bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP160: The
Ring Finger Protein
213 Variant and Characteristics of Plaque, Vascular Remodeling and Hemodynamics in Patients With Intracranial Atherosclerotic Stroke: A High-Resolution Mri and Hemodynamic Study
Authors: Bang Oh Young , Choi Eun-Hyeok , Lee Hanul , Chung Jong-Won , Seo Woo-Keun , Kim Gyeong-Moon , Ki Chang-Seok , Kim Yoon-Chul
Published: January 2019

Background:
Intracranial atherosclerotic stroke is prevalent in Asians. We hypothesized patients with the
Ring Finger protein
213
(
RNF213
) variant, a susceptibility locus for moyamoya disease in East Asians, have different neuroimaging characteristics in terms of vessel wall and hemodynamics.

Methods:
We analyzed consecutive patients with ischemic events in the middle cerebral artery (MCA) distribution and relevant plaque on the distal internal carotid artery or proximal MCA on high-resolution MRI (HR-MRI). Patients with carotid/cardiac sources of embolism or angiographic features of moyamoya disease were excluded. HR-MRI features (e.g., outer vessel diameters and plaque characteristics) and fractional flow (as measured by adjusted signal intensity ratio on time-of-flight MRA) were compared between
RNF213
p.Arg4810Lys variant carriers and non-carriers.

Results:
Of 144 patients included, 44 (29.9%) patients had the
RNF213
variant. Clinical characteristics including age, gender, and vascular risk factors were not different between
RNF213
variant carriers and non-carriers. However, outer vessel diameter was smaller in
RNF213
variant carriers than in non-carriers (p<0.0001 for MCA of relevant stenosis, p<0.0001 for contralateral side, and p<0.001 for basilar artery). Other HR-MRI features including plaque morphology were not different. Fractional flow was diminished in patients with a smaller diameter of the intracranial arteries with the similar degree of stenosis.

Conclusions:
The
RNF213
variant may be associated with vasculogenesis but not with atherogenesis. Patients with this variant had small intracranial arteries predisposing hemodynamic compromise in the presence of intracranial atherosclerosis. Beside anti-atherosclerotic strategies, further studies are warranted to develop a novel therapeutic strategies against
RNF213
vasculopathy in Asians.
Abstract TP161: Differential Expression of
PHACTR1
and
EDN1
in Atheromatous vs. Normal Carotid Tissue
Authors: Green Ilana , Williams Stephen R , Sale Michèle M , Keene Keith L , Worrall Bradford B , Southerland Andrew M
Published: January 2019

Introduction:
Several related neurovascular phenotypes, including cervical artery dissection, fibromuscular dysplasia, large artery stroke, hypertension, and migraine headache are associated with a single nucleotide polymorphism (rs9349378) in the phosphatase and actin regulator-1 (
PHACTR1
) gene recently identified as a distal regulator of the endothelin-1 (
EDN1
) gene. Vascular endothelial cells release EDN1, a potent vasoconstrictor. We hypothesize that atheromatous and normal carotid tissue will differentially express
PHACTR1
and
EDN1
.

Methods:
We obtained gene expression data from the publically available Gene Expression Omnibus Carotid Atheroma Dataset (GSE43292). This resource contains 32 paired samples of carotid atheroma and distant macroscopically intact carotid tissue from the same individual and gene expression data from the Affymetrix Human Gene 1.0 ST Array. We compared log transformed count of signal intensity of
PHACTR1
and
EDN1
expression in the 32 paired samples using a two-sample t-test assuming equal variance with SPSS (IBM, Armonk, NY).

Results:
PHACTR1
expression was lower in atheromatous compared to normal carotid tissue (7.152 vs. 7.399, delta 0.248, 95%CI 0.180 - 0.315, p=1.9 E
-8
).
EDN1
expression did not differ (6.514 and 6.339, delta 0.176, 95%CI -0.004 - 0.356, p = 0.055). with genetic data associating the rs9349378[G] allele with lower levels of expression and atherosclerotic vascular diseases. The lack of differential
EDN1
expression may reflect the small sample size or may challenge the assertion that
EDNI
is the mediator of the
PHACTR1
association. Our data support the hypothesis that this pathway may play an important and potentially variable role in neurovascular phenotypes including large artery atherosclerotic stroke and non-atherosclerotic arteriopathies.
Abstract TP162: Patterns of Pre-Stroke Atherosclerotic Stenosis and Pretreatment Collateral Status in Acute Ischemic Stroke
Authors: Kim Hyung Jun , Jung Kyu-On , Lee Seung-Jae
Published: January 2019

Background:
To date, there is no consensus regarding the factors associated with collaterals in acute ischemic stroke. Our study attempts to examine variables associated with pretreatment collaterals.

Methods:
From our hospital stroke registry, we retrospectively recruited 115 patients with acute anterior circulation infarct considered for endovascular reperfusion therapy. Collateral score (0-3) was rated using pretreatment CT angiography. Score of 0 or 1 (≤50% filling of the occluded territory) was considered as poor collaterals. The patterns of steno-occlusion other than culprit occlusion for infarct were classified into intracranial or extracranial atherosclerotic stenosis based on the location of steno-occlusion (> 50% on CTA).

Results:
Forty five of the 115 patients had poor collaterals. Variables (with univariate P< 0.1) associated with collaterals were, as pretreatment variables, older age ( ≥65 years) (P=0.067), hypertension (P=0.034), diabetes (P=0.093), initial NIHSS (P=0.002), location of culprit occlusion for infarct (P=0.001), intracranial stenosis (P=0.003), and as treatment or post-treatment variables, use of intravenous tissue plasminogen activator (P=0.004), successful recanalization (TICI grade 2b or 3: P=0.009), symptomatic intracranial hemorrhage (P=0.004), final infarct size (P<0.001). When multivariable logistic regression for poor collaterals was performed using the pretreatment variables, internal carotid artery occlusion and intracranial stenosis were significantly associated with poor collaterals (Table).

