bluuebunny/crossref_metadata_2025 huggingface dataset:
Dilatation of common carotid artery is strongly associated with cerebral ischemic stroke with or without the presence of carotid atherosclerosis
Authors: Chen Jiunn-Rong , Bai Chyi-Huey , Chiu Hou-Chang , Pan Wen-Harn
Published: July 2021

P147

Background:
Dilatation of common carotid artery (CCA) was related to age, sex, and body height in population studies. It was also considered a compensatory mechanism to carotid atherosclerotic stenosis. The present study examined the risk of CCA dilatation associated with ischemic stroke (IS) and its relations to carotid atherosclerosis, hypertension, hyperglycemia, fibrinogen, cholesterol, HDL-cholesterol (HDL-C), smoking, and alcohol consumption.
Methods:
A case-control study was carried on 251 first-ever IS patients (age≥40) excluding previous history of myocardial infarction and cancer and 242 non-stroke outpatients. Intraluminal diameter of middle portion of CCA, and plaque thickness in CCA, bulb, internal and external carotid arteries were measured. Information on hypertension and diabetes status and data of life-styles such as smoking and alcohol consumption were collected. Levels of fibrinogen, factor VIIIc, cholesterol, HDL-C and glucose were obtained.
Results:
CCA dilatation was a strong factor for IS (OR=4.13, P=0.0001). It was also associated with hypertension, hyperglycemia, smoking, alcohol consumption, low HDL-C, and high levels of fibrinogen, factor VIIIc, cholesterol, and plaque score. The association remained significant with or without each of the following conditions: hypertension (p=0.0001, p=0.0007), hyperglycemia (p=0.0446, p=0.0001), elevated fibrinogen (p=0.0104, p=0.0001) or factor VIIIc (p=0.2458, p=0.0001), hypercholesterolemia (p=0.0238, p=0.0001), decreased HDL-C (p=0.0012, p=0.0001) and presence of plaque score (p=0.0263, p=0.0003). Adjusting above risk factors, odds ratios of elevated diameter could associated with IS, before (OR=2.21, P=0.0066) and after (OR=6.63, p=0.0055) excluding subjects with plaque.
Conclusion:
Dilatation of CCA is a strong risk factor for IS. The fact the association remained significant without ultrasonic evidence of carotid plaque indicates that IS in Chinese involved a mechanism of active vasculopathy, not just a passive compensatory process to extracranial atherosclerosis.
Eligibility for intravenous thrombolysis in acute stroke: A multicenter prospective study
Authors: Mostacero Enrique , Santos Sonia , Davalos Antonio , Gil-Peralta Alberto , Castillo Jose , Rebollo Mariano , Alvarez-Sabin Jose , Navarro Ricardo , Egido Jose , Vivancos Jose , Roquer Jaume , Gil Antonio
Published: July 2021

P182

Objective:
To elucidate the proportion of patients who would have been eligible for alteplase treatment following the ECASS II criteria in a prospective study conducted in 20 Spanish general or university hospitals.
Methods:
The first 100 consecutive patients with an acute stroke admitted between 9/98 and 4/99 in each participating hospital were evaluated. Data concerning exclusion criteria for tPA, demographic variables, distance to hospital (<5km,5–20km,>20km), time (0–6am,6–12,12–6pm,6–12pm) and place (home, work/street, hospital) of symptoms onset, subject detecting the event (victim, family member, bystander), dispatch system (own initiative, EMS, primary physician, community hospital), delay and type of transport (own transport, basic, or advanced life support ambulance), cardiovascular risk factors, stroke severity (Canadian scale) and type of stroke were recorded.
Results:
Out of 1599 screened patients, 166 (10.4%) fulfilled all criteria for tPA treatment. Multiple reasons for exclusion were time from onset >6h in 23%, or unknown in 23%, delay in neurological attention >6h in 39%, TC not available within 6h from onset in 34%, hemorrhage in 14%, early signs of infarction involving >33% MCA in 8%, TIA or rapidly improving symptoms in 24%, coma or hemiplegia plus forced eye deviation in 5%, hypertension >185/110 in 2%, coagulation abnormalities in 1%, and other reasons in 6%. Univariate analyses showed that high eligibility for tPA was associated with type of the first medical intervention (emergency medical system)(p=0.006), type of transport (basic or advanced life support ambulance)(p<0.0001), stroke severity (p<0.001), and type of stroke (cardioembolic) (p=0.0027). Age, distance to hospital, time and place of stroke onset, subject detecting the event, and risk factors were not significantly related to eligibility.
Conclusions:
Candidates for intravenous tPA treatment within 6 hours from stroke onset are 10% of patients admitted in general hospitals of an EU country. Delay in neurologic attention and CT examination were the main reasons for exclusion. Dispatch system, and type of transport were modifiable factors related to eligibility.
Prognosis of symptomatic and asymptomatic middle cerebral artery disease - a long-term follow-up
Authors: Kern Rolf , Steinke Wolfgang , Prager Robert , Daffertshofer Michael , Hennerici Michael G
Published: July 2021

