DRUG RELATED NITROSOGENESIS, PHOTOCARCINOGENESIS AND ONCOPHARMACOGENESIS OF NODULAR MELANOMA: A CASE RELATED ANALYSIS CONCERNING THE POLYCONTAMINATION OF THE POLYMEDICATION WITH VALSARTAN/HYDROCHLOROTHIAZIDE AND BISOPROLOL

Despite the fact that the pathogenesis of cutaneous melanoma is shrouded in mystery, factors that have been neglected or unnoticed until now have come to the attention in recent years, and in all likelihood, they could also be pivotal. These factors, known as nitrosamines or NDSRIs, are characterized by high carcinogenic and mutagenic potency, and some of them have demonstrated these properties to human DNA as well. Unfortunately, these ingredients also turn up as contaminants in about 300 of the most widely distributed drugs worldwide. According to the most recent literature, some of these ingredients are also identified as potent photocarcinogens, as well as human carcinogens. The intake of these carcinogens in the context of polycontamination of polymedication, has been associated for years with the occurrence of melanomas. The need for cataloguing of nitrosamines , as well as their accurate labelling on drug packaging, would help to classify them even more accurately as carcinogens affecting human DNA. We present once again a patient , who developed nodular melanoma within the context of the intake of 3 potentially nitrosamine/ NDSRIs contaminated antihypertensive drugs (valsartan/ Hydrochlorothiazide/ bisoprolol). Pathogenetic aspects concerning drug-induced nitrosogenesis, photocarcinogenesis and oncopharmacogenesis of skin cancer are discussed. Nitrosogenesis' of Cancer as concept in the medical literature has been known for decades, but in relation to other forms of human cancer. Exogenously mediated drug-mediated nitrosogenesis is a logically conditioned and newly defined concept whose significance with respect to the clinical manifestation of skin cancer is only beginning to grow.

Efficacy and Safety of Oral Factor XIa Inhibitors in Stroke Prevention: A Systematic Review and Meta-Analysis

INTRODUCTION

Despite preventive measures, stroke rates remain high in the primary and secondary prevention settings. Factor XIa inhibition may offer a novel, safe and effective antithrombotic option for stroke prevention.

METHODS

We conducted a systematic review and meta-analysis including all available randomized controlled clinical trials (RCTs) that investigated the efficacy and safety of factor XIa inhibitors versus controls in primary or secondary stroke prevention. The primary efficacy and safety outcomes of interest were symptomatic ischemic stroke (IS) and the composite of major bleeding and clinically relevant non-major bleeding.

RESULTS

Four phase II dose-finding RCTs were included, comprising a total of 4732 patients treated with factor XIa inhibitors versus 1798 controls. Treatment with factor XIa inhibitors did not reduce the risk of IS compared to controls (RR: 0.89; 95% CI: 0.67-1.17). The composite of symptomatic IS and covert infarcts on brain MRI (RR: 1.01; 95% CI: 0.87-1.18), the composite of symptomatic IS and transient ischemic attack (TIA; RR: 0.78; 95% CI: 0.61-1.01), and the composite of major adverse cardiovascular events (RR: 1.07; 95% CI: 0.87-1.31) did not differ between the treatment groups. Treatment with factor XIa inhibitors did not increase the risk of the composite of major bleeding and clinically relevant non-major bleeding (RR: 1.19; 95% CI: 0.65-2.16), major bleeding alone (RR: 1.19; 95% CI: 0.64-2.22), intracranial bleeding (RR: 0.91; 95% CI: 0.26-3.19) or all-cause mortality (RR: 1.21; 95% CI: 0.77-1.90).

CONCLUSION

This meta-analysis provides reassuring evidence regarding the safety of factor XIa inhibitors. These findings, coupled with potential signals of efficacy in reducing IS (and TIA), underscore the importance of ongoing phase III RCTs for providing definitive data regarding the effect of factor XIa inhibition on stroke prevention.

Observation of Collider Muon Neutrinos with the SND@LHC Experiment

We report the direct observation of muon neutrino interactions with the SND@LHC detector at the Large Hadron Collider. A dataset of proton-proton collisions at sqrt[s]=13.6  TeV collected by SND@LHC in 2022 is used, corresponding to an integrated luminosity of 36.8  fb^{-1}. The search is based on information from the active electronic components of the SND@LHC detector, which covers the pseudorapidity region of 7.2<η<8.4, inaccessible to the other experiments at the collider. Muon neutrino candidates are identified through their charged-current interaction topology, with a track propagating through the entire length of the muon detector. After selection cuts, 8 ν_{μ} interaction candidate events remain with an estimated background of 0.086 events, yielding a significance of about 7 standard deviations for the observed ν_{μ} signal.

Ultrasonography Grading of Internal Carotid Artery Disease: Multiparametric German Society of Ultrasound in Medicine (DEGUM) versus Society of Radiologists in Ultrasound (SRU) Consensus Criteria

PURPOSE

 We sought to determine the diagnostic agreement between the revised ultrasonography approach by the German Society of Ultrasound in Medicine (DEGUM) and the established Society of Radiologists in Ultrasound (SRU) consensus criteria for the grading of carotid artery disease.

MATERIALS AND METHODS

 Post-hoc analysis of a prospective multicenter study, in which patients underwent ultrasonography and digital subtraction angiography (DSA) of carotid arteries for validation of the DEGUM approach. According to DEGUM and SRU ultrasonography criteria, carotid arteries were independently categorized into clinically relevant NASCET strata (normal, mild [1-49 %], moderate [50-69 %], severe [70-99 %], occlusion). On DSA, carotid artery findings according to NASCET were considered the reference standard.

RESULTS

 We analyzed 158 ultrasonography and DSA carotid artery pairs. There was substantial agreement between both ultrasonography approaches for severe (κw 0.76, CI95 %: 0.66-0.86), but only fair agreement for moderate (κw 0.38, CI95 %: 0.19-0.58) disease categories. Compared with DSA, both ultrasonography approaches were of equal sensitivity (79.7 % versus 79.7 %; p = 1.0) regarding the identification of severe stenosis, yet the DEGUM approach was more specific than the SRU approach (70.2 % versus 56.4 %, p = 0.0002). There was equality of accuracy parameters (p > 0.05) among both ultrasonography approaches for the other ranges of carotid artery disease.

CONCLUSION

 While the sensitivity was equivalent, false-positive identification of severe carotid artery stenosis appears to be more frequent when using the SRU ultrasonography approach than the revised multiparametric DEGUM approach.

Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis

BACKGROUND

Endovascular treatment (EVT) for acute ischemic stroke (AIS) patients presenting with Alberta Stroke Program Early CT Score (ASPECTS) 0-5 has not yet proven safe and effective by clinical trials.

OBJECTIVES

The aim of the study was to assess whether EVT in AIS patients presenting with low ASPECTS is beneficial.

DESIGN

Systematic review and meta-analysis of available studies in accordance with the PRISMA statement.

DATA SOURCES AND METHODS

We have searched MEDLINE, the Cochrane Central Register of Controlled Trials, and reference lists of articles published until 28 May 2022 with the aim to calculate (1) modified Rankin scale (mRS) score 0-3 at 3 months, (2) mRS score 0-2 at 3 months, (3) symptomatic intracranial hemorrhage (sICH), and (3) mortality at 3 months.

RESULTS

Overall, 24 eligible studies were included in the meta-analysis, comprising a total of 2539 AIS patients with ASPECTS 0-5 treated with EVT. The pooled proportion of EVT-treated patients achieving mRS 0-3 at 3 months was calculated at 38.4%. The pooled proportion of EVT-treated patients achieving mRS 0-2 at 3 months was 25.7%. Regarding safety outcomes, sICH occurred in 12.8% of patients. The 3-month pooled mortality was 30%. In pairwise meta-analysis, patients treated with EVT had a higher likelihood of achieving mRS 0-3 at 3 months compared with patients treated with best medical therapy (BMT, OR: 2.41). sICH occurred more frequently in EVT-treated patients compared with the BMT-treated patients (OR: 2.30). Mortality at 3 months was not different between the two treatment groups (OR: 0.71).

CONCLUSION

EVT may be beneficial for AIS patients with low baseline ASPECTS despite an increased risk for sICH. Further data from randomized-controlled clinical trials are needed to elucidate the role of EVT in this subgroup of AIS patients.

REGISTRATION

The protocol has been registered in the International Prospective Register of Ongoing Systematic Reviews PROSPERO; Registration Number: CRD42022334417.

