bluuebunny/crossref_metadata_2025 huggingface dataset:
Area Deprivation Index and Cardiac Readmissions: Evaluating Risk‐Prediction in an Electronic Health Record
Authors: Johnson Amber E. , Zhu Jianhui , Garrard William , Thoma Floyd W. , Mulukutla Suresh , Kershaw Kiarri N. , Magnani Jared W.
Published: July 2021

Background

Assessment of the social determinants of post‐hospital cardiac care is needed. We examined the association and predictive ability of neighborhood‐level determinants (area deprivation index, ADI), readmission risk, and mortality for heart failure, myocardial ischemia, and atrial fibrillation.

Methods and Results

Using a retrospective (January 1, 2011–December 31, 2018) analysis of a large healthcare system, we assess the predictive ability of ADI on 30‐day and 1‐year readmission and mortality following hospitalization. Cox proportional hazards models analyzed time‐to‐event. Log rank analyses determined survival. C‐statistic and net reclassification index determined the model’s discriminative power. Covariates included age, sex, race, comorbidity, number of medications, length of stay, and insurance. The cohort (n=27 694) had a median follow‐up of 46.5 months. There were 14 469 (52.2%) men and 25 219 White (91.1%) patients. Patients in the highest ADI quintile (versus lowest) were more likely to be admitted within 1 year of index heart failure admission (hazard ratio [HR], 1.25; 95% CI, 1.03‒1.51). Patients with myocardial ischemia in the highest ADI quintile were twice as likely to be readmitted at 1 year (HR, 2.04; 95% CI, 1.44‒2.91]). Patients with atrial fibrillation living in areas with highest ADI were less likely to be admitted within 1 year (HR, 0.79; 95% CI, 0.65‒0.95). As ADI increased, risk of readmission increased, and risk reclassification was improved with ADI in the models. Patients in the highest ADI quintile were 25% more likely to die within a year (HR, 1.25 1.08‒1.44).

Conclusions

Residence in socioeconomically disadvantaged communities predicts rehospitalization and mortality. Measuring neighborhood deprivation can identify individuals at risk following cardiac hospitalization.
Cangrelor: Clinical Data, Contemporary Use, and Future Perspectives
Authors: De Luca Leonardo , Steg Philippe Gabriel , Bhatt Deepak L. , Capodanno Davide , Angiolillo Dominick J.
Published: July 2021

Cangrelor is the only currently available intravenous platelet P2Y
12
receptor inhibitor. It is characterized by potent, predictable, and rapidly reversible antiplatelet effects. Cangrelor has been tested in the large CHAMPION (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition) program, where it was compared with different clopidogrel regimens, and it is currently indicated for use in patients with coronary artery disease undergoing percutaneous coronary intervention. However, the uptake of cangrelor use varies across the globe and may also include patients with profiles different from those enrolled in the registration trials. These observations underscore the need to fully examine the safety and efficacy of cangrelor in postregistration studies. There are several ongoing and planned studies evaluating the use of cangrelor in real‐world practice which will provide important insights to this extent. The current article provides a review on the pharmacology, clinical studies, contemporary use of cangrelor in real‐world practice, a description of ongoing studies, and futuristic insights on potential strategies on how to improve outcomes of patients undergoing percutaneous coronary intervention.
Abstract 160: Tuberosis Sclerosis Complex 1 Mediated Neointima Formation and Arterial Thrombosis Following Vascular Injury
Authors: Kim Eo Jin , Ahn Yong-Joo , Kim Maya Hwewon , Kim Hyung-Hwan
Published: July 2021

Objectives:
Vascular injury and thrombosis are main leading causes of cardiovascular diseases. Tuberous sclerosis complex (TSC) is a genetic disorder caused by heterozygous mutations in either of two genes, TSC1 and TSC2. Although role of TSCs has been implicated in cardiovascular diseases, the tissue- and isoform-specific roles of TSCs in the vascular response to injury are not known.

Methods and Results:
To determine the role of TSC1 in arterial injury and thrombosis, we generated vascular smooth muscle cell-specific TSC1 conditional knockout mice (TSC1SM22-/-) by crossing vascular smooth muscle cell-specific Cre (SM22Cre) mice with TSC1flox/flox mice and performed carotid artery ligation in haploinsufficient TSC1 conditional knockout mice (TSC1SM22+/-) compared with that of WT or haploinsufficient TSC2 knockout mice (TSC2+/-). Acute carotid artery occlusion was investigated by 5% ferric chloride injury. Arterial thrombosis and neointima formation were measured at 14 days after arterial ligation. Expression of proteins was observed by immunoblot analysis. The neointima formation was significantly increased in TSC1SM22+/- mice (intimal thickness/medial thickness ratio; 1.14 ± 0.14, p<0.001) compared with that of WT mice (0.13 ± 0.03). Two weeks after arterial injury, arterial thrombus area was increased in TSC1SM22+/- mice (thrombus area/luminal area ratio; 72.1 ± 4.4, p<0.001) compared with that of WT mice (0.1 ± 0.0) but there are no significant effect in acute arterial thrombosis induced by ferric chloride. Loss of TSC1 and hyper-activation of mammalian target of rapamycin complex 1 including mTOR and S6 proteins were observed by immunoblot analysis of carotid artery tissue lysates of TSC1SM22+/- mice compared with that of WT.

