bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP333: Intracerebral Hemorrhage Volume and Location in Two Population-Based Studies: 1988 and 2008-2012
Authors: Walsh Kyle B , Moomaw Charles , Sekar Padmini , Khoury Jane , Woo Daniel
Published: October 2018

Objective:
To compare two population-based studies of intracerebral hemorrhage (ICH), collected 20 to 24 years apart, with regard to hemorrhage volumes, location, and stroke risk factors.

Methods:
All cases of spontaneous ICH among adult residents of the primarily biracial Greater Cincinnati/Northern Kentucky (GCNK) region were ascertained for 1988 and 7/2008-12/2012. Subject information including age, sex, race, Glasgow Coma Scale, and baseline blood pressure were recorded, along with medical history and prescription of anticoagulant and antiplatelet medications. ICH location was defined as deep, lobar, brainstem, or cerebellar. ICH volume was calculated by the ABC/2 method.

Results:
There were 170 cases of ICH in 1988 and 1101 cases in 2008-2012 fulfilling inclusion criteria. There were no significant differences in mean age (71.2 vs. 70.5 years) or sex (57.7% vs. 51.6% female), but there was a higher proportion of blacks in 2008-2012 compared with 1988 (23.5 vs. 13.5%, P=0.0045). Among the 2008-2012 cases there was significantly less history of ischemic stroke and non-ischemic stroke, and there were no significant differences in history of hypertension, diabetes mellitus, and current smoking. The 2008-2012 cases were prescribed more anticoagulants and antiplatelets. The distribution of ICH location was similar between the two groups. The ICH volumes appear to be lower in 2008-2012 than for 1988 for all hemorrhage locations except the brainstem; however, statistical significance was reached only for deep ICH (Table 1).

Conclusions:
Although the distribution of ICH location was unchanged between 1988 and 2008-2012, deep ICH volume was smaller in the more recent study. This reduction in hemorrhage size occurred despite significantly more anticoagulant and antiplatelet medications in 2008-2012. More research is needed to investigate factors related to ICH size and trends over time.
Abstract WP339: Arterial Spin Labelling Cerebral Perfusion Measurements Demonstrate Normal Blood Flow in Subacute Intracerebral Hemorrhage Patients
Authors: Klahr Ana C , Dowlatshahi Dariush , Buck Brian , Gioia Laura , Kalashyan Hayrapet , Wilman Alan , Jeerakathil Thomas , Emery Derek , Butcher Kenneth
Published: October 2018

Introduction:
Perihematomal hypoperfusion in acute intracerebral hemorrhage (ICH) has been demonstrated using CT perfusion. Although blood pressure (BP) reduction does not appear to impact perihematomal Cerebral Blood Flow (CBF), measurements using contrast are limited to a single time point. It has also been shown that up to 41% of ICH patients develop subacute diffusion-weighted imaging (DWI) lesions on MRI. Arterial Spin Labelling (ASL) is an magnetic resonance imaging (MRI) technique that allows measurement of CBF without a contrast agent, making it suitable for serial measurements. We assessed CBF in ICH patients using ASL and tested the hypothesis that perihematoma perfusion is related to BP.

Methods:
Patients with CT scan confirmed ICH were prospectively recruited within 6 hours of symptom onset. Acute systolic BP (SBP) targets were randomly assigned as part of an ongoing trial. The SBP target remained blinded for this analysis. Patients were assessed with ASL at 48 hours post ICH. The perihematoma region was defined using co-registered susceptibility weighted images to delineate the hematoma border. Relative CBF (rCBF) was calculated as a ratio of the ipsilateral to contralateral ASL measurements.

Results:
Perfusion was measured in 6 ICH patients, none of whom had DWI lesions, 55.38 (43.72, 59.75) hours after onset. Median 48 hour hematoma volume was 23.40 (18.10, 99.90) ml. Mean±SD SBP at 48 hours was 140.20 ± 10.64 mmHg. Mean perihematomal rCBF was 0.95±0.37. Mean hemispheric rCBF was 0.95 ± 0.17. Perihematomal and hemispheric CBF was not lower in the side of the hematoma (
p
>0.583). Hematoma size was unrelated to rCBF (perihematomal R=0.039, 95% CI [-0.880, 0.959],
p
=0.682; hemispheric R=0.00, 95% CI [-0.005, 0.006],
p
=0.932). Systolic BP at the time of the scan, difference between baseline SBP and SBP at the time of the scan, and time spent with SBP <140 mmHg were all not associated with perihematomal or hemispheric rCBF (
p
>0.170).

Conclusion:
It is feasible to measure perihematoma and hemispheric perfusion in ICH patients using ASL, which may be useful for serial CBF assessment, particularly in patients with MRI evidence of ischemia.
Abstract WP342: Description of Pericavity Edema in Patients With Intracerebral Hemorrhage Who Have Undergone Endoscopic Minimally Invasive Evacuation
Authors: Horowitz Maxwell E , Allen Olivia , Chartrain Alex G , Glassberg Brittany , Sakai Yu , Turkheimer Lena , Mocco J , Kellner Christopher P
Published: October 2018

Introduction:
Perihematomal edema (PHE) impacts outcome in spontaneous intracerebral hemorrhage (ICH) and has been well defined. As minimally invasive evacuation methods are formally evaluated, the degree of edema following evacuation may differ from PHE in measurement and time course characteristics. Here we define pericavity edema (PCE) as a new entity and formally evaluate its measurement with a semi-automated threshold-guided technique.

