bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP163: Left Ventricular Systolic Dysfunction is Associated With Larger Burden of White Matter Hyperintensity
Authors: Lee Yong-Seok , Nam Ki Woong , Kwon Hyung-Min
Published: October 2018

Background and Purpose:
Pathogenesis of cerebral white matter hyperintensity (WMH) is unclear, though it has been known to be the major pathology. Diffuse cerebral hypoperfusion related to low cardiac output from left ventricular systolic dysfunction may be a possible contributor, which has not been validated yet in patients with ischemic stroke.

Methods:
We recruited consecutive patients with first-ever stroke patients within 7 days of symptom onset. Left ventricular systolic function was evaluated with ejection fraction from echocardiography. WMH volume was measured quantitatively with semi-automated methods. Sensitivity analysis was performed with the Fazekas scale in both periventricular and subcortical areas.

Results:
A total of 862 patients (mean age 66 years, male 61%) were included, and the median volume of WMH was 3.70 [1.44-11.21] mL. The WMH volumes were negatively correlated with ejection fraction (Pearson correlation efficient = -0.182,
P
< 0.001). In multivariate analysis, lower ejection fraction [β = -0.045, standard error (SE) = 0.008,
P
< 0.001], older age (β = 0.056, SE = 0.005,
P
< 0.001), and frequent diabetes (β = 0.308, SE = 0.133,
P
= 0.021) were significantly associated with WMH volumes. Sensitivity analysis revealed that low ejection fraction remained significant in the periventricular WMH volumes (
P
= 0.039), but not in the subcortical WMH volumes (
P
= 0.565).

Conclusions:
Left ventricular systolic dysfunction is associated with the extent of WMH, especially in periventricular area. These results indicate that cardiac dysfunction may have potential role in the pathogenesis of cerebral WMH
Abstract TP165: The Association Between Coronary Artery Calcium And Cerebral Small Vessel Disease: A Population Based Cross Sectional Study
Authors: Khan Md Maruf Haque , Fujiyoshi Akira , Miura Katsuyuki , Hisamatsu Takashi , Torii Sayuki , Suzuki Sentaro , Shiino Akihiko , Nozaki Kazuhiko , Ohkubo Takayoshi , Ueshima Hirotsugu
Published: October 2018

Cerebral small vessel disease (CSVD) is an important cause of stroke and dementia. Recent evidence showed that coronary artery calcium (CAC), a robust measure of subclinical atherosclerosis, independently predicts future dementia. One potential explanation for this observed link between CAC and dementia is that CAC is related to CSVD. However, limited study directly examined such association.

Aim:
To provide mechanistic explanation for the already-observed positive association between atherosclerosis and dementia.

Methods:
A total of 702 community dwelling men randomly sampled from Kusatsu City, Japan were analyzed. CAC was scored by Agatston’s method. Using MRI (magnetic resonance imaging) we assessed the following components as the measures of CSVD: lacunar infarcts (LI), microbleeds (MB), deep and subcortical white matter hyperintensity (DSWMH) and periventricular hyperintensity (PVH). CAC were categorized as absent (Agatston score=0), mild (more than zero and <100) and moderate to severe (≥100). The associations were assessed by binomial logistic regression analyses. Age (at the time of MRI examination), ever smoker, hypertension, diabetes mellitus and dyslipidemia were used as risk factors covariates. P trends were performed treating CAC category as ordinal.

Results:
Mean age of the participants was 69.7± 8.8 years. Prevalence of CSVD components was significantly higher in groups with higher CAC. LI was significantly associated with mild and moderate-to-severe CAC groups in unadjusted, age and risk factors adjusted analyses. Moreover, DSWMH was significantly associated with moderate-to-severe CAC group in unadjusted analysis as well as in age and risk factors adjusted analyses. But, MB and PVH were significantly associated with mild and moderate-to-severe CAC groups only in unadjusted analysis. After age and risk factors adjusted analyses the associations were no longer significant. Trend for a dose-response relation of CAC with LI and DSWMH were significant in unadjusted, age and risk factors adjusted analyses, but for MB and PVH, trends were significant only in unadjusted analysis. In Conclusion, those with higher CAC were associated with higher odds of having LI and DSWMH. Presence and degree of CAC may be useful in predicting CSVD.
Abstract TP167: Race-ethnic Differences in Barriers To 9-1-1 Use for Acute Stroke in Chicago
Authors: Eisenstein Amy , Song Sarah Y , Kandula Namratha , Richards Christopher T , Mason Maryann , Kwon Soyang , Brown Jen , Beckstrom Heather , Jones Peggy , Washington Knitasha , Wymore Erin , Corado Carlos , Aggarwal Neelum T , Prabhakaran Shyam
Published: October 2018

Introduction:
Racial/ethnic minority and lower income communities are disproportionately affected by stroke. Earlier recognition and treatment after stroke onset improves outcomes. The goal of this study was to understand the barriers to and facilitators of stroke recognition and subsequent action in multi-ethnic, high-risk communities in Chicago to inform a culturally relevant intervention for increasing early hospital arrival after stroke.

Methods:
This qualitative research study, funded by PCORI, engaged community members and stakeholders in development of a focus group guide about stroke recognition and action, participant recruitment, and analysis and interpretation of results. Six (4 in English, 2 in Spanish) focus groups (51 participants) were conducted with African-American (n=26), Caucasian (n=12), and Hispanic adults (n=13) in two communities. Analysis of focus group transcripts was done by 4 team members using constant comparative methods in which initial thematic codes were derived from the focus group guide. Initial codes were applied, results compared, and codes revised until agreement was reached among coders.

