bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W P301: Post Stroke Use of Fluoxetine to Improve Functional Recovery Unrelated to Its Beneficial Effect on Depression
Authors: Krisak Alison
Published: July 2021

Background:
Stroke, the most common cause of long-term disability, is an acute event that can develop into a chronic illness. Recent clinical trials demonstrate that selective serotonin reuptake inhibitors (SSRIs) may be a valuable adjunct to rehabilitation. Following a stroke there is spontaneous reorganization of cerebral motor networks in order to compensate for focal cerebral ischemia. SSRIs are able to optimize this process by stimulating neurogenesis in a manner unrelated to its beneficial effects on depression. Initiating an SSRI post stroke can potentially facilitate a patient’s functional recovery promoting improved quality of life.

Purpose:
The purpose of this literature review is to examine whether administration of an SSRI improves functional recovery in post stroke patients without active depression.

Methods:
Research published between January 1993 and January 2013 that investigated the use of the SSRI, fluoxetine, to optimize functional recovery after stroke was reviewed. Fluoxetine was chosen due to its favorable safety profile and use in the majority of studies. Only randomized, controlled trials that incorporated concurrent rehabilitation in patients without active depression were examined.

Results:
The research demonstrated that fluoxetine has a positive treatment effect on functional recovery. However, due to methodological differences the comparison and pooling of data is limited. Study limitations include small sample size, heterogeneity of stroke type and severity, and time of fluoxetine initiation. Also, measures of functional recovery varied as well as rehabilitation programs.

Conclusion:
In conclusion, the opportunity to improve functional recovery through the use of an SSRI post stroke is promising. Future research should establish a consistent methodology in order to further elucidate the role of SSRIs in reducing disability through its augmentation of neurogenesis. If established as an effective adjunct to post stroke rehabilitation, SSRIs may positively impact long-term outcomes.
Abstract W P32: Association of Low Cerebral Blood Volume With Negative FLAIR Hyperintensity in Acute Ischemic Stroke
Authors: Nagaraja Nandakumar , Luby Marie , Edwardson Matthew , Zand Ramin , Latour Lawrence L
Published: July 2021

Objective:
FLAIR hyperintensity is being used in clinical trials as a surrogate imaging biomarker for stroke onset time to test the safety of thrombolysis. Studies have shown that patients with negative and positive FLAIR hyperintensity overlap at similar time points from stroke onset in the early phase of acute ischemic stroke (AIS). Hyperintensity on FLAIR MRI likely represents increased tissue water content. We sought to determine if cerebral blood volume (CBV) mediates FLAIR hyperintensity in the early phase of AIS.

Methods:
AIS patients seen in 2012 were included in the study if i) onset time was known, ii) an MRI with perfusion was performed within 12 hours of onset time, iii) had imaging confirmed vascular occlusion of ICA, M1, or M2. Following co-registration of raw perfusion images with FLAIR, CBV maps were generated using PMA ASIST™ software. Two raters blinded to clinical information separately evaluated the DWI, FLAIR and CBV maps and measured the signal intensity ratio (SIR) for the brightest region on FLAIR normalized by homologous contra-lateral tissue. The SIR was similarly measured for CBV in same region. FLAIR negative was defined as SIR<1.15, “Low CBV” was defined as CBV SIR <0.5.

Results:
One hundred eighty two patients were screened and 30 met all study criteria; 21 women, with mean age of 71 (± 16) years and median NIHSS 18 (IQR 9-22). Using linear regression analysis, CBV SIR was associated with FLAIR SIR (p <0.049). In the 0-3hr time window, overall CBV was not associated with FLAIR hyperintensity. However, in the 3-7.5hr time window, patients with negative FLAIR were more likely to have low CBV and conversely, patients with positive FLAIR were more likely to have normal CBV.

Conclusion:
CBV likely mediates FLAIR hyperintensity in 3-7.5hr of stroke onset but it has less impact on FLAIR hyperintensity in the first 3 hours of AIS. Low CBV could be a potential surrogate imaging biomarker in addition to FLAIR hyperintensity in the early phase of AIS.
Abstract W P325: Is Obesity a Marker of Good or Bad Functional Outcome After Ischemic Stroke?
Authors: Yeramaneni Samrat , Kissela Brett M , Kleindorfer Dawn O , Alwell Kathleen , Moomaw Charles J , McCarthy Michael , Sucharew Heidi , Lindsell Christopher , Woo Daniel , Khatri Pooja , Flaherty Matthew , Ferioli Simona , Martini Sharyl , de Lod Rios La Rosa Felipe , Mackey Jason , Khoury Jane C
Published: July 2021

Background:
Obesity is at epidemic proportions in our society. There have been conflicting reports on the association between obesity and stroke outcome. We hypothesized that obesity at the time of stroke leads to better relative short-term functional outcome, but poorer longer-term functional outcome, after stroke.

Methods:
A cohort of 964 patients, identified by hot-pursuit in the ED in 2005 and 2010, was followed out to three months post stroke. Functional outcome, as measured by the modified Rankin scale (mRS), was collected at discharge from hospitalization and at 3 months post stroke. Height and weight were collected at time of stroke and body mass index (BMI) was calculated. Normal weight was defined as BMI ≤ 25 kg/m
2
, overweight as BMI 25 to 29 kg/m
2
, and obese as BMI ≥ 30 kg/m
2
. Covariates and confounders considered were age, gender, race, pre-stroke mRS, baseline NIH Stroke Scale Score (NIHSSS), heart disease, diabetes, hypertension, and smoking. Good functional outcome was defined as a mRS score of 0-1 or back to baseline. Multiple logistic regression was used for analysis to assess the association of BMI status and good functional outcome.

