bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP275: Effect of Transcranial Laser and Thrombolytic Combination Therapy on Clinical Function and ATP Production in Small Clot Embolized Rabbits
Authors: Lapchak Paul A , Boitano Paul D
Published: July 2021

Background and Purpose:
Transcranial laser therapy (TLT) and tissue plasminogen activator (tPA) improve behavior when administered following clot-induced strokes. tPA increases cerebral reperfusion and blood flow and TLT also enhances cerebral blood flow and activates mitochondrial function. We hypothesize that a combination therapy may be more effective than individual therapies and that efficacy may be mediated by enhancing mitochondrial function. Therefore, the goal of the present study is to evaluate the effect of combined TLT and tPA therapy on behavioral outcome and cellular ATP content using the rabbit small clot embolic stroke model (RSCEM).

Methods:
The study was conducted randomized and blinded. Male New Zealand white rabbits were embolized by injecting a suspension of small blood clots into brain via a carotid catheter. Using the RSCEM, we studied the effects of continuous wave TLT (7.5 mW/cm2, 2 minutes) alone or in combination with standardized intravenous (IV) tPA (3.3mg/kg) applied 1 hour post-embolization on 3 endpoints: 1) behavioral function measured 2 days [effective stroke dose (P50 in mg) producing neurological deficits in 50% of embolized rabbits], 2) intracerebral hemorrhage (ICH) rate, and 3) cortical adenosine-5'-triphosphate (ATP) content was measured 6 hours following embolization.

Results:
TLT and tPA significantly (p<0.05) increased P50 values by 95% (p=0.026) and 56% (p=0.026) over control, respectively. TLT-tPA increased P50 by 136% over control (p=0.0038 compared to control). Treatment did not affect ICH incidence. Embolization reduced cortical ATP content by 39%; decreases that were attenuated by both TLT and tPA treatment (p<0.05). TLT-tPA further enhanced cortical ATP levels 22% above that measured in naïve control.

Conclusion:
TLT and tPA both effectively and safely improve behavioral outcome in embolized rabbits and attenuate stroke-induced ATP deficits; TLT-tPA did not offer additional clinical benefit, but the TLT-tPA combination produced a synergistic effect on ATP levels. The study suggests that tPA-induced reperfusion in combination with TLT neuroprotection therapy may optimally protect viable cells in the cortex measured using ATP levels as a marker.
Abstract TP30: Risks and Benefits of Bypassing the Emergency Department for Ischemic Stroke Transferred in for Acute Endovascular Therapy
Authors: Deveikis Susan , Albright Karen , Deveikis John , Sands Kara , Shiue Harn , Jones Benjamin A , Sisson April , Lyerly Michael , Harrigan Mark , Gropen Toby
Published: July 2021

Background and Purpose:
Minimizing time from symptom onset to recanalization is crucial to maximizing outcome. Approaches to save time in ET cases including processes to reduce door-to-recanalization times need to be explored.

Methods:
We performed a retrospective review of consecutive ischemic stroke patients transferred to our comprehensive stroke center (CSC) from March 2014 to April 2015. Demographic and clinical data were collected. We compared adverse events (hemorrhagic transformation [HT], DVT, PE, urinary tract infection [UTI], pneumonia [PNA], bacteremia), door-to-recanalization time, and short-term outcomes in patients that were evaluated in the emergency department (ED) prior to ET and patients that were transferred directly to the endovascular suite, bypassing the ED.

Results:
Among the 776 consecutive ischemic stroke patients admitted to our center during the 14-month period, 7% (n=49) received acute ET. Twenty-six of these patients (53%) were transferred to our CSC for ET. Among transfers, 58% (n=15) bypassed the ED. Patients that bypassed the ED had a higher frequency of adverse events (53% vs. 27%, p=0.246), but shorter arrival to recanalization times when compared to patients that did not skip the ED (median 89 vs. 109 minutes p=0.637). Poor functional outcome, as measured by modified Rankin scale (mRS) score of 4-6, was similar between groups (67% vs. 64%, p=1.000), but in-hospital mortality was more frequent in the ED bypass group (33% vs. 18%, p=0.658).

Conclusions:
In our sample of acute ischemic patients transferred for acute ET, nearly 60% of patients bypassed the ED, reducing time to recanalization. This time savings was associated with a clinically higher proportion of adverse events. Standardized protocols for patients transferred to acute ET are needed to reduce time to recanalization without increasing adverse event rates.
Abstract TP312: Simulation Based Education for Neurology Nurses to Improve In-hospital Stroke Emergency Performance
Authors: Gill Rick , Rasmussen Teresa , Garg Ravi , Ray Jessica , McCoyd Matthew , Ruland Sean
Published: July 2021

Introduction:
An in-hospital stroke emergency demands timely decision making and prioritization of tasks by the stroke team nurse. Simulation-based medical education (SBME) focuses on obtaining clinical skills in psychomotor, cognitive and affective domains and is superior to the traditional style of education with improved outcomes of knowledge, skills and behaviors and demonstrable effects for patient-related outcomes. A stroke simulation study at our center showed significant improvements in the cognitive and affective domain of new residents and this next phase aims at incorporating members of the multidisciplinary stroke team.

Hypothesis:
SBME improves stroke emergency performance, particularly for inexperienced stroke team members.

Methods:
Eight neuro ICU nurses participated in a high fidelity patient simulation of an in-hospital ischemic stroke eligible for IV tPA. The nurse independently managed every nursing task including a focused patient assessment, verifying and evaluating vitals and treating appropriately, expediting labs, managing common obstacles and coordinating care with the stroke team. Nurses completed an affective survey, pre- and post-test cognitive assessment and debriefing with feedback. An evaluator completed a real-time checklist of pre-defined tasks and the subject participated in a review of their performance with the stroke team.

