Summer S , Rossenberg-Hasson Yael , Steinberg Gary K
Published: June 2021

Background:
Moyamoya disease (MMD) is a progressive intracranial arteriopathy of unknown etiology affecting adults and children. We aimed to explore plasma cytokines in pediatric and adult cases of MMD. We hypothesized that quantitative and qualitative differences exist between adults and children, and primary idiopathic versus secondary syndromic cases of MMD.

Methods:
We performed plasma cytokine analysis using 63-plex Luminex immunoassay on 227 adults, 90% with primary MMD, and 30 children aged <21 years, 80% with primary MMD, from a single center. Patients with a history of stroke within 1-month of plasma collection were excluded. We fitted a linear regression model using pooled data, with adjustment for age and sex, to assess for differences between primary and secondary patients with respect to each of 60 cytokines. We then conducted a stratified analysis by fitting a set of linear regression models for adults and children separately to examine potential interactions between etiology and age. Statistical significance was adjusted using Bonferroni method to account for multiple testing.

Results:
Three cytokines differed significantly between primary and secondary cases of MMD after Bonferroni correction (p<0.00083), with secondary cases exhibiting higher levels of MCP3 (p=3.8x10
-8
), IP10 (p=5.1x10
-4
), and IL12P40 (p=6.4x10
-4
). Stratified analysis by age identified two cytokines, VEGF (p=7.2x10
-4
) and IL12P70 (p=7.8x10
-4
), that differed significantly among children, with higher levels among secondary versus primary MMD, while the difference was not significant among adults (interaction p<2x10
-4
) (figure 1).

Conclusions:
Syndromic cases of MMD demonstrate higher levels of plasma cytokines compared to primary cases of MMD, and the difference between primary versus secondary MMD is modified by age for some cytokines. This study suggests the importance of including age and etiology of MMD in investigating biomarkers and disease pathogenesis.
Abstract TP215: Clinical Utility of Hypercoagulability Screening in Young Adults With Ischemic Stroke
Authors: Salehi Omran Setareh , Lerario Michael P , Merkler Alexander E , Gialdini Gino , Moya Antonio , Kamel Hooman , DeSancho Maria T , Navi Babak B
Published: June 2021

Introduction:
We aimed to evaluate the ability of current genetic and serological testing to diagnose clinically relevant thrombophilic states in young adults with ischemic stroke.

Methods:
We performed a retrospective cohort study of patients aged 18 to 65 years who presented to Weill Cornell Medical Center between 2011 and 2014 with an ischemic stroke and had laboratory testing for a hypercoagulable state within six months of the index stroke. A hypercoagulable state was diagnosed by the criteria listed in Table 1. The primary outcome was any positive thrombophilia test. The secondary outcome was a change in clinical management based on the thrombophilia testing, defined as a change in antithrombotic selection or patent foramen ovale (PFO) closure. Using Fisher’s exact or Mann-Whitney U tests, we assessed whether the following prespecified risk factors were associated with our outcomes: age, sex, prior venous thromboembolism, family history of stroke, stroke subtype, and presence of PFO.

Results:
Of 146 ischemic stroke patients who met inclusion criteria, the mean age was 47 (±10) years and 47% were women. Of these patients, 61 (42.0%, 95% CI 33.7-49.9%) had at least one positive thrombophilia test and 8 (5.5%, 95% CI 1.7-9.2%) had a resultant change in management. A cryptogenic stroke subtype was documented in 87 patients, of whom 40 (46.0%, 95% CI 35.3-56.7%) had an abnormal hypercoagulability screen and 5 (5.7%, 95% CI 0.8-10.7%) had a change in management. There was no association between cryptogenic stroke subtype and a positive hypercoagulability test (p=0.2). No prespecified risk factors were associated with a positive hypercoagulability screen or a change in clinical management.

Conclusions:
Hypercoagulability screening among young patients with cryptogenic stroke changed clinical management in roughly one of every twenty patients tested. Cryptogenic stroke subtype and other clinical factors were not associated with a positive hypercoagulable screen.
Abstract TP219: D-lactate and Intestinal Fatty-acid Binding Protein Are Elevated in Serum in Patients with Acute Ischemic Stroke
Authors: Camara-Lemarroy Carlos , Escobedo-Zúñiga Nicolás , Guzman-De la Garza Francisco J , Castro-Garza Jorge , Vargas-Villarreal Javier , Góngora-Rivera Fernando
Published: June 2021

Introduction:
Ischemic stroke is associated with gastrointestinal complications such as constipation, dysphagia and fecal incontinence. However, the precise mechanisms involved have not been fully elucidated. D-Lactate and Intestinal Fatty-Acid Binding Protein (IFABP) are markers of intestinal mucosa integrity and barrier function. We evaluated serum concentrations of these markers in patients with acute ischemic stroke.

