bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T MP36: Indocyanine Green Videoangiography for Assessment of Postoperative Hyperperfusion in Moyamoya Disease
Authors: Horie Nobutaka , Morikawa Minoru , Fukuda Yuhtaka , Morofuji Youichi , Hiu Takeshi , Hayashi Kentaro , Izumo Tsuyoshi , Suyama Kazuhiko , Nagata Izumi
Published: March 2022

Introduction:
Postoperative cerebral hyperperfusion (HP) is a notable complication that occurs more frequently in moyamoya disease (MMD) than in atherosclerosis of unknown etiology. This study aimed to clarify the characteristics of intraoperative indocyanine green (ICG) videoangiography in MMD and atherosclerotic disease in terms of postoperative HP.

Methods:
This prospective study included 47 patients with 60 sides that underwent superior temporal artery (STA)-middle cerebral artery (MCA) single bypass. ICG videoangiography was performed after revascularization. The ICG time intensity curve was recorded in the STA, proximal MCA, distal MCA, and superficial Sylvian vein, and the angiographic differences among adult MMD, pediatric MMD, and atherosclerosis were analyzed.

Results:
Twenty two patients (27 sides) had adult MMD, 14 patients (22 sides) had pediatric MMD, and 11 patients (11 sides) had atherosclerosis. Postoperative HP was significantly higher in adult MMD (40.7%) than in pediatric MMD (18.2%) and atherosclerosis (0%). Adult MMD with HP was associated with a longer ICG peak time (P<0.001). There was no significant difference in ICG peak time among presentations in MMD, and no correlation between ICG peak time and preoperative hemodynamic parameters. The ratio of the vessel caliber was also higher in adult MMD with HP (P<0.001).

Conclusions:
ICG videoangiography provides different characteristics of bypass flow among adult MMD, pediatric MMD, and atherosclerosis. Poor distribution and run-off of blood flow from the STA might contribute to postoperative HP in MMD. The occurrence of postoperative HP in MMD could depend on two factors: host STA size and recipient MCA integrity.
Abstract T MP37: Fractional Anisotropy Changes in the Acute Stroke Phase Only Modestly Predict Motor Outcome at 3 Months
Authors: Doughty Christopher , Wang Jasmine , Schlaug Gottfried
Published: March 2022

Background:
A decrease in fractional anisotropy (FA) of the ipsilesional corticospinal tract (CST) distal to ischemic stroke lesions in chronic stroke patients has been associated with poor motor outcome, but in the acute phase no clear FA trends have been observed or used to make outcome predictions.

Methods:
This study followed 40 patients with first-ever ischemic stroke, measuring motor impairment with the Upper Extremity Fugl-Meyer (UE-FM) acutely and at 3 months. Images obtained <3 days after stroke, including FA, were overlaid with a probabilistic CST (blue in Figure 1) derived from healthy subjects to define a cerebral peduncle region of interest ROI and a “nearest slice” ROI (green line in Figure 1), the second slice downstream from the stroke lesion (red in Figure 1). Ipsilesional and contralesional CST FA values as well as Apparent Diffusion Coefficient (ADC) values of regions of interests were compared using a laterality index and related to 3-month motor outcome.

Results:
Asymmetry between ipsilesional and contralesional CST FA values was significant different between patients with bad motor outcome and good outcome, with lower FA of the ipsilesional CST in the bad outcome group. No such asymmetry was seen for the cerebral peduncle ROI using either FA or ADC values. The FA laterality index for the nearest slice ROI was a significant but modest predictor of 3-month motor outcome (R2=0.186, p=.02), with the best predictive value offered by the combination of this imaging variable and the initial motor impairment (R2=0.696, p=.01).

Conclusion:
FA changes of the CST can be detected near the ischemic lesion in the acute phase after stroke, but these changes offer only modest predictive value for eventual motor outcome.
Abstract T MP40: A Home-Based Telerehabilitation System for Patients With Stroke
Authors: Dodakian Lucy , McKenzie Alison , Burke Erin , See Jill , Zhou Robert , Augsberger Rene , Cramer Steven C
Published: March 2022

Evidence suggests that greater duration and intensity of rehabilitation therapy improves outcomes for patients with stroke. Delivery of care is often limited, however, e.g., due to systems of care delivery, cost, rural location, or difficulty travelling. The current study addressed this unmet need by examining the feasibility of a home-based telerehabilitation system. Entry criteria included age >18 yrs, 12-26 wk post stroke, and arm motor deficits (Fugl-Meyer (FM) score 22-55) that were stable. Each subject received 28 d of daily home-based telerehabilitation using a fixed system that we delivered/assembled. Each day consisted of 1 structured hour (testing, BP check, individualized exercises and games, and stroke prevention education) plus up to 1 hour of free play on dozens of games. Each week, subjects had a 1 videoconference with a licensed therapist and 1 with a research assistant; subjects could also phone the lab for technical support if needed. Enrollees were 54±17 yr (mean±SD), 6M/6F, with baseline FM=39±12 (range 23-55). Compliance was excellent, with subjects engaging in therapy 329 of 336 (97.9%) assigned days. Arm motor status improved (FM change 4.8±3.8 points from baseline to 1 mo post-therapy, p=0.0015). Although scores on tests of computer literacy declined with age (r = -0.90 to -0.92, p<0.0001), as expected, the arm motor gains derived from use of this system did not vary with age. The stroke education module was associated with significant gains in stroke prevention knowledge. BP was recorded by the patient, and results automatically transmitted to lab, on 97.9% of assigned days. Therapist videoconferences detected PHQ-2 scores consistent with depression in 3/12 patients. Therapists were able to review patient performances and upload revised therapy settings to the patient’s home system without difficulty at any time of day. Results of this pilot study support the utility of a home-based system to effectively deliver telerehabilitation, improve patient education, screen for complications of stroke, and as well as to provide a means for patient interaction with medical personnel. The use of a computer-based interface offers many opportunities to monitor and improve the health of patients after stroke.
Abstract T MP45: Ethnic Differences in Access to Post-acute Care Following Stroke: The BASIC Project
Authors: Lisabeth Lynda , Ifejika-Jone Nneka , Horn Susan , Wheaton Michael , Skolarus Lesli , Garcia Nelda , Smith Melinda , Morgenstern Lewis
Published: March 2022

