bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 58: Do Ischemic Stroke Patients Treated With Thrombolysis Receive Better Quality Multidisciplinary Stroke Care Than Patients Who Do Not?
Authors: Paley Lizz , Bray Benjamin , James Martin , Campbell James , Cloud Geoffrey , Tyrrell Pippa ,   Intercollegiate Stroke Working Party, Rudd Anthony
Published: July 2021

Background:
Over recent years many stroke services have developed fast track services for stroke thrombolysis. We aimed to identity if such hyperacute provision also improved other aspects of multidisciplinary care by comparison to non-thrombolysed patients.

Methods:
Data were extracted from the national stroke register (Sentinel Stroke National Audit Programme (SSNAP)) of adults with acute ischemic stroke admitted to all hospitals in England and Wales from April 2013-March 2014. The quality of care received was compared across three groups: patients treated with IV-tPA, patients arriving at hospital within a 4h time window of onset but who were not treated with tPA, and patients who arrived outside the 4h time window and who were not treated with tPA.

Results:
Of 65 194 adults admitted with acute ischemic stroke to 194 hospitals, 8 602 (13.2%) were treated with tPA, 20 361 (31.2%) arrived within 4h of onset but were not treated with tPA, and 36 231 (55.6%) arrived outside the time window. A greater proportion of patients treated with tPA were admitted to a stroke unit within 4 hours of hospital arrival (85%) compared to those within the time window but not treated with tPA (57%) or those outside the time window (54%), Chi2 p<0.0001. A similar pattern was observed for being seen by a stroke consultant within 24 hours (92%, 72%, 72% respectively, Chi2 p<0.0001), and for the proportion of patients scanned within 12 hours (100%, 87%, 81% respectively, Chi2 p<0.0001). tPA recipients were more likely to receive a swallow assessment within 4h (83%, 64%, 60%, p<0.0001), and to be assessed by speech and language therapists with 72h (85%, 77%, 78%, p<0.0001). Smaller differences were found for occupational therapy (91%, 85%, 86%, p<0.0001) and physiotherapy assessments within 72h (97%, 93%, 94%, p<0.0001).

Conclusions:
Patients treated with tPA receive faster access to specialist stroke services, and were more likely to receive various aspects of multidisciplinary stroke care. Stroke services should ensure that all patients have rapid access to good quality multidisciplinary stroke care, not just those in receipt of thrombolysis.
Abstract 65: Timing of Complications Related to Current Post tPA Protocol
Authors: Bryant Katja , Anda Kim , Busby Leslie , Camp Deborah , Connely Kerrin , Westbrook Trish , Zimmermann Susan , Gupta Rishi ,   Georgia Stroke Professional Alliance (GA-SPA)
Published: July 2021

The current clinical practice guidelines (CPG) based on the NINDS trial from 1995 recommend that vital signs and neuro checks are completed Q15 min x 2 hrs., Q 30 min x 6 hrs., Q 1 hour x 16 hrs. post administration of IV t-PA. The half-life (t
½α
) of Alteplase is <5 min, therefore the current vigilance of neurological assessments may not be necessary. The purpose of this study was to evaluate the timing of when a symptomatic intracranial hemorrhage (sICH) occured in relation to the administration of IV t-PA.

Results:
A total of 569 patients who received IV t-PA were reviewed. Nine patients, with a mean age of 70 ± 17 years and mean NIHSS of 11, were diagnosed with a sICH within 36 hrs. post IV t-PA administration. The mean time of detecting sICH post IV t-PA administration was 294 minutes. The shortest time was 77 min and the longest time was 814 min (13 hrs and 34 min). The vast majority (77%) of the sICH complications were diagnosed in less than 6 hrs.

Conclusions:
This analysis suggests that sICH occurs early in the course after administration of IV t-PA. Future guidelines may consider reducing the neurological assessment frequency after 12 hours from IV t-PA administration. Prospective controlled studies are required to validate these results.
Abstract 73: Dysregulation of Robo-4 causes Pathological Cerebrovascular Angiogenesis in Diabetes
Authors: Abdelsaid Mohammed , Ergul Adviye
Published: July 2021

Diabetes increases the risk and exacerbates the progress of cerebral complications including stroke and cognitive impairment. Diabetic Goto-Kakizaki (GK) rats suffer loss of vascular integrity and dysfunctional cerebral-neovascularization, despite augmented vascular endothelial growth factor (VEGF). Roundabout-4 (Robo-4) is an endothelial cell (EC) specific member axon guidance molecule that regulates EC stability via inhibiting VEGF signaling but its role in cerebrovascular maturation in diabetes remained unknown. We hypothesized that increased VEGF activation in diabetes reduces Robo-4 and uncouples its protective signaling by promoting its binding to activated β-3 integrin.

Methods:
Immunohistochemistry and immunoblotting are used to assess Robo-4 expression, pericyte/EC ratio and robo-4/β-3 integrin interaction in the brain and isolated microvascular endothelial cells (BMVEC). Transfection was used to overexpress Robo-4 in BMVEC in vitro and EC migration and trans-well permeability assays were used to examine EC function. Stereotaxic injection of adenoviral construct was used for local in vivo overexpression of robo-4 and its impact on neovascularization indices (Vascular Volume (VV), Surface area (SA), Tortuosity index (TI) and Vascular density (VD) was measured using 3D confocal microscopy.