Conclusion:
These findings suggest that regulation of TSC1 and mTOR might be useful for therapeutic intervention in vascular injury and thrombosis.
Decompressive Hemicraniectomy for Massive Cerebral Hemorrhage
Authors: Mayer Stephan A , Connolly E Sander , Bates Joseph E , Sim Allan , McKhann Guy M , Peery Shelly
Published: July 2021

P103

Background:
Hemicraniectomy and durotomy has been shown to be a promising treatment for malignant MCA infarction, but has not been evaluated for cerebral hemorrhage.
Methods:
We analyzed the clinical course and outcome of 15 patients treated with decompressive surgery for space-occupying cerebral hematomas between 9/98 and 6/00. All patients were treated with duroplasty and either hemicraniectomy (n=13) or a “floating” bone flap (n=2); in some patients, hematoma (n=5) and subdural clot (n=2) evacuation was also performed. Outcomes were assessed by telephone interview using the modified Rankin scale (mRS).
Results:
Mean age was 49 years (range 33–66); 8 were women; the lesion was left-sided in 7. Hematoma formation was related to spontaneous aneurysmal rupture (n=7), intra-operative aneurysmal rupture (n=3), hypertensive intracerebral hemorrhage (n= 3), and hemorrhagic infarction (n=2). Surgery was peformed <24 hours after onset in 5 patients, between 24–48 hours in 6, and between 3–5 days in 4. On the day of surgery, mean hematoma volume was 63 ml (range 6–216 ml), mean GCS was 6.3 (range 4–10), and mean NIHSS was 22 (range 13–28); 5 patients had clinical herniation signs. Postoperative CT scans showed significant reductions in both mean septal shift (from 10.3 to 6.1 mm) and pineal shift (from 6.4 to 3.5 mm) (both P<.02). Eighty percent (12/15) of patients survived to discharge, and one died after discharge. After a mean follow up of 5.7 months (range 1–13), one survivor (9%) had no disability (mRS 0–1), four (36%) had slight or moderate disability (mRS 2–3), and six (54%) had moderate or severe disability (mRS 4–5).
Conclusion:
Duroplasty and hemicraniectomy, with or without concurrent hematoma evacuation, may improve survival and recovery in comatose patients with large aneurysmal, hypertensive, or infarct-related cerebral hemorrhages.
Abstract 141: Impact of an Aggressive Medical Management Protocol on Early Risk Factor Measures in the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) Trial
Authors: Turan Tanya N , Nizam Azhar , Lynn Michael J , Derdeyn Colin P , Fiorella David , Lane Bethany F , Steiner Megan , Janis L. S , Chimowitz Marc I ,   SAMMPRIS Investigators
Published: July 2021

Purpose:
SAMMPRIS is the first stroke prevention trial to include protocol-driven aggressive management of multiple vascular risk factors. We sought to determine the impact of this protocol on early risk factor control in the trial.

Materials and Methods:
SAMMPRIS randomized 451 patients with symptomatic 70%-99% intracranial stenosis to aggressive medical management or stenting plus aggressive medical management at 50 USA sites. For the primary risk factor targets (SBP < 140 mm/Hg (<130 if diabetic) and LDL < 70 mg/dL), the study neurologists follow medication titration algorithms and risk factor medications are provided to the patients. Secondary risk factors (diabetes, non-HDL, weight, exercise, and smoking cessation) are managed with assistance from the patient’s primary care physician and a lifestyle modification program (provided). Sites receive patient-specific recommendations and feedback to improve performance. Follow-up continues, but the 30-day data are final. We compared baseline to 30-day risk factor measures using paired t-tests for means and McNemar tests for percentages.

Results:
The differences in risk factor measures between baseline and 30 days are shown in
Table
1.

Conclusions:
The SAMMPRIS protocol resulted in major improvements in controlling most risk factors within 30 days of enrollment, which may have contributed to the lower than expected 30 day stroke rate in the medical group (5.8%). However, the durability of this approach over time will be determined by additional follow-up.
Abstract 195: Beneficial Impact of EMS Routing to Certified Stroke Centers on Door to Imaging Times
Authors: Haley Theresa , Cherin Samantha B , Nasseri Nicole , Sadighi Akha Arezou , Chatfield Fiona , Eckstein Marc , Lyden Pat , Koenig William , Pratt Frank , Sanossian Nerses , Stratton Sam , Sung Gene , Starkman Sidney , Saver Jeffrey ,   FAST-MAG Investigators and Coordinators
Published: July 2021

Background
Effective acute interventions for ischemic and hemorrhagic stroke are time-critical, making rapid brain imaging an important component of high quality stroke care. National guideline recommendations are that initial brain imaging be performed within 25 minutes of ED arrival. Direct EMS routing of acute stroke patients to certified Stroke Centers has the potential to increase the proportion of patients receiving high quality care, including more rapid post arrival brain imaging.

Methods
Data collected in the ongoing, region-wide NIH FAST-MAG trial permitted analysis of the impact of EMS implementation of a stroke center routing policy on door to imaging (DTI) times. FAST-MAG is an NIH, multicenter trial of prehospital initiation of neuroprotective therapy conducted in 228 ambulances transporting patients to 51 adult receiving hospitals in Los Angeles County. In November 2009, the LA EMS Agency instituted a policy of preferentially routing acute stroke patients to Approved Stroke Centers that had been certified by the Joint Commission. Data on patients from all sites was analyzed from 2005-2010.

Results
Among the first 1000 patients enrolled, mean age was 70 (SD 14), 41%were female, median NIHSS was 9 (IQR 3, 17) and onset to door time was 71 (SD 55) minutes. Throughout the 5 year period analyzed, patients cared for at hospitals that would become Approved Stroke Centers (ASCs) had shorter door to imaging times than patients cared for at non-ASCs. Comparing the 9 inaugural ASCs with the 42 others, 34.4 vs 42.3 minutes (0.001). Comparing the 23 eventual ASCs with the 28 non-ASCs, 35.5 vs 46.5 minutes (<0.0001). Preferential EMS routing of patients to ASCs resulted in a reduction of DTI times among the entire cohort: enrollments across all sites before vs after implementation of the routing policy: 44.9 vs 32.0 minutes (<0.0001). With implementation of the routing system, the proportion of patients meeting the 25 minute DTI goal increased from 25% vs 47%, p<0.0001.