Background:
Mexican Americans (MAs) have worse post-stroke functional and neurologic outcomes than non-Hispanic whites (NHWs). Ethnic differences in utilization and intensity of post-acute care (PAC) are possible explanations. We tested the hypothesis that MAs have less utilization and less intense PAC than NHWs in a bi-ethnic stroke population.

Methods:
Stroke patients (n=393) were identified from the BASIC Project (2009-2011). Patients admitted from a nursing home and those discharged to a setting other than home or institutional PAC were excluded. Ethnicity was based on self-report. Utilization of any institutional PAC (inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF)) following hospital discharge was determined from UB-92 claims forms. Intensity of rehabilitation was explored by comparing utilization of IRF versus SNF among those receiving PAC. Hierarchical logistic regression models to account for clustering of patients within hospitals were used to determine the associations between ethnicity and utilization and intensity of PAC. Models were run unadjusted and adjusted for demographics (age, sex), socioeconomic status (insurance, education), clinical stroke factors (NIHSS, stroke type), and pre-stroke factors (comorbidity index, pre-stroke function, pre-stroke cognition).

Results:
Sixty-three percent were MA (n=249); 49% (n=194) were women. Median age was 66 (IQR: 57-78); median NIHSS was 4 (IQR: 2-8). Among MAs, 64% were discharged to home, 21% to a SNF and 15% to an IRF. Among NHWs, 53% were discharged to home, 26% to a SNF, and 22% to an IRF. In the unadjusted model MAs were 39% (OR=0.61; 95% CI: 0.39, 0.94) less likely to utilize institutional PAC than NHWs. After adjustment, MAs were 41% (OR=0.59; 95% CI: 0.32, 1.09) less likely to utilize institutional PAC than NHWs. Among those who utilized PAC there were no ethnic differences in intensity (IRF vs SNF) in unadjusted (p=0.36) or adjusted (p=0.63) analyses.

Conclusion:
We found a trend towards MAs having less utilization of PAC than NHWs following stroke. Additional research with more refined measures of PAC is needed to understand the role that access to, and effectiveness of, rehabilitative services play in ethnic differences in post-stroke outcomes.
Abstract T MP5: Primary Aspiration Thrombectomy With the Penumbra Max Catheter System Allows Rapid Recanalization and Cost Efficiency in Acute Stroke Treatment
Authors: Sivapatham Thinesh , Lassig Jeffrey , Goddard James , Madison Michael , Porth Karen , Stein Lana , Castle Amy , Kolbow Melissa , Hanson Sandra
Published: March 2022

Introduction:
Rapid recanalization remains the goal of acute stroke therapy. Cost effectiveness in stroke treatment is becoming more important. With newer devices such as stentrievers, and improvements upon the older Penumbra aspiration catheters, recanalization rates have improved, but often at the expense of cost containment in stroke treatment.

Hypothesis:
We assessed the hypothesis that primary aspiration thrombectomy for endovascular acute stroke treatment with the newer Penumbra Max catheter system can be performed effectively and at a reduced cost as compared to other available devices

Methods:
We retrospectively reviewed prospectively collected data in 124 patients who underwent endovascular treatment for acute ischemic stroke at our institution from 1/1/2011 through 6/30/2013. All devices were freely available for use. However, from 1/1/2013 through 6/30/2013, we agreed to use aspiration with the Penumbra Max catheter system as the primary technique for thrombectomy, with other devices, including the Penumbra Separator and Solitaire device, available if primary aspiration failed. Variables evaluated were techniques/devices used, recanalization rates, procedural fluoroscopy times (as a relative marker of recanalization times between techniques), and procedural costs.

Results:
Successful recanalization (TICI 2b/3) was achieved in 77% of all cases, with a total ICH rate of 12.1% and sICH of 2.4%. From 1/1/2013 through 6/30/2013 28 patients were treated with primary aspiration using Penumbra Max, with a recanalization rate of 90%. A separator was used in 3 cases and a Solitaire device in 1 patient; with these devices total recanalization was 96%. Primary aspiration using the older Penumbra catheters yielded a recanalization rate of only 59%. Solitaire (n=9) was successful in 70%. TICI 3 recanalization rates were 60% for Penumbra Max, 23% for older Penumbra catheters, and 20% for Solitaire. Average cost/case using the Penumbra Max system was $3243, compared to $5924 as a baseline, yielding a 55% savings. Average fluoroscopy time for Penumbra Max was 22 mins, compared to 36 mins for the older Penumbra catheters and 24 mins for Solitaire.