Results:
Robo-4 expression was reduced in GK brains as well as in isolated BMVEC (35%* and 39%* vs control Wistar). In vitro, over expression of Robo-4 inhibited VEGF-induced permeability (80%*) and cell migration (70%*) in BMVEC vs control. In vivo over expression of Robo-4 improved vascular integrity and maturation as indicated by reduction of all pathological neovascularization indices (VV:70%*, SA:50%*, TI:20%*, VD:50%* vs control) and increased pericyte/EC ratio (40%* vs control). GK rats showed increase interaction between VEGF-activated β-3 integrin and Robo-4. Overexpression of Robo-4 decreased this interaction (40%* vs control). (*P<0.05).

Conclusion:
Restoration of Robo-4 expression decreased pathological neovascularization and improved vessel integrity and maturation. Our results suggest that Robo-4 is a promising therapeutic target in treatment of diabetic pathological brain neovascularization.
Abstract 78: Factors Associated with Thrombotic Events During Pregnancy in the United States: NIS 2000-2010
Authors: Razmara Ali , Cen Steven , Jin Diana L , Sanossian Nerses , Towfighi Amytis
Published: July 2021

Intro:
Thrombosis risk is increased during pregnancy and puerperium. There are no recent data on nationwide trends in thrombotic events during the delivery period. Objective: To determine risk factors for thrombotic events in women hospitalized for deliveries. Methods: Data from the Nationwide Inpatient Sample (2000-2010) were used to identify deliveries. Weighted proportion of pregnancy hospitalizations with comorbid thrombotic events, including TIA, ischemic stroke, hemorrhagic stroke, acute MI, and venous thromboembolism, was determined. Poisson regression was used to identify risk factors for thrombotic events. The first multivariable model adjusted for sociodemographic and hospital factors. The second model in addition adjusted for comorbid conditions. Results: There were 4,305,561 women hospitalized for delivery (21.5 million US deliveries), of which 7,242 (0.17%) had thrombotic events in the peripartum period. From 2000-2010, there was an increase in deliveries with associated thrombotic events observed from 7.46/10K to 34.8/10K. Compared to 2000, deliveries with thromboses was 8-fold more likely in 2010 (RR 7.94, 95% CI 1.98-31.93). There was no significant difference in rates from 2000 to 2010 after adjustment for sociodemographic and hospital factors. From 2000-2010, pregnant women with thrombotic events were older, more likely to be White, to smoke, to lack insurance, to be admitted to rural hospitals, and to be admitted in the South or Midwest. After multivariable adjustment for sociodemographics, hospital factors, and comorbidities, admissions in the South (RR 1.26, 95% CI 1.02-1.55) or Midwest (1.33, 95% CI 1.05-1.68), atrial fibrillation (1.28, 95% CI 1.01-1.62), pre-/eclampsia (5.78, 95% CI 4.37-7.66), dyslipidemia (1.72, 95% CI 1.42-2.09), atrial septal defect (14.38, 95% CI 6.76-30.58), and valvular heart disease (1.67, 95% CI 1.25-2.24) were independently associated with higher risk of thrombotic events. Conclusions: From 2000-2010, there was a sizeable increase in deliveries with associated thrombosis. Identification of factors associated with thrombotic events for women hospitalized for normal pregnancies will aid in targeted interventions to screen for, prevent and treat thrombosis related to pregnancy.
Abstract 84: Where Should Interventions be Focused to Reduce the Black-white Disparity in Stroke Mortality? Insights From the Reasons For Geographic And Racial Differences In Stroke (REGARDS) Study
Authors: Howard George , Moy Claudia S , Howard Virginia J , McClure Leslie A , Kleindorfer Dawn O , Unverzagt Fredrick W , Soliman Elsayed Z , Safford Monika M , Cushman Mary , Cushman Mary , Wadley Virginia G
Published: July 2021

Introduction:
The study of racial disparities in stroke mortality should guide interventions to reduce these disparities. A higher mortality in blacks than whites could result from a higher incidence of stroke in blacks, a higher case-fatality of stroke in blacks, or both. Interventions focusing on primary prevention are needed if incidence is a major contributor to disparities, while interventions addressing treatment are a priority if case-fatality is a major contributor.

Hypothesis:
Higher stroke mortality in REGARDS will be attributable to higher incidence, higher case fatality, or both.

Methods:
29,681 black and white participants aged 45+ were followed for stroke over 7 years. Fatal stroke (stroke mortality) was defined as a stroke event with death within 30-days, incident stroke included all stroke events (regardless of death), and case-fatality as the proportion of stroke events with death within 30-days. Black-white differences in stroke mortality and stroke incidence were assessed using proportional hazards models, and case-fatality using logistic regression (with adjustment for age and sex).

Results:
There were 954 incident events with 242 deaths within 30-days. We showed higher stroke mortality in blacks, with a black-white disparity in fatal stroke at young ages (at age 45, HR = 4.35; 95% CI: 1.94-9.76), but a declining magnitude of the disparity at older ages (at age 85, HR = 0.87; 95% CI: 0.56 - 1.35). The pattern was similar for incident stroke, although the magnitude of the black-white disparity was smaller (at age 45: HR = 2.40; 95% CI: 1.72 - 3.33; at age 85: HR = 0.95; 95% CI: 0.76 - 1.19). There was no evidence of a black-white disparity in case-fatality rate (OR = 1.26; 95% CI: 0.93 - 1.71).

Conclusion:
In a nationwide cohort, we found that the black-white disparity in stroke mortality was primarily attributable to a racial disparity in stroke incidence, not case fatality. Thus, interventions designed to reduce the black-white disparity in stroke mortality require a primary prevention focus aimed at reducing the disparity in stroke incidence. While effective interventions to improve stroke outcomes are needed, these data suggest that improving treatment after the initial event will not reduce black-white disparities in stroke mortality.
Abstract T MP107: Measurement of Acute Brain Hemorrhage in the Pre-hospital Setting
Authors: Murphy Deborah , deKerillis Phil , Frabizzio Jennifer , Nash Bradford , Shah Qaisar
Published: July 2021

Purpose:
Delay in identification and treatment of hemorrhagic stroke can result in severe disability and death. Differentiation of acute stroke is essential to successful emergency treatment and patient outcome. A head CT scan is the gold standard for identifying hemorrhagic stroke. This pilot study evaluates utilization of a handheld infra-red screening device for possible detection of hemorrhagic stroke in the pre-hospital setting.

