bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 2867: Factors Relating To An Early Visit To A Stroke Center In Patients With Transient Ischemic Attack: Analyses Of Data From A Multicenter Retrospective Study
Authors: Uehara Toshiyuki , Suzuki Rieko , Fujinami Jun , Miyagi Tetsuya , Kimura Kazumi , Okada Yasushi , Hasegawa Yasuhiro , Tanahashi Norio , Suzuki Akifumi , Takagi Sigeharu , Nakagawara Joji , Uchiyama Shinichiro , Nagao Takehiko , Nagahiro Shinji , Ogasawara Kuniaki , Matsumoto Masayasu , Arii Kazumasa , Iihara Koji , Toyoda Kazunori , Minematsu Kazuo ,   The Japan TIA Rsch group 09-11
Published: July 2021

Purpose:
As transient ischemic attack (TIA) is a medical emergency associated with a high risk of early recurrent stoke, an immediate seeking medical attention is essential to reduce a risk of stroke after TIA. The purpose of this study was to investigate factors relating to an early visit to a stroke center in patients with TIA, using data of a multicenter retrospective study.

Methods:
The subjects of this study were TIA patients admitted to 13 stroke centers within 7 days after onset between 2008 and 2009. The diagnosis of TIA was made in this study if clinical symptoms lasted less than 24 hours, regardless of imaging findings. We compared baseline characteristics between patients visiting a stroke center within 3 hours of TIA onset (early visit, EV group) and those after the initial 3 hours (late visit, LV group), using Chi-square tests.

Results:
Four hundred sixty-four patients (292 men, mean age of 69 years) were registered. Of them, 240 patients (52%) belonged to the EV group and 220 (47%) used an ambulance. One hundred twenty-seven patients (27.4%) were referred from some other medical facility and 23 patients (5.0%) were from another department within the hospital. As compared to patients in the LV group, those in the EV group more commonly had motor symptoms (p < 0.0001) and consciousness disturbance (p = 0.0027), and were less commonly referred from some other medical facility (p < 0.0001) or from another department (p = 0.0057). Patients were less likely to have a past history of TIA in the EV group than in the LV group, but not significantly (p = 0.065).

Conclusions:
Almost half of TIA patients visited a stroke center within 3 hours after onset. Motor symptoms and consciousness disturbance were related to an early visit. Referrals from some other medical facility or department were associated with delay in a contact to stroke specialists.
Abstract 2907: Endostroke-Registry: An International Multicenter Registry for Mechanical Recanalization Procedures in Acute Stroke
Authors: Singer Oliver C , Berkefeld Joachim ,   ENDOSTROKE Study Group
Published: July 2021

Mechanical recanalization prodecures are increasingly used to treat acute large-vessel stroke. High recanalization rates in patients with proximal vessel occlusions and the direct control of therapeutic success are its major strengths. On the other hand, its clinical benefit as well as the risk/benefit ratio are not well defined by now. Randomized trials comparing endovascular approaches with systemic thrombolysis are still ongoing and present-day evidence is based on non-controlled single arm trials and case series. Within the larger studies (Penumbra Pivotal Stroke Trial, MERCI-trials) a discrepancy between favourable angiographic results and poor clinical outcomes was noticeable with high rates (up to 70%) of patients with “futile recanalization”, leading to a “clinical-angiographic mismatch”. Many factors may contribute to this paradox finding, e.g. patient selection bias (inclusion of patients with contraindications for systemic thrombolysis), too long treatment time windows and periprocedural measures (e.g. general anaesthesia). Amongt these, many other factors need clarification before mechanical recanalization therapies can be used in a broader clinical fashion. To adress some of these questions, we launched an international, investigator-driven, multicenter registry (ENDOSTROKE) to accumulate robust data on clinical outcome, complication rates and procedural issues. Its primary main outcome measure is the clinical status 90 days (or later) after intervention assessed by the MRS. Important clinical, angiographic and procedural parameters, especially time-aspects (e.g. periprocedural time loss or duration of mechanical recanalization procedures) will be analyzed with respect to their influence on clinical outcome. The registry is completely independent from industrial sponsoring and is registered at
www.clinicaltrials.gov
with
NCT01399762
. The registry is currently recruiting patients. 13 mostly academic centers participate in the registry, 120 patients were entered by now in the database with the intention to include approximately 500 patients. At the International Stroke Conference the structure and goals of ENDOSTROKE will be presented.
Abstract 2940: Arrival in the Emergency Department on Nights and Weekends Results in Delayed Administration of Intravenous Thrombolysis for Ischemic Stroke
Authors: Protetch Jack , Quigley Matthew R , Wright David G , Tian Melissa , Tayal Ashis H
Published: July 2021

Background:
Reduced time to administration of intravenous thrombolysis for acute ischemic stroke (AIS) is associated with improved functional outcomes. Less than one-third of AIS patients receive IV rt-PA with a door-to-needle (DTN) ≤ 60 minutes with only modest improvements reported over time. We investigated factors that may adversely prolong DTN time including reduced resident physician experience, low stroke severity on presentation, patient presentation time (day, evening, night) and day of week.

Methods:
A consecutive series of 258 patients with AIS received IV rt-PA at an academic comprehensive stroke center with a developed process for IV rt-PA administration and a neurology training program. Patient presentation times in the emergency department were divided into shifts defined as 07:00-14:59 (day), 15:00-22:59 (evening) and 23:00-06:59 (night). Neurology resident experience level was grouped as July-December (less experienced) vs. January-June (more experienced). Day of the week was grouped into weekday (Monday-Friday) and weekend (Saturday-Sunday). Variables associated with DTN time were assessed by t-test, ANOVA and by logistic regression.

