bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP43: Routine Labs may Help Predict tPA-related Hemorrhagic Transformation: A Role for Serial Monitoring of Prothrombin Time (PT) and Partial Thromboplastin Time (PTT) Post tPA
Authors: Deng Wenjun , Wickham Thomas , McMullin David , Feeney Kathleen , Buonanno Ferdinando , Lo Eng H , Ning MingMing
Published: March 2022

Background:
Intravenous tissue plasminogen activator (tPA) is not routinely followed by blood work due to its reputed short half-life. While there has been a great deal of research on tPA’s extra-vascular effects on the neurovascular unit in the context of hemorrhagic complications, there is little clinical data on the intravascular efficacy of IV tPA - how and where it has its intended effect. Emerging data suggest that tPA may be most effective in the microvasculature and IV therapy may be a good adjunct to intra-arterial (IA) therapy. We previously found through proteomic profiling that the effects of IV tPA can last more than 72 hours. Now, we report that even routine blood labs can potentially help predict hemorrhagic transformation (HT).

Method:
72 stroke patients treated with IV tPA were recruited post IRB approval. Clinical coagulation profiles (PT, PTT, fibrinogen and D-dimer) were performed at 12, 24, 72 hrs post IV tPA. Patients on medications (e.g. anticoagulants) or having other conditions (e.g. liver dysfunction, infection) that may affect these labs were excluded.

Result:
Compared to patients without HT, HT patients had significantly higher PT and PTT (Fig. 1 A,B) as early as 12 hrs post tPA administration and throughout the first 3 days of treatment. ROC analysis suggested PT and PTT at 12 and 24 hrs have potential to predict tPA-induced HT (Figure 1C,D. PT: AUC = 0.848, p = 0.001; PTT: AUC = 0.877; p = 0.003).

Conclusion:
Higher PT and PTT levels within 72 hours of IV tPA are early markers of HT post IV tPA in acute ischemic stroke. Whether these routine labs have value in symptomatic hemorrhage will require further study in a larger cohort. But this proof-of-concept study suggests that tPA efficacy can potentially be followed in real time, even with routine labs. The development of a reliable blood test would be of clinical utility to gauge thrombolytic efficacy in real time to guide and/or triage adjunct treatments.
Abstract TMP49: Translating Ribosome Affinity Purification for Qualitative Assessment of Human Neural Stem Cells Transcripts in the Ischemic Rat Brain
Authors: Azevedo-Pereira Ricardo L , Manley Nathan C , Winge Mårten C , Berry Jack , Sun Guohua , Bliss Tonya , Steinberg Gary K
Published: March 2022

Introduction:
Neural stem cell (NSC) transplantation is being explored as a potential therapy for ischemic stroke (IS). Although research has shown the efficacy of NSCs in IS, little is known about the gene expression profile of the NSCs after transplantation. To date this has been challenging due to the issue of trying to distinguish factors expressed by the transplanted cells from that of surrounding host cells. We have overcome this critical barrier by adapting the novel TRAP (Translating Ribosome Affinity Purification) approach to selectively purify mRNA from transplanted NSCs.

Hypothesis:
Application of TRAP technology can enrich isolation of human NSC transcripts from IS rats and enabling identification of the in vivo gene expression profile of transplanted NSCs.

Methods:
Nude rats were subjected to permanent distal cerebral artery occlusion and after 7 days fetal human NSCs expressing GFP under RPL10a promoter were transplanted into the motor cortex of IS and non-ischemic (NI) rats. Seven days post-transplantation, the graft site was dissected and processed using the TRAP methodology. Seven housekeeping genes (HKG) were analyzed by qPCR in TRAP and non-TRAP samples to determine the level of enrichment of human transcripts. The RNA isolated was converted to cDNA libraries and analyzed using RNAseq technology.

Results:
The expression level of HKG was consistent between samples and groups when analyzed by the Pearson correlation (r ≥ 8.7), indicating that TRAP samples are compatible between them for sequencing analysis. Furthermore, the average enrichment of human HKG was 22.7-fold (range: 3.37-22.76) and 58.8-fold (range: 1.31-154.94) in IS and NI rats, respectively. Preliminary data from MiSeq analysis detected 317 genes differentially expressed between IS and NI rats. Gene ontology analysis of these genes showed enrichment of genes involved in the intracellular process, stem cell biology, extracellular region, and signaling and secreted proteins.

Conclusion:
Our data demonstrate that the application of TRAP is feasible to enrich human NSC transcripts from rat cortex, making analysis of their expression profile in the stroke brain possible. This sets the stage to probe the molecular mechanism of action of transplanted stem cells.
Abstract TMP52: Inactivated Microglia and Inhibition Neutrophil Infiltration Reduce Brain Injury Following Intracerebral Hemorrhage in Mice
Authors: Sun Yongmei , Chen Wenwu , Liu Min , Xu Yuming , Li Yanhong , He Jue , Li Xiaohui , Fang Yuan , Jiang Lingxiu , Fang Jian , Yong V Wee , Xue Mengzhou
Published: March 2022

Introduction:
Microglia become activated and monocytes become macrophages following intracerebral hemorrhage (ICH). They are often called “microglia/macrophage” since it is difficult to differentiate between them. The neutrophils also infiltrate into the injured brain after ICH. Those cells are capable of releasing numerous detrimental mediators.

Hypothesis:
The activation of microglia/macrophage and the infiltrated neutrophils promote brain injury after ICH and that inhibition both of them attenuates brain injury following ICH.

Methods:
10-μl of autologous blood obtained from tail was introduced into the right striatum of adult male mice to produce ICH injury. We used transgenic CD11b thymidine kinase (CD11b-TK) mice where proliferating microglia/macrophage were removed by ganciclovir treatment. Functional grade purified anti-mouse Ly6G/Gr-1 antibodies were used to reduce the neutrophil infiltration. Groups of CD11b-TK mice were treated with ganciclovir and/or anti-mouse Ly6G/Gr-1 antibodies. These mice were killed at 3 days after ICH injury and brain sections were stained for various parameters.

