bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 102: Consistency of Efficacy of PFO Closure in the Gore Reduce Trial
Authors: Kasner Scott E , Sondergaard Lars , Rhodes John F , Anderson Grethe , Iversen Helle K , Nielsen-Kudsk Jens Erik , Settergren Magnus , Sjostrand Christina , Roine Risto O , Hildick-Smith David , Spence J David , Thomassen Lars ,   Gore REDUCE Study Investigators
Published: October 2018

Background:
The Gore REDUCE Clinical Study (REDUCE) demonstrated superiority of PFO closure in conjunction with antiplatelet therapy over antiplatelet therapy alone in reducing the risk of recurrent clinical ischemic stroke or new silent brain infarct in patients with cryptogenic stroke.

Methods:
We randomized 664 subjects with cryptogenic stroke at 63 multinational sites in a 2:1 ratio to either antiplatelet therapy plus PFO closure (with Gore HELEX Septal Occluder or Gore CARDIOFORM Septal Occluder) or antiplatelet therapy alone. Co-primary endpoints were freedom from recurrent clinical ischemic stroke through ≥2 years and incidence of new brain infarct (defined as the composite of clinical ischemic stroke and silent brain infarct) at 2 years. Primary analyses were performed on the intention-to-treat (ITT) population. Per-protocol (PP) analysis included only subjects randomized and treated according to critical protocol requirements (excluding those who violated key eligibility criteria, did not receive the therapy to which they were randomized, or did not comply with protocol-required medical regimen). As-treated (AT) analysis assessed all subjects based on treatment received, regardless of study assignment.

Results:
PFO closure was associated with a highly consistent reduction in risk compared to medical therapy alone in all three analytic cohorts (Table).

Conclusions:
Among selected patients with cryptogenic stroke and PFO, closure of the PFO plus antiplatelet therapy was superior to antiplatelet therapy alone for reducing the risk of subsequent ischemic stroke.
Abstract 104: First Stroke Reduced 44 Percent by Well Tolerated Medications. Stroke Outcomes From the Heart Outcomes Prevention Evaluation 3 Study
Authors: Bosch Jackie , Lonn Eva , Zhu Jun , Pais Prem , Xavier Denis , Dans Antonio , Diaz Rafael , Hart Robert , Yusuf Salim
Published: October 2018

Background:
Most (75%) strokes are first strokes, and primary prevention is crucial for reducing the global burden of stroke The role of fixed-dose antihypertensive therapy and statin drugs for primary stroke prevention has not been adequately defined.

Methods:
Using a 2x2 factorial design, 12,705 participants from 21 countries with an intermediate risk of cardiovascular disease but without overt vascular disease were randomized to fixed-dose candesartan 16 mg plus hydrochlorothiazide (HCTZ) 12.5 mg daily or placebo and to rosuvastatin 10mg daily or placebo.

Results:
Mean age was 66 years, 46% were women, and 166 strokes occurred during a median follow-up of 5.6 years. Mean baseline blood pressure (BP) was 138/82 mmHg and the BP difference between the treatment groups during follow-up averaged 6.0/3.0 mmHg. Stroke was reduced by 20% (confidence interval [CI], 0.59-1.08;
p
=0.14) by candesartan/HCTZ and 30% (CI, 0.52-0.95) by rosuvastatin. In a pre-specified subgroup analysis, participants in the upper third of systolic BP (>143.5 mmHg) had stroke reduced by 42% (CI, 0.37-0.90,
p
=0.02). Rosuvatatin reduced all stroke by 30% (CI, 0.52-0.95;
p
=0.02); but considering hemorrhagic strokes: 15 among those assigned rosuvastatin vs. 12 with rosuvastatin-placebo. Those assigned both rosuvatatin and candesartan/HCTZ had stroke reduced by 44%
(
CI, 0.36-0.87;
p
=0.009). Rates of permanent discontinuation did not differ significantly between active and placebo-assigned patients.

Conclusions:
Fixed-dose candesartan/HCTZ combined with low-dose rosuvastatin reduced first stroke by 44% in patients at intermediate risk of cardiovascular disease and was well-tolerated. Among those with systolic BP >143.5 mmHg, fixed-dose candesartan/HCTZ reduces first stroke by 42%,
Abstract 123: Diagnostic Yield of TEE in Patients With Cryptogenic Stroke and TIA With Normal TTE: A Systematic Review and Meta-Analysis
Authors: Shah Shamik , Wang Yunxia , Gronseth Gary
Published: October 2018

Background:
The diagnostic utility of Transesophageal echocardiography (TEE) in cryptogenic stroke or TIA remains controversial.

Objective:
To perform a systematic review and meta-analysis to estimate an additional diagnostic yield and clinical impact of TEE in patients with cryptogenic stroke and TIA with normal Transthoracic Echocardiography (TTE) results.

Methods:
A PubMed literature review was performed of cohort studies. The studies were excluded if routine stroke work-up was not documented, TTE was not performed on all patients or clear TTE data not available, separate analysis for patients with normal TTE results were not available, did not report all cardiac TEE findings, and included patients with Afib or did not have a separate analysis for patients without Afib.

Results:
Fifteen studies met the criteria, with total of 2054 patients with cryptogenic stroke or TIA with normal TTE results and underwent TEE. All studies were evaluated for internal validity and indirectness. Following TEE findings were noted across different studies: LA/LAA/Aortic thrombus, valvular vegetation, intracardiac tumor, spontaneous echo contrast, PFO, ASA, PFO -ASA combination, valvular abnormalities and complex aortic plaques. 37.5% (29.7% - 45.1%) of patients had additional cardiac findings on TEE. PFO was the second most common abnormality noted after complex aortic plaque. 13.6% (8.1% - 19.1%) of patients required changes in the management after TEE evaluation. Based on the current guidelines, it should change management in 4.1% (2.1% - 6.2%) of patients. It could potentially change management in 30.4% (21.9% - 38.9%) of patients. Analysis was also performed with only class II studies to increase internal validity, which showed additional cardiac findings in 38.4% (28.5% - 48.3%), changed management in 20.2 % (8.7% - 31.8%), should change management in 4.7% (1.5% - 7.9%) and could potentially change management in 30.4% (17.8% - 43.0%) of patients.

