bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 131: Feasibility and Efficacy of Central Blinded Video Rankin Scale Outcome Assessments in a Randomized Clinical Trial
Authors: Oliveira-Filho Jamary , Bezerra Daniel C , Pontes Neto Octavio M , Abud Daniel , Lima Fabricio O , Silva Gisele S , Rebello Leticia C , MontAlverne Francisco , Frudit Michel , Farias Mario B , Cabral Lucas , Zetola Viviane , de Freitas Gabriel R , Liebeskind David S , Wagner Mario B , Molina Carlos , Nogueira Raul G , Martins Sheila O
Published: June 2021

Introduction:
In randomized clinical trials, central adjudication is frequently used for study outcomes. However, stroke trials have historically used site-derived Rankin scale assessments as primary outcome.

Hypothesis:
A central adjudication of Rankin scale assessment is at least as accurate as site-derived assessment.

Methods:
We studied acute stroke survivors from the RESILIENT study, where primary outcome was the consensus Rankin scale rating of two blinded central adjudicators who independently watched video recordings of a 90-day post-stroke structured patient and/or family interview. We compared agreement rates (weighted kappa statistics) between both central adjudicators with that between the blinded site investigator and the consensus reading between central adjudicators.

Results:
Trial randomized 221 patients to thrombectomy or medical treatment alone. At 90 days, 161 (73%) survived and 142/161 (88%) had quality video recordings for central adjudicators. Median (interquartile range) Rankin scores were similarly 3 (2-4) for each central rater and for the site investigators. Agreement rates between central adjudicators was 79.6% (kappa=0.94, p<0.001), while agreement between site investigator and consensus rating from central adjudicators was 76.8% (kappa=0.92, p<0.001).

Conclusions:
Central blinded Rankin scale outcome assessment is feasible and is at least as good as site investigator assessments. For open-label trials with blinded clinical outcome assessment, central adjudication of video-recorded interviews provides safer blinding and accountability.
Abstract 132: Acute Kidney Injury in Acute Ischemic Stroke Patients: Pooled Analysis of ALIAS I and II and IMS III Trials
Authors: Aslam Hunain , Zafar Werdah , Huang Wei , Lobanova Iryna , Siddiq Farhan , Arora Niraj , Nattanmai Premkumar , Gomez Camilo R , Qureshi Adnan I
Published: June 2021

Background:
Acute ischemic stroke patients are at risk of acute kidney injury (AKI) due to volume depletion, contrast exposure and pre-existing co-morbid diseases. We determined the incidence and identified predictors associated with AKI in acute ischemic stroke patients.

Methods:
Data from the Albumin in Acute Ischemic Stroke trial (ALIAS) - I and II and Interventional Management of Stroke (IMS) - III clinical trials were pooled and analyzed in which acute ischemic stroke patients were randomized into either IV albumin, placebo, endovascular or IV thrombolytic treatment groups. Serum creatinine levels from baseline and within day 5 or discharge along with the demographic and comorbidity information was collected. AKI classification was used to ascertain severity of renal dysfunction and based on increase in serum creatinine levels from baseline, stage 1 ≥ 0.3 mg/dl (≥ 26.4umol/L) or (>1.5 to 2-fold), stage 2 (>2 to 3-fold) and stage 3 (>3-fold) were identified. We analyzed the relationship between AKI and mortality at 3 months post randomization.

Results:
A total of 1931 acute ischemic stroke patients (mean age 66± 13 (SD) years; 1024 were men) were analyzed. Any increase in serum creatinine was seen in 691 (35.8%, 95% CI 30%-40%) and AKI was seen in 68 (3.5%, 95% CI 3%-4%) of 1931 patients. Severity of AKI was grade I, II, III in 2.1 %, 0.4%, and 0.1% patients, respectively. The risk of AKI was not higher between those who either underwent CT angiography (2% compared with 4.2%, RR 0.5, 95% CI 0.3-0.8, p=0.02) or endovascular treatment (1.9% compared with 4.1%, RR 0.4, 95% CI 0.2-0.8, p=0.0096). Patients with preexisting hypertension (4.3% compared to 1.5%, RR 2.8, 95% CI 1.3-5.7, p=0.006) and preexisting renal disease (9.1% compared to 3.0%, RR 3.1, 95% CI 1.8-5.3, p=0.006) had higher risk of AKI. Mortality at 3 months was significantly higher among patients with AKI (27% compared with 15%, RR 1.8, 95% CI 1.2-2.7, p=0.0083).

Conclusions:
The incidence of AKI in acute ischemic stroke patients was low and was not higher in patients who underwent CT angiogram or those who received endovascular treatment. Occurrence of AKI increased mortality at 3 months among acute ischemic stroke patients.
Abstract 136: Role of Periodontal Disease on Intracranial Atherosclerosis
Authors: Mascari Rachel , Sen Souvik , Suri Fareed , Wasserman Bruce , Gottesman Rebecca , Rosamond Wayne , Moss Kevin , Beck James
Published: June 2021

Introduction:
Periodontal disease (PD) is a chronic inflammatory process that affects gum and teeth. Due to the role of inflammation on atherosclerosis, we assessed the hypothesis that PD is associated with asymptomatic intracranial atherosclerosis (ICAS) in the Atherosclerosis Risk In Communities (ARIC) study.

Methods:
Full-mouth clinical periodontal measurements (7-indices) collected at 6 sites per tooth from 6155 subjects from the Dental Atherosclerosis in Communities Study (DARIC) without prior stroke were used to differentiate seven periodontal profile classes (PPCs). Of this cohort, a stratified subset underwent 3D time-of-flight MR angiogram and 3D high-isotropic resolution black blood MRI. ICAS was graded according to the criteria established by the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial. In this study, we evaluated the relationship between PD status and severe asymptomatic ICAS, defined as ≥50% stenosis.