Results:
The cohort was 50% female and 21% black and mean (SD) age was 67 (14) years. Prior to stroke mRS was 0 or 1 in 60%. Of the 964 patients; 882 (91%) had valid height and weight to calculate BMI and were alive at discharge; 224 (25%) were normal weight, 324 (37%) overweight and 314 (36%) obese. There was no statistically significant association between functional outcome, either at hospital discharge after stroke or at 3 months post stroke, and obesity status; even after adjusting for the covariates listed above (see table).

Conclusions:
Obesity status at time of stroke is not statistically significantly associated with hospital discharge or three-month functional outcome after stroke. Longer term outcome is to be examined.
Abstract W P351: Plasma Interleukin-6 and C-reactive Protein Are Associated With Acute Diffusion Hyperintensity After Transient Ischemic Attack
Authors: Kelly Peter J , Akijian Layan , Browne Tara , Carty Fiona , Crowe Morgan , Dolan Eamon , Fagan Eimear , Grech Reuben , Harbison Joseph , Horgan Gillian , Kavanagh Eoin , Murphy Sean , Noone Imelda , ORourke Killian , Sheehan Orla , Thornton John , Whelan Clodagh , Williams David , Fitzgibbon Maria
Published: July 2021

Background:
In suspected TIA, DWI hyperintensity confirms the diagnosis of brain ischemia and identifies those with 3-fold risk of early recurrent stroke. However, immediate MRI is expensive and may not be available in many healthcare settings. A simple validated blood test to objectively support the diagnosis of cerebral ischaemia after transient symptoms might have utility in clinical practice. We hypothesised that blood markers of inflammation may be associated with abnormal DWI following TIA.

Methods:
BIO-TIA was a multi-centre prospective study of consecutive patients with clinically-defined TIA, confirmed by a stroke physician. Phlebotomy and stroke protocol MRI were performed within 72 hours of symptoms. Patients with malignancy, active infection, trauma, surgery, definite transient non-ischaemic symptoms or recurrent stroke before phlebotomy/MRI were excluded. Plasma high-sensitivity CRP and interleukin-6 (IL-6) were measured by mass spectrometry.

Results:
In 201 included patients, mean age was 68 years (59% male). Carotid stenosis was present in 26.4% and atrial fibrillation in 29.1%. Mean ABCD2 score was 4.2 (SD 1.3). Acute DWI hyperintensity was observed in 37.8% (76/201). Median hsCRP was 1.78mg/L in DWI-negative, compared with 3.01mg/L in DWI-positive TIA (p=0.04). Median IL-6 was 3.76pg/ml (DWI-negative) versus 4.91pg/ml (DWI-positive) (p=0.04). When the highest quartiles of CRP and IL-6 distributions were compared with quartiles 1-3, the prevalence of DWI hyperintensity was 61.5% (Q4) versus 32.9% (Q1-3) for CRP (p=0.001), and 56.4% (Q4) versus 34.9% [Q1-3) for IL-6 (p=0.02). Thresholds of 4.78mg/L for CRP or 6.21pg/ml for IL-6 had at least 80% specificity for identification of abnormal DWI signal. IL-6 was associated with CRP (rho 0.58), age (rho 0.36), and ABCD2 score (rho 0.18) and carotid stenosis (p≤0.01 for all), but not statin use.

Conclusion:
Our preliminary findings require validation, but suggest that inexpensive, rapidly-measured blood markers are associated with acute DWI hyperintensity after TIA. If validated, blood markers may have utility to support the diagnosis of cerebral ischemia or select patients for early MRI.
Abstract W P354: Effect of Free Fatty Acid on Recurrent Stroke in Stroke Patients With Atrial Fibrillation
Authors: Seo Woo-Keun , Choi Jeong-Yoon , Jung Jin-Man , Cho Kyung Hee , Oh Kyungmi
Published: July 2021

Background:
Although free fatty acid (FFA) has been considered to have a link with atherosclerosis, recently, an association between FFA and atrial fibrillation was reported. In this study, we tried to determine whether FFA could be associated with recurrent stroke in stroke patients with atrial fibrillation.

Methods:
Retrospective analyses of 279 stroke patients who had atrial fibrillation from multicenter hospital-based stroke registry. We examined the effect of FFA on recurrent stroke using survival analysis.

Results:
Twenty-two patients had recurrent stroke (7.9%) during the study periods (mean follow-up duration 16.7 months). The baseline plasma FFA concentration was significantly higher in patients with recurrent stroke (1.54 ± 0.81 mEq/L 1.54 ± 0.81 mEq/L) than those without recurrent stroke (1.09 ± 0.76 mEq/L). In Cox’s survival analysis, plasma FFA concentration (mEq/L) was significantly associated with recurrent stroke in univariate model (HR 1.521, 95% CI 1.094 - 2.114) and model after adjustment for CHADS2 score (HR 1.509, 95% CI 1.056 - 2.156).

Conclusion:
The present study suggested that elevated FFA concentration could be indicator for recurrent stroke in stroke patients with atrial fibrillation.
Abstract W P5: “No Turn Back Approach” to Reduce Treatment Time for Endovascular Treatment of Acute Ischemic Stroke
Authors: Qureshi Adnan I , Egila Hossam , Adil Malik M , Siddiqi Harris , Mian Nidaullah , Hassan Ameer E , Miley Jefferson T , Rodriguez Gustavo J , Suri M Fareed K
Published: July 2021

Background:
A delay in endovascular treatment is less likely if acute ischemic stroke patients proceed from emergency department(ED) to computed tomographic (CT) scanner and directly to angiographic suite (no turn back approach). We determined the feasibility of the “no turn back approach” and its effect on treatment times and patient outcomes.

