bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 2652: Carotid Revascularization Provides Similar Outcomes in Symptomatic and Asymptomatic Patients with <70 Years
Authors: De Rango Paola , Verzini Fabio , Cao Piergiorgio , Cieri Enrico , Giordano Giuseppe , Simonte Gioele , Manzone Alessandra , Lenti Massimo
Published: July 2021

Absolute stroke risk and perioperative stroke risk during carotid revascularization are higher in patients with symptomatic than in those with asymptomatic carotid stenosis. Age is one of the main risk factors for stroke and trials have shown a significant age interaction after carotid stenting (CAS). This study aims to analyze the effect of age on outcomes of carotid revascularization using the 70-year threshold as suggested by CREST.

Methods:
From 2001 to 2010 patients receiving carotid revascularization, either by CAS or by endarterectomy (CEA) were reviewed. Perioperative stroke-death rates and 72-month survival and late stroke incidence were compared in symptomatic and asymptomatic patients with less and more than 70years.

Results:
2196 procedures, 1080 by CAS 1116 by CEA, were reviewed;684 were performed for carotid referable symptoms. Symptomatic patients showed higher perioperative stroke/death risks (3.5% vs 1.9%, p=0.034) and lower 72-months survival (74% vs 82%, p=0.0001) or freedom from late stroke (93% vs 97%, p=0.002) than asymptomatic patients with similar differences detected within CEA or CAS procedure. When only the group of 949 youngsters (≤70y) was analyzed, symptomatic and asymptomatic patients shared similar low perioperative stroke/death risks: 2.1% vs 1.3%, p=0.39. For young symptomatic patients, perioperative stroke/death risk was comparably low in CAS and CEA: 1.8% vs 1.2%. At 72 months, survival (98% vs 97%, p=0.49) and freedom from stroke (89% vs 89%, p=0.33) rates were similarly high in symptomatic and asymptomatic young patients. Comparable risks between the symptomatic and asymptomatic youngsters were found after each CAS (perioperative stroke/death: p=0.64; survival: p=0.10; late stroke: p=0.50) and CEA (perioperative stroke/death: p=0.49; survival: p=0.91; late stroke: p=0.64) procedure. Higher perioperative and late risks were confirmed for symptomatic patients in the elderly (>70y) subgroup (n=1247) regardless of the procedure.

Conclusions:
Outcomes following carotid revascularization are related to patient age. For younger ages (≤70years) symptomatic and asymptomatic patients may share similarly low perioperative and late risks of stroke and death after carotid revascularization whichever the procedure applied.
Abstract 2653: Hypothermia For Intracerebral Hemorrhage: Mortality And Long-term Functional Outcome
Authors: Staykov Dimitre , Wagner Ingrid , Doerfler Arnd , Schwab Stefan , Kollmar Rainer
Published: July 2021

Background
Mild prolonged hypothermia reduces perihemorrhagic edema (PHE) growth and may improve survival after large intracerebral hemorrhage (ICH). However, functional outcome data are scarce and lower mortality after large ICH may be achieved at the cost of higher disability. We investigated the course of edema evolution and long term functional outcome in 22 consecutive patients with large ICH (>25ml) who were treated with hypothermia.

Methods
Mild endovascular hypothermia (35°C) was applied within 12h after symptom onset for a period of 10 days. PHE was measured on computed tomography scans using a semi-automatic threshold based algorithm. Outcome was assessed 90 days and one year after symptom onset.

Results
Twenty-two patients aged 62±9 years with spontaneous supratentorial ICH (58±25ml) received hypothermia. Volumetric analysis showed significantly less PHE in those patients during and after hypothermia, as compared to historical controls who did not receive hypothermia. Twenty patients (91%) survived until day 90 after symptom onset. One year after the bleeding event, eight patients had a modified Rankin scale (mRS) score of 3, eight patients had a mRS of 4, two patients a mRS of 5 and totally four patients had died.

Conclusions
Despite of large initial ICH size, patients treated with hypothermia showed a low mortality rate and eight patients (36%) were able to walk without assistance one year after ICH. Hypothermia may be a promising treatment approach in large ICH. An ongoing multicenter randomized clinical trial (CINCH) is investigating this treatment option.
Abstract 2667: Comparative Effectiveness Analysis of Stroke Center Designations on Patient Outcomes
Authors: Langabeer James R , Seo Munseok , Delgado Rigoberto
Published: July 2021

Background:
Stroke designation has become increasingly important for administrators and physicians of stroke facilities in recent years. Designation (accreditation, recognition) as a stroke center implies to the community tangible evidence of quality, yet no study has assessed the comparative effectiveness of outcomes for designation in stroke.

Methods:
Using 2004 to 2009 for all patients treated for acute ischemic stroke across all 547 hospitals in Texas, we perform a comparative effectiveness analysis. Ischemic strokes include only ICD-9 codes 433-436. De-identified data were obtained from the Texas Health Care Information Collection data files. Hospitals were categorized in three groups: 1) recognition from the American Heart Association Get With the Guidelines Stroke program; 2) accreditation from the Joint Commission as a Primary Stroke Center (PSC), or 3) non-accredited from either of these programs. We compared each of these three subgroups employing various tests for differences and logistic regressions for odds ratios at 95% CI. Outcome measures assessed include mortality rate, average length of stay (ALOS), treatment costs, and use of thrombolysis. We adjusted mortality rates and lytics utilization based on risk mortality, illness severity, and patient age to control for mix and acuity. We calculated lytics rates dividing total cases where lytics were utilized by total ischemic strokes. We adjusted hospital reported charges using a standard cost-charge ratio.