Results:
Subjects showed a 19.4% improvement in the cognitive assessment post-simulation (p=0.02). The affective survey showed nurses were confident in their ability to perform the NIHSS. While there was no significant change in the affective domain post simulation due to the subject groups being too small for statistical comparison, recognition of normal parameters (labs and vitals) for treatment of stroke showed an improvement of 6.25%.

Conclusion:
SBME can facilitate the acquisition of technical skills and non-technical skills such as team work, communication, decision-making and cognizance of personal limitations. This pilot demonstrated that nurses can benefit in the cognitive domain through simulation and feedback indicated that a stroke simulation with increased interaction among stroke team members, with defined roles would add to the fidelity of the simulation.
Abstract TP330: Substantial Progress yet Significant Opportunity for Improvement in Stroke Care in China
Authors: Li Zixiao , Wang Yilong , Xian Ying , Zhao Xingquan , Li Linzi , Wang Chunjuan , Liu Liping , Wang Chunxue , Li Hao , Wang Anxin , Jiang Yong , Wang Yongjun
Published: July 2021

Background:
Stroke is a leading cause of death in China. Yet the adherence to guideline-recommended stroke performance metrics was suboptimal in the past decade. We sought to determine whether adherence changed after the implementation of the China National Quality Management Initiatives.

Methods and Results:
Data were obtained from the China National Stroke Registries (CNSR), and included 132 hospitals (12 173 patients) participated in CNSR Phase I (2007-2008) vs. 219 hospitals (19 604 patients) in CNSR Phase II (2012-2013). The overall adherence increased over time, as reflected by the higher composite score of 0.76 in 2012-2013 as compared with 0.63 in 2007-2008, and the increase in 9 of 13 individual metrics, including dysphagia screening, carotid imaging, rehabilitation evaluation, antithrombotics, lipid-lowering, antihypertensive medications, antidiabetic medications at discharge, smoking cessation, and stroke education). However, there were no significant improvements in the intravenous thrombolytic therapy, early antithrombotics, deep vein thrombosis prophylaxis, and anticoagulation for atrial fibrillation. Multivariate analysis suggested that there was a 1.17-fold increase in the odds of fulfilling care opportunities.

Conclusions:
Adherence to stroke performance metrics increased recently, but significant opportunities remain for further improvement. Continuous stroke quality improvement program should be developed as a national priority in China.
Abstract TP354: Trends in Stroke Severity and Incidence After Endovascular Repair for Descending Thoracic Aorta Diseases
Authors: De Rango Paola , Isernia Giacomo , Simonte Gioele , Marucchini Alessandro , Cieri Enrico , Farchioni Luca , Verzini Fabio
Published: July 2021

Background:
Perioperative stroke is a devastating complication after treatment of descending thoracic aorta disease (DTAD). As to whether developments in Thoracic Endovascular repair (TEVAR) influenced the overall stroke burden of patients with DTAD remains to be defined. This study investigated the current incidence and severity of procedure-related stroke in patients undergoing elective or emergency TEVAR.

Methods:
Patients with DTAD treated by TEVAR were questioned for perioperative stroke. Multivariable logistic regression models with backward variable selection were applied to investigate independent associations with perioperative stroke.

Results:
Between 2003-2015, 141 consecutive TEVAR (71.6% men;mean age 67.3+16.7years) were performed for DTAD: 58 (41.4%) were emergency procedures. The 30-day mortality was 9.2% (13/141) and 10 patients experienced procedure-related stroke. 30-day mortality was increased in patients with stroke: 23% vs. 5.5% (OR 5.2; 95%CI1.16-23.2;P=0.05). Stroke fatality was even more evident in elective repairs (P=0.049). Procedure-related stroke incidence was higher in emergency (13.3% vs. 2.6%;P=0-02), in procedures with left subclavian artery (LSA) coverage (21.4% vs. 3.5%;P=0.004) and in TEVAR performed before 2007 (15.6% vs 3.1%;P= 0.01). The relationship between increased stroke incidence and LSA coverage (35.7% vs. 6.5%;P=0.01) or procedure before 2007 (26.6% vs.5.1%;P=0.02) was particularly evident in TEVAR performed in emergency, while disappeared in elective repairs. Type of disease and age did not affect stroke risk. In multivariable regression, emergency of repair (OR,10.9; 95%CI,1.56-76.5; P=0.0.2), LSA coverage (OR,10.8; 95%CI 1.8-65.6;P=0.009) and procedure after 2007(OR 0.15; 95%CI 0.03-0.88;P=0.04) were confirmed as independently associated with procedure-related stroke as well as female sex (P=0.034).

Conclusions:
With developed technology the incidence of procedure-related stroke after TEVAR has declined. This trend was particularly achieved in emergency procedures where the prompt treatment may not allow for accurate planning. Nevertheless, stroke remains a devastating complication at high fatality risk for patients with DTAD even after elective TEVAR.
Abstract TP38: Impact of CT Perfusion Scan Duration on Lesion Volume
Authors: Kasasbeh Aimen , Christensen Søren , Straka Matus , Mishra Nishant , Bammer Roland , Albers Gregory , Lansberg Maarten
Published: July 2021

Introduction:
There is evidence that CTP volumes are affected by scan duration, but the minimal scan duration needed to obtain reliable volumes has not been established.

Hypothesis:
The minimal CTP scan duration for individual patients depends on the arrival time and width of the injected bolus.