Results:
Among dentate subjects who underwent vascular imaging, 1033 (90%) had 0-50% ICAS and 112 (10%) had ≥50% ICAS. Compared to participants without gum disease (PPC-A), participants with gingivitis (PPC-C) had significantly higher odds of having ≥50% ICAS (Figure 1; Crude OR 2.1, 95% CI 1.2-3.8, p=0.015). This association strengthened after adjusting for the significant confounding variables: age, hypertension, and LDL cholesterol (Adjusted OR 2.4, 95% CI 1.3-4.5, p=0.006).

Conclusion:
We report a significant association between inflammatory PD class and ≥50% asymptomatic ICAS. Because gingivitis is reversible, future studies are needed to determine if treatment of gingivitis can prevent the development and progression of ICAS, thus reducing the risk of stroke.
Abstract 140: Vascular Structure in Brain: Lack of Small Vessel Recovery Following Hypertension
Authors: Baumbach Gary , Sabharwal Rasna , Gerhold Thomas , Chapleau Mark , Faraci Frank M
Published: June 2021

Vascular remodeling is a feature of small vessel disease (SVD), predictive of vascular events, brain injury, and cognitive decline. Hypertension alters vascular structure including diameter and cross-sectional area (CSA) of the vessel wall. While effects of hypertension on large arteries have been studied relatively widely, detailed quantification, including recovery from hypertension in microvessels, is rare. Previously, angiotensin II (Ang II)-dependent hypertension produced increased CSA but reduced internal diameter (ID) of cerebral arterioles (inward remodeling) in brain. Because cerebral arterioles are targets of SVD, we examined the hypothesis that brain microvessels can recover from hypertension after return of mean arterial pressure (MAP) to normal levels. MAP was measured using radiotelemetry in adult male C57BL6J mice at baseline, during infusion of vehicle or Ang II (1.4 mg/kg per day using osmotic mini-pumps) for 28 days, and during a 28 day recovery period (n=5 in each group). Prior to treatment, MAP was similar in both groups, with MAP remaining stable in vehicle treated mice. With Ang II treatment, MAP began to rise on day 3, steadily increasing until day 28. On day 30, MAP began to decrease, reaching levels seen with vehicle on days 46-47. In anesthetized mice, we measured pressure, diameter, and CSA of the vessel wall in maximally dilated arterioles (baseline diameter of 62±3 microns) at 1, 3, 7, 14, 28, and 56 days after pump implantation (n=7-9 in each group). At day 1, ID and CSA were similar in both groups. With vehicle, there was no significant change in CSA or ID at any time point. With Ang II, CSA increased at day 7 and was maintained at days 14 and 28 (P=0.023). ID did not change at day 3 or 7, but was reduced (by ~15%, P=0.011) at 14 and 28 days. During recovery (day 56), CSA returned 63% of the way to normal (compared to vehicle), while ID remained at day 14 and 28 values. In conclusion, CSA changed rapidly during hypertension onset and largely recovered with a reduction in MAP. Inward remodeling developed slowly and did not recover after return of MAP to control levels. The lack of recovery after hypertension has implications for the impact of SVD including hypoperfusion, impaired vasodilation, and augmented injury during ischemia.
Abstract 145: Endovascular Thrombectomy for Large Vessel Ischemic Stroke Patients With Low Aspects: A Systematic Review and Meta-Analysis
Authors: Diestro Jose Danilo , Dmytriw Adam , Broocks Gabriel , Kemmling Andrew , Chen Karen , Phan Kevin , Bharatha Aditya
Published: June 2021

Background:
Most trials for the endovascular thrombectomy (EVT) of large vessel ischemic stroke excluded patients with large core infarcts and low Alberta Stroke Program Early CT Score (ASPECTS). As a result, the current American Heart Association guidelines for acute ischemic stroke reserve Grade 1A recommendation for the use of EVT for patients with an ASPECTS of 6 or more. However recent data from the HERMES collaboration has shown that even stroke patients with large core infarcts may still benefit from EVT.

Objectives:
Through this systematic review, we aim to determine the safety and efficacy of EVT for large vessel ischemic stroke patients with low ASPECTS (5 or less).

Methods:
Medline, Cochrane Central Register of Systematic Reviews and ClinicalTrials.gov were searched for studies appraising the outcomes of EVT for low ASPECTS acute ischemic stroke patients. Patients with low ASPECTS who underwent EVT were compared to those who only received best medical therapy (BMT). A meta-analysis of proportions was done to compare the outcomes of the two groups in terms of symptomatic intracranial hemorrhage, mortality and good 3-month functional outcomes (modified Rankin Scale
<
2).

Results:
Nine studies with a total of 1,196 acutes stroke patients with low ASPECTS (712 undergoing EVT and 484 with only BMT) were included in the study. There was a trend towards a higher rate of sICH in the EVT group (9.2%; 95% CI 6.1% to 13.6%; I
2
53.37%) compared to the BMT group (5.5%; 95% CI 3.7% to 8.1%; I
2
=0%) but this did not reach statistical significance (p=0.11). There was no difference (p=0.41) in the pooled 3-month mortality of EVT patients (30.7%; 95% CI 21.7 to 41.5%; I
2
84.23%) and BMT patients (36.6%; 95% CI 26.4% to 48.1%; I
2
76.2%). Patients who underwent EVT had significantly better (p=0.001) 3-month outcomes, with 27.7% (95% 21.8 to 34.5%; I
2
62.08%) of patients attaining an MRS 0-2 compared to only 3.7% (95% 2.3 to 5.9%; I
2
87.21%) of patients in the BMT.