Conclusions:
Coincidental intracranial atherosclerotic stenosis is associated with pretreatment poor collaterals during acute stage of stroke. It might be because collateral flow is assumed to be largely dependent on flow from non-occluded intracranial arteries neighboring to culprit vascular lesion for infarct.
Abstract TP164: Impact of Early Admission to Inpatient Rehabilitation Facilities on Functional Outcome With Stroke
Authors: Nariaki Shiraishi , Suzuki Yusuke , Matsumoto Daisuke , Jeong Seungwon , Sugiyama Motoya , Hayashi Takahiro , Kondo Katsunori
Published: January 2019

Objective:
To determine whether early admission of patients with stroke into an inpatient rehabilitation facility (IRF) results in motor function improvement during hospitalization.

Methods:
Data were extracted from the Japan association of rehabilitation database for 2,760 patients admitted to IRFs at 28 centers. Early IRF admission was defined as 14 days from stroke onset to IRF admission. Variables surveyed were age; sex; stroke type; length of stay; period from stroke onset to IRF admission; motor functional independence measure (mFIM) and cognitive FIM at admission and discharge; and modified Rankin Scale score before onset, at admission, and at discharge. In addition, the difference between mFIM at admission and at discharge per day (ΔmFIM/day) was calculated by dividing by the length of stay. The average rehabilitation intensity per day was calculated as the total units of rehabilitation during hospitalization divided by the length of hospital stay. We defined intensive rehabilitation as rehabilitation conducted at the first quartile (>2.27 hour/day). Multiple regression analysis and instrumental variable analysis were performed to examine the association of early rehabilitation with activities of daily living (ADL) at discharge.

Results:
ΔmFIM/day was higher in early and intensive rehabilitation. The multiple regression analysis showed that significant improvements in ΔmFIM/day were observed for intensive rehabilitation (partial regression coefficient: 1.56; 95% confidence interval: 0.34-2.8), after controlling for various confounding variables. The instrumental variable analysis showed that ΔmFIM/day was associated with early IRF admission (partial regression coefficient: 0.1; 95% confidence interval: 0.05-0.14).

Conclusion:
Patients with stroke experience greater improvement in ADL if admitted to an IRF within 14 days after stroke onset.
Abstract TP165: Association of Admission versus 24-Hour NIHSS Score With Early Ambulation After Stroke
Authors: Louie Dennis R , Simpson Lisa A , Field Thalia S , Eng Janice J
Published: January 2019

Introduction:
Predicting who will be ambulatory within the first several days after stroke may help support resource allocation, and discharge and rehabilitation planning. The National Institutes of Health Stroke Scale (NIHSS) is commonly used to rate stroke severity. Due to medical intervention or stroke progression, the NIHSS score at admission versus 24 hours can be drastically different. We explored whether presence of leg weakness at admission or 24 hours was most predictive of early ambulation, and other NIHSS score components associated with early ambulation.

Methods:
A consecutive sample of patients admitted to a stroke unit at a comprehensive stroke center was included in this retrospective study. Initial and 24-hour NIHSS scores were examined in conjunction with various demographic and stroke details. Multivariable logistic regression models identified predictors of ambulation within the first week of admission.

Results:
Of 513 stroke patients, 273 (53%) were able to walk with or without assistance within the first 3-5 days post-stroke. The multivariable model utilizing the 24-hour NIHSS combined right and left lower extremity weakness scores had greater predictive value (area under the curve [AUC] = 0.85; 95% confidence interval [CI] 0.81 - 0.88) than the initial score (AUC = 0.74; 95% CI 0.69 - 0.78). In the multivariable analysis, 24-hour combined leg weakness (odds ratio [OR] 0.29; 95% CI 0.22 - 0.39), ataxia (OR 0.63; 95% CI 0.43 - 0.91), and sensation (OR 0.58; 95% CI 0.37 - 0.91) scores were all associated with early ambulation capacity.

Conclusions:
The prediction of early ambulation is more accurate after 24 hours post-stroke. Leg weakness, ataxia, and sensory loss at 24 hours are all negatively associated with ability to ambulate after stroke.
Abstract TP166: The Six Minute Walk Test as a Predictor for Fall Risk in Persons With Stroke
Authors: Regan Elizabeth , Fritz Stacy
Published: January 2019

Introduction:
Persons with stroke have increased risk for recurrent stroke, other chronic health conditions and falls. One option to reduce the risk of worsening health conditions is to increase physical activity by engaging in group medical fitness programs like cardiac rehabilitation (CR). CR programs utilize clinical measures for functional capacity, commonly exercise stress testing or the six-minute-walk test (6MWT). Absent is measurement and focus on balance or balance confidence. Supervising staff may be unaware of fall risk which is an important safety factor for persons with stroke. The purpose of this study was to determine the degree to which the 6MWT is associated with fall risk in community-dwelling persons with stroke.

Methods:
A cross-sectional analysis measured association between the 6MWT and fall risk in 66 persons with stroke. Fall risk is defined as a score on the Activities Balance Confidence Scale (ABC) of < 81.1 based on a study by Beninato et al. (2009) which found significant accuracy of fall prediction with this cutoff (Sensitivity = 1.00, Specificity = 0.72(0.51-0.93)). The 6MWT and the 6MWT combined with other data differing between fall risk groups (e.g. walking speed, Berg Balance Scale and time since stroke) were evaluated using univariate logistic regression to determine influence on fall risk. The best fit model was used in Receiver Operating Characteristic (ROC) analysis to determine the area under the curve (AUC) to detect an increased risk of falls. Likelihood ratios and post-test probabilities were calculated.