Conclusions
Direct EMS routing to certified Stroke Centers reduced times from ED arrival to initial brain imaging, and more than doubled frequency of achievement of the national DTI target. These results support wide national dissemination of regionally organized stroke critical care systems.
Abstract 205: Optimizing Prediction Scores for Poor Outcome After Intra-arterial Therapy for Anterior Circulation Acute Ischemic Stroke
Authors: Sarraj Amrou , Barreto Andrew D , Albright Karen , Sitton Clark , Choi Jeanie , Lutzker Steven L , Bibars Wafi , Martin-Schild Sheryl , Saver Jeffery , Liebeskind David S , Gupta Rishi , Grotta James C , Savitz Sean I
Published: July 2021

Background:
Intra-arterial therapy (IAT) is an approach to promote recanalization of large artery occlusions (LAO) in acute ischemic stroke (AIS) but is resource intensive. Previous studies evaluated different variables that affect clinical outcome after IAT. To better identify patients who have poor outcomes despite IAT, we compared the performance of previous predictive scoring systems that relied either on clinical or imaging variables in patients undergoing IAT. We then combined imaging and clinical variables to optimize a score that would better predict poor outcome after IAT for AIS.

Methods:
We studied consecutive AIS patients undergoing IAT at UT-Houston for LAO (MCA or ICA) from 01/03 to 05/11. We collected demographics and clinical variables and analyzed CT head scans using the ASPECTS scores by raters blinded to outcomes. Independent predictors of poor outcome (mRS 4–6) with p values ≤0.1 were evaluated as score variables using sensitivity analysis and logistic regression. Spearman’s correlation and ROC curves were used to evaluate the final score. Houston Intra-arterial Therapy 2 (HIAT2) score ranged from 0–10 with points for: age (≤59=0, 60–79=2, ≥80 years=4), Glucose (<150=0, ≥150=1), NIHSS (≤10=0), 11–20=1, ≥21=2), ASPECTS (8–10=0, ≤ 7=3). The score was created using 75% of the dataset (build group) and tested on the remaining 25% (test group). Previously published prediction scores (HIAT, THRIVE, ASPECTS) were compared against HIAT2.

Results:
Table 1 shows the clinical features for the 163 patients collected.
Fig 1
shows the proportion of poor outcome based on HIAT-2. Patients with HIAT2 ≥ 5 were more likely to have a poor outcome at discharge (OR 6.43, 95% CI 2.75–15.02, p<.001). After adjusting for reperfusion (TICI≥2b, p=.7) and time from symptom onset to recanalization (p=.4), HIAT2 remained a significant independent predictor of poor outcome (OR 5.88, 95% CI 1.96–17.64, p=.02).
Fig 2
shows the performance of HIAT2 against THRIVE, HIAT and ASPECTS as well as the validation of HIAT-2.

Conclusions:
Clinical prediction scores for patients undergoing IAT (HIAT, THRIVE) proved superior to the ASPECTS score. The HIAT2 score, which combines clinical and imaging variables, performed better than all previous scores in predicting the chance of poor outcome after IAT for anterior circulation LAO.
Abstract 2580: How Frequent Is Impaired Arm And Hand Function After First Occasion Of Stroke? An Unselected Population From A Stroke Unit With A Geographical Catchment.
Authors: Stibrant Sunnerhagen Katharina , Persson Hanna C
Published: July 2021

Introduction
Reduced upper extremity function after stroke has previously been reported in 70-80% of patients with stroke in the acute stage and is one of the most common impairments after acute stroke impaired motor function, both in upper and lower extremity, influence the stroke unit care and planning of the rehabilitation, partly due to the economic costs. There is limited information in upper extremity function within the first days after a stroke. Prior studies include either both first and recurrent stroke or only one type of stroke.

Objectives
To investigate the frequency impaired arm and hand function in an unselected group of patients with first occasion of stroke.

Method
All patients at a stroke unit at Sahlgrenska University Hospital were assessed during 18 months. From the hospital records, the patients were identified, the patient charts were read and first stroke diagnosis was confirmed (by either imaging or clinical assessment). Impaired upper extremity function was defined in the following manner: assessed with the Modified Motor Assessment Scale (M-MAS UAS -95) by physiotherapist working at the stroke unit within 72 hours after stroke onset or if this was found in the patients chart, other standardized assessments of upper extremity function performed by the physical therapist, the occupational therapist or the physicians on the ward.

Results
During the study period 984 patients with first ever stroke (438 women 44.5%) were admitted to the stroke unit. A total of 213 patients were not at the stroke unit within 72 hours after onset and therefore excluded; 90 patients had unclear stroke onset time, 49 patients were located at another ward, 36 patients were in the intensive care unit, 25 in other hospitals in Sweden and 12 patients were hospitalized in another country. There were 771 patients over 18 years old at the stroke unit within 72 hours after stroke onset. Of these 56 patients (7.3%), were not living in the catchment area and therefore excluded. Of the 715 patients living in the geographical catchment area, 58, (8.1%) hade other upper extremity injury prior the stroke onset. Of the remaining first ever stroke patients (n=657), 311 patients (47.3%) hade impaired arm and hand function within 72 hours after stroke onset.

Conclusion
The frequency of impaired upper extremity function in this unselected population of first occasion of stroke is lower than previously reported. The Copenhagen stroke study noted 69 % impaired at admission and 43 % at one week. This indicates that today’s stroke patients present less frequent with impaired motor function in the upper extremity. However, they may have difficulties in functional activities which may influence content of rehabilitation process.
Abstract 2587: Standard Medical Management Is Associated With Improved Quality And Outcome Of Secondary Stroke Prevention In China
Authors: Cui Liying , Peng Bin , Ni Jun , Zhou Lixin , Zhu Yicheng , Yao Ming , Xu Weihai , Wang Jianming , Wang Yongjun , Pu Chuanqiang , Wu Jiang ,   SMART Group
Published: July 2021

Background and objective:
Although guidelines for secondary ischemic stroke have been developed, there is a gap between guidelines and real world. To investigate the current status of secondary ischemic stroke in China and improve the quality of stroke prevention, We design a recommended guideline based program (SMART trial) and implement it in clinic practice to evaluate the feasibility and efficacy of the program.

