bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 132: Final Infarct Volume is a Critical Determinant of Hospitalization Cost in Anterior Circulation Large Vessel Occlusion Stroke
Authors: Streib Christopher , Rangaraju Srikant , Winger Daniel G , Campbell David T , Paolini Stephanie , Jankowitz Brian , Jadhav Ashutosh , Jovin Tudor
Published: June 2021

Background:
Anterior circulation large vessel occlusion (ACLVO) stroke, one of the most devastating stroke subtypes, is associated with substantial economic burden. Identifying predictors of increased ACLVO stroke hospitalization cost is essential to developing cost-effective treatment strategies.

Methods:
We utilized comprehensive patient-level cost-tracking software to calculate hospitalization costs for ACLVO stroke patients at our institution between July 2012-October 2014. Patient demographics and neuroimaging findings were analyzed. Predictors of hospitalization cost were determined using multivariable linear regression. In addition to our primary analysis (all eligible ACLVO patients), we conducted subgroup analyses by treatment (endovascular, IV tPA-only, and no reperfusion therapy) and sensitivity analyses.

Results:
341 patients (median age 69 [IQR 57-80], median NIHSS 16 [IQR 13-21], median hospitalization cost $16,446 [IQR $9823-$27,165]) were included in our primary analysis; final infarct volume (FIV), parenchymal hematoma, age, obstructive sleep apnea, and baseline NIHSS were significant predictors of hospitalization cost (Figure). FIV alone accounted for 20.51% of the total variance in hospitalization cost. Notably, FIV was consistently the most robust predictor of increased cost across primary, subgroup, and sensitivity analyses. Over the observed range of FIVs in our cohort, each additional 1cc of infarcted brain tissue increased hospitalization cost by $122.35.

Conclusion:
FIV is a critical determinant of increased hospitalization cost in ACLVO stroke. Therapies resulting in reduced FIV may not only improve clinical outcomes, but prove cost-effective.
Abstract 160: DNA-Methylation and Aging. Contribution of Biological Age to Recovery After Ischemic Stroke
Authors: Jimenez-Conde Jordi , Soriano-Tarraga Carolina , Giralt-Steinhauer Eva , Mola Marina , Vivanco-Hidalgo Rosa , Ois Angel , Rodriguez-Campello Ana , Cuadrado-Godia Elisa , Roquer Jaume
Published: June 2021

Background:
Stroke has a great impact in functional status of patients, although there are substantial interindividual differences in recovery capacity. Apart from stroke severity, age is considered an important predictor of outcome after stroke, but aging is not only due to chronological age. There are age-related DNA-methylation changes in multiple CpG sites across the genome that can be used to estimate the biological age (b-Age), and we seek to analyze the impact of this b-Age in recovery after an ischemic stroke.

Methods:
We include 600 individuals with acute ischemic stroke assessed in Hospital del Mar (Barcelona). Demographic and clinical data such as chronological age (c-Age), vascular risk factors, NIHSS at admission, recanalization treatment (rtPA or endovascular treatment), previous modified Rankin scale (p-mRS) and 3 months post stroke functional status (3-mRS) were registered. Biological age (b-Age) was estimated with Hannumm algorithm, based on DNA methylation in 71 CpGs.

Results:
The bivariate analyses for association with 3-mRS showed a significant results of NIHSS, c-Age, b-Age, p-mRS, and current smoking (all with p<0.001). Recanalization treatment showed no significant differences in bivariate analysis. In multivariate ordinal models, b-Age kept its significance (p=0.025) nullifying c-Age (p=0.84). Initial NIHSS, p-mRS and recanalization treatment kept also significant results (p<0.001).

Conclusions:
Biological Age, estimated by DNA methylation, is an independent predictor of stroke prognosis, irrespective to chronological age. "Healthy aging” affects the capacity of recovering after an ischemic stroke.
Abstract 181: Determinants of Intracranial Atherosclerotic Enhancement on Vessel Wall MRI in Patients with Acute Ischemic Stroke
Authors: de Havenon Adam , Chauhan Nabeel , Majersik Jennifer , Tirschwell David , Wong Ka-Ho , Chatwin Stephen , Kim Seong-Eun , Parker Dennis , McNally Scott
Published: June 2021

Introduction:
Enhancing intracranial atherosclerotic plaque on high-resolution vessel wall MRI (vwMRI) is a reliable marker of recent thromboembolism, and confers a recurrent stroke risk of up to 30% a year. Post-contrast plaque enhancement (PPE) on vwMRI is thought to represent inflammation, but studies have not fully examined the clinical, serologic or radiologic factors that contribute to PPE.

Methods:
Inpatients with acute ischemic stroke due to intracranial atherosclerosis were prospectively enrolled at a single center from 2015-16. vwMRI was performed on a 3T Siemens Verio and included 3D DANTE pulse sequences, pre- and post-contrast (for PPE identification). Three experienced neuroradiologists interpreted vwMRI using a validated multicontrast technique. The Chi-squared, Fisher’s Exact, and Student’s t-test were used for intergroup differences, and logistic regression was fitted to the primary outcome of PPE.

Results:
Inclusion criteria were met by 35 patients. Atherosclerotic plaques were in the anterior circulation in 21/35 (60%) and PPE was diagnosed in 20/35 (57%) of stroke parent arteries. PPE predictors are shown in
Table 1
with logistic regression in
Table 2
.

