P5744Sleep-disordered breathing assessed by holter-monitoring is associated to worsened one-year clinical outcomes in ischemic stroke patients: a cardiopulmonary coupling analysis

Background

Sleep-disorder breathing (SDB) using polysomnography is closely associated to poor functional and clinical outcomes in ischemic stroke patients. The cardiopulmonary coupling analysis using Holter-monitoring (CPC-Holter analysis) is an emerging feasible modality to investigate SDB.

Purpose

We investigated the association between SDB defined by CPC-Holter analysis and one-year clinical outcome in patients with acute ischemic stroke.

Methods

Total 666 patients with acute ischemic stroke who underwent Holter-monitoring were enrolled. The CPC-Holter analysis was conducted and SDB was defined as the presence of narrow-band (NB) coupling during sleep time. Primary outcome was recurrent ischemic stroke, and secondary outcome was major adverse cerebrovascular event (MACE), a composite of recurrent ischemic stroke, transient ischemic attack, and all-cause mortality within one year since discharge.

Result

The NB coupling was present in 205 (30.8%) of 666 patients with mean age of 64.1±12.8 years. The NB group showed significantly higher incidence of both recurrent ischemic stroke (8.3% vs. 1.4%, p<0.001) and MACE (14.9% vs. 3.0%, p<0.001) within one-year. In multivariate analysis, presence of NB coupling remained as an independent predictor of both recurrent ischemic stroke and MACE (HR: 4.81; 95% CI: 1.73–13.4; p=0.003; and HR 4.17; 95% CI: 1.74–10.0; p<0.001, respectively). The results were consistent after propensity-score matched analysis with 164 patient pairs (C-statistics=0.757).

One-year clinical outcomes Overall population (n=666) PSM population (n=328) no NB (=461) NB (n=205) Log-rank p-value OR (95% CI) no NB (n=164) NB (n=164) Log-rank p-value OR (95% CI) Recurrent ischemic stroke 6 (1.4) 14 (8.3) <0.001 5.73 (2.20–14.9) 3 (2.0) 11 (8.1) 0.026 3.85 (1.07–13.8) Transient ischemic attack 3 (0.7) 3 (1.7) 0.275 2 (1.3) 3 (2.1) 0.633 Hemorrhagic stroke 0 (0.0) 2 (1.2) 0.027 0 (0.0) 2 (1.5) 0.148 Total death 3 (0.7) 9 (4.8) 0.001 2 (1.3) 3 (1.9) 0.641 MACEs 12 (3.0) 25 (14.9) <0.001 4.63 (2.06–10.4) 7 (5.2) 17 (13.1) 0.030 2.95 (1.06–8.21) Data are expressed as n (%). CI = confidence interval; MACE = major adverse cardiovascular event; NB = narrow-band; OR = odds ratio.

One-year clinical outcomes

Conclusion

SDB assessed by CPC-Holter analysis at early phase of ischemic stroke is a powerful prognostic marker for predicting one-year adverse clinical outcomes. The CPC analysis using Holter-monitoring is a useful modality and could be easily applied to predict clinical outcomes in acute ischemic stroke patients.

Baseline D-Dimer Levels as a Risk Assessment Biomarker for Recurrent Stroke in Patients with Combined Atrial Fibrillation and Atherosclerosis

Background: We investigated the effect of D-dimer levels and efficacy of different antithrombotic therapies according to the baseline D-dimer levels on recurrent stroke in patients with atrial fibrillation (AF)-related stroke and atherosclerosis. Methods: We enrolled 1441 patients with AF-related stroke and atherosclerosis in this nationwide multicenter study. The primary outcome measure was the occurrence of recurrent ischemic stroke over a 3-year period. Results: High D-dimer levels (≥2 μg/mL) were significantly associated with higher risk of recurrent ischemic stroke (adjusted hazard ratio (HR), 1.80; 95% confidence interval (CI), 1.13–2.84; p = 0.012). The risk of recurrent stroke was similar between the anticoagulant and the antiplatelet groups in all subjects (adjusted HR, 0.78; 95% CI, 0.46–1.32; p = 0.369). However, in patients with high D-dimer levels (≥2 μg/mL), risk of recurrent stroke was significantly lower in the anticoagulant group than in the antiplatelet group (adjusted HR, 0.40; 95% CI, 0.18–0.87; p = 0.022). Conclusion: Our findings suggested that baseline D-dimer levels could be used as a risk assessment biomarker of recurrent stroke in patients with AF-related stroke and atherosclerosis. High D-dimer levels would facilitate the identification of patients who are more likely to benefit from anticoagulants to ensure secondary prevention of stroke.

Ceria Nanoparticles Fabricated with 6-Aminohexanoic Acid that Overcome Systemic Inflammatory Response Syndrome

Systemic inflammatory response syndrome (SIRS) is self-destructive and uncontrollable inflammatory response of the whole body triggered by infection, trauma, or a variety of severe injuries. Although reactive oxygen species play a pivotal role in the development of SIRS, the trials with conventional antioxidants have failed to improve patient outcome. Ceria nanoparticles (CeNPs) have potent, autocatalytic reactive oxygen species scavenging activities, which may have sufficient therapeutic effects for SIRS. Herein, 3 nm CeNPs are fabricated totally in aqueous phase by using 6-aminohexanoic acid (6-AHA) and their Ce³⁺ to Ce⁴⁺ ratio is increased to enhance antioxidative properties. The obtained 6-AHA-CeNPs demonstrate strong antioxidative and anti-inflammatory effects in various biofluids and inflammatory cells. In SIRS animal models, 6-AHA-CeNPs are demonstrated to reduce multiple organ injuries and inflammation. Moreover, 6-AHA-CeNPs decrease mortality and improve clinical scores of SIRS models. These findings suggest that 6-AHA-CeNPs have potential as a therapeutic nanomedicine for SIRS.

Abstract WP210: Transthoracic Echocardiographic Predictor for Long-Term Outcomes in Real-World Korean Patients With Atrial Fibrillation-Related Stroke: A Multi-Center Cohort Study

Background: While transthoracic echocardiography (TTE) is performed to find out potential embolic sources and certain cardiac abnormalities as a routine workup of stroke, clinical implication of echocardiographic findings for long-term outcomes in atrial fibrillation (AF)-related stroke patients has been unknown.

Methods: This was a sub-study of K-ATTENTION (Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts), a multicenter-based cohort composed of prospective stroke registries from 11 tertiary centers. All stroke survivals enrolled in this study underwent TTE during hospitalization. Echocardiographic findings included left atrial (LA) diameter, left ventricular ejection fraction (LVEF), LV end-diastolic dimension (LVEDV), stenosis and regurgitation of mitral and aortic valves, and peak trans-mitral filling velocity/mean mitral annular velocity during early diastole (E/e’ ratio). Indexed-LA size was acquired as dividing LA size by body surface area. LV systolic function was grouped into normal (LVEF≥55%), mild (55%>LVEF>40%), and severe (LVEF≤40%). Level of E/e’ ratio associated with LV filling pressure was divided into normal (<8), borderline (8-15) and increased (≥15). Outcomes of interest were recurrent stroke, coronary artery disease, and vascular, and all-cause death. We used Cox regression multivariable analyses adjusted by confounding factors.

Results: A total of 1952 patients were finally included. Over a mean follow-up of 1.72±1.31 years, 140 patients had recurrent stroke, 36 had coronary artery disease, and of 236 fatalities, 33 died of a vascular cause. Multivariable analyses demonstrated that severe LV systolic dysfunction was associated with a higher risk of coronary artery disease (hazard ratio [HR] 3.80, 95% confidence interval [CI] 1.53-9.41), vascular death (HR 3.59, 95% CI 1.42-9.10) and all-cause death (HR 2.29, 95% CI 1.47-3.56).

Conclusions: LV ejection fraction could be important predictor for long-term outcomes in AF-related stroke.

Abstract TP519: The Effect of Different Oral Anticoagulants on Vascular Outcomes in Stroke With Atrial Fibrillation: A Real-world Data

Background and Purpose: Little is known about the different effect of outcomes and factors associated with vascular outcomes in stroke patients with atrial fibrillation in real world practice setting especially in Korea. In this study, we investigated the effect of each oral anticoagulants on vascular outcomes using K-ATTENTION (Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts) study.

Methods: Consecutive data of acute stroke patients with atrial fibrillation were collected from 11 centers in Korea from January 2013 to December 2015. Eligibility of inclusion was acute stroke within 7 days from the onset of stroke and diagnosis of non-valvular or valvular atrial fibrillation. Vascular outcomes included ischemic stroke, hemorrhagic stroke, death of any cause, and major adverse cerebro/cardiovascular events (MACE). To describe the effect of each oral anticoagulants on vascular outcomes, we performed time-dependent Cox’s regression analyses with the class of oral anticoagulant as a time dependent covariate. For stroke, hemorrhagic stroke, and any stroke, death was considered as competing risk.

