bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP152: Angiotensin II Receptor Blockers for the Prevention of Post-stroke Epilepsy
Authors: Scheer Richard V , Williams Linda S , Myers Laura E , Zillich Alan J , Cheng Eric M
Published: March 2022

Introduction:
Previous animal studies suggest that post-stroke epileptogenesis is facilitated by activation of albumin-mediated TGF-
β
signaling and that blockade of this pathway with the angiotensin II receptor blocker (ARB) losartan prevents the development of recurrent spontaneous seizures in rat models. We used a large national retrospective cohort to examine the association between post-stroke seizures and ARB exposure among Veterans with ischemic stroke.

Hypothesis:
ARB exposure is negatively associated with post-stroke seizures.

Methods:
We reviewed data from the Veteran’s Affairs Office of Quality and Performance retrospective cohort stroke study, which included Veterans discharged from a VA hospital in 2007 with a primary diagnosis of ischemic stroke. Clinical and demographic data were abstracted by chart review, including NIHSS score. Abstracted data were linked to ICD9 codes for seizure and epilepsy 2 years before and 3 years after stroke admission and to pharmacy data. Patients with seizures prior to stroke admission were excluded. Patients were considered to have ARB exposure if they had a prescription for an ARB at any time during the data collection period. The association between clinical, demographic, and ARB exposure and post-stroke seizures was examined using univariate and multivariate logistic regression analysis.

Results:
Of 3299 eligible patients, 453 (13.7%) were prescribed ARB therapy and 307 (9.3%) had a diagnosis of seizure or epilepsy. In univariate analysis, age, NIHSS, history of ischemic stroke, seizure at onset of stroke, and history of head trauma within 3 months were independently associated (p≤0.10) with post-stroke seizures. In multivariate analysis, only age (OR 1.026; 95% CI 1.014-1.038), NIHSS (0.973; 0.953-0.993), history of ischemic stroke (0.603; 0.460-0.789), and seizure at onset (0.033; 0.014-0.079) were independently associated (p≤0.05) with post-stroke seizures.

Conclusion:
In this retrospective post-stroke cohort, ARB exposure was not associated with a reduction in post-stroke seizures. Further, prospective studies assessing the development of post-stroke seizures and the use of ARBs over time are required.
Abstract TP164: Incidence and Temporal Trends in In-hospital Stroke: a Preliminary Analysis From the Greater Cincinnati/Northern Kentucky Stroke Study
Authors: Kissela Brett M , Khoury Jane C , Alwell Kathleen , Moomaw Charles J , Woo Daniel , Flaherty Matthew L , Adeoye Opeolu , Khatri Pooja , Martini Sharyl R , Mackey Jason , De Los Rios La Rosa Felipe , Ferioli Simona , Broderick Joseph P , Kleindorfer Dawn O
Published: March 2022

Introduction:
In-hospital strokes are often more challenging to treat with acute stroke therapy than strokes that present through the emergency room. It is not well known what percentage of all strokes in a community occur within hospital, or whether the rates of in-hospital stroke are changing over time.

Methods:
All stroke events occurring in the hospital for periods 7/1993-6/1994, 1999, 2005, and 2010 in black and white patients ≥ 20 years of age. Events included ischemic stroke, SAH, ICH and TIAs for this analysis. Rates were age, sex and race standardized to the 2000 U.S. population, and reported per 100,000.

Results:
A total of 1070 stroke events occurred in the hospital in the four study periods (233, 266, 316, and 255, respectively). Mean (std) age was 72 (13) years at the time of stroke, 635 (59%) were female, and 183 (17%) were black. There were a total of 830 (78%) ischemic strokes, 75 (7%) ICH, 12 (1%) SAH, and 153 (14%) TIAs. This distribution of event type did not change significantly over time. Overall rates by year are shown in the table. Among ischemic strokes, subtype/mechanism did not change significantly by period. Overall, 32 of 830 ischemic strokes (4%) received acute thrombolytic therapy, without significant variation by period. Case fatality at 90 days was significantly higher than for strokes that did not begin in-hospital, as might be expected.

Conclusion:
Rates of in-hospital stroke have not changed significantly over time, nor has the rate of acute treatment for ischemic stroke occurring in hospital. This represents a target for system improvement. In-hospital strokes have higher case fatality, likely due to comorbid medical conditions that led to hospital admission.
Abstract TP171: Cerebral Microbleeds and Cerebrovascular Reactivity in the General Population: The Edan Study
Authors: Akoudad Saloua , Gurol Edip , Fotiadis Panagiotis , Koudstaal Peter , Hofman Albert , Ikram Arfan , Greenberg Steven , Vernooij Meike
Published: March 2022

Background:
In patients with symptomatic cerebral amyloid angiopathy (CAA), cerebrovascular reactivity to visual stimuli is reduced. Lobar microbleeds are a diagnostic hallmark of CAA, but are also highly prevalent in asymptomatic individuals. As recent data suggest that the latter group might have CAA, we investigated whether cerebrovascular reactivity is impaired in asymptomatic individuals with lobar microbleeds.

Methods:
From the population-based Rotterdam Study, we invited 35 participants with lobar microbleeds and 15 age-matched controls (all ≥ 55 years) for functional MRI (fMRI) as part of the Early Detection of Angiopathy Network (EDAN) Study. Cerebrovascular reactivity parameters (i.e., amplitude and time to peak responses) were assessed in response to visual stimulation using fMRI. Student’s t-test and linear regression were used to compare fMRI parameters in participants with and without microbleeds.