Functional and technological properties of food additive "Magnetofood" in production of shaped jelly marmalade on agar and pectin

Jelly and marmalade products are "lyophilic colloids" – lyophilic colloidal-dispersed, ie microheterogeneous (multi- or polyphasic) systems based on high molecular weight compounds (gelatin, pectin, agar, etc.). Therefore, the problem of stabilizing their polyphasic structure is relevant. In addition, the expansion and improvement of the production of jelly and marmalade products requires the search for simplified resource- and energy-saving technology, increasing the stability of the colloidal disperse system, improving the quality and extending the shelf life of finished products. Promising technological applications have food additives in the nanometer range, due to specific and stable physical and chemical parameters, a wide range of functional and technological properties. The paper proposes the solution of the problem of stabilization of the polyphase structure of jelly-marmalade products and the formation of their quality by using the food additive "Magnetofood" (based on double oxide of divalent and trivalent iron: FeO×Fe2O3). "Magnetofood" - highly dispersed powder with a particle size (70–80) nm, which has a fairly diverse functional and technological potential: high ζ-potential and surface activity; clusterophilicity and amphiphilicity; complexing, thickening, structuring, stabilizing, thixotropic properties. This allows us to recommend "Magnetofood" as a food additive of complex action to improve the quality and prolong the shelf life of jelly-marmalade products, in particular jelly-shaped marmalade. The surface-active properties of nanoparticles of the food additive "Magnetofood" are determined: a rather significant value of ζ-potential (34-44) mV, amphiphilicity (marginal wetting angle Q<90o by polar-nonpolar medium) - show signs of stability and stability on polyphasic colloidal-dispersed systems , which increases in acidic environments, in solutions of polysaccharides, proteins on average by (55±)%, which is due to clusterophilicity and self-organization of nanoparticles "Magnetofood" into electrostatic complexes with proteins, polysaccharides and their spatial structuring. It was found that the addition of "Magnetofood" in the mass fraction (0,10–0,20)% to the mass of the structurant increases the viscosity of aqueous solutions of gelling agents in (1,22–1,27) times for agar and in (1,24–1,29) times for pectin and the rate of structuring of gel masses in (1,73±0,01) times for agar and in (1,67±0,01) times for pectin due to the structure-forming action of nanoparticles "Magnetofood". In addition, the ability of the gel structure to thixotropy increases by (1,4–1,5) times and the mechanical strength of the gel well by (1,32–1,80) times for agar and (1,49–1,57) times for pectin due to the stabilizing action of Magnetofood nanoparticles, which allows to reduce the amount of gelling agent by (9.0–11.0)% for agar and by (7.0–9.0)% for pectin.

Automated emergent large vessel occlusion detection by artificial intelligence improves stroke workflow in a hub and spoke stroke system of care

BACKGROUND

Emergent large vessel occlusion (ELVO) acute ischemic stroke is a time-sensitive disease.

OBJECTIVE

To describe our experience with artificial intelligence (AI) for automated ELVO detection and its impact on stroke workflow.

METHODS

We conducted a retrospective chart review of code stroke cases in which VizAI was used for automated ELVO detection. Patients with ELVO identified by VizAI were compared with patients with ELVO identified by usual care. Details of treatment, CT angiography (CTA) interpretation by blinded neuroradiologists, and stroke workflow metrics were collected. Univariate statistical comparisons and linear regression analysis were performed to quantify time savings for stroke metrics.

RESULTS

Six hundred and eighty consecutive code strokes were evaluated by AI; 104 patients were diagnosed with ELVO during the study period. Forty-five patients with ELVO were identified by AI and 59 by usual care. Sixty-nine mechanical thrombectomies were performed.Median time from CTA to team notification was shorter for AI ELVOs (7 vs 26 min; p<0.001). Door to arterial puncture was faster for transfer patients with ELVO detected by AI versus usual care transfer patients (141 vs 185 min; p=0.027). AI yielded a time savings of 22 min for team notification and a 23 min reduction in door to arterial puncture for transfer patients.

CONCLUSIONS

AI automated alerts can be incorporated into a comprehensive stroke center hub and spoke system of care. The use of AI to detect ELVO improves clinically meaningful stroke workflow metrics, resulting in faster treatment times for mechanical thrombectomy.

OPERA tau neutrino charged current interactions

The OPERA experiment was designed to discover the vτ appearance in a vμ beam, due to neutrino oscillations. The detector, located in the underground Gran Sasso Laboratory, consisted of a nuclear photographic emulsion/lead target with a mass of about 1.25 kt, complemented by electronic detectors. It was exposed from 2008 to 2012 to the CNGS beam: an almost pure vμ beam with a baseline of 730 km, collecting a total of 1.8·1020 protons on target. The OPERA Collaboration eventually assessed the discovery of vμ→vτ oscillations with a statistical significance of 6.1 σ by observing ten vτ CC interaction candidates. These events have been published on the Open Data Portal at CERN. This paper provides a detailed description of the vτ data sample to make it usable by the whole community.

THE USE OF FOOD ADDITIVE "MAHNETOFООD" IN THE TECHNOLOGY OF FORMED JELLY MARMELADE

Expansion and improvement of production of jelly and marmalade products requires the search for simplified resource- and energy-saving technology, increasing the stability of a colloidals dispersed system and improving the quality of finished products. Promising technological applications have food additives in the nanometer range, due to unique physical and chemical parameters and a wide range of functional and technological properties. The paper proposes a solution to the problem of stabilizing the colloidal structure of jelly marmalade products and the formation of their quality by using a food additive "Magnetofood" (based on oxides of divalent and trivalent iron: FeO·Fe2O3). "Magnetofood" – ultrafine powder with a particle size of ~80 nm, which has a high functional and technological potential: large specific surface area, surface-active, complexing, sorption, stabilizing properties. This allows us to recommend "Magnetofood" as a food additive of complex action to improve the quality and extend the shelf life of jelly marmalade products, in particular molded jelly marmalade. It is established that the addition of food additive "Magnetofood" in the form of an aqueous suspension at the stage of "swelling-dissolution" of the gelling agent improves the shape, surface and consistency; increases the moisture content by 1,15–1,16 times in agar samples and 1,13–1,14 times in pectin samples; reduces the total acidity by 1,05–1,08 times in agar samples and 1,06–1,09 times in pectin samples; inhibits microbial contamination of the surface of marmalade samples. In addition, the rational content of food additive "Magnetofood" – 0,15% by weight of the prescription mixture and the optimal conditions of temperature and humidity during storage of molded jelly marmalade for 90 days: relative humidity φ=(75±2)%, temperature (18±2)oC.

Neutrophil Gelatinase-Associated Lipocalin (NGAL) predict higher risk of serious renal dysfunction in patients with CI-AKI

Introduction

The Neutrophil Gellatinase Associated-Lipocalin (NGAL) as a biomarker for kidney damage is less investigated in terms of risk prediction.

Purpose

The aim of our study was to evaluate the diagnostic power of NGAL in detection of contrast-induced acute kidney injury (CI-AKI) and it's role for evaluation of the risk for serious renal dysfunction (SRD).

Methods

The study included high risk patients with chronic kidney disease (CKD) stage 2 and 3 undergoing coronary angiography and/or angioplasty for stable angina. Blood samples for plasma NGAL and serum creatinine (sCr) were collected baseline at the day before, at 4th and 24th hours after contrast exposure. The original risk scale as validated from Brown was used to calculate SRDcreat based on sCr and modified score was established with calculate SRDngal according to baseline levels of NGAL.

Results

The study enrolled 93 patients divided in control group (n=18/19%), CI-AKI group (n=18/19%), subclinical CI-AKI (n=15/16%), CKD 3a stage (n=33/36%) and CKD 3b stage (n=9/10%). The baseline level of NGAL in control group was 76.40±14.70 ng/ml and didn't change significantly after angiography. In the CI-AKI group NGAL increased early after contrast investigation (at 4th hour 139.59±65.57 ng/ml versus baseline values 121.91±59.37 ng/ml; p=0.003) and maintained this tendency until 24th hour (202.88±225.29 ng/ml; p&lt;0.001). In the subclinical CI-AKI pattern of NGAL was similar to CI-AKI with estimated levels at 4th hour 128.18±99 ng/ml (vs baseline values 76.69±29.32 ng/ml, p=0,002). Groups with CKD showed significantly higher baseline level of NGAL (3a stage – 114.98±29.98 ng/ml and 3b stage – 173.30±47.66 ng/ml, p&lt;0.05). The ROC analysis demonstrated AUC 0.889 (95% CI: 0.768–1.000; p&lt;0.001) for diagnostic power of NGAL at 4th hour to detect CI-AKI and AUC 0.731 (95% CI: 0.539–0.924; p=0.024) at 4th hour to detect subclinical CI-AKI. Estimated risk of SRDcreat was 0.41±0.39% in control group and respectively 0.91±1.53% in CI-AKI group (p=0.20); 0.63±0.54% in subclinical CI-AKI (p=0.18), 1.33±1.29% in CKD 3a stage (p&lt;0.001) and 3.0±2.63% in CKD 3b stage (p&lt;0.001). According to baseline values of NGAL calculated risk of SRDngal were 0.41±0.39% in control group and 2.34±4.05% in CI-AKI group (p=0.02 compared to levels in control patients). In the rest groups SRDngal respectively was 0.99±1.28% for subclinical CI-AKI (p=0.09), 2.01±2.53% for CKD 3a stage (p=0.002), and 4.83±4.12% in CKD 3b stage (p&lt;0.001). Direct comparison of the two scales SRDcreat/SRDngal demonstrated significantly higher levels with measurement of NGAL in CI-AKI group (p=0.03) and CKD 3b stage group (p=0.02).

