bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 3267: Persistence of Hyperdense Middle Cerebral Artery Sign on Follow-up CT Scan is Associated with Poor Outcome in Ischemic Stroke Patients Treated with Intravenous Thrombolysis
Authors: Yeo Leonard L , Paliwal Prakash R , Wakerley Ben , Shen Liang , Ahmad Aftab , Loh Pei K , Ng Kay W , Chong Vincent F , Ong Benjamin K , Venketasubramanian N , Sinha Arvind K , Teoh Hock L , Wong Lily Y , Bathla Girish , Chan Bernard P , Sharma Vijay K
Published: March 2022

Background-
Early identification of reliable predictors of functional outcomes is important for planning rehabilitation strategies in patients with acute ischemic stroke (AIS). Hyperdense middle cerebral artery sign (HMCAS) on unenhanced computerized tomography (CT) of the brain represents presence of thrombus, often associated with poor outcome at 3-months. In thrombolyzed cases, HMCAS may disappear or persist on the follow-up CT scan. We evaluated whether persistence of HMCAS on follow-up CT predicts functional outcome at 3-months.

Methods-
Consecutive AIS patients treated with intravenous thrombolysis between 2007 and 2010 were included. HMCAS was assessed on admission as well as follow-up CT by 2 independent readers, blinded to patient data and outcomes. Data were analyzed for early predictors of poor functional outcome at 3months (modified Rankin scale 2-6points).

Results-
Of the total of 2238 patients admitted during the study period, 226 (10.1%) with anterior circulation AIS treated with intravenous thrombolysis were included. Median age of the IV-TPA treated patients was 65yrs (range 19-92), 63% males and median National Institute of Health Stroke Scale (NIHSS) 16points (range 4-32). HMCAS was observed on admission CT scan in 109 (48.2%) patients and persisted on follow-up CT in 52 (47.7%) of them. Overall, 108 (47.8%) patients achieved poor functional outcome at 3-months. Older age (OR 1.024;95%CI0.999-1.048), admission NIHSS score (OR1.08;95%CI 1.03-1.14,p=0.002) and HMCAS on follow-up CT scan (OR 10.25;95%CI 4.05-25.99,p <0.0001) were associated with poor outcome at 3-months.

Conclusion-
Persistence of HMCAS on the follow up CT scan in AIS patients receiving intravenous thrombolysis is an early predictor of poor functional outcome at 3-months.
Abstract 3272: University Hospitals Stroke System Program (UH-SSP): Leveraging a System-wide CPOE Rollout to Drive Compliance with Best Practices for Stroke
Authors: Mehndiratta Prachi , Fussner Julie , Gifford Carol , Richardson Melissa , Restifo Joyce , Merkel Sandy , McCartney LeighAnn , Sila Cathy
Published: March 2022

INTRODUCTION
The “meaningful use” of electronic medical records requires major shifts in physician behavior, considerable technical support, and substantial financial commitment in an era of shrinking reimbursement. Successful initiatives are widely adopted, simple to use, and multitask in their ability to guide best practices and capture regulatory documentation.

HYPOTHESIS
A system-wide computerized patient order entry (CPOE) rollout can be leveraged to encourage use of a Stroke Orderset and increase compliance with best practices for stroke across a hospital system.

METHODS
The UH-SSP developed a Stroke Orderset embedded with GWTG quality measures and smart reminders for omission of best practices. Implementation was phased in at four Stroke Center hospitals between December 2009 and October 2010. The Stroke Orderset was selected for provider CPOE training. Data from each hospital on Ischemic Stroke / TIA discharges, usage of the Stroke Orderset and compliance with measure #6: Discharge on Statin was collected and reviewed by the Stroke Quality Committee.

RESULTS
Stroke Orderset usage relative to total Ischemic Stroke/ TIA discharges significantly increased at all system hospitals from 15-50% in the first quarter to a high of 35-100% over the next three quarters and was consistently high at 97-100% at UH-Case, where a CPOE had been in place since 1998 and all suspected strokes are admitted to an inpatient Stroke service. Compliance with measure #6 substantially increased at each system hospital: UH-Bedford from 77% to 100%, UH-Geauga from 50% to 89%, UH-Richmond from 51% to 72% (p=0.02) and remained high at UH-Case (97-100%) which led to GWTG Gold Plus and Silver Plus awards at two hospitals. Compliance with measure #6 correlated with Stroke Orderset use at UH-Bedford and UH-Richmond (Pearson coefficients of 0.65 and 0.98 respectively).

CONCLUSIONS
The use of a standard Stroke Orderset increases compliance with best practices for stroke care. A hospital system-wide CPOE rollout was an opportunity for leveraging EMR training of community physicians to educate them on GWTG quality measures for stroke and make rapid changes in their behavior. By encouraging consistent use of a standard Stroke Orderset, any subsequent revisions will continue to update caregivers on current best practices and reinforce optimum patient care.
Abstract 3277: Initial Stroke Severity Measured by Pediatric NIH Stroke Scale Predicts 12-month Outcome in Children
Authors: Ichord Rebecca N , Bastian Rachel A , Abraham Lisa , Benedict Susan L , Bernard Timothy J , Beslow Lauren A , de Veber Gabrielle , Dowling Michael , Friedman Neil R , Fullerton Heather J , Jordan Lori C , Kan Li , Kasner Scott E , Kirton Adam , Amlie-Lefond Catherine , Licht Daniel J , Lo Warren , McClure Chalmer , Pavlakis Steve , Smith Sabrina E , Jawad Abbas F
Published: March 2022

Background:
Stroke is an important cause of death and disability among children. Clinical trials for childhood stroke will require a valid acute clinical stroke scale. We evaluated predictive validity of a pediatric adaptation of the NIH Stroke Scale, (PedNIHSS).