Results:
Themes relating to risk factors, symptoms, knowledge of stroke mechanisms, experience of acute stroke, help seeking, stroke education, recovery, and treatment were identified. Though there was a general understanding of stroke treatments such as “tPA” among all participants, Hispanics frequently discussed folk treatments including "smoothies" and "linseed oil." Specific barriers to calling 9-1-1 included fears about immigration status and fatalism among Hispanics and financial costs and fear/embarrassment of being wrong among African-Americans. Suggestions for stroke education and dissemination included offering resources for low-cost care and treatment among Hispanics and emphasizing neighborhood-level prevalence of stroke among African-Americans.

Conclusions:
This study identified differences in knowledge of treatments and attitudes and specific barriers to acute stroke care in minority and lower income communities in Chicago. These findings underscore the importance of engaging communities to tailor interventions and messages to racial/ethnic barriers and needs.
Abstract TP169: Knowledge of Hypertension as a Stroke Risk Factor and Use of Home Blood Pressure Monitoring. A Preliminary Report From Comprehensive Post-Acute Stroke Services (COMPASS) Study
Authors: Guo Jason C , Cummings Doyle M , Halladay Jacqueline R , Jones Berkeley Sara B , Psioda Matthew A , Duncan Pamela W , Bushnell Cheryl D
Published: October 2018

Background:
Self-monitoring blood pressure (BP) among persons with hypertension is associated with lower BP. The prevalence of BP self-monitoring and factors that may predict this behavior in the early post-acute stroke setting are unknown. Our aim was to identify whether knowledge of high BP as a stroke risk factor, social support, or primary care visits would be independently associated with BP self-monitoring 30 days after discharge in stroke patients.

Methods:
We utilized data from consenting intervention participants in the Comprehensive Post-Acute Stroke Services (COMPASS) Study, who attended the post-discharge clinic visit, and had a 30-day follow-up call (N=528). The primary outcome was self-reported BP monitoring assessed at the 30-day call. The clinic visit included assessment of risk factor knowledge, social support and other clinical and neurological factors. Odds ratios were obtained using logistic mixed models that adjusted for confounders classified as demographic characteristics and clinical factors.

Results:
Among 528 patients (mean age 67 (SD=14), 50.9% female, 80.1% white), 435 (82%) reported self-monitored BP at 30 days. Fifty-seven percent of those who noted high BP as a stroke risk factor monitored BP vs 43% of those who did not acknowledge this risk factor. Knowledge of BP as risk factor was significantly associated with monitoring after adjustment for demographic, but not after adjustment for clinical factors (Table). Those with social support and recent PCP visits also had higher odds of self-monitoring than those without support or PCP visits, respectively, though estimates were highly imprecise.

Conclusions:
Among participants, acknowledging high BP is a stroke risk factor may lead to greater use of self-home BP monitoring at 30 days, although the magnitude of this effect is diminished when adjusted for having a history of hypertension. The COMPASS Study will determine whether BP self-monitoring leads to improved BP control at 90 days.
Abstract TP174: Life’s Simple 7 in Young, Mid and Older aged Australians
Authors: Gall Seana L , Eslick Melanie , Smith Kylie , Venn Alison
Published: October 2018

Background:
There is concern about the rising stroke incidence in younger and middle aged people. We used the AHA’s Life’s Simple 7 index to profile modifiable stroke risk factors by age.

Methods:
Data were from the 2014-15 Australian Health Survey, a cross-sectional population-based survey. We categorized people as younger (>20 to <45 years), middle (≥45 to <65 years) and older (≥65 years) ages. Smoking, diet, BMI, physical activity, blood pressure, cholesterol and glucose were classified into poor (score=0), intermediate (score=1) and ideal (score=2). We classified people has having a low (0 to 4) or high (5 to 7) number of ideal items. Sex-specific prevalence ratios (PR) for ideal risk factors by age group were calculated with Poisson regression with replicate weights applied. The prevalence of ideal risk factors were ranked for each age group.

Results:
There were 15,565 households that participated (85% eligible). In men, the middle (OR 0.28 95% CI 0.20, 0.41) group had the same lower prevalence of high items as the older group (PR 0.21 95% CI 0.12, 0.38) compared to the younger group. This pattern was evident for ideal BMI, blood pressure and cholesterol. In women, the middle (PR 0.32 95% CI 0.26, 0.38) and older (PR 0.15 95% CI 0.10, 0.23) groups had a lower prevalence of high ideal scores than the younger group. The middle (PR 0.64 95% CI 0.57, 0.73) and older (PR 0.56 95% CI 0.49, 0.65) aged women had the same lower prevalence of ideaI BMI compared to the younger group. The older men (PR 2.77 95% CI 1.13, 6.75) and women (PR 2.32 95% CI 1.23, 4.04) more often had ideal diet than the younger group. In men, the 3 worst risk factors were diet, BMI and physical activity across all ages. In women, the 3 worst risk factors were diet, physical activity and BMI for younger and middle groups but diet, physical activity and blood pressure for the older group.

Conclusion:
Middle aged men have a risk factor profile comparable to older aged men, which may explain the rising or plateauing of stroke incidence in this group. Irrespective of age, the worst risk factors were diet, BMI and physical activity. Investment in whole of population, rather than age specific, primary stroke prevention strategies addressing these risk factors should be our priority.
Abstract TP176: Risk Perception in a Multi-ethnic Cohort of Stroke Survivors
Authors: Kui Naishu , Goldmann Emily , Parikh Nina , Appleton Noa , Boden-Albala Bernadette
Published: October 2018

Introduction:
Accurate risk perception is critical for secondary prevention of stroke. Few studies have focused on perceived risk of a recurrent stroke among stroke survivors in a diverse population.