Results:
41 hospitals (7.5%) are recognized by the GWTG Gold or Silver levels, and 77 (14%) were recognized as a Primary Stroke Center. The remainder had neither designation. Of the 275,163 total strokes, 86% were ischemic. ALOS for all patients was 5.3 days, and average hospital costs were $36,529. Average mortality rate was 3.5% and mean lytics utilization was 1.6% across all cases. KW median test confirms that PSC hospitals had significantly lower ALOS compared to the non-accredited group (5.1 days vs. 5.5) and lower costs ($34,428 vs. $38,952). Logistics regressions showed significantly higher lytics rate (OR=3.3) as well as marginally higher mortality rates (OR=1.1). The GWTG subgroup had similar statistically significant results with ALOS (5.1) and costs ($34,792) both being significantly less than the non-accredited group. The odds ratio for lytics usage was exactly twice that of the non-accredited group. Mortality rates however were not significantly different between the two groups.

Conclusion:
Accreditation or designation of stroke facilities is associated with more efficient practice of care and improved processes (shorter stays, lower costs, and improved lytics use). Mortality rate however was marginally higher in one of the two accredited subgroups, but not in the other. Results suggest expansion of strengthening and expansion of designation programs.
Abstract 2671: Thymosin Beta 4 Induced Oligodendrogenesis Is Associated With Upregulation Of Serum Response Factor
Authors: Morris Daniel C , Buller Benjamin , Santra Manoranjan , Chopp Michael , Zhang Zheng Gang
Published: July 2021

Background:
Thymosin beta 4 (Tβ4) is a G-actin sequestering peptide that improves neurological functional outcome when administered 24 hours after onset of stroke to a rat model of embolic stroke. Tβ4 increases the number of oligodendrocyte progenitor cells (OPCs) as well as mature oligodendrocytes (OLs). Mechanisms of Tβ4 induced oligodendrogenesis (OLG) remain unclear. Serum response growth factor (SRF) is a transcriptional factor which binds with ternary complex co-factors to primarily convey an immediate early gene response to influence and orchestrate neuronal migration and differentiation.

Hypothesis:
We tested the hypothesis that Tβ4 upregulates SRF with subsequent increase in the markers of OL differentiation.

Results:
We employed a mouse OPC line (N20.1) to investigate the mechanisms of Tβ4-induced OLG. The cells were plated at a density of 100,000 cells/ml and grown in the presence of 0, 12.5, 25 and 50 ng/ml of Tβ4 (RegeneRx Biopharmaceuticals, Inc.) for 14 days (n=3). Western blot analysis revealed that SRF was dose-dependently upregulated by a factor of 4. Quantitative real time PCR and Western blot analysis showed that Tβ4 treatment induced myelin basic protein (MBP) and 2’, 3’-cyclic nucleotide, 3’-phosphodiesterase (CNPase) expression in a dose-dependent manner by ∼2 fold, indicating the stimulation of OLG. In order to independently demonstrate that SRF promotes the differentiation of progenitor cells into mature oligodendrocytes, SRF was over expressed in the N20.1 cells using a plasmid encoding the SRF gene. After six days SRF over expressed N20.1 cells (n=3) demonstrated an increase of expression of MBP (26 ± 3%) and CNPase (23 ± 3%) when compared to cells transfected with an empty expression plasmid (n=3, MBP, 14 ± 3% and CNPase, 10 ± 4%, p<0.05).

Conclusions:
In this mouse model of OPCs, SRF was upregulated by Tβ4 and may be involved in Tβ4 induced OLG. Further in vivo investigation of SRF is warranted in our rat model of embolic stroke.
Abstract 2695: A Clinical Prediction Rule for Pneumonia after Acute Stroke
Authors: Schepp Sara K , Tirschwell David L , Longstreth W T
Published: July 2021

INTRODUCTION:
Dysphagia screens aim to reduce aspiration and pneumonia (PNA) after stroke. The frequency of PNA after stroke is low, especially in those with mild stroke who have not been intubated. We sought to identify a subset of patients with acute stroke who are at such low risk of PNA that bypassing a dysphagia screen would be justified.

METHODS:
Harborview Medical Center, a tertiary care academic and primary stroke center, maintains a database of all patients admitted with stroke. From this, we identified 1,641 adults admitted to the Neurology service between 2007 and 2010 for acute ischemic or hemorrhagic stroke (HS). We excluded those with subarachnoid hemorrhage, those who had been intubated, except if only for a procedure, and those who lacked admission NIHSS. With PNA as outcome of interest, we sought associations with potential predictors using multiple logistic regression. We then created a score to predict PNA with each item’s weight based upon its magnitude of association with PNA in the multivariable model.

RESULTS:
For the resulting 1,008 subjects, average age was 64.0 (+/- 18.2), 57.8% were male, 64.2% had ischemic stroke, and average NIHSS was 7.7 (+/- 8.5). PNA was diagnosed in 67 (6.6%) during the hospitalization. Age, stroke type, NIHSS, atrial fibrillation (AF), heart failure (HF), and chronic obstructive pulmonary disease (COPD) had significant univariate association with development of PNA. In multivariable models, all but AF retained significance. Adjusted odds ratios and 95% confidence intervals were: age (per year: 1.02, 1.00 - 1.04), NIHSS (per point: 1.04, 1.02 - 1.06), HS (1.67, 1.00 - 2.80), HF (2.62, 1.37 - 5.04), COPD (2.39, 1.23 - 4.64). The PNA score ranged from 0-10 with points assigned as follows: age ≥ 75 (2 pts), NIHSS 5-11 (1pts), NIHSS ≥ 12 (3 pts), HS (1 pt), HF (2 pts), COPD (2 pts). Only 8 cases of PNA were diagnosed in the 452 patients with a score of ≤1 (frequency 1.8%). The remaining 59 cases occurred in those 556 patients with a score of >1 (frequency 10.6%). This predictive model yielded a receiver operator curve with area under the curve of 0.76.

