bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP108: Early Palliative Care Consultation In Patients With Disabling Stroke
Authors: Carrington Justin G , Gill Rick , De La Pena Paula , Despe Joyce , Ruland Sean , Ansari Aziz
Published: February 2023

Severe disability and critical illness due to stroke can be burdensome to patients, caregivers, and resource intensive, particularly in the elderly. Management of these patients is multifaceted and includes optimizing quality of life through palliative care (PC). PC in stroke patients can improve comfort while reducing overutilization of resources unlikely to prolong life or contribute meaningful quality. We investigated the impact of early PC involvement in disabled stroke patients, which we defined as NIH Stroke Score ≥ 5 and ICU admission. A screening program was implemented in 2019 at the Loyola University Medical Center for automatic PC consults in disabling stroke (ischemic or hemorrhagic) patients over age 70 or who require a ventilator. We hypothesized that early PC consultation via this protocol reduced resource consumption without compromising patient care. This pilot study gathered data prospectively for patients with a positive screen from 2020 to 2021 (“screening”, n=71), and retrospectively for those who met screening criteria in 2017 and 2018 prior to its application (“control”, n=193). Comparing the screening and control groups, there was no significant difference in age (75.9 ± 2.7 vs 72.1 ± 1.1, p>0.1), NIH stroke score (16.6 ± 0.5 vs 17.5 ± 0.9, p=0.2), stroke type (61% vs 69% ischemic, p>0.2), or proportion who expired (22% vs 18%, p=0.4). However, the screening group had more frequent code status change from full to DNR/DNI (42% versus 19%, p<0.01) and more frequent discharges to home (20% vs 8%, p<0.01) when compared to the control. These findings suggest that our samples were similar in stroke severity and screening did not affect mortality. More frequent code status changes with PC screening implies better early identification of patient centered goals of care during admission. Increased discharges to home among these patients may reduce overall long term health care utilization with clear future directives. In conclusion, our pilot study demonstrates that early palliative care involvement in patients with disabling stroke is feasible and expedites establishing goals of care without affecting the quality of care patients receive. We plan to further investigate resource utilization including ICU length of stay and cost.
Abstract TP112: Association Of Statin Use And Morbidity-mortality Outcomes In Patients With Acute Stroke And Ldl<70mg/dl: Preliminary Findings From Stroke Registry
Authors: Patel Pinal , Romero Garcia Alberto , Lim Chee Yao , Afzal Afsheen , Sunil Bhaskaran Aditya , Kumari Barkha , Ashraf Rabia , Singh Inderpreet , shariff masood , Wang Kai , GONZALES JEANIE , Shabarek Nehad , Menon Vidya , Duran Israel
Published: February 2023

Introduction:
Stroke outcomes in patients with LDL levels <70mg/dl and the utility of statins in these settings are uncertain given the scarcity of data. Our study aims to develop a unique registry, prospectively follow patients with CVA and an LDL < 70 (with and without Statin), and study their fatal/nonfatal cardiovascular outcomes over five years.

Method:
The study includes patients admitted for stroke and LDL <70 between January 2021 and May 2022. Chart review performed from the stroke registry. We compared two groups (A: Patients on statin before admission vs. B: statin naive patients).

Result:
Among 469 patients admitted for the stroke, 119(25%) patients had LDL <70. 51.3% were on a statin before index admission, and 48.7% were statin naïve. Mean NIHSS was 9.52 in the statin naive group vs 7.39 in patients already on statin. Prevalence of comorbidities were less in group B: DM(45% vs 64%), CHF(7% vs 28%), CAD(14%vs34%), Atrial Fibrillation(8.6% vs 16%), Valvular heart disease(0% vs 6.6%). Incidence of hemorrhagic stroke was higher in Group B(23% vs 8%). Among group B, 53.4%, 20.7% and 25.9% patients had low (0-5), moderate(6-14) and high NIHSS(>14) respectively vs 57.4%, 24.6% and 18% in group A. Mortality was higher in group B in patients admitted with moderate (33.3% vs 13.3%) and severe NIHSS score(18.2% vs 6.7%). Within group B, patients who were started on statin during admission had a lower modified Rankin Scale (mRS) on discharge, compared to patients who were not started on statin(mRS 0 36.6% vs 0%, mRS 4-17.1% vs 29.4%, mRS 5- 9.8% vs 17.6%). Also, mortality was higher in patients not started on statin.

Conclusion:
Patients who were not on statins had higher incidence of hemorrhagic stroke, worse functional status on discharge, and higher mortality than those who were already on statin. Patients who were started on statin during index admission had better functional status on discharge and lower mortality than patients who were never started on statin. Our study highlights the better outcomes at discharge with statin use in stroke patients with LDL<70. Further studies are required to validate these findings and to determine the protective effects of statins in these patients.
Abstract TP113: Stroke Escape Room: A Novel Stroke Education Technique
Authors: Truitt Ginger , Lorenzo Catherine
Published: February 2023

Introduction:
Georgia is one of the leading states in the country with high mortality rates from stroke. Even in post-COVID times, beside nurses have been challenged with obtaining the required number of stroke education hours for the organization’s stroke certification. A Stroke Escape Room was developed as an innovative way to meet annual stroke education hours.

Purpose:
The Stroke Escape Room is designed to help front-line staff achieve their annual stroke education requirements while promoting their understanding and retention of clinical practice guidelines.

Methods:
Three independent stroke patient scenarios were developed. Each patient scenario was associated with a combination access lock box. Participants answer questions about the scenario. The answers to the questions are associated with the numbers to unlock the box and move on to the next scenario. A final lock box contains an evaluation to assess learning. The session took approximately 30 minutes to complete. With course completion, the nurse receives 30 minutes of stroke education credit, a certificate for completion, and a BE FAST badge buddy. Participants were encouraged to attend the activity in small groups with at least one member being a Registered Nurse. A poster displaying stroke related clinical practice guidelines was displayed in the Escape Room.

