bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 52: Global Cerebral Edema in Patients With Primary Intracerebral Hemorrhage: Results From Brain Edema at Cerebral Hemorrhage (BEACH) Study
Authors: Majidi Shahram , Qureshi Mushtaq H , Foster Lydia D , Ewida Amr , Sianati Bahareh , Qureshi Adnan I
Published: October 2018

Background:
Recent data supports presence of neuronal injury and blood brain barrier breakdown in brain regions distant to hematoma in patients with intracerebral hemorrhage (ICH). We determined the prevalence of global cerebral edema and its impact on clinical outcome in patients with ICH recruited in a multicenter clinical trial.

Methods:
BEACH was a pre-planned prospective observational study (N=278) nested in the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH)-2 clinical trial which randomized ICH patients with SBP ≥ 180 mmHg who presented within 4.5 hours of symptom onset. The aim of the ATACH-2 was to ascertain whether SBP reduction to < 140 mmHg would yield reduction in death and disability (defined as modified Rankin Scale 4-6) at 90 days compared to the current guideline. Total brain volume, parenchymal hematoma volume, and peri-hematoma edema volume were measured on CT scans acquired on admission and at 24 (±8) hours (and later intervals when available) post-randomization using computerized image analysis software(Analyze. Inc). Global cerebral edema was defined as 5% or greater increase in the brain volume (excluding parenchymal hematoma and peri-hematoma edema volumes) on follow up CT scan compared with baseline scan.

Results:
A total of 48 (17%) of 278 patients had global cerebral edema by 24 hours CT scan. The median increase in total brain volume was 9 cm3 (range 5 - 20 cm3). Additional occurrence of global cerebral edema was seen in 3% and 1% of patients by 48 hours and 72 hours, respectively. Baseline characteristics were similar, but median NIHSS was higher and median GCS score was lower in patients with global cerebral edema. The prevalence of global cerebral edema was significantly lower in intensive SBP reduction group compared to standard SBP reduction group (12% vs 23%, p-value: 0.02). While not statistically significant, higher rates of death or disability at 90 days were observed among subjects with global cerebral edema within 24 hours (48% vs 36%, p-value: 0.12)

Conclusion:
Global cerebral edema at 24 hours occurred in 17% of the BEACH subgroup of ATACH 2 subjects. Global cerebral edema was associated with higher level of clinical severity of disease and its prevalence was significantly lower among intensive SBP reduction group.
Abstract 53: Comparison of Genetic Ancestry versus Self-Identified Race and Ethnicity as Risk Factor for Intracerebral Hemorrhage
Authors: Marini Sandro , Langefeld Carl D , Lena Umme K , Moomaw Charles J , Testai Fernando D , Kittner Steven J , James Michael L , Rosand Jonathan , Woo Daniel , Anderson Christopher D ,   ERICH Investigators
Published: October 2018

Introduction:
Vascular risk factors (VRFs) and their net effects vary across ethnic populations. We hypothesized that use of DNA-based ancestry informative markers (AIMs), compared with self-reported race/ethnicity (SIRE), would result in better prediction of VRFs and thus improve risk modeling in intracerebral hemorrhage (ICH) across U.S. minority populations.

Methods:
Using data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study (a multi-center case-control study of ICH in whites, blacks, and Hispanics), we utilized 15 AIMs to perform principal component (PC) analysis using variance-standardized relationship matrix dimension reduction. Multivariate logistic regression and tests for independent samples (X
2
and Mann-Whitney U tests) were used to compare PC-defined ancestry and SIRE in their association with VRFs, and to estimate effects within each SIRE. Finally, we compared models for ICH risk including AIMs vs. SIRE.

Results:
Among 4,935 subjects enrolled, 34.7% were blacks, 35.1% whites, and 30.2% Hispanic. PC analysis showed population structure not captured by SIRE [Figure]. Within each self-reported population, PCs values remained significantly associated with VRFs (p <0.001). Regression of PCs against VRF confirmed independent associations of PCs with hypertension across all SIRE (p <0.01) and with diabetes, hypercholesterolemia, coronary artery disease and atrial fibrillation with differing effects between populations. Akaike information criterion (6294 vs. 6286) and Davidson-MacKinnon J test (p <0.001) verified that AIMs significantly improved the ICH risk prediction model over SIRE alone.

Conclusions:
AIMs, particularly among Hispanics and blacks, provide a more detailed assessment of risk exposures in studies that include representative U.S. populations, compared with SIRE alone. This more inclusive ancestry modeling may be a useful tool to improve risk prediction accuracy across other phenotypes
Abstract 58: Therapeutic Effect of Selective Middle Cerebral Artery Cooling Infusion in a Primate Stroke Model
Authors: Wu Di , Chen Jian , Ding Yuchuan , Ji Xunming
Published: October 2018

Introduction:
Selective cooling infusion (SCI) of Lactated Ringer’s solution into ischemic territory supplied by the middle cerebral artery (MCA) has been demonstrated as a safe procedure in stroke patients (Chen et al.,
Stroke,
2016). In order to conduct clinical trials for this therapy, this novel method should be tested in non-human primate (NHP) ischemic stroke models as suggested by the Stroke Therapy Academic Industry Roundtable (STAIR) committee. In the present study, we first developed a realizable thrombus-thrombolysis ischemic model in rhesus monkeys and then we determined whether a SCI of Lactated Ringer’s solution effectively provided a neuroprotection in the NHP with ischemic stroke.

Methods:
An autologous clot was made and injected via a micro-catheter (Prowler -10) into the main trunk of MCA to induce focal ischemia in 24 rhesus monkeys. MCA occlusions were confirmed by DSA. Thrombolysis with rt-PA (0.9mg/kg) was completed 3 h after the onset of ischemia. Twelve ischemic animals, in a randomized manner, received SCI at 10 minutes following rt-PA administration. MRI images, NHPSS, Spetzler scores and modified movement assessment panel were used to evaluate brain infarction, neurological deficits and functional outcome through 30 days.

