bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 14: Effects of Lesion Laterality on Post-Stroke Motor Performance: An ENIGMA Stroke Recovery Analysis
Authors: Liew Sook-Lei , Jahanshad Neda , Aziz-Zadeh Lisa , Birbaumer Niels , Borich Michael , Boyd Lara , Byblow Winston , Craddock Cameron , Dimyan Michael , Ermer Elsa , Goud Anil , Lang Catherine E , Li Junning , Liu Jingchun , Nichols Thomas , Ramos Ander , Roberts Pamela , Sanossian Nerses , Soekadar Surjo , Stinear Cathy , Ward Nick , Wang Junping , Westlye Lars T , Kuceyeski Amy , Winstein Carolee J , Wittenberg George F , Yu Chunshui , Cramer Steven C , Thompson Paul M ,   on behalf of ENIGMA Stroke Recovery
Published: June 2021

The laterality of the lesioned hemisphere is often overlooked in stroke recovery research due to small sample sizes. Here, we used a well-powered dataset from ENIGMA Stroke Recovery (a consortium that harmonizes post-stroke MRIs and behavioral data worldwide; http://enigma.usc.edu) to analyze the effects of left (LHL) versus right (RHL) hemisphere lesions on motor performance. Given the different functional roles of each hemisphere, we hypothesized that the LHL group should show better motor performance, and, consequently, different brain-behavior relationships, compared to the RHL group. Data from over 2000 stroke patients across 20 sites worldwide has been committed. To date, structural T1-weighted MRIs from n=343 (10 sites) have been analyzed (LHL n=174; RHL n=169). ENIGMA protocols extracted volumes of subcortical regions of interest and provided quality control. Regression analyses examined brain volumes as predictors of motor outcomes. Motor scores were combined across scales/sites, with each score expressed as a percentage of the maximum score. Covariates (e.g., age, sex, intracranial volume) and manually marked lesion effects were also modeled. Statistical significance was assessed nonparametrically by permutation. As anticipated, the LHL group had better motor performance compared to the RHL group (t(1,341)=3.07, p=0.0023). In addition, while the combined LHL+RHL analyses showed significant associations between motor scores and volumes of the basal ganglia/lateral ventricles, separate group analyses showed strong associations for the LHL group, but only one association for the RHL group (Table 1). This may suggest that motor recovery following RH lesions is more heterogeneous or relies more on cortical regions/networks that were not assessed here. While further research is needed, these results suggest that laterality of the lesioned hemisphere affects neural patterns related to motor recovery and should be carefully examined.
Abstract 148: Evaluation of Sex, Racial and Geographic Demographics and Outcomes in Clinical Trials of Spontaneous Intracerebral Hemorrhage
Authors: Koffman Lauren , Hanley Daniel , Anderson Craig , Mendelow David , Gregson Barbara , Wang Xia , Lane Karen , McBee Nichol , Dlugash Rachel , Awad Issam , Ziai Wendy ,   VISTA Collaborators
Published: June 2021

Introduction:
As large clinical trials for spontaneous intracerebral hemorrhage (ICH) increasingly influence management, recruitment of diverse populations must be ensured to fully understand the disease process and benefit of interventions to the general public. There is little data on sex, race and outcomes in ICH trials. We hypothesize that women and geographic minorities are underrepresented in ICH clinical trials and that there exist population specific differences in mortality, functional outcomes and response to interventions.

Methods:
Pooled analysis of 5456 subjects from the following clinical trials: VISTA (985), INTERACT I (404) and II (2829), STICH II (597), MISTIE II (141) and CLEAR III (500). Patients were grouped by sex, race, and geographic location. Modified Rankin Scale [mRS] was obtained at 30 days and 3 months.

Results:
More men than women participated in ICH trials (61.9% vs. 38.1%); women were older and more likely to have hypertension; men had more coronary artery disease. Women presented with lower Glasgow Coma scale, higher ICH score and more intraventricular hemorrhage. Day 90 mortality was 13.9% in women and 16.6 % in men (p=0.01); 90 day poor outcome (mRS 3-5) was 57.2% in women and 51.0% in men (p<0.001). Only mortality was significantly different between sexes after adjustment for ICH score. Race representation varied in these clinical trials: 1.5% Hispanic; 6.6% black; 14% Arabic; 31% white and 43.4% Asian. Day 90 mortality and mRS 3-5 were highest in Hispanics (22.1%, 78.3%, respectively) and lowest in Asians (9.5%, 43.8%). Hispanics had higher ICH score, but blacks and Hispanics had lower day 90 mortality compared to whites in adjusted models. Asians had both lower mortality and less day 90 mRS 3-5 vs. whites while Arabics and blacks were more likely to have day 90 mRS 3-5. Study interventions were well balanced by sex and race.

Conclusions:
Sex and race representation in ICH clinical trials only partially equate to current understanding of epidemiology of ICH. There is a lack of trial evidence from Africa and South America and under-representation of women, Hispanics and blacks. Despite higher ICH severity, Hispanics had lower adjusted mortality risk while males had higher risk and Arabics and blacks had worse adjusted poor outcomes.
Abstract 15: Long Term Outcomes of Intravenous Glyburide in Patients 70 Years of Age or Under: Subgroup Analysis From the Phase II GAMES-RP Study of Patients with Large Hemispheric Infarction
Authors: Sheth Kevin N , Cheung Ken , Elm Jordan J , Hinson Holly , Molyneaux Bradley J , Beslow Lauren , Sze Gordon , Ostwaldt Ann-Christin , Kimberly W T ,   GAMES Investigators
Published: June 2021

Background:
Prior evidence suggests that younger patients are at increased risk for the deleterious consequences associated with edema after large hemispheric infarction (LHI). GAMES-RP was a double-blind, randomized, placebo controlled phase 2 study. Patients presenting to 18 centers with baseline infarct volumes between 82 and 300 cm
3
on MRI were randomized 1:1 within 10 hours of symptom onset. Although the primary analysis, which included decompressive craniectomy as part of a composite endpoint, suggested no difference between groups, there was a trend toward decreased mortality for patients treated with IV glyburide.