P201

Objective:
In contrast to extracranial carotid artery stenosis, there are only limited data on the course and prognosis of symptomatic and asymptomatic intracranial arterial disease. Therefore, patients with vascular pathology of the middle cerebral artery (MCA) were followed prospectively using transcranial Doppler sonography (TCD). Patients and
Methods:
We consecutively followed 102 patients with significant MCA stenosis or occlusion detected by TCD. Among a total of 120 MCA stenoses and 11 occlusions, 47 were classified as symptomatic (SMCA) and 84 as asymptomatic (AMCA) at study entry. Neurologic and sonographic investigations were performed at regular intervals of six to 12 months with a mean follow-up time of 29 months. Patients were treated with platelet inhibitors (73%) or low-dose anticoagulation (27%) according to the individual physician’s decision.
Results:
Thirteen of a total of 19 cerebral ischemic events (11 strokes, 8 TIA) occurred in the territory of the qualifying MCA (8 SMCA, 5 AMCA), resulting in an annual incidence of 4.8% (SMCA 6.6%, AMCA 3.3%). 14.6% of the patients treated with platelet inhibitors, but only 7.4% of those treated with anticoagulants suffered new events. Kaplan-Meier analysis showed a significant reduction of events during anticoagulation therapy (p=0.04). According to TCD classification of stenosis, MCA disease was progressive in 11.5%, unchanged in 72.5% and regressive in 16.0%; recurrent symptoms were associated with disease progression in 23%.
Conclusions:
In comparison with the natural history of extracranial arterial disease the annual risk of ischemic events in AMCA disease is significantly higher, whereas in SMCA disease a similar incidence of recurrent events was observed. Regression rate of stenosis grade and the prophylactic effect of anticoagulation therapy in MCA disease is higher than in extracranial stenosis, suggesting different pathomechanisms of obstruction.
Natural History of Intra-cardiac Thrombus in Stroke/TIA Patients
Authors: Sen Souvik , Laowatana Somchai , Oppenheimer Stephen M
Published: July 2021

P209

Background
Intra-cardiac thrombus is a potential source of embolus leading to ischemic cerebrovascular event. The natural history of intra-cardiac thrombus is not known. Objectives To examine the natural history of intra-cardiac thrombus detected by TEE in stroke/TIA patients.
Methods
Eighty-one patients with recent stroke/TIA underwent sequential TEE evaluations at ≤7 days and 9 months from the symptom onset to detect intra-cardiac thrombus (mean age 60, 39 males and 60 black). The TEEs were recorded on VHS videotape and systematically evaluated by two blinded cardiologists for evidence and location of intra-cardiac thrombus (λ=0.72). In case of a disagreement it was adjudicated by a third blinded cardiologist. The stroke risk factors and stroke preventive medications were recorded in patients with and without intracardiac thrombus and compared using χ
2
test.
Results
An intra-cardiac thrombus was found in the initial TEE in 18 (22%) patients (2 in left atrium, 13 in left atrial appendage, 3 in left ventricle) and in the follow-up 9 month TEE in 9 (11%) patients (8 in left atrial appendage, 1 in left ventricle). The intracardiac thrombus had disappeared in 14 (78%) patients in a period of 9 months (2 in left atrium, 9 in left atrial appendage and 3 in left ventricle). Disappearance of intracardiac thrombus correlated strongly with patients anticoagulated with Warfarin (p<0.0001). A new intracardiac thrombus was detected only on the 9 month TEE in 5 (6%) patients (5 in the left atrial appendage, none in the left atrium or left ventricle). The patients with new intracardiac thrombus were significantly (p=0.02) older (mean±SD=70±7 yrs) as compared to those without (59±12 yrs). Three out of five patients with new cardiac thrombus were felt to have small vessel occlusive disease and were on antiplatelet therapy.
Conclusions
Anticoagulation with warfarin for 9 months can result in disappearance of intracardiac thrombus in stroke/TIA patients. Anticoagulation with Warfarin may have a therapeutic role in stroke/TIA patients with intracardiac thrombus. Older patients with lacunar strokes and not on anticoagulation are prone to develop an new intracardiac thrombus.
Are African American stroke patients receiving appropriate carotid ultrasound exams?
Authors: Chaturvedi Seemant , Raman Rema , Leurgans Sue , Gorelick Philip B
Published: July 2021

P211

Background:
Previous studies have suggested that carotid ultrasound (CUS) tests are less likely to be utilized in African American (AA) patients with stroke or TIA compared to whites (
Stroke
1999; 30: 1350). Whether the localization of the cerebral ischemic event or the stroke subtype influences the ordering of carotid imaging tests is unclear.
Objective:
To determine the patterns of CUS utilization in a large cohort of AA stroke patients.
Methods:
The African American Antiplatelet Stroke Prevention Study database was used for this analysis. Stroke localization was evaluated and stroke subtype was also recorded. CUS utilization was analyzed for the various stroke subgroups and statistical significance was determined by chi square testing. To ensure that site variation in CUS use did not explain any observed differences, the Mantel-Haenszel test was applied using the sites as strata.
Results:
As of 7/99, 1087 patients were entered in the database. In 67 patients, the stroke localization was uncertain, leaving 1020 patients for analysis. Using the stroke localization and subtype information available, 479 patients were classified as carotid (CAR) territory, 278 as vertebrobasilar (VB), 139 as indeterminate (IND), and 124 as both territories (BOTH). CAR strokes were further subdivided into lacunar and nonlacunar events. There was a statistically significant difference in the CUS utilization among the five groups. CUS exams were obtained in 56% of VB patients, compared to 75 to 81% in the other groups (p<0.001). For the other groups, CUS was performed in CAR nonlacunar (75.6%), CAR lacunar (76.5%), IND (80.2%), and BOTH (80.8%). There was no difference in CUS use in patients with a lacunar vs. nonlacunar presentation (p=0.816). An adjustment stratified by center among sites with at least 20 patients produced the same statistical significance (p<0.001).
Conclusions:
There appears to be an underutilization of CUS exams in AA patients with carotid territory strokes, especially for patients with a nonlacunar mechanism. This may lead to decreased performance of potentially valuable stroke prevention measures such as carotid endarterectomy in symptomatic AA patients.
Optimal international normalized ratio (INR) in secondary prevention of stroke in non-valvular atrial fibrillation.
Authors: MD Masahiro Yasaka , MD Kazuo Minematsu , MD Takenori Yamaguchi
Published: July 2021

