bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP376: Heme Oxygenase-1 is Essential for Hematoma Clearance After Intracerebral Hemorrhage
Authors: Zhang Liyan , Zhao Xiurong , Sun Guanghua , Aronowski Jaroslaw
Published: June 2021

Background:
After intracerebral hemorrhage (ICH), the red blood cells (RBC) and their hemolytic products within brain hematoma trigger adverse biochemical events, leading to secondary brain injury and neurological deficits. Thus, efficient removal of hematoma components is essential for achieving inflammation resolution and functional recovery. The inducible heme-oxygenase (HO-1) is a key rate-limiting enzyme that catabolizes heme into iron, CO, and biliverdin. The present study investigated the role of HO-1 in microglia/macrophages (MΦ)-mediated phagocytosis of RBC; and also assessed the spatial and temporal expression of HO-1 in ICH-affected brain, as well as its possible role in the clearance of hematoma components following ICH modeled in rodents.

Methods and Results:
First, we employed the rat brain MΦ. Upon exposing to RBC, MΦ phagocytize RBC; and HO-1 was induced during this process. Co-incubating tin-protoporphyrin IX (SnPP, a competitive HO-1 inhibitor) with RBC significantly delayed RBC internalization by MΦ. Removal of SnPP from the culture medium led to a rapid recovery of MΦ’s phagocytic function, suggesting that SnPP-induced inhibition is a reversible process. Subjecting neuron-microglia co-cultures to RBC plus sublethal dose of oxygen-deprivation (an ICH-like insult) triggered neuronal injury, as assessed using neurofilament degradation assay and loss of NeuN-positive cells; and addition of SnPP further aggravated the neuronal injury. Additional studies showed that after ICH, HO-1 is up-regulated in hematoma-affected rat brain tissues starting from 6h, reaching the maximum level at 3-7days, and persisting for at least 10 days after ICH. Double immunohistochemistry of HO-1 and brain cell markers shows that the most HO-1-positive cells are Iba1-positive MΦ. Administration of SnPP for 7 days, (7.5 mg/kg, ip, twice a day) delayed hematoma clearance by 27.8% and significantly impaired the functional recovery, as measured 7 days after ICH. Histological analyses showed that there are more TUNEL-positive neurons in the hematoma-affected brain tissue in SnPP-treated mouse brains.

Conclusion:
Our study suggests that HO-1 is essential for phagocytosis of RBC by MΦ, which is critical for endogenous clearance of hematoma after ICH.
Abstract TP378: Long Term Follow Up Telephone Evaluation of Post Stroke Quality of Life is Feasible and Effective
Authors: Miranda Renata , Ledo Carla , Escobosa Daisa , Giannotti Bizutti Caren Cristina , Ruiz Amanda , Vaccari Andreia , Massaud Rodrigo , Malheiro Daniel , Silva Gisele S
Published: June 2021

Background:
The long-term follow-up of clinical outcomes in patients admitted with acute stroke can identify relevant clinical data in the prevention of stroke recurrence as well as measure the quality of life of such patients. Follow-up after discharge in hospitals without stroke clinics can be a challenge. Therefore we created in our hospital an outcomes measurement nuclei characterized as a data collection center, with the main objective of periodically measuring clinical outcomes and quality of life of patients after hospital discharge.This sector works together with the different clinical specialties in providing information with a focus on outcome indicators, using questionnaires to estimate the parameters of evaluation of health states.Our objective was to describe data obtained from this data collection center evaluating post-discharge quality of life of patients treated in our stroke center 30, 90, 180 days and 01 years after the diagnosis.

Methods:
The study was conducted from January 2012 to March 2016, at a tertiary, general, private hospital in São Paulo, Brazil. Phone calls using the EuroQol instrument (EQ-5D) to measure quality of life were performed. The modified Rankin scale and a structured questionnaire to identify stroke recurrence, readmissions and medication failures were also applied.

Results:
We conducted 2184 telephone calls and obtained 1727 (79%) successful contacts. The mean EQ-5D at 30 days was: 0.732 +/-0.558; at 90 days: 0.722 +/- 0.358; at 180 Days: 0.781 +/- 0.326; and at 12 months 0.766 +/-0.349. During the follow-up, 31 patients (2%) died. The main reasons for censuring patients were unsuccessful contact after 3 attempts (51%); outdated registration data (3%) and refusals (9%).

Conclusion:
In conclusion, monitoring of standardized clinical outcomes after stroke is possible even in private non academic hospitals, allowing the acquisition of quality of care indicators and patient centered outcomes.
Abstract TP379: “Build It and They Will Come”: How Comprehensive Stroke Certification Increases the Number of Transfers
Authors: Robertson Betty
Published: June 2021

Introduction/Background:
Stroke is the leading cause of long-term disability affecting 800,000 people in the U.S. each year. In September 2012 The Joint Commission, in collaboration with the American Heart Association/American Stroke Association’s Brain Attack Coalition, launched the Advanced Certification for Comprehensive Stroke Centers (CSCs). This new level of certification recognizes the significant resources in staff and training that comprehensive stroke centers must have to treat complex stroke. Certification is available only to comprehensive stroke centers in Joint Commission-accredited acute care hospitals. For CSC eligibility, there are numerous requirements and volumes that must be met. The most complicated stroke cases should be treated at the centers best equipped to provide specialized care that lead to better outcomes. Cedar-Sinai became the 4
th
program in the nation to receive this prestigious certification. By providing expert care, numerous clinical trials, and high level treatment and procedures, we have become the center of choice for patients in need of a higher level of care.