Conclusion:
Our meta-analysis suggests that acute stroke patients with low ASPECTS score may still benefit from EVT. Larger registry based studies and randomized controlled trials are needed to further substantiate the findings of our review.
Abstract 147: Outcomes of the Stroke Thromboembolism Registry of Imaging and Pathology: A Multicenter International Study
Authors: Brinjikji Waleed , Fitzgerald Sean , Kallmes David F , Layton Kennith , Hanel Ricardo , Pereira Vitor M , Kvamme Peter , Delgado Josser , Yoo Albert , Jahromi Babak , Almekhlafi Mohammed , Gounis Matthew , Nogueira Raul G
Published: June 2021

Background:
We performed a multicenter prospective clinical registry across 11 centers to study the association between histopathological characteristics of retrieved clots and imaging, stroke etiology and clinical outcomes.

Materials and Methods:
Following IRB approval at the 11 centers, patients were enrolled in the STRIP registry. All retrieved emboli were sent for histopathological analysis with H&E and MSB staining. Demographic variables, comorbidities, stroke etiology, imaging findings and procedural details were collected for each case. We studied the association between clot histopathology and imaging findings, stroke etiology and and revascularization outcomes. Student’s t-test was used for continuous variables and chi-squared testing for categorical variables.

Results:
To date, 1022 patients have been included. There was a significant correlation between platelet rich clots and the absence of hyperdensity on non-contrast CT [p=0.321, p=0.003) and a significant inverse correlation between the percentage of platelets and mean HU on NCCT (p=-0.243, p=0.025). The proportion of platelet-rich clots (55.0% versus 21.2%, p=0.005) and the percentage of platelet content (22.1% versus 13.9%, p=0.03) was significantly higher in patient with large artery atherosclerosis compared to those with a cardioembolic etiology. There was no correlation between RBC density, WBC density, fibrin density or platelet density and revascularization outcomes with stent-retrievers. However, we have found that with aspiration alone, patients with platelet rich clots are less likely to be fully revascularized (i.e. TICI 2c/3) than non-platelet rich clots (OR=0.36, 95%CI=0.12-0.81, P<.0001). Meanwhile, patients with RBC rich clots are more likely to be completely revascularized with aspiration alone than those with RBC poor clots (OR=2.71, 95%CI=1.25-3.24, P=0.02).

Conclusions:
Interim analysis of the STRIP registry suggests that the platelet content of a clot may be the most revealing factor in determining a clot’s etiology, imaging features and revascularization outcome. Platelet rich clots are less dense on NCCT, are associated with a large artery atherosclerosis source and are less likely to be completely revascularized with aspiration alone.
Abstract 15: Medication Inadequacy Accounts for Two-Third of Uncontrolled Hypertension Following Intracerebral Hemorrhage in a Multinational Study
Authors: Teo Kay Cheong , Biffi Alessandro , Leung Ian Y , Leung William C , Wang Yujie , Kourkoulis Christina , Warren Andrew , Henry Jonathan , Chan Koon Ho , Cheung Raymond T , Ho Shu Leong , Gurol Edip , Viswanathan Anand , Greenberg Steven M , Anderson Christopher D , Lau Kui Kai , Rosand Jonathan
Published: June 2021

Introduction:
Intracerebral hemorrhage (ICH) survivors often have severe hypertension and require multiple antihypertensive agents for blood pressure (BP) control. Adequate BP control is vital for ICH prevention, but the majority of ICH survivors have uncontrolled hypertension. To understand how we might improve BP control, we aimed to identify contributors to uncontrolled hypertension, and determine antihypertensive requirements as well as predictors of the need of ≥3 antihypertensives after ICH.

Methods:
We studied 1172 ICH survivors from two independent ICH cohorts: Massachusetts General Hospital (MGH) and the University of Hong Kong (HKU). We defined uncontrolled hypertension (BP ≥140/90 mmHg), inadequately medicated hypertension (uncontrolled hypertension on ≤2 antihypertensives), and resistant hypertension (uncontrolled hypertension on ≥3 antihypertensive classes or controlled hypertension on ≥4 classes) six months after ICH. Baseline predictors of the need for ≥3 antihypertensive agents were derived using multivariate logistic regression.

Results:
At six months post-ICH, 64.3% (502/781) of MGH ICH survivors and 32.7% (128/391) of HKU had uncontrolled hypertension. Resistant hypertension accounted for 33.5% and 29.7% of uncontrolled hypertension in the respective cohorts, while the remaining patients qualified for the designation of inadequately medicated hypertension. Excluding patients with inadequately medicated hypertension, 60.0% of patients in MGH and 37.2% in HKU required ≥3 antihypertensive agents. Age <65 years (odds ratio (OR) 1.80,
p
<0.001), admission systolic BP of >190 mmHg (OR 3.46,
p
<0.001) and a history of hypertension before ICH (OR 3.39,
p
<0.001) predicted the need for ≥3 antihypertensives after ICH.

Conclusion:
Medication inadequacy accounts for around two-thirds of uncontrolled hypertension after ICH, providing an opportunity for intervention to prevent hypertension-related complications, including ICH recurrence. As most ICH survivors required ≥3 antihypertensives for adequate BP control, early inpatient initiation of triple antihypertensive combination therapy should be considered, especially in patients with admission systolic BP of >190 mmHg, known hypertension and aged <65 years.
Abstract 150: Multicenter Validation of SPOT, an Artificial Intelligence Based Tool, to Optimize Selection of Elderly Stroke Patients for Mechanical Thrombectomy - Insights From the STAR Collaboration
Authors: Alawieh Ali M , Alawieh Mohamed Baker , Zaraket Fadi , Chalhoub Reda M , Anadani Mohammad , Keyrouz Salah , Arthur Adam , Kim Joon-Tae , De Leacy Reade , Psychogios Marios , Maier Ilko , Rai Ansaar , Fargen Kyle , Dumont Travis , Kan Peter , Starke Robert M , Spiotta Alejandro
Published: June 2021

Introduction:
Mechanical thrombectomy for acute ischemic stroke (AIS) is the current standard of care based on level 1 evidence from multiple randomized controlled trials. Recently, real-world indications for mechanical thrombectomy (MT) has extended beyond the inclusion criteria used in the majority of trials including elderly patients. We have recently developed a machine-learning based tool, SPOT, to optimize selection of elderly patients for MT based on single-center data. Here, we use a large cohort of international multicenter patients who underwent MT for AIS to externally validate SPOT.

