bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP101: Relationship Between RNF213 p.R4810K (c.14429G>A) Variant and Anatomical Variations of the Circle of Willis
Authors: Eto Futoshi , Yoshimoto Takeshi , Okazaki Shuhei , Fukuma Kazuki , Saito Satoshi , Washida Kazuo , Koga Masatoshi , Toyoda Kazunori , Ihara Masafumi
Published: January 2019

Background and purpose:
RING finger protein 213 (
RNF213
) gene is strongly associated with intracranial arterial stenosis as well as Moyamoya disease and its dysregulation is known to impair cerebral perfusion in rodents. We thus investigated the relationship between
RNF213
p.R4810K (c.14429G>A) variant and the anatomical variations of the circle of Willis in cerebrovascular disease.

Methods:
We consecutively enrolled non-cardioembolic stroke or transient ischemic attack patients with (n = 20) or without (n = 80)
RNF213
p.R4810K (c.14429G>A) variation from those who participated in the biobank of our Institute over the past 2 years. Moyamoya disease cases were excluded. We evaluated anatomical variations of the vessels constituting the circle of the Willis, namely, intracranial internal carotid artery, anterior communicating artery (AcomA), anterior cerebral artery A1 segment, posterior communicating artery (PcomA), posterior cerebral artery P1 segment, and middle cerebral artery M1 segment, using maximum intensity projection of a time-of-flight magnetic resonance angiography collected at 3 Tesla.

Results:
The
RNF213
p.R4810K (c.14429G>A) variant carrier had higher frequency of focal narrowing of the M1 segment compared to the non-carrier (50% vs 10%, p<0.01) and an absence of AcomA (15% vs 3.7%, p=0.09). By contrast, unexpectedly, unilateral or bilateral absence of PcomA was significantly less frequent (25% vs 61%, p<0.01). Multivariate analysis adjusted for age and sex showed that the variant carrier state was independently associated with unilateral or bilateral presence of PcomA (odds ratio (OR) 4.44, 95% confidence interval (CI) 1.01 - 20.6, p<0.05) and focal M1 narrowing (OR 3.30, 95% CI 0.82 - 12.6, p=0.09).

Conclusions:
The
RNF
213 p.R4810K (c.14429G>A) variant carrier showed higher frequency of arteriopathy in the anterior circulation accompanied by higher patency rate of PcomA. In the variant carrier, dysplasia of the anterior circulation arteries may lead to compensatory collateral flow from posterior to anterior circulation through PcomA.
Abstract TMP114: Exploring the Role of Cognitive Function in Secondary Stroke Prevention: Evidence from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) Study
Authors: Kudrin Bertina , Goldmann Emily , Roberts Eric T , Parikh Nina S , Appleton Noa , Boden-Albala Bernadette
Published: January 2019

Studies suggest that cognitive impairment is common, even following mild stroke. Yet, secondary prevention strategies typically do not take into account patients’ cognitive functioning. Data from DESERVE, a secondary stroke prevention trial, were used to investigate relationships between cognition 6 months post-stroke and changes in medication adherence (MA) and total cholesterol (TC) between baseline and 12-month follow-up among mild/moderate stroke and TIA patients. Patients with any documented history of cognitive impairment and those unable to provide informed consent were excluded from the study. At six months, cognition was measured using three cognitively focused variables from the Stroke Impact Scale: Concentration, Remember Things Told to You (‘Memory’) and Orientation in Time. Items were scored from 1 to 5, with 1-3 = severe impairment, 4 = mild impairment, and 5 = no impairment. MA was measured using the 8-item Morisky Medication Adherence Scale. ANCOVA models were used to analyze associations between cognition and changes in MA and TC, and association between MA and TC, adjusting for key socio-demographic and clinical characteristics and intervention status. The analytic sample (n=396) was 48% male, 27% white, 32% black, 35% Hispanic, with mean age 64. Impairment in Memory was 13.4% severe, 13.6% mild, 44.7% none. In fully adjusted models, patients who were severely impaired in Memory, showed less improvement in MA compared to mild and no impairment: 0.3 vs. 0.2 vs 1.3 points (p<0.001, n=275), respectively. There was a U-shape trend relationship between cognitive status and cholesterol change, with no impairment performing best, mild performing worst, and moderate in between (decreases of 27.6 vs 13.1 vs 30.7 mg/dl; p=0.104, n=278 in Memory). The other cognitive domains showed similar relationships in both MA and TC. Cognition was thus related to MA, and MA in turn directly related to TC (b=-7.5, p<0.001, n=223). This is one of the first studies to identify post-stroke cognitive impairment as a potential barrier to effective secondary stroke prevention.
Abstract TMP117: Relationship of Cerebral White Matter Hyperintensity Progression and Leukocyte Activation
Authors: Jickling Glen , Ander Bradley P , Zhan Xinhua , Stamova Boryana , Hull Heather , DeCarli Charlie , Sharp Frank R
Published: January 2019

Background:
Cerebral white matter hyperintensities (WMH) are an important contributor to injury in the aging brain. Progression in WMH volume is associated with cognitive decline and gait impairment. Understanding the factors associated with WMH progression may provide insight to pathogenesis and identify novel treatment targets to improve cognitive health.

Methods:
In 60 patients assessed for a cognitive complaint, an MRI brain was obtained at baseline and then repeated at a median of 5.9 years (IQR 3.5-8.2 years) from start of study. WMH was measured by semi-automated segmentation protocol and rate of progression per year determined. A blood sample was acquired at baseline in a PAXgene tube and used to measure whole genome RNA expression by RNA sequencing. The relationship between rate of WMH progression over time and leukocyte RNA expression was analyzed.

