Comparison of three fluids for calibration of the new Periotron® 8010

BACKGROUND

The aim of the present study was to calibrate the Periotron® model 8010 with volumes of three different fluids (distilled water, serum, and saliva) and to identify which of the three is the most reliable, feasible, and reproducible for routine calibration.

MATERIAL AND METHODS

A total of 450 samples of Periopaper® were divided into three groups (150 each per group): distilled water, serum matrix and saliva. A calibration curve was run with 0.25, 0.50, 0.75, 1.00 and 1.25 µl of each of the fluids, and the results were determined in Periotron units (PU). Statistical analysis was performed with one-way ANOVA followed by Bonferroni's post hoc test and a linear equation.

RESULTS

Distilled water presented the lowest levels of PU at all volumes, while serum showed the highest levels at high volumes. Linear regression equations rendered similar slopes for saliva and distilled water, while serum was statistically different. Saliva presented a reproduction percentage of 99.7%, which indicated better accuracy and precision than serum and distilled water.

CONCLUSIONS

Saliva is more reliable and accurate than water or serum for the purpose of calibration of the Periotron® model 8010, though it shares drawbacks with serum. Distilled water is more easily available and does not require any additional procedure, in addition to producing a similar slope to saliva and a smaller deviation from the media than serum.

Intracranial stenting versus aggressive medical therapy for symptomatic intracranial stenosis: A meta-analysis of multicenter randomized controlled trials and an expert assessment of the current data

BACKGROUND

Intracranial atherosclerotic stenosis (ICAS) is associated with high risk of recurrent strokes despite best medical management (MM). We aimed to synthesize the evidence from randomized studies comparing intracranial stenting plus MM versus MM alone.

METHODS

Comprehensive search of MEDLINE database was performed until May 2023. The data were extracted and pooled as risk ratio (RR) with 95% confidence interval (95% CI).

RESULTS

We included three multicenter RCTs totaling 919 patients. As compared to MM alone, intracranial stenting was associated with statistically significant higher risks of any stroke or death (RR = 2.93, 95%CI [1.80-4.78], p < 0.0001), stroke in the same territory of qualifying artery (RR = 3.56, 95%CI [1.97-6.44], p < 0.0001), any ischemic stroke (RR = 2.22, 95%CI [1.27-3.87], p = 0.005), hemorrhagic stroke (RR = 13.49, 95%CI [2.59-70.15], p = 0.0002), and death (RR = 5.43, 95%CI [1.21-24.40], p = 0.003) within 30 days of randomization. There was a persistent lack of benefit and signals of harm at the last follow up within 1-3 years: any stroke or death (RR = 1.57, 95%CI [0.92-2.67], p = 0.1), stroke in the same territory of qualifying artery (RR = 1.84, 95%CI [0.97-3.50], p = 0.06), any ischemic stroke (RR = 1.56, 95%CI [1.11-2.20], p = 0.01), death (RR = 1.61, 95%CI [0.77-3.38], p = 0.2). The cumulative rate of stroke in the same territory of qualified artery with MM alone within the 1-3-year follow up was lower than expected, with only 47 out of the 450 (10.4%) MM alone patients suffering such events.

CONCLUSION

The findings from this meta-analysis do not recommend stenting as a routine care option for the broader symptomatic ICAS patient population. The rates of recurrent strokes in ICAS patients managed with aggressive MM do not seem to be as high as anticipated. Additional multicenter RCTs including safer devices, larger sample sizes, and patients at higher risk of recurrent events are warranted.

From therapeutic nihilism to armamentarium: A meta-analysis of randomized clinical trials assessing safety and efficacy of endovascular therapy for acute large ischemic strokes

BACKGROUND

Three recent randomized clinical trials (RCTs) investigated the potential benefit of endovascular therapy (EVT) in acute ischemic stroke patients presenting with large infarcts. We aimed to confirm the safety and efficacy of EVT in patients presenting with large infarcts and provide more precise estimations of the treatment effects using study-level meta-analysis.

METHODS

Comprehensive search of MEDLINE database through PubMed till February 2023 was performed including RCTs only. The data were then extracted from the selected studies and pooled as risk ratio (RR) with 95% confidence interval (95% CI).

RESULTS

There were a total of 1005 patients across the three qualifying RCTs. Regarding the functional outcomes assessed by modified Rankin Scale (mRS) score, the analyzed data demonstrated statistically significant differences in favor of thrombectomy for both independent ambulatory status (mRS 0-3: RR = 1.78, 95% CI [1.28, 2.48], p = 0.0006) and functional independence (mRS 0-2: RR = 2.54, 95% CI [1.85, 3.48], p < 0.001). The analyzed data did not demonstrate any statistically significant differences between EVT and medical management alone in terms of 90-day mortality (RR = 0.95, 95% CI [0.78, 1.16], p = 0.61), symptomatic intracranial hemorrhage (RR = 1.83, 95% CI [0.95, 3.55], p = 0.07), and need for hemicraniectomy (RR = 1.22, 95% CI [0.43, 3.41], p = 0.71).

CONCLUSION

This study confirms the benefit of EVT on functional outcomes of patients presenting with large ischemic infarcts without significant differences in the rates of symptomatic intracranial hemorrhage, hemicraniectomy, or 90-day mortality.

Ischemic brain edema: Emerging cellular mechanisms and therapeutic approaches

Brain edema is one of the most devastating consequences of ischemic stroke. Malignant cerebral edema is the main reason accounting for the high mortality rate of large hemispheric strokes. Despite decades of tremendous efforts to elucidate mechanisms underlying the formation of ischemic brain edema and search for therapeutic targets, current treatments for ischemic brain edema remain largely symptom-relieving rather than aiming to stop the formation and progression of edema. Recent preclinical research reveals novel cellular mechanisms underlying edema formation after brain ischemia and reperfusion. Advancement in neuroimaging techniques also offers opportunities for early diagnosis and prediction of malignant brain edema in stroke patients to rapidly adopt life-saving surgical interventions. As reperfusion therapies become increasingly used in clinical practice, understanding how therapeutic reperfusion influences the formation of cerebral edema after ischemic stroke is critical for decision-making and post-reperfusion management. In this review, we summarize these research advances in the past decade on the cellular mechanisms, and evaluation, prediction, and intervention of ischemic brain edema in clinical settings, aiming to provide insight into future preclinical and clinical research on the diagnosis and treatment of brain edema after stroke.

Abstract TP177: Comparison Of Baseline Serum Glucose Concentration Between Fast And Slow Progressor Phenotypes Of Anterior Circulation Large Vessel Occlusion Stroke

Introduction: The determinants of fast and slow progressor phenotypes of infarct growth in anterior circulation large vessel occlusion (ACLVO) remain poorly understood. Previous studies have shown a potential link between baseline serum glucose and acute infarct growth. We assessed whether presenting serum glucose is independently associated with fast or slow progression of infarct growth in ACLVO stroke.

Methods: Retrospective analysis of patients with acute stroke due to intracranial ICA or proximal MCA occlusion across two comprehensive stroke centers from 2014-2019. Baseline CTP or MRI were obtained within 24hours of stroke onset. Fast progressors (ischemic core > 70ml, 0-6 h) and slow progressors (</= 30ml, 6-24 h) were identified. Serum glucose levels were compared in two groups: fast vs. non-fast progressors (0-6 h), slow vs. non-slow progressors (6-24 h). Mann-Whitney test was used for univariate group comparisons. Pearson correlation tested the association between serum glucose and infarct growth rate (core volume / time of stroke onset to imaging).

Results: A total of 350 participants were included (n=178 imaged < 6 hours of stroke onset; n=172 imaged at 6-24 hours of stroke onset). Amongst early presenters, the median glucose was 127 mg/dL for fast progressors (n=32) versus 122 mg/dL in non-fast progressors (n=146), p=0.45. Amongst late presenters, the median glucose was 122 mg/dL for slow progressors versus 133 in non-slow progressors (p=0.085). The correlation between serum glucose concentration and infarct growth rate was 0.03 (p=0.57).

Conclusion: While a numerical trend suggesting lower glucose levels was observed in slow progressors, no significant correlation between hyperacute serum glucose and infarct growth rate was established.

Abstract HUP17: Thrombectomy Outcomes In Relation To Socioeconomic Status By Utilizing Income And Area Deprivation Index Data

Introduction: Socioeconomic status has been shown to affect the outcome of patients in different patient populations. In this study we looked at how stroke patients are affected by using ADI (Area Deprivation Index,) and median income. Higher scores of ADI represent poorer conditions. We hypothesize that patients with higher ADI scores and lower median income will show worse stroke outcomes.

Methods: Our data includes patients who were admitted to University of Pittsburgh Medical Center between March 2020 and March 2022. Our variables include demographics, medical background and COVID-19 status, socioeconomics. Last known well, hospital arrival and recanalization times are used with outcomes measures of TICI grade, hemorrhagic conversion, discharge NIHSS, discharge and mRS.

