bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP67: Pre-Hospital FAST-ED Initiatives Improve t-PA and Endovascular Treatment Times
Authors: Tocre Carrion Camila , Starosciak Amy K , Ramirez Maygret , Gonzalez Ivis C , Ramos Virginia , Strauss Jayme , De Los Rios La Rosa Felipe
Published: October 2018

Introduction:
Acute stroke outcomes largely depend on timely reperfusion treatment. On March 2017 Miami Dade County EMS (MDFR) implemented a pre-hospital FAST-ED scale initiative. Those with a score ≥ 4 bypass other centers for a comprehensive stroke center (CSC) and those with a score ≥ 6 also have the neuro interventional team activated from the field. We sought to analyze the impact of this initiative on treatment times.

Methods:
All stroke cases brought to Baptist Hospital of Miami by MDFR during the months of March, April, and May 2017 were included. Treatment times were compared on vs. off hours and to those with a FAST-ED score ≥6. We compared our data to the immediately preceding 3 months and to the same months 1 year ago. We used the FAST-ED score documented on the run sheet.

Results:
During the first 3 months of the initiative 139 patients were received at our CSC from MDFR. Of these, 84 (60%) were coded as stroke (ischemic, hemorrhagic, or TIA), and 23 (17%) underwent reperfusion treatments. Age, gender, and pre-treatment NIHSS were comparable across time periods. Treatment times are described on Table 1. The initiative led to overall faster door to groin times by 23 min compared to the previous 3 months (n.s.), and 33 min (33%) compared to the previous year (p=0.02). During off hours for FAST-ED ≥ 6, there was a 46 min (43%) improvement from the previous 3 months (p=0.05) and a 69 min (52%) improvement from the previous year (p=0.01). Door to needle time improved only for off hours cases with FAST-ED ≥ 6. Times improved by 10 min (27%) compared to the previous 3 months (p=0.03) and 16 min (37%) compared to the year prior (p=0.01).

Discussion:
The Miami Dade County FAST-ED scale initiative leads to clinical, and statistical, significant faster treatment times for both IV tPA and endovascular treatments. The highest impact is for off-hours and those with a score ≥ 6.
Abstract TMP76: Frequency of Evaluation for Stroke Risk Factors in Patients With Retinal Infarction
Authors: Merkler Alexander , Gialdini Gino , Gupta Ajay , Kamel Hooman
Published: October 2018

Introduction:
Retinal infarction is a form of ischemic stroke and is considered a harbinger of subsequent brain infarction. After a retinal infarction is detected, an urgent stroke evaluation is recommended so that appropriate stroke prevention measures can be instituted. We assessed the frequency of stroke risk factor evaluation in a nationally representative cohort of elderly patients with retinal infarction.

Methods:
We used inpatient and outpatient claims between 2009-2015 from a 5% nationally representative sample of Medicare beneficiaries ≥65 years of age. For this analysis, we identified patients with a diagnosis of retinal infarction documented on a claim submitted by an ophthalmologist. Our outcomes were any form of cervical carotid imaging, any form of heart-rhythm testing, any form of echocardiography, and evaluation by a neurologist. Variables were ascertained using
ICD-9-CM
diagnosis codes,
CPT
codes, and Medicare provider specialty codes. We also used validated
ICD-9-CM
diagnosis codes to ascertain ischemic strokes. The follow-up period was the first 90 days after the initial diagnosis of retinal infarction. We used survival statistics to calculate cumulative rates of outcomes. In a sensitivity analysis, we limited our cohort to patients with ≥2 ophthalmologist claims for retinal infarction, since these patients were more likely to have true retinal infarction and less likely to have been seen by an ophthalmologist simply to rule out the diagnosis.

Results:
We identified 5,688 beneficiaries with retinal infarction. By 90 days, 34.1% (95% confidence interval [CI], 32.8-35.3%) of patients underwent cervical carotid imaging, 28.6% (95% CI, 27.5-29.9%) underwent heart-rhythm testing, 23.3% (95% CI, 22.2-24.4%) underwent echocardiography, and 8.4% (95% CI, 7.7-9.2%) were evaluated by a neurologist. The 90-day cumulative risk of ischemic stroke was 1.0% (95% CI, 0.8-1.3%). Our results were essentially identical in a sensitivity analysis of patients with ≥2 retinal infarction diagnoses.

Conclusions:
Despite recommendations to perform an expedited stroke evaluation after retinal infarction, we found that only one-third of patients with retinal infarction underwent basic testing and fewer than 1 in 10 were seen by a neurologist.
Abstract TMP80: Temporal Trends in Ischemic Stroke Mortality Stratified by Presence of Cancer
Authors: Chatterjee Abhinaba , Merkler Alexander E , Murthy Santosh B , Burch Jaclyn E , Gialdini Gino , Kamel Hooman , NAVI Babak B
Published: October 2018

Background:
About 5% of acute ischemic stroke (AIS) patients have active cancer. Previous work has shown that cancer patients are more likely to die after AIS than non-cancer patients. However, few data exist on how these disparities are changing over time.

Methods:
We identified all patients hospitalized with AIS in the National Inpatient Sample from 1996-2013 using validated ICD-9 diagnosis codes. Our primary predictor was systemic cancer, which was a composite of solid and hematologic tumors with or without metastases. Primary brain tumors were excluded. Our primary outcome was in-hospital death. Survey weights were used to estimate nationally-representative annual rates of in-hospital death among AIS patients with and without cancer. Multivariable logistic regression models adjusting for age, gender, and race were constructed to evaluate the relationship between time, cancer history, and mortality.