Methods:
The PedNIHSS was developed by modifying the adult NIHSS for administration in children. Children 2-18 yrs with acute arterial ischemic stroke were enrolled in a prospective cohort study from 15 North American sites Jan 2007-Oct 2009. Examiners were child neurologists experienced in pediatric stroke, certified in the NIHSS and trained in using the PedNIHSS. Each subject was examined daily for 7 days or until discharge. Outcome at 3 and 12 months was assessed with the Pediatric Stroke Outcome Measure (PSOM). Associations were evaluated using Pearson rank correlation and simple linear regression. Data are mean±SD or median(IQR).

Results:
Among 112 children enrolled, mean age was 10.3±5.3 yr, 60% were male. Stroke mechanism was vasculopathy in 32%, cardioembolic in 30%, other in 17%, and unknown in 21%. Infarcts were in the anterior circulation in 66%, posterior circulation in 26%, both in 8%. Median time from symptom onset to initial PedNIHSS exam was 28 hrs (IQR 18-53). Median initial PedNIHSS score was 6 (IQR 3-13) and maximum 7 (IQR 3-14). Three (3%) children died, and were excluded from further analysis. Outcome data was available in 102(90%) at 3 months and 81(72%) at 12 months. Median PSOM was 1.0 (IQR 0.5-2.5) at 3 months, and 1.0 (IQR 0-2.5) at 12 months. Outcome at 12 months was good (PSOM 0-0.5) in 32/81(40%), moderate (PSOM 1.0-2.0) in 27/81(33%), and severely impaired (PSOM>2.0) in 22/81 (27%). Initial PedNIHSS score significantly predicted global deficits on PSOM at 3 (Adj R
2
=0.32, p<.0001) and 12 months (Adj R
2
=0.26, p<.0001). Maximum PedNIHSS score also significantly predicted PSOM at 3 (Adj R
2
=0.41, P<.0001) and 12 months (Adj R
2
=0.36, P<.0001).(
Fig
).

Conclusion:
Initial stroke severity in children measured by the PedNIHSS is predictive of 3- and 12-month outcome.
Abstract 3278: Aortic Arch Complicated Lesion is Strongly Associated with Recurrence of Ischemic Stroke
Authors: Tachibana Masaki , Wakugawa Yoshiyuki , Kiyohara Takuya , Furuta Yoshihiko , Murao Kei , Matsushita Tomonaga , Yoshimura Sohei , Ishikawa Eiichi , Yasaka Masahiro , Okada Yasushi
Published: March 2022

Background:
Aortic arch plaque is a risk factor for ischemic stroke. The aim of this study was to identify whether aortic arch plaque is also a risk factor for recurrence of ischemic stroke.

Methods:
We performed transesophageal echocardiography for source of emboli in 452 acute stroke patients between 2002 January and 2010 July. We investigated age, gender, incidence of atrial fibrillation, antithrombotic therapy, diabetes mellitus, hypertension, dyslipidemia, history of ischemic heart disease, history of peripheral artery disease, smoking, and transesophageal echocardiographic findings, such as spontaneous echo contrast in the left atrium, patent foramen ovale, and aortic atheroma ≥4.0 mm(complicated plaque). We compared these clinical findings between patients with the first ever stroke and those with recurrent stroke by univariate and multivariate analysis.

Results:
We developed 383 patients with the first ever stroke and 69 patients who had recurrent stroke. Univariate analysis demonstrated that age(66.8±12.1 VS 71.4±9.9, p<0.05), antithrombotic therapy(21% VS 70%, p<0.05, 97 with antiplatelet, 23 with anticoagulation, 9 with both), diabetes mellitus(25% VS 41%, p<0.05), history of ischemic heart disease(9% VS 20%, p<0.05), history of peripheral artery disease(3% VS 7%, p<0.05), smoking(29% VS 14%, p<0.05) and aortic atheroma > or =4.0 mm(40% VS 61%, p<0.05) were associated with recurrence of ischemic stroke. Multivariate analysis showed that antithrombotic therapy (OR 7.55, 95%CI 4.29-13.66) and aortic atheroma > or =4.0 mm (OR 1.83, 95%CI 1.04-3.26) were independently associated with recurrence of ischemic stroke.

Conclusions:
Aortic atheroma > or =4.0 mm seems to associate with reccurence of ischemic stroke regardless of antithrombotic therapy.
Abstract 3310: Functional Outcome in Stroke Patients Enrolled in Early Supported Discharge Program Not Reaching Minimal Clinically Important Change in Functional Independence Measure
Authors: Chang Yuan Hsi , Chong Cheu Shan , Eng Jia Yen , Wong Beryl P , Chai Chee Pei , Chen Zhen Zhen , Hew Wee Kee , Sharma Vijay K , Chan Bernard P
Published: March 2022

Objectives:
Stroke patients discharged home under early supported discharge (ESD) program generally have milder disability compared to patients discharged to in-patient rehabilitation facilities, and may not attain traditionally defined thresholds in minimal clinically important difference (MCID) as measured by Functional Independence Measure (FIM) after therapy. We aim to investigate the functional outcome in patients not attaining MCID compared to those who attained MCID in our ESD program.

Methods:
Consecutive patients admitted with acute stroke and discharged to ESD program of our unit during July 2007 to July 2010 were recruited. Patients were assessed at the initial and final home therapy sessions using FIM, Frenchay Activity Index (FAI), Motoricity Index (MI) and Modified Rankin Scale (MRS). MCID is defined as any increase ≥22 in FIM total score, ≥17 in FIM motor subscore, or ≥3 in FIM cognitive subscore. The proportion of patients with MRS 0-1 at the initial and final ESD sessions were determined separately in patients who attained and in those who did not attain MCID.

