bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP97: Progesterone Attenuates Acute Seizure and Brain Infarction by Modulating Pro-Inflammatory Cytokines in a Mouse Model of Neonatal Stroke
Authors: Atif Fahim , Yousuf Seema , Sayeed Iqbal , Hua Fang , Tang Huiling , Stein Donald G
Published: July 2021

Neonatal stroke is among the top ten causes of childhood death and causes long-term permanent disability and neurological deficits in survivors. In most cases, recurrent clonic seizure is the only clinical manifestation which worsens the stroke outcomes. A treatment or pediatric stroke is essential, but no candidate intervention is supported by substantiated data. We tested the hypothesis that progesterone (P4) treatment would be beneficial in a neonatal model of stroke. P12 CD1 mice (mixed gender) underwent permanent unilateral right common carotid ligation (pUCCL) or sham surgery (n=10/group). Pups which showed seizure activity during the 1h post-pUCCL were randomly assigned to receive P4 (8 mg/kg) or vehicle injections at 1, 3 and every 24h post-pUCCL for 6 days. We assessed acute behavioral seizures (during the first 4h post-pUCCL), serum pro-inflammatory cytokines (IL-1β, IL-6, TNFα at 6, 24 and 48h) and brain infarction (at day 7 by CV-staining). Cytokine data were analyzed by repeated measures one-way ANOVA followed by LSD and Tukey’s tests for independent comparisons. For seizure and infarct data, a two-tailed unpaired t-test was employed. We observed acute seizures during the first 4h post-pUCCL in the vehicle group (90.8±11.77). P4 treatment significantly (
P
<0.05) reduced seizure occurrence (58.4±8.97) by 35% compared to vehicle. Repeated measures ANOVA revealed a significant group effect in IL-1β (F

(2,15)

=110.706;
P
<0.001), IL-6 (F

(2,15
)

=66.067;
P
<0.001), and TNFα (F

(2,15)

=146.263;
P
<0.001) levels. Serum IL-1β, IL-6 and TNFα were significantly higher (
P
<0.001) at 6 and 24h and remained elevated until 48h post-pUCCL in the vehicle group compared to sham. The P4-treated group showed a significant (
P
<0.01) decrease in all pro-inflammatory cytokine levels at all time points. Further, pUCCL resulted in severe hemispheric damage (16.88±1.48) as evidenced by cresyl-violet staining at 7 days post-pUCCL. P4 treatment showed a significant (
P
<0.05) reduction (4.93±1.1) in infarct volume (~70%) compared to vehicle. Our data demonstrate that P4 reduces acute seizures and brain infarction following neonatal stroke by modulating the inflammatory process, and warrants detailed studies of functional outcomes and mechanism of action.
Abstract TP10: Selection Criteria, Is The Clue To Successful Thrombectomy?
Authors: Cardona Pedro , Quesada Helena , Cano Luis , Aja Lucia , MA. De Miquel , Ana Escrig , Francisco Rubio
Published: July 2021

In our comprehensive stroke center we analyze correct selection criteria to use self-expandable retrievable intracranial stents for acute stroke treatment. The criteria for intervention were the onset of neurological symptoms, a National Institute of Health Stroke Scale Score (NIHSS) ≥9 at presentation, large vessel occlusion stroke demonstrated by angio-CT, and failure of intravenous thrombolysis or exclusion criteria to administrate it.

METHODS:
We performed an retrospective analysis of 512 consecutive patients with acute ischemic stroke candidates for thrombectomy, from April of 2010 to June of 2012, that met inclusion criteria for intervention. Experienced vascular neurologists selected 171 patients to undergoing endovascular therapy using retrievable stents (Solitaire,Trevo). Successful recanalization results were assessed by follow-up angiography immediately after the procedure (TIMI 2-3/TICI 2b-3 score), and good functional outcome was considered when ≤2 mRankin score (mRS) was achieved at 90 days.

RESULTS:
A total of 171 patients were treated, 87% with anterior circulation stroke. The mean age was 67.5 years (range 32-87); 58% men. The median NIHSS at presentation was 17 (range 6-26). Recanalization (TICI 2b-3) was achieved in 73% of patients. Symptomatic hemorrhage occurred in 8%. Ninety-day mortality was 19, 5% and good 90-day functional outcome (mRS ≤2) was achieved by 45%. Unsuccessful recanalization (TICI 0-2a) was a significant predictor of poor outcome (mRS≤2: 9%). When we analyzed these patients according to inclusion criteria of IMS trial, 101 patients who met strict criteria achieved good neurological outcome more frequently (51% versus 34%) and significant lower mortality rates (17% vs 28%) compared with the group of 70 patients with IMS exclusion criteria.

CONCLUSIONS:
Efficacy in recanalization, safety of thrombectomy and its consequent good clinical outcome is sufficiently established. It is important an experienced vascular neurologist to select possible candidates (proportion of evaluated/treated patients 3:1). Inclusion criteria for acute stroke trials do not always represent real population of stroke patients as well as their clinical results.
Abstract TP114: Post-stroke Fatigue Is Linked To The IL1RN Polymorphism rs4251961
Authors: Becker Kyra , Phillips Hunter , Lee Ricahrd , Tanzi Patricia , Zierath Dannielle , Cain Kevin , Weinstein Jonathan
Published: July 2021

Background:
Post-stroke fatigue (PSF) is common, but the biological basis of PSF is unknown. We explored the relationship between PSF, systemic inflammation and genetic polymorphisms that affect the immune response.