Results:
A total of 22 staff participated in the activity. The participants attended in groups varying from one participant to four participants. Most (63.6%) participants work in the Emergency Department, 13.6% work on the stroke unit, 13.6% are educators, and 9% work in the Intensive Care Unit. Feedback received was extremely positive. Majority of participants reported positive experience, stating the education technique was fun, engaging, and promoted critical thinking. In addition, more than half the participants requested to use similar technique in other settings.

Conclusion and Next Steps:
Implementing an escape room for learning encouraged participants to interact. This type of educational design promotes collaboration and critical thinking. In conclusion, additional scenarios are being developed along with questions designed to promote critical thinking related to the phases of care.
Abstract TP115: Racial/ethnic Differences In Subacute Blood Pressure Trajectories Following Intracerebral Hemorrhage
Authors: Torres-Lopez Victor M , Hawkes Maximiliano , Rivier Cyprien , Kim Jisoo , Kitlen Eva , Schlechter Maia , Kampp Michael C , Jasak Sara , Petersen Nils H , Kim Jennifer , De Havenon Adam H , Sansing Lauren H , Sheth Kevin N , Falcone Guido J
Published: February 2023

Introduction:
Existing observational evidence indicates that blood pressure (BP) differs by race/ethnicity in the first 24 hours after spontaneous intracerebral hemorrhage (ICH). However, differences in BP across race/ethnic groups beyond this acute period remain understudied.

Hypothesis:
Race/ethnic differences in BP levels and variability persist after the initial 24 hours.

Methods:
We analyzed data from the Yale Longitudinal Study for Acute Brain Injury, an ongoing observational study that longitudinally follows adult (>18 years) patients admitted to the neurocritical care and stroke services of the Yale Health System. For this study, we included patients with ICH enrolled between January 2018 and January 2022 and abstracted from the Electronic Health Record BP measurements obtained during the first 7 days of admission. Mean systolic BP was calculated in 4-hour epochs. Blood pressure variability was calculated as the trough of systolic blood pressures. Multivariable linear regression models were used to analyze differences in systolic BP and BP variability across race/ethnic groups.

Results:
A total of 738 patients (mean age 68, 45% female) were included in the study, including 530 (71.8%) whites, 138 (18.7%) African Americans, and 70 (9.5%) Hispanics. African Americans had trend toward statistically higher systolic BP (beta 2.7, SE 1.49; p= 0.06) as well as higher BP variability than whites (beta 2.34, SE 1.16; p= 0.045) and Hispanics (beta -0.61, SE 1.50; p=0.68). Other factors associated with systolic BP were age (beta 0.17, SE 0.04; p<0.001) and history of hypertension (beta 8.42, SE 1.47; p<0.001). Similarly, age (beta 0.11, SE 0.03; p<0.001) and history of hypertension (beta 3.16, SE 1.15; p<0.001) were also significantly associated with BP variability.

Conclusions:
Among patients with ICH admitted to a single health care system study of acute brain injury, Black race was associated with higher BP variability and, possibly, higher systolic BP. Given the pivotal role of BP management in the care of patients with ICH, further research is needed to understand how the observed differences could translate into race/ethnic-specific strategies to manage BP.
Abstract TP119: Relationships Of Female Sex With Intracerebral Hemorrhage Characteristics And Outcomes
Authors: Mitchell Amanda , Carvalho Poyraz Fernanda , Heinonen Gregory , Cottarelli Azzurra , Mao Eric , Ghoshal Shivani , Agarwal Sachin , Park Soojin , Claassen Jan , Connolly Edward , Roh David
Published: February 2023

Introduction:
Biological sex is known to impact cerebrovascular disease characteristics and clinical outcomes. While in intracerebral hemorrhage (ICH) it is known that biological sex impacts ICH incidence, it is less clear whether biological sex impacts ICH outcomes.

Hypothesis:
Female sex will be associated with ICH characteristics and clinical outcomes.

Methods:
Spontaneous ICH patients enrolled into a prospective observational ICH cohort study between 2009-2020 were assessed. Patients with prior anticoagulant use and secondary etiologies of ICH were excluded from the analysis. Female sex was assessed as the primary exposure variable. Primary analyses assessed relationships of female sex with radiographic outcomes: ICH location, ICH volume, hematoma expansion (>33% and/or >6mL). Secondary analyses assessed relationships of female sex with clinical outcomes: poor discharge neurological outcome (modified Rankin 4-6), and poor discharge disposition (skilled nursing facility, hospice, or inpatient death). Separate multivariable regression models assessed these relationships after adjusting for relevant covariates.

Results:
Of 504 ICH patients analyzed, mean age was 67 (SD 14.9), 46% were female, and median baseline ICH volume was 14.6 mL (IQR 4.98-35.0). In primary analyses, female sex was not associated with ICH volume or hematoma expansion but was associated with lobar ICH location (adjusted OR 1.72, 95% CI: 1.09-2.70). In secondary analyses, female sex was not associated with poor discharge neurological outcomes (adjusted OR 1.40, 95% CI: 0.74-2.64) after adjusting for race, ICH severity, and ICH location. However, there was an association of female sex with poor discharge disposition (adjusted OR 1.91, 95% CI: 1.15-3.16) after adjusting for similar covariates.