Research Question:
Does comprehensive stroke certification lead to an increased number of transfers for higher level of care?

Methods:
Retrospective analysis of the number of acute strokes transferred to Cedars-Sinai between the first years of Comprehensive Stroke Certification in 2012 through 2015.

Results:
2012 yielded a total transfer of 97 patients. In 2015 the volume had risen to 194, a 50% increase in 4 years. It is important to note that in 2014, 4 patients were transferred post TPA infusion (Drip and Ship), the gold standard for treatment of ischemic stroke. 2015 resulted in 25 such transfers, a six fold increase.

Conclusion:
The full spectrum and coordination of services that a CSC is equipped to provide contributes to increased access of specialized care for complex stroke patients. This in turn leads to better outcomes. This not only translates to delivery of timely optimal treatment for stroke patients, but also increases our expertise in delivery of this care.
Abstract TP381: What Does It Take? How to Obtain Nursing Buy-in and Compliance of Neurological and Vital Sign Assessments and Re-assessment for the Stroke Patient
Authors: Morgan Vickey
Published: June 2021

Background:
Prior to intervention, the average stroke patients’ neurological and vital sign assessments were not completed according to the facility’s clinical practice guidelines. This led to lost interventional opportunities as nurses failed to recognize subtle changes in their patient’s condition. This issue is a common challenge discussed among Stroke Coordinators nationwide.

Purpose:
To ensure 90% or greater compliance with neurological assessments, vital sign assessments and documentation. To empower nurses to internalize their ability to create a positive outcome for stroke patients.

Method:
The existing policies and clinical practice guidelines were sound and based on the American Heart Association / American Stroke Association guidelines. Staff education was conducted via the facility intranet, email, newsletters and staff meetings. A goal of 100% attendance of appropriate staff at education session within 30 days was established, conducted and met.

Results:
The facility established the goal of 90% compliance with frequency of ordered neurological checks and vital signs within 4 months as shown by documentation. In less than one month, due to the nurses’ recognition of their ability to make effective interventions in new onset strokes, the facility achieved 99% compliance. The previous compliance baseline was 57%; by July, we had attained 99% compliance.

Conclusion:
By providing nursing staff education on their ability to provide timely interventions based off of maintaining ordered vital sign and neuro check frequency, the nurses realized that they could make a difference. With this simple approach, using the hands-on staff and including them in the massive educational campaign, the facility realized a fast change in compliance with policy and protocols. Allowing the nursing staff who actually preformed the activity to have control, accountability and input resulted in quick, effective change with positive patient outcomes. Allowing them to mold their tools gave them empowerment that helped them to internalize satisfaction in their practice.

Key words: Interventional opportunities, Empowerment, Internalized, Bedside nurse, Peer accountability, Patient safety
Abstract TP382: Increasing Thrombolytic and Endovascular Therapy Utilization Through a Unique Telestroke Partnership
Authors: Elks Ashley , Johnson Rayetta , Guzik Amy K
Published: June 2021

Introduction:
Eastern North Carolina is often considered to be within the “buckle” of the stroke belt. This region of the southeastern United States has a high stroke incidence of and rate of mortality. Vidant Health is a regional health system composed of 8 hospitals serving 29 counties in eastern North Carolina. In 2016, 6 Vidant hospitals partnered with the Wake Forest Baptist Telestroke Network to provide 24/7 access to board certified vascular neurologists and improve access to tPA and neuroendovascular procedures. The Wake Forest Baptist Telestroke Network was established in 2009 to reduce death and disability caused by strokes in North Carolina. While the network serves 20 hospitals across North Carolina, the Vidant partnership is unique in that it houses a regional network within the larger state-wide network.

Method:
Three Vidant hospitals (Beaufort, Edgecombe and Duplin) were added to the network in February, 2016, with the additional three (Bertie, Chowan, and Roanoke-Chowan) joining in May, 2016. Health system wide stroke code policies were established including an endovascular protocol implemented for rapid transfer of appropriate patients to the regional hub, Vidant Medical Center, for interventional therapies.

Results:
With implementation of the endovascular protocol, interventional cases at Vidant Medical Center have increased from 5 in 2015 to 19 in 2016 (as of August). Year to date tPA administration has already surpassed that of 2015 and 2014 at one site (Beaufort, 7 in 2016 vs 6 in 2015 and 3 in 2014), and is on track to surpass previous years’ rates at other network sites. Total stroke transfers year to date at 2 sites have surpassed that of 2015 at 2 sites (Beaufort, 7 in 2016 vs 5 in 2015, and Roanoke-Chowan, 4 in 2016 vs 0 in 2015) and total network transfers to date are over 50% of year- end transfers in 2015 and 2014.

Conclusions:
The partnership between The Wake Forest Baptist Telestroke Network and Vidant Health has created a regional stroke network within a larger state-wide model, increasing availability and utilization of tPA and endovascular therapies in Eastern North Carolina.
Abstract TP384: Acute Ischemic Stroke During the Hospital Stay - Who is at Risk?
Authors: Richardson Melissa , Sinha Brooke
Published: June 2021

Background:
Patients who are admitted to the hospital with a non-stroke diagnosis (NSD) may be at risk for an acute ischemic stroke (AIS). Identifying stroke symptoms for admitted patients with NSD in time for consideration of acute stroke intervention is challenging. Because ‘time is brain’, learning more about patients who may be at risk for AIS during the hospital stay could impact our ability to detect stroke early and improve the patient’s chance for consideration of acute stroke intervention.