Methods:
We conducted a multicenter (47 centers), paralleled, randomized, open label, controlled trial. Patients were randomized to two groups: standard medical management group (SMART group) and usual care group. In SMART group, measures of intervention were chosen based on the stroke sub-type according to the TOAST classification. Advice were given to the patients on stroke prevention . In usual treatment group, measures of intervention were chosen by the physician according to his/her personal knowledge. The main outcomes were the proportion of the patient’s adherence to 5 recommended measures and proportion of patients achieving the treatment target over time, a composite measures (total number of measure performed divided by the total number of eligible patients) was calculated. Secondary outcome was the composite cardiovascular events including new onset ischemic stroke, acute coronary syndrome, new onset hemorrhage stroke, and all causes of deaths.

Results:
Three thousand eight hundred and twenty-one patientswere enrolled into the trial. 1795 patients in standard medical treatment group, 2026 patients in usual care group. Participation in SMART group was associated with improvements in 3 measures and 1 composite measures (one year follow up): antiplatelet agents use (81.1% versus 74.9% ), statins use (55.8% versus 32.9%), antihyperglycemic agents use ( 72.6% versus 66.9% )and composite measures (68.36% versus 58.33%).Increased proportion of patients achieving treatment target were noticed (18 months follow up): blood pressure <140/90mmHg(60.6% versus 42.9%), LDL-C <2.6mmol/L (11.4% versus 9%)and HbA1c≤ 7% ( 6% versus 4.8%). The composite cardiovascular events rate decreased (4.18% versus 4.84%). The cost in hospital reduced 4.66%.

Conclusions:
Standard medical management program was feasible and associated with improved quality and outcome in secondary ischemic stroke prevention. Large scale promotion of this program across China was warranted.
Abstract 2972: Perfusion CT in Patients with Basilar Artery Occlusion: Diagnostic and Prognostic Value in the Basilar Artery International Cooperation Study
Authors: Pallesen Lars P , Puetz Volker , Gerber Johannes , Dzialowski Imanuel , Michel Patrik , Pfefferkorn Thomas , Mattle Heinrich P , Kappelle L. Jaap , Wiedemann Baerbel , Khomenko Andrei , Algra Ale , von Kummer Ruediger , Demchuk Andrew M , Schonewille Wouter J ,   BASICS Study Group
Published: July 2021

Background:
The posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) applied to CT angiography source images (CTA-SI) predicts the functional outcome of patients with basilar artery occlusion (BAO). Compared with CTA-SI, perfusion CT (CTP) may provide added information. We assessed the diagnostic and prognostic impact of CTP compared with CTA-SI among patients in the Basilar Artery International Cooperation Study (BASICS)

Methods:
BASICS was a prospective observational registry of consecutive patients with acute symptomatic BAO. We applied pc-ASPECTS to CTA-SI and cerebral blood volume (CBV), cerebral blood flow (CBF), time-to-peak (TTP) and mean-transit-time (MTT) parameter maps in a 3-reader-consensus with readers blinded to clinical data. Hypoattenuation on CTA-SI, a relative reduction in CBV or CBF, or relative increase in MTT or TTP was rated as abnormal. Clinical outcome was measured with the modified Rankin Scale (mRS) score at 1 month.

Results:
Among 592 patients in the BASICS registry, 27 patients (4.6%) had CTP studies performed. Median (interquartile-range) pc-ASPECTS values on TTP/MTT, CTA-SI, CBF and CBV were 6 (5-8), 7 (5-9), 8 (6-9) and 10 (8.75-10), respectively (p<0.001). The proportion of patients with any perfusion abnormalities in the posterior circulation was highest for TTP/MTT (93%; CI
95%
74% to 99%), compared with 78% (CI
95%
57% to 91%) for both CTA-SI and CBF and 46% (CI
95%
27% to 66%) for CBV (p<0.001). At 1 month, 9 patients (33%) had a favourable outcome (mRS scores 0-3), 8 patients (30%) had an unfavourable outcome (mRS scores 4-5) and 10 patients (37%) were deceased. In univariate analysis, pc-ASPECTS scores did not correlate with outcome mRS scores for all imaging modalities (Spearman’s Rho, p>0.1 for all). All three patients (100%) with a CBV pc-ASPECTS <8 compared to 6 of 23 patients (26%) with a CBV pc-ASPECTS >8 died (p=0.03).

Conclusion:
CTP was performed in a minority of patients in the BASICS registry population. Perfusion disturbances in the posterior circulation were most frequent and most pronounced on TTP and MTT parameter maps. Extensive reduction of CBV, defined as a pc-ASPECTS <8, may indicate patients with a high case fatality.
Abstract 3131: Impact of Undetermined or Other Determined Categories by TOAST on Prognosis After Ischemic Stroke
Authors: Kim Dohoung , Lee Seung-Hoon , Kim Beom Joon , Jung Keun-Hwa , Yu Kyung-Ho , Lee Byung-Chul , Roh Jae-Kyu ,   Korean Stroke Registry Group
Published: July 2021

Background:
A few studies have suggested that stroke subtypes influence the long-term mortality following ischemic stroke. However, the outcome in patients with strokes of undetermined or other determined etiology (OD) has not yet been elucidated.

Method:
We prospectively enrolled acute ischemic stroke and transient ischemic attack patients from 29 hospitals in Korea over a 9-year period. The Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria was used to classify stroke subtype. Stroke of undetermined etiology was further divided into 1) 2 or more cause, 2) negative etiology, and 3) incomplete evaluation (UI). We analyzed the demographics, risk factors, duration of admission, functional outcomes at discharge, 30-day mortality, and any cause mortality after stroke.