Results:
We identified 9.6 million patients with AIS, of whom 491,704 (5.1%) had cancer. The in-hospital death rate among stroke patients with cancer decreased from 21.7% (95% confidence interval [CI], 20.6-22.9%) in 1996 to 13.9% (95% CI, 13.0-14.7%) in 2013, while the death rate among stroke patients without cancer decreased from 9.9% (95% CI, 9.6-10.1%) in 1996 to 6.4% (95% CI, 6.2-6.6%) in 2013 (Figure). After adjustment for demographics, a cancer diagnosis was associated with more than a doubling in odds of death after AIS (odds ratio [OR] 2.34; 95% CI, 2.29-2.38). However, during the 18-year study period, the demographic-adjusted odds of in-hospital death after AIS decreased similarly over time in patients with cancer (OR per year 0.97; 95% CI, 0.96-0.97) as compared to those without (OR per year 0.97; 95% CI, 0.97-0.98).

Conclusions:
Despite improved mortality rates over time, cancer patients with AIS continue to face more than a two-fold increased risk of in-hospital death as compared to non-cancer AIS patients.
Abstract TP1: The Systemic Blood Pressure Variation is Associated With Major Hemorrhagic Transformation in Patients With Successful Recanalization After Mechanical Thrombectomy
Authors: Kim Tae Jung , Kim Jeong-Min , Park Hee-Kwon , Ko Sang-Bae , Yoon Byung-Woo
Published: October 2018

Introduction:
Elevated Blood pressure (BP) is known to be related to hemorrhagic transformation (HT) after ischemic stroke. However, the effect of BP variation on the HT remains unclear, especially in patients with successful recanalization after mechanical thrombectomy.

Hypothesis:
Therefore, we investigated the relationship between BP and HT after mechanical thrombectomy following ischemic stroke.

Methods:
A consecutive 141 patients with acute ischemic stroke and successful recanalization (TICI 2b or TICI 3) were included for the analysis between January 2013 and November 2016. The information on BP was obtained over the first 24 hours using various parameters including mean, maximum (max), minimum (min), difference between max and min (max– min), standard deviation (SD), coefficient of variation (CV), and successive variations (SV) for systolic, diastolic BP, and mean BP. We defined major HT as a parenchymal hematoma type 2 (PH2).

Result:
Among the included patients (age, 66.3; and male. 55.2%), 16 patients (11.3%) developed major HT over the first 24 hours after successful recanalization. Systolic BP
max-min
was significantly increased in patients with major HT compared to those without major HT (61.2 mmHg vs. 44.2 mmHg, P = 0.034) while other BP parameters were not. In addition, systolic BP
max-min
was significantly associated with symptomatic HT (n=11, 7.8%, P = 0.007). After adjusting for confounders, systolic BP
max-min
was independently associated with major HT (Odds ratio, 1.028; 95% confidence interval, 1.004-1.051).

Conclusions:
Our results demonstrated that absolute change of systemic BP over the first 24 hours was associated with major and symptmatic HT after successful mechanical thrombectomy after acute ischemic stroke. This suggests that maintaining stable systolic BP is an important factor in possibly preventing major HT after successful recanalization.
Abstract TP104: Exploring the Noncoding Transcriptome for Novel Therapeutic Targets Against Cerebral Ischemia
Authors: Bhattarai Sunil , Pontarelli Fabrizio , Dharap Ashutosh A
Published: October 2018

The mammalian genome pervasively transcribes a variety of functional noncoding transcripts, including the recently discovered long noncoding RNAs (lncRNAs). LncRNAs play major roles in regulating gene expression in mammals, but their expression and functions in the post-stroke brain remain largely unknown. Using a mouse model of transient focal ischemia, we applied RNA-sequencing to evaluate for the first time the unbiased, genome-wide expression of lncRNAs as a function of reperfusion time in the cerebral cortex. A 1h middle cerebral artery occlusion was conducted in adult male mice and ipsilateral cortices were harvested at 6h, 12h or 24h of reperfusion. RNA was isolated and used for Illumina sequencing. The reads were assembled and mapped to mouse reference genome GRCm38/mm10 and differential expression between the groups was evaluated using TopHat-Cufflinks. We observed that the baseline expression of lncRNAs in the healthy cortex was low, but hundreds of lncRNAs were highly altered after stroke. We identified 1311 isoforms at 6h (1146 upregulated; 165 downregulated), 1287 isoforms at 12h (954 upregulated; 333 downregulated), and 1090 isoforms at 24h (907 upregulated; 183 downregulated) of reperfusion that were significantly altered (absolute fold-change ≥ 2; q-value <0.05) versus sham controls. Of these, 1261 (98%), 1221 (95%) and 1039 (95%) isoforms at 6, 12 and 24h of reperfusion, respectively, were novel lncRNAs. Importantly, hundreds of transcripts that were not detectable in the healthy cortex were robustly expressed in response to stroke, thus representing ischemia-specific lncRNAs. A total of 975 isoforms (74%) at 6h, 815 isoforms (63%) at 12h, and 800 isoforms (73%) at 24h were detected exclusively in the post-stroke cortex. Barring 3 isoforms at 6h, 1 isoform at 12h and 2 isoforms at 24h, all were novel transcripts. Overall, this study reveals a plethora of previously undiscovered, disease-related lncRNAs in the adult post-stroke cortex and identifies distinct reperfusion time-point-dependent expression characteristics. Further investigation of these lncRNAs will elucidate their functional roles in the progression of the post-stroke pathophysiology and may identify new opportunities for therapeutic intervention.
Abstract TP109: Microglial IRF5/4 Regulatory Axis: A Novel Therapeutic Target for Ischemic Stroke
Authors: Mamun Abdullah , Chauhan Anjali , Datar Saumil , Xu Yan , Sharmeen Romana , McCullough Louise D , Liu Fudong
Published: October 2018

Introduction:
The Inflammatory response is a fundamental pathophysiological procedure in stroke, and the activation of microglia characterized by either M1 (pro-inflammatory) or M2 (anti-inflammatory) state is crucial in initiating, sustaining and resolving the post-stroke inflammation. IRF5/4 are key determinants in macrophage polarization. Our previous study has also shown IRF5/4 signaling corresponds to microglial M1/M2 activation in the early/late phases of ischemic stroke respectively. In the present study, we tested our hypothesis that manipulation of IRF5/4 regulatory axis impacts on post-stroke inflammation and stroke outcomes.