Methods:
The primary outcomes were procedures performed with a time interval: 1) between ED arrival and microcatheter placement of <120 minutes; and 2) between CT scan acquisition and microcatheter placement of <90 minutes. We determined the affect of the “no turn back approach” on favorable outcome at discharge.

Results:
There was a significantly higher rate of CT scan acquisition and microcatheter placement time of <90 minutes in patients in whom “no turn back approach” was used (57.6% versus 31.6%, p=0.0007). There was a significantly higher rate of ED arrival to microcatheter placement time of <120 minutes in patients in whom “no turn back approach” was used (31.8% versus 13.7%, p=0.004). In the exploratory analysis, there was a trend towards higher rate of favorable outcomes (OR 1.6, 95% CI 0.9-2.8, p=0.07) among those treated with “no turn back approach” after adjusting for age, admission National Institutes of Health Stroke Scale (NIHSS) score strata, congestive heart failure and diabetes mellitus.

Conclusions:
The “no turn back approach” appeared to be feasible and reduced the time interval between ED arrival and microcatheter placement in acute ischemic stroke patients undergoing endovascular treatment.
Abstract W P52: Combination Argatroban and TPA for Acute Ischemic Stroke: A Matched Case-Control Analysis
Authors: Barreto Andrew D , Mandava Pitchaiah , Guerrero Waldo , Shen Loren , Grotta James C , Kent Thomas A
Published: July 2021

Background and Objective:
Thrombin inhibitors such as Argatroban in combination with full-dose IV-tPA are currently being tested in a series of clinical trials for acute ischemic stroke. A single-arm, phase IIa study (ARTSS-1) of 65 patients treated with low-dose Argatroban + IV-tPA in either the 3 or 4.5 hour treatment window demonstrated an overall sICH rate of 4.6% and 40% complete recanalization within 2-hours. The objective of the study was to assess safety in a matched group of IV-tPA alone patients.

Methods:
pPAIRS
©
performs a post-hoc Euclidean matching of subjects on factors of choice and excludes outliers when no close match is found. We applied these techniques to compare outcomes of Argatroban+tPA treated subjects from ARTSS-1 with tPA treated subjects from NINDS. Matching factors were NIHSS, age, glucose, race, gender, hemisphere, and subtype. Outcomes were sICH, death and mRS 0-1, 0-2 at day 7 and 90.

Results:
Of the 65 Argatroban+TPA patients, 55 and 44 had good NINDS matches at day 7 and 90, respectively. Rates of sICH were identical at both day 7 and 90 between ARTSS-1 and NINDS (3.6% and 2.3%). Mortality was not significantly different (5.5% vs. 3.6% at day 7; p=1.00; and 11.4% in each group at day 90). There was a non-significant trend for higher percent of mRS 0-1 (36.4% vs. 32.0%, p=0.814) and 0-2 (47.7% vs. 43.2%, p=0.823) at day 90 in the ARTSS-1 patients that was not present at day 7. The mRS 0-2 trend remained after excluding ARTSS-1 patients treated with tPA between 3-4.5 hours (see table).

Conclusion:
There is no evidence for significantly increased mortality or symptomatic hemorrhage after addition of low dose Argatroban compared to a NINDS population with similar baseline characteristics particularly in those tPA-treated within 3 hours. A non-significant trend emerged at 90 days for 14% relative improvement in functional outcomes. A larger, Phase IIb, randomized trial (ARTSS-2) is ongoing to determine whether these trends reflect a true treatment effect.
Abstract W P71: Co-Prevalence and Rupture Rate of Brain and Aortic Aneurysms: Single Center Experience
Authors: Jiang Boxiang , Ball Benjamin Z , Gaughen John R , Southerland Andrew M , Worrall Bradford B
Published: July 2021

Introduction:
Rupture of intracranial aneurysm (IA) and abdominal aortic aneurysm (AAA) has devastating consequences. Research shows that IA and AAA share genetic risk factors. We performed a single center clinical record review to identify and characterize a patient population that harbors both IA and AAA.

Method:
We searched the Clinical Record Repository of the University of Virginia Health System. IA and AAA were identified by the ICD-9 code primary or secondary diagnoses: IA (any of 437.3, 747.81 and 430) and AAA (any of 441.0, 441.00, 441, 441.02, 441.3, 441.03, 441.5, 441.6, 441.7 and 441.9). The IA-AAA population was defined by both IA and AAA diagnosis, and characterized by ruptured IA (430) or ruptured AAA (any of 441.0, 441.00, 441.01, 441.02, 441.03, 441.3, 441.5 and 441.6).

Results:
We identified 129 individuals with both IA and AAA, of which 75 (58%) are men. The mean age of the population is 67.6 (±12.4) and the median age is 70 [IQR=60, 77]. The mean age for men is 68.5 (±11.7) and median is 71 [IQR=62, 77]. The mean age for women is 66.2 (±13.5) and median is 68 [IQR=58.5, 76]. The racial make-up is 112 (86.8%) White, 12 (9.3%) Black, 2 (1.6%) Asian, 1 (0.8%) Hispanic, and 2 (1.6%) other. Reported comorbidities include hypertension 100/129 (77.5%), cardiac arrhythmias 63/129 (48.8%), and diabetes 31/129 (24%). Thirty (23%) have documented tobacco use.

Rupture occurred in 98 individuals: 54 (44.2%, 29 men) ruptured IA; 32 (24.8%, 16 men) ruptured aortic aneurysm (AA); 12 (9.3%, 4 men) ruptured both IA and AA. Mortality is 40.3% (52 patients): 18 died in hospital, 8 died within 30 days of discharge, 6 died in 31-90 days, 4 died in 91 days-1 year, 3 died in 2-3 years and 9 died beyond 3 years.