Methods:
We included CTP scans of patients who presented with an acute ischemic stroke. To identify the optimal CTP scan duration, we assessed how truncation of the scan (from 90s to 20s) impacts lesion volumes. We included only patients for whom truncation of the final 10.8 sec (from 90 to 79.2 sec) did not affect lesion volumes to ensure that the subjects had been scanned with sufficient duration. For each included patient, further truncation was used to identify a “stability point”, defined as the minimal scan duration needed to achieve stable estimates of the perfusion lesion. For each patient we also determined the arrival time (t0) and width (full width half max - FWHM) of the Venous Output function (VOF). We used a linear model to test if these VOF features could predict the stability point.

Results:
We analyzed CTP scans of 70 patients with acute ischemic stroke. Of these, 59 (84.3 %) had sufficient scan duration and were included. Both t0 and VOF width were associated with the stability point (R2 = 0.49). Based on the regression model, minimum scan duration is predicted by “t0 + 1.61* FWHM” (p < 0.001) with an interquartile prediction interval from -5 to 7s.

Conclusions:
The minimum CTP scan duration needed for accurate perfusion lesions are patient specific and depend on width and arrival of the injected bolus as expressed by the easy to measure VOF. This knowledge has important clinical implications. After acquisition, it can be used to rate if a scan is of sufficient duration for reliable lesion volume estimation. Prior to acquisition, a low contrast and radiation dose test bolus scan can be used to inform the optimal scan time, thereby limiting the radiation dose to the minimal necessary amount for accurate measurements. For example in our cohort, 52 of 70 patients could have been scanned for just 60 seconds (33% dose reduction) with the same results as a 90 second scan.
Abstract TP39: High Accuracy of Magnetic Resonance T2*- Weighted Sequences for Detection of Intracranial Arterial Thrombus
Authors: Liberato Afonso P , Shah Santosh , Maza Noor , Barnaure Isabelle , Gonzalez Ramon G , Romero Javier M
Published: July 2021

Introduction:
Rapid detection and location of vessel occlusion are pivotal in the intra-arterial management of patients with acute stroke in the emergency room. MRI has demonstrated to detect intravascular thrombus but its accuracy compared to CT angiography has not been well established.

Hypothesis:
Our purpose is to determine the accuracy of 1.5 T MRI T2*-weighted (W) sequences compared to immediate CT angiography as the standard reference imaging modality, for detection of intra-arterial thrombus in patients with suspected acute MCA infarction.

Methods:
Consecutive patients with suspected middle cerebral artery (MCA) territory stroke were selected from 2008 to 2009. The inclusion criteria for the study subjects: CTA, T2*W sequences included on MRI protocol and restricted diffusion in MCA territory on DWI within 12 hrs of clinical onset. Two investigators reviewed DWI and T2*W sequences for the presence of infarction and thrombus. Intracranial internal carotid artery (ICA), M1 and M2 segments of the MCA were accessed. Consensus was reached with a third reviewer for data analyses. Accuracy, sensitivity, specificity, positive and negative predictive values (PPV/NPV) were calculated.

Results:
Fifty-one patients were included in the study, of which 40 patients had confirmed arterial thrombus and 11 patients had normal studies on CTA. Of the subjects with arterial occlusion on CTA, the mean time interval from stroke onset to CTA was 4.2 h +/- 2.3 h (range, 0.4-12h). The mean time interval from CTA to MRI was 29.5 min +/- 11.1 min. Twenty-six cases showed M1 thrombus on CTA, of these, 22 cases had corresponding thrombus and 4 cases had no abnormality in T2*W sequences on MRI. Nevertheless, 25 patients demonstrated no M1 thrombus, either on CTA or MRI. After statistical analyses, we observed an accuracy of 92%, sensitivity of 85%, specificity of 100%, PPV 100% and NPV of 86% for M1 occlusion. The Kappa obtained was 0.79.

Conclusion:
In conclusion, T2*W sequences demonstrated overall high accuracy and specificity for detection of arterial thrombus in the M1 segment of the MCA in patients with suspected acute MCA ischemic stroke.
Abstract TP391: Working Within a Stroke System of Care to Decrease Door to Transfer Times From Spoke to Hub
Authors: Whaley Michelle , Dell Alissa , Chase Melissa , Mooney Melissa , Hulbert Jill , Larson Amy , van Vliet Rebecca , Keiling Brett
Published: July 2021

Background:
Best practice recommends that hospitals treating acute stroke patients have protocols in place to ensure rapid transfer to an advanced facility for a higher level of care, if needed. Our system of hospitals consists of five primary stroke centers (PSC) and one comprehensive stroke center (CSC) in a major metropolitan area. PSCs utilize telemedicine for acute stroke decision-making and patients are transferred to the CSC for consideration of advanced treatments when deemed appropriate by the care team.

Purpose:
Our study objective was to streamline processes at our PSCs to decrease the door to transport time (DTT) to the CSC.

Methods:
Stroke coordinators from the six sister hospitals meet quarterly to collaborate and share best practices in patient care. Our team of nurse leaders determined potential strategies to eliminate wasted time in the transfer process. Team members went back to their home facilities with the goal of generating buy-in from individual caregivers to decrease the time to transport out to the CSC. An overall attitude of urgency was encouraged during meetings with stroke councils and providers. Preliminary imaging results were used to guide decision to transfer, rather than waiting for final results. Some hospitals chose to notify the flight team of potential transport earlier in the emergency department stay, while others are still in the process of affecting change. We collected data on transferred patients with a diagnosis of acute stroke between the dates of 2/1/15-7/31/15 (n=23) and compared against the same time period in 2014 (n=11).

Results:
A total of 34 patients were included in our retrospective chart review. The number of patients transferred for consideration of additional acute treatment increased from 11 in 2014 to 23 during the study period in 2015. When examining patients who transferred and actually received endovascular treatment for acute stroke (n=8 in 2014 versus n=11 in 2015), the mean DTT decreased from 84 minutes in 2014, to 77 minutes in 2015. We also noted that patient transfers were faster during day time hours when compared to night.