Methods:
Microglia specific IRF5/4 conditional knockout (CKO) and lenti-IRF5/4 treated C57BL6 (for IRF5/4 overexpression) mice were subjected to a 60-minute middle cerebral artery occlusion (MCAO). Stroke outcomes including infarct size and behavior deficits were evaluated at 3d and 10d of MCAO. Microglial activation and peripheral immune cell infiltration were determined by flow cytometry (FC). IRF5/4 colocalization with microglia was examined with IHC, and multiplex was performed to measure cytokine levels in both the brain and blood samples.

Results:
At both time points, IRF4 CKO mice exhibited increased infarct lesions and worse behavior outcomes, and this effect was reversed in IRF4 overexpressed mice. In contrast, IRF5 CKO mice had reduced infarct lesions and improved behavior deficits; whereas IRF5 over expression in microglia worsened stroke outcomes. FC results revealed that microglia exhibited M1 phenotype in IRF4 CKO and IRF5 over-expressed mice that concomitantly had pro-inflammatory profile demonstrated by cytokine data; however, IRF5 CKO and IRF4 over-expressed mice had M2 dominant microglia and anti-inflammatory responses. IHC showed IRF5 expression was upregulated in IRF4 CKO and IRF5 over-expressed mice, and IRF4 expression was augmented in IRF5 CKO and IRF4 over-expressed mice.

Conclusion:
IRF5/4 regulatory axis regulates the microglial M1/M2 activation and impacts on stroke outcomes. Manipulation of IRF5/4 regulatory axis represents a novel therapeutic strategy for ischemic stroke.
Abstract TP117: A Systematic Literature Review of Patients With Carotid Free Floating Thrombus and Acute Ischemic Stroke
Authors: Fridman Sebastián , Lownie Stephen P , Mandzia Jennifer L
Published: October 2018

Introduction:
Carotid Free Floating Thrombus (CFFT) includes numerous pathological entities. It is theorized that CFFT leads to ischemic stroke secondary to embolization with high risk of short-term recurrence. There is uncertainty in diagnosis, prognosis, and optimal medical or surgical management of CFFT. To synthesize the vast recent literature, we performed a systematic literature review (SLR) of CFFT.

Methods:
Literature search for Thrombus, Carotid and related terms yielded 3126 results. After a preliminary assessment of 3126 retrieved manuscripts, 273 were reviewed in detail. A total of 144 manuscripts met entry criteria. We present the demographics, risk factors (RF), treatment modality and outcome of stroke or death at 30 days of CFFT patients. Acute treatment modalities consisted of surgical (carotid endarterectomy or stenting within 72 hours) or medical interventions. The relationship between treatment modality and outcome was assessed using logistic regression including relevant RF, antithrombotic type, demographic, imaging, and surgical variables.

Results:
Our SLR yielded 530 CFFT patients with a median age at presentation of 60.5 (IQR 48-71) and 36.2% were females. The majority (64%) of patients had at least one RF. Patients were treated acutely surgically (27.9%) or medically (82.7% with anticoagulation, 16.8% with dual antiplatelet (DA). Thirty-day stroke and death rate was 17.1% in 345 cases with follow-up. Patients receiving dual antiplatelet therapy had an increased risk of stroke or death at 30 days (RRR 30.31, 95% confidence interval, 1.66- 553.22;
P
=0.02) compared to patients not receiving dual antiplatelet therapy. There was no significant relationship between early anticoagulation or acute surgical approach and primary outcome, although a trend favoring anticoagulation over surgical approach was seen (13.6% vs. 21.9%).

Conclusions:
CFFT patients are at a short-term high risk for stroke or death. DA was associated with increased short term risk in these patients; however, the optimal treatment approach remains uncertain. Future studies are needed as RCTs are lacking and publication bias limits our findings.
Abstract TP12: Distribution and Incidence of Fast versus Slow Progressors of Infarct Growth in Large Vessel Occlusion Stroke
Authors: Rocha Marcelo , Desai Shashvat , Jadhav Ashutosh , Jovin Tudor
Published: October 2018

Background and Purpose:
Fast and slow progressors of infarct growth due to a large vessel occlusion (LVO) are commonly observed when patients are considered for acute endovascular therapy. However, the incidence of these clinical phenotypes has not been formally quantified. We aimed to measure the frequency and distribution of fast versus slow infarct growth in LVO patients in different time strata after stroke onset.

Methods:
Retrospective study of consecutive patients with acute LVO admitted to our comprehensive stroke center. Inclusion criteria were: 1. CTA or MRA evidence of intracranial ICA and/or MCA(M1) occlusion, with or without extracranial ICA occlusion. 2. Baseline CTP or MRI DWI before reperfusion therapy and within 25 hours of time of last seen well/stroke onset. Automated core volume measurements were performed using RAPID software (iSchemaView). Fast progressors were defined as having core volumes > 70 cc at early time quantiles (0 - 8 hours). Slow progressors were defined as having core volumes < 10 cc at later time quantiles (> 8 hours). Infarct growth rate was computed using ischemic core volume divided by time from stroke onset to core imaging. Descriptive statistics and univariate analysis were performed.

Results:
A total of 115 patients were included with mean age 69+/-15.5 and NIHSS 16.5+/-7; 66% were females. Patients had MCA occlusion in 81% and intracranial ICA occlusion in 19% of cases. The median time from stroke onset to baseline core imaging was 9.1 hours (IQR, 4 - 14.7) and 53 patients were imaged before 8 hours. The median core volume was 10 (range 0 - 405 ml). In the early time epoch (< 8 hrs), 5/13 patients (38%) had core > 70ml by 3.65 hours (fast progressors). In the later time epoch (> 8 hrs), 29/62 patients (46%) had ischemic cores < 10ml at 25 hours from stroke onset. The median infarct growth rate was 2.6 ml/hr (0 - 14.6) in patients imaged before 8 hours and 1.2 ml/hr (0 - 5.48) in the later time epoch.

