A - 78 Characterization of Post-Stroke Cognitive and Mood Impairment within 1-Year Post-Stroke after Hospital Discharge

OBJECTIVE

To demonstrate the feasibility of cognitive and psychological characterization after stroke during post-discharge neurology visit as part of standard care.

METHOD

From January 1, to April 29, 2023, 33 patients were evaluated using the MoCA and screening tests for aphasia, spatial neglect, depression, and anxiety during their neurology outpatient visit. Neuropsychological measures evaluating attention, processing speed, language, visuospatial, memory, and executive function abilities were also administered. Patients were aged 30-87 years (Mage = 64.8, SDage = 14.2). The sample included 37.1% women and was primarily Black/African American (37.1%) and White (54.3%). The average level of education was some college (Medu = 14.7, SDedu = 32.7). Time between stroke and testing ranged from 0-11 months (Melapsed = 2.8, SDelapsed = 3.1 and 88.6% of patients experienced ischemic stroke.

RESULTS

Over 68% of patients examined demonstrated global cognitive impairment on the MoCA (MMoCA = 21.2, SDMoCA = 5.1). 5.7% of patients met criteria for spatial neglect and 5.7% met criteria for aphasia. A higher percentage demonstrated impairments within visuospatial or language domains (51.4% visuospatial and 34.3% language, respectively. Further, impairments were observed across all other domains assessed, including attention (22.9%), processing speed (31.4%), verbal memory (62.9%), visual memory (54.3%), and executive function (51.4%). Depression and anxiety were present in 42.9% and 37.1% of the sample, respectively. Elapsed time, type of stroke, lateralization of stroke, sex, or mood scores were not associated with lower performance on the MoCA.

CONCLUSIONS

Cognitive and behavioral deficits following stroke can be identified as part of standard neurologic care that may otherwise have been missed, providing an opportunity to intervene and maximize recovery in stroke patients.

Telemedicine impact on post-stroke outpatient follow-up in an academic healthcare network during the COVID-19 pandemic

BACKGROUND

The expansion of telemedicine associated with the COVID-19 pandemic has influenced outpatient medical care. The objective of our study was to determine the impact of telemedicine on post-acute stroke clinic follow-up.

METHODS

We retrospectively evaluated the impact of telemedicine in Emory Healthcare, an academic healthcare system of comprehensive and primary stroke centers in Atlanta, Georgia, on post-hospital stroke clinic follow-up. We compared the frequency of 90-day follow-up in a centralized subspecialty stroke clinic among patients hospitalized before the local COVID-19 pandemic (January 1, 2019- February 28, 2020), during (March 1- April 30, 2020) and after telemedicine implementation (May 1- December 31, 2020). A comparison was made across hospitals less than 1 mile, 10 miles, and 25 miles from the stroke clinic.

RESULTS

Of 1096 ischemic stroke patients discharged home or to a rehab facility during the study period, 342 (31%) had follow-up in the Emory Stroke Clinic (comprehensive stroke center 46%, primary stroke center 10 miles away 18%, primary stroke center 25 miles away 14%). Overall, 90-day follow-up increased from 19% to 41% after telemedicine implementation (p<0.001) with telemedicine appointments amounting for up to 28% of all follow-up visits. In multivariable analysis, factors associated with teleneurology follow-up (vs no follow-up) included discharge from the comprehensive stroke center, thrombectomy treatment, private insurance, private transport to the hospital, NIHSS 0-5 and history of dyslipidemia.

CONCLUSIONS

Despite telemedicine implementation at an academic healthcare network successfully increasing post-stroke discharge follow-up in a centralized subspecialty stroke clinic, the majority of patients did not complete 90-day follow-up during the COVID-19 pandemic.

Factors associated with stroke after COVID-19 vaccination: a statewide analysis

Background

The objective of our study was to evaluate vaccine type, COVID-19 infection, and their association with stroke soon after COVID-19 vaccination.

Methods

In a retrospective cohort study, we estimated the 21-day post-vaccination incidence of stroke among the recipients of the first dose of a COVID-19 vaccine. We linked the Georgia Immunization Registry with the Georgia Coverdell Acute Stroke Registry and the Georgia State Electronic Notifiable Disease Surveillance System data to assess the relative risk of stroke by the vaccine type.

Results

Approximately 5 million adult Georgians received at least one COVID-19 vaccine between 1 December 2020 and 28 February 2022: 54% received BNT162b2, 41% received mRNA-1273, and 5% received Ad26.COV2.S. Those with concurrent COVID-19 infection within 21 days post-vaccination had an increased risk of ischemic (OR = 8.00, 95% CI: 4.18, 15.31) and hemorrhagic stroke (OR = 5.23, 95% CI: 1.11, 24.64) with no evidence for interaction between the vaccine type and concurrent COVID-19 infection. The 21-day post-vaccination incidence of ischemic stroke was 8.14, 11.14, and 10.48 per 100,000 for BNT162b2, mRNA-1273, and Ad26.COV2.S recipients, respectively. After adjusting for age, race, gender, and COVID-19 infection status, there was a 57% higher risk (OR = 1.57, 95% CI: 1.02, 2.42) for ischemic stroke within 21 days of vaccination associated with the Ad26.COV2.S vaccine compared to BNT162b2; there was no difference in stroke risk between mRNA-1273 and BNT162b2.