Conclusions:
The Penumbra Max system is clinically and cost effective in stroke thrombectomy.
Abstract T MP52: Treatment Times are Reduced by Prehospital Initiation of Neuroprotective Stroke Therapy
Authors: Sanoff Randy , Cherin Samantha B , Sanossian Nerses , Conwit Robin , Hamilton Scott , Eckstein Marc , Stratton Samuel , Pratt Franklin , Liebeskind David , Ali Latisha , Kim- Tenser May , Restrepo Lucas , Valdes- Sueiras Miguel , Starkman Sidney , Saver Jeffrey L ,   For The FAST-MAG Investigators and Coordinators
Published: March 2022

Background:
In a typical stroke, every minute the brain loses 1.9 million neurons. An increasing focus of stroke treatment is early initiation. Paramedic initiation of stroke therapy can improve the time from symptom onset to treatment in patients suffering an acute stroke. We sought to characterize the time of prehospital therapy initiation relative to symptom onset, paramedic on-scene arrival and emergency department arrival.

Methods:
All subjects were enrolled in the Field Administration of Stroke Therapy- Magnesium (FAST-MAG) clinical trial, a phase 3 trial of prehospital treatment with magnesium or placebo for patients with a symptom onset less than two hours. Subjects were assessed in the field by paramedics and provided consent via cellular contact with study investigator-physician prior to treatment.

Results:
The 1700 patients enrolled in the FAST-MAG clinical trial, had a mean age of 69 [SD 14] years, 57% were male, 23% were of Hispanic ethnicity, 78% White race, 78% had pre- existing hypertension, 22% with diabetes, and 49% with hyperlipidemia. They called 911 a median [IQR] of 16 [8-36] minutes, and were assessed by on-scene paramedics 24 [15-43] minutes after symptom onset. Paramedics initiated treatment 23 [18-28] minutes after they were on-scene and 10 [5-14] minutes prior to ED arrival. Initial imaging was obtained 28 [19-40] minutes after arrival to the ED. The treatment initiation was 43 [33-58] minutes after symptom onset.

Conclusion:
Pre- hospital initiation of the stroke therapy achieved a time to treatment within 60 minutes in over 75% of cases and led to the earliest recorded treatment trials in a stroke study. The strategy of prehospital initiation is an effective means in reducing time from symptom onset to treatment.
Abstract T MP55: Implementation of an Emergency Department Stroke Unit Improves Clinical Outcomes for Acute Ischemic Stroke Due to Shorter Times to Treatment
Authors: Elijovich Lucas , Al Wafai Ameer , Lennon Joshua , Phillips Jennifer , Wright Leesa , Wahba Mervat , Walther Ray
Published: March 2022

Introduction:
The benefits of IV TPA and endovascular AIS therapy (EVT) have been demonstrated to be time dependent. We hypothesized that a stroke unit embedded in the emergency department (ED) would provide more efficient delivery of acute ischemic stroke (AIS) therapy and result in improved clinical outcomes.

Methods:
Retrospective chart review was performed of the University of Tennessee Health Science Center prospective database of AIS from January 2011 to December 2012 to identify patients treated with IV TPA with or without EVT. The ED stroke unit (EDSU) is run by nurses trained to clinical competencies of our institution’s neurocritical unit. EDSU nurses are only assigned two patients within the unit. Baseline characteristics and details of treatment were abstracted for patients treated in the EDSU and general ED population. Univariate analysis was performed with Chi Square and Student's T-tests. Stepwise multivariate regression analysis (sMVR) was performed to compare characteristics and outcome of patients treated in the two ED locations.

Results:
A total of 160 patients were treated with IV TPA during the study period with 70 treated in the EDSU. Thirty-three patients also received EVT. The average age was 62.2 and mean NIHSS was 10.8. Univariate analysis demonstrated that cocaine use (8.4% vs. 0.0, p=0.02) and smoking (73% vs. 30%, p=0.01) were more common in the ED population while previous stroke (59.0% vs. 21.6%p=0.006) was significantly more frequent in the EDSU group. NIHSS at presentation and discharge were lower in the EDSU (9.4 vs. 12.0, p = 0.006 and 4.3 vs. 6.1, p=0.03). Door-to-needle (DTN) for IV TPA and door to arterial puncture (DAP) for EVT were both significantly shorter in the EDSU (58.7 vs. 74.9 minutes, p=0.0002 and 101 vs. 155, p=0.003). sMVR confirmed that patients in the EDSU had significantly shorter DTN for IV TPA (p=0.0005) and DAP for EVT (p=0.02). sMVR also demonstrated that improved outcome was due to significantly shorter IV TPA DTN time (p=0.04) regardless of location.

Conclusion:
The implementation of an EDSU improved the delivery of time sensitive acute ischemic stroke therapies resulting in improved outcomes. This study supports the investment of resources in ED systems of care specifically tailored to AIS.
Abstract T MP58: Asymptomatic Hemorrhagic Transformation after Acute Ischemic Stroke: Is It Clinically Innocuous?
Authors: Wu Bo
Published: March 2022

Background and Purpose:
Whether asymptomatic hemorrhagic transformation (HT) is clinically innocuous, i.e. unassociated with clinically detectable neurological deterioration, remains an open question. To explore this, we examined whether asymptomatic HT affects long-term mortality, disability and risk of stroke recurrence.

Methods:
We consecutively and prospectively enrolled patients with acute ischemic stroke who were admitted to our hospital. Based on clinical and imaging data, patients were diagnosed as having asymptomatic HT or not, and the two groups were compared in terms of basic clinical characteristics, functional outcomes, mortality, and stroke recurrence.

