bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract NS7: Strategies for Enhancing Stroke Self-management Among Older Stroke Survivors: A Mixed Methods Inquiry
Authors: Sit Janet W , Chair Sek Ying , Choi Kai C , Chan Carmen W , Chan Aileen W , Qiu Xichenhui , Taylor-Piliae Ruth E
Published: June 2021

Introduction:
Older stroke survivors often experience difficulties managing stroke due to coexistent nature of stroke related neurological deficits and age related physical changes. Identifying effective strategies for enhancing stroke self-management in older survivors is needed.

Objective:
Using a mixed methods inquiry approach, this secondary data analysis from a randomised controlled trial examines the role of patient empowerment on self-management among older stroke participants (aged 65 or above), and what strategies (if any) they used for self-management post-stroke.

Methods:
Phase I study composed of a sub-group analysis on 143 older stroke participants (age 77.1±7.6, 51.7% male, 80.4% ischemic stroke) who received a stroke patient empowerment intervention plus usual care (n=66) or usual care only (n=77). Generalized estimating equations were used to assess between-group changes in stroke self-management behaviors and functional recovery (Lawton Instrumental Activities of Daily Living-IADL) over time at baseline (T0) and 3-month post-intervention (T1), using intention-to-treat. During Phase II, in-depth individual interviews by purposive sampling (n=21) were conducted exploring self-management experience post-intervention. Content analysis at both latent and manifest levels were performed.

Results:
Participants receiving the empowerment intervention had significantly better self-management behaviors (all p<0.05, effect size range from 0.36-0.72), and IADL (p=0.003, effect size 0.54) at T1, compared to those receiving usual care only. Content analysis revealed four categories of self-management strategies adopted, namely Visualizing self-manager role; Enhancing resilience; Anticipatory help seeking and Collaborative symptom management. Three barriers to stroke self-management were identified: Accepting disability as part of ageing; Filial piety care concept and Fatigue.

Conclusions:
A patient empowerment intervention engaged older stroke survivors in self-management. Findings of this mixed methods analysis inform important contextual components of care for tailoring interventions for older stroke survivors to foster self-management post-stroke and improve functional recovery.
Abstract TMP100: Outpatient Statin Adherence is Associated with Reduced Recurrent Stroke Risk in Patients with or without Atrial Fibrillation
Authors: Flint Alexander C , Conell Carol , Ren Xiushui , Chan Sheila L , Rao Vivek A , Kamel Hooman , Johnston S. Claiborne
Published: June 2021

Outpatient statin use is known to reduce the risk of recurrent ischemic stroke of atherothrombotic etiology, but it is not known whether statins have similar effects in ischemic stroke associated with atrial fibrillation (AF). We examined the relationship between outpatient statin adherence and the risk of recurrent ischemic stroke in patients with or without AF in a large integrated healthcare delivery system. Among 6,283 patients with ischemic stroke discharged on a statin over a 5 year period, 1,486 (23.7%) had a diagnosis of AF at discharge. Statin adherence rates, measured as percentage of days covered (PDC), averaged 85% (88% for AF patients and 84% for non-AF patients). We observed up to three years after the initial stroke, with an average of two years follow up. In multivariable survival models, after controlling for age, gender, race/ethnicity, and key medical comorbidities, higher statin adherence was found to strongly predict a reduced risk of recurrent ischemic stroke (Figure). In the second year post-stroke, the hazard ratio (HR) associated with a 10% increase in PDC was 0.93 (95% C.I. 0.89-097). The relationship between statin adherence and reduced stroke rates was similar in AF patients (HR 0.94, 95% C.I. 0.84-0.98) and non-AF patients (HR 0.93, 95% C.I. 0.88-0.98). These findings support the use of outpatient statins in all ischemic stroke patients, irrespective of stroke etiology (atherothrombotic vs. atrial fibrillation).
Abstract TMP108: Rates and Predictors of 1 Year of Readmission with Seizures in Patients with Stroke and Stroke Subtypes: Analysis of a National Cohort of 557,033 Stroke Patients
Authors: Chaudhry Saqib A , Mohammad Mohammad R , Gu Shitong , Chaudhry Burhan , Riaz Ahmed , Saeed Ali , Safdar Adnan , Kassab Mounzer , Qureshi Adnan I
Published: June 2021

Background:
Seizures are known sequelae of stroke but the national estimates of seizure related hospitalization in post stroke period are not known.

Objective:
To determine the rates and independent predictors of seizure related hospitalization among patients admitted to hospital with intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) and ischemic stroke (IS).

Methods:
The study population included patients in the 2013 Nationwide Readmissions Database (NRD) over the age of 18 years with a principal diagnosis of SAH (ICD9 = 430xx), ICH (ICD9 = 431xx) and IS (ICD9 = 433x1 & 434x1). Subjects with a secondary diagnosis of arterio-venous malformation, brain tumor, or traumatic brain injury were excluded. Seizures were defined by ICD9 codes (345.0x-345.5x, 345.7x-345.9x,780.39). Cox proportional hazards analysis was used to assess the relative risk of rate of readmission with seizure for patients in the presence of selected comorbidities and potential confounders such as age, sex, and type of stroke.

Results:
A total of 557,033 subjects met all eligibility criteria, of which 497,138, (89.3%) were admitted with IS; 43579(7.8%) with ICH and 16316(2.9%) with SAH. The overall estimated 1 year Kaplan Meir seizure free rate (±SE) was 98.99; it was 99.14% and 99.46% in patients with ICH, SAH and IS respectively. After adjustment for potential confounders, independent predictors of re-admission with seizure within 1 year included female gender (odds ratio, 1.14, 95% confidence interval (CI) 1.02-1.27), age≤60 (OR = 1.26, 95 % CI 1.12-1.41),hemorrhagic stroke (ICH/SAH) (OR =1.18;95 % CI 1.02-1.35), seizure during hospitalization (OR = 7.51, 95 % CI 6.70-8.43 and sodium abnormalities during the hospitalization (OR = 1.43, 95 % CI 1.21-1.69).

