bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP110: Temporally Characteristic Phenotypes of Microglia and Blood-Derived Macrophage on Neuroinflammatory Responses in Cerebral Ischemia Model Using CX3CR1::EGFP Transgenic Mice
Authors: Park Joohyun , Kim Jong Youl , Hyun Young Min , Jung Hosung , Lee Jong Eun
Published: October 2018

Ischemic stroke is a devastating disease, second only to cardiac ischemia as a cause of death worldwide. As the blood supply is insufficient to the brain tissue followed by occlusion of the cerebral artery, molecular cues generated by cerebral ischemia activate the components of innate immunity, promote inflammatory signaling and contribute to tissue damage. Microglia known as an immune cell in the central nervous system (CNS) has functions similar to those of macrophages in the periphery. At the functional point of view, resident microglia (M0) can be polarized by molecular cues: M1 phase microglia and M2 phase microglia. Moreover, blood-brain barrier (BBB) causes the extravasation of blood-derived macrophage. However, the interaction between the microglia and blood-derived macrophage is still unknown.

Methods:
we used CX3CR1::EGFP transgenic mice to visualize the microglia and blood-derived monocytes dynamics on neuroinflammatory responses. Also, we used the two-photon microscope technique on neuroinflammatory responses by transient middle cerebral artery occlusion (tMCAO) intravial system, time-dependently.

Results:
Our preliminary data showed that it is morphologically possible to distinguish activated microglia and infiltrated monocytes from the resident microglia specifically. In addition, infiltrated blood-derived monocytes and resident microglia showed different polarization patterns by specific markers (Iba1, CD86, CD206, and CD45) in time-dependent manners (n=3 / 6h, 1, 3, 5, 7 days) after tMCAO. Furthermore, we performed the cytokine/chemokine array to evaluate the level of specific cytokine/chemokine on ischemic stroke using the serum and brain tissue. In results, the levels of serum and brain tissue of specific cytokine/chemokine showed different levels in all experimental time courses.

Conclusion:
Taken together, the overall data demonstrated that dynamics of microglia and blood-derived macrophage using specific type of transgenic mice could be a novel strategy for regulating the M2 anti-inflammatory microglia phenotype rather than M1 pro-inflammatory microglia and finding the optimal time point of drug treatment attenuating ischemic stroke.
Abstract TP114: Association of Inflammation With Intracranial Atherosclerotic Stenosis
Authors: Duda Julian , Trivedi Tushar , Suri M. Fareed K , Mehta Sonal , Moss Kevin , Offenbacher Steven , Beck James , Gottesman Rebecca F , Rosamond Wayne , Sen Souvik
Published: October 2018

Introduction and Hypothesis:
Intracranial Atherosclerotic Stenosis (ICAS) is associated with 8-10% of all strokes in the U.S. Although there is evidence in the Asian population that inflammation plays a role in ICAS, it has not been shown in the U.S. population. We hypothesized that midlife sensitivity C-reactive protein (hs-CRP), a marker of inflammation, is associated with late-life ICAS in the U.S. population.

Methods:
The Atherosclerosis Risk in Communities (ARIC) study recruited participants from four U.S. communities between 1987-1989. In the ancillary Dental ARIC study, dentate subjects from ARIC undergoing full-mouth examination also had blood samples obtained to measure the serum inflammatory marker, hs-CRP (1996-1998). High sensitivity ELISA assay that had been validated against nephelometry, was used to measure hs-CRP. Of this cohort, a subset (N=909) underwent high resolution 3T magnetic resonance angiogram at a follow-up visit (2011-2013). All images were analyzed in a centralized lab and ICAS was graded as no stenosis/<50% stenosis, or ≥50% stenosis/complete occlusion. Crude and adjusted Odds Ratio (OR, adjusted for age, gender, race, body mass index, hypertension, diabetes, low density lipoprotein level, and smoking) were calculated to test the association between hs-CRP (stratified as <1, 1-3 and >3 mg/l), and ICAS.

Results:
A total of 909 subjects (mean age 62±6, 45% male, 81% Caucasian and 19% African-American), underwent assessment of hs-CRP and ICAS. Compared with the reference group (hs-CRP <1 mg/l) modestly elevated hs-CRP (1-3 mg/l) was not significantly associated with >50% ICAS, on univariate (Crude OR 1.3 95% CI: 0.9-2.0) or multivariable analysis (Adjusted OR 1.3, 95% CI: 0.9-2.0). Elevated hs-CRP (>3mg/l) was significantly associated with >50% ICAS in both univariate (Crude OR 1.6, 95% CI:1.1-2.3) and adjusted model (Adjusted OR 1.6, 95% CI:1.1-2.4).

Conclusions:
In this US population-based community study, we report a significant and independent association between inflammatory marker hs-CRP and ICAS. Further studies are required to test if anti-inflammatory drugs or diet prevents ICAS.
Abstract TP116: Racial Difference in Intracranial Atherosclerotic Plaque Features by High-resolution Vessel Wall MRI
Authors: Hao Qing , Qiao Ye , Gottesman Rebecca , Sam Kevin , Shahriari Mona , Johnson Brenda , Williams Nicole , Wasserman Bruce A
Published: October 2018

Introduction:
Intracranial atherosclerotic stenosis (ICAS), the most common cause of stroke worldwide, is more prevalent in non-white populations including Asian, African-American and Hispanic individuals. We studied the racial difference (white vs non-white) in the plaque features of stroke patients with ICAS using vessel wall MRI (VWMRI).