Methods:
Patients who underwent MT for AIS at 12 comprehensive stroke centers in the US and Europe between 01/2013 and 12/2018 were reviewed. Patients age 80 years or older were included for validation of SPOT. SPOT is designed based on a combination of decision trees and linear regression models to provide binary output of predicted good (mRS 0-2) or poor outcome (mRS 3-6) after MT. SPOT uses admission variables: age, gender, comorbidities, admission NIHSS, baseline mRS score, ASPECT score and whether IV-tPA was administered. Predicted outcome was compared to actual outcome recorded at 90-days after treatment. A receiver operating characteristic curve was used to evaluate the accuracy of SPOT, and the negative predictive value was computed. The rate of post-procedural hemorrhage and mortality were compared between patients predicted by SPOT to have good versus poor outcome.

Results:
A total of 3,228 patients underwent MT for AIS during the study duration, of which 647 patients were at least 80 years of age or older and were included in the study. The average age was 85±5 years, and 65% were females. The median mRS score at 90 days was 4, and 21.3% had a good outcome (mRS 0-2). Of patients predicted by SPOT to have a poor outcome, 90% had a poor outcome. The area under the ROC curve was 0.7. The mortality rate in patients predicted by SPOT to have poor outcome had twice higher mortality than those predicted to have good outcome (55% vs 27%, p<0.001).

Conclusions:
Based on multicenter validation, SPOT presents a clinical decision in aid in assisting for exclusion of elderly patients unlikely to benefit from MT for AIS with a 90% negative predictive value.
Abstract 154: Diabetic Retinopathy and Risk of Stroke: A Secondary Analysis of Accord
Authors: Wong Ka-ho , Peterson Cecilia , Theodore Rock , aitken Kinga , Dela Cruz Michael , Majersik Jennifer , DeHavenon Adam
Published: June 2021

Background:
Diabetic retinopathy is a common microvascular complication of diabetes. Previous research has shown that the macrovascular complications of diabetes, including stroke, are often comorbid with shared and, possibly, synergistic pathology.

Methods:
This is a secondary analysis of the subgroup of patients who enrolled in the ACCORD Eye study of ACCORD. The primary outcome is stroke during follow-up. The primary predictor was presence of diabetic retinopathy on the Early Treatment Diabetic Retinopathy Study Severity Scale as assessed from seven-field stereoscopic fundus photographs at study baseline. We fit adjusted Cox models to the primary outcome to provide hazard ratios for stroke and included interaction terms with the ACCORD randomization arms.

Results:
We included 2,828 patients with a mean (SD) age of 62.1 years and 61.8% were male. The primary outcome of stroke was met by 117 patients during a mean (SD) of 5.4 (1.8) years of follow-up. Diabetic retinopathy was present in 874/2,828 (30.9%) of patients at baseline, and was more common in patients with stroke versus without stroke (41.0 vs 30.5%, p=0.016). In the Cox model, adjusted for baseline patient age, gender, race, total cholesterol, Hgb A1c, smoking, and randomization arm, we found that diabetic retinopathy remained associated with incident stroke (HR 1.60, 95% CI 1.10-2.32, p=0.015) (Figure 1). This association was not affected by randomization to the ACCORD glucose intervention (p=0.305), lipid intervention (p=0.546), or blood pressure intervention (p=0.422).

Conclusion:
Diabetic retinopathy is associated with an increased risk of stroke, which suggests that the microvascular pathology inherent to diabetic retinopathy has larger cardiovascular implications.
Abstract 157: High Systolic Blood Pressure Variability After Successful Reperfusion Therapy in Acute Ischemic Stroke Predicts Unfavorable Outcomes
Authors: Hosoki Satoshi , Miwa Kaori , Yoshimoto Takeshi , Tanaka Kanta , Ikenouchi Hajime , Mizoguchi Tadataka , Kimura Shunsuke , Chiba Tetsuya , Satow Tetsu , Takahashi Jun C , Toyoda Kazunori , Ihara Masafumi , Koga Masatoshi
Published: June 2021

Introduction:
There has been increasing evidence that higher systolic blood pressure variability (SBPV) is related to unfavorable outcomes in patients with stroke. We explored the relation between SBPV and clinical outcomes after reperfusion therapy; intravenous thrombolysis (IVT) and endovascular therapy (EVT).

Methods:
We retrieved data of consecutive patients with acute ischemic stroke (AIS) treated with reperfusion therapy from our prospective stroke registry between October 2005 and December 2018. We calculated the following five SBPV during 24 hours after IVT or EVT; mean, standard deviation (SD), coefficient of variation (CV), successive variation (SV), and average real variability (ARV). Clinical outcomes included unfavorable outcomes as modified Rankin Scale (mRS) score 3-6 at 3 months and symptomatic intracranial hemorrhage (sICH) as any hemorrhage with neurological deterioration of 4 points of more on the National Institute of Health Stroke Scale (NIHSS). Successful reperfusion was indicated with early neurological improvements of 4 points of more on the NIHSS after IVT alone or Thrombolysis in Cerebral Infarction scores of 2b or 3 after EVT alone or EVT combined with IVT.

Results:
Among 933 patients with premorbid mRS scores of 0-1 (72±12 years; 316 women), 426 patients with unfavorable outcomes and 35 patients with sICH were observed. In adjusted analyses, all measures of SBPV but CV were related to unfavorable outcomes, while all measures of SBPV but mean SBP were related to sICH. In 566 patients with successful reperfusion, 228 patients with unfavorable outcomes and 10 patients with sICH were observed. In adjusted analyses, all measures of SBPV but mean SBP were positively related to unfavorable outcomes, while no measures of SBPV were independently related to sICH (table).

