bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 68: The Effect Of Pre-existing Atrial Fibrillation On In-hospital Outcomes In Patients Undergoing Carotid Endarterectomy Or Stent Placement In General Practice
Authors: Watanabe Masaki , Chaudhry Saqib A , Adil Malik M , Majidi Shahram , Alqadri Syeda L , Semaan Edouard , Qureshi Adnan I
Published: July 2021

Background:
Atrial fibrillation (AF) is a relatively common comorbid condition among patients who undergo carotid endarterectomy (CEA) and carotid artery stent placement (CAS); however the outcomes of patients with AF undergoing CAS have not been fully examined. We sought to investigate the impact of AF on in-hospital outcomes of CEA and CAS in general practice.

Methods:
We analyzed the data from the Nationwide Inpatient Sample (NIS), which is representative of all admissions in the United States from 2005 to 2009. The primary end point was postoperative stroke, cardiac complications, postoperative mortality, and composite of these endpoints. Multivariate regression analysis was performed to determine the 1/. the association of AF (compared to without AF); and 2/. the association of CEA (compared with CAS) with the occurrence of postoperative stroke, cardiac complication or death. Covariates included in the logistic regression were patient’s gender, age, ethnicity, comorbid conditions, symptom status (symptomatic vs asymptomatic status), and hospital characteristics.

Results:
Of the total 672,074 patients who underwent CAS or CEA, 8.8% of the procedures were performed in patients with AF. For patients undergoing CEA, AF was associated with an increased risk of postoperative stroke (P<0.0001; OR, 1.57: 95% CI, 1.32-1.86) but not in patients undergoing CAS. The relative risk of composite endpoint of postoperative stroke, cardiac complications, and mortality was increased in patients with AF undergoing CAS (OR 1.43, 95% CI 1.18-1.74) and those undergoing CEA (OR 3.18, 95% CI 2.89-3.49). After adjustment for potential confounders, the odds of composite endpoint of postoperative stroke, cardiac complications, and mortality (OR, 1.31, 95% CI 1.08 - 1.59) were significantly higher among patients who underwent CEA (compared with those who underwent CAS). An inverse relationship was seen in patients without AF in whom the composite endpoint was significantly lower in patients undergoing CEA.

Conclusion:
Our analysis suggests that almost 10% of CAS and CEA are performed in patients with AF in general practice, and higher rates of adverse events are observed among these patients particularly those undergoing CEA.
Abstract TMP87: Improving t-PA Assessment Compliance Using a Hand-Off Communication Tool
Authors: Stebelton Jeanette D , Kozlowski Kelly , Neldberg-Weesen Laurie , Politi Roman
Published: July 2021

Background:
Programs seeking Primary Stroke Center Certification (PSCC) must use a standardized method of delivering clinical care, based on the American Heart/American Stroke Association or equivalent evidenced-based guidelines. After reviewing the assessment activities following the administration of IV tissue plasminogen activator (t-PA), opportunities for improvement were noted. Marquette General Hospital is a 315 bed hospital in Michigan’s Northern Peninsula, and is the only PSC within a 180 mile radius.

Objective:
To improve our program’s processes and assessment activities to attain 100% compliance with t-PA administration clinical guidelines and documentation surrounding the same.

Methods:
A review of records was conducted from December 2011 to July 2012 on all ischemic stroke patients receiving t-PA either at our institution or though the drip and ship transfer method during this time frame. A total of 6 pre-intervention and 3 post-intervention records represented the total t-PA patient volume for this time period (n=9). Specific interventions were developed to improve compliance with t-PA clinical guidelines including: the identification of barriers preventing compliance with assessment activities, obstacles preventing import of vitals to Electronic Medical Record (EMR), development of a standardized process for hand-off communication regarding frequency of vitals and neurological assessments, and a review process to assess correlation of missed assessment activities with patient outcomes.

Results:
Within 3 months after implementation of the process changes, adherence for vitals went from 85% to 95%. Adherence for neurological assessment went from 72% to 90%.

Conclusion:
These interventions were associated with an increase in the program’s assessment activities that are consistent with clinical practice guidelines, suggesting that the development of a standardized process for hand-off communication regarding frequency of vitals and neurological assessments was of benefit to compliance. Further research is needed to evaluate patient outcomes associated with inter-hospital post t-PA transfer and patient assessment nursing protocols.
Abstract TMP94: Complications Are Frequent In The First Month After Hospital Discharge For Stroke And Are Associated With Worse Functional Outcomes
Authors: Katzan Irene L , Liskay Alice M , Martin Siobhan , Thomas Charles , Love Thomas E , Konrad Nancy ,   Ohio Coverdell Investigators
Published: July 2021

Data are growing on medical complications that occur during hospitalization for stroke and on readmission rates, although little is known of complications not resulting in readmission nor their impact on functional outcomes. We performed a comprehensive evaluation of complications occurring in the first month following hospital discharge for stroke and their association with functional outcomes

Methods:
Prospective cohort study of patients admitted for stroke at 6 hospitals participating in the Ohio Coverdell Outcomes Evaluation Project. Hospital-based data was obtained from chart abstraction. Postdischarge information was obtained by phone (5 hosp) or postdischarge visits (1 hosp). Patients who died or had hospice care prior to discharge were excluded.