Objective:
Exploratory analyses of the GAMES-RP trial suggested that overall trend of decreased mortality for patients treated with IV glyburide may be more pronounced with younger patients. We hypothesized that patients age 70 and under who were treated with IV glyburide would have improved long term outcomes compared to placebo.

Methods:
This exploratory analysis included the subset of patients aged
<
70 who met the Per-Protocol definition: IV glyburide (n=35) and placebo (n=30). We analyzed 12-month mortality, functional outcome by analysis of the modified Rankin Scale (mRS), functional improvement on the Barthel Index (BI), and quality of life using the EQ-5D. Differences were analyzed using Fisher’s exact test except for shift analysis, which used a two sided Mann-Whitney test.

Results:
Subjects treated with IV glyburide had lower mortality at 12 months (14% vs 40%, p=0.025, OR 4.00). Shift analysis revealed a trend towards improved functional outcome in IV glyburide treated patients (OR 2.24; p=0.080), higher score on the BI (mean 60.1; SD 37.9 vs mean 39.5; SD 40.1, p=0.03), and higher score on the EQ-5D (mean 0.49; SD 0.31 vs mean 0.33; SD 0.32, p=0.04).

Conclusion:
This post-hoc analysis suggests that patients under 70, who may be at highest risk for poor outcomes secondary to edema after large hemispheric infarction, may have improved survival, better functional outcome and improved quality of life following treatment with IV glyburide. A prospective study is required in this population in order to definitively establish that IV glyburide can improve outcome. Registry: NCT01794182
Abstract 176: HERMES: Collaterals at Angiography Guide Clinical Outcomes
Authors: Liebeskind David S , Jovin Tudor G , Majoie Charles B , Mitchell Peter J , San Román Luis , Campbell Bruce C , van Zwam Wim H , Menon Bijoy K , Saver Jeffrey L , White Philip , Hill Michael D , Muir Keith W , Demchuk Andrew , Dippel Diederik W , Dávalos Antoni , Brown Scott , Goyal Mayank ,   for the HERMES Collaborators
Published: June 2021

Background:
Collateral circulation is a key factor in the pathophysiology of ischemic stroke. We conducted detailed analyses of angiography acquired immediately prior to endovascular therapy in the HERMES collaboration of recent landmark thrombectomy trials to determine predictors of collateral status and assess impact on clinical outcomes.

Methods:
The HERMES Imaging Core, blind to all other clinical and imaging data, independently interpreted conventional angiography acquired immediately prior to endovascular therapy. Collaterals were graded with the ASITN scale, based on available data for the site of arterial occlusion defined on initial injections. The statistical core analyzed the association of collateral grade with demographics, baseline NIHSS, site of arterial occlusion and clinical outcomes of day 90 mRS.

Results:
Angiography of collaterals was available in 376/605 (62%), including ASITN grades 0 in 7 (2%), 1 in 40 (10%), 2 in 182 (48%), 3 in 129 (34%) and 4 in 18 (5%). Elevated blood glucose (p=0.011) and diabetes (p=0.048) were associated with worse collateral grades, but age and NIHSS were unrelated. Better collateral grade was strongly associated with the degree of subsequent TICI reperfusion (p<0.001). The limited numbers of symptomatic intracranial hemorrhage (14/376 or 3.7%) or parenchymal hematomas (18/376 or 4.8%) precluded analysis of association with collateral status. Collaterals had strong impact on mRS shift from baseline to 90 days (p<0.001).

Multivariable regression revealed that better collateral status was a potent determinant (OR 1.37 per grade, p=0.028) of outcomes, equivalent to 4.5 points of NIHSS and 14 years of age in terms of impact on mRS outcomes.

Conclusions:
Collaterals at angiography were a potent determinant of clinical outcomes in recent landmark thrombectomy trials.
Abstract 27: The Georgia Stroke Curriculum (GSC): Provides Free Stroke Education to Healthcare Professionals
Authors: Bryant Katja , Camp Debbie , Goings Denise , Zimmermann Susan ,   Georgia Stroke Professional Alliance (GA-SPA)
Published: June 2021

Background:
In 2015 the Georgia Stroke Professional Alliance (GA-SPA) supported the launch of a free educational platform, the Georgia Stroke Curriculum (GSC). This up-to date, evidence based, peer reviewed stroke education is an alternative to other more costly options. Statewide provider and instructor classes were developed. GSC is a four module, didactic, interactive course focused on the full continuum of care of the acute stroke patient. GSC is peer reviewed by stroke content experts

Purpose:
To expand free state-wide education to all health care professionals committed to improving the quality of stroke care through evidence based stroke education provided by clinical experts, who are trained and provided the latest evidence in stroke care

Methods:
GSC was developed by experienced stroke professionals with an extensive background in neuroscience and stroke care. The three different programs are advanced, core and instructor classes. Modules are peer reviewed by a consortium of stroke content experts, including stroke neurologists, physiatrist, emergency room, neurology, flight and rehabilitation nurses, case managers, stroke coordinators, quality specialists, and paramedics. The initial course was proctored by a stroke neurologist and stroke coordinators. Additional pilot classes were completed at comprehensive, primary, and remote treatment stroke centers

