bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W MP106: Clinical Effectiveness of Anticoagulation with Warfarin among Ischemic Stroke Patients with Atrial Fibrillation: Findings from the Patient-Centered Research into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) Study
Authors: Xian Ying , Wu Jingjing , O’Brien Emily C , Fonarow Gregg C , Olson DaiWai M , Schwamm Lee H , Bhatt Deepak L , Smith Eric E , Hannah Deidre , Lindholm Brianna , Maisch Lesley , Greiner Melissa A , Lytle Barbara L , Pencina Michael J , Peterson Eric D , Hernandez Adrian F
Published: July 2021

Background:
Oral anticoagulation is recommended for ischemic stroke patients with atrial fibrillation, based on clinical trials done in selected populations. However, little is known about whether the clinical benefit of warfarin is preserved outside the clinical trial setting, especially in older patients with ischemic stroke.

Methods:
PROSPER, a PCORI-funded research program designed by stroke survivors and stakeholders, used American Heart Association Get With The Guidelines (GWTG)-Stroke data linked to Medicare claims to evaluate the association between warfarin treatment at discharge and long-term outcomes among ischemic stroke survivors with atrial fibrillation (AF) and no contraindication to or prior anticoagulation therapy. The primary outcome prioritized by patients was home-time (defined as days spent alive and not in inpatient post-acute care facility) within 2-year follow-up after discharge.

Results:
Of 12,552 ischemic stroke patients with AF admitted from 2009-2011, 11,039 (88%) received warfarin treatment at discharge. Compared with those not receiving any anticoagulation, warfarin-treated patients were slightly younger (mean 80 vs. 83, p<0.001), less likely to have a history of prior stroke or coronary artery disease, but had similar stroke severity as measured by NIHSS (median 5 [IQR 2-12] vs. 6 [2-13], p=0.09). After adjustment for all observed baseline characteristics using propensity score inverse probability weighting method, patients discharged on warfarin therapy had 45 more days of home-time during 2-year follow-up than those not receiving any oral anticoagulant (513 vs. 468 days, p<0.001). Warfarin use was also associated with a lower risk of all-cause mortality, cardiovascular readmission or death, and ischemic stroke (Table).

Conclusions:
Among ischemic stroke patients with atrial fibrillation, warfarin therapy was associated with improved long-term outcomes.
Abstract W MP3: Endovascular Therapy in Large Vessel Occlusion Strokes with ASPECTS of 5-7 May Result in Reduced Infarct Volumes and Better Functional Outcomes
Authors: Noorian Ali R , Rangaraju Srikant , Sun C H , Owada Kumiko , Gupta Rishi , Nahab Fadi , Belagaje Samir R , Anderson Aaron M , Frankel Michael R , Nogueira Raul G
Published: July 2021

Introduction:
Intra-arterial therapy (IAT) for large vessel occlusions strokes (LVOS) has been increasingly utilized. The benefit of endovascular reperfusion in patients with mid-range ASPECTS remains to be established.

Materials and methods:
Retrospective analysis of LVOS patients with ASPECTS 5-7 treated with IAT (n=86) or medical therapy alone (±IV t-PA; n=15) at two academic centers from 2009-2012. Definitions employed: Symptomatic ICH: any parenchymal hematoma; Successful reperfusion: modified TICI≥2B; Good and acceptable clinical outcomes: 90-day mRS 0-2 and 0-3, respectively. Final infarct volumes were calculated based on 24-hour post-procedure CT or MRI scans.

Results:
Mean age (67±14 vs. 67±19 years) and baseline NIHSS (20±5 vs. 20±6) were similar in the IAT and medical treatment groups. Successful reperfusion was achieved in 58 (67%) IAT patients. Symptomatic and asymptomatic ICH occurred in 9 (10%) and 31 (36%) IAT patients, respectively. The IAT rates of 90-day good and acceptable outcomes were 20% (17/86) and 33% (28/86), respectively. Successful reperfusion in IAT patients was associated with smaller FIV (p=0.015) and higher rates of good (p=0.02) and acceptable (p=0.03) outcomes. The median final infarct volume was significant lower with IAT vs. medical therapy (80ml [IQR, 38-122] vs. 190ml [121-267], p=0.015). There was a strong trend towards a higher hemicraniectomy requirement in medically vs. endovascularly treated patients (20% versus 6%, p=0.06) despite similar in-hospital mortality (20% versus 26.7 %, p=0.75).

Conclusions:
Despite a low probability of achieving functional independence, IAT in LVOS patients with ASPECTS 5-7 appears to result in smaller final infarct volumes leading to a reduction in the need for hemicraniectomy and decreasing the degree of overall disability. Therefore, it may be a reasonable option for patients and families who favor a shift from severe to moderate disability. Prospective studies utilizing shift in outcome measures are warranted to confirm these results.
Abstract W MP37: Novel Prognostic Scores for Early Prediction of Outcome Following Aneurysmal Subarachnoid Hemorrhage
Authors: Jaja Blessing , Lingsma Hester , Steyerberg Ewout , Macdonald R. Loch ,   SAHIT Investigators
Published: July 2021

Background:
Aneurysmal subarachnoid hemorrhage (SAH) is a cerebrovascular emergency. Currently, clinicians have limited tools to estimate outcomes early after hospitalization. We aimed to develop novel prognostic scores using large cohorts of patients reflecting experience from different settings.

Methods:
Logistic regression analysis was used to develop prediction models for mortality and unfavorable outcomes according to 3-month Glasgow outcome score after SAH based on readily obtained parameters at hospital admission. The development cohort was derived from 10 prospective studies involving 10936 patients in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository. Model performance was assessed by bootstrap internal validation and by cross validation by omission of each of the 10 studies, using R2 statistic, Area under the receiver operating characteristics curve (AUC), and calibration plots. Prognostic scores were developed from the regression coefficients.