P213

[Purpose]
In order to elucidate optimal international normalized ratio (INR) for secondary prevention of stroke in nonvalvular atrial fibrillation (NVAF), we evaluated risk of severe recurrent ischemic stroke and major hemorrhagic complications according to patients’ age and INR.
[Methods]
We analyzed data of two prospective studies, Japanese Nonvalvular Atrial Fibrillation-Embolism Secondary Prevention Cooperative Study (Stroke 2000; 31: 817) and NCVC NVAF Secondary Prevention Study to elucidate relationships of major ischemic stroke and hemorrhage with INR. In both studies, all patients with cardioembolic stroke were given warfarin, monitored with INR every month, and followed up for primary endpoints of ischemic stroke and embolism to other part of the body, and for secondary endpoints of major hemorrhagic complications. There were 206 patients enrolled in total (154 men and 52 women). We divided them into two groups, elderly group aged 70 years or more (n=109, median INR 1.6–1.8) and non-elderly group aged less than 70 years (n=97, median INR 1.8–2.0). We calculated annual occurrence rate of major stroke (NIH stroke scale score >= 10) and severe hemorrhagic complications in the two groups.
[Results]
During the mean follow-up period of 548 days, major stroke was seen in 4 patients with INR<1.6 only in the elderly group (INR=0.95, 1.28, 1.54, 1.57; 13.3%/y in INR<1.6), but in none in the non-elderly group (p=0.0475, Fisher’s exact test between the two groups). In the elderly group, severe hemorrhagic complications occurred in none with INR<2.2 (0%/y), in 5 patients with INR between 2.2 and 3.0 (INR=2.25, 2.59, 2.66, 2.80, 2.98, 17.3%/y), and 2 with INR>=3.0 (INR=3.05, 3.13; 38.4%/y). They occurred in none with INR<3.0 (0%/y) and in 1 with INR>3.0 (INR=3.55, 16.4%/y) in the non-elderly group (p=0.0275 v.s. the elderly group).
[Conclusions]
Both major ischemic stroke and hemorrhage occur more frequently in the elderly than in the non-elderly. In the elderly group, INR between 1.6 and 2.2 seems optimal to prevent both major stroke and hemorrhage, while INR below 3.0 is desired in the non-elderly group to avoid hemorrhagic complications.
Ischemic stroke and depression
Authors: Desmond David W , Remien Robert H , Moroney Joan T , Stern Yaakov , Sano Mary , Williams Janet Bw
Published: July 2021

P219

Objective:
To investigate the frequency and clinical determinants of depression after ischemic stroke.
Methods:
We administered the Structured Interview Guide for the Hamilton Depression Rating Scale (SIGH-D) and neurological, neuropsychological, and functional assessments to 421 patients (age = 71.5 ± 8.0 years) three months after ischemic stroke and 249 stroke-free control subjects. We required a SIGH-D total score > 11 for the identification of clinically significant depression.
Results:
We identified clinically significant depression in 47 of the 421 patients (11.2%) and 13 of the 249 control subjects (5.2%), yielding an unadjusted odds ratio (OR) of 2.3 (95% confidence interval, 1.2 to 4.3) for depression associated with stroke. Logistic regression suggested that depression was independently associated with dementia (OR, 3.2), a major hemispheral stroke syndrome (OR, 1.7), infarcts in the anterior and posterior cerebral artery territories vs. infarcts in other vascular territories (OR, 1.6), and female sex (OR, 1.7). When present, depression tended to be mild and typically remitted in follow-up examinations. Somatic SIGH-D items but not depressed mood best distinguished stroke patients from control subjects and demented from nondemented stroke patients.
Conclusions:
Depression was less frequent, less severe, and less persistent in our stroke cohort than previously reported, possibly due to the underrepresentation of patients with a premorbid history of affective illness. It was associated with more severe stroke, particularly in vascular territories that supply limbic structures, and it was more frequent among patients with dementia and women. Somatic symptoms but not depressed mood best distinguished stroke patients from control subjects and demented from nondemented stroke patients, however, suggesting that stroke is more likely to be associated with a “pseudo-depression of dementia” than a “pseudo-dementia of depression.”
Measuring functional outcomes in stroke trials: Improving inter-rater reliability of the Modified Rankin Scale using a structured interview
Authors: Wilson Lindsay , Grant Marie , Hareendran Asha , Schuitz Ursula , Baird Tracey , Bone Ian , Muir Keith W
Published: July 2021

P227

Background & aims:
The Modified Rankin Scale (MRS) (van Swieten et al, 1988) is widely used in clinical trials to rate disability and handicap after stroke. Although the MRS is a popular measure of functional outcome the categories of the scale are very broadly defined and open to interpretation by raters. Previous work with the Glasgow Outcome Scale indicates that the reliability of functional rating scales may be improved by use of a structured interview (Wilson et al, 1998). The purpose of the present study was to compare the inter-rater reliability of the conventional MRS with the inter-rater reliability of a newly developed structured interview for the MRS (MRS-SI)
Methods:
A structured interview was devised for the MRS covering five areas of everyday function. 63 patients with stable functional state after stroke (stroke 6 to 24 months previously) were recruited to the study and scored on the conventional MRS by two independent observers. These observers then underwent training in use of the MRS-SI. Eight weeks after the first assessment the same observers reassessed 58 of these patients using the MRS-SI.
Results:
To allow comparison between the assessments the analysis of results was restricted to the 58 patients who were rated on both the MRS and MRS-SI. Inter-rater reliability was measured using the kappa statistic (unweighted and weighted using quadratic weights). For the MRS, overall agreement between the two raters was 57% (unweighted kappa 0.44, weighted kappa 0.78); using the MRS-SI, overall agreement was 78% (unweighted kappa 0.70, weighted kappa 0.93).
Conclusions:
Variability between raters in assigning patients to Rankin grades appears to be reduced when using a structured interview for the Modified Rankin Scale. The use of the MRS-SI could potentially improve the quality of results from clinical studies in stroke. A multi-centre study to further establish the improvement in inter-rater reliability is ongoing.
Moya-Moya Syndrome:
1) Risk of bleeding during medical therapy 2) Risk and benefit of Medical vs. Surgical therapy
Authors: Patel Lekhraj , Graybeal Dion , Johnson Mark , Greenlee Ralph , Diaz-Arrastia Ramon , Roach E. Steve , Unwin Hal
Published: July 2021