Results:
Of the 1764 patients enrolled, 143 (8.1%) presented with asymptomatic HT. These patients were more likely to be male, to have experienced atrial fibrillation and cardioembolic stroke, and to have higher NIHSS score on admission than were patients without asymptomatic HT. After adjusting for age, gender, and NIHSS score on admission, the proportion of patients with disability was significantly higher among those with asymptomatic HT than among those without, both at 3 months and 1 year. However, risk of mortality was not significant after adjusting the data. Nevertheless, patients with asymptomatic HT showed a significantly lower cumulative one-year survival rate than did those without asymptomatic HT (P=0.02). Both groups of patients showed similar rates of cumulative stroke recurrence at 1 year (P = 0.54).

Conclusions:
Asymptomatic HT after acute ischemic stroke worsened long-term clinical outcomes, although it did not affect risk of stroke recurrence. These findings suggest that asymptomatic HT should not be considered clinically innocuous.
Abstract T MP61: Cognitive Impairment and Incident Stroke: A Systematic Review and Meta-analysis
Authors: Lee Meng , Saver Jeffrey L , Hong Keun-Sik , Wu Yi-Ling , Liu Hsing-Cheng , Ovbiagele Bruce
Published: March 2022

Background:
Cognitive impairment may be associated with future stroke risk, but results of published studies have been inconsistent.

Objective:
To clarify the qualitative and quantitative relationship of cognitive impairment to incident stroke.

Methods:
We conducted a systematic search of PUBMED and EMBASE from 1947 to February 2013. Inclusion criteria were cohort studies, cognitive function evaluations at baseline, incident stroke ascertainment, follow-ups of at least 1 year, and reporting of quantitative estimates of multivariate adjusted relative risk (RR) and 95% confidence interval (CI) or standard error for stroke associated with cognitive impairment. Two independent reviewers extracted data. Estimates were combined using a random effects model.

Results:
We identified 16 cohort studies with 119,720 participants and 7,688 stroke events. Nine studies used the Mini-Mental State Examination (MMSE) to assess cognitive function, while 7 studies used other cognitive measures. Incident stroke increased among people with baseline cognitive impairment (RR 1.36, 95% CI 1.21 to 1.53, P < 0.001), but significant heterogeneity existed (I2=83%, P< 0.001) (Table). Stratified analysis showed severe cognitive impairment was associated with higher incident stroke risk than mild cognitive impairment (RR 1.55, 95% CI 1.35 to 1.76 vs. RR 1.22, 95% CI 1.13 to 1.31, P for heterogeneity among groups = 0.002), which likely contributed to the heterogeneity among studies.

Conclusions:
Baseline cognitive impairment is associated with a higher risk of incident stroke, even among people with mild cognitive impairment. Cognitive impairment should be more broadly recognized as a possible early clinical manifestation of vascular brain injury, so timely vascular risk factor management can be instituted to potentially avert future strokes and avoid further deterioration of cognitive health.
Abstract T MP72: Temporal Trends in Public Awareness of Stroke Warning Signs and Risk Factors
Authors: Anderson Aaron M , Khoury Jane C , Rademacher Eric , Kissela Brett M , Woo Daniel , Flaherty Matthew L , Khatri Pooja , Adeoye Opeolu , Ferioli Simona , Pancioli Arthur , Broderick Joseph P , Kleindorfer Dawn O
Published: March 2022

Introduction:
Delay in seeking medical attention after stroke symptom onset is the most common reason for low rates of thrombolytic use for ischemic stroke. This may be related to poor recognition of stroke symptoms or lack of awareness of time-sensitive stroke treatments. We describe public knowledge of stroke warning signs (WS) and risk factors (RF), and changes over time.

Methods:
Survey respondents were drawn from our biracial population of 1.3 million using random-digit dialing in 1995, 2000, 2005, and 2011 to reflect the age, race, and gender distribution of stroke patients, based on an ongoing stroke incidence study in the same region. Participants were asked open-ended questions regarding stroke WS and RF. Comparisons over time were made using Armitage test for trend, and multiple logistic regression was used to adjust for covariates.

Results:
Over the study period, 8245 surveys were completed. As shown in the figure, knowledge of 3 correct WS improved steadily over time from 5.4% to 22.6% (p<0.001), and knowledge of 3 correct RF has also improved over time from 2.6% to 5.8% (p<0.001), but has remained relatively low. These improvements in knowledge persisted after controlling for differences in age and education between study periods.

Conclusions:
Public awareness of stroke WS and RF steadily improved from 1995 to 2011. These findings highlight the success of increasing community awareness of stroke WS and RF. Further research is needed to determine if increased stroke awareness leads to changes in care-seeking health behavior and improved stroke prevention.

Figure 1: Comparison of Knowledge of Stroke Warning Signs and Risk Factors between Survey Years, Greater Cincinnati/Northern Kentucky Population
Abstract T MP74: The Effect of Elevated Factor VIII on Glycemic Control in Acute Ischemic Stroke Patients
Authors: Halstead Michael , Gouse Brittany M , Monlezun Dominique J , Brag Katherine , Siegler James E , George Alexander J , Schluter Laurie , El Khoury Ramy , Martin Schild Sheryl
Published: March 2022

Background:
Elevated Factor VIII (FVIII) levels are associated with diabetes mellitus (DM) and hyperglycemia and are common in acute ischemic stroke (AIS). We sought to investigate if elevated FVIII would be associated with insulin administration during hospitalization for AIS.

Methods:
We retrospectively analyzed 219 patients who presented to our center from 07/2008-12/2012 with AIS. Cases were grouped by peristroke FVIII levels (normal: 50-150%; elevated: >150 %;), with a priori subgroup analysis restricted to those with severely elevated FVIII >200%. Per standard orders, glucose is measured at least every 6hrs during the first 48hrs and is treated when >160mg/dl with sliding scale insulin. The odds ratios of receiving various forms of insulin were calculated using logistic regression in four sequentially adjusted models: (1) unadjusted, (2) demographics, (3) added baseline NIHSS and admission glucose and (4) added variables significant in univariate analysis.