Results: Among 3213 stroke patients included in K-ATTENTION study, a total 3033 stroke patients (mean age 73.45 ± 9.93 years old, female 48.5%) were included. Mean CHA2DS2-VASc score was 4.89 ± 1.37. During the study period, a total of 161 ischemic strokes, 46 hemorrhagic strokes, 199 any strokes, 556 death and 720 MACE were captured. Time-dependent Cox’s regression analysis revealed that use of oral anticoagulants [vitamin K antagonist (VKA), dabigatran, rivaroxaban, or apixaban] was associated with significantly lower risk of death and MACE compared with no oral anticoagulants use. Although, there was no difference among oral anticoagulants for ischemic stroke, hemorrhagic stroke, or any stroke when compared with no oral anticoagulants, dabigatran showed a trend of reduced risk of any stroke (HR 0.48, 95%CI 0.23 - 1.01, p = 0.0545).

Conclusion: This real-world data revealed that the use of oral anticoagulants was associated with the reduced risk of MACE and death. However, for ischemic stroke and hemorrhagic stroke, the results were not conclusive. Dabigatran showed a trend of reduced risk of any stroke.

Abstract TMP59: Recent Trends of Stroke Characteristics and Treatment in Korea: Data From Korean Stroke Registry

Introduction: Dynamic changes in lifestyle or healthcare system due to industrialization lead to changes in the pattern of disease. This study investigates the recent trends of acute ischemic stroke characteristics and treatment in Korea, a rapidly developed country.

Methods: We analyzed individual data of ischemic stroke and transient ischemic attack patients from the Korean Stroke Registry (KSR), a nationwide hospital-based stroke database, between August 2014 and May 2018 (2nd generation KSR). We collected demographic data, risk factors, treatment including thrombolysis, and stroke subtypes. Linear or log-linear Poisson regression analyses were performed to assess the changes. Finally, we compared this data from January 2002 to November 2010 (1st generation KSR).

Results: A total 39,291 patients of 2nd generation KSR were included in the analysis. The mean±SD age was 68.0±13.0 years, and 58.3% of the patients were male. Over the 5-year period, the mean age of the patients steadily increased by 0.21 year annually (p<0.001). Proportions of hypertension and diabetes remained stable, but frequency of dyslipidemia increased and prior stroke decreased. Proportion of intravenous thrombolysis remained stable (p=0.147), but intra-arterial thrombectomy increased (p<0.001). Relative proportions of stroke subtypes over the 5 years, small vessel occlusion increased, cardioembolism decreased, and large artery atherosclerosis remained stable. Compared with 46,098 patients of 1st generation KSR, the proportion of arrival within 3 hours increased from 25.6% to 33.9%, and any reperfusion therapy increased 6.8% to 15.3%, especially intravenous thrombolysis increased 5.6% to 11.7%. The proportions of stroke subtype also considerably changed compared with 1st generation KSR (large artery atherosclerosis; 36.1% to 32.6%; cardioembolism; 25.4% to 19.9%; small vessel occlusion; 17.1% to 21.3%).

Conclusions: Stroke characteristics in Korea changed during the first two decades of 21st century. It is likely because of increased lifespan, westernized lifestyle, changed treatment modality and improved public awareness.

Relationship between the Angle of the Posterior Inferior Cerebellar Artery and Cardioembolic Stroke

BACKGROUND

In patients with unilateral posterior inferior cerebellar artery (PICA) territory infarction, the absence of relevant vessel stenosis may make it difficult to determine the etiology of the infarction. The incidence of cardioembolic (CE) infarction and the factors associated with infarction in such patients remains largely unknown. We hypothesized that the PICA angle would affect the flow direction of embolic sources. Thus, we analyzed the association between high-risk CE sources and the PICA angle.

METHODS

Patients with an isolated unilateral PICA territory infarction without relevant vessel stenosis who were admitted between 2014 and 2017 were included from the Korea University Stroke Registry, which includes data from 3 university hospitals. We classified patients according to the presence of CE sources. For each case, we measured the angle between the vertebral artery (VA) and the proximal PICA.

RESULTS

In all, 71 patients met the final study entry criteria. Multivariable analysis showed that the PICA angle was independently associated with the risk of a CE source. The optimal cut-off value using Youden's index was 89°. We classified the PICA shape based on the optimal cut-off value. A CE source was identified in 83.3% of cases in which the PICA angle exceeded 89°.

CONCLUSIONS

The angle between the PICA and VA was an independent predictor of unilateral PICA stroke with high-risk CE sources without relevant artery stenosis, suggesting that an angle greater than 89° could be a new image marker for determining the stroke subtype.

Pretreatment with low-dose fimasartan ameliorates NLRP3 inflammasome-mediated neuroinflammation and brain injury after intracerebral hemorrhage

Nucleotide-binding and oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome, which is composed of an NLRP3 domain, the adaptor molecule apoptosis-associated speck-like protein containing a CARD (ASC) domain, and procaspase-1, plays an important role in the immune pathophysiology of the secondary damage induced by intracerebral hemorrhage (ICH). This study aims to investigate whether pre-stroke treatment with fimasartan, an angiotensin II receptor blocker, has anti-inflammatory effects on ICH by inhibiting the activation of the NLRP3 inflammasome. Sprague-Dawley rats were divided into five groups: sham, vehicle, low-dose (0.5 mg/kg) and regular-doses (1.0 and 3.0 mg/kg) fimasartan. These rats were treated for 30 days before the induction of collagenase-induced ICH and continuously 3 days after surgery. The mean blood pressure (BP) in the low-dose fimasartan group was not significantly different from that of control, and BP in the regular-dose groups was decreased in a dose-dependent manner. Pretreatment with low-dose fimasartan attenuated ICH-induced edema and improved neurological functions. Activation of the NLRP3/ASC/caspase-1 and the NF-κB pathways after ICH was markedly reduced by low-dose fimasartan. The double immunofluorescence staining of brain cells showed a significant decrease in the co-localization of NLRP3 with Iba1 (microglia marker) positive cells by fimasartan treatment. Cultured microglia cells stimulated by hemolysate demonstrated significant activation of the inflammasome, which was reduced by fimasartan. Pretreatment with a low-dose fimasartan alleviated brain damage after acute ICH by inhibiting the NLRP3 inflammasome without lowering MBP. Our study suggests pre-stroke administration of fimasartan could potentially attenuate ICH-induced secondary brain injury by targeting the inflammasome.

Contrast-Enhanced Color-Coded Doppler Sonography in Moyamoya Disease: A Retrospective Study

The purpose of this study was to validate the feasibility of contrast-enhanced transcranial Doppler sonography (CE-TCCD) in the diagnosis of Moyamoya disease (MMD). CE-TCCD data on patients with MMD were analyzed. The CE-TCCD data were classified qualitatively into four patterns by two independent investigators: normal vascular color Doppler signal (pattern 1), augmented color Doppler signal with identifiable vascular structure (pattern 2), confluent color Doppler signal filling more than two-thirds of the display frame without identifiable vascular structure (pattern 3) and confluent color Doppler signal filling full display (pattern 4). To investigate the validity, we compared the CE-TCCD data with traditional transcranial Doppler data and Suzuki grades on cerebral angiography. A total of 32 CE-TCCD studies from 16 MMD patients (male 37.5%, median age 48) were included in this study. The CE-TCCD findings were distributed across patterns 1 (n = 3), 2 (n = 12), 3 (n = 10) and 4 (n = 7) and were correlated with the Suzuki grades (p <0.005) and hemodynamic parameters. Inter-rater reliability was promising (Cronbach α = 0.883). The CE-TCCD test provides distinctive patterns in MMD, according to their stage of progression. CE-TCCD patterns seem to be a reliable and valid means for the evaluation of MMD.

Effect of Statins on Survival Following Stroke in Patients With Cancer

The objective of this study was to investigate the potential benefits of statin therapy initiation in acute stroke in patients with active cancer. This study was conducted in two parts. First, data from patients who are presented with stroke and active cancer were obtained from prospectively collected multicenter hospital-based stroke registries. Patients were classified into statin user and non-user groups; the statin group was further divided into low-potency and high-potency statin subgroups. The primary outcome was time to mortality. Second, we obtained data from the Korean National Health Information Service-National Sample Cohort (NHIS-NSC) database for external validation and analyzed the effect of statins on mortality, taking compliance into consideration. For the stroke registry cohort, statin use was independently associated with reduced mortality in a multivariable model [hazard ratio (HR) = 0.675, 95% confidence interval (CI) = 0.457–0.996]. There was no interaction between statin use and cancer characteristics, vascular risk factors, or laboratory findings. A dose-dependent relationship between statin use and survival was also demonstrated. Analysis of the NHIS-NSC database found a similar association between statin therapy and reduced mortality (adjusted HR = 0.64, 95% CI = 0.45–0.90) and this effect persisted even after controlling for the adherence of statin use (HR = 0.60, 95% CI = 0.41–0.89). Statin therapy could be associated with reduced mortality in patients with acute stroke and active cancer.

Structural and functional characteristics of oestrogen receptor β splice variants: Implications for the ageing brain

Oestrogen receptor (ER)β is a multifunctional nuclear receptor that mediates the actions of oestrogenic compounds. Despite its well defined role in mediating the actions of oestrogens, a substantial body of evidence demonstrates that ERβ has a broad range of physiological functions independent of those normally attributed to oestrogen signalling. These functions can partly be achieved by the activity of several alternatively spliced isoforms that have been identified for ERβ. This short review describes structural differences between the ERβ splice variants that are known to be translated into proteins. Moreover, we discuss how these alternative structures contribute to functional differences in the context of both healthy and pathological conditions. Our review also describes the principal factors that regulate alternative RNA splicing. The alternatively spliced isoforms of ERβ are differentially expressed according to brain region, age and hormonal milieu, emphasising the likelihood that there are precise cell-specific mechanisms regulating ERβ alternative splicing. However, despite these correlative data, the molecular factors regulating alternative ERβ splicing in the brain remain unknown. We also review the basic mechanisms that regulate alternative RNA splicing and use that framework to make logical predictions about ERβ alternative splicing in the brain.