P238

Objective:
To determine the risk and benefit of medical vs. surgical treatment in Moya-Moya disease.
Background:
The optimal management of Moya-Moya disease is unknown. Many investigators favor surgical therapy on the belief that the risk of intracranial bleeding on medical therapy is high (appx.25%). This practice is based on retrospective review of small series.
Method:
We reviewed retrospectively charts of 30 patients, with Moya-Moya disease treated either medically or surgically in our institution from 1986 to 2000. Risk of hemorrhage and risk of recurrent stroke were analyzed in both groups using Fisher’s exact test.
Results:
20/30 patients received only medical therapy. Of these, 13 were treated with warfarin, and 15 with antiplatelet agents (8 received both warfarin and antiplatelet). 10/30 patients were treated surgically (either extracranial-intracranial bypass (ECIC), encephalodural synangiosis (EDS), or omental grafting). 7 of the surgical patients were also treated with either warfarin or antiplatelet agents. There was no hemorrhage in either the medical or surgical groups. Recurrent infarction or TIA risk was similar between the two groups. 6 medically treated patients had recurrent infarction, vs. 4 surgically treated patients (R.R 0.78, 95% C.I.0.45- 1.35, p=0.413).
Conclusion:
Our data does not support the belief that medical therapy (either anticoagulation or antiplatelet therapy) is associated with a high risk of intracranial hemorrhage. The risk of recurrent infarction was similar in the two groups, although our numbers are too small to detect a modest difference between the two therapeutic modalities. Given the rarity of Moya-Moya disease, a multi-institutional trial will be necessary to settle this important issue.
Abstract 118: Intravenous versus Intra-arterial Autologous Bone Marrow Mononuclear cells for Acute Ischemic Stroke
Authors: Yang Bing , Khoury Ramy El , Schaar Krystal , Xi Xiaopei , Savitz Sean.I
Published: July 2021

Background:
Bone marrow mononuclear cells (MNCs) are under investigation as an autologous cell-based therapy for acute ischemic stroke. Both intravenous (IV) and intra-arterial (IA) delivery of MNCs have been brought forward to clinical trials. However, the optimal route of administration for these cells is still unknown and debated. In the present study, we performed a direct comparison of IV vs IA administration of MNCs in a rodent stroke model.

Methods:
Long Evans adult male rats were subjected to middle cerebral artery occlusion (MCAo) for 90 minutes. At 24 hrs after stroke, animals were randomly assigned to either receive saline IV (N=5) or autologous bone marrow derived MNCs 30 million cells/kg via IV (N= 9) injection or an IA (N=8) administration of autologous MNCs 30 million cells/kg. IA infusion was performed over 5 minutes with an infusion pump. Contralateral forepaw use was evaluated by an investigator blinded to treatment groups up to 28 days after stroke. Stroke lesion volume was also measured at 28 days after stroke. Serum cytokines were analyzed from 4 to 28 days after stroke.

Results:
MNCs improved functional recovery and reduced lesion size compared with saline treatment at 28 days after stroke (
Fig
A &
Fig
B, p<0.05). However, there was no significant difference between IV and IA MNC treated groups in either histological or functional outcomes. Serum levels of IL-10 were elevated in animals that received either IV or IA MNCs from 4 to 28 days after stroke, compared with saline controls (Fig C, p<0.05). In addition, serum levels of TNF-α were significantly reduced (Fig D, p<0.05) in both IV and IA MNC treated groups compared to saline controls. We did not observe differences in cytokine levels between IA and IV MNC treated groups for IL-10 and TNF-α. Furthermore, only intravenously administered MNCs led to a significant reduction in serum IL-1β levels, at 4 days after stroke, compared to saline treated controls (p<0.05).

Conclusion:
This is the first study to directly compare delivery routes of bone marrow derived MNCs in a rodent stroke model and assess long term outcomes. MNCs improved neurological recovery and reduced infarction sizes after stroke but we found no differences in outcome based on route of administration. We also found no evidence that either delivery route is superior in modulating the systemic inflammatory response after stroke. These findings have direct clinical implications for the design of clinical trials testing MNCs in patients with ischemic stroke.
Abstract 122: Stroke Patterns And Causative Mechanisms Of Ischemia In Patients With Symptomatic Intracranial Atherosclerotic Stenosis
Authors: Lopez-Cancio Elena , Matheus Maria G , Romano Jose , Liebeskind David S , Prabhakaran Shyam , Lynn Michael J , Cotsonis George , Turan Tanya N , Chimowitz Marc I ,   WASID Study Group
Published: July 2021

Background/objectives:
Putative mechanisms of stroke in intracranial atherosclerotic stenosis (ICAS) include hypoperfusion, artery-to-artery embolism or perforator occlusion, each of which may be characterized by different stroke patterns on neuroimaging. Our aims are to determine: 1) the different stroke patterns in patients with ICAS; 2) the correlation of angiographic factors (collaterals, degree and location of stenosis) with stroke patterns; and 3) if the patterns of recurrent stroke in the same territory are similar to qualifying strokes.

Methods:
From the WASID dataset, we selected patients with a stroke at baseline who had conventional angiographic information on collaterals (n=136), and patients with a recurrent stroke in the territory during follow-up (n= 47). We categorized stroke patterns as follows: for anterior circulation-subcortical (SC), cortical (C), territorial (T), borderzone (BZ) and multiple (M); for posterior circulation,-subcortical (SC), cortical (C), cerebellar (CB) and multiple (M). We defined an embolic mechanism if C, T, CB or multiple were present. The association between stroke patterns and collateral grade assessment (ASITN/SIR), location and degree of stenosis, and treatment assignment (warfarin vs aspirin) was analyzed using Chi-Square and McNemar’s tests.