Results:
The mean age was 76.1 (SD 8.3) years and 61% of participants were female. The median rate of WMH progression over 5.8 years was 1.3 mm
3
/year (IQR 0.27-3.3mm
3
/year). The median WMH volume was 5.5 mL (IQR 2.2-14.2). Patients in the quartile with the highest rate of WMH progression had increased leukocyte expression of genes involved in pattern recognition receptors (INFK, NLRP3, OAS1, TGFB1), interferon signaling (IFI6, IFIT1, IFITM3), and leukocyte extravasation (CLDN5, ICAM1, ITGB3, NCF1, TIMP2). A gene model could predict patients likely to experience a high rate of WMH progression over time with >80% accuracy. This remained significant when adjusted for factors associated with WMH progression.

Conclusions:
Progression of WMH over time is associated with increased expression of genes involved in leukocyte extravasation, pattern recognition receptor activation and interferon signaling. Patients at risk for WMH progression may be identified by leukocyte RNA expression. Further studies are needed to evaluate the role of peripheral inflammation in relation to rate of WMH progression and contribution to cognitive decline.
Abstract TMP19: Mobile Stroke Units have Higher Rates of Recanalization of Emergent Large Vessel Occlusion
Authors: Kerrigan Deborah , Di Lorenzo Rodica , Nour May , Russman Andrew , Uchino Ken , Hussain Muhammad S
Published: January 2019

Introduction:
Emergent Large Vessel Occlusion (ELVO) has low recanalization rates with intravenous tissue plasminogen activator (IV tPA). Ultra-early treatment with IV tPA, however, may lead to higher recanalization rates. Mobile stroke units (MSUs) have been shown to reduce treatment times. We compared the recanalization rates of ELVO patients treated on our MSUs against those treated in the traditional emergency department (ED) setting.

Methods:
We reviewed patients from two MSU programs who were identified to have ELVO treated either in the ED or on the MSU from August 2014 to July 2017. Demographics, imaging characteristics, times to treatment, and recanalization rates were collected and analyzed. Statistical comparison was performed utilizing chi-squared and t-tests.

Results:
One hundred ninety (34 treated on MSU, 156 treated in the ED) ELVO patients were included in the analysis. Baseline characteristics including age (70 years MSU vs. 66 years in ED); sex (MSU 50% female vs. ED 46.8% female) and vessel occlusion location (ICA: MSU 23.5% vs. ED 25.2%; MCA: MSU 67.6% vs. ED 66.9%) were similar between the two groups. However, the MSU group had a higher initial median National Institutes of Health Stroke Scale (NIHSS) score (15.5 vs. 11.6; p = 0.01). The MSU group also had a shorter time from stroke onset to treatment (70 minutes vs. 126 minutes; p = 0.001). Recanalization of ELVO was seen more frequently on the MSU as compared to in the ED (29.4% vs. 22%; p=0.04).

Conclusion:
Higher recanalization rate of ELVO was observed with thrombolysis on mobile stroke units as compared to the emergency department.
Abstract TMP31: Mir363 Treatment Improves Depressive-Like Behavioral Phenotype and Rescues Retrograde Degeneration of Meso-Striatal Projections in Middle-Aged Female Rats
Authors: Panta Aditya , Pandey Sivani , Duncan Irma N , Duhamel Shaelynn , Sohrabji Farida
Published: January 2019

Introduction:
Stroke survivors suffer from long-term physical, cognitive and affective disabilities. Post-stroke depression (PSD), which develops in over one-third of the survivors, disproportionately affects women. Conventional anti-depressant therapies are not as effective in this population of PSD patients.

Hypothesis:
Mir363-3p treatment after stroke will preserve the meso-striatal ‘reward’ pathway in the ischemic hemisphere, and consequently improve chronic development of PSD.

Methods:
Middle-aged SD female rats (12 months) were subjected to ischemic stroke using a vasoconstrictor, Endothelin-1, and randomly assigned to one of two treatment groups: scrambled oligos or mir363-3p mimic. T Maze cost/benefit task (TMCBT), Social Interaction (SI) and Forced Swim Test (FST) were performed up to 100 days after stroke to assess depressive-like behavior. Thereafter, rats were injected with Fluorogold (Flg) into the left and right striatum. Four days later, rats were overdosed with anesthetic, perfused with saline and formaldehyde and the brain removed for cryosectioning. Flg-labeled cells in the VTA and SNc were counted in both hemispheres, using fluorescent illumination.

Results:
After stroke, there was a reduction of high-reward choice (anhedonia) at 98d in the TMCBT in the scrambled group as compared to the mir363-3p group (p=0.0343). SI at 100d decreased 3 fold from the baseline for scrambled group (p=0.0002), but not the mir363-3p group. Similarly, FST at 100d showed significant increase in immobility (helplessness) from baseline for the scrambled group (p=0.0030), but not the mir363-3p group. Neurotrophin levels measured at 3+ months after stroke indicated that circulating BDNF were lower in the scrambled group as compared to Mir363-3p group (p=0.0170). This decrease in BNDF was also accompanied by a reduction in the number of retrogradely-labeled cells in the SNc and VTA in scrambled group. (p=0.022; ischemic Vs non ischemic hemisphere).

Conclusions:
Our previous work shows that mir363-3p treatment given 4h after stroke reduces infarct volume in the acute phase (5days). The current studies show that post-stroke mir363-3p treatment improves long-term stroke disability (3+ months) by improving depressive-like behavior.
Abstract TMP51: Pre-existing Atherosclerotic Risk Factors Increase Short-Term Ischemic Stroke Risk After Traumatic Head or Neck Injury
Authors: Feferman Helayne R , Fullerton Heather J , Numis Adam , Hills Nancy K , Vinson David R , Sidney Stephen , Fox Christine K
Published: January 2019

Introduction:
Trauma is an established risk factor for ischemic stroke in the young. We speculated that atherosclerotic disease, increasingly prevalent at younger ages, could predispose to dissection or artery-to-artery embolism after trauma. In a cohort of young patients with head or neck trauma, we aimed to measure the association of atherosclerotic risk factors with short-term ischemic stroke risk.