Results:
ICH injury resulted in activation of microglia/macrophages through 1-7 days of ICH insult. The area of brain damage peaked at 2-3 days; the number of dying neurons peaked at 1-3 days, the number of infiltrated neutrophils peaked at 1-3 days, while the activation of microglia/macrophages peaked at days 3-4. These findings led us to choose day 3 for further studies. The activation of microglia/macrophage was significantly reduced in CD11b-TK transgenic mice with ganciclovir treatment after ICH. The numbers of infiltrated neutrophils were significantly reduced with anti-mouse Ly6G/Gr-1 antibodies treatment after ICH. Correspondingly, the area of brain damage and the extent of neuronal death were minimal in CD11b-TK mice with ganciclovir and anti-LyG6/Gr-1 antibodies treatment after ICH.

Conclusions:
Both activated microglia/macrophages and the infiltrated neutrophils after ICH promote brain injury. Thus inhibition of their activities reduces ICH brain injury. These results shed light on the advent of new medications for ICH patients, including microglia deactivators and the antibodies to alleviate neutrophil infiltration.
Abstract TMP57: Vascular Endothelial Growth Factor Signaling Contributes to Comorbidity-enhanced Edema in Ischemic Stroke
Authors: Kim Eunhee , Cho Sunghee
Published: March 2022

Introduction:
Stroke-induced brain edema is a life-threatening complication for patient. Pre-clinical studies have shown that comorbidities such as diabetes (DB) and hyperlipidemia (HL) are associated with the enhanced edema, however the underlying mechanism is not clear. Vascular endothelial growth factor (VEGF)-A has a major role in angiogenesis and vascular permeability by binding with the VEGF receptor 2 (VEGFR-2).

Hypothesis:
We therefore hypothesized that VEGF signaling contributes to comorbidity-enhanced edema in ischemic stroke.

Methods:
DB was induced in male C57BL/6 mice by feeding a high fat diet for 8 weeks with or without streptozotocin administration. HL was generated in male ApoE knock-out mice by feeding a high fat diet for 8 weeks. The mice were then subjected to 30 min transient middle cerebral artery occlusion and brain infarct and edema size were determined at 3 days post-stroke. Gene or protein expressions of VEGF-A, VEGFR-2, and the downstream pathway (phospho(p)-Akt and endothelial specific molecule (Esm)-1) were determined in the brain following stroke.

Results:
DB and HL mice displayed hyperglycemia and hyperlipidemia. Following stroke, DB and HL mice exhibited larger infarct and edema, and increased VEGF-A and VEGFR-2 expression compared to normal mice. The increase was accompanied by increased pAkt and Esm1 expression. We also found that the VEGFR-2 gene was positively correlated with the severity of edema in both comorbid conditions but not in normal condition (NC) (Fig. A and B).

Conclusion:
The results demonstrate that the VEGF signaling may underlie for comorbidity-enhanced brain edema in stroke. A treatment strategy aimed at reducing edema by targeting VEGF signaling is suggested for stroke patients with the comorbidities.
Abstract TMP60: RNA Sequencing Reveals Novel MicroRNA Profiles in Neural Progenitor Cells After Stroke
Authors: Liu Xianshuang , Chopp Michael , Pan Wanlong , Fan Baoyan , Wang Xinli , Li Chao , Levin Albert M , Zhang Ruilan , Zhang Zhenggang
Published: March 2022

Background:
Neurogenesis is associated with functional recovery after stroke. However, the underlying molecular mechanisms have not been fully investigated. We hypothesized that stroke changes miRNA profiles in neural progenitor cells (NPCs), which is closely associated with stroke-induced neurogenesis.

Methods and Results:
Using a novel cross-linking immunoprecipitation to crosslink Ago2-RNA complexes followed by RNA sequencing (Ago2 CLIP-seq) approach, we profiled the entire small RNA population in NPCs harvested from the non-ischemic and ischemic subventricular zone (SVZ) of ischemic animals (n=6/group). Ago2 CLIP-seq analysis showed that over 7 million reads were found in normal and ischemic NPC libraries. In non-ischemic NPCs, the top 10 highly enriched miRNAs were miR-26, -27b, -127, -99b, -191, -125b-5p, let-7f, let-7i, -541 and -151. In contrast, stroke significantly changed the top 10 enriched miRNAs. Bioinformatics analysis revealed that these miRNAs could target genes involved in cytoskeleton remodeling, WNT, TGF signaling and cell cycle. Moreover, we detected 18 novel miRNAs (>50 reads) in the non-ischemic and ischemic NPCs. Pc-17172 is one of the novel miRNAs specifically down-regulated in NPCs, which was further validated by quantitative RT-PCR. Conditional knockout of Dicer reduced its expression, indicating that novel pc-17172 follows canonical miRNA biogenesis pathway. To test its biological function, we knocked down its expression by locked nucleic acid and found that the % of Tuj1+ neuroblasts was significantly increased (10 ± 1% vs 6 ± 1% in control group, p<0.05, n=3), whereas the % of BrdU+ cells was decreased (44 ± 5% vs 84 ± 4% in control group, p<0.05). Meanwhile, over-expression of pc-17172 by transfection of its mimics into NPCs significantly decreased the % of Tuj1+ neuroblasts (7 ± 1% vs 12 ± 2% in control group, p<0.05) and increased the % of BrdU+ cells (93 ± 2% vs 80 ± 3%, p<0.05), suggesting reduced pc-17172 is involved in stroke-induced neurogenesis.