Conclusion:
Rate readmission of seizure after stroke within first year is low and there may be residual confounding by severity. Our findings do not support a need for routine prophylactic anti-epileptic drug use after stroke.
Abstract TMP110: Outcomes After Intracerebral Hemorrhage in Patients With Arteriovenous Malformations
Authors: Murthy Santosh , Merkler Alexander E , Omran Setareh S , Gialdini Gino , Iadecola Costantino , Navi Babak B , Kamel Hooman
Published: June 2021

Background:
Few population-level data exist regarding functional outcomes after intracerebral hemorrhage (ICH) caused by a ruptured cerebral arteriovenous malformation (AVM). Our aim was to compare outcomes after ICH from AVM rupture versus other causes of ICH.

Methods:
We performed a retrospective population-based study using data from the Nationwide Inpatient Sample (NIS), a nationally representative survey of hospitalizations across the U.S. We used previously validated

International Classification of Diseases, 9
th
Revision, Clinical Modification

(
ICD-9-CM
) diagnosis codes to identify ICH cases in the NIS from 2002 through 2011. We also performed a confirmatory analysis in a prospective cohort of patients hospitalized with ICH at our medical center from 2011 through 2015. Our predictor variable was a documented AVM. Our primary outcomes were inpatient mortality and home discharge. We used logistic regression to compare outcomes between ICH patients with and without AVM, while adjusting for demographics and medical comorbidities. In the confirmatory analysis of ICH patients at our institution, we additionally adjusted for hematoma size, hematoma location, and the Glasgow Coma Scale score.

Results:
Among 619,167 ICH patients in the NIS, the 4,485 patients (0.7%) with an AVM were younger and had fewer medical comorbidities than patients without AVM. After adjustment for demographics and comorbidities, patients with AVM had lower odds of death (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.40-0.71) and higher odds of home discharge (OR, 2.03; 95% CI, 1.38-2.98) than patients without AVM. In a confirmatory analysis of 342 ICH patients at our institution, the 34 patients (9.9%) with a ruptured AVM had significantly higher odds of independent ambulation at discharge (OR, 4.39, 95% CI, 1.47-13.06) compared to ICH patients without AVM.

Conclusion:
Patients with ICH due to ruptured AVM have more favorable outcomes than patients with other causes of ICH, even after adjustment for demographics, comorbidities, and traditional measures of ICH severity.
Abstract TMP115: Nox-2 and Cerebrovascular Function in Metabolic Syndrome After a Stroke
Authors: Chantler Paul D , Brooks Stephen D , Branyan Kayla W , Asano Shin , Ren Xuefang , Pagano Patrick J , Kelley Eric E , Frisbee Jefferson C
Published: June 2021

Introduction:
The aim here is to elucidate the mechanisms involved in post-stroke cerebrovascular impairments in metabolic syndrome (MetS) that pre-dispose obese patients to more severe post-stroke deficits.

Methods:
1 hr middle cerebral artery occlusion was performed in 17 week old lean (LZR) and obese Zucker (OZR: MetS model) rats. At 24 hr or 15 days post-stroke, the ipsilateral middle cerebral artery (MCA) was cannulated in an ex-vivo microvessel preparation to examine MCA reactivity. Cerebrovascular microvessel density (MVD) was examined 15 days post-stroke via IHC. To examine a potential role of Nox2 and oxidative stress, a specific inhibitor of Nox2 oxidase Nox2-dstat (i.p 10mg/kg) was given during the stroke procedure in OZR.

Results:
In LZR, MCA reactivity was impaired vs. non-stroke control at 24hr post-stroke and remained stable at 15 days post-stroke. In LZR, NO bioavailability was reduced at 24hrs vs. controls, which remained stable at 15 days. In OZR, the MCA impairment was greater at 24 hr vs. LZR, and worsened significantly at 15 days post stroke. NO bioavailability for OZR at 24 hr was similar to LZR stroke, but by 15 days had fallen. MVD was reduced 15 days post-stroke, with a larger loss in OZR vs. LZR. Stroke mortality and infarct size were higher for OZR. Nox2 inhibition restored MCA reactivity, improved MVD and NO levels, and limited stroke infarct size in OZR post-stroke.

Discussion:
Our data suggest that the MetS increases stroke severity and drives a progressive decline in cerebrovascular dysfunction following ischemic stroke. Inhibiting Nox2 production improved stroke outcome in MetS.
Abstract TMP117: Preclinical and Early Clinical Characterization of a Parenterally Administered Direct Factor XIa Inhibitor
Authors: Luettgen Joseph M , Wong Pancras C , Perera Vidya , Wang Zhaoqing , Russo Cesare , Chen Wei , Dorizio Stephanie M , Frost Charles E , Dierks Elizabeth A , Pinto Donald J , Ewing William R , Wexler Ruth R , DeSouza Mary M , LaCreta Frank , Gordon David A , Seiffert Dietmar A , Frost Robert J
Published: June 2021

Introduction:
Acute stroke intervention with antithrombotic agents is limited due to an increased risk of bleeding and a frequent inability to swallow existing oral agents. Preclinical and early clinical data with an antisense oligonucleotide suggest inhibition of Factor XI (FXI) as a means to achieve antithrombotic efficacy with a reduced risk of bleeding. Here we report a preclinical characterization and results from first-in-human studies of BMS-962212, a first in class, direct, reversible, and highly selective IV small molecule inhibitor of FXIa (FXIa K
i
= 0.7 nM).

