bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP171: Hemodynamic Compromise Identified by Oxygen Extraction Fraction Response (OEFR) to Acetazolamide in Stroke Patients With Large Vessel Occlusion
Authors: Nemoto Edwin M , Kuwabara Hiroto , Yonas Howard
Published: January 2019

Hemodynamic compromise identified by cerebrovascular reserve (CVR) and oxygen extraction fraction (OEF) in stroke patients with large artery occlusion is an independent predictor of stroke risk ranging from 27 to 57%. However, comparison of both methods indicates that the sensitivity of CVR is substantially greater than OEF in detecting hemodynamic compromise which may be because CVR includes a vasodilator challenge with acetazolamide as opposed to OEF made in the resting state. We hypothesized that the response of OEF (OEFR) to an acetazolamide challenge would better correlate with CVR than OEF. We examined the correlation between CVR and OEFR to acetazolamide in stroke patients with large artery occlusion.

Methods:
Stroke patients with large artery occlusion (internal carotid or middle cerebral artery) were studied by positron emission tomography (PET) using H2 15O2 (water) for cerebral blood flow (CBF) and 15O2 (gas) for cerebral metabolic rate for oxygen before and after acetazolamide. CVR was calculated as: CVR (%) = [(CBFa- CBFb)/CBFb] X 100; where: CBFb = CBF before acetazolamide, CBFa = CBF after acetazolamide. OEF response (OEFR) was similarly calculated as: OEFR (%) = [(OEFa-OEFb)/OEFb]X100; for the entire middle cerebral artery territory of each hemisphere.

Results:
There was a highly significant (P=0.0001) negative linear correlation between CVR and OEFR indicating increasing ischemic stress (Figure). Hemispheres from three patients showed a positive OEFR.

Discussion:
A positive OEFR in response to a cerebrovascular challenge definitively indicates hemodynamic compromise and eliminates the problem of deciding on the absolute threshold for OEF to signify hemodynamic compromise. A negative OEFR reflects sufficient cerebrovascular reserve relative to oxygen demand.
Abstract WP172: Using a Novel and Noninvasive Cerebral Augmentation Index as Evaluated by External Counterpulsation to Predict Long-term Clinical Outcome After Acute Ischemic Stroke
Authors: Xiong Li , Soo Oi-yan , Wong Ka Sing , Leung Wai-hong
Published: January 2019

Background and Objectives:
External counterpulsation (ECP) is a non-invasive method used to augment cerebral blood flow of patients with ischaemic stroke via induced hypertension. We aimed to investigate whether the cerebral augmentation index (CAI) evaluated by ECP can predict clinical outcomes after acute ischemic stroke.

Methods:
We enrolled acute ischemic stroke patients within 7 days after stroke onset. Bilateral middle cerebral arteries of patients were monitored using transcranial Doppler (TCD). Flow velocity changes before, during and after ECP were, respectively, recorded for 3 mins. The cerebral augmentation index (CAI) was the increase in percentage of the middle cerebral artery mean flow velocity during ECP compared with baseline. TCD data were analysed based on the side ipsilateral or contralateral to the infarct. The modified Rankin Scale (mRS) (good outcome: mRS 0∼2; poor outcome: mRS 3∼6) was evaluated 3 months after the index stroke.

Results:
200 patients were included (mean age, 64.5±8.9 years; 86.5% males). At month 3 after stroke onset, univariate analysis showed that the National Institutes of Health Stroke Scale at recruitment was significantly higher in the poor outcome group, while the bilateral CAIs were significantly lower in the good outcome group than those in the poor outcome group (ipsilateral 3.72±2.94 vs 7.92±6.25, p=0.032; contralateral 4.04±3.82 vs 6.98±6.05, p=0.048). Multivariate logistic regression showed that bilateral CAIs were independently correlated with an unfavorable functional outcome after adjusting for confounding factors.

Conclusions:
The higher degree of cerebral blood flow velocity augmentation on the both sides ipsilateral and contralateral to the infarct induced by ECP is independently correlated with an unfavorable functional outcome after acute ischemic stroke.
Abstract WP177: Long-Term Outcome of Balloon Angioplasty and Stenting for Symptomatic Intracranial Atherosclerotic Stenosis: Comparison Between Pre- and Post-Approval of Wingspan Stent
Authors: Ueda Toshihiro , Takada Tatsuro , Usuki Noriko , Tokuyama Yoshiaki , Takaishi Satoshi , Fukano Takayuki , Tatsuno Kentaro , Hamada Yuki
Published: January 2019

Purpose:
Intracranial atherosclerotic stenosis (ICS) is an important cause of ischemic stroke, particularly in the Asian population. Endovascular treatment, such as balloon angioplasty with and without stenting have emerged as therapeutic options for symptomatic (ICS) since the 1990s and the Wingspan stent was approved at 2014 in Japan. This study was to investigate the periprocedural complication rates, long-term outcome and restenosis of endovascular treatment for ICS in our hospital.

Methods:
We retrospectively analyzed the clinical data of 223 patients with 265 endovascular treatments for high-grade (more than 70%) symptomatic ICS between 1999 and 2017. The lesion was located in in the internal carotid artery in 79, the middle cerebral artery in 113, the basilar artery in 29 and the vertebral artery in 42. Patients were classified into two groups, before (A group, between 1999 and 2013) and after approval of Wingspan (B group, between 2014 and 2017). We selected mainly balloon angioplasty without stenting in the primary treatment. Perioperative and long-term outcomes such as restenosis and the recurrence of strokes were assessed.