Findings:
255 patients (60% male, mean age 65.2, SD11.7 years) were recruited, with home therapy duration from 2-6 weeks. Significant improvements (p<0.001) were found in all the functional outcome measures, with a mean improvement of 16 points (99 to 115) in FIM, 9.2 points (1.2 to 10.4) in FAI, 12 points in upper limb MI (76 to 88), and 14 points in lower limb MI (74 to 88). 126 (49.4%) patients attained MCID after ESD (23.5% in FIM
total
, 37.6% in FIM
motor
and 28.2% in FIM
cognitive
). Patients who attained MCID had significantly lower mean baseline FIM scores compared to those who did not (90 SD19 vs 106 SD16, p<0.001). Significant increases in the proportion of patients with MRS 0-1 were observed both in patients who attained MCID (3.2% to 38.9%) and in those who did not (6.2% to 53.5%) after completion of ESD.

Conclusions:
The utility of the FIM instrument in monitoring functional outcome in stroke patients is limited by the ceiling effect. Patients with milder disability without significant changes in FIM can nevertheless achieve important functional improvements after home therapy offered by an ESD program.
Abstract 3317: Neurofeedback Enhance The Efficacy Of Mental Practice With Motor Imagery In Post-acute Stroke Victims: A Pilot Study.
Authors: Mihara Masahito , Hattori Noriaki , Hatakenaka Megumi , Yagura Hajime , Kawano Teiji , Hino Taro , Miyai Ichiro
Published: March 2022

Background/Objective:
Accumulating evidence indicates that motor imagery and motor execution share common neural networks. Accordingly, mental practice with motor imagery has been implemented in the rehabilitation regimes of stroke patients. However, several studies investigating the efficacy of mental practice with motor imagery revealed inconsistent results. We hypothesized that difficulty for monitoring effort and compliance during motor imagery would cause inconsistency, and feedback of cortical activities (neurofeedback) may enhance the efficacy of mental practice with motor imagery.

Methods:
We recruited 15 post-acute hemiparetic patients with subcortical stroke (9 males, age: 58.7 ± 6.8 years). Averaged duration from onset was 132.1 ± 38.5 days. In addition to the usual training sessions of up to 180 min per day, all participants received 20 min session of the mental practice with motor imagery 3 times a week for 2 weeks. Mental practice consisted of video based motor imagery for 10 min followed by motor imagery with neurofeedback for 10 min. Participants were randomly assigned to the Real group or the Sham group. During neurofeedback, participants performed 16 repetitions of 5 sec motor imagery task, and cortical activation from the contralateral motor cortex was measured by a near infrared spectroscopy (NIRS). In the Real group, cortical activation processed in a real-time fashion was feedbacked, and irrelevant randomized value was feedbacked in the Sham group. Primary outcome measure was the finger and arm subscales of the Fugl-Meyer assessment (FMA), and the action research arm test (ARAT) was also assessed. Upper limb function was assessed at before, immediately after, and two weeks after the mental practice. Motor activity log (MAL), and kinesthetic and visual motor imagery questionnaire was also assessed before and after mental practice. We used repeated measures ANOVA to test the effect of mental practice and neurofeedback. For evaluation of the motor imagery related cortical activation changes during mental practice, contrast between cortical activation in the first and last session was assessed and unpaired t-test for group difference was performed.

Results:
In the finger function subscale in FMA, there was significant effect of time (F2,13=25.622, p<0.001) and interaction between time and group (F2,13=10.689, p<0.005) with more functional gain in the Real group. Mental practice also affected other outcome measures including arm subscale of FMA, ARAT, and MAL, but there was no significant interaction. Enhancement of finger movement imagery related cortical activation was significantly greater in the Real group than the Sham group (t88 =2.046 p<0.05).

Conclusion:
Our results imply that NIRS mediated neurofeedback has a positive add-on effect on the efficacy of mental practice with motor imagery and its related cortical activation.
Abstract 3348: A Novel Role for TLR-3 in Protecting the Immature Brain from Ischemic Injury
Authors: Shi Hui , Hickey Edward , Van Arsdell Glen , Askalan Rand
Published: March 2022

Background:
We have shown that giving a low dose of lipopolysaccharide (LPS) to P7 rat pups will result in 90% reduction in ischemia-induced brain damage. This dramatic LPS neuroprotection was observed in P7rat pups which correspond in terms of brain development to human term newborn but not in P3 or P5 pups which correspond to human premature infant. LPS is a known Toll-like receptor 4 (TLR-4) ligand. We hypothesized that TLRs other than TLR-4 may mediate preconditioning against cerebral ischemic injury in the developing brain

Methods:
Brains from P5 and P7 rats were removed, fixed in 10% formalin, embedded in paraffin and cut in 5μ m coronal sections. TLR-3 and TLR-4 expression was assessed by immunohistochemistry. In subsequent experiment, P5 Rat pups were randomly assigned to TLR-3 specific agonist, poly I:C, treated group (20μ g; IP) or saline treated group. Forty eight hours after the injections, hypoxic-ischemic injury was induced by using the Rice-Vannucci model. Unilateral internal carotid artery ligation in rat pups followed by exposure to 8% hypoxia for approximately 65min will cause a reproducible unilateral infarct ipsilateral to the ligated artery involving caudate, putamen, hippocampus and cortex. Body temperature will be maintained at 37-37.5
0
C during hypoxia using an incubator. Brains were removed 1 week after HI injury, fixed, embedded in paraffin and cut in 5μ m coronal sections. Brain sections were then stained with Hematoxylin and Eosin and infarct volumes were compared between the two groups using Nikon NIS-Element Basic Research Image analysis software system

Results:
TLR-4 was highly expressed in brains of P7 but not in P5 rat pups. The number of TLR-4 positive cells was significantly lower in P5 rat brains compared to P7 pups (
p
< 0.05). TLR-3 was predominately expressed in P5 (
p
< 0.05). There was a significant reduction in infarct volume (
p
= 0.01) in poly I:C P5 treated pups (6.6mm
3
+ SEM 3) compared to saline treated P5 pups (26mm
3
+ SEM 6).