Results:
Anterior circulation patterns (n=72) at baseline were: 14(19%) SC, 5(7%) T, 2(29%) C, 12(17%) BZ and 20(28%) M. All isolated BZ stroke patterns were located in internal borderzone region. BZ pattern was equally distributed among patients with no collaterals (5/40=12%) vs. patients with collaterals (7/32=22%) (p= 0.29) and among patients with moderate (8/43=19%) vs. severe stenosis (4/29=14%) (p=0.59). Posterior circulation patterns (n= 64) at baseline were: 25(39%) SC, 5(8%) C, 10(16%) CB and 24(38%)M. Embolic stroke pattern at baseline was the most frequent (85/136=62.5%). Among patients with a recurrent stroke in the territory (n=47), embolic pattern was also the most frequent (32/47, 68%). The probability of having a recurrent embolic stroke pattern was related to stenosis degree (81% in severe vs 50% in moderate stenosis, p= 0.03), collateral grade (83% with collaterals vs 53% no collaterals, p= 0.09), and previous embolic stroke pattern (74 % who had baseline embolic stroke vs 25% who had baseline non-embolic stroke,p= 0.01). Having a recurrent embolic stroke pattern was not influenced by treatment assignment (67% treated with warfarin vs 69% treated with aspirin, p=0.85).

Conclusions:
Artery-to-artery embolism seems to be the most frequent mechanism of stroke in ICAS patients and was not modified by antithrombotic treatment. Isolated BZ infarcts were less frequent, and were not related to poor collaterals or more severe stenosis.
Abstract 127: Has DRG 559 Increased Administration of r-tPA In Medicare Beneficiaries With Acute Ischemic Stroke?
Authors: Pandey Dilip K , Nwaise Isaac , Bhaumik Dulal , Ruland Sean , Gorelick Philip B
Published: July 2021

IV r-tPA has been shown to be an efficacious and cost-effective treatment for acute ischemic stroke (AIS). Lack of adequate reimbursement for treatment of AIS with r-tPA from the CMS may be a barrier for r-tPA use among Medicare beneficiaries. In October 2005, CMS introduced DRG 559- increased reimbursement for iv r-tPA administration. We evaluated the impact of demograhic factors and DRG 559 on use of iv r-tPA for AIS among Medicare beneficiaries.

Methods:
CMS Medicare claims database from MEDPAR for 2004 and CCW for 2005-07 were accessed. AIS was defined by the presence of a primary diagnosis according to an ICD-9 codes 433 and 434 with a fifth-digit subclassification 1 indicating occlusion with infarction of precerebral and cerebral arteries from DRG 14 and 559. AIS patients receiving iv r-tPA were identified by presence of ICD-9 procedure codes 99.10 and receiving such procedure within one day of admission. r-tPA drip and ship cases were identified and included as r-tPA drip & ship cases in the receiving hospitals. Patients transferred for acute stroke care to another short term general/specialty hospital were excluded as were admissions to hospitals other than short term general/specialty or critical access hospitals and those admissions in the rehab units of the short term general/specialty hospitals. Impact of reimbursement on r-tPA use was assessed using piecewise regression methods in STATA 11.

Results:
From January 2004 to September 2007 a total of 742,368 AIS admissions were evaluated and estimated use of r-tPA by age, sex, race/ethnicity and geographical region is presented in the table. Trends in use of r-tPA are depicted in the
figure
. The estimated intercepts and slopes in the
figure
by pre- and post-DRG 559 and age group depicts the possible effect of increased reimbursement on r-tPA use in this population. A significant increase in r-tPA use with the introduction of DRG 559 in October 2005 (i.e. month = 9 onwards) was noticed by the significant jump (p-value < 0.01) in the intercepts.

Conclusion:
The results generally suggest the highest use of r-tPA among ages 65-75, men, white race and in the Northeast region.The increase in r-tPA use may be explained by the impact of policy change with introduction of higher reimbursement for r-tPA for AIS among Medicare beneficiaries.
Estimates of use of r-tPA by month and age group
Abstract 147: The Association Between Hematocrit and Mortality among Ischemic Stroke Patients
Authors: Sico Jason J , Myers Laura J , Ordin Dede , Williams Linda S , Bravata Dawn M
Published: July 2021

Introduction:
Anemia is associated with higher mortality among patients with such non-stroke vascular conditions as heart failure and myocardial infarction. Less is known regarding the relationship between anemia and mortality among patients with acute ischemic stroke.

Methods:
Medical records were abstracted for a sample of 3965 veterans from 131 Veterans Health Administration (VHA) facilities who were admitted for a confirmed diagnosis of ischemic stroke (fiscal year 2007). Hematocrit (Hct) values from 24-hours of admission were categorized into 6-tiers (≤27%, 28-32%, 33-37%, 38-42%, 43-47%, ≥48%). We excluded patients with: female gender (n=95), incomplete Hct data (n=94), thrombolysis (n=32), and inconsistent death dates (n=6). We used multivariate logistic regression to examine the relationship between anemia and in-hospital, 30-day, 60-day and one-year mortality using multivariate logistic regression models for each time point, adjusting for age, NIHSS, comorbidity (including pneumonia), and Acute Physiology and Chronic Health Evaluation (APACHE)-III scores. The discrimination (c-statistics) and calibration (Hosmer-Lemeshow goodness of fit [HLGOF]) statistics were generated to gauge model performance and fit.