DISCUSSION:
We developed a clinical prediction rule to estimate risk of PNA after acute stroke based upon age, stroke type and severity, and presence of HF and COPD. Presence of dysphagia was not one of the factors we examined because we were interested in seeing if we could identify a subgroup of patients with such low risk of PNA that bypassing a swallowing screen would be justified. Validation of the rule in an independent sample is needed before it could be used to influence clinical decisions. Limits of our study are the reliance on an existing database, which lacked potentially important predictors such as stroke location. Also, we do not know whether PNA was due to aspiration and stroke nor whether HF and COPD played a causal role or merely increased likelihood of PNA detection.
Abstract 2733: The Comparative Importance of `Shared' Risk Factors for Ischemic Stroke and Intracerebral Hemorrhage in Patients with Atrial Fibrillation
Authors: McGrath Emer R , Kapral Moira K , Fang Jiming , O'Donnell Martin J ,   Registry of the Canadian Stroke Network
Published: July 2021

Background:
Optimal prescribing of oral anticoagulants, for the prevention of stroke in patients with atrial fibrillation, requires clinicians to estimate the competing risk of ischemic stroke and intracerebral hemorrhage (ICH). However, a number of risk factors increase the risk of both ischemic stroke and ICH (e.g. age, hypertension and chronic renal disease), and it is unclear how these ‘shared’ risk factors should influence decisions on antithrombotic therapy.

Objective:
To determine the comparative importance of risk factors for ischemic stroke and ICH in patients with atrial fibrillation, focusing primarily on risk factors included in the CHA2DS2VASC (risk of ischemic stroke) and HAS-BLED (risk of major bleeding) scores.

Methods:
Prospective registry of 3,197 patients admitted with acute ischemic stroke or ICH and atrial fibrillation included in the Registry of the Canadian Stroke Network (Jul 03-Mar 08; 11 Regional Stroke Centers in Ontario, Canada). Multivariable analysis was used to determine the association between baseline risk factors (age, sex, history of hypertension, previous stroke or transient ischemic attack, history of congestive heart failure, history of vascular disease, hepatic impairment, current alcohol intake, history of diabetes mellitus, history of gastro-intestinal bleeding, renal impairment, admission INR and antiplatelet therapy) and risk of ischemic stroke versus ICH.

Results:
Of 3,197 patients with atrial fibrillation and acute stroke, 2,806 (87.8%) presented with an ischemic stroke and 391 (12.2%) presented with an ICH. Of the ‘shared’ risk factors, age (OR 1.17; 95% CI 1.04-1.31 per decade) and previous history of stroke (OR 1.40; 95% CI 1.09-1.81) were associated with an increased risk of ischemic stroke relative to ICH, while a history of hypertension (OR 0.90; 95% CI 0.69-1.18) and renal impairment (OR 1.29; 0.96-1.72) were not associated with either stroke subtype, on multivariable analyses. Of the ‘non-shared’ risk factors, alcohol consumption of <2 units/day vs. no consumption (OR 1.61; 95% CI 1.24-2.09), female sex (OR 1.53; 95% CI 1.20-1.96) and a history of vascular disease (OR 1.73; 95% CI 1.30- 2.30) were associated with an increased risk of ischemic stroke relative to ICH. Elevated INR at the time of admission was a significant predictor of ICH, relative to ischemic stroke.

Conclusion:
None of the ‘shared’ risk factors were stronger predictors of ICH compared to ischemic stroke, which has obvious implications for clinical practice. In particular, older age was more strongly associated with ischemic stroke than ICH in patients with atrial fibrillation, and therefore, should be considered as a factor favoring a decision to commence anticoagulant therapy.
Abstract 2736: Is Treatment Of Young Ischemic Stroke Patients Improving? Insights From The Nationwide Inpatient Sample
Authors: Kansara Amit , Chaturvedi Seemant , Bhattacharya Pratik
Published: July 2021

Background and purpose:
Recent studies have shown a trend for increasing use of thrombolysis among acute ischemic stroke (AIS) patients. However, data is lacking for use of thrombolysis among young (19-44 years) AIS patients. It is important to follow the trend as costs and burden of stroke related disability can be significantly higher in young adults as they are more likely to live longer than elderly people with stroke.

Method:
Discharge data were obtained from Nationwide Inpatient Sample from 2001 to 2009. AIS were defined by discharge diagnosis codes from International Classification of Diseases ICD 9 revision (433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, and 436). For thrombolysis treatment ICD 9 code 99.10 was used. For mechanical thrombectomy, code 39.74 was used for year 2006 to 2009. Cochran Armitage test was used for trend analysis.

Result:
From 2001 through 2009, there were an estimated 4,917,217 admissions for acute ischemic stroke. Out of that, 204,703 (4.16%) were young patients with AIS. Numbers of AIS among young adults increased from 19293(3.30% of total AIS) in 2001 to 24816 (4.57%) in 2009 (p<0.0001). 51.4% patients were female in 2001 and 49.3% in 2009. Thrombolysis in young ischemic stroke increased from 354 (1.84% of young AIS) in 2001 to 1237 (4.97%) in 2009 (p<0.0001). Thrombolysis among all AIS increased from 1.00% to 3.84% (p<0.0001) in the same time period. Number of mechanical thrombectomy increased from 53 (0.14%) in 2006 to 527 (0.82%) in 2009 (p<0.0001) in young AIS. In the same time period, mechanical thrombectomy rate in all AIS patients increased from 0.05% to 0.48% (p<0.0001).