Methods:
We retrospectively included stroke patients with etiology being intracranial atherosclerosis who received VWMRI. VWMRI was read by experienced neuroradiologists blinded to other clinic information. Culprit plaque was defined as a plaque in a relevant vessel responsible for the downstream ischemic lesion. In addition to plaque number and degree of the stenosis, other plaques features were analyzed, including degree of plaque enhancement(minimal, moderate and strong), plaque calcification and eccentricity. The association between race, cardiovascular risk factors and plaque features was tested in multivariable models.

Results:
In 64 stroke patients (mean age 55.6±13.4 y, 62.5% male, 43.8% non-whites), the median number of plaque was 3 (range 0-11). Compared with whites, non-whites have a higher number of plaques (median, 4 vs 3, p=0.029). Smoking was associated with presence of extensive plaque (defined as ≥3 plaques) and remained significant after adjustment for other risks factors (non-white race, hypertension, age≥55 and HbA1C≥6.5; adjusted OR 6.9, 95% CI 1.27-37.66). For culprit plaques, presence of ≥50% stenosis, strong plaque enhancement, eccentric pattern and calcification did not differ by race. LDL >100 mg/dl, history of hyperlipidemia and eGFR<60 mL/min/1.73 m
2
were each associated with presence of strong plaque enhancement, eccentric pattern and calcification respectively (OR 1.5, 95% CI 1.5-19.6; OR 9.9, 95% CI 1.1-85.6; OR 24, 95% CI 2.3-247.4; respectively).

Conclusion:
A higher number of intracranial atherosclerotic plaques was revealed by VWMRI in non-white stroke patients with stroke etiology being intracranial atherosclerosis, while the features of their culprit plaque were similar compared with white patients. History of smoking was significantly associated with presence of ≥3 plaques. Studies with larger sample size are needed to validate the above findings.
Abstract TP119: Feasibility of Automated Analysis of Dual-
Venc
4d Flow Mri to Assess Hemodynamics in Patients With Intracranial Atherosclerotic Disease
Authors: Vali Alireza , Aristova Maria , Ansari Sameer A , Muzaffar Ayesha , Prabhakaran Shyam , Markl Michael , Schnell Susanne
Published: October 2018

Purpose:
Advanced imaging and automated image processing techniques were used to demonstrate the feasibility of 4D flow MRI as a clinical tool for assessment of intracranial hemodynamics in patients with intracranial atherosclerotic disease (ICAD).

Introduction:
ICAD patients have a high risk of stroke recurrence, which could be partly due to intracranial hemodynamic failure. Thus, it is critical to assess the impact of ICAD on cerebrovascular flow dynamics. Dual-
venc
4D flow MRI allows the assessment of flow in major intracranial arteries and veins by providing a large dynamic range. A new automated post-processing tool was developed to ease the cumbersome processing task that hinders clinical application of 4D flow MRI.

Method:
Intracranial dual-
venc
4D flow MRI (Fig 1a) was acquired in 20 healthy volunteers (12M, 43±18Y) and three ICAD patients: two men, 65Y with near occlusion and 43Y with 65% stenotic right MCAs and a 70Y woman with stenoses in PCAs and ACAs (> 50%). Post-processing included automated segmentation of vessels, extraction of centerlines, positioning multiple analysis cut-planes (1 mm inter-plane distance) along the vessels, and computing peak velocity (PK) and flow rate (FR) for each vessel (Fig. 1b and 1c).

Results:
Fig. 1d and 1e present cumulative results for the control subjects, which show the PV and FR left/right ratios are close to one. this suggests hemodynamic symmetry between left and right hemispheres for controls. For the 65M patient with RMCA stenosis, the PV ratio/FR ratio in ICA and MCA were 1.37/2.26 and 1.44/7.09. The 43M patient with stenotic RMCA showed asymmetry only in the MCA-FR (1.6). The 70F case had multiple stenoses with the most pronounced asymmetry in PCA-PV and -FR (0.42 and 0.6).

Discussion:
We demonstrated the feasibility of using dual-
venc
4D flow MRI and automated flow analysis tool to quantify hemodynamic markers such as PV, FR and flow asymmetry in ICAD patients with the potential application for ICAD risk stratification.
Abstract TP122: Validation of the Vision Aphasia Neglect (VAN) Screening Tool for Clinical Diagnosis of Emergent Large Vessel Occlusion
Authors: Valadi Nojan , Thomas Catherine A
Published: October 2018

Objective:
Numerous screening tools have emerged in an effort to identify patients with emergent large vessel occlusion (ELVO) for mechanical thrombectomy (MT). The vision, aphasia, and neglect (VAN) screening tool was designed as a quick evaluation of cortical function to predict ELVO and was shown to be effective when used in the emergency room in predicting ELVO with a 100% sensitivity and 90% specificity in the pilot study of 62 patients. The objective of this study was to evaluate the VAN tool as applied to a large patient population and assess its ability to predict ELVO.

Methods:
Emergency visits that resulted in diagnosis of stroke or received thrombolysis for stroke in a community hospital over 18 months were reviewed. The VAN tool was applied, using components of initial NIHSS to identify changes in vision, language, or attention coupled with weakness. Patients were also screened for NIHSS ≥6. These two indices were evaluated for ability to predict ELVO and then candidacy for MT based on guideline criteria for MT.