Methods:
In a substudy of a larger trial that evaluated the role of the immune response on stroke outcome, patients were asked about their level of fatigue at 30, 90, 180, and 365 days after ischemic stroke. (The degree fatigue of was quantified using the Fatigue Assessment Scale [FAS], with possible scores of 10 (minimal fatigue) to 50 (severe fatigue). Plasma cytokine concentrations were analyzed and patients genotyped for polymorphisms in the promoter of the interleukin-1 receptor antagonist (IL-1ra) gene (IL1RN; rs4251961). The minor allele (C) is associated with decreased IL-1ra in healthy adults in comparison with the major (T) allele.

Results:
Of patients for whom FAS scores were available (N=38), there were 16 (41%) with TT, 14 (36%) with CT and 8 (21%) with CC genotypes. The degree of fatigue (median [interquartile range]) was remarkably constant over time (22 [16, 29]) and tended to be higher in patients with a C allele (Figure). The FAS scores for patients with the minor C allele was 26 (17, 32) and was 18 in those without (13, 26; P=0.046). If fatigue is defined as an FAS score greater than the 75th percentile value for all patients (>29), 8/22 (36%) of patients with the C allele experienced fatigue while only 1/16 (6%) patients with TT did (P=0.031). Controlling for stroke severity, age and gender, the odds ratio (95% confidence interval) for developing fatigue (FAS>29) with a C allele was 9.96 (1.13-87.42; P=0.038). The concentration of IL-1ra did not differ among patients with the C allele and those without at any time point and was not associated with the FAS score.

Conclusions:
The rs4251961 polymorphism of IL1RN appears to be associated with PSF. This finding, and the relationship to systemic markers of inflammation, will need to be validated in a larger cohort.
Abstract TP129: Revascularization Risk in Symptomatic versus Asymptomatic Patients - Relative versus Absolute Risk: The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)
Authors: Voeks Jenifer H , Hye Robert J , Brown O.W. , Meschia James F , Lal Brajesh K , Sheffet Alice J , Howard Virginia J , Howard George , Brott Thomas G
Published: July 2021

Background:
Carotid revascularization was addressed by NASCET and ACAS. NASCET showed a 2-year stroke and death of 32.3% in medical patients and a 15.8% incidence in surgical patients (16.5% absolute/51% relative reduction). Similarly, ACAS revealed an 11% 5-year risk in medical patients and 5.1% in surgical patients (5.9% absolute reduction/53% relative reduction). Absolute risk (rather than relative risk) reduction is of prime interest to the patient. However, in these studies, treatment efficacy was assessed on a relative basis, and these procedures were equally efficacious (51% vs. 53% relative risk). The higher event rates in the symptomatic patients resulted in a larger absolute risk reduction in NASCET (16.5% vs. 5.9%). CREST is the only carotid revascularization study to include both symptomatic and asymptomatic patients undergoing CEA or carotid artery stenting (CAS), and we looked at absolute and relative risks associated with both procedures.

Methods:
Treatment differences in CREST by symptomatic status were reviewed and interaction terms analyzed.

Results:
Symptomatic periprocedural stroke and death rates were 6% for CAS vs. 3.2% for CEA (2.8% absolute/47% relative difference/p = 0.02), and were 2.5% for CAS vs. 1.4% for CEA (1.2% absolute/53% relative difference/p = 0.15) for asymptomatic. While treatment differences in periprocedural rates were significant for symptomatic but not asymptomatic patients, there was no difference in treatment efficacy as determined by relative risk reduction. Even the most prominent interaction terms were clearly not significant, p > 0.38.

Discussion:
There is no evidence of a CAS-CEA difference in treatment efficacy by symptomatic status in CREST. There are significant findings in symptomatic patients. This is likely a product of an increased background rate of events in this strata. While symptomatic status can identify a subgroup with an increased background rate, other factors (e.g. age or stenosis) could identify subgroups of asymptomatic patients with high event rates and large absolute treatment differences.
Abstract TP15: Long-term Magnetic Resonance Angiography Follow-up of Recanalized Vessels After Mechanical Clot Extraction
Authors: Enomoto Yukiko , Yoshimura Shinichi , Egashira Yusuke , Iwama Toru
Published: July 2021

Objectives:
Endovascular treatment provides a therapeutic option for acute ischemic stroke patients who are ineligible for, or who do not respond to intravenous thrombolysis. Higher rates of recanalization by mechanical clot extraction device were reportedly associated with better clinical outcome, but the long-term patency of recanalized vessel is unknown.

Methods:
We retrospectively evaluated magnetic resonance angiography (MRA) at 24-hour and 3-month after the endovascular treatment in consecutive acute stroke patients who were treated with mechanical clot extraction device between Oct. 2010 and May 2012 in our institution.

Results:
Fourty-six patients received endovascular treatment for acute ischemic stroke and 35 were treated with mechanical clot extraction devices, Merci and/or Penumbra system, with or without adjunctive therapy. Mean age was 69±12 years, baseline median National Institutes of Health Stroke Scale score was 15 (8 to 24), and occluded vessels were the internal carotid artery in 34%, middle cerebral artery (MCA) in 54%, and vertebro-basilar artery in 11%. Successful recanalization, defined as Thrombolysis In Myocardial Infarction II or III perfusion, was obtained in 32 (91%) patients. During 24-hour after the treatment, reocclusion of the treated vessel was observed in 4 (12.5%) patients. Of 28 eligible patients, 21 (75%) patients had 3-month MRA follow-up. None of the patients had reocclusion, but clinically silent diffuse stenosis was observed in 2 (9.5%) patients. Statistically significant predictors were not identified, but both of the patients were MCA occlusion treated with Merci retriever.