Conclusion:
PPE is associated with stenosis, which was expected, but the association with HgbA1c is novel. All patients with HgbA1c >8 had PPE and a one point HgbA1c rise increased the odds of PPE 3-fold. Hyperglycemia induces vascular oxidative stress by generating reactive oxygen species, quenching nitric oxide, and triggering an inflammatory cascade. Given the high rate of stroke recurrence in PPE patients, aggressive HgbA1c reduction may be a viable treatment target and warrants additional study.
Abstract 192: The Relationship of Platelet-leukocyte Aggregates and Early Brain Injury After Subarachnoid Hemorrhage
Authors: Frontera Jennifer A , Katyshev Vladimir , McIntyre Thomas M , Sehba Fatima A , Weimer Jonathan M , Provencio J. Javier
Published: June 2021

Introduction:
Acute brain injury incurred after aneurysm rupture in subarachnoid hemorrhage (SAH) is a major predictor of poor functional outcome. We hypothesize that platelet-leukocyte aggregates (PLA) form early after SAH and contribute to acute brain injury.

Methods:
A prospective study of antiplatelet-naive SAH patients and controls (patients with unruptured aneurysms undergoing repair) was conducted from 3/2014-3/2016. Platelet-monocyte, platelet-lymphocyte and platelet-neutrophil aggregates in whole blood were measured with and without exposure to a platelet agonist (Thrombin receptor activating peptide [TRAP]) using flow cytometry. PLA within 24h and averaged over 72h from ictus (prior to the onset of delayed cerebral ischemia/vasospasm) were compared between patients with mild (admission Hunt-Hess [HH] 1-3) versus severe early brain injury (EBI; HH 4-5).

Results:
We enrolled 60 SAH patients and 13 controls. PLA were significantly lower in those with severe EBI compared to those with mild EBI (Platelet-monocyte-aggregates 36% versus 53%, P=0.011; Platelet-neutrophil-aggregates 15.2 versus 23.1%, P=0.002) within 24h of ictus and prior to aneurysm repair and remained significantly lower over 72h (both P<0.05). Platelet-monocyte, platelet-neutrophil and platelet-lymphocyte aggregates were also significantly lower in those with severe EBI compared to controls (all P<0.05). The ability of platelets to be stimulated/activated by TRAP to form PLA was also lower in severe EBI patients compared to mild EBI and control patients over 72h (platelet-neutrophil-aggregates 79.7, 88.2 and 92.7%, respectively, P=0.003; platelet-lymphocyte aggregates 9.2, 11.0 and 14.6%, respectively, P=0.022), consistent with prior platelet activation/degranulation.

Conclusions:
PLA are lower, and respond less to stimulation in patients with severe EBI after SAH compared to those with mild EBI and controls. These data suggest that in severe EBI: PLA may form earlier and are cleared, are adherent to endothelium and not shed in the blood, or have migrated into the parenchyma. These hypotheses bear further study.
Abstract 194: Spontaneous Spinal Subarachnoid Hemorrhage: A Mayo Clinic Case Series
Authors: Yost Micah D , Rabinstein Alejandro A
Published: June 2021

Background:
Spontaneous spinal subarachnoid hemorrhage (SSAH) is a rare but serious condition that can lead to a variety of medical complications.

Methods:
Using the Mayo Clinic Rochester database, patients admitted to the Mayo Clinic Rochester, MN hospital with spontaneous SSAH (not iatrogenic or traumatic) between January 2000 and December 2015 were retrospectively reviewed. Demographic and clinical data and functional outcomes as described by the modified Rankin Scale (mRS) score at the time of discharge and at post-admission follow-up were assessed.

Results:
Eight consecutive patients (median age 70 years, range 51-87) were identified. Seven patients presented with acute onset back pain or headache. Seven patients had poorly controlled chronic hypertension. Two patients had vasculitis, and one had an arteriovenous malformation (AVM). An increase in blood pressure was observed in all patients during their acute presentation as compared to their baseline outpatient readings. Complications included cord compression (n = 4), hyponatremia (n = 5), sulcal subarachnoid hemorrhage (n = 2), chronic arachnoiditis (n=1), vasospasm (n=1), and late cord ischemia (n = 1). All eight patients were managed medically including blood pressure control and repeat imaging. One patient had an aneurysm which was embolized, and two received steroids for vasculitis. One patient died during hospitalization, one died within a week of discharge, five had improved mRS score at post-hospitalization follow-up and had unchanged mRS of 1 at discharge and follow-up.

Conclusions:
To our knowledge this is the first compilation of cases of spontaneous SSAH. Risk factors for spontaneous SSAH are hypertension, AVM, vasculitis, coarctation of the aorta, and malignancy. Symptomatic cord compression is not uncommon, but can be managed conservatively.
Abstract 200: Risk Factors Positively Associated with Annual Growth Rate of Brain Aneurysms
Authors: Chien Aichi , Hildebrandt Michelle , Callender Rashida , Ye Yuanqing
Published: June 2021

Introduction:
Previous studies have shown that unruptured intracranial aneurysm (UIA) growth and rupture are strongly associated with each other, with an increasing number of aneurysms followed clinically, especially UIA smaller than 7 mm.

Hypothesis:
Patient-specific and aneurysm-specific clinical and demographic features can predict growth and growth rates of UIA.

Methods:
We studied a cohort of 293 individuals diagnosed with a total of 409 intracranial aneurysms followed for an average of 27.4 months. Associations with aneurysm growth and growth rate were identified for both patient- and aneurysm-specific variables. Growth was defined as a size increase greater than 0.6 mm, with growth rate (mm/year) determined from the change in size of the aneurysm between the first and last measurement.

Results:
Mean initial size at diagnosis was significantly associated with risk of growth (OR: 1.09, 95% CI: 1.01-1.18, p=0.036), as was diagnosis of multiple aneurysms (OR: 2.01, 95% CI: 1.00-4.04, p=0.048) and having a positive family history (OR: 4.25, 95% CI: 1.18-15.3, p=0.041). Diagnosis of coronary artery disease (CAD) (p<0.001), diabetes (p=0.041), and gender (p=0.014) were significant for growth rate. Differences were observed for aneurysms located in different vessels, with an increased occurrence of growth at M-Bifurcation (p=0.015 vs. other MCA sites) and a high growth rate for those located in the BA trunk (p=0.0033 vs. other VABA sites).