Results:
A total of 38,875 patients with ischemic stroke and transient ischemic attack were included in this study. Thirty-day mortality was 3.8%, and overall mortality at the end of follow-up was 23.2%. Mean follow-up duration was 1032±780 days. Thirty-day mortality and long-term mortality was highest in UI group (14.9% and 41.4%, respectively) among all stroke subtypes. The OD and UI subtype was a powerful predictor of 30-day mortality [for OD: odds ratio (OR) 2.18, 95% confidence interval (CI) 1.37-3.47; for UI: OR 3.30, 95% CI 2.65-4.10; large-artery atherosclerosis as a reference] after control of all possible confounders. In addition, the OD and UI subtype was an independent predictor of death during the follow-up [for OD: hazard ratio (HR) 1.81, 95% CI 1.49-2.20; for UI: HR 1.59, 95% CI 1.45-1.74; large-artery atherosclerosis as a reference]. Other independent predictors of long-term mortality were age, sex, body mass index, history of prior stroke, diabetes, dyslipidemia, NIHSS on admission, intrahospital treatment of thrombolytics, and second preventive medication at discharge.

Conclusion:
Our study on subgroups of undetermined and other determined etiology showed heterogenous prognosis.
Abstract 3543: Imaging Correlates of Early Neurologic Deterioration among Patients with Intracerebral Hemorrhage
Authors: Sanossian Nerses , Burgos Adrian M , Liebeskind David S , Starkman Sidney , Villablanca Pablo , Conwit Robin , Eckstein Marc , Pratt Franklin D , Stratton Samuel , Hamilton Scott , Saver Jeffrey L ,   FAST-MAG Investigators and Coordinators
Published: July 2021

Background:
Early neurologic deterioration (END) occurs commonly in intracerebral hemorrhage (ICH) patients being transported by EMS ambulances, but the imaging correlates of END have not been previously delineated.

Methods:
We analyzed consecutive ICH patients in the Field Administration of Stroke Therapy - Magnesium (FAST-MAG) Trial, a phase 3, multicenter of paramedic-initiated magnesium sulfate vs. placebo for stroke patients presenting within 2 hours of symptom onset. END was defined as a 2-point or greater decrease in the Glasgow Coma Scale (GCS) from paramedic evaluation to ED evaluation. Baseline imaging studies were independently analyzed by 2 neurologists for ICH location, volume, presence of intraventricular hemorrhage (IVH), heterogeneity (defined as >20 point difference in Hounsfield units), irregular hematoma borders, multilobulated appearance, and substantial edema (defined as >0.5cm thickness). Leukoaraiosis was graded using the Fazekas scale for periventricular and deep white matter changes (0-3 for each).

Results:
Among 127 patients, mean age was 66 (SD 14) years, 34% were women, 35% were Hispanic ethnicity, 83% white, and 84% had a history of HTN. Patients were evaluated by paramedics a median of 23 (IQR 16, 39) minutes after last known well time (LKWT). At that time, the median GCS was 15 (IQR 15-15) and mean SBP/DBP was 177/95 (SD 34/22). Initial post-arrival brain imaging was performed a median of 94 (IQR 77, 117) min after LKWT. Post-arrival study GCS scores were obtained at a median of 108 (IQR 70, 144) min after LWKT. Early neurologic deterioration occurred in 37 (29%) patients. Among these patients, median first ED GCS was 3 (IQR 3-10). On first imaging, compared with neurologically stable patients, END patients had larger hematoma volume (33 cc v 16 cc, p<0.0001), and more frequent presence of intraventricular extension (45% v 20%, p=0.003), midline shift (58% v 22%), substantial edema (54% v 26%, p=0.038), heterogeneous density (50% v 22%, p=0.006), multilobulated appearance (44% v 18%, p=0.002), and irregular border (39% v 14%, p=0.010). Leukoaraiosis and cortical v subcortical location did not affect rates of END. In multivariate analysis, hematoma volume and presence of IVH were imaging findings independently associated with early neurologic deterioration.

Conclusions:
About 3 in 10 patients with hyperacute ICH neurologically deteriorate during the prehospital and early emergency department course, often before neuroimaging is obtained. Patients with early neurologic deterioration have larger hematoma volume and occurrence of IVH on initial imaging. These findings suggest hematoma expansion prior to ED arrival drives early neurologic deterioration in ICH and emphasize the need for prehospital interventions.
Abstract 3785: Distal Occlusions And Smaller Clots Show High Early Recanalization Rates With iv tPA: Pilot Data From The Multi-center Interrsect Study.
Authors: Menon Bijoy , Sohn Sung-Il , Calleja Ana , Dowlatshahi Dar , Puig Josep , Jin Albert , Poppe Alex , Moreau Francois , Boulanger Jean-Martin , Stewart Teri , Goyal Mayank , Hill Michael D , Demchuk Andrew M ,   INTERRSeCT Study Group
Published: July 2021

Introduction:
We seek to present results from INTERRSeCT, an ongoing prospective multicenter imaging based cohort study aimed at understanding thrombus characteristics on CT that predict early recanalization with intravenous thrombolysis.

Methods:
The pilot data analysed includes any patient (age ≥ 40) presenting to the emergency department with symptoms consistent with ischemic stroke and with evidence of a visible and symptomatic intracranial occlusion on baseline CT-angio. Each patient enrolled in the study had early recanalization assessed on repeat CT-angio within 3-5 hours of baseline imaging or on conventional angio at end of intervention. Imaging data including various thrombus characteristics were analyzed in a core-imaging lab at the University of Calgary.