Purpose:
To identify the characteristic(s) of patients who may experience AIS during the hospital stay for NSD so that they may have an opportunity for timely consideration of acute stroke intervention.

Methods:
The population consisted of patients admitted to the hospital for NSD who had a stroke team activation during the hospital stay (n=46). Records were reviewed over a six month period. These patients records were reviewed for common characteristics that may help predict the risk of AIS.

Results:
Of these patient records, 46 stroke teams were activated for admitted patients with NSD, 23 (50%) had atrial fibrillation or a history of atrial fibrillation (AF) , and 14 (30%) had AIS during the hospital stay . Comparing the two groups, 13 patients experienced AIS during the hospital stay in the clinical setting of AF (28%).

Conclusions:
Patients admitted with NSD who also have AF may be at increased risk of AIS during the hospital stay. Consideration should be given for these patients to have serial neurological exams from the time of admission in order to detect stroke symptoms to improve their chance at consideration for acute stroke intervention.
Abstract TP39: Long-term Imaging Outcomes in Cerebral Small Vessel Disease
Authors: Chen Yan , Liu Renyuan , Xu Wu , Gao Yuanyuan , Xu Xin , Xu Yun
Published: June 2021

Background:
About 90% Older people above the age of 65 years present white matter hyperintensities (WMH) of varying severity when undergoing MRI. However, white matter hyperintensities is one of the characteristic in imaging for cerebral small vessel disease (CSVD). The relationship between WMH volume and lacunar stroke is unknown.

Patients and Methods:
A total of 8475 patients with hypertension and WMH on MRI, which were from Nanjing Drum Tower hospital imaging register center from 2011 to 2015, were studied retrospectively. Age between 60 and 85 years without dementia or parkinsonism. The patients were scanned MRI including DWI, T1W, T2W, FLAIR in 1 time each year, acute lacunar stroke is as an endpoint. Patients with Intracranial atherosclerosis in larger arteries were excluded. Areas of supratentorial WMH were semi-automated segmented on FLAIR sequences using MRIcron software. DWI identificates acute lacunar infarct.

Results:
Of 8475 patients, 599 got acute lacunar stroke and accound for 7.07%. A percentage of 82.5 acute lacunar infarctions were located beside periventricular WMH and merge into white matter disease abnormalities. In compared with patients that were spared from any vascular incidents, higher periventricular WMH volumes were found among the 599 patients in baseline FLAIR images (p=0.012). Furthermore, by annual MRI scan, about 612 patients were found with increased volumes of periventricular WMH, and 86.5% of the patients ended up with acute lacunar stroke. While in patients with stable WMH volumes, only 0.89% of them ended up with vascular incidents. Logistic regression analysis demonstrated that only periventricular WMH volumes were associated with incidence of acute lacunar stroke (p=0.001), while no association of aging (p=0.275) and hypertension (p=0.146) were found.

Conclusion:
This study indicates that periventricular WMH volumes on FLAIR are independent predictors for acute lacunar stroke and suggest that therapies aimed at reducing progression of white matter hyperintensities via regulating hyperintensities and end-arteriole damage may protect against acute lacunar stroke in clinic.
Abstract TP391: Barriers and Facilitators to Self Care in Stroke Survivors
Authors: Babkair Lisa A , Dickson Victoria
Published: June 2021

Background:
Stroke is a major cause of long-term disability and loss of quality of life. People living with stroke face enormous challenges particularly after discharge from acute care adjusting to a new life. Stroke self-care is an important element in preventing stroke recurrence by direct survivors’ attention to stroke secondary prevention. Self-care helps survivors to recapture or learn new skills to manage their daily activities. However, several factors hinder the self-care and interfere with healthcare behaviors. Therefore, identifying the barriers and facilitators for stroke self-care is the key element for improving stroke self-care

Purposes:
To analyze the state of the science in regard to the barriers and facilitators for self-care

Methods:
The electronic databases PubMed, Cumulative Index to Nursing and Allied Health Literature , and PsycInfo were searched. Inclusion criteria included: peer reviewed primary English studies; self-care or self-management as the primary outcome; adult stroke survivors; and published after 2005. The integrative review guidelines were used for analysis.

Results:
From an original of 794 studies identified, 23 met the inclusion criteria and were reviewed. Self-care and self-management concepts were used interchangeably. The barriers to stroke self-care were classified into three categories: individual factors, psychological factors, social and environmental factors. The individual factors were lack of knowledge, decrease individual capacity such as lack of self-confidence and learning capabilities, lack of self-efficacy and motivation, non-adherence to medication, and physical impairment. The psychosocial factors included depression, anxiety, and cognitive impairment. Social and environmental factors were lack of family and social support, lack of professional support, lack of trust in healthcare providers, lack of transportation, low socioeconomic status, and lack of the resources. The facilitators were motivation and social support.

Conclusions:
Overall, quality of the studies was limited by small sample sizes in the intervention studies. Managing healthcare behaviors through understanding the barriers and facilitators will help nurses and stroke survivors in improving self-care.
Abstract TP392: Employing eICU Monitoring for Post-alteplase Sequencing: Optimizing Outcomes
Authors: McGraw Janice , Lada Diane , Compton Sharon
Published: June 2021

Background and Purpose:
Intravenous tissue plasminogen activator is the only Food and Drug Adminsitration-approved treatment for acute ischemic stroke. Post treatment is often monitored in an intensive care unit (ICU) with rigourous sequencing of vital signs and neurological examinations. Despite vigilant nursing assessments, post-activase intensive monitoring demonstrated gaps in capturing all frequencies required not only by Joint Commission requirements but medical industry and safety standards. Current research challenges the need for lengthy ICU monitoring post-thrombolytics.