Conclusions:
The incidence of fast and slow progressors of LVO stroke may be higher than previously anticipated depending on different time quantiles of stroke onset to imaging.
Abstract TP121: High-Resolution Magnetic Resonance Imaging Characteristics of Intracranial Atherosclerotic Plaque and Perforating Artery
Authors: Guo Xiu-hai , Wang Meng-nan , Yang Yu-Jiao , Miao Hui-juan , Ren Ming , Ji Xun-ming , Yang Qi
Published: October 2018

Objective:
Intracranial atherosclerotic disease (ICAD) is a cause of ischemic stroke, with the middle cerebral artery (MCA) being commonly affected. The vulnerable plaque is considered as the cause of stroke. High resolution magnetic resonance imaging (HR-MRI) can help us assess the morphology characteristics and vulnerability of intracranial atherosclerosis plaque. HR-MRI could also provide us such information as microvascular structure of perforating arteries from MCA. The aim of our study was to distinguish the differences in the plaque morphology between symptomatic and asymptomatic MCA stenoses, and the relationship between MCA stenosis and perforating artery.

Method:
41 MCAs with symptomatic stenoses and 33 MCAs with asymptomatic stenoses (both between 50% and 99%) were included. The characteristics of plaques and the perforating arteries were evaluated by HR-MRI.

Results:
Between symptomatic and asymptomatic MCA stenosis groups,vessel morphological characteristics such as the degree of stenosis, remodeling index, wall area index didn’t differ. However, patients with symptomatic MCA stenoses had heavier plaque burden (79.74 ± 1.380 vs 66.72 ± 2.776, P < 0.001). , Symptomatic MCA stenoses showed stronger plaque gadolinium enhancement, including bigger ROI area (4.27 ± 0.266 vs 2.75 ± 0.197 P < 0.001), higher enhancement index (0.46 ± 0.061 vs 0.20 ± 0.067 P = 0.005) and larger enhancement volume (116.34 ± 21.960 vs 35.21 ± 6.535 P < 0.001). With multivariate regression analysis, the plaque burden, the region of interested area, and the enhancement index were independently associated with symptomatic MCA stenosis. The number of perforating arteries of MCAs with moderate to severe stenoses was less than that of normal controls (symptomatic MCA: 3.82 ± 0.165, asymptomatic MCA: 3.85 ± 0.177, normal MCA :4.47±0.162, P=0.006).

Conclusions:
The plaque burden may be a new index in assessing the vulnerability of intracranial atherosclerosis plaques. The plaque burden, the region of interested area, and the enhancement index are independently associated with symptomatic MCA stenosis. The perforating arteries from symptomatic and asymptomatic MCA stenosis are both less than those from normal MCA controls.
Abstract TP130: Recurrent Hemispheric Stroke Syndromes in Symptomatic Atherosclerotic Internal Carotid Artery Occlusions: The COSS Trial
Authors: Nahab Fadi , Rahman Haseeb , Barrow Daniel , Cawley C. Michael , Grubb Robert , Derdeyn Colin , Adams Harold , Zimmerman M. Bridget , Powers William J ,   COSS Investigators
Published: October 2018

Background:
There are limited data on the baseline characteristics and clinical outcomes of patients who have recurrent hemispheric syndromes in the territory of symptomatic atherosclerotic internal carotid artery occlusion (AICAO).

Methods:
Baseline characteristics and clinical outcomes were compared between patients with (rHEM+) and without (rHEM-) recurrent ipsilateral hemispheric syndromes at the time of randomization into the Carotid Occlusion Surgery Study (COSS) based on local investigator clinical impression.

Results:
Of 195 participants who were randomized, 100 (51%) were rHEM+ (50 in each study arm) and 95 were rHEM-(48 nonsurgical, 47 surgical). Baseline characteristics between rHEM+ and rHEM- participants were similar except that rHEM+ participants were more likely to have had a previous stroke prior to entry event (59% vs 22%, p < 0.001) and to have had TIA vs stroke as the entry event (61% vs 20%, p<0.001). All primary endpoints were ipsilateral ischemic strokes. There were no statistically significant differences in the primary endpoint between nonsurgical and surgical participants with rHEM+ (26.3% vs 22.4%, p=0.660) or rHEM- (18.9% vs 19.5%%, p=0.943). For secondary endpoints based on stroke severity and/or death, no important differences were noted between nonsurgical and surgical participants for the rHEMI+ and rHEMI- subgroups (all p > 0.10). For the nonsurgical participants, there was no statistically significant difference in the primary endpoint for those rHEM+ vs rHEM- (26.3% vs 18.9%, p=.410)

Conclusion:
Patients with recurrent hemispheric stroke syndromes enrolled in the COSS trial were more likely to have had previous stroke and to have TIAs as the entry event to randomization. Given the lack of surgical treatment benefit seen in these patients, early aggressive risk factor measures should be prioritized to reduce recurrent strokes, including blood pressure control which was associated with a 70% reduction in stroke in the nonsurgical group in COSS (
Neurology
2014; 82:1027-1032).
Abstract TP146: Trend, Outcomes, and Predictors of Utilization of Speech Rehabilitation Therapy in Acute Ischemic Stroke Hospitalization
Authors: Patel Urvish K , Dhrangdhariya Virali S , Rasul Bakhtiar , Yousuf Salma , Lotlikar Priti P , Habib Anam , Mahvish Gull , Patel Karan , Lavado Liseth , Bhesania Siddharth , Mehta Parag , Jani Vishal
Published: October 2018

Background:
At least one-fourth of all stroke survivors experience language impairments. Many recover within a few months after the stroke, but up to 60% still have language impairments more than six months after a stroke, known as chronic aphasia. We aimed to look the outcomes, cost, a length of stay (LOS), and predictors of utilization of speech rehabilitation therapy (SRT) in stroke patients.