Results:
Of 101 patients included in INTERRSeCT, 63 patients received IV t-PA at baseline. Of these, 40 patients (mean age 71+/- 12.5 yrs, 52% male) treated with IV t-PA alone have been included for this analysis. The median stroke symptom onset to CT time was 134.5 minutes (IQR 77 mins) and median IV t-PA to repeat CTA time was 228 minutes (IQR 82 mins). Overall recanalization rate in this cohort was 24/40 (60%). Recanalization rates by site of occlusion were as follows: ICA - 2/8 (25%), M1 MCA - 4/10 (40%), M2 MCA - 11/15 (73.3%), M3 MCA (n=2), PCA(n=2) and ACA(n=3) - 7/7 (100%) (p=0.01). Median clot lengths by site of occlusion were as follows: ICA (5 cm), M1 MCA (2.44 cm), M2 MCA (1.81 cm), M3 MCA, PCA and ACA combined (0.8 cm). Median clot length at baseline CTA was significantly lower in the recanalizers when compared to the non-recanalizers. (1.64 cm vs 2.68 cm, p = 0.01). (
Table
)

Conclusion:
M2 MCA and other distal occlusions show high early recanalization rates with IV t-PA. These high recanalization rates could be due to smaller clot length.
Abstract 3851: Temporal Distribution of Stroke Volumes and Clinical-Diffusion Mismatch in Patients with Proximal Arterial Occlusions
Authors: Nogueira Raul G , Liebeskind David S , Souza Leticia M , Hao Qing , Furie Karen , Yoo Albert J , Saver Jeffrey ,   Investigators UCLA Stroke, Lev Michael H , Gupta Rishi
Published: July 2021

Background and Purpose:
Previous studies have demonstrated that the benefit of reperfusion therapy declines over time. The Clinical-Diffusion Mismatch (CDM) model has been suggested as surrogate for salvable tissue in acute ischemic stroke (AIS) patients. We sought to describe the temporal behavior profile of infarct volumes and CDM in patients suffering AIS due to proximal arterial occlusion (PAO).

Methods:
We performed a retrospective analysis of consecutive AIS patients admitted to two large academic institutions fulfilling the following criteria: (1) Baseline NIHSS ≥8; (2) PAO defined as MCA-M1, intracranial ICA, or tandem cervical + ICA/MCA-M1 occlusion on admission CTA/MRA; and (3) MRI-DWI performed ≤8 hours from time of stroke onset/last seen well (TSO). CDM was defined as baseline NIHSS ≥8 and DWI volume ≤25cc (as proposed by Davalos et al). Linear regression analysis was performed to define the changes on DWI lesion volume on presentation over time. The observed TSO to MRI were broken down into quartiles to look for any differences in the distribution of the baseline variables over time.

Results:
A total of 132 consecutive patients were identified (mean age, 66±16.8 years; 57% females; mean baseline NIHSS 17.5±5.3; occlusion site: MCA-M1, 64%; intracranial-ICA, 29%; tandem, 5%, mean TSO to DWI, 269.5±105.48 minutes). The mean DWI stroke volume on presentation was 46.7±54.8 cc (range, 0.19-436.1) and 63 (46.7%) patients had CDM. There was no significant changes in age, gender, baseline NIHSS, or occlusion site amongst the different time quartiles. Median infarct volume (cc) increased (quartile #1=8.5; #2=30.1; #3=38.5; #4=29.4) and the chances of having a CDM decreased (p<0.0001) across the different time quartiles. However, there was an overall poor correlation between DWI lesion volume on presentation and TSO to MRI (R-square=0.031,
Figure
) and a significant proportion of the patients still had a CDM at later time epochs (#1=91.1%[20/22]; #2=47.8%[11/23]; #3=34.4%[21/61]; #4=42.3%[11/26]).

Conclusions:
Although infarct volume increases and the amount of penumbral tissue decreases over time, many patients with PAO will still have salvable penumbra at the later time epochs. This reflects individual differences in anatomic and physiological characteristics including the strength of collateral flow and highlights that selected patients may benefit from reperfusion therapy even at the later time windows.
Figure
: Relationship between Baseline DWI Volume (cc) and Time (minutes). Line is best fitted linear regression model.
Abstract 66: Ischemic Lesion Evolution and Hemorrhagic Transformation After Thrombolysis with Neuroprotection in FAST-MAG
Authors: Liebeskind David S , Sanossian Nerses , Burgos Adrian M , Fong Albert K , Chatfield Fiona , Conwit Robin A , Hamilton Scott , Starkman Sidney , Villablanca Pablo , Saver Jeffrey L ,   for the FAST-MAG Investigators and Coordinators
Published: July 2021

Background:
The frequency and range of early infarct signs in acute cerebral ischemia patients have been described in several 6-24 hour cohorts, but are incompletely characterized among under 2 hour presenting patients who actually proceed to receive IV tissue plasminogen activator (tPA). Prompt treatment with tPA improves outcomes after acute ischemic stroke, providing a platform to test promising neuroprotective strategies. We analyzed baseline and 24-hour imaging studies in an initial cohort of thrombolysis cases in the FAST-MAG trial of prehospital initiation of neuroprotection.

Methods:
Baseline and 24-hour CT/MRI studies acquired in 100 consecutive patients enrolled in FAST-MAG and treated with intravenous tPA were rated by two imaging experts for the presence of early ischemic changes (EIC), hyperdense vessel signs (HVS), ASPECTS score, white matter hyperintensities, prior infarction, lesion pattern and hemorrhagic transformation (HT), blind to all other data in the trial.