Methods:
The Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) trial tested the efficacy of a skill-based intervention on blood pressure reduction among stoke/TIA patients. Using baseline data from DESERVE, the relationship between patient demographics, health beliefs and risk perception was assessed. Risk perception was evaluated by the participant’s perception of their risk of having a stroke in the next 10 years using a scale of 0-10 (with 0 being extremely unlikely and 10 being extremely likely), which was then re-categorized into three levels of risk perception: underestimate (<2), accurate (2-4) and overestimate (>4). Risk perception of having a cold within the next 10 years was also collected as a comparison measure. Differences in risk perception across race-ethnic groups were assessed using Chi-squared tests.

Results:
At baseline, 552 stroke/TIA patients were recruited for DESERVE (29.4% white, 35.6% black, 35.0% Hispanic). Overall, 53.4% of patients overestimated their risk; 30.7% underestimated their risk; and only 15.9% accurately perceived their risk of a recurrent stroke. Accurate risk perception for a second stroke was significantly lower than for a cold (15.9% vs. 35.2%, p=0.002). Hispanics were more likely to overestimate their stroke risk compared to non-Hispanics (59.6% vs. 50.2%, p=0.031). Additionally, people who agreed vs. disagreed with the statement “I worry about having a stroke,” were much more likely to overestimate their risk of a recurrent stroke (61.1% vs. 38.6%, p=0.000).

Conclusion:
In this sample of mild stroke/TIA patients, only 15.9% accurately perceived their risk of recurrent stroke. Overestimation of risk was more common among Hispanics than non-Hispanics, which might be explained by the health belief of “fatalism” in Hispanic culture. Future interventions should focus on improving stroke risk perception, especially among Hispanics.
Abstract TP186: The Burden of Diabetes Mellitus in Ischemic Stroke Patients and Its Impact on Recurrent Vascular Events and Survival in Singapore
Authors: The Ei Zune , Ng Mei Yen , Ng Geelyn , Er Bernadette , Quek Amy , Teoh Hock Luen , Chan Bernard , Paliwal Prakash , Sharma Vijay Kurma , Seet Raymond
Published: October 2018

Aims:
Few studies have thoroughly examined the long-term prognostic significance of diabetes mellitus (DM) in ischemic stroke patients. We investigated the burden of DM among ischemic stroke patients and its association with recurrent vascular events and survival in Singapore.

Methods:
Consecutive patients with acute ischemic stroke were recruited from the National University Hospital, Singapore, between January 2011 and December 2012. Demographic, risk factor, stroke etiology and severity, body mass index (BMI) and medication compliance (Morisky Medication Adherence Scale [MMAS-4]) were collected. Cox proportional hazard models were fitted to examine the relationships between these variables and recurrent vascular events (defined as stroke, myocardial infarction and vascular-related event and death) and all-cause mortality, in DM and non-DM patients. Statistical significance was set at
p
<0.05.

Results:
A total of 720 ischemic stroke patients (mean age 60.6 ± 12.3 years; 71% men) were recruited and followed for a mean of 3.5 ± 1.7 years. DM was present in 308 (43%) patients, of whom, 30% were diagnosed for the first-time. DM patients were generally older, have a higher prevalence of hypertension, hyperlipidemia, ischemic heart disease, peripheral vascular disease and medication non-compliance. During this period, 247 (34%) vascular events (53% stroke and transient ischemic attack, 13% myocardial infarction, 12% vascular-related event and 22% vascular-related death) and 97 (14%) deaths were observed. DM patients were more prone to developing recurrent vascular events (HR 1.63, 95% CI 1.22-2.16), vascular death (1.67, 0.97-2.87) and all-cause mortality (1.58, 1.06-2.36) compared with non-DM patients. In a subgroup analysis, DM patients with normal BMI (<23, Asian criteria) have increased risk of developing recurrent vascular events (HR 1.53, 95% CI 1.00-2.35) and death (2.01, 1.14-3.55).

Conclusions:
Ischemic stroke patients with chronic diabetes mellitus are prone to developing recurrent vascular events and have a shorter survival.
Abstract TP187: 24-hour Ambulatory Blood Pressure, Cognitive Performance, and Cerebral Microbleeds in the Elderly
Authors: Paganini-Hill Annlia , Floriolli David , Bryant Natalie , Greenia Dana , Corrada Maria , Kawas Claudia , Fisher Mark
Published: October 2018

Introduction:
Multiple studies suggest a role for blood pressure (BP) variability and nocturnal BP dipping in the development of cerebrovascular disease and cognitive impairment. We analyzed cross-sectional data from a cohort of 90+ year-olds to test the hypothesis that BP variables are associated with cognitive function and cerebral microbleeds (CMB).

Methods:
Study subjects were 121 participants (mean age = 93 years, 63% female) in
The 90+ Study
, a study of aging in individuals aged 90 years and older from a California retirement community. Participants were given a neuropsychological test battery to determine cognitive status. All subjects underwent 24-hour ambulatory BP measurement with a automatic device. MRI scans were available for 26 participants. Over three time frames (24-hour, daytime, nighttime) and separately for SBP and DBP, we represented BP by mean, minimum, maximum, standard deviation (SD), coefficient of variation, average real variability, percentage of high measurements (≥140 mmHg for SBP and ≥90 mmHg for DBP), percentage of low measurements (<90 mmHg for SBP and <60 mmHg for DBP), and nocturnal dip (% change of mean night BP from mean day BP). Differences in means of BP variables between groups based on cognitive status (normal vs cognitively impaired not demented (CIND)/demented) and presence/absence of CMB were tested using t-tests.