Methods:
We performed a cross-sectional study using the Nationwide Inpatient Sample (NIS) (years 2003-2013) in adult hospitalizations for AIS who had undergone SRT. We performed weighted analyses using chi-square, Cochran-Armitage Trend-test, and t-test to find outcomes, trend, and cost and LOS respectively. Multivariate survey logistic regression was done to evaluate the predictors of utilization of SRT.

Results:
Amongst 4,566,282 AIS hospitalizations, 23,597 had SRT. There was a decrease in trend (0.9% in 2003 to 0.55% in 2013, p<0.001). The mean LOS was longer by 2 days, the cost of hospitalization was higher by $11517, and outcomes were poor in AIS patients on SRT compared to those without (Table). The predictors for higher utilization in AIS patients on SRT included African American (aOR: 1.64; 95% CI: 1.48-1.82), Hispanic (aOR: 1.78; 95% CI: 1.52-2.09), Asian/pacific islander (aOR: 2.04; 95% CI: 1.56-2.67), urban teaching hospitals (aOR: 1.40; 95% CI: 1.23-1.60), depression (aOR: 1.16; 95% CI: 1.01-1.35), tPA treatment (aOR: 1.47; 95% CI: 1.20-1.81), alcohol (aOR: 1.33; 95% CI: 1.07-1.64), and atrial fibrillation (aOR: 1.17; 95% CI: 1.05-1.31). Significant predictors for lower utilization included emergency admission type, urban non-teaching hospital, medium bed-size hospitals, large bed-size hospitals, and private insurance.

Conclusion:
High cost and LOS might be responsible for declined utilization of SRT in private insurance payers but poor outcomes even after SRT need further research to evaluate the cost-effectiveness of therapy.
Abstract TP16: Predictors for Successful Mechanical Thrombectomy With Balloon Guide Catheter Assistance
Authors: McCarthy David J , Sur Samir , Snelling Brian , Fortunel Adisson , Yavagal Dileeep , Peterson Eric , Starke Robert
Published: October 2018

Mechanical thrombectomy (MT) has become the standard treatment for large vessel occlusion (LVO) in acute ischemic stroke (AIS) in well-selected patients. Although many devices and strategies exist, use of a balloon-tip guide catheter (BGC) in conjunction with stent-retriever (SR) may hold many advantages. We aim to assess the efficacy and identify predictors of technical success of this unique approach.

We reviewed our prospectively maintained database to identify 93 consecutive cases in which a BGC was used for MT in anteriorcirculation LVO, between February 2015 and September 2016. Various preprocedural and intraprocedural variables were recorded in addition to technical and clinical outcome measures. Predictors of technical and clinical outcome were identified by univariate and multivariable logistic regression analysis.

Successful recanalization of the LVO (mTICI=2b) was achieved in 86.9% (n=80) of cases, including a first-pass success rate of 52.7% (n=49) and complete revascularization of mTICI 3 in 56.5% (n=52) of cases. Average time from groin puncture to reperfusion was 67.9 minutes. The M1 segment was the most common location of the occlusive thrombus (64.5%, n=60). Preoperative IV-tPA was administered in 55.9% (n=52) of cases and 48.4% (n=45) were functionally independent (mRS<=3) at last follow-up. Middle cerebral artery location was strongly predictive of first-pass success resulting in a TICI =2b revascularization (OR 7.10, p=0.018). Preoperative tPA bolus was a predictor of successful first pass (OR 2.88, p=0.017). Intraoperative IA-tPA administration showed increased incidence of post-operative hemorrhagic conversion (OR 4.12, p=0.018). Patients <65 years old were more likely to develop subsequent emboli (OR 2.83, p=0.053). Hemorrhagic conversion (OR 8.33, p=0.001), female gender (OR 2.85, p=0.042), and decreasing mTICI were associated with a poor clinical outcome (mRS>=4; OR 1.76, p=0.008).

BGC use in MT results in a high rate of technical success and excellent clinical outcome in anterior circulation LVOs. While the optimal strategy for performing thrombectomy is unclear, our data suggest BGC in combination with SR may be most effective in removing MCA clots.
Abstract TP160: May-Thurner Syndrome is Associated With Stroke Due to Paradoxical Embolism
Authors: Song Bo , Chou I-ying , Deng Wenjun , Inglessis Ignacio , Elmariah Sammy , Palacios Igor , Camargo-Faye Erica , Silverman Scott , McMullin David , Lo Eng H. , Wang Xiaoying , Xu Yuming , Buonanno Ferdinando S , Ning Mingming
Published: October 2018

Background:
May-Thurner Syndrome (MTS) is a potential risk factor for cryptogenic stroke (CS). While retrospective reports have found important association with MTS in CS, prospective data has been lacking. In this study, we prospectively explored the epidemiology and clinical correlates of MTS patients with cryptogenic stroke.

Method:
Eligible patients were prospectively recruited in accordance with an IRB-approved protocol. All patients underwent full evaluation of etiopathogenesis of stroke such as MRI/MRA, long-term cardiac telemetry (>30 days), echocardiography, and extensive thrombophilia screen (AT3, FV Leiden, Proteins C and S; prothrombin gene mutations, APLAbs, lipoprotein(a), homocysteine) and 1.5T pelvic MRV.

Results:
We prospectively recruited 1,131 acute ischemic stroke patients, with 59 patients with PFO-related CS; 15 (40.5%) had May-Thurner anatomy (MTA), and 6 (16.2%) had MTS. MTS pts are younger (36.33±9.95 vs. 53.35±14.78, p=0.011), with a lower trend for BMI (24.40±4.87 V.S. 31.13±8.75, p=0.051, table 1). Lower BMI is predictive of MTS in CS (<=22) with high specificity 93.3% (AUC=0.756, p=0.007).