Results:
The 6MWT was associated with fall risk in logistic regression (p=0.002) with an odds ratio (OR) of 0.995 (0.991,0.999), p=0.007). The AUC for the univariate 6MWT ROC model (best fit) was 0.701 (p=0.006). The cutoff for increased fall risk was 6MWT < 331.65 meters. The post-test probability of fall risk was 74.3%, increased from a pre-test probability of 59.1%.

Conclusion:
The association between fall risk and 6MWT suggests that in addition to aerobic capacity and motor components, the 6MWT includes a fall risk/balance confidence component. In conclusion, utilizing the 6MWT to screen fall risk in CR and other community exercise programs can enhance safety for persons with stroke without additional testing burden.
Abstract TP167: Prevalence of Growth Hormone Deficiency in the Chronic Phase of Recovery From Stroke
Authors: Kreber Lisa A , Ashley Mark J , Singh Charan K , Randle Kevin D , Masel Brent E , Johnson Christine , Helvie Richard E , Ashley Matthew J , Griesbach Grace S
Published: January 2019

Introduction:
The objective of the current retrospective study was to determine the prevalence of growth hormone deficiency (GHD) in middle-aged patients with ischemic and hemorrhagic stroke who were at least 3 months post-stroke. It was hypothesized a large percentage of patients with stroke would exhibit growth hormone deficiency, as well as, other hormone deficiencies. A secondary objective was to determine if chronic health conditions often associated with stroke were associated with neuroendocrine dysfunction.

Methods:
Clinical records from 139 adult patients (from 2009-2017), who were in the post-acute phase of their recovery, were obtained to analyze findings from standard endocrine blood tests. Patients with a pre-stroke history of endocrine anomalies were excluded from the study. Growth hormone was assessed by the glucagon stimulation test (GST).

Results:
GHD was identified in 54% of the patients with stroke during the chronic phase of recovery. Patients with GHD took longer to be admitted to post-acute rehabilitation compared to patients with normal GH levels. Patients with GHD also had lower levels of follicle stimulating hormone (FSH), triiodothyronine (T3), luteinizing hormone (LH) and sex hormone binding globulin. Body mass index was higher in patients with GHD.

Conclusions:
There is a considerable risk of developing hypopituitarism, particularly GHD, following ischemic or hemorrhagic stroke. In this relatively large sample of middle-aged stroke patients, GHD was associated with decreased levels of T3 and gonadotrophic hormones. Co-morbidities for stroke and neuroendocrine dysfunction overlap and may have implications for recovery following stroke and warrant further investigation.
Abstract TP168: Impairment of Cerebral Blood Flow Autoregulation in Patients With Acute Cerebral Infarction Recovered Within 7-10 Days After Onset
Authors: Katayama Naoki , Odagiri Keiichi , Hakamata Akio , Inui Naoki , Yamauchi Katsuya , Watanabe Hiroshi
Published: January 2019

InIntroduction:
Cerebral blood flow (CBF) autoregulation is impaired after acute cerebral infarction (AIS). Although previous studies revealed that changes in cerebral oxygenation occurred when head-of-bed raised from flat to head-up position within 72hr after onset, chronological changes of this phenomenon had never been evaluated.

Hypothesis:
We hypothesized that the impairment of CBF autoregulation improved within 7-10 days after onset of AIS. We aimed to evaluated the chronological changes in oxygenated- (ΔHbO
2
), deoxygenated- (ΔHb) and total-hemoglobin (ΔtHb) concentration in response to passive sitting between <72hr and 7-10 days after onset of AIS.

Method:
We repeatedly measured forehead ΔHbO2, ΔHb and ΔtHb in response to raise the head-of-bed to 30 degrees from spine within 72hr (1
st
measurement) and 7-10 days (2
nd
measurement) after onset of AIS by using time-resolved near-infrared spectroscopy. Difference in the ΔHbO2, ΔHb and ΔtHb values between two measurements were compared. We also evaluated Spearman Rank Correlation Coefficient of those values between affected and unaffected side in each measurement.

Results:
A total of 37 participants (mean age, 70.4±12.5 years; 13 females) with a first AIS hospitalization in the Seirei Mikatahara General Hospital, Hamamatsu, Japan, were enrolled. No significant differences of ΔHbO
2,
ΔHb or ΔtHb in either affected or unaffected side were observed between two measurements. The ΔHbO
2,
ΔHb or ΔtHb of the affected side did not correlate with those in the unaffected side at the first measurement (ΔHbO
2
; r=0.197, p=0.282, ΔHb; r=0.065, p=0.695. and ΔtHb; r=0.193, p=0.245, respectively). Interestingly, the correlation coefficients of the ΔHbO
2,
ΔHb and ΔtHb between affected and unaffected side at the 2
nd
measurement were statistically significant (ΔHbO
2
; r=0.420, p=0.011, ΔHb; r=0.398, p=0.017. and ΔtHb; r=0.490, p=0.003, respectively).