Results: TICI score and NIHSS on discharge showed significant correlation with median income. mRS 3 months of discharge was correlated with age, COVID19, hypertension, diabetes, hyperlipidemia, smoking, median income, TICI, NIHSS on discharge. In regression analysis, median income showed a significant impact onLKW-to-arrival time and TICI score. However, there can be many omitted variables on its effects on LKW-to-arrival time. Median income, LKW-to-arrival time, and age significantly affect NIHSS on discharge. Median Income, age, and hyperlipidemia have significant impact on death/mortality (mRS=6). Median Income and ADI have significant impact on mRS 3 m on regression without the covariates. After adding the covariates and age is significantly affecting the mRS 3 m.

Conclusions: Median income has significant impacts on stroke patients’ time of treatment and functional outcomes. These patients have less resources to get treatment for stroke and stroke risk factors due to several reasons and less chance for rehabilitation following strokes. ADI data did not show a clear relation with outcome variables despite it is a good indicator of socioeconomic status. With less than 10% of total population, COVID-19 patients were not included in final analysis.

Post-acute sequelae of SARS-CoV-2 associates with physical inactivity in a cohort of COVID-19 survivors

The aim of this study was to determine whether Post-acute Sequelae of SARS-CoV-2 Infection (PASC) are associated with physical inactivity in COVID-19 survivors. This is a cohort study of COVID-19 survivors discharged from a tertiary hospital in Sao Paulo, Brazil. Patients admitted as inpatients due to laboratory-confirmed COVID-19 between March and August 2020 were consecutively invited for a follow-up in-person visit 6 to 11 months after hospitalization. Ten symptoms of PASC were assessed using standardized scales. Physical activity was assessed by questionnaire and participants were classified according to WHO Guidelines. 614 patients were analyzed (age: 56 ± 13 years; 53% male). Frequency of physical inactivity in patients exhibiting none, at least 1, 1-4, and 5 or more symptoms of PASC was 51%, 62%, 58%, and 71%, respectively. Adjusted models showed that patients with one or more persistent PASC symptoms have greater odds of being physically inactive than those without any persistent symptoms (OR: 1.57 [95% CI 1.04-2.39], P = 0.032). Dyspnea (OR: 2.22 [1.50-3.33], P < 0.001), fatigue (OR: 2.01 [1.40-2.90], P < 0.001), insomnia (OR: 1.69 [1.16-2.49], P = 0.007), post-traumatic stress (OR: 1.53 [1.05-2.23], P = 0.028), and severe muscle/joint pain (OR: 1.53 [95% CI 1.08-2.17], P = 0.011) were associated with greater odds of being physically inactive. This study suggests that PASC is associated with physical inactivity, which itself may be considered as a persistent symptom among COVID-19 survivors. This may help in the early identification of patients who could benefit from additional interventions tailored to combat inactivity (even after treatment of PASC), with potential beneficial impacts on overall morbidity/mortality and health systems worldwide.

Predicting the outcome for COVID-19 patients by applying time series classification to electronic health records

Background

COVID-19 caused more than 622 thousand deaths in Brazil. The infection can be asymptomatic and cause mild symptoms, but it also can evolve into a severe disease and lead to death. It is difficult to predict which patients will develop severe disease. There are, in the literature, machine learning models capable of assisting diagnose and predicting outcomes for several diseases, but usually these models require laboratory tests and/or imaging.

Methods

We conducted a observational cohort study that evaluated vital signs and measurements from patients who were admitted to Hospital das Clínicas (São Paulo, Brazil) between March 2020 and October 2021 due to COVID-19. The data was then represented as univariate and multivariate time series, that were used to train and test machine learning models capable of predicting a patient’s outcome.

Results

Time series-based machine learning models are capable of predicting a COVID-19 patient’s outcome with up to 96% general accuracy and 81% accuracy considering only the first hospitalization day. The models can reach up to 99% sensitivity (discharge prediction) and up to 91% specificity (death prediction).

Conclusions

Results indicate that time series-based machine learning models combined with easily obtainable data can predict COVID-19 outcomes and support clinical decisions. With further research, these models can potentially help doctors diagnose other diseases.

Mitochondrial redox impairment and enhanced autophagy in peripheral blood mononuclear cells from type 1 diabetic patients

Type 1 diabetes (T1D) involves critical metabolic disturbances that contribute to an increased cardiovascular risk. Leukocytes are key players in the onset of atherosclerosis due to their interaction with the endothelium. However, whether mitochondrial redox impairment, altered bioenergetics and abnormal autophagy in leukocytes contribute to T1D physiopathology is unclear. In this study we aimed to evaluate the bioenergetic and redox state of peripheral blood mononuclear cells (PBMCs) from T1D patients in comparison to those from healthy subjects, and to assess autophagy induction and leukocyte-endothelial interactions. T1D patients presented lower levels of fast-acting and total antioxidants in their blood, and their leukocytes produced higher amounts of total reactive oxygen species (ROS) and superoxide radical with respect to controls. Basal and ATP-linked respiration were similar in PBMCs from T1D and controls, but T1D PBMCs exhibited reduced spare respiratory capacity and a tendency toward decreased maximal respiration and reduced non-mitochondrial respiration, compared to controls. The autophagy markers P-AMPK, Beclin-1 and LC3-II/LC3-I were increased, while P62 and NBR1 were decreased in T1D PBMCs versus those from controls. Leukocytes from T1D patients displayed lower rolling velocity, higher rolling flux and more adhesion to the endothelium versus controls. Our findings show that T1D impairs mitochondrial function and promotes oxidative stress and autophagy in leukocytes, and suggest that these mechanisms contribute to an increased risk of atherosclerosis by augmenting leukocyte-endothelial interactions.

Aortic valve calcium score: does it correlate with mean transaortic gradient?

Introduction

Aortic valvular calcium score (AVCS) is useful in patients with aortic stenosis for whom echocardiography was not conclusive in grading its severity. Transcatheter aortic valve implantation (TAVI) is an established procedure of treatment in symptomatic severe AS. The burden of aortic valve calcification has been associated with some TAVI related complications (as perivalvular leaks), but at the same time it is well accepted that some degree of calcification is needed to ensure stable anchoring of the prosthesis to the aortic annulus.

Purpose

To assess if there is a correlation between aortic valve calcium score and mean transvalvular gradient 6 months after TAVI – is a higher AVCS correlated with lower mean transaortic gradient after TAVI?

Methods

We performed a single-center, retrospective cohort study including patients who underwent TAVI with a preoperative standardized contrast enhanced MSCT with AVCS available. Clinical and echocardiographic data were collected previously to TAVI (pre-TAVI) and at 6 months follow up (6M-FUP).

Results

A total of 187 patients were included, with 54% female and a mean age of 79.4±9.0 years old. Most patients had tricuspid aortic valve (95.7%); 5 patients had aortic bicuspidy and 3 had aortic valve bioprothesis. Concerning the valve type, 73.3% had new generation prosthesis and the main valve used was the CoreValve Evolut Pro (33.7%). Also, 38,5% needed balloon pre-dilation before TAVI. The mean pre-TAVI aortic transvalvular maximum and mean gradients were 76.5±23.2 mmHg and 48.3±15.5 mmHg, respectively; mean aortic valve area was 0.75±0.16 cm2. The mean AVCS was 2851±1524 AU (Agaston Units); 81.2% of women had AVCS&gt;1300 AU and 74.4% men had AVCS &gt;2000 AU. Comparing transvalvular aortic gradients previously and 6M-FUP after TAVI, there was an average differential of maximum gradient of 61±22 mmHg and of mean gradient of 40±15 mmHg. A negative and weak correlation was found between the AVCS and the maximum gradient (pearson coefficient of −0.181, p=0.02) and between mean gradient at 6M-FUP (pearson coefficient of −0.191, p=0.014).

Discussion and conclusion

AVCS is a significant predictor for death, stroke and perivalvular leaks after TAVI. On the other hand, high AVCS is associated with better seating in the native annulus during deployment. Nevertheless, high AVCS did not strongly correlated with mean transaortic gradient 6 months after TAVI.

Funding Acknowledgement

Type of funding sources: None.

In-Hospital Outcomes and Recurrence of Acute Ischemic Stroke in Patients With Solid Organ Malignancy

BACKGROUND AND OBJECTIVES

The aim of this work was to evaluate the influence of solid organ malignancies on the in-hospital outcomes and recurrent strokes among patients hospitalized with acute ischemic stroke (AIS).

METHODS

Adult hospitalizations with a primary diagnosis of AIS were identified from the Nationwide Readmissions Database from 2016 to 2018. Logistic regression was used to compare the differences in the use of acute stroke interventions and clinical outcomes in patients with and without malignancy. Survival analysis was used to evaluate the risk of readmission due to recurrent stroke after discharge.