Methods:
The study involved collaboration with regional emergency medical services. Device education and competencies were completed by all paramedics. A stroke assessment form was utilized in conjunction with the device on all patients experiencing signs and symptoms of acute stroke. Data obtained by the device was compared to the initial head CT scan obtained in the hospital Emergency Trauma Center.

Results:
A total of 46 patients were enrolled in this pilot study. The device and head CT data were evaluated on ability to detect the presence of hemorrhagic stroke. Of the 46 patients, 7 patients were admitted with hemorrhagic stroke after positive head CT results. Out of these 7 patients, 5 had positive device results. There were 14 patients admitted with a diagnosis of acute ischemic stroke, 8 of these patients had false positive device results. Stroke mimic enrollment included 25 patients, 15 with false positive device results.

Conclusion:
The handheld infra-red screening device detected all hemorrhagic stroke cases that were within the detection abilities of the system. Large vessel ischemic strokes scanned by EMS demonstrated increased blood flow and on the opposite side of the ischemic lesion. Stroke mimics included cardiac abnormality, seizure and dehydration. Several challenges in the use of the device are noted. The 2-3 minutes it took EMS to scan correctly, was too long for scanning stroke patients, decreasing this measurement time appeared to contribute to false positive results. Measurements performed during fast ambulance transport appeared to also cause false positive readings. Difficulty to achieve reliable measurement was also noted with combative and epileptic patients. EMS feedback was provided to the device manufacturer. The researchers recommend continued research to support this effort.
Abstract T MP119: Recombinant Tissue Plasminogen Activator Does Not Impact Mortality in Acute Ischemic Stroke: A Meta-analysis of Randomized Controlled Trials
Authors: Uhrig Drew , Kumar Gyanendra , Fowler Susan , Alexandrov Andrei
Published: July 2021

Background:
Currently there is still some reluctance among emergency physicians and even neurologists to prescribe recombinant tissue plasminogen activator (rt-PA) for acute stroke. The majority of those unlikely to use it are concerned about causing harm to their patient. The object of this meta-analysis was to pool the mortality estimates at various time points following rt-PA administration. We hypothesized that there was a significant difference in mortality of patients treated with rt-PA and those treated with placebo. Methods: The databases PUBMED, EMBASE, SCOPUS, CENTRAL, and clinicaltrials.gov were searched for English-language randomized double blinded, placebo controlled trials of rt-PA. Mortality estimates were pooled and reported separately for days 7, 30, 90, and 180. Pooled relative risk (RR) and 95% confidence intervals were calculated using Dersimonian and Laird Random effects model. A priori designed sensitivity analyses included exclusion sensitivity analysis, and subgroup analysis into studies that included and excluded patients presenting within 3 hours of onset. Results: Eleven trials (N =6905) met the inclusion criteria. Total variance attributable to heterogeneity was not significant (I2 <50%) for any time point except at 30 days (I2, 53%). Publication bias was not significant on Begg’s and Egger’s tests. Mortality was not significantly different between the two groups at any time point. Exclusion sensitivity analysis revealed that exclusion of the NINDS trial rendered the 7 day and 30 day difference significant. Trials that randomized patients beyond 3 hours did not drive the mortality difference seen at any time point. Conclusion: In conclusion, compared with placebo, rt-PA does not impact mortality at any time point after administration through 6 months.
Abstract T MP12: Predictors Of Angiographic Collaterals In Patients Undergoing Intra-arterial Therapy For Acute Ischemic Stroke
Authors: John Seby , Gomes Joao , Uchino Ken , Wisco Dolora , Toth Gabor , Hui Ferdinand , Buttrick Maureen , Stecker Margaret , Hussain Muhammad S
Published: July 2021

Introduction:
Greater degree of collaterals to ischemic brain tissue from large vessel occlusion has been correlated to multiple endpoints including improved outcomes, improved recanalization and smaller infarct volume. The predictors of collateral circulation are poorly understood with inconsistencies in previous studies.

Methods:
Retrospective study from 1/07-12/12 of AIS patients who underwent IAT for ICA/M1 occlusions with TICI 0/1 flow was conducted. Baseline characteristics and treatment times were collected. Collaterals were graded using the angiographic ASITN collateral-flow grading system. Collateral were grouped into "good collaterals” (GC) for grades 3 and 4, and "poor collaterals" (PC) for grades 0, 1 and 2.

Results:
ASITN grading was available in 180 patients including 32 (18%) with GC and 148 (82%) with PC. Baseline demographics of all patients and each group are outlined in Table 1, with significant differences in baseline CT ASPECTS score and IV tPA administration. Multivariable logistic regression analysis demonstrated that female sex, CT ASPECTS and time to first angiographic run were the only independent predictors of GC.