Results:
Amplitude and time to peak responses did not differ between participants with and without microbleeds (respectively, P=0.179 and P=0.555). Participants with microbleeds had slightly higher amplitude responses compared to participants without microbleeds. After excluding individuals with mixed microbleeds (i.e., lobar and non-lobar microbleeds), we found no significant difference in cerebrovascular reactivity for persons with a single microbleed or multiple microbleeds compared to persons without microbleeds.

Conclusions:
In the general population, lobar microbleeds are not related to impaired cerebrovascular reactivity. In asymptomatic individuals, lobar microbleeds may either reflect less advanced CAA pathology insufficient to cause functional vascular impairment, or reflect vascular pathology other than CAA.
Abstract TP172: Prediction of All-cause and Stroke Mortalities by Carotid Intima-media Thickness in a General Population With a 13.7-year Follow-up: the Suita Study
Authors: Kokubo Yoshihiro , Watanabe Makoto , Higashiyama Aya , Watanabe Takuya , Miyamoto Yoshihiro
Published: March 2022

Introduction:
Carotid intima-media thickness (IMT) has been increasingly a subclinical marker for cardiovascular disease (CVD). However, no study has examined the association between IMT and mortality in non-Western peoples. We assessed the hypothesis that carotid IMT was a predictor for mortality in a general Asian population.

Methods:
We studied 5,330 Japanese individuals (mean age 59.8 years, without CVD at the baseline) who completed a baseline survey and carotid atherosclerosis in the Suita Study, and were then followed for 13.7 years on average. Carotid IMT was evaluated by high-resolution ultrasonography with atherosclerotic indexes of IMT in the common carotid artery (CCA) and carotid artery bulb (Bulb). Mean CIMT and BIMT were defined as the averages of the IMT of both proximal and distal walls for both sides of the CCA at points 10 mm proximal and 5 mm distal, respectively, to the beginning of the dilation of each Bulb. Max-CIMT and BIMT was defined as the maximum IMT in the CCA and Bulb scanned areas, respectively. The risks of all-cause mortality across carotid IMT were compared by the use of Cox proportional-hazards models adjusting for age, sex, body mass index, hypertension, total and HDL cholesterol, antihyperlipidemic drug use, diabetes mellitus, smoking and drinking status.

Results:
In 72,923 person-years of follow-up, we documented 972 all-cause mortality (including 66 strokes and 233 CVD). The adjusted hazard ratios (HRs, 95% confidence intervals, CIs) for all-cause mortality and stroke were 1.11 (1.06-1.18) and 1.01 (0.81-1.25), 1.07 (1.05-1.09) and 1.10 (1.00-1.20), 1.04 (1.02-1.07) and 1.06 (0.95-1.17), and 1.04 (1.03-1.05) and 1.06 (1.01-1.11) with 0.1 mm increases in mean-CIMT, mean-BIMT, Max-CIMT, and Max-BIMT, respectively. The adjusted HRs (95% CIs) in the 4th quartiles of mean-CIMT (≥0.95 mm), mean-BIMT (≥1.15 mm), Max-CIMT (≥1.10 mm), and Max-BIMT (≥1.55 mm) for all-cause mortality were 2.05 (1.45-2.91), 1.57 (1.08-2.28), 2.02 (1.27-3.22), and 2.11 (1.38-3.23), compared with their 1st quartiles (<0.775 mm, <0.85 mm, <0.85 mm, and <0.90 mm), respectively.

Conclusions:
Carotid IMT is a strong predictor for all-cause. Especially, Mean- and Max-BIMT are good predictors for stroke mortality in general Asian population.
Abstract TP177: Preoperative Functional Status and Type of Surgery Influences Postoperative Stroke Risk: analysis from the Nationwide Surgical Quality Initiative Program
Authors: Kummer Benjamin R , Hazan Rebecca , Kamel Hooman , Merkler Alexander E , Willey Joshua Z , Middlesworth William , Yaghi Shadi , Elkind Mitchell S , Boehme Amelia K
Published: March 2022

Introduction:
Post-operative stroke (POS) is associated with vascular and cardiac surgery, but this finding has mainly been reported among populations receiving vascular and cardiac procedures. We investigated the association between type of surgery and risk of POS in a large, generalizable inpatient cohort from the American College of Surgeons National Surgical Quality Initiative Program (NSQIP) database.

Hypothesis:
Cardiac and vascular procedures are associated with an increased risk of POS.

Methods:
We identified patients that underwent surgery between the years of 2000 and 2010. Our primary outcome was POS within 30 days of surgery. Using a hierarchical model adjusted for age, race, sex, medical comorbidities and dichotomized functional status, we assessed for clustering between type of surgery and POS. We then determined risk factors for POS while adjusting for clustering. Each surgical type was compared against all other surgical types.

Results:
We identified 729,886 patients, of whom 2,703 (0.3%) developed POS. In the hierarchical analysis, cardiac surgery (incidence rate ratio (IRR) 6.38, 95%CI 5.37-7.55), vascular surgery (IRR 4.41, 95%CI 4.08-4.76), and neurosurgery (IRR 2.05, 95%CI 1.69-2.48) were associated with increased risk of POS. The only patient-level factor associated with surgery type was poor preoperative functional status. Accounting for clustering, patients with poor pre-operative functional status (OR 4.11, 95%CI 3.60-4.69), history of stroke (OR 2.35 95%CI 2.06-2.69), history of transient ischemic attack (OR 2.49 95%CI 2.19-2.83), active smoking (OR 1.20, 95%CI 1.08-1.32), and COPD (OR 1.39 95%CI 1.21-1.59) were at higher risk of POS. There was no interaction between preoperative functional status and type of surgery.