Conclusions

The NGAL is not only a good predictor for clinical/subclinical CI-AKI but can also predict better the level of risk for SRD in patients with CI-AKI than the risk estimated by measurement of sCr. NGAL incorporated in risk calculator may be applied as useful assessment tool in clinical practice.

Funding Acknowledgement

Type of funding source: None

FUNCTIONAL AND TECHNOLOGICAL PROPERTIES OF THE FOOD ADDITIVE MAGNETOFOOD IN THE PRODUCTION OF MARSHMALLOWS

Production of whipped confectionery (marshmallows, pressed fruit paste, sweets with light-textured centres) is a complex process difficult to control. To expand and modernise their production, it is necessary to find simpler technologies, both resource- and energy- saving, to increase the stability of the heterogeneous dispersed system, and to improve the quality of finished products. In this respect, applying food additives of the nanometer range in technology looks very promising due to their unique physicochemical parameters and their many functional and technological properties. In the paper, it is suggested to solve the problem of stabilising the polyphase structure of whipped confectionery products and to form their quality by using the food additive Magnetofood based on ferrous and ferric oxides (FeO×Fe2O3). Magnetofood is  ultrafine  powder  with a  particle  size of ~80 nm. It has a high functional and technological potential: large specific surface and a set of useful properties (the additive is surface- active, with complex-forming, sorption, and stabilising properties). This allows us to recommend Magnetofood as an additive with a complex action to improve the quality and extend the shelf life of sugar confections like fruit paste and fruit jelly products, in particular, white and pink marshmallows. It has been found that addition of Magnetofood in the form of an aqueous suspension at the stage of swelling and dissolution of the gelling agent improves the shape and consistency, reduces the density of the foam structure by 1.12–1.15 times, reduces the amount of gelling agent by 10–12% for agar and by 7–9%  for pectin, increases the mechanical strength of marshmallows by 11.5–12.6% for agar and by 8.2-9.1% for pectin. Besides, the foaming ability of egg white increases by 1.14-1.4 times (with constant foam stability (99±1)% due to the stabilising effect of Magnetofood nanoparticles), and the thixotropic property of the gel structure becomes 1.4–1.5 times as much

Abstract WP196: Selective Serotonin Reuptake Inhibitors (SSRI) for Depression and Functional Recovery After Stroke: A Meta-Analysis

Background: Post-stroke depression is common and it impedes rehabilitation and function recovery after stroke, and numerous trials evaluated SSRI’s for depression prophylaxis. The objective of this study is to assess the use of SSRI for prevention of poststroke depression and the potential effect on functional recovery after stroke.

Methods: We searched electronic databases up to July 2019 for randomized controlled trials of SSRI’s for patients with stroke versus placebo. We calculated pooled odds ratios and 95% CIs by using random-effects models. The primary end points were depression and good functional outcome (modified Rankin Scale score of 0-2) at 90 days post-randomization. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results: Twelve randomized control trials assessing 4,887 patients have been included in the meta-analysis. SSRI treatment after stroke decreased the odds of depression compared to control group (OR = 0.48, 95% CI - 0.30 to 0.78, p=0.003). There was no heterogeneity between the trials (Cochran’s Q statistic 4.623, df 5; P = .337, I 2 =5.626%). The proportion of subjects who achieved mRS 0-2 at 90 days was similar between SSRI and control groups (OR= 3.471, 95% CI - 0.59 to 20.38, p=0.168).

Conclusion: SSRI treatment for the stroke patients reduces the incidence of depression but it does not increase the odds of good functional recovery.

Abstract WP394: Compliance With Statin Therapy and Risk of Recurrent Adverse Events in Intracerebral Hemorrhage: Analysis of the ATACH II Trial

Background: Hypercholesterolemia is associated with increased risk of ischemic strokes. Statin therapy has been shown to reduce risk of cardiovascular mortality including ischemic strokes. Despite these benefits there still exists a debatable effect of statin use in outcome of patients with intracerebral hemorrhage.

Methods: Retrospective analysis was performed using data from the Antihypertensive treatment of acute cerebral hemorrhage II (ATACH-2) trial to determine effect of baseline compliant statin use on occurrence of adverse events, mortality and death and disability at 90 days. We compared demographic, clinical characteristics and outcomes of subjects dichotomized into those on statin therapy at baseline versus those who were not. We performed a multivariate analysis using binary logistic regression model after adjusting for all potential confounders for binary variables as well as linear regression model for continuous variables.

Results: Of the total 1000 participants in the ATACH-2 trial total of 931 responded and were included. Of the 931 there were 271 (29.1%) who were complaint with baseline statin use, with mean age 61.6 SD± 13.0 and 60.9% were males. Those were complaint with statin use had significantly higher rates of previous stroke (13.9% vs 19.7%), coronary artery disease (2.3% vs 7.7%), hyperlipidemia (15.7% vs 42.0%), and type 2 diabetes mellitus (14.2% vs 25.2%). In the multivariate analysis after adjusting for age, race, hypertension, and smoking those who were compliant with baseline statin use had significant lower odds of recurrent hemorrhagic adverse events (OR 0.4, 95% CI 0.21- 0.89; p-value .023) and lower odds of requiring surgical evacuation (OR 0.3, 95% CI 0.12 - 0.91; p-value .032). In a linear regression model those who were compliant with statin use had lower 24hr NIHSS score ( β -1.2, S.E 0.5; p-value .031) and higher baseline GCS score ( β 0.3, S.E 0.1; p-value .02). There was no difference in favorable outcome mRS 0-2 or death in the multivariate analysis.

Conclusion: Patient who are compliant with statin use seem to have higher GCS score at baseline and improved NIHSS scores at 24hrs. They were at lower odds of having recurrent hemorrhagic bleeds after discharge and required less surgical evacuations.

Abstract TP63: Risk of Contrast Induced Nephropathy After Emergency CTA in Stroke Patients: A Meta-Analysis

Background: Contrast agents for computed tomographic angiography (CTA) and perfusion (CTP) are presumed to be nephrotoxic prompting many hospitals to require serum creatinine values prior to imaging likely causing delays in door to needle times. The objective of this study is to assess the risk of developing contrast induced acute kidney injury (AKI) in patients who are undergoing CTA and CTP.

Materials and Methods: We have searched the electronic databases up to July 2019 for studies that reported incidence of AKI in patients who have undergone CTA and CTP. We calculated pooled odds ratios and 95% CIs by using random-effects models for the primary end point being AKI due to contrast induced nephropathy. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews and meta-analyses.

Results: Eight case control studies assessing 4,449 patients have been included in the study. The odds of AKI in CTA/CTP patients versus non-contrast CT was not statistically significant (odds ratio = 0.53, 95% CI = 0.20-1.39, p=0.199). There was no significant heterogeneity between the studies (Cochran’s Q statistic 3.632, df 4; P = .461, I2=2.514%). Overall, no AKI patient required hemodialysis due to contrast induced nephropathy. The absolute number of patients who developed AKI among CTA/CTP patients was lower than among patients who underwent just non-contrast CT (67 versus 87, NS).

Conclusion: The use of contrast agents for CTA/CTP in acute stroke is not associated with an increased risk of developing contrast induced nephropathy nor AKI requiring dialysis.

Abstract WP160: Conivaptan (Combined Vasopressin Receptor Antagonism) Attenuates Cerebral Edema Following Ischemic Stroke in Rodent Model

Objective: To study the potential role of Conivaptan on cerebral edema, infarct volume, neurological deficit and survival.

Introduction: Although vasopressin has a significant detrimental role in stroke-related cerebral edema, the effect of mixed vasopressin antagonism in stroke has not been well studied. We studied the effects of conivaptan on the course of cerebral edema, severity of neurological deficit, infarct volume, aquaporin-4 (AQP4) protein levels and survival after experimental stroke.

Methods: Animals were randomized to receive either conivaptan or vehicle after reperfusion of experimental middle cerebral artery occlusion. The severity of neurological deficit, edema, and infarct volume assessments were performed by an investigator blinded to group assignment. All assessments were performed at either 12h or 24h and Western blot was subsequently used to investigate AQP4 levels.

Results: At 12h, conivaptan-treated mice (n=16) had 6.64±6.50% ipsilateral hemispheric enlargement compared to 16.55±7.05% in control mice (n=16, p=0.0003). Similarly, at 24h, conivaptan-treated mice (n=12) had 6.81±4.63% ipsilateral hemispheric enlargement in comparison to 13.93±5.43% in control mice (n=12, p=0.0023). At 24h, the conivaptan-treated mice had lower neurological deficits in comparison to control (p=0.04). There was no significant effect of conivaptan on infarct size or AQP4 levels in comparison to vehicle, naïve and sham group.

Conclusions: The present study highlights the role of mixed vasopressin receptor antagonism in reducing cerebral edema secondary to brain ischemia. This data suggests the possibility of developing vasopressin antagonism as a new adjuvant in treatment of stroke-related brain edema.

Blood pressure reduction and outcome after endovascular therapy with successful reperfusion: a multicenter study

BACKGROUND

Elevated systolic blood pressure (SBP) after mechanical thrombectomy (MT) correlates with worse outcome. However, the association between SBP reduction (SBPr) and outcome after successful reperfusion with MT is not well established.