Results:
Approximately 2.1% of the N=3750 patients presented with Hcts ≤27%, 6.2% were 28-32%, 17.9% were 33-37%, 36.4% were 38-42%, 28.2% were 43-47%, and 9.1% were ≥48%. Adjusted mortality odds at all time points were 2.5 to 3.5 times higher for those with ≤Hct 27% (p values < 0.013 for in-hospital and 30-day mortality; p values at 6 months and one year were 0.002 and 0.001, respectively). Mortality risk at 6 months and 1 year showed a significant and dose-response relationship to Hct for all Hct groups <38%. High Hcts were independently associated only with in-hospital mortality and only in those with Hct ≥48 (OR 2.9, p=0.004). Models performed well across time points (C=0.813, HLGOF=0.9684 [in-hospital]; C=0.832, HLGOF=0.8186 [30-day]; C=0.863, HLGOF=0.7307 [60-day]; C=0.880, HLGOF=0.4313 [one-year]).

Conclusions:
Even a moderate level of anemia is independently associated with an increased risk of death during the first year following acute ischemic stroke. Very low or very high Hct is associated with early post-stroke mortality. Further work is required to evaluate whether interventions that treat anemia, its complications and underlying etiologies may also reduce post-stroke mortality.
Abstract 157: No Need To Exclude Diabetics From Thrombolysis: Diabetic And Non-diabetic Stroke Patients Profit Equally Well. Report From The Austrian National Stroke Unit Registry
Authors: Brainin Michael , Matz Karl , Teuschl Yvonne , Reindl Beate , Seyfang Leonhard ,   for the Austrian Stroke Unit Registry Group
Published: July 2021

Background:
Diabetes has been known to be a predictor for poor outcome after thrombolysis in stroke patients, and early poststroke glycaemia is known to be associated with higher rates of postthrombolytic symptomatic intracerebral haemorrhages. Therefore, diabetic stroke patients are often excluded from thrombolytic treatment. Up to now comparisons exist only from clinical trials (e.g. VISTA collaboration) and registry data of thrombolysed paients (e.g. SITS registry). No nation-wide data have been investigated for the outcomes of thrombolysis in diabetics and non-diabetics.

Methods:
National database of the Austrian Stroke Unit Registry, 2003-2010 , comprising 34 acute stroke units, comparison of outcome data of thrombolysed and non-thrombolysed diabetic and non-diabetic stroke. Stratification according to sex, age, stroke severity, functional impairment before stroke and recurrent stroke to non-thrombolysed diabetic strokes and to non-diabetic thrombolysed and non-thrombolysed controls. Improvement was defined as the difference between stroke severity at admission and at discharge.

Results:
A modelled cohort of 1,988 r-tPA thrombolysed diabetic stroke patients from 13,246 ischaemic stroke patients were compared according to sex, age, stroke severity, and prestroke disability. A regression model with improvement as depending variable and age, sex, stroke severity, aetiology of stroke, risk factors (including diabetes) and treatment (including thrombolysis) found no effect of diabetes (p=0.854) or the interaction diabetes x thrombolysis (p=0.277), whereas the effect of thrombolysis itself was highly significant (p=0.0001). No differences were found in the number of symptomatic intracerebral haemorrhages after thrombolytic treatment between diabetic strokes (5.2%) and non-diabetic strokes (4.0%). Both groups had a higher risk of intracerebral haemorrhages compared to the non-thrombolysed groups (diabetic 2.9%, non-diabetic 2.6%).

Conclusion:
Data from this nation-wide survey show that diabetic stroke patients have a substantial benefit from thrombolysis and therefore diabetic strokes should not be excluded from thrombolysis treatment.
Abstract 158: Persisting Arterial Occlusion And Risk Of Symptomatic Intracranial Hemorrhage In Systemic Thrombolysis: A Pooled Analysis Of Randomized Sonothrombolysis Studies
Authors: Tsivgoulis Georgios , Barlinn Kristian , Saqqur Maher , Mikulik Robert , Demchuk Andrew M , Sharma Vijay K , Vadikolias Konstantinos , Heliopoulos Ioannis , Schellinger Peter D , Molina Carlos A , Alexandrov Andrei V
Published: July 2021

Background & Purpose:
Recent observational data showed that delayed (>6 hours) recanalization in acute ischemic stroke (AIS) patients treated with systemic thrombolysis may be associated with a higher risk of symptomatic intracranial hemorrhage (sICH). We sought to investigate the relationship of persisting occlusion during the first two hours of iv-tPA and the likelihood of sICH using pooled data from three randomized sonothrombolysis studies.

Subjects & Methods:
We evaluated the risk of sICH among AIS patients randomized in the Combined Lysis of Thrombus in Brain Ischemia (CLOTBUST), Transcranial Ultrasound in Clinical Sonothrombolysis (TUCSON) and a pilot randomized clinical safety study of sonothrombolysis augmentation with ultrasound-activated perflutren-lipid microspheres (Definity study). Acute proximal arterial occlusions were identified in all patients at baseline using Trancranial Doppler (TCD). Patients underwent continuous or intermitted TCD-monitoring for a two-hour period following tPA-bolus. Persisting occlusion was defined as absence of improvement of baseline TIBI flow grade at the end of TCD-monitoring. sICH was defined using ECASS-2 definition as imaging evidence of ICH with clinical worsening (NIHSS≥4) within 72 hours from stroke onset.

Results:
A total of 176 AIS patients (mean age 68±14years, 57% men, median baseline NIHSS-score 16 points, interquartile range 11-20) were randomized in CLOTBUST (n=126), DEFINITY (n=15) and TUCSON (n=35). A total of 75 (43%) and 101 (57%) individuals were randomized to systemic thrombolysis and sonothrombolysis respectively. Persisting occlusion was identified at the end of TCD-monitoring in 65 patients (37%). Patients with persisting occlusion tended to have higher sICH rates compared to individuals with partial or complete recanalization (9.2% vs. 2.7%; p=0.078 by Fisher’s exact test). After adjusting for demographic characteristics, onset-to-treatment time, baseline stroke severity, baseline TIBI flow grade and treatment (sonothrombolysis vs. systemic thrombolysis) persisting occlusion was independently associated with a higher likelihood of sICH (OR:6.29, 95%CI:1.28-30.85; p=0.024).