Results:
The group had a mean age of 70.7±14.3 years, NIHSS score 13.3±6.8, DTN time 70.0±28.1 minutes, onset to ED arrival time 77.5±38.0 minutes. Patients presenting during evening and night hours had prolonged DTN times, day=65.5, evening=71.8 and night=78.3 minutes (p=0.05) by ANOVA. Patients arriving on weekends also had prolonged DTN times weekdays= 66.6 vs. weekends=77.2 minutes (p=.01). Increased time from onset to ED arrival was also associated with reduced DTN time (p<0.001). Age, gender, race, stroke severity on presentation, and resident experience level were not related to DTN time. Both presentation time by shift and day of week were predictive of prolonged DTN time by multivariable analysis (p<0.01).

Conclusions:
Presentation time during the evening and night hours and weekends is associated with prolonged DTN times. Reduced staffing and support on nights and weekends may adversely affect DTN time.
Abstract 2956: Carotid Revascularization in Elderly Asymptomatic Patients: Are the Results Optimal?
Authors: Damani Rahul H , Rayes Mahmoud , Bhattacharya Pratik , Chaturvedi Seemant
Published: July 2021

Objectives:
Assess the hypothesis that patients with asymptomatic carotid stenosis older than 75 years are not on “best medical therapy” and their operative complication exceeds the AHA/ASA 3% threshold.

Background:
According to the Asymptomatic Carotid Atherosclerosis Study (ACAS), the Asymptomatic Carotid Surgery Trial (ACST) and recent AHA/ASA guidelines; benefits of carotid revascularization in asymptomatic patient >75 years would be offset if the operative complications rate exceed 3% and it would be more prudent to manage such patients on “best medical therapy”. How often these guidelines are being followed remains unclear.

Methods:
A retrospective chart review (2009-2011) at three urban, one suburban hospital within 30 miles was performed. Information of carotid revascularization (CEA & CAS) in asymptomatic elderly patients, in-hospital outcomes of stroke/death and/or MI and pre-procedural medications were evaluated. Statistical analysis with chi square testing was used.

Results:
A total of 114 patients met our inclusion criteria. Their features are described below.At four hospitals, the proportion of carotid revascularization done was 62% (114/185). More then quarter and one-third of patients undergoing carotid revascularization were not on statin and beta-blockers, respectively. Further, the rate of in hospital stroke was 4.4%.

Conclusions:
The majority of elderly patients with asymptomatic carotid stenosis patients are still undergoing carotid revascularization with operative complications that exceeded the AHA/ASA 3% threshold. More then quarter of patients in this subgroup are not on “best medical therapy”. These results reinforce the need for a new clinical trial comparing aggressive medical therapy alone vs. aggressive medical therapy and revascularization.
Abstract 3029: Improved Clinical Outcomes in Medicare Beneficiaries with Acute Ischemic Stroke During Initial Implementation of the Get With The Guidelines-Stroke (GWTG-S) Program 2003-2008
Authors: Song Sarah , Fonarow Gregg C , Pan Wendy , Olson DaiWai M , Hernandez Adrian F , Peterson Eric D , Reeves Mathew J , Smith Eric E , Schwamm Lee H , Saver Jeffrey L
Published: July 2021

Background:
The first decade of the 21st century saw several changes in acute ischemic stroke care, including greater use of statins, tobacco cessation counseling, IV rt-PA, formally organized stroke centers, and national performance improvement programs. Changes in clinical outcomes from acute ischemic stroke during this period have not been fully delineated.

Methods:
We examined the national Medicare dataset to analyze clinical outcomes of ischemic stroke patients at hospitals joining Get With The Guidelines-Stroke (GWTG-Stroke) from April 1, 2003 to December 12, 2008. We designated three time periods of interest: 1) pre-period (6 months prior to GWTG-S participation, 2) early period (first 6 months of GWTG-Stroke participation), and 3) late period (6 to 18 months after GWTG-Stroke implementation). Clinical outcomes analyzed included discharge to home; inpatient, 30 day, and 1 year mortality; and 30 day and 1 year rehospitalization for stroke, cardiovascular event, and all cause.

Results:
139,293 patients from 725 sites were included in the analysis. Mean age was 79.5 years, 41% male, 84% white. Patient demographics were similar across the three time periods, with minimal differences in comorbidities (e.g. diabetes, renal disease). Statistically significant changes between pre and late periods included: lower 30 day mortality (15.3% vs. 13.0%, p<.0001), lower 1 year mortality (28.0% vs 25.5%, p<.0001), lower stroke/TIA rehospitalization at 30 days (3.1% vs. 2.4%, p<.0001) and 1 year (9.2% vs. 8.7%, p<.002), lower rehospitalization for cardiovascular event at 30 days (2.9% vs. 2.3%, p<.0001) and 1 year (15.9% vs. 13.5%, p<.0001), and lower all cause rehospitalization at 30 days (17.4% vs. 15.1%, p<.0001) and 1 year (55.8% vs. 53.0%, p<.0001). Intermediate changes were seen during the early period. Rates of inpatient mortality and discharge to home did not change.

Conclusions:
During the first 2 years of participation, clinical outcomes for Medicare beneficiaries with acute ischemic stroke among hospitals joining GWTG-Stroke improved substantially, with 15% lower 30 day mortality rates and 24% lower 30 day rehospitalization rates for stroke or TIA. Further study is planned to determine if similar improvements in outcomes occurred at non-participating hospitals during this time frame.
Abstract 3091: Image Sharing Prior To Transfer Of Patients With Stroke
Authors: Jain Minal , Jain Anunaya , Kanthala Abhijit R , Young Kate C , Jahromi Babak S
Published: July 2021

Introduction:
The lack of 24X7 availability of sub-specialty neurologists and neurosurgeons in regional county hospitals frequently leads to transfer of patients with stroke/ICH to higher tertiary care centers. Transfer of patients without prior communication may delay both diagnosis as well as time sensitive treatments. Recently our institution adopted image sharing prior to transfer to facilitate triage of inter-hospital transfers.