Conclusion:
This is the first study to show that TLR-3 is expressed in the immature brain and mediates preconditioning against ischemic injury. LPS-mediated TLR-4 activation is necessary for inducing preconditioning in P7 rats whereas poly I:C is effective in protecting P5 pups where TLR-3 expression predominates. Therefore, the role of TLRs in protecting the brain from ischemic injury is developmentally determined.
Abstract 3362: Neurological Deterioration And Stroke Recurrence In The Acute Phase Of Japanese Minor Stroke ∼ Fukuoka Stroke Registry ∼
Authors: Fujimoto Shigeru , Sugimori Hiroshi , Jinnouchi Juro , Matsuki Takayuki , Mezuki Satomi , Ishitsuka Takao , Kitazono Takanari
Published: March 2022

Background & Purpose:
A neurological deterioration in the acute phase can be associated with a bad outcome even in the minor stroke. We investigated the predictive factors for an acute neurological deterioration in minor stroke.

Subjects & Methods:
Among the consecutive 3062 stroke patients who were admitted to the 7 stroke centers in Fukuoka prefecture Japan within 7 days after the onset, 2113 patients with acute ischemic stroke with the initial NIH stroke scale score of 7 or less and preclinical modified Rankin scale of 0 or 1 were included in the present study. We observed a neurological deterioration (a NIH stroke scale score worsening of ≥1-point), stroke recurrence, or any death during the first 21 hospital days.

Results:
A neurological deterioration with or without stroke recurrence was observed in 338 (16%) patients. Baseline NIH stroke scale score was not different between patients with and without a neurological deterioration. With regard to the TOAST classification, a neurological deterioration was most frequent in Large-artery atherosclerosis (18.3%), followed by Others (18.2%), Cardioembolism (15.6%), and Small-vessel occlusion (12.2%) in order. In accordance with the site of ischemic lesions, a neurological deterioration was most frequent in patients with both cortex or cerebellar lesions and deep perforating artery lesions (20.2%). A preexisting warfarin use was less frequent (6.8% vs 10%, p=0.0624), diabetes mellitus (42% vs 32%, p=0.0007) and a stenosis of ≥50% in the major brain artery (35% vs 28%, p=0.0133) were more frequent, and the initial values of low density lipoprotein (LDL) cholesterol (122.1±36.5 vs 116.6±34.7 mg/dl, p=0.0100), blood glucose (144.9±66.5 vs 138.9±60.1 mg/dl, p=0.0969), and HbA1c (6.05±1.42 vs 5.91±1.23, p=0.0801) were higher in patients with than without a neurological deterioration. Maximum intima-media thickness of the common carotid artery was relatively thicker in patients with than without a neurological deterioration (1.87±1.55 vs 1.69±0.97 mm, p=0.0624). On multivariate analysis, a stenosis of ≥50% in the major brain artery (OR, 1.40; 95%CI 1.07∼1.85), ischemic lesions including deep perforating artery area (OR, 1.47; 95%CI, 1.10∼1.96), LDL cholesterol (OR, 1.00; 95%CI, 1.00∼1.01), and diabetes mellitus (OR 1.70, 95%CI 1.21∼2.39) had a positive association, and preexisting warfarin use (OR 0.61, 95%CI 0.39∼0.98) had a negative association with a neurological deterioration.

Conclusions:
The major brain artery stenotic lesion, the site of ischemic lesions, LDL cholesterol, and diabetes mellitus were significant predictor for a neurological deterioration in the acute phase of minor stroke. A preexisting warfarin use might decrease the risk of a neurological deterioration.
Abstract 3368: Association of Superoxide Dismutase polymorphism and severity of Brain Infarction
Authors: Gongora-Rivera Fernando , Navar-Vizcarra Sirelda , Ortiz-Lpez Rocio , Calvo-Anguiano C. , Carrasco Diana , Soto-Garca Anally , Barrera-Saldaa Hugo , Villarreal Hctor Jorge
Published: March 2022

Objective.
Determine the relationship between Cu-Zn and Mn Superoxide Dismutase (SOD) polymorphism with the clinical presentation and outcome after acute brain infarct.

Background.
The SOD polymorphism has been linked with mechanisms of damage in Stroke. There are no clinical studies that demonstrate their influences in the severity or prognosis of acute cerebral infarction.

Methods.
Of 195 patients admitted prospectively with stroke in the Department of Neurology, University Hospital “Dr. José Eleuterio González” UANL from June 2008 to July 2010. We included 140 patients with acute brain infarct and 140 healthy controls. We analyzed polymorphisms of superoxide dismutase (Mn CuZn) and compared it with demographic, clinical and neuroimaging studies. We used Chi-square, U-Mann Whiney test and Cox logistic regression adjusted for age, gender and etiology.

Results.
We included 85 (61%) men and 55 (39%) women, mean age 63 ± 1.4 (31-94) years. The most common etiology was atherosclerotic (41%) and small vessels disease (17%). The prevalence of Mn CuZn polymorphism did not differ between healthy subjects and patients with stroke, but the presence of the Ala allele of MnSOD was associated with the occurrence of severe stroke (p=0.016) and a worse functional outcome at hospital discharge (p=0.076).