Conclusions:
Failure to recanalize during the first two hours following tPA-bolus appears to increase sICH risk among AIS treated with standard systemic thrombolysis and sonothrombolysis. Possible mechanisms (elevated blood pressure with persistent occlusion and late, potentially harmful recanalization causing reperfusion injury to infracted brain tissue) are now subject of a prospective multicenter study (CLOTBUST-PRO).
Abstract 168: Prevalence And Characterization Of Neuropsychological Deficits In Lacunar Stroke Patients. The Secondary Prevention Of Small Subcortical Strokes (sps3) Trial
Authors: Benavente Oscar , Pearce Lesly , Jacova Claudia , Hart Robert
Published: July 2021

Background:
Though the important role of lacunar stroke in cognitive impairment and dementia is widely recognized, to date no well-characterized pattern of neuropsychological (NP) impairment has been defined in this stroke subtype.

Methods:
SPS3 is a multi-center international randomized trial that included a well-defined cohort of MRI proven lacunar stroke patients. For the purpose of this analysis we consider NP testing data collected at study entry for all English speaking participants enrolled in North America. The hour-long NPT was administered by a certified examiner and covered a wide range of domains. Raw test scores were converted to standardized scores using normative data which were then entered into a principal component analysis to identify distinct cognitive domains measured. NP status was defined as Not Cognitively Impaired (NCI) and Mild Cognitive Impairment (MCI) if there was impairment in memory and/or non-memory domains.

Results:
Of the 3020 SPS3 participants, 1632 were included in these analyses. Most (85%) scored ≥95 on the Barthel Index. Performances (z-scores) on all NPT were lower than normal for age, and for education and gender. The largest deficits were seen on tests of episodic memory (mean -0.92 to -0.68), verbal fluency (mean -0.89), and motor dexterity (median -2.5). The magnitude of cognitive impairment increased with higher Rankin scores (p < 0.001). Principal component analysis revealed memory and two non-memory domains (perceptual-verbal processing speed, executive functioning). Based on these domains, NP status was 53% NCI, 17% amnestic MCI, 17% amnestic multidomain MCI, and 13% non-amnestic MCI.

Conclusion:
In this large and well-defined cohort of lacunar stroke patients, MCI was present in half of the cohort. The most significant impairments were found on tests of processing speed, motor dexterity, executive function, and episodic memory. Episodic memory appears a central feature in this cohort and should be assessed carefully in future clinical studies and trials directed at subcortical stroke populations. NP deficits appear to be more prevalent than functional deficits (Barthel) in survivors of lacunar stroke.
Abstract 169: Comparative Effectiveness of Surgical v. Medical Management of Carotid Stenosis in the Elderly: The Cardiovascular Health Study
Authors: Halm Ethan , Calvillo-King Linda , Xuan Lei , Zhang Song , Longstreth William T
Published: July 2021

Introduction:
In randomized clinical trials(RCTs), carotid endarterectomy(CEA) reduced risk of death and stroke(D&S)compared to medical therapy(MedRx) in carefully selected patients and surgeons. We hypothesized the benefits of CEA among the elderly in real world practice would be more limited than in RCTs because patients are older and sicker, have shorter life expectancy, and have less experienced surgeons.

Methods:
We conducted a comparative effectiveness study of CEA v MedRx for carotid stenosis in the elderly using data from the Cardiovascular Health Study(CHS), a multicenter, community-based, prospective observational cohort study of participants(Pts) randomly selected from Medicare lists. CHS Pts had intensive evaluation of vascular events, risk factors, & comorbidities. Carotid stenosis was measured via ultrasound(US) at baseline, 5 and 10 years. D&S were ascertained though annual contact and all events were adjudicated. CEA was identified via annual contact and Medicare data. We assessed risk of D&S using Cox proportional hazards regression and propensity scores(PS) to adjust for factors associated with selection for CEA and risk of D&S. We focused on 487 Pts with ≥50% carotid stenosis by US and no prior CEA.

Results:
Overall, 89 Pts had CEA, and 398 MedRx during a median 12.1 years of follow-up. Half were men and 91% white. At baseline, mean age was 73.4 years, 76% had hypertension (HTN), 37% diabetes, 28% coronary heart disease(CHD), 7% prior stroke, and 8% TIA. CEA Pts were older and had more HTN, heart failure, atrial fibrillation, prior stroke, TIA, or CHD and worse self-rated health(v MedRx,all p<.05). In unadjusted analyses, rate of D&S was higher for CEA v MedRx at all time points: 30 days(7.8% v 0.2%), 5 years(39% v 27%), and 10 years(60% v 48%; Hazard Ratio(HR)=1.8; 95%CI: 1.3-2.3). The HR for CEA was unchanged(HR=1.8;CI: 1.2-2.6) with adjustment for PS, neurologic symptoms,and 13 other time varying covariates. Analyses assessing impact of CEA v MedRx on the adjusted, long term hazard of stroke alone also found worse outcomes for CEA(p<.05).

Conclusions:
Elderly CHS Pts with carotid stenosis managed with CEA (v MedRx) had higher long term adjusted risk of D&S and stroke alone. The benefits of CEA shown in younger, healthier patients in RCTs did not extend to the older, sicker CHS Pts, likely better reflecting the impact of CEA in real world practice. CEA in the elderly may result in worse outcomes compared to MedRx.
Abstract 179: Brain Avm Embolization With Onyx: Clinical And Anatomical Results In A Prospective, Multicenter, European Study (BRAVO)
Authors: Pierot Laurent ,   BRAVO investigators
Published: July 2021

Purpose:
The treatment of brain arteriovenous malformations (AVMs) is challenging based on a multidisciplinary approach involving neurosurgery, radiosurgery, and interventional neuroradiology. The embolization of brain AVMS was for a long time performed using particles and glue. Onyx has been recently introduced in the armamentarium for AVM embolization, but large, multicenter evaluation is lacking. BRAVO study was conducted to evaluate the clinical and anatomical results of brain AVM embolization with Onyx.