Results:
Patients with elevated FVIII (n=143) were more likely Black, have a history of diabetes and have higher serum glucose and HbA1C’s on admission. Patients with elevated FVIII received more insulin/day than patients with normal FVIII (median 0.71 units vs 0 units, respectively, p=0.0014). In fully adjusted models, insulin use did not differ between normal or elevated FVIII levels. Patients with severely elevated FVIII, however, were 16 times more likely to receive intermediate/long acting insulin to treat hyperglycemia, compared to those with normal FVIII. The presence of severely elevated FVIII elevations did not predict insulin requirements in adjusted models.

Conclusion:
Our results further support a relationship between FVIII and elevated glucose, particularly in the setting of AIS when hyperglycemia is predictive of poor outcome. Further study is needed to investigate if elevated FVIII levels drive or simply reflect hyperglycemia and may help guide glycemic management in AIS patients.
Abstract T MP8: The Thrive Score Strongly Predicts Outcomes in Patients Treated With the Solitaire Device in the Swift and Star Trials
Authors: Flint Alexander , Mendes Pereira Vitor , Levy Elad I , Saver Jeff , Jovin Tudor , Liebeskind David , Nogueira Raul , Jahan Reza , Cullen Sean
Published: March 2022

Introduction:
The THRIVE score strongly predicts clinical outcome, mortality, and risk of thrombolytic hemorrhage in ischemic stroke patients, and performs similarly well in patients receiving IV tPA, endovascular stroke treatment (EST), or no acute treatment. We recently validated the performance of the THRIVE score in the TREVO-2 trial of a third generation EST device, the Trevo device

Methods:
We examined the relationship between THRIVE and clinical outcomes (good outcome [mRS 0-2] or death at 90 days) among patients in SWIFT and STAR. Receiver-Operator Characteristics (ROC) curve analysis was used to compare THRIVE score performance to other stroke prediction scores. Multivariable logistic regression was used to confirm the independence of THRIVE score from procedure-specific predictors (target vessel recanalization or device used in SWIFT) of outcome.

Results:
THRIVE score strongly predicted good outcome (Figure, A) and death (Figure, B) among patients treated with the Solitaire device in SWIFT and STAR (Mantel-Haenztel Chi-square test for trend P<0.001 for good outcome, P=0.01 for death). In ROC curve comparisons, THRIVE was superior to SPAN-100 (P<0.001) and performed similarly to HIAT (P=0.98) and HIAT-2 (P=0.54). In logistic regression, THRIVE’s prediction of good outcome was not altered after controlling for recanalization (in all Solitaire patients) or after controlling for device used (in the SWIFT RCT).

Conclusions:
The THRIVE score strongly predicts clinical outcome and mortality in patients treated with the Solitaire device in the SWIFT and STAR trials. The lack of interaction between THRIVE and procedure-specific elements such as vessel recanalization or device choice supports the use of the THRIVE score as an a priori selection criterion in stroke clinical trials.
Abstract T MP81: Combination Therapy of Intravenous Glycoprotein IIb-IIIa Inhibitors and Low Dose Tissue Plasminogen Activator for Acute Ischemic Stroke
Authors: Dubey Divyanshu , Banerjee Chirantan , Sawhney Anshudha
Published: March 2022

Introduction:
Glycoprotein IIb/IIIa (Gp IIb/IIIa) inhibitors block platelet aggregation following fibrinolysis. No phase III randomized clinical trial has assessed efficacy of combination therapy [Gp IIb/IIIa + IV tissue plasminogen activator (tPA)] to standard of care in acute ischemic stroke.

Aim:
To conduct a retrospective pooled analysis of data from published prospective studies and randomized phase 1 and 2 trials, to assess efficacy and safety profile of IV combination therapy (Gp IIb/IIIa inhibitors and tPA) in management of acute ischemic stroke.

Methods:
We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed and EMBASE databases, and 3 reviewers independently selected studies reporting safety endpoints and outcome measures in acute ischemic stroke patients treated with low dose tPA + eptifibatide. Demographic/ clinical variables: sex, age, NIH stroke scale (NIHSS) at presentation and Time-to-treatment, Safety endpoint: symptomatic intracranial hemorrhage (sICH), as well as outcome measures: Death at 90 days and modified Rankin score (mRS) 0-1 were consolidated into the two groups. tPA arm of the NINDS tPA trial was included in the tPA only group. Weighted means and proportions were calculated for numeric and categorical variables respectively. Bivariate analysis to compare baseline descriptors, safety endpoints and outcome measures consisted of Fisher’s exact test.

Results:
188 patients comprised the combination therapy arm, whereas the IV tPA arm had 218 patients. Mean NIHSS in the two groups were 12.8 and 14.6 respectively. Mean time-to-treatment was 2.3 hours in combination therapy arm and 2.55 hours in the tPA arm. Treatment with combination therapy was associated with a better functional outcome (mRS 0-1) (OR 1.79, 95% CI 1.15 - 2.80, p <0.01) at 90 days. There was also a significant reduction in the rate of sICH (OR 0.26, 95% CI 0.07 - 0.83) in the combination therapy group. Death at 90 days was not significantly different in the 2 groups (OR 1.26, 95% CI 0.73 - 2.18).