Conclusions:
In a large cohort of surgical inpatients, we found that the risk of POS was significantly associated with cardiac, vascular, and neurosurgical procedures. Certain patient populations, such as those with a dependent pre-operative functional status, may be at a higher risk of POS and may be more likely to undergo cardiac, vascular, or neurosurgical procedures. Further studies are needed to elucidate the relationship between pre-surgical functional status and type of surgery.
Abstract TP18: S-shaped Internal Carotid Artery Curve in Dissection-related Acute Ischemic Stroke
Authors: Haussen Diogo C , Jadhav Ashutosh , Rebello Leticia , Belagaje Samir , Jovin Tudor , Aghaebrahim Amin , Gulati Deepak , Frankel Michael , Nogueira Raul G
Published: March 2022

Background and Purpose:
Craniocervical fibromuscular dysplasia (FMD) has been associated with dissections. Recently, the presence of an S-shaped curve in the ICA has been described as a marker of FMD. We evaluated the occurrence of S-shaped curves in acute ischemic stroke (AIS) patients presenting with ICA steno-occlusive dissections.

Methods:
This was a retrospective review of the interventional database of two academic tertiary care institutions. Cases of carotid dissections were compared with a control group (consecutive non-tandem anterior circulation strokes). The presence of ICA S-shaped curves, C-shaped curves, 360° loops, as well as, FMD changes and atherosclerotic changes at the ICA bulb and curve/loop was determined by evaluation of conventional-angiogram and CTA.

Results:
Twenty-four patients with carotid dissections were identified and compared to 92 controls. The baseline characteristics were similar, with the exception of expected younger age and less prevalent history of hypertension, diabetes and atrial fibrillation in the dissection group. Procedural variables were also similar, with the exception of a large percentage of the use of stentretrievers in the control group. The occurrence of parenchymal hemorrhages, good outcomes and mortality were similar amongst the two groups. The frequency of S-shaped curves on either side was 29% in the dissection group vs. 7% in the control group (p<0.01). The S-shaped ICA curves were typically mirror images within the dissection group (85% of the patients with an S-shaped curves had bilaterally occurrence). The frequency of C-shaped and 360 degree curves was statistically similar between groups. FMD changes within the craniocervical arteries were statistically more common in the patients with dissections. Ten patients of the dissection group had either FMD changes or an S-Shaped curve (41%). Multivariate analysis indicated that S-shaped curves were independently associated with the presence of dissections.

Conclusion:
S-shaped ICA curves are predictably bilateral, independently associated with carotid dissections in patients undergoing thrombectomy for acute ischemic stroke, and may indicate the underlying presence of FMD.
Abstract TP188: Black-White Differences in Susceptibility to Stroke Secondary to Abnormal Sleep Duration
Authors: Akinseye Oluwaseun , Williams Stephen K , Ojike Nwakile I , Seixas Azizi , Zizi Ferdinand , Jean-Louis Girardin , Ogedegbe Olugbenga G
Published: March 2022

Introduction:
A strong predictor of stroke is abnormal sleep duration with both short and long sleep associated with increased stroke risk.

Hypothesis:
We tested the hypothesis that the stroke-sleep association differs based on race and age.

Methods:
Using a hypertensive subset from the NHIS dataset (2004-2013), we assessed the association between stroke prevalence and self-reported sleep duration, stratifying for race and age. Diagnosis of hypertension and stroke was based on self-report. Sleep duration was also self-reported and categorized as short (6 or fewer hours), normal/referent (7-8 h) or long (9 or more hours per day). Race was self-reported and categorized as White or Black. Age at screening was grouped into categories of 18-34, 45-64, and those 65 years and older.

Results:
Of the 403, 621 patients in the NHIS dataset (2004-2013), 50.5 % (n=203794) had a diagnosis of hypertension. The average age of the cohort was 58.1 years (95% CI=57.8-58.4), 50.2% female; 15.4 % of the cohort was Black. The prevalence of abnormally short and long sleep duration was 31.3 % and 11%, respectively. The age-standardized prevalence of stroke amongst the hypertensive population for normal, short and long sleep duration was 3.5%, 4.9%, and 7.6%, respectively. Both short and long sleep duration were significant predictors of stroke (1.17; 95% confidence interval (CI) 1.06 - 1.31 and 2.51; 95% CI 2.44-2.58, respectively). An interaction term added to the model suggested that race and age modified the relationship between sleep duration and stroke (p=0.01). Long sleep was a significant predictor of stroke in all age groups, regardless of race. Short sleep was not a significant predictor of stroke in Whites. Short sleep predicted stroke in the youngest age group of Blacks (1.95; 95% CI 1.01 - 3.74). Conversely, short sleep duration was associated with a lower risk of stroke in the oldest age group of Blacks (0.78; 95% CI 0.58- 1.05).

Conclusions:
Risk of stroke is predicted by abnormal sleep duration. The novel finding is that in this hypertensive cohort, the association between stroke and abnormal sleep duration differs by race and age.
Abstract TP191: Sex Differences in Subsequent Ischemic Stroke After Transient Ischemic Attack: Results From a Prospective Multicenter Study
Authors: Mori Kota , Uehara Toshiyuki , Ohara Tomoyuki , Hayakawa Mikito , Sato Shoichiro , Suzuki Rieko , Toyoda Kazunori , Minematsu Kazuo ,   PROMISE-TIA study Investigators
Published: March 2022

Background and Purpose:
Many studies have been reported about the differences between women and men in acute ischemic stroke, but there was limited data for transient ischemic attack (TIA). The aim of this study was to clarify the sex differences in clinical characteristics and subsequent ischemic stroke in TIA patients.