Methods:
A retrospective chart review was performed on 118 patients who entered Providence Alaska Medical Center for an emergent stroke alert. Data was collected on stroke severity, risk factors and alteplase usage. A comparative analysis was performed to determine the missed sequences out of 36 total entries per patient, from 2014 without eICU monitoring to March of 2016 with eICU assistance.

Results:
With an average of 13% of patients recieving alteplase from a volume of 350 patients annually, 73% of those in ICU completed all 36 entries of post-treatment monitoring prior to the use of eICU collaboration in care. From January, 2015 to March 2016, 97% of the post-alteplase stroke patients recieved the complement of required sequencing.

Conclusion:
Despite recent studies indicating less intensive care is required post-alteplase administration, the use of eICU monitoring in this setting increases the complete complement of neurological and metabolic assessments as ordered. Proposals towards implementing telemedical monitoring in the advent of post-stroke care is useful.
Abstract TP4: Early Recanalization Followed By CEA Improves Functional Independence Compared To Carotid Angioplasty And Stenting
Authors: Humayun Mohammed J , Panjwani Sharjeel , Jumaa Mouhammed A , Zaidi Syed F
Published: June 2021

Background:
Concomitant acute cervical ICA and intracranial large vessel occlusion (ILVO) has a high rate of morbidity and mortality. The most appropriate treatment strategy for the extracranial culprit lesion remains unclear. We report our institutional outcomes with the 2 approaches, emergent carotid endartectomy (CEA) vs. stenting (CAS).

Methods:
Between July 2012 to April 2016, 34 patients with concomitant complete ICA origin occlusion and occlusion of either intracranial ICA, MCA M1 or M2 segments underwent thrombectomy at our center. Demographics, risk factors, treatment modalities, imaging and clinical outcomes were reviewed from a prospectively maintained database. Recanalization, hemorrhagic transformation (HT) with clinical decline of >4 points on the NIHSS and favorable outcome rates mRs of
<
2 at 90 days were compared.

Results:
Of the 34 identified subjects, in 6 patients the proximal lesion was not treated either due to failed MT (N=3), ICA re-occlusion prior to CEA (N=2) or MCA recanalization via trans-circulation access with symptomatic resolution (N=1). Of the remaining 28 patients, 10 (35.7%) underwent emergent CEA within 12 hours following MT, while the remainder 18 (64.3%) had carotid stenting performed during the MT. Rate of IV tPA treatment was higher in CAS (61% vs 10%, p<0.01). Successful TICI 2B/3 recanalization was achieved in 90% of the CEA and 94.1% of stenting patients (p=0.6). Following CAS, 3 patients developed HT while none were noted in the CEA arm. At 90 days, 80% (8/10) of the CEA patients were functionally independent compared to 58.8% (10/18) in the stenting group, although this difference was not statistically different (p=0.3). No deaths in the CEA group were noted as compared to 4 (23.5%) in the stenting arm (p=0.09).

Conclusions:
Our study indicates that for concomitant cervical ICA and ILVO, MT followed by emergent CEA is feasible and may be accompanied with less risk for HT and improved rate of favorable outcome. Further prospective studies are warranted.
Abstract TP401: Chemotherapy-associated Cerebral Vasospasm in Children With Leukemia: A Prospective Study Using Transcranial Doppler Ultrasound
Authors: Sun Lisa R , Ziai Wendy C , Felling Ryan J
Published: June 2021

Introduction:
Intrathecal (IT) cytarabine, an antineoplastic agent with poorly understood neurotoxicity, is commonly administered to children with newly diagnosed leukemia on the first day of induction chemotherapy for central nervous system prophylaxis. Five recent case reports demonstrated severe diffuse cerebral vasospasm leading to neurologic sequelae 4-11 days after administration of IT cytarabine. While these patients developed overt consequences, subclinical vasospasm may lead to more subtle forms of neurotoxicity in a larger group of patients. Recognition of subclinical vasospasm could prevent both overt and subtle consequences.

Objective and Hypothesis:
We evaluated cerebral blood flow velocities (CBFVs), a marker of vasospasm, as measured by transcranial Doppler (TCD) ultrasound, before and after the administration of IT cytarabine. We hypothesized that IT cytarabine increases CBFVs in pediatric leukemia patients in the first two weeks after treatment.

Methods:
In this prospective before and after study, TCDs were performed on each subject prior to induction chemotherapy and subsequently around days +1, +4, and +8 of induction, before other IT medication administration and within the window of expected vasospasm based on prior cases.

Results:
In this interim analysis, we found elevated CBFVs compared to age-matched normal values in all arterial distributions measured (though more prominently in anterior circulation), even prior to the administration of IT chemotherapy. Substantial increases in CBFVs were observed after the administration of IT cytarabine in some subjects, though this trend was not observed in all cases.

Conclusions:
The observed elevations in CBFVs are likely in part due to decreased blood viscosities that resulted from hematologic changes secondary to leukemia. The observed changes in CBFVs after IT cytarabine administration are probably partially due to treatment effects, but the variability between patients suggests that patient and/or disease-specific characteristics may predispose certain children to cerebral vasospasm and its neurologic sequelae. This ongoing study aims to identify clinical features that allow risk stratification in order to develop clinical pathways for preventing neurotoxicity.
Abstract TP402: Sickle Cell Disease in Pediatric Stroke - Inpatient Resource Utilization in the Decade Following STOP
Authors: Taylor J. Michael , Horn Paul , Sucharew Heidi , Abruzzo Todd A , Khoury Jane
Published: June 2021

Background:
Sickle cell disease (SCD) is an important risk factor for stroke in children. Natural history studies demonstrate that greater than 10% of hemoglobin SS patients suffered ischemic stroke prior to age 20 years. In 1998, the Stroke Prevention Trial in Sickle Cell Anemia (STOP) successfully demonstrated the role for routine transfusion therapy in reducing stroke in at risk SCD patients. Fullerton and colleagues then found that first time stroke in SCD decreased in Californian children in the 2 years following STOP. We investigated the stroke rate and health care utilization of children with SCD for two calendar years in the decade following publication of the STOP trial using a national inpatient database.