Conclusion:
In this prospective study, we found MTA and MTS to be very common in PFO CS patients - especially in younger patients with lower BMI and without traditional stroke risk factors. MTS is a novel risk factor that may aide in the diagnosis of PFO CS, and needs further study.
Abstract TP164: Low Free Triiodothyronine Should Be Associated With 3-Month Poor Functional Outcome After Acute Stroke
Authors: Suda Satoshi , Shimoyama Takashi , Aoki Junya , Kanamaru Takuya , Suzuki Kentaro , Sakamoto Yuki , Nagai Koichiro , Sato Takahiro , Arakawa Masafumi , Takeshi Yuho , Nishiyama Yasuhiro , Mishina Masahiro , Kimura Kazumi
Published: October 2018

Objectives:
Thyroid dysfunction has been associated with increased short-term mortality during intensive care unit stay, and with long-term mortality in cardiovascular disease. However, the association between thyroid function and clinical characteristics in patients with acute stroke has not yet been thoroughly studied. The purpose of the present study was to test the hypothesis that thyroid hormone is associated with three-month functional outcome after acute stroke.

Methods:
We retrospectively analyzed 908 consecutive patients with acute stroke (578 men and 330 women; median age: 73 years) who were admitted to our department between September 2014 and November 2016. General blood tests including thyroid stimulating hormone (TSH), free triiodothyronine (FT3), and free thyroxine (FT4), were performed on admission. Neurological severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS) score on admission and modified Rankin Scale (mRS) score at three months after stroke onset. Poor outcome was defined as a modified Rankin Scale (mRS) score of 3-5, or death (mRS score of 6). The impact of thyroid function on three-month outcome was evaluated using multiple logistic regression analysis.

Results:
Poor functional outcome was observed in 384 patients (42.2 %). Age (
P
< 0.0001), female gender (
P
< 0.0001), the presence of diabetes mellitus (
P
= 0.0151), high admission NIHSS score (
P
< 0.0001), smoking (
P
= 0.0064), atrial fibrillation (
P
< 0.0001), high pre-admission mRS score (
P
< 0.0001), low estimated glomerular filtration rate (
P
= 0.0026) and ischemic heart disease (
P
= 0.0061) were significantly associated with poor functional outcome, but no relationships between FT4, TSH and poor functional outcome were found. After adjusting for age, sex, stroke severity, and various comorbidities, lower FT3 values was independently associated with poor functional outcome (odds ratio [OR], 1.60; 95% confidence interval [CI], 1.27-2.03) and mortality (OR, 2.19; 95% CI, 1.58-3.07) at three months after stroke onset.

Conclusions:
Our data suggest that a lower FT3 value upon admission should be considered to have an association with three-month poor functional outcome and mortality in patients with acute stroke.
Abstract TP175: Lower Health-Related Quality of Life (HRQoL) At 3-6 Months After Stroke in Both Women and Men Compared to Those Without Stroke: An Observational Study From The Australian Stroke Clinical Registry (AuSCR)
Authors: Phan Hoang T , Gall Seana L , Blizzard Leigh , Lannin Natasha A , Thrift Amanda G , Anderson Craig , Kim Joosup , Cadilhac Dominique A ,   on behalf of the AuSCR Collaboration
Published: October 2018

Introduction:
Women appear to experience worse HRQoL after stroke than men. However, women without stroke also report poorer health status than men in all ages. Therefore, it is uncertain whether the sex disparity in HRQoL is caused by stroke or other differences between men and women.

Methods:
First-ever strokes admitted to 39 hospitals participating in AuSCR from 2010-2014, had HRQoL assessed at 3-6 months after stroke using EQ-5D-3L and results transformed into utility values for the respondents and among those who died, ranging from -0.516 (worse than death), 0 (death) to 1 (perfect health). Calculated mean EQ5D utility scores for stroke registrants were then stratified by age (<55, 55-64, 65-74 and 75+ years old) and sex. Mean utility (reference) scores of those without stroke in the corresponding age and sex groups were obtained from the South Australian population-based Health Omnibus Survey. We calculated the weighted age-standardized mean difference (MD) scores between those with stroke (AuSCR registrants) and without stroke (population norms), separately for men and women. The difference in weighted MD scores between men and women within the range 0.08-0.12 unit was defined as clinically meaningful.

Results:
After a median follow-up of 139 days, there were 2700 deaths out of 14118 registered cases of stroke. About 60% (6852/11418) of survivors after stroke completed follow-up surveys with EQ5D assessment; 44% being female. In the stroke group, only women aged > 65 years old had significantly lower utility scores than the elderly men of the same age. After standardisation for age, weighted MDs between those with and without stroke were slightly greater for women (MD 0.40 95% CI 0.37, 0.42) compared to men (MD 0.36 95% CI 0.34, 0.38. However, the sex difference in weighted utility scores between those with and without stroke (MD 0.04) was below the clinically meaningful threshold.

Conclusion:
Stroke causes substantial loss of HRQoL in both men and women especially with increasing age. However, the differences in utility scores between those men and women with and without stroke were not clinically relevant. Future studies of sex differences in HRQoL after stroke should consider the innate differences in HRQoL between men and women when reporting results.
Abstract TP178: Sex Differences in Severity of Stroke Risk Factors in the Greater Cincinnati/ Northern Kentucky Stroke Study
Authors: Madsen Tracy E , Khoury Jane C , Jasne Adam , Alwell Kathleen , Moomaw Charles J , Flaherty Matthew L , Adeoye Opeolu , Woo Daniel , Mackey Jason , Ferioli Simona , Martini Sharyl , De Los Rios La Rosa Felipe , Kissela Brett M , Kleindorfer Dawn O
Published: October 2018

Introduction:
Stroke incidence may be decreasing more in men than in women over time, perhaps due to sex differences in risk factor (RF) severity. We sought to investigate potential sex differences in the severity of ischemic stroke (IS) RFs.