Methods:
The PROMISE-TIA registry was a multicenter prospective study in Japan. From June 2011 to December 2013, 1365 patients within 7 days of TIA onset were enrolled. 1314 patients were followed for 90 days and 1226 patients for 1 year. The age-adjusted hazard ratio (HR) for ischemic stroke after TIA was calculated by using Cox regression to assess sex differences.

Results:
Overall, 483 patients were women and 882 were men. Compared with women, men were younger (69±12 years vs. 71±14 years, p=0.005), had more frequently diabetes mellitus (25% vs. 17%, p=0.0007), and had more frequently taken antiplatelet drugs before TIA onset (32% vs. 26%, p=0.002). The current smoking and drinking rate was higher in men than women (29% vs. 8%, p<0.0001, 55% vs. 15%, p<0.0001, respectively). As for the imaging findings, men had more frequently extracranial carotid stenosis (20% vs. 7%, p<0.0001) and positive DWI lesions (35% vs. 29%, p=0.01). The ABCD2 score was similar in both groups but the incidence of ischemic stroke was significantly higher in men than women both 90 days and 1 year (6.6% vs. 4.1%, HR 1.68; 95%CI 1.01-2.90 and 9.3% vs. 4.4%, HR 1.62; 95%CI 1.05-2.58, respectively). There was no significant difference in stroke subtypes between women and men.

Conclusions:
Although there was no significant difference in the ABCD2 score between the sexes, men had a higher risk of ischemic stroke within 90 days or 1 year after TIA onset.
Abstract TP199: Pre-morbid Management of Atrial Fibrillation Does not Modify Short-term Outcome in Acute Ischemic Stroke
Authors: Cyprich Janelle , Boehme Amelia K , Samai Alyana A , George Alexander , Ryan Matthew T , El Khoury Ramy , Martin-Schild Sheryl
Published: March 2022

Background:
Atrial fibrillation (Afib) is an independent risk factor for acute ischemic stroke (AIS). Studies have shown that patients with Afib on admission for AIS have poorer long-term prognoses compared to patients who do not present with pre-morbid Afib, but it is not clear whether stroke severity and outcome are associated with therapeutic anticoagulation. We aimed to determine whether patients with Afib and INR≥2.0 or who are anticoagulated prior to admission (Afib+/C+) have better outcomes following AIS compared to patients with Afib and INR<2.0 and who are not anticoagulated (Afib+/C-).

Methods:
Patients who presented to our center with AIS between 07/2008-07/2014 were included if pertinent past medical history, home medication status, and INR lab values were obtained at admission. Logistic regression was used to assess differences in baseline, in-hospital, and outcome variables in the Afib+/C+ and Afib+/C- groups as compared to patients with no atrial fibrillation (Afib-). The primary outcome measure was poor functional outcome (modified Rankin Scale > 2) on discharge.

Results:
A total of 1,406 cases were analyzed; 1,262 patients (89.8%) in the Afib- group, 90 patients (6.4%) in the Afib+/C- group, and 54 patients (3.8%) in the Afib+/C+ group. Afib- patients were significantly less likely to experience poor functional outcome (OR=0.40, 95% CI 0.21-0.74, p<0.0001). However, significance was lost after adjusting for age, NIHSS score at baseline, and tPA administration. There was no significant difference in the likelihood of poor functional outcome (OR=0.78, 95% CI 0.37-1.67, p=0.4331) between patients in the Afib+/C- and Afib+/C+ groups in the unadjusted model.

Conclusions:
The absence of atrial fibrillation in the setting of AIS is associated with less likelihood of poor functional outcome, but this is driven by imbalances in covariates. While therapeutic anticoagulation reduces stroke occurrence, this did not protect against higher baseline stroke severity and worse functional outcome amongst patients with Afib.
Abstract TP205: Binge Drinking Habit can Increase Risk for Ischemic Stroke in Korean Men
Authors: Lee Soo Joo , Kim Jae Guk , Ko Youngchai , Cho Yong-Jin , Hong Keun-Sik , Park Jong-Moo , Kang Kyusik , Park Tai Hwan , Park Sang-Soon , Lee Kyung Bok , Kim Dae-Hyun , Cha Jae Kwan , Lee Jun , Kim Joon-Tae , Lee Juneyoung , Lee Ji Sung , Han Moon-Ku , Bae Hee-Joon
Published: March 2022

Background and Purpose:
Heavy alcohol consumption increases the risk for all strokes, whereas moderate regular alcohol consumption is associated with a lower risk for ischemic stroke. The effect of binge drinking on ischemic stroke has not been well known. We undertook a population-based case-control study and the purpose of this study was to evaluate the effect of the binge drinking on ischemic stroke risk.

Methods:
Cases were recruited from patients aged 20 over and hospitalized due to first-ever ischemic stroke which was confirmed by diffusion-weighted MRI. Stroke-free controls, obtained from the database of the 4-5th Korean National Health and Nutrition Examination Survey, were matched with the cases by age, sex and education level. All participants completed an interview using a structured questionnaire about alcohol intake. A binge drinking pattern was defined as consuming 6 or more drinks (> 60g of pure alcohol) of the same alcoholic beverage in 1 session. We confined this analysis to male subjects and non-drinkers in past year and were excluded. A conditional logistic regression models were adjusted for age, hypertension, diabetes, coronary artery disease, hyperlipidemia, body mass index and smoking habit. The frequent drinking was defined as 4 times or more a week.

