bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP314: Low Pulse Pressure After Acute Ischemic Stroke Is Associated With Unfavorable Outcomes: The Taiwan Stroke Registry
Authors: tang Sung-Chun , Yin Jiu-Haw , Jeng Jiann-Shing , Hsu Chung Y. ,   Taiwan Stroke Registry Investigators
Published: June 2021

Background / Purpose:
Pulse pressure (PP) is related to cardiac function, arterial stiffness, fluid status and vascular events. The impact of PP on stroke outcome remains to be delineated. The present study aimed to explore the prognostic role of admission PP in patients with acute ischemic stroke (AIS) based on a nationwide stroke registry.

Methods:
We evaluated the association between PP on admission and outcome at 3 months after stroke in AIS patients registered in the Taiwan Stroke Registry, including 56 academic and community hospitals, during 2006~2013.Unfavorable outcome was defined as modified Rankin Scale of 3~6 at 3 months after stroke.

Results:
Of 33,530 patients (female, 40.6%; mean age, 68.8±13.3 years) with AIS, PP on admission had a “reversed J-curve” association with unfavorable outcome. After adjustment for clinical variables including AIS subtypes, initial National Institutes of Health Stroke Scale, systolic and diastolic blood pressure on admission, PP <50 mmHg remained associated with unfavorable outcome (p<0.0001). Compared to patients with PP 50-69 mmHg, the odds ratios of unfavorable outcome were 1.24 (95% confidence interval, 1.13-1.36) with PP 30-49 mmHg and 1.85 (95% confidence interval, 1.50-2.28) with PP<30 mmHg. Furthermore, the prognostic impact of admission PP was similar across all AIS subtypes.

Conclusion:
Low PP on admission carries an unfavorable outcome in patients with AIS.
Abstract TP323: Prevalence And Clinical Character Of Cortical Superficial Siderosis In Stroke Patient
Authors: Suzuki Shizuka , Suda Satoshi , Shimoyama Takashi , Takayama Yohei , Ouchi Takahiro , Arakiawa Masafumi , Okubo Seiji , Aoki Junya , Suzuki Kentaro , Mishina Masahiro , Kimura Kazumi
Published: June 2021

Background and purpose:
Cortical superficial siderosis (CSS) is a neuroimaging marker of cerebral amyloid angiopathy and has been associated with a high risk for intracerebral hemorrhage. However, CSS in acute stroke patients have not been fully investigated. The aim of this study was to assess the prevalence of CSS in both ischemic and hemorrhagic stroke patients. Furthermore, we aimed to assess the relation between CSS and clinical or radiologic characteristics.

Methods:
From September 2014 through June 2016, consecutive acute ischemic and hemorrhagic stroke patients who were admitted to our department within 7 days from symptom onset were retrospectively recruited from the prospective registry. CSS was defined as a homogeneous curvilinear signal intensity (black) on T2*-GRE sequences in the superficial layers of the cerebral cortex, within the subarachnoid space, away from at least three sulci of the hematoma with no corresponding signal hyperintensity on FLAIR sequences, to exclude potential hemorrhagic mimics. We analyzed the association between CSS and the topographic distribution of cerebral microbleeds (MBs), white matter lesions plus cardiovascular risk factors.

Results:
A total of 680 patients (530 ischemic stroke and 150 hemorrhagic stroke; median age 71 years) were enrolled in the present study. CSS was detected in 6 patients (1.1 %) with ischemic stroke and 7 patients (4.7%) with hemorrhagic stroke (
P
< 0.0001). CSS are associated with previous stroke (
P
= 0.0234), hemorrhagic stroke (
P
< 0.0001), white matter lesions (
P
= 0.0105), and lobar and non-lobar MBs (both
P
< 0.0001), but no relationship between age, sex, cardiovascular risk factors and CSS were found. On multivariable logistic regression analysis, high lobar MBs (≥ 2; odds ratio [OR], 74.39; 95% confidence interval [CI], 10.24-1553.25;
P
< 0.0001) and hemorrhagic stroke (OR, 4.30; 95% CI, 1.12-18.14;
P
= 0.0336) were independently associated with the presence of CSS.

Conclusions:
Our results suggest that CSS occurs with high prevalence in hemorrhagic stroke patients and is associated with lobar MBs, while the association between CSS and age, sex and cardiovascular risk factors were not observed.
Abstract TP324: Macrobleeds and Microbleeds: A Vascular Risk Factor Microangiopathy
Authors: Pasi Marco , Charidimou Andreas , Boulouis Gregoire , Auriel Eitan , Haley Kellen , Ayres Alison , Schwab Kristin , Goldstein Joshua , Rosand Jonathan , Viswanathan Anand , Pantoni Leonardo , Greenberg Steven , Gurol Edip
Published: June 2021

Background:
The predominant type of cerebral small vessel disease (SVD) and clinical outcomes of patients who present with a combination of lobar and deep intracerebral hemorrhage (ICH)/microbleed (MB) locations (Mixed-ICH, see figure) is unknown.

Methods:
Out of 391 consecutive ICH, 75 (19%) had Mixed-ICH, and their demographics, clinical/laboratory features, and SVD neuroimaging markers were compared to 191 probable Cerebral Amyloid Angiopathy (CAA-ICH) and 125 strictly deep-MB and ICH (Deep-ICH) patients. ICH-recurrence on follow up was also analyzed.

