bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 3490: Perfusion Defect Is Associated With Poor Prognosis Of Lacunar Infarction.
Authors: Park Jeong Jin , Ryoo Na-Young , Rha Joung-Ho , Park Hee-Kwon
Published: July 2021

Backgrounds:
Small subcortical infarctions are caused by lipohyalinosis and also by microatheroma and microembolism. However, it remained still unknown which clinical or radiological findings could be useful for prediction of long-term prognosis. We sought to find whether perfusion images are associated with long-term poor clinical status.

Methods:
We reviewed 197 patients who admitted from January, 2009 to January, 2011, and who had the lacunae(≤20mm) in the perforator territory of the middle cerebral artery on diffusion-weight MRI(DWI) within 3 days of onset. T2 weighted imaging and perfusion-weighted MRI(PWI) were evaluated in all participants. We divided the patients according to the existence of perfusion defect and analyzed the association between perfusion defect and poor outcomes, defined as modified Rankin score(mRS)≥3 at 3 months

Results:
Among a total 197 patients(69 Men; 63.8±11.2y), 78 subjects(52 Men; 62.4±12.1y) had the perfusion defect on PWI. The subject with perfusion defect had the higher frequency of current smoker(P=0.03) and poor outcomes at 3 months (P=0.002), compared to those without. There was no difference in other risk factors, infarct size or parent artery stenosis between two groups. Multivariate binary regression analysis showed that the perfusion defect was strongly associated with poor outcomes at 3 months(P=0.002;adjusted OR 4.21; adjusted 95% CI,1.73-10.28). The propensity score regression analysis also indicated that perfusion defect could predict the poor prognosis(Propensity score adjusted OR,3.88).

Conclusion:
Perfusion defect of small vessel disease seems to have the influence on the recovery after lacunae. Further study may be needed to find whether the PWI can be useful for diagnosing the various etiology of lacunae.
Abstract 35: 30-Day Risk-Standardized Mortality and Readmission after Ischemic Stroke in Critical Access Hospitals
Authors: Lichtman Judith H , Jones Sara B , Leifheit-Limson Erica C , Wang Yun , Goldstein Larry B
Published: July 2021

Background:
Critical access hospital (CAH) designation identifies hospitals providing emergency and inpatient care to residents of rural communities. Patients with cardiovascular disease and pneumonia have poorer outcomes at CAHs, but stroke outcomes have not been assessed.

Objective:
Compare risk-adjusted 30-day mortality and readmission rates after ischemic stroke for patients treated at critical access and non-critical access hospitals.

Methods:
The cohort included all fee-for-service Medicare beneficiaries 65+ years of age discharged with a primary diagnosis of ischemic stroke (ICD-9 433, 434, 436) in 2006. Risk-standardized mortality and readmission rates at 30 days were compared for patients treated at CAH versus other hospitals using hierarchical logistic regression models, adjusted for patient demographics, medical history, and comorbid conditions.

Results:
There were 10,267 ischemic stroke discharges from 1,165 CAHs and 300,114 discharges from 3,381 non-CAHs. Patients discharged from CAHs were older, more often women and white, and generally had more comorbid conditions. CAHs had higher unadjusted in-hospital (6.4% vs. 4.6%, p<0.001) and 30-day (19.9% vs. 10.9%, p<0.001) mortality rates than non-CAHs, but lower 30-day all-cause readmission (12.4% vs. 13.8%, p<0.001). In risk-standardized analyses, the differences were less marked for 30-day mortality (CAHs vs. non-CAHs; 11.9%±1.4% vs. 10.9%±1.7%, p<0.001), with no difference in 30-day readmission (13.7%±0.6% vs. 13.7%±1.4%, p=0.2787).

Conclusions:
Although there were no differences in readmission rates, stroke patients discharged from CAHs had higher unadjusted mortality than those discharged from non-CAHs. These differences, however, were at least partially explained by differences in patient characteristics. Further research is needed to identify factors contributing to these differences.
Abstract 3515: VEGF And Peroxynitrite Interplay Regulates Cerebral Angiogenic Mediators In Diabetes
Authors: Prakash Roshini , El-Remessy Azza B , Shenoy Somanath P , Fagan Susan C , Ergul Adviye
Published: July 2021

Background:
Diabetes targets micro and macrovascular endothelium differently leading to vascular complications. Although there are extensive studies on retinal and coronary neovascularization, little is known about cerebral neovascularization. Growing evidence suggests that reactive oxygen and nitrogen species such as peroxynitrite can interact in growth factor signaling and mediate VEGF’s angiogenic properties. This study tests the hypothesis that diabetes stimulates cerebral angiogenesis via activation of VEGF and matrix metalloproteases (MMP) in a peroxynitrite-dependent manner.

Methods:
Cerebral microvascular endothelial cells (CMEC) were isolated using immunomagnetic beads from control and diabetic Goto-Kakizaki (GK) rats. Cell proliferation, migration and tube formation assays were used as the indices of angiogenic potential. Protein expression and activity were determined using immunoblotting, slot blots and zymography techniques.

Results:
Angiogenic potential was pronounced in the diabetic group and significantly inhibited by peroxynitrite decomposition catalyst FeTPPS (2.5µM), MMP inhibitor minocycline (50µg/ml) and src kinase inhibitor PP2(1µM) compared to control. Diabetic endothelial conditioned media pronounced angiogenic potential in control CMEC while VEGF neutralizing antibody abrogated this response. Diabetes increased the expression of soluble VEGF A isoforms and activity of cognate receptors. Basal levels of phospho-c-src and peroxynitrite were also increased in the diabetic group. Secreted active MMP-2 and pro-MMP-2 was lower in diabetes while the cellular active MMP-2 and MT1-MMP was higher compared to control. VEGF (30ng/ML) stimulation activated its cognate receptor biophysically, dysregulated c-src activity and increased tyrosine nitration in diabetes. Peroxynitrite inhibition reduced VEGFR2, phosphor-c-src and MT1-MMP even in the presence of VEGF stimulation.