Conclusion:
In this study, late stenosis was observed in the MCA on 3-month follow-up MRA. Long-term follow-up seems to be useful to follow the recanalized vessels, especialy when mechanical devices were used.
Abstract TP155: Do Gender Differences exist in Outcomes Among Patients With Intracranial atherosclerosis?
Authors: Pu Yue H , Liu Li P , Wang Yi L , Pan Yue S , Zhao Xing Q , Wong Ka S , Wang Yong J
Published: July 2021

Background and purpose:
Up to now gender difference in outcomes among patients with intracranial atherosclerosis (ICAS) in china, even in the world has rarely discussed. We went on this study aimed to estimate the gender difference in outcomes among patients with ICAS in Chinese cerebral ischemia patients.

Methods:
We analyzed 1335 men and women with ICAS who were enrolled in the CICAS study. They were followed-up for ischemic stroke recurrence, any cause of death, cerebral vascular events (including TIA, ischemic and hemorrhage stroke), combined endpoints (including cerebral vascular events, angina or myocardial infarction, pulmonary embolism, peripheral vascular events), and unfavorable outcome (mRS 3-6) at 1 year.

Results:
The mean ages were 60.9 (SD, 11.4) and 65.5 (SD, 10.2) for men and women. During the follow-up period, 59 combined end points were documented in women and 106 in men: the 1-year rates were 13.44% and 11.83% for women and men, respectively. Of the combined end points, 49 were recurrent ischemic stroke events (15 in women and 34 in men), and 48 any cause of deaths (23 in women 25 in men). There were 344 unfavorable end points (116 in women and 228 in men). The cumulative probability of death was higher in women, but after adjusted by age, diabetes mellitus, hypertension, family history of stroke, current smoker, heavy drink, hyperhomocystinemia, heart disease, there was no significant difference. There was also lack of difference in 1-year ischemic stroke recurrence, cerebral vascular events, combined endpoints and unfavorable outcome between women and men at 1 year.

Conclusions:
These results suggest no gender difference in outcome among patients with intracranial atherosclerosis in Chinese cerebral ischemia patients.
Abstract TP18: Recanalization in Acute Stroke Interventions with Manual Aspiration Thrombectomy as a Stand Alone Technique
Authors: Aghaebrahim Amin , Jadhav Ashutosh P , Linares Guillermo , Zaidi Syed , Jumaa Mohammad , Jovin Tudor , Jankowitz Brian
Published: July 2021

Background and Purpose:
Manual aspiration thrombectomy (MAT) represents an alternative means to open occluded intracranial vessels. The technique involves advancing a large bore catheter into the thrombus and manually aspirating through a syringe. We have previously reported our experience with nearly 200 patients, however most cases involved the use of an adjunctive device such as the MERCI retriever to facilitate clot disruption or advancement of the catheter through the tortuous carotid siphon. This selected case series represents those patients treated with MAT alone.

Methods:
The University of Pittsburgh acute stroke database was retrospectively reviewed to evaluate those patients presenting with a large vessel intracranial occlusion who were treated with MAT. The decision to treat was based on the amount of brain still considered at risk based on CT, CTP, or MRI, and not on time from onset. Patients were excluded if an adjunctive device was used to facilitate catheter advancement or clot disruption/removal. These devices included the MERCI retriever, Penumbra aspiration system, Solitaire, TREVO, stent, or balloon. Intra-arterial thrombolytics or antiplatelets were allowed.

Results:
Forty-seven patients met the inclusion criteria. The mean/median NIHSS was 17/16. The mean/median time from last seen normal to groin puncture was 8.3/6.5 hours. The mean/median time from groin puncture to recanalization was 50/40 minutes. The target vessel was the basilar, M1, and ICA-terminus in 7, 30, and 10 patients respectively. The mean/median number of aspiration attempts was 1.7/1. All patients achieved at least TIMI 2 recanalization, owing to the fact that failure to achieve this result prompted the use of an adjunctive device. 42/47 patients achieved TICI 2B/3 recanalization.

Conclusions:
Pure MAT without the use of an adjunctive device represents another method to achieve intracranial recanalization with the potential for significant cost savings. Safety and outcomes must still be evaluated.
Abstract TP183: Cerebral Small Vessel Disease - A Population-based Cross-Ethnic Comparison between Chinese and White Elderly Individuals
Authors: Mok Vincent , Ding Ding , Xiong Yunyun , Phan Thanh G , Chu Winnie W , Wang Defeng , Wong Adrian , Zhen Hong , Wong Ka Sing , Srikanth Velandai
Published: July 2021

Background and Purpose:
Ethnic differences have been reported between Asians and Whites in the prevalence of certain stroke subtypes. However, it is unknown if such differences exist with respect to manifestations of cerebral small vessel disease. We compared the prevalence of white matter lesions [WML], lacunes, and microbleeds between Han Chinese and White Australian individuals randomly selected from their respective populations.

Methods:
Magnetic resonance imaging (1.5 Tesla) was performed on participants of the Shanghai Aging Study (n=321, mean age 69±6 years) and Tasmanian Study of Cognition and Gait (n=397, mean age 72±7 years). A single expert rater recorded measures of WML, lacunes, and microbleeds. We compared lesion prevalence between age- and gender-matched subgroups from the two study population. Among all subjects (n=718), we used multivariable logistic regression to examine if ethnicity was associated with the presence of these lesions.