Results:
Mixed-ICH patients had a higher prevalence of hypertension, diabetes, left ventricular hypertrophy rates, higher creatinine values, as well as more prevalent lacunes and basal ganglia (BG) enlarged perivascular spaces (EPVS) than CAA-ICH (all p<0.05). When compared to Deep-ICH, Mixed-ICH patients were older, had higher WMH volumes and MB count, and more prevalent lacunes and centrum semiovale EPVS (all p<0.05). In multivariable models, Mixed-ICH diagnosis was associated with higher creatinine, more lacunes and BG EPVS, than CAA-ICH (all p<0.05). When compared to Deep-ICH, Mixed-ICH patients were older and had more lacunes and MBs in multivariable models (all p<0.05). Annual risk of ICH-recurrence was 5.1% for Mixed-ICH, higher compared to Strictly Deep-ICH but lower than CAA-ICH (1.6% and 10.4%, respectively).

Conclusions:
Mixed-ICH, commonly seen when MRI obtained during etiologic workup, appears to be mostly driven by vascular risk factors similar to Strictly Deep-ICH, but demonstrates more severe parenchymal damage and higher ICH-recurrence risk.
Abstract TP325: Lack of Early Improvement Predicts Poor Clinical Outcome Following Acute Intracerebral Hemorrhage
Authors: Yogendrakumar Vignan , Smith Eric E , Demchuk Andrew M , Aviv RIchard I , Rodriguez-Luna David , Molina Carlos A , Blas Yolanda S , Dzialowski Imanuel , Kobayashi Adam , Boulanger Jean-Martin , Lum Cheemun , Gubitz Gord , Padma Vasantha , Roy Jayanta , Kase Carlos S , Bhatia Rohit , Ali Myzoon , Lyden Patrick D , Hill Michael D , Dowlatshahi Dariush ,   PREDICT/Sunnybrook ICH CTA Study Group,   VISTA Collaboration
Published: June 2021

Background:
Early Neurological Worsening (ENW) is common after ICH, and predicts poor outcome. However, there is limited data as to what degree of ENW best relates to outcome. We used two ICH cohorts to refine and validate a definition of ENW that best predicted 90-day outcomes.

Methods:
We generated receiver operating characteristic (ROC) curves for the association between 24-hour NIHSS change and ICH outcomes using data from the VISTA collaboration. Primary outcome was poor outcome at 90 days (mRS 4-6); secondary outcomes were other mRS cutpoints (mRS 2-6, 3-6, 5-6, 6). We tested the commonly used NIHSS≥4 definition and in addition employed Youden’s J Index to select optimal cutpoints and calculated sensitivity, specificity, and predictive values. Independent predictors of poor outcome were determined via multivariable logistic regression. Definitions were validated in the prospectively collected PREDICT-ICH cohort.

Results:
Using 552 patients from the VISTA cohort, ROC curves of 24hr NIHSS change had an area under the curve of 0.75. NIHSS change of ≥0 at 24hrs was seen in 46.4%. Youden’s method showed an optimum cutoff at -0.5. Based on this, ENW defined as >0 (Sens 43%, Spec 91%, PPV 83%, aOR 7.13 [CI:4.05-12.55]), ≥0 (Sens 65%, Spec 73%, PPV 70%, aOR 5.05 [CI:3.25-7.85]), or ≥-1 (Sens 78%, Spec 59%, PPV 65%, aOR 6.04 [CI:3.75-9.71]) all accurately predicted poor outcome. PPV increased with higher NIHSS cutoffs, but at the cost of lower sensitivities. Regression confirmed that all definitions independently predicted outcome at all mRS cutpoints. ENW definitions reproduced well in the validation cohort of 275 patients.

Conclusion:
All NIHSS cut-offs for ENW predict clinical outcome, regardless of outcome definition. In particular, lack of clinical improvement at 24 hours (i.e. NIHSS is the same or higher) robustly predicted poor outcome, but may not be sufficiently reliable to determine clinical management.
Abstract TP326: Lymphopenia, Infectious Complications and Outcome in Spontaneous Intracerebral Hemorrhage
Authors: Morotti Andrea , Marini Sandro , Jessel Michael J , Schwab Kristin , Ayres Alison M , Kourkoulis Christina , Gurol Edip M , Viswanathan Anand , Greenberg Steven M , Anderson Christopher D , Goldstein Joshua N , Rosand Jonathan
Published: June 2021

Background and Purpose:
lymphopenia is increasingly recognized as a consequence of acute illness and may predispose to infections. We investigated whether admission lymphopenia (AL) is associated with increased risk of infectious complications and poor outcome in patients with spontaneous intracerebral hemorrhage (ICH).

Methods:
we analyzed a prospectively collected cohort of ICH patients ascertained between 1994 and 2015. Subjects were included if they had a lymphocyte count obtained within 24 h from onset and AL was defined as lymphocyte count<1000/uL. Infectious complications were assessed through retrospective chart review and the association between AL, infectious complications and mortality was investigated with a multivariable Cox regression and logistic regression respectively.

Results:
2014 patients met the inclusion criteria (median age 75, males 54.0%) of whom 548 (27.2%) had AL and 605 (30.0%) experienced an infectious complication. Overall case fatality at 90 days was 36.9%. Patients with AL were more severely affected, as highlighted by larger hematoma volume, higher frequency of intraventricular hemorrhage and lower Glasgow Coma Scale score (all p<0.001). AL was independently associated with increased risk of pneumonia (Hazard Ratio [HR] 1.65, 95% confidence interval [CI] 1.32-2.05, p<0.001) and multiple infections (HR 1.75, 95% CI 1.22-2.51, p=0.002). The association with urinary tract infection, sepsis or other infections was not significant. AL was also an independent predictor of 90-day mortality (odds ratio 1.55, 95% CI 1.18-2.04, p=0.002) after adjusting for confounders.