Conclusions:
We have confirmed previous reports that GC is associated with small infarct volume, which corresponds to higher CT ASPECTS score. Odds of GC were 5.7 times in females compared to males, which is inconsistent with previous literature. Previously demonstrated association of hypertension, high admission blood pressure and high NIHSS with lesser collaterals was not seen in our study. Since collaterals affect outcomes in acute ischemic stroke, further studies of predictors of good collaterals are needed.
Abstract T MP14: The Critical Role of Macrophage Migration Inhibitory Factor on Post-Stroke Recovery
Authors: Venna Venugopal R , Benashski Sharon E , Verma Rajkumar , Xu Yan , Capozzi Lori , Liu Fudong , McCullough Louise D
Published: July 2021

Objective:
One-third of stroke survivors are affected by post-stroke depression. Evidence from epidemiological and clinical studies demonstrates that depression either before or after stroke is associated with poor recovery and high mortality. Recently it was found that loss of macrophage migration inhibitory factor (MIF) is associated with depressive behavior and impaired neurogenesis. Therefore, here we tested the hypothesis that MIF plays a role in stroke recovery and that chronic MIF inhibition contributes to post-depressive phenotypes and poor stroke outcomes.

Methods:
C57BL/6 male mice (20-25g; Charles River), were subjected to a 60min right middle cerebral artery occlusion (MCAO) and randomly assigned to vehicle or MIF antagonist, ISO-1 (7mg/kg/day intraperitoneal) treatment. Infarcts quantified with TTC. Recovery was investigated using neurological deficit scores (NDS), corner test, the forced swim test (FST) and the tail suspension test (TST). MIF levels were assessed by ELISA and western-blot (n=4/grp). Further, the effects of MIF loss were tested using knockout (KO) mice. Data are expressed as mean±sem. P value < .05 was set for statistical significance.

Results:
Post-stroke chronic ISO-1 treatment significantly increased immobility in TST at 14d (126±8 vs 83±6s; p<.05), delayed stroke recovery in the corner test (p<.05) and NDS (p<.05) compared to vehicle group. These detrimental effects were observed in parallel to reduced plasma MIF levels (p<.05). Stroke alone did not affect mobility in FST compared to sham (p>.05). Infarct size was similar in ISO-1 and vehicle groups (48±3.2% versus 46±2.8%; p>.05). When subjected MIF KO mice to stroke, similar pattern of delayed post-stroke recovery is observed suggesting that MIF plays a critical role in pre- or post-stroke depression and recovery.

Conclusions:
MIF KO mice had a depressive phenotype at baseline, and poor recovery after stroke compared to WT. Post-stroke MIF inhibition led to the development of a post-stroke depressive phenotype and also led to poorer recovery. These effects are independent of stroke volume. These findings suggest that targeting MIF might be a novel therapeutic strategy to treat post-stroke depression and to enhance recovery in stroke survivors.
Abstract T MP18: In Vivo Expansion of Regulatory T cells with Interleukin-2/Interleukin-2-antibody Complex Protects against Transient Ischemic Stroke
Authors: Zhang Haiyue , Li Peiying , Gao Yanqin , Chen Jun , Hu Xiaoming
Published: July 2021

Background and Purpose:
Our previous work documents the transfer of regulatory T cells (Tregs) in rodent models of ischemic stroke protects acute ischemic brain injury by regulating poststroke inflammatory response and thereby ameliorating BBB disruption. However, the low number of Tregs restricts the clinical feasibility of Treg transfer. Recently, in vivo expansion of Tregs with IL-2/IL-2-antibody complex (IL-2/IL-2Ab) was validated protective in autoimmune diseases model,renal ischemia reperfusion model and atherosclerosis. Here we investigate the beneficial effect of IL-2/IL-2Ab on ischemic stroke and decipher the underlying mechanisms.

Methods:
IL-2/IL-2Ab or isotype IgG was ip injected into C57/BL6 mice for 3 consecutive days. The mice are then subjected to 60-minute middle cerebral artery occlusion (MCAO) or sham operation. Brain infarction, inflammation and neurological performance was assessed up to 7 days after reperfusion.

Results:
Flow cytometry analysis reveals a marked increase of CD4+CD25+Foxp3+ Tregs in the blood, lymph nodes and spleens collected from IL-2/IL-2Ab-treated mice as compared to those from isotype-treated controls. Such Treg elevation could be observed since 3 days after IL-2/IL-2Ab injection and lasts until 7 days after MCAO. Immunochemistry staining confirms the increased number of Foxp3+ cells in the spleen at 3 days after MCAO in IL-2/IL-2Ab-treated mice. IL-2/IL-2Ab promotes function recovery up to 7 days after stroke, as revealed by significantly improved performance in corner test (n=6-9, ***p<0.001), rotarod test (n=8, **p<0.01), cylinder test (n=8, **p<0.01) and adhesive removal test (n=3, *p<0.05). Quantification of TTC staining and microtubule-associated protein (MAP2) staining shows reductions in brain infarct volume at 3 days (n=5-9,*p<0.05) and 7 days (n=7-9,*p<0.01), respectively, after MCAO. Meanwhile, we observed reduced infiltration of peripheral immune cells (CD3+ T cells, MPO+ neutrophils and F4/80+ macrophages) into the ischemic brain.

Conclusions:
Our finding suggests that IL-2/IL-2Ab treatment is a novel and clinical feasible immune therapy to expand Treg population in vivo, reduce post-stroke inflammatory responses and protect against ischemic brain injury.
Abstract T MP35: Frequency, Risk Factors, and Impact of Coexistent Small Vessel Disease in the SAMMPRIS Trial
Authors: Kwon Hyung-Min , Lynn Michael J , Turan Tanya N , Derdeyn Colin P , Fiorella David , Lane Bethany F , Montgomery Jean , Janis L S , Chimowitz Marc I ,   for the SAMMPRIS Investigators
Published: July 2021

Background:
Intracranial atherosclerotic stenosis (ICAS) and small vessel disease (SVD) may coexist. We investigated the frequency and risk factors for SVD in SAMMPRIS patients and the impact of SVD on stroke recurrence in the medical arm of the trial.