Materials and Methods:
BRAVO (Brain ArterioVenous malformations embolization with Onyx) was a multicentric, prospective, consecutive study conducted in 11 neurointerventional centers in Europe. 117 patients harbouring brain AVMs embolized with Onyx were included. Clinical presentation was mostly hemorrhage (30.8%) and epilepsy (27.4%). AVM size was less than 3cm in 52.1% of cases and more than 3cm in 47.9% of cases. A mean number of 2.05 embolization sessions / patient were performed with injection of a mean of 2.4 ml Onyx / session.

Results:
Complete occlusion was obtained with Onyx embolization alone in a high percentage of cases (23.5% of all cases and 36.7% of AVM smaller than 3cm). Intra and post-operative bleeding related to the treatment was observed in 9.4% leading to death in 3.4% and neurologic worsening in 1.7%. Non-hemorrhagic permanent deficits were observed in 6.0% of cases. Treatment related morbidity (mRS>2) and mortality were respectively 5.1% and 4.3%.

Conclusion:
Embolization of brain AVMs with Onyx is associated with a high rate of complete occlusion with acceptable morbidity and mortality. Onyx has to be used as the first line embolization agent for the treatment of brain AVMs.
Abstract 183: Depressive Symptoms and Incident Stroke in Black and White Participants in the REGARDS Study
Authors: Austin Audrey L , Crowe Michael G , Crowther Martha R , Howard Virginia J , Letter Abraham J , Pulley LeaVonne , Scogin Forrest R , Unverzagt Frederick W , Vinson Latrice D , Wadley Virginia G
Published: July 2021

Background and Purpose:
Research suggests that depression may contribute to stroke risk independent of other known risk factors. Most studies examining the impact of depression on stroke have been conducted with predominantly white cohorts, though blacks are known to have higher stroke incidence than whites. The purpose of this study was to examine depressive symptoms as a risk factor for incident stroke in blacks and whites, and determine whether depressive symptomatology was differentially predictive of stroke among blacks and whites.

Methods:
The REasons for Geographic and Racial Differences in Stroke (REGARDS), is a national, population-based longitudinal study designed to examine risk factors associated with black-white and regional disparities in stroke incidence. Among 30,239 participants (42% black) accrued from 2003-2007, excluding those lacking follow-up or data on depressive symptoms, 27,557 were stroke-free at baseline. As of the January 2011 data closure, over an average follow-up of 4.6 years, 548 incident stroke cases were verified by study physicians based on medical records review. The association between baseline depressive symptoms (assessed via the Center for Epidemiological Studies Depression scale, 4-item version) and incident stroke was analyzed with Cox proportional hazards models adjusted for demographic factors (age, race, and sex), stroke risk factors (hypertension, diabetes, smoking, atrial fibrillation, and history of heart disease), and social factors (education, income, and social network).

Results:
For the total sample, depressive symptoms were predictive of incident stroke. The association between depressive symptoms and stroke did not differ significantly based on race (Wald
X
2
= 2.38, p = .1229). However, race-stratified analyses indicated that the association between depressive symptoms and stroke was stronger among whites and non-significant among blacks.

Conclusions:
Depressive symptoms were an independent risk factor for incident stroke among a national sample of blacks and whites. These findings suggest that assessment of depressive symptoms may warrant inclusion in stroke risk scales. The potential for a stronger association in whites than blacks requires further study.
Abstract 185: Declining Subarachnoid Hemorrhage Case-Fatality Rates in a Population
Authors: Mackey Jason , Alwell Kathleen , Khoury Jane C , Moomaw Charles J , Flaherty Matthew L , Zuccarello Mario , Adeoye Opeolu , Woo Daniel , Khatri Pooja , Ferioli Simona , Kissela Brett M , Broderick Joseph P , Kleindorfer Dawn
Published: July 2021

Introduction:
In the last few decades there have been several medical advances in the care of patients with subarachnoid hemorrhage (SAH). But few population-based studies (and none in the United States) have examined outcomes in the same population over time.

Methods:
All SAHs among residents of the Greater Cincinnati/Northern Kentucky (GCNK) region at least 20 years of age were identified using ICD-9 codes 430-436 and verified via study physician review in four distinct study periods. An incidence rate for each time period was calculated. Baseline characteristics, including demographics, risk factors, and functional status, were ascertained, along with hospital discharge modified Rankin score and all-cause 30- and 90-day case-fatality.

Results:
We identified 78 SAHs among residents of the GCNK region in 1988, 85 from 7/1993 to 6/1994, 95 in 1999, and 91 in 2005. The incidence of SAH in the four study periods (age-, race-, and sex-adjusted to the 2000 US population) was 9.4, 9.3, 10.0, and 9.0 per 100,000, respectively. Of the 349 SAHs in the study periods, 326 were diagnosed in an ED or hospital setting, while 23 were diagnosed on autopsy alone. All-cause 30- and 90-day case-fatality rates declined significantly from 1988 to 2005 (
Table
), even when all autopsy-alone cases were excluded.

Conclusions:
While the incidence of SAH remained stable in this population-based region, the 30-day and 90-day case-fatality rates declined significantly. Advances in surgical and medical management, along with systems-based changes such as the emergence of neurocritical care units, have likely led to reduced case-fatality. Future studies should explore the impact of specific factors related to improved case-fatality rates.