Results:
Among the 100 patients, mean age was 72±13 years; 44% were women; and median NIHSS was 14 (IQR 8-20). Initial imaging was obtained a mean of 91±29 minutes after last known well and routine post-thrombolysis imaging was obtained a mean of 23±13 hours later. Modality for initial scans was CT in 92% and MRI in 8%, and for follow-up scans CT in 63% and MRI in 37%. EIC were noted in 44%, including insular ribbon sign in 35%, lenticular obscuration in 28% and cortical effacement in 10%. HVS was visualized in 50%. Initial ASPECTS was median 9 (IQR 8-10) and 7 (IQR 4-9) at 24 hours. 24-hour lesion patterns were characterized as predominantly cortical in 50%, subcortical in 19%, scattered in 23% and no lesion in 8%. At 24 hours, ASPECTS correlated with NIHSS (R=-0.409, p<0.001) whereas specific lesion patterns did not (p=NS). Cortical lesion patterns at 24 hours were predicted by cortical effacement on initial CT (23% vs. 0%, p=0.011). HT occurred in 26%, including 15% HI1, 3% HI2, 4% PH1, 3% PH2 and 1% IVH. Factors associated with HT were lower baseline ASPECTS (7.5 vs. 8.7, p=0.002) and more severe baseline NIHSS (18 vs. 13, p=0.021).

Conclusions:
Among patients imaged a mean of 1.5 hours after onset and then treated with thrombolysis, hyperdense vessel signs are present in one-half and early signs of ischemic parenchymal injury are present in nearly half, but are generally mild. Observed rates of HT were low. Serial imaging of patients treated with field neuroprotective therapies followed by post-arrival thrombolysis is often informative at initial and follow-up time points and has potential as biomarkers to interrogate treatment effects in prehospital neuroprotection studies.
Abstract 72: Refining The Pre-treatment Noncontrast CT ASPECTS Threshold For IAT Selection: Pooled Analysis Of The Penumbra Pivotal Study And PICS Registry
Authors: Yoo Albert J , Chaudhry Zeshan A , Gonzalez R. Gilberto , Goyal Mayank , Demchuk Andrew , Mualem Elan , Buell Hope , Sit Siu Po , Bose Arani ,   The Penumbra Pivotal and PICS Investigators
Published: July 2021

Background:
Previous studies have demonstrated that the Alberta Stroke Program Early CT Score (ASPECTS) on pre-treatment noncontrast CT (NCCT) can be used to identify patients who will benefit from intra-arterial therapy (IAT). Specifically, an ASPECTS threshold of 7 has been identified as clinically important. We sought to test this threshold and further characterize the clinical impact of pre-treatment ASPECTS (pre-ASPECTS) in a large IAT cohort.

Materials and methods:
We identified anterior circulation acute ischemic stroke patients treated with the Penumbra Stroke System in the Pivotal Study and the Penumbra Imaging Collaborative Study (PICS). Inclusion criteria for this analysis were evaluable pre-treatment NCCT and available 90-day modified Rankin Scale (mRS) score. Expert readers graded ischemic change on NCCT using ASPECTS and blinded to all clinical information except stroke side.

Results:
Of 221 patients who fulfilled study criteria, the mean age was 66.0±15.1 years, and median NIHSS score was 16 (IQR 12-21). The cohort was 50.9% (112/220) female. There were 111 (50.2%) right-sided strokes. The target vessel occlusion involved the ICA in 21.9% (48/219), MCA in 77.6% (170/219) and ACA in 0.5% (1/219). The median ASPECTS was 7 (IQR 6-9). TIMI 2-3 reperfusion was achieved in 83% (181/218). Good outcome (mRS 0-2) was achieved in 77 (34.8%) patients at 90 days. Adjusting for age, NIHSS and reperfusion, pre-treatment ASPECTS was an independent predictor of good outcome (O.R. 1.47; 95%C.I.:1.23 to 1.76). Pre-ASPECTS >7 predicted good outcome with a relative risk of 1.80 (95%C.I.:1.23 to 2.64). The proportion of good outcomes was exceedingly low among pre-ASPECTS 0-4 (2.8% [1/36];
Figure
). When trichotomizing pre-ASPECTS at 0-4 (n=36), 5-7 (n=76) and 8-10 (n=109), the median 90-day mRS scores were 6 (IQR 4-6), 3.5 (IQR 2-6) and 3 (IQR 1-4), respectively (p<0.0001). In pairwise comparison, the only significant differences were between pre-ASPECTS 0-4 and the other groups. While there was no effect of reperfusion on outcome among pre-ASPECTS 0-4, TIMI 2-3 reperfusion (p=0.04) and earlier timing of reperfusion (none vs. <300 minutes vs. ≥300 minutes; p=0.03) were associated with better outcomes among pre-ASPECTS 5-10.

Conclusions:
Pre-treatment NCCT ASPECTS is a critical determinant of outcome following IAT. Pre-ASPECTS 0-4 identifies a population of patients who are highly likely to have dismal outcomes and do not benefit from endovascular reperfusion.
Abstract 128: Can Response Adaptive Randomization Increase Participation in Acute Stroke Trials?
Authors: Tehranisa Jason , Meurer William J
Published: July 2021

Introduction:
Acute stroke trials may be improved by using response-adaptive randomization (RAR) because it works in favor of the trial population on average. With RAR, the ratio of participants assigned to each trial arm is adjusted to favor the better performing treatment using outcome information from earlier participants in the clinical trial.

Hypothesis:
When presented a hypothetical acute stroke trial, more patients would agree to a RAR versus a standard clinical trial with all other aspects of trial held constant.

Methods:
This cross-sectional survey included adult ED patients presenting without stroke or other critical illness. A standardized protocol was used and subjects were randomized to view either an RAR or standard hypothetical acute stroke trial. After viewing the video describing the hypothetical trial (http://youtu.be/cKIWduCaPZc), reviewing the consent form, and having questions answered, subjects indicated whether they would consent to the trial. Adequacy of the informed consent process was measured by ICQ-4. A multivariable logistic regression model was fitted to estimate the impact of RAR, while controlling for demographic factors and patient understanding of the design.

Results:
A total of 418 subjects (210 standard 208 RAR) were enrolled. All baseline characteristics were balanced between groups. There was significantly higher participation in the RAR trial (67.3%) versus the standard trial (54.5%), absolute increase: 12.8% (95% CI: 3.7 to 22.2%). The trials were generally well understood by the participants (Table); however standard randomization appeared to be better understood. The RAR group had a higher odds ratio of agreeing to research (O.R. 1.89, 95% CI [1.2 - 2.9]), while adjusting for patient level factors.