Results:
The prevalence rates of confluent WML, lacunes, and microbleeds among Chinese and Whites were 37% vs. 34% (p=0.09), 29% vs. 34% (p=0.24), and 9% vs. 11% (p=0.59), respectively. Subgroup analysis among age- and gender- matched subjects confirmed that confluent WML was more common among Chinese (38.5%) than Whites (28.4%, p=0.01). In multivariable regression, Chinese had a higher risk of confluent WML (odds ratio 1.53, 95% confidence interval 1.04-2.24, p=0.03) independent of other risk factors, but no differences were seen for lacunes and micro bleeds.

Conclusion:
In this population-based cross-national comparison, Chinese had a greater risk of moderate-to-severe WML than white Australians, but had a similar risk of lacunes and microbleeds.
Abstract TP186: Associations Of Durations Of Antiplatelet Use And Vascular Risk Factors With The Presence Of Cerebral Microbleeds
Authors: Yamashiro Kazuo , Tanaka Ryota , Okuma Yasuyuki , Ueno Yuji , Tanaka Yasutaka , Hattori Nobutaka , Urabe Takao
Published: July 2021

The association of the presence of cerebral microbleeds with antiplatelet use remains controversial. Long durations of antiplatelet use and vascular risk factors may have a greater effect on the development of microbleeds than short durations. Our aim in the present study was to determine whether the durations of antiplatelet use and vascular risk factors are associated with cerebral microbleeds. Two hundred twenty outpatients with cerebrovascular disease detected by MRI were examined. Cerebral microbleeds were observed in 71 (32.3%) patients, and deep or infratentorial microbleeds and strictly lobar microbleeds in 53 (24.1%) patients and 18 (8.2%) patients, respectively. To determine the association the between durations of vascular risk factors and antiplatelet use, radiological findings regarding the presence and location of cerebral microbleeds were assessed by multivariate logistic regression analysis adjusted for age, sex, and relevant confounders. The duration of hypertension, the presence of lacunar infarcts and the severity of periventricular hyperintensity were associated with microbleeds in a deep or infratentorial region. Antiplatelet use and its duration of were not associated with the presence or location of microbleeds. Our results suggest that deep or infratentorial microbleeds reflect the severity of hypertensive vasculopathy. Thus, antiplatelet use may not be associated with the presence of cerebral microbleeds.
Abstract TP188: Location of Intracerebral Hemorrhage in a Tri-ethnic Cohort: The ERICH Study
Authors: Birnbaum Lee , Leonard Anne , Andino Julio , Moomaw Charles J , Langfeld Carl , Brown W M , Osborne Jennifer , Martini Sharyl R , Testai Fernando D , Sheth Kevin N , Woo Daniel
Published: July 2021

Background:
The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) is an ongoing case-control study of spontaneous ICH among non-hispanic whites, non-hispanic blacks, and Hispanics. Prior studies have identified hypertension as a greater risk for non-lobar (NL) ICH as compared with lobar (L) ICH. Given the greater reported prevalence of hypertension among black and Hispanic populations, we hypothesized that the location of ICH may differ by race/ethnicity.

Methods:
At the time of this analysis, we had ICH location data, lobar vs. non-lobar, on 648 subjects. We performed univariate analysis on known and potential predictors of ICH location: age, sex, race/ethnicity, hypertension, diabetes, BMI, creatinine, cholesterol, aspirin use, smoking, alcohol use, caffeine use, and INR. INR was dichotomized at >1.1. After forcing in age, sex, race, history of diabetes, aspirin use and INR, we added significant and near-significant (p<0.2) variables in a stepwise fashion to complete our final logistic regression model. Our outcome measure was lobar ICH. Conditional pairwise testing was performed for race/ethnicity.

Results:
Of the 648 subjects (mean age 61.12 ± 14.51 years; 39.8% female; 35.0% Hispanic, 26.5% white, 38.4% black), 181 (27.9%) presented with lobar ICH. Hypertension was present in 525 subjects (75.1% L, 83.3% NL; p=.018), diabetes in 152 (26.0% L, 22.5% NL; p=.348), high cholesterol in 244 (45.9% L, 34.5% NL; p=.008), aspirin use in 200 (37.0% L, 28.5% NL; p=.035), and INR >1.1 (24.1% L, 21.8% NL; p=.535) In our final model, race/ethnicity (p<.024) was associated with location of ICH. Furthermore, white race/ethnicity was associated with L ICH, compared with black (b=.57, p=.016) or Hispanic (b=.56, p=.018). Hypertension (b=-0.63, p=.009) was associated with NL ICH, and smoking (b=0.51, p=.007) was associated with L ICH.

Discussion:
Our results suggest that there are significant racial/ethnic differences in the distribution of lobar and non-lobar ICH. The conditional pairwise testing for race/ethnicity showed a significantly higher rate of lobar ICH in whites, compared with blacks or Hispanics. These findings are intriguing given the differences in case-fatality rates and age at ICH onset.
Abstract TP19: Clinical Outcomes In Patients With Acute Ischemic Stroke Due To Large Vessel Occlusion In The Modern Era: 2010-2011 Experience With 423 Patients.
Authors: Mokin Maxim , Kass-Hout Tareq , Kass-Hout Omar , Veznedaroglu Erol , Nahab Fadi , Khoshnoodi Mohammad Ali , Lopes Demetrius , Chen MIchael , Seals Kevin , Shallwani Hussain , Snyder Kenneth , Siddiqui Adnan , Levy Elad
Published: July 2021

Background and Purpose:
Acute ischemic stroke due to large vessel occlusion is associated with a poor prognosis. With no consensus about the best treatment option, various treatment modalities including conservative management, intravenous tissue plasminogen activator, and endovascular approach are currently being used.