Results:
Of 617 patient cases reviewed, 159 (25.9%) were VAN positive while 233 (37.9%) had an NIHSS ≥6. Sixty-four (64) patients (10.4%) had ELVO. The VAN score had a sensitivity of 61% and a specificity of 76.8% for predicting ELVO, while an NIHSS value ≥6 had a sensitivity of 71.7% and a specificity of 63.6%. Of 38 VAN positive patients with ELVO, only 18 met all current guideline criteria for MT, representing only 11% of all VAN positive patients. Of 43 patients with an NIHSS ≥6 who had ELVO, 19 met criteria for MT, 8.2% of all NIHSS ≥6 patients. Only 19 of 617 stroke patient cases reviewed 19 had ELVO eligible for MT (3.1%).

Discussion:
This study demonstrates that in a much larger population than that of the pilot study, the VAN screening tool for ELVO has a lower sensitivity and specificity than believed. Barring limitations, this population is ten times as large as the pilot study and shows that ELVO as well as ELVO meeting criteria for MT among VAN positive patients are less common than previously predicted by the VAN tool. Continued work needs to analyze and compare ELVO screening tools for predicting ELVO, and guidelines for MT need to adapt in a rapidly evolving field, especially with this and other studies suggesting an even larger population could benefit from MT.
Abstract TP128: Multicenter Experience With Stenting for Carotid Webs
Authors: Haussen Diogo C , Grossberg Jonathan , Leesch Wolfgang , Koch Sebastian , Yavagal Dileep R , Barreira Clara , Pradilla Gustavo , Frankel Michael , Nogueira Raul
Published: October 2018

Background:
Carotid web is a shelf-like lesion in the posterior aspect of the internal carotid bulb and represents an intimal variant of fibromuscular dysplasia. Carotid webs have been associated with recurrent strokes and traditionally treated with surgical excision. We report a multicenter experience of stenting in patients with symptomatic carotid webs.

Methods:
Retrospective review of patients admitted to three comprehensive stroke centers identified to have a carotid web with otherwise negative stroke workup that underwent stenting. A carotid web was defined by the presence of a shelf-like/linear, smooth filling defect in the posterior aspect of the carotid bulb diagnosed by neck CT/MR angiography and confirmed with conventional angiography.

Results:
Twenty patients with symptomatic (80% Stroke/20% TIA) carotid webs were stented. Median age was 48[41-61] years, 7(35%) were male, and 15(75%) Black. Median NIHSS was 11[2-16] while ASPECTS 8[7-8]. Eight (40%) received intravenous thrombolysis and 10 (50%) thrombectomy. All patients were stented on dual antiplatelets (aspirin and clopidogrel[17] or ticagrelor[3]) at a median 9[4-30]days after the last vascular event. Closed-cell stents were used in 75% of cases (XACT [14] and Wallstent [1]) while open-cell stents in 25% (Acculink[5]). No cases required angioplasty for residual stenosis had to be performed. DIstal embolic protection was used in 19 cases (SpiderFX[18] and Emboshield_NAV6[1]) while proximal protection in 1 (MoMa). No periprocedural events occurred with the exception of two cases of hypotension/bradycardia (one requiring 24-hour vasopressors). No parenchymal hematomas were observed but one patient developed vaginal hemorrhage requiring discontinuation of one antiplatelet at 2 months. Modified Rankin Scale 0-2 (independence) at 90 days was recorded in 95% of patients. Clinical follow-up post stent occurred for a median of 4 [2-12] months and no follow-up cerebrovascular events were noted. Follow-up vascular imaging was performed in 95% patients at a median of 3[2-12]months and were all unremarkable.

Conclusions:
Stenting for symptomatic carotid web appears to be a valid, safe, and effective alternative to surgical piecemeal resection. Further studies are warranted.
Abstract TP129: The Feasibility, Safety, and Changes in Systolic Blood Pressure Associated With Endovascular Revascularization of Symptomatic and Chronically Occluded Cervical Internal Carotid Artery (COICA): Using a Newly Suggested Radiographic Classification of COICA: Pilot Study
Authors: Guerrero Waldo R , Hasan David
Published: October 2018

Introduction:
Overall risk of ischemic stroke from a chronically occluded internal carotid artery (COICA) is around »7% per year. We propose 1) a radiographic classification of COICA to determine the technical success and safety of endovascular recanalization of symptomatic COICA and 2) assess changes in systemic blood pressure following successful revascularization.

Methods:
Radiographic imaging of 100 consecutive subjects with COICA was analyzed. A classification of COICA based on morphology and location of occlusion in addition to presence or absence of reconstitution of the distal ICA was utilized. Sixteen symptomatic COICA in 15 subjects refractory to medical therapy (4/15, 26.7% female) from 2016-17 were included. Carotid occlusion was defined as 100% occlusion of the vessel lumen based on CT or MR angiography and confirmed by digital subtraction angiogram.

Results:
Four types (A-D) of radiographic COICA were identified. Type A 29%, Type B 28%, Type C 33%, and Type D 10%. Types A/B were more amenable to safer revascularization than types C/D. Recanalization was successful in 68.75% (11/16 [Type A: 4/4; Type B: 3/3; Type C: 3/4; Type D: 1/5]) of the subjects. Perioperative complications was 4/16, 25%; [0/4 in Type A; 1/3 in type B; 2/4 in type C, and 1/5 in type D]. None of these complications led to permanent morbidity or mortality. Ten of fifteen (62.5%) subjects had improvement in symptoms during 2-6 month follow-up. Eight of ten subjects (80%) with revascularization had significant decrease in systolic blood pressure [SBP) following revascularization [baseline SBP= 141±9 vs. follow-up SBP= 123±8; 95% CI; -25.57 to -10.42; p=0.0001]. The remaining five subjects failing revascularization had no significant change in SBP [Baseline SBP=137±6 vs. follow-up SBP=135±11; 95% CI: -14.92 to 10.9; p=0.73].