Methods:
The 2000 and 2009 Kids’ Inpatient Database (KID) were used for analysis. SCD and stroke cases were identified by ICD-9 codes 282.6x, 430, 431, 432.9, 434.X1, 434.9, 435.9. We queried the KID procedural clinical classification software for utilization of services pertinent to SCD and stroke; transfusion, MRI, and cerebral angio.

Results:
In 2000, SCD was a discharge diagnosis in 34,294 children and 158 (0.46%) children had SCD and stroke. By 2009, discharges with SCD rose to 37,082 children with 212 (0.57%) children carrying both diagnoses. In 2000 and 2009, AIS is the most common stroke type at 83%, males account for 53% of stroke and black race was reported by 92% of SCD and stroke subjects. Procedure utilization is higher in the SCD and stroke population than in SCD without stroke (Figure 1). Blood transfusion is the most common procedure in both study years, significantly higher in stroke subjects.

Conclusion:
For pediatric inpatients with SCD, blood transfusion and diagnostic cerebrovascular procedures were significantly more common in the cohort with comorbid stroke. In the decade after STOP, children hospitalized with SCD and stroke represented less than 0.6% of the total inpatient SCD population.
Abstract TP407: Effects of Remote Ischemic Conditioning on Cerebral Small Vessel Disease Outcomes
Authors: Wang Yuan , Song Haiqing , Dong Kai , Meng Ran , Wang Shuying , Zhang Qian , Huang Xiaoqin , Feng Wuwei , Ovbiagele Bruce , Ji Xunming
Published: June 2021

Objective:
To evaluate the preliminary efficacy of remote ischemic conditioning (RIC) on patients with cerebral small vessel disease (SVD).

Methods:
Thirty patients diagnosed with symptomatic SVD within 30 days of onset were enrolled in this prospectively randomized controlled study for 1 year. All patients received routine medical treatment including treating vascular risk factors according to the guideline. Patients in the experimental group (n=14) were administered 5 cycles consisting of ischemia followed by reperfusion for 5 minutes on bilateral upper limbs twice daily for 1 year. Those in the control group (n=16) underwent sham ischemia-reperfusion cycles. Primary outcome was the change of cognitive function measured by mini-mental state examination (MMSE) and montreal cognitive assessment scale (MoCA), and secondary outcomes were changes of plasma biomarkers, cerebral hemodynamic parameters measured by vascular ultrasound and brain lesions measured by MRI FLAIR both at baseline and at the end of 1 year visit.

Results:
Compared with patients in the control group, patients in the RIC group had higher flow velocity (FV), and lower pulsatility index (PI), but without statistical difference. Patients in the RIC group had improvement in visuospatial and executive abilities (3.86±1.03 vs. 4.43±0.85, p=0.026), reduced plasma triglyceride (1.60±0.74 vs. 1.25±0.38, p=0.019), low density lipoprotein (2.89±0.81 vs. 2.26±0.67, p=0.003) and homocysteine (15.66±10.11 vs. 13.66±9.80 p=0.017). Similarly in the RIC group, the diastolic flow velocity (DFV) of middle cerebral artery (MCA) (right: 33.93±7.67 vs. 36.93±6.12, p=0.032; left: 33.93±7.67 vs. 36.93± 6.12, p=0.032) and the mean flow velocity (MFV) of left MCA (35.00±5.04 vs. 39.50±5.59, p=0.003) increased, and the PI of MCA (right: 1.11±0.19 vs. 1.02±0.14 p=0.030; left: 1.10±0.22 vs. 0.99±0.14, p=0.037) decreased.

Conclusion:
RIC appears to be potentially effective for improving cognition, enhancing cerebral perfusion, and modifying vascular risk factors in SVD patients. Further studies focusing on long-term neurological outcomes and potential mechanisms underlying RIC on SVD patients are needed.
Abstract TP411: Effects of Triflusal and Clopidogrel in Secondary Prevention of Stroke Based on Cytochrome P450 2C19 Genotyping
Authors: Lee Kyung-Yul , Han Sang Won , Kim Yong-Jae , Ahn Seong Hwan , Seo Woo-Keun , Yu Sungwook , Oh Seung-Hun , Kim Youn Nam ,   MAESTRO Investigators
Published: June 2021

Background:
The relationship between stroke recurrence and cytochrome P450 2C19 (CYP2C19) genotype for the secondary prevention of ischemic stroke (IS) is not clearly defined. We investigated the effect of antiplatelet agents based on CYP2C19 genotype in secondary prevention of IS.

Methods:
In this prospective, multicenter, randomized, parallel-group, open-label, and blind genotype trial, we enrolled first non-cardiogenic IS patients within 30 days prior to screening at the 18 tertiary-care hospitals. Participants received 300 mg triflusal twice a day or 75 mg clopidogrel once daily. CYP2C19 genotyping was done in all patients and genotype results were blind during the study. The primary outcome was the time from randomization to first recurrent IS or hemorrhagic stroke. Efficacy analyses were performed using both the modified intention-to- treat population and the per-protocol population. The study is registered with ClinicalTrials.gov (NCT01174693).