Methods:
BMS-962212 at 0.001+0.0063 to 0.46+3.1 mg/kg+mg/kg/h or its vehicle were administered IV in anesthetized rabbit models of electrically-induced carotid artery thrombosis and cuticle bleeding time. To evaluate the pharmacokinetics, pharmacodynamics, safety, and tolerability of BMS-962212 in humans, 6 healthy subjects per dose panel received BMS-962212 at 1.5, 4, 10, and 25 mg/h as 2 hour IV infusions and, respectively, 1, 3, 9, and 20 mg/h as 5 day IV infusions, randomized with placebo. Additionally, 12 healthy subjects received BMS-962212 at 15 mg/h co-administered with 325 mg ASA for 5 days.

Results:
In rabbits, BMS-962212 reduced thrombus weight with an EC
50
of 80 nM. At a dose that produced 80% antithrombotic efficacy, BMS-962212 did not increase bleeding time. BMS-962212 increased ex vivo activated partial thromboplastin time (aPTT) dose-dependently without changing prothrombin time and thrombin time. In humans, IV administration of BMS-962212 was well tolerated with no serious adverse events observed. Within 30 minutes of BMS-962212 administration, >90% of the mean maximal aPTT within each dose group was achieved. Following completion of the infusion, BMS-962212 demonstrated rapid drug elimination with a direct relationship observed with aPTT decreasing by more than 50% within 4 hours. Template bleeding times were not increased by BMS-962212 alone or when co-administered with ASA.

Conclusion:
BMS-962212 exhibits properties suited for investigational use as an acute care antithrombotic agent including robust antithrombotic activity with a low potential to increase bleeding risk in preclinical models, and a rapid onset and offset of aPTT activity in humans.
Abstract TMP118: Potential Therapeutic Benefits of Perlecan Domain V in Preclinical Vascular Dementia and Cerebral Angiopathy
Authors: Trout Amanda L , Zhang Zuohui , Roberts Jill , Grohs Gillian , Patel Ela , Nelson Pete , Hartz Anika M , Bix Greg J
Published: June 2021

Vascular contributions to cognitive impairment and dementia (VCID), the second leading cause of dementia behind Alzheimer’s disease (AD), is a broad term that encompasses a spectrum of initial asymptomatic cerebrovascular changes (seen in small vessel disease and cerebral amyloid angiopathy where pathologic Aβ1-42 protein accumulates around brain blood vessels) to the profound symptomatic damage following acute stroke(s). Cerebrovascular remodeling and new blood vessel growth (angiogenesis) may represent early compensatory changes to reduced cerebral blood flow that can initiate VCID. Angiogenesis, in turn, is supported by various growth factors and the proteolytic turnover of surrounding extracellular matrix. We have demonstrated that one such extracellular matrix protein, perlecan (a heparan sulfate proteoglycan), possesses a C terminal domain V (DV) protein that upon cleavage greatly enhances brain angiogenesis. We characterized VCID induced changes in DV expression in the human parietal cortex and a distinct mouse model (diabetic APP/PS1 knock in (db/AD)), that has a gradual cognitive decline by 9 months with microangiopathy, Aβ1-42 deposition, aneurysms, and microhemorrhages. We also utilized an
in vitro
model of the blood-brain barrier (BBB) to assess the transport of human Aβ1-42 in the presence of DV. In the human parietal cortex, dementia patients had increased expression of DV despite having fewer cells. In db/AD animals (3-6 months), we observed a decrease in BBB proteins (i.e. claudin-5), indicating that altered function correlated with an increase in brain DV expression during the asymptomatic angiogenic stage, which precedes cognitive changes (9-12 months).
In vitro,
DV doubled the transport of Aβ1-42 into the lumen of cerebral microvessels over 24 hours with increased activity and total protein expression of P-glycoprotein (P-gp), one of Aβ’s known transport proteins. Collectively, these data indicate that early cerebrovascular changes induce angiogenic-remodeling that correlates with increased expression of DV. DV, in turn, may further enhance angiogenesis and increase brain Aβ clearance into the vascular compartment through P-gp, suggesting that DV could represent a novel therapeutic for VCID.
Abstract TMP3: Which is a Better Predictor of Clinical Outcome After Endovascular Thrombectomy, Pre-treatment DWI ASPECTS or CT Perfusion?
Authors: Yoshie Tomohide , Ueda Toshihiro , Takada Tatsuro , Nogoshi Shinji , Takaishi Satoshi , Fukano Takayuki , Tokuura Daiki , Tokuyama Yoshiaki , Yamamoto Ryouo , Tatsuno Kentaro
Published: June 2021

Introduction:
Optimal imaging before endovascular thrombectomy for large vessel occlusion remains unclear. We compared pre-treatment DWI ASPECTS and CT perfusion (CTP) to identify which imaging better predicted clinical outcome after endovascular thrombectomy.

Methods:
Prospectively collected date for consecutive patients treated with endovascular thorombectomy for acute intracranial internal carotid artery or M1 occlusion and underwent both MRI and CTP before endovascular thrombectomy was analyzed retrospectively. CTP maps were assessed for relative values (rCBF, rCBV and rMTT) obtained for the MCA cortical regions. Pre-treatment DWI ASPECTS and each relative CTP values were compared between good clinical outcome group and poor clinical outcome group. Receiver operating characteristic (ROC) curve analysis was performed to determine the most accurate imaging parameter for the prediction of good clinical outcome.