Methods:
Of 451 patients enrolled in SAMMPRIS, 313 had baseline brain MRIs read centrally for SVD. SVD was defined by any of the following: old lacunar infarction, Fazekas score of 2-3 for white matter hyperintensities, or microbleeds. We compared risk factors in patients with vs. without SVD using Fisher’s exact test (for percentages), independent groups t test (for means) or Wilcoxon rank sum test (for medians), and compared the survival curves of patients with vs. without SVD in the medical arm for ischemic stroke in the territory of the stenotic artery and any ischemic stroke using the logrank test.

Results:
Of the 313 patients, 161 (51.4%) had SVD on the baseline MRI. Variables that were significantly (p<0.05) higher in patients with SVD were age, diabetes, lipid disorder, baseline SBP, coronary disease, and old infarct in the territory. The Kaplan-Meier curves in the figure show that patients with SVD were at significantly higher risk of any ischemic stroke (p = 0.048) but not stroke in the territory (p = 0.10) compared with patients without SVD.

Conclusion:
SVD in patients with ICAS is common, especially in patients who are older, diabetic, hyperlipidemic, and have higher SBP. Patients with ICAS and coexistent SVD are at higher risk of any ischemic stroke but may not be at higher risk for stroke in the territory.
Abstract T MP47: Ideal Cardiovascular Health Predicts Functional Status: The Northern Manhattan Study
Authors: Dhamoon Mandip S , Dong Chuanhui , Santiago Maria , Elkind Mitchell S , Sacco Ralph L
Published: July 2021

Background:
The American Heart Association’s metric of ideal cardiovascular health (CVH) has been previously associated with vascular events, mortality, and subclinical atherosclerotic disease, but its association with functional impairment independent of cardiovascular disease and stroke has not been explored. We hypothesized that ideal CVH predicts improved long-term functional status after adjusting for incident stroke and myocardial infarction.

Methods:
In the prospective, multiethnic Northern Manhattan Study, stroke-free individuals in northern Manhattan aged >=40 years had annual assessments of disability with the Barthel index (BI), for a median of 13 years. Baseline demographics, medical risk factors, and laboratory studies were collected. Ideal CVH was calculated as a composite of 7 measures, each scored on a scale of 0-2: smoking, body mass index, physical activity, diet, total cholesterol, blood pressure, and fasting plasma glucose. This analysis was based on: 1) number of ideal CVH metrics, and 2) total score of all CVH metrics.

Results:
Of 3219 participants, mean age was 69 years (SD 10), 63% were female, 21% non-Hispanic White, 25% non-Hispanic black, and 54% Hispanic. Twenty percent had 0-1 ideal CVH metrics, 32% had 2, 30% had 3, 14% had 4, and 4% had 5-7. Both the number of ideal CVH categories and higher total CVH metric scores were associated with higher mean BI scores at 5 and 10 years. These gradients persisted when results were adjusted for incident stroke and MI, when mobility and non-mobility domains of the BI were analyzed separately, and when the BI was analyzed dichotomously. At 10 years, in a fully adjusted model, differences in mean BI score were lower for poor versus ideal physical activity (3.48 points, p<0.0001) and fasting glucose (4.58 points, p<0.0001).

Conclusions:
Ideal CVH predicts functional impairment, even after accounting for incident vascular events. Vascular functional impairment is an important outcome, and further research is needed to determine whether it may be improved by optimizing vascular health. Achieving the AHA 2020 goal will not only have favorable effects on stroke and MI, but also likely reduce functional impairment.
Abstract T MP54: High-resolution Magnetic Resonance Imaging of Intracranial Stenosis in Patients Younger Than 35 Years
Authors: Xu Weihai , Li Ming-Li , Gao Shan , Jin Zheng-Yu , Feng Feng , Cui Li-Ying
Published: July 2021

Background:
Using High-resolution magnetic resonance imaging(HRMRI), we aimed to investigate the etiology of intracranial stenosis in patients younger than 35 years.

Methods:
Fifty-four consecutive patients (mean age,29±6 years) with middle cerebral artery stenosis were evaluated by HRMRI. The morphology of artery lesions and clinical data were analyzed. Probable atherosclerotic plaques were diagnosed by the presence of eccentric wall thickening. Probable non-atherosclerotic lesions were diagnosed by the presence of concentric wall thickening and absence of plaques.On quantitative analysis, when constrictive remodeling can be identified by visual inspection, vessel shrinkage was defined.

Results:
Plaques were found in 32 (59%) patients, including 13 patients without any atherosclerosis risk factors. The patients with a plaque tended to be older (p=0.061), male (p=0.013), and more likely have atherosclerosis risk factors(59% vs. 23%, p=0.012), expansive artery remodeling (37.5% vs. 0,p<0.001), and infarctions (75% vs. 45%, p=0.044). The non-atherosclerotic lesions more often displayed vessel shrinkage (100% vs. 31%, p<0.001) and concentric wall enhancement (83% vs.13%, p<0.001).

Conclusion:
In this study, atherosclerosis accounted for a high percentage of intracranial artery stenosis in patients younger than 35 years when HRMRI was introduced into the diagnostic setting. Intracranial non-atherosclerotic stenosis has distinct vascular pathophysiology from atherosclerotic stenosis and is often free from stroke.
Abstract T MP58: Incidence and Etiology of Punctate Infarcts in Ischemic Stroke Patients
Authors: Oliveira-Filho Jamary , Ay Hakan , Shoamanesh Ashkan , Park Kwang Y , Avery Ross , Sorgun Mine , Kim Gyeong-Moon , Greenberg Steven M , Gurol M. Edip
Published: July 2021

Background/Objective:
Punctate infarcts (PI) are increasingly seen on DWI of patients with intracerebral hemorrhage (ICH) due to small vessel disease (SVD). We aimed to determine their incidence and potential causes in a large ischemic stroke (IS) cohort that had thorough etiologic workup.