RESULTS

There were 1,385,840 hospitalizations due to AIS (mean ± SD age 70.4 ± 14.0 years, female 50.2%). Of these, 50,553 (3.7%) had a concurrent diagnosis of solid organ malignancy. The 5 most common malignancies included lung cancer (24.6%), prostate cancer (13.2%), breast cancer (9.3%), pancreatic cancer (6.5%), and colorectal cancer (6.2%). After adjustment for baseline differences, patients with malignancy were more likely to have intraparenchymal hemorrhage (odds ratio [OR] 1.11, 95% CI 1.04-1.19), in-hospital mortality (OR 2.15, 95% CI 2.04-2.28), and discharge disposition other than to home (OR 1.70, 95% CI 1.64-1.75). Patients with malignancy were less likely to receive IV thrombolysis (tissue plasminogen activator [tPA]) and were more likely to undergo mechanical thrombectomy (MT). Among the subgroups of patients treated with tPA or MT, the outcomes were comparable between patients with and without malignancy, except patients with lung cancer remained at a higher risk of mortality and adverse disposition despite these acute stroke interventions. Patients with malignancy were at a higher risk of readmission due to recurrent AIS within 1 year of discharge (hazards ratio 1.18, 95% CI 1.11-1.25), and this risk was driven specifically by the lung and pancreatic cancers.

DISCUSSION

While patients with malignancy generally have worse in-hospital outcomes compared to those without, there is considerable variation in these outcomes according to the different cancer types and the use of acute stroke interventions. The use of tPA and MT is generally safe for eligible patients with an underlying malignancy. Patients with lung and pancreatic cancers have a higher early risk of recurrent stroke and might need more intensive surveillance and careful institution of the optimal secondary prevention measures.

Optimized mouse model of embolic MCAO: From cerebral blood flow to neurological outcomes

The embolic middle cerebral artery occlusion (eMCAO) model mimics ischemic stroke due to large vessel occlusion in humans and is amenable to thrombolytic therapy with rtPA. However, two major obstacles, the difficulty of the eMCAO surgery and unpredictable occurrence of clot autolysis, had impeded its application in mice. In this study, we modified catheters to produce suitable fibrin-rich embolus and optimized the eMCAO model using cerebral blood flow (CBF) monitored by both laser Doppler flowmetry (LDF) and 2D laser speckle contrast imaging (LSCI) to confirm occlusion of MCA. The results showed that longer embolus resulted in higher mortality. There was a compensatory increase in MCA territory perfusion after eMCAO associated with decreased infarct volume; however, this was only partly dependent on recanalization as clot autolysis was only observed in ∼30% of mice. Cortical CBF monitoring with LSCI showed that the size of peri-core area at 3 h displayed the best correlation with infarct volume that is attributed to compensatory collateral blood flow. The peri-core area best predicted functional outcome after eMCAO. In summary, we developed a reliable eMCAO mouse model that better mimics embolic ischemic stroke in humans, which will increase the potential for successful translation of stroke neuroprotective therapies.

The effect of different pulp capping methods on the intrapulpal temperature when using light-cured procedures

Background

To evaluate the intra-pulpal temperature during different direct pulp capping methods and light-cured procedures.

Material and Methods

Class I preparations 5 mm long, 4 mm wide and 4 mm deep were performed in extracted third molars, leaving 0.5 mm of dentin at the pulpal floor with a 1 mm diameter of pulp exposure. Teeth were placed in a customized oral cavity chamber simulator in which the initial temperature was standardized at 36oC. The overall temperature variations (oC) in the pulp chamber during the light-activation processes were recorded live using an infrared camera (FLIR ONE PRO, FLIR Systems). The liners and bases evaluated were: Dycal (Dentisply), TheraCal LC (Bisco), Biodentin (Septodent), Vitrebond Plus (3M/ESPE), and Fuji IX GP (GC), followed by restoration with a bulk fill composite (EvoCeram Bulk Fill, Ivoclar Vivadent). All light-activation procedures were performed with the VALO Grand (Ultradent) light-curing unit. A power analysis was conducted to determine the sample size to provide a power of at least 0.8 with α=0.05. Statistical analyses were performed using ANOVA and Tukey’s test for multiple comparisons.

Results

The intrapulpal temperature increased above a 10oC to 20oC threshold difference for all liners and bases that were light cured. When added as second layers, neither of those could provide thermal insulation following additional light-activated procedures (p=0.25). The higher the number of procedures requiring light-activation, the longer the pulp temperature remained in those increased temperature thresholds.

Conclusions

For direct pulp capping procedures, a reduced number light activation procedures should be indicated to reduce the time intra-pulpal temperature rises above a 10oC threshold.

Key words:Liner, base, calcium hydroxide, glass ionomer, dental adhesive, bulkfill composite.

Color difference between the vita classical shade guide and composite veneers using the dual-layer technique

Background

The purpose of this in vitro study was to evaluate the color difference between the Vita Classical Shade Guide and composite veneers using the dual-layer technique.

Material and Methods

Thirty samples were fabricated using a custom-made mold (Easy Layering Shade Guide Kit, 3M) using two resin composites: Filtek Supreme Ultra (3M); and Estelite Omega (Tokuyama) (n=3). The composite veneers were made by layering the different enamel and body or dentin shades from each composite. The color measurements were taken using a spectrophotometer (Vita Easyshade V®, Vita Zahnfabrik). The ΔE00 between the Vita Classical Shade Guide (Vita Zahnfabrik) and the composite veneers were calculated using the CIEDE2000 formula.

Results

For the composite veneers using Filtek Supreme Ultra, the best match for A1 Vita shade was achieved layering either EA1 with DA2 or DA3; EA2 with DA1 or DA2 (ΔE00= 1.53 ~ 1.96 ± 0.4). For A2 Vita shade the best match would be EA3 with DA3 or EA3 with DA2 (ΔE00= 1.40 ~ 1.85 ± 0.1); or for A3 Vita shade the best match would be EA3 with DA2 2.50±(0.6). For the composite veneers using Estelite Omega, the were no best match for neither A1, A2 or A3 Vita shade (ΔE00> 2.5).

Conclusions

The combination of enamel and dentin shades from Filtek Supreme Ultra provided acceptable color match for A1, A2 and A3 shades from the Vita Shade Guide, while Estelite Omega did not provide acceptable color match for any of the Vita Shade Guide standard shades tested.

Key words:Color, color matching, optical properties, resin composite, layering.

Effect of dental headlights spectrum on the polymerization and working time of light-cured resin composites

Background

The use of dental headlights is a common practice to better illuminate the operatory field and achieve excellence in restorative dentistry. However, visible light-cured dental materials can have reduced working time under headlight illumination. The aim of this study was to evaluate the influence of the spectral irradiance power of two dental headlights on the degree of polymerization and working time of light-curable dental composites.

Material and Methods

Two headlights, StarLight Nano 3 (StarMed) (SN) and Zeon Endevour XL (Orascoptic) (ZE) were characterized using a spectrophotometer coupled to an integrating sphere (MARC® Light Collector, BlueLight Analytics). The degree of conversion of the two composites, Filtek Supreme (3M) and Tetric Prime (Ivoclar Vivadent), was evaluated using an FTIR spectroscope (NicoletTM iS20, Thermo Fisher).

Results

Both headlights emitted a significant amount of blue light. The Zeon headlamp without filter emitted a broader spectrum with lower blue intensity and higher CRI than the White LED of the Nano 3. The Zeon headlamp with the blue blocking filter emitted a broader spectrum than the Orange LED of the Nano 3. There were no differences in the degree of conversion and working time of the Filtek Supreme and Tetric Prime composites when illuminated by the different headlamps. Both Zeon and the White LED of the Nano 3 were capable to cure the composites within only 5-10 minutes of irradiation. There were no changes in the degree of conversion of the composites when the Orange LED of the Nano 3 or the blue blocking filter of the Zeon were used.

Conclusions

Both headlights reduced the working time of light-cured materials. The use of orange filters prevented the composite polymerization and maintained the working time.

Key words:Surgical Headlight, degree of conversion, working time, light-curing.

Calcium Score Predicts Mortality After Revascularization in Critical Limb Ischemia

PURPOSE

The calcium score is a measure of vessel wall calcification and has clinical applications when studied in different vascular beds. The presence of vascular calcification in the arteries of the lower limbs is very common in patients with peripheral arterial disease; however, its relationship with the postoperative outcomes in patients undergoing lower limb revascularization is still poorly studied. The aim of this study is to evaluate association between the calcium score of lower limbs and the postoperative outcomes in patients with peripheral arterial disease undergoing revascularization procedures.

METHODOLOGY

We retrospectively analyzed 88 lower limb revascularization procedures in 72 patients with critical limb ischemia who had enhanced computed tomography for preoperative evaluation. The calcium score was calculated, from the angiographic phase of preoperative computed tomography, in the segments of the aorta, iliac, femoropopliteal, and infrapopliteal. It was also calculated the calcium score of the operated limb, and the total calcium score using a standardized method. The outcomes evaluated were the occurrence of acute myocardial infarction, amputation, patency, technical success, and death from any cause. Patients were followed up through a 12 month period.