Conclusion:
This first attempt to characterize a population with both IA and AAA suggests an especially high risk for aneurysmal rupture, although likely limited by selection bias. Prospective screening for co-prevalence of IA and AAA is necessary to further characterize this high-risk population.
Abstract 110: Thrombospondin Type-1 Domain-Containing Protein 1 (THSD1), an Intracranial Aneurysm Susceptibility Gene, Mediates Cell Adhesion in Human Umbilical Vein Endothelial Cells
Authors: Fang Xiaoqian , Kim Dong H , Santiago-Sim Teresa
Published: July 2021

Introduction:
An intracranial aneurysm (IA) is a weak spot in cerebral blood vessel wall that can lead to its abnormal bulging. Previously, we reported that mutations in
THSD1
, encoding thrombospondin type-1 domain-containing protein 1, are associated with IA in a subset of patients. THSD1 is a transmembrane molecule with a thrombospondin type-1 repeat (TSR). Proteins with TSR domain have been implicated in a variety of processes including regulation of matrix organization, cell adhesion and migration. We have shown that in mouse brain Thsd1 is expressed in endothelial cells.

Hypothesis:
THSD1 plays an important role in maintaining the integrity of the endothelium by promoting adhesion of endothelial cells to the underlying basement membrane.

Methods:
Human umbilical vein endothelial cells are used to investigate the role of THSD1
in vitro
. THSD1 expression was knocked-down by RNA interference. Cell adhesion assay was done on collagen I-coated plates and focal adhesion formation was visualized using immunofluorescence by paxillin and phosphorylated focal adhesion kinase (pFAK) staining. THSD1 re-expression is accomplished by transfection with a pCR3.1-THSD1-encoding plasmid.

Results:
Knockdown of
THSD1
caused striking change in cell morphology and size. Compared to control siRNA-treated cells that exhibited typical cobblestone morphology, THSD1 knockdown cells were narrow and elongated, and were significantly smaller (
p
<0.01). Cell adherence to collagen I-coated plates was also attenuated in THSD1 knockdown cells (
p
<0.01). Consistent with this finding is the observation that the number and size of focal adhesions, based on paxillin and pFAK staining, were significantly reduced after THSD1 knockdown (
p
<0.01). These defects in cell adhesion and focal adhesion formation were rescued by re-expression of wild type THSD1 (
p
<0.05). In contrast, initial studies indicate that expression of mutated versions of THSD1 as seen in human patients (L5F, R450*, E466G, P639L) could not restore cell adhesion and focal adhesion formation to wild type levels.

Conclusions:
Our studies provide evidence for a role of THSD1 and THSD1 mutations in endothelial cell adhesion and suggest a possible mechanism underlying
THSD1
-mediated aneurysm disease.
Abstract 140: High Intensity Signals on Mip Images of Carotid Atherosclerotic Plaques Detected by Routine Three Dimensional Magnetic Resonance Angiography Are Associated With Ischemic Strokes
Authors: Yamada Kiyofumi , Kawasaki Masanori , Yoshimura Shinichi , Nakahara Shigehiro , Sato Yoshikazu
Published: July 2021

Background:
Carotid artery stenosis is one of the major causes of ischemic strokes. Carotid intraplaque hemorrhage (IPH) has been associated with accelerated plaque growth, luminal narrowing and development of symptomatic events. Maximum intensity projection images are easily reformatted from four to five minute, routine, clinical TOF sequences. The aim of this study was to evaluate the relationships between high intensity signal (HIS) in carotid plaques on MIP images detected by routine three dimensional magnetic resonance imaging (3D-TOF MRA) and ischemic strokes.

Materials and Methods:
Sixty patients with carotid stenosis ≥ 50% (North American Symptomatic Carotid Endarterectomy Trial criteria) were included. Carotid IPH was defined as the presence of HIS in carotid plaques on MIP images detected by 3DTOF MRA using the criteria previously we reported. We analyzed the relation between the presence of HIS in the plaques and prior ischemic strokes defined as ischemic lesions on diffusion weighed images of the brain.

Results:
HISs in carotid plaque were present in 27 (44%) of 61 carotid arteries in 60 patients. Prior ipsilateral ischemic strokes occurred more frequently in HIS positive group (17 of 27, 63%) than HIS negative group (3 of 34; 9%) [p<0.001]. In multivariate logistic regression analysis, HIS was the only independent predictor of prior ischemic strokes after being adjusted by age, cardiovascular risk factors, degree of stenosis and history of ischemic heart disease [Odds ratio: 23.0 (95%CI: 5.1 - 103.1), p<0.001].

Conclusions:
HISs in carotid plaques on 3DTOF-MRA MIP images are the only independent determinant of prior ischemic strokes, and they can potentially provide a reliable risk stratification of carotid plaques.
Abstract 161: Safety of Intravenous Thrombolysis in Wake-up Stroke: A Multicenter, Prospective, Open-label Study
Authors: Barreto Andrew D , Fanale Christopher V , Alexandrov Andrei V , Sands Kara A , Gaffney Kevin C , Vahidy Farhaan S , Navalkele Digvijaya D , Tremont Chad C , Hamilton Robert K , Nguyen Claude B , Sarraj Amrou , Lopez George , Gonzales Nicole R , Misra Vivek , Wu Tzu-Ching , Martin-Schild Sheryl , Grotta James C , Savitz Sean I
Published: July 2021

Background and Objectives:
A significant number of ischemic strokes are noticed upon awakening and are not candidates for intravenous recombinant tissue plasminogen activator (rtPA) due to >3 hours from last seen normal (LSN). We tested the safety of rtPA in a multicenter, single-arm, prospective, open-label study (NCT01183533) of rtPA in patients with wake-up stroke (WUS).