Materials and methods:
We included consecutive patients with ischemic stroke, and used healthy, age and sex-matched subjects as controls. We excluded cases determined to be of other or undetermined etiology according to the TOAST classification. Blood was drawn within 24 hours of symptom onset. Serum concentrations of D-Lactate and IFABP were determined using commercially available colorimetric and ELISA kits, respectively.

Results:
We included a total of 61 patients and 20 controls. The majority of patients were male (57.4%), and had a median age of 64 years. The most common cause of stroke was large-vessel atherosclerosis (34.4%), followed by small-vessel occlusion and cardioembolism (32.7% each). Mean admission NIHSS score was 8. IFABP and D-Lactate concentrations were significantly higher in patients than in controls (0.57±1 ng/ml vs. 1.84±2.7 ng/ml, p=0.04 and 0 nmol/μl vs. 0.38±0.66 nmol/μl, p=0.01, respectively). Concentrations were not associated with stroke severity or outcome. Patients with large-artery atherosclerosis and cardiombolic etiology had significantly higher D-Lactate values than patients with small-vessel disease.

Conclusions:
D-Lactate and IFABP were significantly elevated in patients with ischemic stroke. This provides, to our knowledge, for the first time in humans, evidence of intestinal barrier disruption. A stroke-associated systemic stress response could be responsible, but the lack of an association with stroke severity does not support this hypothesis. Embolic or atherosclerotic involvement of the mesenteric vasculature is another possibility. Further studies should aim at looking for a plausible mechanism as well as a possible association between intestinal barrier dysfunction and post-stroke gastrointestinal and infectious complications.
Abstract TP222: Characteristic Phenotype and Prognostic Factors in Magnetic Resonance Perfusion Weighted Image of Cerebral Venous Thrombosis
Authors: Park Moo-seok , Seo Woo-Keun , Bang Oh Young , Chung Chin-Sang , Lee Kwang Ho , Kim Geong-Moon
Published: June 2021

Introduction:
Cerebral venous thrombosis is a rare form disease. It can be difficult to diagnose and predict patient’s outcome. There are a few reports suggesting characteristic image phenotype and hypothesis of prognosis prediction but those are very rare and still controversial. We sought to identify image phenotype and prognostic factors associated with cerebral venous thrombosis using magnetic resonance perfusion weighted image.

Methods:
We retrospectively collected patients who had cerebral venous thrombosis from January 2000 to December 2015. Patients who had underwent magnetic resonance image with perfusion weighted image, non-contrast computerized tomography and magnetic resonance venography were enrolled. Perfusion weighted image was analyzed by visual assessment. We evaluated patient outcome by checking presence of recanalization and disappearance of symptom.

Results:
We collected 35 patients who had cerebral venous thrombosis. The mean age of these patients was 42.91 ± 15.47, and 57% were women. Perfusion abnormalities were observed in 25 cases. Cerebral blood volume abnormality was observed in 31 cases, cerebral blood flow abnormality in 31 cases, mean transit time abnormality in 18 cases, and time to peak abnormality in 22 cases. All perfusion abnormalities were localized in the areas adjacent to the occluded sinuses. In the univariate analyses, our study showed location of cerebral venous thrombosis was correlated with good outcome (transverse sinus:
p
= 0.042, sigmoid sinus:
p
= 0.026). Gradient echo sequences’ vessel sign (
p
= 0.094) and cerebral blood flow on perfusion weighted image (
p
= 0.055) was also related with good outcome. In the multivariate model with adjustment for variables with p<0.10 in the univariate analyses, sigmoid sinus thrombosis (Odd ratio 0.125, 95% confidence interval 0.014-0.756,
p
= 0.034) and increased cerebral blood flow on perfusion weighted image (Odd ratio 17.749, 95% confidence interval 1.427-544.176,
p
= 0.044) remained an independent predictor for good outcome.