Conclusion:
Collectively, the present study reveals profiles of miRNomes in non-ischemic and ischemic NPCs, which provide molecular basis to further investigate the role of miRNAs in mediating adult neurogenesis under physiological and pathophysiological conditions.
Abstract TMP62: Achievable Benchmarks for Quality of Care in the Coverdell Acute Stroke Program
Authors: Reeves Mathew J , Chang Anping , Tong Xin , George Mary G
Published: March 2022

Introduction:
The value of setting performance benchmarks for quality improvement projects remains unclear. The Achievable Benchmarks of Care (ABC™) methodology has been proposed as an objective, reproducible, and data-driven approach, but it has not been widely utilized in stroke registries. We applied the ABC™ methodology to set benchmarks using data from the Coverdell stroke registry.

Methods:
Data were from Paul Coverdell National Acute Stroke Program from 2012-2014. Adherence data were calculated on 14 quality measures including tPA related treatment, hospital care, and discharge care. We applied the ABCTM methodology by first ranking hospitals in descending order of performance for each quality measure. We then calculated the pared mean performance associated with patients selected from these hospitals representing the top 10% and 50% of patients.

Results:
A total of 170 402 acute ischemic strokes from 465 hospitals in 11 states were included. The Figure shows overall 10% and 50% benchmarks (BM) for the 14 quality measures. BMs were high (>90%) for 12 of the 14 measures. Two measures with lower performance were tPA administered among all ischemic stroke patients, and door to needle (DTN) < 60 minutes. However, both measures improved significantly over time. The 10% BM for tPA administration improved from 28% in 2012 to 30% in 2014, while the 10% BM for DTN within 60 minutes improved from 82% in 2012 to 90% in 2014.

Conclusions:
The ABC™ methodology provides an objective method of calculation BMs for care. These data illustrate that BMs are already high for the majority of the quality measures tracked in the registry. Further analyses are ongoing to determine the acceptability of using these BMs to promote further improvements in care across the Coverdell Program.
Abstract TMP63: Region-wide, Prehospital Mobile Tele-Evaluation by a Central Neurologist Reduces Disparities in Lytic Therapy for Acute Stroke
Authors: Sanossian Nerses , Liebeskind David S , Starkman Sidney , Ali Latisha K , Restrepo Lucas , Kim-Tenser May A , Frischmann Lindsey , Conwit Robin , Stratton Samuel , Pratt Franklin D , Eckstein Marc , Saver Jeffrey L ,   FAST-MAG Investigators and Coordinators
Published: March 2022

Background:
Disparities in the delivery of acute stroke care among diverse race-ethnic populations have been well documented, including lower rates of use of intravenous thrombolytic therapy and longer door to needle times. We sought to determine if prehospital mobile telemedical patient evaluation by a neurologist responding to all stroke ambulance transports in a region would reduce these disparities.

Methods:
Subjects were participants in the Phase 3 NIH Field Administration of Stroke Therapy - Magnesium (FAST-MAG) trial of prehospital magnesium vs. placebo within 2 hours from symptom onset. A central neurologist performed mobile prehospital tele-evaluation, using audio or video smartphones, of all study candidate patients being transported by 315 ambulances to 60 hospitals throughout Los Angeles and Orange County. After confirming likely stroke and eliciting informed consent, the neurologist spoke to the attending ED physician in the destination hospital and gave pre-arrival report.

Results:
Of 1700 subjects, race-ethnic distribution included: white, non-Hispanic - 929 (55%): white, Hispanic - 402 (24%); black - 219 (13%); and Asian - 139 (8%).. Among the 1245 (73%) patients with a final diagnosis of acute cerebral ischemia (ACI), 444 (36%) were treated with IV tPA. In all ACI patients, the median time from door to imaging was 28 minutes (IQR 19-42). In the tPA-treated patients, median door to imaging time was 25 mins (18-35) and door to needle time 79 mins (62-104);. There were no differences in rates of tPA utilization among non-Hispanic Whites (35%), Blacks (35%) and Latinos (35%) with cerebral ischemia. There were also no significant differences in door to imaging (24 vs. 28 vs. 25 minutes, p=0.39 or door to needle (83 vs. 77 vs. 78 minutes, p=0.57)

Conclusions:
Central neurologist mobile tele-evaluation of potential stroke patients transported by all ambulances throughout a region with 13.1 million persons is feasible, and is associated with resolution of disparities in use and speed of thrombolytic therapy for acute ischemic stroke.
Abstract TMP66: Sex Disparity in Stroke Quality of Care in a Community-Based Study
Authors: McDermott Mollie , Lisabeth Lynda D , Baek Jonggyu , Adelman Eric E , Garcia Nelda M , Case Erin , Campbell Morgan S , Morgenstern Lewis B , Zahuranec Darin B
Published: March 2022

Introduction:
Studies have suggested that women may receive lower quality of care (QOC) than men, although population-based studies are lacking. We investigated sex disparities in QOC in the Brain Attack Surveillance in Corpus Christi Project.

Methods:
All ischemic stroke patients admitted to one of six Nueces County community hospitals between Feb 2009 and Jun 2012 were prospectively identified. Data regarding compliance with seven performance measures (PMs) were extracted from the medical records. A composite score of QOC representing the number of achieved PMs over all patient-appropriate PMs was calculated. Multivariable models with generalized estimating equations assessed the association between sex and the composite score and between sex and individual PMs. Models were adjusted for hospital clustering, age, and ethnicity, while the model assessing composite score was also adjusted for insurance status, education, pre-stroke functional status (Rankin 0-2), initial NIH stroke scale score, and comorbidity index.

Results:
Compared to men, women were older (median age 72 vs 65), less likely to have a pre-stroke Rankin 0-2 (69% vs 83%), and less likely to identify as married/living together (38% vs 61%). Results for the association of sex with individual PMs are shown below. Women were less likely to receive DVT prophylaxis at 48 hours, an antithrombotic at 48 hours, and to be discharged on an antithrombotic. Women were less likely to be discharged on a cholesterol medication, although this finding was of borderline significance. Women had a lower composite score (mean difference -0.030, 95% CI -0.057 to -0.003).