Conclusion:
Peroxynitrite interacts with VEGF signaling in diabetes and dysregulates c-src and MMPs. Understanding cerebral neovascularization mechanisms will not only open new paths towards developing therapeutic angiogenesis but also prevention of hemorrhagic complications of stroke. N=3-8
*
p≤ 0.05,
**
p≤ 0.005,
***
p≤ 0.001.
Abstract 3531: Clinical Outcomes Following Endovascular Stroke Treatment Facilitated via Telestroke Evaluation
Authors: Demel Stacie , Aghaebrahim Amin , Reddy Vivek , Hammer Maxim , Massaro Lori , Jumaa Mouhammad , Jovin Tudor , Wechsler Lawrence , Zaidi Syed
Published: July 2021

BACKGROUND:
Most stroke patients present to small community hospitals without established stroke pathways or interventional stroke treatment capability. The advent of 2 way audiovisual telestroke systems gives such patients the opportunity to be assessed rapidly by stroke neurologists. Patients who are not candidates for systemic IV tPA or have failed thrombolytic treatment can be identified and transferred to a comprehensive stroke center for potential endovascular treatment. We compared the clinical outcomes of patients undergoing endovascular stroke treatment at University of Pittsburgh Medical Center triaged either through telestroke or non-telestroke means.

METHODS:
Prospective data including demographics, co-morbidities, baseline Alberta Stroke Program Early CT (ASPECT) and National Institute of Health Stroke Scale (NIHSS) score, intervention modality (pharmacological, mechanical or both), time to treatment, clinical outcome, and hemorrhage and mortality rates were compared. Favorable outcome was defined as modified rankin score (mRS) of 2 or less.

RESULTS:
Between 3/2007 and 5/2011, thirty four patients underwent endovascular stroke treatment following telestroke evaluation versus 354 patients who were triaged through other means. Baseline characteristics were similar between the groups. Time to endovascular treatment (595 vs. 767 minutes; p = 0.5), pretreatment with systemic tPA (51.6 vs. 56.9%, p=0.6), recanalization (TIMI ≥ 2; 91.2% vs. 84.8%; p = 0.31), favorable outcome (modified rankin score ≤ 2; 50% vs. 40.4%; p = 0.29) and mortality rates (28.1% vs. 34.9%, p=0.44) were comparable. Multivariate logistic regression model identified young age (OR 0.91, CI 0.88-0.95, p<0.01), successful recanalization (OR 3.3, CI 1.8-6.2, p<0.01), and baseline ASPECT score (OR 6.5, CI 2.4-17.4, p<0.01) as predictors of favorable outcome.

CONCLUSION:
The results of this study suggest that telestroke guided endovascular stroke treatment is feasible and the outcomes are similar to those patients who were triaged by traditional means. Future randomized studies which specifically compare triage via telemedicine vs. telephone or direct emergency department presentation are needed to substantiate these findings.
Abstract 3563: Ischemic Stroke with Early AM Onset is More Severe but Less Frequent
Authors: Denny M. Carter , Albright Karen C , Boehme Amelia K , Beasley T. Mark , Martin-Schild Sheryl
Published: July 2021

Background:
Diurnal fluctuations in clotting factors, occurrence of thrombosis, and stroke have been reported. We sought to evaluate the distribution of stroke occurrence and differences in stroke characteristics and outcomes in a biracial population.

Methods:
Patients presenting to our center with acute ischemic stroke of known symptom onset were identified by retrospective chart review. Patients were grouped into one of four onset periods: 00:01-06:00, 06:01-12:00, 12:01-18:00, and 18:01-00:00. We compared demographics, baseline stroke severity, blood pressure and glucose levels, IV tPA treatment rates, stroke etiology, complications, and early clinical outcomes.

Results:
The 244 patients with a known time of onset were included in analyses; the distribution of stroke onset and comparison of other collected variables are demonstrated in the
figure
and
table
, respectively. Stroke onset 00:01-06:00 was less frequent, but associated with significantly higher median NIHSS score (p=0.005). Patients with stroke onset 00:01-06:00 were more often African-American, had atherothrombotic mechanisms (large artery or small artery infarctions), received IV tPA, and had reduced frequency of good mRS, though statistical significance was not achieved. Time interval of stroke onset was not an independent predictor of death, good outcome (mRS 0-2), or favorable discharge disposition (home or inpatient rehabilitation).

Discussion:
The most severe ischemic strokes occurred in early AM hours, but were less common than stroke onset during other time intervals. A larger sample is required to determine why ischemic stroke is more severe with early AM onset, if blacks are more susceptible to early AM stroke, and if early AM stroke is less responsive to tPA.
Abstract 3637: Virtual Histology Using Intravascular Ultrasound In Assessment Of Intracranial Atherosclerotic Plaques: Correlation With Angiographic And Histopathological Findings
Authors: Majidi Shahram , Hassan Ameer E , Watanabe Masaki , Chaudhry Saqib A , Suri M. Fareed K , Qureshi Adnan I
Published: July 2021

BACKGROUND
Atherosclerotic plaque composition and structure varies in different patients and correlates with risk of plaque rupture and embolization. Virtual histology (VH)-intravascular ultrasonography (IVUS) is the modality of choice for in vivo imaging of the vessel wall of the coronary arteries.

OBJECTIVE
To evaluate the correlation between VH-IVUS, angiographic, histopathological, and macroscopic findings in intracranial vessels.

