bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP42: Equivalent Favorable Outcomes Possible After Thrombectomy for Posterior Circulation Large Vessel Occlusion Compared to Anterior Circulation: The MUSC Experience
Authors: Alawieh Ali M , Turner Raymond D , Turk Aquilla S , Chaudry Mohammad I , Lena Jonathan , Spiotta Alejandro M
Published: October 2018

Introduction:
In acute ischemic stroke (AIS), posterior circulation large vessel occlusions (LVO) have been associated with poorer outcomes compared to anterior circulation LVO. Using a strategy for determining candidacy relying on CT perfusion rather than time parameters, the outcomes of anterior vs. posterior circulation thrombectomy for LVO were compared at a high volume center employing a direct aspiration first pass technique (ADAPT).

Methods:
We retrospectively studied a database of AIS cases that underwent ADAPT thrombectomy for large vessel occlusions. Cases were grouped by anatomical location of thrombectomy (posterior vs. anterior circulation), and analysis was performed on both entire sample size and on matched subsets within each group.

Results:
A total of 436 AIS patients (50.2% women, mean age 67.3 years) underwent ADAPT thrombectomy for LVO during the study period of which 13% of had posterior circulation thrombectomy. Patients with posterior circulation thrombectomy did not show a significant difference in pre-procedural variables including age, baseline NIHSS and onset to groin time compared to anterior circulation (p>0.05). There were also no differences in procedural variables between the two groups. Patients in the posterior group were found to have a similar likelihood of good outcome (mRS 0—2) at 90 days compared to the anterior group (42.9% vs. 43.2% respectively) and a small but not significant increase in mortality at 90 days. Multivariate logistic regression analysis shows that the anatomical location (anterior vs. posterior) is not an independent predictor of good outcome or mortality after thrombectomy. Prominent predictors of outcome/mortality include age, female gender, procedure time, and baseline NIHSS.

Conclusion:
Our findings suggest that posterior circulation thrombectomy for LVO has a similar outcome and a similar rate of post-procedural complications compared to anterior circulation thrombectomy indicating comparable safety and efficacy profiles.
Abstract TP422: Cerebral Perfusion, Functional Connectivity and Cognitive Profile of Patients With Assymptomatic Carotid Stenosis
Authors: Camargo Ana Paula , Silva Pedro , Rodrigues Guilherme , Camilo Millene , Paschoal Andre , Barreira Clara , Abud Daniel , Leoni Renata , Pontes-Neto Octavio M
Published: October 2018

Introduction:
Patients with carotid stenosis, without history of stroke or transient ischemic attack are considered to be asymptomatic. However, many of those patients might have some degree of cognitive decline, changes in perfusion and functional connectivity that may precede clinical events suggesting a high risk for stroke. In this study, we aimed to evaluate the frequency and severity of cerebral blood flow (CBF), functional connectivity (FC) and cognitive performance abnormalities in patients with severe “asymptomatic” carotid artery stenosis (aCAS).

Methods:
Fifteen patients with aCAS >70% and 15 controls were evaluated with 3T MRI, including BOLD-FMRI, Pseudo-continuous Arterial Spin Labeling and Resting-State Brain Networks. The cognitive assessment included tests for executive function, psychomotor speed, attention and memory. We used Mann-Whitney U Test to compare cognition and CBF between groups; Wilcoxon test for intragroup CBF differences; Spearman Correlation Coefficient for associations between CBF, FC and cognition.

Results:
CBF maps in patients with aCAS revealed reduction in blood flow in the gray matter of temporal lobes and internal structures when compared to controls (p<0.05). The cognitive performance of patients with aCAS was lower than the control group for all measures, with significant differences in attention, mnemonic process and executive functions (p<0.05). Patients presented decreased connectivity for the fronto-temporal, salience and dorsal attentional networks (p-FDR<0.01). Additionally, we observed significant correlations (p<0.01) between salience network and the cognitive measures performed in this study.

Conclusions:
Subjects with aCAS showed less expressive networks and significantly lower cognitive performance, indicating deficits in fundamental networks for the identification of relevant stimuli, neural resource coordination, and information processing. We identified preclinical abnormalities in CBF, FC and cognitive performance of patients with aCAS, suggesting that neuroimaging markers in MRI, combined with cognitive assessment, have a great potential to identify the profile of patients with high risk of stroke and cognitive decline.
Abstract TP423: Hesperidin in Citrus Fruits Juice Improves Brain Ischemia-Induced Cognitive Impairment
Authors: Iwanami Jun , Kawakami Moe , Tsukuda Kana , Higaki Akinori , Min Li-Juan , Mogi Masaki , Horiuchi Masatsugu
Published: October 2018

Introduction:
We recently reported that drinking
Citrus iyo
juice (CI) inhibited more effectively vascular remodeling in inflammation-induced vascular injury mouse model than
Citrus unshiu
juice (CU) (PLoS One. 2015). These results led us to explore the possibility that citrus fruits juice drinking could attenuate cognitive decline in transient cerebral ischemia model, focusing on the effects of flavanone, hesperidin, which is more abundantly contained in CI compared with CU and has antioxidant activity.

Methods:
Eight-week-old male C57BL/6 mice were administrated 10 % CI or CU in drinking water or 100 mg/kg/day hesperidin orally by gavage. Two weeks after administration, brain ischemia was induced by bilateral common carotid artery occlusion (BCCAO) for 18 minutes. The Y maze task was performed 2 weeks after BCCAO operation. After cognitive task, cerebral blood flow (CBF) was measured by a laser speckle flowmetry. Cerebral superoxide anion production 24 hours after BCCAO was measured by dihydroethidium (DHE) staining. mRNA levels were measured by quantitative real-time RT-PCR.