Methods:
Retrospective data including demographic information, baseline NIHSS score, site of occlusion (based on CTA, MRA or angiogram), type of treatment and clinical outcomes were collected from 4 centers in the United States during the period of 2010-2011.

Results:
A total of 423 were included in final analysis: 175 patients received conservative medical management, 54 patients received intravenous (IV) thrombolysis alone, and 194 patients had endovascular treatment (with or without prior IV tPA). Younger patients were more likely to receive endovascular treatment (p<0.001). There was no statistically significant difference among the sex and co-morbid conditions among the three groups. Proximal middle cerebral artery was the most commonly involved vessel. Strokes due to basilar artery occlusion or internal carotid artery occlusion were associated with worst outcomes in all three groups. Conservative medical management had the lowest rates of symptomatic intracerebral hemorrhage but also the highest mortality rates at 3 months. Patients who received endovascular treatment within the first 3 hrs had better outcome and lower mortality rates as compared to patients with intervention during 3-8 hours or beyond 8 hrs.

Conclusions:
Our study represents real world experience on the management and outcomes of acute ischemic strokes due to large vessel occlusion. Our results help understand natural history of strokes with large vessel occlusion, as well as modern trends in managing these patients with intravenous and intraarterial treatment approaches.
Abstract TP205: Clinical Aspects Of First-ever Stroke In Patients With Permanent Pacemaker
Authors: Kitayama Jiro , Nakane Hiroshi , Ishikawa Hiromi , Shijo Masahiro , Kamouchi Masahiro , Kitazono Takanari
Published: July 2021

OBJECTIVES:
Recently, increasing numbers of patients take pacemaker implantation: almost sixty thousands in Japan, and no less than two hundreds of thousands in the United States per year. Previous reports have indicated that prevalence of atrial fibrillation (Af) is high, and several coagulation markers are elevated in those with pacemaker. However, the precise features of stroke with implanted device are not clear. We, thus, examined the clinical aspects of stroke in pacemaker patients.

METHODS:
For the present study, we analyzed data from the Fukuoka Stroke Registry that is a multicenter epidemiological study database on acute stroke. From June 1999 to May 2011, 11376 ischemic stroke patients (72±12 years of age, female/male=4613/6763) who admitted to the hospital within seven days after onset were enrolled in the registry. Stroke subtypes were classified according to the diagnostic criteria of TOAST (Trial of Org 10172 in Acute Stroke Treatment).

RESULTS:
A total of 207 patients (1.8% of registered stroke patients) were with pacemaker. Among them, 130 patients had no history of any stroke. They appeared to be a mean age of 81±9 (range 42 to 97) years, and female/male ratio of 77/53. Mean duration from pacemaker implantation to stroke onset was 8±7 (median 6, quartile 3-11) years. 32 patients (25%) were given oral anticoagulant prior to stroke onset; 60 (46%) were on antiplatelet. Prevalence of Af in pacemaker patients was 48% (n=63). In those with Af, 48 patients (76%) were diagnosed as cardioembolic stroke, but only 22 (35%) were on anticoagulation before onset. Even in those without Af, 33 cases (49%) were also diagnosed as cardioembolic. The percentage of subjects with increased plasma D-dimer (≥1.5 μg/ml) was significantly higher in pacemaker group than no-pacemaker group, regardless of the presence or absence of Af (75% vs. 45% with Af; p<0.0001, 74% vs. 25% without Af; p<0.0001).

CONCLUSIONS:
In our current study, stroke in pacemaker patients revealed to have higher incidence of cardiogenic embolism, with or without Af. In addition, the majority was elderly, and failed to receive anticoagulant prior to stroke. It is needed to re-consider therapeutic strategy, including anticoagulation, for prevention of stroke in those with permanent pacemaker.
Abstract TP236: The Stroke Hyperglycemia Insulin Network Effort (SHINE) Trial: A Case Study of a Bayesian Trial Design
Authors: Broglio Kristine R , Connor Jason T , Meurer William J , Durkalski Valerie L , Johnston Karen C ,   for the SHINE and ADAPT-IT Investigators
Published: July 2021

Introduction:
The “Adaptive Designs Accelerating Promising Trials into Treatments (ADAPT-IT)” project is a collaborative effort supported by the NIH and FDA to explore how adaptive clinical trial design might improve the evaluation of drugs and medical devices. We use the NINDS-supported Neurological Emergencies Treatment Trials network as a "laboratory" in which to study the development of adaptive clinical trial designs. The Stroke Hyperglycemia Insulin Network Effort (SHINE) trial was fully funded by the NIH-NINDS at the start of ADAPT-IT and is a currently ongoing phase III trial of tight glucose control in hyperglycemic acute ischemic stroke patients. Within ADAPT-IT, a Bayesian alternative design was developed. The primary endpoint is a severity-adjusted dichotomized 90-day modified Rankin scale (mRS).

Objective:
To present both designs and compare their operating characteristics.

Methods:
10000 trials are simulated under treatment effects ranging from 0% to 7%. We present the mean sample size and probabilities of trial success or futility.

Results:
The SHINE trial design includes a group sequential procedure with 4 interim analyses to monitor for early efficacy and futility. A maximum of 1400 patients provide 80% power to detect a 7% absolute difference between treatment arms with an overall Type I error rate of 5%. The expected sample size is 1050 patients. This design also incorporates sample size re-estimation and response adaptive randomization. The Bayesian alternative would enroll a maximum of 1400 patients, equally randomized, but employs more frequent interim looks based on predictive probabilities and incorporates a longitudinal model of the primary endpoint. This design has similar power and Type I error and would enroll a mean of 733 and 979 patients under the null and alternative hypotheses respectively.