Results:
This trial failed to meet its recruitment goal due to slow enrollment. A total of 784 (73% of required sample size) patients were followed for a mean of 2.5 years. In poor CYP2C19 genotype group (n=484), 30 (6.2%) patients had a recurrent stroke. The risk of recurrent stroke in triflusal group was 2.9% per year and was not significantly different with clopidogrel group (2.2% per year; hazard ratio [HR], 1.23; 95% confidence interval [CI], 0.6 to 2.53). In clopidogrel treatment group (n=393), 20 (5.1%) had a recurrent stroke. The risk of recurrent stroke in good CYP2C19 genotype was 1.6% per year and was not significantly different with poor genotype (2.2% per year; HR, 0.69; 95% CI, 0.26 to 1.79).

Conclusions:
In poor CYP2C19 genotype group, either triflusal or clopidogrel was not superior to the other in the prevention of recurrent stroke.
Abstract TP414: Are Periodic Limb Movements and Obstructive Sleep Apnea Associated with Atrial Fibrillation or Resistant Hypertension in Stroke and TIA Patients?
Authors: Raza Syed Ali , Rangaraju Srikant , Gadodia Gaurav , Marmarchi Labib , Razzak Ammar , Trotti Lynn Marie , Rye David , Davis Brittaine , Henriquez Laura , Belagaje Samir , Bianchi Nicolas , Winningham Melanie , Nahab Fadi
Published: June 2021

Introduction:
Periodic limb movements (PLMs) and obstructive sleep apnea (OSA) have been associated with an increased risk of cardiovascular disease. There are limited data on the frequency of PLMs and OSA among a diverse cohort of stroke patients and their association with resistant hypertension and atrial fibrillation (AF).

Hypothesis:
Stroke and TIA patients with PLMs or moderate-severe OSA are more likely to have resistant hypertension and AF than patients without these findings on diagnostic polysomnography (PSG).

Methods:
Consecutive stroke and TIA patients referred by a vascular neurologist for PSG from October 1, 2012 to September 30, 2015 were included in this analysis. Baseline clinical characteristics and PSG results were collected retrospectively. The frequency of PLMs (mild ≥5/hour, severe ≥15/hour), arousals due to PLMs (≥5/hour), and moderate-severe OSA (Apnea-Hypopnea Index≥15) was evaluated by PSG to determine their association with AF and resistant hypertension, defined as patients whose blood pressure was not at goal with 3 antihypertensive agents of different classes or controlled with 4 or more medications.

Results:
Of 103 patients (mean age 60±15 years, 50% female, 61% non-white, 76% ischemic stroke, 23% resistant hypertension) who underwent PSG (median time from cerebrovascular event to PSG 5 months), 48% had mild PLMs, 28% had severe PLMs, 14% had frequent PLM arousals and 22% had moderate-severe OSA. In multivariable analyses, non-white race was associated with lower likelihood of mild (OR 0.32, 95% CI 0.13 to 0.80) and severe PLMs (OR 0.29, 95% 0.10 to 0.79) and female sex was associated with lower likelihood of frequent PLM arousals (OR 0.38, 95% CI 0.14 to 1.00). Factors associated with moderate-severe OSA included older age (OR 1.06, 95% CI 1.016 to 1.106) and the presence of AF (OR 4.26, 95% CI 1.17 to 15.44). There was no significant association between PLMs, PLM arousals or moderate-severe OSA with resistant hypertension.

Conclusions:
A significant number of stroke and TIA patients have PLMs and moderate-severe OSA. Stroke and TIA patients with AF are more likely to have moderate-severe OSA and should be referred for PSG. The presence of resistant hypertension was not associated with PLMs or moderate-severe OSA in our study.
Abstract TP415: A Pilot Study on the Effect of Neck Irradiation Treatment for Nasopharyngeal Carcinoma on Carotid Artery Stenosis
Authors: Woon Fung Peng , Lim Ee Wei , Lee Moi Pin , Gan Hui Yee , Chang Hui Meng , Soong Yoke Lim , De Silva Deidre A
Published: June 2021

Introduction:
Extracranial carotid stenosis, a risk factor for ischemic stroke, is thought to be accelerated by irradiation to the neck region. Nasopharyngeal carcinoma (NPC) has a predilection for East Asian with an incidence of 200-300 annually in Singapore. We studied the prevalence and severity of extracranial carotid disease in patients with prior neck irradiation for NPC, who were at different timepoints from the time of irradiation.

Hypothesis:
The prevalence of extracranial carotid disease is high among patients with prior neck irradiation, and this may justify a screening programme for early detection and primary stroke prevention.

Methods:
We conducted a pilot study to examine 50 patients (median age 55.2 years) with prior radiation for NPC with intensity-modulated radiation therapy (IMRT): 26 with <5 years after treatment and 24 with >=5 years after treatment. All patients received radiation therapy to the neck. Carotid disease was assessed by duplex sonography for severity of stenosis. The European Carotid Surgery Trial (ECST) criteria was employed for assessment for degree of stenosis.

Results:
Among patients with IMRT >=5 years ago, 25% (6/24) had carotid stenosis of >=50% compared to only 8% (2/26) of patients with IMRT within 5 years. Of these 8 patients with carotid stenosis >=50%, 5 (63%) had plaques with irregular or ulcerated surfaces, which is known to be associated with stroke risk. Based on these preliminary data, the study would require a larger sample size of 100 in each group to be powered at 90% with an alpha of 0.05. All 8 patients with carotid stenosis >=50% from the screening were referred for further evaluation for symptoms and risk factors, and management for secondary stroke prevention.