Conclusions:
In this population-based study, women had a lower overall stroke QOC, although absolute differences in most individual PMs were small. Further investigation into the factors contributing to the gender disparity in guideline-concordant stroke therapy should be pursued.
Abstract TMP70: Assessment of Home Time Following Acute Ischemic Stroke in Medicare Beneficiaries
Authors: Fonarow Gregg C , Liang Li , Thomas Laine , Xian Ying , Saver Jeffrey L , Smith Eric E , Schwamm Lee H , Peterson Eric , Hernandez Adrian , Duncan Pamela W , O'Brien Emily , Bushnell Cheryl , Prvu Bettger Janet
Published: March 2022

Background:
Stroke survivors have identified “home-time” (days spent at home alive and outside of a hospital) as a meaningful outcome. However, home-time has not been well studied as an outcome of interest outside of clinical trials. We aimed to evaluate home-time as a patient-centered outcome in Medicare beneficiaries with ischemic stroke in comparison with modified Rankin Score (mRS) at 90 days and 1 year post event.

Methods:
Patients ≥65 years old enrolled in GWTG-Stroke and AVAIL (Adherence eValuation After Ischemic Stroke Longitudinal) registry were linked to Medicare claims to ascertain home-time, defined as time spent alive and out of a hospital or skilled nursing facility, at 90 days and 1 year after admission for ischemic stroke. The correlation of home-time with mRS at 90 days and 1 year from admission were evaluated graphically and by Pearson correlation coefficients. In addition, to assess the level of agreement between measures, the c-index of 90 day and 1 year home-time predicting 90 day and 1 year mRS 0-2 were determined.

Results:
There were 815 ischemic stroke patients (age median 76 years [IQR 70-82], 46% female, NIHSS median 4 [IQR 2-7]) from 88 participating hospitals. The 90 day and 1 year median home-times were 79 days (IQR 52-86) and 349 days (IQR 303-360). The 90 day and 1 year median mRS were 2 (IQR 1-4) and 2 (IQR 1-4). The Pearson correlation coefficient between 90 day mRS and home-time within 90 days was -0.731 (p-value<.0001) (Figure). The c-index of 90 days home-time predicting 90 day mRS 0-2 was 0.837. The Pearson correlation coefficient between 1 year mRS and home-time within 1 year was -0.713 (p-value<.0001). The c-index of 1 year home-time predicting 12 month mRS 0-2 was 0.828.

Conclusions:
In a population of older ischemic stroke patients, home-time was correlated with and showed a strong level of agreement with mRS at 90 days and 1 year. Home-time may be able to serve as a novel, patient-centered, outcome measure for hospital/transitional stroke care.
Abstract TMP76: Predicting Aspiration Following Stroke Using a New Reliable and Valid Dysphagia Screening
Authors: Raghunath Nirmala R , Danziger Keri , Hepburn-Smith Millie
Published: March 2022

Background:
Bedside dysphagia screening potentially identifies 60% of patients at risk for aspiration. Potential/actual stroke patients may not be identified prior to oral medications/food. Our previous dysphagia screening was challenging to use and as a result, many stroke cases were missed.

Problem:
Potential patients at risk for aspiration pneumonia were not being identified using a dysphagia screening.

Interventions:
A new dysphagia screening instrument was developed by an interdisciplinary team of nurses and speech language pathologists. Pilot reliability testing of the old tool indicated a reliability of 86%, while the new tool was found to be 95% reliable. Validity testing showed that the new dysphagia screening tool predicted patients at risk for dysphagia 96% of the time, while the old instrument predicted dysphagia only 88% of stroke patients. The new dysphagia instrument was implemented in 10/2014, and is now performed for all ED patients who have a non-contrast head CT.Current real-time auditing of core measures and reporting of compliance data is now in place with accountable parties, using concurrent chart review and real-time feedback to Nurse Managers for all missed cases

Results/Conclusions:
Compliance with dysphagia screening has risen from 84% in 9/2014 to 100% in 6/2015. Patients at risk for aspiration/aspiration pneumonia have been successfully identified using the new dysphagia screen and measures are implemented to prevent or treat high risk patients to improve outcomes. Most patients who developed aspiration pneumonia had been previously identified as failing the new dysphagia screen and these patients were maintained npo and placed on aspiration precautions. Mortality rates for inpatient stroke patients dropped by 73% in the 4
th
quarter of 2014, fostering a #1 ranking for inpatient mortality, and top 5% in overall quality for 2014 when benchmarked with other academic medical centers participating in United Health Care (UHC) rankings. The new dysphagia screening instrument and monitoring practices has dramatically improved detection of patients at risk for dysphagia/potential aspiration, and has contributed to a significantly lower rate of inpatient stroke mortality.
Abstract TMP83: Modifiable Factors Influencing Timely Carotid Endarterectomy among Stroke Prevention Clinic Patients
Authors: Gocan Sophia , Bourgoin Aline , Blacquiere Dylan , Shamloul Rany , Stotts Grant
Published: March 2022

For optimal stroke prevention following transient ischemic attack or minor stroke, international best practice guidelines recommend carotid endarterectomy for appropriate candidates as soon possible, with a target of less than two weeks. Research has demonstrated however, that delays to surgery occur frequently, in part due to complex clinical care processes. The goal of our study was to identify modifiable factors which could improve timely access to urgent carotid endarterectomy.

A retrospective chart review was competed, examining transient ischemic attack /stroke patients assessed in four regional Stroke Prevention Clinics between 2011 and 2014, who subsequently underwent carotid endarterectomy. Descriptive statistics were used to examine patient characteristics and time points to carotid surgery. A thematic analysis was performed to identify key factors which enhanced or delayed timelines to carotid endarterectomy. These themes were further analyzed to determine avoidable delays and key success factors.