Conclusions:
The diagnostic yield of TEE to find any additional cardiac findings in patients with cryptogenic stroke or TIA is approximately 38%. Based on this analysis, number needed to diagnose one additional abnormality with TEE that can change management per current guidelines is approximately 21.
Abstract 13: The Feasibility and Development of a Mobile Stroke Unit in a Community Setting
Authors: Crumlett Hillary S , Lindstrom Anne , Mohajer-Esfahani Mehr , Shownkeen Harish
Published: October 2018

Introduction:
Time is brain, the faster a stroke patient is treated the better the outcome. Mobile Stroke Units (MSU) are an innovation in care allowing a specialized team to treat the patient in a pre-hospital setting. As hospitals consider the addition of a MSU, the feasibility of the program must be carefully explored, along with the challenges that come with developing a program. This abstract aims to discuss one hospital’s journey to develop and implement a MSU to bring cutting edge care to the community.

Hypothesis:
A hospital can operate in partnership with local EMS to provide stroke care to patients in the pre-hospital setting.

Methods:
A community hospital conducted a feasibility study to determine the effects of a MSU within their local EMS region. This study involved reviewing market share and trends, as well as, financial metrics. Following the feasibility study, an investment was made to develop a MSU program. Program development consisted of 5 main teams: Compliance/Regulatory, EMS, Communications/Marketing, Operations, and Vehicle Acquisition. Focus was also placed on staffing the MSU with a critical care nurse, critical care paramedic, CT technologist, and a paramedic driver. This team received specialized training, along with local EMS, to care for the stroke patient in the pre-hospital setting. The MSU is equipped with a CT scan and IV alteplase or prothrombin complex concentrate. Additionally, the use of telemedicine is used to include the neurologist and radiologist in the care of the pre-hospital stroke patient.

Results:
The Mobile Stroke Program was successfully launched by this community hospital within 8 months of project kickoff to Go-Live. In the first 6 months of operations, the MSU has been dispatched 182 times and has transported 102 patients from all 6 towns within the EMS region. Endorsement of the MSU services to the community was received from all six Fire Chiefs within the EMS system.

Conclusions:
A community hospital in partnership with local EMS and Department of Regulation can be successful in determining the need, scope, and program criteria for a MSU. This approach can support an expedited timeline while assuring the highest standard of stroke care.>
Abstract 132: Utility of Prophylactic Antiepileptic Drug Administration on Seizure Prevention and Disability Following Intracerebral Hemorrhage in the Ethnic/Racial Variations of Intracerebral Hemorrhage Study
Authors: Savalia Krupa , Sekar Padmini , Moomaw Charles J , Koch Sebastian , Sheth Kevin N , Woo Daniel , Mayson Douglas
Published: October 2018

Background & Purpose:
Intracerebral hemorrhage (ICH) has the highest morbidity and mortality rate of any stroke subtype and clinicians often administer prophylactic anti-epileptic drugs (AEDs) as a means of preventing post-stroke seizures, particularly following lobar hemorrhage (LH). However, evidence for AED efficacy in preventing seizures and reducing disability is lacking given difficulty executing randomized prospective trials. We report an analysis of data from a large prospective observational study of ICH that evaluates the effect of prophylactic AED administration on seizure occurrence and disability following ICH.

Methods:
Primary analysis was performed on 1636 patients with ICH enrolled in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study with subset analysis completed in patients with primary LH (n=562). A propensity score for administration of prophylactic AED was based on age, gender, race, ICH volume, location, presence of intraventricular hemorrhage, ventriculostomy, surgery, GCS, history of ischemic stroke, diabetes, sepsis, dementia, alcohol use and illicit drug use; patients were matched by the closest propensity score (difference <0.1). McNemar’s test was used to compare the occurrence of seizure and disability, defined by Modified Rankin Score (mRS) ≥ 3 at 3 months post ICH, in the treated and untreated groups. Similarly, analysis was performed on patients with LH by matching 281 treated patients with 281 untreated patients.

Results:
Of the 818 matched pairs of patients who were treated with prophylactic AEDs, there was no significant difference in seizure occurrence (p=0.6799) or disability (p=0.6521). Subset analysis of 281 matched pairs of patients with LH revealed no significant difference in seizure occurrence (p=0.1161) or disability (p=0.9146) between those treated with prophylactic AED and untreated patients.

Conclusions:
While prophylactic AED treatment of ICH is not recommended by current guidelines, clinical use remains widespread. Data from the large prospective ERICH study clearly reveal lack of efficacy in administering AEDs for prevention of seizures and reduction of disability following ICH, thus providing strong evidence to influence clinical practice and patient care.
Abstract 136: A Cluster Randomized Trial of a Multifaceted Intervention to Improve Adherence to Evidence-Based Treatments in Acute Ischemic Stroke in China
Authors: Li Zixiao , Wang Yilong , Zhao Xingquan , Wang Chunjuan , Wang Xianwei , Pan Yuesong , Liu Liping , Wang chunxue , Xian Ying , Wang Yongjun ,   GOLDEN BRIDGE Investigators
Published: October 2018

Background:
There are considerable gaps in adherence to evidence-based stroke care in China. Our primary aim was to determine whether a multifaceted quality improvement (QI) intervention could improve adherence to the 9 evidence-based performance measures among Chinese patients with acute ischemic stroke (AIS).