Results:
Sixty-nine patients were eligible for this study. Average age was 74.4 years, median NIHSS on admission was 17. The median time from MRI to CTP was 21 minutes. TICI 2B or more recanalization was achieved in 44 patients. Twenty-four patients achieved good clinical outcomes. DWI ASPECTS (9 vs. 6, p=0.003) and rCBV (0.99 vs. 0.83, p=0.017) were significantly higher in the good clinical outcome group. The area under the ROC curve for good clinical outcome was 0.714 for DWI ASPECTS and 0.676 for rCBV. In the patients with TICI 2B or more recanalization, DWI ASPECTS were significantly higher (9 vs. 6.5, p=0.027) and rCBV tended to be higher (1.01 vs. 0.83, p=0.071) in the good clinical outcome group. The area under the ROC curve was 0.693 for DWI ASPECTS and 0.659 for rCBV in the patients with TICI 2B or more recanalization.

Conclusions:
DWI ASPECTS and rCBV could predict clinical outcome after endovascular thrombectomy. DWI ASPECTS better predicted clinical outcome than CTP.
Abstract TMP35: Clinical Stroke Scales in Predicting Large Vessel Occlusion: A Metaanalysis
Authors: kong W Y , Choong Andrew , Syn Nicholas , Sharma Vijay K , Teoh Hock L , Tan Benjamin , Yeo Leonard L , Chan Bernard P
Published: June 2021

Background:
Identifying large vessel occlusion (LVO) is paramount in the era of endovascular therapy. This can be achieved easily by computed tomography angiogram(CTA) and magnetic resonance angiography(MRA). National Institute Health Stroke Scale(NIHSS) threshold can be used in primary stroke centre(PSC) without these facilities, to identify patients with LVO for transfer to a comprehensive stroke centre (CSC) for mechanical thrombectomy. Alternatively, simplified clinical stroke scales (CSS)can also be used by emergency medical services (EMS) to identify such patients to be directly transported to CSC. We aim to compare various CSS in predicting LVO in ischemic stroke.

Methods:
We searched PUBMED from January 2005 to July 2016 and screened reference lists of included studies, and included all diagnostic accuracy studies that investigate CSS and prediction of LVO confirmed with CTA or MRA. Two authors independently screened titles and abstracts and perform data extraction for analysis. Pooled sensitivity, specificity and diagnostic odd ratio (DOR) of various CSS were obtained using the random effects model.

Result:
8 studies (total 8556 patients) were included for meta-analysis of 3 CSS. This includes the NIHSS≥5, ≥6, ≥10, ≥13; Cincinnati Prehospital Stroke Scale (CPSS)≥2 and Rapid Arterial oCclusion Evaluation (RACE) ≥ 5. Pooled sensivity and specificty for the respective cut off values of these CSS was metaanalysed and presented in table 1. NIHSS≥13 has the highest DOR (26.0), followed by NIHSS≥5 (16.9); whereas other NIHSS thresholds, CPSS and RACE were less predictive. NIHSS≥5 was found to have the highest sensitivity of 0.865 and NIHSS≥13 had the highest specificity of 0.934.

Conclusion:
We found 2 NIHSS thresholds that were most useful for identifying LVO. Depending on resources and preferences of each stroke centre, different NIHSS threshold can be utilized for purpose of ruling in LVO using a high NIHSS threshold, or ruling out LVO using a low NIHSS threshold.
Abstract TMP37: Prevalence of Carotid Webs in Cryptogenic Stroke
Authors: Nunez Joel , Sajedi Payam , Thompson Oluwatosin , Raghavan Prashant , Kittner Steven , Cronin Carolyn
Published: June 2021

Introduction:
Carotid Webs (also termed “atypical FMD”) are characterized by a focal, intraluminal filling defect along the posterior wall of the carotid bulb. They have been reported in association with recurrent stroke in young patients without atherosclerotic risk factors and may represent an unrecognized and potentially treatable cause of stroke. Stroke mechanism appears to be related to sluggish blood flow and thrombi formation. The purpose of our study was to determine the prevalence of carotid webs in patients with cryptogenic stroke after standard complete stroke evaluation.

Methods:
Retrospective analysis of all patients under age 55 presenting with ischemic strokes 9/2009- 8/2015. CTA has been found to be reliable in detecting webs, so was chosen as the modality for interpretation. 119 cryptogenic stroke patients were identified; 41 of these had CTA. De-identified CTAs were evaluated on TerraRecon by two experienced, board certified, fellowship trained neuroradiologists, with disagreement adjudicated by a third neuroradiologist. Readers were blinded to age, gender, and laterality of stroke.

Results:
Carotid webs were identified in 7 (17%) cases. Presenting stroke was on the same side as the carotid web in all cases. One case had superimposed thrombus, zero had atherosclerosis, and zero had classic features of fibromuscular dysplasia. One patient had recurrent strokes in the territory. Mean age of patients with carotid web was 38.3 years (range 30-41) with 6 (86%) women and 1 (14%) male. Five patients (71%) were African American.

Discussion:
Carotid webs were identified in a significant portion of strokes previously diagnosed as cryptogenic. More research is needed to determine the natural history and optimal treatment of patients with carotid webs and more detailed carotid evaluation to identify webs should be considered as part of the stroke evaluation.
Abstract TMP38: Virtual Reality in Stroke Rehabilitation: Identifying Responders in Evrest Multicentre Trial
Authors: Saposnik Gustavo , Cramer Steve , Cohen Leonardo G , Cohen Ashley , laupacis Andreas , Bayley Mark ,   on behalf of EVREST Multicenter Investigators & Stroke Outcomes Rsch Working Group (SORCan)
Published: June 2021

Introduction:
Despite the modest benefits of non-immersive virtual reality (VR) in small, single center studies, our largest trial (EVREST Muticentre) showed no significant difference in motor recovery when VR was compared to an active control. More crucial is to determine the presence of a treatment effect by evaluating respondents.