Seventy-five records were eligible for study inclusion. Completion of carotid endarterectomy within two weeks was achieved for 21% of patients. Six key themes were identified including patient response to stroke, first health care contact, surgical fitness, resource capacity and physician availability (neurology or surgery). Forty four percent of patients did not present to medical attention the day of symptom onset contributing substantially to avoidable delays in care. Furthermore, 79% of patients experienced delays in access to vascular imaging, neurologist assessment and surgical bookings. Success was influenced by distinct triage, rapid diagnostic testing, and physician accessibility strategies. This often required divergence from standard clinical practices and interdepartmental collaboration.

Delayed patient presentation was the most common reason for delayed carotid endarterectomy which highlights the importance of ongoing public awareness strategies. Significant clinical delays were also noted at each step where patients required imaging or consultation. In order to reach carotid endarterectomy benchmarks, quality enhancement approaches will require coordinated, multifaceted care innovations.
Abstract TMP86: Folic Acid Therapy Prevents Stroke in Countries Without Mandatory Folic Acid Food Fortification: A Meta-analysis of Randomized Controlled Trials
Authors: Lee Meng , Chiu Shao-Wen , Saver Jeffrey L , Hong Keun-Sik , Wu Yi-Ling , Ovabiagele Bruce
Published: March 2022

Background:
Additional folic acid treatment appears to have a neutral effect on reducing vascular risk in countries that mandate fortification of food with folic acid (e.g. US and Canada). However, it is uncertain whether folic acid therapy reduces stroke risk in countries without folic acid food fortification.

Objective:
To comprehensively evaluate the efficacy of folic acid therapy on stroke prevention in countries without folic acid food fortification.

Methods:
Pubmed, EMBASE, and Clinicaltrials.gov from January 1966 to August 2015 were searched to identify relevant studies. Relative risk (RR) with 95% CI was used as a measure of the association between folic acid supplementation and risk of stroke, after pooling data across trials in a random-effects model.

Results:
The search identified 14 randomized controlled trials involving treatment with folic acid that had enrolled 71,334 participants, all of which stroke was reported as an outcome measure. Across all trials, folic acid therapy vs. control was associated with a lower risk of stroke (RR=0.84; 95% CI, 0.76-0.93; P=0.0007) and there was no heterogeneity among include trials (P for heterogeneity =0.27, I2=17%) (Figure). The RR of stroke in primary prevention trials was 0.81 (12 trials, 95% CI, 0.72-0.91; P=0.0006). Among 3 trials, which distinguished ischemic from hemorrhagic stroke as endpoints, folic acid therapy reduced risk of ischemic stroke (RR=0.77; 95% CI 0.67-0.90, P=0.0006), but had a neutral effect on hemorrhagic stroke (RR=0.92, 95% CI 0.66-1.28, P=0.61).

Conclusion:
Among people living in countries without mandatory folic acid food fortification, folic acid therapy reduces the occurrence of a stroke.
Abstract TP100: PGE2 EP1-4 Receptor Expression Levels After Intracerebral Hemorrhage in Young, Aged, and EP1 Deficient Mice
Authors: Leclerc Jenna L , Fadool Andrew R , Chambers Chase , Dore Sylvain
Published: March 2022

Intracerebral hemorrhage (ICH) is the most severe form of stroke and is associated with high mortality and morbidity. Neuroinflammation significantly contributes to ICH-induced brain injury and upregulation of prostaglandin E
2
(PGE
2
) has been implicated in modulating these deleterious neuroinflammatory pathways. PGE
2
acts on mainly the four G-protein-coupled E prostanoid (EP) receptors, EP1-4, which each have different downstream signaling pathways, tissue distributions, and expression profiles. We have previously demonstrated that EP1 receptor deletion promotes injury following ICH, whereas deletion of EP2 and EP3 is neuroprotective in an equivalent experimental approach. Here, we aimed to investigate the time course, brain sub-region expression profile, and relative level of EP1-4 mRNA expression in young (5-7mo) and aged (12-13mo) wildtype (WT) and EP1 receptor knockout (EP1
-/-
) mice. Following ICH or sham surgery, EP1-4 mRNA levels were assessed by RT-qPCR. Minimal EP1-4 expression changes are seen at 24h after ICH; although, EP2 (p=0.0.36) and EP4 (p=0.066) are 1.6X increased in the cortex of young WT mice. At 72h post-ICH, EP1 is 3.9x elevated in the cortex (p=0.0003) and 4.6x in the striatum (p=0.012). EP3 is also 1.6x elevated in the cortex (p=0.044). In the contralateral hemisphere, a mean 2.4x increase of EP1-4 (p<0.01) expression is seen. In contrast, at 72h after ICH, EP1
-/-
mice have 0.53x reduced EP3 in the cortex (p=0.030) and 0.68x and 0.71x decreased EP3 (p=0.016) and EP4 (p=0.049), respectively, in the contralateral hemisphere. Aged EP1
-/-
mice show significantly decreased expression levels of EP2-4 in nearly all areas (cortex, striatum, and contralateral hemisphere). Due to the contralateral differences, basal expression levels of EP2-4 were investigated in the EP1
-/-
mice, where EP2 is 2.6x, 3.4x, and 3.8x increased in the cortex, hippocampus, and cerebellum; whereas, EP3 trended oppositely. These data indicate a cross-talk interaction between EP1 and the other EP receptors pre- and post-ICH and an association between age and EP receptor expression levels. A better understanding of EP receptor localization and dynamic expression levels after ICH will facilitate the development of effective pharmacological treatments.
Abstract TP104: A Novel
in vitro
Model of Cerebral Ischemia Using Patient-derived Induced Pluripotent Stem Cells
Authors: Page Shyanne , Munsell Alli , Alahmad Abraham
Published: March 2022

Stroke constitutes the 5th cause of death in the United States and an important cause of morbidity. During ischemic stroke injury, the blood-brain barrier (BBB, part of the neurovascular unit) is compromised as brain microvascular endothelial cells (BMECs) loose their tight junctions complexes, resulting in the loss of the barrier function, unrestricted entrance of water and ions inside the brain parenchyma and neuronal cell death by excitotoxicity and cerebral edema formation.