Aim:
To analyze if image sharing enabled judicious selection of patients more likely to require intensive care/intervention.

Methods:
We analyzed consecutive adult patients with an admission diagnosis of stroke/TIA/carotid stenosis/carotid-dissection/aneursym/hemiplegia/cerebral venous sinus thrombosis for whom an interhospital transfer request was made.

Results:
The cohort had 197 subjects with 52.6% females. The mean age of subjects was 61.1 years (SD 16.1 years). The mean distance of healthcare facilities requesting transfer from our center was 47.7 miles (SD 28.5 miles). Of all transfer requests, 78.7% (155) were accepted to our facility, 14.7% (29) were asked to follow up in outpatient clinics, 3% (6) transfers were cancelled because a higher level of care was deemed unnecessary, 1% (2) patients declined transfer and 2.5% (5) were lost to other facilities. The median stroke severity measured by NIHSS on arrival was 3 (IQR 1 to 8). Images were shared prior to decision making for transfer for 20.3% (40) patients. Fewer patients were accepted for transfer with image sharing (73%) than without (83.7%), although this did not reach statistical significance (z statistic -1.51; p=0.132). There was no significant difference in NIHSS (p=0.3919), neurological status measured by GCS (p=0.294) or age (p=0.9942) between subjects who had image sharing versus those who did not. Amongst all accepted patients 45.1% were deemed to need intensive care and 47.7% received interventions (surgical, medical or advanced diagnostic testing). The proportion of patients who underwent intervention or were admitted to an intensive care unit was much higher when patients’ images were shared prior to transfer (85.2%) when compared to patients transferred without image sharing (56.8%; z statistic 2.755; p=0.006). The odds of undergoing intervention when patients were transferred after image sharing was 4.37 as compared to patients transferred without image sharing (95% CI 1.43 to 13.39).

Conclusion:
Subjects who had their images shared prior to transfer had significantly higher intervention rate. Thus image sharing is a possible tool to increase specificity for selecting patients with stroke related diagnoses, who would benefit from transfer to a tertiary care center.
Abstract 3150: Partnering with Emergency Department Staff Educators Increases the Number of Notifications to the Acute Stroke Research Team
Authors: Reimer Hannah , DuRocher Suzanne , Galiczynski Susan
Published: July 2021

Background:
Preparation for the Joint Commission survey to determine Primary Stroke Center Certification requires extensive education of staff in all areas a stroke patient will be during their hospitalization. Research personnel in the Emergency Department (ED) often rely on clinical staff for notification of potential research participants. When present in the treatment area research personnel are notified in person or find potential participants by reviewing a patient’s chief complaint or admitting diagnosis. When outside the treatment area, particularly during times when on call from outside the hospital, the research staff is dependent on notification by clinical staff.

Methods:
During the survey preparation, ED staff was educated in care of ischemic and hemorrhagic stroke patients according to AHA/ASA guidelines. During the formal nursing education research personnel gave short presentations on currently enrolling acute stroke trials and gave instructions on how to reach the research team in the event that a potential study participant entered the ED. Quarterly research reports were given at the Emergency Medicine resident’s conference. Education was given to the nursing and medical staff from October 2010 through July 2011 when the survey took place. The database of the online paging system was reviewed for the time period April 2010 through July 2011. Test, demonstration, non-stroke study and calls from other institutions were deleted from the data set. The remaining calls were divided by the month in which they were placed.

Results:
The research team received on average 5 calls per month during the six months prior to the AHA/ASA education. During the education time the research team received on average 9.6 calls per month.

Conclusion:
Acute stroke research personnel increase the number of potential patient notifications by participating in ED staff education for the Primary Stroke Center Certification survey.
Abstract 3153: Endoglin Deficiency in Bone Marrow is Sufficient to Cause Vascular Dysplasia in the Adult Mouse Brain After VEGF Stimulation
Authors: Choi Eun-Jung , Walker Espen J. , Jun Kristine , Kuo Robert , Su Hua , Young William L.
Published: July 2021

Background and Objective:
We have previously demonstrated that VEGF overexpression in the brain of adult Eng+/- mice causes vascular abnormalities. We also found that bone marrow-derived cells (BMDCs) home to vascular endothelial growth factor (VEGF)-induced angiogenic foci in the adult mouse brain and contribute to angiogenesis. Impaired angiogenesis in infarcted myocardium of Eng+/- mice was rescued using treatment with healthy human BMDCs but not with BMDCs from Hereditary Hemorrhagic Telangiectasia (HHT1) patients carrying ENG mutations. We hypothesized that ENG-haploinsufficiency in BMDCs can cause cerebrovascular dysplasia in the adult mouse after VEGF stimulation.

Methods:
WT or Eng+/- BM (2×106 cells) were transplanted to lethally irradiated C57BL/6 recipient mice (8-10 weeks old) via tail vein injection. After 4 weeks of BM transplantation, adeno-associated viral vector expressing VEGF (AAV-VEGF, 2×109 genome copies) was stereotactically injected into the basal ganglia. Brain sections were collected at 4 weeks after virus injection. The vascular density (vessels per 20× objective field) and dysplasia index (number of vessels >15µm in diameter per 200 vessels) were quantified on lectin-stained brain sections.