Results:
Complete, partial, or no recanalization of MCA were found in eight animals in each ischemic group with or without SCI. SCI significantly reduced infarct volume and neurological deficits, as well as improved motor function when complete or partial reperfusion were established. However, SCI did not protect ischemic brain if reperfusion was not achieved.

Conclusion:
Clot embolism and different status of thrombolytic outcomes with rt-PA were developed in rhesus monkeys. SCI is a feasible and practicable neuroprotectant in high-order brains. Reperfusion is a prerequisite for neuroprotection induced by SCI.
Abstract 59: Combining Electrical Stimulation With Stem Cell Therapy Improves Endogenous Mechanisms of Stroke Recovery
Authors: Oh Byeongtaek , Song Shang , Levinson Alexa , Lam Vivek , George Paul
Published: October 2018

Introduction:
Brain stimulation techniques to enhance stroke recovery are a promising area of research; however,
in vivo
electrical stimulation combined with neural progenitor cell (NPC) transplantation has not been fully investigated. We propose the use of a conductive polymer scaffold to optimize stem cell therapy and determine mechanisms driving stroke recovery.

Methods:
The conductive polymer system consisting of a polypyrrole scaffold was seeded with NPCs (Aruna Biomedical) and implanted along with a reference electrode (
Fig. 1a
). Immunocompromised rats underwent a distal middle cerebral artery occlusion stroke. After 1 week post-stroke, implantation surgeries were performed. Electrical stimulation (AC: ±400 mV/100Hz for 1 hr, starting 1 day after implantation, n=10) was applied daily for 3 consecutive days. Blinded, behavior testing was performed for 6 weeks. Immunostaining was performed to determine endogenous NPC population (anti-BrdU, Abcam).

Results:
We designed a cannula system to deliver NPCs with
in vivo
electrical stimulation (
Fig. 1a
). Electrically stimulated NPCs (NPC+ES) had an earlier recovery than the other groups (
Fig. 1b
). The unstimulated NPCs (NPC) also outperformed the cannula with the electrical stimulation alone (Polymer+ES), the cannula alone (Polymer), and the sham (Sham) groups. Combined NPC+ES increased post-stroke endogenous stem cells production in the subventricular zones (SVZ) (
Fig. 1b,c
).

Conclusion:
In conclusion, electrical stimulation of NPCs via a conductive polymer implant enhances stroke recovery and increases endogenous stem cell production. Our platform enables the manipulation of NPCs
in vivo
to optimize recovery and evaluate the important mechanisms for functional improvement.
Abstract 62: Evaluating Collateral Flow Territory Stability As A Novel Biomarker Of Recurrent Stroke In Patients With Symptomatic Intracranial Stenosis
Authors: Arteaga Daniel , Strother Megan , Davis Taylor , Faraco Carlos , Scott Allison , Lants Sarah , Donahue Manus
Published: October 2018

Introduction:
Intracranial (IC) collateral pathways provide important indicators of arterial steno-occlusion compensation, however evaluating the adequacy of these pathways is difficult with existing methods. Here, we modulated arterial partial pressure of CO
2
with mild hypercapnic respiratory stimuli to evaluate the stability of cerebral blood flow (CBF) territories in IC stenosis patients as a novel marker of collateralization adequacy.

Methods:
Symptomatic IC stenosis (n=20) and healthy (n=10) volunteers provided written consent and underwent noninvasive vessel-encoded arterial spin labeling. Separate magnetic labeling of the left ICA, right ICA, and vertebral arteries was performed, yielding 3 CBF territories. Scans were performed during normocapnia and hypercapnia (5% CO
2
) and patients were monitored for recurrent stroke for a mean 1.6 years. The primary study variable was the CBF territory shifting index, defined as the percent of voxels changing from normocapnia to hypercapnia; the clinical endpoint was new non-cardioembolic stroke, TIA, or silent cerebral infarct. Significance was defined as two-sided p<0.05.

Results:
10/20 patients experienced a clinical endpoint at or before follow-up. Shifting indices were significantly larger in patients meeting the clinical end-point (1.49±0.32) compared to controls (0.67±0.071; p<0.022) and patients not meeting the endpoint (0.67±0.12; p<0.0089) (
Fig. 1)
. Using 1 standard error above the mean patient shifting index as a threshold, sensitivities and specificities for predicting the clinical endpoint were 70% (7 of 10) and 97% (29 of 30), respectively.

Conclusion:
Mild shifting of major CBF territories during hypercapnia may be elevated in IC stenosis patients at risk for recurrent stroke. This approach may provide a new marker of collateralization adequacy and risk of recurrent ischemic events.
Figure 1: A.
CBF territory shifting in a patient with left ICA stenosis.
B.
Boxplots of shifting indices.
Abstract 65: Magnetic Resonance Plaque Imaging Before Carotid Artery Stenting (MR-CAS) Study: Initial Results
Authors: Yamada Kiyofumi , Shirakawa Manabu , Enomoto Yukiko , Kojima Takao , Wakabayashi Kazuki , Sun Jie , Hippe Daniel , Dongxiang Xu , Hatsukami Thomas , Yuan Chun , Kawasaki Masanori , Yoshimura Shinichi
Published: October 2018

Background:
Carotid artery stenting (CAS) has recently emerged as a potential alternative to carotid endarterectomy. A major disadvantage of CAS is the high incidence of periprocrdural cerebral embolization. Previous studies suggested carotid plaque composition as lesion-specific risk factors for cerebral embolization during CAS, yet prospective studies are lacking. Magnetic resonance imaging (MRI) is a validated, noninvasive technique that affords quantitative analysis of carotid plaque tissue composition. MR-CAS is a prospective multicenter observational study to test the hypothesis that carotid plaque characteristics evaluated by pre-surgical MRI predict ischemic complications after CAS.