Results:
GSC is an expanding educational platform for free professional stroke education for healthcare professionals that is evidenced based, cutting edge with a regional approach, inclusive of feedback from providers, hospitals and healthcare systems. As of August 2016 nearly 70 GSC instructors were trained statewide along with over 500 healthcare professionals. The education has improved professional stroke knowledge as evidenced by an average score of 60% on the pretest to 90% on the posttest

Conclusion:
GSC serves as a free subject matter resource on stroke education to healthcare professionals with a focus on the full continuum of stroke care. The state-wide initiative has improved the knowledge for healthcare professionals in the region. GSC expands the reach of a free, current, evidenced based program as an effective method to enhance stroke education throughout the state
Abstract 32: Per Protocol versus Intent-to-treat Analysis in a Non-inferiority, Randomized Trial of the Safety and Efficacy of the Penumbra 3D Stent Retriever as an Adjunct to Aspiration in Acute Ischemic Stroke
Authors: Frei Donald , Nogueira Raul , Kirmani Jawad , Zaidat Osama O , Lazzaro Marc , Lopes Demetrius , Turk Aquilla S , Heck Donald , Mason Brian , Siddiqui Adnan ,   for the Penumbra 3D Investigators
Published: June 2021

Introduction:
The relative treatment effects for a stent retriever when used as an adjunct to aspiration versus aspiration alone remain unclear. The aim of this study was to demonstrate the safety and efficacy of the Penumbra stent retriever, 3D, when used in conjunction with the Penumbra Aspiration System (3D/PS), was non-inferior to the Penumbra Aspiration System (PS) alone. It remains controversial if a Per Protocol (PP) or an Intent-To-Treat (ITT) analysis is more appropriate for this study design.

Hypothesis:
PP and ITT analyses are comparable for a non-inferiority design trial.

Materials and Methods:
Patients presenting with symptoms of ischemic stroke within 8 hours of onset who had evidence of a LVO (diameter ≥2.5mm) and a NIH Stroke Scale ≥8 were assigned 1:1 to either treatment group. The primary endpoint for effectiveness was angiographic revascularization of the occluded target vessel at immediate post-procedure where the 3D/PS is non-inferior to PS by no more than 15%. Key secondary endpoints were 90 day functional independence as defined by a modified Rankin score 0-2, all-cause mortality and the incidence of symptomatic intracerebral hemorrhage. A Core Laboratory assessed imaging data.

Results:
The trial was terminated in June 2016 after the DSMB voted unanimously that recruiting additional subjects was judged to be both not feasible and unable to alter conclusions. A total of 198 patients were randomized at 25 sites: 98 to the 3D/PS and 100 to the PS alone group. The results indicate the 3D/PS was non-inferior to the PS alone in safety and effectiveness (difference in TICI 2-3=2.6%, 95%CI -5.8 to 11%). PP and ITT analyses showed similar results (Table).

Conclusion:
This is the first Class 1 evidence showing the similarity in safety and effectiveness of a stent retriever when used as an adjunct to aspiration versus aspiration alone in acute stroke from LVO. Both PP and ITT analyses showed similar results.
Abstract 81: Brain Natriuretic Peptides Identifies Stroke Patients Who Benefit From Prolonged and Enhanced Monitoring for Af Detection - A Subgroup Analysis of Find-AF Randomised
Authors: Wachter Rolf , Gröschel Klaus ,   Find-AF randomised Study Group, Hamann Gerhard F , Kermer Pawel , Liman Jan , Gelbrich Götz , Weber-Krüger Mark
Published: June 2021

Background:
Three randomised controlled trials have investigated prolonged monitoring methods for the detection of Atrial Fibrillation (AF) in stroke patients. All have shown that more patients with Atrial Fibrillation are detected by prolonged monitoring, but none has so far investigated if biomarkers identify patients who benefit from the intervention. BNP is of special interest, has retrospective analyses from the WARSS trial showed that BNP identifies patients who might benefit from oral anticoagulation in comparison to Aspirin (Longstreth, Stroke 2013).

Methods:
We analysed brain natriuretic peptide (BNP) measured at randomisation in participants of the Find-AF randomised trial. In brief, Find-AF randomised randomised 402 stroke patients aged 60 years and above with a recent stroke (< 7 days to onset of symptoms) to enhanced and prolonged monitoring (3x10 day Holter ECG) or usual care. The primary endpoint was the detection of AF by 6 months.

Results:
BNP could be measured in 373 of 402 participants (93 %). Patients with AF detected by 6 months had significantly higher BNP values (median 53; IQR 30;169) as compared to patients without AF (median 28; IQR 12;62) (p<0.001). BNP >= 100 pg/ml versus < 100 pg/ml showed a significant interaction with the intervention (p=0.01). The number needed to screen in the overall study was 11, while it was 3 for BNP>100pg/ml and 18 for BNP<100 pg/ml (see Figure).

Conclusion:
BNP identifies a high-risk subgroup of stroke patients with undetected AF.
Abstract 89: Differences in Acute Stroke Care in Primary and Comprehensive Stroke Centers in Florida: An Analysis of the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study- the NINDS Stroke Prevention Intervention Research Program
Authors: Marulanda-Londoño Erika T , Ciliberti-Vargas Maria A , Wang Kefeng , Asdaghi Negar , Ayodele Maranatha , Dong Chuanhui , Gardener Hannah , Gutierrez Carolina M , Burgin W. S , Foster Dianne , Gonzalez Sanchez Juan , Mueller-Kronast Nils , Nobo Ulises L , Robichaux Mary , Rose David Z , Sand Charles , Waddy Salina P , Sacco Ralph L , Rundek Tatjana , Romano Jose G ,   for the FL-PR CReSD Investigators and Collaborators
Published: June 2021

Introduction:
Primary stroke center (PSC) and comprehensive stroke center (CSC) designation in Florida aims to improve delivery of care and outcomes for stroke patients. In line with the goals of the NINDS funded Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study, we sought to compare ischemic stroke performance metrics by stroke center designation in participating Florida hospitals.