Methods:
Patients (n=46) with a primary supratentorial ICH who underwent endoscopic evacuation were included in this study. AnalyzePro software was used to perform semi-automated threshold-guided volume assessment on pre and post evacuation noncontrast head CTs of the hematoma, PHE, the cavity, PCE, and pneumocephalus if present. Two raters analyzed each subject, the first twice, and intraclass correlation coefficient (ICC) values were determined to assess the inter-rater reliability. Statistical analysis was performed on the mean results to determine the change in hematoma volume, edema, cavity size, and degree of pneumocephalus.

Results:
ICC values for all variables were greater than 0.75, indicating good to excellent reliability. The median preoperative PHE was 18.21 cm3, while the postoperative edema was 16.2cm3. There was a mean 78.9% decrease in hematoma and a mean 76.4% increase in edema. In patients with a cavity present, the median size was 10.4cm3.

Conclusions:
In conclusion, PCE was successfully measured using AnalyzePro based on ICC. A mean increase in edema was shown following endoscopic evacuation, similar previous research revealing an increase in edema volume growth immediately following ICH. Further research will aim to define the time course of edema volume change following endoscopic evacuation.
Abstract WP35: Age-Stratified Outcomes After Mechanical Thrombectomy for Large Vessel Occlusion
Authors: Alawieh Ali M , Porto Guilherme , Chatterjee Arindam , Turk Aquilla S , Turner Raymond D , Chaudry Mohammad I , Spiotta Alejandro M
Published: October 2018

Introduction:
Mechanical thrombectomy (MT) has become a significant component in the management of acute ischemic stroke (AIS). The majority of randomized trials establishing the safety and efficacy of MT in AIS have excluded elderly patients above 80 years old. In this work, we assessed the safety and efficacy of MT in different age groups with a focus on how elderly patients respond compared to their younger counterparts.

Methods:
We retrospectively reviewed a database of AIS cases that underwent MT for large vessel occlusions at the Medical University of South Carolina between 01/13 and 03/17. Patients were categorized into 4 age-groups (<80, 80-85, 85-90, and ≥90 years), and baseline characteristics, procedural variables, and 90-day outcomes were compared across the age groups.

Results:
A total of 436 AIS patients (50.2% women, mean age 67.3 years) underwent MT during the study period. Patients in the elderly groups (80-85, 85-90, ≥90) included significantly more females and had a higher NIHSS at baseline compared to younger patients (<80, p<0.01). There were no significant differences in time from onset to treatment, rate of IV or IA tPA, and procedural variables including time to recanalization, final TICI flow, and the number of devices or attempts (p>0.05). There were also no significant differences in the rates of hemorrhagic and other complications across the four groups (p>0.05). Modified Rankin scores (mRS) at 90 days were significantly higher in the 3 elderly groups compared to younger patients (p<0.001), and the likelihood of good outcomes (mRS 0—2) dropped from 50% in the <80 years group to 18.3%, 17.4% and 7.7% in the 80-85, 85-90 and ≥90 groups respectively. A similar and significant trend was seen with 90-day survival that decreased from 85% in the <80 years group to 75%, 59% and 33% in the 80-85, 85-90 and ≥90 groups respectively (p<0.001). We then used multivariate logistic regression analysis to show that age above 80 years is an independent predictor of mortality and vegetative state at 90 days (OR=2.6, p=0.003).

Conclusions:
Our findings suggest that elderly patients above 80 years old are less likely to benefit from MT after AIS compared to younger patients despite not being at a higher risk of immediate complications or post-procedural hemorrhage.
Abstract WP351: Perceptions of Self-management Role, Barriers, Facilitators Among Stroke Survivors: A Qualitative Study
Authors: Chen Lu , Chen Yan , Sit Janet W
Published: October 2018

Introduction:
Stroke self-management (SM) interventions have demonstrated beneficial effects for improving function and stroke outcomes. Little is known about how and what make positive behavioral change (or not) for SM participation and adherence.

Objectives:
To explore, from first-time stroke survivors’ perspectives, the perceived role, facilitators and barriers of stroke SM, and how they deal with day-to-day stroke SM.

Methods:
This qualitative study was embedded in a randomized controlled trial aimed at investigating the effects of a stroke SM program on functional and psychosocial outcomes. All participants in this study, being involved in the intervention group of the trial, were purposively selected based on their SM behavioral change post-intervention. Maximum variation principles, including age, sex and ADL were adopted for participants’ recruitment. Interview data were audio taped, transcribed verbatim and entered into NVIVO 10 for content analysis.

Results:
Findings from 20 stroke informants (age range 41-85, 65% male, ADL score range 65 - 100) revealed three categories including (1) perception of stroke self-management (medical and behavioral management; role management; emotional management, stroke knowledge management), (2) facilitating factors (knowledge and skills established; fear of stroke recurrence; family, professional and peer support; and personal meaningful goals and action plan), and (3) barriers (extent of negative impact of stroke; economy-related factors; environment-related factors; and powerlessness to stroke).

Conclusions:
Stroke participants described approaches that facilitated their SM, and identified barriers that may be amenable to SM counseling strategies for enhancing resilience for SM participation and adherence.
Abstract WP354: Neurovascular Advanced Practice Clinicians - A New Paradigm for Continuity in Acute Stroke Care
Authors: Paolucci Gino A , Fuller Lindsey R , Oliver Lori A , Quinn Katie A , Watkins Christina C , Clark Michael L , McTaggart Ryan A , Jayaraman Mahesh , Saad Ali
Published: October 2018

Background:
Our Neurovascular Advanced Practice Clinician (APC) program is a collaboration between Neurointerventional Radiology (NIR) and the Vascular Neurology Inpatient Service (Ward). Members of this team (nurse practitioners and physician assistants) provide 24/7 coverage and rotate on both services. We will describe the roles of the APC throughout the acute stroke process, on the ward, and in NIR. Typically, one APC is on NIR and one on the ward during the day, and one covering both NIR and ward at night.