Conclusions:
Based on our findings, there is a rationale for screening for carotid disease among patients with prior neck irradiation and the timing of screening is more optimal after 5 years from IMRT. Patients found to have carotid disease should be counselled about risk factor control, antiplatelet medication and possibly carotid intervention for primary stroke prevention.
Abstract TP416: Early Carotid Revascularization Reduces Readmission for Recurrent Ischemic Stroke in Acute Ischemic Stroke Patients: Analysis of United States Nationwide Readmissions Database
Authors: Chaudhry Saqib A , Gu Shitong , Afzal Mohammad R , Riaz Ahmed , Rehman Haseeb , Sachdeva Gautham , Sattar Ahsan , Razak Anmar , Qureshi Adnan I
Published: June 2021

Background:
The rates and determinant of recurrent ischemic stroke in post hospitalization period have not been studied at a national level.

Objective:
To determine the rates and predictors of recurrent ischemic stroke related hospitalization within 1 year post hospitalization in a nationwide cohort of patients admitted for ischemic stroke in United States.

Methods:
The study population included patients in the 2013 Nationwide Readmissions Database (NRD) over the age of 18 years with a principal diagnosis of acute ischemic stroke (ICD9 = 433x1 & 434x1) who survived the initial hospitalization. Cox proportional hazards analysis was used to identify the relative risk (RR) of recurrent ischemic stroke related hospitalization based on age, gender, selected cardiovascular risk factors, and carotid revascularization procedure during initial hospitalization.

Results:
There were 503, 050 patients admitted for primary diagnosis of ischemic stroke; mean age (±SD), 70.7± 13.3 years; and 49.6% were women. Of these 18534 (3.7%) were readmitted to the hospital with principal diagnosis of ischemic stroke during one year follow up. In the Cox proportional hazards analysis adjusting age, gender, and medical comorbidities, independent factors associated with ischemic stroke related readmissions were diabetes (relative risk [RR], 1.31; 95% confidence interval [CI], 1.25-1.36; P < .0001), hypertension (RR, 1.27; 95% CI, 1.19-1.35; P < .0001), atrial fibrillation (RR, 0.87; 95% CI, 0.82-0.92; P < .0001) carotid stent placement (RR, 0.38; 95% CI, 0.31-0.47; P < .0001) and carotid endarterectomy (RR, 0.23; 95% CI, 0.21-0.26; P < .0001).

Conclusion:
Patients with ischemic stroke undergoing carotid revascularization during the initial hospitalization have significantly lower risk of readmission related to another ischemic stroke
Abstract TP423: Trends of Hospitalization Cost of Aneurysmal Subarachnoid Hemorrhage in the United States
Authors: Modi Sumul , Shah Kavit , Affan Muhammad , Tahir Rizwan , Varelas Panayiotis , Marin Horia
Published: June 2021

Background:
Recent large scale studies describing the trends of hospitalization cost secondary to aneurysmal subarachnoid hemorrhage (aSAH) in the United States are lacking. We performed this study to discover these trends and the factors affecting the cost of hospitalization.

Methods:
The Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project from year 2002 to 2013 was searched for patients with a primary diagnosis of subarachnoid hemorrhage International Classification of Diseases - Ninth Revision (ICD-9) code 430) who underwent either clipping or coiling of an aneurysm. Patients with traumatic intracranial hemorrhage, arteriovenous malformation, arteriovenous fistula, cost of care ≤ 0, discharge to another hospital, and any missing variables were excluded. The cost of hospitalization was calculated using total charge and cost-to-charge ratio provided by HCUP, and then was adjusted for inflation (for the year 2016) utilizing the Consumer Price Index inflation calculator. Univariate and multivariable linear regression analysis was performed on selected variables to identify the factors associated with a higher cost of care. The multivariable model was adjusted for calendar year, medical comorbidities (using the Charlson Comorbidity Index), hospital location (urban or rural) and hospital teaching status (teaching or non-teaching).

Results:
We identified 20,905 patients with aSAH over the course of the 12 years. The mean and the median costs of hospitalization were $80,859 and $66,274, respectively. The median cost increased from $53,697 in 2002 to $73,901 in 2013 (p<0.001). Cost was also noted to increase by $2690 with the male gender, $18,877 with the presence of an acute ischemic stroke, $33,942 with the presence of respiratory failure and $18,464 with the requirement of ventriculostomy (all p<0.001). Every decade increase in age was associated with $3022 reduction in the cost (P<0.001).

Conclusion:
Among the factors we studied, higher hospitalization cost was independently associated with the male gender and the presence of ischemic stroke, respiratory failure and the requirement of ventriculostomy. Older age was associated with a lower hospitalization cost.
Abstract TP428: Leukocyte Subpopulation at Day 0 in Aneurysmal Subarachnoid Hemorrhage as Predictor of Cerebral Vasospasm
Authors: Dorneanu Iulia , Castillo Norma , Muhammad Abdullah , Testai Fernando
Published: June 2021

Background:
Aneurysmal subarachnoid hemorrhage (SAH) remains a leading cause of significant morbidity and mortality. Previous studies have shown that there is a systemic inflammatory response, characterized by leukocytosis or leukopenia in SAH. We investigated leukocyte subpopulation in serum and cerebral spinal fluid (CSF) at day 0 as a clinical predictor of delayed neurological deterioration defined as VS at any time during hospital stay.