Methods:
The Multifaceted Intervention to Improve AIS Care (GOLDEN BRIDGE-AIS) trial was a two-arm, multicenter, cluster-randomized, controlled trial. Patient hospitalized with AIS were included. Hospitals were randomized (1:1) to the intervention or a usual care control arm. The multifaceted QI intervention involved a clinical pathway, written care protocols, oversight by a quality coordinator, and a monitoring and feedback system of performance measures. The primary outcome was adherence to AIS evidence-based performance measures.

Results:
4800 patients were enrolled from 40 hospitals, n=2400 intervention and n=2400 control with 12-month follow-up. Interventional hospital patients were more likely to receive acute and discharge treatments than those in the control hospitals (composite measure 88.2% vs 84.8%, adjusted OR, 1.38 [95% CI, 1.11-1.71], p value=0.003) (Table). Kaplan-Meier estimates showed a reduction in the secondary outcomes of 12-month new clinical vascular events in the intervention versus control group (HR 0.73, 95% CI, 0.61-0.87; p value<0.001) (Figure).

Conclusion:
Among patients with AIS treated in China, a multifaceted QI intervention improved the composite adherence to the evidence-based treatments as well as significantly reduced new vascular events.

Trial Registration:
clinicaltrials.gov Identifier: NCT02212912.
Abstract 137: Temporal Trends in U.S. Hospitalization Rates for Subarachnoid Hemorrhage From 1994-2013
Authors: Chatterjee Abhinaba , Merkler Alexander E , Gialdini Gino , Navi Babak B , Kamel Hooman
Published: October 2018

Background:
It is hypothesized that the incidence of subarachnoid hemorrhage (SAH) is decreasing due to a reduction in risk factors and more aggressive treatment of unruptured cerebral aneurysms, but long-term data from broadly representative populations are lacking.

Methods:
We assessed temporal trends in rates of hospitalization for SAH by using the 1994 to 2013 releases of the National Inpatient Sample (NIS), which provides data on a 20% nationally representative sample of U.S. hospitalizations. We used previously validated

International Classification of Diseases, 9
th
Revision, Clinical Modification

codes to identify hospitalizations for nontraumatic SAH. As a comparison, we also identified ICH hospitalizations since ICH shares many risk factors with SAH but is not generally amenable to preventive intervention such as aneurysm coiling or clipping. Population estimates from the U.S. census were used to calculate annual hospitalization rates per 10,000 persons. Rates were age-standardized to the 1994 U.S. general population, and linear least-square error trendlines were generated to facilitate comparisons between trends. Survey weights provided by the NIS were used to calculate nationally representative estimates.

Results:
During the study period, 1,862,545 patients were hospitalized with SAH and 2,292,292 patients were hospitalized with ICH. From 1994 through 2013, the age-standardized hospitalization rate for SAH declined from 5.6 (95% confidence interval [CI], 5.1-6.1) to 3.3 (95% CI, 3.1-3.6) hospitalizations per 10,000 U.S. residents. The age-standardized hospitalization rate for ICH also declined, from 6.4 (95% CI, 6.0-6.7) to 5.1 (95% CI, 4.9-5.4) hospitalizations per 10,000 individuals. Temporal trends were similar for SAH and ICH (Figure).

Conclusions:
We found that hospitalization rates for both SAH steadily declined in the U.S. over the past 2 decades. This was mirrored by a similar decrease in ICH hospitalizations.
Abstract 138: How Far is Too Far? A Decision Analysis Model of Pre-hospital Triage for Potential Large Vessel Occlusion Acute Stroke Patients
Authors: Xu Yaqian , Jiao Boshen , Parikh Neal S , Willey Joshua Z , Boehme Amelia K , Elkind Mitchell S
Published: October 2018

Background and Purpose:
We sought to determine when transporting patients directly to a comprehensive stroke center (CSC; the “mothership”) is favorable compared to a “drip-and-ship” approach while accounting for the varying predictive abilities of pre-hospital large vessel occlusion (LVO) screening methods.

Methods:
We built a decision analysis model to compare anticipated functional outcomes for patients who are within IV-tPA treatment window in “mothership” and “drip-and-ship”. Key branches included IV-tPA eligibility, IV-tPA only or endovascular therapy (ET), successful reperfusion after ET, and treatment effects. In terms of the probability of requiring ET, we assessed three pre-hospital LVO screening methods: no LVO screening, the Rapid Arterial oCclusion Evaluation (RACE) Scale for Stroke, and in-ambulance CT angiography for LVO. Good outcome was defined as mRS 0-1 and, secondarily, mRS 0-2. Imputed probabilities and workflow times were extracted from published studies. We used one-way and two-way sensitivity analyses to vary two key inputs: time from onset to arrival at primary stroke center (PSC) and additional travel time to CSC.

Results:
The relative benefit of the “mothership” approach varied with the likelihood of pre-hospital LVO identification for outcome of mRS 0-1. In the absence of pre-hospital LVO screening, “drip-and-ship” was always favored. When pre-hospital CT angiography is used, “mothership” is always favored. When modeling the use of the RACE Scale for patients with onset-to-PSC arrival time less than 70 minutes, “mothership” was favored if the additional travel time to CSC was less than 21 minutes. When onset-to-PSC arrival time passed 70 minutes, “mothership” was favored for additional travel times up to 48 minutes (Figure).

Conclusion:
The results of our decision analysis model suggest that, in addition to transport times, pre-hospital LVO screening and time from stroke onset could influence triage decision making.
Abstract 146: Renal Cysts and Stroke in the General Population: The Rotterdam Study
Authors: Sedaghat Sanaz , Darwish Murad Sarwa , Stricker Bruno H. , Zietse Robert , Hoorn Ewout J. , Ikram M.Arfan
Published: October 2018

Introduction:
Renal cysts have been generally regarded as benign incidental findings on ultrasound or CT scan. Nevertheless, recent data suggest that such cysts might reflect early stages of end-organ damage. Given the similarities of cerebral and renal vasculatures, in this population-based study we sought to investigate whether individuals with the renal cysts have higher prevalence of cerebrovascular accidents.