Conclusion:
Thrombolysis rate among young AIS significantly increased from 2001 to 2009. Thrombolysis rate was higher in young AIS than all AIS for all the years from 2001 to 2009. Mechanical thrombectomy rate also significantly increased from 2006 to 2009 among young AIS and it was almost twice the rate all AIS patients. Data on outcomes of young AIS treated with thrombolysis or mechanical thrombectomy are needed.
Abstract 2750: Comparison of Enterprise with Neuroform Stent-Assisted Coiling of Intracranial Aneurysms
Authors: Kadkhodayan Yasha , Rhodes Nicholas , Blackburn Spiros , Derdeyn Colin P , Cross DeWitte T , Moran Christopher J
Published: July 2021

INTRODUCTION:
The Enterprise (Codman, Raynham, MA) is the first closed-cell stent designed to treat wide-necked intracranial aneurysms. Advantages of the design can include improvement in keeping coils within the aneurysm and the ability of the stent to be partially deployed and recaptured. We compared the technical and clinical complications of the Enterprise with the Neuroform (Stryker, Kalamazoo, MI).

METHODS:
Between March 2007 and June 2011, Enterprise stent-assisted coil embolization was attempted for 106 aneurysms in 96 patients (mean age 58, 81 female) who were enrolled in a prospective registry. Deployment success and difficulty, stent movement and misplacement, and 30 day symptomatic neurological events were compared with a prospective cohort of patients treated with all generations of the Neuroform using a two-tailed Fisher exact test with p < 0.05 accepted for significance.

RESULTS:
Enterprise stent deployment success was high (107 of 113 attempts, 94.7%) with 101 of the 106 aneurysms receiving a stent. The delivery microcatheter could not be positioned in 5 cases. Two stents were deployed with difficulty (1 guide catheter change and 1 recapture prior to deployment). Six cases required a second stent for misplaced stents (n = 4), stent movement on coiling attempt (n = 1) and down-sizing because a longer stent could not be unsheathed (n = 1). There were 12 periprocedural thromboembolic or hemorrhagic events consisting of 7 transient ischemic attacks (TIA), 3 ischemic strokes and 2 intracranial hemorrhages. One TIA was attributed to non-compliance with antiplatelet therapy. One hemorrhage presented 2 days later, thought to be related to antiplatelet therapy. Results are compared with the Neuroform in the
table
below.

CONCLUSION:
The Enterprise is significantly easier to deploy than the Neuroform; however, there are more thromboembolic complications in the form of periprocedural TIA and stroke. Hemorrhagic complication rates were similar.
Abstract 2766: Hemodynamic Changes Following Direct EC-IC Bypass In Moyamoya Disease Patients Measured Using Combined Arterial Spin Labeling And Dynamic Susceptibility Contrast MR Imaging
Authors: Zaharchuk Greg , Spilker Ryan L , Steinberg Gary K
Published: July 2021

Background:
The goal of direct bypass in Moyamoya patients is to reduce the risk of future strokes, presumably by improving cerebral hemodynamics. Combined ASL and DSC MR perfusion imaging (CAD-perfusion) is a new quantitative methodology to measure perfusion parameters (
1
).

Methods:
We applied this method to 20 newly-diagnosed, symptomatic Moyamoya patients (11 bilateral, 9 unilateral). Imaging was acquired at 3T (GE MR 750, Waukesha, WI) before and approximately 6 months following direct STA-MCA anastomosis. ASL was performed using 3D fast-spin-echo background-suppressed pseudocontinuous ASL with the following parameters (TR/TE/label time/post-label delay 5500/2.5/1500/2000 ms; spatial resolution 3 × 3 × 4 mm; imaging time 4:37). DSC was performed using gradient-echo EPI with the following parameters (TR/TE 1800/40 ms; 1.9 × 1.9 × 5 mm; 0.1 mmol/kg Multihance contrast). Images were co-registered, placed into template space, and resliced to 10 mm axial slice thickness corresponding to the ASPECTS slices using SPM8. CAD-perfusion images (CAD-CBF and CAD-CBV) were created using standard methods (
1
). Analysis was by hemisphere (n=20 posterior, n=31 bypassed anterior, and n=9 non-bypassed anterior regions). Hemodynamic measurements were made in mixed cortical ROI’s. The Wilcoxon rank-sum test was used to assess significance at the p<0.05 level.

Results:
6 months following bypass, Tmax in the bypassed anterior circulation decreased significantly (from 3.6±1.2 to 3.0±0.9 sec, p=0.019) but did not change in either the non-bypassed anterior circulation or posterior circulation. CAD-CBF did not increase in any of the three regions; in particular, no increase was seen in the anterior bypassed regions (from 34.8±8.5 to 36.8±8.1 ml/100 g/min, p>0.05). This is consistent with prior reports suggesting that baseline CBF does not change following bypass (
2
). Interestingly, CAD-CBV was significantly increased in all regions following bypass; this change was largest in the non-bypassed anterior circulation (from 4.5±1.0 to 6.1±2.3%, p=0.035).

Conclusion:
Hemodynamic changes following bypass are complex and involve both hemispheres. CAD-perfusion MRI allows the ability to follow these parameters in a quantitative way.
Abstract 2779: The Safety of Intravenous Thrombolysis for Ischemic Stroke in Patients With Pre-Existing Cerebral Aneurysms: A Retrospective, Hospital-Based Study
Authors: Edwards Nancy , Kamel Hooman , Josephson S. Andrew
Published: July 2021

Background and Purpose:
Unruptured cerebral aneurysms are currently considered a contraindication to intravenous tissue plasminogen activator (IV tPA) for acute ischemic stroke. This is due to a theoretical increase in the risk of hemorrhage from aneurysm rupture, although it is unknown whether this risk is significant. We sought to determine the safety of IV tPA administration in a cohort of patients with pre-existing aneurysms.

Methods:
We reviewed the medical records of patients treated for acute ischemic stroke with IV tPA during an 11-year period at two academic medical centers. We identified a subset of patients with unruptured cerebral aneurysms present on pre-thrombolysis vascular imaging. Our outcomes of interest were any intracranial hemorrhage (ICH), symptomatic ICH, and subarachnoid hemorrhage (SAH). Fisher’s exact test was used to compare the rates of hemorrhage among patients with and without aneurysms.