Results:
In A group (n=163, aged 63.5±10.2 years), 157 lesions were treated with balloon angioplasty and 31 (16.5%) with coronary stent. In B group (n=60, aged 66.4±13.3 years), 39 lesions were treated with balloon angioplasty and 38 (49%) with Wingspan stent. Overall technical success rates were 96% in balloon angioplasty and 100% in stenting groups. The 30-day rate of stroke, TIA and death were 4.3% in A group and 3.9 % in B group. In B group, there was one patient who had subacute in-stent thrombosis with major stroke and 2 minor strokes. There were no stroke and vascular events during follow-up periods in B group. Eight patients (13%) in B group had restenosis after the procedure and 7 patients were retreated.

Conclusions:
This study demonstrates the safety and efficacy of balloon angioplasty with and without stenting for symptomatic intracranial atherosclerotic stenosis if patients are properly selected. We suggest that a more judicious use of intracranial stents may be responsible for better postprocedure outcome.
Abstract WP180: Association Between Medicare Reform and Access to Rehabilitation in Ischemic Stroke Patients
Authors: Ifejika Nneka L , Vahidy Farhaan , Reeves Mathew , Xian Ying , Gezmu Tefera , Liang Li , Matsouaka Roland , Grotta James C , Savitz Sean I ,   Get with the Guidelines - Stroke
Published: January 2019

Introduction:
In 2010, the Centers for Medicare and Medicaid Services (CMS) implemented the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Rule, requiring IRF patients to tolerate 3 hours of daily therapy (PT &OT/SLP). If unable, rehab at a skilled nursing facility (SNF) is recommended, contrasting the 2016 AHA Stroke Rehabilitation Guidelines for optimal recovery.

Hypothesis:
Stroke patients are more likely to receive rehab at a SNF compared to an IRF after implementation of the CMS 2010 IRF PPS Rule.

Methods:
We calculated the proportion of stroke patients discharged to IRF vs home and SNF vs home using prospectively collected registry data from Get with the Guidelines - Stroke, for a cohort of ischemic (85.7%) and hemorrhagic (14.3%) stroke patients between 2008 and 2015 (n=1,962,933). Univariate analyses compared stroke severity by NIHSS, sociodemographic/clinical characteristics and in hospital rehabilitation assessments. Multivariable regression modeling assessed the association between CMS 2010 IRF PPS Rule and age, teaching versus non-teaching hospital and US geographic region.

Results:
Post CMS 2010 IRF PPS Rule, 1 out of 15 ischemic stroke patients had lower IRF rehab odds (OR 0.94; 95%CI 0.92-0.95; P<0.0001); 1 out of 9 ischemic stroke patients had higher SNF rehab odds (OR 1.12, 95% CI 1.10-1.14; P<0.0001). Multivariable regression - ischemic stroke: Across all ages, in the South, Northeast and at teaching hospitals, the odds of IRF rehab decreased and the odds of SNF rehab increased after implementation of CMS 2010 IRF PPS Rule (Fig 1 & 2).

Conclusions:
Ischemic stroke patients, with similar clinical histories & stroke severity, had decreased odds of inpatient rehabilitation facility rehab and increased odds of skilled nursing facility rehab after implementation of the CMS 2010 IRF PPS Rule. Additional studies analyzing the effects of low intensity SNF rehab versus IRF rehab on return home and long-term disability are needed.
Abstract WP183: Clinical Outcome in Cardioembolic Stroke Patients Receiving DOACs versus Warfarin: K-PLUS Registry
Authors: Singu Takaomi , Nakajima Makoto , Inatomi Yuichiro , Yonehara Toshiro , Wada Kuniyasu , Terasaki Tadashi , Kouzaki Yanosuke , Ito Yasuyuki , Hashimoto Yoichiro , Ando Yukio ,   K-PLUS investigators
Published: January 2019

Introduction:
Relationship between the selection of oral anticoagulants after acute stroke as secondary prevention and clinical outcome is not elucidated. Our aim is to compare clinical outcome in patients receiving direct oral anticoagulants (DOACs) versus warfarin after their stroke.

Methods:
In the regional stroke registry, K-PLUS, 1,019 consecutive patients with cardioembolic stroke who were prescribed anticoagulants were retrospectively enrolled from April 2011 to May 2016. Patients with premorbid modified Rankin Scale score of 3 or more and those with incomplete clinical data were excluded. The residual 323 patients were divided into 2 groups by their receiving anticoagulants after their stroke: the warfarin group and the DOACs group. Clinical characteristics, length of hospital stay, Functional Independence Measure (FIM) scores on admission and at discharge of rehabilitation hospital, and mean daily FIM gain were compared between the 2 groups.

Results:
In the 323 patients, median age was 79 (interquartile range: 73-85) years and 176 (54.5%) were men. A total of 146 patients (46.2%) was prescribed DOACs (dabigatran in 15, rivaroxaban in 46, apixaban in 72, and edoxaban in 13). Median age (81 vs. 79 in median,
p
= .03) and NIHSS score on acute hospital admission (10 in DOACs vs. 17 in warfarin,
p
< .01) were lower, and length of acute hospital stay was shorter (13 vs. 17 days,
p
< .01) in the DOACs group than the warfarin group. In rehabilitation hospitals, both FIM score on admission (86 vs. 32,
p
< .01) and daily FIM gain (0.22 vs. 0.10,
p
< .01) was significantly higher in the DOACs group. On multivariate analysis, DOACs prescription (odds ratio 1.79; 95% CI, 1.10-2.93) and NIHSS on acute hospital admission (1.04 per 1 point; 1.01-1.08) were correlated with daily FIM gain ≥ 0.15, independent of other factors including age, length of acute hospital stay, and FIM on admission of rehabilitation hospital.