Results:
Follow-up information 30-51days postdischarge was available in 378 of 573 patients. Mean age was 68.6 and admit NIHSS was 3.9. Death occurred < 30d postdischarge in 3.2% (n=12) and unplanned readmission < 30d occurred in 9.6% (n=35) of patients alive through f/u. Most common reasons for readmission were cardiovascular (19.5%, 8/41). Complications not requiring readmission occurred in 19.4% (n=71); infections (29.6%), falls (18.3%) and cardiovascular issues (1.9%) were most common. Patients who were readmitted had higher rates of hospital UTI (17.1 vs 7.3%, p=.04) and pneumonia (11.4 vs 3.1%, p=.039) and h/o CAD (40.0% vs 23.7%, p=.04), with no differences in dc destination, admit NIHSS, and dc Rankin among other factors. Patients that were readmitted had worse functional outcomes at 1 mo (Rankin 2.8 vs 2.1, p=.001), even after adjustment (p=.02). Patients with complications that were not readmitted had more diabetes (42.2 vs 27.5%, p=0.021) but were otherwise similar to those without. However, their Rankin scores improved less often (42.2 vs 55.6%, p=.04) and they had worse Rankin scores at 30d (2.4 vs 2.1, p=.03) which persisted after adjustment (p=.01).

Conclusion:
Medical complications occurred in 26.2% of patients within the 1st month of hospital discharge. Despite similar functional status at discharge, patients with complications, regardless of whether they were readmitted, had worse functional status at 1 mo. Prevention of these complications may lead to improve stroke outcomes.
Abstract TMP99: Pediatric Intracerebral Hemorrhage: Acute Symptomatic Seizures and Epilepsy
Authors: Beslow Lauren A , Abend Nicholas S , Gindville Melissa C , Bastian Rachel A , Licht Daniel J , Smith Sabrina E , Ichord Rebecca N , Jordan Lori C
Published: July 2021

Background and Objectives:
We aimed to define the incidence of acute symptomatic seizures and of remote symptomatic seizures and epilepsy after spontaneous pediatric intracerebral hemorrhage (ICH).

Methods:
Pediatric patients with spontaneous ICH presenting between 2007 and 2012 at three tertiary care centers were prospectively identified. Acute symptomatic seizures were defined as seizures occurring from presentation to 7 days after ICH. Survival analysis was used to assess development of a first remote symptomatic seizure and epilepsy (2 or more unprovoked seizures >7 days after ICH). Log-rank tests were used to examine putative risk factors for development of remote symptomatic seizures and epilepsy.

Results:
Seventy-three pediatric subjects with spontaneous ICH were identified, including 20 perinatal (≥37 weeks gestation to 28 days) and 53 childhood subjects (>28 days to <18 years). Acute symptomatic seizures occurred in 12 (60%) perinatal and 23 (43%) childhood subjects, p=.29, Fisher’s exact. Median age of childhood subjects with acute symptomatic seizures was younger than those without (2.2 versus 10.8 years, p=.006, rank-sum). Electrographic-only seizures occurred in 28% of 32 subjects who had continuous EEG monitoring. Follow-up was not different between perinatal and childhood subjects (median 371 versus 340 days), p=.68, rank-sum. One and two-year remote symptomatic seizure-free survival were 82% (95% CI 68-91%) and 67% (95% CI 46-82%). One and two-year epilepsy-free survival were 96% (95% CI 83-99%) and 87% (95% CI 65-95%). Elevated intracranial pressure (ICP) requiring urgent intervention was a risk factor for remote symptomatic seizures and epilepsy (p=.024 and p=.037, log-rank test).

Conclusions:
Acute symptomatic seizures are common in both perinatal and childhood ICH. Continuous EEG monitoring may identify electrographic-only seizures in some subjects. By two-years after ICH it is estimated that about one-third of patients will have a single remote symptomatic seizures and that about 13% will develop epilepsy. Elevated ICP requiring intervention is a risk factor for remote symptomatic seizures and epilepsy.
Abstract TP102: Hyperexpression Of Adiponectin Improves Long-term Stroke Outcome In Young And Aged Mice
Authors: Miao Jie , Shen Linhui , Tang Yaohui , Wang Yongting , Yuan Falei , Zhao Yongju , Yang Guoyuan
Published: July 2021

Introduction:
Previous studies showed that adiponectin (APN) has benefits on acute phase of ischemic brain injury. However, its role for neurobehavior recovery after stroke remains unclear, especially in aged rodents. In this study, we explored whether hyperexpression of APN could improve long-term recovery after stroke in both young and aged mice.

Methods:
Adeno-associated viral vector carrying APN gene (AAV-APN) was stereotactically injected in the striatum of adult (3 months) and aged CD-1 mice (20-22 months). One week after injection, transient middle cerebral artery occlusion (tMCAO) was performed. Expression of APN and its receptors in adult and aged stroke mice was assessed by Real-time PCR,western blot and immunohistochemistry. Cortical atrophy volume, Neurobehavior tests, angiogenesis and neurogenesis were also explored. Expression of phospho-AMPK and VEGF were investigated by western blot to further study the mechanism of APN.

Results:
In both adult and aged mice after stroke, immunohistochemistry and western blot analysis showed that expression of APN and its receptor AdipoR1 was increased. Comparing to the AAV-GFP and saline treated mice, cortical atrophy volume was attenuated, neurobehavior recovery was improved and angiogenesis was increased in the AAV-APN transduced mice (p<0.05). In addition, the expression of phospho-AMPK and VEGF was increased in the AAV-APN transduced adult and aged mice after cerebral ischemia (p<0.05). Moreover, phospho-AMPK inhibitor compound C treated AAV-APN-transduced mice developed larger atrophy volume (p<0.05), and the number of microvessels was significantly decreased compared to the control mice (p<0.05). P-AMPK,VEGF protein levels and VEGF mRNA level in the AAV-APN-transduced mice with compound C treatment were significantly reduced (p<0.05).

