bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP81: Regional, Race-Ethnic and Sex Disparities in Lifestyle Interventions: Data from the Florida Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study - the NINDS Stroke Prevention Intervention Research Program
Authors: Ciliberti-Vargas Maria A , Wang Kefeng , Oluwole Sofia , Marulanda-Londoño Erika , Ayodele Maranatha , Dong Chuanhui , Gutierrez Carolina M , Burgin W. S , Foster Dianne , Garcia-Rivera Enid J , Gonzalez- Sanchez Juan , Robichaux Mary , Waddy Salina P , Zevallos Juan C , Romano Jose G , Rundek Tatjana , Sacco Ralph L , Koch Sebastian ,   for the FL-PR CReSD Investigators and Collaborators
Published: June 2021

Background:
As key components of the AHA Life’s Simple 7 campaign, lifestyle modifications play an integral role in the prevention of vascular disease. Little is known about the prevalence of lifestyle modification counseling in patients with acute ischemic stroke (AIS). We sought to investigate disparities in the delivery of lifestyle interventions to AIS patients in the large NINDS-funded FL-PR CReSD Registry of Get With The Guidelines-Stroke (GWTG-S) data.

Methods:
GWTG-S collects data on the provision of several lifestyle interventions including counseling on exercise/weight loss, Therapeutic Lifestyle Changes (TLC) diet, diabetes (DM) education and antihypertensive (low sodium) diet. 80,598 AIS cases were prospectively included from 82 sites (69 FL; 13 PR) from 2010-2016. Multilevel logistic regression models adjusted for age, race, and aphasia were used to evaluate differences in the provision of lifestyle interventions as indicated for patients prior to hospital discharge.

Results:
Among AIS cases, 51% were men, 62% non-Hispanic White (NHW), 18% NH-Black (NHB), 13% FL-Hispanic (FLH), and 6% PR-Hispanic (PRH). Mean age was 71±14 years. The highest mean BMI was in PRH (29±7 kg/m
2
), with the lowest in NHW (27±6 kg/m
2
) and FLH (28±6 kg/m
2
). Despite this, PRH were less likely to receive exercise/weight loss counseling compared to NHW (OR 0.43, 95% CI 0.20-0.90) and FLH (OR 0.46, 95% CI 0.22-0.97). PRH also had lower odds of receiving TLC diet counseling compared to NHW and FLH (OR 0.32, 95% CI 0.15-0.68). Though NHB presented with higher rates of DM compared to NHW (38% vs. 25%), they were less likely to receive DM education (OR 0.95, 95% CI 0.91-0.99). Women were less likely to receive TLC diet counseling (OR 0.94, 95% CI 0.90-0.98) and DM education (OR 0.94, CI 0.92-0.97) compared to men. Despite higher HTN frequency in women and NHB (67% and 69%), both were less likely to receive low sodium diet recommendations as compared to men (OR 0.94, 95% CI 0.92-0.97) and NHW (OR 0.95, 95% CI 0.91-0.99).

Conclusion:
Overall, disparities were identified in the provision of several lifestyle interventions in AIS patients. These interventions can benefit all and providers should continue counseling patients regarding modifiable risk factors to prevent future stroke.
Abstract TP112: Mechanism of Recurrent Stroke in Patients with Atherosclerotic Vertebrobasilar Disease in Relation to Hemodynamics
Authors: Schaafsma Joanna D , Silver Frank L , Kasner Scott E , Caplan Louis R , Rose-Finnell Linda , Pandey Dilip K , Charbel Fady T , Amin-Hanjani Sepideh ,   For the VERiTAS Study Group
Published: June 2021

Objectives:
Patients with symptomatic atherosclerotic vertebrobasilar disease are at high risk for recurrent stroke and we have demonstrated that distal flow status is independently associated with this risk. Our aim was to assess the mechanism of recurrent strokes in these patients related to their distal flow status.

Methods:
Patients with symptomatic atherosclerotic vertebrobasilar disease were enrolled in a prospective longitudinal cohort study (VERiTAS) with a median follow-up of 23 months. Large-vessel flow in the posterior circulation distal to the stenosis and/or occlusion was measured on quantitative MR angiography and dichotomized into normal or low flow. Three observers, who were blinded to the distal flow status, independently reviewed the imaging done at the time of the recurrent stroke to classify the most likely stroke mechanism.

Results:
Ten out of 72 enrolled patients had a recurrent stroke in the posterior circulation. Four patients were determined to have embolic infarcts, four patients had infarcts caused by plaques that occluded a branch or perforating artery (junctional plaques), and two patients had imaging that suggested hemodynamic infarction.

Five of the ten patients with recurrent strokes had low distal flow. Of these, two patients had hemodynamic infarcts, one patient had an embolic infarct, and two patients had a junctional plaque.

None of the five patients with normal flow had hemodynamic infarcts, three patients had embolic infarcts, and two patients had a junctional plaque.

Conclusion:
Despite the small numbers, there seems to be a higher risk of hemodynamic infarction in patients with low flow distal to symptomatic vertebrobasilar disease than in the presence of normal distal flow. This would confirm the hypothesis that in addition to embolic strokes and those related to junctional plaque, patients with low distal flow are at risk for hemodynamic infarction. Further studies are required to determine whether flow measurements could be used to select patients who may benefit from endovascular treatment of atherosclerotic vertebrobasilar disease.
Abstract TP128: Prognosis and Stratification of High-risk Patients with Mild (<50%), but Unstable Stenosis of Internal Carotid Artery - Multi-center Observational Study in Japan
Authors: Kuroda Satoshi , Ogasawara Kuniaki , Uno Masaaki ,   MUSIC Study Investigators
Published: June 2021

Background and Purpose:
Previous clinical trials have shown that clinical benefits of carotid endarterectomy (CEA) are unclear in symptomatic mild (<50%) stenosis of the internal carotid artery. However, it is not rare that the patients with mild carotid stenosis repeat TIA or ischemic stroke in spite of the best medical treatments. Although only the degree of stenosis have been accepted as “gold standard” in deciding treatment strategy, recent development of non-invasive MR imaging enables us to identify unstable plaque. Therefore, we have designed “
M
ild, but
U
nstable
S
tenosis of
I
nternal
C
arotid artery (MUSIC) Study” in Japan. The objectives of this nation-wide, multicenter prospective study are to clarify the prognosis of patients with symptomatic mild carotid stenosis and identify the predictors for the patients at higher risk for recurrent TIA and ischemic stroke in spite of the best medical treatments. Impact of CEA is also evaluated in those refractory to the best medical treatments.