Conclusions:
While there were no clear intergroup sex differences in ICH severity or neurological outcomes, female sex was associated with worse discharge disposition. Further work is required to clarify whether these disposition differences are due to disease specific complications, characteristics, or if there are other social disparities responsible for these outcome differences.
Abstract TP13: Is Tenecteplase Associated Recanalization Dependent On Thrombus Length?
Authors: Snyder Thomas , Fourcand Farah , Singh Zamir , Ghori Arifa , Gadallah Nancy E , Dubinski Ilya , Panezai Spozhmy , Kirmani Ayman , Mehta Siddhart , Kirmani Jawad F
Published: February 2023

Introduction:
Recent evidence supports that IV tenecteplase (TNK) is non-inferior to IV alteplase when administered to eligible patients with acute ischemic stroke (AIS). Studies suggest that alteplase does not effectively lyse clots ≥ 8mm. However, the neurovascular characteristics of TNK are rapidly evolving. The aim of this study was to evaluate the efficacy of TNK in clot lysis ≥ 8mm as measured by hyperdense sign on CT for internal carotid artery (ICA) and middle cerebral artery (MCA M1 and M2 segment) occlusion.

Methods:
We conducted a retrospective cohort study of prospectively collected AIS patients who presented to our comprehensive stroke center, received TNK, and had hyperdense sign on CT head. Hyperdense signs were detected using 0.625 mm slices in retrospective fashion, blinded to the clinical scenario with regards to laterality. Revascularization was defined as modified Thrombolysis in Cerebral Infarction (mTICI) score on first run of digital subtraction angiography prior to intervention, follow up CTA or MRA without large vessel occlusion (LVO), and/or with improved clinical symptoms that correlate with hyperdense sign. Social science statistics software was used for data analysis.

Results:
From October 2020 to June 2022, out of 77 AIS patients who received TNK, 25 subjects (≥ 8mm, n=19) had associated hyperdense signs. Mean age was 67.16 (95% CI 60.05, 74.27). Median NIHSS was 14 (95% CI 11.378, 19.50). Mean thrombus length was 17.64 mm (95% CI, 13.26, 22.02). Twenty-one percent (n=4) of 19 subjects with hyperdense signs ≥ 8mm recanalized post-TNK (n=3 angiography, n=1 MRA). Thirty-three percent (n=2) of 6 subjects with hyperdense signs < 8mm recanalized post-TNK. There was not a statistically significant difference between recanalization rates in hyperdense signs ≥ 8mm or < 8mm (Fisher exact test statistic=0.61). There was not a statistically significant difference between intracerebral hemorrhage rates in hyperdense signs ≥ 8mm or < 8mm (Fisher exact test statistic=1).

Conclusion:
Our study suggests that tenecteplase may be associated with higher thrombolytic-related recanalization in thrombi measuring 8mm or greater as compared to historical alteplase experience. Larger, prospective studies are needed to corroborate our findings.
Abstract TP133: Efficacy Of Mechanical Thrombectomy For The Posterior Circulation Stroke
Authors: Okuda Tomohiro , Arimura Koichi , Ido Keisuke , Tokunaga So , Yamaguchi Shinya , Yoshida Hidenori , Kameda Katsuharu , Takagishi Soh , Iwaki Katsuma , Koyanagi Yuya , Nakamizo Akira , Yoshimoto Koji
Published: February 2023

Background and Purpose:
The efficacy of mechanical thrombectomy (MT) for posterior circulation large vessel occlusions has not been fully elucidated. We investigated the efficacy and safety of MT for posterior circulation stroke (PCS) compared with anterior circulation stroke (ACS).

Methods:
We analyzed 885 consecutive patients who underwent MT for acute ischemic stroke between January 2013 and December 2020 at six comprehensive stroke centers. The patients were divided into two groups; the PCS and ACS group. The procedural and clinical outcomes were compared between the groups.

Results:
A total of 767 patients (PCS group, 83; ACS group, 684), were analyzed. PCS patients were significantly younger (75 vs. 79, P = 0.008) and had a higher NIHSS score at baseline (23 vs 19, p=0.012) and longer door to puncture time (97 vs 73 min, p=0.009). The rate of male (67.0 vs 46.9% p<0.001) and atherosclerotic brain infarction (22.8 vs 8.3% p<0.001) were higher, comorbid atrial fibrillation (50.6 vs 64.4% p=0.022) was fewer in the PCA group. The rate of mTICI 3 recanalization at the first pass (40.9 vs 28.5% p=0.019) was significantly higher in the PCS group. However, the rates of final mTICI ≥ 2b recanalization (86.6 vs 83.8% p=0.491), symptomatic hemorrhagic complications, good clinical outcome at 90 days (34.3 vs 32.5% p=0.767), and mortality (22.3 vs 16% p=0.184) were similar in the groups. In the PCS group, the single use of a stent retriever for the first pass was associated with higher mortality rate compared with use of ADAPT or combined technique (38.6 vs 12.2% p=0.012).

Conclusions:
MT for PCS seemed to be beneficial, having similar complication, recanalization rate, and clinical outcomes with ACS.
Abstract TP145: Mechanical Thrombectomy Beyond 24 Hours
Authors: Pandhi Abhi , Chandra Rahul , Abdulrazzak Mohammad , Alrohimi Anas , Bain Mark , Moore Nina , Hussain Muhammad , Wadden Daniel , Bullen Jennifer , Toth Gabor
Published: February 2023

Background:
Multiple randomized controlled trials have shown that mechanical thrombectomy (MT) is superior to medical therapy. However, no robust evidence is available to assess the effectiveness of MT beyond the 24-hour window. In this study, we aimed to determine the safety and efficacy of MT in patients undergoing MT for stroke beyond 24 hours from last known normal (LKN).

Methods:
Retrospective review of a prospectively collected database for subjects who met extended window trial criteria, but underwent MT beyond 24 hours. Recorded variables included age, sex, NIHSS at baseline and at discharge, risk factors, level of occlusion, access site, thrombectomy method. Safety and efficacy outcomes included symptomatic intracerebral hemorrhage (sICH), procedural complications, number of passes, successful recanalization (TICI 2b-3), Δ NIHSS (baseline-discharge), favorable outcomes (mRS 0-2) at 90 days.