Methods:
Consecutive patients with MRI-confirmed IS within 72 hours of onset were enrolled. Subjects had either a single high-risk embolic source (cardioembolic or large vessel disease) or no embolic source. PIs were classified by their relationship to the primary infarct as within or outside the same vascular territory. White matter disease burden (WMDB) and microbleed counts were obtained to be used as markers of severity of SVD. Multivariable regression models were constructed to assess the association between PIs and potential etiologies (embolism vs SVD).

Results:
We analyzed 946 IS patients, mean age 69 +/- 15 years, 46% female. We detected PI (≤5mm) in 269 (28%) subjects, 190 (71%) within the vascular territory of the primary infarct. Large-vessel atherosclerosis (p<0.001), cardioembolic source (p<0.001), higher WMDB (p=0.032) and lower systolic blood pressure (SBP, p=0.024) were independently associated with the presence of PI. While lower SBP was associated with PI in any location (p<0.05), WMDB was only associated with PI outside the vascular territory of the primary infarct (p=0.033); and large vessel atherosclerosis was only associated with PI within the vascular territory of the primary infarct (p=0.004).

Conclusions:
PIs occurring within the vascular territory of a larger infarct are more likely to have a proximal embolic source, but those occurring outside are more likely related to SVD. Their relatively high incidence and diverse etiologic associations in a cohort of IS patients emphasize the importance of research into their mechanisms.
Abstract T MP7: Single Center Experience With A Direct Aspiration Technique (adapt) For Endovascular Treatment Of Acute Ischemic Stroke
Authors: BLANC RAPHAEL , Redjem Hocine , bartolini Bruno , Ciccio Gabriele , Robert Thomas , Paul Emile Labeyrie , BenHassen Wajih , Pistocchi silvia , Piotin Michel
Published: July 2021

Background:
We report our single center experience of endovascular treatment of stroke by the technique of direct clot aspiration.

Methods:
From September 2013 to July 2014, from our prospectively gathered database, we reviewed 114 patients presenting with large vessels occlusion in the settings of acute ischemic stroke and treated with the ADAPT technique in first intention.

Results:
Hundred and fourteen patients (55 female and 54 male patients (mean age: 64 y.o) presented with a median NIHSS score of 15,9 (1-26). The localisation of arterial occlusion was the MCA in 52/114 (45%), the ICA in 16/114 (14%), a tandem occlusion in 35/114 (30,7%) and the vertebro basilar territory in 11/114 (9,65%). Procedures were performed under sedation in 66% of cases and general anesthesia in 33%. The aspiration technique alone was successful in achieving TICI 2b/3 in 48,2% of cases (55/114) with a mean of 2 passes. The additional use of stent retrievers improved the TICI 2b/3 revascularization rate to 87,5%. With aspiration alone, the average time from groin puncture to at least TICI 2b recanalization was 37 min (from clot contact to recanalisation: 17 min). Ninety day functional outcomes was available for 87/114 patients with 50% of good functional outcomes (mRS≤ 0-2) and 15% death (mRS 6). For the overal series there were 10 cases (8,7%) of procedural complications (one non occlusive dissection, 4 distal emboli, and 5 Subarachnoid hemorrhages) and 2 symptomatic intracerebral hemorrhages (2,5%).

Discussion:
The aspiration technique utilizing large bore aspiration catheters technique alone was effective in 48% of the cases being fast, safe and simple, but to achieve a recanalization rate of 87,5% it add to be completed by the use of stentrievers in the other cases. The relevance of this technique needs to studied in larger prospective multicentric studies.
Abstract T MP82: Can Patients Select the Best Hospital for Carotid Revascularization?
Authors: Chaturvedi Seemant
Published: July 2021

Introduction:
Carotid revascularization guidelines have emphasized for the past two decades that the periprocedural complication rates should be monitored and made available to referring physicians. There has also been a movement in recent years towards greater transparency with regard to the communication of health outcomes directly to patients.

Objective:
To evaluate the hypothesis that publicly available data for patients contemplating a carotid revascularization procedure would be sparse.

Methods:
The Federal government’s Medicare Hospital Compare website (
www.medicare.gov/hospitalcompare
) was evaluated with regard to carotid endarterectomy (CEA) and carotid artery stenting (CAS). Information was sought regarding procedural volumes at 30 hospitals within 50 miles of a single metropolitan area. We also determined whether hospital or surgeon CEA or CAS complication rates were provided. Hospital characteristics were evaluated in relation to release of information.

Results:
A 12 month data collection period was evaluated (2011-12). Information was available for CEA only (DRG codes 38 and 39, with and without complications or comorbidities). Eight of 30 hospitals (27%) provided procedural volumes for these two codes, nine hospitals (30%) provided partial data, and 13 hospitals (43%) did not provide any information. During the 12 month period, procedural volumes ranged from 12-56. No information was provided regarding hospital periprocedural stroke/death rates. No information was provided regarding individual surgeon outcomes. None of the four hospitals affiliated with a for-profit health system provided complete information and neither of two Veterans Affairs hospitals provided data on CEA volumes. No data was provided with regard to CAS volumes or outcomes.