Methods:
Adults <3 months of stroke with a Chedoke-McMaster >3 were randomized to receive VR using the Nintendo Wii™ gaming system (VRWii) vs. recreational activities (playing cards, ‘Jenga’, domino) (RA). All participants received usual care consisting of conventional rehabilitation at each center. Participants received an intensive program of 10 sessions of either VR or RA, 60 minutes each, over a 2-week period. The primary outcome was a difference in motor performance between groups using the Wolf Motor Function test (WMFT) at the end of the intervention. We defined respondents based on the accepted minimally clinically important difference (MCID) of ≥20% improvement from the baseline WMFT.
1
Secondary outcomes included a MCID of 30% in the Stroke impact Scale (hand) and in the perception of improvement.
2

Results:
Between May 2012 and Oct, 2015, 141 patients received either VRWii (n=71) or RA (n=70). Mean age was 62±12 years. Overall, 63 (53%) participants achieved the MCID (47% % in the VRWii vs 58% RA; p=0.32) at the end of the intervention and 81% 4-weeks post intervention (74 % in the VRWii vs 87% RA; p= 0.21). The total duration of each intervention between respondents and non-respondents was similar (589±57 vs. 579±31 min; p=0.47). Multivariable analysis revealed no difference in the response to VRWii compared to RA (OR 0.63; 95%CI 0.30-1.33). Other outcomes are summarized in the Table.

Conclusions:
The responder analysis in EVREST Multicenter showed no significant difference between groups (VRWii vs RA) for the primary and secondary outcomes. Our results are in agreement with prior analyses that compared mean change across groups.
Abstract TMP51: Ischemic Stroke in Patient with Primary Brain Tumors: Mechanisms and Risk of Recurrence
Authors: Burch Jaclyn E , Parikh Neal S , Kamel Hooman , DeAngelis Lisa M , Navi Babak B
Published: June 2021

Introduction:
Patients with systemic cancer often develop acute ischemic stroke from unique mechanisms, including cancer-mediated hypercoagulability, and their risk of recurrence is high. Conversely, stroke mechanisms in patients with primary brain tumors are incompletely understood, and the risk of recurrent thromboembolism in these patients is uncertain.

Methods:
We performed a retrospective cohort study of adult patients treated for a primary brain tumor at Memorial Sloan Kettering Cancer Center who were diagnosed with MRI-confirmed acute ischemic stroke from 2005 to 2015. Study neurologists used all available electronic records to collect data on patients’ cancer history, stroke risk factors, treatments, and outcomes. Stroke mechanisms, including the TOAST stroke subtype classification, were adjudicated by consensus. The primary outcome was recurrent thromboembolism (arterial or venous) and the secondary outcome was recurrent ischemic stroke. Kaplan-Meier survival statistics were used to calculate cumulative outcome rates, and multivariate Cox proportional hazards analysis was used to evaluate the association between several prespecified potential risk factors and outcomes.

Results:
We identified 83 patients with primary brain tumors and acute ischemic stroke. Median age was 60 years (IQR 51-67) and 53% were women. Tumors were mostly gliomas (72%) and meningiomas (13%). Prior head and neck radiotherapy was common (71%). Most strokes were from unconventional mechanisms, particularly radiation vasculopathy (36%) and surgical manipulation (19%). Small- or large-vessel disease or cardioembolism caused 13% of strokes, while 28% were cryptogenic. Median survival from index stroke was 2.2 years. Cumulative rates of recurrent thromboembolism were 11% at 30 days, 17% at 180 days, and 27% at 360 days; while cumulative rates of recurrent stroke were 5% at 30 days, 8% at 180 days, and 13% at 360 days. We found no significant predictors of outcomes, although radiation vasculopathy was nonsignificantly associated with recurrent stroke (HR 2.4, 95% CI 0.7-7.8).

Conclusions:
Patients with primary brain tumors generally develop strokes from unique mechanisms and their risk of recurrence is high.
Abstract TMP56: Differential Effect of Left versus Right White Matter Hyperintensity Burden on Functional Decline: The Northern Manhattan Study
Authors: Dhamoon Mandip S , Cheung Ying-Kuen , Bagci Ahmet M , Varela Dalila , Alperin Noam , Elkind Mitchell S , Sacco Ralph L , Wright Clinton B
Published: June 2021

Background:
We previously showed that overall brain white matter hyperintensity volume (WMHV) was associated with accelerated long-term functional decline. Asymmetry of brain dysfunction may disrupt brain network efficiency. We hypothesized that greater left-right WMHV asymmetry was associated with functional trajectories.

Methods:
In the Northern Manhattan MRI study, participants had brain MRI with axial T1, T2, and fluid attenuated inversion recovery sequences, with baseline interview and examination. Volumetric WMHV distribution across 14 brain regions (brainstem, cerebellum, and bilateral frontal, occipital, temporal, and parietal lobes, and bilateral anterior and posterior periventricular white matter) was determined separately by combining bimodal image intensity distribution and atlas based methods.. Participants had annual functional assessments with the Barthel index (BI, range 0-100) over a mean of 7.3 years. Generalized estimating equations models estimated associations of regional WMHV and regional left-right asymmetry with baseline BI and change over time, adjusted for baseline medical risk factors, sociodemographics, and cognition, and stroke and myocardial infarction during follow-up.

Results:
Among 1195 participants, mean age was 71 (SD 9) years, 39% were male, 67% had hypertension and 19% diabetes. Greater WMHV asymmetry in the frontal lobes (-3.53 BI points per unit greater WMHV on the right compared to left, 95% CI -0.18, -6.88) and whole brain (-7.23 BI points, 95% CI 0.07, -14.54) was associated with lower overall function. Greater WMHV asymmetry in the frontal lobes (-0.74 additional BI points per year per unit greater WMHV on the right compared to left, 95% CI 0.05, -1.54) and parietal lobes (1.11 additional BI points per year, 95% CI 0.30, 1.93) was independently associated with accelerated functional decline. Periventricular WMHV asymmetry was not associated with function.