Methods:
We analyzed 74,623 cases with acute ischemic stroke from 26 CSC and 40 PSC from January 2010-April 2016. We described patient demographics, comorbidities and Get With The Guidelines-Stroke performance metrics of defect free care (compliance with 7 pre-defined performance core measures), door to CT time (DTCT) ≤25 mins and door to needle time (DTN) ≤60 mins.

Results:
Compared with PSC patients, CSC patients were younger (70 ± 15 vs. 71 ± 14 years, p<.0001), more likely male (51% vs. 50%, p=.0008), more likely Hispanic (17% vs. 10%, p<.0001) and Black (21% vs. 17%, p<.0001), had more severe strokes (NIHSS median 5 (IQR 2-12) vs. 4 (IQR 1-9); NIHSS ≥16, 12% vs. 9%, p <.0001), were more likely to have atrial fibrillation (19% vs. 17%, p<.0001), and were more likely to arrive by EMS (55% vs. 46%, p<.0001). CSC cases were more likely to have faster DTCT (44 vs. 48 mins, p=.0124
;
<
25 mins 33% vs. 31%, p<.0001). More patients in CSC received thrombolysis (12% vs. 9%, p<.0001), with faster DTN (59 vs. 71 min, p <.0001; ≤60 minutes 53% vs. 37%, p <.0001). Patients in CSC had greater rates of defect free care (85% vs. 82.4%, p<.0001). Blacks had longer median DTCT than Whites and Hispanics in both CSC (56 mins Blacks vs. 41 mins Whites and Hispanics) and PSC (60 mins Blacks, 44 mins Whites, 57 mins Hispanics). Blacks in CSC had longer median DTN (63 mins) than Whites (60 mins) and Hispanics (53 mins). Hispanics had longer median DTN (73 mins) in PSC than Blacks (70 mins) and Whites (70 mins).

Conclusion:
Patients treated in CSC, compared with those treated in PSC, received better defect-free care and had lower DTCT and DTN times. Race-ethnic disparities in performance metrics are still evident in both CSC and PSC. Identification of these disparities is important to design interventions to reduce disparities and improve stroke quality of care for all.
Abstract TMP44: Personalizing Rehabilitation for Stroke Survivors- A Big Data Approach
Authors: Kiran Swathi , Godlove Jason , Advani Mahendra , Anantha Veera
Published: June 2021

Introduction:
Advances in connected health delivery provides a unique opportunity to maximize intervention effectiveness for stroke patients. It has also helped collect large sets of data to facilitate clinical decision making. This vastly insightful data is used to personalize neurorehabilitation where the evidence for gains in chronic stroke patients is weak.

Methods:
Over a span of 2 years (2013-2015), data was anonymously aggregated and analyzed from over 2,500 patients with post-stroke aphasia. Data was collected using a mobile therapy platform, Constant Therapy, which has 60 evidenced-based language and cognitive therapy tasks. The program was used by patients in the home and clinic under the guidance of a clinician, or under their own volition if not regularly seeing a clinician. This program dynamically adapted to each patient’s progress. Patients who completed between 3 and 1000 treatment sessions were analyzed to determine which tasks showed statistically significant changes. These data were compared with control patients who completed tests at two separate time points but with no intervening treatment.

Results:
Despite the older demographic of patients (median age = 64 yrs), they performed an average of over 20 minutes on home therapy every day. The analyses take into account the number of patients who completed a specific task and show a significant change (all
p
<.05) for accuracy or latency. For example, the 2-step Auditory Command task (which requires a user to follow 2-step directions) showed a 12 point gain in accuracy and 39% improvement in processing speed in 1,200 patients. The results also show that patients with higher initial severity scores showed significant gains in accuracy, and reach similar post-treatment accuracy to those with lower severity scores, provided that they received an appropriate dosage of therapy. In contrast, control patients showed minimal gains on tasks that were assigned.

Conclusion:
These results show that all patients, including the most severe, can make progress in their rehabilitation when treatment is individualized for them. Analysis of large data sets can be used to inform rehabilitation by highlighting therapies that are effective while accounting for etiology and individual variability.
Abstract TP259: Accuracy of EMS Identification of Acute Strokes Eligible for tPA Treatment in Kaiser Stroke EXPRESS Program
Authors: Klingman Jeffrey G , Bhopale Sunil , Hatfield Meghan , Wilson Benjamin , Klingman Lauren , Nguyen-Huynh Mai N ,   on behalf of KPNC Stroke FORCE team
Published: June 2021

Background:
Field-based diversion for potential stroke patients who may qualify for endovascular stroke therapy (EST) has been proposed more widely in 2015. In 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke care work flow for all its 21 stroke centers, which included rapid evaluation of all stroke alerts by a stroke neurologist via teleneurology. We investigated the accuracy of EMS-activated stroke alerts.

Methods:
From 1/1/16 to 7/10/16, all acute strokes presenting to an ED between 7 AM and midnight were assessed upon arrival by a teleneurologist. We reviewed all telestroke cases to determine the frequency of tPA given, cancelled stroke alerts, and the reasons for not treating with IV t-PA, particularly among ambulance arrivals. Multivariate logistic regression was used to assess age, gender, race, Kaiser membership, and mode of ED arrival as predictors of stroke alert cancellation.