Methods:
We aimed to enroll 40 WUS patients with disabling deficits. Patients were 18-80; NIHSS ≤25; and selected only on the appearance of non-contrast CT (i.e., <1/3 MCA territory hypodensity). Standard dose (0.9mg/kg) intravenous rtPA had to be started ≤3 hours of awakening. The primary safety outcome was symptomatic intracerebral hemorrhage (ICH) with pre-planned stopping rules and data safety board oversight. Other endpoints included: asymptomatic ICH, clinical improvement in NIHSS and 90-day modified Rankin Scale score (mRS).

Results:
Between 10/2010 and 10/2013, all pre-planned patients were enrolled. Four patients (10%) were subsequently determined to be mimics. Baseline characteristics, treatment and outcome data are shown in the table. No symptomatic ICH or parenchymal hematomas occurred.

Conclusion:
Intravenous thrombolysis appears to be safe in WUS patients selected by non-contrast CT. A randomized effectiveness trial appears feasible using a similar, pragmatic design.
Abstract 224: Increased Total Homocysteine Levels Are Associated With the Risk of Dementia Independently of Cerebral Small-vessel Disease
Authors: Miwa Kaori , Okazaki Shuhei , Yagita Yoshiki , Sakaguchi Manabu , Mochizuki Hideki , Kitagawa Kazuo
Published: July 2021

Objectives:
Increased serum total homocysteine (tHcy) levels have been associated with not only vascular injury but also dementia. However, given an association between Hcy and vascular injury, such as cerebral small-vessel disease (SVD) or renal impairment, to what extent Hcy would impact future dementia beyond these confouders is unknown. We assessed the predictive value of tHcy levels with the risk of dementia in patients with vascular risk factors, when controlling for the MRI-findings and renal imapirment.

Methods:
Within a Japanese cohort of partients with vascular risk factors in an observational study from 2001, we evaluated the association between tHcy levels at baseline, defined as a continuous variable (per 1 μmol/L) and as a categorical variable (the tertile of tHcy), the prevalence of MRI-findings, and incident all-cause dementia during follow-up. Baseline brain MRI was used to determine SVD (lacuna, white matter hyperintensities and cerebral microbleeds [CMBs]) and atrophy (medial-temporal lobe atrophy). Cox proportional hazards analyses were performed for predictors of dementia adjusting for age, sex, APOEε4 allele, educational level, cerebrovascular events, estimated glomerular filtration rate (eGFR), vascular risk factors, and MRI-findings.

Results:
Of the 643 subjects (mean:67.2±8.4years, male:59%, 12.9±2.6years of schooling), in multivariable analyses adjusted for age, sex, hypertension, cerebrovascular events, eGFR, and intima-media thickness, the highest tHcy tertile (vs lowest) were associated with lacuna, CMBs and strictly deep CMBs, respectively. During the mean 7.3-year follow-up (range:3-13), 47 incident dementia patients (Alzheimer’s disease:24; vascular dementia:18; mixed-type:3; other:2) were diagnosed. In multivariable analyses adjusted for age, sex, cerebrovascular events, eGFR, and MRI-findings, tHcy level or the highest tertile of tHcy for all-cause dementia remained significant, respectively (relative risk [RR]1.09: p=0.02, RR;2.59: p=0.021).

Conclusions:
Our results provide additional evidence of Hcy that leads to increased susceptibility to the risk of dementia, suggesting that this association may be mediated by independent mechanisms.
Abstract NS26: Pre-hospital Stroke Evaluation Using Expanded Stroke Screening Tools
Authors: Hamm Theresa , Helland Brian
Published: July 2021

Background and Purpose:
The Cincinnati Pre-Hospital Stroke scale is a quick and accurate method for identifying stroke in the EMS setting. In 1999, Kothari et. al. demonstrated that the Cincinnati Pre-Hospital Stroke Scale (CPSS) identified 87% of acute anterior circulation strokes. We hypothesize that adding additional criteria from the NIH Stroke Scale to the CPSS will increase EMS providers’ ability to recognize stroke syndromes beyond anterior circulation strokes in the EMS setting.

In Iowa, current EMS protocols use the CPSS for field stroke examinations as a minimum standard. The addition of additional elements from the NIH Stroke Scale that specifically evaluate posterior circulation should improve stroke recognition in the field. The Miami Emergency Neurological Deficit exam (MEND) specifically meets these criteria: it is based on the CPSS, and adds elements of the NIHSS that evaluate posterior circulation. This should allow EMS providers to triage and transport more patients to a primary stroke center.

Methods:
A retrospective chart review was done within a 22 month period at a Joint Commission Certified Primary Stroke Center. Only patients with confirmed diagnosis of stroke were included; TIA and all other diagnoses were excluded. Patient symptoms were listed and the exam criteria for both the CPSS and MEND were applied. The vascular distribution of stroke for each patient was evaluated to confirm results. Results: 732 patients presented in the 22 month period. 468 (64%) were identified using CPSS criteria.644 (88%) were identified using MEND criteria. This results in an increase of 176 (24%) patients who would have been recognized as experiencing an acute stroke using the MEND exam.