Methods and Results:
MUSIC Study is conducted in Japan, using a multi-center prospective observational design (UMIN000023635). The MUSIC Study Group is composed of 28 hospitals. This study will register totally 250 patients who are 20 years or older, experience TIA, ischemic stroke, or retinal ischemia in the ipsilateral carotid territory, have mild (<50%) stenosis in the ipsilateral cervical carotid artery, and are independent in daily life (modified Rankin scale=0-2). Using MRI, plaque components are precisely evaluated in all patients. After informed consent is obtained, their clinical and radiological data are registered. They are followed up for two years and MRI/MRA examinations are repeated at 6, 12, and 24 months after the enrollment. Primary endpoint includes the incidence of ischemic stroke in the ipsilateral carotid territory. Secondary endpoints include the incidence of all-ischemic stroke, ipsilateral or all TIA, ipsilateral or all retina ischemia, all stroke, all death, de novo silent cerebral infarct, and progression of carotid stenosis.

Conclusion:
In this conference, we emphasize the importance to identify the patients at higher risk for recurrent ischemic events due to symptomatic mild carotid stenosis in spite of the best medical treatments.
Abstract TP142: Cerebellar Transcranial Direct Stimulation to Augment Aphasia Therapy
Authors: Sebastian Rajani , Tippett Donna , Celnik Pablo , Hillis Argye E
Published: June 2021

Introduction:
Previous studies indicate that anodal transcranial Direct Current Stimulation (A-tDCS) to left hemisphere or cathodal tDCS (C-tDCS) to right hemisphere might augment aphasia therapy to facilitate language recovery after chronic stroke and that cerebellar tDCS can augment verbal fluency and learning in healthy controls.

Hypothesis:
A-tDCS or C-tDCS) plus naming therapy results in improved naming performance for trained and untrained items from baseline to post-treatment compared to sham plus naming therapy in chronic aphasia.

Methods:
Six patients with large, chronic left middle cerebral artery (MCA) ischemic stroke and one patient with large bilateral MCA strokes participated in a randomized, double-blind, sham controlled, within-subject crossover trial (15 sessions of sham + naming therapy and 15 sessions of tDCS + naming therapy, in random order, separated by 2 months). 4 patients were randomly assigned to A-tDCS and 3 patients were assigned to C-tDCS. We used 2 mA for stimulation over right cerebellum for the first 20 minutes of computer-delivered naming therapy. Within-subjects within-treatments analysis using McNemar’s test for correlated responses to evaluate gains from each of the treatment conditions. An alpha level of p<0.05 was considered significant.

Results:
tDCS + naming treatment produced significant gains in naming of both trained and untrained items in 3/4 patients with anodal stimulation and 3/3 patients with cathodal treatment. Sham + naming treatment produced gains for only trained items, and only in 4/7 participants.

Discussion:
A-tDCS or C-tDCS improved generalization of improvements to untrained stimuli after naming therapy for most patients. Results indicate potential usefulness of right cerebellar tDCS to augment naming therapy after chronic post stroke aphasia with large left or bilateral lesions.
Abstract TP2: Disparities in Delivery of Endovascular Therapy: Who Gets it and Where? The Florida Puerto Rico Collaboration to Reduce Stroke Disparities Study
Authors: Asdaghi Negar , Granzoti Cintra Lais , Wang Kefeng , Ciliberti-Vargas Maria A , Koch Sebastian , Gardener Hannah , Dong Chuanhui , Marulanda-Londono Erika , Rose David Z , Waddy Salina P , Mueller-Kronast Nils , Robichaux Mary , Foster Dianne , Garcia Enid J , Rundek Tatjana , Sacco Ralph L , Romano Jose G ,   for the FL-PR CReSD Investigators and Collaborators
Published: June 2021

Background and Purpose:
Endovascular thrombectomy improves functional outcome in select ischemic stroke patients. In the NINDS-funded CReSD Registry we sought to determine the clinical, hospital and regional characteristics associated with use of this therapy in patients presenting with acute ischemic stroke.

Methods:
Ischemic stroke patients within 24 hours of onset were prospectively included from 82 sites in Florida and Puerto Rico from January 2010 to April 2016. Independent predictors of endovascular therapy were evaluated using multivariable logistic regression with generalized estimating equations.

Results:
Among 58,204 patients with acute ischemic stroke (50% male, 65% white, 15% black, 20% Hispanic, mean age±SD 71±14 yrs), 2105 (3.6%) received endovascular thrombectomy (50.9% men, 62.3% white, 13.7% black, 24% Hispanic, mean age±SD 70±15yrs) with (35.2%) or without intravenous thrombolysis. Patients who received endovascular therapy had a significantly lower risk of vascular risk factors except for Afib (33.7% vs 19.0%), more severe strokes (median NIHSS 15 vs. 5) and were more likely to arrive quickly (126 min vs. 210 min), via EMS (70.4% vs. 59.6%) or as a transfer from another hospital (20.8% vs 5.8%,) during working hours (47.7% vs. 45.6%), to large hospitals (≥ 680 beds) (48.3% vs 28.8%), and treated in South Florida (47.3% vs. 35.9%) as compared to those not receiving this treatment. In multivariable analysis; age (OR 0.97, 95% CI 0.96- 0.98), Blacks (OR 0.68, 95% CI 0.56-2.28) vs. White, off-hour presentation (OR 0.76, 95% CI 0.66- 0.96), to regions other than South Florida (North OR 0.40, 95% CI 0.17-0.93, Panhandle OR 0.12, 95% CI 0.04-0.36) remained independently associated with lower use of endovascular therapy. In contrast, Hispanics (OR 1.28, 95% CI 1.03- 1.69) vs. White and presenting to large hospital (OR 4.92, 95% CI 1.05- to 22.6) were associated with higher use of endovascular treatment.