Despite the important effort to find neuroprotective agents capable to partially improve neuronal cell survival and restore the BBB function, our ability to translate findings from animal studies to clinical trials is still hampered by an important failure rate. One of the possible caveats we hypothesize that contributes to such important failure rate is the absence of a pre-clinical human model capable to ease the translation. We speculate that a human in vitro model of the neurovascular unit encompassing human BMECs, neurons and astrocytes may help improve such translation.

In this study, we describe a novel in vitro model based on human induced pluripotent stem (iPSCs) cells. Using IMR90-c4 as an iPSC line, we were capable to differentiate BMECs, astrocytes and neurons.

Using oxygen-glucose deprivation (OGD stress), we were able to demonstrate the ability of our iPSC-derived BMECs to respond to such injury by a loss of the cell barrier function similarly, such cellular response was similar to hCMEC/D3 monolayers (an immortalized human BMEC line commonly used). In contrast, iPSC-derived astrocytes showed a remarkable compliance to prolonged OGD stress, showing some consistency with the previous literature. In the other hand, preliminary data obtained with iPSC-derived neurons displayed a rapid decrease in cell viability and increase in cell death suggesting similarities with studies using primary neural cell cultures.

Taken together, we document a differentiation protocol capable to obtain pure iPSC-derived BMECs, astrocytes and neurons lineages allowing us to investigate the cellular and molecular response to stroke injury in vitro. Such model may provide an interesting alternative model to improve our probability to identify novel stroke neuroprotective drug candidates.
Abstract TP11: Treatment Times and Outcomes With Utilization of Telemedicine Prior to Transfer for Stroke Endovascular Therapy
Authors: Al-Bayati Alhamza R , Kenmuir Cynthia L , Shoirah Hazem , Aghaebrahim Amin , Hammer Maxim D , Jadhav Ashutosh P , Jovin Tudor G , Reddy Vivek K , Starr Matthew T , Wechsler Lawrence R
Published: March 2022

Background:
Reducing time to treatment is important for acute stroke therapy including intravenous tPA and endovascular therapy. Remote evaluation of acute stroke patients by telemedicine may help triage patients for endovascular therapy and facilitate earlier treatment.

Purpose:
We aimed to evaluate efficiency and clinical outcome using telemedicine as a screening tool prior to transfer of stroke patients to comprehensive stroke centers for endovascular therapy.

Methods:
We retrospective reviewed patients receiving endovascular therapy at the University of Pittsburgh Medical Center from January 2014 through May 2015 who were initially evaluated for acute stroke at an outside facility and transferred to our hospital. We statistically analyzed our data using unpaired T test with equal standard deviation.

Results:
116 patients treated with endovascular therapy were identified. 35 (30.1%) had telemedicine (TM) evaluations prior to transfer and 81 (69.8%) were transferred without telemedicine screening (NTM). The average age was 68 years in TM group and 67 years in NTM group. 71% of TM patients received IV TPA compared to 30% of NTM patients. The average NIHSS on arrival was 17 among TM and 16 in NTM. The mean time from door to groin puncture was 54 minutes in TM patients compared to 66 minutes in NTM group (p=0.37). Good outcomes (mRS < 2) occurred in 54% of TM cases and 36% of the NTM group (p=0.12). Poor outcomes (mRS 5-6) were 21% in TM patients and 40% in the NTM group (p=0.08). TICI 2b/3 revascularization was achieved in 88.5% and 88.9% in TM and NTM groups respectively (p=0.2).

Conclusion:
Evaluating acute stroke patients using telemedicine prior to transfer to comprehensive stroke centers may reduce time to intervention and improve selection of patients more likely to benefit from endovascular therapy.
Abstract TP110: Polymerase δ-Interacting Protein 2 Regulates Astrocyte Activation in Ischemic Stroke
Authors: Hernandes Marina S , Lassègue Bernard , Yepes Manuel , Griendling Kathy
Published: March 2022

Introduction:
Polymerase δ-Interacting Protein 2 (Poldip2) is a binding partner of Nox4 NADPH oxidase and carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1). Nox4 and CEACAM1 have been implicated in stroke, but with different outcomes: both contribute to neurodegeneration but only CEACAM1 contributes to blood brain barrier (BBB) dysfunction. However, the underlying mechanisms are still obscure.

Hypothesis:
Poldip2+/- mice may be protected from the consequences of transient middle cerebral artery occlusion (tMCAO).

Methods:
tMCAO was induced in wild type (WT) and Poldip2+/- mice. The volume of the ischemic lesion was measured in TTC-stained sections. BBB breakdown was evaluated by Evans blue dye extravasation. Poldip2 protein expression was evaluated by immunofluorescence and western blotting. RT-PCR was used to measure mRNA levels of cytokines, MMPs and TIMPs. Astrocytes were transfected with Poldip2 siRNA in culture and mRNA levels of cytokines were evaluated.