Conclusions:
This analysis takes advantage of a large longitudinal cohort with multiple follow-up measurements to provide further insight regarding the characteristics of UIA growth behavior. While our data further confirm that aneurysm rupture and growth share a similar set of risk factors (size, multiplicity and family history), we additionally that found patients with CAD or diabetes had a higher aneurysm growth rate, and therefore might require more frequent follow up.
Abstract 33: The Impact Transfer Status, Level of Stroke Center Certification, and Hospital Thrombectomy Volume on the Outcome of Acute Ischemic Stroke Patients with Emergent Large Vessel Occlusion
Authors: Tarpley Jason W , Lucas Lindsay , Ho Joseph T , Ovando Renee , Baraban Elizabeth
Published: June 2021

Introduction:
Recent thrombectomy trials for emergent large vessel occlusion (ELVO) have spurred an international debate regarding the best way to get ELVO patients to the right centers quickly. Here we attempt to identify triage features associated with the best patient outcomes.

Methods:
A large, multi-hospital health system Get With The Guidelines stroke registry was used to identify patients >18 years old who had intra-arterial (IA) treatment of ELVO between January 2012 and June 2016. Primary outcomes were modified Rankin score (mRS) at discharge and discharge disposition. Generalized linear regression models were used to identify which of the variables on the figure’s Y-axis were related to the outcomes.

Results:
We identified 562 ELVO patients who received IA-treatment. Patients were more likely to have greater disability if they were treated at a PSC (AOR=3.14; p=.004), were a transfer (AOR = 5.18, p=.001), had a higher NIHSS score (AOR = 1.10; p<.001), were older (AOR=1.04; p=.003), or had longer Door to IA times (AOR = 1.01; p=.008). Compared to discharge to home, patients were more likely to be sent to hospice or expire if they were treated at a PSC (AOR=2.28; p=.021), were a transfer (AOR=2.39, p=.047), had a higher NIHSS (AOR=1.19; p<.001), were older (AOR = 1.06; <.001), or had longer Door to IA times (AOR = 1.01; p=.009). Patients were more likely to be sent to a SNF if they if they were a transfer (AOR = 2.70, p=.014), had a higher NIHSS score (AOR=1.13; p<.001), were older (AOR = 1.06; <.001), or had longer Door to IA times (AOR = 1.01; p=.029).

Conclusions:
Being treated locally rather than transferred, at a comprehensive rather than primary stroke center, and with shorter door to IA times were the strongest drivers of good outcome. Conversely, the annual IA treatment volume was not a driver of outcome.
Abstract 51: Differences in Stroke Management do not Account for the Greater Long-term Mortality After Stroke in Women Compared to Men: Australian Stroke Clinical Registry (AuSCR)
Authors: Phan Hoang T , Cadilhac Dominique , Thrift Amanda G , Blizzard Leigh , Anderson Craig , Kim Joosup , Gall Seana
Published: June 2021

Introduction:
Women have been reported to receive evidence-based care less often than men, but it is uncertain whether this contributes to sex differences in outcomes after stroke. We examined this using data obtained from the Australian Stroke Clinical Registry (AuSCR).

Methods:
We included first-ever strokes admitted to 40 hospitals participating in the AuSCR during 2010-2013. Mortality one year after stroke was obtained from linkage to the National Death Index. Multilevel Poisson modelling, accounting for hospital, was used to estimate the mortality rate ratio (MRR) for women compared to men. Multivariable models were adjusted for sociodemographics, stroke type, severity (ability to walk on admission) and the provision of evidence-based therapies while in hospital (stroke unit care, thrombolysis, secondary prevention medications, dysphagia screening and mobilization).

Results:
Data were available for 9,549 strokes (47% women, 80% ischaemic stroke). Women, compared to men, were older (mean [SD] 75.0 [15.0] vs 70.3 [13.9], p<0.001) and less able to walk on admission (32% vs 41%, p<0.001). Overall, there were no sex differences in access to evidence-based therapies in hospital, although it appeared that slightly fewer women were admitted to a stroke unit (79% vs 81%, p=0.001). In a subset of patients from Queensland (n=3,013), women were less often mobilised (74% vs 79%, p=0.04) or administered aspirin within 48 hours of stroke onset (66% vs 74%, p<0.001). Mortality was greater in women than men at one year (MRR
crude
1.42 [95% CI 1.31, 1.55]). This association was attenuated when adjusting for age and severity of stroke (MRR
adjusted
1.00 [95% CI 0.92, 1.09] but not by any of the evidence-based therapies.

Conclusion:
Greater mortality in women was associated with differences in age and stroke severity and not differences in access to care. Improvements in care for the elderly and the management of modifiable factors of stroke severity should reduce sex differences in outcomes.
Abstract 57: Brain-heart Interaction: Age Aggravates Cardiac Damage After Cerebral Ischemic Stroke
Authors: Chen Zhili , Yan Tao , Zhao Qiang , Shen Yi , Li Wei , Chopp Michael , Chopp Michael , Chen Jieli
Published: June 2021

Background:
The incidence of cardiovascular diseases is approximately three times higher in patients with neurological diseases than in patients without neurological diseases. Clinical findings have demonstrated that 70% of stroke patients exhibit cardiac dysfunction. Myocardial injury may occur after stroke in the absence of primary cardiac causes. In this study, we tested the hypothesis that age affects brain-heart interaction after cerebral ischemic stroke, and that aging increases cardiac dysfunction after stroke.