Conclusions.
SOD polymorphisms are not associated with the occurrence of stroke, but may influence the severity of their clinical presentation.
Abstract 3386: The “True Value” of the Primary Stroke Center Designation
Authors: Selco Scott L
Published: March 2022

Background:
The “true value” to a community hospital of achieving the Joint Commission Primary Stroke Center (PSC) designation is unknown. On 8/26/2010 St. Rose Dominican Hospitals Siena Campus became Clark County, Nevada’s, ninth PSC. For 3 years prior to becoming a PSC our local fire company (Henderson, NV) bypassed our hospital so that suspected acute stroke patients could be taken to a PSC. Furthermore, on 1/1/2010 a County mandate was passed designating transport of patients with suspected acute stroke to a PSC. During the period August 1, 2007 to August 25, 2010 stroke patients were admitted to our hospital but we were restricted from receiving suspected acute strokes from pre-hospital providers. Our aim was to determine the true value to a community hospital of achieving the Joint Commission PSC designation in the first six months of operation.

Methods:
Using the Horizon Performance Management™ database we categorized inpatient admissions into stroke ICD-9-CM (Group 1), closely-stroke-related ICD-9-CM (Group 2), and loosely-stroke-related ICD-9-CM diagnoses (Group 3). Percent change in admissions alone and as a function of total inpatient admissions, and percent change in average contribution margin ($US) [net revenue - variable costs] for the three stroke and stroke-related categories were analyzed. We compared data for the 6-month epoch 9/1/2010 - 2/28/2011 to the average data from the same 6-month epochs in 2007-8, 2008-9, 2009-10.

Results:
45%, 31%, and 21% increases in admissions were observed for Groups 1, 2, and 3, respectively. Admissions, as a percentage of total inpatient admissions, increased 5.97%, 0.64%, and 2.18% in Groups 1, 2, and 3, respectively. For Groups 1 & 2 combined the increase was 3.55% and for all groups combined was 5.73%. The percent increase in average contribution margin was 90%, 22%, and 25% for Groups 1, 2, and 3, respectively.

Conclusions:
The present method was utilized to estimate the “true value” of the PSC designation to a community hospital. The present study indicates that stroke and stroke-related inpatient admissions increase, along with contribution margins, after PSC designation. Lesser increases in Groups 2 and 3 vs. Group 1 (stroke) likely represent the “halo effect”, reflecting an increase in admissions for conditions similar to stroke, but that are not stroke, transported to a hospital by virtue of being a PSC. Future analyses should focus on length of stay and outcome measures in community PSCs.
Abstract 3398: Excessive Supraventricular Ectopic Activity On 24h-Holter Predicts Paroxysmal Atrial Fibrillation In Patients With Cerebral Ischemia Presenting In Sinus Rhythm
Authors: Weber-Krüger Mark , Stahrenberg Raoul , Niehaus Cord F , Seegers Joachim , Vollmann Dirk , Hasenfuβ Gerd , Gröschel Klaus , Wachter Rolf
Published: March 2022

Background
Detection of paroxysmal atrial fibrillation (PAF) in patients with cerebral ischemia is challenging. Echocardiography (LAVI/á, an index of left atrial remodeling) can select a subgroup of patients for extended ECG-monitoring. Excessive supraventricular ectopic activity (ESVEA), measured as atrial premature beats (APB) and longest supraventricular run on 24h-Holter-ECG (SV-run
24h
) may further improve prediction of PAF.

Methods
Retrospective analysis from a prospective monocentric observational trial (Find-AF) in patients >18y with cerebral ischemia (ISRCTN 46104198). PAF was diagnosed by 7d-Holter monitoring. Transthoracic echocardiography parameters were prospectively assessed. ESVEA was quantified in one 24h interval, which had to be free from PAF. For the present analysis, 44 patients with atrial fibrillation at baseline and 20 patients with limited evaluability for ESVEA (9 with pacemaker rhythms, 4 with low-quality recordings and 7 with PAF who had no 24h interval free from PAF) were excluded.

Results
PAF was detected in 21 out of 215 patients (9.8%) of the analysis population. PAF was more prevalent in those with ESVEA above the median: 17.3 vs. 2.7% for APB > vs. <= 4/h (p<0.001 chi-square test); 15.9 vs. 3.7% for SV-run
24h
> vs. <= 5 beats (p=0.003). ESVEA differed between PAF and Non-PAF: APB median 17/h [IQR 9; 143] vs. 4/h [1; 15] and SV-run
24h
10 [7; 18] vs. 0 [0; 8] beats (both p<0.001, Mann-Whitney-U test). Both parameters discriminated moderately between PAF and Non-PAF (area under the receiver-operator-characteristics curve 0.751 and 0.730, respectively). In multivariate analysis with age, sex, body-mass index, systolic blood pressure, hypertension, heart failure and LAVI/á as covariates, log(APB/h) (p=0.027) and log(SV-run
24h
) (p=0.022) were independently predictive for the presence of PAF. 0% of patients with normal LAVI/á and APB <=4/h, 5.6% of those with either abnormal LAVI/á or APB >4/h, and 27.1% of those with both abnormal LAVI/á and APB >4/h had PAF (p<0.001 chi-square). Results were similar when PAF-cases were included that had been diagnosed clinically until 1-year follow-up.

Conclusions
In patients with cerebral ischemia, ESVEA discriminates PAF from Non-PAF beyond clinical factors and LAVI/á. PAF is ruled out in patients with normal LAVI/á and APB <=4/h, while prevalence is high in those with abnormal LAVI/á and APB >4/h.
Abstract 34: Predictors of Readmission to Hospital Following Acute Stroke
Authors: Stamplecoski Melissa , Fang Jiming , Kapral Moira K , Silver Frank L
Published: March 2022

Background:
Readmission to hospital following discharge for acute stroke has been estimated in previous studies to be about 30% and recurrent stroke is known to be associated with a higher mortality and worse functional outcome than a first stroke. The aim of this study was to develop a risk-standardized model that identified potential predictors of readmission at 30 days, 1 year and 2 years following discharge for acute stroke.