Methods:
Between 2009 and 2014, renal ultrasound was performed on 2,984 participants from the population-based Rotterdam Study (mean age: 71.9 ± 9.0 years, 57% female). Individuals who were found to have renal cysts were categorized into single and multiple cysts carriers. Stroke and transient ischemic attacks (TIA) cases were identified using digital record linkage with general practitioners and medical specialists in the research area. Multivariate logistic regression models were applied to assess the link between single and multiple renal cysts carriers and prevalent stroke and TIAs.

Results:
Single renal cyst was found in 508 (17.0%) individuals and 197 (6.6%) participants had multiple cysts. Subjects with a single renal cyst compared to no cyst had 1.63 (95% CI: 1.01, 2.64) higher odds of having concomitant stroke. This association was more pronounced in individuals with multiple renal cysts. Subjects with multiple cysts had 2.14 (95% CI: 1.20, 3.82) higher odds of having stroke compared to individuals without cyst. There was no significant association between single or multiple renal cysts and TIAs; odds ratio (OR): 1.06 (95% CI: 0.70, 1.59) and OR: 1.29 (95% CI: 0.74, 2.23), respectively. All these associations were independent of age, sex, systolic and diastolic blood pressure, body mass index, smoking, history of cardiovascular disease, diabetes mellitus and kidney function.

Conclusion:
In this large population-based study we show that there is a dose dependent association between renal cysts and prevalent stroke. This data questions the general consensus that renal cysts are of no clinical significance as they might signal higher degrees of vascular damages in the brain circulation.
Abstract 154: Three-Month Modified Rankin Scale Score Predicts 5-Year Post-Stroke Dementia And Institutionalization Outcomes: A Population-Based Prospective Cohort Study
Authors: Ganesh Aravind , Pendlebury Sarah T , Wharton Rose M , Luengo-Fernandez Ramon , Rothwell Peter M ,   Oxford Vascular Study
Published: October 2018

Background:
Dementia and institutionalization are known long-term complications of stroke, but the extent to which post-stroke disability – as captured by the modified Rankin Scale (mRS) in trials – predicts these outcomes remains unclear. Quantifying this relationship can inform prognostication and cost-effectiveness analyses.

Methods:
In consecutive 3-month survivors of ischaemic stroke in a population-based prospective cohort (Oxford Vascular Study;2002-2014), we established post-stroke dementia (excluding pre-stroke dementia) and tracked institutionalization (admission to nursing or residential care home) through overlapping methods of cognitive testing and interview-based assessments of patients and carers, and ongoing searches of primary care and hospital records. We related 3-month mRS to 5-year dementia and institutionalization using age/sex-adjusted Cox and logistic regressions (repeated excluding premorbid mRS>2), and compared the area under the receiver operating characteristics curves (AUC) for logistic models versus age/sex alone.

Results:
Among 1,425 survivors, 3-month mRS independently predicted 5-year dementia and institutionalization whether or not those with premorbid disability were excluded, with mRS of 3-5 carrying higher hazards of each outcome than mRS 0-2; aHR(dementia)=3.37, 95%CI 2.63-4.32, aHR(institutionalization)=6.33, 4.53-8.85, p<0.0001. However, each step up the mRS ladder was associated with a jump in hazard for each outcome; e.g. aHR(dementia) vs mRS=0 for mRS=1: 0.91, 95%CI 0.48-1.75, p=0.78; mRS=2: 1.56, 0.84-2.92, p=0.16; mRS=3: 2.86, 1.54-5.30, p=0.001; mRS=4: 4.61, 2.46-8.63, p<0.0001; mRS=5: 9.79, 5.13-18.7, p<0.0001. Logistic models including the mRS, particularly in its ordinal form, predicted 5-year dementia or institutionalization better than age/sex alone (e.g. AUC for dementia with only age/sex: 0.72, 95%CI 0.69-0.75; with 3-month mRS: 0.79, 0.76-0.82, p<0.0001).

Conclusions:
3-month mRS strongly predicts post-stroke dementia and institutionalization, both of which should be considered in cost-effectiveness analyses of acute treatments. The incremental rise in hazard with each step up the mRS ladder further supports using ordinal analysis of the mRS in trials.
Abstract 158: Time to Decision and Treatment With Tissue Plasminogen Activator Using Telemedicine versus an On-board Physician on a Mobile Stroke Unit
Authors: Bowry Ritvij , Parker Stephanie , Yamal Jose-Miguel , Appana Savitri , Rangel-Gutierrez Nicole , Wu Tzu-Ching , Grotta James C
Published: October 2018

Background:
Mobile stroke units (MSU) can speed treatment with intravenous tissue plasminogen activator (tPA) for stroke patients. MSUs may use either an on-board (OB) or telemedicine (TM) based vascular neurologist (VN) for deciding tPA treatment. In the first phase of this study, we showed that agreement on giving tPA between a TM and OB-VN on a MSU is the same as between two VNs evaluating the same patient on site in the emergency department. In that phase, the actual treatment was determined by the OB-VN so that the TM-VN decision was delayed. In this phase, we determined the time from MSU arrival to tPA treatment decision and treatment when the TM-VN was the primary decision-maker and compared these to the same metrics for the OB-VN in the first phase.

Methods:
After MSU arrival on-scene, with the assistance of the OB nurse and paramedic, the TM-VN directed the evaluation of the patient, the CT scan was directly pushed to the TM-VN via a cloud-based picture archiving and communication system, and the TM-VN made the decision whether or not to treat. Times from MSU arrival to tPA decision and tPA bolus were compared to the same metrics for the OB-VN during the first phase of the study using a 2-sample t-test with log-transformation to satisfy t-test assumptions. Median times and interquartile range (IQR) were calculated for each group (Table 1).