Materials and Methods:
We enrolled 128 arteries which underwent CAS. Multicontrast MRI was performed prior to CAS. Quantitative analysis of carotid plaque composition was done blinded to clinical information, including measures of intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), and calcification. Pre- and post-CAS diffusion weighted (DW) MRI were performed to detect new cerebral infarction after CAS. New ischemic symptoms within 30 days after CAS were also recorded. Associations between quantitative measures of plaque composition and new ischemic lesions on DW-MRI and new ischemic symptoms were evaluated.

Results:
Fifty arteries (39%) had new DW-MRI positive lesions in the ipsilateral carotid territory after CAS. Five patients (3.9%) developed new ischemic symptoms within 30 days after CAS. There were no significant differences in IPH volume or LRNC volume between the groups with and without ipsilateral DW-MRI positive lesions (IPH: 42 mm
3
[95%CI: 0-1140] vs. 20 mm
3
[0-804] p=0.55, LRNC: 240 mm
3
[0-1606] vs. 312 mm
3
[0-1374] p=0.76). However, IPH and LRNC volume were significantly larger in the patients with new ischemic symptoms after CAS than those without (IPH: 323 mm
3
[95%CI: 18-478] vs. 22 mm
3
[0-1140] p=0.009, LRNC: 501 mm
3
[392-1185] vs. 261 mm
3
[0-1606] p=0.013).

Conclusions:
Quantitative measures of carotid plaque composition predicted new ischemic symptoms after CAS but not new DW-MRI.
Abstract 66: Practical Application of Serial Measurement of Cardiac Troponin I for Risk Stratification in Acute Ischemic Stroke
Authors: Ahn Sung-Ho , Han Jung-Hee , Kim Soo-Young , Kang Dong-Wha , Kim Jong S. , Kwon Sun U.
Published: October 2018

Background:
Serum cardiac troponin can be increased in acute ischemic stroke and regarded as a prognostic marker after stroke as similar as coronary artery disease (CAD). However, interpretation of troponin elevation in ischemic stroke patients is complex. Therefore, the aim of this study was to elucidate the possible causes and long-term prognostic value of troponin elevation in ischemic stroke patients.

Methods:
In a prospective, single center cohort study, we performed serial measurement of serum troponin and 12-lead electrocardiogram (ECG) at 48 hours after stroke onset followed by admission. Based on troponin I level at 48 hours, patients were categorized into 3 groups; elevated (≥0.04 ng/mL), minimally elevated (0.040-0.010 ng/mL) and non-detectable (<0.010 ng/mL) level. Comorbidities with possible impact on troponin elevation were documented based on either historical information or abnormalities in disease-related biomarkers. The primary endpoint was death and major adverse cardiac and cerebrovascular event (MACCE).

Results:
Among 1092 consecutive patients during 2-year period, 145 patients (13.3%) and 335 patients (30.7%) had a positive and minor elevation troponin. Multivariable analysis identified six-comorbidities included atrial fibrillation (AF), hypertrophic myocardium (HM), heart failure (HF), chronic kidney disease (CKD), active cancer and possibly ischemic heart disease (IHD), and composite neurological factor (defined as moderate to severe deficits or insular lesions) associated with troponin elevation. In a multivariate Cox model, minimally and elevated troponin were independently associated with death (hazard ratio [HR]: 1.77, 95% confidence interval [CI]: 1.07-2.91 for minor elevation and HR: 3.63, 95% CI: 2.13-6.19 for positive troponin) and combined endpoints of MACCE.

Conclusions:
Troponin elevation even minor elevation are associated with mortality and MACCE in patients with acute stage of ischemic stroke.
Abstract 74: Analysis of Genome-Wide Blood DNA Methylation Profile in Moyamoya Disease
Authors: Ito Masaki , Cheng Michelle Y , Lee Alex G , Teo Mario , Shoemaker Lorelei D , Steinberg Gary K
Published: October 2018

Background:
Moyamoya disease (MMD) is a rare cerebrovascular disorder of unknown cause. Epigenetic regulations such as methylation play key role in gene expression and cerebrovascular diseases, however, methylation changes in MMD has not been previously reported. To understand the methylation profile of MMD, we performed a genome-wide DNA methylation analysis of whole blood from MMD patients.

Method:
Twenty-eight female adult patients and age-/sex- matched 10 healthy control volunteers (34.2 ± 1.3y) were included. All patients developed TIA or headache and were diagnosed as typical MMD (n=19 and 9), predominantly with Suzuki’s angiographical stage 3. DNA was extracted from frozen whole blood and processed with bisulfide conversion. Genome-wide DNA methylation profile was screened using Illumina 850K EPIC microarray. Blood DNA methylome and clinical characteristics were analyzed.

Results:
Self-declared race was predominantly Asian or Caucasian (n=14 and 13 in MMD, n=6 and 3 in control). Eleven patients showed asymptomatic cerebral infarct. MMD susceptible variant (rs112735431) was confirmed only in 4 Asian MMD. We observed distinct blood DNA methylation profile between Asian and Caucasian. There was no significant correlation between the methylation profile and symptom, infarct lesion, nor MMD susceptible variant. Our data revealed 51% of differentially methylated CpG probes (DMPs) in Caucasian MMD (P<0.01), located at CpG island or shore (51% of all the 5782 DMPs), and 3742 genes were regulated by these island/shore locating DMPs. IPA disease and bio-function profiler indicated that these genes involved in the adhesion of T lymphocytes and monocytes, as well as transmigration of peripheral blood lymphocytes.