Conclusions:
Our results showed that overexpression of APN attenuates brain atrophy, improves neurobehavior recovery in both adult and aged mice, which is mediated by VEGF up regulation and the AMPK signaling pathway. Our findings suggest that APN may have great potential for ischemic stroke, even in aged animals.
Abstract TP111: Activation of the Brain Renin-Angiotensin System by Translational Approaches Following Stroke Onset Is Neuroprotective in a Rat Model of Ischemic Stroke
Authors: Bennion Douglas M , Donnangelo Lauren , Pioquinto David , Regenhardt Robert , Raizada Mohan K , Sumners Colin
Published: July 2021

Background:
Toward discovering novel stroke therapies, recent research has shown that activation of the newly-discovered angiotensin converting enzyme 2/angiotensin-(1-7)/mas (ACE2/Ang-(1-7)/Mas) pathway, a counter-regulatory axis of the brain renin-angiotensin system, is neuroprotective in ischemic stroke in rats. Specifically, intraventricular administration of the novel ACE2 activator diminazine aceturate (DIZE) before and during an ischemic stroke decreases cerebral infarct and neurologic deficits. Efficacy must now be demonstrated using minimally-invasive methods if this therapy is to be translated to the care of human patients. In this study, we assessed the hypothesis that systemic administration of DIZE post ischemic stroke would be neuroprotective.

Methods:
Adult male Sprague-Dawley rats underwent ischemic stroke by endothelin-1 induced middle cerebral artery occlusion and were randomly divided into 2 groups (n=9-10/set): 1) intraperitoneal (IP) administrations of DIZE (7.5 mg/kg) at 4, 24, and 48 h after stroke; 2) IP administrations of 0.9% saline vehicle at the same time points. At 24 and 72 h after stroke, rats underwent blinded neurologic assessments. Immediately following the 72 h tests, animals were sacrificed, cerebral infarct volumes assessed by TTC staining, and IL-1β expression in the stroke region analyzed by rt-PCR. Data are expressed as mean ± SEM with significance inferred at p<0.05.

Results:
Mean infarct volume was significantly decreased by IP injections of DIZE (9.4% ± 4.35) as compared to control (22.8%±3.6, p=0.039). At 24 h post stroke, neurologic deficits (Garcia Scale) were significantly improved in the DIZE treated group (16.7±0.40) versus the saline group (15.22±0.57, p=0.037). Although DIZE tended to improve neurologic deficits 72 h post stroke, this trend was not significant. Finally, DIZE treatment significantly reduced mRNA expression of IL-1β (0.43 ± 0.14) in the cerebral cortical stroke region as compared to saline treatment (1.47±0.08, p=0.001).

Conclusions:
Our findings suggest that targeting the ACE2/Ang-(1-7)/Mas axis post stroke can improve function, decrease inflammation, and reduce infarct volume - a significant translational step in brain renin-angiotensin system research.
Abstract TP12: Safety of Antiplatelet Agents within 24 hours of Intra-arterial Thrombolytic Administration in Acute Ischemic Stroke Patients
Authors: Hassan Ameer E , Adil Malik M , Rahman Haseeb A , Rahim Basit , Chaudhry Saqib A , Qureshi Adnan I
Published: July 2021

Background:
Current American Heart Association guidelines recommend withholding all antiplatelet use within 24 hours of thrombolytic use because of concerns regarding an increased risk of intracerebral hemorrhage (ICH). The increased use of emergent thrombectomy, angioplasty, and stent placement in endovascular treatment of acute stroke has prompted a reconsideration of antiplatelet use within 24-hour period.

Objective:
To determine if there is an increased rate of poor outcomes and ICH in acute ischemic stroke patients that undergo intra-arterial thrombolysis (IAT) and are started on antiplatelets within 24 hours of thrombolytics.

Methods:
All IAT treated acute ischemic stroke patients identified through a prospective database maintained from two comprehensive stroke centers over a 6-year period. Patients’ clinical characteristics, timing of antiplatelet agents, rates of poor outcome at discharge (modified Rankin score [mRS] of >3) and ICH were obtained and analyzed.

Results:
Among the total 115 patients that underwent IAT, 65 patients (mean age 60 ± 16.4; 60% men) were started on antiplatelet agents within 24 hours. 43 (66%) patients were started on single antiplatelet, 19 (29%) on dual antiplatelet, and 3 (4.7%) on triple antiplatelet agents within 24 hours of IAT. The proportion of patients with admission NIHSS score>20 was similar in patients who received antiplatelet agents within 24 hours versus those who received them after 24 hours (22% versus 24%, p=0.8) Compared with patients in whom antiplatelets were started after 24 hours, there was no significant difference in the rates of post-procedure ICH (20% versus 9%, p=0.09) and in-hospital mortality (12% versus 12%, p=0.9) in patients started on antiplatelets within 24 hours. There was no significant difference in the rates of poor outcomes (64% versus 71%, p=0.5) between the two groups.

Conclusions:
Despite the existing recommendation advising against the initiation of antiplatelet agents within 24 hours of thrombolysis, there seems to be no significant risk of increased ICH or mortality with such a practice in IAT cases. Larger prospective studies are needed to identify the benefit of early initiation of antiplatelet agents before broad use is implemented.
Abstract TP131: Factors Influencing the Prognosis of Symptomatic and Asymptomatic Intracranial Atherosclerosis after Antiplatelet treatment: Substudy of Trials of Cilostazol in Symptomatic Intracranial Stenosis -2
Authors: Kim Bum Joon , Rha Joung Ho , Kim Dong-Eog , Kim Hahn Young , Lee Ju Hun , Bae Hee-Joon , Han Moon-Ku , Kang Dong-Wha , Kim Jong S. , Kwon Sun U.
Published: July 2021

Background:
Intracranial atherosclerosis (ICAS) is a major cause of stroke, and the degree of stenosis changes dynamically during medical treatment. However, factors associated with the prognosis of ICAS are not verified clearly. Therefore, we have investigated the factors which are related to the prognosis of symptomatic and asymptomatic ICAS.