Results:
The TM-VN was, on average, 3 minutes slower in making the tPA decision compared with the OB-VN (OB: 18 minutes [IQR 14-23] versus TM: 21 minutes [IQR 16-26], p=0.05). There was no difference however, in the time to tPA bolus between the two groups [OB: 23 minutes (IQR 19-30) versus TM: 24 minutes (IQR 19-28), p=0.70, with 95% confidence interval [-2.18-3.24].

Conclusion:
A telemedicine based VN can treat a patient with tPA on a MSU as quickly as an on-board VN.
Abstract 159: Acute Aspirin Plus Cilostazol Dual Therapy for Non-cardioembolic Stroke Study (ADS)
Authors: Aoki Junya , Kimura Kazumi , Abe Koji , Uno Masaaki , Okada Yasushi , Urabe Takao , Fujimoto Shigeru , Matsuoka Hideki , Yamagata Sen , Yamagami Hiroshi , Yamamoto Yasumasa , Yonehara Toshiro , Inoue Takeshi ,   ADS study group
Published: October 2018

Hypothesis:
The aim of the present study was to investigate the efficacy and safety of antiplatelet (aspirin plus cilostazol) dual therapy for non-cardioembolic stroke patients within 48 h of symptom onset.

Methods:
ADS is an investigator initiated, a prospective, multicenter (34 hospitals in Japan), randomized, and an aspirin-controlled study. Acute stroke patients with non-cardioembolic stroke within 48 hours of onset were studied. Only patients with preadmission mRS score 0-2 were included. Subjects were randomly allocated to the combination therapy with aspirin 81-200mg plus cilostazol 200mg (Dual group) and the single therapy with aspirin 81-200mg (Aspirin group) for 14 days. After the 14 days, all patients took the cilostazol 200mg for 3 months. Primary outcomes include 1) the neurological worsening within 14 day of onset; and 2) the rates of transient ischemic attack (TIA), stroke recurrence, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) within 14 days of onset. Secondary outcome included mRS score at 3 months after stroke.

Results:
1,201 patients (796 [66%] men; median age [interquartile range], 69 [61-77] years) were randomized 1:1 to either the dual group or the aspirin group. Initial National Institutes of Health Stroke Scale score was similar as 2 (1-4) in both groups (p=0.617). As a primary outcome, the neurological worsening within 14 days was similarly observed in the dual and in the aspirin group (10.5% vs. 9.7%, P=0.701). The rates of TIA and stroke recurrence in the dual and in the aspirin group were also similar as 0.2% vs. 0.2% (p=1.000), and 1.2% vs. 1.3% (p=1.000), respectively. As a safety outcome, each group had one patient with ICH (0.2% vs. 0.2%, p=1.000). Only 1 patient (0.2%) in the dual group complained of SAH within 14 days of stroke onset, though it was asymptomatic (p=1.000). Regarding the secondary outcome, although preadmission mRS score of 0 was infrequent in the dual group (84% vs. 89%, p=0.054), the rate of mRS 0-1 at 3 months seemed to be frequent in the dual group than aspirin group (69% vs. 64% p=0.075).

Conclusions:
Dual antiplatelet therapy using cilostazol and aspirin does not reduce the rate of short-term neurological worsening. However, this combined therapy may improve the clinical outcome at 3 months of onset.
Abstract 161: Temporal Trends in the Use of Acute Recanalization Therapies for Ischemic Stroke in Patients With Systemic Cancer
Authors: Chatterjee Abhinaba , Merkler Alexander E , Murthy Santosh B , Burch Jaclyn E , Gialdini Gino , Kamel Hooman , NAVI Babak B
Published: October 2018

Background:
Whether cancer patients receive acute recanalization therapies as often as non-cancer patients with acute ischemic stroke (AIS) is uncertain. Additionally, while use of recanalization therapies for AIS have increased over time, it is unknown whether similar trends have occurred among stroke patients with cancer.

Methods:
Using ICD-9 diagnosis codes, we identified all patients hospitalized with AIS in the National Inpatient Sample (NIS) from 1998-2013. Our primary predictor was systemic cancer, which was a composite of solid and hematologic tumors with or without metastases. Primary brain tumors were excluded. Our primary outcome was use of intravenous tissue plasminogen activator (IV-tPA). Our secondary outcome was use of endovascular therapy (EVT). Annual estimates of nationwide recanalization therapy use were calculated.

Results:
Among 8.5M patients with AIS, 439,905 (5.2%) had cancer. The rate of IV-tPA use among AIS patients with cancer increased from 0.01% (95% CI 0.00-0.02%) in 1998 to 4.23% (95% CI 3.72-4.75%) in 2013; while the rate of IV-tPA use among AIS patients without cancer increased from 0.02% (95% CI 0.01-0.02%) in 1998 to 6.38% (95% CI 6.16-6.61%) in 2013 (Figure). The demographic-adjusted odds ratio per year of receiving IV-tPA was similar in patients with cancer (1.21; 95% CI 1.20-1.23) and in those without (1.20; 95% CI 1.19-1.21). The rate of EVT use among AIS patients with cancer increased from 0.05% (95% CI 0.02-0.07%) in 2006 (no procedures reported in NIS before then) to 1.07% (95% CI 0.81-1.33%) in 2013; while the rate of EVT use among AIS patients without cancer increased from 0.09% (95% CI 0.00-0.18%) in 2006 to 1.09% (95% CI 0.95-1.22%) in 2013.