Conclusion:
Patients receiving DOACs after their cardioembolic stroke might achieve better clinical outcome than those with warfarin.
Abstract WP193: Genetic Polymorphisms Negatively Impact Upper Limb Motor Recovery After Stroke - A Meta-analysis
Authors: Subramanian Sandeep K , Birnbaum Lee A
Published: January 2019

Upper limb (UL) hemiparesis is one of the most disabling consequences of a stroke. In addition to spontaneous recovery, post-stroke motor recovery is associated with adaptive neuroplasticity and motor learning. Factors affecting motor learning and adaptive neuroplasticity include the presence of genetic polymorphisms. Evidence is emerging that these polymorphisms can influence UL motor recovery. However, the implications of these polymorphisms on rehabilitation are unclear. Using a systematic review and meta analysis, we examined the influence of genetic polymorphisms on post-stroke UL motor recovery. We conducted a systematic review of the published literature in English language. The Down’s and Black checklist helped evaluate the quality of the published studies. We compared changes in UL motor impairment and activity levels between groups with and without the polymorphisms using standardized mean differences and derived summary effect sizes. Seven studies that examined the effects of genetic polymorphisms on UL motor recovery were obtained. The studies examined the effects of polymorphisms (presence of met alleles) in brain derived neurotrophic factor (BDNF, 5 studies) and Catechol-
O
-Methyltransferase (COMT, 1 study). One study assessed the effects of Apolipoprotein polymorphism (ApoE ε4). The Fugl Meyer Assessment and Wolf Motor Function Test outcomes assessed motor impairment and activity levels respectively. The quality of the published studies ranged from fair to good. The meta analysis revealed that presence of met allele in BDNF negatively influenced the recovery of motor impairment (moderate effect size -0.47). In addition, recovery of activity levels for people with moderate and high levels of motor ability (effect sizes -1.39 and -7.37 respectively) were also negatively impacted by the presence of met allele in BDNF. The met allele in COMT also negatively influenced recovery of motor impairment (effect size -2.66). Presence of ApoE ε4 did not influence UL motor recovery. In conclusion, the presence of genetic polymorphisms negatively influences the recovery of UL motor impairment and activity. These factors need to be considered while selecting rehabilitation interventions to maximize levels of UL motor recovery post-stroke.
Abstract WP194: Influence of Selective Seratonin Reuptake Inhibitors on Aphasia Recovery: Preliminary Data From a Clinical Trial
Authors: Hillis Argye E
Published: January 2019

Background:
In an ongoing trial on the effects of transcranial direct current stimulation (tDCS vs sham) plus language therapy on aphasia recovery in subacute stroke, we are evaluating the effects of SSRI use (with or without tDCS) on aphasia recovery.

Hypothesis:
Mean change in correct Content Units (CU) produced in a picture description (primary outcome variable) is influenced by SSRI use, independently of depression, age, and sex.

Methods:
We analyzed data from 17 participants (with aphasia within 3 months of single left hemisphere ischemic stroke) who have completed 2-month post-treatment follow-up. We expect to have data on 30 by February, 2019. Participants described a picture (scored for CU), and were administered the Philadelphia Naming Test (PNT), Hopkins Assessment of Naming Actions (HANA), and retold the Cinderella Story (scored for CU per minute) before treatment and 2 months post-treatment. They were also administered the Patient Health Questionnaire-9 at each time point to evaluate depression. Treatment was a computer-delivered naming treatment plus either tDCS (1 mA, for first 30 minutes) or sham (randomly assigned), for 15 sessions. SSRI use depended on physician’s discretion. We remain blinded to treatment group; but we analyzed effects of SSRI (independent of depression, age, and sex) on achieving highest quartile change in CU using logistic regression. We compared mean change in each test in SSRI users vs nonusers with Wilcoxon Rank Sum tests.

Results:
Five participants took daily SSRI. There were no significant differences between SSRI users and nonusers in age, education, or any test at baseline. Together, SSRI use, PHQ9, age, and education predicted highest quartile of change in CU; pseudo r2 = 0.62 (p=0.016). SSRI users were more likely to achieve the highest quartile in CU (OR: 50.9; 95%CI: 0.15-16975), compared to nonusers. Although there were no significant differences between SSRI users and nonusers in change on any of the tests (likely due to low power), SSRI users showed higher mean improvements on all tests compared to nonusers; CU: 6.5 vs 1.7; PNT: 68.6 vs 50.9; HANA: 7.4 vs 1.8; Cinderella Story: 12.1 vs 10.9.

Conclusions:
Preliminary data indicate that daily SSRI may positively affect language gains with subacute aphasia treatment.
Abstract WP195: Cerebellar Magnetic Stimulation for Long-Lasting Dizziness After Brainstem Stroke
Authors: Johkura Ken , Kudo Yosuke , Sugawara Eriko , Amari Kazumitsu , Yamamoto Masahiro
Published: January 2019

Introduction:
Brainstem stroke sometimes causes long-lasting dizziness. A cerebellar control disorder of the vestibulo-ocular reflex (VOR) has been postulated as a mechanism of dizziness in such patients. We conducted a proof-of-principle cohort study to assess the potential efficacy of cerebellar repetitive transcranial magnetic stimulation (rTMS) as treatment for long-lasting post-brainstem stroke dizziness.

Methods:
We first applied cerebellar rTMS in healthy volunteers (n=11) and showed that cerebellar intermittent theta burst stimulation (iTBS) affected vestibulocerebellar neural activity. Then, we enrolled 11 patients with long-lasting post-brainstem stroke dizziness (lateral medullary infarction, 9; lateral pontine infarction, 1; and lateral pontine hemorrhage, 1), applied cerebellar rTMS (iTBS for 5 days), and followed these patients up for clinical symptoms (Dizziness Handicap Inventory [DHI]), signs (nystagmus), and VOR gain.

Results:
After rTMS, DHI scores were significantly reduced with disappearance or attenuation of the ipsilesional nystagmus characteristic of the long-lasting post-brainstem stroke dizziness. Reduction in the absolute VOR gain was also associated with reduced DHI scores. Relative cerebellar blood flow to the brainstem, measured in 4 patients, was increased. However, the effects of cerebellar rTMS did not always persist.