Conclusion:
High SBPV after successful reperfusion therapy contributed to unfavorable outcomes, suggesting high SBPV after reperfusion therapy might need more attention.
Abstract 159: Trends in Dual Antiplatelet Therapy Prescription Patterns for Secondary Prevention in Patients With Noncardioembolic Ischemic Stroke
Authors: Xian Ying , Shrader Peter , Smith Eric , Fonarow Gregg C , Bhatt Deepak L , Matsouaka Roland , Lytle Barbara , Schwamm Lee H , Peterson Eric D
Published: June 2021

Background:
The recommendations for dual antiplatelet (DAPT aspirin + clopidogrel) for secondary stroke prevention has evolved over time. Following the publication of CHANCE trial (07/2013), the AHA/ASA updated the DAPT recommendations from Class III harm (10/2010) for patient with noncardioembolic ischemic stroke, to Class IIb benefit ≥ risk (02/2014), and Class IIa benefit >> risk (03/2018) for a subgroup of patients with minor stroke (NIHSS≤3). Subsequent to the last guideline update, the POINT trial (05/2018) provided further support for the effectiveness of DAPT.

Methods:
We evaluated antiplatelet prescription patterns of 1,024,074 noncardioembolic ischemic stroke survivors (median age 65 years and 46% women) eligible for antiplatelet therapy (no contraindications) and discharged from the Get With The Guidelines-Stroke Hospitals between Q1 2011 and Q1 2019.

Results:
Baseline patient characteristics were similar within the four periods: pre-CHANCE (01/2011-07/2013), pre-2014 guideline update (08/2013-02/2014), pre-POINT/2018 guideline update (03/2014-05/2018), and post-POINT (06/2018-03/2019). Use of DAPT gradually increased from 16.7% in the pre-CHANCE period, to 19.4% pre-2014 guideline update, 23.3% pre-POINT/2018 guideline update, and 29.8% post-POINT period (p<0.001, Figure). Yet increase in DAPT use was observed over time for individuals with NIHSS≤3 (17.1%, 19.9%, 24.1%, and 31.4%, p<0.001) and those with NIHSS>3 (18.7%, 22.8%, 28.3%, and 28.3%, p<0.001).

Conclusions:
A sustained increase in DAPT use for secondary stroke prevention was observed after publication of pivotal trials and AHA guideline updates. While recommended for minor strokes or TIA only, such increase was also observed in ischemic stroke patients with NIHSS>3, where the risk-benefit ratio of DAPT remains to be established.
Abstract 164: Variation in Acute Ischemic Stroke Metrics for Nationally Certified versus Self-Attested Comprehensive Stroke Centers in the Florida Stroke Registry
Authors: Marulanda-Londono Erika T , Bustillo Antonio , Sand Charles , Landreth Mark D , Gutierrez Carolina , Fenelon Kathy , Asdaghi Negar , Dong Chuanhui , Hanel Ricardo A , Mehta Brijesh , Mokim Maxim , Mueller-Kronast Nils , Wang Kefeng , Rundek Tatjana , Romano Jose G , Sacco Ralph L
Published: June 2021

Background:
The Florida Stroke Act set criteria for comprehensive stroke centers (CSC). Hospitals could be certified by a national agency (The Joint Commission (TJC), Det Norske Veritas (DNV), Healthcare Facilities Accreditation Program (HFAP)) or could self-attest as fulfilling CSC criteria. This study aimed to evaluate whether nationally certified (NC) and self-attested hospitals (SA) have similar quality of care in acute ischemic stroke (AIS).

Methods:
The study population included AIS cases from 37 CSCs (74% of FL CSCs) in the FL-Stroke Registry, a multi-hospital registry using Get With the Guidelines-Stroke data from Jan 2013-Dec 2018. Hospital and patient level characteristics and stroke metrics were evaluated using unadjusted and adjusted (age, sex, race and NIH) analyses.

Results:
13 NC-CSCs with 32,061 AIS cases and 24 SA-CSCs with 46,363 AIS cases were included. NCs were larger, with younger patients (71 (60-81) vs 72 (61-82)) and more severe strokes (median NIH; 5 vs 4, NIH ≥ 16; 15.4 vs 11.9%
p
<.0001). Overall IV tPA utilization (15.4% vs 13.9%
p
<.0001) and EVT treatment (9.8% vs 7.3%
p
<.0001) were better in NC CSCs. Median door to CT (23 min (11-76) vs 30 (12-75)
p
<.001) and door to needle time (38 min (27-51) vs 43(30-56)
p
<.001) were faster in NC CSCs. In adjusted analysis those arriving to NC by 3 hrs were more likely to get tPA in extended 3-4.5-hour window (OR 1.65, 95% CI 1.10, 2.47
p
=.01).

Conclusion:
Among FL-Stroke Registry CSCs, AIS performance and treatment measures are superior in NC CSC when compared to SA CSCs. These findings have crucial implications for stroke systems of care in Florida and supported recent change in legislation regarding CSC center certification.
Abstract 167: Efficacy of Endovascular Treatment for Idiopathic Intracranial Hypertension: Cerebral Venous Sinus Stenosis Treated by Stenting
Authors: Chen Jian , Jiao Liqun , Zhao Wenbo , Ding Yuchuan , Zhang Hongqi , Ji Xunming
Published: June 2021

Objective:
To explore the diagnosis of cerebral venous sinus stenosis (CVSS) in idiopathic intracranial hypertension (IIH), and to evaluate the efficacy and risk of venous sinus stenting treatment for CVSS.