Results:
Administration of CI, CU or hesperidin did not influence systolic blood pressure, bodyweight and brain weight. Cognitive function was impaired with the increase in superoxide anion production after BCCAO. The cognitive impairment was more effectively attenuated by the administration of CI with the significant increase in CBF than sham group. Interestingly, we also observed that the treatment with hesperidin significantly prevented cognitive decline after BCCAO. Superoxide anion production determined by DHE was attenuated by CI or hesperidin, not by CU. The increases in mRNA levels of tumor necrosis factor (TNF)-α in the brain of the brain 24 hours after BCCAO was prevented by hesperidin. Two weeks after BCCAO, expression of mRNA of NADPH oxidase subunits in the brain tended to decrease in treatment with hesperidin. AT1, AT2 and Mas receptor mRNA expression in the brain did not differ among three groups.

Conclusion:
These results suggest that the intake of hesperidin in citrus fruits juice should prevent cognitive decline after brain ischemia at least in part due to reduction of oxidative stress, inflammatory cytokine and an increase in CBF.
Abstract TP426: Major Cognitive Improvement in Patients With High Grade Intracranial Stenosis (70-99%) Within 3 Months of Transient Ischemic Attack or Minor Ischemic Stroke
Authors: Suri Muhammad F , Saeed Omar , Qureshi Adnan I
Published: October 2018

Importance:
Cognitive impairment appears to be common manifestation in patients with high grade intracranial stenosis. The rates of improvement in cognitive impairment and associated factors are not well known.

Objective:
Identify the rates and predictors of major cognitive improvement in patients with non-disabling stroke or TIA attributed to 70%-99% stenosis of a major intracranial artery.

Methods:
A post hoc analysis of patients in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) Trial was performed. Each patient underwent cognitive assessment using the Montreal Cognitive Assessment (MoCA) prior to (within 30 day of TIA or non-disabling stroke) and at 3 months post randomization. Major cognitive improvement was defined by an increase in Montreal Cognitive Assessment score of 2 points or greater at follow up evaluation.

Results:
A total of 172 (38.1%, 95% confidence interval [CI] 32.8 - 44.2) of 451 patients randomized had major improvement in cognitive assessment. The rate of major cognitive improvement was 151 (33.5% 95% CI 28.5 - 39.2) and 21 (4.7% 95% CI 3.0 - 7.0) among patients with MoCA score of <26 and ≥26 at baseline evaluation. The rates of major cognitive improvement did not differ between patients who were randomized to stent placement compared with best medical treatment (85 [49.4%] versus 87 [50.6%], relative risk [RR] 1.1, p=0.4). The rates of major cognitive improvement were significantly higher among patients aged ≥65 years (72 [41.9%] versus 55 [31.1%], relative risk [RR] 0.8, p=.03) and those with systolic BP ≥140 mm Hg at follow up visit (53 [30.8%] versus 39 (22.0%), relative risk [RR] 0.9, p=.05). There was a trend towards lower rates of major cognitive improvement in patients with HbA1C >6 at baseline assessment. No relationship between LDL cholesterol ≥70 mg/dl at baseline or follow up visit and major cognitive improvement was identified.

Conclusions:
A relatively high rate of major cognitive improvement was observed in patients with high grade symptomatic intracranial stenosis within 3 months. The paradoxical relationship between greater age and higher systolic blood pressure at follow up evaluation with major cognitive improvement require further studies.
Abstract TP43: Trends in Interhospital Transfers and Mechanical Thrombectomy for Acute Ischemic Stroke
Authors: George Benjamin P , Pieters Thomas A , Zammit Christopher , Sheth Kevin N , Bhalla Tarun
Published: October 2018

Introduction:
Stroke care in the US is becoming increasingly regionalized. Many patients undergo interhospital transfer to obtain access to specialized, time-sensitive interventions such as mechanical thrombectomy.

Methods:
We used the stratified survey design of the US Nationwide Inpatient Sample, 2009-2014, to examine nationwide trends in interhospital transfers for ischemic stroke and the relationship between transfers and thrombectomy.
International Classification of Disease—Ninth Revision
diagnosis and procedure codes were used to identify acute stroke admissions and inpatient procedures (tissue plasminogen activator [tPA] administration and thrombectomy), respectively. The analysis was restricted to hospitals with the capabilities to perform thrombectomy. Trends were assessed using a Cochran-Armitage test.

Results:
From 2009 to 2014, an estimated 759,648 ischemic stroke admissions were identified within hospitals offering thrombectomy (102,674 in 2009; 154,280 in 2014). The proportion of stroke admissions to these hospitals that underwent interhospital transfer prior to arrival increased from 13.5% (n=13,811) in 2009 to 18.9% (n=19,175) in 2014 (
P
trend<0.001). Compared to “front door” patients, transfers were more likely to receive tPA (10.7% vs. 26.5%;
P
<0.001) and thrombectomy (2.7% vs. 5.7%;
P
<0.001). The proportion of transfers that received thrombectomy increased from 4.5% (n=625) to 6.0% (n=1,745) from 2009 to 2014 (
P
trend=0.016). Approximately 30% of patients receiving thrombectomy for ischemic stroke were transferred from another acute care facility (n=7,328). Among patients receiving tPA, transferred patients were slightly less likely to receive thrombectomy compared to those arriving by “front door” at thrombectomy performing centers (13.9% vs. 15.4%;
P
=0.004).