OBJECTIVE

To investigate the association between SBPr in the first 24 hours after successful reperfusion and the functional and safety outcomes of MT.

METHODS

A multicenter retrospective study, which included 10 comprehensive stroke centers, was carried out. Patients with acute ischemic stroke and anterior circulation large vessel occlusions who achieved successful reperfusion via MT were included. SBPr was calculated using the formula 100×([admission SBP-mean SBP]/admission SBP). Poor outcome was defined as a modified Rankin Scale (mRS) score of 3-6 at 90 days. Safety endpoints included symptomatic intracerebral hemorrhage, mortality, and requirement for hemicraniectomy during admission. A generalized mixed linear model was used to study the association between SBPr and outcomes.

RESULTS

A total of 1361 patients were included in the final analysis. SBPr as a continuous variable was inversely associated with poor outcome (OR=0.97; 95% CI 0.95 to 0.98; p<0.001) but not with the safety outcomes. Subanalysis based on reperfusion status showed that SBPr was associated with lower odds of poor outcome only in patients with complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI 3)) but not in patients with incomplete reperfusion (mTICI 2b). When SBPr was divided into categories (<1%, 1%-10%, 11%-20%, >20%), the rate of poor outcome was highest in the first group.

CONCLUSION

SBPr in the first 24 hours after successful reperfusion was inversely associated with poor outcome. No association between SBPr and safety outcome was found.

Intravenous thrombolysis pretreatment and other predictors of infarct in a new previously unaffected territory (INT) in ELVO strokes treated with mechanical thrombectomy

INTRODUCTION

One uncommon complication of mechanical thrombectomy (MT) is an infarct in a new previously unaffected territory (infarct in new territory (INT)).

OBJECTIVE

To evaluate the predictors of INT with special focus on intravenous thrombolysis(IVT)pretreatmentbefore MT.

METHODS

Consecutive patients with emergent large vessel occlusion (ELVO) treated with MT during a 5-year period were evaluated. INT was defined using standardized methodology proposed by ESCAPE investigators. The predictors of INT and its impact on outcomes were investigated.

RESULTS

A total of 419 consecutive patients with ELVO received MT (mean age 64±15 years, 50% men, median baseline National Institutes of Health Stroke Scale score 16 points (IQR 11-20), 69% pretreated with IVT). The incidence of INT was lower in patients treated with combination therapy (IVTandMT) than in patients treated with MT alone, respectively (10% vs 20%; p=0.011). The INT group had more patients with posterior circulation occlusions than the group without INT (28% vs 10%, respectively; p<0.001). The rates of 3-month functional independence were lower in patients with INT (30% vs 50%; p=0.007). IVT pretreatment was not independently related to INT (OR=0.75; 95% CI 0.32 to 1.76), and INT did not emerge as an independent predictor of 3-month functional independence (OR=0.69; 95% CI 0.29 to 1.62) on multivariable logistic regression models. Location of posterior circulation occlusion was independently associated with a higher odds of INT (OR=3.33; 95% CI 1.43 to 7.69; p=0.005).

CONCLUSIONS

IVT pretreatment is not independently associated with a lower likelihood of INT in patients with ELVO treated with MT. Patients with ELVO with posterior circulation occlusion are more likely to have INT after MT.

Impact of pretreatment with intravenous thrombolysis on reperfusion status in acute strokes treated with mechanical thrombectomy

Introduction

We sought to evaluate the impact of pretreatment with intravenous thrombolysis (IVT) on the rate and speed of successful reperfusion (SR) in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT) in a high-volume tertiary care stroke center.

Methods

Consecutive patients with ELVO treated with MT were evaluated. Outcomes were compared between patients who underwent combined IVT and MT (IVT+MT) and those treated with direct MT (dMT). The elapsed time between groin puncture to beginning of reperfusion (GPTBRT) and the numbers of device passes required to achieve SR were also documented.

Results

A total of 287 and 132 patients were treated with IVT+MT and dMT, respectively. The IVT+MT group had higher SR (73.8% vs 62.9%; p=0.023) and 3-month functional independence (modified Rankin Scale score 0–2;51.6% vs 38.2%; p=0.008) rates. The median GPTBRT was shorter in the IVT+MT group (48 (IQR 33–70) vs 70 (IQR 44–98) min; p<0.001). Among patients who achieved SR (n=292), the median number of required device passes was lower in the IVT+MT subgroup (1 (IQR 1–1) vs 2 (IQR 1–2); p<0.001), while the rate of patients requiring ≤2 device passes was higher (98% vs 77%; p<0.001). IVT+MT was independently related to higher odds of SR (OR 1.64; 95% CI 1.03 to 2.61; p=0.036) and shorter GPTBRT (unstandardized linear regression coefficient −20.39; 95% CI −27.56 to –13.22; p<0.001) on multivariable analyses adjusting for potential confounders. Among patients with SR, IVT+MT was independently associated with a higher likelihood of ≤2 device passes (OR 14.63; 95% CI 4.46 to 48.00; p<0.001).

Conclusions

IVT pretreatment appears to increase the rates of SR and shortens the duration of the endovascular procedure by requiring fewer device passes in patients with ELVO treated with MT.

Abstract 3: Effect of BP Goal on Outcome post Mechanical Thrombectomy: Multicenter Study

Introduction: Current AHA/ASA guidelines recommend keeping blood pressure (BP) <180/105 after successful recanalization with MT. However, due to a concern of reperfusion injury, different BP goals are utilized across various endovascular centers. In this study, we compared functional and hemorrhagic outcomes between different BP goals.

Methods: This was a multicenter international retrospective study that included 7 comprehensive stroke centers. Inclusion criteria were anterior circulation large vessel occlusion (LVO) that was treated with MT, and successful recanalization at the conclusion of the procedure. Patients were divided into three groups based on systolic BP (SBP) goals in the first 24 hours post MT. Group 1) included patients with SBP goal ≤140 mm Hg or ≤120 mm Hg; group 2 included patients with SBP goal ≤160 mm Hg; group 3) included patients with SBP goal ≤220 mm Hg or ≤180 mm Hg. Successful recanalization was defined as TICI 2b-3. Outcome measures included symptomatic intracerebral hemorrhage (sICH), 90-day modified Rankin Scale (mRS), and 90-day mortality.

Results: A total of 985 patients were included in the study. More patients in group 3 were white and had Afib than groups 1-2. Likewise, more patients in group 3 received IV tPA. Complete recanalization (TICI 2c-3) was achieved in 88.2%, 53.6%, and 73.2% in groups 1,2,3 respectively (p <0.001). With respect to outcome, mRS 0-2 was achieved in 50%, 52, and 38% of patients (p=0.001) in groups 1,2,3 respectively. Similarly, sICH occurred in 2.8%, 7.1%, and 5.2% (p=0.04) in the respective groups. In multivariate analysis, moderate and intensive BP goals (groups 1-2) were associated with mRS 0-2 but not with sICH or mortality. In subgroup analysis that included only patients who achieved BP goal, group 1 but not 2 or 3 were associated with functional outcome.

Conclusion: Blood pressure goals ≤140 and ≤160 were associated with favorable functional outcome.

Abstract TP24: Impact of Pretreatment With Intravenous Thrombolysis on Reperfusion Status in Emergent Large Vessel Occlusion (ELVO) Patients Treated With Mechanical Thrombectomy (MT)

Introduction: It currently remains unclear whether pre-treatment with intravenous thrombolysis (IVT) provides any additional benefits to emergent large vessel occlusion (ELVO) patients undergoing mechanical thrombectomy (MT). We sought to evaluate the impact of pretreatment with IVT on the rate and the speed of complete reperfusion (CR) in LVO patients treated with MT in a high-volume tertiary care stroke center.

Methods: Consecutive ELVO patients treated with MT during a five-year period were evaluated. Baseline stroke severity was assessed by NIHSS-score. Standard safety [symptomatic Intracranial Hemorrhage (sICH) by SITS-MOST definition] and efficacy outcomes [CR (modified Thrombolysis in Cerebral Infarction IIb/III), 3-month functional independence (FI; modified Rankin Scale scores of 0-2)] were compared between patients who underwent combined IVT and MT (IVT+MT) vs. direct MT (dMT). The elapsed time between groin puncture to beginning of reperfusion (GPTBRT) and the numbers of device passes (DP) required to achieve CR were also documented.

Results: A total of 287 and 132 patients were treated with IVT+MT and dMT respectively. The IVT+MT group had higher CR (74% vs. 63%; p=0.023) and FI (52% vs.38%; p=0.008) rates and shorter median GPTBRT (48 vs. 70 min; p<0.001). The two groups did not differ in sICH rates (7% vs. 9%; p=0.368). Among patients who achieved CR, the median number of required DP was lower in the IVT+MT subgroup (1 vs. 2; p<0.001) and the rate of patients requiring ≤2 DP was higher (98% vs. 77%; p<0.001). IVT+MT was independently related to higher odds of CR (OR:1.64; 95%:1.03-2.61; p=0.036) and shorter GPTBRT (unstandardized linear regression coefficient: -20; 95%CI: -12, -27; p<0.001) on multivariable analyses adjusting for potential confounders including demographics, vascular risk factors, collateral status, stroke severity, location of occlusion and onset to groin puncture time. Among patients with CR, IVT+MT was independently associated with higher likelihood of ≤2 DP (OR:14.75; 95%:4.72-46.04; p<0.001).