Conclusion:
Our study showed the potential efficacy of cerebellar rTMS for treatment of long-lasting post-brainstem stroke dizziness. Further large-scale randomized studies are warranted to confirm our findings.
Abstract WP198: Sex Differences of Functional Recovery Pattern After the First-ever Stroke in Korea: The KOSCO Study
Authors: Shin Mina , Chang Won Hyuk , Kim Deog Yung , Sohn Min Kyun , Lee Jongmin , Lee Sam-Gyu , Shin Yong-il , Kim Soo-Yeon , Oh Gyung-Jae , Lee Yang-Soo , Joo Min Cheol , Han Eun Young , Han Jun Hee , Ahn Jeounghoon , Choi Yong-Joo , Kang Sung Hyun , Lee Kang Hee , Kim Young Taek , Shin Minyoung , Kim Yun-Hee
Published: January 2019

Objective:
The objective of this study was to investigate differences of functional recovery pattern and the factors associated with recovery pattern between male and female stroke patients.

Methods:
This study was an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation (KOSCO) designed as 10 years long-term follow-up study of stroke patients. We analyzed serial data up to 24 months of multi-facet functional assessments such as Korean-Modified Barthel Index (K-MBI), Fugl-Meyer Assessment (FMA), Functional ambulation classification (FAC), American Speech-Language-Hearing Association-National Outcomes Measurement System (ASHA-NOMS), Korean version of Frenchay Aphasia Screening Test (K-FAST) to identify sex-specific differences after adjustments for difference with age, type of stroke, premorbid functional level, degree of comorbidity, and multi-facet functional levels at 7 day after stroke.

Results:
Out of total 10,636 stroke patients (6,043 male and 4,593 female), female patients showed significantly older age, lower education level, lower body mass index, worse premorbid functional level, higher co-morbidity and more severe initial severity assessed by NIHSS compared with male stroke patients (p<0.05, Table 1). Even after multiple adjustments for differences, multi-facet functional outcomes were more severe in female stroke patients such as lower FMA, K-FAST, and FAC at 7 day; lower K-MBI, K-FAST, and FAC at 3, 12, and 24 months; lower ASHA-NOMS at 24 months (p<0.05, Table 2).

Conclusion:
The results of this study could provide more specific information for establishing the stroke rehabilitation strategy according to sex.
Abstract WP202: Race/ethnicity Matters: Differences in Stroke Inpatient Medical Rehabilitation Outcomes for Communities of Color
Authors: García James J , Warren Karlita
Published: January 2019

Introduction:
Stroke is a leading cause of disability and death in the United States. Racial/ethnic people with stroke demonstrate lower functional independence measure (FIM) scores before and after inpatient medical rehabilitation compared to non-Hispanic Whites. Racial/ethnic differences in FIM scores have implications for discharge.

Method:
This is a cross-sectional and retrospective analysis of data extracted and pooled across years 2002-2018. Inclusion criteria were: 1) stroke as a primary diagnosis and 2) non-Hispanic White (NHW), Hispanic, non-Hispanic Black (NHB), and non-Hispanic Asian (NHA) patients. Per systematic review evidence, ICD codes 430-438/I60-I69 were used to identify stroke diagnoses. Dependent variables were: length of stay (LOS), admission FIM Cognitive and Motor Total, FIM efficiency, FIM change per day, discharge FIM Cognitive and Motor Total, and discharge to home. NHWs were used as the reference group.

Results:
There were 3,911 patients across the study period. Age, gender, and admission year were used as covariates. There were racial/ethnic differences in LOS,
F
(3, 3853) = 2.658,
p
= .047,
partial η2
= .002, with NHAs having longer LOS. Racial/ethnic differences in admission FIM scores were found,
F
(6, 7750) = 6.727,
p
< .001,
Wilks' λ
= .989,
partial η2
= .006, with NHAs and Hispanics showing lower cognitive and motor scores. There were no racial/ethnic differences in cognitive or motor efficiency. Racial/ethnic differences in FIM change per day emerged,
F
(3, 3854) = 4240,
p
= .005,
partial η2
= .003, with Hispanics and NHBs having lower change per day. Racial/ethnic differences in discharge FIM scores were noted,
F
(6, 7704) = 4.865,
p
< .001,
Wilks' λ
= .992,
partial η2
= .004, with NHAs and Hispanics having lower total cognitive scores but only Hispanics had lower motor scores. Lastly, Hispanics had higher odds of being discharged home compared to other racial/ethnic groups (
OR
= 1.246,
95% CI
= 1.046-1.485,
p
= .014).

Discussion:
Controlling for covariates, there were significant racial/ethnic differences in stroke inpatient medical rehabilitation outcomes, particularly for Hispanics. Factors involved in creating/maintaining post-stroke rehabilitation disparities for Hispanics (and others) are discussed.
Abstract WP21: Successful Reperfusion With Thrombectomy in Patients With Large Dwi Lesion is Associated With Reduced Occurrence of Malignant Stroke
Authors: Sabben Candice , Desilles Jean-Philippe , Charbonneau Frederique , Savatovsky Julien , Sadik Jean-Claude , Escalard Simon , Redjem Hocine , Smajda Stanislas , Ciccio Gabriele , Blanc Raphael , Fahed Robert , Ben Maacha Malek , Morvan Erwan , Obadia Alexandre , Le Guerinel Caroline , Engrand Nicolas , Labreuche Julien , Mazighi Mikael , Obadia Michael , Piotin Michel
Published: January 2019

Introduction:
Malignant middle cerebral artery infarction (MMI) is a severe complication of ischaemic stroke (IS), with a mortality rate up to 80%. Diffusion-weighted imaging (DWI) lesion volume larger than 82 millilitres on cerebral MRI performed within the six first hours is known to be predictive of MMI. These patients, with “malignant profile”, were mostly excluded of endovascular therapy (EVT) randomised trials. The aim of our study was to evaluate whether successful reperfusion after EVT in patients presenting IS with large DWI lesion decreased occurrence of malignant stroke.