Conclusion

Concurrent COVID-19 infection had the strongest association with early ischemic and hemorrhagic stroke after the first dose of COVID-19 vaccination. Although not all determinants of stroke, particularly comorbidities, were considered in this analysis, the Ad26.COV2.S vaccine was associated with a higher risk of early post-vaccination ischemic stroke than BNT162b2.

Abstract TP185: Lipoprotein(a) Levels In Patients With Embolic Stroke Of Undetermined Source And Its Association With Non-stenotic Atherosclerotic Disease

Background: Lipoprotein(a) [Lp(a)]has been linked to increased atherosclerotic cardiovascular disease risk however there is limited data on Lp(a) in ischemic stroke subtypes. Current cholesterol management and ASCVD prevention guidelines include Lp(a) >50 mg/dL as a risk enhancer.

Methods: This is a retrospective cohort of consecutive embolic stroke of undetermined source (ESUS) patients seen at the Emory Stroke Clinic and underwent Lp(a) testing in the outpatient setting from January 1, 2020 to March 31, 2022. Abnormal levels were defined as ≥ 30 mg/dl. Cerebrovascular imaging was reviewed by a board-certified neuroradiologist who was blinded to Lp(a) data.

Results: Of 105 ESUS patients [median age 57 years (IQR 44-68), 51% female, 44% African American (AA)], median Lp(a) was 40 mg/dl (IQR 15-74) with 67 patients (64%) having Lp(a) ≥ 30 mg/dl, 45 (43%) ≥ 50 mg/dl and 30 (29%) having Lp(a) ≥ 70 mg/dl. Lp(a) levels were higher in AAs compared to other races (median 46 mg/dl vs 26 mg/dl , p= 0.002). Lp(a) level ≥ 30 mg/dl was associated with a higher serum D-dimer level median 536 (IQR 337-947, p=0.02), non-large vessel occlusion (LVO) stroke on initial imaging (p=0.012) and absence of MRI-FLAIR sequence abnormalities (p=0.044). In the subset of ESUS patients who underwent CT angiography of the head and neck (n=46), patients with Lp(a) level ≥ 50 mg/dl were more likely to have non-stenotic atherosclerotic plaque ipsilateral to the stroke territory (OR 6.1, 95% CI 1.3-28, p= 0.02).

Conclusion: Lp(a) level ≥ 50 mg/dl was present in 43% of our cohort. This may be an under-recognized risk factor in ESUS. Further investigation is needed regarding the impact of Lp(a) on ESUS however our results suggest that ESUS patients with ≥ 50 mg/dl may benefit from a careful assessment of cerebrovascular imaging for ipsilateral non-stenotic atherosclerotic plaque in the territory of the stroke.

Abstract NS3: Telemedicine Impact On Post-stroke Outpatient Follow-up In An Academic Healthcare Network

Introduction: The expansion of telemedicine associated with the COVID-19 pandemic has influenced outpatient medical care. The objective of our study was to determine the impact of telemedicine on post-acute stroke clinic follow-up.

Methods: With this retrospective cohort study, we evaluated the impact of telemedicine in Emory Healthcare, an academic healthcare system of comprehensive (CSC) and primary stroke centers (PSC) in Atlanta, Georgia, on post-hospital stroke clinic follow-up. We compared the frequency of successful post-hospitalization follow-up in a centralized subspecialty stroke clinic among patients hospitalized before the local COVID-19 pandemic (January 1- February 28, 2020), during (March 1- April 30, 2020) and after telemedicine implementation (May 1- December 31, 2020). A comparison was made across network hospitals less than 1 mile (CSC) and 25 miles (PSC25) from the specialty stroke clinic.

Results: Of the 553 ischemic stroke patients [median age 68 years (IQR 58-79), median NIHSS 4 (IQR 1-8)] discharged home or to a rehab facility during the study period, 241 (43.6%) had follow-up in the Emory Stroke Clinic (CSC=48%, PSC25=23%). Overall, 90-day follow-up increased from 31% before to 48% after telemedicine implementation. Similarly, telemedicine appointments increased from 19% to 72% of the follow-up visits. The increase in follow-up visits was modest among CSC patients, from 41% to 51% (p=0.16), relative to the increase among PSC25 patients (5.3% to 31%, p=0.002).

Conclusions: Telemedicine implementation at an academic healthcare network successfully increased post-stroke discharge follow-up in a centralized subspecialty stroke clinic for hospitalized patients up to 25 miles from the clinic site. However, more work is required to facilitate follow up in the majority of patients.

Anticoagulation Therapy Reduces Recurrent Stroke in Embolic Stroke of Undetermined Source Patients With Elevated Coagulation Markers or Severe Left Atrial Enlargement

Background: The objective of this study was to evaluate if anticoagulation therapy reduces recurrent stroke in embolic stroke of undetermined source (ESUS) patients with left atrial enlargement (LAE) or abnormal markers of coagulation and hemostatic activity (MOCHA) compared to antiplatelet therapy.