Conclusion:
This pilot study suggests that our proposed classification of COICA may be a useful guide to determine technical feasibility and safety of revascularization of symptomatic COICA using endovascular techniques. Successful revascularization may lead to significant decrease in SBP post procedure. A phase-2 trial to assess the safety and efficacy of this technique and to validate COICA classification in larger cohort is warranted.
Abstract TP131: Intracranial Plaque Enhancement on Vessel Wall MRI and the Oral Microbiome
Authors: de Havenon Adam H , McNally J Scott , Pedersen Matthew A , Majersik Jennifer J , Parker Dennis , Fagatele Lilly , Wong Ka-Ho , Fischer Kael F
Published: October 2018

Introduction:
Alterations in the oral microbiome are associated with the development of cardiovascular disease. Post-contrast plaque enhancement (PPE) on vessel wall MRI is associated with symptomatic intracranial atherosclerosis and increased risk of stroke recurrence, but the mechanism remains unknown.

Hypothesis:
We hypothesized that the oral microbiome in patients with PPE of the stroke parent artery would be distinct from those without PPE, offering insight into the pathophysiology of PPE.

Methods:
We conducted a prospective study of patients with ischemic stroke due to intracranial atherosclerosis, who underwent vessel wall MRI and oral swab within 14 days of stroke. MRI was interpreted by a blinded neuroradiologist and the oral microbiome was analyzed using validated genomic techniques. The diversity of bacterial species was tested with the Wilcoxon signed-rank test.

Results:
Thirty-two patients were included in our analysis, of which 20/32 had PPE (62%). No significant difference was found in bacterial species abundance between patients with or without PPE (p=0.745) (Figures 1+2), but 2/20 (10%) patients with PPE had elevated Mycoplasma species, which were absent in all the patients without PPE.

Conclusions:
Although we did not find an association between PPE and alterations in the oral microbiome, the identification of Mycoplasma in patients with PPE is of interest. Mycoplasma has been identified in histologic samples of ruptured atherosclerotic plaques. A larger study will be required to investigate this association and determine the impact of the oral microbiome on PPE when controlling for cardiovascular risk factors.
Abstract TP133: A Network Approach to Identifying New Candidates for Ischemic Stroke
Authors: Lescure Tyler N , Carrera Joseph F , Malik Rainer , Hsu Fang-Chi , Chen Wei-Min , Keene Keith L , Yang Qiong , Dave Tushar , Mitchell Braxton , Seshadri Sudha , Sale Michele M , Worrall Bradford B , Williams Stephen R
Published: October 2018

Introduction:
Recent success identifying genetic variation in ischemic stroke (IS) has yet to translate into actionable targets or pathways. Weighted Gene Co-Expression Network Analysis (WGCNA) uses an unsupervised approach to cluster genes into modules based on co-expression profiles. Modules likely contain biologically related genes. The correlation between a gene’s expression and the module’s overall expression pattern (eigengene) defines connectivity. Genes with high connectivity may inform and supplement genome-wide association studies (GWAS).

Methods:
Gene Expression in Carotid Artery GSE43292 (GEO) resource contains publically available Affymetrix Human GeneChip Gene 1.0 ST data from 34 carotid atherosclerotic plaques and paired normal carotid tissue from the same individual. WGCNA resulted in 16 co-expression modules tested against the atherosclerosis phenotype. Significant modules had strong correlation between module eigengene and atherosclerosis. We took the top genes from significantly associated modules and looked them up in two existing IS genetic datasets: Stroke Genetic Network (SiGN) (17,000 IS cases & 32,000 controls) and METASTROKE (10,307 cases & 19,326 controls). We conducted a secondary GWAS informed by WGCNA for only known functional variants in METASTROKE with replication in SiGN.

Results:
Five of 16 modules showed evidence of association with two standouts (“Turquoise” and “Brown”) both enriched for genes associated with vascular disease related traits (carotid IMT, coronary artery disease, etc.) and contain genes associated with IS, especially large artery atherosclerotic stroke (including HDAC9). We took the top 20 genes from these modules, not currently known to associate with IS, and looking them up in SiGN and METASTROKE, we found association with variants in three genomic regions (SLC7A7, ATXN2/SH2B3, ALDH2). The informed GWAS approach identified ADAMTSL3 as a potential novel translational target.

Conclusion:
Leveraging expression data in a convergent genomics approach holds promise to supplement on-going GWAS and accelerate identification of potential translational targets. Gene ontology analyses of genes from the top modules are underway.
Abstract TP135: Control of Vascular Risk Factors at Baseline in CREST-2
Authors: Meschia James F , Barrett Kevin M , Roubin Gary S , Heck Donald , Jones Michael , Wechsler Lawrence , Rapp Joseph H , Turan Tanya N , Demaerschalk Bart M , Lal Brajesh K , Voeks Jenifer H , Howard George , Howard Virginia J , Brott Thomas G
Published: October 2018

Rationale:
Asymptomatic carotid stenosis is commonly seen in medical practice. CREST-2 is a pair of concurrent two-arm multi-site randomized trials of intensive medical management versus intensive medical management in combination with revascularization by endarterectomy or stenting. It is not known how often patients entering the trials have opportunities for further risk factor reduction at study entry and whether these opportunities vary across trial centers.