Summary:
An APC responds to all Code Strokes and works with the neurology resident to facilitate acute therapy. They review imaging in real time and confirm findings with the radiologist. When indicated, the APC works with ED and neurology staff to facilitate rapid administration of tPA. For Large Vessel Occlusion (LVO) stroke, the APC discusses the case with the NIR attending and facilitates prompt transfer to the NIR suite. Once in the suite, the APC assists the attending performing the procedure. For after hours cases, they ready the suite for neurointerventional team arrival. Post procedure, the APC assists in patient transfer to the stroke unit. In NIR, The APCs handle pre- and post-procedure documentation, orders, and participate as assistants. The APCs routinely obtain arterial access for endovascular procedures and perform closure of the arteriotomy. The APCs also follow inpatients after a procedure, write daily progress notes and are responsible for the care of patients admitted to the NIR service. On the ward, the APCs manage their own patients, present at rounds and develop a plan in conjunction with the attending physician. Their role includes obtaining detailed history and physical exam, ordering medications, ordering and interpreting diagnostic tests. They write daily progress notes and generate discharge summaries.

Conclusion:
Our Neurovascular APC program is a unique collaboration between service lines caring for the acute stroke patient. The APCs are an invaluable resource in all facets of the care of these patients. This novel design allows APCs to participate in the stroke patient’s management across the continuum of hospital care from ED arrival to hospital discharge.
Abstract WP355: Evaluation of a Checklist to Identify Early Signs of Hyperperfusion Syndrome After Carotid Endarterectomy
Authors: Yasunaga Megumi , Takahara Kenta , Kameda Katsuharu , Haga Sei , Sayama Tetsuro , Arihiro Shoji , Arakawa Shuji , Morioka Takato
Published: October 2018

Background and purpose:
Hyperperfusion syndrome (HPS) occurs in only 1-3% of patients after carotid endarterectomy (CEA). However, it can cause severe cerebral hemorrhage and may be lethal. Therefore, nurses need to be able to recognize the early signs of HPS and report them to the physician. In this study, we aimed to investigate the applicability of using the Intensive Care Delirium Screening Checklist (ICDSC) to discover early signs of postoperative HPS after CEA, allowing nurses to report the signs and possibly prevent disease progression.

Method:
The study included 96 Japanese patients average age 71.9 ± 8.3 years old undergoing CEA from May 2008 to May 2017. There were 9 patients in the HPS group and 87 in the non-HPS group. Research design was a methodological study. To analyze differences between normally distributed continuous variables, the average value ± standard deviation was calculated and a t test used to compare between groups. For non-normally distributed continuous variables, the median and the range were calculated, and the Wilcoxon rank sum test was used to compare between groups. Ethical approval was granted by the Ethics Review Committee of the research execution facility.

Result:
There was no significant difference in the patient characteristics in both groups. There was also no significant difference in the number of patients exhibiting signs of delirium (>4 points in total on the ICDSC) between the HPS group (n=8) and the non-HPS group (n=10). However, patients in the HPS group were unable to engage in conversation, while those in the non-HPS group responded to the nurses’ questions and several patients were able to engage in lucid conversation. The HPS group thus scored significantly higher than the non-HPS group on the "inappropriate speech or mood" ICDSC item (100% in the HPS group vs. 20% in the non-HPS group, P <0.001). In addition, on the "symptom fluctuation" item, the non-HPS group scored significantly higher than the HPS group (0% in the HPS group vs. 100% in the non-HPS group, P <0.001).

Conclusion:
A total ICDSC score >4 and the presence of "inappropriate speech or mood" or "symptom fluctuation" strongly suggest the presence of HPS. In conclusion suggest that ICDSC is effective in identifying the early clinical signs of HPS after CEA.
Abstract WP357: Suitability and Contents Coverage of Stroke-related Websites for Stroke Management
Authors: Lee Mikyoung , Shin Cha-Nam , An Kyungeh
Published: October 2018

Background:
Websites are commonly used by Korean-Americans (KAs) stroke survivors and caregivers to obtain information and resources for stroke management. Suitability and contents coverage of the websites have not been evaluated.

Purpose:
This study aimed to evaluate stroke-related websites for (1) the suitability (easy to read, understand, and engage in stroke care) and (2) the content coverage to meet the information-needs of KAs.

Methods:
The search terms ‘stroke,’ ‘CVA,’ ‘,’ and ‘’ were used to find stroke-related websites on Google and Yahoo. Excluding duplicates appeared on the 1
st
and 2
nd
pages after searching, 42 websites (15 in English, 27 in Korean) were selected. Suitability was determined by the National Library of Medicine’s Internet Health Information Evaluation tool and the 23-items Suitability Assessment of Materials both in 3-point scale (superior=2, adequate=1, or not suitable=0). Scores were summed and converted to a percentage for determining overall suitability. Content coverage was determined by presence or absence of the information on the 47-items Stroke Information Content Checklist. Three independent raters evaluated each website (interrater reliability ranged .63 to 1.00).

Result:
For the suitability, 18 out of 42 websites met less than 40 % of suitability criteria (=not suitable). Only two were written at 5
th
grade or lower level. Interactive motivations for desired healthy behaviors, graphical directions, and multiple language translations were lacking. For the content coverage, pathophysiology, signs, and impairments of a stroke were most covered (36-38 websites), while contents about coping strategies, sleeping problems, sexual needs, caregiver stress, and financial/legal concerns were limited (0-6 websites).