Conclusions:
In this large population-based study with long-term repeated measures of function, greater regional WMHV asymmetry was associated with lower function and functional decline, especially with greater WMHV on the right. In addition to global WMHV, WHMV asymmetry may be an important predictor of long-term functional decline.
Abstract TMP58: Determinants of White Matter Hyperintensity in Acute Ischemic Stroke Patients: The MRI-GENIE Study
Authors: Giese Anne-Katrin , Schirmer Markus D , Dalca Adrian V , Sridharan Ramesh , Cloonan Lisa , Xu Huichun , Cole John W , McArdle Patrick F , Broderick Joseph P , Jimenez-Conde Jordi , Jern Christina , Kissela Brett M , Kleindorfer Dawn O , Lemmens Robin , Lindgren Arne , Meschia James F , Rundek Tatjana , Sacco Ralph L , Schmidt Reinhold , Sharma Pankaj , Slowik Agnieszka , Thijs Vincent , Woo Daniel , Worrall Bradford B , Wu Ona , Kittner Steven J , Mitchell Braxton D , Rosand Jonathan , Golland Polina , Rost Natalia S
Published: June 2021

Introduction:
White matter hyperintensity (WMH) is a highly heritable trait and a significant contributor to stroke risk and severity. Vascular risk factors contribute to WMH severity; however, knowledge of the determinants of WMH in acute ischemic stroke (AIS) is still limited.

Hypothesis:
WMH volume (WMHv) varies across AIS subtypes and is modified by vascular risk factors.

Methods:
We extracted WMHv from the clinical MRI scans of 2683 AIS subjects from the MRI-Genetics Interface Exploration (MRI-GENIE) study using a novel fully-automated, volumetric analysis pipeline. Demographic data, stroke risk factors and stroke subtyping for the Causative Classification of Stroke (CCS) were performed at each of the 12 international study sites. WMHv was natural log-transformed for linear regression analyses.

Results:
Median WMHv was 5.7cm
3
(interquartile range (IQR): 2.2-12.8cm
3
). In univariable analysis, age (63.1 ± 14.7 years, β=0.04, SE=0.002), prior stroke (10.2%, β=0.66, SE=0.08), hypertension (65.4%, β=0.75, SE=0.05), diabetes mellitus (23.1%, β=0.35, SE=0.06), coronary artery disease (17.6%, β=0.04, SE=0.002), and atrial fibrillation (14.6%, β=0.48, SE=0.07) were significant predictors of WMHv (all p<0.0001), as well as smoking status (52.2%, β=0.15, SE=0.05, p=0.005), race (16.5% Non-Caucasian, β=0.25, SE=0.07) and ethnicity (8.2% Hispanic, β=0.30, SE=0.11) (all p<0.01). In multivariable analysis, age (β=0.04, SE=0.002), prior stroke (β=0.56, SE=0.08), hypertension (β=0.33, SE=0.05), smoking status (β=0.16, SE=0.05), race (β=0.42, SE=0.06), and ethnicity (β=0.34, SE=0.09) were independent predictors of WMHv (all p<0.0001), as well as diabetes mellitus (β=0.13, SE=0.06, p=0.02). WMHv differed significantly (p<0.0001, unadjusted) across CCS stroke subtypes: cardioembolic stroke (8.0cm
3
, IQR: 4.2-15.4cm
3
), large-artery stroke (6.9cm
3
, IQR: 3.1-14.7cm
3
), small-vessel stroke (5.8cm
3
, IQR: 2.5-13.5cm
3
), stroke of undetermined (4.7cm
3
, IQR: 1.6-11.0cm
3
) or other (2.55cm
3
, IQR: 0.9-8.8cm
3
) causes.

Conclusion:
In this largest-to-date, multicenter hospital-based cohort of AIS patients with automated WMHv analysis, common vascular risk factors contribute significantly to WMH burden and WMHv varies by CCS subtype.
Abstract TMP62: Utility of the Los Angeles Motor Scale to Identify Emergency Large Vessel Occlusion in Acute Stroke
Authors: Tadi Prasannna , Reddy Pranav , Pemmasani Sravanthi , Fakhri Nasir , Siket Matthew , Jayaraman Mahesh V , McTaggart Ryan , Saad Ali , Yaghi Shadi , Machan Jason T , Silver Brian
Published: June 2021

Introduction:
Stroke is a common medical emergency. The outcome depends upon access to stroke specialists, rapid scanning, assessment, and treatments. Identification of large vessel occlusion (LVO) is critical in the selection of patients for emergency embolectomy (clot removal) in patients with acute ischemic stroke. A pre-hospital stroke severity scale, such as the Los Angeles Motor Scale (LAMS) may have utility in selecting appropriate patients for CTA, while minimizing radiation exposure risk to the population as a whole.

Methods:
This was a retrospective analysis of 249 consecutive code stroke activations at a comprehensive stroke center during a 3.5 month period using a LAMS cutoff of ≥4 to trigger CTA acquisition. We determined the sensitivity, specificity, positive predictive value, and negative predictive value of using LAMS to detect large vessel occlusion (LVO). Gold standard was any vessel imaging within 24 hours. Inter-rater reliability of LAMS scoring was determined by blinded scoring of physical exam data from the chart by 3 neurovascular physicians.

Results:
There were 249 code stroke activations during the study period: 91 acute CTAs were recommended based on LAMS scoring. 20 large vessel occlusions were detected. 158 patients did not have a CTA acutely; none had a LVO during subsequent vessel imaging. The sensitivity is 100%, negative predictive value 100%, specificity 69%, positive predictive value 22% of the LAMS triage method. Inter-rater Reliability: Shrout-Fleiss pairwise weighted kappa coefficients between the three raters on LAMS scores were 0.67, 0.55, and 0.62. Kappa coefficients for pairs of raters when LAMS were dichotomized as <3 vs 4-5 were 0.64, 0.50, and 0.71. Clinically meaningful disagreements were evident.