Conclusion:
Although cerebral oxygenation changes in relation to posture change did not correlate between affected or unaffected side within 72hr after onset, this difference was improved in 7-10 days after onset. Our result suggested that the impairment of CBF autoregulation improved, at least partially, within 7-10 days after onset of AIS.
Abstract TP17: Outcomes of Large Vessel Occlusion Patients in a Multi-Hospital System With Nihss<6 Treated With Endovascular Thrombectomy vs Medical Management
Authors: Augustine Steven B , Tarpley Jason , Lucas Lindsay , Baraban Elizabeth
Published: January 2019

With the publication of the 2018 updated acute stroke management guidelines, the American Stroke Association very publically proclaimed the safety and efficacy of endovascular thrombectomy (EVT) for the treatment of acute ischemic stroke due to proximal large vessel occlusion in individuals with NIHSS >=6. The appropriate management of individuals who present with less severe large vessel occlusion (NIHSS < 6) is less certain. Anecdotally, many individuals with low presenting NIHSS who are treated with EVT do well; conversely, about 20% of medically managed stroke patients deteriorate.

We retrospectively analyzed stroke data obtained from a multi-hospital system for large vessel occlusion patients with admission NIHSS < 6 discharged between January 2014 and May 2018, excluding those <18 years of age and those with time of onset or last known well that is unknown or >24hours. Outcomes included length of stay and percentage of patients who died in-hospital or were discharged to hospice, had a discharge other than to home or rehab, and had a discharge mRS ≥2.

A total of 144 patients were included with 45% (n=65) treated by EVT. Those who were treated were younger, had higher admit NIHSS, and were more likely to be transfers. There were no significant differences in in-hospital mortality or discharge to hospice, discharge other than to home or rehab, or discharge mRS ≥2. EVT-treated patients had longer lengths of stay after adjusting for age, admission NIHSS, and LKW-to-door time (+36% (CI: 8, 64); p=0.012). Of EVT-treated patients, 3.1% (n=2) had a sICH and 90.3% (n=56 out of 62) had a successful reperfusion.

When using medical judgment to evaluate the benefit of treating low NIHSS stroke, Interventionists are likely to select individuals who are more symptomatic or have been referred by an outside facility, a trend that achieved significance within our sample. Although the length of stay for individuals treated with EVT was on average one day longer than those who were medically managed, there was no significant difference in complications or outcomes between the two groups. Our findings are consistent with similar analyses and help argue for the safety of EVT for select individuals with presenting NIHSS < 6.
Abstract TP172: Global Insight into Long-term Stroke Outcomes Using the Post Stroke Checklist
Authors: Olver John H , Fedele Bianca , Ni Mary , Frayne Judith , McKenzie Dean
Published: January 2019

Objectives:
There are long-term consequences following an individual suffering from a stroke. Despite clinical recommendations, there remains an absence of continued follow-up support for patients in most regions of the world. Estimates in the current literature estimate that 50% of patients are discharged without rehabilitation input and within two weeks, 50% of patients report having unmet needs. The Post Stroke Checklist (PSC) was designed for the long-term surveillance of continuing difficulties post stroke. This study aimed to evaluate international patterns of unmet needs following stroke, using the PSC.

Methods:
The PSC (endorsed by the World Stroke Organization and incorporated into the Canadian Stroke Best Practice Recommendations) identifies common long-term problems after stroke and appropriate referral pathways to address them. The PSC has been administered internationally including publications from Italy, Singapore and the UK’s stroke populations. This study follows this succession and trialed the PSC in an Australian (n=112) and Chinese (n=97) population at six months post stroke.

Results:
Between the samples (n=209), adjusted comparisons found a significantly higher proportion of unmet needs in China (mean= 4.67) compared with Australia (mean= 3.49). On the PSC, the most common unmet needs for both countries were similar including: absence of information regarding secondary prevention of stroke, cognitive difficulties and difficulties participating in life activities. The proportions affected on the PSC items differed between the two countries; with significantly greater difficulties in daily living activities, mobility, mood changes for China (p<.05). In Australia, greater incidences were reported for spasticity, incontinence (p<.05) and communication. The paper will also contrast these results with the other published international studies.

Conclusion:
Recording long-term functional disability post stroke highlights specific unmet needs and can encourage better support for community follow-up from governments, funding agencies and clinical programs. Providing international perspectives on these outcomes can also inspire changes in the post-hospital phase where pathways for treatment remain disjointed.
Abstract TP174: Clustering and Predicting Functional Recovery Patterns of the First-ever Ischemic Stroke Using Artificial Intelligence: The KOSCO Study
Authors: Chang Won Hyuk , Shin Mina , Shin Yong-il , Sohn Min Kyun , Lee Jongmin , Kim Deog Yung , Lee Sam-Gyu , Kim Soo-Yeon , Oh Gyung-Jae , Lee Yang-Soo , Joo Min Cheol , Han Eun Young , Han Jun Hee , Ahn Jeounghoon , Lee Kang Hee , Kang Sung Hyun , Choi Yong-Joo , Kim Young Taek , Choi Mon-Taek , Kim Yun-Hee
Published: January 2019

Objective:
The objective of this study was to apply the clustering approach of multi-facet functional recovery pattern with big data of in the Korean Stroke Cohort for Functioning and Rehabilitation (KOSCO) using artificial intelligence, and to provide valuable prediction models for clinically use.

Methods:
This study was an interim analysis of the KOSCO designed as 10 years long-term follow-up study of stroke patients. We analyzed data of participants who completed functional assessments from 7 days to 12 months after ischemic stroke onset. Functional assessments included Korean modified Barthel Index (K-MBI), Korean Mini-Mental State Examination (K-MMSE), Fugl-Meyer Assessment (FMA), Functional Ambulatory Category (FAC), the American Speech-Language-Hearing Association National Outcome Measurement System Swallowing Scale (ASHA-NOMS), and Short Korean Version of Frenchay Aphasia Screening Test (Short K-FAST). The cluster analysis using artificial intelligence was performed for multi-facet functional recovery patterns of independency, motor, ambulation, cognition, language, and swallowing functions. After the cluster analysis, a group of rehabilitation specialists reviewed the clinical meaningfulness with clustered population, whether the groups had high homogeneity and representativeness of the clinical stroke recovery patterns. After these clustering approaches, a prediction model using machine learning was performed. The accuracy of classification of this prediction model was evaluated by comparing how much the prediction was equivalent to the actual clustering result.