Results:
Cognitive status was normal in 97 subjects, CIND/demented in 24. Mean nocturnal dips (both SBP and DBP) differed significantly between the two groups, with normal participants having on average greater dip levels (6.6 vs 1.3, p=0.006 for SBP and 11 vs 4.4, p=0.002 for DBP). No other BP variable showed a large or significant difference. Greater nocturnal dips were also related to better performance on cognitive test scores related to language, recent memory, and visual-spatial ability. MRI findings showed subjects with CMB (n=18) had higher SD of daytime SBP than those without (n=8) (20 vs 16, p=0.03). Those with CMB also had a greater proportion of high nighttime DBP (≥90 mmHg) readings (3.6 vs 0, p=0.03).

Conclusions:
Among 90+ year olds, altered nocturnal BP dipping may have a role in cognitive impairment, while SBP variation and diastolic hypertension may contribute to development of microbleeds.
Abstract TP190: Incongruence Between Survivors and Family Caregivers About Survivor Function is Associated With Poor Outcomes for Both Members of the Dyad
Authors: McCarthy Michael J , Bakas Tamilyn , Nelson Erik , Schellinger Jeffrey , Black Kalyn , Kissela Brett
Published: October 2018

Introduction:
Stroke survivors (SS) and their family caregivers (CG) often disagree about how well the survivor is regaining function. This disagreement (or “incongruence”) may contribute to poor outcomes. This study explored the extent to which incongruence: (1) Differs by survivor function domain (memory/thinking, communication, IADLs, mobility, social participation); (2) Increases or decreases over time without intervention, and; (3) Is associated with emotional distress, subjective stress, and depressive symptoms in both SS and CG.

Methods:
Structured survey interviews based on valid measures were conducted with 31 SS and CG separately, at 3 and 6 months post-stroke (enrollment and follow-up). Paired sample t-tests were used to examine incongruence in each domain, at enrollment and follow-up, as well as changes in incongruence over time. Bivariate correlations were used to examine the association between incongruence at enrollment and SS and CG outcomes at follow-up. A less stringent alpha (p=.10) was used due to the exploratory nature of the study.

Results:
SS generally perceived their function as better than CG perceived it at each time point, with significant differences in the memory/thinking (p<.05) and communication (p<.05) domains. Incongruence did not change naturally over time, except for social participation incongruence which showed a marginal increase (p<.10). For SS: IADL incongruence at enrollment was associated with follow-up emotional distress (p<.05) and depressive symptoms (p<.10). For CG: IADL incongruence at enrollment was associated with follow-up emotional distress (p<.10), stress (p<.01), and depressive symptoms (p<.01); communication incongruence was associated with emotional distress (p<.10) and stress (p<.10); and mobility incongruence was associated with depressive symptoms (p<.10).

Conclusions:
This study supports previous research showing that SS and CG often have incongruent perceptions about survivor function. Additionally, it demonstrates that incongruence generally does not improve by itself and that it may be detrimental for both SS and CG outcomes. Further research with larger samples should be directed at the mitigation of incongruence and strategies to improve outcomes for both SS and CG.
Abstract TP191: Association Between Myocardial Infarction and Brain Infarction on Magnetic Resonance Imaging
Authors: Merkler Alexander , Baradaran Hediyeh , Myeni Pavan K , Gialdini Gino , Navi Babak B , Goyal Parag , Safford Monika M , Okin Peter M , Weinsaft Jonathan W , Gupta Ajay , Kamel Hooman
Published: October 2018

Introduction:
The relationship between myocardial infarction and brain infarction remains incompletely understood. Magnetic resonance imaging (MRI) offers excellent characterization of infarction in both the heart and brain.

Methods:
We performed a retrospective cross-sectional study at our hospital to evaluate the association between myocardial infarction and brain infarction as detected on MRI. We identified all adult patients who underwent both cardiac MRI and brain MRI within 6 months of each other during the period 2014-2017. Myocardial infarction was identified by the presence of myocardial scar on delayed enhancement cardiac MRI. A neuroradiologist investigator reviewed all brain MRI studies to characterize acute and chronic infarcts. In secondary analyses, we evaluated the association between myocardial infarction and cortical versus subcortical brain infarction. The chi-square test was use to compare categorical variables.

Results:
We identified 211 adults who underwent cardiac MRI and brain MRI within 6 months of each other. Myocardial infarction was present in 66 (31.3%) of cardiac MRIs. Brain infarction was present in 112 (53.1%) of brain MRIs, 61 (28.9%) of which were cortical infarcts, 33 (15.6%) subcortical, and 18 (8.5%) posterior fossa. Myocardial infarction was more common in patients with brain infarction (41.1%; 95% confidence interval [CI], 31.9-50.8%) than in patients without brain infarction (20.2%; 95% CI, 12.8-29.5%) (
P
= 0.001). In secondary analyses, myocardial infarction was most common in patients with cortical brain infarcts (50.8%; 95% CI, 37.7-63.9%), less common in patients with only subcortical infarcts (27.3%; 95% CI, 13.3-45.5%), and least common in those with no brain infarcts (
P
value for comparison among groups, < 0.001).

Conclusions:
We found an association between myocardial infarction and brain infarction on MRI. The association was strongest between myocardial infarcts and cortical brain infarcts.
Abstract TP195: Frequency of and Factors Associated With “Stroke on Wheels” in United States: An Analysis of National Emergency Department Sample 2013-2014
Authors: Saleem Muhammad A , Naseem Nishath , Qureshi Adnan I
Published: October 2018

Background:
The occurrence of stroke during driving motor vehicles “stroke on wheels” and unique consideration pertaining to such an event are not well recognized.