Conclusions:
From 2009 to 2014, interhospital stroke transfers to thrombectomy performing hospitals more than doubled. For every ~5 additional stroke transfers over the time period examined, one additional transferred patient received thrombectomy. As stroke systems of care continue to evolve across the US, the optimization of stroke transfers presents an opportunity to increase access to meaningful interventions such as thrombectomy.
Abstract TP47: Prediction of Stroke Outcome With Immediate Post-Thrombolysis Magnetic Resonance Imaging
Authors: Shin Jaewon , Jang Hyun-soon , Kim Keon Ha , Jeon Pyoung , Chung Jong-Won , Seo Woo-Keun , Bang Oh Young , Lee Kwang Ho , Kim Gyeong-Moon
Published: October 2018

Background:
Early recanalization and adequate collateral blood flow are strong surrogates for functional recovery in endovascular stroke treatment. We sought to evaluate the prognostic value of immediate post-thrombolysis magnetic resonance imaging (MRI).

Methods:
Consecutive patients with acute ischemic stroke who underwent endovascular treatment were enrolled. We measured diffusion-weighted MRI (DWI) and perfusion-weighted MRI (PWI) lesion volume, mismatch ratio, and DWI and PWI lesion volume change before and immediate after treatment. Outcome was measured with modified Rankin Scale (mRS) at 90 days, early neurological improvement (NIHSS ≥ 8) within 7 days, and any intracerebral hemorrhage. Multivariate analysis and
c
-statistics were used to identify prognostic value of MR parameters.

Results:
A total of 65 patients with a complete pre- and post-thrombolysis MRI were included. Mean age was 65±18 years, median baseline NIHSS score was 14, and median time from symptom onset to endovascular treatment was 192 minutes. Median time from endovascular treatment to post-treatment MRI was 20 minutes. After control of initial stroke severity and complete recanalization on angiography, post-thrombolysis PWI lesion volume remained an independent predictor of favorable outcome (
p
= 0.017, odds ratio [OR] = 0.970, 95% confidence interval [CI] = 0.946-0.995), and early neurological improvement (
p
= 0.014, OR = 0.957, 95% CI = 0.923-0.991), whereas DWI lesion volume, mismatch ratio, and DWI and PWI lesion volume changes did not show statistical significance. None of the measured variables predicts intracerebral hemorrhage. Post-thrombolysis PWI lesion volume revealed area under the curve of 0.821 (p < 0.001, 95% CI = 0.722-0.920) for favorable outcome and 0.878 (p < 0.001, 95% CI = 0.799-0.957) for early neurological improvement.

Conclusions:
Perfusion lesion volume on immediate post-thrombolysis MRI more accurately predicts functional recovery and early neurological improvement than pre-treatment DWI and PWI parameters.
Abstract TP49: Quantitative Evaluation of Proton Magnetic Resonance Spectroscopy on protection of Human Urinary Kallidinogenase in Neurons Against Ischemic Stroke
Authors: Wang Moli , zhang yifan , Guo Yunguan , Li Jingkai
Published: October 2018

Introduction and Hypothesis:
To evaluate the effect of Human Urinary Kallidinogenase (HUK) regarding the changes to brain metabolites in patients with acute ischemic cerebral infarction (AIS) by magnetic resonance spectroscopy.

Methods:
From 1, 2014 to 10, 2016, 57 patients with AIS who having MRI within 72 hours of onset of symptoms were randomly divided into an observation group and a control group. The control group was given standard care while the observation group was treated with HUK in additional to standard care. The levels of N-acetyl aspartate (NAA) and creatine (Cr) in the brain were measured by multi-voxel Proton magnetic resonance spectroscopy (MRS) before and one week after intervention The National Institutes of Health Stroke Scale (NIHSS) was performed using the Improved Rankin scale (mRA) score, Barthel index (BI) to evaluate clinical efficacy. The obtained data were assessed using percentages, t test, and F test in the SPSS 19.0 software.

Results:
The values of NAA, NAA/Cr, the NIHSS score, and the mRS were not significantly different between the two groups (P> 0.05) at baseline before the treatment. One week post-observation, the values of both NAA and NAA/Cr in the central infarcted area were lower than before in both groups before the observation P <0.05). The NAA and NAA/Cr in the peripheral infarcted areas of the observation group were higher than those in the control group , and the increase of NAA and NAA / Cr in the observation group was higher than that in the control group ( HUK group vs. Control group: NAA, NAA/Cr. P<0.05: respectively). In addition, the NIHSS score, mRS score, and BI index were higher in the observation group than in the control group (P <0.05).

Conclusion:
Treating patients with AIS with HUK can improve both the brain metabolic profile as well as patient’s clinical outcomes.
Abstract TP53: Evaluation of Hyperperfusion Phenomenon After Carotid and Cerebral Revascularization Using Arterial Spin Labeling Perfusion MRI
Authors: Takenobu Yohei , Ishii Akira , Yoshida Kazumichi , Takagi Yasushi , Miyamoto Susumu
Published: October 2018

Background and Purpose:
Evaluation of cerebral blood flow (CBF) after carotid and cerebral revascularization is essential for early detection of hyperperfusion phenomenon. Single photon emission computed tomography (SPECT) is considered to be a standard modality for evaluation of CBF. It has, however, difficulty in real-time and repetitive evaluation. Recently, arterial spin labeling MRI (ASL-MRI) has evolved with advantages of its immediacy and repetitivity. The purpose of this study is to elucidate the usefulness of ASL-MRI for evaluation of CBF after carotid and cerebral revascularization.

Methods:
We screened the adult patients who underwent ASL-MRI and SPECT within 24 hours of interval after carotid endarterectomy (CEA), carotid stenting (CAS), or extracranial-intracranial bypass (EC-IC bypass). After excluding the cases of poor image quality, 63 cases (23 CEA, 22 CAS, 18 EC-IC bypass) were enrolled into the study. ASL-MRI (Siemens 3.0T Magnetom Prisma; 2D-PICORE, Voxel size 1.5x1.5x4mm, TR/TE/TI=4000/15.66/1800-2500) were obtained within 24 hours after surgery. SPECT were obtained using N-isopropyl-p-[123I]iodoamphetamine with autoradiography technique. If abnormal CBF increase (≧20%) were detected, patients were treated with anti-hypertensive therapy, and underwent repeated ASL-MRI and SPECT for therapeutic evaluation.