Methods: ESUS patients from January 1, 2017, to June 30, 2019, underwent outpatient cardiac monitoring and the MOCHA profile (serum d-dimer, prothrombin fragment 1.2, thrombin–antithrombin complex, and fibrin monomer). Anticoagulation was offered to patients with abnormal MOCHA (≥2 elevated markers) or left atrial volume index 40 mL/m². Patients were evaluated for recurrent stroke or major hemorrhage at routine clinical follow-up. We compared this patient cohort (cohort 2) to a historical cohort (cohort 1) who underwent the same protocol but remained on antiplatelet therapy.

Results: Baseline characteristics in cohort 2 (n = 196; mean age = 63 ± 16 years, 59% female, 49% non-White) were similar to cohort 1 (n = 42) except that cohort 2 had less diabetes (43 vs. 24%, p = 0.01) and more tobacco use (26 vs. 43%, p = 0.04). Overall, 45 patients (23%) in cohort 2 initiated anticoagulation based on abnormal MOCHA or LAE. During mean follow-up of 13 ± 10 months, cohort 2 had significantly lower recurrent stroke rates than cohort 1 (14 vs. 3%, p = 0.009) with no major hemorrhages.

Conclusions: Anticoagulation therapy in a subgroup of ESUS patients with abnormal MOCHA or severe LAE may be associated with a reduced rate of recurrent stroke compared to antiplatelet therapy. A prospective, randomized study is warranted to validate these results.

The Utility of the Markers of Coagulation and Hemostatic Activation Profile in the Management of Embolic Strokes of Undetermined Source

BACKGROUND

Potential causes of embolic stroke of undetermined source (ESUS) include occult malignancy, venous thrombosis (VTE) with paradoxical embolism, and hypercoagulable disorders. Given the association of markers of coagulation and hemostatic activation (MOCHA) with these causes, the objective of this study was to validate the utility of the MOCHA profile in identifying the underlying cause of stroke.

METHODS

We prospectively identified ESUS patients from January 1, 2017 to December 1, 2019 who underwent MOCHA profile (plasma d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer) testing. Abnormal MOCHA profile was defined as ≥ 2 abnormal markers. New diagnoses of malignancy, VTE, hypercoagulable disorders and recurrent stroke were identified during routine clinical follow-up.

RESULTS

Of 236 ESUS patients, 104 (44%) patients had an abnormal MOCHA profile. In multivariable analyses the number of MOCHA abnormalities was significantly associated with malignancy, VTE, and hypercoagulable disorders (OR 2.59, CI 95% 1.78-3.76, p<0.001). Sensitivity, specificity, positive predictive value, and negative predictive value of an abnormal MOCHA profile for the combined outcome of malignancy, VTE, and hypercoagulability was 96%, 62%, 23%, and 99% respectively.

DISCUSSION

The MOCHA profile was able to identify ESUS patients more likely to have malignancy, VTE, and hypercoagulable disorders during follow-up. Our results show that a normal MOCHA profile in ESUS patients can effectively rule out these potential causes of ESUS.

Markers of coagulation and hemostatic activation aid in identifying causes of cryptogenic stroke

OBJECTIVE

To test the hypothesis that markers of coagulation and hemostatic activation (MOCHA) help identify causes of cryptogenic stroke, we obtained serum measurements on 132 patients and followed them up to identify causes of stroke.

METHODS

Consecutive patients with cryptogenic stroke who met embolic stroke of undetermined source (ESUS) criteria from January 1, 2017, to October 31, 2018, underwent outpatient cardiac monitoring and the MOCHA profile (serum D-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, and fibrin monomer) obtained ≥2 weeks after the index stroke; abnormal MOCHA profile was defined as ≥2 elevated markers. Prespecified endpoints monitored during routine clinical visits included new atrial fibrillation (AF), malignancy, venous thromboembolism (VTE), or other defined hypercoagulable states (HS).

RESULTS

Overall, 132 patients with ESUS (mean age 64 ± 15 years, 61% female, 51% nonwhite) met study criteria. During a median follow-up of 10 (interquartile range 7-14) months, AF, malignancy, VTE, or HS was identified in 31 (23%) patients; the 53 (40%) patients with ESUS with abnormal MOCHA were significantly more likely than patients with normal levels to have subsequent new diagnoses of malignancy (21% vs 0%, p < 0.001), VTE (9% vs 0%, p = 0.009), or HS (11% vs 0%, p = 0.004) but not AF (8% vs 9%, p = 0.79). The combination of 4 normal MOCHA and normal left atrial size (n = 30) had 100% sensitivity for ruling out the prespecified endpoints.

CONCLUSION

The MOCHA profile identified patients with cryptogenic stroke more likely to have new malignancy, VTE, or HS during short-term follow-up and may be useful in direct evaluation for underlying causes of cryptogenic stroke.

Abstract WP264: Frequency of Hypercoagulability in Patients With Embolic Stroke of Undetermined Source and Patent Foramen Ovale

Introduction: Patent foramen ovale (PFO) is more commonly found in patients with cryptogenic stroke and paradoxical embolism is commonly assumed to be the primary mechanism. Our objective was to determine the frequency of hypercoagulability in cryptogenic stroke patients and PFO.