Methods:
Nested case-control study of patients (birth to 50 years old) with head or neck trauma while enrolled in a population-based Northern California integrated healthcare delivery system, 1997-2011. Within the trauma cohort, we identified ischemic stroke ICD-9 codes within 4 weeks of head or neck injury. A panel of neurologists reviewed charts to confirm cases of arterial ischemic stroke and determine whether stroke was attributed to trauma. Three controls per case were randomly identified from the trauma cohort. Atherosclerotic risk factors were abstracted from charts only when documented prior to trauma. We compared cases to controls using logistic regression.

Results:
The trauma cohort included 120,494 emergency encounters or hospital admissions for head or neck injury over the 15-year study period. We confirmed 45 cases of arterial ischemic stroke attributed to trauma and randomly identified 135 stroke-free controls for comparison. Stroke risk was not associated with sex or race/ethnicity, but was age-related: for each decade older, stroke risk increased 70% (OR 1.7, 95% CI 1.4-2.2). Other pre-existing atherosclerotic risk factors also increased stroke risk. Cases were more likely than controls to have atherosclerotic risk factors documented in the medical record prior to trauma, including hypertension, diabetes mellitus, elevated cholesterol, and history of smoking (Table).

Conclusions:
Pre-existing atherosclerotic risk factors appear to increase short-term ischemic stroke risk after head or neck injury.
Abstract TMP52: Basilar Artery Tortuosity and Elongation and Risk of Ischemic Stroke and Death: The Northern Manhattan Study
Authors: Salehi Omran Setareh , Elkind Mitchell S , Alperin Noam , Bagci Ahmet , Guerrero Daysi , Rundek Tatjana , Sacco Ralph L , Wright Clinton B , Gutierrez Jose
Published: January 2019

Background:
Basilar artery (BA) dolichoectasia is defined as dilatation, tortuosity, and/or elongation of the basilar artery. Hospital-based studies have demonstrated an association between BA dilatation and risk of death and stroke. We hypothesized that BA tortuosity and elongation increase risk of death and stroke independent of BA dilatation.

Methods:
We included stroke-free participants in the Northern Manhattan Study, a population-based prospective cohort study, with an available time of flight MRA. BA tortuosity was defined as BA localization lateral to margin of the clivus, and BA elongation as BA tip distal to margin of the sella. BA diameters were obtained with semi-automated in-house software. Primary outcomes were any death and ischemic stroke. Cox proportional hazards models were used to obtain hazards ratios [HR] and 95% confidence intervals [CI] after adjusting for demographics and vascular risks.

Results:
Participants (N=1032, mean age 70.7 years, 39.5% men, 65.7% Hispanic) were followed on average for 10.4 ± 3.1 years after their MRA. Among these, 97 (9.4%) had BA tortuosity, 294 (28.5%) had BA elongation, and 98 (9.5%) had both tortuosity and elongation. Participants with BA tortuosity were more likely men, and participants with BA elongation were older, more likely women, non-Hispanic white and were more likely hypertensive. There was no association between BA tortuosity (HR 0.89; 95% CI 0.73 – 1.09, P=0.27), BA elongation (HR 1.12; 0.96 – 1.31, P=0.14), or BA dilatation (HR 1.03; 95% CI 0.84 – 1.27, P=0.76) and risk of death. There was an interaction between BA tortuosity and elongation (P for interaction=0.02); BA elongation was associated with an increased risk of death only among those with BA tortuosity (HR 2.06; 1.29 – 3.29; P=0.002). Adjusting for BA dilatation attenuated the association (HR 1.66; 0.99 – 2.81, P=0.05). We found no association between BA tortuosity (HR 0.92; 95% CI 0.77 – 1.10) or elongation (HR 1.07; 95% CI 0.92 – 1.23), or their combination, and ischemic stroke.

Conclusion:
Stroke-free individuals with both basilar elongation and tortuosity may have a higher risk of death, but not stroke. Further studies of vasculopathy seen in dolichoectasia and its relationship to systemic vascular disease and mortality are warranted.
Abstract TMP53: Mexican Americans and Non-Hispanic Whites Have Different Prestroke Comorbidity Profiles: Results From the Brain Attack Surveillance in Corpus Christi Project
Authors: Jiang Xiaqing , Cigolle Christine T , Morgenstern Lewis B , Sánchez Brisa N , Claflin Edward S , Lisabeth Lynda D
Published: January 2019

Introduction:
Multiple comorbid conditions (MCC) explain variation in stroke outcomes beyond the damage caused by the stroke. Mexican Americans (MAs) and non-Hispanic Whites (NHWs) may have a different spectrum and severity of MCC, which may contribute to ethnic differences in stroke outcomes. We sought to determine the clustering of MCC in ischemic stroke patients as well as ethnic differences.

Methods:
MA and NHWs with ischemic stroke (2008-2017) from the Brain Attack Surveillance in Corpus Christi Project were studied. Twenty-two prestroke comorbidities (prevalence >1%) were identified using ICD codes and medical records from acute hospitalizations. Latent class analysis was used to identify comorbidity clusters (class). Multinomial logistic regression was used to assess age-adjusted ethnic differences in class membership.

Results:
Of 1,670 patients, 49% were male, 68% were MA, mean age was 69 (SD=13). MAs were younger, more likely to be obese, and have hypertension, diabetes, and renal and liver failure, but less likely to have arrhythmia and chronic pulmonary disease. Three latent classes were identified (Figure). Class 1 had a high prevalence of uncomplicated hypertension and diabetes but low prevalence of other comorbidities. Class 2 and 3 had similarly higher prevalence for most comorbidities, except that the prevalence of renal failure, and complicated hypertension and diabetes in Class 2 and arrhythmia in Class 3 were relatively higher. Compared with NHWs, MAs were more likely to be in Class 1 (OR 1.72, 95%CI: 1.15-2.56) and Class 2 (OR 2.18, 95%CI: 1.63-3.10) versus Class 3.