Methods:
This study is performed as a substudy of Trials of cilostazol in symptomatic intracranial stenosis (TOSS)-2. From 20 centers, 409 patients with acute symptomatic ICAS were participated. The prognosis of ICAS was categorized to regression, progression and no change according to the change of MR angiogram between base-line and 7 months of antiplatelet treatment. Factors including clinical, laboratory data and the severity of stenosis were compared among the patients grouped by the prognosis of symptomatic or asymptomatic ICAS.

Results:
After treatment, symptomatic ICAS regressed in 110 patients and progressed in 52 patients, and asymptomatic ICAS regressed in 38 patients and progressed in 19 patients. Higher initial severity of symptomatic ICAS and high density lipoprotein (HDL) cholesterol were independently related with lesser progression of symptomatic ICAS (p<0.001 and p=0.013; respectively). And for asymptomatic ICAS, higher initial severity of asymptomatic ICAS, use of angiotensin receptor blocker (ARB) and lower initial fasting glucose level were related with lesser progression (p<0.001, p=0.010 and p=0.008; respectively).

Conclusion:
The higher initial degree of stenosis was related with a better radiologic outcome of ICAS after medical treatment. Therefore, though the initial severity is high, ICAS may regress by appropriate treatment with antiplatelet agents.
Abstract TP133: Previous Stroke and Carotid Stenting Predict Periprocedural Risk of Symptomatic Carotid Intervention in a Large Community Hospital Vascular Registry
Authors: Baraban Elizabeth , Stuchiner Tamela , Williamson Weldon K , Ellis David , Zerr Kathryn J , Lowenkopf Ted
Published: July 2021

Introduction:
Published analysis of the NASCET and ECST studies revealed a significant impact of the timing of surgery from symptomatic event, type of symptomatic event, gender, and age on patient outcomes.

Hypothesis:
Identified periprocedural risks of age, gender, timing of procedure, and type of symptomatic event will predict carotid endarterectomy complications in a large community hospital vascular registry and be similar for patients undergoing carotid stenting.

Methods:
Patients were prospectively enrolled in a community hospital carotid vascular registry. The study included patients diagnosed with stroke or transient ischemic attack (TIA) who subsequently underwent carotid endarterectomy or stenting. Procedural risk was defined by occurrence of stroke, myocardial infarction (MI) post-operatively or death within 30 days of the procedure. Multiple logistic regression was conducted to predict procedural risk using age (<65, 65-74, ≥75), gender, time to intervention (<2 weeks, 2-4 weeks, >4 weeks), type of symptom event (TIA, stroke, ocular only) and procedure (stent versus endarterectomy) as predictors.

Results:
Seven hundred and one patients with symptomatic carotid disease were included in the analysis. Over 60% were male and the mean age was 71.2 years. Time of symptom onset to intervention was as follows: 29.7% at <2 weeks, 32.9% at 2-4 weeks and 31.2% at >4 weeks. Twenty-eight patients (4.0%) had post-operative stroke or death within 30 days. No patients experienced an MI. Multiple logistic regression results indicate that the symptomatic event of stroke (n=194) compared to ocular only symptoms (n=257) (Odds Ratio (OR)=2.82, p=.032) and carotid stenting (n=93) versus carotid endarterectomy (n=608) (OR=2.45, p=.046) were significant predictors of periprocedural risk. Timing, gender, age, and TIA symptom event were not significant predictors.

Conclusions:
Our study of symptomatic carotid disease showed that patients with a stroke and those undergoing carotid stenting were at higher risk of periprocedural complications. Timing of surgery, age, gender and TIA symptom events did not have an effect. Future analyses will focus on the risk or benefit of these procedures on long-term functional outcomes.
Abstract TP135: White Matter Hyperintensities in Relation to Severity of Intracranial Atherosclerotic Stenosis
Authors: Park Jong-Ho , Kim Dong-Sun , Han Hyun Jeong
Published: July 2021

Background & Objectives:
White matter hyperintensities (WMH) is regarded as a small-vessel disease because the accompanying silent infarcts are predominantly lacunes and share the same pathological basis with WMH. Endothelial dysfunction is known to play a cardinal role in progression of WMH. Accordingly, atherosclerotic burden might be associated with the development of WMH. Because metabolic syndrome (MetS) is associated with an increased risk of WMH and with intracranial atherosclerotic stenosis (ICAS), we assessed the hypothesis that WMH might be related to ICAS in ischemic stroke patients. We compared a severity of WMH among the ICAS, extracranial (ECAS), and no cerebral atherosclerotic stenosis (NCAS) groups.

Methods:
We conducted a cross-sectional study in 605 Korean patients with acute ischemic stroke (mean age 67.7±12.8; 347 males), who underwent brain MRI/MRA. The severity of deep WMH (d-WMH, n=495) and periventricular WMH (pv-WMH, n=521) was rated separately. Irrespective of index stroke mechanisms, patients were classified into three groups: ICAS (n=294), extracranial (ECAS, n=63), and no cerebral atherosclerotic stenosis (NCAS, n=248). Stenosis groups and demographics, including the presence of MetS, were compared between patients with d-/pv-WMH and without.