Conclusion:
Our results indicate that significant methylation changes occur in the blood of MMD patients. In Caucasian MMD, circulating T lymphocytes and monocytes may have a role in disease development, since these cells are known to participate in thickened fibrocellular intima in MMD. Ongoing studies are identifying the correlation of DNA methylation in blood and gene expression in the vascular tissue. Blood DNA methylation changes may be related with the risk of Caucasian MMD.
Abstract 76: Transient Depletion of Microglia Reduces the Severity of Brain Arteriovenous Malformation in a Mouse Model
Authors: Ma Li , Zhu Wan , Zhan Lei , Zhang Rui , Li Qiang , Bao Chen , Weiss Miriam , Wang Andrew , Su Hua
Published: October 2018

Background and purpose:
Accumulation of macrophages and microglia is evidenced in the lesions of human and mouse brain arteriovenous malformations (bAVMs) with or without hemorrhage, suggesting that these cells play an active role in bAVM pathogenesis. We hypothesize that transient depletion of microglia reduces bAVM severity.

Methods:
Brain AVM was induced in adult mice that have activin-like kinase 1 (
Alk1,
an AVM causative gene) gene exons 4-6 floxed by co-injection of an adenoviral vectors expressing Cre-recombinase and an adeno-associated viral vectors expressing vascular endothelial growth factor into the basal ganglia. Brain microglia were depleted transiently by administration of an inhibitor of colony stimulating factor receptor (CSF1R inhibitor, 180 mg/kg/day of body weight) through chow for 7 days starting 1- (when angiogenesis occurred) or 8-weeks (when bAVMs had formed) after model induction. Brain AVM severity was analyzed through quantification of abnormal vessels, macrophage/microglia and hemorrhage (Prussian blue staining) in the lesion (n=6).

Results:
Administration of CSF1R inhibitor to wild-type mice for 7 days depleted 93% of microglia in their brains. CSF1R inhibitor treatment starting at 1-week after model induction inhibited bAVM formation. There were less abnormal vessels in the treated group (14±0.9 vessels/mm
2
) compared to that in the control group (23±0.9 vessels/mm
2
,
P
=0.001) at 8 weeks after model induction. Administration of CSF1R inhibitor starting 8-weeks after the model induction when bAVMs were fully formed also reduced the number of abnormal vessels (control: 25±1.4 vessels/mm2 vs. treated: 14.±0.8 vessels/mm2,
P
<0.001) analyzed at 9-weeks after model induction when the treatment stopped. CSF1R inhibitor treatment has also reduced the number of microglia in bAVM lesion (
P
=0.03 for 1-week-group and
P
=0.003 for 8-week-group), which was correlated with the reduction of abnormal vessels (

R
2

=0.63,
P
=0.0001) and hemorrhage.

Conclusion:
Transient depletion of microglia could be developed into a new therapy for reduction of bAVM severity.
Abstract 8: The Impact of Nursing to Achieve Door to Drug Times of ≤ 45 Minutes in Acute Ischemic Stroke
Authors: Beland Dawn K , Philipp Leah , Loughrey Danielle , Kujawski Katelyn , Alexander Danette , Krawczynski Michelle , Nouh Amre
Published: October 2018

The Impact of Nursing to Achieve Door-to-Drug Times of ≤ 45 Minutes in Acute Ischemic Stroke

Background:
Nursing care in a large urban university affiliated Level 1 Trauma and Comprehensive Stroke Center faces a series of competing priorities. The goal of door-to-drug for alteplase in acute ischemic stroke is 60 minutes. As time is brain, every 15 minutes saved increases the odds of good functional outcome.

Objective:
To evaluate the impact of alteplase reconstitution by nurses at the bedside in the Emergency Department (ED) on door to drug times compared with traditional pharmacy reconstitution process.

Methods:
A retrospective quality improvement project evaluating all stroke patients treated with alteplase at our institution from October 2016 - June 2017 was completed yielding 60 patients. Door-to-drug times using traditional pharmacy reconstitution from October 2016 to January 2017 (n=32) was compared to nursing reconstitution from February 2017 to June 2017 (n=28). The proportion of patients with door-to-drug times of ≤ 45 minutes in both groups was evaluated. T-test for independent means for time differences and Chi-square test of proportions was used to calculate the statistical significance in time reduction between both patient cohorts.

Results:
As compared to pharmacy reconstitution, the mean door-to-drug times for nursing was 15 minutes shorter with nursing (50.75 +/-21.2 vs. 65.9 +/-29.8 minutes) (
p=0.029
). The proportion of patients within the 45 minute time window in the nursing cohort was more than double that with the pharmacy (60% [n=17] vs. 27.8% [n=7], p=0.02). Furthermore, there were no reported dosing errors in either group.

Conclusions:
In our study, nursing reconstitution at the bedside reduced door-to-drug times by 15 minutes and doubled the proportion of patients receiving alteplase within the 45 minute mark. Eliminating treatment delays for patients with acute ischemic stroke lowers in-hospital mortality and reduces long term disability. Efficient nursing reconstitution directly impacts the patient’s door to drug time which contributes to their functional outcome by providing a better chance for a disability-free life.
Abstract 80: Older Patients Benefit More From Complete Recanalization Following Thrombectomy
Authors: Jayaraman Mahesh V , Kiskhovich Thomas , Hemendinger Morgan , Baird Grayson L , Tung Eric L , Yaghi Shadi , Cutting Shawna , Haas Richard A , McTaggart Ryan A
Published: October 2018

Introduction:
Higher rates of recanalization following thrombectomy are associated with better clinical outcomes. Specifically, patients with TICI 2c or 3 recanalization have higher degrees of functional independence as compared with TICI 2b recanalization. Older age is also associated with worse outcomes. We sought to determine if the magnitude of difference in outcomes between TICI 2c/3 and 2b is affected by age.