Conclusions:
Simulations suggest that the designs have similar power and Type I error. The Bayesian alternative, with more frequent looks, has a greater chance of stopping early for overwhelming efficacy or futility. The Bayesian alternative will be retrospectively executed upon completion of SHINE to later compare the designs based on their use of patient resources, time, and strength of conclusions in a real world setting.
Abstract TP244: Distinguishing Stroke Mimics From Strokes Prior To Treatment With tPA
Authors: Deline Christopher J , Khoury Naim , Heitsch Laura , Ford Andrea L , Tabor Connor Lisa , Lee Jin-Moo
Published: July 2021

Introduction:
Up to 25% of patients treated with IV tPA are later found to have stroke mimics. Despite low rates of hemorrhagic transformation in these patients, avoiding exposure to unnecessary risk is desirable. Here, we define baseline demographic and clinical characteristics of strokes vs. stroke mimics that might help distinguish these two populations prior to treatment decisions.

Methods:
All patients treated with IV tPA at our tertiary care academic medical center are registered in a prospectively maintained database. Consecutive patients from 1/09 to 6/12 were entered in this study. Demographic, historical, and neuro exam findings (20 variables) from stroke or stroke mimic patients (based on the discharge diagnosis) were examined. Spearman correlations and binary logistic regression were used to determine variables contributing to mimic status. Post-hoc correlations of individual NIHSS items with mimic status were examined.

Results:
During this period, 346 patients were treated with IV tPA of which 38 (11%) were stroke mimics. Logistic regression revealed that age (B = -0.61,
p
< 0.001), history of drug use (B = 1.508,
p
<0.05), and acute NIHSS facial score (B = -1.12,
p
< 0.01) significantly predicted mimic status. Sex (B = -1.043,
p
= .066) and “drip and ship” status (B = 1.04,
p
= .063) were marginal predictors, whereas history of depression, epilepsy, and number of ED visits in the past 5 years failed to predict mimic status. The logistic regression equation accounted for 39% of the variance in mimic status. Post-hoc Spearman correlations of NIHSS categories with mimic status found that total score (
r
= -0.16), visual field loss (
r
= -0.16), gaze deviation (
r
= -0.21), facial weakness (r = -0.22), dysarthria (r = -0.19), and neglect (
r
= -0.18) were all variables significantly associated with acute stroke.

Conclusion:
Younger age, female gender, history of drug use, and treatment at outlying facility (drip and ship) were associated with stroke mimics. NIHSS categories associated with acute stroke were visual field loss, gaze deviation, facial droop, dysarthria and neglect. Identifying baseline variables that help distinguish mimics may minimize inappropriate treatment with tPA.
Abstract TP25: Early Major Neurologic Improvement after Endovascular Therapy in Acute Ischemic Stroke
Authors: Cardona Luzma , Wisco Dolora , Man Shu-Mei , George Pravin , Cheng-Ching Esteban , Tateishi Yohei , Aoki Junya , Hussain M. Shazam , Uchino Ken
Published: July 2021

Background and Purpose:
Intravenous thrombolysis is associated with early major neurologic improvement, which is reported to occur in about a quarter of patients after 24 hrs. The aim of the study is to evaluate the frequency and predictors of early major improvement in patient with ischemic stroke after undergoing acute intra-arterial therapy.

Materials and methods:
Prospective collected database of patients undergoing intra-arterial therapy for the acute ischemic stroke from January 2008 to December 2011 was reviewed. The NIHSS was used to assess severity of stroke in patients upon admission, 24 hrs after procedure and at hospital discharge. Major neurological improvement was defined as improvement of NIHSS by more or equal to 8 or absolute NIHSS of 0 or 1. Arterial recanalization was defined as thrombolysis in cerebral infarction grade 2b or 3. Favorable outcome was defined as modified Rankin scale of 0-2 at 1 month and 3 months. Demographic and radiographic data were collected.

Results:
MNI was seen in 28 out of 138 (20%) of patients at 24 hours but was not associated with a 30 day or 90 day favorable outcome. MNI at discharge was seen in 47 of 148 (31%) patients and was associated with a 30 day and 90 day favorable outcomes of 0-2 on mRankin (Odds Ratio (OR) : 9.1, 95% confidence interval (CI): 3.7-22.5). Recanalization was associated with MNI at 24 hours (OR 3.1, 95% CI: 1.2-7.9) and MNI at discharge (OR 2.8, 95% CI: 1.3-6.0). Among pre-treatment variables, MNI at discharge was associated with imaging by pre-treatment Alberta Stroke Program Early CT Score (median 9 with MNI, 8 without MNI, p=0.03) and time to treatment (median 5.2 hours with MNI v 7.2 hours without MNI, p<0.01). Age and baseline NIHSS were not associated with MNI. In a logistic regression model, favorable outcome at 90 days was independently associated with baseline NIHSS and MNI at discharge.

Conclusions:
MNI after intra-arterial therapy was seen in about a quarter of patients and was associated with higher CT ASPECT scores, time to therapy, and arterial recanalization. MNI at discharge was an independent predictor of long term outcome.
Abstract TP252: Stroke Risk After Blunt Cerebrovascular Injury With Dissection
Authors: Nguyen Thanh N , Farivari Nina , Mian Asim Z , Pikula Aleksandra , Kase Carlos S , Norbash Alexander M , Burke Peter A , Mahoney Eric J
Published: July 2021

INTRODUCTION:
Blunt cerebrovascular injuries (BCVI) are common in trauma. The natural history of stroke in patients with traumatic dissection has not been well investigated. The goal of this study was to evaluate the risk of stroke with BCVI related dissection in the internal carotid (ICA) or vertebral artery (VA) territory.