FLAIR vascular hyperintensities predict early ischemic recurrence in TIA

Objective

To evaluate the relationship between fluid-attenuated inversion recovery (FLAIR) vascular hyperintensity (FVH) and early ischemic lesion recurrence (follow-up diffusion-weighted imaging [FU-DWI] [+]) in patients with lesion-negative TIA.

Methods

We recruited consecutive patients with lesion-negative TIA within 24 hours of symptom onset, who underwent follow-up MRI during the acute period. FVH was defined as a focal or serpentine high signal intensity on FLAIR images. Other potential confounders were adjusted to evaluate the relationship between FVH and FU-DWI (+). Furthermore, to compare clinical outcomes between the FU-DWI (+) and FU-DWI (−) groups, we assessed 1-year recurrent ischemic stroke or TIA.

Results

Among 392 patients with lesion-negative TIA, 82 patients had FU-DWI (+) on the follow-up MRI. In the multivariate analysis, FVH remained an independent predictor of FU-DWI (+) (adjusted odds ratio [aOR] = 4.77, 95% confidence interval [CI] 2.45–9.29, p < 0.001). The time to initial MRI (aOR = 0.49, 95% CI = 0.33–0.70, p < 0.001) and intracranial atherosclerosis (aOR = 2.07, 95% CI = 1.10–3.92, p = 0.025) were also associated with FU-DWI (+), independent of FVH. In clinical outcomes, the FU-DWI (+) group showed more frequent 1-year recurrent ischemic stroke events than the FU-DWI (−) group (10.7% vs 3.1%, respectively, p = 0.007).

Conclusions

FVH is associated with FU-DWI (+) in patients with lesion-negative TIA. As FU-DWI (+) frequently occurs during the acute period and has a subsequent worse outcome after discharge, additional radiologic or clinical markers for it are necessary.

Abstract 179: Novel Theranostic Protocells for Intracerebral Hemorrhage

Background and Aims: Theranostics is an emerging concept of integrating therapy and imaging into a single platform. Intracerebral hemorrhage (ICH) causes intense inflammation by toxic effect of hematoma itself and mechanical disruption of brain tissue, which is a promising target of theranostics. We developed a novel theranostic protocells loaded with cerium oxide nanoparticles (CeNPs) for treatment and iron-oxide nanoparticles (FeNPs) for imaging.

Method: We synthesized 100-nm mesoporous silica nanoparticle (MSN) as a bio-compatiable nanocarrier, incorporated FeNPs in the core and CeNPs on the surface, and encapsulated MSN with lipid bilayer. Reactive oxygen species (ROS) scavenging and cytoprotective effects of the protocells were assessed in RAW264.7 cells. Brain water content, macrophage infiltration, and behavior function (corner turn and forelimb use asymmetry) were measured in collagenase-induced rodent ICH model after injecting the protocells. Serial brain MR imaging was also performed to confirm diagnostic ability of working site of protocells.

Results: The protocells were monodisperse in water and highly loaded with CeNPs, which exhibited a strong ROS scavenging (-26%, P<0.05) and cytoprotective effects (-51%, P<0.01). The protocells reduced macrophage infiltration (-58%, P<0.01) and brain edema (-1% water content, P<0.01) and improved neurologic outcome (+15% corner turn, P<0.05). In serial T2-weighted MR imaging, the protocells that reached peri-hematomal area were clearly visualized.

Conclusions: As the first theranostic nanobiomaterial, our protocells successfully visualized its working site in peri-hematomal area by MR imaging, and improved inflammatory status and neurologic outcomes after ICH. Beyond its potential for ICH theranosis, protocells could be generalized to other inflammatory diseases.

Abstract WP177: Alcohol Consumption: Benefit versus Harm in Vascular Events and Overall Mortality

Background: Alcohol consumption is associated with negative consequences including liver disease, major trauma and various cancers. However, a paradoxical beneficial effect of alcohol has been documented for cardiovascular disease in a large meta-analysis. On the other hand, a similar relationship has not been consistently documented or modest for the risk of stroke due to its heterogeneity in subtypes and pathophysiology. In this context, more comprehensive approaches using a representative dataset and composite outcomes are required to clarify the differential effects of alcohol on cardio-cerebrovascular disease (CCVD).

Methods: The Korean National Health Insurance Service (NHIS) is the sole provider of full-coverage health insurance for Korean citizens. NHIS-National Sample Cohort (NHIS-NSC) was a standardized cohort representative of Korean population. Based on biennial health exam at 2003 and 2004, we investigated the relationship between alcohol consumption and the incidence of CCVDs [ischemic stroke (IS), hemorrhagic stroke (HS) and myocardial infarction (MI)] and all-cause mortality until 2013, using multivariable Cox proportional hazards models.

Results: Among 204,557 participants (median follow up, 9.1 years), the following events were observed: IS 3,274; HS 1,056; MI 1,065 ; and all-cause mortality 8,771 cases. The hazards for IS and MI remained below the null point for the moderate alcohol consumption, but the risk for HS increased in heavy drinkers. In composite outcome indices, moderate consumption was associated with a lower risk for CCVD and all-cause mortality; however, the risk for all-cause mortality was significantly elevated in cases of heavy drinkers.

Conclusions: Alcohol consumption was associated with a decreased risk of both CCVD, specifically ischemic vascular disease, and all-cause mortality at moderate dose, but this protective relationship was offset by an increase in the risk for HS and mortality at heavy dose.

Nocturnal Desaturation is Associated With Neurological Deterioration Following Ischemic Stroke: A Retrospective Observational Study

STUDY OBJECTIVES

The mechanism of early neurological deterioration (END) in patients with stroke remains unclear. We assessed the relationship between nocturnal oxygen desaturation (NOD) in the stroke unit (SU) and END, especially occurring at nighttime, following acute stroke.

METHODS

A retrospective analysis was performed on a total of 276 patients with ischemic stroke who were admitted to the SU between July 2013 and June 2015. The oxygen desaturation index was calculated from pulse oximetry data sampled every 1 minute during 9 hours on the first night (10:00 PM to 7:00 AM) after admission, and NOD was defined as oxygen desaturation index ≥ 5 events/h. END was defined as an increase of ≥ 2 points from the baseline National Institutes of Health Stroke Scale during 7 days after onset. We compared clinical characteristics and NOD between patients with and without END.

RESULTS

Among the included patients (mean age 69.2; male 55.4%), 42 patients (15.2%) experienced END. The proportion of NOD was significantly greater in the END group (45.2% versus 12.8%, P < .001). After adjusting for confounders, NOD was independently associated with END (odds ratio 7.57; 95% confidence interval 3.14-18.27). Among END patients, 47.6% patients (n = 20) had END during nighttime. Moreover, NOD was more frequent in patients with END during nighttime compared to those with END during daytime (73.7% versus 26.1%, P = .002).

CONCLUSIONS

NOD in the SU was associated with END, especially during nighttime, after ischemic stroke. This suggests that treatment of sleep-disordered breathing could be a modifiable factor to possibly reduce the risk of neurological worsening among acute stroke patients.

Physical Activity Frequency and the Risk of Stroke: A Nationwide Cohort Study in Korea

Background

The current guideline recommends moderate‐ to vigorous‐intensity physical activity (PA) at least 40 min/day for 3 to 4 days/week. Although recent evidence has demonstrated that low‐dose PA could reduce cardiovascular mortality, the relationship between low‐dose PA and the risk of stroke remains uncertain.

Methods and Results

Using data from a nation‐wide sample cohort in Korea, we examined 336 326 individuals who received a general health examination between 2009 and 2010. Level of PA was assessed using a questionnaire for weekly PA frequencies regarding 3 intensity categories: light, moderate, and vigorous. Moderate‐ to vigorous‐intensity PA (MVPA) was classified into 4 frequency categories: none, 1 to 2, 3 to 4, or ≥5 times/week. Cox proportional hazard models were constructed to estimate the risk of stroke. During the average follow‐up of 3.6 years, 2213 stroke cases occurred. MVPA was none in 50%, 1 to 2 times/week in 20%, 3 to 4 times/week in 13%, and ≥5 times/week in 18% of the cohort. Individuals with MVPA 1 to 2 times/week had a 16% reduced risk of stroke (adjusted hazard ratio, 0.84; 95% confidence interval, 0.73–0.96) compared with those with no MVPA. The population attributable fraction of no MVPA was 12%, which was the second most important risk factor for a stroke after hypertension.

Conclusions

Even 1 to 2 times a week of MVPA might be beneficial to prevent a first‐ever stroke in the general population, although a quantitative validation of the questionnaire is needed. From a public health perspective, we need to encourage inactive people to start exercising with more‐achievable goals.