Results:
Predictor variable with the strongest prognostic strength was neurologic status (partial R2 = 12.03%), followed by age (1.91%), treatment modality (1.25%), Fisher grade of CT clot burden (0.65%), history of hypertension (0.37%), aneurysm size (0.12%) and aneurysm location (0.06%). These predictors were combined to develop 3 sets of hierarchical scores based on the coefficients of the regression models. The AUC at bootstrap validation was 0.79-0.80, and at cross validation was 0.64-0.85. Calibration plots demonstrated satisfactory agreement between predicted and observed probabilities of the outcomes.

Conclusions:
The novel prognostic scores have good predictive ability and potential for broad application as they have been developed from prospective cohorts reflecting experience from different centers globally.
Abstract W MP49: Classifying M1/M2 Monocytes by JAK/STAT Activation After Murine Intracerebral Hemorrhage
Authors: Hammond Matthew D , Lorenzo Erica C , Taylor Roslyn A , Ai Youxi , Sansing Lauren H
Published: July 2021

Background:
The immune response following intracerebral hemorrhage (ICH) is an important component of secondary injury that requires further study. Flow cytometry is used to quantify and phenotype recruited leukocytes after murine ICH. Current methods using density gradients have long processing times that reduce the ability to detect phosphorylation states and often yield few neutrophils. Here, we demonstrate the utility of a new method for homogenizing brains and staining for intracellular signaling proteins. This technique results in improved cell recovery and allows us to more precisely classify monocyte polarization states as either M1 pro-inflammatory or M2 anti-inflammatory. Methods: Mouse brains were digested to single-cell suspensions 1-10 days after collagenase ICH. To compare methods, brains were centrifuged on a percoll density gradient or simply homogenized on ice with phosphatase inhibitors. The latter samples were stained extracellularly, fixed with paraformaldehyde, permeabilized in methanol, and then stained intracellularly for phosphorylated STAT molecules (pSTATs). Results: This new method resulted in better neutrophil recovery, yielding 12,190 ± 5,603 neutrophils vs. 1,576 ± 458 neutrophils with percoll at day 3 (p<0.02; n=3-5). No differences were seen in the numbers of monocytes, T cells, or microglia collected between the two methods (p>0.05; n=3-5). Intracellular staining for pSTATs allowed us to identify activated components of the JAK/STAT signaling pathway. All monocytes had high pSTAT1 at day 1, but it steadily declined to day 10. Ly6Clow and Ly6C– monocytes increased pSTAT6 over time, whereas Ly6Chi monocytes did not. Conclusions: This study demonstrates an improved method for recovering leukocytes from mouse brains and staining for pSTATs. Using this technique, we show that Ly6Chi monocytes, which are known to worsen ICH disability, lack pSTAT6 and display an early pro-inflammatory M1 phenotype. In contrast, the Ly6Clow and Ly6C– monocytes both elevate pSTAT6 over time, suggesting they become M2 polarized and may contribute to later repair. Decreasing M1 monocyte polarization and accelerating M2 polarization could be accomplished by targeting pSTATs and may represent a novel treatment strategy in ICH.
Abstract W MP50: Pair Housing Reverses the Detrimental Effect of Social Isolation and Restores BDNF and MBP in Aged Mice after Stroke
Authors: Verma Rajkumar , Harris Nia , Friedler Brett , Crapser Joshua , Patel Anita , Venna Venugopal , McCullough Louise
Published: July 2021

Background:
Age is an important non-modifiable risk factor for stroke. Stroke rates double every decade after age 55. Social isolation (SI) exacerbates behavioural deficits, slows functional recovery and worsens histological injury after stroke in young animals, primarily by increasing the inflammatory response. However, the inflammatory response differs in aging, and whether the detrimental effects of SI are seen in aged animals is unknown. We hypothesize that acute and chronic post stroke SI will worsen stroke pathology and recovery in aged mice and pair housing (PH) will reverse these effects.

Methods:
Eighteen-month-old male C57BL/6 mice were pair housed (PH) for two weeks prior to stroke and randomly assigned to various housing conditions immediately after stroke. Behavioral analysis was done weekly starting at day 7. Mice were sacrificed either at 72 hours or 4 weeks after 60-minute right MCAO or sham surgery (n=9-10/group).

Results:
Mice isolated after stroke (ST-ISO) mice had significantly greater hemispheric infarct volume and neurological deficit scores (p<.05. n=13/group) than pair-housed (PH) stroke mice at 72 hours. SI mice that were isolated immediately after stroke showed significantly higher plasma IL-6 levels compared to PH sham (P<.001, n=13/group ) or PH stroke mice (P<.05) after 72 hour, but levels were similar by 4 weeks post-stroke (n=9-14/group). No change in tissue atrophy was seen after 4 weeks, however a significant interaction [F (1, 28) = 259.6, P<0.001] between housing and stroke was found in the Novel Object Recognition Task (NORT) at day 14. PH led to increased expression of Brain-derived neurotrophic factor (BDNF) and myelin basic protein (MBP) by IHC and western blot (n=5/group for IHC and n= 4/ western blot).

Conclusions:
Social isolation immediately after stroke led to enhanced injury acutely. Despite similar infarcts at 4 weeks, SI mice had delayed behavioral recovery. Pair housing led to increased expression of BDNF and myelin protein expression. Therefore, the beneficial effects of pair housing may be related to BDNF and MBP expression and enhanced recovery after injury in aged animals.
Abstract W MP61: Relationship Between Tracheostomy and Readmission Rates Among Mechanically Ventilated Patients with Stroke
Authors: Lahiri Shouri , Navi Babak , Lapidus Daniel M , Agarwal Sachin , Mangat Halinder S , Claassen Jan , Park Soojin , Mayer Stephan A , Kamel Hooman
Published: July 2021

Introduction:
Patients with ischemic stroke (IS), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH) who undergo mechanical ventilation (MV) frequently require tracheostomy for management of persistent respiratory failure. Given the potential complications of chronic immobility and respiratory failure, these patients may be at high risk for hospital readmission.