Conclusion:
Use of an expanded stroke exam by EMS providers will result in a higher recognition rate for anterior and posterior circulation acute stroke.
Abstract NS4: Challenges and Lessons Learned in an Ongoing Randomized Controlled Trial to Test the Effectiveness of a Multicomponent Intervention in Improving Delirium Outcomes in Acute Stroke
Authors: Rice Karen L , Bennett Marsha , Berger Linley , Jennings Bethany , Barry Erin , Egger Raymond , Eckhardt Lynn , Lacoste Nicole , Mathew Sheena , Ryan Stephanie , Vidal Gabriel , Gropen Toby , Houghton David , Diggs Erica , Tiley John , St. John Jennilee , Egger Allison , Galarneau David , Gaines Kenneth , Ely E. Wesley
Published: July 2021

Delirium in acute stroke has higher morbidity and mortality than those without delirium. This two-group randomized controlled trial (RCT) tests if a multicomponent intervention improves delirium outcomes in stroke patients at a comprehensive stroke center. This presentation describes the challenges in managing a RCT in acute stroke. Scientific rigor requires coordinating staff, enrolling adequate sample size, assuring intervention fidelity, and fostering data integrity. A sample of 282 subjects is required for 80% power (α=0.05) to determine a 10% reduction in incident delirium. Eligibility includes acute stroke, aged ≥ 50 years, no aphasia or delirium on admit. Subjects randomized to Usual Care (UC) or Delirium Care (DC). Both groups receive standardized Stroke Care. DC subjects receive a multicomponent intervention: 1) pharmacist recommendations using Anticholinergic Drug scale scores; and 2) therapeutic activities. NIHSS, Montreal Cognitive Assessment (MoCA), Confusion Assessment Method (CAM), and mRS are used to determine primary (delirium) and secondary endpoints (LOS, neurological deficit, functional status). A total of 513 patients screened over 289 consecutive days required unbudgeted staff. The 310 excluded [aphasia (94), baseline delirium (36), critically ill (92), LOS <2 days (69), other causes (19)] unexpectedly impacted enrollment. Of eligible, 66% (133/203) consented; UC (n=65), DC (n=68). Hospital volunteers engaged DC subjects in therapeutic activities twice daily, including holidays. Two pharmacists independently made recommendations for each group. Outcome data were validated at daily rounds. Stroke-related cognitive dysfunction required more time than norm to complete the MoCA. Both the CAM and team consensus was used to confirm delirium. Lessons learned: 1) study staff attending rounds was key to enrollment, intervention fidelity, and data integrity; 2) securing a pool of on-call volunteers to sustain therapeutic activities was required; and 3) additional and unanticipated resources were needed. In conclusion, successful conduct of a RCT in acute stroke patients requires a dedicated well-trained study staff 7 days a week, including holidays.
Abstract T MP103: Effect of Follow-up Phone Calls on 30-day Readmission Rates for Stroke Patients
Authors: Anderson Kelly
Published: July 2021

Background and Purpose:
Patients who are hospitalized for a stroke or TIA go home with a great deal of information about risk factors, medications, diet and exercise, signs and symptoms of stroke and follow-up care. This information may be difficult for the patient or caregiver to understand and can be overwhelming in the face of a new life-changing event. In addition, The Centers for Medicare and Medicaid Services will start publicly reporting 30-day readmission rates beginning in 2016. The purpose of this study is to determine if follow-up phone calls with a nurse help to reduce 30 day readmission rates for patients with stroke and TIA.

Methods:
This study utilized a convenience sample of adult patients who were admitted for ischemic stroke, ICH, SAH or TIA from March 2013 to February 2014. Patients in the intervention group participated in a phone call seven days after discharge to assess their compliance with medications, physician appointments and lifestyle changes. The proportion of readmissions between the groups was compared with Fisher’s exact test.

Results:
The total number of patients enrolled in the study was 586 and there were no significant differences in demographics between the control and intervention groups. Of the 533 patients in the control group, 54 (10%) of them were readmitted, including 11 patients readmitted for elective surgical procedures. Of the 52 patients in the intervention group, 3 (5.7%) of them were readmitted before the 7-day phone call. Of the 49 patients who participated in the 7-day phone call, none of them were readmitted (
p
=0.0098).

Conclusions:
Patients who participate in a 7-day phone call appear to benefit and are less likely to be readmitted to the hospital. Other strategies may need to be considered for patients who are at higher risk, and thus more likely to be readmitted within seven days of discharge. In addition, some providers may wish to reconsider how they schedule elective procedures for secondary stroke prevention.
Abstract T MP113: Mortality after Gastrointestinal Hemorrhage in Patients taking Dabigatran and Warfarin
Authors: Vaughan Sarrazin Mary , Mazur Alexander , Cram Peter , Jones Michael P , Chrischilles Elizabeth
Published: July 2021

Background:
Clinical trial data suggest greater likelihood of gastrointestinal (GI) bleeding for patients taking dabigatran 150 mg compared to warfarin, and similar likelihood for patients taking dabigatran 75 mg. Dabigatran-associated GI bleeding is concerning because no antidote exists to reverse the effects of dabigatran, possibly increasing the likelihood of death.

Objective:
Examine mortality after GI bleeding for patients taking warfarin, dabigatran 150mg, or dabigatran 75mg.

Method:
We used Medicare inpatient, carrier, and pharmacy claims for beneficiaries age 65 or older with new atrial fibrillation from 11/2010 through 12/2011 who received dabigatran 150mg, dabigatran 75mg, or warfarin. GI bleeds were identified by the primary diagnosis on inpatient claims, and death dates were determined from the CMS enrollment file.

Patient demographics, comorbid conditions, and prior health service use were determined from claims incurred during the 12 months prior to the GI bleed. Each patient taking dabigatran 150 mg or 75 mg was matched to a single patient taking warfarin based on patient characteristics at the time of the bleed using an optimal propensity matching algorithm.

Results:
Of 2,889 GI bleeding events, 2326 (81%), 465 (16%), and 98 (3%) occurred in patients taking warfarin, dabigatran 150 mg, and dabigatran 75 mg, respectively. Compared to patients taking warfarin, patients on dabigatran 150mg were less likely to have renal disease, heart failure, or previous GI bleed, and had fewer previous inpatient days of care. In contrast, patients on dabigatran 75 mg were older and more likely to have renal disease, heart failure, or previous GI bleed compared to patients taking warfarin. The unadjusted 30-day mortality rate was 5.3%, 6.5%, and 8.1% for patients taking warfarin, dabigatran 150 mg, and dabigatran 75 mg and did not differ significantly by anticoagulant type. In the propensity-matched samples, mortality was similar for patients taking dabigatran 150 mg compared to warfarin (6.6% vs. 5.5%; p=0.49), and dabigatran 75 mg compared to warfarin (8.2% vs. 5.1%; p=0.39).