Treatment of Cryptogenic Stroke with Active Cancer with a New Oral Anticoagulant

BACKGROUND

Low-molecular weight heparin (LMWH) was shown to be effective and safe in treating venous thromboembolism, and generally used for stroke in cancer patients, but its effects on stroke are unclear. We compared clinical outcomes between LMWH and new oral anticoagulant (NOAC) in patients with cancer-related stroke.

METHODS

We enrolled patients with cryptogenic ischemic stroke with active cancer who were treated with LMWH or NOAC between May 2012 and June 2015. The clinical outcomes, including early neurologic deterioration, early radiologic recurrence, 3-month modified Rankin scale score, 90-day mortality, cardio-cerebrovascular recurrence, and bleeding complications, were compared.

RESULTS

Among 48 patients, 7 patients were treated with NOAC, and the remaining 41 patients with LMWH. Overall, the participants presented poor outcomes, including 20 (42%) early neurologic deteriorations, 28 (58%) early radiologic recurrences, 34 (71%) poor modified Rankin scale scores, 27 (56%) 90-day mortality events, 24 (50%) cardio-cerebrovascular recurrences, and 18 (38%) bleeding complications, that led to a change or temporary hold in medication in 12 cases. No statistical differences were found between the 2 groups in terms of demographic, clinical, or cardiovascular risk factors and clinical outcomes.

CONCLUSIONS

NOAC showed the similar clinical outcomes and safety compared with LMWH in the treatment of cryptogenic ischemic stroke in active cancer patients.

Retinal Vein Occlusion as the Surrogate Marker for Premature Brain Aging in Young Patients

Purpose

We investigated cerebral small vessel disease (SVD) in patients with incidental retinal vein occlusion (RVO).

Methods

This retrospective, case-control, observational trial included 125 patients with RVO who underwent brain magnetic resonance imaging (MRI) and 1105 age-matched controls who underwent comprehensive medical interviews and MRI. Underlying cardiovascular diseases and MRI findings were investigated in the patients with RVO according to age (<60 or ≥60 years) and RVO occlusion level (central or branch). The characteristics of underlying cardiovascular disease and MRI findings were compared between the younger patients with RVO and age-matched controls. The cerebrovascular burden also was assessed in the younger patients with RVO.

Results

The mean age of the patients with RVO was 63.9 ± 12.1 years and the predominant underlying disease was hypertension (72/125, 58%). The older RVO group had a longer history of hypertension and less smoking history. The prevalence of cerebral SVD in the RVO group was 54% (68/125), and was significantly higher in older than in younger patients with RVO (62% [53/86] vs. 38% [15/39], P = 0.016). However, the latter had a significantly higher prevalence of cerebral SVD than their age-matched controls (38% [15/39] vs. 4% [47/1105], P < 0.001). There was no difference in prevalence of cerebral SVD between the central and branch RVO groups (P = 0.478).

Conclusions

Cerebral SVD presented frequently in patients with RVO and was magnified in young patients, suggesting that RVO is a surrogate marker for cerebral SVD.

Ceria-Zirconia Nanoparticles as an Enhanced Multi-Antioxidant for Sepsis Treatment

The two oxidation states of ceria nanoparticles, Ce³⁺ and Ce⁴⁺ , play a pivotal role in scavenging reactive oxygen species (ROS). In particular, Ce³⁺ is largely responsible for removing O₂^- and ^. OH that are associated with inflammatory response and cell death. The synthesis is reported of 2 nm ceria-zirconia nanoparticles (CZ NPs) that possess a higher Ce³⁺ /Ce⁴⁺ ratio and faster conversion from Ce⁴⁺ to Ce³⁺ than those exhibited by ceria nanoparticles. The obtained Ce_0.7 Zr_0.3 O₂ (7CZ) NPs greatly improve ROS scavenging performance, thus regulating inflammatory cells in a very low dose. Moreover, 7CZ NPs are demonstrated to be effective in reducing mortality and systemic inflammation in two representative sepsis models. These findings suggest that 7CZ NPs have the potential as a therapeutic nanomedicine for treating ROS-related inflammatory diseases.

Fabrication of nitrogen-doped nano-onions and their electrocatalytic activity toward the oxygen reduction reaction

Nitrogen-doped nano-onions (NNO) were prepared as electrocatalytic materials for the oxygen reduction reaction (ORR). The nano-onions (NO), spherical graphitic material particles, were prepared by pyrolysis of nanodiamonds (ND). Oxidized NO (ONO) was prepared from NO by a modified Hummers’ method, and this was mixed with urea, followed by pyrolysis, resulting in the formation of NNO. The nitrogen content and molar ratio of nitrogen-containing groups in the NNOs were varied by controlling the oxygen content of ONO to explore the effect of nitrogen content on the ORR activity. The formation of NO was confirmed by Raman spectroscopy, X-ray diffraction analysis, and high-resolution transmission electron microscopy. X-ray photoelectron spectroscopy analyses were conducted to confirm the formation of the NNO and the structures of the nitrogen-containing groups in the NNOs. The ORR activities of the NNOs were investigated using a rotating disk electrode. The NNOs showed a higher onset potential than that of NO, and the ORR activity of the NNO could be improved by increasing the number of active sites (nitrogen-containing groups) in the NNO. In addition, the NNO exhibited better long-term stability and resistance toward methanol crossover in the ORR than the platinum-based catalysts.

Cerebral Small Vessel Disease in Branch Retinal Artery Occlusion

Purpose

We investigated the pathophysiology of branch retinal artery occlusion (BRAO) by evaluating the retina, brain, and carotid artery in patients with BRAO.

Methods

This study was a retrospective registry study. We used 46 eyes from 46 patients with acute BRAO and evaluated the medical history, including previous cardiovascular disease, and compared brain magnetic resonance images (MRI) and carotid artery stenosis state between the embolic BRAO group and nonembolic BRAO group. We measured differences in cerebrovascular characteristics, including brain MRI, according to the existence of retinal emboli.

Results

The embolic BRAO group tended to have a significantly higher likelihood of cardiovascular disease history, including ischemic heart disease and smoking history (P = 0.018 and P < 0.001, respectively). In addition, the embolic group had a higher frequency of acute cerebral infarctions and stenotic carotid arteries (P = 0.017 and P = 0.028, respectively). Although the overall frequency of cerebral small vessel disease (SVD) did not differ between embolic and nonembolic groups, the nonembolic BRAO group showed a significantly higher prevalence of cerebral SVD without large vessel pathology (P = 0.008).

Conclusions

Patients with BRAO showed different cerebrovascular characteristics following retinal emboli, including brain MRI findings. The results suggest that we must consider SVD etiology as well as large vessel disease mechanisms in the pathophysiology of BRAO.

Predictors of 30-day mortality and the risk of recurrent systemic thromboembolism in cancer patients suffering acute ischemic stroke

BACKGROUND

Stroke in cancer patients is not rare but is a devastating event with high mortality. However, the predictors of mortality in stroke patients with cancer have not been well addressed. D-dimer could be a useful predictor because it can reflect both thromboembolic events and advanced stages of cancer.

AIM

In this study, we evaluate the possibility of D-dimer as a predictor of 30-day mortality in stroke patients with active cancer.

METHODS

We included 210 ischemic stroke patients with active cancer. The 30-day mortality data were collected by reviewing medical records. We also collected follow-up D-dimer levels in 106 (50%) participants to evaluate the effects of treatment response on D-dimer levels.

RESULTS

Of the 210 participants, 30-day mortality occurred in 28 (13%) patients. Higher initial NIHSS scores, D-dimer levels, and CRP levels as well as frequent cryptogenic mechanism, systemic metastasis, multiple vascular territory lesion, hemorrhagic transformation, and larger infarct volume were related to 30-day mortality. In the multivariate analysis, D-dimer [adjusted OR (aOR) = 2.19; 95% CI, 1.46-3.28, P < 0.001] predicted 30-day mortality after adjusting for confounders. The initial NIHSS score (aOR = 1.07; 95% CI, 1.00-1.14, P = 0.043) and hemorrhagic transformation (aOR = 3.02; 95% CI, 1.10-8.29, P = 0.032) were also significant independent of D-dimer levels. In the analysis of D-dimer changes after treatment, the mortality group showed no significant decrease in D-dimer levels, despite treatment, while the survivor group showed the opposite response.

CONCLUSIONS

D-dimer levels may predict 30-day mortality in acute ischemic stroke patients with active cancer.

Abstract TP315: D-dimer is Associated With 30-day Mortality in Acute Ischemic Stroke With Active Cancer

Background: Stroke in cancer patients is not rare, but is a devastating event with high mortality. However, the predictors of mortality in stroke patients with cancer have not been well addressed. D-dimer could be a useful predictor because it can reflect both thromboembolic events and advanced stages of cancer. In this study, we evaluate the possibility of D-dimer as a predictor of 30-day mortality in stroke patients with active cancer.

Methods: We included 210 ischemic stroke patients with active cancer. The data of 30-day mortality were collected by reviewing medical records. We also collected follow-up D-dimer levels in 106 (50%) participants to evaluate the effects of treatment response on D-dimer levels.