Conclusions: IVT pretreatment increases the rates of CR and shortens the duration of endovascular procedure by requiring fewer DP in ELVO patients treated with MT.

Abstract TP416: Safety and Efficacy Outcomes of Intravenous Thrombolysis (IVT) for In-Hospital Stroke

Introduction: Cross-sectional data suggest that IVT in patients with in-hospital (IHS) acute ischemic stroke (AIS) onset is associated with unfavourable outcomes compared to out-of-hospital (OHS) stroke onset patients. We sought to compare safety and efficacy outcomes between IHS and OHS patients treated with IVT.

Methods: Consecutive AIS patients treated with IVT during a five-year period in a tertiary care stroke center were prospectively evaluated. Demographics, vascular risk factors, admission blood pressure and serum glucose levels were documented. Baseline stroke severity and early hypodensity on baseline CT were assessed using NIHSS-score and ASPECTS by certified physicians. Three-month functional outcome was evaluated by mRS-score. We compared the following outcomes between IHS and OHS patients: 1.symptomatic intracranial hemorrhage (sICH) 2.favourable functional outcome (FFO) [3-month mRS scores of 0-1], 3.Functional independence (FI) [3-month mRS scores of 0-2], 4. Mortality at three months.

Results: Of 1264 IVT-treated AIS patients, we identified 51 (4%) subjects with IHS. Baseline median NIHSS-score was higher in IHS (10 points; IQR: 6-16 vs. 6 points; IQR: 3-12; p=0.004), while median onset-to-treatment was shorter (75 min; IQR: 37-115 vs. 135 min; IQR: 100-185; p<0.001). In univariable analyses, IHS patients had higher three-month mortality rates (21% vs. 9%; p=0.009). There were no differences (p>0.1) between the two groups in FFO, FI and sICH rates. IHS was associated with higher likelihood three-month mortality (OR: 3.1; 95%CI: 1.2-7.8; p=0.016) on multivariable logistic regression models adjusting for demographics, risk factors, onset-to-treatment time, admission blood pressure and serum glucose levels, baseline NIHSS and ASPECTS.

Conclusions: IHS patients treated with IVT have more severe strokes and higher mortality rates compared to OHS patients. IVT for IHS is not associated with higher hemorrhagic complications.

Abstract TMP3: Blood Pressure Variability Within 24 Hours After Mechanical Thrombectomy Correlates With Worse Outcome

Introduction: blood pressure variability (BPV) in the acute phase following ischemic stroke is associated with worse outcomes, especially in patients with large vessel occlusions. However, the relationship between BPV and outcome after successful recanalization is not well documented.

Objective: The aim of this study was to evaluate the association between BPV and outcome after successful recanalization.

Methods: This was a retrospective multicenter study of patients with anterior circulation large vessel occlusions who achieved successful recanalization with MT. Successful recanalization was defined as TICI≥2b. BP was recorded in hourly intervals for 24 hours post MT. BPV was defined as the difference between maximum and minimum blood pressure within 24 hours. BPV was calculated for mean arterial pressure (MAP), systolic BP (SBP), and diastolic BP (DBP). Outcome measures included 90 days mRS, symptomatic ICH (sICH), and mortality. sICH was defined based on ECASS criteria. Good outcome was defined as mRS 0-2.

Results: A total of 985 patients were included. SBP and MAP variability were higher in poor outcome group (65.2±26 vs. 57± 24.6; p <0.001, and 49.7±21.2 vs. 46.9± 22.3; p=0.048 respectively). Likewise, SBP and MAP variability were higher in sICH group. The association between SBP variability and 90 day mRS, sICH, and mortality remained significant after adjusting for potential confounders.

Conclusion: Higher blood pressure variability was associated with worse functional outcomes, higher likelihood of symptomatic hemorrhage, and increased mortality.

Abstract TMP11: Emergency Room Door-to-Puncture Time Since 2015: Observations From the BEST-MSU Study

Introduction: The impact of a Mobile stroke unit (MSU) on access to Endovascular Thrombectomy (ET) is a pre-specified BEST-MSU sub-study. On the MSU, ET decision-making steps such as CT, neurologic exam, and tPA treatment are completed prior to Emergency Room (ER) arrival. We hypothesized that such pre-ER assessment of potential ET patients on a MSU improves metrics.

Methods: BEST-MSU is a prospective comparative effectiveness study of MSU vs Standard Management by Emergency Medical Services (SM). We compared ER door-to-puncture-time (mins, DTPT) among the following groups of MSU and SM patients: all ET patients (ETP), ET patients post-tPA (ETT), and ET patients post-tPA meeting thrombolytic adjudication criteria (ETTA) over the first four years of the study.

Results: There were 161 ETP (67 SM, 94 MSU), 140 ETT (55 SM, 85 MSU), and 126 ETTA (50 SM, 76 MSU) patients. DTPT was shorter for MSU patients (ETP 89 vs 99, p=0.01; ETT 93 vs 100, p=0.03; ETTA 93 vs 99.5, p=0.03). From 2015 to 2018, DTPT decreased at a faster rate for SM compared with MSU-managed patients, improving by about an hour (Figure).

Conclusion: Pre-ER ET evaluation on a MSU results in faster DTPT. Since 2015, dramatic improvement in ER ET metrics has attenuated this difference. However, DTPT of 90-100 mins in all groups indicates substantial room for improvement.

Abstract WP477: ICH in a Mid-South Mobile Stroke Unit Sample: Demographics, Clinical Findings, and Geospatial Distribution

Background: Clinical and geospatial differences in acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) patients within stroke belt region mobile stroke units (MSU) have not been described. We sought to understand presentation differences in the Mid-South.

Methods: Consecutive MSU patients were analyzed for demographic, call, and clinical characteristics. Cases were geocoded, spatially joined to zip code shapefile with raw counts normalized to population; incidence rates were calculated and symbolized by mathematical natural breaks.

Results: 292 AIS and 29 ICHs were transported in 52 weeks; age was similar (ICH 63 + 15 vs. AIS 64 + 15), cases were mostly female (ICH 64%; AIS 60%), with African Americans (AA) significantly more likely to have AIS (74%) compared to ICH (64%; p=0.023). Median ICH NIHSS was significantly higher (median 9.5, IQR 5.5-17) then AIS NIHSS (median 5, IQR 2-9; p<0.001), as were SBP (ICH 184 + 37mmHg vs. AIS 159 + 35mmHg; p<0.001) and DBP (ICH 104 + 21mmHg vs. AIS 91 + 21mmHg; p=0.003). ICH patients were significantly more likely to be treated within the first 60 minutes of symptom onset (p<0.001) then AIS. High incidence ICH territories were geospatially defined.

Conclusions: Mid-South ICH MSU patients have surprisingly different demographics than National data, and were most commonly female, but less likely to be of AA. A discreet geospatial ICH pattern was identified for high ICH risk.

Abstract TP436: Minimally Invasive Endoscopic Hematoma Evacuation vs. Best Medical Management for Spontaneous Basal Ganglia Intracerebral Hemorrhage

Background: We conducted a case-control study to assess the relative safety and efficacy of Apollo assisted minimally invasive endoscopic surgery (MIS) for clot evacuation in patients with basal-ganglia intracerebral hemorrhage (ICH).

Methods: We evaluated consecutive patients with acute basal ganglia ICH at a single center over a 42-month period. Patients received either best medical management according to established guidelines (controls) or Apollo assisted MIS (cases) with best medical management. The following outcomes were compared before and after propensity-score matching (PSM): in-hospital mortality, discharge National Institutes of Health Stroke Scale (NIHSS) score, discharge disposition, modified Rankin Scale scores at discharge and at 3 months.

Results: Among 224 ICH patients, 19 (8.5%) underwent MIS [mean age 50.9±10.9; 26.3% female, median ICH volume 40 (IQR; 25-51)]. The interventional cohort was younger with higher ICH volume and stroke severity as compared to the medically managed cohort. After PSM, 18 patients in the MIS cohort were matched to 54 medically managed individuals. The two cohorts did not differ in any of the baseline characteristics. The median ICH volume at 24 hours was lower in the intervention group [40cm 3 (IQR:25-50) vs. 15cm 3 (IQR:5-20), p<0.001). The two cohorts did not differ in any of the pre-specified outcomes measures with the exception of in-hospital mortality which was lower in intervention cohort (28% vs. 56%, p=0.041). The three-month mortality rates tended to be lower in the intervention cohort (38% vs. 60%, p=0.107). The intensive care unit length of stay was similar in the two groups [median LOS in days (IQR): intervention: 9 (7-12) vs. control: 9 (6-12), p=0.497]. The distribution of mRS-scores at discharge and at three months did not differ between the intervention and the control cohort (p by Cochran-Mantel-Haenszel test>0.4).