Conclusions:
There are significant race, regional and hospital disparities in delivery of endovascular care. Efforts should me made to improve access to endovascular treatment in patients presenting across the region to all stroke centers.
Abstract TP230: Prehospital Timeline of Mobile Stroke Treatment Unit and Traditional Ambulance
Authors: Mathew Jason , Buletko Andrew Blake , Taqui Ather , Reimer Andrew , Winners Stacey , Thacker Tapan , Rasmussen Peter , Hussain Muhammad S , Russman Andrew , Wisco Dolora , Uchino Ken ,   on behalf of the Cleveland Prehosptial Acute Stroke Treatment (PHAST) Group
Published: June 2021

Introduction:
Prehospital evaluation and response is vital to effective and early delivery of acute stroke treatment. We aimed to compare the times across various prehospital times among stroke patients arriving by municipal EMS and MSTU.

Methods:
We performed a retrospective study of 107 patients with a final diagnosis of ischemic stroke within our hospital system from June 2014 to July 2015. We compared on scene arrival, hospital arrival, and time of physician assessment of patients evaluated on MSTU to traditional municipal EMS. Times are reported as medians and groups were compared by Rank-Sum Test.

Results:
Of 107 patients, 49 patients were evaluated by traditional EMS and 58 evaluated by MSTU. Time from dispatch to scene arrival was median 9 min (IQR 5.5 - 12min) in EMS group and median 12 min (IQR 8-16 min) n MSTU (p<0.01). Time on scene was 17 min (IQR 14 - 24min) in EMS group and median 42 min (IQR 36-48 min) in MSTU. There was no difference within the MSTU group in time on-scene among those treated with IV tpA (43 min) and those without (41 min, p=.08 ). After dispatch, patients arrived in hospital by EMS earlier (median 40 min, IQR 33-49min) than by MSTU (median 72 min, IQR 58-81min, p<.01), but patients on MSTU were evaluated by a physician at median 28 (IQR 21.5-34.5) min after dispatch.

Conclusion:
Early evaluation of ischemic stroke patients with MSTU, doubles the time on scene compared to municipal EMS.
Abstract TP234: The Effect of Early Treatment with Magnesium on Blood Pressure Variability in Hyperacute Stroke
Authors: Kim Joseph , Saver Jeffrey L , Liebeskind David S , Starkman Sidney , Hamilton Scott , Chung Pil-Wook , Sanossian Nerses ,   FAST-MAG Trial Investigators
Published: June 2021

Background:
Increased blood pressure (BP) variability has been associated with worse outcomes in acute stroke. Magnesium has been shown to have both vasoactive and cardio-active properties that could potentially attenuate blood pressure variability emergently.

Objective:
To investigate whether intravenous magnesium sulfate can minimize blood pressure variability in hyperacute stroke.

Methods:
All patients with a diagnosis of stroke (cerebral ischemia, intracerebral hemorrhage) enrolled in the NIH Field Administration of Stroke Therapy-Magnesium (FAST-MAG) phase 3 trial were included. FAST-MAG was a multicenter, randomized, double-blind, placebo-controlled study looking at whether initiation of magnesium sulfate (20 grams/24 hours) in the prehospital setting of acute stroke would reduce disability. Study agent was initiated prior to hospital arrival < 2 hours from symptom onset. Blood pressure variability was defined as the standard deviation (SD) of systolic blood pressure of all readings obtained by 4 hours after initiation of study agent. BP variability was compared using t-test of the bootstrapped SD between groups.

Results:
In total, 1,700 patients were included in the study with a median of 6 (IQR 5-6) BP readings, of which 1,245 had cerebral ischemia (CI), 387 had intracerebral hemorrhage (ICH), and 68 had stroke mimics. Of those with CI, 632 received magnesium and 613 placebo; the standard deviation of systolic blood pressure was not significantly different between those who received magnesium and those who did not (14.9mmHg vs. 15.3mmHg, p=0.315). In the ICH population (195 magnesium, 192 placebo), magnesium treatment also did not affect BP variability (22.5mmHg vs. 21.1mmHg, p=0.197). For the overall study group, hyperacute magnesium treatment had no effect on blood pressure variability (16.7mmHg vs. 16.6mmHg, p=.907).

Conclusion:
Treatment with magnesium did not reduce BP variability in hyperacute stroke.
Abstract TP235: Deterioration and Improvement in the Field: Comparative Detection by Los Angeles Motor Scale and Glasgow Coma Scale in Acute, EMS-transported Stroke Patients
Authors: Tipirneni Anita , Shkirkova Kristina , Sanossian Nerses , Starkman Sidney , Hamilton Scott , Liebeskind David , Stratton Samuel , Pratt Franklin , Sharma Latisha , Restrepo Lucas , Kim-Tenser May , Valdes-Sueiras Miguel , Conwit Robin , Saver Jeffrey ,   The FAST-MAG Investigators
Published: June 2021

Background:
Stroke evolution after hospital arrival is well characterized for acute cerebral ischemia and intracranial hemorrhage. But with the advent of patient routing to designated stroke centers, and of prehospital stroke therapeutic trials, it is important to characterize stroke evolution in the earliest, prehospital moments of onset. Initial studies have prehospital evolution using serial Glasgow Coma Scale (GCS) assessment; however, GCS assesses level of consciousness rather than focal deficits.