Conclusions:
A system-wide, collaborative approach between PSCs and CSCs can decrease DTT when nurse leaders and providers streamline processes.
Abstract TP423: A Fast Assessment of Diet in Stroke (FADS)
Authors: Dearborn Jennifer L , Roach Haleigh , Narwal Pooja , Peterson Meghan , Talegawkar Sameera , Gottesman Rebecca F , Fernandez Maria Luz , Schindler Joseph , Kernan Walter N
Published: July 2021

Objectives:
To design and validate a questionnaire to identify stroke patients with an unhealthy diet.

Hypothesis:
A simple questionnaire can accurately identify patients with dietary patterns associated with increased risk for vascular disease.

Methods:
An expert panel identified the components of a healthy diet thought to be important for secondary stroke prevention and drafted ten candidate survey questions. A focus group of four stroke patients (2 men, 2 women) from Yale New Haven Hospital reviewed the questions to refine the wording. From this group, the investigator chose five questions to create the Fast Assessment of Diet in Stroke (FADS) score. To validate the score, among 20 patients with acute ischemic stroke, we compared FADS score to the score on an established “gold standard” measure of adherence to the Mediterranean-type diet, the Mediterranean Diet Score (MDS). The MDS has a range of 0 (lowest adherence to the diet) to 9 (highest adherence). We used ROC curve analysis to identify the FADS score with optimal performance. Based on population means in non-Mediterranean countries, we defined an unhealthy diet as an MDS score <4.

Results and Conclusions:
The mean MDS score in the population was 3.2 (range 2 to 5). 74% of participants were defined as having an unhealthy diet (MDS <4). The aROC was 0.77. A FADS score ≤3 had had the highest sum for sensitivity and specificity (sensitivity = 79%, specificity = 50%). However, for clinical purposes, a FADS score of <3 may be most effective in selecting patients who need dietary counseling (sensitivity = 46%, specificity = 100%). The FADS score takes less than 2 minutes to administer and accurately identifies stroke patients who need dietary counseling. The low sensitivity, however, indicates that further development is required and that testing against other established gold standards of dietary quality should be completed. This work is under way.
Abstract TP457: Brain Functional Alterations in Patients With Leukoaraiosis Associated Mild Cognitive Impairment
Authors: Li Na , Zhang Yu Mei , Wang Yong Jun
Published: July 2021

Background and aims:
Recent studies demonstrated that a signal change of functional magnetic resonance imaging (fMRI) in certain brain areas during the resting state is a significant marker in patients with mild cognitive impairment (MCI). However, the research of resting-state fMRI (rs-fMRI) on leukoaraiosis (LA) associated MCI is scarce. The aim of this study was to investigate differences of the rs-fMRI default network between patients with LA-associated MCI and normal subjects, and provide functional imaging evidence of LA-associated MCI during early stages of the disease.

Method:
All subjects were outpatients or thier residents of the Department of Neurology of the Beijing Tiantan Hospital. They were divided into MCI group and control group according to their cognitive function assessing by the Hamilton Depression Scale, Clinical Dementia Rating (CDR), Mini Mental State Exam and Montreal Cognitive Assessment. Demographic information was recorded. Brain MRI characteristics were assessed using the Fazekas scale. The independent components of fMRI data were analyzed by fMRI tool box. The experimental data and confounding factors were analyzed by General Liner Model.

Results:
A total of 31 right-handed patients with LA-associated MCI and 27 right-handed healthy control subjects were included. The active areas participating in the resting state for LA-associated MCI group were mostly consistent with those of the control group. Compared with controls, the LA-associated MCI patients exhibited significantly lower blood oxygen level-dependent (BOLD) signals in the left anterior cingulate cortex (P=0.021) and right parahippocampal gyrus (P=0.032). Whereas higher BOLD signals during the resting state in LA-associated MCI patients were observed in the left caudate nucleus (P=0.015), right frontal lobe (P=0.004), superior temporal gyrus and inferior parietal gyrus (P=0.001), No significant difference was shown in the posterior cingulate cortex and precuneus (P=0.138).

Conclusion:
Our findings demonstrated that the discriminating functional activation in specific brain areas could be identified in patients with LA-associated MCI, which might be used as an useful neuroimaging evidence for the early recognition of these patients.
Abstract TP56: The Impact of Early Ischemic Changes on Head CT on Hemorrhagic Conversion and Outcomes in Patients With Acute Ischemic Stroke
Authors: Khawaja Ayaz , Albright Karen , Hays Shapshak Angela , Shiue Harn , Sisson April , Bavarsad Shahripour Reza , Kaur Manmeet , Lyerly Michael , Gropen Toby
Published: July 2021

Background:
Early ischemic changes (EIC) on head CT are associated with increased hemorrhagic transformation (HT) following treatment with TPA. We examined the associations between EIC, HT, and outcomes in patients treated and not treated with IV TPA.

Methods:
We conducted a retrospective review of consecutive acute ischemic stroke (AIS) patients presenting to our CSC from April 2014 to March 2015. Demographic and clinical data, including initial head CT findings (parenchymal hypodensity, loss of gray-white differentiation, sulcal effacement, hyperdense vessel) were collected. HT on repeat neuroimaging, poor functional outcome, as measured by a modified Rankin Scale (mRS) of 3-6, and in-hospital mortality were assessed.