METHODS
Twelve different postmortem intracranial vessels; including middle cerebral artery, basilar artery, and anterior cerebral artery, were randomly selected. Contrast enhanced angiographic images were acquired. Then IVUS catheter (Eagle Eye Gold, 20 MHZ Digital, s5 Imaging System, Volcano Corp.) advanced within the arteries to obtain gray-scale and VH at regions of interest. The vessels were subsequently transected to obtain macroscopic images with Nikon Digital Camera DXM 1200C. The tissue was fixed, processed, and stained with hematoxylin and eosin staining. Finally, IVUS images were compared with angiographic, direct visualization, and histopatholical findings; regarding luminal stenosis, vessel wall thickness, and plaque content. Plaque content was categorized as: dark green, fibrous; yellow/green, fibrofatty; white, calcified; red, necrotic lipid core plaque on images.

RESULTS
Out of 12 samples, 10 had atherosclerotic plaques in direct visualization. Angiographic stenosis was seen in 3 of these 10 arteries. Five arteries had outside protrusion of the plaque without any intraluminal stenosis. In the remaining 2 samples there was neither stenosis nor outer protrusion. Plaques were visualized in gray-scale IVUS as increased wall thickness, outer wall irregularity, protrusion, and/or hyperdense signal. The accuracy of IVUS to identify plaques was 100% compared with macroscopic visualization of the vessels. Fibrous and lipid deposition in the intima of the arterial wall seen in the histological sections was highly correlated (Pearson’s coefficient of 0.93) with VH-IVUS findings (
Figure 1
).

CONCLUSIONS
These findings support new application of VH-IVUS in intracranial vessels especially with externally protruding angiographically negative plaques with the anticipated availability of smaller and more navigable IVUS catheters.
Figure 1
. A: a cross-sectional macroscopic view of anterior cerebral artery showing plaque within the vessel wall. B: Histological section of the vessel. C: VH-IVUS image from the same location.
Abstract 3653: Akt3 Offers Stronger Protection than Akt1 Against Brain Injury by Differentially Promoting Mtor Protein Levels In Both In Vitro and In Vivo Stroke Models
Authors: Xie Rong , Cheng Michelle , Li Mei , Sapolsky Robert , Zhao Heng
Published: July 2021

Background and Objective:
Akt is a serine-threonine kinase that plays critical role in promoting cell survival. Akt consists of three isoforms (Akt1, 2, 3), with Akt3 predominantly expressed in the brain. Although Akt pathway has been shown to mediate neuronal survival in cerebral ischemic injury, it is unclear how these Akt isoforms contribute to neuronal protection, and whether exogenous Akt can protect the brain against ischemic injury or not. In this study, we over-expressed Akt isoforms and its downstream signaling proteins such as FKHR and PRAS40 to investigate the role of the Akt pathway along with its potential relationship with the mTOR pathway in stroke.

Methods:
Sprauge Dawley rats (250∼280g) were used for all studies. A lentiviral vector consists of a CMV promoter driving IRES-eGFP was used to clone an active Akt 1 and 3 (cAKt 1 and 3), dominant-negative Akt (AktDN), active FKHR (AAA FKHR), and PRAS40. Lentivirus expressing these genes were added to primary mixed cortical cultures for two days prior to oxygen glucose deprivation (OGD) (MOI=1:5). Neuronal survival was measured by LDH release. Lentivirus were stereotaxically injected into the cortex, and rats were subjected to focal ischemia induced by distal MCA occlusion combined with bilateral CCA occlusion. Western blotting and immunofluorescent confocal microscopy were used to detect the expression of Akt isoforms and other proteins in both the Akt and mTOR pathways.

Results:
Western blotting analysis showed that both endogenous Akt1 and 3 proteins degraded as early as 1 h after stroke, while Akt2 protein remained unchanged until 24 h after stroke. In vitro studies showed that over-expression of both constitutively active cAkt1 and cAkt3 decreased LDH release after OGD, while AktDN worsened neuronal death (
P
<0.05). In vivo over-expression of cAkt1, cAkt3 and PRAS40 reduced infarct size after stroke (
P
<0.01). Gene transfer of cAkt1 and 3 also promoted protein levels of pAkt (phosphorylated Akt), pPRAS40, pFKHR, pPTEN, pmTOR, but not pGSK3β. Both in vitro and in vivo studies showed that over-expression of cAkt3 resulted in a stronger protection than cAkt1 (
P
<0.05). Interestingly, cAkt3 gene transfer preserved both endogenous protein levels of Akt1 and 3, whereas cAkt1 gene transfer only preserved endogenous Akt1. Furthermore, cAkt3 promoted higher pmTOR levels than cAkt1. Treatment of rapamycin, an mTOR inhibitor, blocked the protective effects of both cAkt1 and cAkt3 both in vitro and in vivo.

Conclusion:
Lentiviral-mediated overexpression of cAkt3 confers stronger protection than that of cAkt1, by maintaining both endogenous Akt1 and Akt3, as well as promoting higher mTOR activities after stroke.
Abstract 3729: Delayed Hematoma Expansion Occurs After ICH: Observations from the Safety of Pioglitazone for Hematoma Resolution in INtraCerebral Hemorrhage (SHRINC) trial
Authors: Sangha Navdeep S , Vahidy Farhaan , Kasam Mallikarjunarao , Rahbar Mohammed , Andrew Bursaw , Pen Hui , Misra Vivek , Sosa Lenis , Martinez Rebecca , Pandurengan Renga , Aronowski Jarek , Zhao Xiurong , Grotta James C , Gonzales Nicole
Published: July 2021

Background and Purpose
Early hematoma expansion (EHE) has been described in the first 48 hours. SHRINC is a phase 2 prospective safety trial whose primary objective is to assess the safety of pioglitazone (PIO) when administered to patients with spontaneous intracerebral hemorrhage (SICH) compared to standard care. A secondary objective is to characterize the changes in hematoma resolution and expansion over time. This prospective study addresses the natural history, clinical impact, and associated risk factors of late hematoma expansion (LEX) by serial magnetic resonance imaging (MRI) after SICH.