Methods:
In the NIH FAST-MAG trial database, we analyzed patient deficit evolution from time of first paramedic assessment to early post-arrival assessment in the ED, using serial scores on the GCS, serial scores on the Los Angeles Motor Scale (LAMS) (a prehospital stroke deficit measure), and the Paramedic Global Impression of Change (PGIC) score, a 5 point Likert paramedic-clinician score.

Results:
Among 1632 acute, EMS-transported neurovascular disease patients, 1,245 (76.3%) had a final diagnosis of acute cerebral ischemia and 387 (23.7%) of acute intracranial hemorrhage. Time of paramedic initial assessment was median 23 mins (IQR 14-41) after onset and time of early ED assessment 58 mins (IQR 46-78). Considering score changes by 2 or more as salient, overall the LAMS and GCS indicated approximately equal frequencies of prehospital deterioration (LAMS 11.1%, GCS 12.0%), but the LAMS indicated higher frequencies of prehospital improvement (LAMS 24.5% vs GCS 5.7%, p<0.001), due to the ceiling constraint of the GCS. The LAMS correlated more strongly than the GCS with the paramedic global impression of change among all patients, r=0.31 vs 0.19, and especially in acute cerebral ischemia patients, r=0.27 vs 0.08). The prehospital course differed by stroke subtype on the LAMS: acute cerebral ischemia: improved 30.7%, worsened 7.1%, stable 62.25%; intracranial hemorrhage: improved 4.5%, worsened 24.2%, stable 71.3%.

Conclusions:
Focal deficit scales are superior to the GCS in characterizing prehospital stroke evolution. Change in neurologic status occurs in more than one-third of acute stroke patients during transport and the early ED, with improvement more common in acute cerebral ischemia and deterioration more common in ICH.
Abstract TP276: Perlecan Is Required for the Maintenance of the Blood-Brain Barrier through the Interaction with Pericytes in a Mouse Ischemic Stroke Model
Authors: Nakamura Kuniyuki , Ikeuchi Tomoko , Zhang Peipei , Rhodes Craig , Chiba Yuta , Ago Tetsuro , Mukouyama Yoh-suke , Yamada Yoshihiko
Published: June 2021

Introduction:
The disruption of the blood-brain barrier (BBB) is a contributing factor for the deterioration of brain damages in ischemic stroke. Recent studies revealed that microvascular pericytes are involved in the maintenance of the BBB and in the repair process through platelet-derived growth factor receptor β (PDGFRβ), the expression of which is increased around the ischemic lesion. Here we focus on perlecan, the major heparan sulfate proteoglycan in the basement membrane (BM). It is expressed by endothelial cells in the brain and is implicated in many biological functions. In this report, we have studied the role of Perlecan in the BBB breakdown and in the subsequent repair process after ischemic stroke in a mouse model. We hypothesized that perlecan may play a protective role in the disruption of BBB through the interaction with pericytes after ischemic stroke.

Methods:
To elucidate the role of perlecan in the brain vasculature, we induced a 60-minute transient middle cerebral artery occlusion (MCAO) in adult conditional
perlecan
-deficient (

Perlecan
-/-

-Tg) mice, which express the perlecan transgene only in the cartilage to rescue the perinatal lethality of
perlecan
-deficient mice.

Results:
Although the BBB formation and function in the brain vasculature appeared to be unaffected in

Perlecan
-/-

-Tg mice under healthy condition,

Perlecan
-/-

-Tg mice demonstrated larger infarct volumes and more BBB leakage than control mice on post-surgery day (PSD) 2 after MCAO.

Perlecan
-/-

-Tg mice exhibited less PDGFRβ-positive pericytes around the ischemic lesion on PSD 3 to 7 than control mice, suggesting that the perlecan deficiency suppressed pericyte activation. At a mechanistic level, integrin α5, a potential receptor for perlecan, was detectable in both endothelial cells and pericytes in the ischemic lesion, suggesting that endothelial cell-derived perlecan may regulate pericyte activation in response to ischemia through integrin α5.

Conclusions:
Our results suggest that perlecan is required for the activation of pericytes and thereby, contributing to the endothelial cell-pericyte integrity in the BBB maintenance after ischemic stroke.
Abstract TP308: Transitional Care in Stroke Certified and Non-certified Hospitals: The Comprehensive Post-Acute Stroke Services (COMPASS) Study
Authors: Prvu Bettger Janet , Jones Sara , Kucharska-Newton Anna , Freburger Janet , Ambrosius Walter , Sissine Mysha , Rosamond Wayne , Bushnell Cheryl , Duncan Pamela ,   for the COMPASS Investigative Team
Published: June 2021

Background:
Greater than 50% of stroke patients are discharged home from the hospital, most with continuing care needs. In the absence of evidence-based transitional care interventions for stroke patients, procedures likely vary by hospital even among stroke-certified hospitals with requirements for transitional care protocols. We examined the standard of transitional care among NC hospitals enrolled in the COMPASS study comparing stroke-certified and non-certified hospitals.

Methods:
Hospitals completed an online, self-administered, web-based questionnaire to assess usual care related to hospitals’ transitional care strategy, stroke program structural components, discharge planning processes, and post-discharge patient management and follow-up. Response frequencies were compared between stroke certified versus non-certified hospitals using chi-squared statistics and Fisher’s exact test.

Results:
As of July 2016, the first 27 hospitals enrolled (of 40 expected) completed the survey (67% certified as a primary or comprehensive stroke center). On average, 54% of stroke patients were discharged home. Processes supporting hospital-to-home care transitions, such as timely follow-up calls and follow-up with neurology, were infrequent and overall less common for non-certified hospitals (Table). Assessment of post-discharge outcomes was particularly infrequent among non-certified sites (11%) compared with certified sites (56%). Uptake of transitional care management billing codes and quality metrics was low for both certified and non-certified hospitals.