Results:
We identified 236 eligible patients, of whom 22 had unruptured cerebral aneurysms. The rate of ICH among patients with aneurysms (14%, 95% CI 3-35%) did not significantly differ from the rate among patients without aneurysms (19%, 95% CI 14-25%). None of the patients with aneurysms developed symptomatic ICH (0%, 95% CI 0-15%), compared with 10 of 214 patients without aneurysms (5%, 95% CI 2-8%). Similar proportions of patients developed SAH (5%, 95% CI 0-23% versus 6%, 95% CI 3-10%).

Conclusion:
Our findings suggest that IV tPA for acute ischemic stroke is safe to administer in patients with pre-existing cerebral aneurysms as the risk of aneurysm rupture and symptomatic ICH is low.
Abstract 2781: Prevalence and Characterization of Cerebral Microbleeds in Lacunar Stroke Patients: Observations from the Secondary Prevention Small Subcortical Strokes (SPS3) Trial
Authors: Shoamanesh Ashkan , Szychowski Jeff , Catanese Luciana , Benavente Oscar
Published: July 2021

Background:
The prevalence of cerebral microbleeds (CMBs) has been reported to be high in patients with cerebrovascular disease and particularly in those with cerebral small vessel disease; i.e. lacunar strokes. However, methodological limitations of previous studies imposed by small sample sizes and the absence of a clear classification of stroke subtypes hampers the conclusions regarding prevalence and characterization of CMBs in lacunar stroke patients.

Methods:
SPS3 is a multi-center international randomized trial including a well-defined cohort of MRI proven lacunar stroke patients. We investigated patients within this population who had an axial T2*- GRE sequence available as part of their baseline clinical MRI. The Brain Observer MicroBleed Scale was used to rate the presence and topography of CMBs. CMB severity was graded as either absent, 1-2 CMBs or >2 CMBs. We compared baseline characteristics and vascular risk factors between patients with CMBs and those without and between the defined CMB severity grades.

Results:
Of the 651 MRIs analyzed, 237 (36%) had CMBs. Patients with CMBs were more often male (73% vs 62%, p<0.01) and Hispanic (49% vs 39%, p=0.02), were more likely to have hypertension (95% vs 90%, p=0.01) and prior lacunar stroke (13% vs 7%, p=0.01), and had lower baseline mean Cognitive Abilities Screening Instrument (CASI) scores (80 vs 86, p<0.01). Male gender [OR 1.85 (95% CI, 1.26 to 2.70)], prior lacunar stroke [OR 2.19 (95% CI, 1.19 to 4.03)] and lower baseline CASI scores [OR 0.97 (95% CI, 0.95 to 0.98)] remained significant following multivariate analysis. A significant association was found between increasing CMB severity and decreasing CASI scores (p<0.01), an increased presence of multiple lacunar infarcts (p<0.0001) and moderate-severe white matter hyperintensities on MRI (p<0.0001).

Conclusions:
Preliminary results of this large and well-defined cohort of lacunar stroke suggest a high prevalence of CMBs. A significant association was observed between CMBs and gender and a history of lacunar stroke. CMB severity was associated with multiple infarcts and severity of white matter disease on MRI, as well as lower cognitive function. Ongoing data from SPS3 will likely elucidate whether prognosis and response to therapy differ in patients with CMBs.
Abstract 2786: Moyamoya Syndrome Associated With Graves' Disease: Report Of 16 Cases
Authors: NI Jun , ZHOU Li-xin , WEI Yan-ping , DUAN Lian , GAO Shan , CUI Li-ying
Published: July 2021

Background and purpose
Moyamoya disease is a cerebrovascular disorder characterized by bilateral progressive stenosis and occlusion of terminal portions of internal carotid artery (ICA) accompanying by typical net-like collateral vessels. Patients with both the characteristic moyamoya vasculopathy and the associated conditions are categorized as moyamoya syndrome. These conditions include sickle cell disease, neurofibromatosis type 1, Down’s disease, cranial therapeutic irradiation and other rare diseases. Moyamoya syndrome associated with Graves’ disease has been rarely reported and the underlying coexisting mechanism remains unclear. The aim of this study is to identify the clinical and radiological findings of the patients with simultaneous diagnosis of moyamoya syndrome and Graves’ disease. Possible mechanisms predisposing these individuals to ischemic accidents are discussed.

Methods
We retrospectively identified 12 patients in Peking Union Medical College Hospital and 4 patients in 307 hospital of PLA between May 2000 and December 2010. All patients were female and mean age (range) was 35.13±12.34 years (11-57 years). The patients were diagnosed with Graves’ disease in endocrinology clinic which meet the full diagnostic criteria and no atherosclerotic factor was found in them. Moyamoya vasculopathy was definitely or probably diagnosed by digital subtract angiography or magnetic resonance angiography. The clinical characteristics and prognosis, laboratory data, vascular radiological characteristics were all collected.

Results
Stenosis or occlusion of bilateral distal ICA and/or proximal anterior /middle cerebral arteries was found in 13 patients. Three patients had unilateral distal ICA stenosis and abnormal collateral vessels. PCA stenosis was found in 2 patients. Fifteen patients presented with infarction or transient ischemic attack and one with dizziness. Interestingly, thyroid function tests demonstrated predominantly elevated thyroxine and suppressed thyroid stimulating hormone level in 15 patients when cerebrovascular accidents occurred. All patients received antithyroid therapy and two had recurrent ischemic attack after several months of drug withdrawal. Four patients underwent revascularization procedures after normalization of their hormonal conditions in 307 Hospital of PLA and their neurologic status has remained stable during follow-up.