Results: Of the 210 participants, 30-day mortality occurred in 28 (13%) patients. Higher initial NIHSS score, D-dimer levels, CRP levels, frequent cryptogenic mechanism, systemic metastasis, multiple vascular territory lesion, hemorrhagic transformation, and larger infarct volume were related to 30-day mortality. In the multivariate analysis, D-dimer [adjusted OR (aOR) = 2.19; 95% CI, 1.46-3.28, P < 0.001] predicted 30-day mortality after adjusting for confounders. Initial NIHSS score (aOR = 1.07; 95% CI, 1.00-1.14, P = 0.043) and hemorrhagic transformation (aOR = 3.02; 95% CI, 1.10-8.29, P = 0.032) were also significant independently from D-dimer levels. In the analysis of D-dimer changes after treatment, the mortality group showed no significant decrease of D-dimer levels, despite treatment, while the survivor group showed opposite responses.

Conclusions: D-dimer levels may predict 30-day mortality in acute ischemic stroke patients with active cancer.

Cystatin C is a useful predictor of early neurological deterioration following ischaemic stroke in elderly patients with normal renal function

Introduction

Cystatin C has been suggested as a sensitive marker of renal function. A high level of cystatin C is related to cardiovascular disease and stroke in elderly patients. We investigated the relationship between levels of cystatin C and early neurological deterioration with acute ischaemic stroke in elderly patients without chronic kidney disease.

Patients and methods

We evaluated a total of 771 elderly patients (mean age, 72.2; male, 59.0%) without chronic kidney disease who were admitted following acute ischaemic stroke between March 2010 and January 2015. The patients were divided into four groups based on the quartiles of serum cystatin C values. Early neurological deterioration was defined as an increase of ≥2 points from the baseline National Institutes of Health Stroke Scale score during the 7 days following onset. We compared the clinical characteristics and cystatin C concentrations between patients with and without early neurological deterioration.

Results

Eighty-six patients (11.2%) experienced early neurological deterioration. The percentage values of the higher (third and fourth) quartiles were significantly higher in the early neurological deterioration group (30.2% vs. 24.4% and 34.9% vs. 23.8%, P = 0.002). After adjustment for covariates, higher cystatin C levels were independently associated with a higher risk of early neurological deterioration: odds ratio (95% confidence interval) for second quartile 1.59 (0.70-3.58), third quartile 2.75 (1.25-6.04), fourth quartile 3.12 (1.36-7.16); P for trend 0.026.

Discussion and conclusions

This study demonstrated that cystatin C concentrations in elderly patients without chronic kidney disease were associated with early neurological deterioration following acute stroke. This suggests that cystatin C level could be a useful predictor for early neurological deterioration following acute stroke.

D-dimer as a predictor of early neurologic deterioration in cryptogenic stroke with active cancer

BACKGROUND AND PURPOSE

The occurrence of stroke in cancer patients is caused by conventional vascular risk factors and cancer-specific mechanisms. However, cryptogenic stroke in patients with cancer was considered to be more related to cancer-specific hypercoagulability. In this study, we investigated the potential of the D-dimer level to serve as a predictor of early neurologic deterioration (END) in cryptogenic stroke patients with active cancer.

METHODS

We recruited 109 cryptogenic stroke patients with active cancer within 72 h of symptom onset. We defined END as an increase of ≥1 point in the motor National Institutes of Health Stroke Scale (NIHSS) score or ≥2 points in the total NIHSS score within 72 h of admission. After adjusting for potential confounding factors in the multivariate analysis, we calculated the odds ratios (ORs) and confidence intervals (CIs) of D-dimer in the prediction of END.

RESULTS

Among 109 patients, END events were identified in 34 (31%) patients within 72 h. END was significantly associated with systemic metastasis, multiple vascular territory lesions on the initial magnetic resonance imaging (MRI), initial NIHSS score and D-dimer levels. In the multivariate analysis, the D-dimer level (adjusted OR, 1.11; 95% CI, 1.04-1.17; P < 0.01) and initial NIHSS score (adjusted OR, 1.08; 95% CI, 1.01-1.15; P = 0.03) predicted END after adjusting for potential confounding factors. In the subgroup analysis of 72 follow-up MRIs, D-dimer level was also correlated with new territory lesions on the follow-up MRI in a dose-dependent manner.

CONCLUSION

Ischemic stroke patients with active cancer and elevated D-dimer levels appear to be at increased risk for END recurrent thromboembolic stroke.

Association of serum uric acid and cardioembolic stroke in patients with acute ischemic stroke

BACKGROUND

Although high uric acid levels have been reported to be a risk factor for cardiovascular disease and stroke, the relationship between serum uric acid (SUA) levels and cardioembolic stroke (CES) has not been fully elucidated. In this study, we sought to investigate the relationship between the risk of CES and SUA levels. We hypothesized that SUA concentrations are associated with CES.

METHODS

We retrospectively analyzed 2350 patients with acute ischemic stroke who were admitted to the Seoul National University Hospital between 2002 and 2010. The participants were stratified into five groups according to SUA levels obtained within 24h after stroke onset. The association between SUA levels and CES was evaluated using multivariable logistic regression models.

RESULTS

Of the 2350 patients, 412 (27.7%) were classified with CES, and 1077 (72.3%) were classified with non-CES, including LAA (large artery atherosclerosis) and SVO (small vessel occlusion). Among the acute stroke patients, SUA levels were higher in those with atrial fibrillation and other cardiovascular risk factors. Compared with the non-CES patients, the CES patients were more likely to fall in the highest quintile of SUA level. Multivariate analysis revealed that the patients with SUA concentrations in the highest quintile were associated with CES (OR=2.59, 95% CI: 1.35-4.97), test for trend P<0.001. Similar results were obtained for gender-based subgroups by (in men, OR=2.34, 95% CI: 1.06-5.15 and in women OR=3.41, 95% CI: 1.15-10.07), test for trend P<0.01 and P<0.001, respectively.

CONCLUSION

SUA level is associated with the risk of CES in acute ischemic stroke patients of both sexes. Further prospective clinical trials of lowering SUA to prevent CES may be worth considering.

Prolonged sleep increases the risk of intracerebral haemorrhage: a nationwide case-control study

BACKGROUND AND PURPOSE

Although abnormal sleep duration is positively associated with increased risk for cardiovascular disease and mortality, the specific impact on intracerebral haemorrhage (ICH) risk remains unclear. The relationship between sleep duration and the risk of ICH was investigated in our study.

METHODS

A nationwide, multicentre matched case-control study was performed to investigate the risk factors for haemorrhagic stroke, using patients from 33 hospitals in Korea. In all, 490 patients with ICH and 980 age- and sex-matched controls were enrolled. Detailed information regarding sleep, sociodemographic factors, lifestyle and medical history before ICH onset was obtained using qualified structured questionnaires. Sleep duration was categorized and the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a conditional logistic regression with 7 h as the reference duration.

RESULTS

The number of subjects with long sleep duration, more than 8 h, was significantly greater in the ICH group than in the control group (≥8 h, 30.4% vs. 22.6%, P = 0.002). After controlling for relevant confounding factors, longer sleep duration was found to be independently associated with the risk of ICH in a dose-response manner (8 h, OR 1.57, 95% CI 1.00-2.47; ≥9 h, OR 5.00, 95% CI 2.18-11.47).

CONCLUSIONS

Our study suggested that long sleep duration is positively associated with an increased ICH risk in a dose-dependent manner. Further studies on the relationship linking long sleep duration with increased risk of ICH are required.

Tachycardia burden in stroke unit is associated with functional outcome after ischemic stroke

BACKGROUND

Stroke unit care is associated with decrease in mortality and improvement in neurological outcome in patients with acute stroke. Heart rate is a commonly monitored variable in the stroke unit. However, little is known about tachycardia burden in the stroke unit and its association with outcome.

AIMS

To investigate the effects of tachycardia burden in the stroke unit on functional outcome in patients with acute ischemic stroke.

METHODS

We collected data from 246 patients with acute ischemic stroke admitted to our stroke unit between July 2013 and June 2014. Tachycardia burden was defined as duration of heart rate over 95 per minute divided by the total monitoring time, using the heart rate data sampled every 1 min. We divided the study population into quartiles of tachycardia burden and analyzed their association with poor three-month functional outcome (modified Rankin Scale score of ≥3).

RESULTS

Among included patients (age, 67.4 ± 12.8; male, 53.7%), tachycardia burden was 0.7% (median, interquartile range [0.1-5.7%]). The patients with higher tachycardia burdens were older, more likely to have higher stroke severity, cardioembolic etiology, atrial fibrillation, fever, pneumonia, higher initial glucose level, and higher white blood cell count. As compared with the lowest quartile (<0.1%), the highest quartile of tachycardia burden (≥6.0%) was significantly associated with poor outcome (adjusted odds ratio, 5.10; 95% confidence interval, 1.38-18.90; p = 0.01) after adjustment for covariates.

CONCLUSIONS

Patients with increased tachycardia burden during stroke unit stay have poor functional outcome. Countermeasures against worsening factors might be utilized for patients with increased tachycardia burden.