Conclusions: Minimally invasive Apollo assisted endoscopic hematoma evacuation was associated with lower rates of in-hospital mortality in patients with spontaneous basal ganglia ICH. These findings support a randomized controlled trial of MIS versus medical-management for ICH.

Abstract 96: Efficacy and Safety of Oral Anticoagulants in Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis

Introduction: Data regarding the efficacy and safety of oral anticoagulants [vitamin K antagonists (VKA) and direct oral anticoagulants (DOAC)] among patients with chronic kidney disease (CKD) remain scarce.

Methods: We conducted a systematic review and meta-analysis of studies involving CKD patients treated on OACs. The following outcomes were evaluated: ischemic stroke (IS), intracerebral hemorrhage (ICH), combined ischemic and hemorrhagic stroke (stroke combined ), stroke or systemic embolism (S/SE), mortality, and major bleeding events. CKD was defined based on creatinine clearance (CrCl) as determined by Cockgroft-Gault formula, ranging from mild (CrCl: 60-89 ml/min), moderate (CrCl: 30-59 ml/min) and severe (CrCl: 15-29 ml/min). Patients with CrCl<15ml/min on hemodialysis or underwent transplantation were excluded.

Results: We identified 16 studies (7 comparing DOAC vs. VKA & 9 comparing VKA vs. no VKA) comprising 88,610 patients. VKA use (vs. no VKA) was associated with reduced risk of IS [RR=0.71 (95%CI: 0.58-0.88), I 2 =55%] and mortality [RR=0.70 (95%CI: 0.62-0.78), I 2 =66%], but increased the risk of ICH [RR=1.57 (95%CI: 1.22-2.02), I 2 =0%]. In comparison to VKA, DOAC use demonstrated lower risk of ICH [RR=0.43 (95%CI: 0.33-0.56), I 2 =13%], stroke combined [RR=0.83 (95%CI: 0.72-0.96), I 2 =0%], S/SE [RR=0.73 (95%CI: 0.62-0.85), I 2 =45%] and major bleeding [RR=0.77 (95%CI: 0.66-0.90), I 2 =72%]. In adjusted analyses, VKA use (vs. no VKA) was associated with reduced mortality [HR adj =0.68 (95%CI: 0.61-0.76), I 2 =49%], whereas DOAC (vs. VKA) use reduced the risk of ICH [HR adj =0.39 (95%CI: 0.30-0.50), I 2 =0%] and S/SE [HR adj =0.75 (95%CI: 0.65-0.88), I 2 =14%]. Our sensitivity analyses comparing different DOACs showed that factor Xa inhibitors consistently reduced stroke combined [RR=0.84 (95%CI: 0.73-0.96), I 2 =0%], mortality [RR=0.84 (95%CI: 0.70-1.00), I 2 =0%], ICH [RR=0.45 (95%CI: 0.24-0.85), I 2 =42%] and major bleeding [RR=0.76 (95%CI: 0.64-0.91), I 2 =48%].

Conclusions: Amongst CKD patients treated with OAC, DOACs present with a better safety and efficacy profile in various cardiovascular outcomes.

Abstract 153: Blood Pressure and Outcome After Mechanical Thrombectomy: A Multicenter Study

Introduction: Hypertension is a known predictor of poor outcome and hemorrhagic complications after ischemic stroke. However, the effect of blood pressure (BP) on outcome of those undergoing mechanical thrombectomy and especially after successful recanalization is not well understood. In this study, we investigated the association between BP parameters and outcome measures after successful recanalization with MT.

Methods: This was a retrospective, multicenter study, involving 7 comprehensive stroke centers, of patients with acute ischemic stroke due to large vessel occlusion who achieved successful recanalization with MT. Systolic BP (SBP), diastolic BP (DBP) and mean arterial pressure (MAP) were obtained at frequent intervals (at least hourly) for each patient in the first 24 hours following MT. Outcome measures included 90 day-modified Rankin Scale (mRS), 90-day morality, and symptomatic intracerebral hemorrhage (sICH). Successful recanalization was defined as TICI 2b-3, and sICH as any hemorrhage associated with > 4 points increase in NIHSS. A mixed logistic model was used to identify predictors of functional and hemorrhagic outcomes.

Results: A total of 989 patients were included, of whom 453 (45.8%) achieved good outcome, defined as an mRS of 0-2. Mean, and maximum SBP were higher in the poor outcome group (131.6 +15 vs. 127 +14.3; p <0.001, and 166± 24.7 vs. 158±24.3; p<0.001, respectively). There was no significant difference in the rest of BP measurement between the two groups. With respect to hemorrhagic complications, 40 (4.2%) patients develop sICH after MT. SBP, DBP and MAP were higher in sICH group. Table 1 summarizes multivariable analysis results.

Conclusion: Higher blood pressure was associated with hemorrhagic complications, and worse functional outcome following successful mechanical thrombectomy.

Abstract WP17: Blood Pressure Reduction Within 24 Hours After Mechanical Thrombectomy Does Not Correlate With Outcome: A Collaborative Pooled Analysis

Introduction: Previous studies showed that lowering blood pressure in the acute phase after stroke may be harmful. However, the effect of blood pressure lowering on outcome after successful recanalization is not well known.

Objective: The aim of this study was to evaluate the association between systolic blood pressure (SBP) reduction and outcome of thrombectomy after successful recanalization.

Methods: This was a retrospective multicenter study of patients with anterior circulation large vessel occlusions who achieved successful recanalization (TICI 2b-3) with MT. Degree of SBP reduction was calculated using the following formula: 100*(admission SBP - minimum SBP within 24 hours)/admission SBP. Patients were divided into two groups: group 1) included patients with ≤25% SBP drop; group 2) included patients with > 25% SBP drop. Outcome measures included 90 days mRS, symptomatic ICH (sICH), and mortality

Results: Of 991 screened patients, 917 had available admission SBP data. Average age was 68+14 years. The average admission SBP was 143 ±27 mm Hg. 383 (38.6%) patients had less than 25% SBP reduction, whereas 495 (49.9%) had > 25% SBP reduction in the first 24 hrs. There was no difference in the proportion of patients who achieved good outcome (mRS) between the two groups. Likewise there was no difference in the rate of sICH between two groups (4..2% vs. 4.5%;p=0.84). SBP reduction was not significantly associated with functional outcome on multivariate analysis (OR=1.003; 95% CI 0.99-1.013, p=0.54).

Conclusion: blood pressure lowering after successful recanalization appears to be safe and was not associated with worse outcome. Further studies are needed to determine whether BP lowering is actually beneficial

Final Results of the OPERA Experiment on ν_{τ} Appearance in the CNGS Neutrino Beam

The OPERA experiment was designed to study ν_{μ}→ν_{τ} oscillations in the appearance mode in the CERN to Gran Sasso Neutrino beam (CNGS). In this Letter, we report the final analysis of the full data sample collected between 2008 and 2012, corresponding to 17.97×10^{19} protons on target. Selection criteria looser than in previous analyses have produced ten ν_{τ} candidate events, thus reducing the statistical uncertainty in the measurement of the oscillation parameters and of ν_{τ} properties. A multivariate approach for event identification has been applied to the candidate events and the discovery of ν_{τ} appearance is confirmed with an improved significance level of 6.1σ. |Δm_{32}^{2}| has been measured, in appearance mode, with an accuracy of 20%. The measurement of the ν_{τ} charged-current cross section, for the first time with a negligible contamination from ν[over ¯]_{τ}, and the first direct evidence for the ν_{τ} lepton number are also reported.

Abstract TP68: Shorter Door-to-Needle Time is the Only Independent Predictor for Initiation of Intravenous Thrombolysis (IVT) Within the Golden Hour

Introduction: Administration of tPA in the first 60 min post-onset, the golden hour (GH), is associated with improved functional outcomes but remains unachievable in the vast majority of patients. We sought to identify independent predictors of IVT in the GH in a prospective, multi-center study.

Methods: AIS patients treated with IVT during a five-year period in two tertiary care stroke centers were evaluated. Demographics, vascular risk factors, onset to treatment time, door-to-needle time (DTN) admission blood pressure and serum glucose levels were documented. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. The etiopathogenic mechanism of AIS was documented using TOAST criteria. Subjects with in-hospital stroke or treated in the mobile stroke unit were excluded.

Results: Out of total 658 IVT-treated AIS patients (mean age 64±15 years; 50% men; median NIHSS-score 6, IQR: 4-12) we identified 26 (4%) subjects treated in the GH (mean age 62±15 years; 46% men; median NIHSS-score 8, IQR: 4-12). GH patients had shorter median DTN (23 min, IQR: 18-44 vs. 38 min, IQR: 26-49). DTN 2 30 min was more prevalent in the GH group (62% vs. 20%; p<0.001). DTN emerged as the only independent predictor of IVT in the GH in multivariable logistic regression models adjusting for demographics, risk factors, admission blood pressure and serum glucose levels, TOAST subtype, baseline NIHSS and ASPECTS. A 10-min delay in DTN approximately halved the odds of IVT in the GH (OR: 0.54; 95%CI: 0.41-0.71; p<0.001). Alternatively, DTN equal or less than 30min increased exponentially the likelihood of tPA initiation in the GH (OR: 6.29; 95%CI: 2.78-14.25; p<0.001).