Conclusions:
AL is common in ICH and associated with increased risk of infectious complications and poor outcome. Further studies will be needed to determine whether prophylactic antibiotics in ICH patients with AL can improve outcome.
Abstract TP327: Timing of Ventriculostomy and Ventricular Shunting for Intracranial Hemorrhage: A National Inpatient Sample Study
Authors: Peters Steven , Tirschwell David
Published: June 2021

Background:
Intraventricular hemorrhage requiring ventriculostomy (EVD) placement is a frequent complication of spontaneous intracerebral hemorrhage (ICH). Urgent EVD may be warranted for management of acute hydrocephalus, and a subset of these patients will require permanent ventricular shunt (VS) placement. In contrast to hydrocephalus following sub-arachnoid hemorrhage, less is known about the frequency and timing of EVD and VS placement after ICH.

Methods:
Using the 2010-2012 National Inpatient Sample, we selected patients with ICD-9 codes for ICH, excluded secondary causes, and examined procedure dates for EVD and VS placement.

Results:
Of 35,991 primary ICH patients, 2,392 (6.7%) received an EVD, 89% within the first 3 days of admission and 64% within the first day. Placement of a VS occurred in 268 patients (0.7%) overall. VS placement occurred in 143 of 2,129 (6.7%) of those receiving an EVD in the first 72 hours and 34 of 263 (12.9%) receiving an EVD after 72 hours (p<0.001). Median time to shunt placement following EVD was 15 days (IQR 11-21) vs 16.5 (IQR 13-21) for those with EVD within vs after 72 hours (p=0.2). 82 (0.2%) received a VS without an initial EVD at a median of 14 days (IQR 9-18). Kaplan-Meier analysis revealed that among those remaining alive and in hospital at 14 and 21 days, 5% and 11%, respectively, underwent shunt placement following EVD.

To analyze the effect of VS timing following EVD, we compared those undergoing VS in the first two weeks versus later than two weeks. Following multivariate logistic regression, only age 70 -80 was associated with early shunt placement (OR 4.8, 95%CI 1.2-19). No effect on mortality or rate of home discharge was seen. Length of stay was shorter in those with early versus later VS (20 vs 32 days, p<0.001)

Conclusion:
Persistent hydrocephalus following EVD placement for ICH is rare overall but VS is required in up to 12% of a subset of patients. EVD placement after the initial 72 hours was associated with an increased rate of VS, while older age was associated with earlier VS placement after EVD. Better understanding of the risk factors associated with persistent hydrocephalus will help optimize patient selection and timing of treatment.
Abstract TP329: Venous Collateral Drainage Patterns Predict Clinical Worsening in Dural Venous Sinus Thrombosis
Authors: Sheth Sunil A , Trieu Harry , Liebeskind David S , Saver Jeffrey L , Szeder Viktor , Jahan Reza , Tateshima Satoshi , Duckwiler Gary
Published: June 2021

Background:
Dural venous sinus thrombosis (DVST) is an increasingly recognized cause of a wide array of neurological symptoms, with outcomes that range from complete recovery to death. Approximately 23% of patients with DVST will worsen after initial presentation, as a result of restricted venous outflow and venous hypertension, but early identification of this subset is challenging. A venous collateral scale (VCS) that grades alternative drainage routes may improve prediction of clinical deterioration.

Methods:
From our institutional database, we identified patients with documented DVST on dedicated venous imaging (MR, CT or catheter angiography) from January 2010 to July 2016. Patients were excluded for thrombosis related to arteriovenous fistulae. The VCS (Table) was created and scores were determined from cerebrovascular venous imaging at presentation by two reviewers blinded to subsequent imaging and clinical data.

Results:
Among 28 patients that met criteria, median age was 42 (IQR 24-57) and 50% (14/28) were female. Presentation symptoms included intracranial hemorrhage in 40% (11/28) and headache without hemorrhage in 18% (5/28). Transverse sinus occlusion was present in 68% (19/28), and superior sagittal sinus occlusion in 39% (11/28). 82% (23/28) of patients were treated with anticoagulation, and 18% (5/28) with endovascular thrombectomy. New hemorrhage or expansion of initial hemorrhage occurred in 21% (6/28). In-hospital mortality occurred in 18% (5/28). VCS was 0 in 18% (5/28), 1 in 39% (11/28), and 2 in 46% (12/28). Lower VCS was significantly associated with development of new hemorrhage or expansion of initial hemorrhage (62% vs. 0%, VCS 0-1 vs. 2, p<0.01). VCS demonstrated excellent discrimination for in-hospital clinical worsening (C-statistic 0.85).

Conclusions:
The type and quality of venous collaterals influence outcome in DVST. VCS helps identify patients who are likely to deteriorate and may need additional early interventions.
Abstract TP34: Endovascular Thrombectomy for M1 Vessel Occlusion: Comparison Between Stent Retriever Mediated Thrombectomy and Forced Aspiration Thrombectomy
Authors: Nunes Michelle , Aguilar-Salinas Pedro , Varzoni Thais , Entwistle John , Sauvageau Eric , Hanel Ricardo , Aghaebrahim Amin
Published: June 2021

Introduction:
An evolution in endovascular approaches has been observed in the last decade with stent retrievers (ST) being the latest generation of devices. Stent retriever thrombectomy and manual aspiration (MAT) have each shown to lead to high rates of recanalization as single modality endovascular stroke therapy. We aimed to compare clinical outcomes, efficacy and safety of ‘stent retriever mediated manual aspiration thrombectomy’ and manual aspiration thrombectomy (MAT) alone.