Methods:
We analyzed data from eleven stroke centres in Ontario participating in Phase 3 of the Registry of the Canadian Stroke Network (RCSN). Consecutive patients admitted between July 1, 2003 and March 31, 2008 with ischemic stroke, TIA or intracerebral hemorrhage (ICH) who were alive at discharge were included in the analysis. Records were linked to a provincial administrative database to determine readmission within 30 days, 1 year and 2 years. Competing risks (death and readmission) time-to-event Cox modeling was used to evaluate potential predictors of readmission including age, sex, risk factors, initial stroke severity, comorbidities, type of stroke and discharge medications, for all stroke patients and those with ischemic stroke, TIA or ICH.

Results:
The final cohort consisted of 12,432 patients admitted with a final diagnosis of ischemic stroke, TIA or ICH. The mean patient age was 70.6 years, 46.7% were female and 19.8% had severe deficits on admission (Canadian Neurological Scale, 0 - 5.5). The readmission rate for any reason at 30 days, 1 year and 2 years was 9.6%, 31.4% and 42.3%, respectively, while the mortality rate for those same periods was 2.9%, 13.2% and 19.6%. The readmission rate for recurrent stroke at 30 days, 1 year and 2 years was 2.9%, 6.1% and 8.0%, respectively. Readmission at 30 days for all causes was highest for TIA patients (13.5%) and similar for ischemic stroke and ICH patients (9.0 and 8.5%). Factors associated with a lower rate of readmission for all causes included admission to a stroke unit, use of statins, warfarin and a lower modified Rankin Scale (mRS) at discharge (all p<0.05). Factors that increased the rate of readmission included the presence of atrial fibrillation, angina, peripheral vascular disease, diabetes, smoking, elevated creatinine and cancer (all p<0.05).

Conclusions:
Our data suggest that there are determinants of hospital readmission that can be used in a prediction model that serve to correct for case mix when comparing hospital-level readmission rates. Some of the predictors such as the use of stroke units, cigarette smoking, atrial fibrillation and statins at discharge provide potential opportunities to intervene and lower readmission rates.
Abstract 3401: Characterization of the Infarct Pattern Caused By Complex Aortic Arch Atheroma: DWI and Multi-detector Row CT study
Authors: Kim Suk Jae , Ryoo Sookyung , Hwang Jaechun , Noh Hyun Jin , Park Jae Hyun , Choe Yeon Hyeon , Bang Oh Young
Published: March 2022

Background:
Aortic arch atheroma (AAA) has been accepted as a possbile embolic source in patients with ischemic stroke, especially cryptogenic stroke. In this study, we aimed to evaluate clinical and radiological characteristics including lesion pattern on DWI in acute stroke patients associated with complex AAA detected by multidetector row computed tomography (MDCT).

Methods:
Form September 2008 through May 2011, patients who were presented with acute ischemic stroke and underwent MDCT were found in a prospective stroke registry. Patients without evident stroke etiology were included and classified by presence of complex AAA. Complex AAA was defined as at least 6 mm thick adjacent to the aortic wall, ulcerated plaque, or vulnerable plaque. The characteristics of DWI lesions were analyzed in terms of the number and size of the lesions, and the involved vascular territories

Results:
A total of 62 cryptogenic stroke patients were included in this study. The complex AAA was observed in 14 (22.6%) patients. The patients with complex AAA were older than those with no/simple AAA. There were no differences between groups in terms of vascular risk factors, laboratory findings, and pre-stroke medication. DWI analysis revealed that complex AAA group had a more chance to have multiple and small lesions in multiple vascular territories that mainly located in cortical and border-zone regions than no/simple AAA group (
Figure
). Multiple logistric regression analysis showed that age (OR 1.17; 95% CI 1.02-1.40) and multiple small lesions in multiple vascular territories (OR 31.32; 95% CI 3.99-245.67) were independently associated with the complex AAA.

Conclusion:
The results of DWI pattern analysis indicate that complex AAA demonstrated by MDCT is associated with multiple small scattered lesions in multiple vascular territories.
Figure
. Summation map of all patient’ diffusion-weighted imaging in patients with complex aortic arch atheroma. The majority of lesions are small and located in cortical and border-zone regions.
Abstract 3406: Circulating Cancer Cell Microparticles Expressing Tissue Factors in Patients with Cancer-Related Stroke
Authors: Kim Suk Jae , Cho Yeon Hee , Hyung Na Kyum , Moon Gyeong Joon , Ahn Myung Ju , Bang Oh Young
Published: March 2022

Backgrounds:
Circulating microparticles (MP) are reported to be functional in various disease conditions. There is considerable interest in assessing the potential role of tissue factor-bearing microparticles (TF
+
MP) in the pathogenesis of the hypercoagulable state accompanying cancer. We tested that the levels of circulating cancer cells MP expressing tissue factors in patients with cancer-related stroke.

Methods:
The expression of epithelial cell adhesion molecule
(EpCAM)
which is a cell surface molecule that is known to be highly expressed in non-small cell lung cancer (NSCLC) and tissue factors on circulating MP was evaluated by flow cytometry from 60 NSCLC patients with ischemic stroke (C+S group), 30 NSCLC without ischemic storke (C group), 30 ischemic stroke without cancer (S group), and 30 healthy subjects (H group). Conventional stroke mechanisms (CSMs) were determined using cardiologic and vascular studies and C+S group was subdivided depending on presence of CSMs. Additionally, the coagulation status was assessed based on the serum D-dimer levels.