Conclusion:
Further research is needed for culturally sensitive information-needs among ethnic groups. A handy tool for health consumers to assess trustworthiness of web-based health information is urgently needed.
Abstract WP369: Knowing the Score: Documentation of Bleeding Scores for Hemorrhagic Stroke Patients
Authors: Steiner Nili E , Paletz Laurie , Wolber Nicole , Robertson Betty , Levesque Denise , Guerra Sonia , Nunez Nancy
Published: October 2018

Background:
Intracranial hemorrhage (ICH) scores and Hunt and Hess/Fisher scores (HHF) are important components in the documentation of hemorrhagic strokes. The accurate and timely documentation of these scores is a mandatory data point measure for Joint Commission (JC) certified Comprehensive Stroke Centers. The purpose of this project is to discuss the measures we implemented to improve documentation of the ICH and HHF scores and to highlight the remarkable improvement of documentation of the scores with our efforts.

Purpose:
The purpose of this project was to discover if a specific, user-friendly template and targeted education would increase documentation compliance.

Methods:
We did a retrospective review of percentage of compliance in documentation of ICH and HHF scores before the measure was mandated by the JC. We implemented the ICH and HHF score template into the Neuro ICU template and educated practitioners on the JC measure requirement and awareness of the template. We also educated our Code Brain team to document the scores upon initial assessment. We track and trended documentation with monthly review of percentage of compliance. We continue to provide feedback to practitioners when score documentation is not present in medical record and continue to monitor percentage of compliance.

Results:
The percentage of compliance at the beginning of the data capture for this measurement (Jan 2015) was approximately 6% for the first two quarters of 2015. After the implementation of the score template, the percentage of compliance was 50% for the last two quarters of 2015. We continued to meet with the Neuro ICU for targeted education of the measure requirement and provided feedback in cases of missing documentation. With the continued feedback and education, the percentage of compliance increased to approximately 92% in 2016, a huge improvement from 2015.

Conclusions:
Providing an user friendly template for practitioners along with education and feedback helped dramatically increase the compliance of documentation for an mandatory JC measure.
Abstract WP371: Safe and Rapid Interfacility Transport of Drip and Ship Patients
Authors: Conahan Erin , Hickey Timothy , Mathiesen Claranne
Published: October 2018

Background and Issues:
Stroke care delivery continues to undergo dynamic changes as evolving treatment extends the critical reperfusion time window. Stroke centers have responded by improving approaches to rapidly transport patients receiving alteplase or who have been identified as endovascular eligible. Limited literature exists discussing interfacility transport during ischemic stroke reperfusion.

Purpose:
We describe the outcomes of a quality assurance (QA) process of auditing interfacility transfers to ensure adherence to protocol when transporting drip and ship patients. This approach has been recognized as a best practice during CSC certification.

Methods:
As the number of interfacility transfers increased, the stroke team met with the aeromedical and critical care ground transport team to develop ongoing QA processes for the care of patients during transport. Competencies and education for crew and ongoing quality metrics were established. Revisions were made to stroke transport protocols to more closely align with the American Stroke Association guidelines. Retrospective chart review of protocol adherence and complications was completed monthly with feedback provided to the transport teams.

Results:
Since 2015 this CSC admitted 2911 stroke patients with 860 neuro transfers by 4 helicopters and 2 ground critical care transport teams. Retrospective analysis of 116 drip and ship transport charts was completed. There were no life-threatening complications or major neurological deterioration in our sample. One airway event resolved with intubation in transit. Common protocol deviations involved timing of vital signs and neuro checks and titration of vasoactive medications.

Conclusion:
Logistics of interfacility transport continues to evolve as more patients are referred to CSC’s for advanced interventions. Access to highly-trained transport teams provides rapid and safe passage during reperfusion. Crew education and ongoing QA encourages continual performance improvement, improves communication and reinforces protocol adherence. Dissemination of best practices is critical as limited specialized neurovascular services will continue to require interfacility patient movement to access advanced stroke resources.
Abstract WP377: Implementation Of A Stroke Clinical Operations Nurse (scon) Decreases Door To Needle Time
Authors: gottbrath diedra , Remmel Kerri , Liu Ruolan
Published: October 2018

Introduction:
Evidence-based practice shows that the earlier a patient presenting with an acute ischemic stroke receives IV-tpa the better the outcomes. The stroke clinical operations nurse role was developed to help streamline door-to-needle (DTN) time for patients being treated with Alteplase (IV-tPA). Adding experienced, stroke trained, critical care nurses, or Stroke Clinical Operations Nurses, on the stroke team as part of the response to acute stroke patients presenting within 12 hours of stroke, our hospital has been able to drive DTN time down and increase the number of patients treated within the 45 and 60 minute window since implementation.

Method:
Retrospective review of all patients who received IV-tPA from Jan 2013 –June 2017. January 2013- June 2016 is the pre-implementation data and July 2016- June 2017 is post implementation data. We compared DTN time and percentage of DTN less than 45 minutes after implementation of stroke dedicated nursing service. Mean and median were calculated. Two-tailed student T-test was used for comparison and a statistical significance was determined at 0.05 level.

Results:
Total of 313 patients who received Iv-tPA from 2013 to June 2016, and 85 patients from July 2016 to June 2017. There was significant decrease in mean (44.5 ± 0.6 vs 41.6+1.3 min) and median (45 vs 40 min) of DTN within 60 min after the start of the service. Meanwhile, there was a significant increase of percentage of DTN within 45 min (37.7% vs 49.4%). There was a significant decrease in DTN time (mean: 37.5 ± 0.5 vs 35.0 ± 1 min; and median: 39 vs 36.7 min) in groups of DTN within 45 min.