Methods:
This is a retrospective study of non-traumatic SAH. Leukocyte subpopulations data in serum and CSF at day 0 were prospectively collected and compared with the development of clinical vasospasm (VS) vs no VS during the entirety of the patient’s hospital admission. Data was analyzed using univariate analysis. Clinical VS was defined as development of new focal neurological signs, deterioration in level of consciousness, or both, when the cause was felt to be ischemia attributable to VS after other possible causes of worsening (hydrocephalus, seizure, etc.).

Results:
A total of 47 subjects were screened and included in the analysis; 35 of these had no clinical VS and 12 had clinical VS. In those with and without VS, there was a significant difference in elevated leukocyte counts (16.9 vs. 12.5, p<.001) and neutrophils (13.3 vs. 10.4, p<.044). VS was not associated with monocytes (1.8 vs .48, p<0.30) or with lymphocytes (1.3 vs. 1.4, p<0.60). When adjusting for fever in a logistic regression model, this association held for leukocyte count (OR:1.32, p<0.012) and was borderline significant for neutrophils (OR:1.20, p<0.051).

Conclusion:
There was a statistically significant association between total serum leukocyte at day 0 and incidence of VS. Neutrophils may also identify potential neurological deterioration. Total serum leukocyte may be a valuable predictor of VS and neurological deterioration in general.
Abstract TP43: Changes to Observed Longitudinal Patterns of Task Activation in Motor Areas after Stroke Revealed by Hemodynamic Scaling of Functional Magnetic Resonance Imaging
Authors: Raut Ryan V , Nair Veena A , Sattin Justin A , Prabhakaran Vivek
Published: June 2021

Introduction:
Despite its prevalence in stroke research, the vascular dependence of functional MRI (fMRI) makes it susceptible to changes in factors such as vascular reactivity that may occur over the course of stroke recovery, potentially confounding longitudinal findings. Scaling fMRI data with respect to vascular properties may account for some of the high variability often observed in patterns of motor task activation throughout recovery.

Hypothesis:
We hypothesized that scaling fMRI data by the amplitude of resting-state fluctuations (RSFA), an estimate of vascular reactivity, would reduce intersubject variability of motor task activation in both patients and similarly-aged controls while minimizing between-group differences and revealing a more consistent pattern of changes in activation associated with stroke recovery.

Methods:
24 ischemic stroke patients (ages 44-84 years, mean = 64) were scanned at early (2-12 days, mean = 5) and late (mean = 11 months) stages after onset. 20 healthy controls (ages 47-74 years, mean = 59) were also scanned, 11 of whom were scanned again after ~6 months. Subjects performed two 20-second-block finger-tapping tasks, one with each hand, and a 10-minute resting-state fMRI scan, from which the scaling factor (RSFA) was computed. Percent signal change and activation volume before and after scaling were measured across several bilateral motor areas and compared between groups and within each group longitudinally.

Results:
Scaling with RSFA significantly reduced intersubject variability of intensity and extent of activation in both groups while mitigating between-group differences in activation in multiple motor areas. Further, scaling revealed a significant reduction of activation across motor regions in stroke patients over time that was not apparent without scaling. This pattern more closely resembled that of controls, for which it was evident both before and after scaling.

Conclusions:
Our findings point to a role for fMRI calibration in longitudinal studies of plasticity and recovery after stroke, and suggest that the large variability often observed in activation patterns associated with recovery may in part be vascular in origin.
Abstract TP432: Predictors for Dementia Conversion in Cerebral Amyloid Angiopathy From a Stroke Unit
Authors: Xiong Li , Valenti Raffaella , Charidimou Andreas , Boulouis Gregoire , Roongpiboonsopit Duangnapa , Van Veluw Susanne J , Martinez-Ramirez Sergi , Ayres Alison , Alessandro Biffi , Gurol Edip , Greenberg Steven , Viswanathan Anand
Published: June 2021

Objective:
Cerebral amyloid angiopathy (CAA) is increasing recognized as a cause of cognitive impairment and dementia in older individuals. This study aimed to investigate predictors of dementia, including imaging markers, in CAA patients from a stroke unit.

Methods:
A total of 71 non-demented patients from a stroke unit were included according to modified Boston Criteria for probable CAA with available cognitive follow up. These CAA patients included both patients with and patients without previous intracerebral hemorrhage (ICH). At baseline, neuroimaging markers, including lobar microbleeds (CMBs), white matter hyperintensities (WMH), cortical superficial siderosis (cSS) and MRI-visible centrum semiovale perivascular spaces (CSO-PVS) were assessed. The small vessel disease (SVD) score for CAA was calculated by the scores of CMBs, WMH, cSS and CSO-PVS. The association between these neuroimaging markers and dementia conversion was analyzed.

Results:
The median follow up time is 1.91 years (quartiles 1.14-4.23 years). Fourteen (19.72%) CAA patients developed dementia during follow up period. Thirty-seven CAA patients (52.11%) had previous symptomatic ICH. Age, lobar CMBs≥20 and SVD score were selected from the univariate Cox-regression analysis with p value less than 0.1 (Table1). In a backward stepwise multivariabte analysis including age, previous ICH history and either SVD score or number of CMBs, age and SVD score independently predicted dementia conversion (Table 1). The individual neuroimaging markers for SVD related brain damage (CSO-PVS, cSS, lobar MBs and WMH) did not predict dementia conversion for probable CAA patients.

Conclusion:
Our results demonstrate that cognitive deterioration of CAA patients appears attributed to cumulative CAA related vasculopathic changes.