Methods: Consecutive patients with embolic stroke of undetermined source (ESUS) seen at the Emory Clinic from January 1, 2017 to June 30, 2019 who underwent echocardiogram with bubble study and markers of coagulation and hemostatic activation (MOCHA) testing (serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer) were included; abnormal MOCHA was defined as ≥ 2 elevated markers. Venous thromboembolism, malignancy, other defined hypercoagulable state, and the composite outcome were assessed at routine follow-up and compared across groups based on PFO status.

Results: Of 172 patients (mean age 63 ± 16 years, 60% female), 40 (23%) had a PFO. Compared to the PFO- group, the PFO+ group was younger (p=<0.001), less likely to have hypertension (p<0.001) and diabetes (p=0.011), and had a higher ROPE score (p=0.007) (Table 1). There was no difference in the frequency of abnormal MOCHA between groups and the composite outcome was less frequent in PFO+ versus PFO- patients (p=0.017). In the subgroup of patients <60 years old, there was no difference in the frequency of abnormal MOCHA and the composite outcome.

Conclusion: Hypercoagulability as measured by MOCHA was not associated with the presence of PFO in ESUS patients. Based on our results, ESUS patients should undergo a detailed evaluation for alternative causes of stroke other than paradoxical embolism.

Abstract WMP118: Anticoagulation Therapy Reduces Recurrent Stroke in Embolic Stroke of Undetermined Source (ESUS) Patients With Elevated Coagulation Markers or Severe Left Atrial Enlargement

Introduction: Left atrial enlargement (LAE) and markers of coagulation and hemostatic activation (MOCHA) have previously been shown to identify ESUS patients who are more likely to have subsequent diagnosis of atrial fibrillation (AF), malignancy or recurrent strokes. The objective of this study was to evaluate if anticoagulation therapy reduces recurrent stroke in ESUS patients with LAE or abnormal MOCHA.

Methods: Consecutive ESUS patients seen in the Emory Clinic from January 1, 2017, to June 30, 2019, underwent outpatient cardiac monitoring and the MOCHA profile (serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer) obtained ≥ 2 weeks after the index stroke. All patients were on antiplatelet therapy at the time of testing. Anticoagulation was offered to patients with an abnormal MOCHA (≥ 2 elevated markers) or severe LAE (LA volume index >40 ml/m 2 ). Patients were evaluated for AF, malignancy, recurrent stroke or hemorrhage at routine clinical follow-up. We compared this patient cohort (cohort 2) to a historical cohort (cohort 1) who underwent the same protocol but remained on antiplatelet therapy during follow-up.

Results: Baseline characteristics and endpoints are shown in the Table. Overall 46 (23%) patients in Cohort 2 initiated anticoagulation based on abnormal MOCHA or severe LAE. Cohort 2 had significantly lower rates of recurrent stroke than cohort 1 (14% vs. 3%, p=0.008) with no major hemorrhages.

Conclusion: Anticoagulation therapy in a subgroup of ESUS patients with abnormal MOCHA or severe LAE may be associated with a reduced rate of recurrent stroke. A prospective, multicenter study is warranted to validate these results.

Abstract 27: Biomarkers of Coagulation and Hemostatic Activation in the Post-Acute Period Effectively Rule Out Hypercoagulable States in Patients With Embolic Stroke of Undetermined Source

Introduction: We previously reported that markers of coagulation and hemostatic activation (MOCHA) have been associated with malignancy, venous thromboembolism (VTE) and hypercoagulable states in embolic stroke of undetermined source (ESUS) patients. The objective of our study was to identify independent predictors of these endpoints.

Methods: Consecutive ESUS patients seen at the Emory Clinic from January 1, 2017 to June 30, 2019 underwent a MOCHA profile (d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer) and were followed prospectively for new diagnoses of malignancy, VTE, other defined hypercoagulable states and the composite outcome. Abnormal MOCHA was defined as ≥ 2 elevated markers. Multivariable analyses were performed to identify predictors of the composite outcome.

Results: Of 188 patients (mean age 63 ±16 years, 59% female, 50% Caucasian) included in the study period, 25 (13%) had the composite outcome. The median time between ESUS to MOCHA testing was 45 days (IQR 23-88). Abnormal MOCHA profile was the only independent predictor of the composite outcome (OR 2.34, 1.64-3.32, p<0.001) (AUC 0.824); age, sex, race, any history of tobacco use, hypertension, diabetes, history of stroke, cortical stroke, migraine, and left atrial size were not predictive. Abnormal MOCHA had a 96% sensitivity, 32% positive predictive value and 99% negative predictive value for the composite outcome.

Conclusions: This study confirms that a normal MOCHA profile in the post-acute time period can rule out ESUS patients with malignancy, VTE or other underlying hypercoagulable states.