Conclusion:
Implementation of the SCON decreased the Door-to-Needle (DTN) time and improves the number of patients being treated with IV Alteplase in the 45 and 60 minute time window goals. The implementation of the SCON will serve as a new model for early management of patients with acute ischemic stroke to deliver the highest quality patient services across the state and nationwide.
Abstract WP388: Basilar Artery Diameter is Associated With Cerebral Small Vessel Disease and the Duration of Enzyme-replacement Therapy in Fabry Disease
Authors: Miwa Kaori , Sakai Norio , Yagita Yoshiki , Takeuchi Mariko , Todo Kenichi , Sakaguchi Manabu , Mochizuki Hideki
Published: October 2018

Introduction:
Fabry disease (FD), an X-linked lysosomal storage disorder, causes intracellular accumulation of glycosphingolipids leading to progressive renal, cardiac, and cerebrovascular disease. Enzyme replacement therapy (ERT) is effective in reducing cardiac hypertrophy but has a limited effect on renal function, whereas there is still no clear evidence of the benefit of ERT for incident stroke. An enlarged basilar artery (BA) diameter has been of particular interest as an early and potential risk factor for stroke. However, the long-term effect of ERT for BA diameter in patients with FD are unknown.

Hypothesis:
We hypothesized that effect of ERT exerts a certain influence on for BA diameter in patients with FD. The aim of our study was to investigate the clinical characteristics of BA diameter in patients with FD.

Methods:
We retrospectively enrolled consecutive patients with FD who were treated ERT and underwent brain MRI. The short axis of BA diameter was measured at the midpons level on the axial T2-weighted image. Baseline MRI was used to determine cerebral small vessel disease (SVD); lacuna, white matter hyperintensities [WMH] and atrophy. Linear regression analyses were performed to evaluate the variables associated with BA diameter.

Results:
We enrolled 30 patients (mean age; 41.3 ± 15.1 years, male; 14). The baseline BA diameter was 3.16 ± 0.51 mm. Hypertension, cardiomegaly, chronic kidney disease, previous stroke, lacuna, and WMH were associated with initial BA diameter. Follow-up MRI was performed in 18 patients (male; 10) after a mean interval of 5.2 ± 3.7 years. Annual change in BA diameter was 0.06 ± 0.12 mm. Enlargement of BA diameter was positively correlated with baseline lacuna and severity of WMH. Furthermore, the duration of therapy between baseline ERT and follow-up MRI was inversely correlated with annual change of BA diameter (β= -0.518, P= 0.033). Given the stratification of the patient groups for gender, only male patients are observed for the significant correlation (β=-0.706, P= 0.022).

Conclusion:
In FD patients, enlarged BA diameter was associated with SVD. Furthermore, ERT might modify the natural course of BA diameter, especially for male patients.
Abstract WP393: The Impact of Prior Antithrombotics on Stroke Severity in Patients With Nonvalvular Atrial Fibrillation
Authors: Kim Young Dae , Jung Yo Han , Choi Hye-Yeon , Lee Kyung Yul , Cheon Kyeong Yeol , Han Sang Won , Park Joong Hyun , Cho Han-Jin , Park Hyung Jong , Nam Hyo Suk , Heo Ji Hoe
Published: October 2018

Background and purpose:
In this study, we investigated the stroke severity was associated with the prior antithrombotic medication including novel Vitamin K antagonist oral anticoagulants (NOACs) in patients with nonvalvular atrial fibrillation (NVAF).

Methods:
We included 801 consecutive acute ischemic stroke or transient ischemic attack patients with NVAF who were admitted to 6 hospitals between August 2013 and January 2017 in the present study. Stroke severity was assessed using the National Institute of Health Stroke Scale (NIHSS). Prior antithrombotics before index stroke were categorized into 5 groups: no antithrombotics, only antiplatelet, warfarin with international normalized ratio (INR) <2, warfarin with INR ≥2, and NOACs. We investigated whether there were differences in initial stroke severity according to the prior antithrombotics in stroke patients with NVAF.

Results:
A total of 801 acute ischemic stroke or transient ischemic stroke patients with NVAF were enrolled. Among the 801 patients, the 34 (4.2%) had been treated with warfarin with INR ≥2, 146 (18.2%) with warfarin with INR ≥2, 70 (8.7%) with NOACs, 347 (43.3%) with only antiplatelet, and 204 (25.5%) without any antithrombotics. The median NIHSS score was 5 (IQR 1-14). Compared with the no antithrombotics group (9.5, IQR 2-16), the NIHSS was lower in the warfarin with INR ≥2 (4, 1-7.3) and the only antiplatelet group (4, IQR 1-12), while the warfarin with INR <2 (6, IQR 2-14) or the NOACs group (4, IQR 1-15) had similar stroke severity. Multivariate analysis adjusting the CHA2DS2-VASc score showed stroke severity was milder in patients with warfarin with INR ≥2 (b -4.680, SE 1.399, p=0.001), those with antiplatelet only (b -2.528, SE 0.667, p<0.001), or those with NOACs (b -2.290, SE 1.049, p=0.029), compared with those without any antithrombotics.

Conclusions:
Our data indicate that the prior anticoagulation was related with milder initial stroke severity in patients with NVAF.
Abstract WP40: Deep White Matter Lesions on Pre-transfer Diffusion-Weighted Imaging Predicts Subsequent Intracranial Hemorrhage After Emergent Endovascuar Therapy
Authors: Miura Masatomo , Nakajima Makoto , Numa Soichiro , Uchida Kazutaka , Shirakawa Manabu , Ando Yukio , Yoshimura Shinichi
Published: October 2018

Background:
In acute ischemic stroke, emergent transportation to comprehensive stroke center (CSC) is crucial for appropriate endovascular therapy (EVT). However, time delay for transfer increase the risk of subsequent intracranial hemorrhage (ICH), Ischemic change in the deep white matter on diffusion-weighted imaging (DWI-W) is one of neuroradiological predictors for subsequent ICH and poor outcome. We hypothesized that pre-transfer DWI-W and DWI-ASPECTS might predict subsequent ICH after EVT.