Results:
Case (n=682) and control (n=1592) were included in this analysis. The binge drinking habit was found in 365 (53.5%) of the cases and 495 (31.1%) of the controls. Compared with non-binge drinkers, the odd ratio for ischemic stroke among binge drinkers was 2.96 (95% CI, 2.18-4.03) after adjusting the confounders. Compared with non-binge drinkers, the harmful association with ischemic stroke in occasional binge drinkers who drank less than 4 times a week (OR 2.31, 95%CI 1.61-3.31) and in frequent binge drinker who drank 4 times or more a week (OR 4.25, 95%CI 2.79-6.48).

Conclusions:
This result suggests that a binge drinking habit may have a harmful effect on ischemic stroke.
Abstract TP21: Patterns of Stroke Transfers and Predictors for Thrombectomy Post-MR CLEAN: a Single Center Experience
Authors: Catanese Luciana , Griessenauer Christoph , Tarsia Joseph , Cohen Wendy , Shoamanesh Ashkan , Kumar Sandeep , Lioutas Vasileios , Selim Magdy , Thomas Ajith , Ogilvy Christopher
Published: March 2022

Introduction:
Recent trial data demonstrating benefit of endovascular therapy (EVT) in acute ischemic stroke (AIS) patients has led to increased referrals to stroke centers for consideration of EVT. We aimed to characterize the baseline predictors and patterns of transfer for patients undergoing EVT.

Methods:
We reviewed data of consecutive AIS patients who were transferred to our institution between 02-to-07/2015 within 6 hours of stroke onset for potential EVT. We compared baseline demographics, vascular risk factors (age, diabetes, hypertension, coronary or carotid disease, atrial fibrillation, anticoagulation use, prior history of stroke/TIA), NIHSS, ASPECTS, time from symptom onset to CT and to tPA infusion, transfer time and presence of large vessel occlusion between patients who underwent EVT versus those who did not upon transfer.

Results:
Forty-three AIS patients were transferred to our institution within 6h of stroke onset and after treatment with IV tPA at outside hospitals for potential EVT; (age: 30-101, 42% women, 44% underwent EVT). In comparison to patients treated medically, those who underwent EVT had greater frequency of proximal arterial occlusion (95% vs. 38%, p<0.001) and higher baseline NIHSS scores (mean: 17 vs. 9, p<0.001). Although not statistically significant, the EVT group was younger (62 vs. 71 years) and had shorter transfer times (161 vs. 135 min). NIHSS (OR 1.2, 95% CI 1.0-1.5), but not proximal vessel occlusion (OR 6.5, 95% CI 0.5-81.9), independently predicted those who underwent EVT in a multivariable regression analysis. NIHSS was highly discriminatory for individuals undergoing EVT (area under the receiver operating characteristic curve: 0.9, p<0.001), with a NIHSS threshold of 9 having a negative predictive value of 100% and positive predictive value of 66%.

Conclusion:
In this single center study; NIHSS was the only independent predictor of EVT in AIS transferred within 6 hours of symptom onset. A NIHSS threshold of less than 9 seemed to discriminate patients who did not ultimately undergo EVT at our institution. The limited work-up prior transfer and prolonged transfer time highlights the need for regional and national efforts to maximize the utility and benefit of EVT for AIS patients.
Abstract TP211: Pediatric Age, but Not Treatment and Imaging Findings, Impacts Outcome in Contrast Induced Encephalopathy
Authors: Janjua Nazli , Moalem Alimohammed , Panichpisal Kessarin , Tse-Chang Karen , Jones Kimberly , Keasler Debbie , Desai Bhupat
Published: March 2022

Background:
Contrast induced encephalopathy (CIE) following radiographic procedures, though a well-recognized complication, occurs sporadically enough that its diagnosis, prognosis, and treatment remain undefined and varied.

Objective:
We sought to identify clinical and radiographic criteria as well as treatment experience vis a vis reported outcomes.

Methods:
We identified case reports in PUBMED using search terms “contrast induced encephalopathy/neurotoxicity” from which we collected clinical and radiographic variables.

Results:
Among 52 reports (total 79 patients, including our own unpublished 3 cases) the mean age was 60±16 years, with similar gender distribution. Multiple different contrast media were used (mean dose, 207 ±158 mL). Onset was typically immediate, though delayed cases up to 39 days later occurred. There were 3 confirmed cases (n=2, direct evidence of contrast in cerebrospinal fluid; n=1, autopsy excluded other cause of abnormality) which we classified as ‘definite CIE’. No imaging hallmark features were described in 30 patients, whom we classified as ‘possible CIE.’ The remaining 47, ‘probable CIE,’ demonstrated either diffuse edema or enhancement, with the latter being a more common finding (enhancement=33, 42% vs 11, 14%). Administered treatments included: hydration (n=31), steroids (n=10), hyperosmolar agents (n=4), anti-hypertensives (n=3), anti-convulsants (n=3), thrombolytics (n=3), hemodialysis (n=2), hemicraniectomy (n=1), and n-acetylcysteine. (n=1). There was no correlation between imaging features nor treatment modality and final outcome. Resolution occurred within 5 ±9 days. While most patients improved, 9 (11%) had no/incomplete improvement including 2 (2.5%) who expired. The 2 fatal cases occurred among the only 2 children in the entire series, p<0.001.