Methods:
We identified 157 consecutive patients with anterior circulation LVO over 24 months at a single center. Angiograms were reviewed blinded to clinical outcome. In 24 patients, TICI 2b or greater recanalization could not be achieved. This left 133 patients for analysis, with TICI 2c/3 recanalization in 72, and TICI 2b in 61. Primary outcome measures were independence (defined as mRs 0-2 at 90 days), and Utility weighted Rankin at 90 days. We analyzed the relationship between age and outcomes, comparing the TICI 2c/3 vs. 2b groups.

Results:
Patient age ranged from 19 to 92, median 73 (IQR 61-82). Median NIHSS was 17 (IQR 13-20). Median [IQR] time from imaging to reperfusion was 106 [80-141.5] minutes in the TICI 2c/3 group and 124 [86-150] minutes in the TICI 2b group, and did not increase with age. When comparing the relationship between age and outcomes, there was a greater decrease in functional outcome in those with TICI 2b versus TICI 2c/3 reperfusion. In patients younger than 70, 19/29 (66%) with TICI 2b achieved independence at 90 days, as compared with 19/26 (73%) in the TICI 2c/3 group. In patients 70 and older, 9/32 (28%) with TICI 2b achieved independence at 90 days, as compared with 26/46 (57%) in the TICI 2c/3 group, a significant difference (p=.02). The relationship between age and utility weighted Rankin at 90 days is highly significant (p=.0067) and summarized in the figure.

Conclusions:
The additional benefit of TICI 2c/3 over TICI 2b increases significantly with age. Higher levels of recanalization may benefit older patients to a greater extent.
Abstract 84: Collaterals Drive Reperfusion in Stratis
Authors: Liebeskind David S , Mueller-Kronast Nils H , Aziz-Sultan M A , Froehler Michael T , Klucznik Richard P , Saver Jeffrey L , Sanossian Nerses , Zaidat Osama O , Hellinger Frank R , Yavagal Dileep R , Yao Tom L , Nogueira Raul G , Jahan Reza , Haussen Diogo C ,   for the STRATIS Investigators
Published: October 2018

Background:
Collateral circulation to the ischemic territory is a pivotal factor in outcomes after acute ischemic stroke. Extent of angiographic collaterals prior to endovascular therapy has been linked with reperfusion in previous trials, yet the mechanism remains unclear. We analyzed whether downstream collateral grade influences the pace and degree of ultimate reperfusion.

Methods:
The angiography dataset collated by the STRATIS Core Lab was analyzed to relate the grade of collateral circulation (ASITN) with adjudicated procedural time metrics to exact time of first TICI ≥ 2A and with the final eTICI score, delineating reperfusion into 7 distinct categories.

Results:
Collateral grade on routine angiography injections was available in 574/984 (58%) of STRATIS subjects (age 67.5 ± 15.1, 47% women, baseline NIHSS 16.8 ± 5.5). Collaterals included 203/574 (35.4%) with ASITN 3-4, 291/574 (50.7%) ASITN 2 and 80/574 (13.9%) ASITN 0-1. TICI ≥ 2A was achieved at 32.4 ± 23.5 minutes from angiography start and 26.4 ± 18.6 minutes from visualization of the arterial occlusion. The eTICI included 78 TICI 3 (13.6%), 140 TICI 2C (24.4%), 226 TICI o2B (39.3%), 68 TICI m2B (11.8%), 44 TICI 2A (7.7%), 4 TICI 1 (0.7%) and 14 TICI 0 (2.4%). More robust collateral grade was strongly associated with lower NIHSS (15.9 ± 5.4 (ASITN 3-4); 16.7 ± 5.5 (ASITN 2); 19.6 ± 5.1 (ASITN 0-1); p<0.001). Intervals from angiography start, visualization of the arterial occlusion and first device pass to TICI ≥ 2A were all shorter in ASITN 3-4 versus 0-2, with time from first device pass to TICI ≥ 2A reaching statistical significance (p=0.034). Better collaterals were also strongly linked with more extensive reperfusion (Figure).

Collaterals and reperfusion were linked at all occlusion sites (ICA, M1, M2, BA).

Conclusions:
Collaterals on routinely available angiography prior to thrombectomy in STRATIS were strikingly tied to both the speed and degree of final reperfusion, across every site of arterial occlusion.
Abstract 89: Topographic Distributions of Intracranial Adventitial Vasa Vasorum and Correlations With Atherosclerosis: A Postmortem Study
Authors: Zheng Lu , Yang Wen Jie , Fisher Mark , Niu Chun Bo , Wong Ka Sing , Ng Ho Keung , Leung Wai Hong Thomas , Chen Xiang Yan
Published: October 2018

Background and Purpose:
Vasa vasorum, which constitutes a network of microvasculature, plays a nutritive and drainable role in vessel walls of arteries. The existence of vasa vasorum within brain vasculature is rarely reported. Based on a series of cerebral artery specimens, we aimed to describe the distribution features of vasa vasorum among intracranial arteries, including middle cerebral arteries (MCAs), basilar arteries (BAs) and vertebral arteries (VAs) and potential effects of vasa vasorum on atherosclerosis morphology.

Methods:
One hundred and fifty- seven arteries (64 MCAs, 32 Bas and 61 VAs) were obtained from consecutively recruited 32 autopsy cases aged 45 years or above. Routine histology and immunostaining processing were performed to identify the presence of adventitial vasa vasorum and to study the phenotypes and specific components of intracranial atherosclerotic lesions.