Results:
After the machine learning in supervised manners on artificial intelligence, recovery patterns after stroke could be classified into ten groups. Each group showed a different multi-facet functional recovery pattern from 7 day to 12 months, and this clustering showed a clinically acceptance. In addition, the accuracy in classification with clinical characteristics at 7 days showed more than 73.0%.

Conclusion:
The results of this study demonstrated the potentials of the clustering and predicting functional recovery patterns of stroke patients using artificial intelligence.
Abstract TP175: Changes in Brain Network After High Frequency Repetitive Transcranial Magnetic Stimulation Based on Brain Activation During Language Performance in Chronic Stroke Patients With Non-Fluent Aphasia
Authors: Kwon Sohyun , Paik Nam-Jong , Park Jihong
Published: January 2019

Introduction:
In post-stroke aphasia rehabilitation, repetitive transcranial stimulation (rTMS) aimed to reinforce the activity of the brain regions in the left hemisphere. In the present study, we performed functional near-infrared spectroscopy (fNIRS) with excitatory rTMS treatment for selection of the most appropriate application of stimulation and detection of the changes in cortical brain network. The purpose of this study is to assess the changes in brain network after high frequency rTMS in post-stroke non-fluent aphasia patients.

Methods:
Five right-handed patients with post-stroke non-fluent aphasia were included in this study. The most activated area of left hemisphere in fNIRS analysis was selected for stimulation. 34 channels were set by arranging 12 sensors and detectors at intervals of 3cm covering Broca and Wernicke areas. Excitatory rTMS (10Hz, 800 stimuli, 100% of resting motor threshold, tangential to scalp) at the most activated area with navigation system was done in combination with 30 minutes’ speech therapy for 10 consecutive days. Western aphasia battery (WAB) and fNIRS evaluation before (T0), right after 10 sessions of treatment (T1) and 2 months after the last treatment session (T2) were done. The changes in brain network were analyzed by the graph theoretical approach.

Results:
The scores from subtests in WAB have increased after excitatory rTMS combined with speech therapy in all subjects (Figure 1). The thresholded correlation in the area of stimulation became higher in all patients. The changes of network parameters such as global efficiency and small-worldness in Broca and Wernicke area was significant after rTMS in all patients.

Conclusion:
Aphasia quotient and scores from all subtests in WAB have increased significantly after targeted excitatory rTMS combined with speech therapy in all subjects. The efficiency in brain language network has been changed after excitatory rTMS.
Abstract TP176: Increased Resiliency is Associated With Better Recovery Trajectory Among Community Dwelling Stroke Survivors
Authors: Gyawali Prajwal , Chow Wei Zhen , Ong Lin K , Nilsson Michael , Walker Rohan F
Published: January 2019

Background:
The unanticipated devastating changes affecting the quality of life post-stroke leads to chronic stress. Elevated stress has been associated with the several worst outcomes of stroke. However, not all stroke survivors with acute stress advances to the stage of severe unfavourable outcomes. Apart from stroke severity, the functional outcome of stroke is embedded within the complex settings of individual’s unique personality traits such as resiliency. In this ongoing project, we aim to explore the relationship between resiliency and stress in stroke survivors and more importantly, we aim to investigate how they influence the recovery trajectory of stroke survivors.

Methods:
Community dwelling stroke survivors were recruited from Hunter Stroke Research Register. Demographics data, anthropometrics data and medical history related to cardiometabolic diseases were recorded. Stroke recovery was assessed from Stroke Impact Scale -version 3. Self-reported resilience was assessed using the Brief Resiliency Scale and Connor Davidson Resilience Scale. The level of stress was assessed using Perceived Stress Scale-10. Data were analysed using IBM SPSS Statistics.

Results:
All of the recruited stroke survivors (N=45; age: 62.6±13.49; male/female: 25/20; ischaemic/haemorrhagic: 29/16) were at the chronic phase of their stroke recovery. The strong inverse association was found between the level of resilience and the level of stress. Resiliency level correlated significantly with 6 out of 8 domains of stroke impact scale. There was no correlation between the level of stress and resiliency with demographics, anthropometric variables and associated cardiometabolic conditions. In stepwise multiple regression analysis, resiliency level was significantly associated with several domains of stroke impact scale and it accounted for the significant proportion of variance in stroke recovery.

Conclusion:
Since, resilience was inversely associated with stress level and higher resilience level was associated with favourable stroke recovery trajectory; equipping stroke survivor’s skills in building and maintaining resilience will reduce the level of stress and promote recovery at chronic phase post-stroke.
Abstract TP178: Pre-existing Volume of White Matter Disease Predicts Ischemic Stroke
Authors: Andere Ariana J , Yaghi Shadi , Chang Andrew D , Collins Scott , Merck Derek , McTaggart Ryan A , Jayaraman Mahesh V , MacGrory Brian C , Burton Tina M , Furie Karen L , Cutting Shawna
Published: January 2019

Background:
Patients are more likely to develop white matter disease (WMD) and microhemorrhage (MH) after ischemic stroke. Little is known about whether stroke patients had an increased prevalence of these findings before a stroke compared to patients who did not go on to develop a stroke.