Results:
A total of 39 patients were included with a median age of 69 (IQR 61.5, 73.5); 54% were females. Hypertension was the most frequent risk factor in 76% of patients; 23 % of patients were smokers. Half of the patients had M1 occlusion (48.7%). Median preprocedural NIHSS was 11 (IQR 7.0, 19.5). Successful revascularization was achieved in 87%; median number of passes was 2 (IQR 1.0,3.0). Median ΔNIHSS was 3.0 (IQR -1.5, 8.0). Favorable outcome was achieved in 49% (95% CI: 34%-64%), and 95% were free of complications. A total of 3 patients (7.7%) had sICH. In an exploratory analysis, posterior circulation occlusion was associated with higher risk of poor mRS at 90 days (OR: 14.7, p = 0.016). Additionally, favorable discharge facility (home, home health, or rehab) was associated with a much lower risk of poor mRS at 90 days (OR: 0.11, p = 0.004).

Conclusions:
Our single center study of MT beyond 24 hours showed comparable clinical outcomes and safety profile to large MT trials within 24 hours, especially in anterior circulation occlusions. Posterior circulation occlusions were associated with worse outcomes, which warrants further investigation.
Abstract TP154: Outcomes Of Acute Carotid Stenting With Or Without Intravenous Thrombolysis Among Patients With Acute Tandem Occlusion: Insights From STAR
Authors: Essibayi Muhammed Amir , Anadani Mohammad , Almallouhi Eyad , Yaghi Shadi , Lajthia Orgest , Maier Ilko , Jabbour Pascal M , Kim Joon-Tae , Quintero Wolfe Stacey , rai ansaar , Starke Robert , Psychogios Marios , Shaban Amir , Arthur Adam S , Yoshimura Shinichi , Howard Brian , Alawieh Ali , Fragata Isabel , Cuellar Hugo , Polifka Adam , Mascitelli Justin , Osbun Joshua , Matouk Charles , Park Min S , Levitt Michael , Dumont Travis , Williamson Richard , Altschul David , Spiotta Alejandro M , Al Kasab Sami
Published: February 2023

Introduction:
Emergency carotid artery stenting during mechanical thrombectomy has emerged as an effective emergent treatment for tandem carotid occlusions. Nevertheless, scarce evidence is available about the safety of this procedure in patients who received intravenous tPA before thrombectomy. Herein, we investigate the safety of acute carotid stenting among patients who received intravenous tPA in a large international multicenter registry.

Methods:
Patients from the Stroke Thrombectomy and Aneurysm Registry between 2010 and 2022 were analyzed. Only patients with concomitant occlusions of cervical carotid and proximal ipsilateral intracranial segments of the internal carotid or middle cerebral artery were included in the final analyses. Patients were divided into two groups, depending on tPA administration. The primary outcome was 90-day good clinical outcome (mRS 0-2), and the primary safety outcome was symptomatic intracranial hemorrhage. Univariate and multivariate regressions were performed adjusting for variables of clinical importance.

Results:
Among 9812 with acute ischemic stroke in the registry, 132 patients had acute tandem occlusion and underwent carotid stenting; of those, 60 patients received IV tPA. Compared to non-intravenous thrombolytics, patients with IV tPA had a higher male prevalence (78.3% Vs 54.4%, P=0.005) and better ASPECT scores (9 Vs 8, P=0.022) with a shorter time from onset to puncture (241 Vs 672 minutes, P<0.001). There was no difference in rates of successful revascularization (94% Vs 95.5%, P=NS), good clinical outcome (50.8% Vs 61.4%, P=NS), symptomatic intracranial hemorrhage (15.3% Vs 14.5%, P=NS) or procedural complications (15% Vs 11.6%, P=NS) between the tPA and non-tPA groups.

Conclusion:
The use of IV tPA did not affect the safety or efficacy of emergent carotid stenting in the setting of acute tandem occlusion.
Abstract TP155: Patient Centered Outcomes In Pediatric Moyamoya Arteriopathy
Authors: Ahmad Syed Ameen , Gatti John R , Peterson Rachel K , Malone Laura A , Sun Lisa R
Published: February 2023

Introduction:
Little is known about quality of life, sleep, and mental health in children with moyamoya arteriopathy (MMA). A better understanding of patient-centered outcomes may lead to improved counseling and treatment of childhood MMA.

Methods:
MMA patients <26 years old (when developmentally appropriate) and their parents/guardians completed a series of validated, age-appropriate questionnaires. Measures included the Pediatric Quality of Life (PedsQL) Inventory (assessing health-related quality of life), Patient-Reported Outcomes Information System (PROMIS) sleep questionnaires (assessing sleep disturbance, defined as disturbed sleep, and sleep impairment, defined as impairment of daily activities due to poor sleep), and PROMIS depression/anxiety questionnaires.

Results:
Seventeen participants with MMA were enrolled, with 8 children and 17 parent proxies completing questionnaires. Median age was 7.3 years (IQR 6.6, 10.1 years). The cohort included 8 (47%) females and children with both moyamoya disease (n=9, 53%) and moyamoya syndrome (sickle cell disease n=4, neurofibromatosis n=3, hemophilia A n=1). On the PedsQL (100 = best quality of life), children with MMA scored relatively low in emotional (mean = 73.2), social (mean = 74.5), and school/work (mean = 72.1) quality of life domains compared to the physical (mean = 82.6) domain. On parent proxy PROMIS sleep questionnaires, 53% of children with MMA qualified as having sleep disturbance (41% moderate-severe) and 47% had sleep impairment (35% moderate-severe). Of 25 child and parent proxy PROMIS depression/anxiety forms, 48% indicated moderate-severe anxiety and 24% moderate-severe depressive symptoms.