Methods:
Baseline data on 683 patients from 109 clinical sites were used for these analyses. We determined the rates of control at baseline for systolic blood pressure (SBP), defined as <140 mmHg (or ≥140 with >15mmHg orthostatic drop), and low density lipoprotein (LDL), defined as <70 mg/dl. We then tested differences in these baseline control rates by site-related characteristics, including site type, StrokeNet site vs. not, specialty of site Principal Investigator (PI), type of hospital, central vs local IRB, type of research team and whether site is enrolling in one or both trials. P-value <0.05 was considered significant.

Results:
At baseline, the mean SBP was 140.4±20.5 mmHg, but only 62% of participants were in target. The mean LDL at baseline was 83.7±36.9, mg/dl, with 42% in target. None of the site characteristics were associated with a higher level of control for SBP at baseline. The only characteristic associated with having a higher level of LDL control was sites enrolling in only the CAS trial (57%) compared to those enrolling in the CEA only (24%) or in both trials (42%) (p=0.02).

Conclusions:
Opportunities to improve on risk factors are common among CREST-2 participants, but site characteristics did not predict the likelihood of being at goal for SBP while sites enrolling in only the CAS trial had a higher level of LDL control.
Abstract TP137: Relationship Between Risk Factor Control and Physician Specialty in the CREST2 Trial
Authors: Turan Tanya N , Voeks Jenifer H , Barrett Kevin M , Brown Robert D , Chaturvedi Seemant , Chimowitz Marc , Demaerschalk Bart M , Emmady Prabhu , Howard George , Howard Virginia J , Huston John , Jones Michael , Lal Brajesh K , Lazar Ronald M , Meschia James F , Moore Wesley S , Moy Claudia S , Roldan Ana M , Roubin Gary S , Brott Thomas
Published: October 2018

Background:
In CREST2, intensive medical management of subjects’ vascular risk factors is overseen by the site Principal Investigator (PI) and implemented by a designated Medical Management Physician (MMP) and coordinator. These physicians have different specialties and experience with risk factor management. We sought to determine the relationship between risk factor control and PI and MMP specialty.

Methods:
Data on 613 patients with at least 1 follow-up visit from 105 CREST2 sites were used for these analyses. CREST2 sites were categorized based on both PI specialty and MMP specialty. Specialty of the site-designated primary MMP was used for sites with more than one MMP. We compared the percentage of patients in target at last follow-up visit for the primary risk factors, LDL < 70 mg/dL and SBP <140 mm Hg, among PI specialties and MMP specialties, using the chi-square test.

Results:
The table shows the number of patients by PI and MMP specialty, as well as their control of SBP and LDL. There were no significant differences in control of SBP or LDL by PI specialty. There was a trend toward an association between LDL control and MMP specialty, with higher rates of LDL control at sites with Internal Medicine MMP specialists and lower rates of control with Vascular Surgery MMPs. SBP control rates were not significantly different across MMP specialties.

Conclusions:
In this early analysis of risk factor control in the CREST2 study, site PI and MMP specialty did not have a significant effect on LDL and SBP during follow-up. This suggests that protocol care pathways are generalizable to diverse physicians.
Abstract TP139: Transcranial Direct Current Stimulation as an Adjuvant to an Intensive Comprehensive Aphasia Program in Chronic Stroke
Authors: Shamapant Shilpa , Wortman-Jutt Susan , Boutin Elise , Bennett Sarah , Oromendia Clara , Gerber Linda , Marquardt Thomas P , Edwards Dylan J
Published: October 2018

Background and Purpose:
In this proof-of-concept pilot study, transcranial direct current stimulation (tDCS) was used as an adjuvant to speech therapy in an intensive comprehensive aphasia program (ICAP).

Methods:
Using a double-blind, sham controlled, between-group design, 1 mA of direct current was delivered via NEO-24 PiStim gel electrodes using a Starstim tDCS device.The anode was placed over the inferior frontal gyrus (FC5), with the cathode placed over the supra-orbital frontal area (AF8) of the contralesional side during the first 20 minutes of daily intensive speech therapy for a period of 15 consecutive weekdays, commencing on day-1 of an 8-week ICAP. Pre- and post-treatment standardized assessments and discourse analysis, as well as bi-weekly trained and untrained probes, were used as outcome measures.

Results:
Six subjects were analyzed; three received ICAP-tDCS and three received ICAP-sham. Five subjects were male. Ages ranged from 50 to 67 years. Time post-stroke at enrollment ranged from 8 months to 5.2 years. Subjects receiving ICAP-tDCS treatment demonstrated significantly higher improvement than ICAP-sham patients on the Boston Naming Test ( p=0.05), trained and untrained probes (p=0.05, untrained absolute increase p=0.05, percent increase p=0.38), and picture-description discourse (absolute increase p=0.05, percent increase p=0.38). There was no difference in the improvement of Western Aphasia Battery-AQ between ICAP-tDCS and ICAP-sham patients (absolute and percent increases both p=0.28). No adverse effects of tDCS or intensive behavioral training were reported. Following completion of the initial 3 weeks of adjunctive tDCS and tDCS-sham treatment, all subjects continued participation in the ICAP therapy with behavioral intervention only, and concluded the 8-week program.

Conclusions:
In this proof-of-concept pilot rehabilitation study, we demonstrate significant language improvements in chronic post-stroke aphasia, following intensive speech therapy combined with tDCS. Results should be confirmed in a larger randomized clinical trial.
Abstract TP141: Feasibility of Online Training and Certification for the Fugl-Meyer Motor Assessment in Stroke Recovery Trials
Authors: See Jill , Augsburger Renee , McKenzie Alison , Dodakian Lucy , CRAMER Steven C
Published: October 2018

Introduction:
Standardized measurement of clinical outcomes across sites and over time is critical to clinical trials. Barriers to outcome measure training include availability of standardized materials and time to train, plus wide geographic distribution of trial personnel. To address these, an online training and certification program based on NIHSS testing was developed and implemented for the Fugl Meyer Motor Assessment (FMMA) in support of multisite stroke recovery trials.