Results:
Among 157 intracranial cerebral arteries, adventitial vasa vasorum were present most frequently in the vertebral arteries (77%), followed by basilar arteries (44%) and middle cerebral arteries (20%). Arteries with adventitial vasa vasorum had greater thickness of tunica adventitia (0.10±0.06 mm vs. 0.06±0.03 mm,
p
< 0.001) and larger size in diameters (3.41± 0.73 mm vs. 2.97± 0.66 mm,
p
< 0.001). The occurrence of adventitial vasa vasorum correlated with high frequency of complicated plaques and higher rate of concentric atherosclerotic lesions (70% vs. 36%,
p
< 0.001).

Conclusion:
For the first time, our study demonstrated the presence of adventitial vasa vasorum within brain vasculature, especially at vertebral arteries. The correlations between adventitial vasa vasorum and intraplaque hemorrhage, inflammation and calcification suggest that adventitial vasa vasorum may serve as a predictor of unstable atherosclerotic lesions. Further studies are required to explore the biological behavior of adventitial vasa vasorum within cerebral arteries.
Abstract 98: Point-of-care Testing of Coagulation in Patients Treated With the Non-vitamin K Antagonist Oral Anticoagulant Edoxaban
Authors: Härtig Florian J , Birschmann Ingvild , Peter Andreas , Weyland Charlotte , Dehnert Monique , Martin Lilija , Sonnleitner Matthias , Kuhn Joachim , Ziemann Ulf , Poli Sven
Published: October 2018

Introduction:
Edoxaban, alongside other non-vitamin K antagonist oral anticoagulants (NOAC), is increasingly used for stroke prevention in patients with atrial fibrillation. Despite treatment, stroke rate in these patients remains one to two percent per year. In this growing population of edoxaban/NOAC-treated stroke patients, rapid assessment of coagulation would be useful to guide the decision for thrombolysis or reversal therapy in case of a neurovascular emergency. However, no data exists on the effect of edoxaban on available point-of-care test (POCT) systems.

Hypothesis:
Test assays of the commercially available CoaguChek® (CC) and Hemochron® are able to detect clinically relevant concentrations of edoxaban in a blood sample.

Methods:
We studied patients receiving their first dose of edoxaban. Subjects receiving other anticoagulants were excluded. Six blood samples were collected from each patient: before drug intake, 30 minutes, one, two, and eight hours after intake, as well as before the next dose. Coagulation-POCT and mass spectrometry for gold standard-determination of edoxaban plasma concentration were performed at each time point.

Results:
120 blood samples from 20 edoxaban-treated patients were analyzed. Edoxaban concentrations ranged from 0 to 302ng/mL. CC-INR ranged from 0.9 to 2.3. Pearson’s correlation coefficient showed a strong correlation between CC-INR and edoxaban concentrations (r=0.73). Edoxaban concentrations > 30ng/mL (threshold for thrombolysis according to the European Stroke Organisation) were detected by CC-INR ≥ 1.1 with 96% sensitivity and 44% specificity (89% sensitivity and 88% specificity for CC-INR ≥ 1.2; AUC=0.92).

Conclusions:
Our study represents the first systematic evaluation of coagulation POCT in edoxaban-treated patients. Available coagulation POCT devices may be able to reliably detect clinically relevant edoxaban concentrations in blood samples of stroke patients in the emergency setting. In addition to edoxaban-POCT analyses, we will present further data on NOAC-specific POCT from our SPOCT-NOAC study.
Abstract NS1: Blood Pressure Medications at Hospital Discharge
Authors: Lantzy Amanda , Denny M. Carter , Sharrief Anjail , Carlson-Chalifoux Ashley , Feit Preethy , Simo Leticia
Published: October 2018

Introduction:
Recurrent strokes carry a higher risk of disability and mortality than first-ever acute ischemic stroke (AIS). Several studies have demonstrated that controlling blood pressure (BP) reduces the risk of recurrent stroke. National guidelines suggest diuretics and ACE inhibitors (ACE-i) may be preferred for BP control in stroke survivors.

Hypothesis:
We hypothesized that there would be a wide variation in the classes of blood pressure medications prescribed to adult AIS patients at the time of hospital discharge.

Methods:
We reviewed 483 consecutive adult AIS patients admitted to our institution from January 2015 to April 2017. ICH, SAH and TIA patients were excluded. BP medications were categorized by type according to the Get with the Guidelines (GWTG) database. Hypertension was defined as a known past medical history of hypertension on admission. Exploratory and descriptive analyses were performed.

Results:
Baseline characteristics and discharge disposition are in shown in table 1. Of the 483 AIS patients, 373 (77.2%) had a known history of hypertension. Among the patients, 335 (90%) were prescribed BP medications at discharge, 135 (40%) received an ACE-i , 69 (21%) an angiotensin receptor blocker (ARB), 121 (36%) a diuretic, 182 (54%) a beta blocker, 134 (40%) a calcium channel blocker, and 10% other BP medications.

Conclusions:
There is wide variation in classes of BP medications prescribed at hospital discharge after AIS. Although ACE-i and diuretics are recommended in the AHA/ASA guidelines for BP treatment after AIS, they were not prescribed to the majority of AIS patients. Further studies are needed to evaluate in-hospital antihypertensive medication prescribing patterns in a national multi-center study.
Abstract NS5: It Takes a Village: And Other Lessons Learned from a Large Volume Comprehensive Stroke Center
Authors: Gonzales Isabel , Shaw Sandi G , Cooper Stephanie , Lightford Mallory , Indupuru Hari K , Fraher Christopher J , Harrison Nicole , Savitz Sean I , Vahidy Farhaan S
Published: October 2018

Introduction:
The Joint Commission (TJC) certification as a Comprehensive Stroke Center (CSC) entails coordination across multiple units of clinical / academic institutions, and the demands on resources are daunting. Certification standards lack resource allocation recommendations. We present data on workload quantum and resource requirements based on experiences from a TJC certified, high-volume CSC.