Methods:
Young adult (2-3 months), middle age (8-9 months) and aged (17-18 months) male C57BL mice were subjected to distal middle cerebral artery occlusion (dMCAo) or sham control (n=10/group). Cardiac hemodynamics and function were measured by transthoracic Doppler echocardiography. Mice were sacrificed at 28 days after surgery. Immunostaining of heart tissues were performed. To elucidate the mechanisms of stroke mediated cardiac dysfunction, heart tissue flow cytometry was employed to measure myocardial inflammation at 4 days after stroke in middle aged mice (n=6/group).

Results:
1) Stroke mice exhibited an age dependent decrease in cardiac function: Stroke in young adult mice induced mild cardiac dysfunction; While the middle age and aged stroke mice exhibited significantly increased cardiac dysfunction compared to age matched sham controls, respectively (p<0.05). Middle age stroke mice exhibit significantly decreased ejection fraction (EF), and increased left ventricular systolic volume (LVVOLs) and LV volume during diastole (LVVOLd); Aged stroke mice exhibited significantly decreased EF and fractional shortening, increased LVVOLs LVVOLd, LV end-diastolic and end-systolic diameter, when compared to age matched sham controls, respectively. 2) Middle age and aged stroke mice exhibited significantly increased myocyte hypertrophy and fibrosis measured by Sirius red collagen staining. 3) Middle aged stroke mice exhibited significantly increased CD45 and CD11b
high
/CD45
+
inflammation cell infiltration in the heart compared to middle age sham controls.

Conclusion:
Stroke induces cardiac dysfunction. Age affects brain-heart interaction, and age aggravates heart damage after cerebral ischemic stroke.
Abstract 6: Interim Report of the Weave Trial: First 102 Consecutive on Label Patients
Authors: Alexander Michael J , Chaloupka John C , Zauner Alois , Baxter Blaise , Callison Richard , Yu Wengui
Published: June 2021

Purpose:
The initial FDA approval trial of the self-expanding Wingspan stent for symptomatic intracranial atherosclerotic disease demonstrated a 4.5% periprocedural complication rate. Subsequently, similar on-label registry data was reported. The WEAVE Trial is a prospective, consecutive enrollment, single-arm, post-market surveillance trial evaluating periprocedural outcomes in patients with the revised FDA indications for use.

Methods:
Data for the first 102 on-label patients for which completed data is available are included in this report. The primary analysis endpoints included periprocedural stroke, death, or symptomatic bleed within 72 hours of the stenting procedure in patients who were treated on label. A subgroup of the participating sites included anti-platelet therapy resistance testing and correction, if needed, in their treatment of the patient. All patient outcomes were separately adjudicated by a stroke Neurologist by 72 to 96 hours post procedure.

Results:
In the initial 122 consecutive patients enrolled with completed data, 102 patients were treated on label and are included in the primary analysis, and 20 patients were treated off label and were part of secondary analyses. The mean stenosis in the primary analysis group was 83% with target artery break down as follows: 40.2% MCA, 25.5% ICA, 19.6% Basilar, 14.7% Vertebral or VB junction. Of the 102 patients in the primary analysis, 3 patients (2.9%) reached a primary endpoint of stroke, symptomatic bleed, or death within 72 hours. In the off label group, 4 of the 20 patients (20%) reached a primary endpoint within that period.

Conclusions:
The early interim analysis of the first 102 patients of WEAVE trial has demonstrated a very low periprocedural morbidity and mortality of 2.9%. This is lower than the high periprocedural event rate in the SAMMPRIS trial, and statistically better than the outcomes in the off label group (Fisher’s Exact test p value 0.014). This early data provides impetus to continue to collect data in this trial, and lends support to the concept that refined patient selection criteria and establishment of best practice techniques and management for these patients can substantially decrease the peri-procedural risk of intracranial stenting.
Abstract 62: Sanguinate
TM
Opens Collaterals, Improves Reperfusion and Decreases Infarct in Hypertensive Rats
Authors: Cipolla Marilyn , Linfante Italo , Abuchowski Abe , Jubin Ronald , Chan Siu-Lung
Published: June 2021

Background:
The PEGylated cell-free carboxyhemoglobin gas exchanger Sanguinate
TM
(SG) has multiple beneficial actions that may improve stroke outcome including anti-inflammatory, vasodilatory and oxygen delivery capacity. We investigated the ability of SG to improve infarction in spontaneously hypertensive rats (SHR) that are known to have vasoconstricted pial collaterals and poor stroke outcome.

Methods:
SHR were treated IV with SG (8 ml/kg; n=8) or vehicle (Lactated Ringer’s; n=6) plus tPA (0.9 mg/ml) after 30 min of proximal middle cerebral artery occlusion (MCAO) by filament occlusion. Pial collateral and reperfusion flow were measured for 2 hrs of occlusion and 2 hrs reperfusion using dual laser Doppler probes in the core (Bregma -2mm, lateral +4mm) and collateral (Bregma +2mm, lateral +3mm) territories. Collateral openings (number and duration (min)) were assessed off cerebral blood flow (CBF) tracings, defined as independent of changes in blood pressure (Fig. 1; arrows show openings). Infarction was measured using triphenyltetrazolium chloride (TTC). Animals were anesthetized with chloral hydrate and ventilated to maintain blood gases within normal ranges.

Results:
Vehicle-treated SHR had incomplete reperfusion and poor collaterals that was improved by SG. During MCAO, SG increased the number of collateral openings from 1.0±0.8 to 3.1±0.8 (p=0.03) and duration of openings from 6.0±5.8 to 35.4±9.8 min (p=0.04; Fig. 2). Reperfusion CBF was -43±6% of baseline in vehicle-treated, but only -7±19% of baseline in SG-treated animals. Improved collateral and reperfusion flow with SG was associated with decreased infarct volume vs. vehicle (28.8±3.2% vs. 18.8±2.3%; p<0.05). The presence of tPA had no effect in either group.