Conclusion:
The diagnostic approach to CIE may be systemized based on the identification of hallmark radiologic findings, which, whether present or absent, do not appear to affect outcome. Though hydration and supportive remedies are most common, other treatments were not associated with hastened or worsened symptom resolution. And while the outcome of CIE among adults is generally benign, it may be fatal in children.
Abstract TP214: Serum Activity of Angiotensin Converting Enzyme 2 is Decreased During Ischemic Stroke in Humans
Authors: Bennion Douglas M , Rosado Christian A , Haltigan Emily A , Sumners Colin , Waters Michael F
Published: March 2022

Introduction:
Abundant preclinical studies show efficacy for therapies targeted to the protective axis of the renin-angiotensin system in stroke. The expression and activity of angiotensin converting enzyme 2 (ACE2), a cardio and neuro-protective carboxypeptidase in this axis, have recently been shown to be dynamically altered during stroke in animal models.

Hypothesis:
The aim of this study was to characterize the previously unexplored changes in activity of ACE2, and other RAS enzymes, in the serum of patients experiencing acute ischemic stroke.

Methods:
Blood samples were obtained from patients with acute ischemic stroke (n=20) at presentation and again at three days post-stroke and enzyme activity levels in isolated serum were analyzed by fluorometric assay. These were compared to enzyme activity levels in samples obtained from a cohort of patients presenting with transient ischemic attack or other clinical presentations mimicking stroke and from healthy control participants (n=20).

Results:
Ischemic stroke resulted in significantly lower levels of serum ACE2 activity at an average of 3.5 hours after stroke as compared to both transient ischemic attack/stroke mimic and healthy control participant levels, followed three days later by an increase back to control levels. ACE activity was also significantly decreased following stroke, but without increases at three days. Renin enzyme activity during stroke did not significantly differ from controls at either time point. Serum ACE2 activity was negatively correlated with systolic blood pressure at presentation among stroke patients, while activity levels from a separate cohort of healthy young adults were positively correlated. Multiple regression analyses indicated that ACE2 activity levels were significantly correlated with a diagnosis of ischemic stroke, with those in the lowest tertile of all participants were at 7.7 times increased odds of having had a stroke.

Conclusions:
The characterization of the dynamic and novel changes in serum ACE2 activity in human stroke, which concur with preclinical studies, along with the demonstration of correlations with systolic blood pressure, provides new insight for the development of therapies that target this protective system in ischemic stroke.
Abstract TP215: Atrial Fibrillation and Flutter as a Cause of Stroke in an Unspecific Stroke Population. Stroke Subtypes in the Findaf Randomised Study
Authors: Messerschmid Anna , Heuschmann Peter U , Behnke Nico , Schulte Anna , Jürries Falko , Liman Jan , Hamann Gerhard F , Kermer Pawel , Gelbrich Götz , Weber-Krüger Mark , Gröschel Klaus , Wachter Rolf
Published: March 2022

Introduction:
The intensity of AF detection modalities in stroke patients has been modulated by the stroke subtype. Hence, most studies have been performed in so called cryptogenic stroke. However, it has never been proven that AF is more prevalent in cryptogenic stroke as compared to non-cryptogenic stroke. The Find-AF randomised trial (ISRCTN 46104198) is a randomised trial comparing prolonged Holter ECG monitoring (3x 10 day monitoring) and usual care in 400 patients with ischemic stroke. The primary results of Find-AF randomised will be submitted for presentation as a late breaking clinical trial to ISC 2016. In contrast to previous randomised trials (e. g. EMBRACE and CRYSTAL-AF), this trial will include all ischemic stroke patients, not only cryptogenic strokes.

Hypothesis:
We hypothesized that the AF detection rate is independent from the stroke subtype according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST), but is associated with clinical variables (e. g. age, NIHSS, prevalence of coronary artery disease).

Methods:
402 patients with ischemic stroke were recruited on certified stroke units within seven days after the index event. Stroke was classified by the Trial of Org 10172 in Acute Stroke Treatment (TOAST), dividing the patient collective into five subgroups according to the most likely stroke etiology.

Results:
The following table presents a preliminary assessment of relevant baseline characteristics of 392 participants (full data set will be available upon abstract presentation.

In addition, all index strokes will be independently assessed by an adjudication committee, consisting of three neurologists. We will present AF detection rates in different stroke subtypes.

Conclusion:
If our hypothesis is correct, future studies on AF detection in stroke patients should not be confined to stroke subtypes (e. g. cryptogenic or embolic stroke of unknown source), but rather include clinical parameters to increase the probability of finding AF.
Abstract TP224: CHA2DS2-VASc Scores Are Correlated With Left Atrial Enlargement in Patients With Non-valvular Atrial Fibrillation-related Stroke
Authors: Kim Joong-Seok , Kim Tae-Won , Koo Jaseong
Published: March 2022

Background:
In patients with non-valvular atrial fibrillation (NVAF), the CHA2DS2-VASc risk factors (Congestive heart failure, Hypertension, Age, Diabetes, prior Stroke/transient ischemic attack, vascular disease, female sex) are known to be associated with developing ischemic stroke. However, the mechanisms how the CHA2DS2-VASc risk factors increase the risk of ischemic stroke in NVAF has not been well understood in terms of the pathophysiologies of thrombogenesis. Virchow’s triad, including atrial tissue damage, hypercoagulable state, and blood stasis, was proposed to play a role in the pathophysiologic mechanism of thrombogenesis in NVAF, and blood stasis in AF occurs not only because of loss of atrial systole but also in relation to left atrial dilatation. The aim of this study was to evaluate the relationship between CHA2DS2-VASc risk factors and left atrial enlargement. We also assessed which factors among the CHA2DS2-VASc risk factors are most contributable to left atrial enlargement.