Conclusions:
Children with MMA have high rates of poor quality of life, sleep disturbance, sleep impairment, anxiety, and depressive symptoms. Future directions include comparison of patient centered outcomes in MMA to children with other stroke etiologies as well as unaffected siblings. A better understanding of patient centered outcomes will allow for improved counseling and targeted therapies to address MMA-related sleep, emotional, social, and school-based impairment.
Abstract TP160: The Non-stenosing Carotid Artery Plaque In Embolic Stroke Of Undetermined Source: A Retrospective Study
Authors: Jumah Ammar , Aboul Nour Hassan O , Intikhab Osama , Choudhury Omar , Gagi Karam , Fana Michael , Alhajala Hisham , Alsrouji Owais , Alkhoujah Mohammad , Eltous Lara , Schultz Lonni , Latack Katie , Chebl Alex , Marin Horia , Miller Daniel
Published: February 2023

Introduction:
Atherosclerotic cervical ICA disease is one of the major causes of ischemic stroke. The risk of stroke from mild to moderate stenoses (i.e., <50% stenosis) might be underestimated. Further investigation is mandated to describe the association between high-risk plaque features and ESUS.

Methods:
This was a retrospective observational study. Using the stroke registry of our hospital's system between June 20th 2016 and June 20th 2021, we reviewed data for patients diagnosed with ESUS according to previously published definition criteria. Using CTA, we analyzed laterality of high-risk plaque features in relation to the stroke side, and then we identified the incidence of recurrent stroke events.

Results:
Out of 1779 patients with cryptogenic ischemic stroke, only 152 met the inclusion criteria for ESUS. We Compared high-risk plaque features ipsilateral to stroke side as to contralaterally. There were significantly more ulcerations defined as >1 mm depression (19.08% vs 5.26%, p<.0001), plaque thickness >3 mm (19.08% vs 7.24%, p=0.001), and plaque length >1cm (13.16% vs 5.92%, p=0.0218). Also, there was a significant difference in stenosis of ipsilateral to stroke when compared contralaterally, especially for stenoses of 10-30% and 31-49% (17.76% vs 10.53% and 5.26% vs 2.63%, respectively. p=0.0327). There was also a significant difference in plaque component; both components (soft and calcified) and only soft plaque (42.76% vs 23.68% and 17.76% vs 9.21%, respectively. p<.0001) were more prevalent ipsilaterally. In total, 17 patients were found to have a recurrent stroke event, 8 patients had an ipsilateral stroke to the index event, 7 had a bilateral and 2 had a contralateral event.

Conclusion:
ESUS is more commonly found ipsilateral to high-risk plaque features. The small number of our sample is definitely a limitation. Further large and multicenter studies aiming to form precise prediction models and scoring systems are needed to help guide treatment.
Abstract TP173: Factors Associated With Decision-making To Close A PFO For Secondary Stroke Prevention
Authors: Al Banna Mona , Marsical Melissa , Salari Apameh , Streib Christopher D , Lakshminarayan Kamakshi , Jasne Adam , Forman Rachel , Amin Hardik , Catucci Amanda , Asnes Jermey , Keeshan Britton C , Sharma Richa
Published: February 2023

Background:
Clinical trial evidence supports patent foramen ovale (PFO) closure to reduce recurrent stroke risk in select patients. Guidelines recommend a multi-disciplinary approach to identify patients who may benefit from PFO closure. We assess factors associated with the decision to close PFO in a real-world cohort.

Methods:
We studied patients from University of Minnesota Medical Center and Yale-New Haven Hospital with TIA or ischemic stroke and PFOs evaluated by dedicated multidisciplinary teams of vascular neurologists and interventional cardiologists at each institution. Demographic, clinical, radiographic, and echocardiographic information was extracted by chart review. The study outcome was PFO closure. Descriptive analyses were performed comparing characteristics associated with PFO closure using Mann Whitney test and Chi-squared test. Multivariable logistic regression model was built with variables significant in descriptive analyses.

Results:
The analytic cohort included 173 patients, of whom 58 patients (33.5%) underwent closure (39.8% of Yale and 20% of UMMC patients were closed). Patients who were closed versus not were similar in age (median age 56 [IQR 21] versus 58 [IQR 21] years), sex, race, diagnosis of TIA or stroke, and co-morbidities except malignancy which was significantly less prevalent among closed patients (2.3% versus 12.1%). Closed patients had a higher RoPE score (median 6 versus 5, p=0.032), and were more likely to have a stroke or TIA of undetermined etiology (55.2 versus 49.6%) and high-risk PFO characteristics (p<0.001, Table). High-risk PFO characteristics (OR 6.4, 95% CI 2.1-19.7), RoPE score (OR 1.5, 95% CI 1.1-2.1), and undetermined etiology (OR 5.5, 95% CI 1.1-28.3) were independent predictors of PFO closure.

Conclusions and Relevance:
In this study of a real-world cohort, we identify patient characteristics that drive decision-making for PFO closure for secondary stroke prevention.
Abstract TP182: Relationship Between Cardiovascular Calcification And Stroke Incidence
Authors: Wada Shinichi , Iwanaga Yoshitaka , Nakai Michikazu , Miyamoto Yoshihiro , Noguchi Teruo
Published: February 2023

Purpose:
To assess the relationship between cardiovascular calcifications including coronary artery (CAC), aortic valve (AVC), and aortic root (ARC) and stroke incidence in patients with suspected coronary artery disease (CAD).