Results:
There were 2192 stroke alerts activated. Of these, 1332 (60.7%) arrived by EMS and 860 (39.2%) by non-EMS transport. Of patients arriving by EMS, 651 (48.9%) were cancelled and deemed ineligible for IV t-PA. Most common reasons for cancellation were: last time known well (LTKW) out of range (23%), stroke mimic (33%), symptom resolution (19%), new data regarding goals of care (2%), and other (22.5%). The remaining 681 (51.1%) ambulance arrivals were potential candidates for IV tPA. Subsequently, 334 (50.4%) of them received tPA. Reasons for tPA not given included subsequent resolution of symptoms, concerning CT findings (such as bleed), INR>1.7 in patients on warfarin, further information clarifying time of onset. Among those who arrived by EMS and received IV t-PA, all had CTA and 103 (30.8%) were found to have a large vessel occlusion and 74 (71.8%) underwent EST. In multivariate analysis for all cancelled stroke alerts, arrival by non-EMS transport (OR=1.74, 95% CI 1.44-2.10, p<0.001) was more likely to be cancelled.

Conclusions:
Close to half of EMS-activated stroke alerts were cancelled upon initial assessment. Only 5% of patients initially identified by EMS as having a potential acute stroke ultimately underwent EST. Better determination of LTKW and stroke symptoms would improve the accuracy of EMS-initiated stroke alerts.
Abstract TP311: Does Age Affect Race/Ethnic Differences in Discharge Ambulation Status? Data From the Florida Puerto Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study - The NINDS Stroke Prevention Intervention Research Program
Authors: Oluwole Sofia , Wang Kefeng , Ciliberti-Vargas Maria A , Gutierrez Carolina M , Perez-Martinez Enmanuel , Dong Chuanhui , Marulanda-Londoño Erika , Ayodele Maranatha , Gardener Hannah , Burgin W. S , Foster Dianne , Garcia-Rivera Enid J , Gonzalez- Sanchez Juan , Robichaux Mary , Rose David Z , Waddy Salina P , Zevallos Juan C , Sacco Ralph L , Rundek Tatjana ,   for the FL-PR CReSD Investigators and Collaborators
Published: June 2021

Background:
Among stroke survivors, worse functional outcomes have been reported in race/ethnic minority groups. Race/ethnic differences in post-stroke independent ambulation may be evident early and largely influenced by age. Independent ambulation is defined as the ability to walk without supervision or assistance from another person. Discharge ambulation status may have implications for long term rehabilitation after stroke. We sought to determine the impact of age on race/ethnic differences in discharge ambulation status in the large NINDS-funded FL-PR CReSD Registry of Get With The Guidelines-Stroke (GWTG-S) data.

Methods:
Discharge ambulation status was analyzed for 51,859 acute ischemic stroke (AIS) survivors from 69 FL and 13 PR sites. Multivariate logistic regression models were used to test whether age modifies the relationship between race/ethnicity and independent ambulation at discharge (IAD). Stratified analyses were performed in 3 age groups: 18-64, 65-79, 80+. Models were adjusted for sex, vascular risk factors, independent ambulation status at admission and hospital characteristics.

Results:
IAD was achieved in 52%, of which 71% were non-Hispanic White (NHW), 13% NH Black (NHB), 12% FL Hispanic (FLH), and 4% PR Hispanic (PRH). IAD was most common in NHW (57%), followed by FLH (53%), NHB (47%), and PRH (40%). Older age was associated with lower odds of IAD (18-64: 68%, 65-79: 54%, 80+: 32%). After full adjustment, IAD was less likely in older [65-79 vs 18-64: OR 0.68, 95% CI 0.63-0.73; 80+: OR 0.35, 95% CI 0.32-0.39] and NHB vs. NHW patients [OR 0.85, 95% CI 0.78-0.92]. In age-stratified analyses, NHBs were less likely than NHWs to achieve IAD among those age 65-79 (47% vs. 57%) and 80+ (29% vs 34%) [OR 0.79, 95% CI 0.70-0.90; OR 0.76, 95% CI 0.65-0.88]. This association was not seen in the 18-64 age group (66% vs 69%), [OR 0.97, 95% CI 0.88-1.06].

Conclusions:
About half of AIS survivors are unable to ambulate independently after stroke at discharge. Elderly NHB are less likely to IAD, though the disparity is not observed in working age adults. Post-stroke ambulation is a public health issue that substantially contributes to the economic burden of US healthcare. Further studies are warranted to identify causes of race/ethnic disparities in IAD.
Abstract TP93: Topically Applied Adipose-derived Mesenchymal Stem Cell Treatment In Experimental Focal Cerebral Ischemia
Authors: Wong George ,   HMRF01120666 Investigators
Published: June 2021

Background and purpose:
Disability is common after severe stroke resulting from major cerebral artery occlusion despite adoption of prophylactic decompressive craniectomy. Experimental mesenchymal stem cell treatments are commonly administrated through systemic infusion, with limitations in dosage. In this study, the neuro-modulation effect of topical mesenchymal stem cells (MSCs) was tested in a rodent middle carotid artery occlusion (MCAO) model.

Methods:
Twenty-four hours after MCAO, craniotomy was made and 0.8 x 10
6
GFP-MSCs were topically applied to the ipsilateral parietal cortex (N=30). In the control group, saline were topically applied to the ipsilateral parietal cortex (N=30).