Results:
Abnormal CBF increase were observed in 6 cases (2 CEA, 2 CAS, and 2 EC-IC bypass) in SPECT, and 4 (2 CEA, 2 EC-IC bypass) in ASL-MRI. In CEA, 2 cases of CBF increase detected in SPECT were also detected in ASL-MRI. In CAS, ASL-MRI did not visualize CBF increase as clearly as in SPECT. In EC-IC bypass, 2 cases of CBF increase detected in SPECT were also detected in ASL-MRI. The patient with increased CBF after revascularization surgery were treated with anti-hypertensive drugs and remained asymptomatic.

Conclusion:
ASL-MRI was useful for evaluation and early detection of abnormal CBF in CEA and EC-IC bypass, although not in CAS. Decay of radiofrequency pulse due to metallic material is supposed to be the reason. In cases of CEA and EC-IC bypass, ASL-MRI is expected to be an alternative to SPECT with its advantage of immediacy and repetitivity.
Abstract TP6: Evaluation of Patients With High NIH Stroke Scale as Thrombectomy Candidates Using the Kentucky Appalachian Stroke Registry (KApSR)
Authors: Fraser Justin F , Kitzman Patrick , Wolfe Marc , Elkins Kelley , Bix Gregory J , Dobbs Michael R
Published: October 2018

Background:
Mechanical thrombectomy has become standard of care for emergent large vessel occlusive (ELVO) stroke. Estimates of incidence for thrombectomy eligibility vary significantly. NIH Stroke Scale (NIHSS) of 9 or greater is highly predictive of large vessel occlusion. Using our Kentucky Appalachian Stroke Registry (KApSR), we evaluated regional trends in stroke admissions with NIHSS of 10 or more to determine effects and needs in thrombectomy utilization.

Methods:
Using the KApSR database that captures patients throughout the Appalachian region in our stroke network, we evaluated patients admitted with ischemic stroke with NIHSS > 9 anytime during admission. We recorded demographics, comorbidities, treatment (thrombectomy, decompressive craniectomy), and county of origin. Change in NIHSS from admission to discharge was measured as an indicator of inpatient outcome. Summary statistics and analyses were performed on SPSS; p<0.05 was significant.

Results:
From 2010 to 2016, 2250 patients were included; 132 (5.9%) underwent thrombectomy. 66.8% were admitted with NIHSS > 9. Annual utilization of thrombectomy increased over time from 0.8% in 2010 to 10.6% in 2016. When thrombectomy was considered, median change in NIHSS was -2 (IQR 8) in patients without thrombectomy versus -5 (IQR 12) in patients who underwent thrombectomy; the difference was significant (p<0.001). Furthermore, while the median change in NIHSS remained stable for non-thrombectomy patients, it improved over time for thrombectomy patients (Figure 1).

Conclusion:
Among patients with significant inpatient ischemic stroke, a majority present with NIHSS greater than 9. While thrombectomy has become more common, it was only utilized in 10.6% of patients in 2016. Furthermore, patients who underwent thrombectomy has significant inpatient clinical improvement compared to those that did not. Thus, further efforts are necessary to maximize the use of thrombectomy when appropriate.
Abstract TP61: Determinants of CT Perfusion Misrepresentation of Ischemic Core in Endovascular Stroke Therapy
Authors: Rosenbaum-Halevi David , Vahidy Farhaan S , Daileda Taylor , Chen P. Roc , Yoo Albert J , Liang Conrad W , Savitz Sean I , Sheth Sunil A
Published: October 2018

Introduction:
CT Perfusion (CTP) has become an essential tool in determining candidates for endovascular stroke therapy (EST), particularly in later time windows. However, the reliability of CTP to define infarct core may vary based on time of onset and other clinical factors.

Methods:
From our prospective institutional registry, we identified patients between 1/2014 - 3/2017 that underwent EST with successful reperfusion (TICI 2b/3), pre-procedure CTP and 24hr MRI. Source CTP data were analyzed using OleaSphere (La Ciotat, France) rCBF<30% and RAPID (IschemiaView, CA) rCBF<30%. Mismatch (MM) was defined as >10cc disparity between CTP core and 24hr DWI. Multivariate logistic regression assessed factors associated with MM (p<0.05 significant, p<0.10 trend).

Results:
Among 109 patients (60 with RAPID) studied, mean age was 63±15, median NIHSS 19[15.5-22], median ASPECTS 8 [7-10], and occlusion location ICA in 19 (17%) and M1 in 90 (83%). CTA collateral grades were 0-2a in 70 (64.2%) and 2b/3 in 36 (35.8%). Median time from onset to CT (LKW-CT) was 128 [77-212] min, and from CTP to recanalization (CTR) of 142.5[111.5-169.5] min. MM occurred in 84 (77%, 8(7.3%) infarct shrinking and 76 (69.7%) infarct growth) using Olea and 38 (63.3%, 1(1.7%) infarct shrinking and 37(61.7%) infarct growth) using RAPID. In adjusted multivariable regression, MM was significantly associated with larger CTP core and lower NIHSS with RAPID (ORs 1.06, 0.87) and larger CT core and poor collaterals with Olea (ORs 1.04, 0.35). Infarct growth was significantly associated with core size, NIHSS and a trend towards LKW-CT in RAPID (ORs 1.05, 0.88, 1.78 and Figure), and collaterals in Olea (OR 0.31). CTR was not associated with infarct growth.