Methods:
40 patients with refractory IIH complicated with CVSS underwent examination with magnetic resonance venography (MRV), digital subtraction angiography (DSA) and direct retrograde cerebral venography and manometry to confirm morphologic features of IlH and measure venous pressure.The CSF pressure on lumbar puncture ranged from 250 to 500 mmH
2
O with normal composition. All patients had headache, and funduscopic examination demonstrated papilledema for all patients. 28 patients who showed severe stenosis of venous sinuses with the pressure gradient across the stenosis >100 mmH
2
O were treated with venous sinus stenting and were followed-up for more than 12 months.Intrasinus pressures were recorded before and after the procedure and correlated with clinical outcome during the follow-up period.

Results:
Sinus stenting angioplasty was successful in all 28 patients.In all patients venous sinus stenosis was improved after stenting procedure (the residual stenosis rate<20%) and intrasinus pressure was reduced (the pressure gradient vanished or<20 mmH
2
O ).The clinical symptoms in all the patients were improved or disappeared at discharge and intracranial pressures were normalized within 3 months after the procedure.During the follow-up period of (16.3±11) months (range 12 to 36 months),no patient had recurrence of IIH.In all cases, DSA or MRV was performed at 12-month follow-up and demonstrated the absence of sinus thrombosis or in-stent stenosis.

Conclusions:
Patients with refractory IIH should be assessed for CVSS. MRV or DSA was recommended for these patients as a routine work-up.Cerebral venography and manometry are helpful to evaluate the relation between venous outflow obstruction and intracranial hypertension.If severe CVSS is presented in patients who experienced medical treatment failure, endovascular stent placement could be an alternative to classic surgical approaches. Additional randomized and controlled clinical research is deserved.
Abstract 17: An Evaluation of Patient Disposition and Long-term Health-related Quality of Life In MISTIE III: Opportunities to Improve Decision Making for Critically Ill Intracerebral Hemorrhage Patients
Authors: Carhuapoma Lourdes , Avadhani Radhika , Ostapkovich Noeleen , Lane Karen , McBee Nichol , Carhuapoma Juan R , Ziai Wendy , Awad Issam , Thompson Richard E , Hanley Daniel F
Published: June 2021

Introduction:
Recovery in intracerebral hemorrhage (ICH) is prolonged and unpredictable, resulting in challenges in estimating health-related quality of life (HRQoL). We describe HRQoL and patient disposition for ICH survivors with similar clinical characteristics to ICH patients who had withdrawal of life-sustaining treatment (WoLST).

Methods:
Using MISTIE III trial data (N = 499), we performed a matched cohort analysis using a published modified severity index (mSI) to compare ICH survivors (N = 379) with WoLST patients (N = 61). We used multivariable logistic regression adjusting for age, Glasgow Coma Score, deep ICH location, stability ICH and intraventricular hemorrhage volume and ≥ 3 comorbidities to create the mSI. After matching survivors with equal mSI to WoLST patients, we compared EuroQoL (EQ) visual analog scale (VAS) scores (US norm 69-76; range 0-100) by mSI quartile and patient disposition.

Results:
We matched 224 survivors to WoLST patients by mSI (range 0-6.5), with data at all timepoints. Given the large mSI range, EQ VAS scores and patient disposition were evaluated by mSI quartile groups. The median (interquartile range [IQR]) EQ VAS score increase for all mSI groups from day 30 (D30) to 180 (D180) was 20 (0-35.5,
p
< 0.0001), and 23.5 (5-40,
p
< 0.0001) for D30 to 365 (D365). The highest percentage of survivors for all mSI groups were home by D365 (G1 55%, G2 88%, G3 84.5%, G4 90%). Median (IQR) EQ VAS scores by mSI quartile, patient disposition and timepoint are reported below.

Conclusion:
ICH survivors, matching WoLST individuals, in all mSI groups demonstrated improvement in HRQoL over time, and the majority were home by D365. This study challenges current practice of identifying poor outcomes in concert with decision making employing WoLST in ICH. If goals of care are to include return to home and HRQoL, these results strongly suggest that prognostication can be improved. Prospective studies of ICH prognostication and decision making are needed.
Abstract 173: Chronic Cerebral Hypoperfusion Induces Cognitive Impairment and Aggravates the Progression of Cardiac and Renal Dysfunction
Authors: Qian Yu , Chopp Michael , Shen Yi , Venkat Poornima , Chen Zhili , Li Wei , Zacharek Alex , Landschoot-Ward Julie , An Lulu , Chen Jieli
Published: June 2021

Background:
Vascular contributions to cognitive impairment and dementia (VICD) are major health problems worldwide. Heart-kidney deficit and dementia frequently coexist, but little is known whether VICD induces cardiac and kidney deficit absent from primary heart and kidney deficit. The purpose of this study was to investigate the effect of VCID on white matter (WM) injury and cognitive impairment, as well as how VCID affects heart and kidney function at 2 and 8 months after bilateral common carotid artery stenosis (BCAS) in a mouse model of VICD.

Methods:
Adult male C57BL/6J (8-months) mice were subjected to Sham and BCAS surgery using micro coils with inner diameter of 0.16 mm. Cognitive functional tests and cardiac function were measured before mice were sacrificed at 2 months post BCAS (2M-BCAS) and at 8 months post BCAS (8M-BCAS), respectively. The brains, hearts and kidneys were then harvested for histological and immunohistochemical (IHC) staining. Significant statistics were determined as p<0.05.

Results:
Compared to Sham group, mice in 2M-BCAS and 8M-BCAS group both exhibit significantly: 1) increased cognitive deficits identified by decreasing the novel object recognition (NOR) test, social interaction test and Morris water maze test. 2) increased axonal/WM injury by decreasing Bielschowsky silver and Luxol fast blue density. 3) decreased left ventricular ejection fraction (LVEF) measured by echocardiogram. 4) increased heart iba-1, cardiac and renal fibrosis indicated by picrosirius red (PSR) staining. 5) increased mesangial proliferation and thickening of the glomerular basement membrane (GBM). Compared to 2M-BCAS, 8M-BCAS mice exhibit significantly: 1) worse axonal/WM injury. 2) worse LVEF and fractional shortening (FS). 3) increased heart iba-1 expression as well as cardiac and renal fibrosis. 4) induced severer mesangial proliferation and thickening of GBM.