Results:
After topical MSC treatment, neurological assessments with Rotarod test (at days 3, 7, and 10) and Morris Water Maze test (at days 3, 7, and 14) were significantly better, as compared to the control group; the infarct volume was also smaller. MSCs were found in the penumbra of the infarct 3 days after topical application. In the PCR array analysis of the RNA extracted from penumbra cortex, topical application of MSCs changed 10 gene expressions in the penumbra at day 3 (fold change >1.25, p<0.05 after Bonferroni corrections for multiple comparisons). The seven up-regulated genes (Apoe, Ascl1, Efnb1, Mef2c,Nog,S100a6, B2m) involve neuronal migration, neuronal differentiation, neuronal cell fate determination, regulation of synaptic plasticity, axonogensis;, growth factors, and cell adhesion. Pax2, Pax3 and Th were downregulated. Pax2 and Pax3 are related to apoptosis. Both Apoe and Thl involve synaptic transmission.

Conclusions:
Topically applied MSCs reduced cerebral infarction volume and improved the neurological function from cerebral ischemia resulting from a major cerebral artery occlusion in a rodent experimental model.
Abstract WP176: Assessing Genome-wide Associations With Ischemic Stroke Using Alternate Definitions of Stroke Subtypes: The SiGN Study
Authors: Pulit Sara , Ay Hakan , Brown Robert D , Gamble Dale M , Kittner Steven J , McArdle Patrick M , Meschia James F , Worrall Bradford B ,   for the NINDS-SiGN Investigators
Published: June 2021

Stroke subtype classification, applying standard criteria to clinical data, can reduce the heterogeneity of ischemic stroke for genetics studies. To date, most of the replicated genetic loci for ischemic stroke appear subtype-specific. Increasing homogeneity of phenotype comes with a trade-off in sample size, which influences the potential for successful identification of new loci. We estimated genetic associations using the union and intersection of two widely used stroke subtyping systems to assess the influence of sample size and homogeneity on test statistics.

Methods:
The Stroke Genetics Network (SiGN) study used both the Causative Classification of Stroke (CCS) and the Trial of ORG10172 Acute Stroke Trial (TOAST) classification systems. The CCS generates both a causal and a phenotypic subtype. Using all available data from case-control strata from the a previously performed GWAS, we focused on three main stroke subtypes: cardioembolic (CE), large artery atherosclerosis (LAA), and small artery occlusion (SAO). We estimated genetic associations with the union of the two CCS outputs and TOAST (
eg
called CE by
at least one
method) and the intersection (
eg
called CE by
all three
methods). Our modelling approach included a fixed-effects meta-analysis, i.e. pooling stratum specific estimates from logistic regression models using 10 principle components to account for genetic ancestry responsible for population stratification.

Results:
The majority of confirmatory findings from SiGN (
PITX2
and
ZFHX3
for CE and
HDAC9
for LAA) were evident in both models and in both the union and intersection of the subtyping systems. Some findings (
TSPAN2
in LAA) showed up best in the intersection with stronger corresponding p-values and odds ratios whereas other findings (12q24 for SAO) appear stronger in all of the union analyses, but were also evident in intersection analyses. We identify 16 potential novel loci, 6 of which appear in numerous analyses.

Conclusion:
Both expanding and refining stroke subtypes may help in the identification of additional stroke genetic risk variants and should be considered as complementary to a single classification system. We are pursuing replication of the novel findings.
Abstract WP337: Septic Shock is Associated with Poor Clinical Outcomes in Patients with Ischemic Stroke
Authors: Silva Gisele S , Miranda Renata , Massaud Rodrigo , Vaccari Andreia , Cendoroglo Neto Miguel
Published: June 2021

Background:
Medical complications are potential barriers to optimal recovery after acute ischemic stroke. Hypotension and shock can be particularly deleterious to the recovery of the penumbral tissue. The frequency of shock in patients admitted with acute stroke has not been systematically evaluated. We assessed the hypothesis that shock is not uncommon after ischemic stroke and is related to clinical prognosis.

Methods:
We evaluated a prospectively collected database of consecutive patients admitted to a tertiary hospital with acute ischemic stroke from January 2010 to December 2015. Shock was defined as persisting hypotension requiring vasopressors to maintain mean arterial pressure ≥65 mmHg.

Results:
A total of 1145 patients (mean age 72 +/-16 years, 56% males) were evaluated. Shock was diagnosed in 15 patients (1.3%). These patients were similar in age, gender, blood pressure at hospital admission, and previous history of coronary artery disease to patients without shock. Sepsis was the most common single etiology of the shock (93%). Septic source was pulmonary in 60%, abdominal in 13%, undetermined in 20% and blood borne in 6.6%. Septic shock was diagnosed at a median of 14 days [8,20] after hospital admission. Patients who developed shock had a higher National Institutes of Health Stroke Scale (NIHSS) at admission (12 [8,20] vs 3 [1,10], p<0.01), a higher frequency of diabetes (60% vs 30%, p=0.01), urinary tract infection (27% vs 4.8%, p<0.01), pneumonia (47% versus 4.5%, p<0.01), acute renal (33% vs 0.7%, p<0.01) and respiratory (53% vs 1.8%, p<0.01) failures. Length of hospital stay (39 [29,156] vs 8 days [4, 15], p<0.01) and ICU stay (19[7, 27.5] vs 0 days [0,3], p<0.01) were higher in patients with shock. Shock was associated with a hospital mortality of 80% vs 9% in patients without shock (p<0.01). In multivariate logistic regression analysis, only pneumonia (OR: 16.9, [4.1-69.4],p<0.01) and NIHSS 1.07 [1.01-1.15, p=0.04] at admission were predictors of developing shock during hospital admission.