Conclusion:
Distinct MCC clusters, patterned by ethnicity, were identified. Efforts to target specific minority populations to reduce stroke disparities may benefit from addressing the ethnic-specific MCC clusters.
Abstract TMP57: Racial Disparities in Recurrent Stroke Rates: Preliminary Results From the Greater Cincinnati/Northern Kentucky Population in 2015
Authors: Kleindorfer Dawn O , Sucharew Heidi , Alwell Kathleen , Moomaw Charles J , Woo Daniel , Ferioli Simona , Flaherty Matthew L , Mackey Jason , De Los Rios La Rosa Felipe , Demel Stacie , Jasne Adam , Walsh Kyle , Star Michael , Slavin Sabreena , Kissela Brett M
Published: January 2019

Introduction:
The REGARDS study previously reported a lack of racial disparity in recurrent ischemic stroke (IS) events, despite large racial differences in incident IS. We sought to evaluate recurrent stroke rates at 1 year after an index ischemic (IS) or hemorrhagic (ICH and SAH) stroke or TIA within a large, biracial population representative of the US in terms of % blacks and sociodemographics with a large number of index events

Methods:
The Greater Cincinnati/Northern Kentucky Stroke Study ascertained all hospitalized strokes and TIAs among residents of a 5-county population of 1.3 million in 7/1/14-12/31/14 (blacks only) and 2015 (all residents), as well as recurrent strokes (but not TIAs) in 2016. One year risk of recurrent stroke was estimated by Kaplan-Meier analysis. Association between recurrent stroke and demographics/risk factors was assessed by proportional hazards analysis.

Results:
Among the 2014-15 cases, there were 3883 index events (2512 IS, 374 ICH, 92 SAH, 900 TIA, 5 unknown type). Median age was 70 (IQR 59, 81); 27% were black and 54% female. Recurrent events within 12 months of the index event occurred in 319 patients (276 IS, 38 ICH, 5 SAH). Those with recurrence were more likely black than those without (34% vs 27%, p<0.01). No differences between those with recurrence and those without was seen for age at index event (median 70 vs 70, p=0.33) or sex (female 56% vs 54%, p=0.44). One-year risk of recurrent stroke was 9.3% overall (11.3% black, 8.6% white); 10.0% after index IS, 11.2% for ICH/SAH, 7.2% after TIA. Hazard ratio for risk of recurrent stroke for blacks compared with whites, adjusted for age and sex, was 1.38 (95% CI 1.09, 1.75).

Discussion:
The risk of recurrent stroke was significantly associated with index event type and stroke risk factors (hypertension, diabetes, smoking, and prior stroke). Black race was not a significant independent predictor of recurrent stroke after adjusting for other known stroke risk factors.
Abstract TMP6: NIH Stroke Scale as the Primary Outcome Measure for Trials of Acute Treatment of Ischemic Stroke
Authors: Chalos Vicky , van der Ende Nadinda , Lingsma Hester F , Mulder Maxim J , Venema Esmee , Dijkland Simone A , Berkhemer Olvert A , Yoo Albert , Broderick Jospeh P , Palesch Yuko Y , Yeatts Sharon D , Roos Yvo B , van Oostenbrugge Robert J , van Zwam Wim , Majoie Charles B , Van der Lugt Aad , Roozenbeek Bob , Dippel Diederik W ,   MR CLEAN investigators
Published: January 2019

Background:
The 90-day modified Rankin Scale (mRS) is the most commonly used primary outcome measure in stroke treatment trials, but has drawbacks, including the potential loss of subjects due to prolonged follow-up. An alternative may be the NIH Stroke Scale (NIHSS) early after stroke, which is frequently used as a secondary outcome measure. The aim of this study was to evaluate whether the NIHSS assessed within one week after trial inclusion could serve as a primary outcome measure for trials of acute ischaemic stroke treatment.

Methods:
We used the Prentice criteria to evaluate NIHSS 1 day and 5-7 days after trial inclusion as primary outcome measures in two trials of endovascular treatment (EVT): the positive MR CLEAN and the neutral IMS III. The four Prentice criteria evaluate a surrogate endpoint against a true endpoint (Figure). We adjusted for age, baseline NIHSS, collateral score, and time of symptom onset to randomization.

Results:
The Prentice criteria were met for NIHSS at 1 day and 5-7 days in MR CLEAN (n=500). We found a significant treatment effect of EVT on the mRS and on the NIHSS at 1 day and 5-7 days. After adjustment for NIHSS at 1 day and 5-7 days, the effect of EVT on mRS decreased from common odds ratio 1·69 (95%CI: 1·22-2·33) to respectively 1·33 (95%CI: 0·95-1·85) and 1·21 (95%CI: 0·86-1·72). In IMS III (n=656) there was no treatment effect on NIHSS at 1 day (p=0.56) and 5-7 days (p=0.28), coinciding with the absence of a treatment effect on mRS.

Conclusion:
NIHSS is able to replace the mRS at 90 days as a measure of treatment effect. NIHSS within one week after trial inclusion may be used as a primary outcome measure in trials of acute ischemic stroke treatment, particularly in phase II(b) trials. This could minimize loss to follow-up, and reduce trial duration and costs.
Abstract TMP69: The Use of Oral Anticoagulants in Patients With Atrial Fibrillation in the Emergency Department
Authors: Hua Hope , Sur Nicole , Choi Jungwon A , Polineni Sai P , Lee Lilly C , Chaturvedi Seemant
Published: January 2019

Background:
Atrial Fibrillation (AF) is the leading cause of embolic stroke and is associated with a 5-fold increased risk of stroke. Currently, less than 50% of high-risk patients are receiving a prescription for oral anticoagulants (OACs). Guidelines for Primary Prevention of Stroke recommend the emergency department (ED) as an important location for physicians to identify patients with AF and start them on OACs.