Results:
The level of EpCAM
+
MP did not differ between C+S and C groups. However, the level of EpCAM
+
TF
+
MP was increased in C+S without CSMs than in those with CSMs and other groups (C, S, and H group) (
Figure
). Correlation analysis showed that levels of EpCAM
+
TF
+
were increased with the increase in the serum D-dimer levels. Moreover, EpCAM
+
TF
+
MP did not change although the serum D-dimer levels were decreased after anticoagulation treatment.

Conclusion:
Our data showed TF
+
MP originated from cancer cells has an important role in the pathogenesis of the cancer-related stroke.
Figure
. EpCAM
+
TF
+
MP is significantly increased in C+S without CSMs group than those with CSMs and C, S, and H group.
Abstract 3417: Pixel by Pixel Comparison of CTP-Defined Infarct Core on Concurrent Non-Contrast CT
Authors: McVerry Ferghal , Dani Krishna A , MacDougall Niall J , Muir Keith W
Published: March 2022

Introduction
Interobserver agreement for the presence of early ischemic changes on non-contrast CT (NCCT) in potential thrombolysis candidates can be poor even among experienced raters. CT perfusion (CTP) may demonstrate infarct core and penumbra according to proposed thresholds but the extent of correlation between CTP defined core and hypodensity on hyperacute NCCT is unclear

Methods
A pixel by pixel comparison between NCCT and concurrent CTP obtained <6hrs from symptom onset was performed for patients with symptomatic arterial occlusions. Segmentation was performed using time-averaged CTP raw images to compare core and normal tissue pixels for grey and white matter separately. Core was defined as relative Cerebral Blood Flow (CBF) of <45% of normal tissue. NCCT was co-registered to the baseline frames of the concurrent CTP using a rigid body transformation. Core pixels were extracted from CTP and transposed to NCCT. Hounsfield unit (HU) values in CTP-defined core and normal tissue were quantified for grey and white matter. Receiver operating characteristic (ROC) curve analysis was performed to assess the predictive value of NCCT hypodensity and CTP-defined core.

Results
CT and CTP were compared for 33 patients. Mean age was 72 years (SD 12), median NIHSS was 16 (IQR 11-20) and mean time from symptom onset to CTP was 191 minutes (SD 63). Area under the curve (AUC) for prediction of grey and white matter core by NCCT was 0.641 and 0.601 respectively. The most frequently occurring optimum HU cut-points were 29 and 28 for grey and white matter respectively .These cut-points were associated with low overall specificity for detecting core (Median ± IQR= 0.48, 0.32-0.59 and 0.36, 0.26-0.44) but higher sensitivity (Median ±IQR 0.79, 0.62-0.87 and 0.83, 0.73-0.89) for grey and white matter

Conclusion
Objectively determined hypodensity on NCCT has low sensitivity and specificity for prediction of ischemic core tissue defined by CT perfusion. Thresholds were similar for both grey and white matter. NCCT scans without established hypodensity may still have irreversibly infarcted pixels which can be detected with CTP. Prospective evaluation of the added value of CTP-defined core on decision making in acute stroke is needed.
Abstract 3424: Comprehensive and Primary Stroke Centers: Outcomes from the SouthEast Texas Regional Advisory Committee
Authors: Censullo Joan , Rives David , Chiu David
Published: March 2022

Background:
Collaboration among the different levels of stroke care centers is essential to population coverage of the nation’s most debilitating disease. The prevalence of stroke in Southeast Texas is higher than the national average. Consequently, the state mandated Regional Advisory Committee (RAC) has targeted inter-institutional stroke care collaboration to benefit its service area. Regional hospitals are required to submit data on stroke performance in order to differentiate care capabilities and to ensure quality at each care level. This investigation analyzed the outcomes of Support (level 3), Primary (level 2), Comprehensive stroke care facilities (level 1).

Methods:
Three and a half years of regional hospital data (21,994 patient cases) from the Solucients
®
data base was reviewed. Panel data was analyzed using STATA 11.0 software. Univariate and multivariable techniques were employed to analyze outcomes against institutional designations.

Results:
For non-acute stroke, MSDRGs 64-68 statistically significant associations were found between length of stay (p> 0.000, coef= 1.06), 30 day readmission (p> 0.005, coef= 0.32), mortality (p> 0.031, coef= 0.0196) with Comprehensive stroke centers having comparable to slightly higher rates, seen in the low coefficients. This is likely reflective of the higher severity cared for by tertiary referral centers and needs to be further investigated. For acute-stroke, MSDRGs 61-63 (stroke with thrombolytics) no differences in outcomes were found: 30 day readmission- p> 0.071, coef= 0.062. Mortality- p> 0.38, coef= 0.022, and length of stay- p> 0.882, coef= -0.079. Thrombolytic administration rates were 2.7%, 3.3%, 9.3% at stroke support, Primary level, and Comprehensive centers, respectively.

Conclusions:
Care differences existed across the three different stroke capability institutional classifications, but not in the expected directionality. Rationale for the contrary findings may be found in the illness severity make-up inherent to each level of stroke care, in the accuracy of self-reported care capable status, or the sensitive accuracy of the data set. Further research is needed. This is the first investigation to look at quantifiable differences in stroke outcomes according to institutional stroke care capability.
Abstract 3430: Superficial and Large Infarcts on Neuroimaging in Patients with Cryptogenic Stroke are Associated with the Presence or Absence of Patent Foramen Ovale
Authors: Thaler David E , Ruthazer Robin , Weimar Christian , Serena Joaquín , Mas Jean-Louis , Homma Shunichi , Michel Patrik , Elkind Mitchell S , Nedeltchev Krassen , Mono Marie-Luise , Mattle Heinrich , DiTullio Marco , Kent David M
Published: March 2022

Introduction
We aim to determine whether radiological findings are associated with patent foramen ovale (PFO) among patients with cryptogenic stroke (CS). Radiological findings associated with the presence of a PFO may represent stroke patterns typical of paradoxical embolism which may be distinct from other mechanisms of CS.