Conclusion:
Significant variation exists in the infrastructure and processes supporting care transitions for stroke patients among COMPASS hospitals in NC. COMPASS as a pragmatic cluster-randomized trial will compare outcomes among hospitals that implement a CMS-directed model of transitional care with those hospitals that provide highly variable transitional care services.
Abstract WMP113: Headache At Stroke Onset Is Present In Half Of All Older Children With Arterial Ischemic Stroke
Authors: Billinghurst Lori L , Kirton Adam , Pavlakis Steven , Lee Jo Ellen , Titomanlio Luigi , Fryer Robert , Kirkham Fenella , Jastrzab Laura E , deVeber Gabrielle , Dowling Micheal M , Mineyko Aleksandra ,   International Pediatric Stroke Study (IPSS) Investigators
Published: June 2021

Introduction:
Headache at stroke onset occurs in up to a quarter of adults and is associated with younger age, female gender, right hemisphere and cerebellar infarcts. Little is known about headache at stroke onset in children.

Methods:
Children (29 days-18 years) with clinical and radiographic confirmation of arterial ischemic stroke were prospectively enrolled in the International Pediatric Stroke Study from 2003-2014. Details regarding demographics, stroke presentation and infarct location were obtained from the multi-center, pediatric stroke registry. Headache at stroke presentation was classified and annotated in the registry by the individual site investigators as present, absent or unclear.

Results:
We analyzed 2103 children. Half of all subjects ≥ 6 yo reported headache at stroke onset (N=509/1047, 49%; Figure). Headache was less prevalent in children < 6 yo (N=112/1056, 11%; p<0.001), though headache presentation was more commonly classified as unclear (10% vs 32%; p<0.001). In children ≥ 6 yo, headache was significantly associated with papilledema (p = 0.03) and vertigo (p = 0.01), but not with hemiparesis (p = 0.11), visual field deficit (p = 0.90), aphasia (p = 0.35), dysarthria (p = 0.44), or ataxia (p = 0.50). Headache was more common in posterior than anterior circulation infarcts (p<0.001). There was a significant association between headache and right or bilateral hemisphere infarcts (p = 0.04) but not with gender (p = 0.76).

Conclusion:
Headache is more prevalent in children than adults at stroke ictus and shares similar associations, including infarcts involving the posterior circulation and right hemisphere. Headache may be under-reported in young infants and children due to pre-verbal stages of development. These findings have implications for early identification and treatment of pediatric stroke and warrant further investigation in prospective studies to distinguish stroke from more common benign mimics, including migraine.
Abstract WMP99: Hematoma Retraction in Spontaneous Intracerebral Hemorrhage: Frequency, Functional Significance and Relation to Perihematomal Edema
Authors: Ziai Wendy , Anderson Craig , Parry-Jones Adrian , Hurford Robert , Yenokyan Gayane , Murthy Santosh , Mcbee Nichol , Dlugash Rachel , Awad Issam , Hanley Daniel F ,   the VISTA Collaboration
Published: June 2021

Background:
The natural history of spontaneous intracerebral hematomas (ICH) is for variable degree of early hematoma retraction (HR), which may determine perihematomal brain edema (PHE), but such inter-relationships have not been rigorously studied.

Methods:
A pooled analysis of 760 computed tomography (CT) scans within 24±12 hours and 1197 CT scans within 72±12 hours of diagnostic CT (0-6 hours from symptom onset), from non-surgical ICH patients included in the Virtual International Stroke Trials Archive (VISTA), and INTERACT I, CLEAR III and MISTIE II clinical trials. Multivariable logistic regression was used to assess independent associations of HR and good 90-day functional outcome (modified Rankin scale [mRS] <3).

Results:
Median (IQR) diagnostic ICH volume was 11.4 (6.1-22.8) mL. HR occurred at defined thresholds in 5.8% (3mL), 2.4% (6mL) and 2.8% (33%), and in 10.3%, 4.0% and 4.6%, at 24 and 72 hours, respectively. Median retraction volumes at 24/72 hours were -0.9[-2.2, -0.3] and -1.2[-2.9, -0.5) mL, respectively. Between 13.2% and 24% of patients met common hematoma expansion definitions. Clot retraction volume at 24/72 hours was significantly correlated with diagnostic ICH volume (Spearman’s rho: -0.65/-0.64; p<0.001), ICH score, baseline NIHSS and higher baseline serum glucose, but inversely correlated with 24/72 hour PHE volume after adjustment for ICH volume (p=0.02; p=0.006, respectively). There was a negative correlation between clot retraction and good outcome; after adjustment for age, admission Glasgow coma scale (GCS), ICH and IVH volumes: each 1 mL smaller clot retraction at 24 hours was associated with almost 2.5-fold increase in odds of good outcome (95%CI:1.15- to 5.24) for clot retractions between 2 and 5 mL. There was no significant association with good outcomes for clot retractions less than 2 mL, after adjustment for severity indicators. No patient with clot retraction >5mL had good outcome (N = 20).

Conclusion:
HR is uncommon and continues to increase over first 72 hours after ICH. Greater HR is associated with more severe ICH, but with less PHE volume, and predicts a poor outcome. Further study is required to better understand these findings.
Abstract WP3: Occluded Vessel Location is a Predictor of Clinical Outcome in the Natural History of Acute Ischemic Stroke From Large Vessel Occlusion Eligible for Mechanical Thrombectomy
Authors: Grunwald Iris , Sneade Mary , Bock Birgit , Janardhan Vallabh , Ammar Lynne , Barraza Leticia , Stankiewicz Trisha , Liang Franco , Kuo Sophia , Buell Hope , Bose Arani , Sit Siu Po ,   For The FIRST/SOS Investigators
Published: June 2021

Purpose:
The preponderance of evidence suggests that target vessel locations (TVL) are important predictors of outcomes in acute ischemic stroke (AIS). However, few studies have examined in detail their correlation in the natural history of a cohort of patients with ICA, M1 and M2 vessel occlusions who are eligible for, but untreated with, mechanical thrombectomy.