Methods:
The data from the National Emergency Department Sample (NEDS) 2013-2014 was analyzed to generate national estimates of “stroke on wheels”. The NEDS contains data for emergency department (ED) visits from ≈1000 hospitals located in 33 States and the District of Columbia, approximating a 20-percent stratified sample of U.S. hospital-based ED visits. We also compared the demographic, clinical, and treatment characteristics of patients with “stroke on wheels” and those with other form of strokes.

Results:
A total of 1164 (0.06%) of 1,805,447 patients with stroke experienced “stroke on wheels”. Patients with “stroke on wheels” were less likely to be aged ≥80 years (17.2% versus 28.6%, p<0.001) and more likely to be men (66.3% versus 47.5%, p<0.001). The primary payer type was private insurance including HMO in patients with “stroke on wheels” (49.1% versus 19.5%, p<0.001). Patients with “stroke on wheels” were more likely to have atrial fibrillation (20.8% versus 17.3%, p=0.001) and previous stroke (16.3% versus 10.7%, p<0.001). The rate of ischemic stroke (70.5% versus 52.0%, p<0.001) was higher among patients with "stroke on wheels". There was no difference in the rate of utilization of intravenous thrombolysis in ischemic stroke patients with “stroke on wheels” and those with other form of strokes. Patients with “stroke on wheels” were more likely to be admitted to the same hospital (83% versus 71.7%, p,0.001) and subsequently discharged with none to minimal disability (53.7% versus 44%, p<0.001). In regard to injury sustained, patients with “stroke on wheels”, International Classification of Disease Program for Injury Categorization score of 1-10, 11-20, and >20 were seen in 40%, 2.3%, and 1.2% of patients, respectively.

Conclusions:
We present the unique attributes of occurrence of “stroke on wheels” to enable greater recognition and appropriate triage.
Abstract TP196: Incidence of Atrial Fibrillation in Patients With Recent Ischemic Stroke versus Matched Controls
Authors: Kamel Hooman , Witsch Jens , Merkler Alexander E , Sheth Kevin N , Navi Babak B
Published: October 2018

Introduction:
Atrial fibrillation (AF) is often newly diagnosed during heart-rhythm monitoring after ischemic stroke. It is unclear whether this represents pre-existing AF that led to stroke, AF that was triggered by stroke, or AF that would also be seen in stroke-free patients with comparable vascular risk factors.

Methods:
We compared AF incidence after hospitalization for ischemic stroke, hemorrhagic stroke, and non-stroke conditions. We used inpatient and outpatient claims data from 2008-2015 from a nationally representative 5% sample of Medicare beneficiaries. We used validated
ICD-9-CM
codes for AF and stroke to identify patients hospitalized with a first-recorded ischemic or hemorrhagic stroke and no documented AF, and matched them in a 1:1 ratio by age, sex, race, calendar year, vascular risk factors, and Charlson comorbidities. We then matched these stroke patients in a 1:1 ratio to patients hospitalized for non-stroke diagnoses. We used survival statistics and Cox regression to compare post-discharge AF incidence among the three matched groups.

Results:
We matched 2,650 patients with ischemic stroke, 2,650 with hemorrhagic stroke, and 5,300 controls. The post-discharge incidence of AF was 3.4% (95% CI, 3.1-3.7%) per year after ischemic stroke, 2.2% (95% CI, 1.9-2.5%) per year after hemorrhagic stroke, and 2.6% (2.4-2.8%) per year after non-stroke hospitalization. Compared to non-stroke controls, hemorrhagic stroke was associated with a similar risk of AF (HR, 0.9; 95% CI, 0.8-1.0;
P
= 0.13) and ischemic stroke was associated with a higher risk of AF (HR, 1.4; 95% CI, 1.2-1.6). These findings were unchanged in sensitivity analyses censoring at the time of post-discharge heart-rhythm monitoring or limiting the outcome to AF diagnoses made by a cardiologist.

Conclusions:
AF was diagnosed more often after hospitalization for ischemic stroke than hemorrhagic stroke or non-stroke conditions.
Abstract TP197: Stroke Mortality in Argentina. A population-based Epidemiological Study, EstEPA
Authors: Dossi Daiana E , Pujol-Lereis Virginia A , Gomez-Schneider Maia M , Gonzalez Claudio , Hawkes Maximiliano A , Rodriguez Lucci Federico , Alet Matías J , Povedano Guillermo , Melcon Mario O , Ameriso Sebastiãn F
Published: October 2018

Introduction:
Stroke is a leading cause of mortality and disability worldwide. It is the fifth cause of death in the United States. The burden of cerebrovascular disease is high in low and middle-income countries and it is estimated to increase in the future. Regional epidemiological data is essential to assess the real impact of the disease and to plan rational adjudication of public health resources. Stroke mortality data in Latin America, including Argentina, are scant. We aimed to determine mortality from all causes, including stroke, in a sample representative of the Argentinean population.

Methods:
EstEPA is a population-based study to assess the prevalence, incidence and mortality of stroke and its distribution by age, gender and clinical subtype in General Villegas county (pop. 32.500 inhab.), province of Buenos Aires, Argentina. Mortality data was obtained from all death certificates issued in General Villegas between August 1
st
2015 and July 31
st
2016. Further relevant information was obtained from medical records, family and primary physicians interviews. Ischemic strokes, non-traumatic intracerebral hemorrhages and non-traumatic subarachnoid hemorrhages were recorded.