Conclusion:
In conclusion, shock was an infrequent but severe complication in patients with stroke and was associated with a very high mortality. Sepsis was the most important etiology.
Abstract WP37: Evidence of Late Hemorrhage in Ischemic Stroke Patients Treated With Intravenous Alteplase: A Post Hoc Analysis of the Multicenter MR WITNESS Trial (NCT01282242)
Authors: Boulouis Gregoire , Schwamm Lee H , Latour Lawrence L , Song Shlee S , Yoo Albert J , Lev Michael H , Ford Andria L , Hsia Amie , Betensky Rebecca , Muzikansky Alona , Lauer Arne , Cougo Pedro , Copen William A , Harris Gordon J , Warach Steven , Wu Ona ,   for the MRWITNESS Investigators
Published: June 2021

Introduction:
Although early hemorrhagic transformation (HT) in acute ischemic stroke has been studied, less is known about patients who develop hemorrhage after the acute phase. We hypothesized that patients with late hemorrhage (LH) would have more severe strokes than those without, and tested this hypothesis in a cohort of thrombolysed patients from the MR WITNESS trial.

Methods:
Subjects were recruited from 10 sites between Jan 2011-Oct 2015. MR WITNESS enrolled subjects if they were last seen between 4.5 and 24 hours prior to evaluation, but otherwise qualified for IV tPA in the 3-4.5 hr window per AHA guidelines, and if their brain MRI findings indicated very early infarction: either no FLAIR hyperintensity or subtle hyperintensity, ie signal increase <15% compared to the contralateral hemisphere. Patients with early (≤48 hours) HT (defined per ECASS criteria) were excluded from analysis. Late hemorrhage was defined as imaging manifestation of hemorrhage on 30 days MRI in patient without manifestation of HT at 48h. Good outcome was pre-specified as modified Rankin Scale (mRS) 0-1 at 90 d. Univariate comparisons utilized Fisher’s exact test and Wilcoxon Rank Sums 2-sample exact test for categorical and continuous variables, respectively.

Results:
Among the 80 patients included in the MR WITNESS cohort, 53 met our inclusion criteria and were analysed. When compared to those with no HT, patients with LH had larger baseline infarct volumes and perfusion defects, as well as more frequent proximal vessel occlusion at baseline (all p <0.01, See Table). Patients with LH also demonstrated worse functional outcome at 90 days (mRS, Median [IQR], 3 [1.75-4] vs 1 [0-2], p=0.006, Table).

Conclusion:
Patients with LH demonstrate a more severe imaging profile at baseline and a worse functional outcome at 90 days when compared to patients without hemorrhage. Understanding the underlying pathophysiology of LH may shed light on to the mechanisms of acute and subacute brain injury.
Abstract WP89: Preliminary Single-center Experience with Neuroform Atlas Stent-assisted Coiling for Unruptured Intracranial Aneurysms
Authors: Ciccio’ Gabriele , Smajda Stanislas , Robert Thomas , Blanc Raphael , Redjem Hocine , Takezawa Hidesato , Sasannejad Payam , Piotin Michel
Published: June 2021

Background and Purpose:
Expandable stents have broadened the spectrum of endovascular treatment of intracranial aneurysms. The Neuroform ATLAS, a nitinol self-expanding, hybrid/open-cell stent, is the evolution of the Neuroform EZ supposing to ease the navigability of the system into intra-cranial arteries, through a low-profile 0.017 inch delivery catheter. We present herein our initial experience in the treatment of intracranial aneurysms with this stent.

Materials and Method:
We compiled data from consecutive patients of our institution from July 2015 to June 2016 who underwent stent-assisted coiling with the Neuroform ATLAS. Clinical and angiographic results were analyzed retrospectively.

Results:
Thirty-six intracranial saccular aneurysms (18 MCA, 10 AcoA, 4 ICA bifurcation, 2 basilar tip, 1 vertebral-PICA, 1 pericallosal artery) in 35 patients (24 women, 11 men, mean age 60 years) were consecutively treated. The stent was used in 32 previously untreated aneurysms, and in 4 cases of recanalization. One single stent was used in 15 aneurysms while 21 aneurysms (58.3%) were treated with 2 stents in a “Y” configuration. The immediate post-treatment angiography showed a complete occlusion in 19 cases (52.7%), a residual neck in 4 cases (11.1%) and a residual aneurysmal contrast filling in 13 cases (36.1%). Two complications occurred (5.5%), the first due to an associated aneurysm perforation (mRs 1), and the second due to parent vessel perforation (mRs 6). Both of them occurred after the stent implantation. We don’t report any case of attempted stenting treatment.

Conclusion:
The Neuroform ATLAS Delivery System is an effective device for treatment of complex intracranial aneurysms, allowing good conformability and stability with a high level of navigability. The 2 main advantages are its low profile and the cell-design allowing easy mesh crossing to perform Y-stenting procedures.

Key words:
Neuroform ATLAS, Neuroform EZ, Stent-assisted coiling, cerebral aneurysm.
Abbreviations:
mRs: modified Rankin Scale, AcoA: Anterior communicating artery, PICA: posterior inferior cerebellar artery.
Abstract 125: Observation versus Treatment for Low-Grade Intracranial Dural Arteriovenous Fistulas: A Multicenter Matched Cohort Study
Authors: Chen Ching-jen , Buell Thomas , Guniganti Ridhima , Abecassis Isaac , Lanzino Giuseppe , Kansagra Akash , Derdeyn Colin , Amin-Hanjani Sepideh , Levitt Michael , Alaraj Ali , Starke Robert , Fox W. Christopher , Gross Bradley , Bulters Diederik , Durnford Andrew , Kim Louis , van Dijk Marc , Zipfel Gregory , Sheehan Jason ,   CONDOR
Published: June 2021

Background and Purpose:
Given the benign natural history of intracranial low-grade dural arteriovenous fistulas (dAVFs), their routine treatment remains controversial. The aim of this study is to compare the outcomes of low-grade dAVF treatment to conservative management.