Conclusion:
Combination of low dose IV tPA with Gp IIb/IIIa inhibitor is associated with a better functional outcome at 90 days, as well as a reduction in sICH rates in patients with acute ischemic stroke, as compared to 0.9g/kg IV tPA.
Abstract T MP87: Comparison of Medicare Claims vs. Physician Adjudication for Identifying Acute Strokes in the Women's Health Initiative
Authors: Lakshminarayan Kamakshi , Larson Joe , Virnig Beth , Burwen Dale
Published: March 2022

Background:
Many clinical trials and observational studies use medical record review for ascertaining outcomes. One large, long-running study, the Women’s Health Initiative (WHI) ascertains stroke events using participant self-report and subsequent physician review of medical records. This is resource-intensive.

Purpose:
To assess whether Medicare data can reliably ascertain stroke events in the WHI.

Methods:
Subjects were WHI participants with fee-for-service Medicare coverage. Stroke events from the start of WHI in 1993 through 2007 were included. Discharge diagnoses in hospitalization claims were used to create 4 stroke definitions for Medicare data. Definition 1: stroke codes in any position; Definition 2: primary position stroke codes; Definitions 3: hemorrhagic stroke codes; Definition 4: ischemic stroke codes. WHI data were randomly split into training (50%) and test sets. A concordance matrix was used to examine agreement between WHI and Medicare stroke diagnosis. Algorithm performance was optimized on the training data set. A WHI stroke and a Medicare stroke were considered a match if they occurred within +/- 7 days of each other. We excluded cases where medical records were unavailable and those without a reported WHI event within 7 days of Medicare stroke (n=239).

Results:
Training data (n=24,428): There were 577 WHI strokes and 557 Medicare strokes using definition 1. Of these, 478 were a match as defined above. Algorithm performance: Specificity (SP) 99.7%; Negative Predictive Value (NPV) 99.7%; Sensitivity (SN) 82.8%; Positive Predictive Value (PPV) 85.8%; kappa 0.84. Test data set (n=24,422, see Table: Definition 1, algorithm performance was SP 99.7%, NPV 99.7, SN 82.0, PPV 84.6, kappa 0.83. Results were similar for all 4 stroke definitions.

Conclusion:
Our study provides insights about the performance characteristics of Medicare data that can facilitate appropriate use of these vast data sources for outcome ascertainment in large studies.
Abstract T MP9: Analysis of MR RESCUE Dataset Employing DEFUSE 2 Target Mismatch Criteria for Defining Penumbra
Authors: Kidwell Chelsea S , Jahan Reza , Gornbein Jeffrey , Alger Jeffry R , Nenov Val , Ajani Zahra , Feng Lei , Meyer Brett C , Olson Scott , Schwamm Lee H , Yoo Albert J , Marshall Randolph S , Meyer Philip M , Yavagal Dileep R , Wintermark Max , Norato Gina , Russell Laura , Hsieh Courtney , Guzy Judy , Starkman Sidney , Saver Jeffrey L ,   MR RESCUE Investigators
Published: March 2022

Background:
The MR RESCUE trial failed to show a benefit of endovascular therapy over standard medical care for first generation thrombectomy devices within 8 hours of onset of acute ischemic stroke. We now report a subset analysis of patients enrolled with MRI, employing DEFUSE 2 criteria to define favorable penumbral pattern (target mismatch) which differed from MR RESCUE penumbral prediction criteria.

Methods:
Patients with large vessel, anterior circulation strokes were randomized to mechanical embolectomy (Merci Retriever or Penumbra System) or standard care. Patients were categorized as having a favorable penumbral or non-penumbral pattern employing the DEFUSE 2 criteria for target mismatch ([Tmax > 6s / thresholded ADC < 600 х 10
−6
mm
2
/s] > 1.8, thresholded ADC < 70 cc, and Tmax > 10 s < 100 cc).

Results:
Among 118 total patients, 94 qualified for this analysis. Mean age was 65.8, mean time to enrollment 5.6 hours, median NIHSS 17, and 47% had target mismatch. Predicted core volume using DEFUSE 2 criteria (thresholded ADC volume < 600 х 10
−6
mm
2
/s) was 18.8 cc (target mismatch) and 64.3 cc (non-target mismatch; p<0.001). Revascularization in the embolectomy group was achieved in 62% (TICI 2a-3), and 21% (TICI 2b-3). Among all patients, mean 90-day mRS scores did not differ between embolectomy and standard care (3.8 vs 3.8; p=0.92). In patients with target mismatch, embolectomy was not superior to standard care (mean mRS 3.5 vs 3.3, p=0.78). Similarly, in patients without target mismatch, embolectomy was not superior (4.1 vs 4.3, p=0.67). Furthermore, there was no interaction between pretreatment penumbral imaging pattern employing DEFUSE 2 target mismatch criteria and treatment assignment in these 90-day mRS scores (p=0.11).

Conclusions:
In this analysis MR RESCUE patients enrolled with pretreatment MRI, use of the DEFUSE 2 criteria for target mismatch as a definition of penumbral pattern failed to identify a subset of patients with improved outcomes when treated with embolectomy. Further randomized, controlled studies employing new generation thrombectomy devices are needed to validate target mismatch as a selection criterion for acute stroke treatments.
Abstract T MP94: Congestive Heart (or Cardiac) Failure: Risk Factors, Clinical Features and Outcomes in Patients With an Acute Ischemic Stroke
Authors: pongmoragot jitphapa , Saposnik Gustavo , Lee Douglas , Park Tai Hwan , Fang Jiming , Austin Peter
Published: March 2022

Introduction:
Congestive heart failure (CHF) is a relatively common comorbid condition in stroke patients. Limited information is known regarding CHF in patients with an acute ischemic stroke (AIS).