Results:
There were 286 confirmed deaths for a general mortality rate of 8.8‰. The leading causes of death were cardiovascular disease (23%), infections and pneumonias (18%) and cancer (11%). With 24 confirmed cases, stroke was the fourth cause of death representing 8.4% of all obits (n=24). More women than men died of stroke (16 vs 8). There were 6 ischemic, 6 hemorrhagic and 12 undetermined strokes. Other less frequent causes of death were chronic respiratory diseases (7%), trauma (7%), dementia (5%), gastrointestinal diseases (4%), renal diseases (3%) and perinatal deaths (3%).

Conclusion:
This is the first epidemiological study assessing stroke mortality in Argentina. In this sample, representative of the Argentinean population at large, stroke was the fourth cause of death. These results were similar to statistics from Western hemisphere countries.
Abstract TP210: Oxygen Extraction Fraction is Increased in the Borderzone Region of Healthy Young Adults
Authors: Ford Andria L , Guilliams Kristin , Fields Melanie , Ragan Dustin , Fellah Slim , Eldeniz Cihat , Binkley Michael , Chen Yasheng , Shimony Josh , Vo Katie , Blinder Morey , Hulbert Monica , McKinstry Robert , An Hongyu , Lee Jin-Moo
Published: October 2018

Background:
We have previously shown that the borderzone region demonstrates ischemic physiology, with low cerebral blood flow (CBF) and increased oxygen extraction fraction (OEF), in pediatric sickle cell anemia (SCA). This region is vulnerable in SCA as evidenced by increased infarct burden. Here we studied healthy adults to determine if borderzone physiology exists in the absence of apparent vascular disease.

Methods:
Healthy (N=17, 33 ± 9 yr) and SCA (N=13, 28 ± 7 yr) adults were recruited from a tertiary care SCA clinic. Individuals with vascular risk factors or chronic medical or neurological diseases were excluded. SCA subjects were excluded for stroke, vasculopathy, or transfusion therapy. Brain MRIs were prospectively obtained including: T1, FLAIR, dynamic susceptibility contrast (CBF), and asymmetric spin echo (OEF). Within each subject, 3 regions of low CBF were derived by normalizing CBF to its peak CBF. For gray matter (GM), regions were: < 25
th
%, 25-50
th
%, and 50-75
th
% of mean thalamic CBF. For white matter (WM), regions were: < 25
th
%, 25-35
th
%, and 35-45
th
% of mean GM CBF. Mean OEF across the 3 CBF regions were compared using Friedman test to account for repeated measures (Fig*).

Results:
Figure demonstrates the approximated borderzone with heatmaps (# of subjects with WM CBF < 25
th
%) for healthy and SCA adults, alongside average OEF maps for each cohort. Both in healthy and SCA adults, GM and WM OEF were elevated in the region of lowest CBF. Furthermore, relative tissue volumes of CBF < 25
th
% were higher in SCA than controls (GM: 16 vs 11%, p<0.001; WM: 33 vs 23% p<0.001), suggesting disease may redistribute CBF, effectively enlarging the borderzone.

Conclusion:
We found ischemic physiology (low CBF / high OEF) in the borderzone of healthy adults. Additional stressors limiting cerebral oxygen delivery such as chronic anemia in SCA or carotid occlusion may lead to enlargement of the borderzone, further elevation of OEF, and a heightened vulnerability to infarction.
Abstract TP212: 24
S
-Hydroxycholesterol as a Serum Biomarker for Acute Stroke
Authors: Khan Nadeem I , Thompson Bonne , Jones Donald , Shang Ty
Published: October 2018

Introduction:
Several serum based biomarkers for acute stroke have been identified, but the clinical values of these biomarkers have not been realized due to inadequate sensitivity and specificity in their measurements. 24
S
-Hydroxycholesterol is a stable metabolite of cholesterol synthesized by neurons of the CNS, and released to the serum at a constant rate.

Hypothesis:
We hypothesized that serum 24
S
-Hydroxycholesterol would be an ideal biomarker for acute stroke.

Methods:
Acute stroke patients presenting to ED were enrolled after informed consent. Serum samples were collected in ED and levels of 24
S
-Hydroxycholesterol were determined by mass spectrometry. We enrolled 63 patients from October 2015 to October 2016. Of these 63 patients, 60 presented within 8 hours from onset of symptoms. Patients were categorized as no stroke, ischemic stroke, and intracerebral hemorrhage. We compared serum 24
S
-Hydroxycholesterol levels in each group and the variation in 24
S
-Hydroxycholesterol levels with regard to presenting NIHSS.

Result:
Out of the 63 patients enrolled, 22 did not have a stroke, 36 had ischemic stroke, and 5 had intracerebral hemorrhage. The mean 24
S
-Hydroxycholesterol levels were 54 ng/ml, 58 ng/ml and 75 ng/ml in the no stroke group, ischemic stroke group and intracerebral hemorrhage group, respectively. No correlation was observed between NIHSS and 24
S
-Hydroxycholesterol levels. Difference in 24
S
-Hydroxycholesterol levels between no stroke and intracerebral hemorrhage patients was statistically significant, but was limited by the small sample size (P = 0.047).

Conclusion:
24
S
-Hydroxycholesterol may be a useful serum biomarker for intracerebral hemorrhage. Analyses in a larger population is needed to determine the practical importance of this biomarker.
Abstract TP213: Retinal Microvascular Abnormalities as Markers of Cerebrovascular Disease: A Meta-Analysis
Authors: Dumitrascu Oana M , Demaerschalk Bart M , Valencia Sanchez Cristina , Almader-Douglas Diana , O’Carroll Cumara B , Aguilar Maria I , Lyden Patrick D , Kumar Gyanendra
Published: October 2018

Introduction:
Despite the recognized linkage between retinal microvascular abnormalities and cerebrovascular ischemic diseases (CVD), the retinal findings’ standardization and the degree of association remain unclear. We aimed to investigate the quantitative association between various retinal microvascular signs and CVD.