Methods:
Using previously validated ICD-9-CM codes and statewide administrative claims data from California (2005-2011), Florida (2005-2012), and New York (2006-2011), we compared readmission rates among patients with a first-recorded stroke (IS, ICH, or SAH) who received MV and were discharged with or without a tracheostomy. Survival statistics and Poisson regression analyses with robust standard errors were used to report rates of hospital readmission and the association between tracheostomy and readmission rates.

Results:
Among 39,881 patients with stroke who underwent MV, 10,690 received a tracheostomy. The rate of any readmission was 21.1% (95% CI 20.3-21.9%) at 1 month and 45.1% (95% CI 44.2-46.1%) at 1 year among patients with tracheostomy versus 17.1% (95% CI 16.6-17.5%) and 35.3% (95% CI 34.8-35.9%) among those without a tracheostomy. The overall readmission rate throughout follow-up was 5.03 (95% CI 5.00-5.07) readmissions per 100 patients per month in those with tracheostomy versus 3.69 (95% CI 3.64-3.73) in those without tracheostomy. After adjustment for stroke type, demographic characteristics, vascular risk factors, Elixhauser comorbidities, stroke complications (e.g., seizures), and discharge disposition from the index hospitalization, tracheostomy was associated with a slightly increased readmission rate (incidence rate ratio, 1.04; 95% CI 1.00-1.08, p=0.04).

Conclusion:
Readmission rates among mechanically ventilated patients with stroke were not substantially higher than overall readmission rates seen in the general hospitalized population of elderly patients. There was a statistically significant but not clinically meaningful association between tracheostomy placement and readmission rates. These data may be helpful when counseling the families of patients with severe stroke.
Abstract W MP66: Rates of Ischemic Stroke after Intracranial Hemorrhage in a Population-Based Sample of Patients with Atrial Fibrillation
Authors: Lerario Michael P , Gialdini Gino , Lapidus Daniel , Shaw Mesha , Navi Babak , Kamel Hooman
Published: July 2021

Introduction:
Patients with atrial fibrillation (AF) who experience intracranial hemorrhage (ICH) often cannot tolerate anticoagulant therapy and presumably face a higher risk of thromboembolism. However, there are little population-based data on long-term rates of stroke after ICH in patients with AF.

Methods:
Using validated diagnosis codes and administrative claims data from all nonfederal acute care hospitals and emergency departments in California, Florida, and New York from 2005 to 2012, we identified patients at their first encounter with a recorded diagnosis of AF. We excluded patients with diagnoses of stroke or ICH prior to their index visit or a diagnosis of stroke at the index visit. A time-varying covariate was used to account for ICH (intracerebral or subarachnoid hemorrhage) at the index visit or during follow-up. Kaplan-Meier survival statistics were used to calculate cumulative rates of stroke, and Cox proportional hazard analysis was used to evaluate the relationship between incident ICH and stroke while adjusting for the CHA
2
DS
2
VASc score.

Results:
During a mean 3.2 years of follow-up among 2,376,207 patients with AF, 25,243 (1.06%) developed ICH and 93,183 (3.92%) developed stroke. The cumulative 1-year rate of stroke was 6.50% (95% CI, 6.06-6.96%) after ICH versus 2.22% (95% CI, 2.20-2.24) in those without ICH. ICH remained associated with higher stroke risk after adjusting for the CHA
2
DS
2
VASc score (HR, 2.29; 95% CI, 2.18-2.40). Among patients with ICH, stroke risk rose in step with the CHA
2
DS
2
VASc score.

Conclusions:
In a large population-based cohort, patients with AF faced a substantially higher risk of stroke after ICH. This risk rose proportionally with increasing CHA
2
DS
2
VASc score. These findings point to patients with AF and ICH as a vulnerable population who may especially benefit from therapeutic alternatives to anticoagulant therapy for preventing thromboembolism in AF.
Abstract W MP67: Non-traditional Serum Lipid Indices and Recurrent Stroke Risk
Authors: Park Jong-Ho , Ovbiagele Bruce
Published: July 2021

Background:
Expert consensus guidelines recommend low-density lipoprotein (LDL) cholesterol as the primary serum lipid target for recurrent stroke risk reduction. Indeed, emerging evidence suggests that non-traditional serum lipid indices may be better predictors of vascular risk than LDL. Triglycerides (TG)/high-density lipoprotein (HDL) is a powerful independent predictor of all-cause mortality and cardiovascular events. Furthermore, total cholesterol (TC)/HDL ratio, LDL/HDL and non-HDL have all been independently linked with greater coronary heart disease (CHD) risk. Little is known about the effects non-traditional serum lipid indices on recurrent vascular risk after a recent stroke.

Method:
We analyzed the Vitamin Intervention for Stroke Prevention study database comprising 3680 recent (<120 days) ischemic stroke patients followed up for 2 years. Independent associations of each 4 lipid index (TG/HDL, TC/HDL, LDL/HDL, and non-HDL) with recurrent stroke (primary outcome) and stroke/coronary heart disease (CHD)/vascular death (secondary outcome) were analyzed. Each of the 4 groups was stratified into quintiles according to the distribution of lipid indices.

Results:
Of all indices evaluated only TG/HDL was consistently and independently related to both outcomes: compared with the lowest quintile (≤1.93), the highest TG/HDL quintile (≥6.22) was associated with stroke [adjusted hazard ratio (AHR), 1.56; 95% CI, 1.05–2.32] and stroke/CHD/vascular death (AHR 1.39, 95% CI, 1.05–1.83), including adjustment for lipid modifier use. Compared with the lowest quintile (≤3.50), the highest TC/HDL quintile (≥5.98) was associated with stroke/CHD/vascular death (AHR 1.44, 95% CI, 1.03–2.01). LDL/HDL, non-HDL, elevated TG alone, and low HDL alone, were not independently linked to either outcome.