Methods:
145 patients with M1 vessel circulation stroke and had undergone thrombectomy treatment were identified between March 2014 and June 2016 in two high volume centers. The patient’s data were retrospectively analyzed to evaluate the technical characteristics, angiographic outcome (Thrombolysis In Cerebral Infarct - TICI score) and clinical outcome at discharge (NIHSS and mRS)

Results:
69 patients were treated with ST (Solitaire and Trevo) and 76 with MAT. IV-TPA was administered in 37.4% of cases. Effective recanalization, TICI grades 2b/3, was achieved in 84.1% of cases treated with ST and in 89.5% treated with aspiration with no statistical significance between the two techniques. Symptomatic cerebral hemorrhage was found in 4.3% of the cases. Favorable outcome defined as a mRS of 0-2 at discharge was found in 38% of cases with higher rates in the group treated with ST (56.1% vs 33.3%; p 0.01).

Conclusion:
Stent retriever mediated manual aspiration thrombectomy is a safe and efficacious method of achieving high revascularization rates for M1 vessel occlusion with improved outcomes at discharge.
Abstract TP341: Outcomes of Obese Patients With Intracerebral Hemorrhage
Authors: Iwuchukwu Ifeanyi , Ryder Jessica A , Jennings Bethany , Feliciano Philip , Nguyen Doan , Mahale Nikit , Sabharwal Vivek , McGrade Harold , Velander Alan
Published: June 2021

Introduction:
Obesity is a known risk factor for cardiovascular disease and stroke. However, an obesity paradox - improved outcomes in obese patients, has been reported in coronary artery disease, cardiac surgery and ischemic stroke. We report a possible obesity paradox in patients with intracerebral hemorrhage (ICH).

Methods:
We retrospectively reviewed our prospectively collected database of patients diagnosed with ICH in our institution between November 2012 and March 2016. Trauma, malignancy, postoperative, vascular malformations associated hemorrhages and hemorrhagic conversion of ischemic strokes were excluded. Demographics, clinical, laboratory and imaging characteristics were collected. We defined obesity as body mass index (BMI) >30kg/m
2
; overweight 25-29.9kg/m
2
; normal weight 18.5-24.9kg/m
2
and underweight <18.5kg/m
2
. Poor outcome was defined by hematoma expansion >30% increase in ICH volume or discharge to nursing home, long-term acute facility or death (‘poor-discharge’). Continuous variables were analyzed using an analysis of variance and a fisher exact test or chi-square test for categorical variables. A p value <0.05 was set for significance.

Results:
429 patients met criteria for our study. 50.1% were female, median age 64 years (SD 15.6) and BMI 27.4 (SD 7.9). There were 16 (3.7%) underweight; 131 (30.8%) normal weight; 138 (32.2%) overweight and 144 (33.6%) obese patients. Bivariate analysis across groups showed female gender (75% vs 56.5% vs 57% vs 50% p=0.015), diabetes mellitus (13.3% vs 20.6% vs 32.1% vs 33.3% p=0.041), systolic pressure (SBP) (177.5 vs 168 vs 175 vs 185 p=0.003), HbA1c (5.7 vs 5.9 vs 6.2 vs 6.5 p=0.0002), discharge poor outcome (43.8% vs 54.2% vs 55.8% vs 36.8% p=0.005) were significant. There was no difference in ICH volume and hematoma expansion. On multivariate analysis, only age (OR 1.02, CI 1.01 - 1.04 p=0.0004) SBP ≥ 140mmhg (OR 0.49, CI0.25 - 0.95, p=0.035) Admission glucose ≥180 (OR 2.71, CI 1.58 - 4.4.67 p=0.0003) and BMI >30kg/m
2
(OR 0.5, CI 0.29 - 0.87 p= 0.014) remained independent predictors of poor outcome.

Conclusion:
In our cohort, obese patients were more likely to have a good outcome suggesting the presence of an obesity paradox in outcome following intracerebral hemorrhage.
Abstract TP342: Early Erythrolysis in Hematoma After Experimental Hemorrhage
Authors: Dang Ge , Wu Gang , Zeng Yiwei , Hua Ya , Keep Richard F , Xi Guohua
Published: June 2021

Background:
Erythrolysis in the clot after intracerebral hemorrhage (ICH) and the release of hemoglobin causes brain injury but it is unclear when such lysis occurs. The present study examined early erythrolysis in rats.

>Methods:
Male Sprague-Dawley, spontaneously hypertensive (SHR) and Wistar Kyoto (WKY) rats had an intracaudate injection of 100μl autologous blood or a needle insertion (sham). All rats had T2 and T2* MRI scanning and brains were used for histology and CD163 (a hemoglobin scavenger receptor) and DARPP-32 (a neuronal marker) immunohistochemistry.

Results:
There was marked heterogeneity within the hematoma on T2* MRI, with a hyper- or isointense core and a hypointense periphery at days 1 and 3. Hematoxylin and eosin staining in the same animals showed significant erythrolysis in the core with the formation of erythrocyte ghosts. While the periphery of hematoma had erythrocytes with normal profiles, the border of the periphery and the center displayed distorted erythrocytes and areas with ghost erythrocytes. The degree of erythrolysis was correlated with the severity of neuronal loss (marked by DARPP 32) after ICH (r = 0.791, n = 18,
p
< 0.01). Perihematomal CD163 was increased by day 1 after ICH and may be involved in clearing hemoglobin caused by early hemolysis (303 ± 128 at day 1 and 453 ± 57 cells/mm
2
at day 3, p<0.01). Only a few CD163 positive cells were observed in the ipsilateral basal ganglia of sham controls and in the contralateral basal ganglia of ICH rats. ICH resulted in more severe erythrolysis (e.g. 18.3 ± 4.5 vs. 8.1 ± 5.2 %, p< 0.01 at day 1), neuronal loss (30.0 ± 5.6 vs. 14.1 ± 4.4 %, p<0.05 at day 1), and CD 163 upregulation (p< 0.05) in SHR than in WKY rats.