Methods:
This program includes Fugl Meyer Arm (FMA) and Leg (FML) components, runs on a web host, and is based on a valid, reliable approach to FMMA testing known to decrease variance in scoring (See et al, NNR, 2013;27:732-741). The website hosts training courses, reference manuals, video patient cases for formal certification testing plus 3 rounds of recertification; each round has 2 separate patients. A passing score of 90% is required. After each course, feedback is given.

Results:
This program has served as the primary training, certification, and recertification mechanism for 4 multisite recovery trials, including 1 NIH-funded US trial and 3 industry-sponsored international trials. Three trials certify on both FMA and FML, and 1 on FMA only, as primary endpoint. Evaluators are recertified every 4-6 months. The 299 clinicians from 5 countries registered include PT/OT (n=136), MD (n=37), and RN/NP/PA (n=15). For FMA training, 299 persons have registered and 197 completed. For the first round of FMA certification, 267 have registered and 171 passed (mean 1.89 attempts to pass). For the second FMA (first recertification), 78 registered and 65 passed. The passing rate increased with successive rounds of recertification. Similar numbers have been achieved for FML training, certification, and recertification.

Conclusions:
The FMMA has established value for capturing treatment-related motor gains in stroke recovery trials. The current online training program is efficient and effective for training, certifying, and recertifying examiners in arm and leg FMMA. Clinical trial assessors training with this program can be expected to provide more accurate and less variable FMMA scores, which increases statistical power, reduces sample sizes, and reduces the cost of clinical trials.
Abstract TP144: Delays to In-hospital Rehabilitation Worsen Quality of Life After TIA and Ischemic Stroke
Authors: Capo-Lugo Carmen E , Askew Robert L , Naidech Andrew , Prabhakaran Shyam
Published: October 2018

Objective:
Early rehabilitation has been suggested to improve outcomes after stroke, though evidence is controversial. The purpose of this study is to assess the impact of time to in-hospital (acute) rehabilitation on health-related quality of life (HRQoL) and disability.

Methods:
Patients with ischemic stroke or TIA were enrolled in a prospective observational cohort study. At 1-month, HRQoL was assessed using Neuro-QOL measures of executive function (EF), general cognitive concerns (GCC), upper extremity dexterity (UED), and lower extremity mobility (LEM). Disability was assessed with the modified Rankin Scale (mRS) and the Barthel Index (BI). Time to acute rehabilitation evaluation and treatment were defined as time (in days) from hospital admission to first rehabilitation evaluation and treatment, respectively. The sample was stratified by baseline NIHSS score to investigate potential differential effects. Linear and logistic regression models with robust standard errors estimated the effect of time to rehabilitation services on patient outcomes while controlling for age, baseline NIHSS score, TOAST and stroke subtype.

Results:
Among the 553 participants analyzed (mean age 67 years; 51.9% male; 64.4% white; 88.8% ischemic stroke), the median time from hospital admission to acute rehabilitation evaluation was 2 [IQR: 1-3] days. For those with NIHSS score <5, longer time to rehabilitation evaluation was associated with worse BI scores (BI <100: OR=0.818, p=0.008), EF T-scores (b=-0.871, p=0.001), and GCC T-scores (b=-0.614, p=0.009) at 1-month. In those with NIHSS score ≥5, longer time to rehabilitation treatment was associated with increased disability (i.e., mRS>=2: OR=1.15, p=0.039) and worse LEM T-scores (b=-0.591, p=0.046) at 1 month.

Conclusions:
Longer time to initiation of acute rehabilitation has differential effects on post-stroke disability and HRQoL at 1-month after ischemic stroke and TIA. The effect of time to acute rehabilitation evaluation is more impactful for those with mild deficits, while the effect of time to treatment is more impactful for those with moderate to severe deficits. Minimizing time to in-hospital rehabilitation evaluations and treatments might improve outcomes after ischemic stroke and TIA.
Abstract TP150: Kinematic Visual Biofeedback is Best When Training Novel Swallowing Behaviors in Dysphagic Patients After Stroke
Authors: Humbert Ianessa A , Vose Alicia
Published: October 2018

Introduction:
Dysphagia (swallowing impairment) is a common and often life threatening problem after stroke. Submental surface electromyography (ssEMG) visual feedback is a commonly used clinical tool to train novel swallowing maneuvers, even though its effectiveness has been questioned in studies of healthy adults. This study compares the effect of ssEMG and videofluoroscopy (VF) visual biofeedback on hyo-laryngeal accuracy when training the volitional laryngeal closure swallowing maneuver (vLVC) in post-stroke patients with dysphagia. The vLVC maneuver involves swallowing first, then maintaining laryngeal vestibule closure for at least 2 seconds. This study also examines the accuracy of clinician judgements about patient vLVC performance.

Hypothesis:
Accuracy will be reduced when only ssEMG (non-kinematic) versus VF (kinematic) visual feedback is used to teach the vLVC.