Methods:
Consecutive patients with acute ischemic stroke and NVAF who were anticoagulation-naïve were enrolled. Left atrial volume (LAV) and left atrial volume index (LAVI) were assessed using the biplane area-length method, following the American Society of Echocardiography standard guidelines. The association between CHA2DS2-VASc risk factors and left atrial enlargement were assessed. The contribution of each individual burden of CHA2DS2-VASc risk factors to left atrial enlargement was also evaluated.

Results:
A total of 98 patients who presented with acute ischemic stroke due to NVAF were enrolled. Correlation analysis showed that total CHA2DS2-VASc score was significantly correlated with left atrial volume index (r=0.33, p=0.002). The regression analysis showed that hypertension (t=0.25, p=0.014), congestive heart failure (t=0.20, p=0.045) and peripheral vascular disease (t=0.39, p<0.001) among the CHA2DS2-VASc scores were associated with left atrial enlargement.

Conclusion:
The CHA2DS2-VASc scores, particularly hypertension, congestive heart failure and peripheral vascular disease, were associated left atrial enlargement (LAE) in patients with acute ischemic stroke due to NVAF.
Abstract TP227: Clinical and Radiological Features of Respiratory Dysfunction in Patients with Medullary Infarction
Authors: Ikeda Ken , Sawada Masahiro , Morioka Harumi , Nagasawa Junpei , Miura Ken , Kyuzen Maya , Hanashiro Sayori , Yanagihashi Masaru , Ishikawa Yuchi , Hirayama Takehisa , Takazawa Takanori , Kawabe Kiyokazu , Kiyozuka Testuhito , Iwasaki Yasuo
Published: March 2022

Background:
Little is known about clinical features and lesion topography in patients with dyspnic medullary infarction (MI). We aimed to evaluate the frequency and the clinicoradiological profile in dyspnic MI patients.

Methods:
Clinical records and magnetic resonance (MR) imaging findings were reviewed serially in 2144 inpatients (1211 men and 933 women) with acute ischemic stroke from 2007 to 2013. The prevalence and the clinicoradiological features were analyzed in DMI patients. Patients with extensive infarction in the brainstem or the posterior circulation area, and cerebral hernia were excluded.

Results:
Ninety-five patients (47 men and 48 women) developed MI. Six patients (2 men and 4 women) had respiratory dysfunction. The prevalence of dyspnic MI was 6.3% (4.3% in men and 8.3% in women) in MI patients, and 0.3% (0.2 % in men and 0.4% in women) in cerebral infarction patients. Neurological examination revealed cough syncope after hiccup, circulatory failure, bulbar palsy, sensory deficits or dysuria in dyspnic MI patients. The prognosis was poor in 4 patients, and recovered in each one patient with and without intervention. The mean age (SD) was 70.0 (22.0) years. MR imaging disclosed three types of lesion topography: 1) the bilateral medial and the right tegmental lesions in the upper and the middle medulla oblongata, 2) the right-predominant extensive lesions in the lower medulla oblongata, and 3) the left lateral and tegmental lesions in the lower medulla oblongata. MR angiography and cerebral angiography showed severe degree of atherosclerotic changes, dural arteriovenous fistula or dissection in the vertebral artery.

Conclusion:
The present study indicated that the prevalence of dyspneic MI was 0.3% among patients with ischemic stroke and 6.3% among MI patients. The symptomatic profile suggested cough, hiccup and additional damages of the urinary center and the circulatory center near the respiratory center in the medulla oblongata. The pathognomonic lesions were found unilaterally or bilaterally in the distinct medullary territory, including the medullary tegmentum. Arteriosclerosis, arterial dissection and vascular malformation of the vertebral artery could play a crucial role in the pathogenesis of the distinct lesion topography.
Abstract TP238: Evaluation of Transfer Delays for Emergent Stroke Patients From Regional Centers to a Comprehensive Center
Authors: Froehler Michael T , Espaillat Kiersten
Published: March 2022

Introduction:
There is overwhelming evidence that endovascular treatment is beneficial for most acute stroke patients suffering a large vessel occlusion (LVO). It is also clear that all revascularization strategies are strongly time-dependent. Endovascular treatment is unavailable at most stroke-ready hospitals, and efficient transfer of these patients is increasingly important. We sought to assess the time to treatment for patients transferred from regional hospitals, vs. patients arriving directly at our CSC.

Methods:
We evaluated the treatment times for the last 20 patients that received both IV tPA and endovascular treatment at our center. IV tPA could have been administered at the regional hospital, but all patients received endovascular treatment at the CSC. We evaluated common stroke quality metrics, plus transfer time for patients coming from another hospital. We measured transfer time as the length of time between acceptance of the patient and patient arrival to the CSC.

Results:
We evaluated the most recent 20 patients receiving IV tPA and endovascular treatment since the new endovascular trials had been published. There were 6 patients undergoing interhospital transfer (IHT), and 14 that presented directly to the CSC. Door to tPA times were 93 minutes at regional hospitals vs. 56 minutes at the CSC. Door to groin puncture did not differ between the two groups. Time from symptom onset to groin puncture was significantly longer in the IHT patients - 287 minutes vs. 195 minutes. This difference was accounted for by transfer time, which averaged 126 minutes and was significantly affected by delays between transfer acceptance to the CSC and regional hospitals calling for transport, which averaged 47 minutes (range 0-141 minutes).