Conclusions:
Smaller infarction with early SG treatment may be related to its ability to open constricted collaterals in SHR and improve reperfusion. Thus, SG may be able to extend the time window for endovascular or tPA treatment.
Abstract 69: Distinct Grouping of Systolic Blood Pressure Trajectories During the First 24 Hours After Stroke Admission and Their Outcomes
Authors: Kim Beom Joon , Han Moon-Ku , Cho Yong-Jin , Hong Keun-Sik , Lee Jun , Kim Joon-Tae , Park Tai Hwan , Lee Ji Sung , Lee Juneyoung , Bae Hee-Joon
Published: June 2021

Background:
Blood pressure of ischemic stroke patients is a potentially modifiable clinical prognostic factor during acute period. However, BP changes dynamically over time and its temporal variation during acute stage has not received much attention.

Methods:
From a total of 3795 acute ischemic stroke patients who arrived within 24 hours after onset, we selected 2723 eligible patients who had more than 5 systolic blood pressure (SBP) measurements during 24 hours after arrival. To predict group SBPs for 8 time-points during the first 24 hours, a measured SBP reading was imputed to the nearest missing point. Trajectory grouping of acute stroke patients was estimated using PROC TRAJ, with delta BIC and prespecified modeling parameters. Early neurological deterioration (END) was captured during admission and recurrent vascular events was collected through a structured telephone interview at 1 years after.

Results:
Of the included cases, mean age at onset was 68 ± 13 year-old. NIHSS score at arrival was median 4 [2, 10] and recanalization treatment was done in 598 (22%). Hypertension was diagnosed in 1930 (71%). Based on 48,445 SBP readings during the first 24 hours after arrival, stroke cases were grouped into 5 distinct SBP trajectories as shown in the Figure: Group 1 (low BP), 17%; Group 2 (stable BP), 41%; Group 3 (rapidly stabilized SBP), 11%; Group 4 (higher SBP), 23%; Group 5 (extremely high SBP without stabilization), 8%. Trajectory grouping was independently associated with END and recurrent vascular events (see Figure). Group 1 had low odds of having END (adjusted OR [95% CI]; 0.62 [0.44-0.87], but Group 4 and 5 showed higher probability of having END (1.34 [1.04-1.73] and 1.76 [1.22-2.51]) and recurrent vascular events until 1 year (1.28 [1.00-1.64] and 1.82 [1.29-2.55]). However, Group 3 had comparable risks with Group 2.

Conclusion:
It was documented that SBP may successfully grouped into distinct trajectories, which are associated with outcomes after stroke.
Abstract 79: 30-Day Cardiac Monitoring is Feasible and Effective in a Community Setting
Authors: Mehdiratta Manu , Parker Brent , Bickford Suzanne , Khomitska Inna , Tingle Jeremy , Hoosein Sharon , Desai Jamsheed , Perez Yael
Published: June 2021

Prolonged cardiac rhythm monitoring reveals atrial fibrillation (AF) in 16-42% of patients who undergo monitoring for up to 6 months after a cryptogenic stroke. The feasibility of prolonged cardiac monitoring, AF detection rates and the impact of earlier screening after suspected cardioembolic infarct in a community setting is unknown.

Methods:
This prospective study examined patient compliance and AF detection rates with prolonged cardiac monitoring started within 30 days of a stroke/TIA. 181 patients ≥ 55 years old with a suspected cardioembolic stroke/TIA that occurred in the preceding 30 days were referred for 30-day cardiac monitoring. Patients were educated about reasons for monitoring and test procedures for 15-20 minutes. A Spiderflash-t or Northeast DR 200 monitor, programmed for detecting AF, was used. Auto-triggered and patient-activated recordings obtained during two consecutive 15-day monitoring periods were assessed. Either 3-day serial ECG or ≥24h Holter monitor was also completed in 119/181 patients. The primary outcome was patient compliance with 30 days of monitoring. Secondary outcomes included detection of any duration of AF within the two monitoring periods.

Results:
The compliance rate for the full 30-day monitoring period was 98.9% (179/181). AF was detected on 30-day monitor in 11.6% (21/181) of patients. Of the patients who received both 3-day serial ECG or ≥24h Holter and 30-day monitoring, AF was only detected in 0.84% (1/119) with 3-day serial ECG and/or Holter monitoring vs. 14.3% (17/119) with 30-day monitoring. AF was detected in 76.2% (16/21) of patients in the first 15 day period. 14 patients had AF lasting longer than 6 minutes, 5 had AF lasting between 30 secs - 6 min and 2 had AF < 30 secs. Of patients who completed the 30-day monitoring, 38.8% had AF recurring through the 30 days. 85.7% (18/21) of patients were switched to a novel oral anticoagulant (NOAC), while 3 patients died and thus could not be switched to a NOAC.

In conclusion, 30-day cardiac monitoring is feasible in a community setting with high compliance rates, yields similar AF detection rates as seen in clinical trials and positively impacts patient management. There are missed opportunities for secondary stroke prevention in the community without 30-day monitoring.
Abstract 90: Cost-Benefit Comparison of Inpatient versus Clinical Decision Unit Management of TIA
Authors: Nair Deepak , Gibbons Michael , Wang Huaping , Kim Min-Chul , Beck Judi , Swanson-Devlin Teresa , Jahnel Jan , Mathews Maureen , Couri Candace , Wang David
Published: June 2021

Introduction:
Because TIA increases the risk of subsequent stroke, rapid TIA management is key to stroke prevention. Controversy remains regarding the appropriate site of care for TIA patients. Recent literature shows high variability in care processes, admission rates, timeliness of interventions, cost of care, and outcomes, regardless of site of care. We developed a rapid TIA management process in our Clinical Decision Unit (CDU) to reduce cost and adverse outcomes. TIA patients that present to our ED are admitted to the CDU, but transfer patients with TIA are admitted to the inpatient unit (IPU).