Methods:
We analysed data collected between 2014 and 2018, in a monocentric prospective IS patients registry treated with EVT. Patients were selected if they had a malignant profile and could be eligible to a craniectomy. Thus, selected patients were less than 65-years old, with a severe stroke defined by National Institutes of Health Stroke Scale (NIHSS) score > 15 and with DWI lesion larger than 82ml. We compared patients with successful recanalization (defined by Thrombolysis in Cerebral Ischemia (TICI) 2b or 3) and poor recanalization (TICI 0, 1 or 2A). Primary end point was malignant stroke rate. Secondary end points were craniectomy, haemorrhagic complications, 90-days all-cause mortality rates and 90-days favourable outcome (defined by modified Rankin Scale 0-2).

Results:
From 2014 to 2018, 66 patients were selected. MMI occurred in 27 patients (42%), and 22 (33%) had effectively craniectomy. Successful recanalization was observed for 46 patients (69.7%). MMI occurrence was significantly lower in the latter patients compared to the poor recanalization group (14/44(31.8%) vs 13/20(65.0%); OR=0.25 (0.08-0.77), p = 0.015). Less craniectomies were performed in the successful recanalization group (12/46 (26.1%) vs 10/20 (50.0%); OR=0.35 (011-1.06), p=0.063).There was no significant difference in symptomatic intracranial haemorrhage rate; in 90-days favourable outcome and all causes mortality rate between the two groups.

Conclusion:
Successful recanalization performed in IS patients with large DWI lesion decreases the occurrence of malignant strokes and the need for craniectomy procedure. Further data with a larger sample or from randomized studies are needed.
Abstract WP211: Exome Association Analysis of Small Vessel Young Onset Ischemic Stroke
Authors: Jaworek Thomas , Ryan Kathy , Gaynor Brady , McArdle Patrick , Stine Oscar C , Aparicio Hugo J , Gao Yan , Lin Xiaochen , Groves Megan L , Kittner Steven J , Wilson James , Yang Qiong , Seshadri Sudha , Lui Simin , Mitchell Braxton D , Xu Huichun , Cole John W
Published: January 2019

Background:
Cerebral small vessel disease accounts for ~25-30% of strokes and is a leading cause of age- and hypertension-related cognitive decline and disability. Specific treatments for cerebral small vessel disease are lacking, and therapeutic options for secondary prevention are limited as compared to other common causes of stroke. Identifying stroke-associated protein coding variants is a promising tool to better understand disease etiology and identify novel targets.

Methods:
The GEOS Study was initiated as a biracial population-based study of cases with first-ever ischemic stroke 15 to 49 years of age and controls. All participants had prior GWAS and underwent Illumina exome-chip genotyping. Logistic regression analysis was conducted to identify associated variants after accounting for population substructure using Principal Component Analysis based on GWAS array data. Gene-based aggregation testing (SKAT) and meta-analysis were performed using seqMeta with ethnicity-specific GWAS PCs. Covariates for these analyses included age and gender. This was followed by Ingenuity Pathway Analyses on the top genes.

Results:
Gene-based testing using a filter (cumulative MAC>40, # of SNPs per gene≥2, missingness=0) was performed on 7448 genes in 123 small vessel cases and 727 non-stroke controls. Two genes reached exome wide statistical significance (p<6.7*10
-6
) in the meta-analyses:
FNDC9
(Fibronectin type III domain containing 9, p=9.2*10
-7
) and
ASXL1
(ASXL Transcriptional Regulator 1, p=3.4*10
-7
). Although no individual SNPs reached genome-wide significance (3x10
-7
), a rare missense variant in
ASXL1
(MAF=0.02, p=3.5*10
-6
) was near the threshold.
ASXL1
SNPs have been associated with an increased risk of CVD. Pathway analyses of the top 438 genes (p<0.05) from the gene-based results identified the nuclear receptor signaling pathway related to lipid/glucose metabolism, and the neurotransmitter glutamate receptor signaling and neurodevelopment notch signaling pathways. Efforts to replicate these findings in independent data sets are ongoing.

Conclusion:
Exome-based analyses of small vessel young-onset ischemic stroke is a promising methodology to identify novel genetic risk variants, genes and pathways.
Abstract WP215: Stroke Knowledge Over Time among Multi-ethnic Stroke Survivors in New York City
Authors: Schram Benjamin , Roberts Eric T , Appleton Noa , Parikh Nina S , Goldmann Emily , Boden-Albala Bernadette
Published: January 2019

Background:
Stroke knowledge, which includes awareness of symptoms, risk factors and treatment options, is critical to preventing stroke and improving outcomes. In recent years there have been significant state, federal, and private initiatives to improve “door to needle time” including efforts towards lay education about acute stroke as an emergency; however, their impact is unknown. We assessed stroke knowledge over time among mild/moderate stroke/TIA patients in New York City in two large clinical trials, the Stroke Warning Information and Faster Treatment (SWIFT) study and the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) study.

Methods:
Basline data from SWIFT was collected between 2005-2009 and for DESERVE between 2012-2016. Before randomization, patients were asked closed-ended questions focused on stroke symptoms, risk factors and preparedness behaviors. Proportions of correct responses were calculated and logistic regression was used to assess the change in knowledge over time while controlling for education, age, gender, and race/ethnicity. We also assessed whether stroke knowledge changed differentially over time by race or gender using product terms.

Results:
A total of 1,190 participants from SWIFT and 552 from DESERVE were included in the analysis. The pooled sample was 50.1% female, 23.9% non-Hispanic black, 43.4% non-Hispanic white, and 48.4% Hispanic, mean age 64.3. The brain was correctly identified as the site where stroke occurs by 78.14%, all 5 symptoms of stroke were correctly identified by 40.64% (replying ‘yes’ to hemiparesis, hemisensory loss, difficulty speaking, blurred vision and ‘no’ to chest pain), and 6 or more risk factors were identified by 75.55% of participants in both cohorts. The odds of identifying the brain as the location of a stroke increased each year (OR=1.05, p<0.01) as did correctly identifying 6 or more risk factors of stroke (OR=1.03, p<0.01)
.
Correct responses to all 5 symptoms did not significantly change over time. Knowledge over time did not change differentially by race or gender.