Conclusions:
Despite the importance of determining a hospital’s and surgeon’s track record with regard to CEA and CAS outcomes, the quality of information publicly available to patients (and referring physicians) is dismal. Almost half of the hospitals in this metropolitan area did not even provide CEA procedural volumes. Patients and referring physicians should be provided with higher quality information if they are to make informed medical decisions regarding CEA and CAS.
Abstract T MP86: A Prospective Study of the Effect of Dehydration on Stroke Severity and Short Term Outcome
Authors: Bahouth Mona N , Hillis Argye , Gottesman Rebecca
Published: July 2021

Background:
Many ischemic stroke patients present to the hospital in a state of dehydration. We hypothesized that patients who were dehydrated at the time of acute stroke would have more severe stroke and worse short term outcomes.

Methods:
We enrolled consecutive ischemic stroke patients within 12 hours from their last normal neurological exam at a single academic health system. Patients with renal failure or who were unable to undergo MRI were excluded. Surrogate markers for dehydration were defined as BUN/Creatinine ratio >15 and urine specific gravity >1.010. Stroke severity was determined based on clinical examination (NIHSS score) and lesion volume measured on diffusion weighted MRI. The primary outcome of interest was change in NIHSS from admission to discharge.

Results:
We surveyed 383 ischemic stroke admissions to our comprehensive stroke center. Of these, 168 met inclusion criteria with 126/168 (75%) having complete laboratory and MRI data. 44% of our patients were dehydrated at the time of admission, with no difference in demographics between the dehydrated and hydrated groups. Baseline NIHSS (6.7 vs 7.3; p=0.63) and lesion volumes (12 vs 16; p=0.48) were similar in the two groups. 42% of dehydrated patients were in the worst short term quartile of NIHSS change, as compared with 17% of the hydrated group (p=0.02). Dehydration remained a significant predictor of having the worst NIHSS change, after adjustment for age, initial NIHSS, lesion volume, and admission glucose (OR=4.34, 95% CI 1.75-10.76).

Conclusions:
Nearly half of acute stroke patients admitted to the hospital are dehydrated by surrogate laboratory markers. Acute stroke patients with markers of dehydration demonstrate greater worsening in NIHSS scores as compared with hydrated patients, independent of infarct size. Results suggest an opportunity for an inexpensive and globally available treatment to optimize functional outcomes of the stroke patient.
Abstract T P104: Remodeling of Intracranial Atherosclerotic Plaques
Authors: Wang Li , Yu Simon C.H. , Siu Deyond , Soo Yannie OY , Wong Lawrence K.S. , Leung Thomas W.
Published: July 2021

Background:
Rupture-prone plaques may cause recurrent thrombo-embolic stroke. Little is known how symptomatic intracranial atherosclerotic plaques would remodel under current treatment.

Method:
We recruited acute stroke patients with high-grade (>70%) symptomatic intracranial atherosclerotic stenosis for optimal medical treatment. Interval changes of plaque morphology were assessed by 3D-rotational angiography at baseline and 12 months. Morphological parameters included plaque surface (smooth/irregular/ulcerated), thickness, length (total length, maximal stenosis length), maximal stenosis distribution (proximal/central/distal), thickness-to-length ratio (ratio=thickness/total length), eccentricity, and plaque upstroke angulation. We stratified angiographic outcomes into 1) Progressive (surface morphology evolved from smooth to become irregular/ulcerated); 2) Static (surface morphology unchanged); and 3) Regressive (surface morphology from irregular/ulcerated to smooth).

Results:
Among the recruited 32 patients (age 66.3±8.9yrs, male 71.9%), we observed significant difference in plaque surface (ulcerated: 21.9% to 9.4%, p=0.01), thickness (1.54±0.41mm to 1.33±0.45mm, p=0.01), maximal stenosis distribution (central: 50.0% to 65.6%, p<0.001), and thickness-to-length ratio (0.30±0.13 to 0.26±0.10, p=0.046). Plaque surface morphology remained unchanged in 25 patients (78.1%), progressive in 2 patients (6.3%), and regressive in 5 patients (15.6%, Figure). One patient (3%) developed recurrent ischemic stroke.

Conclusion:
Symptomatic intracranial atherosclerotic plaques may regress with medical therapy alone. Healing of ulcers and positive remodeling are evident in some plaques.
Abstract T P111: General Anesthetic Use and Clopidogrel Resistance During Neurovascular Stenting Procedures
Authors: Shwe Yamin , Ortega-Gutierrez Santiago , Altschul David , Kim Jinu , Chen Karen , Paramasivam Srinivasan , Berenstein Alejandro , Fifi Johanna
Published: July 2021

Purpose:
To determine the effect of general anesthesia on clopidogrel resistance among patients undergoing intracranial stenting procedures

Background:
Clopidogrel resistance is associated with increased periprocedural thromboembolic complications in neurovascular stenting procedures. Clopidogrel is metabolized by cytochrome P450 system to an active drug that irreversibly binds to the platelet ADP receptor P2Y12 and inhibits downstream platelet aggregation. General anesthetics are commonly used in intracranial stenting procedures and are known to inhibit cytochrome P450 monooxygenases. Therefore we hypothesized that the use of common general anesthetics would be associated with increased clopidogrel resistance.

Methods:
We conducted a retrospective chart review of 41 patients who underwent intracranial stenting and coiling procedures under general anesthesia from 2010-2013. We analyzed the 35/41 who had platelet assays performed within twenty-four hours both before and after the procedure (VerifyNow, Accumetrics, Inc., San Diego, CA, USA). P2Y12 reaction unit (PRU) was used to measure platelet resistance, with values ≤178 indicating increased bleeding risk, 179-238 therapeutic, and ≥239 thrombogenic. Pre-procedural and post-procedural mean PRU values were compared using t tests to determine the effect of general anesthesia on clopidogrel resistance.