Conclusions:
Patients with acute LVO were treated later if they underwent IHT rather than presenting directly to a CSC. Transfer from regional hospitals was slow, averaging 126 minutes. The transfer time was strongly affected by delays in arranging for transportation, which averaged 47 minutes. Transportation planning is thus a clear target for improving IHT times. Furthermore, as patients presenting directly to the CSC were treated faster, the possibility of taking severe stroke patients directly to a CSC should be studied.
Abstract TP242: Optimization of In-hospital Workflow of Acute Stroke Patients
Authors: Schregel Katharina , Tsogkas Ioannis , Behme Daniel , Knauth Michael , Hinz Jose , Liman Jan , Psychogios Marios Nikos
Published: March 2022

Introduction:
Time from symptom onset to recanalization and especially from admission to recanalization are important factors in the treatment of acute stroke patients with large vessel occlusion.

Hypothesis:
Frequent team meetings between neurologists, neuroradiologists and anesthesiologists as well as a new interdisciplinary standard operating procedure (SOP) would lead to a significant reduction of time from admission to recanalization in treating acute stroke patients. A shift to better clinical outcomes would be documented after implementation of the new SOP.

Methods:
Data were extracted from a prospectively documented university hospital stroke database. 315 patients were divided into a) 242 patients treated with mechanical thrombectomy prior to the new SOP from 2007 until 2013 and b) 73 patients treated with mechanical thrombectomy after implementation of the new SOP from 2014 to now.

Results:
Symptom onset to admission time was not statistically significant between the two groups. Time from admission to groin puncture was massively reduced from 120 to 65 minutes after implementation of the new SOP (P < 0,0001). Groin to recanalization time was also significantly reduced (P=0,0011). The use of a stent retriever was not a significant factor in reducing times from groin puncture to recanalization. Implementation of the new SOP led to a significant shift of clinical outcomes after mechanical thrombectomy.

Conclusions:
Interdisciplinary team work and implementation of a new SOP led to a significant reduction of in-hospital examination, transportation, imaging and treatment times in our stroke center. Better clinical outcomes were reported with faster treatment times.
Abstract TP248: Can the Door to Needle Time Metric Be Achieved via Telestroke?
Authors: Asaithambi Ganesh , Castle Amy L , Sperl Michael A , Ravichandran Jayashree , Gupta Aditi , Ho Bridget M , Hanson Sandra K
Published: March 2022

Background:
The administration of intravenous thrombolysis (IVT) to stroke patients via telestroke (TS) can be safe and effective. It remains unclear how quickly IVT occurs during TS evaluations. We sought to compare door to needle times (DNT) between patients receiving IVT who present directly to our comprehensive stroke center (CSC) and those presenting to community hospitals in our TS network.

Methods:
Consecutive acute ischemic stroke (AIS) patients who presented to emergency departments and received IVT between August 2014 and June 2015 were identified at our CSC and TS network. Median DNTs with interquartile ranges (IQR) were calculated in each cohort. Outcomes measured included rates of symptomatic intracerebral hemorrhage, in-hospital mortality, and discharge to home or an acute rehabilitation unit (ARU).

Results:
During the study period, 117 AIS patients (mean age 71±15 years, 47% women) receiving IVT were included in the analysis (65 CSC, 52 TS). Median DNT at our CSC was significantly shorter compared to TS DNT (CSC 43 [IQR 35,55] minutes vs TS 54 [IQR 41,71.25] minutes, p=0.005). The proportion of patients receiving IVT within 60 minutes of presentation was significantly higher at our CSC compared to our TS network (CSC 84.6% vs TS 63.5%, p=0.01). Favorable discharge to home or ARU was similar (CSC 76.9% vs TS 75%, p=0.83).

Conclusion:
Guideline-recommended DNTs ≤60 minutes can be achieved in community hospitals with TS guidance. Initiatives are required to better resemble DNTs found at stroke centers.
Abstract TP253: Evaluating the Benefits of a Stroke Control Center Through a Power Analysis
Authors: Janjua Ahmad U , Grigoryan Mikayel , Waterman Mark , Ehleben Carole , Qureshi Sakib
Published: March 2022

Introduction and Hypothesis:
The new emphasis placed on endovascular therapy for stroke patients suffering from a large vessel occlusion (LVO) will require enhanced EMS prehospital notification and advanced endovascular team readiness. We postulate that establishing a Stroke Control Center (SCC) will likely decrease first medical contact-to-emergency department (ED) door times in rural areas, reduce time to optimal intervention in metros, and lead to improved clinical outcomes for rural and urban communities.

Methods:
A power analysis was completed using stroke records from the Georgia Coverdell Acute Stroke Registry (8258 patients from 2009-2013) in order to establish the sample size needed to produce a pilot program that could address multiple parameters and measure gains from baseline. A power of 0.90 and alpha level of 0.05 were chosen for two metrics: decreasing ED door-to needle time from 59 minutes in 2013 to 54 minutes and decreasing first medical contact-to-ED door time from 214 minutes in 2013 to 180 minutes. Modeled after Poison Control Centers, the program aims to establish an on-call SCC staffed by stroke specialists that field calls from EMS providers and deliver a mechanism for verifying LVO stroke symptoms while connecting EMS with receiving EDs. This liaison would be supported by a unique application for mobile devices that collects real-time information on both transport and clinical parameters. This data in turn would drive the choice of transport destination and alert receiving EDs so that the necessary imaging and interventional preparation could be initiated while the patient was still in transit. A training and certification program for participating EMS personnel would also be established.

Results:
Results show that if ED door-to-needle time were decreased to 54 minutes a sample size of 338 patients would be sufficient to validate significance. Decreasing first medical contact-to-ED door time to 180 minutes would similarly require 1138 patients.

Conclusions:
A SCC provides an achievable model to improve stroke care by reducing time to optimal treatment and can be customized to the needs of geography and patient characteristics.