Methods:
In the multicenter prospective cohort study, 1187 patients with suspicious of CAD who underwent coronary computed tomography were registered. Cardiovascular events were recorded with prospective follow-up. Cox proportional hazard model with adjustment for total points of Framingham risk score composed with age, sex, total-cholesterol, high-density lipoprotein cholesterol, diabetes mellitus and smoking were conducted. Hazard ratio (HR) and 95% confidence interval (CI) were calculated.

Results:
A total of 980 patients (mean age, 65 ± 7 years; female, 45.8%) with assessment of CAC, AVC and ARC Agatston scores were analyzed. During a median follow-up of 4.0 years), 19 patients developed stroke and 67 developed cardiac events. Cox proportional hazard analyses showed CAC or AVC Agatston scores were significantly associated with incidence of stroke (Agatston score [/+100 points], HR 1.09 [95% CI: 1.06-1.13], and HR 1.09 [95%CI: 1.05-1.13], respectively). In contrast, CAC or ARC Agatston scores were associated with incidence of cardiac events (Agatston score [/+100 points], HR 1.07 [95%CI: 1.05-1.10], and HR 1.04 [95%CI: 1.02-1.07], respectively).

Conclusion:
Although higher CAC Agatston scores were significantly associated with incidence of both stroke and cardiac events, higher AVC and ARC were associated with incidence of stroke and cardiac events, respectively.
Abstract TP187: The Mortality Cost Of Air Pollution And Carbon Dioxide Related To Mobile Stroke Unit Operation
Authors: Cierny Marek
Published: February 2023

Background:
Mobile stroke units (MSU) have reduced time to thrombolysis, improved outcomes in ischemic stroke, but their sustainability and external costs have not been thoroughly evaluated. Fossil fuel combustion produces carbon dioxide (CO
2
) and air pollution, which contribute to global climate crisis and excess mortality.
Aim:
To estimate the mortality cost of MSU due to increment of CO
2
and air pollution from fuel burned by MSU.

Methods:
Fuel cost of annual operation of MSU, obtained through correspondence, was used to obtain annual volume of gasoline burned by MSU. Estimate of excess global mortality between 2020 and 2100 from CO
2
-related climate change per increment of CO
2
was obtain from literature on the Mortality Cost of Carbon. Assuming the annual city-wide fuel consumption by road vehicles (publicly available) is directly proportional to excess mortality attributable to local traffic-related fine particulate matter (PM
2.5
) air pollution (obtained from the literature), I estimated the increment of excess mortality related to air pollution produced by MSU operations.

Results:
Annual operation of one MSU burned 14.552 EUR of fuel, or 10.3 ton of gasoline, producing 24.7 ton of CO
2
. Such an increment of CO
2
in 2020 is expected to cause 0.0056 excess deaths (95% CI -0.0042, 0.0168) globally between 2020 and 2100 by contribution to climate crisis. In Berlin, mobile sources burn about 1.250.000 tons of liquid fossil fuel annually; and ~744 of annual deaths are attributable to traffic-related air pollution [2.17% (95% CI 1.55%, 2.79%) of total mortality]. Assuming the emission factor of MSU is the same as the local vehicle average, MSU-related air pollution leads to 0.0061 excess deaths (95% CI: 0.0044, 0.0079) per MSU-year.

Conclusion:
Fossil fuel combustion related to MSU operation is estimated to cause 0.0117 excess annual deaths (95% CI 0.0002, 0.0247) due to contribution to local air pollution and global climate crisis.
Abstract TP205: Organic Anion Transporting Polypeptides: Endogenous Blood-brain Barrier Transporters That Are Required For Statins To Exert Neuroprotective Effects In Ischemic Stroke
Authors: Williams Erica I , Betterton Robert , Stanton Joshua A , Lochhead Jeffrey J , Davis Thomas P , Ronaldson Patrick T
Published: February 2023

Clinical development of new drugs for ischemic stroke has been challenging. In contrast, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (i.e., statins) are routinely administered to stroke patients because they improve neurological outcomes. This property of statins requires delivery across the blood-brain barrier (BBB). We have uncovered a BBB uptake transporter for statins: organic anion transporting polypeptide 1a4 (Oatp1a4). Our goal was to determine whether Oatp-mediated transport at the BBB is a required mechanism for a commonly prescribed statin (i.e., atorvastatin; ATV) to exert neuroprotective effects following ischemic stroke.

Methods:
Male Sprague-Dawley rats (200-250 g) were subjected to middle cerebral artery occlusion (MCAO; 90 min) followed by reperfusion. ATV (20 mg/kg, i.v.) was administered 2 h following intraluminal suture removal. Involvement of Oatp-mediated transport was determined using fexofenadine (FEX; 3.2 mg/kg, i.v.), a competitive Oatp inhibitor. Oatp1a4 transport activity was measured by
in situ
brain perfusion. Following MCAO/reperfusion, infarction volumes and brain edema ratios were calculated from TTC-stained brain tissue slices. Hippocampal neuronal cell numbers were assessed by immunofluorescence imaging of neuronal nuclei (NeuN) staining. Post-stroke functional outcomes were assessed via neurological deficit scores and rotarod analysis. At 2 h post-MCAO, ATV uptake was increased in ischemic brain tissue. FEX blocked blood-to-brain uptake of ATV, which confirmed involvement of an Oatp-mediated transport mechanism. ATV reduced post-MCAO infarction volume and brain edema ratio, increased hippocampal NeuN staining, and improved neurological outcomes. All positive effects of ATV were attenuated by co-administration of FEX.