RESULTS

Among the 88 procedures performed, 31 (43.1%) lesions were classified as Trans-Atlantic Inter-Society Consensus Document II D. There were 66 (75%) endovascular procedures, 16 (18.2%) open surgery, and 6 (6.8%) hybrid interventions. No statistically significant relationship was found between the calcium score of the segments (aorta, iliac, femoropopliteal, infrapopliteal, the operated limb, and total calcium score) and the outcomes of acute myocardial infarction, amputation, patency, and technical success in any of the periods analyzed. The calcium score of the operated limb was higher in patients who died within 30 days and 6 months (6571 vs 2590.6; p=0.026) and (5227.8 vs 2335.3; p=0.036).

CONCLUSION

A standardized calcium score calculation method with the angiographic phase of the computed tomography is feasible and reproducible. Higher values of the calcifications of the operated limb are related to a greater chance of death in the postoperative period. The calcium score of the operated limb can be considered as a marker of clinical severity and prognosis in this group of patients.

Change and predictive ability of circulating immunoregulatory lymphocytes in long-term outcomes of acute ischemic stroke

Lymphocytes play an important role in the immune response after stroke. However, our knowledge of the circulating lymphocytes in ischemic stroke is limited. Herein, we collected the blood samples of clinical ischemic stroke patients to detect the change of lymphocytes from admission to 3 months after ischemic stroke by flow cytometry. A total of 87 healthy controls and 210 patients were enrolled, and the percentages of circulating T cells, CD4⁺ T cells, CD8⁺ T cells, double negative T cells (DNTs), CD4⁺ regulatory T cells (Tregs), CD8⁺ Tregs, B cells and regulatory B cells (Bregs) were measured. Among patients, B cells, Bregs and CD8⁺ Tregs increased significantly, while CD4⁺ Tregs dropped and soon reversed after ischemic stroke. CD4⁺ Tregs, CD8⁺ Tregs, and DNTs also showed high correlations with the infarct volume and neurological scores of patients. Moreover, these lymphocytes enhanced the predictive ability of long-term prognosis of neurological scores when added to basic clinical information. The percentage of CD4⁺ Tregs within lymphocytes showed high correlations with both acute and long-term neurological outcomes, which exhibited a great independent predictive ability. These findings suggest that CD4⁺ Tregs can be a biomarker to predict stroke outcomes and improve existing therapeutic strategies of immunoregulatory lymphocytes.

Clinical characteristics of fast and slow progressors of infarct growth in anterior circulation large vessel occlusion stroke

Fast and slow progressor phenotypes of infarct growth due to anterior circulation large vessel occlusion (ACLVO) remain poorly understood. We aimed to define clinical predictors of fast and slow progressors in a retrospective study of patients with ACLVO who underwent baseline advanced imaging within 24 hours of stroke onset. Fast progressors (ischemic core > 70 ml, < 6 hours after onset) and slow progressors (ischemic core ≤ 30 ml, 6 to 24 hours after onset) were identified amongst 185 patients. Clinical and laboratory variables were tested for association with fast or slow progressor status. In the early epoch, no significant differences were found between fast progressors and controls. In the delayed epoch, slow progressors had a median NIHSS of 14 versus 20 (p < 0.01) and MCA occlusion in 80% versus 63% (p < 0.05) relative to controls. In multivariate analyses, NIHSS (OR 0.83, 95% CI 0.73-0.95), hyperlipidemia (OR 4.24, 95% CI 1.01 - 19.3) and hemoglobin concentration (OR 0.75, 95% CI 0.57 - 0.99) were independently associated with slow progressor status. This study indicates that lower initial stroke symptom severity, a history of hyperlipidemia and mild anemia are associated with individual tolerance to ACLVO stroke.

Early Risk of Readmission Following Hospitalization for Reversible Cerebral Vasoconstriction Syndrome

OBJECTIVE

For evaluation of 90-day readmissions after an inpatient admission for reversible cerebral vasoconstriction syndrome (RCVS), hospitalizations due to RCVS were identified from the Nationwide Readmissions Database from 2016 to 2017.

METHODS

The primary outcome of interest was nonelective readmission within 90 days of index hospitalization discharge. Survival analysis was performed, and multivariable Cox proportional hazards regression was used to determine the factors associated with readmission.

RESULTS

Among the 1,157 hospitalizations due to RCVS during the study period (mean ± SD age 48.6 ± 16.1 years, women 76.4%), 164 (14.2%) patients had nonelective readmission within 90 days of discharge. The most common reasons for readmissions included acute cerebrovascular events (18.9%), continued or recurrent symptoms of RCVS (13.4%), infections (11.6%), and headache (9.8%). Diabetes, history of tobacco use, opioid use, and longer length of index hospitalization were independent predictors of 90-day readmission. For readmissions, the mean (SD) length of stay was 5.2 (6.1) days, and the mean (SD) cost per hospitalization was $14,214 ($15,140). There was no in-hospital mortality; however, 37.2% of patients were not discharged to home.

CONCLUSION

Nearly 14% of patients with RCVS are readmitted within 90 days of discharge, and a significant proportion of these readmissions are due to the ongoing/recurrent symptoms or neurologic sequelae of RCVS. Given that these patients are at a risk of early recurrence/worsening of their symptoms, an early postdischarge follow-up plan may need to be integrated into their care.

POS0872 CLINICAL FEATURES AND OUTCOME OF 1054 PATIENTS WITH SYSTEMIC SCLEROSIS: AN ANALYSIS OF THE PORTUGUESE REUMA.PT REGISTRY FOR SCLERODERMA (REUMA.PT/SSC)

Background:

Systemic sclerosis (SSc) may present distinctive manifestations and survival in different ethnic and geographic groups.

Objectives:

To describe the clinical features, treatments, and survival of adult SSc patients registered in Reuma.pt/SSc.

Methods:

Demographic features, SSc subsets, fulfilment of classification criteria, clinical and immunologic characteristics, comorbidities, medication and deaths were reviewed. Survival was calculated for patients included in the registry within the first 2 years of diagnosis.

Results:

In total, 1054 patients were included, 87.5% female, mean age at diagnosis 52.7 ± 14.8 years. The most common subset was limited cutaneous (lc)SSc (56.3%), followed by diffuse cutaneous (dc)SSc (17.5%), preclinical SSc (13%), overlap syndrome (9.8%) and SSc sine scleroderma (3.3%). Raynaud’s phenomenon (93.4%) and skin thickening (76.9%) were the most observed manifestations. Gastrointestinal (62.8% vs 47.8%), pulmonary (59.5% vs 23%) and cardiac (12.8% vs 6.9%) involvement were significantly more prevalent in dcSSc compared to lcSSc (Table 1). 52.5% of patients were ACA positive and 21% anti-topoisomerase positive, with significant differences between lcSSc and dcSSc. One third of patients was treated with immunomodulators, 53.6% with vasodilators, 23% received glucocorticoids and 2.3% biologics.

During the median follow-up 12.4 years, 83 deaths (7.9%) were verified. The overall 1, 2 and 5 years survival was 98.0%, 96.8% and 92.6% respectively, without significant differences between lcSSc and dcSSc (Figure 1).

Conclusion:

Reuma.pt/SSc register is useful in routine patient monitoring and contributes to improve knowledge about this rare and complex disease. Clinical features of Portuguese SSc patients are similar to what has been described in other populations although the overall 5-year survival in recently diagnosed patients appears to be higher than previously reported.

Table 1.

Cumulative clinical and immunologic characteristics of Portuguese SSc patients

Clinical and immunologic featuresTotalN=1054Limited cutaneous SScN= 576 (56.3%)Diffuse cutaneous SScN=180 (17.5%)P valueSkin involvement – N(%) N=987688 (90.6)525 (90.7)180 (100)<0.01Skin thickening * – N (%) N= 962680 (76.9)512 (88.9)180 (100)<0.01Digital ulcers – N (%) N=970325(33.5)186 (34.7)4 (51.5)<0.01Raynaud’s Phenomenon – N (%) N=1010943 (93.4)539 (95.7)157 (92.4)0.06Musculoskeletal involvement – N(%) N=972346 (45.6)247 (42.7)99 (55)<0.01Cardiac involvement –N(%) – N=92471 (7.7)36 (6.9)19 (12.8)0.02Renal involvement –N(%) – N= 91717 (1.9)8!1.5)6 (4.1)0.07Gastrointestinal involvement - N(%) N=933508 (48.2)277 (47.8)113 (62.8)<0.01Pulmonary involvement – N(%) N=915261 (28.5)119 (23)88 (59.5)<0.01PAH – N(%) N= 87114 (1.6)10 (2)1 (0.7)0.23Intersticial lung disease – N(%) N=765218 (28.5)100 (22.7)75 (57.7)<0.01Antinuclear antibodies - N(%) N=1040934 (89.8)522 (90.2)154 (88.5)0.57Anti-centromere – N(%) N= 1027540 (52.6)383 (67.1)16 (9.5)<0.01Anti-Scl70 – N(%) N=1020214 (21)12 (3.3)104 (60.1)<0.01Anti-RNA polymerase III – N(%) N=71025 (3.5)12 (3.3)7 (5.6)0.38ComorbiditiesHypertension – N(%) N=431117 (27.1)76 (29.7)67 (20.7)0.1Hyperlipidemia – N(%) N=43171 (13.4)72 (12.2)24 (15.9)0.08Neoplasia – N(%) N=105429 (2.8)12 (2.1)7 (3.9)0.14

PDE-5 (phosdiasterase-5); PPIs (proton pump inhibitors); PAH-Pulmonary arterial hypertension confirmed by right heart catheterization. Immunomodulators includes Metothrexate, Leflunomide, Hydroxycloroquine; Azathioprine, Mycophenolate Mofetil and Cyclophosphamide; * Does not include sclerodactyly.