Methods:
We retrospectively identified patients admitted to our institution with ischemic stroke between 5/16 - 12/17 who had magnetic resonance imaging (MRI) of the brain between 30 days-2 years prior to their stroke. Age and gender-matched controls for the initial MRI were identified for pair-wise comparison. Automatic segmentations of gray and white matter volumes and manual segmentation of WMD and MH (size<10mm) were completed using 3D Slicer 4.5 and 4.9, respectively. Univariate analyses and multivariate models were performed to determine factors associated with stroke. This included demographic factors and traditional vascular risk factors.

Results:
Among the 96 patients in our study, stroke patients (n=48, mean age 68, 50% female) had lower rates of cancer (p=0.03) but higher rates of hyperlipidemia (p=0.024) compared to controls. Stroke patients exhibited greater WMD volume (15.7±20.2 vs 7.3±10.4 mL, p= 0.012) compared to controls, but not MH number (p=0.29) or total MH volume (p=0.26). Although history of stroke was associated with new presentation of stroke (72.9% vs 22.9%, p<0.001), prior stroke was not linked to an overall difference in WMD volume (13.7±17.6 vs 9.4±15.3mL, p=0.20), gray to white matter ratio (1.27±0.54 vs 1.21±0.74 mL, p=0.68), MH number (p=0.36) or total MH volume (p=0.39). After adjusting for confounders, pre-existing WMD volume remained an independent predictor of stroke (adjusted OR 1.042 per one point increase, 95% CI 1.001-1.086, p=0.046).

Conclusion:
Increased volume of white matter disease correlates with a greater risk of future ischemic stroke. These results should be validated in subsequent studies.
Abstract TP18: Impact of Reperfusion Therapy on Short-Term Outcome in Patients With Mild Acute Ischemic Stroke
Authors: Nomura Eiichi , Himeno Takahiro , Takemaru Makoto , Kanbara Mizuki , Ota Shinzo
Published: January 2019

Purposes:
The efficacy of reperfusion therapies (RT), including both intravenous recombinant tissue plasminogen activator (iv rt-PA) and any endovascular therapy (EVT) for mild acute ischemic stroke (AIS), is yet to be established. The present study aimed to evaluate the impact of RT on mild AIS patients outcome compared with non-RT.

Methods:
Of all 9775 AIS patients admitted in our hospital between 2006 and 2017, those patients with values of 0-1 on the modified Rankin Scale (mRS) prior to the onset of AIS and of ≤ 10 on the National Institute of Health Stroke Scale (NIHSS) just before the therapy was started were selected. Of these, RT patients and comparable non-RT patients were selected using propensity score matching. The RT group included patients with iv rt-PA and any EVT (local arterial infusion of Urokinase, percutaneous transluminal angioplasty, Merci retriever, Penumbra system, and any stent retriever). The primary outcome was mRS 0-1 at three months after the onset, which was defined as an excellent outcome. Subgroup analysis for patients with NIHSS ≤ 5, 6-10, small vessel occlusion (SVO), and non-SVO was also performed.

Results:
Of the selected 3089 patients, we constructed the 526 (263 each) propensity score-matched patients cohort. The propensity score-matched RT patients consisted of 135 solely iv rt-PA, 109 EVT, and 19 both. The non-RT patients had a median age of 72 compared to 73 years for the RT patients and the median NIHSS was 5 in both patient groups. The frequencies of excellent outcome in RT and non-RT patients did not differ significantly with 57.8 % and 52.1 %, respectively. The odds ratio and 95 % confidence interval (CI) of RT patients for an excellent outcome was 1.26 (0.89-1.78). In the subgroup analysis, odds ratios of patients with NIHSS ≤ 5, NIHSS 6-10, SVO, and non-SVO were 0.97 (0.61-1.56), 1.75 (1.01-3.03), 1.24 (0.57-2.70), and 1.27 (0.86-1.86), respectively.

Conclusion:
The present study found an excellent outcome of RT only in patients with NIHSS 6-10. Further studies may be warranted to investigate the efficacy of RT for patients with mildest AIS (NIHSS ≤ 5).
Abstract TP182: Physical Therapy/Occupational Therapy Evaluation Within the First 24-Hours for Patients Who Have Received Intravenous Alteplase
Authors: Sinogui Cynthia , Barzo Melissa , Zrelak Patricia , Murphy Ryan , Jennings Amber , Hartman Jonathan
Published: January 2019

Background:
Designated Stroke Centers are required by The Joint Commission to evaluate all acute ischemic stroke (AIS) patients for rehabilitation prior to discharge. Timing of this evaluation is controversial.

Purpose:
To evaluate the feasibility and safety of having a Physical Therapist (PT) or Occupational Therapist (OT) evaluate AIS patients within 24 hours of alteplase administration.

Methods:
Based on a comprehensive literature review, various committee discussions and agreement, the PT/OT team initiated evaluations within 24-hours for AIS patients treated with alteplase. The target post-alteplase evaluation time was 12-hours. Medical stability was determined by the physician as evidenced by an initial request for PT/OT evaluation. Prior to the evaluation, the therapist performed a thorough chart review. Patients with unstable vital signs, a fluctuating neurological assessment, and/or inability to participate in therapies were excluded. During the therapy evaluation, reassessment was ongoing. If any adverse change was observed, the evaluation was immediately stopped, the patient placed back in bed, and the primary nurse and/or physician notified.

Results:
A baseline review of data was performed. In 2016, 77 patients received alteplase, none of whom were evaluated within 24-hours following alteplase administration. Evaluations within 24 hours post-alteplase began in mid-March 2017 and continued through July 2018. A total of 103 patients received alteplase during this period, of whom 11 patients met initial exclusion criteria. Of these, 83% (76/92) were seen within the initial 24-hour timeframe. All patients reviewed and evaluated by the team were in the Intensive Care Unit. No mobility-associated complication or adverse neurologic change occurred during therapy evaluations or because of mobilization within the initial 24-hours.