Conclusions:
Our study suggest that cerebral blood flow is able to predict good outcome in cerebral venous thrombosis. It is similar to penumbra phenomenon in ischemic stroke.
Abstract TP223: Characterizing Ischemic Stroke and Hemorrhagic Conversion in Infectious Endocarditis
Authors: Marquardt Robert J , Cho Sung-Min , Zhang Lucy , Thatikunta Prateek , Uchino Ken , Wisco Dolora
Published: June 2021

Introduction:
Ischemic stroke is a common complication of infective endocarditis (IE) and can delay valve surgery. Identifying risk factors for acute ischemic stroke (AIS) and hemorrhagic conversion may help in perioperative risk assessment of these patients.

Methods:
Retrospective analysis was done on 116 consecutive patients with IE seen by stroke neurology at a tertiary center from January 2015 through July 2016. Clinical and radiographic characteristics were collected in a population whose initial evaluation was for acute stroke management or preoperative risk evaluation. Descriptive statistics were used to identify risk factors for AIS, defined as clinical or silent infarct, both with and without hemorrhagic conversion.

Results:
Among 116 patients with IE, AIS occurred in 82 (70.6%) with a median NIH Stroke Scale of 3 (interquartile range (IQR) 0-12) and a median MRI volume of 13.5mL (IQR 1.4-42mL). Of AIS patients, 25 (30%) had silent infarct, 6 (7%) had concurrent primary ICH without a clear ischemic component and 25 (30%) had hemorrhagic conversion. AIS was associated with remote stroke on imaging (OR 1.27), history of diabetes (OR 1.22), and > 1 vegetation on echocardiogram (OR 1.29), but not history of atrial fibrillation, microhemorrhages or mycotic aneurysm on imaging, MRI enhancing lesions, aortic versus mitral valve involvement, vegetation size, organism involved, IV drug abuse, or pre-admission antithrombotic use. Microhemorrhages on MRI susceptibility-weighted images occurred in 66 (80%) AIS patients, and was associated with hemorrhagic conversion (OR 1.35). Mycotic aneurysm was found in 4 patients with hemorrhagic conversion, but this was not significant (OR 1.0). A total of 48 AIS patients (58.5%) underwent valve surgery. Additional stroke occurred while awaiting surgery in 10 AIS patients (OR 1.20), 6 were new ischemic stroke and 4 were new ICH. Post-operatively there were 1 new AIS and 3 new ICH complications.

Conclusion:
The incidence of acute ischemic stroke in our population was 70.6%, with a third being silent infarcts. Hemorrhagic conversion occurred in 30% and was associated with cerebral microhemorrhages.
Abstract TP226: Predictors and Impact of Paramedic Recognition of Hemorrhagic Stroke
Authors: Oostema John A , Negronrolon Christian , Reeves Mathew J
Published: June 2021

Introduction:
Utilization of EMS is associated with faster emergency department evaluation and treatment of patients with stroke, especially among EMS-recognized patients. However, most research focuses on patients with ischemic stroke. We sought to identify factors associated with prehospital recognition of hemorrhagic stroke and the impact of recognition on prehospital and in-hospital care.

Methods:
A cohort of hospital-confirmed hemorrhagic stroke cases transported by EMS to 2 primary stroke centers in Kent County, Michigan over a 12-month time period was assembled. Data regarding prehospital care (Cincinnati stroke screen [CPSS] documentation, GCS, clinical signs and symptoms, transportation times, and paramedic impression) were linked to in-hospital data on door-to-CT (DTCT) times, mortality, and discharge disposition. We examined the relationships between clinical factors and stroke recognition by paramedics as well as between recognition and in-hospital outcomes.

Results:
Over 12 months, 73 confirmed hemorrhagic stroke patients arrived by EMS. Forty-seven (64.4%) were correctly identified by EMS as stroke; 26 (35.6%) were missed. EMS recognition was associated with greater likelihood CPSS documentation, intracerebral hemorrhage, dispatch impression of stroke, absence of seizure, and higher systolic blood pressure (Table). Multiple logistic regression confirmed a strong independent relationship between CPSS documentation and stroke recognition (OR 40.3 [5.0 to 323.5]). EMS recognized cases had shorter on-scene times (17 vs. 21 minutes, p=0.004), total transport times (33 vs. 43 minutes, p=0.003), and DTCT times (30 vs. 48 minutes, p=0.004). Recognition was not associated with mortality or discharge disposition.

Conclusion:
CPSS documentation is strongly associated with hemorrhagic stroke recognition by EMS providers. EMS recognition is associated with more efficient transportation and faster DTCT times upon hospital arrival.