Methods:
Retrospectively, we identified TIA cases by ICD coding, and reviewed records from 4/1/2012 to 3/31/2016 for patients in the CDU and in the IPU. We compared length of stay (LOS), cost of care, readmission rates, and TIA/stroke recurrence between the two groups. Statistical analysis included Chi-square and Wilcoxon two-sample test for recurrence and readmission rates, and generalized linear modeling and Poisson analysis for LOS and cost analysis.

Results:
A total of 731 patients presented for TIA management in the study period; 393 in CDU, and 338 in IPU. There was no statistical difference in age or sex between the two groups. Mean LOS (hours) in CDU vs IPU was 15 vs 108 (p<0.001), respectively. Total cost of care in CDU vs IPU was $3,835 vs $11,904 (p<0.001), respectively. Univariate analysis showed no appreciable difference in recurrent TIA or stroke rates; multivariate analysis of stroke recurrence for CDU (1.0%) vs IPU (3.6%) did show a small difference (p=0.024). When factoring in reduction of stroke recurrence, the final cost savings of the CDU program equaled $8,258 per patient. There was no difference in readmission rates between the two groups.

Conclusion:
Using a rapid TIA management protocol yielded a significantly lower LOS and cost per patient. This may justify an avoidance of inpatient admission for TIA patients.
Abstract 98: Midlife Vascular Risk Factors and Incident Dementia in the ARIC Cohort
Authors: Gottesman Rebecca F , Albert Marilyn , Coker Laura , Coresh Josef , Davis Sonia M , Deal Jennifer A , McKhann Guy M , Mosley Thomas H , Sharrett A. Richey , Schneider Andrea L , Windham B. Gwen , Wruck Lisa M , Knopman David S
Published: June 2021

Background:
Vascular risk factors have been associated with risk of cognitive decline, with increasing evidence that midlife exposure to these risk factors may be most important in conferring late-life risk of cognitive impairment. We explored associations between vascular risk factors measured in midlife and the development of dementia over 25 years in the biracial Atherosclerosis Risk in Communities (ARIC) cohort.

Methods:
Participants in the ARIC study were recruited from four U.S. communities in 1987-1989, at ages 45-64, with four additional in-person visits, surveillance for hospitalizations, annual phone calls, and repeated cognitive evaluations over a 25-year period. In 2011-2013, ARIC participants were seen for the ARIC Neurocognitive Study (ARIC-NCS), and underwent a detailed neurocognitive battery and informant interviews. Through adjudicated review, dementia cases were defined. Additional dementia cases were identified through the telephone interview for cognitive status (TICS) or informant interview for those participants not attending ARIC-NCS; or by a prior dementia ICD-9 code during a hospitalization.

Results:
Of 15,744 participants in the cohort, 1516 cases of dementia were identified, of whom over one third were among black participants. Risk of dementia was highest in individuals of black race, with less than a high school education, older age, APOE ε4 carriage, and who, at ARIC baseline, had hypertension, diabetes, or were current smokers (table). APOE ε4 and smoking were each stronger risk factors for dementia in whites than in blacks.

Discussion:
Vascular risk factors measured in midlife are associated with increased risk of dementia in this biracial cohort, in black and white participants. The risk associated with diabetes nears the increased risk associated with having an APOE ε4 allele. Further studies are needed to evaluate the mechanism of and opportunities for prevention of the cognitive sequelae of these risk factors in midlife.
Abstract NS12: Nursing-led Intervention to Improve Use of Prolonged Arrhythmia and Polysomnography in Veterans with Ischemic Stroke
Authors: Bottomley Sharon , Keefner Lisa , Sico Jason J
Published: June 2021

Background:
Current AHA/ASA ischemic stroke prevention guidelines provide updated recommendations regarding prolonged arrhythmia monitoring to detect occult atrial fibrillation and polysomnography referral (PSG) for obstructive sleep apnea (OSA) assessment. While these assessments are traditionally considered “outpatient” testing, we sought to determine the feasibility of starting these referrals during the hospitalization period.

Methods:
We used Lean Six Sigma process improvement methods to process map the current and future states of obtaining prolonged arrhythmia monitoring and PSG at a single VA Medical Center. Working with stakeholders in neurology, cardiology, and sleep medicine we devised standard operating procedures for obtaining referrals for these respective testing during hospitalization. A stroke nurse coordinated all referrals.

Results:
Our single site intervention period was from 10/1/2015 to 2/29/2016, during which 21 patients were admitted to the neurology service with an ischemic stroke. At baseline, no patients received orders by hospital discharge for prolonged arrhythmia monitoring or PSG. Potential benefits and adverse effects of testing were discussed with Veterans. Of the twelve patients (57.1%) eligible for prolonged arrhythmia monitoring, half the patients agreed to the testing and were discharged with either a Holter monitor/implantable loop recorder. Of the 18 patients (85.7%) eligible for PSG, six agreed to the testing, with one patient receiving testing during hospitalization and the remaining patients received PSG after discharge. One Veteran was diagnosed with atrial fibrillation, whereas all Veterans receiving PSG were diagnosed with varying degrees of OSA. Positive test results initiated referrals to appropriate specialists for additional management. Length of hospital stay was not increased in order to receive the additional coordinated care.