Conclusions:
Compared with classical moyamoya disease, moyamoya syndrome associated Graves’ disease more commonly presented asymmetric stenosis or occlusion and PCA lesions. Cerebrovascular hemodynamic changes attributable to thyrotoxicosis might be responsible for ischemic attack and further studies are required to verify this hypothesis.
Abstract 2803: Cilostazol Reduces Carotid Atherothrombotic Plaques In Patients With Acute Ischemic Stroke During A 6-month Follow-up
Authors: Nakamura Tomomi , Tsuruta Shinji , UCHIYAMA SHINICHIRO
Published: July 2021

Introduction:
We previously reported that patients treated with aspirin plus cilostazol during the acute phase of ischemic stroke had less neurological deterioration than those treated with aspirin alone. However, the mechanisms of this beneficial effect remain unknown. Although cilostazol has been reported to induce regression of carotid atherosclerosis in patients with type 2 diabetes mellitus, no report has focused on patients with acute ischemic stroke. Therefore, we performed carotid ultrasonography in a sub-study of a randomized trial to investigate the effects of aspirin plus cilostazol on the progression of carotid plaques and intima-media thickness (IMT) during the first 6 months after acute ischemic stroke.

Patients and Methods:
This randomized study compared the effects of oral aspirin alone to aspirin plus cilostazol in patients admitted to our hospital due to non-cardioembolic ischemic stroke within 48 h of stroke onset. Maximum IMT within the internal and common carotid arteries (max IMT) and plaque score (PS) were examined on admission and 6 months after study entry. No other antithrombotic drugs were administered during the follow-up period. For statistical analysis, on-treatment analysis was conducted, and patients who had adverse effects due to aspirin or cilostazol and were treated with other antithrombotics due to neurological deterioration (NIH Stroke Scale score ≥1) were excluded from the analysis.

Results:
Seventy-six patients were enrolled in the study and randomly allocated to one of the treatment groups. During the 6-month follow-up, 10 patients in the aspirin group and 3 in the aspirin plus cilostazol group experienced neurological deterioration. As a result, 16 patients in the aspirin group and 26 in the aspirin plus cilostazol group completed the 6-month follow-up. Vascular risk factors and use of antihypertensive or lipid-lowering drugs did not significantly differ between the groups. In the aspirin plus cilostazol group, the changes in max IMT had a tendency towards regression when compared with the aspirin group (-0.23 ± 0.60 vs. 0.10 ± 0.53; p = 0.08). The regression in PS was significantly greater in the aspirin plus cilostazol group than in the aspirin group (-1.02 ± 2.20 vs. 1.00 ± 2.27; p = 0.0068).

Conclusion:
Compared to treatment with aspirin alone, treatment with aspirin plus cilostazol is more effective for preventing progression of carotid plaques for 6 months after stroke onset.
Abstract 2834: Elevated Blood and Cerebrospinal Fluid Matrix Metalloproteinase-9 is Associated with Poor 3-month Outcome Following Subarachnoid Hemorrhage
Authors: Chou Sherry H , Feske Steven K , Simmons Suzanne , Orzell Susanne , Bauer David , Marckmann Andrea , Du Rose , Lo Eng H , Ning MingMing
Published: July 2021

Background
There is growing evidence supporting the role of inflammation in early brain injury (EBI) and cerebral vasospasm following subarachnoid hemorrhage (SAH). Matrix Metalloproteinases (MMP) are released by inflammatory cells and can mediate EBI via disruption of the extracellular matrix. MMPs also cleave endothelin-1 (ET-1) into strongly vasoactive fragments and may thereby mediate vasospasm, which can further worsen SAH outcome. We hypothesize that elevated MMP-9 in human cerebrospinal fluid (CSF) is associated with vasospasm and SAH outcome, and therefore a potential clinical biomarker.

Methods
We prospectively enrolled consecutive SAH subjects, banked serial blood and CSF samples, and evaluated their 3- and 6-month modified Rankins scores (mRS) via telephone follow-up. Angiographic vasospasm was defined as >50% reduction in vessel caliber on angiography on post-SAH day 6-8. Poor outcome was defined as mRS>2. We compared blood and CSF MMP-9 by ELISA on post SAH days 0-1, 2-3, 4-5, 6-8, and 10-14 in a cohort of SAH subjects (N=35) with respect to vasospasm and to 3-month outcome. Continuous variables were compared using student t-test or Wilcoxan rank sum test depending on data normality. Repeated measurements were analyzed using longitudinal regression.

Results
The study population had a mean age of 53 years and has 54% female. Sixty percent of subjects presented with Hunt and Hess grade of 3 and above. Fifty-four percent developed vasospasm and 32% achieved poor 3-month outcome. Elevation of CSF MMP-9 throughout post SAH days 0-14 was associated with poor 3-month outcome (p=0.008). Specifically, elevated CSF MMP-9 on post SAH day 2-3 (p=0.05) and blood MMP-9 on post SAH day 4-5 (p=0.045) were associated with poor 3-month outcome (
Figure 1
). Blood MMP-9 correlated strongly with blood leukocyte count (r=0.56, p=0.007). Neither CSF nor blood MMP-9 correlated with vasospasm.

Conclusion
Early elevation of CSF and blood MMP-9 are associated with poor 3-month outcome but not with vasospasm in SAH. Leukocytes are likely a significant source of blood but not CSF MMP-9. Blood and CSF MMP-9 may mediate neuronal death in SAH via mechanisms independent of angiographic vasospasm. Further studies are necessary to determine the source of CSF MMP-9 and the mechanism by which it mediates poor outcome in SAH. Larger prospective studies are necessary to validate CSF MMP-9 as a predictive biomarker for SAH outcome.
Abstract 2851: Intravenous Heparin For The Treatment Of Intraluminal Thrombus In Patients With Acute Ischemic Stroke
Authors: Mokin Maxim , Kass-Hout Tareq , Kass-Hout Omar , Kan Peter , Siddiqui Adnan , Levy Elad , Snyder Kenneth
Published: July 2021

Background and objectives:
Current American Stroke Association/American Heart Association recommendations on the management of acute ischemic stroke do not recommend early use of heparin owing to increased risk of bleeding complications. However, for select patients, such as those with strokes associated with intraluminal thrombus, intravenous (IV) heparin might prove to be beneficial.