Hypothesis:
retinal microvascular abnormalities best predictive of CVD could be identified by synthesizing estimates of CVD risk from population-based studies.

Methods:
We followed MOOSE guidelines and systematically searched 6 databases through September 2016 for studies evaluating the association between retinal microvascular abnormalities and white matter hyperintense lesions (WMHI), lacunar infarcts (LI), and cerebral infarctions (CI). Adjusted and unadjusted odds ratios (ORs) and confidence intervals were pooled into the analyses using the DerSimonian and Laird random effects model. Study quality and dissemination biases were assessed and integrated.

Results:
Thirty-four prospective studies encompassing 84,144 patients were eligible for meta-analysis. After adjustment for vascular risk factors, focal arteriolar narrowing was associated with WMHI (OR, 1.24 [1.01-1.79]), LI (OR, 1.77 [1.14-2.74]), and CI (OR, 1.75 [1.14-2.69]). Venular dilation was significantly associated with LI (OR, 1.46 [1.10-1.93]), whereas retinal hemorrhage was associated with WMHI (OR, 2.23 [1.34-3.70]). Arteriovenous nicking was associated with WMHI (OR, 1.51 [1.22-1.88]) and LI (OR, 1.70 [1.05-2.76]). Any retinopathy exhibited significant association with WMHI, LI, and CI. Heterogeneity was significant (

I
2

>50%) for all syntheses except retinal hemorrhages and WMHI, retinopathy and CI (

I
2

=0.0%) and respectively LI (

I
2

=45.80%).

Conclusions:
Retinal hemorrhages were most highly associated with WMHI. Focal arteriolar narrowing and retinopathy were associated with WMHI, LI, and CI. Our findings may assist in the development of a noninvasive retinal microvascular tool for routine use in CVD research and clinical practice.
Abstract TP214: Progression of Stroke Deficits in Patients Presenting With Mild Symptoms: The Underlying Etiology Determines Prognosis
Authors: Akhtar Naveed , Salam Abdul , Kamran Saadat , ElKhider Hisham , Al-Makki Soha , Mhjob Noha , ElShiekh Lubna , AlHussain Hassan , Ali Musab , Khodair Rola , Wadiwala Faisal , Bhutta Zain , Khan Rabia A , Deleu Dirk , Shuaib Ashfaq
Published: October 2018

Introduction:
Many acute stroke patients present with mild symptoms, make it difficult to determine whether they should be treated with reperfusion strategies or not. The symptoms of such patients may frequently show progression. We hypothesized that localization based on clinical examination and multi-model imaging will be very helpful in determining patients most likely to have a bad outcome.

Methods:
We interrogated the Hamad Stroke Database to evaluate 90-days outcome in patients with acute ischemic stroke admitted within 4 hours and a NIHSS score of ≤6. Patients were evaluated based on the localization (lacunar or cortical), abnormalities on multi-model imaging and whether they were treated with rt-PA or not. The 90-day mRS was used to determine outcome.

Results:
During the study period 4016 patients were admitted with acute stroke. Mild stroke with arrival within 4 hours was diagnosed in 365 patients [no thrombolysis: 269 (lacunar: 155; cortical: 114), thrombolysis: 96 (lacunar: 38; cortical: 58)]. The rt-PA treated patients had significantly higher NIHSS (4.8±1.2 versus 2.3±1.6, p<0.0001), increased risk of complications (18.8% versus 4.1%, p<0.001) and longer hospital stay (median -Inter quartile range- 4 {2-6} versus 3 {2-5} days, p=0.002). Imaging abnormalities, including intracranial arterial occlusions and CTP mismatch were more frequent in rt-PA treated patients. The mRS at discharge (36.5% versus 14.8%, p<0.001) and 90 days (24% versus 12.6%, p=0.009) was significantly worse in patients with both cortical stroke in rt-PA-treated and untreated patients.

Conclusions:
The prognosis in patients with mild stroke depends on location of the lesion (lacunar versus cortical). Patients who receive rt-PA have significantly larger deficits, increased imaging abnormalities and higher rates of complications that may explain the poor prognosis in such subjects.
Abstract TP22: Stent Retriever Diameter and Impact on Reperfusion Rates in Intracranial Carotid Occlusions
Authors: Haussen Diogo C , Grossberg Jonathan , Bouslama Mehdi , Barreira Clara , Belagaje Samir , Anderson Aaron , Frankel Michael , Nogueira Raul G
Published: October 2018

Background:
The impact of oversized stent-retrievers in reperfusion rates during thrombectomy is unclear. Devices matching the vessel diameter may lead to proportionally larger cells and facilitate device-clot integration. We aim to evaluate if the device diameter may impact reperfusion rates in stroke thrombectomy.

Methods:
This is a retrospective analysis of a prospectively collected database from a single comprehensive stroke center. We included patients with intracranial carotid occlusions in which stent-retrievers (Trevo or Solitaire devices) were used as the first strategy, from September 2010-March 2017, and compared the 4mm vs 6mm diameter groups. 3mm devices and other retriever-like devices were excluded. Primary outcome was first pass reperfusion (modified TICI2b-3 with the first device pass).