Conclusions:
Of various non-traditional serum lipid indices, elevated baseline TG/HDL and TC/HDL predict future vascular risk after a stroke, but only elevated TG/HDL is related to risk of recurrent stroke. Future studies should assess the role of TG/HDL as a potential therapeutic target for global vascular risk reduction after stroke.
Abstract W MP72: Sleep and Timing of Recurrent Events in a Mild Stroke Population: Results of the SWIFT Study
Authors: Roberts Eric , Quarles Leigh , Torrico Veronica , Boden-Albala Bernadette
Published: July 2021

Sleep is an important contributor to cardiovascular disease; we have previously reported it is a risk factor for incident vascular events. It is thought that sleep apena may be the primary mechanism through which sleep disturbance is associated with vascular events. Little is known, however, about the association between sleep and recurrent events. The aim of this analysis was to determine the association between sleep problems and the risk of recurrent vascular events in an elderly, multiethnic population. This analysis uses data from SWIFT, a randomized clinical trial conducted in northern Manhattan designed to test a stroke preparedness intervention. Sleep was measured with the MOS sleep scale. MOS is a 12 item questionnaire that produces 8 validated scales. We report results using the snoring (1 question), shortness of breath during sleep (1 question), and sleep problem index 2 (9 questions) scales. Outcomes were collected prospectively through active surveillance. We used Cox Models to test whether our measures of sleep were associated with an increased hazard of having a recurrent event. SWIFT randomized 1193 stroke participants: mean age 63 years +- 15.14; 50% female; 17% black, 51% Hispanic, 26% white, 6% other. In models adjusted for treatment assignment, race, age, gender, education, marital status and baseline measures of hypertension, diabetes, smoking and NIH stroke scale the sleep problems index 2 was associated with an increased hazard of a first recurrent stroke or TIA (HR=1.91, p-value=0.02), whereas our measures of snoring (HR=1.20, p-value=0.43) and shortness of breath during sleep (HR=1.39, p-value=0.46) were not. The same pattern of results held for a composite measure of first recurrent stroke, TIA, MI or vascular death: sleep problems index 2 (HR=1.97, p-value=0.003), snoring (HR=1.10, p-value=0.62) and shortness of breath during sleep (HR=1.59, p-value=0.18). Our results highlight the contribution of sleep to the risk of recurrent vascular events in a population of mild and moderate stroke/TIA survivors. Importantly, this result is not driven by snoring or trouble breathing at night and is independent of hypertension, smoking and diabetes.
Abstract W MP75: Increase Usage of Acute Stroke Thrombolysis Leads to Better Outcome: The Emergency Medical Service-Discharge Diagnosis Data Linkage Analysis over Three Years
Authors: Cotter Amanda , Heidari Khosrow , Androulakis Michelle , Griffin Andrea , Cartrett Karen , Sen Souvik
Published: July 2021

Background and Objective:
South Carolina is located in the “buckle” of the stoke belt. Use of the emergency medical services (EMS), intravenous tissue plasminogen activator (IV t-PA) in acute stroke and its correlates, including outcomes have not been trended over time. To study the annual trends in the above acute stroke care parameters we linked the EMS database with the statewide hospital discharge records stored at South Carolina Department of Health and Environmental Control (SC DHEC).

Methods:
The ongoing statewide EMS database linkage with the hospital discharge records stored at SC DHEC, allow us to track EMS and acute stroke thrombolysis in real-time. Patients with a discharge diagnosis of ischemic stroke were included in the analysis. Patients transported via EMS were compared with patients not transported by EMS. Variables considered included patient demographics, stroke center status of the hospital, telemedicine usage and treatment with IV t-PA for the calendar years of 2010-2012.

Results:
In the calendar years of 2010-2012, 10,377; 10,532 and 10,900 hospitalized patients in SC were assigned a primary discharge diagnosis of ischemic stroke respectively. Of these, the number of patients transported by EMS that received IV t-PA (7.1%, 9.5% and 10.2%, in the years 2010-12; χ2 trend =15.3, p < 0.0001) shows a significant increasing linear trend over the number of patients that were not transported by EMS that received IV t-PA (2.5%, 3.6% and 3.7%, in the years 2010-12). Over the three years, patients that are treated with IV t-PA were more likely to be discharged home (39%, 42% and 49% in the years 2010-12 ) and less likely to be discharged to a healthcare institution or expire (61%, 58% and 51% in the years 2010-12; χ2 trend=9.3, p =0.002).

Conclusion:
Transportation by EMS increased the likelihood of receiving IV t-PA. Over three years, IV t-PA usage led to better outcome including increasing discharge to home, decreasing discharge to healthcare institution and death. The real-time data linkage methodology may allow us in future to test the impact of statewide interventions geared to promote the usage of EMS and IV t-PA.
Abstract W MP84: Telestroke Network Cost-Effectiveness in the Pacific Northwest: Geography and Facility Size Support a Cost-Sharing Model Between Hub and Spoke
Authors: Okon Nicholas , Nelson Richard , Majersik Jennifer , Lesko Alexandra , Bhatt Archit , Baraban Elizabeth
Published: July 2021

Background:
Stroke care in the Pacific Northwest (PNW) is challenging due to vast distances between small facilities and stroke experts. Regional stroke centers have adopted telestroke to meet this challenge, but often bear the entire cost burden. We sought to determine the effect of distance and facility size on cost-effectiveness of telestroke implementation within our PNW Telestroke Network.