Figure 1.

Panel A - Survival in years from diagnosis of patients with SSc included in Reuma.pt in the first 2 years of disease (N=472). Panel B - survival according to SSc subset (lcSSc and dcSSC).

Disclosure of Interests:

None declared

Transferring Occlusal Anatomy from Worn Temporary Crowns to Zirconium Oxide Crowns

Purpose/Aim: To evaluate the accuracy of transferring the occlusal anatomy of provisional crowns to monolithic zirconium oxide crowns. Materials and Methods: From a prepared typodont-tooth (#36), ten CAD/CAM provisional polymethylethacrylate crowns were fabricated with the E4D system. Each provisional crown had its occlusion adjusted. They were scanned (E4D) and the .stl files of the crown preparations were merged with the files from the adjusted crowns (3 shape software) to produce ten polished monolithic zirconium oxide crowns. For comparison, provisional and monolithic zirconium oxide crowns were scanned (True-Definition scanner), the .stl files aligned, converted into a normalized 76x76-matrix, analyzed with ANOVA with repeated measures and Tukey's test. To generate deviation distribution tables and difference plots, .stl files (provisional crowns and monolithic zirconium oxide crowns) were merged with Geomagic software. Results: There were significant differences between provisional crowns and monolithic zirconium oxide crowns. The differences were manly in the fissure area. 86% of the calculated deviations were between + 0.06mm and - 0.04mm, 42.4% of all data points were within ± 0.022mm with a SD of 0.005mm. The main differences were in the fissures, requiring clinically none or only minimal occlusal adjustments for these zirconium oxide crowns.

Remote Longitudinal Inpatient Acute Stroke Care Via Telestroke

OBJECTIVES

While telestroke 'hub-and-spoke' systems are a well-established model for improving acute stroke care at spoke facilities, utility beyond the hyperacute phase is unknown. In patients receiving intravenous thrombolysis via telemedicine, care at spoke facilities has been shown to be associated with longer length of stay and worse outcomes. We sought to explore the impact of ongoing stroke care by a vascular neurologist via telemedicine compared to care provided by local neurologists.

METHODS

A network spoke facility protocol was revised to pilot telestroke consultation with a hub vascular neurologist for all patients presenting to the emergency department with ischemic stroke or transient ischemic attack regardless of time since onset or severity. Subsequent telestroke rounds were performed for patients who received initial telestroke consultation. Key outcome measures were length of stay, 30-day readmission and mortality and 90-day mRS. Results during the pilot (post-cohort) were compared to the same hospital's previous outcomes (pre-cohort).

RESULTS

Of 257 enrolled patients, 67% were in the post-cohort. Forty percent (69) of the post-cohort received an initial telestroke consult. In spoke-retained patients followed by telestroke rounds (55), median length of stay decreased by 0.8 days (P = 0.01). Readmission and mortality rates did not differ significantly between groups (19.5 vs. 9.1%, P = 0.14 and 3.9 vs. 3.6%, P = 1, respectively). The favorable functional outcome rate was similar between groups (47.3% vs 65.9%, P = 0.50).

CONCLUSIONS

Longitudinal stroke care via telestroke may be economically viable through length of stay reduction. Randomized prospective studies are needed to confirm our findings and further investigate this model's potential benefits.

Predictors and outcomes of ischemic stroke in reversible cerebral vasoconstriction syndrome

INTRODUCTION

The clinical factors predisposing to ischemic stroke in reversible cerebral vasoconstriction syndrome (RCVS) are unclear. In this observational cross-sectional study, we aimed to evaluate the risk factors and clinical outcomes associated with the development of ischemic stroke in patients with RCVS.

METHODS

We utilized the Nationwide Readmissions Database 2016-2017 to identify all hospitalizations with RCVS, with or without acute ischemic stroke. Independent predictors of and clinical outcomes associated with ischemic stroke were analyzed using logistic regression.

RESULTS

Among 1065 hospitalizations for RCVS (mean ± SD age 49.0 ± 16.7 years, female 69.7%), 267 (25.1%) had ischemic stroke. Patients with ischemic stroke were more likely to have hypertension (OR 2.33, 95% CI 1.51-3.60), diabetes (OR 1.81, 95% CI 1.11-2.98), and tobacco use (OR 1.64, 95% CI 1.16-2.33) and were less likely to have a history of migraine (OR 0.56, 95% CI 0.35-0.90). Ischemic stroke was associated with higher odds of cerebral edema (OR 3.15, 95% CI 1.31-7.57) and respiratory failure (OR 2.39, 95% CI 1.28-4.44). Patients with ischemic stroke also had longer hospital stay by a mean duration of 6.7 days, P < 0.001, higher hospital charges by a mean of $72,961, P < 0.001, and a higher likelihood of not being discharged to home (OR 3.57, 95% CI 2.39-5.33). They had higher in-hospital mortality rate; however, the difference was not statistically significant.

CONCLUSION

Ischemic stroke affects nearly 25% of patients with RCVS and is associated with adverse clinical outcomes. RCVS patients with cerebrovascular risk factors might have a higher predisposition for developing ischemic lesions during the disease process.

Predictors and outcomes of hemorrhagic stroke in reversible cerebral vasoconstriction syndrome

BACKGROUND

Intracranial hemorrhage (ICH) is the most common neurologic complication of reversible cerebral vasoconstriction syndrome (RCVS). In this study, we compared hemorrhagic and non-hemorrhagic RCVS with an aim to evaluate the risk factors and short-term clinical outcomes of hemorrhagic lesions.

METHODS

We used the Nationwide Readmissions Database 2016-2017 to identify all hospitalizations due to RCVS. Predictors and clinical outcomes of ICH were analyzed using logistic regression analysis.

RESULTS

Among the total 1834 hospitalizations for RCVS during the study period (mean ± SD age:48.4 ± 15.6 years, female:75.8%), 768 (41.9%) had occurrence of ICH. Patients with ICH were more likely to be female (OR:2.72, 95% CI:1.86-3.97), have a history of hypertension (OR:1.63, 95% CI:1.20-2.22) and cocaine use (OR:3.11, 95% CI:1.49-6.51), and were less likely to have a history of diabetes (OR:0.52, 95% CI:0.32-0.84) and heart failure (OR:0.34, 95% CI:0.14-0.84). Hemorrhagic RCVS was associated with higher odds of cerebral edema (OR:10.71, 95% CI:5.75-19.97), new onset seizure (OR:2.24, 95% CI:1.08-4.61), respiratory failure (OR:2.40, 95% CI:1.37-4.22) and gastrostomy tube placement (OR:3.20, 95% CI:1.07-9.58). Patients with hemorrhagic lesions also had longer length of hospital stay (mean difference 5.5 days), higher hospital charges (mean difference $105,547), and a lower likelihood of discharge to home (OR:0.61, 95% CI:0.43-0.86). There was, however, no significant difference in the in-hospital mortality.

CONCLUSIONS

ICH affects nearly 42% of patients with RCVS and is associated with increased rate of other neurologic complications and adverse discharge disposition, thus putting into question the prevailing conception that RCVS is generally a benign disorder with a self-limiting clinical course.

Genome-wide transcriptomic analysis of microglia reveals impaired responses in aged mice after cerebral ischemia

Senescence-associated alterations in microglia may have profound impact on cerebral homeostasis and stroke outcomes. However, the lack of a transcriptome-wide comparison between young and aged microglia in the context of ischemia limits our understanding of aging-related mechanisms. Herein, we performed RNA sequencing analysis of microglia purified from cerebral hemispheres of young adult (10-week-old) and aged (18-month-old) mice five days after distal middle cerebral artery occlusion or after sham operation. Considerable transcriptional differences were observed between young and aged microglia in healthy brains, indicating heightened chronic inflammation in aged microglia. Following stroke, the overall transcriptional activation was more robust (>13-fold in the number of genes upregulated) in young microglia than in aged microglia. Gene clusters with functional implications in immune inflammatory responses, immune cell chemotaxis, tissue remodeling, and cell-cell interactions were markedly activated in microglia of young but not aged stroke mice. Consistent with the genomic profiling predictions, post-stroke cerebral infiltration of peripheral immune cells was markedly decreased in aged mice compared to young mice. Moreover, post-ischemic aged microglia demonstrated reduced interaction with neighboring neurons and diminished polarity toward the infarct lesion. These alterations in microglial gene response and behavior may contribute to aging-driven vulnerability and poorer recovery after ischemic stroke.