Conclusion:
T2*MRI detectable early erythrolysis occurred in the clot after ICH, and activated CD163. Hypertension is associated with enhanced erythrolysis in the hematoma and more brain injury.
Abstract TP349: Recombinant Slit2 Reduces Brain Water Content and Attenuates Neurobehavioral Deficits Following Intracerebral Hemorrhage in a Murine Model
Authors: Burchell Sherrefa R , Reis Cesar , Yu Lingyan , Xu Ningbo , Zhang John H , Tang Jiping
Published: June 2021

Introduction and Hypothesis:
Intracerebral hemorrhage (ICH) remains the least treatable and most fatal stroke subtype, being associated with significant vascular disruption, which leads to edema development and the recruitment of inflammatory agents. Slit2, one of a family of three large secreted proteins, has been found to regulate cell proliferation, adhesion, and migration through its receptor, roundabout (Robo)1. We have previously found that administration of recombinant Slit2 (rSlit2) improved outcomes after surgical brain injury. Thus, we hypothesized that Slit2, through the Robo1 receptor, could mitigate ICH-induced neuroinflammation by reducing leukocyte migration, thereby decreasing brain water content (BWC), and improving neurobehavior.

Methods:
ICH was induced in CD-1 mice by collagenase infusion, as previously established. To determine the expression of Slit2 and Robo1 after ICH, a time course profile (3, 6, 12, 24, and 72 hours) of both proteins was developed by Western Blotting. Then, animals were randomly divided into 5 groups: sham, vehicle, 3μg/kg rSlit2, 10μg/kg rSlit2, and 30μg/kg rSlit2. rSlit2 was administered 1h after ICH, and BWC and neurobehavior assessed at 24 and 72 hours. Western blots and immunohistochemistry will be done to evaluate leukocyte infiltration and other inflammatory markers.

Results:
Endogenous Slit2 and Robo1 were initially decreased, and then increased after ICH, in comparison to sham. Treatment with rSlit2 significantly reduced brain water content at 24 hours and improved neurological scores. At 72h, there was a tendency for improved brain water content and neurobehavior. We further anticipate that rSlit2 treatment will attenuate leukocyte migration to the injury site, as well as inhibit other pro-inflammatory signals, and these through its action on Robo1.

Conclusions:
Recombinant Slit2 improved outcomes after murine ICH (BWC and neurological deficits). We expect that this occurs through the inhibition of inflammatory signaling.
Abstract TP355: Cardiovascular Screening at Menopause Will Decrease the Incidence of Stroke and Irreversible Disability
Authors: Murphy Jill C
Published: June 2021

Background and Purpose:
Stroke is the 3
rd
leading cause of death in women and a leading cause of irreversible disability. Physical changes occur during menopause, increasing risk factors for coronary artery disease and stroke. Baby Boomers coming of age will increase the incidence of stroke in the female population. The direct and indirect cost of cardiovascular disease and stroke total more than $320.1 billion a year. The purpose of this research is to make evident, a preventive cardiovascular screening program completed at menopause will decrease mortality and irreversible harm in post-menopausal women; evaluate and compare the healthcare savings for preventive care versus post-stroke treatment; to gain support for further research in menopausal changes, preventive screenings and stroke and to establish support of legislators and insurance companies.

Methods:
A quantitative and systematic literature review was conducted. Six thousand women reach menopause every day, totaling 2,190,000 a year. An odds ratio of 1:1 participation in the screening was calculated at a probable variable. One in five of these women will have a stroke in their lifetime. A variable of 20% stroke prevention rate, based on pre-screening and subsequent treatment was assigned (n=43,800). Individual cost of care post-stroke estimates at (n=$42,767). A cost-benefit analysis was completed on post-stroke care versus preventive screening costs (n=$1468), based on current preventive program costs.

Results:
The analysis indicated (n=43,800) women will avoid stroke and/or disability due to cardiovascular preventive screening and warranted treatment versus (n=219,000) who will have a stroke without these measures. This equates to healthcare savings of $253,997,547 a year.

Conclusions:
Quantitative and systematic literature review and the cost-benefit analysis indicates preventive screenings at menopause will save lives, decrease irreversible disability and healthcare costs. A randomized controlled clinical trial is necessary to further substantiate the significance of preventive screenings and early cardiovascular interventions in menopausal women.
Abstract TP363: Paramedic Angiographic Correlates (PACman): Utility of the Los Angeles Motor Score (LAMS) in Predicting Large Vessel Occlusions
Authors: Brandler Ethan S , Perez Karol , Thode Henry , Fiorella David
Published: June 2021

Introduction:
For many patients with large vessel occlusions (LVO), endovascular therapy significantly improves patient outcomes. Data are needed to inform the decision when bypass a local primary stroke center for an endovascular center.

Hypothesis:
The LAMS and other physical findings can predict LVO.

Methods:
Interim analysis of a convenience sample of stroke code patients presenting to a suburban tertiary care center ED. Paramedics examined patients using the LAMS. Without any specific additional training, paramedics were also asked to assess for leg weakness, visual disturbances, altered level of consciousness, and language abnormalities (dysarthria, aphasia). Sensitivity and specificity of a LAMS score of ≥ 4 were calculated. A stepwise logistical regression on the other physical exam elements that might predict LVO was performed.

Results:
190 cases, mean age (SD) 67 (18), 51% female; 85 (45%) had an acute stroke, 44 (23%) had LVO. For stroke prediction, LAMS’ sensitivity = 70% and specificity = 80%. ROC = 80% (95% CI 74-86%). For prediction of LVO, only LAMS as a complete test was associated with LVO (OR 1.78 per LAMS point ( 95% CI 1.42-2.23). Sensitivity of this model was 27%, specificity 95%. By including the LAMS components individually as potential predictors of LVO, grip strength superseded LAMS as the only predictor of LVO. Odds ratio for LAMS prediction of LVO was 4.18 per point, 95% CI 2.48-7.04, sensitivity 49%, specificity 92%. ROC =75% (95% CI 66-84%).