Conclusion:
There was a small increase in stroke knowledge over time between 2005-2016 in our urban, multi-ethnic cohorts, though levels remain suboptimal.
Abstract WP219: Risk of Ischemic Stroke in Veterans With TBI and PTSD: VA Retrospective Study
Authors: Shah Shamik , Oni Olurinde , Thakur Hemant , Maalouf Salwa , Sharma Ram , Sharma Mukut , Oehlert Mary , Singh Vikas
Published: January 2019

Background:
Traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) are associated with chronic vascular inflammation and an increased risk of chronic multisystem dysfunction including metabolic syndrome, sleep apnea, hypothalamic-pituitary-adrenal axis dysfunction which increases the future risk of cerebrovascular events.

Objective:
To assess the future risk of ischemic stroke in veterans with TBI and PTSD.

Methods:
Using VA national database, we conducted a retrospective cohort study of veterans who received care in VHA from December 1998 to May 2014 and were diagnosed with PTSD alone, TBI alone or both. Univariate, multivariate, propensity-score matched, and survival analyses were conducted on the cohorts to determine and compare the incidences and hazard ratios (HR) for incident ischemic stroke in the three diagnosis groups.

Results:
Of 1,339,937 veterans diagnosed with PTSD, TBI or both, we excluded those with missing data on matching variables and those whose diagnosis of ischemic stroke preceded PTSD and/or TBI diagnosis. Final cohort comprises of 922,892 veterans: PTSD (800,555), TBI (63,219), both (59,118). The incidence of ischemic stroke was significantly higher in the TBI group (6,865; 11.61%) compared to PTSD (36,337; 4.54%) and both (4,130; 6.53%). The cohort was analyzed in three groups TBI vs. PTSD, PTSD+TBI vs. PTSD, and PTSD+TBI vs. TBI with calculation of adjusted HR, which was 2.076 (1.989-2.167, p<0.0001), 2.166 (2.046-2.292, p<0.0001) and 1.060 (1.008-1.113, p=0.0216) respectively. The analysis was adjusted for demographics, cardiovascular risk factors, various comorbid conditions and relevant medications. Kaplan Meier curves were plotted to compare the time to events among these groups.

Conclusions:
TBI is associated with higher risk of ischemic stroke compared to PTSD. TBI and PTSD together further increases this risk. Large scale population based prospective studies would be needed to further investigate this.
Abstract WP233: Distinct Vascular Profile in Middle-Aged Migraineurs: Higher Pulse Wave Velocity, Putaminal État Criblé and Incomplete Posterior Circle of Willis
Authors: Ikeda Ken , Sawada Masahiro , Morioka Harumi , Nagasawa Junpei , Miura Ken , Hanashiro Sayori , Kyuzen Maya , Yanagihashi Masaru , Takazawa Takanori , Murata Kiyoko , Kawabe Kiyokazu , Iwasaki Yasuo
Published: January 2019

Background:
Migraineurs may develop stroke and cardiovascular diseases (CVD). We evaluated vascular findings in middle-aged migraineurs without CVD risks.

Methods:
Migraine was diagnosed according to ICHD-3 by direct interview and neurological examination. Migraine was classified into migraine with aura (MA) and migraine without aura (MO). Frequency of migraine attacks were denoted as < 1 /mo or ≥ 1 /mo. Severity of migraine was scaled by Headache Impact Test-6. Usual CVD risk factors of smoking, obesity, hypertension, diabetes mellitus and dyslipidemia were examined. Brachial-ankle pulse wave velocity (baPWV) and ankle brachial index (ABI) were measured using a plethysmography. Brain magnetic resonance imaging (MRI) and angiography (MRA) were performed. Circle of Willis (CW) on MRA was morphologically classified into 2 types: complete posterior CW defined as the presence of both posterior communicating arteries and both P1 segments of posterior cerebral arteries, and other patterns of incomplete posterior CW (Ikeda et al. Headache 2007).

Results:
A total of 317 migraineurs (235 women and 82 men) were diagnosed. Thirty patients with CVD risk factors were excluded, and the study was completed in 287 migraineurs (215 women and 72 men), MA (n=56) and MO (n=231). Mean age (SD) was 44.0 (9.3) years. Consecutive 300 age- and sex-matched controls without migraine and CVD risks were prepared during the study. Compared to controls, baPWV was increased in migraineurs (P<0.05) and MA patients (P<0.01). ABI did not differ between migraineurs and controls. Other clinical findings of migraineurs were not linked to baPWV and ABI. MRI disclosed higher frequency of putaminal état criblé in migraineurs (P<0.05) and MA patients (P<0.01) compared to controls. Three MA patients were diagnosed with hereditary cerebral angiopathy of CADASIL (n=1), Moyamoya disease (n=1) and cavernous angioma (n=1). Morphological CW studies lower frequency of complete posterior CW in migraineurs (P<0.05) and MA patients (P<0.01) compared to controls.