Results:
To examine the angiogenic response to VEGF, the vascular density around the AAV-VEGF injection site was analyzed. The mean vascular density increased in all mice with VEGF stimulation. Mice transplanted with Eng+/- BM showed less vascular density compared to mice transplanted with WT BM. The mean vascular densities were167 ± 21 (Eng+/-BM, n=4) and 202 ± 15 (WT BM, n=5) (P<0.01). Further, mice with WT BM had angiogenesis with normal vascular morphology. In contrast, mice with Eng+/- BM had markedly enlarged and dysmorphic vessels. To assess the degree of the dysplastic response, dysplasia index was analyzed. Mice with Eng+/- BM had several fold-higher dysplasia index than mice with WT BM: 2.6 ± 1.4 (Eng+/- BM) versus 0.7 ± 0.4 (WT BM) (P<0.01).

Conclusions:
In the adult mouse after VEGF stimulation, ENG-deficiency in BM (1) caused a 17% reduction in brain angiogenic response, and (2) increased cerebrovascular dysplasia, compared to control animals. These data support the possibility that cerebrovascular malformations resulting from VEGF stimulation with ENG-haploinsufficiency is attributable to impaired cell-autonomous monocyte/macrophage function, in contrast to the view that ENG dysfunction is primarily an endothelial phenomenon.
Abstract 3171: Low Stroke Incidence In Asymptomatic Carotid Stenosis Under Optimal Risk Factor Control.
Authors: Zurru Maria C , Brescacin Laura , Alonzo Claudia , Orzuza Gabriela , Ortega Fabiana , Villarroel Victor , Waisman Gabriel , Waisman Luis , Cristiano Edgardo
Published: July 2021

Background:
benefits of interventional procedures for the treatment of asymptomatic carotid stenosis (ACS) are still under debate. Our objective was to evaluate the risk of vascular events in a cohort of patients with ACS under optimal medical treatment.

Methods:
patients with ACS ≥50% were prospectively evaluated. Data on demographic and vascular risk factor profile and control under pharmacological treatment were collected. Severity of carotid stenosis was confirmed by at least two methods (Doppler ultrasonography, angioresonance, angiotomography or digital angiography) and evolution over time was evaluated by Doppler ultrasonography performed by the same operator, blinded to clinical data. Primary end-points were coronary events and ispsilateral ischemic stroke (IIS).

Results:
ninety two patients were included between January 2007 and December 2010. Mean age was 72±8 years, 35% were women. Mayor vascular risk factors were: hypertension (97%), dyslipidemia (90%), obesity (40%), diabetes (30%), smoking or former smoking (51%), history of coronary heart disease (37%) and peripheral vascular disease (32%). Average follow-up was 667±509 days (range 180-1870 days).
Table
1 shows vascular risk factor control during follow-up. One IIS (1.08%; 95% CI 0.19-5.9; 5.8/1000 person/year) and 2 acute myocardial infarction (2.17%; 95% CI 0.6-7.5; 11.73/1000 person/year) were observed. Eighteen percent of patients had stenosis 50-70%, 68% between 70-90% and 13% ≥ 90%. After one year most of patients showed no changes in stenosis severity (76%), 5.56% had progression and 6.52% had regression; 14.1% had no control.

Conclusion:
optimal pharmacological treatment was related to a very low incidence of vascular events. These data reassert the efficacy of intensive medical treatment in delaying atherosclerotic plaque progression and carotid disease complications.
Abstract 3173: Imaging Findings at the Earliest Stages of Intracerebral Hemorrhage
Authors: Burgos Adrian M , Sanossian Nerses , Liebeskind David , Groysman Leonid , Villablanca Pablo , Conwit Robin , Eckstein Marc , Starkman Sidney , Saver Jeffrey L ,   FAST-MAG Investigators and Coordinators
Published: July 2021

Background:
Imaging findings in intracerebral hemorrhage (ICH) patients at ultra-early time points have not been well characterized.

Objective:
To describe imaging findings in consecutive ICH patients being transported by ambulance within 2 hours from symptom onset.

Methods:
We analyzed consecutive ICH patients enrolled in the multicenter, NIH Field Administration of Stroke Therapy (FAST-MAG) clinical trial. First brain imaging studies obtained in the ED were independently reviewed by 2 neurologists for ICH location, volume, presence of intraventricular hemorrhage (IVH), heterogeneity (defined as >20 point difference in Hounsfield units), irregular borders, multilobulation, and substantial edema (defined as >0.5cm). Leukoaraiosis was graded using the Fazekas scale for periventricular and deep white matter changes (0-3 for each).

Results:
Among 127 patients (enrolled en route to 23 hospitals), mean age was 66 (SD 14), 34% were women, 35% had Hispanic ethnicity, 83% were white, and 84% had a history of HTN. At time of first field evaluation by paramedics [mean 31 (SD 23) minutes after last known well time (LKWT)], the initial BP was 177/95 (SD 34/22) and median (IQR) Glasgow Coma Scale of 15 (15-15). First brain imaging studies were obtained a mean of 100 (SD 35, range 54-255) minutes after LKWT, and were CT in 90% and MRI in 10%. Location of ICH was most often in the lentiform nucleus (42%) followed by thalamus (40%), and cortex (4%), with one case each of caudate, pons, and cerebellar deep nuclei. The mean volume of initial hematoma was 19.6 (SD 23) ml. IVH was present in 45 (35%), significant edema in 13 (10%), and midline shift in 24 (19%). Hemorrhage density was heterogeneous in 34 (27%), multilobulated in 55 (43%) and with irregular borders in 77 (60%). Leukoaraiosis (LA) was common, with moderate to severe LA (Fazekas grades 2, 3) present in the periventricular region in 58% and deep regions centrum semiovale in 35%.