METHODS:
We instituted a protocol in 2007 for CTA of the head and neck in BCVI patients to look for dissection. Criteria for CTA were patients with skull base fractures, cervical spine injury, neurological deficit, or infarction on head CT. Patients with a dissection were followed clinically for development of stroke by the trauma and neurointerventional teams. A follow-up phone call was prospectively obtained at the time of data analysis for patients with confirmed dissection for interim stroke evaluation. IRB approval was obtained.

RESULTS:
51 patients were identified with an abnormal CTA for BCVI. Patients were excluded due to dissection in the external carotid (n=1), vasospasm(n=12), <1 month follow-up due to death (n=7). Of the remaining 31 patients with dissection in the analysis, the injury mechanism was: 18 MVAs, 11 falls, and 2 altercations. Location of injury was VA (n=24), ICA (n=8), and PICA (n=1). Two patients had lesions in the VA and ICA. There were 4 pseudoaneurysms (12.9%). Patients were treated with aspirin (n=27, mean 223 days); or anticoagulants (n=7, mean 114 days). Most patients (22/31, 71%) were treated with antithrombotics within 3 days of injury. One patient had a carotid stent for progressive stenosis. Mean follow-up (clinical/imaging) was 18.5+6.6 months (range 1-53 months); 19/31 (61%) patients had > 6 months follow-up. Six patients had neurological symptoms of which 3 were attributed to cervical cord injury, 1 to stroke after bypass surgery (for carotid artery avulsion), and 1 with diffuse axonal injury. One patient developed ataxia 3 days after MVC and had a cerebellar stroke. The cumulative incidence of stroke was therefore 1/31 (3.2%).

CONCLUSION:
The incidence of stroke after carotid or vertebral artery dissection related to BCVI is low with good prognosis. Larger prospective studies are of interest to better define stroke risk in this population.
Abstract TP3: Rate of Utilization and Determinants of Withdrawal of Care Among Acute Ischemic Stroke Patients Treated with Thrombolytics
Authors: Qureshi Adnan I , Adil Malik M , Rahman Haseeb A , Suri M Fareed K
Published: July 2021

Background:
Our current practices for utilization of thrombolytics are based on the results of clinical trials with no or restricted use of “withdrawal of care” among treated patients. The increasing use of “withdrawal of care” in routine practice may lead to suboptimal outcomes among acute ischemic stroke patients treated with thrombolytics.

Objective:
To identify the rate and determinants of “withdrawal of care” among acute ischemic stroke patients treated with thrombolytics in Nationwide Inpatient Survey (NIS) data files from 2002 to 2010.

Methods:
We determined the frequency of “withdrawal of care” and compared the demographic, clinical characteristics, and in-hospital outcomes among thrombolytic treated ischemic stroke patients stratified by use of “withdrawal of care”.

Results:
“Withdrawal of care” during hospitalization was instituted in 4327 (3.1%) of the 136854 acute ischemic stroke patients treated with thrombolytics. The mean age [±standard deviation] of the patients who underwent “withdrawal of care” was significantly higher (79±11.5 years versus 68±14.7, p<0.001). In the stepwise logistic regression, female sex (odds ratio [OR] 1.4, 95% confidence interval [1.1-1.7]), presence of atrial fibrillation (OR 2.1, 95% CI 1.8-2.5), and intracerebral hemorrhage (OR 3.2, 95% CI 2.5-4.1) were significant predictors of “withdrawal of care” among thrombolytic treated ischemic stroke patient. Large sized hospitals (OR 1.5, 95% CI 1.1-2.0), and teaching hospitals (OR 1.4, 95% CI 1.0-1.9) were more likely to use withdrawal of care. The rate of intubation and mechanical ventilation were significantly higher among patients who underwent “withdrawal of care”. In-hospital mortality (61% versus 8.6%, p=<0.0001) and the mean hospitalization charges ($84,072±79674 versus $69,104±75014, p<0.0001) were significantly higher among those with “withdrawal of care."

Conclusions:
Our results identify several individual and institution related factors that determine the use of “withdrawal of care” among thrombolytic treated ischemic stroke patients. The excessively high mortality and resource utilization mandates a more evidence based policy for “withdrawal of care” in these patients.
Abstract TP317: Mobile Technology Profile of Stroke Survivors and Caregivers: Preliminary Results from a National Survey
Authors: Pandey Abhishek , Bretz Miranda , Jensen Amy , Henasey Denise , Troung Andrew , Lushbough Catherine , Balucani Clotilde , Arnedo Vanessa , Burton Dee , Fraser-White Marilyn , Browne Ruth , Szarek Michael , Levine Steven R ,   The Mobile Applications for Stroke (MAPPS) Investigators
Published: July 2021

Background:
Recent estimates are that approximately 110 million Americans have access to nearly 14,000 health-related apps. There is a paucity in applications specific for stroke, either survivors or caregivers.

Objective:
Qualitative survey of stroke survivors and caregivers’ needs, attitudes, knowledge, and behaviors concerning mobile technology (m-TECH) was assessed through an online medium.

Methods:
National Stroke Association (NSA) elicited responses from a random, national sample of 601 stroke survivors and caregivers. The 25-question survey asked about how stroke survivors and caregivers track their health information, use smartphones and available health-related applications, and their perceived needs and preferences for a potential smartphone application. Data were collected on demographics, health tracking behavior, smartphone and mobile health application use, and interest in health management applications. Responses were collected through open source online survey application, LimeSurvey.