Methods:
Stroke participants (N=14) underwent 2 study phases. Phase 1: first demonstrated ability to perform the vLVC accurately. Phase 2 was vLVC training. Participants were randomized into three biofeedback groups including the ssEMG Group (ssEMG biofeedback in phases 1 and 2), the VF Group (VF biofeedback in phases 1 and 2), and the Mixed Group (VF phase 1, ssEMG phase 2). A clinician provided real-time, verbal cueing utilizing the assigned visual biofeedback to promote vLVC accuracy. The clinician could only see the assigned type of feedback also seen by the patient, although both VF and ssEMG were recorded for all participants.

Results:
Both accuracy of vLVC training performance and clinician feedback were worst in the ssEMG group compared to the VF and Mixed Groups (linear mixed models p<0.001).

Conclusions:
Swallowing airway protection requires precisely timed movements of small, hidden laryngeal and pharyngeal structures. Kinematic feedback may be required to ensure that target swallowing movements are being trained in rehabilitation.
Abstract TP153: Repetitive Peripheral Sensory Stimulation in Stroke: a Systematic Review and Meta-Analysis
Authors: Conforto Adriana B , Anjos Sarah , Silva Arnaldo , Conti Juliana , Machado André G , Cohen Leonardo G
Published: October 2018

Background:
Enhancement of sensory input in the form of repetitive peripheral sensory stimulation (RPSS) can enhance excitability of the motor cortex and upper limb performance.

Objective:
To perform a systematic review and meta-analysis of effects of RPSS compared to control stimulation on improvement of motor impairments in the upper limb of subjects with stroke.

Methods:
We searched studies published between 1948 until July, 2016 and selected eight studies that applied a specific paradigm of stimulation (trains of 1 millisecond pulses at 10Hz delivered at 1 Hz). Continuous data were analyzed with pooled means of standard deviations of results of active versus control interventions with the Cohen and Hedges formulas. Adverse events were also assessed.

Results:
There was significant heterogeneity when data from all eight studies that included subjects at early (n=3) or chronic (n=5) stages after stroke were included, but not when only data from studies in the chronic phase were analyzed. There was a statistically significant beneficial effect of RPSS on motor performance in subjects in the chronic phase with an overall small effect size (standard mean difference between active and control RPSS, 0.45; 95% confidence interval, 0.07, 0.84). When data from the three studies that included subjects at an early stage after stroke were added, the effect was no longer statistically significant. No serious adverse events were reported.

Conclusions:
RPSS is a safe intervention with potential to become an adjuvant tool for upper extremity paresis rehabilitation in subjects with stroke in the chronic phase.
Abstract TP156: Migraine and Non-migraine Headaches Following Diagnostic Catheter Based Cerebral Angiography: A Prospective Study
Authors: Naseem Nishath , Saeed Omar , Saleem Muhammad A , Wallery Shawn S , Qureshi Adnan I
Published: October 2018

Background:
No reliable estimates of headaches following catheter based cerebral angiography are available. We performed a prospective study to ascertain the frequency and type of headaches following cerebral angiography including time to resolution.

Methods:
Consecutive patients who underwent diagnostic catheter based cerebral angiography through the transfemoral (or infrequently radial) route using iodixanol (270 mg/ml) injection were included. Each patient underwent a brief neurological assessment after the procedure by a board-certified neurologist and more detailed assessment was performed if any patient reported occurrence of any headache. The headaches were classified as migraine if the diagnostic criteria specified by International Headache Society were met. The severity of headache was classified using a visual analog scale rating from 0-10. Another endpoint was the time to reach pain free status for two consecutive hours.

Results:
A total of 168 patients (mean age 60.5 ±SD 16.2 years; 90 were men) underwent diagnostic cerebral angiography. Of the 168 patients, 5 (3.0%, 95% confidence interval [CI]1.1%-6.6%) reported occurrence of migraine headaches and14 (8.3%, 95% CI 4.7%-13.7%) reported occurrence of non-migraine headaches. The median severity of migraine headaches was 10/10 and time (in minutes) to resolution of headaches was 140 minutes (range 60-360); two patient did not have complete resolution within 48 hrs of procedure. Of the patients with history of migraine, 3 (1.8%, 95% CI 0.5%-4.9%) reported occurrence of migraine headaches and 5 (3.0% 95% CI 1.0%-6.6%) reported occurrence of non-migraine headaches. Occurrence rates for migraine headaches in men and women were 1.1% (95% CI 0.1%-5.5%) and 3.9% (95% CI 1.0%-10.7%), respectively. Occurrence rates for migraine headaches was very high among patients with arterial dissections: 22.2 %, (95% CI 3.7% - 73.4%), although numbers were small.

Conclusions:
We provide occurrence rates of migraine and non-migraine headaches, an under recognized adverse event, in patients undergoing catheter based cerebral angiography.
Abstract TP162: Association Between Factor V Gene Polymorphism and Risk of Ischemic Stroke: Meta-analysis
Authors: Alhazzani Adel A , Kumar Amit
Published: October 2018

Background:
Ischemic stroke (IS) is a complex multifactorial and polygenic disease. Studies on association between Factor V G1691A gene polymorphism and ischemic stroke have shown conflicting results. To address this issue, we conducted a meta-analysis to determine the precise role of Factor V gene polymorphism with risk of ischemic stroke

Materials and Methods:
We searched electronic databases PubMed, Trip Data Base, Medline, EMBASE and Google Scholar (last search dated March 2017). Pooled odds ratios (ORs) with 95% confidence intervals (CIs) from random- and fixed-effects models were calculated.