Conclusion:
PT/OT neurological evaluations within 24-hours of alteplase administration did not result in adverse events or complications. Although difficult to quantify, therapy staff determined this change in practice was beneficial to patients as it allowed for earlier mobilization and initiation of the rehabilitation plan.
Abstract TP184: Upper-body Exoskeleton Assisted Stroke Rehabilitation Therapy in Complex Multi-joint Movements
Authors: de Oliveira Ana C , Warburton Kevin , Ogden Evan M , Yun Youngmok , Whitford Bob , Cowperthwaite Matthew , Lee Robert K , Deshpande Ashish D
Published: January 2019

Introduction:
Impaired coordination within the shoulder complex is a frequent symptom in post-stroke survivors. However, most devices that have undergone clinical trials are unable to actively assist the full movement of the shoulder girdle.

Purpose:
In this study, we aim to evaluate the safety of the Harmony robot in post-stroke rehabilitation and to understand the needs of the user and the clinicians.

Methods:
The Harmony exoskeleton is a bilateral device with seven degrees-of-freedom in each arm, which has an anatomical shoulder mechanism that can provide active assistance for the shoulder girdle. Each subject underwent seven one-hour training sessions in which six arm trajectories based on functional therapeutic exercises were trained with robotic assistance. Position and torque data during movements were captured by the robot’s sensors. Heart rate, blood pressure, and subject pain and safety perception of the robot were measured in each session.

Results:
Three (3) subjects have completed the study. The mean donning and doffing times were 3’56” and 1’21”, respectively. The mean improvement in Fugl-Meyer UE and Action Research Arm Test scores was 6 and 4.3 points, respectively. The stability of the glenohumeral joint during multi-joint 3D movements was maintained as evaluated by an occupational therapist. All subjects reported their safety perception to be maximal (very safe); no adverse events have been reported. The mean anxiety score of the subjects was 1.4 on a scale from 1 (no anxiety) through 10 (extreme anxiety). The mean heart rate change during a session was 4.1 bpm, suggesting subjects were not showing signs of exhaustion or stress; average variation in heart rate across sessions was 11 bpm. No moderate or severe pain was reported along the experiments.

Conclusions:
These results suggest that the Harmony exoskeleton can safely assist in the completion of complex upper-limb movements with reasonably short donning-and-doffing times. Our results also suggest that robotic-assisted therapy has great potential to motivate and engage patients in their treatment.
Abstract TP186: Impact of Long-term Left Ventricular Assist Device Support on Human Brain: A Case-control Study Using MRI
Authors: Murase Sho , Okazaki Shuhei , Todo Kenichi , Misumi Yusuke , Yoshioka Daisuke , Sawa Yoshiki , Mochizuki Hideki
Published: January 2019

Introduction:
Left ventricular assist device (LVAD) implantation improves the prognosis of patients with severe heart failure; however, the potential impact of long-term LVAD support on the brain remains unclear. The aim of this case-control study was to examine the characteristics of brain MRI in patients after long-term LVAD support.

Methods:
We retrospectively reviewed consecutive adult patients who underwent continuous-flow LVAD implantation in our hospital from 2010 to 2017, and those who underwent brain MRI after successful LVAD explantation were enrolled in this study. Age- and sex-matched control subjects (1:1) were selected from a pool of normal subjects who underwent MRI examination for screening purposes. The number and location of cerebral microbleeds (CMBs) and superficial siderosis, and the severity of white matter hyperintensity (WMH) and cerebral atrophy were compared between LVAD patients and controls.

Results:
We enrolled 49 LVAD patients and 49 controls. In LVAD patients, cardiomyopathy (84%) was the most common underlying heart disease. Heart transplantation was performed in 46 patients (94%) and 3 removed LVAD due to myocardial recovery. The median age was 41 years (range 19-66), and the median LVAD support time was 32 months (4-52). Nineteen patients developed symptomatic stroke (10 ischemic and 10 hemorrhagic) during LVAD support. Except for one, almost all (98%) LVAD patients had one or more CMBs, and the number of CMBs was much higher in the LVAD patients (mean, IQR: 7, 3-11 vs 0, 0-0: p<0.001) than controls. Superficial siderosis was positive in 15 (31%) of LVAD patients, but not in controls. The severity of WMH was significantly higher both in deep subcortical (p=0.01), and periventricular region (p=0.04) than controls. In quantitative analyses of cerebral atrophy, bicaudate ratio (0.105±0.023 vs 0.089±0.019: p<0.001) and cella-media index (0.160±0.033 vs 0.141±0.024: p<0.001) were significantly higher in LVAD patients than controls.

Conclusions:
Patients after long-term LVAD support showed a high prevalence of CMBs and superficial siderosis, and more severe WMH and cerebral atrophy compared to age- and sex-matched controls. Long-term LVAD support may cause cerebral small vessel disease.
Abstract TP188: Trends in Costs Associated With Endovascular and Surgical Treatments for Unruptured Intracranial Aneurysm Among Commercially Insured Patients
Authors: Khanna Rahul , Rai Ansaar , Crivera Concetta , Kumari Rashmi , Patino Nataly , Chekani Farid
Published: January 2019

Objectives:
Limited studies have examined economic outcomes of endovascular coiling (EVC) and/ or surgical clipping (SC) for unruptured intracranial aneurysm (UIA) from a payer perspective. This study evaluated trends in payments for index admission and 365-day follow-up (including index admission) among UIA patients treated with EVC or SC.