Conclusions:
Among ICH patients presenting within the first 2h, deep hemorrhages predominate over superficial and intraventricular extension is already present in one-third, but ICH volume is moderate and substantial edema present in only one-tenth. These findings suggest substantial opportunities for intervention to avert hemorrhage and edema growth ultra-early after ICH onset.
Abstract 3183: Prognosis of Mild Ischemic Stroke with Large Vessel Occlusion
Authors: Cheng-Ching Esteban , Cerejo Russell , Uchino Ken , Hussain Muhammad S , Toth Gabor
Published: July 2021

Background and purpose
Large vessel occlusion (LVO) in acute ischemic stroke has been reported to be an independent predictor of unfavorable clinical outcome. However, the prognosis and optimal treatment of patients with only mild neurologic deficits due to LVO are not known.

Methods
We performed a retrospective chart review from a database of stroke patients admitted to our large academic medical center between July 1, 2010 and June 30
,
2011. Inclusion criteria were acute stroke or TIA, presentation within 9 hours from symptom onset, large vessel occlusion as a culprit of ischemic symptoms, and mild stroke severity with initial NIH Stroke Scale (NIHSS) score <8.

Results
We identified 59 patients with mild ischemic stroke or TIA, who were evaluated within 9 hours from onset. Of these, 13 (22%) had culprit large vessel occlusions. Five were female, 1 had diabetes, 12 had hypertension, 7 had hyperlipidemia, 2 had atrial fibrillation and 7 were smokers. The median NIHSS score was 5. The location of arterial occlusions were 5 in M1 segment of the middle cerebral artery (MCA), 6 in M2 segment of MCA, 1 each in posterior cerebral and vertebral arteries. Two patients received acute therapy, 1 with intravenous thrombolysis and 1 with endovascular therapy. Reasons for withholding thrombolytic therapy were time window in 8, mild stroke severity in 2, and atypical presentations in 2. Reasons for withholding acute endovascular therapy were mild stroke severity in 7, imaging finding in 2, technical considerations in 2, and lack of consent in 1. From hospital admission to discharge, 10 (77%) patients had symptom improvement, 2 had worsening, and one was unchanged. At 30 days, 5 (38%) had good outcome with a modified Rankin Scale (mRS) of 0-1. Three (23%) had mRS of 2, one (8%) patient had mRS of 3. Outcomes for 4 patients were unknown.

Conclusions
A significant proportion of patients presenting with mild ischemic symptoms has large vessel occlusion. Acute treatment in this population is frequently withheld due to mild severity or thrombolytic time window. Despite mild symptoms at presentation, some patients are left with moderate disability. Optimal treatment options for this population should be further evaluated in a larger group of patients.
Abstract 3232: Distal Embolization Predicts Infarct Growth and Futile Recanalization after Endovascular Stroke Therapy
Authors: Almekhlafi Mohammed A , Modi Jayesh , Menon Bijoy , Goel Ankur , Demchuk Andrew M , Goyal Mayank
Published: July 2021

OBJECTIVE
With the growing use of intra-arterial devices in acute stroke therapy, distal embolization (DE) is increasingly encountered. Reports described the incidence of these emboli but none so far linked them to the futile recanalization phenomenon. We report DE impact on clinical and radiographic outcomes in relation to futile recanalization.

METHODS
This is a retrospective longitudinal cohort including all anterior circulation stroke patients treated using intra-arterial therapy in our center between 2005 and 2011. Patients enrolled in randomized trials were excluded. Baseline and follow-up CT scans were scored by a stroke neurologist and a neuro-radiologist blinded to the clinical and angiographic data. Angiograms were reviewed by an experienced interventional neuro-radiologist blinded to the clinical and radiographic outcome. DE is defined as any luminal filling defect in the arterial tree distal to the thrombus or any new luminal filling defect in a different arterial territory evaluated at final cerebral angiogram. Infarct growth was defined as a drop of two points in ASPECTS on noncontrast CT follow up scan compared to baseline.

RESULTS
Eighty two patients (mean age 68 [13.8] years, median NIHSS 17[IQR 7], median ASPECTS 8[2]) were studied. Intravenous tPA was used in 63%. The median onset-to-puncture time was 209 (119) minutes. The occlusion site was the L/T-type carotid occlusion in 22%, proximal MCA in 53.7%, and M2-MCA in 24.3%. The Merci device was used in 28%, Penumbra system in 31.7%, angioplasty balloon in 18.3%, and retrievable stents in 11%. Intra-arterial tPA was also used in 59% of cases. Successful recanalization (TICI 2b/3) was achieved in 43%. Distal emboli occurred in 45.1% of cases, 10% of which were in the ACA territory. Despite successful recanalization, infarct growth occurred in 28.6% of patients. DE occurred in 80% (8/10) of those with infarct growth and recanalized vs. 60% (15/25) in those who had no infarct growth and recanalized. Good clinical outcome (mRS 0-2) at discharge was noted in 58.3% of patients with successful recanalization and no DE, 30.4% in those with successful recanalization and DE, and 17% in those who did not recanalize (TICI 0-2a) (p=0.015).