Methods:
We used a decision analytic model with input parameters obtained from patient-level clinical and hospital costs and reimbursements from the Oregon Providence Telestroke Network using pre- and post-telestroke implementation data. Using a one-year time horizon, we calculated the cost-effectiveness of telestroke for spoke facility characteristics of: (1) stroke volume (</≥ 25/yr), (2) distance to hub facility (</≥ 130 miles), and (3) number of hospital beds (</≥ 70). Data included all acute ischemic stroke patients presenting at the spoke hospitals within 4.5 hours of symptom onset. Probability inputs included IV-tPA treatment rates and transfer status. Effectiveness, measured as quality adjusted life years (QALYs), and costs, were combined to calculate incremental cost effectiveness ratios (ICERs) for the spoke hospitals. ICER’s of <$50,000-$120,000/QALY are considered cost-effective. Outcomes were stratified by percentage of cost burden for implementation by the spoke.

Results:
See Table 1.

Conclusions:
Our results suggest that despite the unique characteristics of the PNW, telestroke remained cost effective and the cost effectiveness of telestroke was not affected by bedsize, distance from hub or stroke volumes. Thus, a cost-sharing model may be a feasible solution to telestroke network economic sustainability.
Abstract W P13: Time To Recanalization With New Thrombectomy Devices In Intra-arterial Therapy For Acute Ischemic Stroke
Authors: John Seby , Wisco Dolora , Uchino Ken , Toth Gabor , Cheng-Ching Esteban , Man Shumei , Hussain Muhammad S
Published: July 2021

Introduction:
Faster time to recanalization is a strong predictor of good outcome after acute ischemic stroke (AIS) from large vessel occlusion (LVO). Intra-arterial therapy is an option for AIS from LVO, but studies have not shown benefit with this modality. This may be related to delayed recanalization time. We compared the speed of recanalization with newer devices

Methods:
Retrospective study of patients who underwent IAT for AIS from 1/10 -6/14 at our institution was conducted. Data regarding baseline demographics, treatment times and thrombectomy devices were recorded for all patients who achieved successful recanalization defined as TICI2b-3. Comparisons were drawn between the patients who underwent IAT with the Penumbra aspiration system (Penumbra Inc, Alameda, CA), stent-trievers and direct aspiration (DA) with new large bore catheters such as 5 MAX and 5 MAX ACE (Penumbra Inc).

Results:
113 patients achieved successful recanalization. Penumbra aspiration was used in 48 (42.4%), stent-trievers in 37 (32.7%) and direct aspiration in 28 (24.7%) patients. Baseline demographics are detailed in the table and were non-significant between groups. Time from first run to recanalization was shortest in the DA group (49.5 ± 31.6 minutes), followed by Penumbra aspiration system (61.5 ± 39.8) and stent-trievers (71.6 ± 35.1). DA was significantly faster than Penumbra aspiration system (p 0.0354) and the stent-triever (0.0100).

Conclusion:
Improvements in device technology and interventional technique allows for effective recanalization in significantly shorter times compared to previous methods. The impact of these developments will have to be tested in randomized controlled trials to assess its influence on outcomes
Abstract W P135: Usability of a Virtual Reality Tool for In-Home Stroke Rehabilitation: A Case Series
Authors: Proffitt Rachel , Lange Belinda , Sevick Marisa
Published: July 2021

Stroke is the leading cause of serious, long-term disability in the United States. Exercise and activity in the chronic phase of stroke have shown to be beneficial in achieving and maintaining improvements in motor and ADL function. Interactive video games and virtual reality (VR) have also shown to be effective in improving motor function following stroke. We developed a prototype VR rehabilitation tool called Mystic Isle that uses the Microsoft Kinect sensor and a standard PC. The purpose of this case series was to explore the usability of Mystic Isle as a 5-week intervention to improve performance of client identified activities for adults (>21 years) with chronic stroke (>6 months post) in the home setting. Three participants with chronic stroke completed the five week intervention. Outcomes were measured at baseline, immediately pre-intervention (after a 2 week delay from baseline), and immediately post-intervention. The intervention was conducted in each participant’s home. The results of the Canadian Occupational Performance Measure at baseline guided the choice of the virtual tasks for the intervention. The participants were instructed to complete 4 hours each week. The primary outcome was usability and feasibility of the intervention measured with the Game Experience Questionnaire, the System Usability Questionnaire, and a semi-structured interview. Primary outcome data were analyzed using a mixed methods grounded theory approach. Secondary outcomes included motor impairment, quality of life and occupational performance measured using standard clinical measures. Two of the three participants had very positive responses to the intervention and use of the VR tool in the home setting. All three participants demonstrated improvements in quality of life from pre- to post-intervention and improvements in motor function were scattered across participants. All participants expressed the desire to use the system in the future if improvements were made to increase the usability of the system for the home setting. They also spoke about how they attempted to integrate the game into their daily routine or schedule. A major barrier to use for all participants was a busy day that left them too fatigued to interact with the system and complete the intervention.
Abstract W P156: Arterial Stiffness in Older Adults With and Without Stroke
Authors: Tang Ada , Shkredova Daria , Stouth Derek W , MacDonald Maureen J , Heisz Jennifer J
Published: July 2021