Methods:
A retrospective review was completed of AF patients in the ED from 2014-2018 at a large health system. The prevalence of OAC prescription was identified in three different cohorts: 1) patients discharged from the ED, 2) those admitted under observation status and discharged within 48 hours, and 3) those admitted to inpatient. CHA
2
D
2
-VASc scores were calculated and risk factors were reviewed.

Results:
We identified 438 patients: 106 in the ED cohort, 132 in the observation cohort and 200 in the inpatient cohort. The average age was 63.1. 77.9% had hypertension and 46.35% were women. The average CHA
2
D
2
-VASc score was 2.45 in the ED cohort, 2.56 in the observation cohort and 3.35 in the inpatient cohort. ED physicians addressed AF in 77% of the ED cohort. Out of the high-risk patients (CHA
2
D
2
-VASc score ≥ 2) discharged from the ED, 17% were newly prescribed an OAC compared to 74% of patients who were admitted under observation status and 78% of patients admitted to inpatient. (7/40 [17.5%] vs 39/53 [73.6%]; p<.0001 and 83/107 [77.6%]; p<.0001) Direct OACs were more commonly prescribed over Warfarin across all three groups. (92.3% in ED, 88.5% in observation, 82.5% in inpatient).

Conclusions:
Patients with AF are more likely to be prescribed an OAC if admitted to inpatient or under observation status compared to the ED. There were many missed opportunities in the ED to start patients on OACs. Further studies should identify barriers to OAC prescription in the ED to implement better practice strategies.
Abstract TMP73: The Community Engagement for Early Recognition and Immediate Action in Stroke (CEERIAS) Study: Primary Results
Authors: Prabhakaran Shyam , Kwon Soyang , Wymore Erin , Song Sarah Y , Brown Jen , Mason Maryann , Kandula Namratha , Jones Peggy , Eisenstein Amy , Beckstrom Heather , Richards Christopher T , Washington Knitasha V , Aggarwal Neelum T
Published: January 2019

Introduction:
Early hospital arrival after stroke increases access to proven treatments and improves outcomes. We hypothesized that a community-engaged stroke preparedness intervention to overcome barriers to early activation of 9-1-1 would increase early hospital arrival and emergency medical services (EMS) use after stroke in high-risk neighborhoods in Chicago.

Methods:
We partnered with stakeholders in a South Side Chicago community with a high stroke incidence and in close proximity to a primary stroke center to develop a community stroke preparedness intervention. The intervention was delivered by “stroke promoters”, trained lay persons from the target neighborhood who utilized in-person discussions to overcome barriers and obtain stroke preparedness pledges as measured by “Pacts to Act FAST”. We applied an interrupted time-series analysis at the target hospital to study the effects of the intervention on EMS utilization and hospital arrival within 3 hours of symptom onset among patients with confirmed ischemic stroke. We compared these results to 6 North Side Chicago stroke centers and 17 St. Louis stroke centers as concurrent controls.

Results:
During a 12-month period, 242 stroke promoters distributed >110,000 educational materials, participated in 167 community events, and registered 39,975 Pacts to Act FAST, reaching 19.4% of residents in the target South Side neighborhoods. Early arrival increased (0.5%/month post-intervention; p=0.124 for slope change) at the target hospital but was not different compared to North Side hospitals (p=0.560) or St. Louis hospitals (p=0.072). The effect on early arrival was significant among patients <66 years old (0.8%/month increase; p=0.036), men (1.2%/month increase; p=0.026), and African-Americans (0.9%/month increase; p=0.037). No effect was observed on EMS use.

Conclusions:
Using a community-engaged approach to deliver a stroke preparedness intervention in Chicago, we observed a modest increase in early hospital arrival after confirmed stroke, which was more pronounced in younger, male, and African-Americans patients. Future efforts should consider improving message penetration and sustainability using novel personal approaches such as social media.
Abstract TMP76: Direct Assessment of Health Utilities Among Patients With Intracerebral Hemorrhage Using the Standard Gamble Method
Authors: Slaughter Kristen B , Bambhroliya Arvind B , Meeks Jennifer R , Ahmed Wamda O , Bowry Ritvij , Behrouz Reza , Mir Osman , Begley Charles E , Tyson Jon E , Miller Charles C , Warach Steven J , McCullough Louise D , Savitz Sean I , Vahidy Farhaan S
Published: January 2019

Introduction:
EuroQoL-5 Dimension (EQ-5D) is a validated albeit indirect method to derive health utilities (HU). Conversely, Standard Gamble (SG) directly measures patients’ valuation of their health state. We compare in-hospital and day-90 SG Utilities (SGU) among intracerebral hemorrhage (ICH) patients and report a three-way association between SGU, EQ-5D and mRS at day-90.

Methods:
Primary ICH patients were enrolled in a multisite cohort and underwent in-hospital and day-90 assessments for the mRS, EQ-5D, and SG. SG entails providing patients a choice between their current health state and a hypothetical treatment (a pill) with varying chances of either perfect health or a painless death. Higher SGU (scale 0 - 1) indicates a lower risk-tolerance for death; thus, a higher valuation of one’s health state. Median and interquartile range (IQR) are reported. Logistic regression was used to estimate the likelihood of low SGU (≤ 0.6) and Wilcoxson paired signed rank test compared in-hospital and day-90 SGU.

Results:
In-hospital and day-90 SG was obtained from 381 and 280 patients respectively (including 236 paired observations). Median (IQR) in-hospital and day-90SGU were 0.85 (0.40-0.98) and 0.98 (0.75-1.00) (p < 0.001). In-hospital SGU were lower with advancing age (p = 0.007), with higher NIHSS and ICH scores (p < 0.001), and with greater treatment intensity. Proxies evaluated lower SGU (p < 0.001). In the adjustedmodel, higher NIHSS and proxy assessments were independently associated with lower SGU, along with an interaction between age and SGU by race (white vs. black) (Figure). Day-90 SGU and mRS were correlated (p < 0.001), however SGU were increasinglyhigher than the EQ-5D HU at higher mRS scores (Figure).