Conclusion:
When performed by paramedics and EMTs in an enriched stroke code population, LAMS can be used to identify LVO with high specificity. Specifically, the hand grip element predicts LVO. The overall poor sensitivity of all stroke scales for stroke in general is unlikely to change.
Abstract TP377: Advancing Comprehensive Stroke Outcomes Through Concurrent Data Abstraction
Authors: Amuda Maryam A , Smith Dewanda , Nichols Shelley
Published: June 2021

Background:
An opportunity existed to improve the chart abstraction process to include concurrent review of stroke patients and allow the application of current evidence based practices in real-time. The utilization of Get With The Guidelines (GWTG)/Quintiles and EPIC Medical Charting System optimizes the entry method of data collection in the acute care environment. Comprehensive Stroke Center requirements create more robust data requirements with the need for improvement and maintenance to ensure the quality of patient care.

Methods:
In order to maintain external data requirements, we constructed a formal timeline for data abstraction. We then defined a specific schedule to coordinate with GWTG and The Joint Commission submission timelines using the time and date of patient arrival and discharge for concurrent data. This allowed us to focus on a population at risk of missing essential measures of timely care. This was accomplished through interaction and monitoring of stroke patients including daily real-time interactions with the inter-professional team.

Results:
In April 2016 we fully deployed this method of concurrent data abstraction to maximize quality care for time sensitive stroke measures. From the first quarter of 2016 to the second quarter of 2016, there was demonstrated improvement in three major outcomes: administration of venous thromboembolism (95.2% to 96.0%), thrombolytic therapy (96.8% to 98.5%), and dysphasia screenings (83.1% to 88.2%).

Conclusions:
Progressing to concurrent abstraction created a stronger environment of accountability and care provision. Developing a schedule and process for data abstraction assists the comprehensive inter-professional team to treat stroke patients expediently with accordance to the American Stroke Association national guidelines. This proactive process generates timely awareness to address elements of care to optimize stroke outcomes.
Abstract TP38: Core Growth Speed as a Marker of Collateral Circulation Status in Acute Ischemic Stroke with Known Onset Time
Authors: Blanco-García Laura , Cortijo Elisa , De Lera Mercedes , Calleja Ana , Usero María , Castaño Miguel , Pérez-Fernández Santiago , Arenillas Juan
Published: June 2021

Objective:
We aimed to evaluate the parameter
core growth speed
(CGS) as a marker of collateral circulation status (CC) in acute ischemic stroke, and to compare it with other brain perfusion-derived markers of collateral capacity.

Methods:
We retrospectively studied acute ischemic stroke patients who were evaluated with urgent computed tomography perfusion (CTP) and CT angiography. Inclusion criteria comprised known time of onset and anterior circulation proximal occlusion. Collateral circulation was assessed on CTP-source images and rated as poor (0-1) vs. good (2-3) following a previously published scale. CTP maps were computed using Neuroscape 2.0 software by Olea Medical. Infarct core volume was calculated as the brain tissue with >70% reduction in cerebral blood flow (CBF) as compared to the unaffected side. CGS was obtained by dividing core volume by the time from stroke onset to CTP acquisition. Relative cerebral blood volume (rCBV), relative CBF, and hypoperfusion index ratio (HIR = Tmax>10s/Tmax>6s) were used as comparators.

Results:
We included 41 patients (mean age 71 years; median NIHSS 17; median onset-CTP time 150 minutes). We observed a positive correlation between CGS and HIR (ρ= 0.517 p< 0.001), and negative correlations between rCBV and CGS (ρ= -0.669 p<0.0001), and rCBF and CGS (ρ= -0.749 p<0.0001). Collateral circulation was categorized as poor or good in 15 and 26 patients respectively. A gradual descend in CGS was seen as CC improved (p=0.0005). A logistic regression model adjusted by rCBV, rCBF and HIR identified CGS as independently associated with CC. The association of CGS with good CC in a ROC curve was highly significant (p=0.002, area under the curve 0.8).

Conclusion:
Core growth speed is robustly associated with collateral circulation status. This parameter can be directly obtained from infarct core volume without the need to process other perfusion or angiographic images, if the time of onset is well known.
Abstract TP394: The 3- R’s of a Stroke Program: Recognize Staff, Raise Alteplase Administration, Reduce Door-to-Needle times
Authors: Goings Denise
Published: June 2021

Background:
Early recognition of an acute stroke with timely administration of Alteplase has been shown to reduce disability by as much as 30% at 90-days. The American Heart Association/American Stroke Association endorses Alteplase be administered as quickly as possible. Emergency Department (ED) staff engagement is key to early recognition and rapid treatment of the acute stroke patient.

Purpose:
The purpose of the Stroke Recognition Dinner was to strengthen ED staff engagement in the Stroke Program by promoting rapid assessment and treatment of the acute stroke patient. Reducing Alteplase door-to-needle (DTN) times leads to improved patient outcomes.

Methods:
Tracking delivery times revealed delays and lost opportunities in Alteplase administration in the ED. DTN times were analyzed before and after the recognition dinner by graphing times and comparing results. The results indicated the percentage of patients receiving Alteplase increased while the DTN times decreased after the March 2016 recognition dinner. Physicians and Nurses have formed a genuine excitement for rapidly assessing and treating the acute stroke patient.