Conclusion:
Cancer patients with AIS receive IV-tPA about two-thirds as often as non-cancer patients with AIS and this disparity has persisted over time despite increased utilization rates in both groups. Use of endovascular therapy is similar between cancer and non-cancer AIS patients.
Abstract 173: Atrial Cardiopathy and the Risk of Ischemic Stroke in the Cardiovascular Health Study
Authors: Kamel Hooman , Bartz Traci M , Elkind Mitchell S , Okin Peter M , Thacker Evan L , Patton Kristen K , Stein Phyllis K , deFilippi Christopher , Gottesman Rebecca F , Heckbert Susan R , Kronmal Richard A , Soliman Elsayed Z , Longstreth Will T
Published: October 2018

Introduction:
Several lines of evidence indicate that some cases of cryptogenic stroke may be due to an atrial cardiopathy that forms a nidus for thrombus formation and embolization even in the absence of atrial fibrillation (AF).

Hypothesis:
We hypothesized that evidence of atrial cardiopathy other than AF is independently associated with stroke.

Methods:
We examined the association between several markers of atrial cardiopathy and the risk of ischemic stroke among participants in the Cardiovascular Health Study, which prospectively enrolled community-dwelling adults ≥65 years of age. The exposures of interest were P-wave terminal force in electrocardiogram lead V
1
(PTFV
1
), left atrial dimension on echocardiogram, amino terminal pro-B-type natriuretic peptide (NT-proBNP), and incident AF. The primary outcome was adjudicated ischemic stroke. We used Cox proportional hazards analysis to examine associations with stroke for all four markers together along with adjustment for traditional vascular risk factors.

Results:
Among 3,723 participants who were free of stroke and AF at baseline and who had data on all atrial cardiopathy markers, 585 patients (15.7%) experienced an incident ischemic stroke during a median 12.9 years of follow-up. When the four atrial cardiopathy markers were combined in one model along with traditional vascular risk factors, we found significant associations with stroke for PTFV
1
(hazard ratio [HR] per 1,000 μV*ms, 1.04; 95% confidence interval [CI], 1.0006-1.08), NT-proBNP (HR per doubling of NT-proBNP, 1.09; 95% CI, 1.03-1.16), and incident AF (HR, 2.04; 95% CI, 1.67-2.48), but not left atrial dimension (HR per cm, 0.96; 95% CI, 0.84-1.10).

Conclusions:
In a large, prospective, longitudinal study, we found that evidence of abnormal atrial substrate, defined more broadly than just AF, was associated with subsequent ischemic stroke. These findings support the hypothesis that left atrial thromboembolism can occur in the absence of AF.
Abstract 179: Novel Theranostic Protocells for Intracerebral Hemorrhage
Authors: Jeong Han-Gil , Kang Dong-Wan , Cha Bong Geun , Nam Myong-Joo , Kim Chi Kyung , Kim Do Yeon , Ki Seul Ki , Kim Jaeyun , Lee Seung-Hoon
Published: October 2018

Background and Aims:
Theranostics is an emerging concept of integrating therapy and imaging into a single platform. Intracerebral hemorrhage (ICH) causes intense inflammation by toxic effect of hematoma itself and mechanical disruption of brain tissue, which is a promising target of theranostics. We developed a novel theranostic protocells loaded with cerium oxide nanoparticles (CeNPs) for treatment and iron-oxide nanoparticles (FeNPs) for imaging.

Method:
We synthesized 100-nm mesoporous silica nanoparticle (MSN) as a bio-compatiable nanocarrier, incorporated FeNPs in the core and CeNPs on the surface, and encapsulated MSN with lipid bilayer. Reactive oxygen species (ROS) scavenging and cytoprotective effects of the protocells were assessed in RAW264.7 cells. Brain water content, macrophage infiltration, and behavior function (corner turn and forelimb use asymmetry) were measured in collagenase-induced rodent ICH model after injecting the protocells. Serial brain MR imaging was also performed to confirm diagnostic ability of working site of protocells.

Results:
The protocells were monodisperse in water and highly loaded with CeNPs, which exhibited a strong ROS scavenging (-26%, P<0.05) and cytoprotective effects (-51%, P<0.01). The protocells reduced macrophage infiltration (-58%, P<0.01) and brain edema (-1% water content, P<0.01) and improved neurologic outcome (+15% corner turn, P<0.05). In serial T2-weighted MR imaging, the protocells that reached peri-hematomal area were clearly visualized.

Conclusions:
As the first theranostic nanobiomaterial, our protocells successfully visualized its working site in peri-hematomal area by MR imaging, and improved inflammatory status and neurologic outcomes after ICH. Beyond its potential for ICH theranosis, protocells could be generalized to other inflammatory diseases.
Abstract 18: Anticonvulsant Medication Practice Varies After Pediatric Arterial Ischemic Stroke
Authors: Guiliams Kristin P , Dowling Michael M , Zafeiriou Dimitrios I , Friedman Neil , deVeber Gabrielle , Fox Christine K
Published: October 2018

Introduction:
Acute symptomatic seizures are common after pediatric arterial ischemic stroke (AIS). We sought to analyze practice variation in anticonvulsant medication treatment (ACM) after AIS. We hypothesized that ACM practice varies but is related to age, acute seizure frequency and duration, cortical involvement, and hemorrhagic conversion.

Methods:
Seizures in Pediatric Stroke (SIPS), an international, prospective study, enrolled neonatal (<28 days) and childhood (<19 years) acute AIS patients 3/2011-8/2012. Seizures and ACM were recorded. Among patients with acute seizures (<7 days post-stroke), we used univariate Spearman’s correlations to determine association between ACM and clinical predictors at both discharge and 12-month time points. Variables with p <0.05 at univariate analysis were entered into a logistic regression model.

Results:
Among 116 patients, 27 neonates and 31 children (ages 0.2-17 years) had an acute seizure. In neonates, 24 (89%) had ACM continued after discharge, but only 4 (15%) remained on ACM at 12 m (3 having had post-discharge seizure). Phenobarbital was the most common ACM in neonates at discharge (n=14) and 12m (n=2, levetiracetam = 2). In children, 23 (74%) had ACM at discharge, and 17 (57%) remained on ACM at 12m (7 having had a post-discharge seizure). All patients in study with post-discharge seizure were discharged on ACM. Two neonates and 1 child with post-discharge seizure were not on ACM at 12m. Levetiracetam was the most common ACM in children at discharge (n=11) and 12m (n=9). No single variable correlated with discharge ACM (Table). ACM at 12 m correlated with neonatal stroke, >10 seizures in acute period, and post-discharge seizure. In logistic regression, all variables remained significant.