Conclusion:
The present study suggested vascular changes of baPWV, putaminal état criblé and CW shape in migraineurs, especially in MA sufferers. The distinct vascular profile could contribute to higher risk of stroke and CVD in migraineurs.
Abstract WP236: Trends in Antithrombotic Therapy Use and Clinical Outcome in Acute Ischemic Stroke and Atrial Fibrillation in a Hispanic Population in the Era of Direct Oral Anticoagulants
Authors: Flores-Silva Fernando Daniel , Chiquete Erwin , Martinez-Carrillo Francisco , Gomez-Brockmann Pedro , Montes-Ramirez Juan Esteban , Echeverria-Vargas Juan Antonio , Cordova-López Patricio , Perezfigueroa-Olivas Victor , Zacarías-Mateos Esteban , Salama-Frisbie Richard , Cantú-Brito Carlos
Published: January 2019

Introduction and Purpose:
Guidelines strongly recommend oral anticoagulation (OAC) for stroke prevention for individuals with atrial fibrillation (AF). Before introduction of direct oral anticoagulants (DOAs) in 2011, we demonstrated that in our Hispanic population most of the patients with AF admitted with an acute stroke were receiving antiplatelets or no antithrombotic therapy. This study examined the trends in antithrombotic use in AF after the introduction of DOAs.

Methods:
Patients with transient ischemic attack [TIA] and ischemic stroke [IS] enrolled in Mexican national registries of general public hospitals (n=4172) were analyzed to select patients with previous AF (n=534). Hemorrhagic stroke was excluded. Primary end points were (1) to compare pre-stroke antithrombotic treatment between patients who had a stroke from 2002-2010 versus 2011-2018, and (2) to compare short-term outcome regarding pre-stroke treatment and between both time periods.

Results:
Prevalence of AF was 12.8% (534/4172), age 73.8 ±13.3; 170 (31.8%) had had a previous IS/TIA. CHA
2
DS
2
-VASc 3.89 ±1.8, HAS-BLED 2.3 ± 1.1. When comparing antithrombotic therapy between both time periods we found: no anticoagulant therapy 71.8% vs 66.9%, subtherapeutic levels of those receiving vitamin-K antagonists (VKAs) 20.2% vs 10.5%, therapeutic VKA 8% vs 14.3%, and DOAs use of 14.3% (only last period). OAC effective therapy was lower in patients without previous IS/TIA (9.9% versus 17.1%). Patients using OAC in therapeutic range or DOAs at the time of stroke had better outcome when compared with individuals taking antiplatelets or no antithrombotics (P <0.05). Short-term modified Rankin Scale (mRS) between both time periods were mRS 0-2: 36.9% vs 40.6%, mRs 3-5: 36.4% vs 46.6%, and death 26.7% vs 12.8% (
p
= 0.003).

Conclusions:
In our Hispanic population underuse of effective anticoagulant therapy is still prevalent even in the new DOAs era (more >70%). VKA in therapeutic ranges or DOAs use had less disability and mortality on short-term outcome. There is a low frequency of DOAs in our public general hospital population.
Abstract WP263: Wall Motion Abnormalities on Transthoracic Echocardiography in the Setting of Ischemic Stroke Reflect Underlying Cardiac Disease and May Warrant an Ischemic Cardiac Evaluation
Authors: Yaghi Shadi , Chang Andrew , Ricci Brittany , Mac Grory Brian , Cutting Shawna , Burton Tina , Dakay Katarina , McTaggart Ryan , Jayaraman Mahesh , Schomer Ashley , Merkler Alexander , Reznik Michael , Lerario Michael , Gupta Ajay , Song Christopher , Kamel Hooman , Elkind Mitchell S , Furie Karen
Published: January 2019

Background and Purpose:
Patients with acute ischemic stroke (AIS) are at a heightened risk of cardiovascular events. We hypothesize that wall motion abnormalities (WMA) on transthoracic echocardiography (TTE) in the setting of AIS reflect underlying heart disease rather than reversible cardiac strain caused by the stroke.

Methods:
Data was abstracted from a single center prospective AIS database over 18 months and included all patients with acute ischemic stroke who underwent a TTE. The presence of WMA was abstracted from the TTE report. Univariate analyses and predefined multivariable models were performed to determine factors associated with WMA, including demographic factors (age and sex), risk factors (hypertension, diabetes, hyperlipidemia, history of stroke, atrial fibrillation, congestive heart failure, coronary heart disease, and smoking), NIHSS score, cardiac markers (positive troponin, ECG evidence of prior myocardial infarction, ejection fraction), and insular location of infarct.

Results:
We identified 1044 patients who met the inclusion criteria; 139 (13.3%) had evidence of WMA, of which only 23 patients had no history of heart disease or ECG evidence of prior myocardial infarction. Among these 23 patients, 12 had a follow up TTE after the stroke and WMA persisted in 92.7% (11/12) of patients. On fully adjusted models, factors associated with WMA are older age (OR per SD 1.03, 95% CI 1.001-1.05; p=0.009), congestive heart failure (OR 4.44, 95% CI 2.39-8.33, p<0.001), history of coronary artery disease or ECG evidence prior myocardial infarction (OR 27.03, 95% CI 14.93-50.0, p<0.001), and elevated serum troponin levels (OR 2.00, 95% CI 1.06-3.75, p=0.031).

Conclusion:
In AIS patients, WMA on TTE may reflect underlying cardiac disease and warrant further cardiovascular evaluation particularly in those without known history of cardiac disease. Future studies are needed to investigate the cost-effectiveness of this approach.
Abstract WP265: Racial Differences in Left Atrial Size Among Patients With Ischemic Stroke
Authors: Kamel Hooman , Alwell Kathleen , Kissela Brett , Moomaw Charles J , Sucharew Heidi G , Woo Daniel , Flaherty Matthew , Ferioli Simona , Demel Stacie , Walsh Kyl , Mackey Jason , De Los Rios La Rosa Felipe , Jasne Adam , Slavin Sabreena , Martini Sharyl , Adeoye Opeolu , Soliman Elsayed Z , Levitan Emily , Baig Tehniyat , Kleindorfer Dawn O
Published: January 2019

Introduction:
Blacks in the U.S. face twice the risk of ischemic stroke as whites, and this disparity is not fully explained by established stroke risk factors. Although atrial fibrillation (AF) is a major risk factor for stroke, blacks are less often diagnosed with AF than whites. It is unclear whether this paradox exists because AF is less thoroughly ascertained in blacks compared to whites or because blacks have less predisposing substrate and thus a truly lower risk of AF.