Introduction:
Silent cerebrovascular infarcts resulting from vascular disease can manifest as a decline in cognitive function. These silent events are also associated with increased risk of clinically overt stroke. Arterial stiffness is a marker that represents atherosclerotic progression and is a predictor of cardiovascular events and mortality. This study examined the relationship between arterial stiffness and cognitive impairment between adults aged 50-80 years old with and without stroke. Hypothesis: We hypothesized that elevated arterial stiffness would be observed in individuals with stroke, and also be associated with increased cognitive impairment across all participants. Methods: Cognition was assessed using the Montreal Cognitive Assessment (MoCA). Arterial stiffness was quantified using carotid-femoral pulse wave velocity (cfPWV, in m/s), calculated as cfPWV=D/Δt, where D was the distance measured between arterial sites and Δt was the pulse transit time. Higher values represent increased stiffness, and values >10 m/s are associated with increased risk for cardiovascular events. Results: Twenty-five participants were assessed: 11 participants 4.7±2.4 years post-stroke and 14 older adults without stroke. The non-stroke group was older (73.1±3.9 vs. 65.2±9.4 years, P=0.009), while the stroke group had lower MoCA scores (21.2±3.2 vs. 24.4±2.8, P=0.01). There were no between-group differences in cfPWV (stroke 9.4 m/s vs. older adults 9.9 m/s, P=0.49), when controlling for age and MoCA scores. In backward regression analysis, age explained 21% of the variance of cfPWV (P=0.03), while MoCA was not a contributor. Conclusions: In conclusion, these results suggest that age is a significant correlate of arterial stiffness, regardless of the presence of stroke or cognitive impairment. Ongoing work will examine whether stroke history also contributes to arterial stiffness when groups are matched for age.
Abstract W P170: Effect of “Snoring Alone” and “Snoring Plus Phenomenon” on Cardiovascular Diseases, or Fatal, or Nonfatalstroke
Authors: Mohammad Yousef M , Malik Ahmed A , Saeed Omar , Suri M. Fared K , Qureshi Adnan I
Published: July 2021

Background:
We evaluated the effect of snoring and snoring with unique habitual sleep patterns on cardiovascular events.

Methods:
We analyzed the data from Women's Health Initiative (WHI) observational study. The participants in the observational study were 93,676 women aged 50-79 years who were recruited from September 1994 to December 1998, with annual follow-up through August 14, 2009 (an average of 8 years). Cox proportional hazards analysis was used to examine the effect of snoring alone and snoring with sleep duration >8 hours and/or frequent daytime napping (snoring plus phenomenon) and the outcome of total cardiovascular disease defined as cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke after adjusting for potential confounders.

Results:
Of the 93676 participants, 25777 reported snoring alone and 329 reported snoring plus phenomenon. The cumulative endpoint of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke was seen in 1140 of 25777 (p<.0001) and 24 of 329 (p<.0001) participants with snoring alone and snoring plus phenomenon compared with 3316 of 61396 non snoring participants. Compared with non-snoring participants, snoring plus phenomenon was not associated with an increased risk of cardiovascular endpoint (relative risk [RR] 1.1, 95% confidence interval [CI] 0.8 -1.4, p=0.6), after adjusting for age/gender, hypertension, diabetes mellitus, cigarette smoking, and hyperlipidemia. Snoring alone was not associated with risk of cardiovascular endpoint (RR 0.9, 95% CI 0.5 -1.5, p=0.6). The risk of non-fatal and fatal stroke was higher among participants with snoring plus phenomenon (RR 1.7, 95% CI 1.0 -3.0, p=0.047) but not snoring alone (RR 0.8 95% CI 0.6 -1.0, p=0.07) after adjusting for potential confounders.

Conclusions:
Persons with snoring plus phenomenon (but not snoring alone) are at risk of cardiovascular endpoints of nonfatal and fatal strokes.
Abstract W P19: Large Single Center Experience of Safety of Parenteral Infusion and Maintenance of Antiplatelets in Patients with Acute Ischemic Stroke undergoing Mechanical Thrombectomy and Thrombolysis
Authors: Kirmani Jawad F , Hussain Mohammed , Mehta Siddhart , Brar Jaskiran , Chahal Harina , Ahmad Javaad , Korya Daniel , Khan Nile , Karim Erfan , Moussavi Mohammad
Published: July 2021

Background and Objective:
Lack of achieving complete recanalization in acute strokes using only IV thrombolysis has led to the evolution of a multimodal acute ischemic stroke paradigm which includes combination of intra-arterial tPA, mechanical thrombectomy and stenting. There is limited data on safety of administering intra-arterial and intra-venous antiplatelet agents within the acute stroke treatment paradigm to maintain target vessel recanalization.

Methods:
Of the total patients with acute ischemic strokes presented between 2010-13 to our university affiliated comprehensive stroke center, patients that received IA and IV Eptifibatide were retrospectively classified into two groups: Group A underwent emergent intracranial stenting with IV and or IA r-tPa and/or mechanical thrombectomy. Group B underwent IV r-tPa/ IA r-tPa /IA Eptifibatide and/or mechanical thrombectomy with no intracranial stenting. Eptifibatide was administered intra-arterially as a 135-μg/kg single-dose bolus, and then continued on intravenous infusion of 0.5-μg/kg/min post-procedurally. Charts were reviewed for all patients to assess for complications including groin hematoma, asymptomatic and symptomatic hemorrhages, epistaxis and gross hematuria.

Results:
Of the total of 2016 patients with ischemic strokes, 326 patients received acute stroke treatment and a total of 138 patients received IA and IV Eptifibatide. Group A with acute stenting (82 patients, mean age 68, 49% males [n=40]) and Group B without stenting (56 patients, mean age 73, 54% males [n=30]) received IV Eptifibatide infusion for a mean duration of 19 hours (range 0 to 364 hours). In Group A, 7.3% [n= 6] showed symptomatic ICH, 4.9% [n=4] asymptomatic ICH, 3.7% [n=3] groin hematomas, 2.4% [n=2] nose bleeds. In Group B, 7.1 % [n=4] had asymptomatic hemorrhages and 1.8% [n=1] showed gross hematuria.