Methods
SHRINC aims to enroll 78 subjects between the ages of 18-80 with a SICH of ≥ 5 ml. This analysis includes the first 42 patients enrolled. Four subjects were excluded because they did not have an MRI after day 2. A baseline CTH was performed followed by an MRI within 24 hours of symptom onset. Hematoma volume (Hv) was measured on FLAIR sequences using a previously published semi-automated range of interest method. LEX was defined as an increase in Hv > 0.5 ml after the 48 hour MRI. Factors associated with LEX were evaluated with logistic regression. Longitudinal analyses were used for measurements taken over the follow up period.

Results:
Ten (26.3%) of 38 subjects displayed LEX. Eight subjects had LEX between day 2 to 14, and 4 between days 14 to 28. The median initial Hv was 16.1cc in LEX patients and 24.1cc in those without expansion (NEX) (p=0.23). Lower platelet counts (p=0.04) and BUN levels (p=0.03) were associated with LEX in univariate analysis. Multivariate analysis suggested that those with higher BUN levels were less likely to have LEX (OR=0.81; 95%CI 0.65-0.99). Blood pressure and EHE (13.2%) were not associated with LEX. There was no difference in neurological worsening (NIHSS increase ≥ 4), 6 month mRS or death between LEX and NEX.

Conclusion:
This is the first prospective study to address LEX with serial MRIs. LEX occurs between day 2 to 14 and day 14 to 28. Elevated BUN levels may decrease the likelihood of LEX. A limitation of our study is that the effect of PIO on LEX could not be evaluated because SHRINC is a blinded trial. Further studies will assess the pathophysiology of LEX and its potential implications in clinical trials evaluating hematoma growth and resolution.
Abstract 3730: Length Of Hospitalization And Discharge Disposition Among Acute Ischemic Stroke Patients With Moderate To Severe Stroke by Treatment
Authors: Koehler Steven A , Hammer Maxim , Reddy Vivek , Jumaa Houhammad , Zaidi Syed , Jovin Tudor
Published: July 2021

Background:
Data regarding length of stay and discharge disposition in patients with moderate to severe stroke are scarce. We sought to determine Length of Stay (LoS) in a consecutive group of patients admitted at a large academic center and assess for any possible difference in LoS at discharge by treatment modality received and by vessels occlusion status.

Methods:
Retrospective review of a database comprising acute ischemic stroke patients admitted to our center between 1/1/2009-3/31/2011. Patient Demographics, treatment modality (IV thrombolytic tissue plasminogen activator (IVtPA), Endovascular (IA), no thrombolytic (NT), LoS, occlusion of major cerebral arteries and discharge disposition were collected. Inclusion criteria were AIS with admission NIHSS ≥10.

Results:
A total of 744 patients 361 (48.5%) male, mean age 69.9 years were identified. Treatment modalities: 174 (23%) IVtPA, 177 (24%) IA, 393 (53%) NT. Median NIHSS 16.5 and not significant among the 3 groups (P=.603). Mean LoS was 7.38 days (SD 7.4) with no significant difference between the 3 groups (P=.056). Occlusion to one of the 3 cerebral arteries (ICA, MCA, BA) was: 84% in IVtPA, 100% in IA, 87% in NT. Discharge disposition and LoS by treatment and occlusions are shown in the
Table
. Among patients treated with
IVtPA
(n=174) mean LoS was 6.33 days (range 1-27). LoS was significantly longer among those without occlusion vs with any occlusion (P=.001). Among patients that received
IA
(n=177) mean LoS was 8.21 days (range 0-74). Among patients received
NT
(n=393) the mean LoS was 7.47 days (range 0-64).

Conclusions:
Thrombolytic therapy (IV or EV) in patients with strokes is not associated with longer hospitalizations duration. A significant difference between death rates in patients receiving IA thrombolytic (22%) compared to IV (32%) or NT (30%) was found with fewer death among those that received IA (P= .008). Patients discharged to long term care facilities have regardless of treatment longer LoS (12.41v 6.14) (P>.000).
Abstract 3734: Presurgical fMRI and Morbidity Outcomes in Patients with Vascular Lesions
Authors: Radtke Andrew C , Pankratz Joshua , Holdsworth Ryan , Baniulis Dovile , Kornder Nicole , Voss Jed , Nair Veena A , Gallagher Tom A , Moritz Chad , Meyerand Beth , Prabhakaran Vivek
Published: July 2021

Background
fMRI is being increasingly used as an adjunct imaging technique for preoperative planning for patients with various brain lesions. The proximity of the lesion to eloquent cortex is a major factor in guiding surgical planning. Our group has previously reported significant association between the distance between brain tumor periphery and area of fMRI activation (Lesion-Activation Distance; LAD) and morbidity and mortality outcomes. This study investigated the relationship between vascular lesion LAD and morbidity.

Methods
This study was a retrospective analysis of data from patients with vascular lesions [arteriovenous malformations (AVMs) (n=49), and cavernomas (n=57)], who had received fMRI as part of their preoperative planning. The preoperative fMRI included motor mapping (n=87) and/or language mapping (n=102). The fMRI paradigms were chosen based on observed preoperative weakness (aphasia, paresis) and anticipated functional areas of the brain that may be affected by treatment.

Results
Multiple logistic regression analyses showed that a model that combines Age and Language LAD was a significant predictor of postoperative deficits (p= 0.04). Broca’s LAD(1-2 cm) X Age was a significant predictor of postoperative deficits (change in odds ratio (OR) =0.82, CI:0.68-0.98). The relationship between Brocas’s LAD and postoperative aphasia and Broca’s LAD and pre and postoperative aphasia trended towards significance (p = .08 and p =.07 respectively). Wernicke’s LAD, independently or combined with Age, was not a significant predictor of postoperative deficits. Binary logistic regression analysis for SMC LAD and postop deficits did not reach significance (p =.10). There were no significant differences in postoperative language or motor deficits as a function of gender or handedness.