Objective:
We evaluated clinical characteristics, predisposing factors, and outcomes in stroke patients with history of CHF.

Methods:
We prospectively included AIS patients admitted to the institutions participating in the Registry of the Canadian Stroke Network (RCSN) between 2003 and 2008. History of chronic congestive heart failure (CHF) determined from medical records, physical examination and investigations. Primary outcome was death or disability at discharge (modified Rankin scale equal to or greater than 3). Secondary outcomes included admission ICU, disposition, length of hospital stay, death at 3 months and at 1 year and 30 day hospital readmissions. Logistic regression and survival analyses were performed to determine the association of risk factors with the outcomes of interest.

Results:
Among 12,686 patients with AIS, CHF was found in 1152 (9.1%) of patients. Mean age was 78.5±11 years. CHF patients were more likely to have hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, atrial fibrillation, vulvular heart disease and peripheral vascular disease. CHF more likely presented with a severe stroke (25.8% vs 14.1%, p<0.0001) and cardioembolic stroke subtype (42.2% vs 21.3%, p<0.0001). CHF was associated with higher risk of death at 30-days (24.2% vs 11.2%; p<0.0001) and at 1-year (44% vs 20.6;p<0.0001) and disability at discharge (70.3% vs 56%; p<0.0001). Mean length of stay was longer in stroke patients with CHF (15.51±23.91 vs 12.65±19.76 ; p=0.013). In the multivariate analysis, CHF (OR 1.18; 95%CI 1.01- 1.37) was an independent predictor of death and disability after adjusting age, stroke severity, and other comorbid conditions.

Conclusions:
In this large cohort study, CHF occurred in 9.1% of AIS patients. Stroke patients with CHF had poorer outcomes and longer hospitalization. Furthermore, after adjusting age, stroke severity and comorbidity, CHF was an independent predictor of death and disability.
Abstract T MP97: Efficacy of Poststroke Intensive Rosuvastatin Treatment for Aortogenic Embolic Stroke: Episteme Trial
Authors: Ueno Yuji , Yamashiro Kazuo , Tanaka Yasutaka , Watanabe Masao , Shimada Yoshiaki , Kuroki Takuma , Miyamoto Nobukazu , Daimon Masao , Tanaka Ryota , Miyauchi Katsumi , Daida Hiroyuki , Hattori Nobutaka , Urabe Takao
Published: March 2022

Background:
Large atheromatous aortic plaques (AAPs) are associated with stroke recurrence. Rosuvastatin is a potent lipid-lowering agent and repress atherosclerosis. Whether rosuvastatin has anti-atherogenic effect for AAPs in stroke patients has been unclear. We performed repeated transesophageal echocardiography (TEE) examinations and analyzed the changes of AAPs after rosuvastatin treatment in stroke patients.

Methods:
This trial is prospective randomized open label study. Inclusion patients were acute ischemic stroke with hypercholesterolemia and AAPs ≥4 mm in thickness on TEE. The patients are randomly assigned to either a group treated with 5 mg/day rosuvastatin or a control group. Primary endpoint is the changes in volume and composition of AAPs after 6 months using TEE. Biochemical findings are analyzed. By using repeated TEE and binary image analysis, we compared the dynamic changes in plaque composition of AAPs before and after therapy in the two groups.

Results:
102 patients were undergoing TEE, and 23 had AAPs greater than 4 mm in thickness. Of them, 16 patients (age, 68±9 years; 16 male) with acute ischemic stroke were undergoing repeated TEE and enrolled to the study. The rosuvastatin-treated and control groups had 9 and 7 patients, and 16 and 16 AAPs ≥4mm, respectively. In the rosuvastatin-treated group, the changes in low-density lipoprotein-cholesterol (LDL-C), non-high-density lipoprotein-cholesterol (non-HDL-C), and LDL-C/HDL-C ratio from baseline to end of follow-up were -42.7±10.2%, -38.5±11.1%, and -41.9±8.9%, respectively, which reached significant differences compared to the control (P<0.05). In repeated TEE, there was no significant difference in changes of plaque size among two groups. Rosuvastatin significantly increased high-echoic plaques area from baseline to end of follow-up, whereas the control group showed decrease in high-echoic plaques area (58.2±63.7 vs –14.3±31.5, P<0.001).

Conclusions:
Rosuvastatin improved lipid profiles, and exerted robust morphological change of AAPs from lipid-rich to fibrous content. The EPISTEME trial provided an evidence for a therapeutic strategy for aortogenic brain embolism.
Abstract T P11: Motor Component of National Institute of Health Stroke Scale Effect on Functional Outcome and Mortality at Discharge in Patient Receiving Endovascular Therapy
Authors: Dababneh Haitham , Bashir Asif , Hussain Mohammed , Misthal Sara , moussavi mohammad , Kirmani Jawad
Published: March 2022

Background and Purpose:
Predicting the patient outcome after a vascular event can be very challenging. The National Institute of Health (NIH) developed a standardized scale to evaluate the severity of a stroke at presentation. The objective of this analysis was to study the effect of the motor component of the NIH Stroke Scale (NIHSS) on a patient’s functional outcome at discharge.

Methods:
This is a retrospective analysis of all patients (n= 97) that presented to our hospital with ischemic stroke and received mechanical thrombectomy between January 2009 and July 2012 and had all the components of NIHSS baseline documented at presentation. Statistical analysis was performed using the R statistical package and XLSTAT-Pro 2011. Spearman correlations (P value <0.05) for non-normally distributed data were used to independently evaluate the correlation of each of the NIHSS components with patient functional outcome at discharge using modified rankin scale (mRS). mRS of 2 or less represented a good functional outcome.