Conclusions:
Our data indicate that BCAS not only induces progressive long-term cognitive impairment and WM/axonal damage, but also induces progressive cardiac and renal dysfunction compared to sham control mice.
Abstract 181: Community Paramedicine’s Impact on Readmission Reduction
Authors: Morrison Kathy , Wattai Brandon , Reichwein Raymond , Velasco Cesar , Richardson Alicia
Published: June 2021

Stroke readmissions within 30 days have been identified by the Centers for Medicare & Medicaid Services (CMS) as a measure of hospital quality. Readmitted stroke patients experience greater mortality, longer lengths of stay, and higher cost per stay. This Comprehensive Stroke Center has had a follow up program since 2010 which includes a 48 hour phone nurse call, a 7 day clinical pharmacist phone call, and stroke clinic visit/phone call at 30 days and 90 days. This process produced a 50% readmission reduction between 2013 and 2018, however opportunities to further reduce stroke readmissions remain.

Methods:
In 2018, a process was launched where specially-trained Community Paramedicine professionals visit stroke patients at home @ 7-10 days post discharge. This visit includes education reinforcement, social evaluation and support, medical examination, and interventions. The model was previously found to demonstrably reduce heart failure readmissions. Referrals are made to this team by coordinators for ischemic and hemorrhagic patients discharged to home or rehab. Findings and needs are communicated directly to relevant health system elements.

Results:
From July 2018 through June 2019, CP visited 156 (23%) of the 669 patients discharged to home and acute rehab. Only 1 patient (0.6%) of those visited was readmitted, while 52 (10%) of the 513 not visited were readmitted within 30 days. During the visits, they identified key barriers such as medication errors, absence of help in the home (despite having previously reported they would have help), lack of transportation, and overwhelmed caregivers. They ensured that pill organizers were utilized, reviewed upcoming appointments, assisted with arranging transportation, and provided education and helping strategies to caregivers. Feedback from the patients has been overwhelmingly positive.

Conclusion:
Stroke Centers are accountable to improve stroke patients’ transitions of care at discharge to reduce readmissions and ensure optimal recovery. Community Paramedicine personnel are well-suited to positively impact readmission rates in stroke patients.
Abstract 183: Time to Alteplase and Symptomatic Intracranial Hemorrhage Complication Rates
Authors: Farooq Muhammad U , Thomas Kathie
Published: June 2021

Background/Objective:
The American Heart Association’s Target Stroke initiative focuses on reducing door-to-needle time for faster treatment with Alteplase and improved patient outcomes. The concern for reducing door-to-needle time is that there will be an increase in complication rates, specifically the rate of symptomatic intracranial hemorrhage (ICH). This study sought to review whether reduced door-to-needle times were associated with increased rates of complications in Midwest hospitals.

Methods:
A retrospective review of acute ischemic stroke patients treated with Alteplase was conducted from 2010-2018 in 13 Midwestern states (IN, IL, KS, KY, MI, MN, NO, ND, OH, SD, and WI) using the American Stroke Association’s Get With The Guidelines (GWTG) Stroke database. Percentage of eligible patients treated with Alteplase, treatment times, and complication rates were reviewed.

Results:
From 2010-2018 the rate of ischemic stroke patients treated with Alteplase in the approved 3-hour window increased from 68.9% to 88.5%. The number of patients treated with Alteplase in 60 minutes increased from 24.1% in 2010 to 74.9% in 2018. The median time to treatment for Alteplase was reduced from 80 minutes in 2010 to 46 minutes in 2018. The rate of complications associated with thrombolytics was 6.5% in 2010 and dropped to 4.5% in 2018. This is statistically significant at a p-value of .05.

Conclusions:
In the Midwest Region, a reduction in door-to-needle times was not associated with increased complication rates. Interestingly, a reduction in door-to-needle times was associated with a reduction in complication rates. This supports the American Heart Association’s new Target Stroke Phase III initiative which seeks to further reduce door-to-needle times.
Abstract 2: French Acute Cerebral Multimodal Imaging to Select Patients for Mechanical Thrombectomy Final Results
Authors: Olivot Jean Marc , Albucher Jean François , Guenego Adrien , Mlynash Michael , Sibon Igor , Viguier Alain , Tourdias Thomas , Calviere Lionel , Bonneville Fabrice , Drif Amel , Raposo Nicolas , Darcourt Jean , Christensen Soren , Rousseau Vanessa , Januel Anne Christine , Mazighi Mikael , Menegon Patrice , Sommet Agnes , Thalamas Claire , Albers Gregory W , Cognard Christophe
Published: June 2021

Introduction:
Target mismatch (TMM) identifies salvageable penumbra independent of time from stroke onset. Current guidelines do not recommend advanced imaging to select patients for mechanical thrombectomy (MT) within 6 hours after onset but indicate that more research is needed. To address this question, we designed a prospective multicenter cohort study to compare the rate of functional neurological recovery (mRS ≤2 @ 3 months) in patients treated by MT for ICA/M1/M2 occlusions within 6 hours after onset according to the presence of a TMM on baseline imaging.

Hypothesis:
60% of patients with TMM vs. 35% of no TMM, would achieve an mRS≤2 at 3 months. Sample size calculation: 200 patients.