Conclusion:
The complications of IV and IA Eptifibatide are not significantly higher than those associated with the existing acute ischemic stroke treatment paradigm. Larger, multi-centered prospective trials are warranted to corroborate our findings.
Abstract W P203: Early Recurrence or Worsening of Transient Ischemic Attack or Minor Ischemic Stroke
Authors: Yamamoto Yasumasa , Nagakane Yoshinari , Makita Naoki , Ashida Shinji
Published: July 2021

Purpose:
The present study aimed to assess the rate of and predictors for early recurrence or worsening after transient ischemic attack (TIA) or minor ischemic stroke (MIS). Methods: From 1806 consecutive patients with acute ischemic stroke, 474 patients with TIA or MIS have been studied. MIS was defined by an NIH Stroke Scale (NIHSS) score ≤3. The primary outcome was total events that include new-onset stroke or TIA and early worsening in patients with MIS in the first 90 days. Worsening was defined as clinical deterioration by ≥2 points on the NIHSS. Patients were classified into 6 stroke subtypes, i.e., G1: Intracranial atherothrombotic (ATB) (n=53), G2: Extracranial ATB (34), G3: Cardioembolic (85), G4: Penetrating artery (PA) disease (200), G5: Coagulopathy (9), and G6: Other embolism included paradoxical (22), aortogenic (31) and cryptogenic (44) embolism. Patients were also classified into 4 groups in terms of diffusion weighted image (DWI) pattern, i.e., D1: Single cortical and subcortical (n=53), D2: Multiple cortical and subcortical (108), D3: Penetrating artery territory (209) and D4: None (90). Results: Penetrating artery disease as stroke subtype is most prevalent (42.1%). There were 83 total events, of those 65% were worsening. Higher NIHSS (≥2) at admission and positive DWI were significantly higher in the group with events than without (OR: 1.67, 2.39, respectively). Most worsening occurred within 6 days. The incidence of total events/ worsening in different stroke subtypes were G1: 13 (24.5%)/8 (15.0%), G2: 8 (23.4)/4 (11.7), G3: 13 (15.2)/ 8 (9.4), G4: 41 (20.5)/32 (16.0), G5: 2 (22.2) /1 (11.1), and G6: 6 (6.4) /3 (3.2). Total event were higher in G1, G2 and G4, and worsening were higher in G1 (60% of total events) and G4 (80%). The incidence of total events/ worsening in different DWI patterns were D1: 8 (11.9%)/5 (7.4%), D2: 21 (19.4)/14 (12.9), D3: 46 (22.0)/ 36 (17.2), D4: 8 (8.8)/0 (0). Total events were higher in D2 and D3, of those worsening was 66.6% in D2 and 78.2% in D3. Conclusions: A majority of events after TIA/MIS was worsening that is prevalent especially in the patients with intracranial ATB and PA disease and those with high DWI signals of multiple cortical and PA territory. A strategy to halt progressive stroke should be tailored.
Abstract W P21: Should We Perform Thrombectomy In Patients With Wake-up Strokes? A Case Series Using Ct Perfusion For Patient Selection
Authors: Vidal Gabriel , Milburn James , Bennett Garrett , Sabharwal Vivek , Al Hasan Mustafa
Published: July 2021

Background and objectives:
Approximately 25% of patients who present with acute ischemic stroke are wake-up strokes. These patients are often not treated with IV thrombolytics because of unclear onset of symptoms. Little data exists on endovascular therapy as acute treatment for this population, particularly with an aspiration technique. The objective of this study is to compare outcomes of patients who presented with wake-up strokes due to large vessel occlusion treated with neuroendovascular procedures versus those who received conservative treatment, based on a 2-year (2012-2013), single center experience at Ochsner Medical Center in New Orleans, LA.

Method:
24 consecutive patients, who presented with wake-up strokes, were outside the IV tPA window, and had both CTA confirmed intracranial LVO and CT-perfusion data upon arrival to our institution were retrospectively studied. Patients with hemorrhages, tandem lesions, or high-grade carotid stenosis were excluded from this analysis. Decision to perform endovascular treatment was made by the vascular neurologist and neuro-interventionalist based on stroke severity and CTA/perfusion data. Patients in group 1 (n = 8) underwent endovascular revascularization procedures; patients in group 2 (n = 16) were treated conservatively (medical management alone). Presentation NIHSS, risk factors, mortality, discharge NIHSS, discharge mRS, and follow up mRS were compared.

Results:
There were no statistical differences in patient population regarding age, gender, and risk factors. There was no statistical difference in their initial NIHSS (16.8 vs. 21.8, p=0.05162), or mortality (0% vs 21%, pr=0.262). The two groups were statistically different in their discharge NIHSS (7.25 vs 21.81, p<0.00045), discharge mRS (2 vs 5, p<0.00001), clinic follow up mRS (1.37 vs 4.94, p<0.00001), and good outcome at discharge (mRS 0-2)(75% vs 0%, pr<0.0002).

Conclusion:
Patients with wake-up strokes, LVO, and favorable CT-perfusion data who underwent neuroendovascular reperfusion treatment had significantly better outcomes in our population, despite similar stroke severity at presentation. This suggests that with careful selection, neuroendovascular therapy for wake-up strokes may lead to improved outcomes.
Abstract W P230: Tetrahydrobiopterin Attenuates Cerebrovascular Oxidative Stress in Tg2576 Mouse Model of Alzheimer’s Disease
Authors: Santhanam Anantha Vijay R , d'Uscio Livius V , Katusic Zvonimir S
Published: July 2021

Background:
The present study was designed to test the hypothesis that supplementation of tetrahydrobiopterin (BH4) to transgenic mice expressing the Swedish double mutation of human amyloid precursor protein (Tg2576 mice) results in restoration of BH4 levels required for activation of endothelial nitric oxide synthase (eNOS), and in turn, prevents oxidative stress in cerebral microvasculature.

Methods:
Cerebral microvessels were obtained from 4-5 months old female wild-type and Tg2576 mice. Biopterin levels, enzymatic activity of GTP cyclohydrolase I (GTPCH-I) and superoxide production were measured by HPLC. The effects of supplementation of BH4 on oxidative stress were studied by injecting wild-type and Tg2576 mice subcutaneously with 100 mol/kg (b.w.) of BH
4
([
6R
]-5,6,7,8-tetrahydro-L-biopterin dihydrochloride; [
6R
]-BH4).