Conclusions:
Our data demonstrate ATV requires functional expression of an endogenous BBB transporter (i.e., Oatp1a4) to exert neuroprotective effects and promote post-stroke recovery. These novel and translational findings provide mechanistic evidence on the critical role of BBB transporters in delivery of stroke drugs to the ischemic brain, information that can facilitate therapeutic advancement in clinical trials.
Abstract TP207: Effects Of Dietary Genistein And Estrogen On Post-stroke Inflammation: Relation To Age And Length Of Estrogen Deprivation.
Authors: Schreihofer Derek , Oppong-gyebi Anthony
Published: February 2023

Background:
Poststroke inflammation plays an important role in the pathophysiology and prognosis of ischemic stroke. Preclinical investigations with the soy-derived phytoestrogen genistein have shown neuroprotective effects under conditions of brain ischemia. However, little is known about how endogenous estrogen deprivation and age influence the neuroprotection of genistein following focal cerebral ischemia. In this study, we investigated the effects of dietary genistein (Gen) on chronic poststroke inflammation and the probable mechanisms underlying its inflammatory responses after hypogonadism.

Method:
Young adult (~3-4 months) and proven retired breeder middle-aged Sprague-Dawley rats (~9 months) were used in the study. Rats were ovariectomized and randomly assigned to different durations of hypogonadism (2 vs 12 wks) followed by a two-wk pretreatment with Gen or 17β-estradiol (E2) implant before inducing 60 min. middle cerebral artery occlusion. After 21 days post-ischemia reperfusion, brains were harvested and processed for biochemical analyses to determine the effect of Gen and E2 on the Interleukin-6 (IL-6) and Transforming Growth Factor (TGF-β1) as surrogate markers of M1 and M2 activation respectively. GAP43 was further investigated as a marker of functional recovery.

Results:
Although there were no significant effects in the ischemic hemisphere, Gen treatment reduced IL-6 expression in the contralateral hemisphere in young subjects while E2 did not affect IL-6 across lengths of hypogonadism in the young cohort (p%lt0.05). After short-term estrogen deprivation, E2 and Gen increased TGF-β1 at the contralateral hemisphere in both young rats and middle-aged rats (p%lt0.05). Gen but not E2 increased GAP43 at the contralateral hemisphere of the young following short-term hypogonadism (p%lt0.05).

Conclusion:
Our results show that Gen reduces contralateral M1 activation in young ovariectomized rat brains independent of the length of estrogen deprivation after focal cerebral ischemia. Both Gen and E2 differentially promote M2 activation as a function of age but may not influence the inflammatory response in the ischemic hemisphere following extended reperfusion poststroke.
Abstract TP21: Association Of Periodontal Disease And Small Vessel Disease In Stroke And Transient Ischemic Attack Patients
Authors: Martin Chylee , McCain Caylee , Pikel Karly , Meyer Jaclyn , Logue Makenzie , Sen Souvik
Published: February 2023

Introduction:
Few studies have systematically investigated the association between periodontal disease (PD) and small vessel disease (SVD) in stroke/TIA patients. White matter hyperintensity (WMH) is a manifestation of SVD in the brain and is a surrogate for vascular cognitive impairment.

Methods:
Consecutive stroke/TIA patients admitted to our tertiary stroke center were assessed for PD as a part of a stroke study. PD was defined as moderate/severe periodontitis by Center for Disease Control/American Academy of Periodontology Working Group. Periventricular (PVWMH) and deep white matter (DWMH) were rated visually on axial FLAIR imaging using the 4-point Fazeka scale and were categorized into none/mild (grades 0-1) or moderate/severe (grades 2-3). Total WMHs were dichotomized into none/mild (grades 0-2) or moderate/severe (grades 3-6). Student t-tests were performed to test continuous variables, and X
2
test was used to compare categorical variables. Multivariable analysis was conducted using multiple logistic regression to test the association between PD and WMH.

Results:
A total of 861 consecutive patients, 404 with PD and 457 without PD, were compared for moderate/severe PVWMH and DWMH. Patients with PD were more likely to be African American (AA) compared to whites (55% vs. 36%, p<0.001). They were also more likely to be smokers (62% vs. 42%, p<0.001). Patients with PD were similar in age (63.7±12.0 vs. 63.4 ± 12.8), gender, hypertension, diabetes, hyperlipidemia, and atrial fibrillation status. PD was associated with total WMH (OR 1.51, 95% 1.14-2.00) and DWMH (OR 1.46, 95% 1.08-1.97). PD was not significantly associated with PVWMH (OR 1.30, 95% 0.98-1.73). These associations remained significant after adjusting for age, gender, race, hypertension, diabetes, and smoking for total WMH (Adj. OR 1.38, 95% 1.01-1.88) and DWMH (Adj. OR 1.37, 95% 1.00-1.90) and remained nonsignificant for PVWMH (Adj. OR 1.24, 95% 0.91-1.70).

Conclusion:
Stroke/TIA patients with PD were more likely to be AA and smokers. We report significant independent associations of PD with total WMH and DWMH manifestations of SVD. This suggests that stroke risk in AA and smokers may be partly mediated by SVD.
Abstract TP217: Combination Treatment By Lipid Mediators Triggers Synergistic Protection Of Ischemic Penumbra After Experimental Stroke
Authors: Bazan Nicolas G , Reid Madigan , Mukherjee Pranab , Obenaus Andre , Khoutorova Larissa , Shelvin Kierany , Ji Jeff , Belayev Ludmila
Published: February 2023

Objective:
Acute ischemic stroke encompasses the penumbra, an area of hypoperfusion surrounding the core with a lifespan of few hours unless reperfusion is restored. Despite this short time window, the penumbra is potentially salvageable and is a target for neuroprotection. This study aimed to determine the neuroprotection of docosanoids, Neuroprotectin D1 (NPD1) and Resolvin D1 (RvD1), on the ischemic penumbra. These lipid mediators are biosynthesized “on-demand” in response to stroke onset to resolve neuroinflammation, restore homeostasis and functional integrity.