Conclusions:
Death after GI bleeding does not differ for patients taking dabigatran or warfarin, despite the lack of antidote for dabigatran.
Abstract T MP44: Secondary Stroke Prevention Prescribing in a National Cohort
Authors: Albright Karen , Boehme Amelia K , Howard Virginia , Howard George , Judd Suzanne , Rhodes David , Anderson Aaron , McClure Leslie , Safford Monika , Limdi Nita , Blackburn Justin
Published: July 2021

Background and Purpose:
Secondary stroke prevention medications (SSPs) have been shown to prevent recurrent stroke, but few national reports of prescribing SSPs are available from hospitals regardless of their participation in national quality improvement programs. We examined SSP prescribing at discharge following hospitalization for adjudicated incident ischemic stroke (IS) in a large national cohort and unselected hospitals.

Methods:
We performed a retrospective review of incident IS admissions within the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort; admissions were to unselected hospitals. Exclusions were history of stroke, hospital death, missing data, and prevalent use of the medication of interest. Race, sex, age, rurality of residence (as defined by Rural Urban Commuting Area codes) were obtained at REGARDS baseline. Admission and discharge medications were obtained from hospital records. Associations between characteristics and discharge SSP prescriptions were examined using logistic regression adjusting for race, age, sex, and rurality.

Results:
From 2003-2011, of 657 IS, 429 met inclusion criteria. Mean age of participants was 73 (42% Black, 49% female, 27% non-urban). Antithrombotic therapy (antiplatelet/anticoagulant) was prescribed for 87%, statins 36% (10% 80mg), and ACE-I/ARB for 16%. We observed no statistically significant differences in prescribing antithrombotics or statins by race, sex, age, or rurality. Participants in non-urban areas had lower odds of ACE-I/ARB at discharge (OR 0.38, 0.15-0.98), with no differences by race, sex, or age.

Conclusions:
The majority of participants with incident IS within REGARDS were newly prescribed antithrombotics at discharge but alarmingly few were newly prescribed statins or ACE-I/ARBs. Our findings among incident SSP users differ from previous reports among prevalent users within hospitals participating in a national quality improvement program. More studies of quality of care after IS at unselected hospitals are needed.
Abstract T MP57: Coexisting Cerebrovascular Disease and Risk of Occult Atrial Fibrillation in Patients With Embolic Stroke of Undetermined Source
Authors: Rojo Esther , Sandín-Fuentes María , Calleja Ana I , Largaespada Gabriel , Cortijo Elisa , García-Morán Emilio , Ruiz-Piñero Marina , García-Bermejo Pablo , López-Mesonero Luis , Rubio Jerónimo , Arenillas Juan F
Published: July 2021

Background and objective:
Secondary prevention after embolic stroke of undetermined source (ESUS) remains a clinical problem. Presence of asymptomatic cerebral large-artery atherosclerosis or small vessel disease could be aprioristically taken as an indicator of a lower risk for an occult cardiac source of emboli, thus influencing our secondary prevention strategy. We aimed to study the relationship between presence and degree of coexisting cerebrovascular disease and the risk of occult paroxysmal atrial fibrillation (OPAF) in ESUS patients.

Methods:
Longitudinal prospective study in patients fulfilling ESUS criteria after complete neurovascular and cardiac diagnostic workup, who were implanted with a subcutaneous REVEAL-XT loop-recorder to detect OPAF and followed-up for≥ 6 months. At baseline, cerebral large-artery atherosclerosis was assessed with cervical and transcranial ultrasound. Brain magnetic resonance imaging was used to evaluate small vessel disease. Periventricular (PV) and subcortical (SC) white matter hiperintensities (WMH) were categorized using the Fazekas score.

Results:
We studied 136 ESUS patients from October 2010 to December 2013 (71 men, mean age 67), who were followed-up for a mean time of 594 days. OPAF was detected in 56 (41%) of them. No relationship was found between extracranial or intracranial atherosclerosis and OPAF. Kaplan-Meier curves and crude Cox-regression analyses found associations between OPAF risk and age, smoking, CHA2DS2VASC score, presence of lacunar infarctions, and presence and degree of PVWMH & SCWMH. A multivariable-adjusted Cox regression model identified grade 2-3 PVWMH (HR 3.6, [2.0-6.5], p<0.001) and age as independent predictors of OPAF.

Conclusion:
Coexisting small vessel disease, specifically in the form of periventricular WMH, is a predictor of OPAF in ESUS patients. Presence of large-artery atherosclerosis does not lower the risk for OPAF. Therefore, OPAF should be actively pursued in ESUS patients regardless the coexistence of asymptomatic cerebrovascular disease.
Abstract T MP74: The Diagnosis, Etiologic Classification, and Safe Discharge of Ischemic Strokes with Transient Symptoms from an Emergency Department Observation Unit
Authors: Siket Matthew S , Ndon Idara U , Baird Janette R , Madsen Tracy E , Merck Lisa H , Napoli Anthony M , Paolucci Gino , Seigel Todd A , Tran Virginia M , Silver Brian
Published: July 2021

Background:
Patients with a clinical diagnosis of transient ischemic attack (TIA) who have imaging evidence of infarction portend a high risk of short-term recurrent stroke. Emergency Department Observation Units (EDOU) offer an alternative to hospital admission and are becoming increasingly utilized for acute cerebrovascular emergencies.