Conclusion:
MM between CTP core and MRI infarct occurs frequently, with both infarct growth and shrinkage. The likelihood of infarct growth appears to be related to LKW-CT and collaterals, suggesting that CTP thresholding in later time windows may need to adjusted.
Abstract TP63: Pretreatment Infarct Topography and Clinical Outcome in Acute Ischemic Stroke. A THRACE Substudy
Authors: Xie Yu , Micard Emilien , Liao Liang , Chen Bailiang , Soudant Marc , Felblinger Jacques , Guillemin Francis , Hossu Gabriela , Bracard Serge
Published: October 2018

Background and purpose:
Infarct topography has been suggested to predict functional outcome in ischemic stroke patients. However, little evidence could be found in regard to pretreatment imaging. We aimed to elucidate the impact of pretreatment infarct topography in predicting functional outcome in acute ischemic stroke.

Methods:
Our work is a sub-study of THRACE. 144 acute stroke patients assigned to receive intravenous thrombolysis plus mechanical thrombectomy were included. Infarct lesions were semi-automatically segmented on baseline diffusion weighted images. Regional lesion locations were decided according to automated anatomical labeling and JHU-WhiteMatter-labels atlases. A threshold was established in order to define, for each region, which percentage of infarction can predict poor clinical outcome (3 month-mRs 3-6) and then to define whether a region could be considered as infarcted. Finally, univariate and multivariate logistic analysis were performed.

Results:
In univariate analysis, basal ganglia, insula, inferior frontal and inferior parietal gyrus, temporal lobe, amygdala, internal capsule, corona radiata, superior longitudinal fasciculus, posterior thalamic radiation and uncinate fasciculus lesions were implicated in poor functional outcome in left-hemisphere stroke. Significant regions in right hemisphere were basal ganglia, temporal lobe, insula, amygdala, hippocampus and uncinate fasciculus. In multivariate analysis, eloquent regions for poor functional outcome were left internal capsule (OR=0.09), left inferior parietal gyrus (OR=0.03), right superior temporal gyrus (OR=0.09) and right amygdala (OR=0.03).

Conclusion:
Pretreatment infarct topography provides important prognostic value in functional outcome after acute ischemic stroke, and may optimize the individualized treatment decision-making.
Abstract TP69: Baseline Characteristics and Outcomes of Stroke Mimics in The Rapid Intervention With Glyceryl Trinitrate In Hypertensive Stroke Trial-2 (RIGHT-2): An Interim Analysis
Authors: Appleton Jason P , Scutt Polly , Dixon Mark , Howard Harriet , Law Zhe K , Havard Diane , Sprigg Nikola , Bath Philip M
Published: October 2018

Introduction:
The ongoing Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial (RIGHT-2) is testing the safety and efficacy of paramedic-delivered transdermal glyceryl trinitrate (GTN) in patients with ultra-acute stroke. We sought to assess whether stroke mimics have a benign outcome in comparison to stroke patients.

Methods:
RIGHT-2 is an ongoing prospective randomised single-blind blinded-endpoint parallel group trial enrolling 1050 previously independently patients with suspected stroke (Face Arm Speech Test score ≥2/3) within 4 hours of onset. Consenting patients are randomised to receive GTN or sham patch in the pre-hospital setting. The primary outcome is the modified Rankin scale (mRS) assessed at day 90. Data are number (%) or mean (standard deviation).

Results:
As of July 2017, 600 patients had been recruited of which 146 (24.3%) were stroke mimics. Mimics were younger, age 65.1 (18.1) years; had a lower NIHSS 5.6 (6.3) vs 11.4 (7.4); and higher Glasgow coma scale, 14.3 (1.8) vs 13.6 (2.3) than stroke participants. The most common diagnoses were: seizure (16%), migraine/headache (16%) and functional (10%). Of those who have completed day 90 follow-up compared with stroke, mimics had significantly better functional outcome, mRS 2.6 (2.0) vs 3.9 (1.8), p<0.0001, and quality of life, and lower disability and depression scores, and a lower death rate, 11 (12.1%) vs 73 (26.4%), p=0.0047.

Conclusion:
Although their outcome is better than stroke participants, mimics do not necessarily have benign outcomes. Pragmatic pre-hospital trials with safety data on mimics may ultimately ease implementation of interventions into clinical practice.
Abstract TP70: Systemic Review of Intravenous tPA for Patients With Central Retinal Artery Occlusion
Authors: Alkuwaiti Mohammed , Bongiorno Connie , Logue Christopher , Male Shailesh , Miller Benjamin , Engel Kevin , Reshi Rwoof A , Anderson David , Urrutia Victor , Streib Christopher
Published: October 2018

Introduction:
Central retinal artery occlusion (CRAO) causes monocular visual loss adversely impacting quality of life and functional outcome. Spontaneous visual recovery occurs in only 10-20% of patients. Thrombolysis with IV tPA been reported in small series. We aim to summarize existing data on efficacy and safety of IV tPA for CRAO.

Methods:
We performed a systematic literature review (SLR) of studies of IV tPA in CRAO using Cochrane, Embase and Medline databases. Data extracted from the studies included: demographics, dose, timing, and infusion rate of IV tPA, concomitant anticoagulation, symptomatic intracranial hemorrhage (sICH), and post-treatment visual acuity (VA). Improvement in VA was defined as improvement ≥ 0.3 log mar.