Methods:
Consecutive patients eligible for MT within 6 hrs after onset, who underwent CTP or DWI/PWI imaging before treatment were enrolled. No NIHSS or ASPECTS restrictions were applied. Treating teams were blinded of CTP/DWI/PWI maps. mRS at 3 months was rated by an investigator blinded to clinical/imaging/treatment information. Automatically processed maps by RAPID software were reviewed after the end of follow-up. TMM definition followed EXTEND-IA criteria: MM volume >10mL, MM ratio>1.2, Core volume <70 mL. Mismatch (MM) was defined by MM ratio>1.2 and MM volume>10 mL. Imaging-based subgroups (TMM vs. No TMM) were defined after the end of follow-up.

Results:
218 patients were enrolled. Baseline imaging profile distribution was 71% TMM, 29% no TMM, (in the no TMM group, 76% had a core volume > 70 mL); 82% MM and 18% no MM. Reperfusion(TICI 2B-3) was achieved in 86% of the patients after a median delay of 4.4 hrs (95%CI 3.6-5.9). 61% of the patients in the TMM group vs. 35% in the no TMM group had an mRS ≤2 @ 3 months, p<0.001 (adjustment for age, onset to reperfusion, NIHSS, reperfusion and baseline imbalances). Reperfusion vs. no reperfusion was associated with an increased rate of good outcome in the TMM and MM groups (61% vs. 38% p=0.039 and 60% vs. 32%, p=0.016) but not in the no TMM or No MM groups (35% vs. 33%, NS; 35 vs. 45%., NS).

Conclusion:
Patients with salvageable penumbra on advanced imaging experienced a larger benefit from MT than those without. Patients with no penumbra did not appear to benefit from reperfusion.
Abstract 32: Intravenous Tpa Delays Door-to-puncture Time in Acute Ischemic Stroke With Large Vessel Occlusion
Authors: Atchaneeyasakul Kunakorn , Desai Shashvat , Dolia Jay , Shah Kavit , Brown Merritt , Rocha Marcelo , Molyneaux Bradley , Starr Matthew , Saver Jeffrey L , Jovin Tudor , Jadhav Ashutosh
Published: June 2021

Background:
The current 2018 AHA/ASA Guidelines for early stroke management recommend use of IV tPA in all eligible acute ischemic stroke patients within 4.5 hours of onset while being considered for mechanical thrombectomy (MT). Whether or not tPA administration is beneficial prior to thrombectomy is still an ongoing debate. Potential delay of MT initiation due to tPA start is a major concern but has not been well-delineated in empirical studies.

Methods:
In a prospective large volume comprehensive stroke center registry, we analyzed all patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO) treated with thrombectomy between 2012-2017, who arrived directly from field to ED within 4.5h of last known well. Patients without contraindication to IV-tPA are given bolus dose in the scanner suite and the remainder of the 1h infusion en route to and in the angio-suite to prevent delay.

Results:
Among 777 thrombectomy patients identified in the database, 237 arrived directly within 4.5 hours from onset, including 65.8% (156) not treated with IV-tPA and 34.2% (81) receiving IV-tPA, both well-matched in age and NIHSS. Overall, the door-to-needle (DTN) time was 40m (IQR31-56), surpassing the Target Stroke national targets (60m and 45m) active during the study period. However, median door-to-puncture (DTP) time was 22m longer in the IV-tPA group, 74 vs 52m (p<0.001). IV-tPA was not independently associated with better recanalization rate (TICI 2B-3 95.9% vs 92.9%) or functional independent outcome (modified Rankin score 0-2) at 90 days, 37.3% vs 39.4%.

Conclusion:
IV-tPA administration in AIS-LVO was associated with delayed door-to-puncture times in a comprehensive stroke center with efficient DTN times surpassing advanced national targets, without change in recanalization rate or outcomes. Randomized trials are needed to determine the net positive, neutral, or negative effect of IV-tPA in this population.
Abstract 36: Nanoparticulate Matter Exposure Causes a Time-Dependent Activation of Inflammatory Microglia With Associated White Matter Damage in a Mouse Model
Authors: Connor Michelle , Baertsch Hans , Shkirkova Kristina , Knebel Ashley , Lamorie-Foote Krista , Liu Qinghai , Sioutas Constantinos , Mack William
Published: June 2021

Introduction:
Exposure to ambient air pollution, specifically the nano-scale subfraction (nPM; particles <200nm diameter), is associated with white matter damage and neurocognitive decline in both experimental and human studies. The histopathology and cognitive correlates are similar to those observed in vascular dementia and small vessel ischemic disease. nPM-associated white matter damage involves microglial activation. However, the microglial phenotype and time course of white matter damage remain uncharacterized. This study examines myelin injury and microglia activation in the corpus callosum of mice exposed to 3 weeks (45 hours) and 10 weeks (150 hours) of nPM.

Methods:
Air pollution consisting primarily of traffic-related emissions was collected from an urban area in Los Angeles; nPM was isolated and stored. Mice were exposed to either re-aerosolized nPM or filtered air for 3 weeks (45 hours) or 10 weeks (150 hours) (n=18/group). Activated microglia were characterized by immunohistochemical staining of Iba-1+iNOS to identify M1 pro-inflammatory cells, and Iba-1+Arg to identify M2 anti-inflammatory cells. Myelin injury was assessed by immunohistochemical staining of myelin associated glycoprotein (MAG), a marker of normal myelin; and degraded myelin basic protein (dMBP), specific for myelin degradation.

Results:
M1 pro-inflammatory microglia were significantly increased in the corpus callosum of mice exposed 10 weeks of nPM compared to filtered air (p<0.05). This was accompanied by a significant decrease in MAG (p<0.05), and increase in dMBP (p<0.05) immunofluorescent density. Mice exposed to 3 weeks of nPM did not demonstrate any differences in microglia activation or white matter injury, compared to mice exposed to filtered air (p=NS).

Conclusion:
10 week, but not 3 week, exposure to nPM results in inflammatory microglia activation and myelin injury in the corpus callosum of mice. M1 pro-inflammatory microglia release inflammatory cytokines and reactive oxygen/ nitrogen species, which may contribute to the white matter damage observed in this model.