Conclusions
These results suggest that both age and the proximity of a vascular lesion to language LAD are factors that can help predict postoperative outcomes, especially for Broca’s LAD. The lack of similar results when investigating the relationship between Wernicke’s LAD and postoperative deficits suggests potential brain reorganization and/or robustness of this brain region. These results have implications for the potential use of fMRI as a presurgical tool for language mapping in patients with vascular lesions.
Abstract 3735: Utility A Second 24-hours Holter Monitoring For The Diagnosis Of Paroxismal Atrial Fibrillation After An Acute Stroke
Authors: Correas Callero Elisa , Martinez-Sanchez Patricia , Prefasi Gomar Daniel , Fuentes Gimeno Blanca , Ruiz Ares Gerardo , Martinez Martinez Marta , Diez-Tejedor Exuperio
Published: July 2021

OBJETIVE:
to assess the utility of a second 24-hours Holter monitoring for the diagnosis of paroxysmal atrial fibrillation (PAF) in patients with suspected cardioembolic ischemic stroke.

METHODS:
prospective study of ischemic stroke patients (brain infarction/TIA) treated in a Stroke Center (June 2010-February 2011). A first 24-hours Holter monitoring was performed if PAF was suspected and, if it was negative, a second 24-hours Holter monitoring was performed. Variables analyzed: demographic data, vascular risk factors, stroke severity and etiological subtype, presence of carotid plaques by duplex ultrasound, enlarged left atrial by transthoracic/transesophageal echocardiography and presence of chronic/acute brain infarctions by neuroimaging (CT/MRI).

RESULTS:
219 patients included, mean age 69.8 (SD 13.5) years, 55.3% male. 17.8% have previous atrial fibrillation (AF). In 14 (6.4%) patients AF was diagnosed by ECG on admission or by serial ECG in the Stroke Unit. 24-hours Holter was performed in 101 patients to assess the presence of PAF, 85 cases during hospitalization and 16 at the outpatient clinic. This 24-hours Holter diagnosed PAF in 28.7% (29/101) of patients. A second 24-hours Holter was performed at the outpatient clinic in 21 cryptogenic brain ischemia patients. The mean time from the first to the second Holter was 143.3 (SD 72.2) days. This second 24-hours Holter detected PAF in 2 (9.5%) patients.

CONCLUSION:
a second 24-hours Holter monitoring at the outpatient clinic could detect PAF in almost 10% of cryptogenic ischemic stroke patients.
Abstract 3745: General Versus Local Anesthesia In Endovascular Therapy For Acute Ischemic Stroke (ais) In Anterior Vessel Occlusions. A Case-control Study
Authors: Gomis Meritxell , Ribo Marc , Millán MÓnica , Rubiera Marta , Pérez de la Ossa Natalia , Pagola Jorge , Dorado Laura , Flores A , Castaño Carlos , Alvarez-Sabin José , Dávalos Antoni , Molina Carlos
Published: July 2021

Background and purpose
Recent evidence supports the shift from general (GA) to local (LA) anesthesia in endovascular acute stroke therapy. However, the optimal modality of anesthesia during this type of procedure has not been established in controlled studies. We compared safety and efficacy on clinical and imaging outcomes between these two sedation modalities in a case-control study.

Methods
Retrospective observational case-control study of patients with AIS and anterior arterial occlusions treated with endovascular therapy (EVT) according to similar protocols (direct IA, bridging IV t-PA/IA and failed or contraindicated IV t-PA) in two tertiary academic stroke centers that used two different sedation modalities as standard of care, the first under GA and the second under LA. From 298 patients consecutively registered between 2008 and 2011, a total of 206 were classified in two groups (GA, n=103; LA, n=103) matched by age and baseline NIHSS, blind to outcome variables. Outcome variables were ischemic lesion volume and symptomatic ICH at 24-36h, functional dependence (Rankin >3) and mortality at 3 months. Logistic regression and interaction analyses were used to evaluate the effect of GA/LA on outcome variables.

Results
GA and LA groups were comparable regarding TOAST classification, occlusion site (for GA/LA n= 24/27 ICA or TICA; 51/50 MCA-1; 12/10 MCA-2; 16/16 tandem ICA-MCA), prior IV t-PA use (n= 54/61) and preprocedure TICI score. However, the time from onset to groin puncture (TOGP) was longer in GA patients (median hours, 5.0/3.6) who were more frequently treated following MRI mismatch criteria (n= 55/7). At 24-36 hours, median infarct volume was 25/56 cc (p=0.02) and sICH was found in 10/7 patients (p=NS). Ninety-four patients in each group had completed the 3 months follow-up. Functional dependence was found in 58/55 patients and mortality in 23/33 (p=NS). The adjusted OR of GA for poor functional outcome was 1.83 (95%CI, 0.84-3.97). There was a GA*TOGP interaction on poor outcome: in the TOGP <5 hours group (n=125) the OR of GA was 2.57 (1.02-6.47) whereas it was 0.18 (0.02-1.67) in the TOGP >5 h group (n=57).

Conclusions
This case-control study shows that endovascular acute stroke therapy under GA results in comparable clinical and radiographic outcomes than under LA. However, GA seems to be associated with poor outcome in patients treated in less than 5 hours.
Abstract 3784: Postdischarge Follow-up Appointments After Stroke In Ohio - Current Status And Room For Improvement
Authors: Katzan Irene , Liskay Alice , Maloney Martin Siobhan , Konrad Nancy , Pryor Barbara ,   Ohio Coverdell Registry
Published: July 2021

Background:
There is an increasing realization of the importance of postdischarge follow-up (f/u) after hospitalization for stroke. As a quality improvement initiative of the Ohio Coverdell Stroke Registry, several questions related to post-discharge f/u appointments were added to the Ohio Coverdell Get with the Guideline - Stroke data collection form.