Neurothrombectomy for Acute Ischemic Stroke Across Clinical Trial Design and Technique: A Single Center Pooled Analysis

Introduction: The practice of endovascular therapy has evolved dramatically over the last 10 years with randomized clinical trials investigating the benefit of thrombectomy in select patient populations based on time of presentation, imaging criteria, and procedural technique. We sought to understand the benefit of thrombectomy in patients treated within the context of a clinical trial at a single academic center.

Methods: Patient-level data recorded in case forms and core-lab adjudicated data were analyzed from patients enrolled in RCTs investigating the benefit of endovascular thrombectomy over medical management (IMSIII, MR RESCUE, ESCAPE, SWIFT PRIME, and DAWN) between 2007 and 2017 at a single academic referral center.

Results: A total of 134 patients (intervention group, n = 81; medical group, n = 53) were identified across five clinical trials (IMSIII, n = 46; MR RESCUE, n = 4; ESCAPE, n = 24; SWIFT PRIME, n = 14; DAWN, n = 46). There were no significant differences between the treatment arm and control arm in terms of age, gender, baseline NIHSS, ASPECTS, and site of occlusion. Rates of good outcome were superior in the intervention group with early neurological recovery (NIHSS of 0–1 or increase NIHSS of 8 points at 24 h) at a higher rate of 49% vs. 17% (p = <0.001) and higher rates of functional independence (90 day mRS 0–2 of 53% vs. 26%, p = 0.002). In multivariate logistic regression analysis, lower NIHSS and younger age were predictors of good outcome. There were comparable rates of good outcome irrespective of clinical trial, imaging selection criteria (CTP vs. MRI), early vs. late time window (0–6 h vs. 6–24 h) and procedural technique (Merci vs. Solitaire/Trevo device). There were no differences in rates of sICH, PH-2 or mortality in the intervention group vs. medical group.

Conclusions: At a large academic center, the benefit of endovascular therapy over medical therapy is observed irrespective of clinical trial design, patient selection or procedural technique.

Learnings from a decade experience of a community-based HIV and STI testing and counseling center in Lisbon – Portugal

Background

In the context of an increased number of men who have sex with men (MSM) being diagnosed with HIV infection in many European countries, it became a matter of maximum priority to consider new strategies to monitor and tackle the epidemic. In this scenario, CheckpointLX and a cohort study were projected as a sexual health and research center oriented towards MSM in Portugal.

Methods

In 2011 CheckpointLX was launched in Lisbon as a community-based center for anonymous and free rapid HIV and other sexually transmitted diseases (STI) testing with a strong component of counseling for sexual health, specially targeted at MSM. In the case of a reactive test, a medical appointment is proposed and scheduled. The Lisbon Cohort of MSM is an ongoing observational prospective study conducted at CheckpointLX. Collected data include sexual behaviors, preventive strategies, and history of STI.

Results

Until July 2019, 7,351 HIV-negative MSM chose to participate in the Lisbon Cohort of MSM. 3,523 had at least one follow-up visit. The median age was 29 (IQR 25 - 37), and 27% were born in a foreign country, including 15% born in Africa and South America. HIV incidence increased up until 2015, reaching 5 reactive tests per 100 tested annually. There has been a sustained decrease in HIV observed since 2015. The use of HIV prevention tools was provided: 31% used condoms consistently, 3% reported PrEP, and 4% PEP.

Conclusions

A decade since the beginning of this experience shows positive results, such as increased access and testing. We promoted a stigma-free service that facilitated MSM's and other key population's access to sexual health care. We contribute unique data for assisting in the monitoring of the Dublin Declaration in Portugal.

Delayed functional independence after thrombectomy: temporal characteristics and predictors

Background

Variability in early neurological improvement after endovascular thrombectomy (EVT) for large vessel occlusion (LVO) stroke is well documented. Understanding the temporal progression of functional independence after EVT, especially delayed functional independence in patients who do not experience early improvement, is essential for prognostication and rehabilitation.

Objective

To determine the incidence of early and delayed functional independence and identify associated predictors after EVT.

Methods

A retrospective analysis of prospectively collected data on patients undergoing EVT in the setting of anterior circulation LVO was performed. Demographic, clinical, radiological, treatment, and procedural information were analyzed. Incidence and predictors of early functional independence (EFI, modified Rankin Scale (mRS) score 0–2 at discharge) and delayed functional independence (DFI, mRS score 0–2 at 90 days in non-EFI patients) were analyzed.

Results

Three hundred and fifty-five patients met the study criteria. 55% were women and mean age was 71±15. Mean National Institutes of Health Stroke Scale (NIHSS) score was 17±6 and median Alberta Stroke Program Early CT Score was 9 (8-10). EFI was observed in 21% (73) of patients. Among non-EFI patients (282), DFI was observed in 30% (85) of patients. Shorter time to treatment (p=0.03), lower 24 hours NIHSS score (p<0.001), and smaller follow-up infarct volume (p=0.003) were independent predictors of EFI. Younger age (p=0.011), lower 24 hours NIHSS score (p=0.001), and absence of parenchymal hemorrhage (PH2; p=0.039) were independent predictors of DFI.

Conclusion

Approximately one-fifth of patients experience EFI and one-third of non-early improvers experience DFI. Younger age, lower 24 hours NIHSS score, and absence of parenchymal hemorrhage were independent predictors of DFI among non-early improvers. Further studies are required to improve our understanding of DFI.

Interaction between time, ASPECTS, and clinical mismatch

Background

Imaging-based patient selection for neurothrombectomy is reliant on the identification of irreversibly damaged brain tissue (core) and salvageable tissue (penumbra). The DAWN trial used the clinical-core mismatch (CCM) paradigm (clinical deficit out of proportion to infarct volume). We aim to determine the prevalence of CCM in large vessel occlusion (LVO) strokes and study the impact of time and the Alberta Stroke Program Early CT Score (ASPECTS) on the likelihood of mismatch.

Methods

We performed a retrospective observational analysis of internal carotid artery/middle cerebral artery M1 occlusions with available advanced imaging (relative cerebral blood flow/MRI). We used automated software for infarct volume analysis and ASPECTS determination. The prevalence of CCM and the impact of time and ASPECTS were analyzed.

Result

One hundred and eighty-five LVO strokes were included. Mean age was 71±15 years and median National Institutes of Health Stroke Scale score was 17 (range 12–21). Mean ischemic core volume was 50±69 mL. Within 0–24 hours, CCM was present in 53% and ranged from 63% in 0–3 hours to 25% at 21–24 hours (p=0.03). Prevalence of mismatch reduced 1.6% for every 1 hour increase in time to imaging. CCM prevalence by ASPECTS groups was: ASPECTS 9–10: 77%, ASPECTS 6–8: 65%, ASPECTS 0–5: 13% (p<0.01), with a 6.4% decrement for every 1 point decrease in ASPECTS. The prevalence of mismatch did not diminish over time among ASPECTS groups and higher ASPECTS was an independent predictor of CCM (OR 1.4 (95% CI 1.1 to 1.7), p<0.001).

Conclusions

CCM is present in 57% and 50% of LVO strokes in the 0–6 and 6–24 hour window, respectively. The prevalence of mismatch declines with increasing time (1.6%/hour) and decreasing ASPECTS (6.4%/point). Among ASPECTS groups the prevalence of mismatch does not decline over time. These data support the use of an ASPECTS-based paradigm for late window patient selection.

RNA sequencing reveals novel macrophage transcriptome favoring neurovascular plasticity after ischemic stroke

Blood monocytes/macrophages infiltrate the brain after ischemic stroke and critically influence brain injury and regeneration. We investigated stroke-induced transcriptomic changes of monocytes/macrophages by RNA sequencing profiling, using a mouse model of permanent focal cerebral ischemia. Compared to non-ischemic conditions, brain ischemia induced only moderate genomic changes in blood monocytes, but triggered robust genomic reprogramming in monocytes/macrophages invading the brain. Surprisingly, functional enrichment analysis of the transcriptome of brain macrophages revealed significant overrepresentation of biological processes linked to neurovascular remodeling, such as angiogenesis and axonal regeneration, as early as five days after stroke, suggesting a previously underappreciated role for macrophages in initiating post-stroke brain repair. Upstream Regulator analysis predicted peroxisome proliferator-activated receptor gamma (PPARγ) as a master regulator driving the transcriptional reprogramming in post-stroke brain macrophages. Importantly, myeloid cell-specific PPARγ knockout (mKO) mice demonstrated lower post-stroke angiogenesis and neurogenesis than wild-type mice, which correlated significantly with the exacerbation of post-stroke neurological deficits in mKO mice. Collectively, our findings reveal a novel repair-enhancing transcriptome in brain macrophages during post-stroke neurovascular remodeling. As a master switch controlling genomic reprogramming, PPARγ is a rational therapeutic target for promoting and maintaining beneficial macrophage functions, facilitating neurorestoration, and improving long-term functional recovery after ischemic stroke.