Abstract WP529: Anticoagulation Therapy Reduces Recurrent Stroke in Embolic Stroke of Undetermined Source (ESUS) Patients With Elevated Markers of Coagulation and Hemostatic Activation

Introduction: Markers of coagulation and hemostatic activation (MOCHA) have previously been shown to identify ESUS patients who are more likely to have subsequent diagnosis of atrial fibrillation (AF), malignancy, venous thromboembolism (VTE) or other defined hypercoagulable disorders. The objective of this study was to evaluate whether anticoagulation therapy reduces recurrent stroke in ESUS patients with an abnormal MOCHA profile.

Methods: Consecutive ESUS patients seen in the Emory Clinic from January 1, 2017 to June 30, 2018 underwent outpatient cardiac monitoring and the MOCHA profile including serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer obtained ≥ 2 weeks after the index stroke. All patients were on antiplatelet therapy at the time of MOCHA testing and an abnormal MOCHA profile was defined as ≥ 2 elevated markers. Anticoagulation was offered to patients with an abnormal MOCHA and patients were evaluated for recurrent stroke or hemorrhage at routine clinical follow-up. We compared this patient cohort (cohort 2) to a historical cohort (cohort 1) who underwent the same protocol but remained on antiplatelet therapy during follow-up.

Results: Baseline characteristics were similar between cohorts except that cohort 2 was less likely to have diabetes (43% vs 23%, p=0.004), less likely to have an abnormal MOCHA profile (55% vs 36%, p=0.008) and had a shorter duration of follow-up (mean months 13 vs 7, p=0.0001). Cohorts had similar rates of the composite endpoint of AF, malignancy, VTE or other defined hypercoagulable disorder (33% vs 26%, p=0.43). MOCHA profile was obtained a median of 33 (IQR 15-57) days after index stroke in cohort 2; 41 (36%) patients were offered the option of anticoagulation therapy due to an abnormal MOCHA profile of which 32 (78%) chose anticoagulation. Cohort 2 had significantly lower rates of recurrent stroke than cohort 1 (14% vs. 0.9%, IRR 0.14, p=0.01) with no major hemorrhages seen in either group.

Conclusion: This study suggests that anticoagulation therapy in a subgroup of ESUS patients with abnormal MOCHA profile may be associated with a reduced rate of recurrent stroke. A prospective, randomized study is needed to confirm these findings.

Abstract 122: Markers of Coagulation and Hemostatic Activation Identify Embolic Stroke of Undetermined Source (ESUS) Patients who are at Risk of Recurrent Thrombotic Events on Antiplatelet Therapy: A Validation Study

Introduction: Markers of coagulation and hemostatic activation (MOCHA) have previously been shown to identify ESUS patients who are more likely to have subsequent diagnosis of atrial fibrillation (AF) or malignancy. The objective of this study was to validate these results in a larger ESUS cohort.

Methods: Consecutive ESUS patients seen in the Emory Clinic from January 1, 2017 to June 30, 2018 underwent outpatient cardiac monitoring and the MOCHA profile including serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer obtained ≥ 2 weeks after the index stroke. All patients were on antiplatelet therapy at the time of MOCHA testing and an abnormal MOCHA profile was defined as ≥ 2 elevated markers. Prespecified endpoints monitored during routine clinical follow-up included diagnosis of AF, malignancy, venous thromboembolism (VTE) or other defined hypercoagulable states.

Results: During the study period, 113 ESUS patients (mean age 64 +/- 15 years, 63% female, 54% non-white) underwent prolonged cardiac monitoring (70% MCOT, 42% ILR) and MOCHA profile testing (median days from stroke 33, IQR 15-57). During a mean follow-up of 7 ± 4 months, AF, malignancy, VTE or other defined hypercoagulable state was identified in 30 (27%) patients; the 41 (36%) ESUS patients with an abnormal MOCHA profile were significantly more likely to have an endpoint than patients with a normal profile (59% vs 8%, p<0.0001). The absence of any elevated MOCHA tests (n=41) had 100% sensitivity for the prespecified endpoints.

Conclusion: In this validation study, we found that the MOCHA profile identified ESUS patients more likely to have AF, malignancy, VTE or other defined hypercoagulable states during follow-up and may identify a subgroup of ESUS patients who could benefit from early anticoagulation; a normal MOCHA profile identifies ESUS patients who have a low risk of developing these endpoints on antiplatelet therapy.

Abstract WP278: Markers of Coagulation and Hemostatic Activation in Embolic Stroke of Undetermined Source (ESUS) Patients With Patent Foramen Ovale

Introduction: Recent randomized trials have shown that patent foramen ovale (PFO) closure combined with antiplatelet therapy in cryptogenic stroke patients ≤ 60 years of age is associated with a reduced risk of stroke compared to antiplatelet therapy alone, presumably by preventing a paradoxical embolism. The objective of this study was to evaluate the MOCHA profile, a sensitive marker of venous thromboembolism (VTE), in ESUS patients with PFO.

Methods: Consecutive ESUS patients ≥ 18 years of age seen in the Emory Clinic from January 1, 2017 to June 30, 2018 underwent testing of MOCHA including serum d-dimer (DD), prothrombin fragment 1.2 (PTF1.2), thrombin-antithrombin (TAT) complex and fibrin monomer (FM). All patients were on antiplatelet therapy at the time of MOCHA testing and an abnormal MOCHA profile was defined as ≥ 2 elevated markers. We compared baseline characteristics and clinical outcomes between patients with and without PFO.