Hypothesis:
We sought to determine whether an EDOU protocol emphasizing etiologic determination and individualized secondary prevention could be a safe alternative to hospital admission for suspected TIA patients with and without brain infarction.

Methods:
We prospectively studied 189 patients admitted to the TIA EDOU of a single tertiary care academic medical center. There was no ABCD2 cutoff for eligibility and exclusion criteria included persistent deficits or another diagnosis warranting hospitalization. Patients underwent DW-MRI/MRA of the head and neck unless contraindicated, transthoracic echocardiogram and bedside neurologist evaluation. Etiologic subtyping was determined using the Causative Classification System (CCS). 30-day follow-up was performed on all patients by telephone and/or review of medical records. This study was approved by the hospital IRB.

Results:
Acute ischemic stroke was diagnosed in 31 (16%) of patients, including 30 with DWI lesions and 1 in whom MRI was contraindicated, but had clinical worsening while in the EDOU. An evident or probable etiology was determined by CCS subtyping in 38% of strokes and 32% of TIAs (17% atherosclerosis, 12% cardioembolism, 5% small vessel). Of the total cohort, 84% were discharged from the EDOU including 16 (52%) with confirmed stroke. Median LOS was 22 hours (IQR: 17-25). At 30 days, one patient was found to have a small recurrent stroke (0.7%). There was 1 non-stroke related death. Twenty (11%) overall returned to the ED, the vast majority (70%) from the non-stroke cohort.

Conclusions:
Not all ischemic stroke patients require hospitalization. An EDOU is a safe and effective alternative for the complete diagnostic evaluation and management of patients with transient neurologic symptoms. Further study of cost and quality effectiveness in warranted.
Abstract T MP80: Comparison of ICD-9-CM and Clinical Diagnoses for Stroke Patients in the Paul Coverdell National Acute Stroke Registry, 2013
Authors: Chang Tiffany E , George Mary G
Published: July 2021

Background:
Few large studies have examined the comparison of ICD-9-CM codes and clinical diagnoses (CDX) for acute stroke patients. We analyzed the concordance between these two coding systems for patients entered in the Paul Coverdell National Acute Stroke Registry (PCNASR). We hypothesized that discordance between patient-level ICD-9-CM codes and clinical diagnoses will result in differences in outcomes on stroke performance measures (PMs).

Methods:
Eleven states submitted 90,035 records between Jan 1 and Dec 31, 2013. In-hospital strokes and records with multiple or missing CDXs were excluded from the analysis, resulting in a final sample size of 85,024. Clinical diagnoses were defined as: ischemic stroke (IS), transient ischemic attack (TIA), subarachnoid hemorrhagic stroke (SAH), intracerebral hemorrhagic stroke (ICH), stroke not specified (SNS), admission for carotid intervention only (CI), and other. Data was analyzed by comparing the documented principal ICD-9-CM code and final CDX of each patient. Any discordance between ICD-9-CM codes and CDX was analyzed further by examining its effect on outcomes of ten stroke performance measures (PMs) collected by PCNASR.

Results:
The agreement rate between ICD-9-CM codes and clinical diagnoses differs by stroke type (94.1% (IS) to 1.6% (SNS)) (Table 1). Discordance in diagnosis led to differences in outcomes on stroke PMs (range: difference of 0.1-1.03 percentage points; p-value < 0.05 for 5 measures), with 8 out of the 10 PMs having improved performance when ICD-9-CM codes are used (data not shown). Using only cases where the CDX is the same as the ICD-9-CM results in even higher adherence to PMs.

Conclusion:
In conclusion, due to discrepancies between ICD-9-CM codes and clinical diagnoses, outcomes on stroke PMs can vary significantly, depending on the diagnosis method used.
Abstract T P119: Challenges Associated with Access to Stroke Rehabilitation for Patients with Cognitive Impairment in Toronto
Authors: Linkewich Elizabeth , Tahair Nicola , Donald Michelle , Quant Sylvia
Published: July 2021

Background:
Cognitive Impairment (CI) affects up to 60% of stroke survivors and is associated with poorer recovery and decreased function. Toronto clinicians report limited access to inpatient rehabilitation for stroke patients with CI.

Purpose:
To inform system planning that aligns with best practice for stroke patients with CI, the Toronto Stroke Networks examined: 1) access to inpatient rehabilitation services for stroke patients with CI; 2) facility differences with respect to referral decisions; and 3) the frequency of documented standardized cognitive screening (SCS) in inpatient rehabilitation referrals.

Methods:
Data were abstracted from the E-Stroke Rehab Referral System for fiscal years 2012-2014. Initial high intensity rehabilitation (HIR) referrals for 5 rehabilitation facilities in Toronto were analyzed to examine: percentage of referrals accepted, declined, and declined due to CI, and percentage of referrals reporting SCS in referral documentation. These data were further stratified by facility. A survey of cognitive rehabilitation was completed across 6 rehabilitation facilities.

Results:
There are no cognitive rehabilitation services that cater specifically to stroke patients reported in Toronto. Of the total number of HIR referrals (n=5005), 68.3% of initial referrals were accepted and 18.2% declined. Of the declined referrals (n=910), 17.5% were declined due to CI with variability across the 5 rehabilitation facilities ranging from 0.6 to 46.5%. Further, when examining referrals that were pending a decision or declined due to CI (n=508), 78.5% (range 48-100%) of these referrals across, 10 referring acute care facilities, had no documented SCS.

Conclusions:
Stroke patients with CI do not have adequate or consistent access to stroke rehabilitation across sites within Toronto. Additionally, there is a lack of documented SCS in rehabilitation referrals, which could impact access to rehabilitation. This work will further inform educational initiatives that support increased access to inpatient rehabilitation for persons with stroke and CI.