Methods
This project is part of the Risk of Paradoxical Embolism (RoPE) Study, an international collaboration that has combined individual-level data for subjects with CS and TIA who have known PFO status from 12 component studies (n=3665). For this study 7 databases (n=3023) were used that included subjects with and without PFO, and with radiologic data. Five variables were tested for their relationship with PFO status: 1)
protocol-defined large vs. small infarct
, 2)
Index stroke seen on imaging, 3) superficial vs. deep infarct, 4) multiple index lesions, 5) Prior stroke,
i.e. chronic infarct on index imaging.

Results
are presented in the
table
. Odds ratios and p-values are adjusted for age, database, sex, diabetes, hypertension, smoking, and history of stroke/TIA. This is the largest study to report the radiological characteristics of patients with CS who are known to have, or not to have, a PFO. Some prior studies had null findings but were limited by small sample size and low statistical power. Because CS unrelated to PFO may also be embolic, the radiological pattern of paradoxical embolism may not be expected to be different from other cryptogenic emboli. Despite this, PFOs were significantly more common in CS patients with large and with superficial infarcts. Conversely, infarcts that were small and deep were associated with PFO absence. This suggests that lacunar disease may account for some non-PFO related CS.

Conclusion
Participants were significantly more likely to have a PFO if they had 1) an index stroke seen on neuroimaging, 2) a large stroke, 3) a superficial stroke; there was no effect of the variables prior (
i.e.
chronic) infarct or multiple vs. single infarcts. Further analyses may help to clarify the ability of neuroimaging to predict the finding of a PFO.
Abstract 3444: Characteristics and Prognostic Significance of Pseudodissection Phenomenon Associated with Acute Distal Internal Carotid Artery Occlusion
Authors: Siddiq Farhan , Chaudhry Saqib A , Das Paramita , Khatri Rakesh , Rodriguez Gustavo J , Qureshi Adnan I
Published: March 2022

Background:
Acute stroke from intracranial internal carotid artery (ICA) occlusion can occasionally resemble angiographic cervical ICA dissection which may cause delays in endovascular acute stroke treatment.

Objective:
To determine the angiographic characteristics of the phenomemon of “pseudodissection” and its clinical implications in acute stroke endovascular treatment.

Material and Methods:
Retrospective analysis of angiographic and clinical data of 31 patients with acute stroke from ICA occlusion, treated with endovascular therapy at two University affiliated institutions was performed. Pseudodissection was defined as angiographic appearance of typical ICA dissection with evidence of normal inner vascular wall upon further catheter exploration. A cadaver model was then created duplicating intracranial ICA occlusion to demonstrate out hypothesis.

Results:
Angiographic appearance pseudodissection was identified in 7 out of 31 patients (22.6%). Six patients had guide catheters placed proximal to pseudodissection in anticipation of stent placement for treatment of dissection. All 7 patients had further exploration of the presumed dissected segment (6 microcatheter, 1 diagnostic catheter) which demonstrated normal vascular inner wall. The location of the clot was more common in the petro-cavernous segment in the pseudodissection patients (5/7, 71%). Carotid terminus clot was more common in non pseudodissection patients compared to pseduodissection patients (18/24, 75% versus 2/7, 29% respectively, p < 0.0001). Recanalization was less common in pseudodissection patients compared to non pseudodissection patients (3/7 and 21/24 respectively, p 0.029). We then created a cadaver model with intracranial ICA occlusion at the level of posterior communicating artery to demonstrate the phenomenon of pseudodissection as result of lack of contrast runoff in a closed vessel system.

Conclusion:
Early recognition of pseudodissection in the ICA is important in the setting of acute stroke to avoid delay in treatment of intracranial ICA occlusion. This phenomenon is probably seen in the setting of distal ICA occlusion which prohibits any fluid transit through the vessel.
Abstract 3462: A Novel Web based modified Rankin Scale program for certification and patient self assessment scoring in the Antihypertensive Treatment in Acute Cerebral Hemorrhage (ATACH II) Trial
Authors: Khatri Rakesh , Connelly Bo , Chaudhry Saqib A , Maland Erik , Algiers Lawrence , Abbott Emily , Tekle Wodowossen G , Khan Amir , Hassan Ameer E , Qureshi Adnan I
Published: March 2022

Background:
The modified Rankin Scale (mRS) is a commonly used disability scale in clinical trials pertaining to acute stroke. Previous studies suggest that requiring the use of certification programs can improve the accuracy of mRS grading. We developed two mRS video tools for use in the multinational ATACH II trial. These tools train medical professionals on assessing mRS and enable patients, or their caregivers, to ascertain their own mRS score.

Methods:
After conducting a thorough literature review and interviewing numerous accomplished neurologists, we focused the development of our mRS resources around two concepts: key differentiating points and standard interview questions. The certification program consists of two elements: an educational video and an assessment. The educational video describes the mRS scale in four formats: Power Point slides with narrator explanation, simulated clinical interviews, videos of patients outside of the clinical setting, and narrator overview of specific levels. After watching this video, users proceed to the assessment where they are asked to assess the mRS score of six patients based on visual assessment and specific answers to the six foundation interview questions. Users are required to assess all six scenarios correctly in order to pass.

Results:
To date 61 individuals have taken the certification course and test. 54 passed (88.5%) and 7 failed (11.4%) the test. The pass rate was very high in physicians and study coordinators (95.7% and 80.6%).

Conclusion:
A novel web based tool for mRS certification is described. We are currently designing validation studies for each of these tools. Pilot study is undergoing to validate the patient self assessment grading.