Results: During the study period, 113 ESUS patients (mean age 64 +/- 15 years, 63% female, 54% non-white, 20% PFO) underwent MOCHA profile testing; 37 (32.7%) were ≤ 60 years of age. In the subgroup ≤ 60 years of age, the 11 (23%) PFO+ patients were younger (mean age 40 vs 46, p=0.009), more likely to be white (55% vs 35%, p=0.0001) and had higher ROPE score (median 8 vs 6, p=0.06) than PFO- patients. There was no significant difference between PFO+ and PFO- patients in the frequency of abnormal MOCHA (18% vs 19%), mean DD, PTF1.2, TAT, FM and frequency of VTE (1 event in each group). PFO+ and PFO- patients had a high frequency of migraine with aura (64%, 38%, p=0.15) and headache days in the month prior to stroke (mean 11 vs 5, p=0.72). In multivariable analysis of the overall cohort, age (OR 1.14 1.06-1.22 p<0.001) and ROPE score (OR 2.29 1.13-4.65 p=0.02) were significantly associated with abnormal MOCHA while PFO status (p=0.4) and migraine (p=0.23) were not.

Conclusion: In ESUS patients ≤ 60 years of age, there was no difference in the MOCHA profile between PFO+ and PFO- patients. The high frequency of migraine with aura and headache days in the month prior to stroke regardless of PFO status needs further study to evaluate its role in young ESUS patients.

Coagulation markers and echocardiography predict atrial fibrillation, malignancy or recurrent stroke after cryptogenic stroke

We evaluated the utility of left atrial volume index (LAVI) and markers of coagulation and hemostatic activation (MOCHA) in cryptogenic stroke (CS) patients to identify those more likely to have subsequent diagnosis of atrial fibrillation (AF), malignancy or recurrent stroke during follow-up.Consecutive CS patients who met embolic stroke of undetermined source (ESUS) who underwent transthoracic echocardiography and outpatient cardiac monitoring following stroke were identified from the Emory cardiac registry. In a subset of consecutive patients, d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer (MOCHA panel) were obtained ≥2 weeks post-stroke and repeated ≥4 weeks later if abnormal; abnormal MOCHA panel was defined as ≥2 elevated markers which did not normalize when repeated. We assessed the predictive abilities of LAVI and the MOCHA panel to identify patients with subsequent diagnosis of AF, malignancy, recurrent stroke or the composite outcome during follow-up.Of 94 CS patients (mean age 64 ± 15 years, 54% female, 63% non-white, mean follow-up 1.4 ± 0.8 years) who underwent prolonged cardiac monitoring, 15 (16%) had new AF. Severe LA enlargement (vs normal) was associated with AF (P < .06). In 42 CS patients with MOCHA panel testing (mean follow-up 1.1 ± 0.6 years), 14 (33%) had the composite outcome and all had abnormal MOCHA. ROC analysis showed LAVI and abnormal MOCHA together outperformed either test alone with good predictive ability for the composite outcome (AUC 0.84).We report the novel use of the MOCHA panel in CS patients to identify a subgroup of patients more likely to have occult AF, occult malignancy or recurrent stroke during follow-up. A normal MOCHA panel identified a subgroup of CS patients at low risk for recurrent stroke on antiplatelet therapy. Further study is warranted to evaluate whether the combination of an elevated LAVI and abnormal MOCHA panel identifies a subgroup of CS patients who may benefit from early anticoagulation for secondary stroke prevention.

Over-the-counter analgesic powder use in patients presenting with intracerebral hemorrhage: A case series

INTRODUCTION

Over-the-counter (OTC) analgesics including aspirin-containing powder formulations (BC Powder, Goody's Powder) (ACPFs) are commonly utilized in the United States. While the ACPFs have been associated with upper gastrointestinal bleeding, we describe a case series of patients presenting with intracerebral hemorrhage (ICH) within 24 hours of ingestion.

METHODS

We reviewed all ICH patients presenting to a comprehensive stroke center from September 1, 2014 through June 30, 2016 to identify patients who reported taking BC Powder or Goody's Powder within 7 days of their stroke. Baseline characteristics, medication use, stroke risk factors, clinical imaging, and laboratory testing were reviewed retrospectively.

RESULTS

Of 334 patients admitted with ICH during the study period, 6 (2%) reported use of OTC analgesic powders within 1 week of their index stroke. All had consumed at least 1 packet within 24 hours of their ICH. All patients were African American and all except 1 patient were females. Three patients had no identified traditional stroke risk factors and 3 other patients had evidence of mild hypertension history.

CONCLUSIONS

Over-the-counter analgesic powders containing high doses of aspirin including BC Powder and Goody's Powder may contribute to ICH in patients with no or minimal risk factors. Providers should inquire about the use of these powders in ICH patients particularly among African Americans.