Results:
Poldip2+/- and WT mice displayed comparable infarct sizes following tMCAO (n=6). A decrease in Evans blue dye extravasation was observed in Poldip2+/- mice (25±3 vs 6±2uM/g) (n=7). Upregulation of cytokine mRNA following tMCAO was also attenuated in Poldip2+/- mice (n=5): MCP-1(253±34 vs 83±23AU), IL-6 (134±38 vs 38±10AU), TNFα (39±12 vs 12±3AU), MMP-2 (19±3 vs 10±1AU), MMP-9 (253±12 vs 13±3AU) and TIMP-1 (286±110 vs 61±15AU). Poldip2 protein expression increased in the ischemic brain of WT mice after tMCAO (69±4 vs 20±5AU) and was predominantly located in astrocytes (n=4). Poldip2 protein expression was also increased in astrocytes following oxygen and glucose deprivation (79±15 vs 27±5AU) (n=6), and Poldip2 siRNA prevented cytokine induction under these conditions.

Conclusions:
In conclusion, Poldip2 contributes to stroke-induced BBB breakdown via its ability to inhibit a pro- inflammatory response in perivascular astrocytes.
Abstract TP116: Prevalence, Risk Factors and Healing Rates of Duplex Detected Carotid Plaque Ulcers
Authors: Dharmadhikari Sushrut , Bennett Ari , Campo Nelly , Romano Jose , Koch Sebastian
Published: March 2022

Introduction:
Carotid plaque ulcers confer an increased risk for stroke and TIA in both symptomatic and asymptomatic carotid artery stenosis. In historical studies, smoking has been associated with carotid ulceration. Little is known about healing rates of ulcers or development of new ulcers. Carotid Duplex studies are easily obtained and repeated to non-invasively monitor progression of carotid stenosis. We aimed to determine prevalence, risk factors and healing rates of ultrasound detected carotid plaque ulcers in an outpatient neurosonology laboratory.

Methods:
We retrospectively reviewed our database of 5837 carotid Duplex studies performed in an outpatient ultrasound laboratory affiliated with the neurological department of an academic center. A carotid ulcer was defined as a deep indentation in a carotid plaque which had a minimum width of 2mm and a well-defined back wall, as determined by B-mode, color, and B-flow imaging.

Results:
A total of 3215 patients underwent a first Duplex study, and 2522 studies were obtained in follow-up. Of these 127(4%) patients had a carotid ulcer. Demographics were available on 111 patients. Ulceration was associated with increased age (69.1 ± 8.4 vs No 64.3 ± 13.5 years; p< 0.001), hypertension (90.1% vs 50.6%; p< 0.001), dyslipidemia (79.3% vs 64.7%; p< 0.001), coronary artery disease (CAD) (32.4% vs 16.3%; p< 0.001) and current smoking (19.8% vs 7.9%; p< 0.001). Ulcer was found on initial study in 82 (3%) patients. Ipsilateral degree of stenosis for patients with a carotid ulcer exceeded 50% in 36% (46/127). 65 ulcers were followed serially. Median number of scans was 6 over a mean follow-up of 42±30 months. 31/65 (48%) healed. No factors, including statin use, was associated with ulcer healing.

Conclusions:
We report a low prevalence of duplex detected carotid plaque ulcers. Ulceration was associated with traditional atherosclerotic risk factors including advanced age, hypertension, dyslipidemia, CAD and current smoking. Carotid ulcers healed in approximately 50% patients with follow-up, and, in a minority of patients, a new ulcer developed during serial studies. Factors associated with ulcer healing remain poorly understood.
Abstract TP119: Angiogenic Factor Profiling in Medical Treatment of Intracranial Atherosclerosis (ICAS)
Authors: Gonzalez Nestor R , Liou Raymond J , Rao Neal , Hinman Jason D , Restrepo Lucas , Ali Latisha , Connolly Mark J , Toscano Juan F , Liebeskind David S , Martin Neil A , Iruela-Arispe Luisa , Saver Jeffrey
Published: March 2022

Objective:
The purpose of this study was to identify circulating angiogenic factor profiles associated to success or failure of intensive medical treatment in ICAS patients.

Methods:
Prospective observational study of circulating angiogenic factors in 72 patients with ICAS treated medically. Twenty-one pro and antiangiogenic factors were isolated from plasma in patients with intracranial arterial stenosis greater than 70% due to ICAS. Patients were followed for 6 months and mRS were collected. Failure to medical management was defined as presence of TIA or stroke within 30 days of presentation. Levels of angiogenic factors were determined by plasma multiplex sandwich ELISA. Samples were run in duplicate with variation coefficient lower than 20%. Angiogenic profiles (APs) were defined using Principal Component Analysis (PCA). Seven profiles were selected (Eigenvalue greater than 1.0). A logistic regression model was built for the outcome variable medical management failure/success using the 7 APs as predictors. An ordinal logistic regression model was built to predict the outcome variable mRS at 6 months using age, gender, baseline mRS and APs as predictors.

Results:
Seventy-two patients with ICAS were included. Mean age was 61.8 (SD 12.3)yrs. There were 53% females. The predominant region of stenosis was the MCA. Of the 7 APs defined by PCA, the regression model identified AP-4 as significantly associated to failure of medical management (P=0.02). AP-4 was characterized by high levels of HGF and the anti-angiogenic factors VEGFR1, Endostatin, Angiostatin, VEGFR3, and TSP2. In the long-term follow up, AP-4 was positively associated with mRS, independently of baseline mRS and age (P=0.002).

Conclusion:
In this extensive prospective study of angiogenic factors in patients with ICAS, a profile characterized by elevation of HGF and several circulating anti-angiogenic factors was strongly associated with failure to medical management and poor outcomes at 6 months.
Abstract TP130: Safety and Efficacy of Vertebral Artery Stenting for Chronic Vertebrobasilar Insufficiency
Authors: Parthasarathy Sudharshan , Kelly-Tolley Ursula , Sachdev Harmeet S , Guisado Raul , Padidar Arash M , Malek Reza
Published: March 2022

Introduction:
While vertebral artery stenting (VAS) in acute ischemic stroke (AIS) has been previously studied, the safety and efficacy of VAS for resolution of chronic vertebrobasilar insufficiency (VBI) symptoms outside of the AIS setting has not been extensively evaluated. Symptoms associated with chronic VBI include dizziness, vertigo, diplopia, blurred vision, ataxia and syncope.