Results:
Thirty-five (6%) individuals (range 18-91+ years; 55% female) completed the survey, evenly split between: stroke survivors and caregivers; 41% completed some college. The majority of respondents (73%) tracked their health information to manage risk factors to prevent stroke: medication tracking (82%), monitoring blood pressure and cholesterol (77%), and managing medical appointments (73%). The greatest barrier to tracking health information was forgetfulness (41%). Half owned smartphones, with 27% Android users and 14% iPhone users, with almost half (45%) reporting to have downloaded applications on their smartphones that they used (41%), including multiple times a day (32%). Additionally, 23% of the smartphone users reported using their phones to track health information. Majority (60%) of respondents expressed interest in smartphone apps that can help managing health information and half (50%) were interested in helping with the application development.

Conclusions:
Recognizing concern over generalizability, these preliminary results suggest a clear need for patient-centered mobile health applications in personal health management tailored specifically for stroke survivors and caregivers.
Abstract TP330: TIA A Shorter Stay
Authors: Paletz Laurie , Steiner Nili , Robertson Betty , Wolber Nicole , Song Shlee , Armstrong Naty , Lyden Patrick
Published: July 2021

Background:
In the United States, between 200 and 500 thousand Transient Ischemic Attacks (TIAS) are reported yearly, only 50% report symptoms to their physician. Rapid action is of critical importance to reduce risk of brain injury. TIA is a chance for timely lifestyle changes or medical intervention. Momentary signs could precede a potentially fatal stroke or could be a stroke. TIA is recognized as an emergent warning sign of underlying disease. Hospital admission is costly and may be unacceptable to symptom free patients. We developed a rapid work up, CODE TIA, to faciltate patient stays of less than 23 hours.

Method:
We reviewed methods to decrease length of stay(LOS), decrease unnecessary tests ordered, treat & educate patients to prevent stroke where appropriate, send them home, treated in a reasonable time frame. We conducted extensive staff education. A CODE TIA sticker was created & placed on the front of TIA patients’ charts to alert staff to the time left until the proposed discharge.TIA order sets were developed and MDs were educated to use them. A TIA checklist for nurses was created to follow patient’s progress & any pending tests. A
TIA pathway
handout was also created for patients. This visual record enables the patient to participate in their own care and track their progress.The stroke team meets monthly to discuss data & opportunities for improvement. For example, discharge delays occurred while waiting for bubble studies (TEE with echocontrast). We trained & certified all stroke nurses to administer echocontrast.Delays for echocardiography were eliminated.

Results:
The LOS was 3.66 days for patients diagnosised with TIA.The data shows that the CODE TIA program is successful. We have decreased the LOS dramatically. Since August, we had 59 patients the TIA pathway. Of these,31(52%) converted to a regular stay if co-morbidities or diagnosis of stroke was discovered. Interestingly, 28 (47%) patients went home in 0.92 days. That is a 74.9% decrease in the patient’s LOS. Patients diagnosed withTIA, not on pathway, had a LOS of 1.6 days.

Conclusion:
A directed TIA pathway, with extensive education, order sets, patient materials & aggressive stroke team involvement yielded significant reduction in LOS.Outcome studies needed to assure stroke risk reduction.
Abstract TP332: Utilizing a Neuro Intermediate Unit in Caring for Post-Thrombolysis Stroke Patients
Authors: Ramos Leah C , Steffen Cynthia , Gay Sarah , Chalela Julio
Published: July 2021

Background:
Historically stroke patients receiving intravenous tPA are admitted to an intensive care unit (ICU). Providing post-tPA care in a non-ICU setting could result in cost reduction and allow allocation of ICU beds to other critically ill patients. We sought to determine if care can be provided safely and effectively for post-tPA patients in a Neuro Intermediate Unit (NIU).

Materials and Methods:
This is a retrospective case series study performed in a tertiary academic medical center with a comprehensive, accredited, stroke program. We analyzed ischemic stroke patients admitted to our NIU during a 24-month period. A standardized data collection form was used to abstract data from medical records.

Results:
During a 24-month period 104 patients were admitted for post-tPA stroke care. The sample is composed of 60 males and 44 females. The median age was 69.5 and the mean age was 67.96. The sample is composed of 72 (69%) White and 32 (31%) Black patients. The mean admission NIHSS was 9.32. The most common stroke risk factors were hypertension (76%), diabetes mellitus (25%), hyperlipidemia (51%), tobacco use (21%), atrial fibrillation (21%), prior stroke (26%), congestive heart failure (20%), and coronary artery disease (21%). Mean admission systolic blood pressure was 143.5 mm Hg. For blood pressure management, 18% of the patients received medication by intravenous push and 5.7% by continuous infusion to meet established goals. Gastrointestinal hemorrhage was seen in 1.9%, intracranial hemorrhage in 3.8%, and blood transfusions needed in 1.9%. Insulin drips were needed to control persistent hyperglycemia in 3.8%. Sepsis occurred in 0.96% patients. The rate of fatality was 3.8%. Excellent functional outcome as defined as Modified Rankin Score (mRS) less than 2 was seen in 46% of patients and minimal to no disability (mRS
< 1
) was seen in 35.6%.

Conclusions:
In this retrospective study, stroke patients receiving intravenous tPA admitted to an NIU had similar outcomes and complications to that described in previous data. Significant cost savings can be accomplished by admitting thrombolysis patients to an NIU without compromising patient safety. Specialized nursing care available in a stroke unit is a key component in improving patient outcome.