Hypothesis:
Based on our prior work, we hypothesized that black patients with ischemic stroke less often have left atrial enlargement, a major predisposing factor for AF.

Methods:
We compared left atrial size in black versus white patients in the Greater Cincinnati/Northern Kentucky Stroke Study, a study of racial disparities in stroke incidence in a nationally representative population of 1.3 million. We obtained reports of echocardiograms performed for stroke evaluation among patients in the 2010 and 2015 study periods. Patients with known AF or atrial flutter were excluded. Investigators blinded to patients’ characteristics abstracted left atrial diameter from echocardiogram reports. Linear regression was used to examine the association between race and left atrial diameter after adjustment for demographics, body mass index, and comorbidities.

Results:
Among 2,980 cases of ischemic stroke without AF, the median age was 66 years, 52% were female, and 30% were black. The overall mean left atrial diameter was 3.65 (±0.69) cm. Despite a higher burden of vascular risk factors and comorbidities, blacks had significantly smaller left atrial diameters (mean difference, -0.10 cm; 95% CI, -0.04 to -0.17 cm). This difference persisted after adjustment for demographics, comorbidities, and body mass index (adjusted mean difference, -0.15 cm; 95% CI, -0.09 to -0.21 cm).

Conclusions:
In a population-based sample, we found that black patients with ischemic stroke had smaller left atrial size than white patients. Our results suggest that the paradox of greater stroke risk but lower AF risk in blacks compared with whites at least partly stems from a lesser degree of AF substrate in blacks.
Abstract WP288: Impact of Prehospital LVO Tools on the Delay of Care and Redistribution of Patients between Primary and Comprehensive Stroke Centers
Authors: Hussein Haitham M , Brown Morgan M , Herrmann Amanda A , Anderson Daniel C
Published: January 2019

Introduction:
Several tools have been developed aimed at predicting large vessel occlusion (LVO) in the prehospital setting. If these tools are used to bypass Alteplase-but-not-thrombectomy-capable hospitals, this would speed the care for some patients, delay it for others, and unnecessarily redistribute some patients between hospitals.

Methods:
We examined a hypothetical scenario of 1,000 patients evaluated by EMS for possible stroke. We used data published by RACE (Rapid Arterial oCclusion Evaluation) that included 357 patients to calculate the rates of the different stroke subtypes. Ischemic stroke represented 67.2% of patients, hemorrhagic stroke 14.6%, transient ischemic attack 5.6%, and stroke mimic 12.6%. We applied the following assumptions: rate of LVO as 20% of total ischemic stroke, all patients evaluated by EMS within 3 hours from their last known well time with a rate of tPA utilization is 50%, endovascular-capable hospital is further away, similar door-to-needle (DTN) time in all hospitals, delay in DTN in false positive patients, and delay in door-to-groin time (DTG) in false negative patients. Seven tools were studied using published values for sensitivity and specificity.

Results:
Using no tools would lead to evaluation of all patients at the nearer hospital first, leading to delay in DTG of all 134 LVO patients, however no delay in DTN. Comparing the various tools, DTN delay would be highest with Cincinnati Prehospital Stroke Severity Scale (CPSSS; n=175) and least with 3-item stroke scale (3I-SS; n=23). DTG delay would be highest with Prehospital Acute Stroke Severity (PASS) and Field Assessment Stroke Triage for Emergency Destination (FAST-ED) (n=52 for both) and least with RACE (n=20). Redistribution of patients would be highest with CPSSS and lowest with 3I-SS (reduction in patient volume to non-thrombectomy capable hospital 63% and 16% respectively and increase in volume for the thrombectomy-capable hospital by 371% and 19% respectively).

Conclusion:
Current tools have a very wide variation in performance. Although some tools would likely reduce the delay in DTG time for most (but not all) LVO patients, they risk delaying care for other patients and may cause an unnecessary redistribution of patients between hospitals.
Abstract WP289: Implementation of Secure Messaging System Reduces Response to Page Time in Telestroke Network
Authors: Hackett Chris T , Rahangdale Rahul , Rana Sandeep S , Fishman Robert , Wright David G , Noah Patty , Tayal Ashis H
Published: January 2019

Introduction:
Timeliness of a response to page by telestroke physicians is an important component in a telestroke network. Accrediting organizations such as the Joint Commission require telemedicine to be available within 20 minutes of the request. We implemented a secure messaging system to improve physician communication. We hypothesized that implementation of a secure messaging system would improve communication, reduce telestroke physician response to page and reduce door-to-needle (DTN) times compared to the previous pager-based system.

Methods:
We reviewed data collected as part of our telestroke quality program. We compared response to page times for one year before and after initiation of the secure messaging system. Additionally, we compared DTN times during the same epochs.

Results:
Seven hundred and sixty-five telestroke consults were completed in the year prior to implementation of the secure messaging system and 941 telestroke consults were completed in the year following implementation. Telestroke response to page time decreased significantly between pre (
mean rank
1005;
median
4 min) and post (
mean rank
731 ;
median
2 min) implementation of the secure messaging system (
U
= 244,240 ,
p
< .001,
r
= .28). A significantly greater percentage of telestroke neurologist response times occurred within 20 minutes when using secure messaging 936/941 (99.5%) compared to pagers, 751/765 (98.2%),
χ
2 (1,
N
= 1706) = 6.46,
p
= .01,
φ
= .06. DTN was lower when using secure messaging (64 min) compared to the prior paging system (66 min), but this difference was not statistically significant (
p
= .74).

Conclusions:
In conclusion, implementation of a secure messaging system improved communication in our telestroke network and reduced telestroke response to page compared to our prior paging system. Implementation of the secure messaging system did not significantly reduce DTN times.