Results:
A total of 679 patients were included (50.4% men). One hundred and eight patients (15.9%) received IV TPA. EIC were observed in 38.5% of untreated patients and 17.6% in IV TPA treated patients (p<0.0001). For patients treated with IV TPA, EIC was seen more frequently in patients with pre-stroke anticoagulant use (26.3% vs. 6.7%, p=0.010) and less frequently in patients with pre-stroke statin use (15.8% vs. 43.3%, p=0.025). A higher proportion of HT was observed in patients with EIC (12.8% vs. 6.8%, p=0.016 untreated, 36.8% vs. 14.6%, p=0.024 IV TPA) and with hyperdense artery sign (8.2% vs. 3.7%, p=0.022 untreated, 36.8% vs. 15.7%, p=0.035 IV TPA). For untreated patients, EIC was observed in a larger proportion of patients with an NIHSS>14 (14.8% vs. 9.6%, p=0.016), and discharge mRS 3-6 (53.6% vs. 44.5%, p=0.040). For patients treated with IV TPA, in-hospital mortality was more common in patients with EIC (31.6% vs. 10.0%, p=0.013).

Conclusions:
In untreated patients, EIC may serve as a harbinger for HT on repeat imaging and poor functional outcome at discharge, whereas in patients treated with IV TPA, it is associated with HT and in-hospital mortality. Patients with EIC may be at increased risk of HT and poor outcomes even without thrombolytics.
Abstract TP57: Assessing Acute Infarct Growth and Evolution Using Apparent Diffusion Coefficient and Quantitative R2 Imaging
Authors: Gupta Sah Rani , Khan Saad , Mahajan Ajay , Forkert Nils D , Tsang Adrian , Hafeez Moiz , Tariq Sana , d'Esterre Christopher D , Barber Phillip A
Published: July 2021

Introduction:
Ischemic stroke is caused by cellular injury to the neurovascular unit. During the early stages of stroke onset, MR diffusion-weighted Imaging (DWI) provides sensitive detection of cytotoxic injury. However, measurement of free-water with quantitative R2 (qR2) relaxometry is generally ignored.

Hypothesis:
Inclusion of qR2 with DWI will better characterize the heterogeneity of acute ischemia and infarct growth.

Methods:
36 ischemic stroke patients (age; 72 ± 17) were imaged acutely (baseline) and at 24h on a 3 T MR scanner. Apparent diffusion coefficient (ADC) and qR2 maps were calculated from DWI and multi-echo T2 data sets using ANTONIA software. Volumetric segmentation of qR2 lesions were performed using a threshold -12.5% of the mean contra lateral side value. ADC lesions were segmented using a threshold of 630x10^-6mm^2/s. Lesion overlap of qR2 and ADC segmented volumes was also calculated using DICE coefficient.

Results:
Time from stroke onset to MRI was 4:5 ± 0.16h, and recanalization was confirmed (10 ± 1.3h) in the acute period. Treatment was provided with tPA in 27/36 (75%) or endovascular therapy in 15/36 (41.7%) or both in 9/36 (25%). Ischemic lesions were identified in 31/36 (86%) patients based on ADC. ADC lesions were identified in 23/31 (74%) at baseline and 27/31 (87%) at 24h, QR2 lesions were observed in 14/27 (52 %) at baseline and 15/27 (56%) at 24h. The Figure shows ADC and qR2 volume changes over time. QR2 and ADC volume overlap was 10.7% at baseline and 19.9% at 24h. The percentage change in qR2 lesion was 189.2%, compared to ADC lesion growth of 90.50%. Lesion growth was more frequently demonstrated by qR2 than ADC (Fishers exact p<0.05).

Conclusion:
Acute ischemic lesion growth size was more frequently demonstrated by qR2 than by ADC. Acquisition of ADC alone underestimates severity of acute ischemia and infarct growth. Combining quantitative MRI using ADC and qR2 provide improved characterization of acute infarct evolution.
Abstract TP74: Early Administration of Tissue-plasminogen Activator Improves the Long-term Clinical Outcome at 5 Years After Onset
Authors: Aoki Junya , Kimura Kazumi , Sakamoto Yuki
Published: July 2021

Introduction & Hypothesis:
Data on long-term outcomes after tissue-plasminogen activator (tPA) therapy are limited. We evaluated the rate of favorable outcomes and mortality at 5 years after tPA therapy and investigated factors related to long-term clinical outcomes.

Methods:
Telephone interviews were used to assess the to the the modified Rankin Scale (mRS) scores at 3 months, 6 months, 1 year, 2 years, 3 years, 4 years, and 5 years after tPA therapy after written informed consent was obtained. When a telephone interview was not successfully accomplished, an interview letter was sent as an alternative method. Favorable outcome was defined as mRS 0-2, and unfavorable outcome was as mRS 3-6. Multivariate logistic regression analysis was conducted to investigate factors associated with favorable outcomes and mortality at 5 years after tPA therapy.

Results:
From 2005 to 2013, 256 (median age, 77 [interquartile range, 68-84] years; 157 [61%] males) patients were enrolled. The onset-to-treatment time (OTT) was 153 (120-176) minutes. At 3 months after tPA therapy, the median mRS score was assessed as 3 (1-5). Kaplan-Meier curve showed that favorable outcomes after 5 years after tPA therapy occurred in 45% patients and that the mortality rate was 40%. Univariate analysis showed that OTT was 123 (107-172) minutes in patients with favorable outcomes and 155 (124-172) minutes in patients with non-favorable outcomes (p=0.046). In addition, OTT was 157 (133-172) minutes in the death group and 123 (106-169) minutes in the survival group (p=0.001). Multivariate regression analysis indicated that OTT was an independent factor related to favorable outcomes (odds ratio 0.97, 95% confidence interval 0.95-0.99, p=0.008) and mortality (odds ratio 1.04, 95% confidence interval 1.02-1.06, p=0.001). Receiver operating characteristic curve analysis showed that OTT ≥ 136 minutes was the optimal cut-off value to predict favorable outcome at 5 years after tPA therapy, with a sensitivity of 0.67, a specificity of 0.70, and an area under curve (AUC) of 0.662 (p=0.016), and that to predict death within 5 years after tPA therapy, with a sensitivity of 0.70, a specificity of 0.66, and an AUC of 0.679 (p=0.001).