Methods:
Male Sprague-Dawley rats (270-360g) were anesthetized with isoflurane/nitrous oxide and received 2h of middle cerebral artery occlusion (MCAo) by intraluminal suture. Neurological status was evaluated at 60 min, and on days 1, 2, 3, 7, and 14, a grading scale of 0-12 was employed. Rats were treated with NPD1 (222 μg/kg) and RvD1 (222 μg/kg) or vehicle (n=6-10 / group). Treatments were administered IV (NPD1 at 3h and RvD1 at 3h 15min) and vehicle (saline at 3h) after the onset of MCAo. There were four groups: NPD1+RvD1 and vehicle, 7 days’ survival, and NPD1+RvD1 and vehicle, 14 days’ survival. Rats were perfused with 4% paraformaldehyde on days 7 and 14, and an
ex vivo
brain MRI was conducted using 11.7 T MRI. Hierarchal region splitting was used to distinguish the core from the penumbra.

Results:
Combinatory treatment with NPD1+RvD1 improved behavioral scores vs. vehicle-treated rats in both 7-day and 14-day groups. In the 7-day NPD1+RvD1 treatment group, the neurological scores improved on days 1, 2, 3, and 7 by 26, 31, 36, and 37% compared to the vehicle group. In the 14-day NPD1+RvD1 treatment group, the neurological scores improved on days 1, 2, 3, 7, and 14 by 29, 31, 32, 34, and 34% compared to the vehicle group. Ischemic penumbra, core, and total lesion volumes (computed from T2WI) were reduced by NPD1+RvD1 treatment by 94, 96, and 95%, respectively.

Conclusion:
Combination treatment by NPD1 plus RvD1 affords synergistic neuroprotection in the post-ischemic brain when treatment is administered at 3 h after stroke onset. We are currently exploring the cell-specific and molecular mechanisms involved. These findings open avenues for ischemic stroke therapeutics.
Abstract TP219: Rns60 Brain Protection In Mouse Ischemic Stroke Mitigates Plasma Tau And Cortical Microvascular Perfusion
Authors: Baena-Caldas Gloria P , Li Jie , Ghosh Supurna , Kalmes Andreas A , Barone Frank C , Moreno Herman , Hernandez A. Ivan
Published: February 2023

Introduction:
RNS60 is 0.9% saline solution hypothesized to contain oxygen nanobubbles. Recently, we showed that 13 days of RNS60 treatment after transient middle cerebral artery occlusion (tMCAo) preserves recovery of memory and reduces brain infarction, neuronal cell death, microglial activation, amyloid pathology, and white matter damage. Previously, we also demonstrated the relationship between white matter demyelination and circulating tau in tMCAo. Here we report that RNS60 decreases plasma tau and increases cortical microvascular perfusion (MVP).

Methods:
Male C57BL/6J mice, 3-4 months old, were randomly divided into sham surgery or unilateral 60-minute tMCAo. Each group was subdivided into three treatment arms, receiving daily intraperitoneal administration of 0.2 mL of RNS60, pressurized normal saline (PNS60), or normal saline (NS) starting 2 hours after surgery for 13 days. Treatment assignments were blinded throughout the study. To assess circulating tau, plasma was collected before surgery and on day 14 post-surgery (after MVP measurements). Animals were then euthanized to assess infarct volume using TTC staining.

Results:
RNS60 treatment significantly (p<0.05) reduced brain infarction by 90% compared to controls, reduced plasma tau by 74% of controls, and significantly (p<0.05) increased MVP in motor cortex by 38% and by 39% in the parietal cortex.

Conclusion:
RNS60-treated mice exhibit significant brain protection after ischemic stroke and display decreased plasma tau levels and a significant increase in microvascular perfusion. Ongoing studies are investigating whether increased MVP is due to activation of angiogenesis. These data further support the evaluation of RNS60 in clinical stroke trials.
Abstract TP223: Cerebral Microbleeds In Sickle Cell Disease
Authors: Fang Chuo , Yan Jiamin , Kiven Stacy , Liu Jihua , Paganini-Hill Annlia , Cribbs David H , Gupta Kalpna , Fisher Mark
Published: February 2023

Introduction:
Stroke due to sickle cell disease is often attributed to large vessel involvement in the disorder. The role of cerebral microvascular disease in sickle cell disease has received little attention. In this study, we examined development of cerebral microvascular lesions in a mouse model of sickle cell disease. We focused on cerebral microhemorrhages, the neuropathologic substrate of cerebral microbleeds.

Methods:
We studied microvascular disease in a well-characterized mouse model of humanized transgenic sickle (HbSS-BERK) and control (HbAA-BERK) mice expressing >99% human sickle hemoglobin (Hb) and normal human HbA, respectively. HbSS-BERK express human α and βS globins on a mixed genetic background. HbAA-BERK mice express normal human α and βA globin thus producing only normal human hemoglobin A, on the same mixed genetic background as HbSS-BERK. Seven- to nine-month-old mice (N=18 HbSS, N=12 HbAA) were examined. We collected mouse brains and performed standard histology using Prussian blue staining to detect CMH formation at 20x magnification. The average number, total area, and size of Prussian blue-positive deposits were quantified. In separate studies, Toluidine Blue staining was used to identify mast cells.

Results:
HbSS mice showed approximately 70% more cerebral microhemorrhages than controls (mean±SE of 1.17± 0.22 vs 0.69±0.13 number/cm
2,
p=0.04). Lesion size did not differ between HbSS and control mice. Activated mast cells were identified in HbSS mouse brain but not in control mice.

Conclusions:
In this mouse model of sickle cell disease, HbSS mice demonstrated significantly increased development of cerebral microhemorrhages. These findings emphasize the potential importance of cerebral microvascular disease in sickle cell disease. Cerebral mast cell activation in sickle cell disease may be a novel target for investigation.