Transforming Growth Factor Beta-Activated Kinase 1-Dependent Microglial and Macrophage Responses Aggravate Long-Term Outcomes After Ischemic Stroke

Background and Purpose- Microglia/macrophages (Mi/MΦ) can profoundly influence stroke outcomes by acquiring functionally dominant phenotypes (proinflammatory or anti-inflammatory; deleterious or salutary). Identification of the molecular mechanisms that dictate the functional status of Mi/MΦ after brain ischemia/reperfusion may reveal novel therapeutic targets for stroke. We hypothesized that activation of TAK1 (transforming growth factor beta-activated kinase 1), a key MAP3K upstream of multiple inflammation-regulating pathways, drives Mi/MΦ toward a proinflammatory phenotype and potentiates ischemia/reperfusion brain injury. Methods- Young adult mice were subjected to 1 hour of middle cerebral artery occlusion (MCAO) followed by reperfusion. TAK1 was targeted by tamoxifen-induced Mi/MΦ-specific knockout or administration of a selective inhibitor 5Z-7-Oxozeaenol after MCAO. Neurobehavioral deficits and long-term gray matter and white matter injury were assessed up to 35 days after MCAO. Mi/MΦ functional status and brain inflammatory profiles were assessed 3 days after MCAO by RNA-seq, flow cytometry, and immunohistochemistry. Results- TAK1 Mi/MΦ-specific knockout markedly ameliorated neurological deficits in the rotarod and cylinder tests for at least 35 days after MCAO. Mechanistically, RNA-seq of purified brain Mi/MΦ demonstrated that proinflammatory genes and their predicted biological functions were downregulated or inhibited in microglia and macrophages from TAK1 Mi/MΦ-specific knockout mice versus WT mice 3 days after MCAO. Consistent with the anti-inflammatory phenotype of Mi/MΦ-specific knockout, oxozeaenol treatment mitigated neuroinflammation 3 days after MCAO, manifested by less Iba1⁺/CD16⁺ proinflammatory Mi/MΦ and suppressed brain invasion of various peripheral immune cells. Oxozeaenol treatment beginning 2 hours after MCAO improved long-term sensorimotor and cognitive functions in the foot fault, rotarod, and water maze tests. Furthermore, Oxozeaenol promoted both gray matter and white matter integrity 35 days after MCAO. Conclusions- TAK1 promotes ischemia/reperfusion-induced inflammation, brain injury, and maladaptive behavior by enhancing proinflammatory and deleterious Mi/MΦ responses. Therefore, TAK1 inhibition is a promising therapy to improve long-term stroke outcomes.

Abstract WP163: Clinical Characteristics of Fast and Slow Progressors of Infarct Growth Due to Anterior Circulation Large Vessel Occlusion

Background and Purpose: Inter-individual variability of fast to slow progression of early infarct growth in anterior circulation large vessel occlusion (ACLVO) stroke has been previously well quantified. However, the underlying pathophysiology of these clinical phenotypes remains poorly understood. We aimed to determine clinical and radiographic variables associated with fast or slow progressor phenotypes of ACLVO stroke.

Methods: Single-center retrospective study of all patients with intracranial ICA or MCA occlusion, with or without tandem cervical ICA occlusion, who underwent baseline advanced imaging including CTP or MRI within 24 hours of stroke onset. Fast progressors (ischemic core > 70 ml, < 6 hours of stroke onset) and slow progressors (ischemic core ≤ 30 ml, > 6 to 24 hours of stroke onset) were identified. Demographics, co-morbidities, admission NIHSS and ACLVO type were tested in univariate and multivariate analysis for association with fast or slow progressor status.

Results: A total of 185 patients were included with mean age 71 ± 15 and NIHSS 17 ± 7; 60% were female. Patients had occlusion of the MCA in 72% or the intracranial ICA in 28% of cases. Of these, 20% had a tandem cervical ICA occlusion. In the early epoch, there were no significant differences in age, sex, NIHSS, co-morbidities or ACLVO type between fast progressors (n=19) versus controls (n=56). In the delayed epoch, the mean NIHSS was 14±6 in slow progressors (n=61) versus 19±7 in controls (n=49). Slow progressors had MCA occlusion in 80% versus 63% (p < 0.05) and tandem occlusion in 10% versus 35% of controls (p < 0.01). In multivariate logistic regression modeling, age (OR 1.04, 95% CI 1.01-1.07) and NIHSS (OR 0.87, 95% CI 0.81-0.93) but not ACLVO types were independently associated with slow progressor status.

Conclusions: Although greater frequency of MCA occlusion and absence of tandem cervical ICA occlusion were prevalent amongst slow progressors, only age and NIHSS were independent predictors. Future studies are needed to better characterize the underlying clinical substrates for fast versus slow progression of ACLVO stroke.

Abstract WP21: “Stunned Brain”– Early versus Delayed Clinical Recovery After Neurothrombectomy

Introduction: Heterogeneity in early neurological improvement after neurothrombectomy for large vessel occlusion (LVO) stroke is well documented. Delayed clinical recovery is observed in a subset of patients who do not experience early improvement. Understanding the temporality of clinical recovery after thrombectomy is essential in guiding prognostication and targeting rehabilitation. In this study, we aim to describe the characteristics and incidence of early and delayed clinical recovery and identify their predictors after LVO stroke thrombectomy.

Methods: A retrospective analysis of prospectively-collected data on patients undergoing anterior circulation LVO stroke thrombectomy. Demographic characteristics, clinical and radiological data, treatment and procedural information were extracted and analyzed. Characteristics and predictors of early clinical recovery (ECR-1-NIHSS <6 at 24 hours and ECR-2-mRS 0-2 at discharge) and delayed clinical recovery (DCR-1 and 2- mRS 0-2 at 90 days) were analyzed. Statistical analyses were performed on SPSS 23 (IBM, Armonk, NY).

Results: Three hundred and fifty-five patients met study criteria. 55% (195) were females and mean age was 71±15 years. Mean NIHSS score and median ASPECTS were 17±6 and 9 (8-10), respectively. ECR-1 and ECR-2 were observed in 31% (115) and 21% (73) patients, respectively. Among non-ECR patients, delayed recovery was observed in 27-30% of patients. Lower NIHSS [OR-0.83 (0.75-0.91), p=<0.01] and higher ASPECTS [OR-2.14, (1.29-3.54), p=0.003] scores were independent predictors of ECR-1 and younger age [OR-0.96 (0.94-0.99), p=0.01] and absence on parenchymal hemorrhage (PH) [OR-3.1 (1.3-7.1), p=0.007] were independent predictors of DCR-1. Among non-early improvers, patients <80 years and without PH have a 40% chance of DCR compared to no patients over 80 years with parenchymal hemorrhage experiencing DCR.

Conclusion: About one-third of patients experience early clinical recovery (ECR-1-31%) and approximately one-third (DCR-1-30%) of non-early improvers experience delayed clinical recovery. Lower NIHSS score and higher ASPECTS predict ECR while younger age and absence of parenchymal hemorrhage predict DCR.

Abstract 110: RNA Sequencing Reveals Novel Macrophage Transcriptome Favoring Neurovascular Plasticity After Ischemic Stroke

Introduction: Blood monocytes/macrophages (MΦ) infiltrate the brain in massive numbers after ischemic stroke, but their functional roles in the post-stroke brain remain elusive.

Methods: We sorted CD11b + CD45 high monocytes/MΦ from mouse blood and brain 5d after distal MCAO (dMCAO) and investigated their transcriptomic profiles by RNA-seq (n=3/group).

Results: Robust genomic changes occurred in MΦ invading the post-dMCAO brain compared to their counterparts in the blood (3196 differentially expressed genes with >2 fold changes; FDR<0.05). In addition to their canonical role in immune responses, brain MΦ expressed unique transcriptomic programs which may favor post-stroke neurovascular repair. Functional enrichment analysis of brain MΦ transcriptome revealed significant overrepresentation (p<0.01) of 110 biological processes linked to neurovascular remodeling and plasticity (e.g., angiogenesis and axonal regeneration), suggesting a previously underappreciated role for MΦ in post-stroke brain repair. Upstream Regulator analysis predicted PPARγ as a master regulator (z-score=2.64, p<10 -15 ) that drives the transcriptional reprogramming in post-stroke brain MΦ and dictates their functional phenotype. Accordingly, tamoxifen-induced, myeloid cell-specific PPARγ knockout mice demonstrated less post-stroke angiogenesis (BrdU+CD31 staining) and neurogenesis (BrdU+NeuN) than WT mice (n=9/group, p<0.01), which correlated significantly with the exacerbation of neurological deficits in these mice (n=9/group, p<0.01 vs WT in foot fault and adhesive removal tests) at 35d after dMCAO.

Conclusions: Our study reveals a novel repair-enhancing transcriptome in brain MΦ during post-stroke neurovascular remodeling. As a master molecule controlling genomic reprogramming, PPARγ is a rational therapeutic target for promoting beneficial MΦ functions, and facilitating neurorestoration and long term functional recovery after ischemic stroke.