Conclusion:
ACM management after acute post-stroke seizures varies widely in pediatric stroke. Neonates rarely, but children frequently, are continued on ACM up to 1 year, even without further seizures.
Abstract 181: Stroke Induces a Differential Colonic Epithelial Response and Leads to Impaired Gut Integrity and Increased Post-Stroke Infections in Aged Mice
Authors: Lee Juneyoung , Spychala Monica , d’Aigle John , Quaicoe Victoria , McCullough Louise D , Venna Venugopal R
Published: October 2018

Introduction:
Infection is an important complication in the acute phase after stroke which effects up to 65% of stroke patients. These infections can in turn cause sepsis, which is a major contributor to hospital mortality. Emerging evidence indicates that these infections originate from the host commensal microbiota. We have found that stroke leads to increased gut permeability and bacterial translocation and that aged mice are more susceptible to post-stroke infections compared to young. We further investigated the possibility of how the response to infection differs between young and aged mice.

Hypothesis:
Impaired gut epithelial-specific response after stroke in aged mice leads to increased risk of infections and impaired recovery.

Methods:
Young (8-10 wks) and aged (18-20 mos) male mice (n=4-5/group) were subjected to either sham or 60-minute middle cerebral artery occlusion (MCAO) followed by reperfusion. Mice were sacrificed at day 8 after stroke. One cohort of mice (n=3/group) was evaluated for the histology and hypoxic barrier integrity. Finally, colonic epithelial cells (cECs) were isolated and changes of the gene expression in cECs were examined (n=4-5/group).

Results:
Epithelial dysfunction was observed in aged mice, including a decrease in goblet cells and mucus layer (
P
<0.05). Furthermore, stroke induced the loss of hypoxic barrier in the gut of aged mice. Intriguingly, multiple epithelial antimicrobial peptides of the regenerating islet-derived protein (Reg) family genes, which are produced by epithelial cells including deep secretory cells, were highly up-regulated following stroke only in young mice [~20 fold change in Reg3β and Reg3γ (
P
<0.05); ~2 fold change in Reg4 (
P
<0.05)]. In addition, aged mice showed decreased expression levels of goblet cell-secreting mucin (Muc) (~1.4 fold change in Muc2,
P
<0.05), whereas young mice retained expression after stroke.

Conclusions:
Our data indicates that 1) both aging and stroke impairs gut integrity and possibly leads to increase of infections and 2) epithelial cells could differentially respond to external stimuli after stroke, in an age-dependent manner. The current study provides the first insight into how intestinal epithelium is involved in the brain-gut axis in stroke.
Abstract 187: Temporal Trends in Sex and Age Disparities in Acute Ischemic Stroke Treatment and Outcomes in the United States From 2004 to 2014
Authors: Saini Vasu , Otite Fadar O , Khandelwal Priyank , Yavagal Dileep R , Chaturvedi Seemant , Malik Amer M
Published: October 2018

Background:
Data on trends in intravenous thrombolysis (tPA) and mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients are outdated. We aim to: (1) Evaluate current age and sex-specific trends in tPA and MT usage following AIS in the USA (2) Compare in-hospital mortality and moderate-to-severe disability between men and women following tPA and/or MT.

Methods:
A total of 4,579,246 admissions was identified with the diagnosis of AIS from 2004-2014 using the National Inpatient Sample (NIS). Patients receiving IV tPA and/or MT were identified using ICD-9 procedural codes and Medicare Diagnosis-related Group codes. Weights provided in the NIS were used to compute overall unadjusted weighted frequency of IV tPA and MT in subgroups characterized by age and sex. Multivariate models were used to evaluate trends in tPA and MT usage in both sexes and to assess their association with in-hospital mortality and moderate-to-severe disability.

Results:
Across the study period from 2004 to 2014, tPA use increased by >300% in both men (1.8% to 8.0%) and women (1.3% to 7.7%) but by 2014 marked disparity still existed by age (figure 1). MT use also increased by >300% from 2004-2014 in both sexes (males 0.1% to 2.1% versus females 0.1 to 1.8%) but proportion of younger patients (18-39 years) receiving MT was higher compared to other age groups in both men and women (figure 1). After multivariable adjustment, there is no significant difference in MT amongst either sex, but women were less likely to receive IV tPA (OR 0.92, 95%CI 0.90-0.94, p<0.001). There is no sexual disparity in odds of in-hospital mortality following tPA and/or MT but odds of moderate-to-severe disability following tPA was higher in women compared to men (OR 1.19, 95%CI 1.13-1.26, p<0.001).

Conclusion:
TPA and MT use has increased significantly in the USA over the last decade but disparities in tPA usage and outcome by age and sex still exist.
Abstract 189: Identifying Patients at Highest Risk of Developing Atrial Fibrillation and the Role of Remote Prior Stroke: Insights From the REVEAL AF Study
Authors: Elkind Mitchell S , Wachter Rolf , Verma Atul , Kowey Peter R , Halperin Jonathan L , Gersh Bernard J , Ziegler Paul D , Pouliot Erika , Reiffel James A
Published: October 2018

Introduction:
Recent trials using insertable cardiac monitors (ICMs) show high rates of atrial fibrillation (AF) in those at risk of developing AF based on demographics. Further identifying subsets who could benefit most from ICMs is desirable. We evaluated if the recently-developed HAVOC risk score which has predicted AF in cryptogenic stroke patients also predicts AF detection by ICMs in those without a recent stroke.