Results:
The ICAS group showed a higher d-WMH / pv-WMH grade (1.61±0.85 / 1.64±0.80) than both the ECAS (1.29±0.87 / 1.21±0.77) and NCAS (1.15±0.92 / 1.21±0.82) groups (
P
<0.001 for all). Patients with more severe ICAS were more likely to have higher grades of d-WMH and pv-WMH (
P
<0.001 for all). Patients with higher grades of d-WMH and pv-WMH had a higher incidence of ICAS (
P
<0.001 for all) but not of ECAS or NCAS. Patients with a greater number of MetS components were more likely to have higher grades of d-WMH and pv-PWMH (
P
<0.001 for all). With a multivariable analysis, a dose-response relationship was observed between the presence of ICAS and the WMH: (1) for d-WMH, OR=3.25 (95% CI, 1.18-8.96) for 2 ICAS, OR=6.39 (1.84-22.14) for ≥3 ICAS, (2) for pv-WMH, OR=2.22 (95% CI, 1.25-3.95) for 2 ICAS, OR=3.40 (1.89-6.09) for ≥3 ICAS versus 1 ICAS.

Conclusions:
ICAS, rather than ECAS or NCAS is a predictor of d-/pv-WMH. ICAS burden might be the substrate for chronic cerebral hypoperfusion.
Abstract TP136: Cilostazol Inhibits Inflammation and Endothelial Cell Damage in Patients with Severe Carotid Disease
Authors: Yamazaki Masako , Okada Yoshikazu , Kawashima Akitsugu , Yamaguchi Koji , Yoneyama Taku , Uchiyama Shinichiro
Published: July 2021

Background:
Cilostazol is an antiplatelet agent, which is known also to have protective effects on endothelial cell. We studied effects of cilostazol on markers of inflammation and endothelial cell damage in patients with severe carotid disease, who underwent carotid endoarterectomy (CEA).

Methods:
We measured high sensitivity CRP (hsCRP), soluble vascular cellular adhesion molecule (VCAM)-1, soluble E-selectin, soluble intercellular adhesion molecule-1 and von Willebrand Factor antigen (vWF) in 45 patients who underwent CEA (38 males and 7 females, mean age was 69 years). Venous blood was taken from each patient before (Pre) and 3 days (Day3), 10 days (Day10), 4 weeks and 1 year (Post) after CEA. Each marker was compared between patients who were treated with aspirin alone (aspirin group, 18 cases) and those treated with cilostazol alone or cilostazol plus aspirin (cilostazol group, 17 cases).

Results:
The levels of hsCRP, VCAM-1, E-selectin and vWF at Day3 and the levels of hsCRP and VCAM-1 on Day10 were significantly higher than those at PreCEA. The alterations of those markers were not significantly different between the aspirin and cilotazol groups. The levels of hsCRP in the cilostazol group were significantly lower than those in aspirin group at both PreCEA and PostCEA. The levels of VCAM-1 at PreCEA in the cilostazol group were significantly lower than those in the aspirin group.

Conclusions:
The results suggested that cilostazol inhibits inflammation and endothelial cell damage in patients with severe carotid disease, although its protective effects did not reduce the endothelial cell damage induced by CEA when compared with aspirin.
Abstract TP144: Mechanisms And Prognosis Of Acute Ischemic Stroke Related To Acute Aortic Dissection
Authors: Lee Seung-Jae , Shim Dong-Suk , Han Si-Ryung
Published: July 2021

Background:
Acute aortic dissection (AD) is one of the lethal cardiac diseases involving the aorta. Although pain is a typical symptom, stroke may not rarely occur with the occlusive dissection of aortic branches or hypotension under the condition of AD. We attempted to explores the clinical features, possible mechanisms and prognosis of acute ischemic stroke (AIS) related to AD

Method:
Medical records of 278 consecutive patients with AD (165 with type A and 113 with type B dissection) over 11.5 years were retrospectively analyzed for clinical history, CT or MRI findings and outcome. AIS were categorized into early- or delayed-onset stroke. Early-onset stroke was defined as an AIS presented at admission, and delayed-onset stroke was an AIS which were developed during the two months after the first admission.

Results:
26 (9.4%) patients experienced an ischemic stroke, which included 22 with type A and 4 with type B dissection. 8 patients (2.9%) including a case of TIA had an early-onset stroke, whereas delayed-onset stroke occurred in 18 patients (6.5%) postoperatively or under medical treatment. Early-onset stroke was all referable to the anterior circulation, predominantly right-sided (87.5%). One or more main branches of the aortic arch were involved in 6 out of 8 patients (75%) with early-onset stroke. Innominate artery was most frequently involved (75.0%). In contrast, delayed-onset stroke affected similarly bilateral carotid territories, and also included lesions in bilateral carotid, posterior-circulation and anterior/posterior-circulation territories. Among the 26 patients, 8 patients (30.8%) expired within 6 months of the disease onset (3 cases from hemispheric stroke with brain herniation, 2 cases from aortic rupture, 2 cases from sepsis with multiple organ failure and a case from mesentery ischemia and renal failure). Additionally, 9 patients (34.6%) remained functionally dependent six months later.

Conclusion:
AD not infrequently causes AIS with grave prognosis, especially in patients with type A dissection. The presumed mechanisms were aortic branch dissection causing luminal occlusion and emboli from thrombosed vascular lumen and hypotension under the condition of AD.
Abstract TP152: Computed Tomography Perfusion Parameter to Predict Cerebral Hyperperfusion Phenomenon Following Carotid Artery Stenting
Authors: Takahashi Yoichiro , Mori Takahisa , Iwata Tomonori , Miyazaki Yuichi , Nakazaki Masahito , Mizokami Koji
Published: July 2021

Background:
Although SPECT is useful for predicting and finding cerebral hyperperfusion phenomenon (CHP) following carotid artery stenting (CAS), there are few institutions that could perform SPECT during peri-CAS period. The purpose of our study is to evaluate whether or not parameters derived from CT perfusion (CTP) used widely can predict CHP.