Methods:
We identified all incident IS in 2010 by screening all local hospital ICD-9 codes 430–436 among residents of the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) region, a biracial population of 1.3 million. Relevant information was extracted from the medical record, including 4 IS RFs: hypertension (HTN), hyperlipidemia (HL), diabetes (DM), and body mass index (BMI). Only hospitalized incident stroke cases were included. RF severity in women vs. men was compared using multivariable analysis adjusted for age, race, insurance status, and poverty status (whether patient lived in an area with ≥ 20% below the poverty line). Severity of respective RFs were assessed using systolic blood pressure at 24 hours and presence of left ventricular hypertrophy (LVH) on ECG or echocardiogram (for HTN), Hemoglobin A1c (HbA1c) (for DM), and total cholesterol (TC) and LDL levels (for HL). For HTN-, HL-, and DM-specific analyses of severity only IS patients with pre-existing diagnoses as determined by their medical record were included. For BMI, all IS patients were included.

Results:
A total of 1737 patients met eligibility; 55.8% were women, and 19.6% were black. After adjusting for age, race, insurance status, and poverty, women had TC levels and mean BMIs that were significantly higher than men (Table). LDL levels among those with HL, likelihood of having LVH in those with HTN, and mean HbA1c in those with DM were similar between sexes.

Conclusions:
Among adults with IS in the GCNKSS, RF severity was similar by sex apart from small differences in BMI and TC. Future directions for research include possible sex differences in RF severity in incident vs. recurrent stroke, in RF severity after adjusting for medication use, and undiagnosed RFs.
Abstract TP185: Diuretic Use and the Risk of Vertebral Fracture After Stroke: A Population-based Cohort Study
Authors: Huang Huei-Kai , Lin Shu-Man
Published: October 2018

Introduction:
Stroke is a major risk factor for vertebral fracture. Hypertension is a very common comorbidity observed in stroke patients, and diuretics have been widely used for the treatment of hypertension. Our study investigated whether treatment with thiazides or loop diuretics affects the risk of vertebral fracture after stroke.

Methods:
A population-based propensity-matched cohort study was conducted using the Taiwan National Health Insurance Research Database. Patients with a new diagnosis of stroke between 2000 and 2011 were included. After propensity score matching, 9468 patients were included in the analysis of the effect of thiazides, of who 4734 received thiazides within 2 years after stroke. To analyze the loop diuretic effect, 4728 patients were included, of who 2364 received loop diuretics. A Cox proportional hazards regression model was used to calculate the hazard ratios (HRs) of vertebral fractures among patients according to thiazide or loop diuretic use within 2 years following stroke. Sensitivity analyses based on the duration of thiazide or loop diuretic use were further conducted.

Results:
There was no significant difference in vertebral fracture risk between thiazide users and non-users (adjusted HR [aHR] = 1.14, 95% confidence interval [CI] = 0.88–1.47, p = 0.316). Loop diuretic users had a significantly higher vertebral fracture risk than non-users (aHR = 1.45, 95% CI = 1.06–1.98, p = 0.019). However, the sensitivity analysis revealed that short-term thiazide use (exposure duration <90 days within 2 years after stroke) significantly increased the risk of vertebral fracture versus non-use (aHR = 1.38, 95% CI = 1.02–1.88, p = 0.039). Only short-term loop diuretic users had significantly higher risk of vertebral fracture (aHR = 1.56, 95% CI = 1.11–2.20, p = 0.011). The other two subgroups with longer exposure duration in analyses for both thiazides and loop diuretics revealed no significant effect.

Conclusions:
Short-term thiazide or loop diuretic use was associated with an increased risk of vertebral fracture after stroke. We believe that physicians should be aware of this potential association.
Abstract TP188: The Association of Hypertension and Severity of White Matter Hyperintensities is Different in Each Stroke Subtype of Large Artery Atherosclerosis and Small Vessel Occlusion
Authors: Lee Jun , Gwon Jungim , Kim Mingyeong
Published: October 2018

Introduction:
Although white matter hyperintensities (WMH) on brain MRIs are associated with common vascular risk factors, the mechanisms underlying progression of WMH are still poorly understood.

Hypothesis:
We aim to investigate the association between common vascular risk factors and the severity of WMH according to the subtypes of ischemic stroke.

Methods:
Consecutive patients admitted due to ischemic stroke or TIA were included (n=841). Large artery disease (LAD) and small vessel occlusion (SVO) were defined according to the SSS-TOAST classification. WMH were categorized into two groups: no/mild and moderate/severe using Fazekas scale. Demographics, vascular risk factors and laboratory results were compared between the two groups (LAD vs SVO) in total and separately.

Results:
A total of 228 patients who underwent brain MRI within seven days after onset were eligible (n=170 in LAD, n=58 in SVO). Patients with LAD were older than those with SVO (mean age 67 years vs. 60 years, p<0.001), but the proportion of patients with moderate/severe WMH did not significantly differ between the two groups (28.2% vs 29.3%, p=0.876). Older age and hypertension were independent risk factors of moderate/severe WMH (OR=3.94 [2.46-6.30] with an increased age of 10 years; OR=5.14 [1.70-15.56], P=0.004 for hypertension) after adjustment of common cardiovascular risk factors. In patients with LAD, independent risk factors of moderate/severe WMH were age (OR=3.86 [1.83-8.12] for every ten-year increase, P<0.001) and hypertension (OR=5.64 [1.51-21.1], P=0.01). On the other hand, age was the only independent risk factor in patients with SVO (OR=3.03 [1.28-7.19] for every ten-year increase, P=0.012).