Methods:
Participants from the prospective REVEAL AF study, which reported frequent clinically unrecognized AF in patients at risk for AF (CHADS
2
scores ≥3 or =2 with ≥1 additional risk factor), with ICM data and not on anti-arrhythmic drugs were included. Ischemic stroke <1 year ago excluded participation. HAVOC scores were calculated using points for hypertension (2), age ≥75 (2), valvular disease (2), vascular disease (1), obesity (1), congestive heart failure (4), and coronary artery disease (2). Prior stroke, an AF outcome, generally not a cause, is not included. Score classification is: low (0-4), intermediate (5-9), or high (10-14). Corresponding AF detection rates were compared via the log-rank test.

Results:
Among 391 participants, 95 (24%), 241 (62%), and 55 (14%) had low, intermediate, and high HAVOC scores, respectively. At 18 months, AF incidence was significantly less for those with low (19.5%) vs intermediate (32.1%) or high (34.2%) scores (p=0.045, Figure). At 18 months, AF incidence was similar among those with (n=79) vs. without (n=312) a history of remote stroke (27.1% vs. 29.9%; p>0.05, median time from stroke to ICM insertion=4 years).

Conclusions:
The HAVOC risk score identified a subset of high risk individuals at greatest risk of developing AF. AF incidence rates were similar among those with and without prior remote stroke. Remote strokes may not be a strong predictor of AF in this population. HAVOC scores could be a useful approach to identify those at high likelihood of manifesting AF, as best documented by long-term monitoring.
Abstract 191: Divergent Short-Term Post-Stroke Outcomes for African Americans Post-Stroke: Lower Mortality, but Greater Disability
Authors: Burke James F , Feng Chunyang , Skolarus Lesli E
Published: October 2018

Background:
African Americans (AAs) have more post-stroke disability than non-Hispanic whites (NHWs). Little is known about when this difference emerges. We explored whether this difference exists at the time of post-acute care initiation.

Methods:
Medicare fee-for-service beneficiaries hospitalized from 2010-2014 with a primary stroke diagnosis (ICD-9-CM 431, 433.x1, 434.x1, 436) were identified. We first estimated adjusted and unadjusted proportions of inpatient mortality/hospice discharge, by race. Of survivors, initial post-stroke function was measured by linking Medicare functional assessment files for Inpatient Rehabilitation (IRF), Skilled Nursing (SNF) and Home Health (HHA). Each assessment file contains measures of initial function based on the Functional Independence Measure (FIM). Cross-walks were applied to the SNF and HHA assessments to generate a FIM-based score for these settings (Pseudo-FIM) using 6 motor FIM items scored 0-7 for a total 6-42 point scale (higher is better). Initial motor FIM/Pseudo-FIM was estimated across all 3 settings and in each setting by race. Adjusted analyses accounted for demographics, ICH, comorbidities, tPA and hospital effects using multi-level regression with random hospital intercepts.

Results:
435,371 NHW and 66,707 AA stroke patients were identified. 10.2% of AAs and 14.5% of NHWs (p < 0.001) died or were discharged to hospice, a difference that attenuated slightly after adjustment. Across all settings, AAs had a lower unadjusted motor FIM than NHWs (28.6 vs. 30.5, difference = -1.9, p < 0.001), that attenuated slightly after adjustment (difference -1.7, p < 0.001). Similar unadjusted findings were present across all individual settings for AAs vs. NHWs: IRF (29.8 vs. 31.6, diff = -1.8, p < 0.001), SNF (21.0 vs. 24.7, diff=-3.7, p < 0.001), HHA (33.8 vs. 36.0, diff = -2.2, p < 0.001). Trends were minimally altered by adjustment.

Conclusions:
Mortality and disability immediately after stroke hospitalization diverge by race. Compared to NHWs, AAs have lower early mortality, bit worse motor function across rehab settings. These data suggest that racial differences in patient treatment preferences surrounding mortality-disability trade-offs may exist.
Abstract 196: Comorbid Psychiatric Disease is Associated With Lower Rates of Thrombolysis in Ischemic Stroke
Authors: Bongiorno Diana M , Daumit Gail L , Gottesman Rebecca F , Faigle Roland
Published: October 2018

Introduction:
Intravenous thrombolysis (IVT) improves outcomes after acute ischemic strokes (AIS) but is underutilized in vulnerable patients such as racial minorities, women, and those with low income. At the same time, mental illness affects 20% of U.S. adults, and these individuals are more likely than those without mental illness to experience inequities in treatment for a range of medical conditions, and are more likely to die within a year if they have a stroke. We aimed to determine if comorbid psychiatric disease is associated with differences in IVT use in AIS.

Methods:
We studied AIS admissions, identified by ICD9-CM codes, from 2007-2011 in the Nationwide Inpatient Sample. Psychiatric disease was defined by ICD9-CM codes for secondary diagnoses of schizophrenia or other psychoses, anxiety, depression, or bipolar disorder. We used logistic regression to test the association between IVT and psychiatric disease, controlling for demographic, clinical, and hospital factors.

Results:
In total, 335,923 AIS cases met inclusion criteria, of which 12.8% had any of the specified psychiatric comorbidities. IVT was used in 3.6% of those with, and 4.5% of those without, comorbid psychiatric disease (
p
< 0.001). In multivariable logistic regression, having any psychiatric disease was associated with 20% decreased odds of receiving IVT (OR 0.80, 95% CI 0.76-0.85, Table 1). When each psychiatric diagnosis was analyzed separately, schizophrenia and other psychoses, anxiety, and depression were associated with significantly lower odds of receiving IVT (Table 1).

Conclusions:
AIS patients with comorbid psychiatric disease have significantly lower odds of receiving IVT. Understanding barriers to IVT use in such patients may help in developing interventions aimed at improving outcomes and increasing access to evidence-based stroke care.