Results:
Our SLR yielded 19 articles, identifying 137 patients who received IV tPA for CRAO. 55 patients (40%) received IV tPA within 4.5 hours. 71 patients (52%) received the standard dose and infusion rate of IV tPA used in acute ischemic stroke (AIS). Concomitant use of IV heparin within 24 hours was reported in 53 patients (36%). Follow-up VA was available for 67 subjects: 61% improved, 33% were unchanged, and 6% worsened. sICH occurred in 4 cases (2.9%) with 1 death (0.7%). All cases of sICH were associated with at least one deviation from AIS IV tPA guidelines (dose [n=2], concomitant heparin infusion [n=3], timing [n=3]).

Conclusion:
Our SLR found substantial heterogeneity in study design regarding IV tPA utilization for CRAO. The majority of CRAO patients did not receive IV tPA per AIS protocol. The reported improvement in VA for CRAO patients receiving IV tPA was considerably higher than the known natural history, however, sICH rates were not inconsequential. sICH was associated with deviation from established AIS IV tPA guidelines. Further study through prospective registries and/or randomized trials are warranted.
Abstract TP71: One-twentieth of Acute Ischemic Stroke With Anticoagulation Therapy for Venous Thromboembolism Have Hemorrhagic Complications
Authors: Mitsumura Hidetaka , Komatsu Teppei , Sakuta Kenichi , Sakai Kenichiro , Terasawa Yuka , Iguchi Yasuyuki
Published: October 2018

Background and Purpose:
The availability of direct-acting oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF) and venous thromboembolism (VTE) has changed the therapeutic landscape of anticoagulation therapy, but the guideline-based recommendation of anticoagulation therapy for the acute stroke patients with VTE is unclear. Our aim of this study is to survey clinical characteristics of acute stroke patients with VTE in new treatment paradigms including DOACs.

Methods:
Subjects were acute stroke patients within 7 days from onset with VTE detected by enhanced CT and/or ultrasound of leg veins. VTE evaluation was performed for the patients as follows; presence of right-to-left shunts by transcranial Doppler, elevation of D-dimer, and suspected embolic stroke of undetermined source. We analyzed the following information: 1) the prevalence of VTE among acute stroke patients, 2) clinical information of VTE (i.e. subtype and symptom of VTE), 3) treatment details for stroke and VTE, 4) hemorrhagic complication after VTE treatment.

Results:
From October 2012 to June 2017, we registered 1077 acute stroke patients. We underwent the VTE evaluation for 226 patients (21%). Of them, 65 patients (39 female, mean age of 76 years, 6% of all patients, and 29% of patients with examination) had VTE (deep vein thrombosis (DVT); 52, pulmonary embolisms (PE); 2, DVT+PE; 11). In 65 patients with VTE, ischemic stroke was 60 cases. Antiplatelet agents were given for 35 of these 60 cases before starting therapy for VTE. Medications for VTE were as follows; 29 cases with DOACs, 14 with warfarin, 7 with warfarin following heparin, and 9 with heparin alone. Hemorrhagic complication occurred in 3 of 60 case of ischemic stroke with VTE (5%). One case had intraventricular hemorrhage after starting DOAC following 200mg aspirin, and muscle hematoma was found in the other two cases using warfarin following heparin.

Conclusions:
Prevalence of VTE was 6% of acute stroke patients in our preliminary survey. After medication for acute ischemic stroke with VTE, 5% of them had hemorrhagic complication. We should choose anticoagulation therapy for acute stroke patients with VTE focused on former use of antiplatelet drug and hemorrhagic complication.
Abstract TP72: Transcranial Direct Current Stimulation (tDCS) for Neuroprotection in Acute Cerebral Ischemia: Meta-analysis of Preclinical Studies and Implications for Human Clinical Trials
Authors: Bahr Hosseini Mersedeh , Hou Jessey , Bikson Marom , Iacoboni Marco , Saver Jeffrey L
Published: October 2018

Introduction:
Transcranial direct current stimulation (tDCS) is a noninvasive neuromodulation technique safe and promising in early human studies of nonacute disorders (depression, OCD, stroke recovery), and also reported to confer direct neuroprotection and vasodilation in animal models of acute cerebral ischemia. Systematic review of preclinical acute cerebral ischemia studies would aid planning for potential initial human clinical trials.

Method:
A systematic Medline search identified controlled, preclinical studies of tDCS in acute ischemic stroke. Studies were categorized according to stimulation type (hemispheric cathodal; hemispheric anodal; targeted cerebellar fastigial nucleus). Stratified meta-analysis assessed effect of tDCS on final infarct volume.

Results:
The systematic search identified 17 controlled comparisons of tDCS in preclinical acute cerebral ischemia models, including a total of 256 animals, all with middle cerebral artery occlusion. Hemispheric cathodal stimulation was used in 3 experiments (32 animals), hemispheric anodal stimulation in 1 experiment (8 animals) and fastigial nucleus stimulation in 13 experiments (91 animals). Overall, tDCS reduced final infarct volume by 27.5 cc (95% CI 25.33-29.74, P<0.00001). Heterogeneity of effect by stimulation type was noted (I
2
=90.5%), with the greatest infarct reduction with cathodal - 34.9 cc (95% CI 30.60-39.18, P< 0.00001), followed by targeted fastigial nucleus - 26.8 cc (95% CI 25.33-29.53, P< 0.00001), and anodal - 17.8 cc (95% CI 11.42-24.18, P< 0.00001). In the cathodal studies, stimulation was started 30-45 minutes after ischemia onset.