Conclusions:
Accuracy and ease-of-use makes LAMS an ideal clinical tool to rapidly assess acute stroke patients for LVO and emergency mechanical thrombectomy. LAMS demonstrated excellent sensitivity in excluding patients who did not have a LVO. Appropriate training is required to ensure accuracy of LAMS scoring by providers.
Abstract TMP67: Impact of Pre-Hospital Stroke Alerts and Parallel Process on Door-to-Puncture Times in Large Vessel Occlusion
Authors: Mehta Brijesh P , Nogueira Raul G , Goyal Mayank , Menon Bijoy K , Smith Eric E , Katz Randy , Antevy Peter , Jadhav Ashutosh P , Leslie-Mazwi Thabele M , Chandra Ronil V , Duong Hoang D , Ellis Mark , Roche Timothy S , Yoo Albert J
Published: June 2021

Background:
Endovascular mechanical thrombectomy is now the standard of care for acute strokes with large vessel occlusion (LVO). Time to reperfusion is a significant predictor of favorable outcomes in strokes caused by LVO. Pre-hospital notification by Emergency Medical Services (EMS) and parallel in-hospital processes may reduce time to treatment.

Methods:
A single center stroke redesign initiative was launched with implementation of: 1) EMS pre-hospital stroke alerts comprised of last known well (LKW) time, neurological deficits, estimated time of arrival; 2) immediate notification of NeuroInterventionalist (NI) if presence of severe deficits (e.g., gaze preference, aphasia, hemiplegia); 3) early activation (i.e., pre-imaging) of cath lab team based on clinical judgement of NI.

Results:
A retrospective analysis was performed on 164 consecutive stroke patients transported by EMS who underwent mechanical thrombectomy for LVO from August 2014 to July 2016. The median NIHSS score was 17. Pre-hospital EMS stroke alerts were called in 80% (n=132) of treated patients. Among patients with EMS alerts, the NI was notified prior to imaging in 64% (n=80) of cases and the cath lab team was mobilized in parallel for 33 patients. The median door-to-puncture times for patients with EMS alerts + cath lab activation pre-imaging vs EMS alerts + cath lab activation post-imaging vs no EMS alerts were: 66, 79, and 100 minutes, respectively (p<0.05). The impact of field notification was even more pronounced after hours: median door-to-puncture time 76 minutes with EMS alerts (n=70) compared to 111 minutes without EMS alerts (n=21). For patients treated with bridging therapy (IV tPA + IA thrombectomy), the picture-to-puncture interval was notably shorter among patients with EMS alerts, 62 vs 80 minutes (p<0.05).

Conclusion:
We demonstrate a stroke system of care aimed to reduce time to treatment in patients with LVO. In the new era of mechanical thrombectomy, this is the first study to show feasibility and efficacy of pre-hospital EMS stroke alerts triggering early activation of the cath lab team in patients with possible LVO. Development of regional stroke protocols aligning EMS with efficient in-hospital processes are now a top priority.
Abstract TMP72: Modeling the Impact of Interhospital Transfer Protocol Design on Mechanical Thrombectomy Eligibility and Outcomes in a Large Metropolitan Area
Authors: Parikh Neal S , Chatterjee Abhinaba , Merkler Alexander E , Gialdini Gino , Kummer Benjamin R , Mir Saad A , Lerario Michael P , Navi Babak B , Kamel Hooman
Published: June 2021

Introduction:
The effect of mechanical thrombectomy (MT) on functional outcomes after acute ischemic stroke is time-dependent. Interhospital transfer (IHT) introduces delays between stroke onset and MT.

Methods:
We created models of two IHT network designs in New York City involving 26 Department of Health designated stroke centers without MT capabilities (spokes) and 14 hospitals able to perform MT (hubs). In Model A, all patients were transferred from the initial hospital without MT capabilities to the closest hub irrespective of hospital affiliation. In Model B, all patients were transferred to the closest affiliated hub. We calculated the number of patients eligible for MT presenting to each spoke annually using publicly available data. With Google Traffic API software, we estimated travel times between spoke and hub hospitals under constant conditions that approximated ambulance travel. We determined the effect of transfer time on MT eligibility based on a reported 2.5% reduction in odds of MT per minute of travel delay beyond a minimum threshold. Rates of a good functional outcome (modified Rankin Scale score 0-2) were predicted based on MT trial data. Last, we calculated the efficiency advantage needed among affiliated hospitals (Model B) to offset increased travel times.

Results:
In our models, 371 patients (interquartile range [IQR], 229-628) with a stroke amenable to MT present to New York City spoke hospitals without MT capability each year. The mean travel time to the closest hub was 15.9 (±5.7) minutes in Model A versus 23.0 (±9.5) minutes to the closest affiliated hub in Model B. Transferring patients to the closest hub irrespective of affiliation (Model A) resulted in 71 (IQR, 44-120) additional patients being eligible for MT upon arrival and thereby an additional 14 (IQR, 8-23) patients achieving functional independence per year. To attenuate the differences in outcomes between Model A and Model B, a 10.9-minute decrease was required in the combined door-in to door-out time at the spoke plus the door-in to MT-start time at the affiliated hub.

Conclusions:
Optimizing IHT networks requires balancing the efficiency gains of transferring to affiliated hospitals with the travel delays resulting from bypassing nearby MT-capable centers.
Abstract TMP76: Stroke Quality-of-care Metrics in Comprehensive and Primary Stroke Centers and Non-stroke Centers
Authors: Jasne Adam S , Sucharew Heidi , Alwell Kathleen , Moomaw Charles J , Flaherty Matthew , Adeoye Opeolu , Woo Daniel , Mackey Jason , Ferioli Simona , Martini Sharyl , de los Rios la Rosa Felipe , Kissela Brett M , Kleindorfer Dawn O
Published: June 2021

Introduction:
Measuring the quality of stroke care has become increasingly important, but real-world data are limited, especially because many hospitals do not track their own statistics. We sought to determine differences in quality-of-care metrics for ischemic stroke (IS) among non-stroke centers, primary stroke centers (PSC), and comprehensive stroke centers (CSC).