Methods:
Four questions related to documentation of f/u appointments made prior to discharge was added to the GWTG-Stroke form in 2009 including: f/u with a neurologist, f/u with the patient’s primary care physician (PCP), whether a new PCP was assigned in patients without one and lastly whether f/u was made with a newly assigned PCP. Analysis of data was performed after excluding patients who died or were made comfort care during the stroke admission. Generalized estimating equation (GEE) was used to adjust for correlations within hospitals.

Results:
There were 15,712 patients between 1/2009 to 7/1/2011, with mean age 68.9 (SD 14.6) The majority (79.8%) were white and 52.5% were female. At least one f/u question was completed in 49% patients (n=7757), with completion rates increasing over time. F/u appointments with PCP were documented prior to discharge in 12.4% (676/5455) cases. A new PCP was assigned in 26.6% (173/651) pts without one and f/u appointments were documented in 14.0% (105/751) with these new assignments. Appointments with a neurologist were made 26.3% (1042/3967). Rates of documented f/u with both PCP and neurologists improved over the study period. Using adjusted means, rates of neurology f/u were higher in males than females (16.1.0% vs 15.0%, p<0001) blacks vs whites (24.90 vs 12.8%, p<0.0001) and in pts discharged to rehab vs home (25.8% vs 13.5% p<.0001). The pattern was similar for PCP f/u. There was wide variability in rates of documented f/u appointments across hospitals (range 0 - 100%).

Implications:
Establishing postdischarge f/u with PCPs and neurologists represents a potentially measurable and clinically important avenue to optimize outcomes after stroke. Data from Ohio Coverdell suggests considerable room for improvement in making with f/u appointments with both PCPs and neurologists. Further evaluation of the impact of postdischarge f/u and its potential use as a quality measure is warranted.
Abstract 3849: The Optimal Target for Thrombolytic Trials: The Interaction of Mismatch Size and IV tPA Treatment in Predicting Good Clinical Outcome
Authors: Magadan Alejandro , Luby Marie , Warach Steven
Published: July 2021

Introduction:
Because IV tPA treatment initiated within 4.5 hours is the only acute stroke therapy of proven clinical efficacy, this population offers the greatest validity for determining imaging markers that optimally would differentiate clinical outcomes in treated vs. placebo patients in later time-window clinical trials. The Perfusion Diffusion Mismatch (PDM) approximates the ischemic penumbra, but there is no consensus on the optimal definition or threshold to be used in trials. We assessed the relationship of mismatch size to clinical outcome of an IV tPA treated sample compared with an untreated cohort.

Methods:
We selected patients from the NINDS Lesion Evolution of Stroke and Ischemia On Neuroimaging (LESION) database who met the following criteria: 1) treated with standard IV tPA 2) received multimodal MRI pre-treatment including diffusion (DWI) and perfusion imaging (PWI), 3) had interpretable MRI imaging showing 4) non-lacunar infarcts or lesions less than 100 ml volumes on DWI and 5) follow-up modified Rankin Score (mRS). We also selected 23 acute stroke patients who did not receive treatment but otherwise met the same criteria. Volumes were measured from the DWI and Mean Transit Time (MTT) images. PDM was defined as either a volume (MTT-DWI) or a percentage (MTT-DWI/MTT). Good outcome was defined as mRS of 0-1. Logistic regression was performed to predict good outcome with covariates of age, initial NIHSS, PDM size, tPA treatment, and tPA treatment by PDM size interaction.

Result:
Ninety-six patients were treated with IV tPA, 23 patients had no treatment. The
figures
, showing the unadjusted proportions of patients achieving good outcome as a function of minimum PDM size, suggest greater separation of treated and untreated patients at larger PDM sizes. For percentage PDM a significant interaction of tPA treatment by PDM size was observed at ≥ 80% (p=0.029), indicating that the benefit of tPA treatment is greater for PDM ≥ 80%. For volume PDM, the interaction of tPA treatment by PDM size trended positive at ≥ 50 ml (p=0.058).

Conclusion:
Greater differences in clinical outcomes with IV tPA versus untreated patients were evident with PDM ≥ 80% or ≥ 50 ml. These minimums of PDM size suggest an optimal target for thrombolytic trials.
Abstract 3861: The Effect of Stroke Survivor and Caregiver Family Function and Mutuality on Post Stroke Depression
Authors: Godwin Kyler M , Swank Paul , Ostwald Sharon K
Published: July 2021

Background:
Post-stroke depression is common among both stroke survivors and their caregivers. This secondary data analysis explored the effect that stroke survivor and caregiver family function and mutuality, a measure of the perceived positive aspects of the caregiving relationship, had on the depression of spousal dyads over the first 12 months post discharge from inpatient rehabilitation.

Methods:
Longitudinal meditational analysis was employed to examine the mediating effect of mutuality on the dyads’ perception of family function and caregiver and stroke survivor depression over time. The model was estimated in MPlus version 6.1 using bootstrap estimation with 1000 draws. The final structural model had good model fit to the data with a
chi
square
(
df=
16;
N
=
132)
of 17.55,
p
=.35, a comparative fit index (CFI) of 0.996, and root mean square error of approximation (RMSEA) of 0.027 (CI = 0-.087).

Results:
This study included 159 stroke survivors and their spousal caregivers who were an average (standard deviation) age of 66.4 (9.1) and 62.5 (10.5) years, respectively. The majority of stroke survivors were predominately male and non-Hispanic white, although almost 40% of the sample was represented by ethnic minorities. Mutuality was not found to mediate the relationship between caregivers’ and stroke survivors’ perception of family function at baseline and their own or their partners’ depression at 12 months as hypothesized. However, caregivers who perceived healthier family functioning at baseline and stroke survivors who had higher perceived mutuality at 12 months had lower depression at one year post discharge from inpatient rehabilitation (-.117, p=.048; -1.007, p=.034, respectively). Additionally, caregiver mutuality at 6 months, but not at baseline or 12 months, was found to be inversely related to caregiver depression at 12 months (-1.06, p=.04).