Conclusions:
Transcranial direct current stimulation reduces final infarct volume across animal preclinical studies. The greatest neuroprotective effect is observed with hemispheric cathodal stimulation, with treatment initiation in a time frame achievable in human prehospital clinical trials. Human clinical trials of hemispheric cathodal tDCS are warranted.
Abstract TP73: Better Functional Outcomes in Patients Treated versus Not Treated for Mild Stroke
Authors: Carnahan Bridget , Corless Leslie , Lucas Lindsay , Baraban Elizabeth , Yanase Lisa R
Published: October 2018

Introduction:
IV alteplase (tPA) decreases long-term disability from acute ischemic stroke (AIS). Many patients do not receive tPA due to mild stroke symptoms (NIHSS < 5), even when they meet criteria for treatment, perhaps due to concern that risk of treatment in these populations outweighs benefit. This study compares outcomes for acute ischemic stroke (AIS) patients with mild symptoms who received tPA versus those who did not.

Methods:
Data obtained from a multi-hospital system’s Get With The Guidelines registry included AIS patients with admission NIHSS of less than five who were discharged between January 2014 and December 2016 and presented within 4.5 hours of onset of stroke symptoms. Patients were excluded if they had an in-hospital stroke or were not treated due to a reason other than mild stroke symptoms. Outcomes included discharge modified Rankin Scores (mRS) categorized as no-to-mild disability (mRS≤2) vs moderate disability to death (mRS≥3), hospital length of stay (LOS) and discharge disposition. Generalized linear and Cox proportional hazard models were used to compare outcomes adjusting for admission NIHSS, age, mode of arrival, gender, and last known well to arrival time.

Results:
A total of 854 patients met inclusion criteria with 53.5% (n=457) treated with tPA and 46.5% (n=397) excluded from treatment for mild stroke only. Median age was 68 (interquartile range = 57 to 77) years and 47% were female. Patients who were excluded from treatment for mild stroke were 2.33 times more likely to have discharge mRS≥3 than patients with mild symptoms treated with tPA (p=0.014). There were no statistically significant differences in likelihood of discharge to home or length of stay.

Conclusion:
Patients with mild strokes excluded from tPA treatment for mild symptoms were more likely to be disabled based on discharge mRS than those treated with tPA. Physicians should consider treating patients with mild symptoms with tPA to improve patient outcomes.
Abstract TP74: Delayed Treatment of Intravenous Thrombolysis in Stroke Patients With Minor Stroke
Authors: Yoo Joonsang , Sohn Sung-Il , Kim Jinkwon , Ahn Seonghwan , Lee Kijeong , Baek Jang-Hyun , Kim Kyoungsub , Hong Jeong-Ho , Koo Jaseong , Kim Young Dae , Kwak Jaehyuk , Nam Hyo Suk , Heo Ji Hoe
Published: October 2018

Background and purpose:
Rapid administration of IV tissue plasminogen activator (tPA) is crucial for better outcome in acute stroke treatment. While IV tPA is more frequently used in patients with minor stroke, the recognition of stroke and behavior of medical staffs in the emergency department (ED) may be different according to the severity of stroke symptoms. In this study, we investigated time to intervention is different according the stroke severity in stroke patients treated with IV tPA.

Methods:
We included consecutive patients who underwent IV thrombolysis during 1.5 year-period after IV tPA had been used regardless of stroke severity in the five university hospitals. Minor stroke was defined as a National Institute of Health Stroke Scale score <5. We compared various intervals from arrival at ED to treatment between patients with minor stroke and those with nonminor stroke. Delayed treatment was defined as door-to-needle time over 40 min.

Results:
During the study period, a total of 356 patients who admitted to the emergency department received IV tPA treatment. Median door-to-needle time was significantly longer in the minor stroke group than the non-minor stroke (43 min, interquartile range [IQR 35 - 54 vs. 37 min, [IQR 30 - 46], p<0.001). Among various steps to intervention, door-to-notification time (7 min [IQR 4 - 12] vs. 5 min [IQR 3 - 8], p<0.001) and notification-to-imaging time (12 min [IQR 8 - 17] vs. 10 min [IQR 6 - 15], p=0.033) were significantly longer in the minor stroke group than the non-minor stroke group. However, image-to-needle time was not significantly different between the groups. Among 356 patients, door-to-needle time was over 40 min in 157 patients (44.1%). After adjusting age, sex, and presence of alarm system, minor stroke was associated with the delayed treatment (OR 2.48; 95% confidence interval [1.49 - 4.16], p=0.001) in the multivariable analysis.

Conclusions:
Door-to-needle time was longer in patients with minor stroke than those with non-minor stroke, which was mainly ascribed to delayed door-to-notification time and notification-to-image time. Efforts to improve stroke recognition and medical professional’s behavior at triage are required in patient with minor stroke.
Abstract TP75: Prognosis in Mild or Rapidly Improving Ischemic Stroke Not Treated With Recombinant Tissue Plasminogen Activator: Fukuoka Stroke Registry
Authors: Sakai Shota , Osaki Masato , Kimura Shunsuke , Hidaka Masaoki , Arakawa Shuji , Ago Tetsuro , Matsuo Ryu , Kamouchi Masahiro , Kitazono Takanari
Published: October 2018

Background and Aims:
Recombinant tissue plasminogen activator (rt-PA) is often withheld for mild or rapidly improving acute ischemic stroke. The aim of this study is to determine risk factors for poor outcomes in such cases.

Method:
This study included 772 consecutive acute ischemic stroke patients from the Fukuoka Stroke Registry who did not receive rt-PA therapy because of mild or rapidly improving symptoms. Logistic regression analysis was performed to determine the predictors of poor outcomes (modified Rankin Scale 3-6 at 3 months after onset).