Conclusion:
Divergence between directly and in-directly assessed HU at high levels of functional disability warrant careful prognostication of ICH outcomes, and should be considered in designing early end-of-life care discussions with families and patients.
Abstract TMP81: Long Term Well-Being in Informal Caregivers in Relation to Functional Dependency of Stroke Survivors - Observations From the Swedish Stroke Register
Authors: Sennfalt Stefan , Ullberg Teresa
Published: January 2019

Background:
Informal caregivers to stroke survivors provide a large amount of day-to-day assistance, which can put significant strain on their well-being. The aims of this study were to describe caregiver assistance, community support as well as long-term psychological well-being of caregivers in relation to degree of dependency of the stroke survivor.

Method:
Data on patients with stroke in 2011 and 2013 with a corresponding 3- and 5-year follow-up from both the stroke survivor and their informal caregiver (forming dyads) were obtained from the Swedish Stroke Register. Variables relating to caregiver assistance, community support and caregiver psychological well-being were analyzed. Psychological health was assessed using questions translated from the 36-item short-form health survey.

Results:
In total, 5063 dyads were included. The degree of survivor dependency was a strong predictor of poor psychological health in caregivers. Poor psychological well-being was present in 35.6% of caregivers of completely dependent survivors, 18.5% of the partially dependent and 9% of the independent. In a wide range of activities of daily living almost half of caregivers of completely dependent survivors provided assistance often or always. Moreover, 68% of informal caregivers to completely dependent patients were unable to leave the survivor alone for more than 3 hours and 89.6% had less time to pursue own interests. There was also a significant unmet need for caregiver support.

Conclusion:
Degree of survivor dependency was a strong predictor of poor caregiver psychological health. Survivor and caregiver health were closely interrelated and support needs to be provided to both groups.
Abstract TMP82: Rates and Predictors of Stroke Mimics Among In-Hospital Code Stroke Activations
Authors: Nguyen Ivy , Muccilli Alexandra , Ragole Thomas , Ciano Mark , Ortega Monique , Kim Anthony S
Published: January 2019

Introduction:
In-hospital strokes have a different pattern of risk factors, etiologies, and mimics than strokes that are initially evaluated in the Emergency Department. In-hospital stroke patients often have multiple confounding comorbidities which may provide alternative explanations for suspected stroke symptoms.

Objective:
To characterize strokes vs. stroke mimics among in-hospital Code Stroke activations.

Methods:
We identified all adults with an in-hospital Code Stroke activation between September 2014 and February 2018 at a single academic medical center (660 beds) and abstracted the reason for Code Stroke activation, comorbidities, primary inpatient service, patient location, NIHSS, and final diagnosis from comprehensive electronic health records. Univariate and multivariate logistic regression were used to assess the association between clinical variables and stroke mimics.

Results:
Of 461 in-hospital Code Stroke activations, the final diagnoses were 110 (24%) ischemic stroke or TIA, 35 (7.5%) intracranial hemorrhage, and 316 (68.5%) stroke mimics. Of the 85 patients with a final diagnosis of ischemic stroke, 9 (8%) received tPA and 2 underwent embolectomy (1.8%). The most common reason for Code Stroke activation was altered mental status (48%). Altered mental status (OR 0.20, 95% CI 0.10-0.39) and previously-known CNS tumor (OR 0.18, CI 0.05-0.69) were least likely to be associated with a final diagnosis of stroke. The most common stroke mimics were toxic/metabolic encephalopathy, seizure, and delirium. Limb weakness (OR 6.93, CI 3.86-12.7), recent cardiac/vascular procedure (OR 5.03, CI 1.92-8.89) and NIHSS (OR 1.09 per point, CI 1.05-1.13) were predictive of stroke in multivariate analysis.

Conclusions:
A majority of in-hospital Code Stroke activations are for stroke mimics. Altered mental status was the most common reason for Code Stroke activation, yet was least likely to be associated with a final diagnosis of stroke. While rapid recognition of stroke symptoms and timely Code Stroke activations are critical to maximizing opportunities to apply acute interventions, variability in the reasons for Code Stroke activation particularly for undifferentiated altered mental status may be a target for future optimization.
Abstract TMP88: Prevalence of Right-to-left Cardiac Shunt in the Greek Population is High and Impacts on the Interpretation of the Risk of Paradoxical Embolism (RoPE) Score
Authors: Koutroulou Ioanna , Tsivgoulis George , Tsalikakis Dimitrios , Karacostas Dimitrios , Grigoriadis Nikolaos , Karapanayiotides Theodoros
Published: January 2019

Introduction:
The RoPE score calculates the probability that patent foramen ovale (PFO) is causally related to stroke (PFO attributable fraction, PFO-af), based on PFO prevalence in patients with cryptogenic stroke compared with that in control subjects. The latter has been estimated at 25%; however, PFO prevalence in nonselected populations varies widely. Since PFO prevalence in Greeks remains unknown, we aimed to define it and to calculate PFO-af stratified by RoPE score in a cohort of patients with embolic stroke of undetermined source (ESUS).

Methods:
Right-to-left cardiac shunt (RLS) was detected according to the international consensus criteria in healthy subjects (H, n=115, women=65) and patients with ESUS (n=84, women=42) ≤55 years old. Each subject underwent unilateral middle cerebral artery transcranial Doppler (TCD) recording (Sonaratek, Natus) with a 2-MHz probe after infusion of agitated saline, at rest and after a controlled Valsalva maneuver. We characterized RLS as large (>20 microbubbles or curtain), moderate (10median) and low (≤median) RoPE score groups and calculated the corresponding PFO-af.