Results:
Group analysis including gender, mean age, mean NIHSS and mortality at discharge was as follows: Female 49.5%, 72.9, 14.7 and 13.4%. All Motor components of NIHSS had a significant correlation (Rho=0.24, P value <0.05) with poor patient outcome at discharge, meaning a higher motor score at presentation represented a worse outcome at discharge. A higher NIHSS had a significant correlation with poor functional outcome (Rho=0.41, P value <0.05).

Conclusion:
In conclusion, admission motor grade may serve as a good predictor of disability and mortality in patients undergoing mechanical thrombectomy with acute ischemic stroke. Further validation by a prospective study with a larger sample size is warranted.
Abstract T P112: Independent Contributions of Education, Anti-Depressants, and Other Factors in Aphasia Recovery
Authors: Suneja Aarushi , Fernandez Marlis , Hillis Argye
Published: March 2022

BACKGROUND AND PURPOSE:
The greatest aphasia recovery after stroke occurs in the first 3 months, and the degree of recovery is fairly predictable by initial severity. Degree of recovery of after 3 months is highly variable. We sought to determine factors (age, education, time post onset (TPO), infarct volume, medications) that influence language recovery after 3 months.

METHODS:
We tested 45 chronic, left-hemisphere stroke patients (mean age 54.9 years; education of 14.7 years; TPO 35.4 months; volume of lesion of 126 cc) on the WAB. Comprehension, repetition, and naming summary scores and total of these scores were used as outcome variables. “Spontaneous speech” scores were omitted because of lower reliably in scoring. Infarct volume was measured on MRI FLAIR sequences. Multivariable linear regression analyses were used to identify predictors of recovery.

RESULTS:
WAB total score beyond 3 months was independently predicted only by education (for model including education, age, TPO, infarct volume: r
2
= 0.32; p=0.004). Repetition was also predicted only by education (p=0.007). However, naming was also predicted by age (p=.003). For those not on antidepressants, naming was significantly influenced by age, education, TPO, and volume of lesion, independently of each other (r
2
for this model = 0.66; p<0.0001). For those on antidepressants, naming was predicted only by education (p=0.03). There were no differences between patients who had never taken antidepressants and those currently taking antidepressants in age, education, TPO, volume of lesion, total WAB score (mean 23.7 vs 28.3), comprehension (8.3/10 vs. 9.9/10), or naming (7.5/10 vs. 8.8/10), but patients who had never taken anti-depressants tended to have lower repetition scores (mean 8.1/10 vs. 9.6/10; p=0.05).

CONCLUSION:
Education may provide a “cognitive reserve” for stroke patients; higher education is robustly associated with better recovery of language scores, even after controlling for age, lesion volume, and TPO. Younger age, longer TPO, and small infarcts are all independently associated with better recovery of naming. Anti-depressants may be associated with better short-term memory and concentration, and therefore associated with a tendency for better recovery of repetition.
Abstract T P118: Participation in Extended Activities of Daily Living is an Important Determinant of Long-Term Quality of Life in Stroke Patients after an Early Supported Discharge Program
Authors: Chen Zhenzhen , Eng Jia Yen , Lin Yiwei , Ong Siew Seang , Lim Lilian , Lui Eunice , Ee Jie Min , Chan Bernard Poon Lap
Published: March 2022

Objective:
We previously found stroke patients who underwent home therapy in our Early Supported Discharge (ESD) program had excellent improvement in basic activities of daily living (ADL). Their extended ADL remained impaired after ESD but showed significant improvement after 1 year. We hypothesize that improvement in extended ADL is an important determinant of long-term quality of life (QOL) in this group of stroke patients.

Methods:
Consecutive stroke patients enrolled in an ESD program in a tertiary hospital in Singapore from August 2007 to July 2012 were recruited. Basic and extended ADL functions were assessed using the Functional Independence Measure (FIM) and Frenchay Activities Index (FAI) respectively, pre- and post-ESD. FAI and SF-36 were administered via telephone interview 1 year after stroke onset. Multiple linear regression analyses with the 8 scales of SF-36 were carried out to determine their associations with variables including age, sex, FIM pre-ESD, FIM change (pre- to post-ESD), premorbid FAI, FAI post-ESD and FAI change (post-ESD to 1 year follow-up).

Results:
Data from 243 patients (60.9% male, mean age 64.7, SD11.8 years) were available for analysis. They received an average of 7.5 home therapy sessions. FIM improved from 100(17) pre-ESD to 115(15) post-ESD. FAI was 21.7(9.4) premorbid, 11.1(7.6) post-ESD and 17.9(10.3) at 1 year. Multiple regression analyses revealed 8 models which were statistically significant and explained 10-50% of the variance in SF-36 scales. In particular, 50% of the variance in Physical Functioning can be explained by the following factors: female gender (β=-.20, p<.001), FIM pre-ESD (β=.28, p<.001), FIM change (β=.15, p<.01), FAI post-ESD (β=.28, p<.001) and FAI change (β=.40, p<.001). Improvement in FAI scores from post-ESD to 1 year follow-up was positively associated with all 8 scales of SF-36 at 1 year.

Conclusion:
Compared to improvement in basic ADL after ESD, continued improvement in extended ADL including leisure, work and outdoor activities is a more important determinant of long-term QOL after stroke. Facilitating stroke patients in extended ADL participation and community reintegration after ESD is therefore a potentially important but currently neglected aspect in ESD for stroke patients.