Conclusions:
This study highlights the importance of focusing on the relational aspects of stroke. A stroke does not only happen to the stroke survivor. It affects his or her family, and it oftentimes changes the life of both the stroke survivor and their spousal caregiver. Health professionals should encourage couples who have experienced a stroke to focus on the positive aspects of the caregiving relationship to mitigate post-stroke depression.
Abstract 3884: Stroke Subtypes in Hispanic Patients in the NINDS Stroke Genetics Network (SiGN): A Comparison of Two Classification Systems
Authors: Katsnelson Michael , Rundek Tatjana , Sacco Ralph , Gardener Hannah , Malik Shaneela , Southerland Andrew , Brown Robert , Barrett Kevin , Ossi Ra'id , Arsava Ethem , Rexrode Kathryn , Biffi Alessandro , Helenius Joanna , Huq Mohammed , Labovitz Daniel , Weissman Darren , Sheikh Huma , Rhodes David , Saraf Neha , Brenner David , Peddareddygari Leema , Rosand Jonathan , Woo Daniel , Smoller Sylvia , Arnett Donna , Grewal Raji , Worrall Bradford , Meschia James , Ay Hakan , Kittner Steven
Published: July 2021

Objectives:
Identification of gene variants of stroke subtypes is important for the development of tailored ischemic stroke therapies among various ethnic groups. Valid and reliable determination of ischemic stroke subtype is essential for achieving this goal and to standardize a classification scheme across multi-center studies and different populations. Causative Classification System for Ischemic Stroke (CCS) is a novel computerized subclassification tool developed to improve reliability and accuracy of classifying stroke types. The CCS algorithm relies on both phenotypic and causative stroke variables. A Hispanic subset of the SiGN, an important and distinct target population with greater risk of certain stroke subtypes, was evaluated with Trial of Org 10172 in Acute Stroke Treatment (TOAST) and CCS and the agreement between the two classification systems was analyzed.

Methods:
Over 6000 subjects at 15 sites across US and Europe were enrolled, with TOAST and CCS locally adjudicated. Blood collection and central data quality control (10% central readjudication) were performed on all participants. A subset of Hispanics was analyzed for the purpose of this study and the agreement between the TOAST and CCS were assessed by kappa statistic.

Findings:
Hispanics (n=595, 10.9%) compared to non-Hispanics (n=5457) were more likely to be younger (63.7 vs. 64.0), male (55% vs. 46%) and have fewer of the traditional stroke risk factors HTN (54% vs. 64%), Afib (11% vs. 14%), DM(23% vs. 25%), CAD(16% vs. 20%) and smoking(19% vs. 22%). While the TOAST showed no differences between stroke subtypes for Hispanic vs. non-Hispanics, in CCS, Hispanics were classified with more of large vessel (22% vs. 20%), cardioembolic (37% vs. 30%) and small vessel strokes (13% vs. 9%) and fewer with undetermined etiology (28% vs. 40%) as compared to non-Hispanics. TOAST and CCS offered moderate correlation across all stroke types in Hispanics: kappa of 0.66 for large artery atherosclerosis, 0.58 for cardioembolic, and 0.58 for small artery occlusion.

Conclusion:
CCS offers a more sensitive and accurate system for subphenotyping of strokes in Hispanics who tended to have relatively fewer risk factors and unclassified strokes. Further studies correlating the two classification systems and their relation to genotyping data are warranted.
Abstract 3916: Rapidly Improving Stroke Symptoms: Relation to Stroke Volumes and Discharge Disposition
Authors: Balucani Clotilde , Levine Steven , Khoury Jane Khoury , Khatri Pooja , Saver Jeffrey L , Broderick Joespeh P
Published: July 2021

Background:
Rapidly improving stroke symptoms (RISS) is a frequently cited reason for not giving IV rt-PA. However, prior studies have suggested that outcome of acute ischemic stroke patients presenting with RISS is not invariably benign. This raises the possibility that stroke-related disability may be relatively common after RISS.

Objective:
To explore both discharge disposition and 3-month CT lesion volume in patients with and without RISS based on various pre-specified definitions in The NINDS rt-PA Stroke Study cohort.

Methods:
The NINDS rt-PA Stroke Study dataset was used to compare baseline to 2-hour NIH Stroke Scale scores (NIHSSS). We calculated baseline NIHSSS - 2hr NIHSSS (positive = improvement [IMP], negative = worsening). Definitions of RISS were raw change in NIHSSS (≥ 4 point IMP) and percent change in NIHSSS (≥ 25% IMP and ≥ 50% IMP). Chi-square and multiple logistic regression modeling were used to assess the association of RISS with outcomes measures. Discharge disposition included: home; relative/friend; rehabilitation; nursing home; death; other. CT lesion volume was based on the 3-month CT scan as previously calculated as a pre-specified secondary outcome of the 2 trials.

Results:
In the 624 subjects, RISS frequency depended on definition used. Frequencies (all %s) of RISS compared to no-RISS who were discharged Home were 55 vs. 30 for ≥ 4 point IMP, 64 vs. 23 for ≥ 25% IMP, and 78 vs. 30 for ≥ 50% IMP. Frequencies for Discharge to Rehabilitation (RISS vs. no-RISS) were: 1 vs. 36, 14 vs. 41, and 10 vs. 36. Nursing Home discharge frequencies were: 5 vs. 11, 4 vs. 12, and 1 vs. 11. Across all definitions of RISS there was a significant difference in discharge status favoring RISS (all p values < 0.001). Three-month CT lesion volumes (cm3): for RISS ≥ 4 point IMP were: 7.51 [95% Confidence Interval (CI): 1.52, 12.34] vs. no-RISS 19.95 (CI: 2.71, 26.42); for RISS ≥ 25%: 4.64 (CI: 1.07, 7.41) vs. no-RISS 25.96 (CI: 2.99, 33.96); for RISS ≥ 50% IMP: 3.14 (CI: 0.44, 6.36) vs. no-RISS 19.75 (CI: 2.73, 25.50). All p values <0.001.There were no statistically significant rt-PA treatment interactions for CT volume (lowest p-value 0.28) and for discharge status (lowest p-value 0.13).