Results:
RLS was detected in 43.5% (50/115) of H and 50% (42/84) of ESUS. Large RLS tended to occur more often in ESUS compared to H [29.8% (25/84)] vs 18.3% (21/115); p=0.06]. The RoPE score median in patients with ESUS and RLS was 8 (interquartile range: 7,9). Patients with high RoPE score (9-10) had PFO-af of 64.4 whereas patients with low score (0-8) had PFO-af of 4.4. For any individual stratum up to RopE score 6, the PFO-af was null.

Conclusions:
The prevalence of RLS in Greeks is quite higher than the average used by the RoPE study. Despite a 50% chance of having RLS of any size, patients with ESUS have large RLS at least 60% more often than the general population. We suggest that optimal calculation of the PFO-af corresponding to RoPE score strata relies on the accurate estimation of PFO prevalence in national/ethnic populations. The proposed RoPE score cutoff of >6 for having a probable PFO-related stroke may overestimate the probability in patients deriving from populations with high RLS prevalence.
Abstract TMP93: Comparative Occurrence of Ischemic Stroke with Rhythm versus Rate Control Strategy in a National Prospective Cohort of Atrial Fibrillation
Authors: Kang Ki-woon , Kim Jae Guk , Lee Young Soo , Choi Eue-Keun , Cha Myung-Jin , Lee Jung-Myung , Kim Jin-Bae , Park Junbeom , Park Jinkyu , Kim Tae-Hoon , Uhm Jae-Sun , Shim Jaemin , Kim Jun , Park HyungWook , Kim Changsoo , Joung Boyoung
Published: January 2019

Introduction:
Comparative occurrence of ischemic stroke for rhythm versus rate control in patients with non-valvular atrial fibrillation (NVAF) has been still inconclusive. The aim of this study was to compare differences of ischemic stroke occurrence between the rhythm and rate control strategies in AF patients.

Methods:
The CODE-AF registry prospectively enrolled 6,280 consecutive patients who were treated for NVAF at 10 tertiary referral centers in South Korea. Of these, 2,513 (40.0%) NVAF patients (age, 67±10 years; male, 61.8%) were clinically followed up for 1-year and divided into rate control 1,233 (49.0%) and rhythm control 1280 (51.0%) group.

Results:
Those treated with the rhythm control group were younger, and had less proportions of underlying disease compared to those treated with the rate control strategy. After propensity score matching analysis, 1,800 of these patients was compared and analyzed between rate control and rhythm control group. Those treated with the rhythm control group were similar in the baseline characteristics including CHA
2
DS
2
-VASC score compared to those treated with the rate control strategy. The rate of oral anticoagulation, all bleeding, and hospitalization were also similarly between two groups. The incidence rate of ischemic stroke in the rhythm control group was significantly lower than rate control group (0.7 vs. 6.9 per 1000 person-years, p=0.011).

Conclusion:
In this national prospective AF cohort, the rhythm control strategy demonstrated beneficial effect to lower the risk of ischemic stroke during 1-year follow-up compared to rate control strategy.
Abstract TMP94: Oxidized Low-Density Lipoprotein and Low-Density Lipoprotein Have Combined Utility in Predicting Outcomes of Minor Stroke and TIA
Authors: Wang Anxin , Dai Liye , Zhang Nan , Meng Xia , Lin Jinxi , Zuo Yingting , Li Hao , Wang Yilong , Wang Yongjun
Published: January 2019

Objective:
To estimate the association of different combination of circulating LDL and oxLDL levels with the outcomes of acute minor ischemic stroke and transient ischemic attack (TIA).

Methods:
In the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) trial, a subgroup of 3019 patients with elevated baseline oxLDL and LDL levels were analyzed. Patients were divided into four groups according to different combination of LDL and oxLDL levels. The associations of LDL and oxLDL with prognosis of patients using multivariable Cox regression models.

Results:
Among 3019 patients included in this study, the median (interquartile range) of oxLDL, and LDL were 13.96 (6.65-28.81) ug/dL, 3.1(2.5-3.8) mmol/L, respectively. Compared with those with low LDL and oxLDL levels (LDL < 3.37mmol/L with oxLDL <13.96 ug/dL), patients with conformably high levels of LDL and oxLDL (LDL ≥3.37mmol/L , oxLDL ≥13.96 ug/dL) were associated with an increased risk of recurrent stroke at 90 days(HR,1.88; 95% CI,1.37-2.57)) and 1 year (HR,1.71; 95% CI,1.29-2.27). Neither elevated level of oxLDL or LDL increased alone showed statistical significance. Similar results were observed for poor functional outcome.

Conclusions:
Presence of both elevated oxLDL and LDL levels can predict an increased risk of recurrent stroke and poor functional outcome in minor stroke or high- risk TIA patients. The presence of both oxLDL and LDL might have a combined effect.
Abstract TMP95: Patients With Stroke Are Not Meeting American Heart Association Secondary Prevention Recommendations
Authors: Ndunda Paul M , Muutu Tabitha M
Published: January 2019

Introduction:
Stroke occurs in 795 000 people and causes 133 000 deaths every year in the US. Around 185 000 stroke survivors get recurrent attacks annually. There is a need to understand the adherence to secondary prevention measures if the AHA’s 2020 impact goal is to be achieved. Atherosclerotic cardiovascular disease risk factors remain prevalent in the US but there is limited data on the use of secondary preventive measures among patients with stroke. The objective of this study was to assess the use of secondary preventive measures in patients with stroke and assess for any gender and racial disparities in adherence.

Methods:
This study is an analysis of the 2015 Behavioral Risk Factor Surveillance System a chronic disease survey conducted by the CDC. The sample included 18 269 subjects with a history of stroke. The secondary preventive measures analyzed included: exercise, diet, smoking cessation, alcohol intake, body mass index, use of blood pressure medications in hypertensives and the use of aspirin. Gender and racial disparities were analyzed using logistic regression analysis and age, race, education, and income were adjusted for in the outcomes.