CONCLUSIONS
DE is common in the setting of endovascular stroke therapy and is associated with infarct growth and worse outcomes despite successful recanalization. DE may be one factor contributing to the futile recanalization phenomenon. This retrospective, single center experience needs to be validated in endovascular clinical trials.
Abstract 3302: Vascular Endothelial Growth Factor Receptor Inhibition Impairs Intracerebral Hemorrhage-induced angiogenesis
Authors: Cui Han-Jin , Liu Qi-Ting , Zhou Hua-Jun , TANG TAO
Published: July 2021

Background and purpose:
Our previous work has proved that Intracerebral hemorrhage (ICH) induces angiogenesis, accompanied by upregulation of vascular endothelial growth factor (VEGF) and its receptors. As the most potent mitogen of endothelial cells (ECs), VEGF must bind to its receptor_vascular endothelial growth factor receptor-2, to make it be phosphorylated, which plays the roles in promoting proliferation, migration, survival of ECs. In this study, our purpose is to investigate the effect of VEGF receptor inhibition on angiogenesis after ICH.

Method:
Fifteen Kunming mice were randomly divided into 3 groups, including sham control (n=5), ICH group (n=5), and SU5416-treated group (n=5). ICH model was induced by injection collagenase type VII into right globus pallidus stereotaxically. SU5416-treated group was injected by SU5416 (10 mg/kg per dose) intraperitoneally after ICH induction. Intraperitoneal injection of 5-bromo-2'-deoxyuridine (BrdU) was used to label new-born ECs. Neurological severity score (NSS), corner turn test and foot-fault test were used to investigate the neurological function at 1d, 3d and 7d following the surgery. Angiogenesis and the level of p-VEGFR-2 were evaluated at 7d by immunohistochemistry.

Results:
At 1d, there is no difference between the two ICH-induced groups in NSS, corner turn test, foot-fault test; at 3d and 7d, the NSS in ICH group is significantly lower than that of SU5416-treated group (
P
<0.05), and the times for right-turn and foot-fault in ICH group are notably fewer than those of SU5416-treated group (
P
<0.05). At 7d, no expression of p-VEGFR-2 was detected in sham control animals, while the expression of p-VEGFR-2 in ICH group is notably higher than that in SU5416-treated group (
P
<0.05); and the expression of p-VEGFR-2 is located in vWF-immunoreactive ECs; there is no BrdU-labeled nuclear in vessels observed in sham-control mice, but BrdU-labeled nuclei in vessels in ICH group are remarkably more than those in SU5416-treated group (
P
<0.05).

Conclusions:
Activation of VEGFR-2 is an important mechanism for angiogenesis after ICH, which is related with the recovery of neurological behavioral function.
Abstract 3305: Intensive Lipid-lowering and Early Functional Outcome in Acute Ischemic Stroke: Propensity Score Matching Analysis
Authors: Seo Woo-Keun , Eun Mi-Yeon , Kim Ji Hyun , Oh Kyungmi , Koh Seong-Beom
Published: July 2021

Background
This retrospective case-control study was designed to compare the effect of early high-dose atorvastatin treatment on early functional outcome in acute ischemic stroke patients using propensity score matching (PSM).

Study design and population
Acute ischemic stroke patients were selected from prospectively collected hospital-based stroke registry. Because the purpose of this study was comparing two treatment strategies for statin treatment, patients with cardioembolic stroke subtype or other-etiology were excluded. Patients were allocated into two groups: Intensive treatment group (atorvastatin 80mg; IT) and conventional treatment group (atorvastatin 10-40mg or other lipid-lowering agent; CT). All the patients were prescribed for aspirin 300mg at admission except for the patients who were considered for thrombolysis. After admission, the patients were prescribed for antithrombotics according to the clinical decision of the attending physician. All other practice guidelines except management of dyslipidemia were followed for previously published guidelines for management of stroke patients. Detailed demographic factors, vascular risk factors, laboratory parameters and vascular imaging were recorded. The end points were composed of two parameters. First, early neurological deterioration (END) defined as 4 points or more deterioration of National Institute of Health Stroke Score (NIHSS) from admission to the seventh hospital day. In case of discharge before the seventh hospital day, NIHSS at discharge was substituted for that of the seventh hospital day. Second, favorable outcome was defined as 0-2 of modified Rankin Score (mRS) measured at 3 months from the onset of stroke. Because baseline characteristics between the groups was supposed to be different, propensity score matching was performed to adjust for potential selection biases and confounding. A logistic regression model was fitted relating treatment strategies (IT and CT) to pretreatment patient characteristics. For the comparison between IT and CT in terms of END and favorable outcome, McNemar test were performed.

Results:
Among the study population, data of 178 patients for IT and 218 patients for CT were collected. Between the groups, history of previous stroke, TOAST classification, and previous medication of clopidogrel showed significant difference. There was no significant difference of 90-day favorable outcome and END. After PSM, 116 patients for each group were selected. There was no significant difference of baseline characteristics between the groups after PSM. There was no significant difference between IT and CT in terms of 90-day favorable outcome (75.3% in IT and 78.4% in CT, p = 0.457) and END (IT 72.3%, CT 78.6%, p = 0.097).

Conclusion
In this study, effect of intensive lipid-lowering treatment in acute stroke patients was negligible in terms of early functional outcome.
Abstract 3379: Benefiting the Community; The Impact of Joining a Regional Stroke Network
Authors: Papesh Nancy D , Gebel James
Published: July 2021

Background:
The Cleveland Clinic Health System (CCHS) consists of a large tertiary care center and 10 regional hospitals. It is organized both clinically and administratively into multispecialty organ based Institutes rather than departments. The CCHS re-introduced a regional initiative to standardize stroke care in 2008. Medina Hospital is a 118-bed community hospital in rural North-eastern Ohio, where there is a high stroke burden and previously minimal IV tPA use. Medina Hospital joined the CCHS Stroke Network in November 2009.