Methods:
We conducted a retrospective analysis of acute ischemic stroke cases associated with intraluminal thrombus of intracranial and extracranial arteries in the corresponding vascular territories to identify patients in whom treatment with IV heparin resulted in near-complete or complete lysis of the thrombus. Imaging findings from computed tomographic (CT) perfusion and angiography, magnetic resonance imaging, and/or digital subtraction angiography were used to describe the location of intraluminal thrombus immediately before and after treatment with IV heparin.

Results:
Eighteen patients with confirmed intraluminal thrombus by CT angiography (CTA) received treatment with IV heparin alone (median duration 3.5 days; range 1-8 days). The median NIHSS score was 2.5 (range 0-15) on admission and 1 (range 0-9) at discharge. Nine patients had complete lysis, and 9 patients had partial lysis of the thrombus with improved flow distal to the location of the thrombus. None of the patients developed intracranial hemorrhage.

Conclusion:
For strokes associated with intraluminal thrombus, IV heparin might prove to be an effective treatment strategy. Further studies are necessary to evaluate the efficacy and safety of treatment with IV heparin in those patients.
Abstract 2858: Topographical Distribution of Brain Microbleeds and Global Cognitive Function in Adults without Neurological Disorders
Authors: Yakushiji Yusuke , Noguchi Tomoyuki , Hara Megumi , Nishihara Masashi , Eriguchi Makoto , Nanri Yusuke , Nishiyama Masanori , Hirotsu Tatsumi , Nakajima Junko , Kuroda Yasuo , Hara Hideo
Published: July 2021

Background and Purpose:
Brain microbleeds (MBs) have been recognized to be associated with cognitive decline, and can be pathologically and topographically divided into cerebral amyloid angiopathy (CAA)-related MBs (lobar MBs) and hypertensive vasculopathy-related MBs (deep or infratentorial MBs). We assessed the hypothesis that different effects on global cognitive function might be seen with different topographical distributions of MBs.

Methods:
A total of 1278 consecutive adults (mean age, 58 years) without neurological disorders who had undergone health-screening tests of the brain were studied prospectively. Gradient-echo T2*-weighted MRI using a 1.5-T system was used to detect MBs. Subjects were divided into four groups: without MBs; with lobar MBs; with MBs in deep or infratentorial areas (deep MBs); and with MBs in both areas (diffuse MBs). The Mini-Mental State Examination (MMSE) was administered to determine cognitive functions. MMSE scores <27 were regarded as subnormal. Logistic regression modeling was used to evaluate associations between subnormal MMSE score and topographical distribution of MBs, as well as presence of MBs.

Results:
MBs were detected in the brain for 98 of 1279 subjects (8%), including 36 subjects (3%) with lobar MBs, 48 (4%) with deep MBs, and 14 (1%) with diffuse MBs. Subnormal MMSE scores were found in 76 subjects (6%), and were significantly associated with higher age, higher systolic blood pressure, shorter duration of education, severe white matter hyperintensities, and presence of MBs. After adjusting for these related factors, presence of any MBs (odds ratio (OR), 2.29; 95% confidence interval (CI), 1.17-4.46), and topographical distributional patterns of deep MBs (OR, 2.86; 95%CI, 1.20-6.78) and diffuse MBs (OR, 5.72; 95%CI, 1.59-20.54) were significantly associated with subnormal MMSE score, whereas lobar MBs were not (OR, 0.79; 95%CI, 0.18-3.47). Scores for total MMSE and “attention and calculation” were significantly lower with deep MBs (
P
<0.05 each) and diffuse MBs (
P
<0.01 each) compared with no MBs.

Conclusions:
Regarding the presence of any MBs, hypertensive vasculopathy-related MBs appear to be the main cause of global cognitive dysfunction in neurologically healthy adults. In most middle-aged subjects, effects of CAA-related MBs on cognitive function might not yet be apparent.
Abstract 2876: Factors Associated with Transient Symptoms in Ischemic Stroke
Authors: Lee Soo Ji , Park Tai Hwan , Park Sang-Soon , Lee Kyung Bok , Ko Youngchai , Lee Soo Joo , Kang Kyusik , Park Jong-Moo , Lee Jun , Kim Dae-Hyun , Cha Jae-Kwan , Kim Dong-Eog , Kim Joon-Tae , Yu Kyung-Ho , Cho Yong-Jin , Hong Keun-Sik , Han Moon-Ku , Lee Ji Sung , Lee Juneyoung , Bae Hee-Joon
Published: July 2021

Background and Purpose:
There may be no qualitative difference of the causes and risk factors between transient symptoms with infarction (TSI) on diffusion weighted images and ischemic stroke. However, it is uncertain for baseline characteristics which associate with transient symptoms in ischemic stroke. We compared the clinical profiles of patients with TSI with those with ischemic stroke.

Methods:
Consecutive patients presented within 24 hours of ischemic stroke onset with diffusion abnormalities between April 2008 and March 2011 were identified from a nationwide multicenter prospective stroke registry. Clinical profiles including risk factors, medication histories, laboratory findings, and stroke subtypes according to Trial of ORG 10172 in Acute Stroke Treatment criteria were compared between patients with TSI and those with ischemic stroke.