Conclusions:
Implementation of a nursing coordinated program designed to improve delivery of guideline concordant post stroke arrhythmia monitoring and OSA assessment could be feasibly implemented using existing infrastructure without prolonging length of stay.
Abstract TMP12: Aspiration Thrombectomy Works Better Wn Time from Stroke Onset to Clot Contact is Shorter
Authors: Blanc Raphael , Redjem Hocine , Ciccio Gabriele , Smadja Stanislas , Desilles Jean Philippe , Labreuche Julien , Mazighi Mikael , Lapergue Bertrand , Piotin Michel
Published: June 2021

Background and Purpose:
The technique of A Direct Aspiration, First Pass for the Endovascular Treatment of Stroke (ADAPT) has been reported to be fast, safe and effective for the treatment of acute ischemic stroke(AIS). The aim of this study is to determine the preoperative factors that affect success of the aspiration component of the technique in ischemic stroke patients with large vessel occlusion in the anterior circulation.

Methods:
We enrolled all 347 consecutive patients with anterior circulation AIS admitted for mechanical thrombectomy (MT) at our institution from August 2013 to October 2015 and treated by ADAPT. Baseline and procedural characteristics, mTICI scores and 3-month mRS were captured and analyzed.

Results:
Among the 347 patients (occlusion sites: MCA=200, 58%; ICA Siphon=89, 25%; Tandem=58, 17%), aspiration component led to successful reperfusion (mTICI 2b/3 scores) in 56% (193/347 patients), stent retrievers were required in 40 % and a total successful final reperfusion rate of 83% (288/345) was achieved. Overall mRS 0-2 at 90 days was reported in 45% (144/323). Only two factors positively influenced the success of the aspiration component: an isolated MCA occlusion (
p<
0.001) and a shorter time from stroke onset to clot contact (
p=
0.018). Overall procedural complications occurred in 13.3% of patients (48/345).

Conclusion:
In this large retrospective study, ADAPT technique was shown to be safe and effective for anterior circulation AIS with a final successful reperfusion achieved in 83%. Delay from onset to clot contact and the site of arterial occlusion were predictors for reperfusion.
Abstract TMP121: Gender Differences in Functional Outcomes After Acute Ischemic Stroke: The Role of White Matter Structural Integrity
Authors: Etherton Mark , Wu Ona , Cougo Pedro , Giese Anne-Katrin , Cloonan Lisa , Fitzpatrick Kaitlin , Kanakis Allison , Boulouis Gregoire , Karadeli Hasan , Lauer Arne , Rosand Jonathan , Furie Karen , Rost Natalia
Published: June 2021

Background:
Women are known to have worse post-stroke outcomes; however, the underlying mechanisms remain unclear. We evaluated sex-specific clinical and neuroimaging characteristics linked to cerebrovascular brain health in association with functional recovery after acute ischemic stroke (AIS).

Methods:
We reviewed 316 AIS patients with acute MRI (<48 hours from symptom onset) and modified Rankin scale score (mRS) assessed at 3-6 months post-stroke. Acute infarct volume on diffusion-weighted imaging (DWIv) and white matter hyperintensity volume (WMHv) on FLAIR sequences were determined using a validated semi-automated method. Mean diffusivity (MD) and fractional anisotropy (FA) of normal appearing white matter (NAWM) were derived from the contralesional hemisphere. Wilcoxon rank sum, Spearman correlation, and Fisher’s exact tests were used at p-value <0.05, as appropriate.

Results:
Women comprised 41.1% of this AIS cohort, and as compared to men, they were older (68 vs. 62.8 years, p = 0.002), had higher prevalence of atrial fibrillation (21.5% vs. 12.4%, p = 0.04), and less tobacco use (21.1% vs. 36.3%, p = 0.03). There was no statistically significant difference between men and women in admission stroke severity, TOAST stroke subtype distribution, DWIv or WMHv. However, women were significantly less likely to have a favorable outcome (mRS <2), as compared to men (53.7% vs. 68.5%, p = 0.01). Both FA (ρ -0.18, p=0.04) and MD (ρ 0.28, p=0.002) values in NAWM correlated with follow-up mRS in women, but only MD (ρ 0.26, p=0.0004) in men.

Conclusion:
Despite no differences in admission NIHSS, acute infarct size, WMH burden or stroke subtype, women with AIS had significantly worse post-stroke

outcomes in our cohort. Our findings suggest that microstructural integrity, as assessed by NAWM diffusivity anisotropy measurements, may represent a neuroimaging correlate of worse outcomes in women. The correlation between markers of white matter microstructural integrity and long-term mRS provides insight into the underlying mechanisms of disease that may influence functional recovery after stroke.
Abstract TMP23: Intravenous Thrombolysis in Unknown-onset Stroke
Authors: Dorado Laura , Ahmed Niaz , Thomalla Götz , Lozano Manuel , Malojcic Branko , Wani Mushtaq , Millán Mònica , Tomek Ales , Dávalos Antoni
Published: June 2021

Background and Purpose:
Unknown onset (UKO) stroke patients are at present excluded from thrombolytic therapy thrombolysis according to approval criteria and guideline recommendations. However, a number of them might benefit from the treatment. We aim to study the safety and efficacy of intravenous (IV) tissue plasminogen activator (tPA) in ischemic stroke patients with UKO of symptoms compared to those treated within 4.5 hours in a large cohort.

Methods:
Data were analyzed from 47,237 patients with acute ischemic stroke receiving IV-tPA in hospitals participating in the SITS International Stroke Thrombolysis Registry between 2010 and 2014. Two groups were defined: 1) patients with UKO, (n=502) and 2) patients treated within 4.5 hours of stroke onset, (n=44,875). Outcome measures were symptomatic intracerebral haemorrhage (SICH)-SITS, mortality at 3 months and functional independency as a score in the modified Rankin Scale (mRS) of 0-2 at 3 months.