Methods:
We retrospectively collected acute stroke patients transferred for EVT to our CSC from October 2013 to July 2017. Patients who underwent MRI before transportation were analyzed. We investigated whether presence of DWI-W was associated with subsequent ICH, and compared the usefulness of ASPECTS+W with traditional scoring system in predicting subsequent ICH after EVT.

Results:
A total of 99 patients (aged 73.6 ± 11.4 years; initial NIHSS score, median 17 [IQR 10 - 22]; DWI-ASPECTS, 7 [6 - 8]; ASPECTS+W, 8 [6 - 9]) were included. DWI-W was detected in 49 patients (49%), and 35 (35%) developed subsequent ICH. Patients with DWI-W had significantly higher NIHSS score (18 vs. 14, p = 0.038), and developed subsequent ICH after EVT more frequently (46% vs. 24%, p = 0.021) compared to those without. In multivariate analysis, presence of DWI-W (OR 2.86; 95% CI 1.15 - 7.47; p =0.023), presence of dyslipidemia (OR 2.87; 95% CI 1.01 - 8.41; p = 0.046), and administration of IV-tPA (OR 2.74; 95% CI 1.11 - 7.12; p = 0.028) predicted ICH independently. In additional analyses with different models, lower ASPECTS+W (OR 0.79 per point increase; 95% CI 0.64 - 0.98; p = 0.031) predicted ICH better than DWI-ASPECTS (OR 0.80 per point increase; 95% CI 0.63 - 1.01; p = 0.064) did.

Conclusions:
Presence of DWI-W on MRI before transportation is a useful predictor of subsequent ICH after EVT.
Abstract WP402: Increased Body Mass Index is Associated With Hereditary Hypercoagulable State of PFO-related Cryptogenic Stroke
Authors: Song Bo , Pei Lulu , Deng Wenjun , Fisher Lindsay , Chou I-ying , Camargo-Faye Erica , McMullin David , Lo Eng H. , Wang Xiaoying , Xu Yuming , Buonanno Ferdinando S , Ning Mingming
Published: October 2018

Background:
Hereditary hypercoagulation is an important risk factor in patent foramen ovale (PFO) related cryptogenic stroke (CS). Body mass index (BMI) has been associated with venous thrombosis by genetic and hereditary factors. Since the pathogenesis of PFO-related stroke is considered to be due to paradoxical thrombus from the venous system, it is imperative to explore the relationship between hereditary hypercoagulation and BMI.

Methods:
Eligible patients were consecutively and prospectively recruited in accordance with an IRB. All patients underwent full evaluation of stroke etiopathogenesis, including MRI/MRA, long-term (>30 days) cardiac telemetry, echocardiography, and extensive hypercoagulable screening (protein S, protein C, FV
Leiden
, PTGM, ATIII, APLAb, lupus anticoagulant, lipoprotein(a), homocysteine).

Results:
In 1,131 consecutively recruited acute ischemic stroke patients, 59 (17.1%) were diagnosed with PFO-related CS and hereditary hypercoagulable state. BMI was statistically significantly higher in patients with hereditary hypercoagulable state (36.01±8.88 vs. 29.14±6.58, P=0.023). Higher BMI (>=35.5) can independently predict hereditary hypercoagulable state in PFO CS with high specificity (90.9%, AUC 0.72, p=0.05) compared to other stroke risk factors.

Conclusion:
We found that hereditary hypercoagulation was more common in obese PFO-related CS patients, independent of DM status. While metabolic syndrome is well studied in diabetic patients with CVD, to our knowledge, this is first report of its importance in PFO-related CS. Further studies are needed to validate these initial findings.
Abstract WP405: Ultra-short-term Blood Pressure Variability is Increased in Ischemic Stroke Patients Compared to Controls
Authors: Wong Ka-Ho , Majersik Jennifer J , Tirschwell David , Mickolio Kole , Fagatele Lilly , de Havenon Adam H
Published: October 2018

Introduction:
Systolic blood pressure variability (BPV) is increased after ischemic stroke and higher levels are associated with worse outcome. Accurate quantification of BPV requires frequent measurement, which is not practical with conventional sphygmomanometry. Finger photo-plethysmography allows non-invasive continuous blood pressure measurement and has been validated against invasive measurement techniques.

Hypothesis:
Ultra-short-term BPV (uBPV) will be higher in patients with recent ischemic stroke compared to controls.

Methods:
We measured uBPV in 10 patients: 5 with stroke in the last 14 days (mean=6 days) and 5 healthy controls. Blood pressure was recorded with an ADInstruments NIBP System (Figure 1) for 15 minutes with 200 measurements/second. For each patient, the 15 minutes was divided into 10 epochs of 90 seconds. uBPV was calculated for each epoch and we used a linear mixed-effects model to account for repeated and clustered observations.

Results:
There was a mean±SD of 172,265±11,354 measurements per patient and 17,226±2,274 measurements per epoch. All measures of systolic uBPV were significantly higher in the stroke patients compared to controls (Table 1). The identical analyses were performed for diastolic and mean arterial blood pressure without significant results.