Abstract TMP45: Usefulness of Susceptibility Vessel Sign With Bright Vessel Appearance in Acute Ischemic Stroke

Background: Red thrombi, composed of fibrin and trapped erythrocytes, have magnetic susceptibility effect. Susceptibility vessel sign (SVS) is visualized more sensitively using susceptibility weighted imaging (SWI) than T2*-weighted imaging. Bright vessel appearance (BVA) on arterial spin labeling (ASL) imaging can visualize occluded arterial segment by arterial transit artifact, more sensitively in small and peripheral branches. We investigated the usefulness of SWI-SVS with BVA to visualize different thrombus and predict stroke mechanisms.

Methods: From a total of 564 stroke cases who admitted to Seoul National University Hospital in 2014, the authors collected eligible cases with the following inclusion criteria; (1) Lesion-documented ischemic stroke (N=425); (2) SWI and ASL MRI performed (N=407); (3) Symptomatic arterial occlusion with BVA (N=141). All images were analyzed for the presence and location of SWI-SVS and BVA. The location of SWI-SVS and BVA were classified into (1) proximal, large arteries; distal ICA, M1/2, A1, P1, basilar artery, V4 and (2) peripheral, small arteries; M3/4, P2/3, A2/3, lenticulostriate arteries, three cerebellar arteries. The relationships between SWI-SVS in the presence of BVA and stroke etiologies are explored.

Results: Male was 58.2% (n=82) and mean age was 65.7±14.3. Thirty-four percent (n=48/141) of BVA and 30.3% (n=30/99) of SVS was located within small, peripheral arteries. SWI-SVS was more commonly associated with other determined etiology (20.2% vs. 4.8%) and cardioembolism (39.4% vs. 14.3%), but less with large artery atherosclerosis (26.3% vs. 69.0%, P <0.01) compared to the patients without SWI-SVS. Cancer-related hypercoagulability (60%, n=12/20) was most common in other determined cases with SWI-SVS. Multivariate analysis showed that SWI-SVS was an independent predictor of other determined etiology (adjusted OR, 7.20; 95% CI, 1.48-34.99) and cardioembolism (adjusted OR, 5.76; 95% CI, 1.27-26.02)

Conclusions: SWI-SVS with BVA may predict ischemic stroke of cardioembolism and other determined etiology. Occlusions of small, peripheral arteries are well visualized with BVA and composition of thrombus can be identified by SWI-SVS.

Abstract WP265: Anti-inflammatory Effects Of Ceria Nanoparticles In Experimental Intracerebral Hemorrhage Models

Aim: Ceria nanoparticles (NPs) are potent anti-oxidants because of their small size and surface characteristics. In addition to this, they have anti-inflammatory effects. However, their effects on post-stroke inflammation have not been evaluated in experimental intracerebral hemorrhage (ICH).

Methods: Ceria NPs were made by a modified double-decomposition method. RAW 264.7 macrophages (MΦs) were activated by 30% hemolysate from blood by checking morphology and inflammatory products. They were treated by 0.125 mM ceria NPs or not. Overall reactive oxygen species (ROS) after the activation of MΦs were measured by oxidized DCF-DA in FACS. Inflammatory cytokines, IL-1β and TNF-α, were evaluated by ELISA, and inflammatory end-products, COX2 and iNOS, were done by Western blots. Animal ICH was induced by the stereotactic injection of collagenase into the rat brain, and ceria NPs were injected intravenously. Water contents were measured by wet and dry weights of brain after induction of ICH. We calculated hematoma volumes by an image-analyzer and the recruitment of MΦs in perihematomal area by the immunofluorescent staining using CD68 antibody.

Results: Ceria NPs were made as 3-nm small sized, uniform round-shaped, and well-dispersed agents, which were suitable for biomedical applications. Ceria NPs reduced oxidized DCF-DA (a marker of overall ROS) after hemolysate-induced activation of MΦs (ceria-treated group, 391 unit vs. control, 567 unit, P=0.03). In this in vitro hemorrhage model, MΦs secreted less cytokines, IL-1β and TNF-α, in ceria-treated group than control, and in Western blots, the expression of COX2 and iNOS decreased in ceria group compared to control. In rat ICH model, ceria NPs reduced water contents in hemorrhagic hemisphere, which is closely related to perihematomal inflammation (0.5 mg/kg ceria group, 79,9% vs. control, 81.1%, P=0.01). Although hematoma volumes were not different between two groups, the CD68-positive MΦs in immunofluorescent staining were less recruited into the perihematomal area in ceria-treated group than control.

Conclusion: Ceria NPs decreased inflammation after ICH in both in vitro and in vivo models. From these anti-inflammatory effects, they could be potential therapeutic agents in acute period after ICH.

Abstract TP325: Impact of Nocturnal Desaturation on Early Neurological Deterioration Following Ischemic Stroke

Introduction: The mechanisms of early neurological deterioration (END) in patients with acute stroke remain unclear. Despite that systemic hypoxia is associated with stroke risk and poor outcome following acute stroke, the association between nocturnal desaturation and END remains to be elucidated

Hypothesis: We assessed the relationship between nocturnal oxygen desaturation in the stroke unit and END in patients with acute stroke.

Methods: A consecutive 225 patients with acute ischemic stroke who were admitted to the stroke unit within 7 days after stroke onset between July 2013 and June 2014 were included for analysis Physiological variables including pulse oximetry were sampled every 1 minute. The ODI was calculated using pulse oximetry data during 9 hours on the first night (10:00 PM-7:00 AM) of the stroke unit admission and nocturnal oxygen desaturation was defined as an ODI of 5 or greater per hour. We compared the clinical characteristics, nocturnal oxygen desaturation, laboratory findings, and radiologic findings in patients with and without END.

Results: Among the total patients, 52.4 % were male, with a mean age of 66.8 years. Twenty patients experienced early neurological worsening after stroke onset. The proportion of patients with nocturnal desaturation was significantly greater in the group of patients who also showed END (40.0% vs. 9.8%, P < 0.001). Moreover, more patients with END showed poor outcomes at 3 months (65.0% vs. 28.8%, P = 0.001). The stroke lesion locations did not significantly differ between the two groups. After controlling for relevant confounding factors, we found that nocturnal oxygen desaturation was associated with a risk of END (Odds ratio, 5.81; 95% confidence interval, 1.57-21.51).

Conclusions: In conclusion, our study found that recurrent nocturnal desaturation in the stroke unit was associated with END in patients with acute stroke. In this context, our data could suggest that intensive monitoring of nocturnal desaturation in the stroke unit could be an important factor in preventing the risk of END and poor outcomes following acute stroke. .

Abstract TP145: Cystatin C is a Strong Predictor of Short-term Functional Outcome After Ischemic Stroke in Patients With Chronic Kidney Disease

Introduction: Serum cystatin C has emerged as a risk factor of cardiovascular disease and death. Cystatin C is promoted a better marker of renal function compared to estimated glomerular filtration rate (GFR). However, the impact of cystatin C on the functional outcome after ischemic stroke in patients with CKD remains unclear.

Hypothesis: We assessed the prognostic value of cystatin C for functional outcome after ischemic stroke in CKD patients.

Methods: A consecutive 239 patients with CKD who were admitted within 7 days after ischemic stroke onset between January 2010 and February 2014 were included for analysis. An estimated GFR < 60mL/min/1.73 m 2 defined CKD. We compared the demographic information, clinical characteristics and laboratory findings including serum cystatin C level. We evaluated the short-term outcomes using a modified Rankin Scale (mRS) at three-months after onset of ischemic stroke. We divided patients into two groups with favorable outcome (mRS score ≤2) and unfavorable outcome (mRS score ≥3).

Results: Among the total patients, 36.0% (n=86) patients had unfavorable outcome. These patients were mostly male (52.9%), with a mean age of 73.5 years. Older age, atrial fibrillation and history of previous stroke were significantly higher in the unfavorable outcome group. Participants with unfavorable outcome tended to have lower body mass index, higher initial NIHSS, lower estimated GFR, and higher C-reactive protein concentration. Compared to the favorable outcome group, cystatin C level was significantly higher (1.25±0.41 vs. 1.54±0.64 mg/dL, P = 0.001) in the unfavorable outcome group. After controlling for confounding factors, higher cystatin C levels were independently related to the unfavorable outcome at three-months (Odds ratio, 3.19; 95% Confidence interval, 1.02-9.96). In contrast, estimated GFR did not show any significant association with the unfavorable outcome (Odds ratio, 1.01; 95% Confidence interval, 0.96-1.06).

Conclusions: In conclusion, our study showed that elevated cystatin C levels were independently associated with the unfavorable functional outcome after ischemic stroke in patients with CKD. Cystatin C may be a potent predictor of short-term functional outcome after ischemic stroke in CKD patients.

Abstract WP369: Long Sleep Duration as a Risk Factor for Intracerebral Hemorrhage: a Nationwide, Multicenter Case-control Study

Introduction: Sleep duration has been regarded as a potential risk factor for cardiovascular disease and stroke. Short sleep duration is linked with higher stroke incidence, and mortality. Moreover, and paradoxically, long sleep duration is also reported to be positively associated with stroke incidence. However, the impact of sleep duration on the intracerebral hemorrhage (ICH) risk remains unclear.

Hypothesis: We assessed the relationship between sleep duration and the risk of ICH.