Methods:
We conducted a desk audit of frequency-based CSC staff activities. An outside team member conducted interviews, followed by collective adjudication for precise categorization. Redundant and overlapping tasks were removed iteratively, and activities were cross-linked with other sources (meeting minutes, individual calendars, on-call schedules). Person-time per task is a product of number of hours and team members. Person-Hours/Day (PHD) were determined by factoring task frequency. PHDs were used to calculate Full Time Employee (FTE) requirements. Volumes were obtained from our CSC registries.

Results:
Our CSC received 2,840 patients between 4/1/2016 and 3/31/2017. Among ischemic stroke patients, 30.5% received IV tPA and 119 underwent intra-arterial thrombectomy. Overall, 60 independent activities were divided into 7 mutually exclusive categories (Table 1). Daily, weekly, and monthly activities collectively constituted 83.3% of all the activities. A total of 67.43 PHDs were computed of which data processes are the most resource consumptive (32.07 PHD) followed by core measures tracking (13.8 PHD) (Figure 1). Collectively, the top two activities account for 68% of all PHD and approximate a requirement of six FTEs. Details of activities will be presented.

Conclusion:
Adequate planning and continual assessment of resources is imperative to optimal CSC operations and patients’ quality of care. Resources are significantly volume driven. Integrative nature of data processes are central to CSC functioning and necessitate resource evaluation.
Abstract NS8: The Effects of Integration and Implementation of a Stroke Nurse Navigator Program in a Comprehensive Stroke Center
Authors: Sher Karen , Greco-Dugan Judith , Babcock Mary , Schouten Erika , Nouh Amre
Published: October 2018

Background:
Post stroke care is complex for patients and families. A stroke nurse navigator is able to improve continuity through the transition from inpatient to outpatient realms promoting follow up, compliance, and improved patient satisfaction.

Objective:
To highlight the need and efficacy of a stroke nurse navigator program for certified stroke centers.

Methods:
We retrospectively reviewed all patient encounters from March 2017-July 2017 performed by our navigator. Approximately 1000 stroke patients are seen annually at our institution. The navigator meets with the patients and families within 24 to 48 hours prior to discharge and establishes contact. A series of calls are made to patients including one at 7-14 days, 30 days, 90 days (MRS) and one year post discharge. Referrals, patient acuity levels based on needs (low, medium, high), urgent needs, and medical inquiries are tracked after each of these calls. All calls and referrals were analyzed.

Results:
During the four month data collection period, 202 stroke patients were called and approximately 83% were evaluated in-house prior to discharge. A total of 286 calls were completed as follows: 67% within 7-14 days, 17% within 20-45 and 16% within 90 days. Of the 202 patients called, 78% were designated as low, 19% as medium, and 3% as high complexity after the initial call. A total of 46 referrals were made including 6 for medical evaluation in the clinic, 4 to social work; 4 to local support groups; 1 each to our community liaison, marketing group and behavioral health; and 23 patients were identified as candidates for an active stroke research study. Assistance with FMLA forms and disability claims was provided to 6 patients.

Conclusion:
Despite over two-thirds of patients being designated as low complexity, 1 in 5 patients required further assistance or a referral after discharge. The stroke nurse navigator role provides a much needed link between the inpatient and outpatient setting and is an integral part of the stroke program.
Abstract TMP1: Post-Interventional Contrast Staining After Endovascular Thrombectomy Does Not Influence Clinical Prognosis
Authors: An Hong , Zhao Wenbo , Ding Yuchuan , Ji Xunming
Published: October 2018

Introduction:
Post-interventional contrast staining(PICS) is a common phenomenon in acute ischemic stroke (AIS) patients treated with endovascular thrombectomy(ET). Due to the small sample size in the previous studies and the limitations of image evaluation by conventional CT, determining the incidence of PICS and its consequences in AIS patients is difficult. Thus, we evaluated the incidence of PICS in AIS patients treated with ET, and its influences on functional outcome of stroke patients.

Methods:
180 patients who received ET in XuanWu Hospital were analyzed retrospectively. All patients were examined by dual-energy CT (DECT) but not conventional CT within 24 h after ET. The primary outcome was the incidence of PICS. The second outcome was symptomatic ICH (sICH) according to the ECASS-III definition, as well as functional outcome assessed by modified Ranks scale (mRS), with mRS scores 0-1 indicating no disability, mRS scores 0-2 indicating functional independence and mRS scores 6 indicating death.

Results:
50 of 180 patients (27.8%) had PICS in post-treatment DECT scans. We first used basic statistic analyses, showing that PICS decreased the percentage of favorable clinical prognosis in anterior circulation stroke at both 3-month (P<0.05 for mRS scores at 0-1 and 0-2) and long-term follow up of 12 (3-26.5) months (P<0.05 for mRS scores at 0-1 and 0-2). An increase in the risk of both total ICH/sICH (P<0.001) and mortality (P<0.05) in posterior circulation stroke at 3-month follow up. However, the logistic regression analyses further revealed that PICS only increased total (P<0.01) but not sICH risk. Furthermore, the logistic regression analyses did not show statistical difference in good clinical outcomes or mortality between the two groups. In the logistic regression analyses, we adjusted relative confusing factors, including age, baseline NIHSS, hypertension, DM, AF, etiology of stroke, time from onset to groin puncture, ASPECT score, pretreatment with antiplatelet or anticoagulation drugs, additional intra-arterial thrombolysis, intravenous alteplase, location of occluded arteries, sICH, and TICI scores for clinical outcomes and/or sICH.