Conclusion:
This study demonstrates the feasibility of measuring BPV in stroke patients with finger photo-plethysmography, which was well tolerated and showed the expected increase in systolic BPV after stroke. Our data also introduce the concept of uBPV as a measure of BPV after stroke, which warrants additional study and correlation with clinical and radiographic outcomes.
Abstract WP406: Endothelial Function is Impaired in Embolic Stroke of Undetermined Source (ESUS)
Authors: Shirai Yuka , Toi Sono , Kubota Megumi , Adachi Utako , Kitagawa Kazuo
Published: October 2018

Background:
Impairment of endothelial function is associated with atherosclerosis and atrial fibrillation, and could underlie several types of ischemic stroke. Recently, embolic stroke of undetermined source (ESUS) has attracted much attention as the major cause of cryptogenic stroke.

Objective:
The purpose of this study was to clarify the endothelial function in patients with ESUS and compare it with those with other major ischemic stroke subtypes and without a history of stroke.

Material and Methods:
Between 2015 September and 2017 July, we have prospectively enrolled 402 outpatients with any vascular risk factors or with a history of cerebrovascular events, who had undergone brain MRI within a year and had any sign of cerebral vessel disease. Among them, 230 patients underwent flow-mediated vasodilation (FMD) test to evaluate vascular endothelial function. The subject group was classified into No stroke group and five stroke subtype groups; large artery atherosclerosis (LAA), small vessel disease (SVO), cardiogenic embolism (CE), ESUS, and others (Other stroke). Endothelial function was expressed as percent increase of brachial vessel diameter (%FMD) after interruption of blood flow with mechanical compression for five minutes.

Results:
The age of subjects was 69.5±10.6 years old, and 61% of them were males. The prevalence of hypertension, diabetes, dyslipidemia, chronic kidney disease, atrial fibrillation, and a history of stroke were 69%, 28%, 51%, 20%, 10%, and 57% respectively. The %FMD of total subjects was 5.16±2.60%; %FMD of stroke subtypes were 5.19±0.32% in No stroke (n=100), 5.02±0.60% in LAA (n=18), 5.19±0.37% in SVO (n = 47), 4.97±0.63% in CE (n=16), 3.55±0.50% in ESUS (n=26), 6.55±0.53% in Other stroke (n=23). The %FMD was significantly lower in ESUS than those in No stroke, SVO, Other stroke (p<0.05). No significant difference in %FMD was observed between ESUS group and LAA or CE group.

Conclusion:
This study clearly showed that vascular endothelial function of patients with ESUS was significantly impaired. Endothelial dysfunction could underlie development of atrial fibrillation, atherosclerotic plaque or thrombus formation in patients with ESUS.
Abstract WP411: Identification and Characterization of Human Meningeal Lymphatics
Authors: Adham Zachariah O , Goodman James R , Woltjer Randall , Iliff Jeffrey J
Published: October 2018

Late onset Alzheimer’s Disease (AD) is the most common form of dementia, affecting 40 million patients and countless families worldwide. AD is characterized by accumulation of amyloid beta (Aß) in the brain and central nervous system (CNS). A growing body of evidence indicates that while Aß production is unchanged, its clearance from the CNS is attenuated in late onset AD. Therefore, it is critical to determine how Aβ is cleared from the brain and if these processes differ in healthy and AD patients. Recently, two groups independently reported that a network of meningeal lymphatic vasculature participates in the clearance of solutes and macromolecules from the brain and cerebrospinal fluid of mice. However the presence of meningeal lymphatic vessels and their potential role in the clearance of Aß has not yet been defined in humans. Therefore, to determine if human meningeal lymphatic vessels absorb Aβ, we used immunofluorescence to examine superior sagittal sinus-associated dura mater tissue in a cohort of 21 patient samples including 6 subjects with no diagnosed dementia (control), 7 subjects with histopathologically confirmed AD, and 8 with diagnosis of mixed or other dementia. We found podoplanin (PDPN) positive, lumenized vessels in 19/21 patient samples, with 5/6 in control patients, 7/7 in AD patients and 7/8 in other or mixed dementia patients. These vessels were located in the dura mater, lateral to the superior sagittal sinus, and ranged from approximately 10 to 500 microns in diameter. Trace Aβ immunoreactivity was colocalized with podoplanin-positive vessels in 1/5 control, 1/7 AD, and 1/7 other or mixed dementia patients. Aß reactivity was found in meningeal blood vessels of 0/6 control, 1/7 AD, and 0/7 other or mixed dementia patients. To our knowledge, these data are the first to robustly support the existence of lymphatic vasculature in the human meninges. The data further suggest that Aß does not appear to widely deposit along wither these meningeal lymphatic or blood vessels, even among AD subjects.
Abstract WP412: Fibronectin Increases the Paravascular Deposition of Amyloid-β in Aging and Stroke
Authors: Howe Matthew D , Atadja Louise A , Furr Joseph W , Mohan Eric C , McCullough Louise D , Urayama Akihiko
Published: October 2018

Introduction:
Ischemic stroke is a major risk factor for cerebral amyloid angiopathy (CAA), which may be driven by alterations in the paravascular transport of cerebrospinal fluid (CSF) amyloid-β
1-40
(Aβ
40
) through the basement membrane (BM). Post-stroke BM thickening may favor CSF Aβ
40
deposition within brain microvessels. This study identifies BM fibronectin (FN) and its receptor, α5β1 integrin, as novel drivers of paravascular Aβ
40
deposition after stroke in aged animals.

Hypothesis:
We hypothesize that stroke-induced FN expression induces paravascular deposition of CSF Aβ
40
within the brain. This may worsen with aging due to increased FN binding to α5β1 integrin.