Conclusion:
In conclusion, this study showed that there is a different association between hypertension and severity of WMH in each stroke subtype. Other potential mechanisms of WMH, those not associated with traditional vascular risk factors, may be associated with progression of WMH.
Abstract TP203: The Effect of Concurrent Presence of Atherosclerotic Disease in Other Arterial Distributions in Patients With Symptomatic Intracranial Stenosis
Authors: Qureshi Adnan I , Saeed Omar , Malik Ahmed A
Published: October 2018

Objective:
To determine the effect of concurrent presence of atherosclerotic disease in other arterial distributions (ADOAD) on risk of 30 day stroke or death and ischemic stroke in the territory of the symptomatic intracranial artery beyond 30 days after enrollment in patients with severe (70-99%) intracranial stenosis recruited in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) Trial.

Methods:
Patients with known history of myocardial infarction, angina, carotid endarterectomy, coronary artery bypass surgery, previous angioplasty and stenting, or peripheral arterial disease at baseline evaluation were classified as those with concurrent presence of ADOAD. Hazards ratio (HR) for primary event during follow up was estimated using Cox proportional hazards analysis after adjusting for age, gender, location of stenosis, and treatment allocated (stent placement versus best medical treatment).

Results:
A total of 126 of 451 patients included had concurrent presence of ADOAD. After adjusting for potential confounders, the risk of primary endpoint was not significantly different in patients with concurrent presence of ADOAD (HR 1.14, 95% confidence interval [CI] 0.7 - 1.9). The treatment effect of stent placement (compared with best medical treatment) was not different in patients with concurrent presence of ADOAD (HR of 0.9 and 1.1, respectively) after adjusting for potential cofounders. The risk of any ischemic stroke (HR 1.3, 95% CI 0.8 - 2.3) and death (HR 1.4, 95% CI 0.3 - 7.1) during follow up was not different with concurrent presence of ADOAD.

Conclusions:
There was no effect on cardiovascular endpoints in patients with high grade symptomatic intracranial stenosis and concurrent presence of ADOAD from both natural history and treatment perspective.
Abstract TP205: Cerebrovascular Diseases in Hispanic Patients With Systemic Lupus Erythematosus
Authors: Cantú-Brito Carlos , Guraieb-Chaín Paola , Valdés-Ferrer Sergio I , Soto-Mota Adriãn , Guerrero-Torres Lorena , Chiquete-Anaya Erwin
Published: October 2018

Introduction:
Systemic Lupus Erythematosus (SLE) is an autoimmune disease that increases the risk for stroke. Here, we determined prevalence, stroke type, mechanism, and long-term outcome of patients with SLE-associated stroke.

Methods:
From an institutional cohort of 4454 patients with SLE, we identified 131 with stroke. We collected demographical data, time elapsed between SLE diagnosis and stroke onset, and data related to specific stroke type.

Results:
Prevalence of stroke in SLE was 2.9%. Figure shows the distribution of the stroke by type, as well as potential mechanisms. Median time from SLE diagnosis to stroke onset was 60 months (IQR 12-141) with high variability among stroke types. In 60% of patients with CVT and 30% of those with ischemic stroke, events occurred within the first 12 months of SLE diagnosis; indeed, stroke occurred prior to SLE (6%) or SLE was diagnosed during the clinical evaluation to ischemic stroke or CVT (10%). In contrast, 30% of ischemic strokes and 80% of hemorrhagic strokes occurred several years after diagnosis of SLE. An excellent clinical recovery at hospital discharge was observed in 68%. During a median follow-up of 84 months in 124 survivors of the acute phase, case fatality rate was 8.3%. Recurrence was observed in 7.2%.

Conclusion:
Prevalence of stroke in this large cohort of SLE patients was 2.9%. CVT commonly occurred early after SLE diagnosis. Patients with ischemic strokes had a bimodal presentation, occurring either prior to -or shortly after- the diagnosis of SLE, or after a delay of several years. In contrast, 80% of hemorrhagic strokes occurred several years after diagnosis of SLE. Long-term clinical outcome was usually favorable.
Abstract TP207: The Effect of Religion on Risk of Incident Cardiovascular Events in Post-Menopausal Women
Authors: Saeed Omar , Malik Ahmed A , Qureshi Adnan I
Published: October 2018

Objective:
The goal of this study was to determine the effect of religion on occurrence of cardiovascular in diseases in a large prospective cohort of postmenopausal women.

Methods:
The data were analyzed for 80,805 women 50-79 years of age who were enrolled in the observational arm of the Women’s Health Initiative Study. The effect of religion (Catholic, Protestant, and Jewish) on risk of ischemic stroke, hemorrhagic stroke, any stroke, myocardial infarction, and cardiovascular deaths was determined over a period of 12 ± 1 years (mean ± SD) using Cox proportional hazards analysis after adjusting for age, ethnicity, body mass index, systolic blood pressure, cigarette smoking, atrial fibrillation, and congestive heart failure.

Results:
Of the 80,805 participants, 48301, 25390, and 7114 women reported the religion as Protestants, Catholics, and Jewish, respectively. The mean (SD) systolic blood pressure was significantly lower in Jewish women (124.3 [18.0], p<0.001) and Catholic women (126.7[17.7, p<0.001) compared with Protestant women (127.8[18]). Jewish women had significantly lower rates of diabetes, mellitus, atrial fibrillation, and active cigarette smoking. Compared with Catholic women, Jewish women had a significantly lower risk of ischemic stroke (hazards ratio [HR] 0.78, 95% confidence interval [CI] 0.65-0.94, p<0.008), any stroke (HR 0.78, 95% CI 0.67-0.92, p<0.008), and cardiovascular death (HR 0.79, 95% CI 0.66-0.96, p=0.02). No difference was noted in the risk of myocardial infarction (HR 0.91, 95% CI 0.78-01.1, p=0.2). There were no differences in the risk of ischemic stroke, any stroke, myocardial infarction, and cardiovascular death between Catholic and Protestant women.

Conclusions:
There appeared to be a lower risk of any stroke and ischemic stroke (bout no myocardial infarction) among post-menopausal Jewish women. Further studies may identify the underlying reasons for the observed difference and may have implications for identifying innovative preventive strategies.