Results:
Eighty-six patients (11.1%) showed a poor outcome. Compared to patients with a good outcome (n=686), those with a poor outcome were older (78±10 vs. 68±13 years, p<0.0001) and had higher initial NIH Stroke Scale (quartile value 3-4 vs. 1-2, p<0.0001). A poor outcome was more frequent among patients with chronic kidney disease (10.4% vs. 4.8%, p=0.0293), atrial fibrillation (24.4% vs. 15.0%, p=0.0252), cortical symptoms (20.9% vs. 8.6%, p=0.0003), limb paralysis (34.8% vs. 23.3%, p=0.0190), and branch atheromatous disease (15.1% vs. 3.6%, p<0.0001). In multivariate analysis, age (every 1 year, odds ratio [OR] 1.08, 95% confidence interval [CI] 1.05-1.10, p<0.0001), chronic kidney disease (OR 1.78, 95% CI 1.11-2.83, p=0.0151), cortical symptoms (OR 2.27, 95% CI 1.19-4.21, p=0.0125), and limb paralysis (OR 1.67, 95% CI 1.04-2.66, p=0.0312) were positively associated with a poor outcome.

Conclusion:
In patients with older age, chronic kidney disease, cortical symptoms, or limb paralysis, rt-PA administration should be considered even for mild or rapidly improving stroke.
Abstract TP76: Increased Regulatory T Cells After Treatment of Poly (adp-ribose) Polymerase-1 Inhibitor in Patients With Acute Ischemic Stroke
Authors: Kim Young Seo , Kim Hyun Young , Noh Min Young , Kim Seung Hyun
Published: October 2018

Background:
Regulatory T cells (Tregs) have been suggested to have modulatory function of immune response and improve outcome after ischemic stroke. Thus, various strategies to increase Treg in animal model of ischemic stroke have been studied with successful results. The aim of this study is to demonstrate Treg (CD4
+
CD25
+
FoxP3
+
) proportion in peripheral blood of ischemic stroke patient and the potential effect of poly (ADP-ribose) polymerase-1 (PARP-1) inhibitor on Treg proportion.

Methods:
Peripheral blood samples were collected from 12 ischemic stroke patients (within 72 hours of stroke onset) and 5 control subjects. Demographics and clinical information were obtained from patients and control subjects. Fluorescence-activate cell sorting (FACS) analyses and quantitative reverse transcription polymerase chain reaction (qRT-PCR) were performed with peripheral blood mononuclear cells (PBMCs) before and after PARP-1 inhibitor (3-AB, JPI-289 1 μm, JPI-289 10 μm) treatment for 24 hours.

Results:
Treg proportion was significantly higher in healthy control (3.5 ± 1.8 %) than ischemic stroke patients (1.6 ± 0.6 %) (
p
< 0.001). In ischemic stroke patients, regulatory T cell proportion was positively correlated with age (r = 0.595,
p
= 0.041), but did not show association with infarct volume (r = 0.367,
p
= 0.241). After PARP-1 inhibitor treatment, the proportion of Treg was increased in high dose (10 μm) JPI-289 group (2.1 ± 0.7 %). However, 3-AB and low dose (1 μm) JPI-289 did not show significant changes of Treg proportion. RT-PCR showed increased expression of Treg associated transcription factors such as FoxP3 and CTLA-4 mRNA after PARP-1 inhibitor treatment. PARP-1 inhibitor treatment also decreased pro-inflammatory cytokines such as IFN-γ, TNF-α, and IL-17 and increased anti-inflammatory cytokines such as IL-4, IL-10, and TGF-β1.

Conclusion:
Treg proportion was decreased in patient with acute ischemic stroke. However, it was up-regulated after treatment of PARP-1 inhibitors, especially with high dose JPI-289. In addition, PARP-1 inhibitor showed possible anti-inflammatory effect by regulating cytokines. PARP-1 inhibitor may ameliorate outcome of ischemic stroke by immune modulation.
Abstract TP77: Novel Experimental Aneurysm Model in Swine With Hemodynamic Change After Endovascular Treatment; "Recanalization and Regrowth Model"
Authors: KAN ISSEI , Yuki Ichiro , Kostadin Karagiozov , Kodama Tomonobu , Ikemura Ayako , Suzuki Takashi , Takao Hiroyuki , Ishibashi Toshihiro , Murayama Yuichi
Published: October 2018

Introduction:
Very few animal model can simulates aneurysmal growth and recanalization after endovascular treatment. It was indicated that swine aneurysm model has increased thrombogenicity, which can lead to better healing. We modified the aneurysm model by inducing double anti-platelet therapy to reduce thrombogenisity. It was to establish a large animal model with improved patency, and moreover simulating the recanalization followed by aneurysmal growth. This study is to evaluate reproducibility and feasibility of the modified swine aneurysm model for the evaluation of new endovascular devices.

Methods:
Sidewall aneurysm was surgically created on the bilateral carotid arteries using a vein graft. A total of eighteen aneurysms were created in 9 swine. Endovascular treatment was performed just after the creation. Aspirin 100mg and clopidogrel 75mg were given five days prior to the surgery and kept until harvesting at day14. Endovascular treatment was performed in following device combinations: coil embolization with stent (n=11) and coil alone (n=7). Volume Embolization Ration (VER) was measured in every aneurysm.

Results:
Mean aneurysm neck size was 6.3mm, and mean fundus size was 9.5mm. Mean VER was 9.9%. Recanalization or aneurysmal rupture was seen on 83.3% (n=15). Average VER is significantly lower in ruptured group than that in un-ruptured group (7.3% vs. 11.6%, P<0.001). Mortality rate due to aneurysmal rupture was 27.7%. However, after the amendment of the protocol with higher VER, the mortality rate was reduced. Recanalization was observed along with the inflow-area in representative cases. The histologic analysis showed recanalized component, which was consistent with the CFD results (Figure).

Conclusion:
The modification in the swine aneurysm model reproduced the recanalization and aneurysmal growth after the treatment. This model may contribute to the evaluation of the new endovascular devices by simulating the similar clinical settings.