Methods:
Young (3 months-old) and aged (18 months-old) male mice were subjected to experimental stroke, and fluorescent tracers were intracisternally microinjected 30 days later to measure brain uptake of CSF Aβ
40
. BM thickening (lectin staining), as well as endogenous levels of FN and α5β1 integrin, were measured by immunohistochemistry and Western blot. To assess FN-Aβ
40
binding, naïve young and aged mice were intracisternally injected with FN or vehicle, and Aβ
40
uptake from CSF measured. Statistical significance was confirmed by two-way ANOVA with Dunnet’s post-hoc test.

Results:
Stroke enhanced paravascular Aβ
40
deposition compared to size-matched dextran in young animals (
p<.05
), which worsened with aging (
p<.001
). Interestingly, BM thickening positively correlated with paravascular Aβ
40
deposition after stroke in both age groups (R=.98,
p<.001
). Furthermore, FN levels increased in both young (
p<.05
) and aged (
p<.05
) cortex after stroke, with additional increases seen in α5β1 integrin expression in aged cortex at baseline (
p<.05
) and with stroke (
p<.01
). Finally, FN exhibited affinity for Aβ
40
in vitro
(IC50= 216nM), and FN infusion increased paravascular Aβ
40
deposition
in vivo
(
p<.05
), which worsened with aging (
p<.05
)
.

Conclusion:
These results indicate that FN induces paravascular Aβ
40
deposition after stroke. Furthermore, increased α5β1 integrin may ‘prime’ the aged vasculature for FN-Aβ binding, worsening Aβ
40
deposition after stroke in aged animals. Targeting FN-Aβ adhesion may provide a novel therapeutic avenue to reduce CAA in stroke survivors.
Abstract WP415: Posterior Distribution of White Matter Damage Correlates to Visuospatial Impairment in Cerebral Amyloid Angiopathy
Authors: Su Ya , Ling Yifeng , Dong Qiang , Cheng Xin
Published: October 2018

Introduction:
Several studies have revealed that patients with cerebral amyloid angiopathy (CAA) have cognitive decline relating to MRI changes especially white matter damage (WMD). CAA showing preference for posterior regions was in accordance with visual cortex, however few focused on visuospatial function and its related imaging makers in CAA.

Hypothesis:
Severity and distribution of WMD correlate to visuospatial function in CAA patients.

Methods:
We enrolled non-demented probable CAA patients based on modified Boston criteria in a single hospital, and normal elder people from Shanghai Aging Study. CAA-related WMD included WMH volumes and brain network connection changes measured by regional mean fractional anisotropy (FA), and was evaluated from aspects of severity (mean FA and WMH volumes) and distribution pattern (posterior-anterior gradient). CAA patients completed a standard cognitive test battery for visuospatial function and others. The association of WMD and cognitive domains were analyzed by univariate regression model.

Results:
28 non-demented CAA patients and 56 normal controls were enrolled. For WMD, CAA patients demonstrated prominently increased WMH volumes (3.89 mm
3
versus 28.84mm
3
, p<0.001) and posterior-anterior gradient (-22% versus 17%, p=0.004), and decreased posterior mean FA (0.365 versus 0.350, p=0.037), without differences in global and anterior mean FA. For cognitive function in CAA patients, there was no association between severity of WMD and any cognitive domain. Only posterior-anterior gradient of regional FA (β=0.538, p=0.015) and WMH volumes (β=-0.599, p=0.005) significantly related to visuospatial function, which was not found in other domains.

Conclusions:
Posterior predisposition of decreased brain network connections and increased WMH volumes correlated to visuospatial impairment, which might help to understand the possible mechanism of cognitive decline in CAA patients.
Abstract WP417: Novel Animal Model for Cerebral Small Vessel Disease
Authors: Ren Xuefang , Quintana Dominic , Hu Heng , Lewis Sara , Rellick Stephanie , Simpkins James W , Alvi Muhammad
Published: October 2018

Introduction:
Cerebral small vessel disease (SVD) is a common finding in patients with stroke. It can manifest as white matter hyperintensities (WMH), microbleeds or lacunar strokes. Presence of SVD is an independent risk factor for stroke and is considered a poor prognostic factor in stroke recovery. In addition, SVD has been associated with vascular dementia, depression and gait disorder. There are no good animal models to study SVD.

Hypothesis:
The precise mechanism behind development of SVD is not clearly understood. It’s likely a result of multiple different processes including decreased blood flow, inflammation with blood brain barrier disruption, degeneration and myelin breakdown. We try to study the role of reduced blood flow and inflammation in the development of SVD with the eventual goal of developing an agent that may prevent the development or progression of SVD.

Methods:
We remodeled a novel murine SVD model - asymmetric common carotid artery surgery (ACAS), published recently. We placed an ameroid constrictor around the right common carotid artery (CCA) which gradually narrows and eventually occludes vessels by releasing hygroscopic casein material, and a microcoil around the left CCA in mice. This model causes gradual narrowing of the vessels and a significant reduction of cerebral blood flow as detected by Laser Speckle Imager. These mice were compared to sham control which underwent a sham surgery without any vessel occlusion (n=7 per group). Animals were monitored for 30 days.

Results:
In the ACAS group, the model caused morbidity in all mice and death in 2 of 7 mice. Histologically, we observed marked vacuoles in white matter evaluated by H&E staining. We devised a severity score based on the extent of white matter damage and presence of infarcts under microscope. Based on this score, the damage was significantly worse in the ACAS group as compared with sham controls.

Conclusions:
These findings demonstrate the role of gradual blood flow reduction in development of SVD. We plan to further study the mechanisms behind SVD and develop novel treatments with the goal of preventing SVD.