Methods:
Patients who underwent CTP before elective CAS and SPECT before and immediately after elective CAS in our institution from December 2010 to May 2012. We defined CHP as post-CAS increase of more than 10% of the ratio of cerebral blood flow (CBF) in the territory of the affected middle cerebral artery (MCA) divided by CBF in the ipsilateral cerebellum (MCA/CE ratio) measured by SPECT. We assessed the correlation of pre-CAS CTP’s parameters’ ratio to MCA/CE ratio change between pre-CAS and post-CAS SPECT. The CTP’s parameters’ ratio was calculated as (parameters in the affected side divided by in the unaffected side). CTP parameters we assessed are as follows: time-to-peak (TTP), mean-transit-time (MTT), cerebral blood volume (CBV) and CBF.

Results:
Fifty patients were analyzed. Pre-CAS TTP ratio showed a significant positive correlation with MCA/CE ratio change (r = 0.2863, p = 0.044). Other parameters (MTT, CBV and CBF) had no significant correlation. The cut-off value of pre-CAS TTP ratio was 1.08 to predict CHP (AUC = 0.77859, p = 0.032).

Conclusion:
Increase of pre-CAS TTP ratio is probably correlated with CHP following elective CAS.
Abstract TP157: Clinical Significance of the Ivy Sign on FLAIR MRI in Moyamoya Disease
Authors: Seo Kwonduk , Kim Ji Hwa , Lee Kee Oog , Lee Kyung-Yul
Published: July 2021

Background and purpose:
Leptomeningeal collateral is well developed in patient with moyamoya disease, and it appears as high signal intensity (Ivy sign) on FLAIR images. Some studies reported correlations between Ivy sign and cerebral vascular reserve, but the clinical meaning of Ivy sign is still uncertain. Therefore, we aimed to investigate the clinical significance of Ivy sign in moyamoya disease.

Methods:
FLAIR images of 87 patients with moyamoya disease were reviewed by two neurologists blinded to any clinical information. In order to decide dominant hemisphere with Ivy sign, we divided cerebral hemisphere into 4 regions from anterior to posterior, and each region was scored (0-3 point) based on the prominence of Ivy sign. Clinical findings were obtained by retrospective chart reviews.

Results:
Ivy sign was observed in all moyamoya patients. The score of patients with nonspecific symptom was lower than the patients with complete stroke (4.88±2.85 vs 7.85±3.54, p=0.045). The score was lower in mild symptom group (nonspecific symptom or single event of TIA) than the severe symptom group (recurrent TIA or complete stroke) (6.38±0.90 vs 7.83±0.43, p=0.045). Dominant hemispheric Ivy sign (IDH) could be determined in 79 patients and 58 patients of them had lateralizing symptom. The side of IDH was significantly correlated with side of symptoms (p=0.002). Twenty-nine patients of 37 with right IDH (78.4%) had clinical symptom on the left side, and 13 out of 21 with left IDH (61.9%) was symptomatic on the right side. Ischemic or hemorrhagic lesions were detected on MRI in 50 patients and 10 patients of them had bilateral lesions of similar size. The side of IDH was correlated with the side of MRI lesion (p=0.036).

Conclusions:
Ivy sign was detected in all patients with moyamoya disease. Since the sign was highly correlated with clinical findings, more prominent sign may suggest more frequent and severe clinical events. Ivy sign can be utilized as a means of determining treatment option and predicting clinical outcome.
Abstract TP159: Correlation Between Arterial Stiffness And The Severity Of Acute Cerebral Infarction
Authors: LEE YEONG-BAE , Park Joo-Hwan , Kim Eunja , Kim Ki-Tae , Lee Ju Kang , Lee Ju-Hun , San Jung , Koh Seong-Ho
Published: July 2021

Arterial stiffness is an independent predictor of cardiovascular disease and stroke and can be evaluated by measuring pulse wave velocity(PWV) between 2 sites in the arterial tree, with a higher PWV indicating stiffer arteries. Recent studies have demonstrated that arterial stiffness is associated with intracranial large artery disease and the severity of cerebral small vessel disease. The aim of this study is to clarify whether pulse wave velocity value predict initial severity of acute ischemic stroke.

We enrolled consecutive patients with acute ischemic stroke. Demographic factors, laboratory data, brain imaging, neurological exam and arterial stiffness measured by brachial ankle PWV (baPWV) were evaluated on admission in all subjects. The subtype of acute ischemic stroke was classified according to the TOAST classification. All patients were categorized into two groups based on the initial severity of stroke, indicated by modified Rankin Scale(mRS). Severe group was defined as a mRS ≥ 3 at admission. Unpaired student’s t-test or Mann-whitney U-test were used to compare maximal and meanbaPWV values between two groups.

We enrolled 78 patients. According to the TOAST classification, the etiology of stroke was large artery disease (LAD) in 34 patients, small vessel disease (SVD) in 23 patients, and other subtypes in 12 patients. There were 28 patients with good outcome and 41 patients with poor outcome. The maximal and mean baPWV values were significantly increased in inpatients with high mRS score (2120.17± 527.75, 1999.21 ± 437.46) compared with those with low mRS score (1751.96 ± 363.49, 1723.14 ± 353.02)(p=0.001, p=0.007). In patients with SVD subtype, there was significant difference in maximal and mean baPWVvalues between two groups (p=0.030, p=0.047), whereas there was no significant difference in baPWV in patients with LAD subtype (p=0.141, p=0.172).