Conclusion:
The RAR trial attracted more research participation than standard randomization and has potential to increase recruitment and offer benefit to future trial participants.
Abstract T MP110: Central Retinal Artery Occlusion in Patients with Sickle Cell Disease
Authors: Khan Hashim , Chughtai Morad , Malik Ahmed A , Qureshi Adnan I , Suri Fareed K
Published: July 2021

Objective:
To determine the rate of and risk factors for incident central retinal artery occlusion (CRAO) among patients with sickle cell disease enrolled in a large cohort with longitudinal follow-up.

Background:
Sickle cell disease increases the risk of ischemic stroke among women but the risk of CRAO is not studied.

Design/Methods:
A total of 4085 patients from newborns to 77 years-old, were enrolled in Phase 1 of Cooperative Study of Sickle Cell Disease from 23 centers across the US. Participants underwent a baseline examination for assessment of demographics, prior medical history, lab assessments, and clinical data. Post baseline data included routine follow-up examinations, measures of organ damage, and collection of acute and chronic complications. The risk factors for CRAO were identified using Cox Proportional Hazards analysis.

Results:
A total of 9 (0.002%) of 4085 patients with sickle cell disease developed CRAO over a mean follow-up of 5.2 (95% CI 0.9 - 11.3) months, with an estimated incidence of 0.02 per 100 patient years. The incidence of CRAO was 0.03 per 100 patient years and 0.05 per 100 patient years in men and women, respectively. The history of previous stroke (2.6% versus 0.0%, p=0.7) and the proportion of patients diagnosed with large arterial occlusive disease (55.6% versus 7.7%, p=<0.001) was greater in those who developed CRAO compared to those who did not develop CRAO. History of exchange transfusions (2.7 % versus 22.2 %, p=0.02) and cigarette smoking (13.7 % versus 22.2 %, p =0.4) were more common among patients who developed CRAO. The hematocrit (%) (mean ± SD) was similar between patients who did or did not develop CRAO (29.5 ± 9.6 versus 27.3 ± 5.6, p=0.3). At completion of follow-up, 22.2% (n=2) patients with CRAO reported disability compared with 11.1% (n=455) patients without CRAO (p=0.7)

Conclusions:
The incidence of CRAO is relatively high among patients with sickle cell disease and was associated with disability.
Review of the bee genus Pseudoanthidium Friese, 1898 (Hymenoptera: Apoidea: Megachilidae: Anthidiini) of China with descriptions of three new species
Authors: NIU ZE-QING , LUO A-RONG , GRISWOLD TERRY , ZHU CHAO-DONG
Published: July 2021

The carder bee genus Pseudoanthidium Friese, 1898, is revised from China. Eight species are confirmed to occur in China, including three new species: Pseudoanthidium (Pseudoanthidium) yanruae Niu & Zhu, sp. nov., P. (P.) kunesense Niu & Zhu, sp. nov., P. (P.) chenggongense Niu & Zhu, sp. nov. There is also one new generic assignment and synonymy: Anthidium kryzhanovskii Wu, 1962 is a junior synonym of P. (P.) orientale (Bingham, 1897). Pseudoanthidium (P.) campulodonta (Wu, 1990) is synonymized with P. (P.) tenellum (Mocsáry, 1880). Here we provide descriptions for the three new species and an illustrated key to the known Chinese Pseudoanthidium.
Effects of Pacemaker Implantation on Sudden Cardiac Death Rate and Quality of Life in Atrial Fibrillation Patients With Ventricular Pauses
Authors: Li Yao-Dong , Hong Yi-Fan , Ma Jian-Hua , Cao Gui-Qiu , Zhou Xian-Hui , Zhang Jiang-Hua , Xing Qiang , Tang Bao-Peng
Published: July 2021

Ventricular arrest is a rare arrhythmic disease in the clinic; 35% to 55% of cases are associated with atrial fibrillation (AF). It is well known that ventricular arrest for ≥3 seconds can lead to brain symptoms such as dizziness and even syncope, but it is not clear whether ventricular pauses (≥3 seconds) with AF will lead to sudden cardiac death. If the implantation of a pacemaker can improve the quality of life of patients with permanent AF with ventricular arrest and whether it has a long-term protective effect on sudden cardiac death. To this end, we conducted a prospective follow-up observation study, which was conducted through telephone interviews and clinical hospital observation to obtain information on the quality of life, survival rate, and other details. The results show that for patients with permanent AF with ventricular arrest, pacemaker implantation cannot reduce sudden cardiac death, cardiovascular events, and stroke nor can it improve the cumulative survival rate. Fortunately, the implantation of pacemakers can improve the quality of life of patients.
Bargaining for gender equality in Aotearoa New Zealand: Flexible work arrangements in collective agreements, 2007–2019
Authors: Proctor-Thomson Sarah , Donnelly Noelle , Parker Jane
Published: July 2021

Collective bargaining remains an important yet underexplored mechanism in the pursuit of workplace gender equality. Through gender equality bargaining efforts, unions seek to address the lack of equity for working women. Yet little is known of the extent of equality bargaining provisions, or about where provisions and the factors that influence their availability occur. Contributing to this disparity is a lack of data measuring gender equality provisions in collective agreements. This article analyses key trends in the collective regulation of flexible work provisions in Aotearoa New Zealand from 2007 to 2019. Results show modest growth in the scope and coverage of flexible work provisions, the majority of which have occurred in the public sector. Marked differences across sectors and industries suggest the influence of factors such as women’s rising labour force participation and feminisation of union membership and its leadership, particularly within industries where union density has grown. Findings underscore the need for contextualisation of collective regulation in opportunity structures and the ongoing frailty of women’s access to gender equality.