Hypothesis:
VAS for patients with chronic VBI symptoms is safe, will have few peri-procedural complications and improve clinical symptoms.

Methods:
Between January 2005 and June 2015, our group performed VAS on 94 patients after careful evaluation of the contribution of contralateral vertebral artery and posterior communicating artery flow into the basilar artery. Of the 94, 38.2% (n=36) had a clinical history of chronic VBI symptoms; AIS was excluded by imaging and consultation with a stroke neurologist. A detailed retrospective chart review was completed for these patients. Multiple variables including age, sex and cardiovascular co-morbidities were studied. Improvement of clinical symptoms was evaluated by chart review of follow-up visits.

Results:
There were no major complications including strokes or deaths from VAS in 36 patients (25 Males, 11 Females; Age 71.1, SD 9.6). Two patients had minor complications: an allergic reaction to contrast and GI bleed that were effectively medically managed. Prior to VAS stenting, 31 of 36 patients reported dizziness, vertigo, syncope or falls, 1 reported diplopia or blurry vision, and 4 reported multiple VBI symptoms. Overall, 77.8% reported clinical improvement on follow-up (3 patients were lost to follow-up).

Conclusions:
Given a zero percent stroke and death rate at 30 days and a 78% overall improvement of clinical symptoms, we conclude that VAS is a safe and efficacious procedure for chronic VBI when performed by experienced neuro-interventional radiologists in carefully selected patients.
Abstract TP131: Degree of Stenosis by Angiography Does not Influence Risk of Endarterectomy or Stenting in Patients With Severe Asymptomatic Carotid Stenosis
Authors: Roubin Gary S , Lal Brajesh K , Voeks Jenifer H , Heck Donald V , Brooks William H , Bozorgchami Hormozd , Brott Thomas G ,   for the CREST Investigators
Published: March 2022

Introduction:
Increasing stenosis has been questioned as a factor increasing risk of carotid endarterectomy (CEA) or carotid stenting (CAS) in patients with severe asymptomatic carotid stenosis.

Hypothesis:
Greater severity of carotid stenosis is associated with higher rates of periprocedural stroke and death following revascularization for asymptomatic patients.

Methods:
Asymptomatic patients with carotid stenosis ≥ 70% by ultrasound or ≥ 60% by angiogram were eligible for the Carotid Revascularization Endarterectomy vs Stenting Trial (CREST). Patients who had a catheter-angiogram were divided into tertiles based on the degree of stenosis. Outcomes were the occurrence of any stroke or death at 30 days. Proportional hazards models adjusting for age and treatment were used to assess risk of 30 day stroke or death by tertile of stenosis.

Results:
Among 1181 asymptomatic patients, qualifying angiograms were done for 662 patients who had assigned procedure performed within 30 days of randomization. Median % stenosis was 62.6, 73.4, and 83.0 for the tertiles that otherwise differed only for female sex (40% female in tertile 1, 36% in tertile 2, 29% in tertile 3, p=0.01). The 30-day stroke and death rates did not differ significantly by severity of stenosis (Table), but the number of stroke and deaths was only 14 across the tertiles (Table). Similarly meaningful comparison of CEA vs CAS was not possible.

Conclusion:
This is the largest contemporary study of carotid angiograms performed in patients with severe asymptomatic carotid stenosis. No relationship was detected between severity of stenosis and 30-day stroke and death. The safety of CEA and CAS in asymptomatic patients limits detection of other factors that may increase risk because so few events complicate these procedures.
Abstract TP148: The Montreal Assessment of Connected Speech Offers Good Psychometric Properties to Monitor Ecological Language Recovery in Post-stroke Aphasia
Authors: Zumbansen Anna , Frachon Joséphine , Quiquempois Dorothée , Hébert Sylvie , Thiel Alexander
Published: March 2022

Introduction:
Clinical trials in post-stroke aphasia measure language outcomes with available standardized tests. Most of these are primarily diagnostic tools and without evaluated test-retest reliability and responsiveness to change. They do not have parallel versions to prevent learning bias, and their language tasks (e.g., naming) lack ecological validity. The Montreal Assessment of Connected Speech (MACS) was designed to address these issues. Patients are asked to freely describe five pictures illustrating scenes of daily life. Speech samples are scored for their efficiency in transmitting correct information (% correct content units out of the total number of words). Inter-rater reliability (r = .84; R2 = 0.70) and three parallel versions were validated with 105 healthy young and older francophone adults.

Hypothesis:
The MACS has good test-retest reliability (Spearman’s coefficient > .8; Wilcoxon signed-rank test p > .05) and responsiveness to change (discriminates between improved and unimproved patients with area under the receiver operating characteristic curve [AUC] >.8).

Methods:
Patients with subacute or chronic aphasia undergoing intensive speech therapy at the Jewish General Hospital in Montreal with improvement in the Boston Naming Test were included in the improved group (n = 7; 3 females; age mean = 64.1 [SD = 10.8]). Patients with chronic post-stroke aphasia receiving no speech therapy were recruited from an association in the Montreal area for the unimproved group (n = 12; 7 females; age mean 62.4 [SD = 11.6]). All participants were French-speaking, had good or corrected visual acuity and underwent pseudorandomized parallel versions of the MACS at T1 and T2 with a two-week interval between them.

Results:
Correlation between scores at T1 and T2 (rs(12) = .97, p < .001) and stability (Z = -1.38, p = .17) were found in unimproved patients. Score changes showed good discriminative ability between groups (AUC = .81, p = .03).

Conclusion:
Good test-retest reliability and responsiveness to change make the MACS a promising standardized tool for aphasia clinical trials in stroke patients.