Conclusion:
Early tPA administration can improves long-term clinical outcomes.
Abstract WMP118: A Radio-clinical Scale to Predict Long-term Outcome After Brain Arteriovenous Malformation Rupture: The Ruptured AVM Prognostic Score
Authors: Shotar Eimad , Debarre Mathieu , Sourour Nader-Antoine , Di Maria Federico , Gabrieli Joseph , Nouet Aurélien , Chiras Jacques , Degos Vincent , Clarençon Frédéric
Published: July 2021

Background and Purpose:
Brain arteriovenous malformations (BAVMs) are a leading cause of intracranial hemorrhage in young adults. Contrary to subarachnoid hemorrhage, there is no validated scale dedicated to stratifying patients with BAVM rupture. We aimed to design a new BAVM prognostic score.

Methods:
Records of 135 patients with 139 BAVM rupture events consecutively admitted to a tertiary care center during 11 years were reviewed. Independent predictors of long-term poor outcome (modified Rankin scale (mRS) > 3) more than one year after admission were identified. A risk stratification scale was developed and compared to the intracerebral hemorrhage (ICH) score to predict poor outcome and delta mRS (difference between follow-up and baseline pre-hemorrhage mRS).

Results:
Multivariate logistic regression followed by stepwise analysis determined that consciousness level (odd ratio [OR] 6.5, 95% confidence interval (CI) [3.09-13.7], P < 10-3), hematoma volume (OR 1.84, 95% CI [1.21-2.8], P = 0.005) and intraventricular hemorrhage (OR 7.46, 95% CI [2.66-21], P-value < 10-3) were independently associated with 1-year poor outcome. A 12-scale simplified score for ruptured BAVM prognostication was constructed combining consciousness level, hematoma volume and intraventricular hemorrhage . This new score was a stronger predictor of poor outcome (P=0.009) and delta mRS 3 (P=0.01) than ICH score.

Conclusion:
We propose a new admission score (the Ruptured AVM Prognostic Score [RAPS]) dedicated to stratifying the risk of poor long-term outcome after BAVM rupture. This easy to use score may serve both to improve communication between healthcare providers and consistency in clinical research.
Abstract WMP16: Eloquence-Weighted Imaging Improves Clinical Outcomes Prediction in Endovascular Stroke Therapy
Authors: Sheth Sunil A , Liebeskind David S , Liang Conrad W , Yoo Albert J , Jahan Reza , Nogueira Raul G , Pereira Vitor M , Gralla Jan , Albers Greg , Goyal Mayank , Saver Jeffey L
Published: July 2021

Background:
Larger infarct size at presentation as determined by ASPECTS is associated with reduced likelihood of good outcome in acute ischemic stroke. However, infarct volume alone explains only a modest fraction (∼30%) of the variation in stroke outcome. Incorporating the relative eloquence of each ASPECTS region may improve the predictive power.

Methods:
In the combined database of the SWIFT and STAR trials, we identified patients treated with the Solitaire stent retriever. Using the 24hr CT scan, a multivariate linear regression was used to determine the relative contribution of each ASPECTS region, separately in each hemisphere, to freedom from disability (mRS 0-2) at 90 days. The coefficients from the regression were used to create an Eloquence-weighted ASPECTS score (EL-ASPECTS), which was compared against the original in predicting outcome based on the presentation CT scan.

Results:
Among 254 patients treated with ET, average age was 68, 64% were female, and NIHSS was mean 16 (SD +/- 5). Mean ASPECTS at presentation was 8.2 and 6.4 at 24 hrs. The most commonly involved ASPECTS regions were the lentiform nuclei (70%), insula (55%), and caudate (52%). In multivariate analysis, for the right hemisphere on 24hr CT, preservation of M1 (OR 1.6) and M4 (OR 1.2) regions were most strongly predictive of good outcome. For the left hemisphere on 24 hr CT, preservation of M3 (OR 2.6), and M5 (OR 2.5) and involvement of M2 (OR -1.9) were most predictive. Eloquence weights were assigned to all 20 R/L ASPECTS regions to create EL-ASPECTS. EL-ASPECTS, compared with original ASPECTS, demonstrated improved discrimination for independent functional outcome for right hemisphere (C-statistic 0.78 vs. 0.69), left hemisphere (0.78 vs. 0.72), and all stroke patients (0.76 vs. 0.70). On presentation CTs, multivariate analyses including age and presentation NIHSS demonstrated EL-ASPECTS but not original ASPECTS was predictive of good clinical outcome (OR 1.65, p<.01). Higher C-statistic values were seen with EL-ASPECTS in analysis of presentation CT scans.

Conclusions:
Incorporation of regional weighting into ASPECTS improves the ability to predict who will achieve independent functional outcomes with endovascular therapy in acute ischemic stroke.
Abstract WMP18: Thrombus Length Estimation on Delayed Gadolinium-enhanced T1
Authors: Yan Shenqiang , Chen Qingmeng , Xu Mengjun , Lou Min
Published: July 2021

Objective:
Previous studies revealed a close relationship between thrombus length and recanalization rate after intravenous thrombolysis (IVT). However, there is no effective measurement of thrombus length on MRI. As a novel approach, we prospectively adjusted the order of sequence acquisition to obtain delayed gadolinium-enhanced T1 (dGE-T1) and thereby assess thrombus length on dGE-T1 to evaluate its predictive value for recanalization after IVT.