Results:
Patients in UKO group were older (74 [65-82] vs. 72 [62-79] years, p<0.001), and had more severe stroke at baseline as measured by NIH Stroke Scale (12 [7-18] vs. 11 [6-17], p<0.001) than ≤4.5h. SICH-SITS occurred in 2.7% vs. 1.6% (p=0.052). At 3 months, mortality was higher (22%vs.16.9%, p=0.01) and functional independency was lower (46.8% vs. 56.2%, p<0.001) in the UKO group than ≤4.5h. In the multivariate analysis, these differences disappeared after adjustment baseline imbalances; SICH-SITS (OR0.98; 95% CI [0.43-2.21], p=0.962), mortality (OR0.88; 95% CI [0.64-1.20], p=0.435) and functional independency (OR 0.71; 95% CI [0.48-1.04], p=0.083).

Conclusions:
Our data suggest no excess risk of SICH in patients with UKO stroke treated with tPA and similar rate of functional independency and mortality than patients treated within 4.5 hours.
Abstract TMP28: Aging Predicts Levels of Antiangiogenic Factors and Stroke in Intracranial Atherosclerosis
Authors: Gonzalez Nestor R , Kurth Florian , Liou Raymond J , Song Shlee , Alexander Michael J , Schievink Wouter , Schiraldi Michael , Saver Jeffrey
Published: June 2021

Introduction:
Stroke risk more than doubles each decade after the age of 55. In patients with intracranial atherosclerosis (ICAS), the SAMMPRIS study showed that individuals 60 years or older had a higher risk of recurrent stroke or death (17%) than younger patients (12%) despite intensive medical management (IMM). In prior studies, an antiangiogenic profile has been associated with higher rates of failure to IMM in stroke. The purpose of this study is to evaluate the hypothesis that aging is an independent predictor of higher circulating levels of antiangiogenic factors endostatin and angiostatin in ICAS.

Methods:
Prospective observational longitudinal study of circulating angiogenic factors in 74 patients with ICAS treated medically. Patients with ICAS greater than 70% had angiostatin and endostatin measured in duplicate via ELISA at baseline and were followed for 6 months. Mixed model analysis was performed for the outcome variables endostatin and angiostatin. Predictor variables included age, gender, smoking history, hypertension (HTN), hyperlipidemia (HLD), Diabetes 2, obesity, coronary artery disease (CAD) and peripheral artery disease (PAD). Classification and regression tree (CART) analysis were used to select the threshold age for the longitudinal model.

Results:
Age was a significant independent predictor of higher levels of endostatin (p=0.002) and angiostatin (p<0.001). Age older than 52 was significantly associated with higher levels of endostatin (p=0.03), and age older than 70 with higher levels of angiostatin (p=0.005). Additional significant factors associated with higher levels of antiangiogenic circulating factors included PAD, HTN, HLD, and obesity.

Conclusion:
Aging is a significant independent predictor of elevated antiangiogenic circulating factors, which are associated to failure to IMM in ICAS. Antiangiogenesis can potentially represent a common path for multimorbidity of advanced age.
Abstract TMP34: The Challenge and Yield of Racially and Ethnically Diverse Patient Populations in Low Event-Rate Clinical Trials
Authors: Sheffet Alice J , Sam Albert , Jamil Zafar , Weaver Fred , Chiu David , Voeks Jenifer , Howard Virginia J , Tom MeeLee , Hughes Susan E , Flaxman Linda , Longbottom Mary E , Brott Thomas G
Published: June 2021

Background:
Concern for underrepresentation of minorities in clinical trials has focused on enrollment proportions and generalizability. The interplay of trial event-rates with diversity has not been emphasized.

Methods:
The Carotid Revascularization Endarterectomy vs Stent Trial (CREST) randomized 2502 patients and compared them by race, ethnicity, baseline characteristics, and primary outcome (any peri-procedural stroke, death or MI and subsequent ipsilateral stroke up to 10 years); those with unknown race or ethnicity were excluded. Proportional hazards models adjusting for age, sex, symptomatic status and treatment were used to test for a treatment by race/ethnicity interaction.

Results:
One-hundred-nine patients (4.4%) were black, 32 (1.3%) Asian, 2332 (93.4%) white, 11 (0.4%) other by self-report, and 18 (0.7%) unknown; 90 (3.6%) were Hispanic, 2377 (95%) non-Hispanic, and 35 (1.4%) unknown. Compared to whites, racial minorities were younger (mean age 67±8.9 vs 69±8.8, p=0.004), more often female (44% vs 34%, p=0.01), symptomatic (63 vs 52%, p=0.01), and diabetic (51% vs 29%, p<0.0001), but less often dyslipidemic (76% vs 85%, p=0.004), current smokers (19% vs 27%, p=0.04), or had a history of cardiovascular disease (34% vs 46%, p=0.007). Hispanics were more often diabetic (48% vs 30%, p=0.0002). The rate of the primary endpoint was 10.9%±0.9% at 10 years, and did not differ by race or ethnicity (p
inter
>0.24). In the context of this low rate, even if minority recruitment were increased to represent 50% of study participants, and if the treatment difference in one race were a greater hazard of HR = 1.49 (anticipated alternative hypothesis), then the hazard ratio in the other group would need to be <0.73, or >3.31, to have 90% power of detection.

Conclusions:
The proportion of racial and ethnicity participation in CREST was suboptimal at < 10%. Primary outcomes did not differ by minority or ethnic status. However, in low event-rate trials very high and even unrealistic enrollment goals for diversity, for example ≥50%, may still be insufficient for detection of outcome differences by race or ethnicity.