Conclusions: Shorter DTN is the only independent predictor of IVT initiation within the GH. Continued improvements in systems of acute stroke care should aim to further reduce DTN in order to increase the availability of tPA delivery in the GH.

Antiplatelet pretreatment and outcomes following mechanical thrombectomy for emergent large vessel occlusion strokes

BACKGROUND

Few data are available regarding the safety and efficacy of antiplatelet (APT) pretreatment in acute ischemic stroke (AIS) patients with emergent large vessel occlusions (ELVO) treated with mechanical thrombectomy (MT). We sought to evaluate the association of APT pretreatment with safety and efficacy outcomes following MT for ELVO.

METHODS

Consecutive ELVO patients treated with MT during a 4-year period in a tertiary stroke center were evaluated. The following outcomes were documented using standard definitions: symptomatic intracranial hemorrhage (sICH), successful recanalization (SR; modified TICI score 2b/3), mortality, and functional independence (modified Rankin Scale scores of 0-2).

RESULTS

The study population included 217 patients with ELVO (mean age 62±14 years, 50% men, median NIH Stroke Scale score 16). APT pretreatment was documented in 71 cases (33%). Patients with APT pretreatment had higher SR rates (77% vs 61%; P=0.013). The two groups did not differ in terms of sICH (6% vs 7%), 3-month mortality (25% vs 26%), and 3-month functional independence (50% vs 48%). Pretreatment with APT was independently associated with increased likelihood of SR (OR 2.18, 95% CI1.01 to 4.73; P=0.048) on multivariable logistic regression models adjusting for potential confounders. A significant interaction (P=0.014) of intravenous thrombolysis (IVT) pretreatment on the association of pre-hospital antiplatelet use with SR was detected. APT pretreatment was associated with SR (OR 2.74, 95% CI 1.15 to 6.54; P=0.024) in patients treated with combination therapy (IVT and MT) but not in those treated with direct MT (OR 1.78, 95% CI 0.63 to 5.03; P=0.276).

CONCLUSION

APT pretreatment does not increase the risk of sICH and may independently improve the odds of SR in patients with ELVO treated with MT. The former association appears to be modified by IVT.

Benefits of stroke treatment delivered using a mobile stroke unit trial

Rationale

Mobile stroke units speed treatment for acute ischemic stroke, thereby possibly improving outcomes.

Aim

To compare mobile stroke unit and standard management clinical outcomes, healthcare utilization, and cost-effectiveness in tissue plasminogen activator-eligible acute ischemic stroke patients calling 911.

Sample size

693. Eighty percent power with 0.05 type I error rate to detect a difference of 0.09 in mean utility-weighted modified Rankin scale between groups.

Design

Phase III, multicenter, prospective cluster-randomized (mobile stroke unit versus standard management weeks) comparative effectiveness study in tissue plasminogen activator-eligible patients.

Outcomes

Primary: Ninety-day mean utility-weighted modified Rankin scale. Coprimary: cost-effectiveness based on EQ5D quality of life and one year poststroke costs.

Analysis

Two-sample t-test and linear regression adjusting for covariates; incremental cost-effectiveness ratio and net benefit regression.

Results

As of March 2017, 288 tissue plasminogen activator-eligible patients have been enrolled (173 in the mobile stroke unit arm and 115 in the standard management arm). Two new centers start in early 2017 with target end of recruitment September 2019.

Conclusion

This is the first randomized study to test for disability, healthcare utilization, and cost-effectiveness of a mobile stroke unit. The progress of the study suggests that it is feasible. Management of tissue plasminogen activator eligible acute ischemic stroke patients by a mobile stroke unit could potentially result in less disability and healthcare utilization, and be cost effective. Mobile stroke units are very costly. This trial may determine if the fixed cost can be justified by a reduction in disability and healthcare utilization.

Clinical Trial Registration

NCT02190500.

Acute management of stroke in Iran: Obstacles and solutions

Background: Stroke is among the leading causes of mortality and permanent disability in the world. Iran is located in the stroke belt and has a high age-adjusted stroke incidence rate. In this multistep prospective qualitative study, we aimed at investigating the status and challenges of stroke management in Iran and explore possible solutions. Methods: In the first and second phase, we attempted to define the status of stroke management in Iran by searching the relevant literature and conducting semi-structured interviews with health-care providers in thirteen hospitals located in seven large cities in Iran. In the third phase, we tried to recommend possible solutions based on international standards and experience, as well as interviews with stroke experts in Iran and the United States. Results: Little public awareness of stroke symptoms and its urgency, low prioritization for stroke management, and an inadequate number of stroke-ready hospitals are some of the major obstacles toward timely treatment of stroke in Iran. Every hospital in our pool except two hospitals had guideline-based algorithms for the administration of intravenous thrombolysis. However, there was no single call activation system for stroke alert. Data from some of the centers showed that hospital arrival of stroke patients to final decision-making took 116-160 minutes. Although there were four endovascular programs in our target areas, there was no center with 24-hour coverage. Conclusion: There are many challenges as well as potentials for improvement of stroke care in Iran. Improving public knowledge of stroke and establishing an organized and comprehensive stroke program in the hospitals will improve acute stroke management in Iran. The Iranian ministry of health should define and advocate the establishment of stroke centers, track the rate of death and disability from stroke, introduce pathways to improve the quality of stroke care through national data monitoring systems, and eliminate disparities in stroke care.

Abstract TP49: Racial Difference in Cerebral Microbleed Burden in the Mid-South United States

Introduction: Although intracerebral hemorrhage (ICH) is more common among African Americans, data on the burden of cerebral microbleeds (CMBs) among different racial populations is limited. The purpose of this study is to compare the number, associated factors, and topography of CMBs between African-American and white populations in the Mid-South United States.

Methods: We reviewed consecutive patients who had magnetic resonance imaging (MRI) of brain at four tertiary centers in Memphis, Tennessee in a two-year period. T2*-weighted MRIs were assessed for the number, location, and topography of CMBs as well as other acute and chronic cerebrovascular diseases. We compared, by race, the baseline characteristics and clinical findings of patients with CMBs.

Results: Out of 6,107 patients screened for this study, 176 (3%) patients (mean age: 63±15 years, 49% men, 77% African American, median CMB count: 8) had CMB on their brain imaging. There was a significant difference between African-American and white patients in terms of number of CMBs (16.5±18 vs. 6.5±5.5, p<001). There was no significant difference between two groups in terms of CMB location, gender, body mass index, history of head trauma as well as seizure, coronary artery, peripheral vascular, liver, and kidney disease. However, African-American group had a higher rate of clinical and silent stroke (92% vs. 71%, p=003), ICH (29% vs. 3%, p=.001), and severe leukoaraiosis (62% vs. 39%, p=.003). After adjusting for potential confounders, the African-American race was independently (p<0.014) associated with a higher CMB burden in multivariable logistic regression analyses.

Conclusion: Our results suggest that African-American race might be independently associated with a higher CMB burden.

Sex and Stroke in Thrombolyzed Patients and Controls

Background and Purpose—

We hypothesized that any sex-related difference in outcome poststroke is explained by other prognostic factors and that the response to intravenous recombinant tissue-type plasminogen activator (r-tPA) is equal in males and females after adjustment for such factors.

Methods—

We accessed an independent collection of randomized clinical trials—the VISTA (Virtual International Stroke Trials Archive). Data were preprocessed by selecting complete cases (n=8028) and matching females to males (coarsened exact matching, n=4575, 24.3% r-tPA). Outcome was assessed by the 7-point modified Rankin Scale (mRS) measured at 90 days after ischemic stroke. Relationship among variables was estimated by adjusted regression analysis.

Results—

In nonthrombolyzed patients, ordinal analysis of mRS adjusting for stroke- and sex-related prognostic factors suggested comparable outcomes for females and males (odds ratio, 0.96; 95% confidence interval, 0.85–1.06). Females responded comparably to r-tPA as did males, irrespective of the outcome definition of mRS (ordinal: P Interaction =0.46, relative excess risk because of interaction=0). The number needed to treat was 6.8 and 11.2 for 1 female to achieve mRS score of 0 to 2 and 0 to 1, which was highly congruent with males. Analysis for a nonlinear variation of age-by-sex revealed a good outcome for females <45 years with significant disadvantage thereafter (mRS score of 0–2: P Interaction =0.004). No relationship between sex, r-tPA, and bleeding complications was evident.

Conclusions—

Functional outcome (mRS) without r-tPA was overall similar between the sexes, as was the response to r-tPA. Nonlinear sex-by-age interaction improved estimates of functional independence; this should be considered in sex-related studies in stroke.