Methods:
We performed a retrospective review of dAVF patients derived from 12 institutions participating in the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR). Patients with low-grade (Borden I) dAVFs were included and categorized into treatment and observation cohorts. Primary outcome was defined as modified Rankin Scale (mRS) score at final follow-up. Secondary outcomes were rates of excellent (mRS 0-1) and good (mRS 0-2) functional outcomes, symptomatic improvement, mortality, and obliteration at final follow-up.

Results:
The treatment and observation cohorts comprised 230 and 112 patients, respectively. At last follow up, no difference in primary or secondary outcomes was observed between the two cohorts, with the exception of obliteration, which was higher in the treatment cohort (79.3% vs. 28.2%, p<0.001; Table 1). The two cohorts were then matched in a 1:1 ratio, resulting in 64 patients in each matched cohort. No difference in primary or secondary outcomes was observed between the matched cohorts, with the exception of obliteration, which was higher in the matched treatment cohort (75.4% vs. 28.6%, p<0.001; Table 2). Subgroup analysis of symptomatic patients demonstrated higher obliteration rate in the treatment cohort, but no difference in primary or other secondary outcomes were found.

Conclusions:
Low-grade dAVF treatment was not associated with increased functional disability compared to conservative management. Although higher obliteration rates were achieved in the treatment cohort, rates of symptomatic improvement were similar between the two cohorts. This study did not provide evidence to support the routine treatment of low-grade dAVFs.
Abstract TMP47: Impact of Medicare Reform on Inpatient Rehabilitation Facility Access for Hemorrhagic Stroke Patients
Authors: Ifejika Nneka L , Vahidy Farhaan , Reeves Mathew , Ying Xian , Matsouaka Roland , Fonarow Gregg , Savitz Sean , Grotta James C ,   Get with the Guidelines - Stroke
Published: June 2021

Introduction:
There is growing evidence that ICH patients make larger & faster recovery gains compared to ischemic stroke patients. Inpatient rehabilitation facility (IRF) care can significantly facilitate improvement. In 2010, changes to IRF admission criteria potentially restricted access. We hypothesize the Centers for Medicare and Medicaid Services (CMS) 2010 IRF Prospective Payment System Rule decreased IRF access & increased skilled nursing facility (SNF) utilization in ICH patients.

Methods:
The proportion of ICH survivors discharged to IRF, SNF or home was estimated using GWTG-Stroke data between 1/1/2008 & 12/31/2015 (n=265,444). Two binary hierarchical models determined the association between the 1/1/2010 CMS admission criteria change for IRFs and discharge setting, adjusting for patient & hospital characteristics. Subgroup analyses evaluated the effects of age, region & hospital type. Sensitivity analyses used complete NIHSS data (≈49%).

Results:
The prevalence of the 3 discharge destinations changed significantly over time (CMH row-mean-score P<0.0001; Figure 1). IRF rehab odds decreased and SNF rehab odds increased for ICH patients compared to home after the CMS 2010 IRF PPS Rule (Figure 2a & 2b). Decreased IRF rehab odds were found in patients age<65, Western US location or at non-teaching hospitals (Figure 2a). Increased SNF rehab odds were found in patients age≥65, Midwest location or at teaching hospitals (Figure 2b).

Conclusions:
IRF Rehab odds decreased and SNF rehab odds increased during the time period after CMS 2010 IRF PPS Rule implementation in ICH patients. The impact of such legislative changes on patient outcomes warrants further study.
Abstract TMP62: Early Experience Utilizing Artificial Intelligence Shows Significant Reduction in Transfer Times and Length of Stay in a Hub and Spoke Model
Authors: Hassan Ameer E , Ringheanu Victor M , Rabah Rani , Preston Laurie , Qureshi Adnan I
Published: June 2021

Background:
Viz.ai artificial intelligence (AI) software utilizes AI powered large vessel occlusion (LVO) detection technology which automatically identifies suspected LVO through CT angiogram (CTA) imaging and alerts on-call stroke teams. We performed this analysis to determine if utilization of AI software can reduce the time interval between CTA at a primary stroke center (PSC) and arrival time at a comprehensive stroke center (CSC).

Methods:
We compared time interval between CTA and time of arrival for all LVO transfer patients from a single spoke PSC to our CSC prior to (Feb. 2017 to Nov. 2018) and after (Nov. 2018 to May 2019) incorporating Viz.ai. Using a prospectively collected stroke database at a CSC, demographics, transfer time (CTA time to time of arrival at CSC), modified Rankin Scale at discharge (mRS dc), mortality rate at discharge, length of stay (LOS) in hospital and neurological ICU, and intracranial hemorrhage rates were examined.

Results:
There were a total of 43 patients during the study period (average age 70.77 ± 12.54 yrs., 51.16% women). Analysis of 28 patients from the pre-Viz.ai (average age 71.64 ± 12.28 yrs., 46.4% women), and 15 patients from the post-Viz.ai (average age 69.13 ± 13.29 yrs., 60.0% women); see Table 1 for comparison of baseline characteristics and outcomes. Following implementation of Viz.ai, CTA time at PSC to time of arrival at CSC was significantly reduced by an average of 66 min. (mean CTA to time of arrival, 171 min. vs 105 min; P= 0.0163); significant reductions were also noted in the overall LOS (9.7 days vs 7.2 days; P= 0.0324) and LOS in the neurological ICU (6.4 days vs 2.9 days; P= 0.0039).

Conclusions:
The incorporation of Viz.ai was associated with a significant improvement in transfer times for LVO patients as well as a significant reduction in the overall hospital LOS and LOS in the neurological ICU. More extensive studies are warranted to expand on the ability of AI technology to improve transfer times and outcomes for LVO patients.