Conclusions:
Post hoc exploratory analyses suggest that based on all definitions of RISS used, those patients with RISS were consistently and significantly discharged to a more favorable location than those without RISS. These findings were also consonant with CT lesion volumes at 3 months being significantly smaller for each definition of RISS vs. no RISS. However, while patients with RISS do better in these exploratory outcomes, they still commonly have evidence of cerebral infarction and approximately 2 of 3 with ≥ 4 point IMP and 1 in 5 with at least 50% IMP are not discharged home.
Abstract 4: Angiographic Predictors of Stroke after Carotid Artery Stenting - A Qualitative and Quantitative Analysis of 1070 Patients in the Carotid Revascularization Endarterectomy versus Stenting Trial
Authors: Roubin Gary S , Popma Jeffrey J , Almonacid Alexandra , Morrish William F , Katzen Barry T , Chakhtoura Elie , Lal Brajesh K , Voeks Jenifer H , Meschia James F , Brott Thomas G
Published: July 2021

Background
Carotid artery stent (CAS) placement may be used as an alternative to carotid endarterectomy in selected patients with symptomatic and asymptomatic carotid artery disease. Perhaps because stroke is an uncommon event after CAS, the angiographic predictors of stroke have been incompletely described.

Methods
A total of 1070 catheter-based angiograms were centrally reviewed in patients undergoing CAS enrolled in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Of these patients, 43 (4%) experienced periprocedural stroke. Angiograms were reviewed using qualitative and quantitative methodology before and after CAS. Reviews were done blinded to patient outcomes and strokes were adjudicated by a central committee blinded to results of angiography. The view showing the greatest carotid stenosis severity was selected. Extreme tortuosity was defined as 2 severe bends >90 degrees (maximum angulation/20 mm segment) beyond the target lesion, sequential lesions as lesions separated by ≥10 mm, and narrow mouth ulcer as a discrete area of contrast extension beyond the normal arterial lumen with a narrow inlet into the ulceration.

Results
The internal carotid artery reference diameter was 4.2 ± 0.8 mm, the minimal lumen diameter was 1.1 ± 0.6 mm, and the baseline % diameter stenosis was 74.1 ± 11.6%. There were no differences in vessel size or severity of the stenosis in patients with and without stroke. Morphologic predictors significantly related to the risk of subsequent stroke are listed in the
Table
. Calcification, lesion eccentricity, baseline flow, and distance from the bifurcation were not predictive of periprocedural stroke (p > 0.05).

Conclusion
In CREST, four angiographic variables were found to increase risk for stroke during and within 30 days after CAS: severe distal tortuosity, sequential lesions, lesion length > 20 mm, and narrow mouth ulcer. Angiographic characteristics beyond percent stenosis may help in patient selection in terms of best revascularization option.
Abstract 4039: Validation Of The Totaled Heath Risks in Vascular Events (THRIVE) Score For Predicting Outcomes After Endovascular Stroke Treatment
Authors: Flint Alexander , Kamel Hooman , Rao Vivek , Cullen Sean , Faigeles Bonnie , Smith Wade
Published: July 2021

Background:
We recently developed a novel clinical prediction tool, the Totaled Health Risks in Vascular Events (THRIVE) score, that predicts outcomes after endovascular stroke treatment. The THRIVE score, which incorporates age, NIH Stroke Scale (NIHSS) score, and three medical comorbidities (hypertension, diabetes mellitus, and atrial fibrillation), was developed using data from the MERCI and Multi MERCI Trials, two clinical trials of the Merci family of endovascular stroke treatment devices.

Methods:
In order to perform external validation to demonstrate the reliability of our prediction tool, we applied the THRIVE score to patients from the Merci Registry, the largest clinical series of patients to date undergoing endovascular stroke treatment. We examined the predictive utility of the THRIVE score across the range of clinical outcomes and used Receiver-Operator Characteristics curve analysis and ordinal logistic regression to formally compare score performance in the two data sets.

Results:
We find that the THRIVE score predicts good outcome, death, and the full range of the modified Rankin Scale in a similar fashion between the MERCI Trials and the Merci Registry. In Receiver-Operator Characteristics curve comparisons, the area under the curve (AUC) for the ROC curves for good outcome was not significantly different between MERCI Trial patients (AUC = 0.293, 95% C.I. = 0.231 to 0.355) and Merci Registry patients (AUC = 0.266, 95% C.I. = 0.230 to 0.302) (P = 0.47), and the AUC for the ROC curves for death was not significantly different between MERCI Trial patients (AUC = 0.692, 95% C.I. = 0.632 to 0.752) and Merci Registry patients (AUC = 0.717, 95% C.I. = 0.683 to 0.750) (P = 0.48). The THRIVE score (0 to 9) predicts mRS (0 to 6) in ordinal logistic regression in a similar fashion for the MERCI Trials (OR = 1.47, 95% C.I. 1.31 to 1.65, P < 0.001) and the Merci Registry (OR = 1.61, 95% C.I. 1.51 to 1.72, P < 0.001).

Conclusion:
The THRIVE score reliably predicts outcomes after endovascular stroke treatment. The THRIVE score may be useful as a prognostic tool in clinical practice and as a means to perform severity adjustments in clinical stroke research. A THRIVE score calculator is available at
www.thrivescore.org