The main finding of our study is that arterial stiffness indicated by baPWV is associated with the initial severity of acute ischemic stroke. Because initial stroke severity is strongly associated with functional outcome of stroke, this findings suggest that measurement of baPWV may predict long-term outcome in patients with stroke especially in those with TOAST classification confirmed as SVD.
Abstract TP163: Metabolic Syndrome, Raised Serum Uric Acid And Poor Leptomeningeal Collateral Status In Patients With Acute Ischemic Strokes
Authors: Menon Bijoy K , Smith Eric E , Coutts Shelagh B , Welsh Donald G , Faber James E , Nambiar Vivek K , Goyal Mayank , Hill Michael D , Demchuk Andrew M , Cho Kyung-Hee , Chang Hyuk-won , Hong Jeung-Ho , Sohn Sung I
Published: July 2021

Introduction:
Leptomeningeal collaterals are native (pre-existing) anastomoses that cross-connect a small number of distal-most arterioles within the crowns of the cerebral artery trees. We seek to identify potentially modifiable determinants associated with variability in leptomeningeal collateral status in patients with acute ischemic stroke.

Methods:
Data is from the Keimyung Stroke Registry, a prospectively collected dataset of patients with acute ischemic stroke from Daegu, South Korea. Patients with M 1 segment middle cerebral artery (MCA) +/- intracranial internal carotid artery (ICA) occlusions on baseline CT-angio from May 2004 to July 2009 were included in the study.Baseline and follow-up imaging was analyzed at the imaging core lab of the Calgary Stroke Program. Two readers blinded to all clinical information assessed leptomeningeal collaterals on baseline CT-angio by consensus using the regional leptomeningeal score (rLMC).

Results:
Of 206 patients[mean age66.9±11.6 years, median baseline NIHSS 14 (IQR11-20), median stroke symptom onset to CT-angio time 166 minutes (IQR 96-262)], 133 patients (64.6%) had poor collateral status at baseline (rLMC score 11-20). On univariate analyses, patients with poor collateral status at baseline were older, hypertensive, had higher blood glucose values, higher white blood cell count at baseline, higher D-dimer and serum uric acid levels (measured next day morning) and were more likely to have metabolic syndrome as per ATP III criteria. Multivariable modeling identified metabolic syndrome (OR 3.22 95% CI 1.69-6.15, p<0.001), raised serum uric acid (per 1mg/dl OR 1.35 95% CI 1.12-1.62, p<0.01) and age (per year, OR 1.03 95% CI 1-1.05, p=0.03) as independent predictors of poor leptomeningeal collateral status at baseline.

Conclusion:
Metabolic syndrome and hyperuricemia are modifiable determinants associated with poor leptomeningeal collateral status in patients with acute ischemic stroke. This knowledge could potentially help in focusing research on appropriate therapeutic strategies for modulating function of leptomeningeal collaterals.
Abstract TP167: Suppression of High-mobility Group Protein Box-1 Signaling by Eicosapentaenoic Acid Ameliorates Brain Ischemic Damage in Oophorectomized Rats
Authors: Sumiyoshi Manabu , Kitazato Keiko T , Yagi Kenji , Shimada Kenji , Matsushita Nobuhisa , Tada Yoshiteru , Kanematsu Yasuhisa , Satomi Junichiro , Nagahiro Shinji
Published: July 2021

Background and Purpose—
Cerebral ischemia triggers the acute inflammation that has been associated with an increase in brain damage. In male rats exposed to ischemic insult, high-mobility group protein box-1 (HMGB1) activates inflammatory pathways via its receptor for advanced glycation products (RAGE) and its toll-like receptors (TLRs). We examined the role of these molecules in female rats with experimental ischemic brain damage. We further investigated the efficacy of eicosapentaenoic acid (EPA) against cerebral ischemia and its effect on HMGB1 signaling.

Methods—
Before 90-min middle cerebral artery occlusion-reperfusion, 5-week-old female Sprague-Dawley rats were subjected to bilateral oophorectomy (OVX
+
) and pretreated with 500mg/kg/day EPA for 4 weeks. The relationship between the efficacy of EPA and the regulation of HMGB1 signaling were investigated using peroxisome proliferator-activated receptor gamma (PPARγ) agonist pioglitazone, PPARγ inhibitor GW9662, and vehicle-control.

Results—
In parallel with the expansion of the cortical infarct size, HMGB1 signaling after cerebral ischemia was increased in OVX
+
rats. The mRNA level of TLR9 and RAGE but not TLR2 and TLR4 was moderately increased by cerebral ischemia and significantly higher in OVX
+
- than OVX
-
rats. The HMGB1 signal in the OVX
+
rats pretreated with EPA was inhibited in a PPARγ-dependent and independent manner. These effects were associated with a reduction in the infarct size.

Conclusions—
We first demonstrate that cortical infarct facilitated by OVX is associated with augmented HMGB1 signaling and that the augmented HMGB1 signaling was suppressed by EPA. To assess whether EPA treatment is a promising strategy further clinical studies are required in postmenopausal women.
Abstract TP173: Stroke Education by Using a Comic Book and Animated Cartoon Improve Stroke Knowledge among Junior High School Students
Authors: Amano Tatsuo , Yokota Chiaki , Sakamoto Yuki , Shigehatake Yuya , Inoue Yasuteru , Miyashita Fumio , Toyoda Kazunori , Minematsu Kazuo
Published: July 2021

Background and Purpose:
We have reported that stroke lesson by stroke neurologists for junior high school students improved their stroke knowledge. For the next step, we investigated whether junior high school students could get the knowledge only by stroke education with a comic book and animated cartoon, which we produced to spread the stroke knowledge widely.