Results:
The mean age of the study cohort was 66.8 years (SD =12.1). White, black and Hispanic patients represented 75.1%, 11.5% and 4.7% respectively. Females comprised 58.3%. Comorbidities included: hypertension (73.4%), coronary heart disease (37.5%), dyslipidemia (35.7%), diabetes mellitus (30.4%) and chronic kidney disease (11.6%). Among stroke patients, 57.9% reported ever smoking and 42% of them still smoked. Only 11.3% met both the AHA aerobic and muscle strengthening exercise guidelines. Thirty six percent of stroke patients undertook more than 150 minutes of aerobic exercise and 12% did 1-149 minutes per week. Obesity/overweight was present in 69.9%. Only 59% of patients with stroke were using aspirin while among hypertensive patients, 90.7% took their blood pressure medications. There were major racial and gender disparities in smoking status, obesity, diet, BMI and use of BP medications and aspirin.

Conclusion:
Patients with stroke do not meet AHA lifestyle modification and aspirin recommendations. There are major gender and racial disparities in the use of stroke secondary preventive measures.
Abstract TMP97: Impact of Intima Media Thickness on Stroke Recurrence in Patients With Transient Ischemic Attack
Authors: Kuwashiro Takahiro , Yamashiro Takayuki , Mori Kota , Funamizu Yukihisa , Tokunaga Keisuke , Gotoh Seiji , Yasaka Masahiro , Okada Yasushi
Published: January 2019

Introduction:
Carotid stenosis lesions are a risk factor for stroke recurrence after transient ischemic attack (TIA) and are taken into consideration when determining the ABCD
3
-I score. However, few reports have examined the impact of the degree of maximum intima media thickness (max IMT) by sonographic examination on stroke recurrence.

Hypothesis:
We hypothesized that a larger max IMT would be associated with a greater risk of stroke recurrence.

Methods:
We enrolled 3,100 consecutive acute stroke patients who were hospitalized in our stroke center from June 2007 to February 2016. The clinical characteristics of patients were assessed on admission, and the clinical course of all patients was subsequently followed. Patients were divided into four groups based on the level of max IMT: I (max IMT < 1.1 mm), II (max IMT ≥ 1.1 but < 2.1 mm), III (max IMT ≥ 2.1 but < 3.1 mm), and IV (max IMT ≥ 3.1 mm). We performed multivariate cox proportional hazards analyses to determine the influence of max IMT grade in these groups on stroke recurrence.

Results:
Of all patients, 468 (295 men, 68 ± 13 years) cases with TIA were investigated in the present study. Thirty-seven patients (9.2%) suffered recurrence of ischemic stroke during the follow-up period of three months. The three-months gross recurrence rate was 7.7% in group I, 8.7% in group II, 11.4% in group III, and 28.6% in group IV. The Kaplan-Meier method revealed significantly different cumulative recurrence rates of ischemic stroke in the four groups of patients, as shown in Figure 1 (I vs. IV, p < 0.01, log-rank test). On Cox proportional analysis with adjustments for multiple confounding factors, group IV (hazard ratio: 6.17, 95% confidence interval: 1.86-8.52, p < 0.05) had a greater risk of stroke recurrence compared with group I (reference).

Conclusions:
There is a significant relationship between the level of max IMT and recurrence of ischemic stroke. TIA patients with a larger max IMT have a greater risk of stroke recurrence.
Abstract TP101: The Benefit of IV Thrombolysis in Acute Ischemic Stroke: Meta-Analysis of All Trials at the (Near) Close of the Standalone IV Lytic RCT Era
Authors: Saver Jeffrey L , Wardlaw Joanna M
Published: January 2019

Background:
After 3 decades, the era of randomized trials of intravenous thrombolysis(IVT) as a standalone therapy in acute ischemic stroke is now closing, with the completion of extension-seeking trials in elders, nondisabling deficit patients, and imaging-selected late patients, and with the advent of endovascular thrombectomy. A (near) final summary meta-analysis of RCTs of IVT versus control is merited.

Methods:
Systematic literature search to identify all RCTs of IVT vs control since 1990. Efficacy and safety endpoints analyzed using fixed-effects meta-analysis.

Results:
A total of 28 RCTs compared IV thrombolysis with control within 9h of ischemic stroke onset, enrolling 10,677 patients, including 27 RCTs (n=10,346) in patients with disabling deficits and 1 RCT (n=313) in patients with nondisabling deficits. Agents tested were tissue plasminogen activator (tPA), urokinase, streptokinase, and desmoteplase. About 3/4 of patients (n=8122) come from 17 RCTs testing IV tPA. Among patients presenting only or predominantly with disabling deficits, treatment with IV tPA yielded increased freedom from disability (mRS 0-1), relative risk (RR) 1.21 (95%CI 1.14-1.29, P <0.00001), increased functional independence (mRS 0-2), RR 1.11 (95%CI 1.05-1.17, P =0.0002), increased symptomatic intracerebral hemorrhage, RR 3.89 (95%CI 3.02-5.01, P <0.00001), and did not alter mortality, RR 1.07 (95%CI 0.95-1.20). Similar benefit was noted in the 27 trials assessing all 4 lytic drugs, e.g. increased freedom from disability (mRS 0-1): 35.1% thrombolysis, 28.8% control; RR: 1.21, 95% CI: 1.14-1.28; P <0.00001. No benefit was noted in the 1 trial for nondisabling deficits.

Conclusion:
The (near) final accumulated evidence confirms that, as a class, IV thrombolytics are beneficial for acute ischemic stroke patients with disabling deficits, and are the appropriate foundation for further advances in acute cerebral ischemia therapeutics.