Hypothesis:
We hypothesized that after joining the formally organized stroke CCHS system of care, the proportion of stroke patients receiving IV tPA and the timeliness of administration of acute thrombolytic therapy would both significantly increase.

Methods:
Data was analyzed from our prospective participation in the Get with the Guidelines-Stroke and the Ohio Coverdell Stroke Registries. Baseline data regarding quality, outcomes and stroke performance measures were reviewed. CCHS initially supported acute stroke care in early 2010 with a telemedicine cart and then introduced 24/7 emergency, on-site, CCHS neurologist, acute stroke call coverage in late 2010. Standardized CCHS stroke care pathways and order sets were also introduced in 2010. The proportion of stroke patients treated with IV tPA in 2010 and 2011 (post- joining CCHS) was compared to 2009 (2-sided Fisher’s exact test), and door-to-needle times were compared from 2010 to 2011 (unpaired t-test).

Results:
IV tPA treatment utilization increased from 0/69 patients (0%) in 2009 to 9/67 patients (11.8%) in 2010 [exact p=.0033] and 11/46 (19.3%) in the first 7 months of 2011 [exact p=.0001]. Door-to-needle times improved from a mean of 81.4 (95%CI 66.4 to 96.4) minutes in 2010 to 61.7 (95% CI 52.7 to 70.8) minutes in 2011 (p=.0158).

Conclusions:
Participation in an organized formal collaborative regional hospital stroke treatment network resulted in dramatic improvements from zero IV tPA utilization to greatly exceeding the national benchmark averages for both percentage treatment with IV tPA and door-to-needle time in a rural area where patients previously had minimal access to acute stroke expertise.
Abstract 3434: Sleep Apnea as a Risk Factor in Patients with Chronic Microvascular Changes and Silent Infarcts
Authors: Kepplinger Jessica , Barlinn Kristian , Boehme Amelia K , Pallesen Lars-Peder , Schrempf Wiebke , Gerber Johannes , Albright Karen C , Alexandrov Andrei V , Bodechtel Ulf
Published: July 2021

Background&Purpose:
Although clinically silent infarcts (CSI) have been linked to an increased risk of stroke, only limited data exist regarding associated risk factors. Sleep apnea (SA), as an independent stroke risk factor itself, is associated with chronic microvascular changes (CMC), yet the relationship between SA and CSI remains unclear. We sought to determine the frequency and severity of SA in patients with CSI or CMC as well as how SA relates to outcomes in these patients.

Subjects&Methods:
Over an 18-month period, consecutive patients with acute cerebral ischemia prospectively underwent overnight in-hospital respiratory polygraphy within 5 days from symptom-onset. Sleep apnea was present when apnea-hypopnea-index (AHI) was ≥5/h. We collected demographics and clinical variables at baseline. All CTs and MRIs were independently reviewed by a neuroradiologist who was blinded to the sleep study findings and outcome. CSI was defined as any lesion consistent with a remote ischemic infarct without known history of a corresponding neurologic deficit. CMC was defined as diffuse white matter alterations not attributable to another neurologic condition. Modified Rankin Scale (mRS) was used to assess functional outcome at discharge and 180 days. Baseline demographics were analyzed using chi-square and Wilcoxon rank sum test. Correlations and logistic regression were used to predict CSI and CMC.

Results:
We evaluated a total of 56 patients for the presence of SA. Demographics, clinical variables and outcomes are shown in the
Table
. SA was present in 91% (n=51) of the study population. There was no correlation between AHI and the presence of CMC (p=0.75). After adjustment for gender, AHI was found to be a significant independent predictor of CSI (OR 1.04, 95%CI 1.0-1.08; p=0.03). In patients who had either CSI or CMC, the higher the AHI the less likely favorable functional outcome (mRS 0-2) was achieved at discharge (OR=0.94, 95%CI 0.89-0.99; p=0.02). AHI was not a significant independent predictor of functional outcome at 180 days (p=0.25).

Conclusions:
In our study population, SA was found to be frequent in both CMC and CSI with >1/3 of CMC patients and >1/2 of CSI patients having severe SA. Moreover, SA was found to be an independent predictor of clinically silent infarcts. The less favorable outcome in CSI and CMC patients with high AHI warrants further investigation in these at-risk populations, perhaps with early non-invasive ventilatory correction of sleep apnea.
Abstract 3446: Inpatient Code Stroke Protocol: A Quality Improvement and Knowledge Translation Strategy for a Challenging Scenario
Authors: Willems Jacqueline D , Skrabka Krsytyna , Nisenbaum Roseane , Barnaby Judith , Kostyrko Pawel , Saposnik Gustavo
Published: July 2021

Background:
Stroke care faces a clinical challenge in treating inhospital strokes, which account for about 15% of all strokes. Prior studies showed an inequity in the assessment and treatment of inpatients who suffer a stroke versus out-of hospital. For example, inpatients have longer time to initial assessment, CT and are less likely (wait longer) to receive tissue plasminogen activator (t-PA). There is limited research evaluating the efficacy of inpatient code stroke protocols (ICSP) on access to and quality of hyper-acute stroke care.

Objective:
To evaluate the efficacy of the ICSP in a large tertiary care hospital.

Methods:
This prospective study evaluated a quality improvement strategy involving ICSP implementation at St Michael’s Hospital in 2009. The ICSP focuses on the identification of stroke symptoms and timely notification of most responsible physician, then leverages the Emergency Department code stroke process. A 3-month hospital-wide implementation period involved 60 min. education sessions with a minimum of 2 sessions per unit. Demographic factors, presenting symptoms, stroke severity, vascular risk factors as well as time of: symptoms onset, CT; and physician assessment were collected by chart abstraction after ethics approval. The primary outcomes was time from last seen normal (LSN) to CT scan. Secondary outcomes include time from LSN to initial assessment (IA), medical complications and number of patients receiving endovascular interventions or intravenous thrombolysis. The analysis was completed by comparing unadjusted and adjusted outcomes pre and post implementation of the ICSP. Descriptive statistics and robust regression was completed using SAS 9.0.