Methods:
The Greater Cincinnati/Northern Kentucky (GCNK) Stroke Study measures temporal trends in the incidence of stroke in a biracial population of 1.3 million. Adult IS cases in 2010 from the GCNK region were ascertained from all local hospitals via ICD-9 codes 430-436 using retrospective chart review. Hospitals included 10 non-stroke centers, 2 PSCs, and 1 PSC that earned CSC status in 2013. Differences in IS patients’ demographics, medical histories, and quality measures were evaluated among hospital categories using chi-square, Fisher’s exact, and Kruskal-Wallis tests. Quality measures were matched to Get With The Guidelines-Stroke (GWTG-S) when possible, although data regarding the appropriateness for non-treatment were not available.

Results:
In 2010, there were 1,981 IS patients in our population (55% female, 21% black) with a median age of 71 years. Of these, 83 were transferred to a different hospital type. There were significant differences in the demographics and medical histories of IS patients, as well as the majority of quality measures, with the CSC and PSCs demonstrating greater compliance with most metrics. (Table)

Conclusions:
We found significant hospital-level differences in both premorbid patient characteristics and quality-of-care metrics depending on the hospital stroke certification status. To our knowledge, this is the first measurement of best-practice care specifically involving hospitals not participating in national quality improvement programs, such as GWTG-S. These differences may help inform quality improvement efforts across hospital types.
Abstract TMP80: Urban and Rural Differences in Process of Care and Outcomes Among Patients With Acute Ischemic Stroke: Results From China National Stroke Registry II
Authors: Gu Hongqiu , Li Zixiao , Wang Chunjuan , Wang Caiyun , Yang Xin , Zhang Xinmiao , Pan Yuesong , Ma Xudong , Liu Liping , Zhao Xingquan , Wang Yilong , Wang Yongjun
Published: June 2021

Introduction:
Although urban and rural differences in care or outcomes are pervasive in many areas of medicine, little is known whether processes of acute ischemic stroke (AIS) care or outcomes are different between urban and rural patients in China.

Methods:
We analyzed China National Stroke Registry II data from June 2012 to January 2013. Urban and rural patients were classified by insurance types of urban basic medical insurance schemes and new rural cooperative medical schemes. Processes of care were examined by 13 individual national guideline-recommended indicators and composite score. Patients’ outcomes included all-cause death, stroke recurrence, and disability (modified Rankin Score ≥3) at 3, 6 and 12 month after discharge. Propensity score matching was used to balance the baseline characteristics. Cox model with shared frailty model and logistic regression with generalized estimating equation were employed to analyze the outcomes.

Results:
Among 19 604 AIS patients, there were 7747 (39.5%) rural and 10 021 (51.1%) urban patients. After matching, 5231 pairs of rural and urban subjects were analyzed. Totally, urban and rural patients had similar processes of care composite score (0.76±0.18 versus 0.77±0.18) (Figure 1). However, comparing to urban patients, rural patients had higher hazard of stroke recurrence and death at 3, 6 and 12 months, and higher odds of disability at 3 months (Table 1).

Conclusions:
Processes of care were similar between urban and rural patients with AIS. However, rural AIS patients had worse unfavorable clinical outcomes after discharge. Difference of stroke care after discharge should be further explored among rural and urban AIS patients.
Abstract TMP83: Long-term Risk of Venous Thromboembolism After Stroke
Authors: Murthy Santosh B , Merkler Alexander E , Gialdini Gino , Chatterjee Abhinaba , Iadecola Costantino , Navi Babak B , Kamel Hooman
Published: June 2021

Background:
There are few data on the long-term risk of venous thromboembolism (VTE) among stroke survivors. We aimed to compare the incidence of VTE amongst patients with ischemic stroke versus those with intracerebral hemorrhage (ICH).

Methods:
We identified all adults discharged from nonfederal acute care hospitals in CA, NY, and FL between 2005 and 2012 with previously validated
ICD-9-CM
codes for ischemic stroke and ICH. Our primary outcome of VTE was defined as pulmonary embolism or deep vein thrombosis. To capture incident cases of VTE, we excluded patients with a VTE prior to or during the index stroke. Kaplan-Meier survival statistics were used to calculate the cumulative rate of incident VTE. Cox regression was used to compare the risk of VTE after stroke while adjusting for demographics, vascular risk factors, and Elixhauser comorbidity index. As there was a violation of the proportional-hazards assumption, we calculated separate hazard ratios (HR) for each year of follow-up.

Results:
We identified 834,660 patients with stroke, of whom 712,440 (85.3%) had ischemic stroke and 112,220 (14.7%) had ICH. Over a mean follow-up of 2.8 (+/-2.4) years, 19,937 (2.4%) developed VTE. After 7 years, the cumulative rate of VTE was 4.7% (95% confidence interval [CI], 4.5-4.9%) in patients with ICH and 4.4% (95% CI, 4.3-4.5%) in patients with ischemic stroke. In multivariable analysis, VTE risk was higher in the first year after ICH compared to ischemic stroke (HR 1.51; 95% CI, 1.43-1.58). However, following the first year, the hazard of VTE was higher among patients with ischemic stroke versus those with ICH (Figure).

Conclusions:
The risk of VTE after stroke varies by stroke type and time. Patients with ICH have a higher risk of VTE in the first year after stroke as compared to those with ischemic stroke while patients with ischemic stroke have a higher risk beyond 1 year.