Results:
Of the 1204 thrombectomies performed within the study period, 150 met inclusion criteria (Trevo: 64/Solitaire: 86/6mm device:67 /4mm: 83). Age, gender, comorbidities and the use of IV tPA were comparable between groups. NIHSS was similar between the 4mm vs 6mm devices (19[14-22] vs 18.5[14-22];p=0.64), as well as time from last normal to puncture (403[260-626] minutes vs 344 [209-816];p=0.54), and ASPECTS (7[6-9] vs 8[7-9];p=0.25), respectively. Patients with 4mm devices had less tandem disease (11% vs 28%,p=0.01). The use of local aspiration was similar between groups (7vs9%p=0.76) for the 4mm and 6mm devices. First-pass mTICI2b-3/mTICI3 reperfusion was achieved in similar proportion between the 4mm vs 6mm groups: 52%vs.56%;p=0.62 / 32%vs22%;p=0.20, respectively. Parenchymal hematomas (16% vs 9%;p=0.22) and subarachnoid hemorrhage (5% vs 7%;p=0.74) were similar between the 4mm and 6mm arms. Independent outcome at 3months was more common in the 4mm vs 6mm groups (28%vs50%;p=0.03). Multivariable analysis indicated mRS0-2 at 90-days independently associated with first-pass reperfusion and demonstrated no impact of device diameter on first-pass reperfusion.

Conclusions:
The use of 6mm stent retrievers for intracranial carotid occlusions had demonstrated benefit over 4mm devices for chances of first pass reperfusion.
Abstract TP228: Secondary Transfer of Acute Stroke Patients Within a Large Urban Stroke System (2012-2016)
Authors: Sanossian Nerses , Bosson Nichole , Gaushe-Hill Marianne , Liebeskind David S , Saver Jeffrey L
Published: October 2018

Background:
We sought to characterize changes in the frequency of secondary transfer of EMS-transported stroke patients within a large urban stroke system of care. We hypothesized an increase in secondary stroke transfers given the recent emphasis on thrombectomy treatment.

Methods:
Los Angeles County Emergency Medical Services Agency (LAC-EMS) operates a regional stroke system of care with transport of patients with suspected acute stroke identified by EMS in the field to the closest ASC. Current ASC designation does not distinguish primary from comprehensive stroke centers. Each ASC provides data on patient characteristics, treatment, outcome, and final disposition to LAC-EMS. We identified all cases of secondary transfer out of the primary receiving emergency department over a 5-year period (2012 to 2016).

Results:
Among 23,586 EMS transports, there were 943 transfers to another acute care hospital. Transferred patients had a mean age of 66 (SD 16) and were 49% female, 59% White race, and 27% Hispanic ethnicity. Final diagnoses were cerebral ischemia (62%), intracerebral hemorrhage (19%), subarachnoid hemorrhage (14%), and non-stroke diagnosis (5%). The median initial NIHSS was 16 (IQR 9-23) and 50% of patients with cerebral ischemia were treated with intravenous thrombolytic therapy. The reason for transfer was higher level of care in 98% and not reported in 2%. The figure shows the annual trends by diagnosis. The total number of transfers increased steadily from 91 in 2012 to 296 in 2016, with the proportion of transfers for cerebral ischemia increasing in 2015-2016 compared to the prior years (68% vs. 55%).

Conclusions:
Secondary transfer of EMS-triaged stroke patients increased from 2012 to 2016, particularly for cerebral ischemia in the last 2 years of observation. The higher frequency of ischemic stroke secondary transfers may reflect increased utilization of thrombectomy following publication of positive clinical trial data starting on 12/17/2014.
Abstract TP231: Predicting Emergency Medical Services Use in a Rural State
Authors: Hohenboken Jenna , Torner James , Rindels Erin , Whitmer Angela , Leira Enrique , Mueller Michael ,   Iowa Stroke Registry
Published: October 2018

Introduction:
Hospital arrival by emergency medical services (EMS) is important for decreasing time from stroke onset to arrival and increasing the rate of rtPA use. In rural states, like Iowa, EMS is an often volunteer and dispersed resource which may influence the use of private vehicles.

Objective:
The objective of this study was to identify predictors of EMS use compared to private vehicle transport in Iowa stroke patients.

Methods:
A retrospective analysis was conducted using 2016 data collected by the Iowa Stroke Registry. The Iowa Stroke Registry is a statewide, concurrent database used to improve the Iowa Stroke System and quality of stroke care between EMS and hospitals in Iowa (1 comprehensive center, 15 primary centers, and 9 acute stroke hospitals). Inclusion was limited to arrival by EMS or private vehicles in the year 2016; all other arrivals were excluded. Predictors of EMS use were evaluated from admission, arrival, demographic, medical history, and hospital data. Chi square analyses and multivariate logistic regression were performed to determine associations and predictors of EMS use. Significance was at the 0.05 probability level.

Results:
The inclusion criteria was met by 2650 patients with 1335 (50.4%) arriving by EMS. A total of 1739 patient records were included in the analysis and 829 (47.7%) arrivals were from EMS compared to private vehicles. Results from the multivariate analysis indicated that EMS use was significantly associated with patients aged 65 or older, Native Americans, neurological symptoms of altered consciousness, aphasia, and weakness, history of atrial fibrillation, antidepressant medication use, hormone replacement therapy, and arrival in the northeast, south central, and southeast regions of the state. Private vehicle use was associated with resolved stroke symptoms at initial exam and the ability to ambulate independently prior to stroke. Patients arriving by EMS were more likely to arrive in the first 2 hours of symptom onset and receive rtPA compared to private vehicle arrivals.

Conclusion:
The proportion of arrivals by EMS and private vehicles were similar in 2016. Neurological symptoms of stroke, age, ambulatory status and region of the state were the most influential factors in determining EMS use.