Results:
Overall, there were 245 inhospital strokes during the study period (152 pre and 93 post ICSP implementation). Mean age was 69.8 yrs, 60% were male. Most inpatient strokes occurred on cardiovascular services (42.9%). Main results summarized in
table
. There was no difference in the number of patients receiving thrombolysis or endovascular treatment. After adjustment for covariates, the ICS was associated with a significant reduction of 288 minutes (95%CI -566, -10) in time from LSN to CT. Similarly, there was significant reduction of 307 (95%CI -532, -82) in time from LSN to IA.

Conclusions:
Implementation of the ICSP resulted in improvements in the process indicators related to assessment and treatment of hyper-acute stroke. Similar quality improvement strategies can be implemented to ameliorate disparities between care for inpatients and outpatient presenting with an acute ischemic stroke.
Abstract 3456: Incidence of Vasospasm and Outcomes in Angiography-negative Perimesencephalic Subarachnoid Hemorrhage with and without Ventricular Extension
Authors: Bonder Bryan J , Vargas Edwin A , Jung Richard , Sharma Jitendra , Blackham Kristine A
Published: July 2021

Background:
Angiography negative perimesencephalic subarachnoid hemorrhage (SAH) is considered a relatively benign entity compared to aneurysmal SAH. However, some patients with angiography negative perimesencephalic subarachnoid hemorrhage with extension of hemorrhage beyond the perimesencephalic area are at increased risk for vasospasm. Here we present a series of 21 patients with angiography negative perimesencephalic pattern of SAH both with and without ventricular extension and describe their incidence of vasospasm and clinical outcomes.

Methods:
Retrospective chart review was performed among patients who underwent invasive angiography from 8/2007-6/2010. Inclusion criteria were presenting clinical symptoms typical of SAH, computed tomography (CT) evidence of perimesencephalic SAH with or without ventricular extension, no recent trauma or stroke, and cerebral angiography negative for aneurysm or arteriovenous malformation. 21 patients, 8 men and 13 women, with a mean age of 55.1 years met these criteria. The presenting CTs were examined and a modified Fisher Grade assigned. The patients’ clinical course was reviewed for incidence and treatment of vasospasm. The patients’ discharge summaries were evaluated and each patient given a modified Rankin Scale score.

Results:
The modified Fisher Scale score derived from the presenting CT was 1 for 29% (n=6), 2 for 5% (n=1), 3 for 19% (n=4), and 4 for 47% (n=10) of the patients. Amongst the 52% (n=11) of patients with intraventricular hemorrhage as defined by a modified Fisher Scale score of 2 or 4, 24% (n=5) developed angiographical evidence of vasospasm. 10% (n=2) of the patients required intra-arterial verapamil. 90% (n=9) of patients without intraventricular extension had good outcomes at discharge as defined by modified Rankin Scale score less than or equal to 2, while only 36% (n=4) of patients with angiography negative SAH with intraventricular extension had good outcomes.

Conclusions:
Although angiography negative perimesencephalic SAH is considered to have less associated morbidity and mortality than aneurysmal perimesencephalic SAH, patients with extension of hemorrhage into the ventricles are at increased risk for vasospasm and poor functional outcomes.
Abstract 3474: Early Supported Discharge for Post-Stroke Inpatient Rehabilitation: Who and What are we Talking About?
Authors: Meyer Matthew , Teasell Robert , Thind Amardeep , Koval John , Speechley Mark
Published: July 2021

Background and Purpose
Early supported discharge (ESD) post stroke has been demonstrated as a cost-effective strategy for provision of rehabilitation to eligible patients. However, consensus on which patients are best-suited for ESD has yet to be established. This systematic review was designed to retrieve information on patients included in all published, peer-reviewed literature pertaining to ESD for post-stroke rehabilitation with the goal of identifying common criteria used to infer candidacy for ESD.

Methods
A systematic review of the literature was performed in three electronic databases (Medline, Embase, CINAHL) for peer-reviewed journal articles evaluating ESD for post-stroke rehabilitation published between January 1980 and September 2010. Research studies were considered if 1) they only included patients with primary diagnosis of stroke 2) the intervention under study was outpatient or community-based rehabilitation (ESD) as an alternative to in-hospital rehabilitation and 3) inclusion/ exclusion criteria and/or patient data at time of discharge to the community were reported. Information about study design, inclusion/exclusion criteria, discharge patient data and study results were collected.

Results
In total, 612 journal articles were screened and 20 were included for further assessment. No consensus on ESD suitability could be derived from the identified studies. Interventions under study ranged from organized in-home rehabilitation to “hospital at home” where therapy was provided by family members. On average, 34.7% (13%-70%) of patients screened for ESD candidacy were identified as suitable, but little consistency in screening procedures or criteria were noted. Recruitment generally took place within the first week post stroke but extended to as many as 4 weeks post stroke, while the average day of discharge into an ESD program ranged from 1 to as many as 42 days post stroke. Nine articles reported information about patient’s functional level within 48 hours of discharge to ESD, however, 27 different measures of patient function were reported.

Conclusions
Most research to date suggests that ESD is an effective strategy for providing rehabilitation to patients post-stroke. However, based on current research it is not possible to derive definitive criteria by which candidates for ESD can be identified. Future research is warranted.