Results:
A total of 6,766 patients were identified, of whom 226 (3.3%) had TSI. In both univariate and multivariate analyses, younger age (62.1±12.0 vs. 67.8±12.7 [mean±SD]; β=-0.027, p<0.001), occurrence during activity (90.3 vs. 72%; β=1.123, p<0.001), more history of TIA (15 vs 2.4%; β=1.952, p<0.001), less history of stroke (14.6 vs. 22.2%; β=-0.483, p=0.007), less diabetes mellitus (20.4 vs. 30.6%, β=-0.503, p=0.001), and more cryptogenic stroke (21.7 vs. 8.2%; β=0.831, p<0.001) were associated with TSI. Prestroke use of statin or antiplatelet agents, prothrombin time, and platelet count were not associated with TSI. However, TSI patients were more likely to be on anti-coagulants (β=0.791, p=0.007) despite less likelihood of history of atrial fibrillation (β=-0.631, p=0.004) in multivariate analysis.

Conclusions:
TSI differs from ischemic stroke in various initial clinical aspects. Further study is needed to determine whether these different clinical features affect higher early risk of recurrence of stroke in TSI.
Abstract 2877: Ultra-early Endovascular Embolization Of Ruptured Cerebral Aneurysms Increases The Risk Of Hematoma Growth Unrelated To Aneurysmal Rebleeding
Authors: Egashira Yusuke , Yoshimura Shinichi , Enomoto Yukiko , Yamada Kiyofumi , Asano Takahiko , Iwama Toru
Published: July 2021

Background and purpose:
Hematoma growth unrelated to aneurysmal rebleeding has been poorly studied, but is not a rare complication following endovascular embolization of ruptured cerebral aneurysms. The aim of this study is to elucidate the possible risk factors for this phenomenon.

Methods:
We included 101 consecutive patients with subarachnoid hemorrhage (SAH) who underwent endosaccular embolization at our institution within 72 hours of symptom onset in this study. All endovascular procedures were conducted under intraprocedural systemic anticoagulation. Age, gender, hypertension, diabetes, preoperative antiplatelet or anticoagulation use, neurological grade, Fisher computed tomography group, location and size of the aneurysm, the grade of aneurysm occlusion, and timing of endovascular procedure were retrospectively analyzed to find the risk factors for hematoma growth.

Results:
This series included 32 men (31.7%) and 69 women (68.3%), and the mean age ± SD was 65.5 ± 14.0 years. The mean time ± SD from onset to endovascular procedure was 12.1 ± 14.0 hours. Following the procedure, hematoma growth unrelated to aneurysmal rebleeding occurred in 14 patients (13.9%), and 10 of the 14 patients required surgical removal of hematoma and/or ventriculostomy to control intracranial pressure. All 14 patients had an anterior circulation aneurysm and had Fisher group 3 or 4 SAH. Ultra-early embolization (conducted within 6 hours after onset), female gender, history of hypertension, and poor neurological grade (WFNS grades 4 and 5) were significant risk factors of hematoma growth (p < 0.05 for all) by the univariate logistic analysis. In multivariate analysis, ultra-early embolization (OR, 18.0; 95% CI, 3.26-338; p = 0.0002), and female gender (OR, 9.83; 95% CI, 1.73-187; p = 0.0067) were independent risk factors for this phenomenon. Anterior circulation aneurysm and Fisher group 3 or 4 SAH did not suit for the logistic regression model, but were found to be significant risk factors by chi-square test (p = 0.018 and 0.022, respectively).

Conclusions:
Ultra-early endovascular embolization for ruptured cerebral aneurysm under systemic anticoagulation increases the risk of growth of hematomas unrelated to aneurysmal rebleeding. In addition, women with anterior circulation aneurysm presenting with dense focal SAH or intracerebral hematoma are at higher risk for this phenomenon.
Abstract 2879: Acute Injury to Specific Neural Systems Predicts Outcome of Individual Behaviors
Authors: Abedi Garen , Treister Andrew , Riley Jeff , Le Vu , Cramer Steven C
Published: July 2021

INTRODUCTION:
Improved methods are needed for early prediction of modality-specific outcomes. While global outcome measures are important after stroke, modality-specific endpoints such as arm motor function or language are also important. Different modalities recover to different extents, post-acute treatment often revolves around specific modalities (e.g., physiotherapy for weakness), and patients want to know what they will be able to do once recovery plateaus. Modality-specific endpoints are the primary outcome measure in many restorative stroke trials and indeed have been the basis for regulatory approval. The current study hypothesized that measuring injury to a specific neural system will improve prediction of the modality-specific behavior arising from that system, as compared to a global injury measure such as infarct volume.

METHODS:
For 74 patients in the GAIN studies who received an MRI <6 hr after stroke onset and survived to 3 months, predictors of global (NIHSS total) and modality-specific (arm motor function, NIHSS Q5; leg motor, Q6) outcome measures were examined using stepwise logistic regression modeling. Predictors in each model included respective baseline scores, infarct volume, % corticospinal tract injury, age, hypertension, diabetes, hypercholesterolemia, and AFib.

RESULTS:
Patients were age 65 +− 13 yrs, and had median NIHSS score =15 at baseline and =05 at 3mo. For the model predicting whether total NIHSS score at 3mo was 0, R
∧
2 =0.27 (p=0.0006), with baseline total NIHSS score and infarct volume remaining as significant predictors. For the model predicting whether arm motor function was normal at 3mo (NIHSS Q5=0), R
∧
2 was 0.38 (p<0.0001), with baseline NIHSS-Q5 subscore and % corticospinal tract injury being significant predictors. For the model predicting whether leg motor function was normal at 3 mo (NIHSS Q6=0), R
∧
2 was 0.16 (p<0.002), with baseline NIHSS-Q6 subscore and % corticospinal tract injury being significant predictors. Voxel lesion symptom mapping in these 74 subjects supported above results and also suggested other brain areas whose injury might influence motor outcome.

CONCLUSIONS:
An acute measure of injury to a specific neural system is useful for predicting 3mo outcome of the behavior arising from that system. On the other hand, global outcomes are best predicted by global measures. These findings are of value because early prediction of the 3mo values for modality-specific measures can potentially aid prognosis, guide treatment decisions, provide mechanistic insights, and inform entry criteria in restorative stroke trials.