Results:
We found significantly increased post-procedure PRUs compared to pre-procedure PRUs. Mean PRU twenty-four hours before procedure was 214±34 (95% CI 180-248) compared with 260±25.24 (95% CI 235-285) twenty-four hours after the procedure (p<0.05). Out of 35 patients, 27 (77%) had increased PRUs post- procedure compared to pre-procedure.

Conclusion:
Clopidogrel resistance is increased following endovascular stenting procedures. We propose that this occurs through competitive interaction with CYP isoforms by general anesthetics. We are not aware of any prior studies demonstrating an association between general anesthetics and clopidogrel resistance. Further prospective studies are needed to further define this observation.
Abstract T P118: Left Ventricle Ejection Fraction as Prognostic Factor of Functional Outcome in Ischemic Stroke
Authors: Gongora-Rivera Fernando , Muruet Walter , Lara-Campos Jackeline , Villarreal-Montemayor Héctor J , Villarreal-Velázquez Héctor J , Delgado-Aguilar Stephanie , González-Garza Lizeth , Cordero-Pérez Adolfo C , González-Aquines Alejandro ,   GECEN Investigators
Published: July 2021

Background:
Ischemic stroke is a leading cause of functional disability worldwide. Few studies have evaluated the relationship between Left Ventricle Ejection Fraction (LVEF) and the functional outcome after ischemic Stroke, however it has been shown that there is an important correlation between LVEF and Cerebral Blood Flow (CBF). The effects of LVEF on CBF may have critical implications on the post-ischemic brain.

Objective:
To determine if LVEF can be used as a prognostic factor in ischemic stroke

Methods:
We carried out a prospective, analytic, cohort study. We included stroke patients from our Neurovascular Resgistry (iReNe). We only included patients with complete information and that agreed to participate in the study. LVEF was measured during patients’ in-hospital stay. Clinical Follow up was done at 3 and 12 months using the modified Rankin Scale (mRs).

Results:
We included 129 patients with follow up at 3 months, from these, 69.5% of them had follow up at 12 months. Our study population was composed of 65.9% males, the mean age was 62.88 ± 13.18, 60.5% had hypertension, 49.6% diabetes mellitus, 27.9% dyslipidemia. Stroke subtypes according to TOAST were 38% atherothrombotic, 27.1% small vessel disease, 21.7% Cardioembolic and 13.2% were undetermined. The proportion of patients that died was 9.3%. We found that patients with good functional outcome (mRs 0-3) at 3 months had a mean LVEF of 57.22 vs an mean LVEF of 53.13 for the patients in the poor functional outcome group (mRs 4-6), p=0.020; Patients with good functional outcome (mRs 0-3) at 12 months had a mean LVEF of 57.38 vs 49.29 for patients with poor functional outcome (mRs 4-6), p=0.029. After performing a multivariate logistic regression analysis adjusted for sex, age and admission NIHSS, we found that LVEF maintained statistical significance.

Conclusions:
We found that a reduce LVEF is a factor of long term poor functional outcome in patients with ischemic stroke. Our results suggest that even relatively small reductions in LVEF may have a detrimental effect in recovery after ischemic stroke.
Abstract T P16: Indirect Comparison of Functional Outcomes in Stroke Patients Following Endovascular Versus Best Medical Treatment: Insights From Defuse 2 and Axis 2
Authors: Wouters Anke , Lemmens Robin , Christensen Soren , Wilms Guido , Mlynash Michael , Schneider Armin , Laage Rico , Lansberg Maarten G , Albers Gregory W , Thijs Vincent ,   AXIS 2 Investigators,   DEFUSE 2 Investigators
Published: July 2021

Background:
Imaging based selection of acute ischemic stroke patients may improve clinical outcomes after endovascular therapy. DEFUSE 2 was a prospective cohort study of ischemic stroke patients who underwent a baseline MRI scan before endovascular therapy. In DEFUSE 2 reperfusion was associated with increased good functional outcome in patients with the target mismatch (TMM) profile, but not in patients without TMM. AXIS 2 was a randomized, controlled, MRI based trial of IV GM-CSF versus placebo. This study, in which endovascular therapy was not permitted, did not show improved functional outcomes between GM-CSF and placebo. We performed an indirect comparison between the outcomes seen in DEFUSE 2 and a control group from AXIS 2.

Methods:
Patients from AXIS 2 with a confirmed large vessel occlusion of the MCA or ICA on MR angiography, obtained within 9 hours after symptom onset, were selected as a control-group for patients from DEFUSE 2. The primary endpoint was good functional outcome at day 90 defined as a modified Rankin scale score of 0-2. Reperfusion status could only be assessed in the DEFUSE 2 cohort. We performed a stratified analysis based on the presence of TMM for both studies and reperfusion status in DEFUSE 2.

Results:
We compared good functional outcome in 102 patients (TMM in n=47, 49%) from AXIS 2 and 98 patients (TMM in n=78, 80%) from DEFUSE 2. After correction for differences in age, NIHSS and DWI volume, rates of good functional outcome were similar, 43% in DEFUSE 2 compared to 30 % in AXIS 2 (OR 0.9, 95%CI 0.5-1.7). In DEFUSE 2 patients with the TMM profile in whom reperfusion was achieved, the rate of good functional outcome was increased compared to TMM patients in AXIS 2, 64% versus 32% (OR 3.2, 95%CI 1.2-8.4). In TMM patients from DEFUSE 2 without reperfusion, the rate of good functional outcome was similar (31%), to the TMM patients in AXIS 2 (OR 1.0, 95%CI 0.4-2.3). No difference in outcomes was observed regardless of reperfusion status when a TMM was not present.

Conclusion:
This indirect, controlled comparison suggests that endovascular treatment resulting in reperfusion may lead to improved outcomes in patients with the TMM profile.