Abstract TP248: Reduced Door-in-Door-Out Time Increases the Likelihood of Endovascular Thrombectomy for Large Vessel Occlusion Patients

Introduction: Endovascular thrombectomy (EVT) is recommended for patients with large vessel occlusion (LVO) presenting within 24 hours of last seen well (LSW). Unfortunately, patients transferred from spoke hospitals to receive EVT have poorer outcomes compared to those presenting directly to the hub, underscoring the importance of rapid transfer timing - door-in-door-out (DIDO).

Methods: Data were analyzed from consecutive acute ischemic stroke patients with proximal large vessel occlusions (LVO) transferred to our comprehensive stroke center for EVT. The following variable were studied: DIDO, baseline NIHSS/mRS, presentation CT ASPECTs, site of LVO, treatment, and clinical outcome.

Results: Ninety patients with internal carotid or middle cerebral artery (M1) occlusion at the spoke hospital were included in the study. At the hub hospital, 75% (68) underwent emergent cerebral angiography (DSA) with intent to perform EVT. Reasons for not undergoing angiography at hub hospital included large stroke burden (59%) and improvement in NIHSS score (41%). Overall, DIDO time was 184 (130-285) minutes. Mean DIDO time was significantly lower for patients who underwent DSA at hub hospital compared to patients who did not (207 versus 272 minutes, p=0.031). 92% (12) of patients with DIDO <=120 minutes (n=13) underwent EVT compared to 73% (56) of patients with DIDO >120 minutes (n=77). Every 30-minute delay after 120 minutes lead to a 6% reduction in the likelihood of EVT. Lower DIDO time [OR-0.92 (0.9-0.96), p=0.04] and higher ASPECTS score [OR-1.4 (1.1-1.9), p=0.013] at spoke hospital are predictors of EVT at hub hospital.

Conclusion: Reduced DIDO times are associated with higher likelihood of receiving EVT. DIDO should be treated on par as in-hospital time metrics and methods should be in place to optimize transfer times.

Abstract TP2: Impact of Neglect on Outcomes After Right Hemisphere Stroke Thrombectomy

Introduction: Right Hemisphere Strokes (RHS) are characterized by severe motor and sensory deficits and signs of neglect including extinction and inattention. National Institutes of Health Stroke Scale (NIHSS) score provides an objective measurement of presence or absence of neglect. Data regarding the impact of neglect on outcomes after RHS thrombectomy are lacking. We hypothesize that the presence of neglect in RHS is associated with worse outcomes after thrombectomy in RHS.

Methods: Retrospective analysis of prospectively collected database of right sided anterior circulation large vessel occlusion [internal carotid and/or middle cerebral artery M1] strokes at a comprehensive stroke center. Patients with successful recanalization (TICI≥ 2B) and complete follow-up data were included in the study. Two group of RHS were identified- with and without neglect by itemized NIHSS. Baseline characteristics and outcomes were compared.

Results: A total of 172 patients were included in the study. Median NIHSS score was 15 (11-18) and median ASPECTS was 9 (8-10). Signs of neglect were observed in 63% (108) of patients. In multivariate analyses, younger age [0.9 (0.8-0.95) p=<0.01] and higher ASPECTS [1.8 (1.1-3.1) p=0.015] were independent predictors of mRS 0-2 at 90 days. Absence of neglect [0.39 (0.13-1.1) p=0.07] may predict good outcome. Independent predictors of mortality on multivariate analyses included older age [1.1 (1.03-1.15) p =0.001], presence of atrial fibrillation [0.3 (0.1-1) p=0.05] and diabetes mellitus [0.16 (0.05-0.53) p=0.003]. Presence of neglect [2.5 (0.9-6.6) p=0.06] and lower ASPECTS [0.7 (0.4-1) p=0.06] may predict mortality.

Conclusion: Signs of neglect were observed in approximately 63% of right hemisphere LVO strokes. Presence of neglect may predict poor functional outcome and mortality at 90 days after thrombectomy for right hemisphere strokes. Further studies are required to evaluate the impact of thrombectomy on recovery of neglect.

Abstract 32: Intravenous Tpa Delays Door-to-puncture Time in Acute Ischemic Stroke With Large Vessel Occlusion

Background: The current 2018 AHA/ASA Guidelines for early stroke management recommend use of IV tPA in all eligible acute ischemic stroke patients within 4.5 hours of onset while being considered for mechanical thrombectomy (MT). Whether or not tPA administration is beneficial prior to thrombectomy is still an ongoing debate. Potential delay of MT initiation due to tPA start is a major concern but has not been well-delineated in empirical studies.

Methods: In a prospective large volume comprehensive stroke center registry, we analyzed all patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO) treated with thrombectomy between 2012-2017, who arrived directly from field to ED within 4.5h of last known well. Patients without contraindication to IV-tPA are given bolus dose in the scanner suite and the remainder of the 1h infusion en route to and in the angio-suite to prevent delay.

Results: Among 777 thrombectomy patients identified in the database, 237 arrived directly within 4.5 hours from onset, including 65.8% (156) not treated with IV-tPA and 34.2% (81) receiving IV-tPA, both well-matched in age and NIHSS. Overall, the door-to-needle (DTN) time was 40m (IQR31-56), surpassing the Target Stroke national targets (60m and 45m) active during the study period. However, median door-to-puncture (DTP) time was 22m longer in the IV-tPA group, 74 vs 52m (p<0.001). IV-tPA was not independently associated with better recanalization rate (TICI 2B-3 95.9% vs 92.9%) or functional independent outcome (modified Rankin score 0-2) at 90 days, 37.3% vs 39.4%.

Conclusion: IV-tPA administration in AIS-LVO was associated with delayed door-to-puncture times in a comprehensive stroke center with efficient DTN times surpassing advanced national targets, without change in recanalization rate or outcomes. Randomized trials are needed to determine the net positive, neutral, or negative effect of IV-tPA in this population.

Abstract TP77: Impact of Time and Aspects on Clinical Core Mismatch in Large Vessel Occlusion Strokes

Introduction: Patient selection for endovascular thrombectomy (EVT) for anterior circulation large vessel occlusion (LVO) strokes in the 6-24-hour time window is dependent on delineating clinical core mismatch (CCM) as defined by DAWN trial criteria. In contrast, patient selection in the early window (0-6 hours) can be performed using ASPECTS on CT head. We aim to determine the prevalence of DAWN-CCM in LVO strokes and the impact of time and ASPECTS.

Methods: Retrospective analysis of large vessel occlusion [internal carotid and middle cerebral artery-M1] strokes at a CSC. Consecutive patients who underwent CT perfusion or MRI within 120 minutes of CT head were included in the study (treated and untreated). Ischemic core volume was assessed using RAPID [IschemaView] and ASPECTS using automated ASPECTS [Brainomix]. CCM was defined using DAWN trial criteria [DAWN-CCM: NIHSS ≥10 and core <31 ml, NIHSS ≥20 and core <51 ml].

Results: A total of 116 patients were included. Mean age was 71 ±14 and 62% were females. Mean ischemic core volume and median ASPECTS were 46 ±65 ml and 8 (6-9), respectively. In patients with NIHSS score ≥10 (98), 57% had DAWN-CCM in the 0-24-hour window. Proportion of patients with DAWN-CCM in 6-24-hour window was 70% (6-12 hours), 50% (12-18 hours), and 50% (18-24 hours) [p=0.35]. Proportion of patients with DAWN-CCM by ASPECTS group was 88% (ASPECTS 9-10), 64% (ASPECTS 6-8) and 13% (ASPECTS 0-5) [p=<0.01] (Figure 1). Probability of DAWN-CCM declines by 7% for every 2 hours increase in TLKW to imaging, and by 13% for every 1-point decrease in ASPECTS.

Conclusion: Approximately 57% of LVO strokes have clinical core mismatch. LVO strokes with DAWN-CCM decline with increasing time and decreasing ASPECTS. ASPECTS alone may be sufficient to identify patients with DAWN-CCM in a resource limited setting and avoid time consuming advanced imaging.

A new species of spiny driftwood catfish Spinipterus (Siluriformes: Auchenipteridae) from the Amazon basin

An expedition to the middle Rio Purus basin uncovered a remarkable new species of the genus Spinipterus. The new species has a very distinct and conspicuous colour pattern resembling a jaguar and it is almost four times larger than Spinipterus acsi, a small specimen (32 mm L_S ) from Caño Santa Rita, a right bank tributary of Río Nanay in Peru and a second specimen was reported from Rio Juruá, Amazonas State, Brazil. Although the new species is more similar in size and colour pattern to Liosomadoras, it shares the synapomorphies for Spinipterus. The new species differs from the congener by the following characters: (a) colour pattern with large black rosette-like spots over a light yellow to brown background (v. brown background with small dark blotches over the body); (b) adult body size reaching 104.5 mm L_S (v. maximum known size 37.1 mm L_S ); (c) posterior process of cleithrum short, never reaching vertical through the dorsal-fin origin (v. posterior process long, surpassing vertical through the dorsal-fin origin); (d) seven soft pectoral-fin rays (v. six); (e) caudal fin truncated (v. caudal fin rounded).