Methods: We performed a nationwide, multicenter matched case-control study to investigate the risk factors for hemorrhagic stroke, using patients from 33 hospitals in Korea. We enrolled a total of 490 patients with ICH and 980 age- and sex-matched controls. We obtained information regarding sleep, sociodemographic factors, lifestyle, and medical history before ICH onset, using qualified structured questionnaires. Sleep duration was categorized as ≤5, 6, 7, 8, and ≥9 hours. We chose sleep duration of 7 h as the reference duration.

Results: The included patients were mostly male (58.2%) with a mean age of 57 years. The number of subjects with long sleep duration, more than 8 h, was significantly greater in the ICH group than in the control group (≥8 h, 30.4% vs. 22.6%, P = 0.002). Compared to 7 h, long sleep duration participants tended to be older, be more hypertensive, and be more likely to have blue collar jobs, lower education levels, and poorer marital status (i.e., unmarried or divorced/separated). After controlling for confounding factors, we found that longer sleep duration was independently associated with the risk of ICH in a dose-response manner (8 h: Odds ratio, 1.44; confidence interval, 1.01-2.07; ≥9 h: Odds ratio, 2.60; confidence interval, 1.50–4.49).

Conclusions: In conclusion, our study suggested that long sleep duration is positively related to ICH risk in a dose-dependent manner. In this context, our data might suggest that sleep duration is a modifiable risk factor for ICH.

Abstract TP17: Uric Acid Consumption in the Patients Receiving Intraarterial Thrombectomy

Background: Previous clinical studies indicated that serum uric acid (UA) level was correlated with better neurologic outcome, and UA might work as an antioxidant against reactive oxygen species, especially in ischemic-reperfusion injury.

Hypothesis: If UA has a neuroprotective function against ischemic-reperfusion injury, serum UA will be recruited and the level will be lowered during the period of acute ischemic stroke after intra-arterial (IA) thrombectomy.

Methods: Among a total of 251 patients who received IA thrombectomy in our hospital from 2005 March to 2015 Aug, we selected the study population according to the following inclusion criteria (N=140): (1) UA level measured within one week after IA thrombectomy; (2) Thrombolysis in Cerebral Infarction perfusion grade (TICI)>0; (3) no recurrence or no severe morbidity or mortality during the acute period. Neurologic severity was assessed via National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS). The improvement of outcome during admission is assessed via the difference between discharge and admission NIHSS (dNIHSS) scores, and mRS (dmRS) scores. UA consumption ratio was calculated as [(log value of initial serum UA level)- (follow up UA level within 1 week)] / (log value of initial serum UA level).

Results: UA consumption ratio was significantly correlated with discharge mRS in linear regression analysis (R 2 =0.122, p <0.001). In terms of outcome improvement, UA consumption ratio was also correlated with dmRS (R 2 =0.033, p =0.03), and dNIHSS (R 2 =0.08, p =0.0005). When we classified the UA consumption ratio as quintiles, mRS scores at discharge were lower in the highest quintile (OR=0.26, p =0.002), and in the second highest quintile (OR=0.33, p =0.01), than in the lowest quintile. In addition, calculated vessel occlusion time (from admission to hospital and completion of recanalization) was positively correlated with UA consumption ratio(R 2 =0.05, p =0.04) in patients with outcome improvement (dmRS>0).

Conclusions: In summary, this study showed that UA consumption was associated with better neurologic outcome and also with the vessel occlusion time. These results suggest that serum UA might be used as an endogenous neuroprotective source against ischemia-reperfusion injury.

Abstract TP196: Nocturnal Desaturation is a Possible Risk Factor for Wake-up Ischemic Strokes

Introduction: Wake-up stroke (WUS) may represent a specific subgroup and comprise of a quarter of all ischemic strokes. Nocturnal desaturation secondary due to sleep apnea is an independent risk factor for stroke, however, the association between nocturnal desaturation and WUS remains unclear.

Hypothesis: We assessed the relationship between the overnight oxygen desaturation index (ODI) and WUS in patients with acute stroke in the stroke unit.

Methods: A consecutive 225 patients with acute ischemic stroke who were admitted to the stroke unit within 7 days after stroke onset between July 2013 and June 2014 were included for analysis. Physiological variables including pulse oximetry were sampled every 1 minute. The ODI was calculated using pulse oximetry data during 9 hours on the first night (10:00 PM-7:00 AM) of the stroke unit admission and nocturnal oxygen desaturation was defined as an ODI of 5 or greater per hour. We compared the clinical characteristics, nocturnal oxygen desaturation, laboratory findings, and radiologic findings in patients with and without WUS.

Results: Among the total patients, 26.2% (n=59) patients had WUS. These patients were mostly male (52.4%), with a mean age of 66.8 years. The proportion of nocturnal desaturation was significantly greater in WUS compared to non-WUS (23.7% vs. 8.4%, P = 0.002). The age, gender, vascular risk factors, stroke severity, and stroke lesion locations were similar in the two groups (WUS and non-WUS). After controlling for relevant confounding factors, nocturnal oxygen desaturation in the first night of the stroke unit stay was significantly more common in patients with WUS (Odds ratio, 4.39; 95% confidence interval, 1.76-10.93).

Conclusions: Nocturnal desaturation was more frequently observed in patients with WUS over the first night stay in the stroke unit. This suggests that nocturnal desaturation is a possible and modifiable risk factor for the occurrence of WUS.

Abstract TP6: Prediction of Clot Fragility and Recanalization Outcome Using Susceptibility Vessel Sign on Susceptibility Weighted Image

Introduction: Susceptibility vessel sign (SVS) on T2*-weighted imaging (T2*WI) is associated with a high proportion of RBCs. Susceptibility weighted imaging (SWI) is more sensitive to visualize SVS than T2*WI, resulting both RBC- and platelet-rich thrombi detectable. Clot composition and burden impact the success of recanalization therapy, but how SVS influences the likelihood of recanalization is still debated.

Hypothesis: We assessed the hypothesis that increased conspicuity of SWI-SVS reflects high proportion of RBCs and subsequent recanalization by endovascular treatment.

Methods: From total of 143 ischemic stroke patients who was performed endovascular treatment between February 2010 and June 2015, the authors collected eligible cases with the following inclusion criteria; (1) SWI performed before endovascular treatment (N=123); (2) intracranial portion of ICA, MCA, and ACA occlusion (N=93). We excluded 4 cases with SWI of poor quality and analyzed 89 cases. Clinical information including stroke subtype, use of rt-PA, and time from puncture to recanalization was analyzed. All MR images and angiographies were analyzed for the presence, location, diameter, length, and volume (diameter*length) of SWI-SVS, and TICI grade.

Results: Female was 47.2% (n=42) and mean age was 68.4±13.2. SWI-SVS was identified in 77.5% (n=69) of patients. SWI-SVS was more commonly associated with cardioembolism (CE; 49 of 57, 86.0%) than with other stroke subtypes (20 of 32, 62.5%; P =0.011). SVS length (11.20±7.96 vs. 6.90±7.03 mm; P =0.013) and diameter (4.72±2.53 vs. 2.48±2.21 mm; P <0.001) were longer in CE group than the other. SVS diameter was longer in recanalization group (TICI≥2b) than in non-recanalization group (4.21±2.63 vs. 2.82±2.42 mm; P =0.040). Multivariate analysis showed that SVS diameter and volume were independent predictors of CE and recanalization, respectively (OR, 1.67 and 1.02; 95% CI, 1.15-2.41 and 1.00-1.04; P =0.007 and 0.005).

Conclusions: Diameter and volume of SWI-SVS can predict cardioembolic stroke and recanalization, respectively. It may be useful for choosing the optimal treatment based on clot composition.

Creatine kinase isoenzyme activity during and after an ultra-distance (200 km) run

It is commonly assumed that creatine kinase (CK) activity in plasma is related to the state of an inflammatory response at 24-48 h, and also it has shown biphasic patterns after a marathon run. No information is available on CK isoenzymes after an ultra-marathon run. The purpose of the present study is to examine the CK isoenzymes after a 200 km ultra-marathon run and during the subsequent recovery. Blood samples were obtained during registration 1 2 h before the 200-km race and during the race at 100 km, 150 km and at the end of 200 km, as well as after a 24 h period of recovery. Thirty-two male ultra-distance runners participated in the study. Serum CPK showed a marked increase throughout the race and 24 h recovery period (p < 0.001). Serum CK during the race occurs mostly in the CK-MM isoform and only minutely in the CK-MB isoform and is unchanged in the CK-BB isoform. High-sensitivity C-reactive protein (hs-CRP), oestradiol, AST and ALT increased significantly from the pre-race value at 100 km and a further increase took place by the end of the 200 km run. The results of our study demonstrate a different release pattern of creatine kinase after an ultra-distance (200 km) run compared to the studies of marathon running and intense eccentric exercise, and changes in several biomarkers, indicative of muscle damage during the race, were much more pronounced during the latter half (100–200 km) of the race. However, the increases in plasma concentration of muscle enzymes may reflect not only structural damage, but also their rate of clearance.

Anti-inflammatory effects of fimasartan via Akt, ERK, and NFκB pathways on astrocytes stimulated by hemolysate

OBJECTIVE

The aim of this study was to investigate whether fimasartan, a novel angiotensin II receptor blocker, modulates hemolysate-induced inflammation in astrocytes.