Results:
There has been a 25minute reduction in overall DTN times from 3
rd
quarter 2015 (July) (n = 2) to 3
rd
quarter 2016 (July) (n = 6). Times from 1
st
quarter 2016 (n = 12) to 3
rd
quarter 2016 (July) (n = 6) produced a 13minute reduction in DTN. Alteplase administration increased from 14.7% 2
nd
quarter 2015 (n = 15, d = 102) to 16.9% (n = 18, d = 106) 2
nd
quarter 2016.

Conclusion:
Recognizing and rewarding Emergency Department staff improved staff engagement thereby increasing Alteplase administration, decreasing DTN times, and improving patient outcomes.
Abstract TP397: Clinical And Functional Outcome Of Adult Patients Diagnosed With Moyamoya Disease In Childhood
Authors: Fam David , Dlamini Nomazulu , Jaigobin Cheryl
Published: June 2021

Background:
Moyamoya disease is a progressive occlusive arteriopathy of the terminal ICA and its branches, leading to the formation of unstable collateral vessels. The disease is found worldwide, and is associated with a number of predisposing conditions, termed moyamoya syndrome. Currently there is a paucity of data on the natural history of moyamoya disease in North America, especially the long-term outcome of pediatric moyamoya.

Objective:
Our objectives were to determine the rate of recurrent TIA, ischemic stroke and intracerebral hemorrhage in patients presenting with pediatric Moyamoya disease and to assess long-term functional outcome.

Methods:
This study was a retrospective chart review of 52 patients presenting with pediatric moyamoya disease. We included patients aged 18 or older with a diagnosis of moyamoya disease or syndrome. All patients had confirmatory baseline vascular imaging (MRA or CTA +/- cerebral angiography). Baseline demographic variables and annual vascular event recurrence risk were obtained from the records. Modified Rankin Score (MRS) at presentation and last follow-up were determined from clinical records.

Results:
Of the original cohort, 34 patients were included for analysis. The mean age of the patients was 23.9 years. The mean age at presentation was 9 years (SD=4) with an average follow-up of 11.3 years (SD=5.1) for a total of 383 patient years. There was slight female predominance (1.4:1). Fifty percent of patients (17) presented with ischemic stroke. A total of 26 patients (76%) underwent surgery, with 7 (21%) requiring repeat surgery. The annual vascular recurrent event rate was 5.0% (19/383), which was not significantly different between surgical and non-surgical groups or between different moyamoya syndrome subtypes. Most of the recurrent events were TIA (annual recurrence 3.7%). There was no significant difference between initial MRS, MRS at last follow-up and mean change in MRS between surgical and non-surgical groups.

Conclusion:
Our study is the largest North American natural history study of pediatric moyamoya. Our observations indicate that pediatric moyamoya in North America have low recurrent vascular event rates and long-term functional outcomes are good, even in conservatively managed patients.
Abstract TP406: Ipsilesional Myelination is Impaired in Children With Perinatal Arterial Stroke
Authors: Yu Sabrina , Carlson Helen , Kirton Adam
Published: June 2021

Introduction:
Stroke is a leading cause of perinatal brain injury and cerebral palsy. Current therapeutic efforts focus on optimizing developmental curves but the biological processes dictating these outcomes are poorly understood. Alterations in myelination are recognized as a major determinant of outcome in preterm brain injury but are unexplored in perinatal stroke (PS).

Hypothesis:
Ipsilesional delays in myelination occur in children with PS and are associated with poor developmental outcome.

Methods:
Participants were identified through the Alberta Perinatal Stroke Project, a population-based research cohort. Inclusion criteria were: 1) MRI-confirmed, unilateral arterial PS, 2) T1-weighted MRI >6mo, 3) absence of other neurological disorders, 4) neurological outcome (Pediatric Stroke Outcome Measure, PSOM), and 5) motor assessments (Assisting Hand Assessment, AHA; Melbourne Assessment). FreeSurfer software measured hemispheric asymmetry in myelination intensity. A second method using ImageJ validated the detection of myelination asymmetry. Overall PSOM scores were classified as poor (>1) or not. Repeated measures ANOVA compared perilesional, ipsilesional remote, and contralesional homologous regions. Myelination ratios for stroke cases were compared to typically developing controls (t-test), PSOM scores (t-test), and motor assessments (Pearson’s correlation).

Results:
Nineteen arterial stroke cases (mean age: 13.73±4.0yo) and 27 controls (mean age: 12.52±3.7yo) were studied. Stroke cases showed a greater degree of asymmetry with lower myelination in the lesioned hemisphere, compared to controls (p<0.001). Myelination in perilesional regions was decreased compared to ipsilesional remote (p<0.001) and contralesional homologous areas (p<0.001). Ipsilesional remote regions were decreased compared to homologous regions on the contralesional hemisphere (p=0.009). Contralesional myelination was also less than controls (p<0.001). Myelination ratios were not associated with PSOM, AHA, or Melbourne scores (p=0.144, 0.218, 0.366 respectively).

Conclusion:
Myelination of uninjured brain in the lesioned hemisphere is altered in children with PS. Further study is required to determine clinical significance.
Abstract TP408: Temporal Relationship of AF and Oral Anticoagulation to Major Bleeding Events in Patients with Cardiovascular Implantable Electronic Devices
Authors: Askari Mariam , Zielger Paul D , Schmitt Susan K , Fan Jun , Ullal Aditya J , Turakhia Mintu P
Published: June 2021

Introduction:
After diagnosis of atrial fibrillation (AF), oral anticoagulation (OAC) is taken daily and may increase risk of bleeding, even during AF-free periods. We explored temporal discordance between AF and major bleeding events (MBE) in patients with cardiovascular implantable electronic devices (CIED).