Abstract 120: Measures of Coagulation and Hemostatic Activation Outperform Left Atrial Structural Parameters in Identifying Embolic Stroke of Undetermined Source (ESUS) Patients Who May Benefit From Early Anticoagulation

Introduction: The objective of this study was to evaluate left atrial (LA) echocardiographic parameters and a novel panel of serum biomarkers to identify ESUS patients who may benefit from early anticoagulation.

Methods: We prospectively identified ESUS patients seen in the Emory Clinic from January 1, 2015 to June 30, 2017 who underwent prolonged cardiac monitoring with mobile cardiac outpatient telemetry (MCOT) and/or implantable loop recorder (ILR). In a subset of consecutive patients, 4 measures of coagulation and hemostatic activation (MOCHA) including d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer were obtained ≥ 2 weeks after the index stroke and repeated if abnormal. We evaluated the ability of LA structural parameters to identify patients with atrial fibrillation (AF) on monitoring and the ability of abnormal MOCHA levels to identify patients who had the composite outcome of newly diagnosed AF, malignancy, or recurrent stroke.

Results: During the study period, 92 ESUS patients (mean age 64 +/- 15 years, 54% female, 62% non-white, mean follow-up 1.4 +/- 0.8 years) underwent prolonged cardiac monitoring (65% MCOT, 62% ILR, 38% MCOT+ILR); 16 (17%) were found to have AF. Severe LA enlargement (vs normal) was associated with subsequent detection of AF (p=0.09) however LA diameter and LA volume index were not. Baseline characteristics of ESUS patients who underwent MOCHA testing (n=44) were similar to patients who did not except that those tested were younger (60 vs 67 years, p=0.04); over mean follow-up of 1.2 +/- 0.8 years, 18 (41%) patients had newly diagnosed AF, malignancy or recurrent stroke. ESUS patients with persistently abnormal (vs normal) MOCHA levels were significantly more likely to have newly diagnosed AF, malignancy or recurrent stroke (OR 11.3, 95% CI 2.5-50.1, p=0.001); elevated levels of ≥ 3 MOCHA markers had a 67% sensitivity and 81% specificity for identifying patients with the composite outcome.

Conclusion: Abnormal MOCHA levels identified ESUS patients who were more likely to have newly diagnosed AF, malignancy or recurrent stroke over follow-up and may be more effective than LA structural abnormalities in identifying patients who could benefit from early anticoagulation.

Abstract TP414: Are Periodic Limb Movements and Obstructive Sleep Apnea Associated with Atrial Fibrillation or Resistant Hypertension in Stroke and TIA Patients?

Introduction: Periodic limb movements (PLMs) and obstructive sleep apnea (OSA) have been associated with an increased risk of cardiovascular disease. There are limited data on the frequency of PLMs and OSA among a diverse cohort of stroke patients and their association with resistant hypertension and atrial fibrillation (AF).

Hypothesis: Stroke and TIA patients with PLMs or moderate-severe OSA are more likely to have resistant hypertension and AF than patients without these findings on diagnostic polysomnography (PSG).

Methods: Consecutive stroke and TIA patients referred by a vascular neurologist for PSG from October 1, 2012 to September 30, 2015 were included in this analysis. Baseline clinical characteristics and PSG results were collected retrospectively. The frequency of PLMs (mild ≥5/hour, severe ≥15/hour), arousals due to PLMs (≥5/hour), and moderate-severe OSA (Apnea-Hypopnea Index≥15) was evaluated by PSG to determine their association with AF and resistant hypertension, defined as patients whose blood pressure was not at goal with 3 antihypertensive agents of different classes or controlled with 4 or more medications.

Results: Of 103 patients (mean age 60±15 years, 50% female, 61% non-white, 76% ischemic stroke, 23% resistant hypertension) who underwent PSG (median time from cerebrovascular event to PSG 5 months), 48% had mild PLMs, 28% had severe PLMs, 14% had frequent PLM arousals and 22% had moderate-severe OSA. In multivariable analyses, non-white race was associated with lower likelihood of mild (OR 0.32, 95% CI 0.13 to 0.80) and severe PLMs (OR 0.29, 95% 0.10 to 0.79) and female sex was associated with lower likelihood of frequent PLM arousals (OR 0.38, 95% CI 0.14 to 1.00). Factors associated with moderate-severe OSA included older age (OR 1.06, 95% CI 1.016 to 1.106) and the presence of AF (OR 4.26, 95% CI 1.17 to 15.44). There was no significant association between PLMs, PLM arousals or moderate-severe OSA with resistant hypertension.

Conclusions: A significant number of stroke and TIA patients have PLMs and moderate-severe OSA. Stroke and TIA patients with AF are more likely to have moderate-severe OSA and should be referred for PSG. The presence of resistant hypertension was not associated with PLMs or moderate-severe OSA in our study.

Clopidogrel plus Aspirin for Symptomatic Intracranial Atherosclerotic Stenosis: A Pilot Study

BACKGROUND AND PURPOSE

There are limited data on the optimal duration of dual antiplatelet therapy for secondary stroke prevention in patients with symptomatic intracranial atherosclerotic disease.