Results:
Enzymatic activity of GTPCH-I, rate limiting enzyme in BH4 biosynthesis, was not different between cerebral microvessels of wild-type and Tg2576 mice. However, bioavailability of BH4, was significantly reduced in cerebral microvessels of Tg2576 mice (P<0.05, n=8). Production of superoxide anions was significantly elevated in cerebral microvessels of Tg2576 mice (P<0.01, n=6), indicative of oxidative stress. This increased superoxide anion production was abolished by L-NAME, a NOS inhibitor, suggestive of eNOS uncoupling (P<0.05, n=6). Supplementation of [
6R
]-BH4 to wild-type and Tg2576 mice resulted in significant increase in BH4 bioavailability (P<0.05, n=6). Notably, supplementation of [
6R
]-BH4 abrogated the increase in superoxide anion production in cerebral microvessels of Tg2576 mice (P<0.05, n=5), while superoxide anion production remained unchanged in cerebral microvessels of WT mice. Furthermore, the inhibitory effects of L-NAME on superoxide anion production in cerebral microvessels of Tg2576 mice were abolished following [
6R
]-BH4 supplementation (P<0.05, n=4).

Conclusion:
Supplementation of [
6R
]-BH4 restored bioavailability of BH4, thereby abrogating superoxide anion production derived from eNOS. Our results suggest that uncoupling of eNOS contributes to oxidative stress in cerebral microvessels of Tg2576 mice.
Abstract W P246: Prostaglandin E2 EP2 Receptor Signaling Aggravates Intracerebral Hemorrhage-Induced Brain Injury
Authors: Leclerc Jenna L , Immergluck Joshua , Lampert Andrew , Diller Matthew , Doré Sylvain
Published: July 2021

Inflammation after intracerebral hemorrhage (ICH) is a key component to secondary brain injury, a major cause of morbidity and disability after ICH. Prostaglandin E2 (PGE
2
) plays an important role in modulating inflammatory responses and in many neurologic disorders. PGE
2
binds with high affinity to the G-protein-coupled receptors EP1, EP2, EP3, and EP4, which collectively mediate its neuroimmunomodulatory effects. We and others have documented that the EP2 receptor mediates the neuroprotective properties of PGE
2
in neuronal cultures and in the middle cerebral artery occlusion model of ischemia/reperfusion-induced brain injury. The present study aimed to investigate the role of EP2 receptor signaling on anatomical and functional outcomes after ICH. The collagenase model was used to induce an ICH in wildtype (WT) and EP2
-/-
mice (n=8-11/group). After 72h, mice were sacrificed and brains collected for Cresyl Violet staining and lesion volume quantification. The EP2
-/-
displayed significantly reduced lesion volumes when compared to WT controls (p<0.005). The EP2
-/-
also showed reduced cortical and striatal microglial activation (p<0.05), and less cortical astrocyte activation (p<0.05). Collectively, these results suggest that PGE
2
-EP2 receptor signaling aggravates ICH-induced brain injury in vivo, which is in contrast to previous reports in stroke models, highlighting the dynamic role of the EP2 receptor in modulating inflammatory responses following brain damage. Further investigations are necessary in order to identify the mechanism of EP2-mediated hematoma resolution. Additional studies using a selective EP2 receptor antagonist could lead to the development of improved drugs that minimize the side effects often associated with anti-inflammatory medications in order to help prevent or improve neurologic recovery following ICH.
Abstract W P255: Neuroprotective Effects Of Thyroid Hormone - T2 (3,5-diiodo-I-thyronine) After Transient MCAO In Mice
Authors: Mdzinarishvili Alexander , Sadana Prabodh
Published: July 2021

T2 (3,5-diiodo-I-thyronine) is an active metabolite of T3 (3,3’,5’-triiodothyronine), a key hormone secreted by the thyroid gland. It has been found to significantly increase mitochondrial respiration and cytochrome oxidizes activity in both in vitro and in vivo studies. T2 has a much more rapid stimulation of metabolic rate (1 hour for T2 vs 24 hours for T3). Neuroprotective effects of T3 have previously been demonstrated. Here, we have investigated the neuroprotective effects of T2 on brain ischemia and edema formation in t-MCAO mice model of brain stroke.

CD-1 mice (25-30 g) were treated with T2 (5 mg/kg) or vehicle control (PBS) by i.v. injection through the jugular vein 30 min before brain stroke was induced. To confirm appropriate placement of the monofilament suture, cortical blood perfusion values were monitored by Laser-Doppler flowmetry during surgical preparation and for 30 min after cerebral ischemia. After 1h of t-MCAO monofilament suture was withdrawn for blood reperfusion and animals were sacrificed after 24h. 1 mm coronal brain slices were prepared and stained with 1% TTC (2,3,5-triphenyltetrazolium chloride) for t-MCAO. Volumes of brain ischemia and edema formation were evaluated.

In vivo results for t-MCAO (1h) showed that T2 (5 mg/kg) reduced brain infarct volume by 42% (p<0.005), and edema formation by 65% (p<0.001). Preliminary gene expression studies showed that T2 has marked influence on gene programs involved in neuronal energy metabolism, mitochondrial biogenesis, ROS generation and brain edema. Ongoing work in our lab is elucidating the exact mechanisms of neuroprotective actions of T2. Neuroprotective effects of T2 in t-MCAO brain stroke model suggest that T2 is a potential new candidate for developing of neuroprotective therapies for brain ischemia and edema. Our studies showed that T2, even though mechanistically distinct from T3, retains the neuroprotective activity of T3 in ischemic stroke and raises the possibility that T2 activity has a role in the neuroprotection seen by T3.