Hypothesis:
We hypothesize that, similar to the broader stroke cohort, there is a correlation between TVL and outcomes.

Methods:
The SOS and FIRST trials were prospective, multicenter studies evaluating the natural history of a stroke cohort eligible for mechanical thrombectomy but did not receive the treatment. Enrolled patients presented with symptoms of AIS due to LVO and were refractory or ineligible for rtPA treatment. Functional independence was defined as a mRS score 0-2 at 90 days. Incidence of death, intracranial hemorrhage (ICH), serious adverse events (SAEs), and mortality were assessed for association with TVL.

Results:
A total of 238 patients (median age: 71) met study criteria. Occlusions were reported in the ICA (32.5%), M1 (54.4%), M2 (8.9%), and basilar artery (1.7%). At 90 days, 9.2% of ICA, 12.1% of MCA M1, 25.0% of MCA M2, and 0.0% of basilar artery patients achieved functional independence as defined by a mRS score of 0-2. Although the rate of SAEs was similar between ICA (83.3%), M1 (81.4%), and basilar artery (75%), the rate was lowered in patients with M2 occlusion (61.9%, p<0.05). There were also significantly fewer mortalities associated with occlusion of the M1 (27.4%, p<0.01) and M2 (10.0%, p<0.01) when compared to ICA occlusions (40.8%).

Conclusion:
Similar to the broader patients with AIS, there is a significant correlation between TVL and outcomes in patients with LVO eligible for mechanical thrombectomy. Although occlusion of smaller vessels (i.e. M2) predicts better functional outcome, 75% of patients will not reach functional independence.
Abstract 148: Mechanical Thrombectomy for Distal Occlusions: Efficacy, Functional and Safety Outcomes. Insights From the STAR Collaboration
Authors: Anadani Mohammad , Alawieh Ali , Arthur Adam S , Kim Joon-Tae , De Leacy Reade , Maier Ilko , Psychogios Marios-Nikos , Rai Ansaar , Keyrouz Salah , Fargen Kyle M , Dumont Travis M , Kan Peter , Starke Robert M , Spiotta Alejandro M ,   On behalf of STAR collaborators
Published: June 2021

Background:
Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke due to large vessel occlusions. There is strong evidence supporting the benefit of MT in proximal anterior circulation vessel occlusions and basilar occlusions. However, data regarding the efficacy and safety of MT in distal occlusions is scarce. In this study, we aim to report the efficacy, functional and safety outcomes of MT for distal occlusions.

Methods:
This a retrospective study from 14 comprehensive stroke centers across 4 countries. For the purpose of this study, distal occlusion was defined as MCA occlusion distal to M2 (M3-4 segments), any segments of ACA and any segments of PCA. Patients with concomitant proximal occlusions were excluded from this study.

Results:
Of 2826 patients, 111 patients were included in this study (mean (SD) age: 69 (13), 51% of patients were female, and 52% received tPA). Median onset to groin time was 241 (IQR, 136 minutes), median NIHSS on admission was 11 (IQR, 8), and median ASPECTS was 10 (IQR, 1). The procedure was done using ADAPT, stent retriever, and Solumbra techniques in 58%, 17% and 15% of patients respectively. Successful revascularization (mTICI 2b-3) and complete revascularization (mTICI 3) were achieved in 78% and 35% of our cohort, respectively. Median procedure time (puncture to revascularization or end of the procedure) was 29 minutes (IQR 42 minutes) and the median number of attempts was 1 (IQR=2). Five percent of patients suffered procedural complications Hemorrhagic complications occurred in 11% of patients of whom only 4% were PH2 hemorrhage. At the last follow up, mRS 0-2 was achieved in 53% of patients.

Conclusion:
Up to our knowledge, this represents the largest study to the date investigating the safety and efficacy of MT in distal occlusions treatment. MT was safe and achieved a high rate of successful revascularization with an acceptable safety profile.
Abstract 26: Predictors of Atrial Cardiopathy Among Patients in the Arcadia Trial: An Analysis of the First 924 Patients
Authors: Elkind Mitchell , Longstreth Will , Tirschwell David , Kronmal Richard , Chaturvedi Seemant , Moy Claudia , Broderick Joseph , Meinzer Caitlyn , Kamel Hooman ,   the ARCADIA Investigators
Published: June 2021

Background:
Atrial cardiopathy (AC) in absence of atrial fibrillation is a suspected cause of embolic stroke of undetermined source (ESUS). Predictors of AC remain incompletely characterized. We hypothesized that demographics, vascular risk factors, and time from stroke presentation to assessment for AC predict AC among ESUS patients.

Methods:
ARCADIA is an ongoing, investigator-initiated, NINDS-funded, multicenter, randomized trial of standard dose apixaban versus aspirin 81 mg daily among consented patients with ESUS and biomarker evidence of AC, defined as any of: N-terminal pro-brain natriuretic peptide (NT-proBNP) > 250 pg/ml; P wave terminal force velocity on ECG lead V1>5,000 μV*ms; or echocardiographic left atrial diameter index ≥3 cm/m
2
. Patients may be enrolled up to 120 days after stroke. We used multivariable regression modelling to estimate relative risks and 95% confidence intervals (RR, 95%CI) for association of predictors with AC.