Methods:
We reviewed prospectively collected clinical and imaging data from acute ischemic stroke patients with middle cerebral artery (MCA) occlusion who underwent multimodal MRI before and 24 hours after IVT. Perfusion-weighted imaging (PWI) was performed followed by conventional T1. We measured thrombus length on dGE-T1 and examined its association with MCA recanalization.

Results:
Of the included 74 patients, the median age was 66 years and 28 (37.8%) were women. Median baseline NIHSS score was 13 (IQR 6-17). Thrombus length was 8.18 ± 4.56 mm on dGE-T1, which was an acceptable predictor for no recanalization (odds ratio 1.196; 95% CI: 1.015 to 1.409; p=0.033), with a receiver-operator characteristic of 0.732 (95% CI: 0.619 to 0.845; p=0.001). The optimal cut-off point was identified at 6.77 mm, which yielded a sensitivity of 77.8% , a specificity of 57.9%, and odds ratio 4.81 (95% CI: 1.742 to 13.292; p=0.002). Moreover, no one achieved recanalization after IVT when length of thrombus exceeded 14 mm on dGE-T1.

Conclusions:
The dGE-T1, obtained by simply adjusting scanning order in multimodal MRI protocol, is a useful tool for thrombus length estimation and MCA recanalization prediction after IVT.
Abstract WMP32: Variation in the Rates of Acute Ischemic Stroke Transfers Between Hospitals in the United States
Authors: Ali Syed F , Fonarow Gregg , Smith Eric , Liang Li , Sutter Robert , Xian Ying , Peterson Eric , Bhatt Deepak , Schwamm Lee
Published: July 2021

Background:
Many patients are transferred from emergency departments or inpatient units to stroke centers for advanced acute ischemic stroke (AIS) care, especially after intravenous tissue plasminogen activator (tPA). We sought to determine variation in the rates of AIS patient transfer in the US.

Methods:
Using data from the national Get With The Guidelines-Stroke registry, we analyzed AIS cases from 01/2010 to 03/14. Transfer-in was defined as transfer of AIS patients from other hospitals. Due to large sample size, instead of p-values, standardized differences were reported and a map of transfer-in rates across the US constructed.

Results:
Of the 970,390 patients discharged from 1,646 hospitals in the US, 87% were admitted via the ER or direct admission (front door) vs. 13% transferred-in. While most hospitals (61%) had transfer-in rates of < 5% of all AIS patients, a minority (17%) had high (>15%) transfer-in rates. High transfer-in hospitals were more often in the Midwest, were larger, and had higher annual AIS and IV tPA case volumes, and were also more often teaching hospitals and stroke centers (primary or comprehensive) (Table and Figure).. IV tPA was used more frequently in eligible patients in high-volume transfer-in hospitals (Table); otherwise, stroke quality of care was similar.

Conclusions:
There is significant regional- and state-level variability in the transfer of AIS patients. This may reflect differences in resource availability and the distribution of smaller, under-resourced hospitals that frequently transfer patients for advanced care after stabilization. Additional research is warranted to understand this variation.
Abstract WMP37: Neurovascular Protection by Telmisartan Via Reducing Neuroinflammation in SHR-SR Brain After Ischemic Stroke
Authors: Kono Syoichiro , Kurata Tomoko , Sato Kota , Hishikawa Nozomi , Yamashita Toru , Deguchi Kentaro , Abe Koji
Published: July 2021

Telmisartan is a highly lipid soluble angiotensin receptor blocker (ARB) which improves insulin sensitivity and reduces triglyceride levels, thus is called metabo-sartan. We examined effects of telmisartan on neurovascular unit (NAGO, collagen IV, and GFAP) and neuroinflammation (MMP-9 and inflammasome) in brain of stroke-resistant spontaneously hypertensive rat (SHR-SR). At 12 weeks of age, SHR-SR received transient middle cerebral artery occlusion (tMCAO) for 90 min, and were divided into the following 3 groups, i.e., vehicle group, low-dose telmisartan group (0.3 mg/kg/day), and high-dose telmisartan group (3 mg/kg/day,
p.o.
). Immunohistological analysis at ages 6, 12 and 18 months showed progressive decreases of NAGO-positive endothelium and collagen IV positive basement membrane, and progressive increases of MMP-9-positive neurons, GFAP-positive astrocytes, and NLRP3-positive inflammasome in the cerebral cortex of vehicle group. Low dose telmisartan reduced such changes without lowering blood pressure (BP), and high dose telmisartan further improved such changes with lowering BP. The present findings suggest that a persistent hypertension caused a long lasting inflammation after tMCAO in SHR-SR which accelerated neurovascular disruption and emergent inflammasome, and that telmisartan greatly reduced such inflammation and protected the neurovascular unit via its pleiotropic effects in living hypertensive rat brain after ischemic stroke.
Abstract WMP51: Patients’ Social Networks Influence Timing of Hospital Arrival After Acute Ischemic Stroke: a Mixed Methods Study
Authors: Dhand Amar , Luke Douglas , Tsiaklides Michael , Lang Catherine , Lee Jin-Moo
Published: July 2021

Introduction:
Delay in hospital arrival is a major reason for stroke patients’ exclusion from acute therapy. Risk factors for delay include older age, minor symptoms, and living alone. Personal social networks, consisting of the structure and content of relationships around a patient, are important and modifiable factors to health behavior. This study examined the role and mechanisms of patients’ social networks in prehospital delay.

Hypothesis:
Social network structure is an independent risk factor of prehospital delay through social influence mechanisms.