METHODS

We stimulated astrocytes with hemolysate to induce hemorrhagic inflammation in vitro. Astrocytes were pretreated with fimasartan and then incubated with hemolysate at different durations. Anti-inflammatory cell signaling molecules including Akt, extracellular signal regulated kinase (ERK), NFκB and cyclooxygenase-2 (COX-2) were assessed by western blotting. Pro-inflammatory mediators were evaluated by real-time RT-PCR and ELISA.

RESULTS

The stimulation by hemolysate generated a robust activation of inflammatory signaling pathways in astrocytes. Hemolysate increased the phosphorylation of Akt at 1 h, and ERK1/2 at 20 min compared with the control group and promoted the degradation of IκBα. Pretreated fimasartan significantly decreased hemolysate-induced phosphorylation of Akt and ERK1/2. In addition, fimasartan also suppressed NFκB-related inflammatory pathways induced by hemolysate, including reduction of the gene expression of NFκB, and decreased nuclear translocation of NFκB and degradation of IκB. This reduction of inflammatory upstream pathways decreased the expression of inflammatory end-products: COX-2 and interleukin-1 (IL-1β). Furthermore, the expression of COX-2 was attenuated by both Akt inhibitor (LY294002) and ERK inhibitor (U0126), and IκBα degradation was suppressed by LY294002.

CONCLUSIONS

These results demonstrate that pretreatment with fimasartan to astrocytes suppresses the inflammatory responses induced by hemolysate. Akt, ERK and NFκB were associated with hemolysate-induced COX-2 and IL-1β expression. Based on these mechanisms, fimasartan could be a candidate anti-inflammatory regulator for the treatment of intracerebral hemorrhage.

Assessment of early therapeutic response to sorafenib in renal cell carcinoma xenografts by dynamic contrast-enhanced and diffusion-weighted MR imaging

OBJECTIVE

To investigate the feasibility of dynamic contrast-enhanced MRI (DCE-MRI) and diffusion-weighted MRI (DWI) in monitoring early therapeutic response to sorafenib in renal cell carcinoma (RCC) xenograft models.

METHODS

Sorafenib (40 mg kg(-1)) was administered orally to BALB/c nude mice (n = 9) bearing subcutaneous tumours of human RCC ACHN xenografts. DCE-MRI and DWI were obtained 0, 1, 3 and 7 days after therapy, and DCE-MRI parameters (K(trans) and ve) and apparent diffusion coefficient (ADC) values were calculated. Tumour size and volume changes were correlated with changes in DCE-MRI parameters or ADC values after therapy.

RESULTS

Following therapy, K(trans) showed a significant decrease over time (p = 0.005), whereas ve did not demonstrate significant changes between time points (p = 0.97). ADC values showed a progressive increase over time (p = 0.004). Compared with pre-therapy, K(trans) showed a significant decrease after 3 days of therapy (p = 0.039), and ADC values increased significantly after 7 days (p = 0.039). Tumour size and volume did not show significant changes during 7 days. Tumour size and volume changes were not associated with changes in DCE-MRI parameters or ADC values.

CONCLUSION

DCE-MRI and DWI may show early physiological changes within 1 week after initiating sorafenib treatment on human RCC xenografts.

ADVANCES IN KNOWLEDGE

The quantitative parameters of DCE-MRI and DWI may offer the potential for assessing early therapeutic response to sorafenib in clinical trials.

Obesity-stroke paradox and initial neurological severity

BACKGROUND AND PURPOSE

An obesity paradox in patients with stroke has been documented. However, although the initial neurological severity (INS) is generally the most important prognostic factor, the impact of this paradox has not been considered in most previous studies. We sought to investigate the impact of obesity on INS in patients with ischaemic stroke and to investigate whether it is a significant risk factor for short-term outcomes.

METHODS

A total of 2670 patients from Seoul National University Hospital with ischaemic stroke were enrolled from October 2002 to May 2013. Baseline information, including body mass index (BMI) and INS, was collected at admission. Associations between obesity and INS were analysed. In addition, we evaluated the effect of BMI on modified Rankin Scale (mRS) 3 months after stroke onset.

RESULTS

Among the 2670 patients, patients whose BMI levels were higher than the chosen reference level had reduced risks of moderate to severe INS (Q2: OR, 0.65; 95% CI 0.49 to 0.87; Q3: OR, 0.48; 95% CI 0.35 to 0.65; Q4: OR, 0.39; 95% CI 0.28 to 0.54; and Q5: 0.31; 95% CI 0.22 to 0.44). In addition, of the 703 patients with available 3-month mRS patients with higher BMI levels seem to have had more favourable outcomes. Such associations disappeared after adjusting for INS.

CONCLUSIONS

In our study, although obesity was associated with better short-term functional outcomes, INS might be a more important prognostic factor. Therefore, initial status should also be considered when considering an 'obesity paradox' in chronic diseases.

Prognostic importance of weight change on short-term functional outcome in acute ischemic stroke

BACKGROUND

Controversy exists regarding the question of whether weight change decreases or increases the risk of mortality.

AIM

The aim of this study was to evaluate the prognostic importance of weight change on short-term outcomes in acute ischemic stroke patients.

METHODS

A total of 654 patients with acute ischemic stroke were enrolled in this study from March 2010 to May 2013. We assessed the weight change of each participant between admission and discharge from the Department of Neurology. Weight change was defined as change ≥0·05 kg/baseline body mass index unit. We evaluated the short-term outcomes using a modified Rankin Scale at three-months after the onset of a stroke.

RESULTS

Among the 654 patients, 35·2% were included in the weight-change group. Weight loss occurred in 24·6% of the participants during the hospital stay following the stroke, which lasted an average of nine-days. Compared with the weight-stable group, the pronounced weight-loss group had a higher risk of unfavorable outcomes (odds ratio 2·43; 95% confidence interval 1·12-5·25).

CONCLUSIONS

Short-term weight loss after stroke appears to be more common than we expected, and our results suggest that it is associated with unfavorable functional outcomes. Therefore, clinical nutrition should be considered as a component of medical treatment and weight loss should be monitored as an indicator of malnutrition.

A Novel Computerized Clinical Decision Support System for Treating Thrombolysis in Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Thrombolysis is underused in acute ischemic stroke, mainly due to the reluctance of physicians to treat thrombolysis patients. However, a computerized clinical decision support system can help physicians to develop individualized stroke treatments.

METHODS

A consecutive series of 958 patients, hospitalized within 12 hours of ischemic stroke onset from a representative clinical center in Korea, was used to establish a prognostic model. Multivariable logistic regression was used to develop the model for global and safety outcomes. An external validation of developed model was performed using 954 patients data obtained from 5 university hospitals or regional stroke centers.

RESULTS

Final global outcome predictors were age; previous modified Rankin scale score; initial National Institutes of Health Stroke Scale (NIHSS) score; previous stroke; diabetes; prior use of antiplatelet treatment, antihypertensive drugs, and statins; lacunae; thrombolysis; onset to treatment time; and systolic blood pressure. Final safety outcome predictors were age, initial NIHSS score, thrombolysis, onset to treatment time, systolic blood pressure, and glucose level. The discriminative ability of the prognostic model showed a C-statistic of 0.89 and 0.84 for the global and safety outcomes, respectively. Internal and external validation showed similar C-statistic results. After updating the model, calibration slopes were corrected from 0.68 to 1.0 and from 0.96 to 1.0 for the global and safety outcome models, respectively.

CONCLUSIONS

A novel computerized outcome prediction model for thrombolysis after ischemic stroke was developed using large amounts of clinical information. After external validation and updating, the model's performance was deemed clinically satisfactory.

Abstract T MP42: Mitral Ratio of Peak Early to Late Diastolic Filling Velocity as a Predictor of Mortality in Acute Ischemic Stroke

Background: Diastolic dysfunction has a significant impact on symptoms, functional outcomes, and prognosis in ischemic stroke patients. The ratio of peak early to late diastolic filling velocity (E/A) is the simplest and most commonly used index to assess diastolic dysfunction.

Methods: One thousand seven hundred seven patients with acute ischemic stroke who had a transthoracic echocardiogram during admission were identified. We classified patients into 3 groups by E/A ratios based on the previous literature search. We conducted binary logistic regression analysis for death, vascular death, and stroke death.

Results: Among a total of 1707 patients, 261 (15.3%) had E/A <0.6 and 124 (7.3%) had E/A>1.5. All cause death was higher with E/A <0.6 or E/A >1.5 compared to E/A 0.6-1.5 (25.7% and 16.9% versus 15.1%), as was vascular death (10.2% and 8.5% versus 5.8%). After adjusting for age, gender, previous stroke history, hypertension, diabetes, smoking, dyslipidemia, atrial fibrillation, stroke subtype, left ventricular end-diastolic diameter, LA/Ao ratio, mitral E deceleration time, relative wall motion abnormality, and initial stroke severities, the relative risk of all-cause death with E/A >1.5 was 2.24 (95% CI, 1.14-4.33; p= 0.02); the relative risk of vascular death with E/A>1.5 was 3.50 (95% CI, 1.39-8.80; p<0.01 ); the relative risk of stroke death with E/A >1.5 was 3.42 (95% CI, 1.21-9.69; p=0.02 ).

Conclusion: The E/A>1.5 is associated with 2-fold increased all-cause mortality and 3-fold vascular and stroke mortalities independent of covariates in ischemic stroke patients.