Methods:
A retrospective analysis of Truven MarketScan® Commercial Claims and Encounters (CCAE) database was conducted. The study sample included patients aged ≥ 18 years with a diagnosis of UIA who underwent EVC or SC between 2011 and 2016 (index hospitalization). The following exclusion criteria were applied: patients with a history of subarachnoid hemorrhage (SAH) or EVC/SC treatment in 12 months baseline; concurrent diagnosis of SAH during index hospitalization or lack of continuous enrollment in 12 months baseline period. Using Mann-Kendall test, we examined trends in payments for index admission and 365-day all-cause healthcare utilization (medical services and prescription). All costs were adjusted to 2016 US dollar.

Results:
A total of 3,294 patients met the eligibility criteria. The mean age of patients was 52.53 years (SD= 8.64) and 76.56% were female. The proportions of patients treated with EVC (vs. SC) increased from 67.80% in 2011 to 75.84% in 2016 (p= 0.01). The average index admission cost was $54,853 and the mean 365-day follow-up cost was $89,398. Mean index admission cost was $52,163 in 2011 and $64,193 in 2016 (p= 0.19). However, mean 365-day all-cause follow-up costs increased from $87,741 in 2011 to $94,096 in 2016 (p= 0.04).

Conclusions:
The 365-day all-cause follow-up costs associated with endovascular and surgical treatment among UIA patients increased significantly over the study period. There is significant economic burden for UIA patients undergoing neurointerventional procedures.
Abstract TP189: Diagnosis and Treatment Trends of Cerebral Venous Thrombosis in a Large Observational Cohort
Authors: Bushnaq Saif , Bambhroliya Arvind , Vahidy Farhaan , Sarraj Amrou , Savitz Sean , Sheth Sunil
Published: January 2019

Background:
Cerebral Venous Thrombosis (CVT) is an increasingly recognized etiology of a wide array of neurological presentations ranging from headache to coma with limited treatment options. Here, we review population-level trends in the diagnosis, treatment and outcomes of CVT.

Methods:
Using administrative data on all discharges from hospitals in New York (2005-2014) and Florida (2005-2015), we identified patients with CVT. Patients with trauma and pyogenic CVT were excluded. Primary outcomes included hospital length of stay and discharge disposition. Linear and logistic regressions were adjusted for age, sex, year of treatment, and hypercoagulability. Results are provided as median [IQR], mean ± SD and OR [95% CI].

Results:
Among 1876 patients diagnosed with CVT, median age was 59 [42 - 73] and 60% were female. 61% of the cohort was white, 17% African American and 13% Hispanic. Hypertension was present in 53%, diabetes in 21%, 18% smoked and 4% were diagnosed with a hypercoagulable disorder. 230 (12%) of patients presented with intracerebral hemorrhage. Over the 10-year span of the study, the number of patients diagnosed with CVT annually increased (136 vs. 227, 2005 vs. 2014). 81 (4.3%) of patient were treated with endovascular thrombectomy and/or thrombolysis. This proportion increased significantly over the course of the study (1% vs. 5%, 2005 vs. 2014, p<0.05). In adjusted logistic regression, the likelihood of discharge home versus in-hospital mortality/SNF did not change over the course of the study period (p=0.8). In the subset of patients presenting with intracranial hemorrhage, thrombectomy was associated with increased length of stay (eta
2
0.02, p<0.05, adjusted linear regression), but there was no effect on likelihood of discharge home (p=0.5) or in-hospital mortality/discharge to SNF (p=0.4).

Conclusions:
In this large observational cohort study over 10-years, we identify an increasing frequency of diagnosis of CVT, without notable changes in discharge outcomes. These findings support the need for further targeted therapies for patients with CVT.
Abstract TP191: Serum Homocysteine Level is Associated With Cerebral Small Vessel Disease in a Healthy Population
Authors: Kwon Hyung-Min , Nam Ki-Woon , Jeong Han-Yeong , Park Jin-Ho , Kwon Hyuktae , Jeong Su-Min
Published: January 2019

Objective:
To evaluate the relationship between serum homocysteine (Hcy) levels and cerebral small vessel disease (cSVD) in a healthy population.

Methods:
We included consecutive subjects who visited our department for health check-ups between 2006 and 2013. We rated white matter hyperintensity (WMH) volumes using both the Fazekas score and semi-automated quantitative methods. We also evaluated lacunes, cerebral microbleeds (CMBs), and enlarged perivascular spaces (EPVSs) which are involved in cSVD. To assess the dose-dependent relationship between Hcy and cSVD parameters, wescored the burdens of each radiological marker of cSVD.

Results:
A total of 1,578 subjects were included (median WMH volume: 1.00 mL; frequencies of lacunes, CMBs, and moderate-to-severe EPVS: 4%, 7%, and 39%, respectively). In the multivariate analysis, Hcy remained a significant predictor of the WMH volume (B = 0.209; 95% confidence interval [CI] = 0.033 to 0.385, P = 0.020), presence of CMBs (adjusted odds ratio [aOR] = 2.800; 95% CI = 1.104 to 7.105, P = 0.030), and moderate-to-severe EPVSs (aOR = 5.906; 95% CI = 3.523 to 9.901, P < 0.001) after adjusting for confounders. Furthermore, Hcy had positive associations with periventricularFazekas score (P = 0.001, P for trend < 0.001), subcortical Fazekas score (P = 0.003, P for trend = 0.005), and moderate-to-severe EPVS lesion burden (P < 0.001, P for trend < 0.001) in a dose-dependent manner.

Conclusions:
Elevated Hcy level is correlated with cSVD development in a dose-dependent manner. These findings provide us with clues for further studies of the pathophysiology of cSVD.