Fluorescence Amplification Method for Forward Genetic Discovery of Factors in Human mRNA Degradation

Nonsense-mediated decay (NMD) degrades mRNAs containing a premature termination codon (PTC). PTCs are a frequent cause of human genetic diseases, and the NMD pathway is known to modulate disease severity. Since partial NMD attenuation can potentially enhance nonsense suppression therapies, better definition of human-specific NMD is required. However, the majority of NMD factors were first discovered in model organisms and then subsequently identified by homology in human. Sensitivity and throughput limitations of existing approaches have hindered systematic forward genetic screening for NMD factors in human cells. We developed a method of in vivo amplification of NMD reporter fluorescence (Fireworks) that enables CRISPR-based forward genetic screening for NMD pathway defects in human cells. The Fireworks genetic screen identifies multiple known NMD factors and numerous human candidate genes, providing a platform for discovery of additional key factors in human mRNA degradation.

Abstract 166: Supervised Learning Based Detection of Stroke and Stroke Mimic

Background & Purpose: Up to 30% of treated patients for suspected acute ischemic stroke (AIS) could be stroke mimic (SM). Using a balanced clinical dataset, we have developed a supervised learning method from artificial intelligence to classify AIS/transient ischemic attack (TIA) and SM in an emergency room (ER) setting.

Methods: We labeled and randomly partitioned consecutive patients who received intravenous thrombolysis for suspected AIS in three tertiary centers during a three year period. The clinical data includes patients’ demographic information, past medical history, blood pressure and glucose level at presentation, NIH Stroke Scale, and presence of facial weakness. The clinical data were used to create a balanced training and testing set. We developed an Artificial Neural Network (ANN) model on patients’ clinical data, using the training set ( Figure 1). The model was used to classify the diagnosis of AIS/TIA versus SM. The ANN model was subsequently assessed using the testing set. In addition, we compared the ANN model with three regression models (ordinary least squares, logistic, and reduced logistic model).

Results: In total 803 patients (mean age 62±15 years, 52% men, median admission NIHSS-score: 6 points, IQR 3-11) were analyzed. Data from 56 random patients, not included in the training set, were used to test the model. Of 56 predictions, 49 were correct (19 out of 20 correct prediction for SM, and 30 out of 36 correct prediction for AIS/TIA). Additional analysis indicated that the model detects SM with 95% sensitivity (95%, CI: 73-99%) and 83% specificity (95%, CI: 66-93%). We further performed a 10-fold cross validation to better estimate the performance of the model. In addition, the three regression models were comparable to the ANN model at a specific adjusted threshold.

Conclusions: This study highlights a potential for ANN to discriminate AIS/TIA and SM. This model can be further optimized and integrated in patient management software in an ER setting.

β-Blockers, Pneumonia, and Outcome After Ischemic Stroke

Background and Purpose—

Increased sympathetic drive after stroke is involved in the pathophysiology of several complications including poststroke immunudepression. β-Blocker (BB) therapy has been suggested to have neuroprotective properties and to decrease infectious complications after stroke. We aimed to examine the effects of random pre- and on-stroke BB exposure on mortality, functional outcome, and occurrence of pneumonia after ischemic stroke.

Methods—

Data including standard demographic and clinical variables as well as prestroke and on-stroke antihypertensive medication, incidence of pneumonia, functional outcome defined using modified Rankin Scale and mortality at 3 months were extracted from the Virtual International Stroke Trials Archive. For statistical analysis multivariable Poisson regression was used.

Results—

In total, 5212 patients were analyzed. A total of 1155 (22.2%) patients were treated with BB before stroke onset and 244 (4.7%) patients were newly started with BB in the acute phase of stroke. Mortality was 17.5%, favorable outcome (defined as modified Rankin Scale, 0–2) occurred in 58.2% and pneumonia in 8.2% of patients. Prestroke BB showed no association with mortality. On-stroke BB was associated with reduced mortality (adjusted risk ratio, 0.63; 95% confidence interval, 0.42–0.96). Neither prestroke BB nor on-stroke BB showed an association with functional outcome. Both prestroke and on-stroke BB were associated with reduced frequency of pneumonia (adjusted risk ratio, 0.77; 95% confidence interval, 0.6–0.98 and risk ratio, 0.49; 95% confidence interval, 0.25–0.95).

Conclusions—

In this large nonrandomized comparison, on-stroke BB was associated with reduced mortality. Prestroke and on-stroke BB were inversely associated with incidence of nosocomial pneumonia. Randomized trials investigating the potential of β-blockade in acute stroke may be warranted.

Abstract T P47: Feasibility of Rapid Short Sequence Magnetic Resonance Imaging for Screening Stroke Mimics within the IV-tPA Treatment Window - A Pilot Study

Background & Purposes: Up to 30 percent of patients presenting with acute onset of neurological symptoms may suffer from stroke mimics (SMs). MRI is highly sensitive for detection of acute ischemia; however, its clinical utility in the acute stage is limited secondary to the complexity, availability, and time required for a comprehensive brain MRI. In this pilot study, we investigated the feasibility of rapid short sequence (RSS) MRI to screen possible SMs while keeping the door-to-needle (DTN) time below one hour.

Subjects & Methods: We developed clinical criteria to clinically suspect possible SMs and deployed RSS MRI in those patients presenting with acute stroke like-symptoms. Our RSS MRI protocol takes 5-6 minutes and includes DWI, ADC, and FLAIR sequences. The patients also received a non-contrast CT head at the time of ER presentation as standard of care. The new processes to our code stroke protocol included adding MRI technicians to the code stroke, the stroke nurse or physician filling out the MRI screening sheet and transporting the patient to the MRI suite. The stroke physicians were also available at the MRI console to read the MRI and the stroke team was on standby to initiate IV tPA infusion in the MR suite, if it was indicated.

Results: In a 9-month period, we evaluated 35 patients, who met our criteria for possible SMs, using RSS MRI (mean age 49, 78% women, median NIHSS 4). Three patients had diagnosis of an acute ischemic stroke on RSS MRI and received IV TPA while still in the MR suite. The DTN time ranged from 48 to 58 minutes. The median door-to-imaging time was 43 minutes (range 38-49). All of our patients with a RSS MRI negative for acute stroke had a final diagnosis other than stroke.

Conclusions: Our preliminary results show that RSS MRI can be rapidly obtained in selected patients without delaying the DTN time. This screening method avoids unnecessary IV-tPA administration to SMs.

Abstract T MP119: Recombinant Tissue Plasminogen Activator Does Not Impact Mortality in Acute Ischemic Stroke: A Meta-analysis of Randomized Controlled Trials

Background: Currently there is still some reluctance among emergency physicians and even neurologists to prescribe recombinant tissue plasminogen activator (rt-PA) for acute stroke. The majority of those unlikely to use it are concerned about causing harm to their patient. The object of this meta-analysis was to pool the mortality estimates at various time points following rt-PA administration. We hypothesized that there was a significant difference in mortality of patients treated with rt-PA and those treated with placebo. Methods: The databases PUBMED, EMBASE, SCOPUS, CENTRAL, and clinicaltrials.gov were searched for English-language randomized double blinded, placebo controlled trials of rt-PA. Mortality estimates were pooled and reported separately for days 7, 30, 90, and 180. Pooled relative risk (RR) and 95% confidence intervals were calculated using Dersimonian and Laird Random effects model. A priori designed sensitivity analyses included exclusion sensitivity analysis, and subgroup analysis into studies that included and excluded patients presenting within 3 hours of onset. Results: Eleven trials (N =6905) met the inclusion criteria. Total variance attributable to heterogeneity was not significant (I2 <50%) for any time point except at 30 days (I2, 53%). Publication bias was not significant on Begg’s and Egger’s tests. Mortality was not significantly different between the two groups at any time point. Exclusion sensitivity analysis revealed that exclusion of the NINDS trial rendered the 7 day and 30 day difference significant. Trials that randomized patients beyond 3 hours did not drive the mortality difference seen at any time point. Conclusion: In conclusion, compared with placebo, rt-PA does not impact mortality at any time point after administration through 6 months.

Abstract T P273: Internet-Based Information Seeking Behavior for Transient Ischemic Attack

Background &Purpose: In recent years, Internet became an increasingly important tool for accessing health information and is being used more frequently to promote public health. In this study, we used Google search data to explore information seeking behavior for transient ischemic attack (TIA).

Methods: We selected two groups of keywords related to TIA -“Transient Ischemic Attack” and “Mini Stroke” - after examining several related search keywords. We obtained all available online search data performed in the United States from the Google search engine for a ten year span - January 2004 to December 2013. The monthly and daily search data for the selected keywords were analyzed - using a moving window strategy - to explore the trends, peaks and declining effects.

Results: There were three significant concurrent peaks in the Google search data for the selected keywords. Each peak was directly associated with media coverage and news headlines related to the incident of TIA in a public figure. (Figure 1) Following each event, it took an average of two weeks for the search trend to return to its respective average value. The trend was steady for “Transient Ischemic Attack”; however, the search interest for the keyword “mini stroke” shows a steady increase. The overall search interest for the selected keywords was significantly higher in the southeastern United States.

Conclusions: Our study shows that changes in online search behavior can be associated with media coverage of key events (in our case TIA) in public figures. These findings suggest that online health promotion campaigns might be more effective if increased promptly after similar media coverage.