Conclusion:
PICS was common in AIS patients with ET, but it did not affect functional outcome and sICH.
Abstract TMP102: Predicting Recovery and Outcome After Pediatric Stroke
Authors: Felling Ryan J , Rafay Mubeen F , Bernard Timothy , Carpenter Jessica L , Dlamini Noma , Hassanein Sahar M , Jordan Lori C , Noetzel Michael J , Rivkin Michael J , Shapiro Kevin , deVeber Gabrielle
Published: October 2018

We aimed to characterize the timing of recovery and predictors of outcome following pediatric stroke, with the hypothesis that the recovery pattern after stroke is influenced by age. While the immature brain is often presumed to have an increased capacity for neuroplasticity, there is little direct data examining how recovery differs in children of different ages. We reviewed data for children with arterial ischemic stroke (AIS) who were enrolled in the International Pediatric Stroke Study, a prospective registry of children with stroke. Inclusion criteria included a diagnosis of AIS and the availability of outcome at two years after the index stroke event. A subset of these patients who had multiple assessments over time were used to study longitudinal patterns of recovery. We investigated demographic, clinical, and radiologic associations with both early outcome at discharge and long term outcome at two years using multinomial logistic regression. Categorical outcomes at each timepoint were defined by Pediatric Stroke Outcome Measure (PSOM). We studied longitudinal recovery using time-to-event (survival) analysis. 614 out of 4,294 patients met our inclusion criteria. 202 patients had perinatal AIS while 412 had childhood AIS. Perinatal AIS was associated with significant worsening between discharge and two years, as neurologic impairment became more apparent, but with better outcomes at both timepoints compared with childhood AIS (moderate/severe: 14% vs 49% at discharge, 47% vs 54% at 2 years). Predictors of severe deficits in univariate analyses included age at stroke (perinatal vs. childhood), hemiparesis or decreased consciousness at presentation, anterior circulation, and large vessel involvement. In longitudinal analysis, improvement in PSOM occurred for a longer time after stroke onset in younger children compared to older children. Although age has a strong influence on recovery after pediatric stroke, all children had the capacity to demonstrate recovery over extended periods of time. Understanding the timing and predictors of recovery will allow us to better target therapies to the appropriate windows of opportunity, thereby improving outcomes after pediatric stroke.
Abstract TMP105: Subclinical Hypertension as a Predictor of Moyamoya Syndrome in Patients With Down Syndrome
Authors: Santoro Jonathan D , Lee Sarah , Mlynash Michael , Nguyen Thuy T , Lazzareschi Daniel V , Mayne Elizabeth E , Steinberg Gary K
Published: October 2018

This study sought to investigate subclinical changes in blood pressure in patients with Down syndrome prior to the acute presentation of patients with moyamoya syndrome (MMS) and compares this to patients with only Down syndrome (DS). 31 patients with MMS treated at Stanford University Hospital were retrospectively reviewed. Three blood pressure recordings from periods 6-12 months, 12-18 months, and 18-24 months, were obtained for each patient. These recordings were then compared against a retrospectively identified cohort of children with only DS. Statistical analysis was performed using generalized linear models with generalized estimating equations to account for blood pressures obtained at multiple time points. Median blood pressure percentiles in patients with MMS and DS from further to closer time-points were noted to be 33.5% (15-52) at 18-24 months, 42% (28-61) at 12-18 months, and 69.5% (39-73) at 6-12 months, compared to 29.3% (21-48.3) average in the DS only controls. There was no significant difference between the 18-24 month and 12-18 month periods (p=0.094), although there was a significant difference between the 6-12 month period and both the 12-18 month period and 18-24 month period (p<0.001). Adjusted for age and sex, the months from presentation were significantly reversely associated with increase of blood pressure percentile (p=0.001). This study identifies that subclinical elevations in blood pressure may predict development of MMD in patients with DS. Further prospective studies are needed to identify at risk patients with DS earlier to prevent irreversible neurologic injury.
Abstract TMP111: Physical Activity among Stroke Patients in the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) Study
Authors: Sun Jie , Goldmann Emily , Parikh Nina S , Appleton Noa , Boden-Albala Bernadette
Published: October 2018

Introduction:
Previous research has emphasized the importance of physical activity in preventing secondary stroke. However, approaches to improving physical activity after stroke have been suboptimal, particularly among race-ethnic groups.

Methods:
The DESERVE study was an RCT of a skills-based educational intervention in a multi-ethnic cohort of mild stroke/ TIA patients. The current analysis compared physical activity at one year post-discharge between intervention and usual care arms in DESERVE. Patients reported whether or not they participated in any moderate or vigorous physical activity for at least 10 minutes in the past month. Participation in any physical activity was compared between trial arms overall and stratified by race/ethnicity using chi-square tests.

Results:
A total of 338 patients were included in the analysis (n=171 intervention, n=167 usual care; 29.2% non-Hispanic white, 34.2% non-Hispanic black, 33.9% Hispanic). Overall, 50.3% of patients participated in any physical activity in the past month. There was no difference in physical activity between the trial arms (p=0.91). Among Hispanics, participating in any physical activity was significantly greater in the intervention arm than in the usual care (intervention 43.6% vs. usual care 22.4%, p=0.01). There was no association between intervention arm and physical activity among non-Hispanic whites (intervention 58.1% vs. usual care 72.0%, p=0.16) and non-Hispanic blacks (intervention 50.9% vs. usual care 54.2%, p=0.74).

Conclusion:
Participation in a skills-based intervention was associated with significantly greater physical activity one year post-discharge among Hispanic stroke/TIA patients. Providing culturally-tailored, skills-based tools and strategies that focus on behavior modification, such as improving physical activity, has the potential to improve stroke outcomes and reduce stroke disparities.