Results:
Among 924 ESUS patients who met inclusion/exclusion criteria as of July 16, 2019, 251 met
>
1 AC criterion (164 NT-proBNP, 114 PTFV1, 4 echo). Compared to those without AC (n=673), those with AC were older (69.0
+
14.5 versus 64.0
+
15.0 years) and more often women (52.2% versus 40.9%). Multivariable predictors of AC were age (RR per decade 1.20, 95%CI 1.09-1.32), race (black versus other RR 1.20, 95%CI 0.95-1.52), sex (RR for women 1.22, 95%CI 0.98-1.52), hemoglobin (per unit RR 0.94, 95%CI 0.88-1.01), and cardiovascular/peripheral arterial disease, RR 1.48, 95%CI 1.16-1.88). Prior history of stroke or TIA, hypertension, diabetes, smoking, cancer, sleep apnea, and time from stroke to consent and blood draw for NT-proBNP were not associated with AC.

Conclusions:
Older age, female sex, black race, relative anemia, and history of vascular disease associate with AC among ESUS patients. Absence of association with time to assessment, particularly testing for NT-proBNP, provides indirect evidence that AC is not a reaction to stroke, but a stable condition, and supports patients being assessed for ARCADIA participation up to 4 months post stroke. The moderate strength of demographic associations with AC further underscores the importance of enrolling unselected ESUS patients into ARCADIA.
Abstract 28: Genetic Variants From Lysine-Specific Demethylase 4C (KDM4C) Associated With White Matter Hyperintensity Burden in Ischemic Stroke Patients
Authors: Li Jiang , Abedi Vida , Giese Anne-Karin , Schirmer Markus D , Donahue Kathleen , Nardin Marco , Rost Natalia S ,   Regeneron Genetic Cntr, Zand Ramin , Griessenauer Christoph J
Published: June 2021

Introduction:
Although white matter hyperintensities (WMH) have been linked to cerebrovascular disease, the exact pathogenesis is not known. The purpose of this study was to identify common variants associated with WMH burden among patients with an acute ischemic stroke (AIS) through a genome-wide association study (GWAS).

Methods:
A total of 946 AIS patients with validated European ancestry and MRI data were included in this study. WMH volume (WMHv), as a quantitative trait, was calculated by a fully-automated quantification process, which integrates the automated brain extraction, intensity normalization, and WMH segmentation using spatial priors. The GWAS was carried out by a linear mixed regression model (GEMMA), adjusted for covariates, to account for the potential population structure and relatedness. The WMHv ranked in top and bottom quantile were converted to a binary trait which represent high and low WMHv subgroups.

Results:
The rs10815506 (MAF = 0.043; β=3.89; p=6.66E-09), at an intronic region of
KDM4C
, which encodes Lysine-specific demethylase 4C
,
was the top signal associated with WMHv. This SNP is in high linkage disequilibrium (LD) (R
2
= 0.79; D’ = 0.93) with rs35389625, a nonsynonymous variant (Asn>Ser), predicted to be pathogenic by SIFT and Polyphen. The rs35389625 was also associated with WMHv but at a lower significance level (MAF=0.040; β=3.19; p=3.21E-06). Patients with homozygous mutant alleles (GG) of rs35389625 showed significantly increased WMHv (14.93±10.15) than GA (7.94±8.48) and AA (5.09±5.85) carriers. Both rs10815506 and rs35389625 also predicted a subset of high and low WMHv group (OR=2.81, p=0.005; OR=2.42, p=0.016, respectively). No significant interaction between the top SNPs at
KDM4C
and other risk factors was identified in their association with WMHv. We also conducted a candidate-gene analysis by including several known SNPs, gathered from a reported meta-analysis for WMH. The frequency of MTHFR677 cytosine/thymine (rs1801133) showed difference between lower and upper quantile groups with OR=2.18 for T allele (p=0.030), the direction of which was consistent with previous studies.

Conclusion:
This study provides the first evidence that genetic variants at
KDM4C
are associated with WMH in AIS patients.
Abstract 34: Kentucky Stroke Encounter Quality Improvement Project Statewide Collaboration to Improve Alteplase Utilization, Decrease Door to Needle Times, and Impact Outcomes: A 10 Year Review
Authors: Moore Kari D , Hundley Lynn , Hunt Polly , Singletary Bill , Merritt Allison , Bobo Bonita , Graham Amy , Block Starr ,   SEQIP Hosps
Published: June 2021

Background:
Evidence shows systems change interventions improve care and outcomes for stroke patients. Geopolitical boundaries have been a barrier to improving regional systems of care. Despite efforts nationally, regionally, and locally alteplase use for ischemic stroke has remained low and door to needle (DTN) times exceeded 60 minutes. Kentucky created the Stroke Encounter Quality Improvement Project (SEQIP) in 2009 to share best practices and improve stroke systems of care across the Commonwealth.

Purpose:
The aim was to utilize and share best practice models among 23 SEQIP hospitals in KY to improve tPA utilization, decrease DTN times, and improve outcomes.

Methods:
Hospitals implemented a statewide quality improvement plan focused on identifying barriers, removing barriers, and implementing best practice strategies regarding thrombolytic therapy. Accountability was achieved with ongoing GWTG data tracking, teleconferences, and face to face meetings from January 2009 through December 2018 sharing strategies and solutions for best practice.

Results:
SEQIP’s participating hospitals achieved significant improvement in thrombolytic administration over 10 years. The percent of all AIS patients receiving tPA increased from 4.61% in 2009 to 8.80% in 2018 (OR=2.0, p <0.0001). Alteplase use in eligible patients arriving by 2 hours and treated by 3 hours improved from 59.6% to 88.5% (OR=5.2, p <0.0001). Alteplase use in eligible patients arriving by 3.5 hours to 4.5 hours increased from 24.9% to 55.1% (OR=5.0, p <0.0001). Median DTN times decreased from 74 minutes to 49 minutes (p<0.0001). Complication rates of symptomatic hemorrhage were consistent with NINDS data and < 6% from 2009-2018. The tPA in-hospital mortality rate in 2009 was 11.7% and by 2018, decreased to 3.6% (p=0.00016). In 2009, 28.4% of tPA patients were discharged home and by 2018, that had increased to 47.9% (p <0.00001). In 2009, 32.1% of tPA patients were able to walk independently at d/c and by 2018 had increased to 43.6% (p = 0.00359).