Methods:
We produce a comic book and a 10-minutes animated cartoon instructing stroke risk factors, stroke sign and symptoms, and encouraging immediate calling for emergent medical service (EMS) on identification of stroke signs and symptoms (the FAST message). Three stories were involved in this comic book and animated cartoon. The first one was a case of acute ischemic stroke treated successfully with hyperacute thrombolytic therapy. The remaining 2 stories were cases of transient ischemic attack; a case of preventing stroke successfully with an appropriate action of his family, but the other case of suffering from a completed stroke with delay of the hospital visit due to the lack of stroke symptom knowledge. From December 2011 to March 2012, 493 students in 15 classes of the 1
st
grade (12 - 13 years old) of 3 junior high schools were enrolled. Each subject was distributed the comic book and watched the animated cartoon. Stroke lessons were not performed. Questionnaires on stroke knowledge were examined before, immediately after, and 3 months after the intervention.

Results:
Proportions of correct answer in all questions except arrhythmia were significantly higher immediately after the intervention than at baseline. At 3 month, higher proportions of correct answer for facial palsy, speech disturbance, hemiplegia, numbness of one side, calling 119 for stroke, alcohol drinking, smoking, and obesity were preserved as compared with those at baseline;75% vs. 33%, 91% vs. 60%, 79% vs. 52%, 58% vs. 51%, 79% vs. 52%, 90% vs. 85%, 96% vs.72%, 69% vs.54%, 35% vs.22%, respectively (p<0.05). Fifty six percentages of students answered correctly the FAST message.

Conclusions:
Stroke education by using our homemade comic book and animated cartoon improved knowledge about stroke among junior high school students.
Abstract TP202: Atrial Fibrillation In Young Stroke Patients: Do We Underestimate Its Prevalence?
Authors: Prefasi Daniel , Martinez-Sanchez Patricia , Rodriguez-Sanz Ana , Fuentes Blanca , Ruiz-Ares Gerardo , Filgueiras-Rama David , Diez-Tejedor Exuperio
Published: July 2021

BACKGROUND:
Our knowledge of the presence of atrial fibrillation (AF) in young stroke patients is scarce. Our objective was to analyze the frequency of AF in ischemic stroke (IS) patients up to 50 years of age and its relationship with stroke severity and outcomes.

METHODS:
Prospective observational study of consecutive IS patients up to 50 years of age admitted to a stroke center during a five-year period (2007-2011). A complete cardiology study was performed with daily electrocardiogram (ECG) and cardiac monitoring for 72 hours as well as echocardiography. In cases of stroke of unknown etiology, a 24-hour Holter monitoring was performed, which was repeated as necessary. We analyzed baseline data, previously or newly diagnosed AF, structural heart disease (SHD) (valvulopathy/cardiomyopathy), stroke severity on admission measured by the NIHSS (moderate-severe stroke if NIHSS≥5) and 3-month outcomes according to the mRS (good outcome if mRS ≤2). AF was classified as AF associated with SHD (AF-SHD) and AF not associated with SHD (AF-NSHD).

RESULTS:
One hundred fifty-seven patients were included (mean age 41.1 years, 58.6% male). Sixteen subjects (10.2%) presented AF, 5 with AF-NSHD and 11 with AF-SHD. AF was previously known in 10 patients (6.4%), 2 with AF-NSHD and 8 with AF-SHD. A multivariate analysis showed an independent association between AF and moderate-severe IS (OR 3.882, 95%CI: 1.277-11.799), but AF was not an independent prognostic factor.

CONCLUSION:
AF is present in up to 10% of young patients with IS and is associated with increased NIHSS scores.
Abstract TP245: Impact Of A County-wide Prehospital Destination Protocol On Thrombolytic Rates For Acute Ischemic Stroke (AIS)
Authors: Govindarajan Prasanthi , Ghilarducci David , Shiboski Stephen , Cook Larry , Grimes Barbara , Johnston S Claiborne
Published: July 2021

Background:
Higher IV t-PA rates were observed statewide after regionalization of stroke.

Objectives:
We describe the IV t-PA rates in ambulance transported acute ischemic stroke (AIS) patients before and during implementation of a county wide prehospital stroke center destination protocol(SDP)and examine the association between SDP and IV t-PA rates in ambulance transported AIS patients.

Methods:
This is a cross-sectional observational study of patients with a hospital based diagnosis of AIS identified using validated ICD- 9 codes. Patient records from 2005-2007 were obtained from the discharge abstract file of the statewide administrative database and were linked to the prehospital electronic records using patient level identifiers and probabilistic linkage methodology. Thrombolytic use for AIS was identified using the procedure codes in the discharge database. We excluded direct admissions and inter-facility transfers. IV t_PA rate by year was calculated.Logistic regression was used to determine association between SDP and the IV t_PA rate in AIS patients after controlling for patient and hospital demographics, stroke center designation and teaching status of the hospital, patient residence and day of the week using logistic regression. Data analysis was performed using SAS 9.2

Results:
During a 3 year period, 6181 patients with a primary or secondary diagnosis of stroke were transported by ambulance. Mean age at time of admission was 74 (+/-15) years; 54% (n=3312) were females and 63% (n=3870) were whites. Majority of patients were treated at stroke centers 4132 (70%) and 6005 (97%) were treated at community hospitals. Among ambulance transports, IV t-PA rate did not increase during the implementation of the stroke center designation protocol (pre protocol phase 2.82%, post protocol phase 2.85%, p value 0.95). After controlling for patient demographics, stroke center status, teaching status of the hospital and the weekend effect, SDP implementation was not independently associated with increased rate of IV t-PA in AIS (OR 0.96, 95 CI 0.63-1.47).

Conclusions:
Among ambulance transported patients, our preliminary findings do not show an increase in thrombolytic rates during implementation of a stroke center destination program.