METHODS

Consecutive patients presenting with high-grade (70-99%) symptomatic intracranial stenosis from January 1, 2011, to December 31, 2013, and evaluated within 30 days of the index event were eligible for this analysis. All patients underwent treatment with aspirin plus clopidogrel for a target duration of 12 months along with aggressive medical management based on the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) protocol; all patients were given gastrointestinal prophylaxis for the duration of their aspirin and clopidogrel treatment. Clinical and safety outcomes of our cohort were compared with the medical arm of the SAMMPRIS trial cohort (n = 227).

RESULTS

Our cohort included 25 patients that met the inclusion criteria. Achievement of blood pressure and LDL cholesterol targets were similar between our cohort and the SAMMPRIS cohort. At 1 year, the rates of stroke, myocardial infarction or vascular death were 0% in our cohort and 16% in the SAMMPRIS cohort (p = 0.03). At 1 year, major bleeding rates were similar between our cohort and the SAMMPRIS cohort (4 vs. 2.2%, p = 1.0).

CONCLUSION

A prolonged course of dual antiplatelet therapy for symptomatic intracranial atherosclerotic disease may be associated with less vascular events with no increase in hemorrhagic complications.

Abstract 106: A Simple Screening Tool to Identify Stroke or TIA Patients With Moderate or Severe Obstructive Sleep Apnea: The CHA2TS2 Score

Introduction: The frequency of obstructive sleep apnea (OSA) among stroke and TIA patients varies from 14% to 72% depending on apnea-hypopnea index (AHI) cut-off points and the study population. Various screening tools have been validated in unselected patients referred for diagnostic polysomnography (DP) but a screening tool that identifies stroke/TIA patients at highest risk of moderate-severe OSA is lacking.

Hypothesis: A simple screening tool that considers medical comorbidities and sleep-related symptoms can identify stroke/TIA patients who are most likely to have moderate-severe OSA.

Methods: Consecutive stroke and TIA patients referred by vascular neurology for DP from September 2012 to February 2015 were included in a retrospective analysis. Baseline clinical characteristics, DP results and outcomes were collected retrospectively. Moderate-severe OSA was defined as AHI≥15.

Results: Of 65 patients (mean age 61±14 years, 48% female, 51% African-American) included in this analysis, 19 (29.2%) were diagnosed with moderate-severe OSA. In multivariable analysis using backward elimination (entry and exit thresholds 0.15), predictors of moderate-severe OSA included history of Coronary artery disease, Hyperlipidemia, older Age, history of Atrial fibrillation, former or current Tobacco use and self- or family-reported Snoring or daytime Sleepiness (CHA2TS2). Variables excluded were sex, race, hypertension, diabetes, depression, chronic obstructive pulmonary disease, patent foramen ovale, body mass index, stroke subtype and wakeup onset . The CHA2TS2 model had excellent predictive power for moderate-severe OSA (AUC= 0.91). CHA2TS2 ≥5 had 100% sensitivity and 54% specificity for detecting moderate-severe OSA.

Conclusions: We developed a simple screening tool that can identify stroke and TIA patients who have high likelihood of having moderate or severe OSA identified on their DP. Prospective validation of CHA2TS2 score is currently underway.

Abstract 206: High False Positive Rates of Atrial Fibrillation Detection Among Stroke Patients who Receive Medtronic Implantable Loop Recorders

Introduction: Atrial fibrillation is a known risk factor for the development of stroke. Implantable loop recorders (ILRs) have specific algorithms to detect occult atrial fibrillation and can be used in patients with cryptogenic stroke. There is limited data on the frequency of false positive atrial fibrillation detected by the Medtronic ILR.

Hypothesis: Medtronic ILRs have a high rate of false positives but despite this are still effective at detecting atrial fibrillation in patients with cryptogenic stroke.

Methods: All stroke patients who underwent ILR placement from Jan 1, 2013 to June 30, 2015 were prospectively collected through an administrative database. Baseline and clinical characteristics were retrospectively obtained. A random sampling of ILR tracings identified as atrial fibrillation by the Medtronic algorithm was adjudicated by a board certified electrophysiologist for accuracy.

Results: Among 52 patients with a history of ischemic stroke or TIA (mean age 68±14 years, 58% male, 83% white), there were 166 rhythm strips identified as atrial fibrillation by the Medtronic algorithm which were adjudicated. Of the 166 strips reviewed, 140 (84%) were incorrectly identified as atrial fibrillation; of those false positives, adjudication identified 57% as premature atrial complexes(PACs), 22% as T wave over-sensing, 10% due to noise, 5.0% due to premature ventricular complexes (PVCs), 2.9% due to under-sensing, and 2.9% due to sinus arrhythmia. Of the 38 (73%) patients who had ILR implantation for cryptogenic stroke, 4 (11%) were identified as having true atrial fibrillation by ILR after adjudication over 413 patient-months of monitoring; mean time to atrial fibrillation detection was 93 days after implantation.

Conclusions: Stroke patients who undergo Medtronic ILR placement have high false positive rates of atrial fibrillation detected with the Medtronic algorithm. When adequately reviewed by a trained cardiologist for accuracy, the Medtronic ILRs remain effective at detecting atrial fibrillation in cryptogenic stroke patients.