Methods:
We linked Veterans Administration (VA) and Medicare data to CIED remote monitoring data. Analyses were restricted to Medtronic cardiac rhythm devices with atrial leads, which provide a daily, continuous measure of AF burden. We identified the earliest date of monitoring and searched for a subsequent MBE (including but not limited to intracranial hemorrhaging, gastrointestinal bleeds, and vascular bleeds) from 2004 to 2015. We restricted analysis to patients with <75% coverage of remote monitoring in the 90 days before and after MBE and with OAC prescription and pill coverage in the 90 days prior and on day of MBE. Patients were categorized into 4 groups based on the presence of AF ≥ 6 minutes on any of the 90 days on or prior to MBE and 90 days after MBE: NO/NO, NO/YES, YES/NO, YES/YES.

Results:
There were 189 patients meeting inclusion criteria (69±9.4 years, CHA
2
DS
2
-VASc 4.3±1.4). Of these, 99 (52%) of patients had no AF≥ 6 min in the 90 days on or before MBE (NO/NO). Among all patients, there were 3 ischemic strokes, 2 ICH, 33 MBE, and 83 deaths following the index MBE. Across all categories, the risk of recurrent MBE and death was substantially higher than stroke or ICH and only 7% with no AF pre had AF post (NO/YES). (TABLE)

Conclusion:
Among CIED patients on OAC, most did not have AF at the time of MBE. Risk of MBE and death was substantially higher than stroke or ICH and call into question rationale to remain on indefinite OAC. Long-term AF monitoring may prove useful and requires evaluation.
Abstract TP417: Plasma D-dimer Elevation Predicts Poor Functional Outcomes Through Systemic Complications After Aneurysmal Subarachnoid Hemorrhage
Authors: Fukuda Hitoshi , Yamamoto Yu , Handa Akira , Kurosaki Yoshitaka , Yamagata Sen
Published: June 2021

Introduction:
Plasma D-dimer levels elevate during acute stage of aneurysmal subarachnoid hemorrhage (SAH) and are associated with poor functional outcomes. However, the mechanism in which D-dimer elevation on admission affects functional outcomes remains unknown.

Hypothesis:
We hypothesize that D-dimer levels on admission are correlated with systemic complications rather than neurological complications, and therefore have an additive predictive value on conventional risk factors for poor functional outcomes.

Methods:
A total of 187 patients with aneurymal SAH were retrospectively analyzed from a single center, observational cohort database. Correlations of plasma D-dimer levels on admission with patients’ characteristics, initial presentation, neurological complications, and systemic complications were identified. We also evaluated additive value of D-dimer elevation on admission for poor functional outcomes by comparing predictive models with and without D-dimer.

Result and Conclusions:
D-dimer elevation on admission was associated with increasing age, women, and severity of SAH. Patients with higher D-dimer levels had increased likelihood of nosocomial infections (OR 1.22 [95% CI 1.07-1.39], p = 0.004), serum sodium disorders (OR 1.11 [95% CI 1.01-1.23], p = 0.033), and cardiopulmonary complications (OR 1.20 [95% CI 1.04-1.37], p = 0.01) by multivariable analysis. D-dimer elevation was an independent risk factor of poor functional outcomes (modified Rankin scale 3-6, OR 1.50 [95% CI 1.15-1.95], p = 0.003). A novel prediction model with D-dimer had significantly better discrimination ability for poor outcomes than conventional models without D-dimer, evaluated by C statistics, net reclassification improvement, and integrated discrimination improvement methods. These results suggest that elevated D-dimer levels on admission were independently correlated with systemic complications, and had an additive value for outcome prediction on conventional risk factors after aneurysmal SAH.
Abstract TP419: A Common Data Language for Clinical Research Studies: The National Institute of Neurological Disorders and Stroke and National Library of Medicine Cerebral Aneurysms and Subarachnoid Hemorrhage Common Data Elements Version 1.0 Recommendations
Authors: Odenkirchen Joanne , Amos Liz , Ludet Christophe , Sheikh Muniza , Ala’i Sherita , Esterlitz Joy , Suarez Jose
Published: June 2021

Introduction:
The National Institute of Neurological Disorders and Stroke (NINDS) and the National Library of Medicine (NLM) initiated development of cerebral aneurysms and subarachnoid hemorrhage (SAH)-specific Common Data Elements (CDEs) in 2015 as part of a joint project to develop data standards for funded clinical research in neuroscience.

Objective:
Through the development of these data standards for clinical research, the NINDS and NLM SAH joint CDE initiative strives to improve SAH data collection by increasing efficiency, improving data quality, reducing study start-up time, facilitating data sharing/meta-analyses and helping educate new clinical investigators.

Methods:
The working group consisted of international members with varied fields of expertise related to SAH and was divided into domains such as subject characteristics and assessments and exams. They developed a set of SAH-specific CDE recommendations by selecting among, refining and adding to existing field-tested data elements. Recommendations, based on reviewing the established Stroke CDEs as well as other disease-specific CDEs, were uploaded to the NIH CDE Repository. Following an internal working group review of recommendations, the SAH CDEs will be vetted during a public review on the NINDS website.

Results:
Version 1.0 of the SAH CDEs will be available in early 2017. New SAH CDEs and recommendations will include those developed for unruptured intracranial aneurysms and long-term therapies. The NINDS CDE website provides uniform names and structures for each data element, as well as guidance documents and template case report forms using the CDEs.

Conclusion:
The NINDS encourages the use of CDEs by the clinical research community in order to standardize the collection of research data across studies. The NINDS CDEs are a continually evolving resource, requiring updates as research advancements indicate. These newly developed SAH CDEs will serve to be a valuable starting point for researchers and facilitate streamlining and sharing data. Information provided at this meeting will include examples of how the SAH CDEs may be used by a research study, demonstrations of navigating the NINDS CDE and NIH CDE Repository websites and how users can submit feedback.