Methods:
Seventy consecutive patients with mild acute ischemic stroke were interviewed in the hospital. An established social network analysis instrument was used to assess personal network structure and composition. This was followed by semi-structured interviews in 14 patients focused on the arrival process. Fast arrival was defined as before 6 hours, and slow was after 6 hours.

Results:
There were 32 slow and 38 fast arrivers. The mean age (63) and NIHSS (3) did not differ between groups. Subcortical stroke location (53% versus 26%) and being unmarried (75% versus 44%) were more common in slow compared to fast arrivers (p<0.05). After controlling for known risk factors, social network structure was significantly associated with arrival time. As shown in figure 1, patients (A) who had networks with high constraint (e.g., strong ties among all network members) were slower to arrive than patients (B) with low constraint (e.g., weak or no ties among network members). Constraint had an adjusted OR=1.08 (95% CI 1.03-1.13, p<0.005) for slow arrival. Mechanisms revealed from qualitative analysis were social capital benefits in fast arrivers, and family members’ perceptual bias to minimize symptoms in slow arrivers.

Conclusions:
Patients’ social network structure is an independent risk factor for prehospital delay. These results may be used to develop network-tailored stroke education.
Abstract WMP7: Cost Effectiveness of Stent-retriever Thrombectomy Compared With Intravenous Thrombolytic Therapy Alone in Acute Ischemic Stroke Patients
Authors: Chaudhry Saqib A , Ishfaq Muhammad F , Sivagnanam Kamesh , Qureshi Adnan I
Published: July 2021

Introduction:
Despite recent clinical trials demonstrating greater benefit with mechanical thrombectomy,thehigher cost associated with thrombectomy may limit its broad applicability.

Objective:
To determine the cost-effectiveness of stent-retriever thrombectomy plus IV-tPA versus IV-tPA alone in acute ischemic stroke patients.

Method:
The probability of individual primaryendpoints was obtained from the results of the SWIFT PRIME trial that compared98 acute ischemic stroke patients who received intravenous rt-PA alone with 98 patients who had mechanical thrombectomy with IV rt-PA (combination therapy). Total cost associated with each therapeutic intervention was derived from hospitalization cost and cost associated with primary and secondary endpoints of dependence, independence and death in each group. All probabilities, quality-of-life factors, and costs were estimated from the published literature. Costs were adjusted for inflation. A Monte Carlo simulation model was built to compare the health benefits and costs associated with combination therapy compared with IV-tPA alone. Overall costs and QALY’s were varied around probability values from the SWIFT PRIME trial to generate the simulation. Standard errors were used for generating variability.Incremental cost effectiveness ratio and cost effectiveness acceptability curves were also derived.

Results:
The cost effectiveness acceptability plane was completely situated in the south-east quadrant. This denotes that thrombectomy along with t-PA was both cheaper as well as improved Quality of life when compared to t-PA alone. Overall, QALYs for the thrombectomy and Iv-tPA and IV-tPA groups were 0.60(0.005) and 0.51(0.004), respectively (ranging from 0.0 [death] to 0.77 [independent]. Overall cost of combination therapy was $754,790 (12,303) and for IV-tPA alone was $933,190($7,495). The incremental cost effectiveness ratio was -$21,450 ($1,857)per QALY. The major costs in the tPA arm were a result of greater dependence at 90 days.

Conclusion:
In acute ischemic stroke patients and major arterial occlusion, stent-retriever thrombectomy in addition to intravenous t-PA,is both cost effective and improves quality of life.
Abstract WMP98: Thrombophilia Risk Factors in Perinatal Stroke: 213 Consecutive Cases
Authors: Lehman Laura , Beaute Jeanette , Malkin Hayley , Rivkin Michael , Trenor Cameron
Published: July 2021

Introduction:
Perinatal stroke, including neonatal and presumed perinatal presentation, is the most common type of pediatric stroke. No guidelines exist for evaluation after perinatal stroke and the roles of thrombophilia, arteriopathy and cardiac anomalies are unclear. We took a systematic approach to perinatal stroke evaluation to better understand these risk factors.

Hypothesis:
Thrombophilia, arteriopathy and cardiac anomalies are more common in perinatal stroke and may predict recurrence.

Methods:
After IRB-approval, we reviewed records of perinatal stroke patients from August 2008 to July 2015. Demographics, echocardiography, MRA and thrombophilia testing were collected. Statistical analysis is descriptive.

Results:
Among 213 children with perinatal stroke, 92 (43.2%) were female and mean age at diagnosis was 1.56 years. Caucasians comprised 69.5%, African-Americans, 7.5%, Asians, 1.9%, other, 8% and undeclared, 13.1%. Presentation was neonatal (113, 53.1%) or presumed perinatal (100, 46.9%). Strokes were classified as arterial (140, 65.7%), venous (51, 23.9%), both (4, 1.9%) or uncertain (19, 8.5%) by imaging. Mean length of follow-up was 3.2 years. Of 213 patients, 10 (4.7%) experienced recurrent events (4 transient ischemic attack, 3 sinovenous thrombosis and 3 arterial ischemic stroke). Thrombophilia data are presented in Table 1. After excluding venous events, 162 patients were evaluated for arteriopathy, cardiac risk factors and recurrence. Of eight recurrences in this group, none had arteriopathy, 3 (37.5%) had patent foramen ovale and none had other cardiac risk factors, compared to 5/108 (4.6%), 52/102 (51%) and 7/102 (6.8%) in the non-recurrent cases.

Conclusions:
Arteriopathy and cardiac anomalies were not associated with recurrence. Some thrombophilia tests appear enriched in perinatal stroke. With few cases of recurrence after perinatal stroke, it is unclear whether thrombophilia predicts recurrence.