Conclusions:
Geopolitical boundaries can be overcome and collaboration can be sustained among competing hospitals through sharing of best practices to safely increase utilization of tPA in eligible patients, decrease DTN times, and improve outcomes.
Abstract 56: Neuroimaging in Ischemic Stroke is Different Between Men and Women in the Defuse 3 Cohort
Authors: Dula Adrienne N , Mlynash Michael , Zuck Nathan D , Albers Gregory W , Warach Steven J ,   DEFUSE 3 Investigators
Published: June 2021

Introduction:
Clinical deficits from ischemic stroke are more severe in women but the pathophysiological basis of this sex difference is unknown. Sex differences in core and penumbral volumes were assessed in this sub-study of the Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke (DEFUSE)-3 clinical trial.

Methods:
DEFUSE 3 randomized patients to thrombectomy or medical management who presented 6-16 hours from last known well with proximal middle cerebral artery or internal carotid artery occlusion and had target core and perfusion mismatch volumes on CT or MRI. Using univariate and adjusted regression models, the effect of sex was assessed on pre-randomization measures of core, perfusion, and mismatch volumes and hypoperfusion intensity ratio, and on core volume growth using 24-hour scans.

Results:
All patients were included in the analysis (n=182) with 90 men and 92 women. There was no sex difference in the site of baseline arterial occlusion. Adjusted by age, baseline NIHSS, baseline modified Rankin score, time to randomization, and imaging modality, women had smaller core, hypoperfusion, and penumbral volumes than men. Median (IQR) volumes for core were 8.0 mL (1.9-18.4) in women vs 12.6 mL (2.7-29.6) in men, for

T
max

>6 seconds 89.0 mL (63.8-131.7) vs 133.9 mL (87.0-175.4), and for mismatch 82.1 (53.8-112.8) vs 108.2 (64.1-149.2). The hypoperfusion intensity ratio was lower in women, 0.31 (0.15-0.46) vs. 0.39 (0.26-0.57),
p
= 0.006, indicating better collateral circulation, which was consistent with the observed slower ischemic core growth than men within the medical group (p = 0.003).

Conclusions:
In the large vessel ischemic stroke cohort selected for DEFUSE 3, women had imaging evidence of better collateral circulation, smaller baseline core volumes, and slower ischemic core growth. These observations suggest sex differences in hemodynamic and temporal features of anterior circulation large artery occlusions.
Abstract TMP5: Vessel Status Findings in Patient Candidates Transferred for Endovascular Treatment. Data From Catalonia’s Code Stroke Registry
Authors: Flores Alan , Ustrell Xavier , Seró Laia , Pellisé Anna , Viñas Jaume , Paula Rodriguez , Rubiera Marta , Ribó Marc , Krupinski Jurek , Más Natalia , Garcia Sonia , Palomeras Ernesto , Cocho Dolores , Canovas David , Purroy Francisco , Serena Joaquim , Zaragoza Jose , Obach Victor , Perez de la Ossa Natalia , Pere Cardona , Molina Carlos A. , Abilleira Sonia ,   Catalan Stroke Code and Reperfusion Consortium.
Published: June 2021

The aim of this study was to determine changes in vessel status between PSC and CSC according to site and occlusion level, rtPA-treatment, and pre-specified time intervals.

Methods:
Observational, multicenter study, from a prospective, government-mandated, population-based registry. We selected data from candidates to EVT with documented LVO at PSC who were transferred to CSC from January 2017 to June 2019. We used clinical variables and time intervals as the Symptom-Onset to Vascular-Imaging at CSC (SOTVI2). The primary endpoint was defined as no-occlusion/distal occlusion ineligible for EVT at CSC arrival (NOEVTatCSC) as was utilized.

Results:
From 589 patients, 37% received rtPA. Rate of NOEVTatCSC was 10.5% (n: 62) and 87% were treated with rtPA, being 35.8% of causes to exclude EVT at CSC arrival. In univariate analysis, lower baseline-NIHSS (median 12 vs. 16 p<0.01), RACE-scale (median 5 vs. 6; p=0.04) and SOTVI2-time (mean-minutes 268.7 vs. 317.2; p=0.04), rtPA treatment (13.7% Vs. 5.0%; p<0.01), and M2 occlusion (16.8% Vs. 9%; p= 0.02) were associated with NOEVTatCSC. In multivariate analysis, only rtPA-treatment was associated with NOEVTatCSC (OR: 4.65, 95%CI: 1.73-12.4, p= 0.003). In the rtPA subgroup, Basilar occlusion (28% Vs. 12%; p=0.04), lower baseline-NIHSS (13 Vs. 16; p<0.01) and SOTVI2 times ≤240 minutes (28.9% Vs. 15.4%; p=0.02) were associated with NOEVTatCSC. In Multivariate analysis SOVI2 ≤240 minutes (OR: 2.109 95%CI: 1.008-4.401, p=0.04) emerged as the only predictor of NOEVTatCSC. Changes in the vessel status according to initial occlusion at PSC in anterior circulation were observed, and occurred in both; proximal and distal direction. In 11.2% of cases, occlusion site at CSC was more proximal than at PSC.

Conclusion:
In patient candidates for EVT transferred from PSC to CSC, NOEVTatCSC is infrequent making the need of a second vascular study before the angiogram at CSC arguable. Despite of its modest effect, tPA-treatment at PSC is the only factor associated with NOEVTatCSC. This could be most relevant in basilar occlusions and in the first 4-hours. Changes in the vessel status according to initial occlusion in PSC occur in anterior circulation. Future studies addressed to determine factors related to these changes are warranted.