Results:
Forty case-control studies fulfilled our inclusion criteria comprising 6860 patients and 18025 controls. 19 studies were conducted in young adults (mean age < or = 40 years), 17 studies were conducted in the subjects with old onset of stroke (mean age > 40) years and 5 studies did not report the mean age at recruitment. The significant associations between Factor V G1691A gene polymorphism and risk of ischemic stroke were observed in dominant model (odds ratio [OR] 1.40; 95% CI:1.22 to 1.62, P-value = <0.001. Stratified analysis suggested strong association of Factor V and risk of Ischemic stroke in cases with young onset (<=40 years) odds ratio 1.84; 95% CI: 1.47 to 2.30) but failed to reach to threshold of statistical significance in cases who had onset of stroke at old age (>40 years). Across all the included studies, Factor V heterozygous state was observed in 423 of 6860 cases (6.1%) and 1069 of 18025 controls (5.9%), yielding a fixed effect odds ratio of 1.40 (95% CI: 1.22 to 1.62).

Conclusion:
Factor V G1691A genetic polymorphism was associated with risk of ischemic stroke mainly in young adults. Further prospective studies are needed to validate these findings.

Keywords:
Factor V gene polymorphism, Meta-analysis,Ischemic stroke, Cardiovascular Disorder, Stroke
Abstract TP166: Frequency of Brain Death in Acute Cerebrovascular Disease Related Mortality
Authors: Khatri Rakesh , Vellipuram Anantha R , Maud Alberto , Afzal Mohammad Rauf , Qureshi Mohtashim A , Qureshi Ihtesham A , Piriyawat Paisith , Cruz-Flores Salvador , Rodriguez Gustavo J
Published: October 2018

Background:
Despite the frequent occurrence of brain death in intensive care unit, the prevalence rate of brain death in ischemic stroke (IS), intracranial hemorrhage (ICH) and subarachnoid hemorrhage (SAH) is not known at national level. In addition the prevalence of cardiac arrest in these patients is not established.

Methods:
From 2012, ICD-9-CM includes a specific code for brain death (348.82). Brain death patients were identified from the nationwide in-patient sample database for the years 2012 to 2014. Associated in-hospital cardiac arrest patients were also identified under each category. Demographics, medical comorbidities, in-hospital complications, procedures, length of stay and hospital charges were compared.

Results:
Rate of brain death was highest in SAH related mortality (22%, 3255 brain deaths/ 14620 in-hospital mortality), followed by ICH, (12.5%, 5760 brain deaths/ 45945 in-hospital mortality) and ischemic stroke (3%, 1840 brain death/62285 in-hospital mortality). Majority of the patients had brain death secondary to neurological insult (ICH n=5260, 91.3%; SAH n= 2625 (80.6%) and IS n=1640, 89.1%) without any secondary diagnosis of in-hospital cardiac arrest. Length of stay was shorter in patients with SAH and ICH (mean 2.92±4.13 days and 2.53±3.56 days respectively) compared to IS patients (mean 4.93 ± 10.2 days, p < 0.001) suggesting brain death is an early event in hemorrhagic stroke.

Conclusion:
Brain death in the majority of cerebrovascular patients occurs as a result of primary neurological insult without associated cardiac arrest. It occurs much earlier in hemorrhagic stroke compared to ischemic stroke.
Abstract TP168: Racial Disparities in Stroke Risk Factors and Interventions in an Underserved Metropolitan Population
Authors: Frontera Jennifer A , Scher Erica , Arcot Karthikeyan , Boden-Albala Bernadette , Liff Jeremy , Ogedegbe Olugbenga , Turkel-Parella David , Tiwari Ambooj , Farkas Jeffrey
Published: October 2018

Introduction:
Direct comparisons of stroke risk factors and rates of acute stroke treatment between Asians, Blacks and Whites are limited due to a lack of racial diversity in typical hospital catchment areas.

Methods:
Consecutive patients with ischemic or hemorrhagic stroke (intracerebral [ICH] or subarachnoid hemorrhage [SAH]) admitted to a single, comprehensive stroke center located in a racially diverse, underserved metropolitan area were prospectively enrolled in a registry between 9/2014-2/2017. Stroke risk factors, admission NIHSS, insurance status and acute stroke treatments (including IV tPA and/or mechanical thrombectomy) were compared between Asian, White and Black patients.

Results:
Of 1045 stroke patients, 170 (16%) were Asian, 226 (22%) were Black and 649 (62%) were White. Asians had significantly higher rates of ICH than Blacks or Whites (17% versus 6% and 8%, respectively, P<0.001), while Blacks had higher rates of SAH than other race groups (12% versus 3% among Asians and Whites, P=0.002). Compared to Whites and Asians, Blacks were younger, more often female and had higher BMI (body mass index) than other race groups, though they had lower rates of hyperlipidemia (all P<0.05). Asians and Blacks were more than twice as likely to be uninsured or on Medicaid than whites (28%, 27% and 11%, respectively; P<0.001). Rates of IV tPA use among patients with ischemic stroke were significantly lower in Blacks (3%) than Asians (10%) or Whites (10%) after adjusting for NIHSS, anticoagulation and insurance status (P=0.002). While mechanical thrombectomy occurred more often in Asians (23%) and Blacks (23%) than whites (15%), this difference was non-significant after adjusting for NIHSS. Good discharge disposition (home, acute or home rehabilitation) was similar across racial groups after adjusting for age and NIHSS.

Conclusions:
In a single site study with minimal geographic/environmental heterogeneity, Asians and Blacks had higher rates of hemorrhagic strokes than Whites and higher rates of being underinsured. Rates of IV tPA utilization were lowest among Blacks, though rates of mechanical thrombectomy were similar across races. Lower rates of IV tpa use appear related to factors other than insurance status or treatment bias.