bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP42: Reducing 30-day Stroke Readmissions Using a Multi-Step Quality Improvement Approach
Authors: Harmon Melissa , Souza Stephanie , Paolucci Gino , Grilli Anais , Khan Farhan , Perelstein Elizabeth , Burton Tina , Furie Karen L , Yaghi Shadi
Published: February 2024

Background:
Thirty-day all-cause readmissions occur in about 12% of acute ischemic stroke (AIS) patients, are associated with a 4-fold increase in mortality, and are associated with increased cost utilization. Therefore, reducing 30-day readmissions in AIS patients is of paramount importance. In this study, we aimed to test the effect of a multi-step quality improvement (QI) initiative on readmission rates in hospitalized AIS patients.

Methods:
We included all patients discharged from a Comprehensive Stroke Center with a diagnosis of AIS or TIA over a 3-year period. The pre-intervention period was 1/1/2020 - 9/30/2021. The approach was instituted on 10/1/2021. After a 3-month washout, the post-intervention period was 1/1/2022 - 6/30/2023. Intervention measures are below.1. An inpatient checklist was instituted to help providers identify and address common problems before AIS/TIA patients were discharged.2. Complex patients discharged home would receive a call shortly after discharge to ensure good understanding of their care and next steps. Such patients were also scheduled to follow up in a rapid access clinic within 2 weeks of discharge.3. Complex patients discharged to a facility required a handoff call to the facility’s accepting provider.4. All readmissions were reviewed in our monthly QI meeting, with efforts to identify preventable causes.We used t-tests to compare mean observed to expected (O:E) length of stay and mortality metrics between the pre- and post-intervention periods. We used Chi Square tests to compare overall readmission rates.

Results:
Over the study period, 2532 patients were discharged with a principal diagnosis of AIS or TIA, and the all-cause 30-day readmission rate was 8.8% (223/2532). Compared to pre-intervention, the post-intervention period had a lower 30-day readmission rate (7.6% vs. 10.2%, p = 0.023), a non-significantly lower mean O:E mortality rate (0.71 vs. 0.82, p = 0.252), and a non-significantly lower mean O:E hospital length of stay (0.92 vs. 0.88, p = 0.13).

Conclusion:
At a Comprehensive Stroke Center, a multi-step approach for transitions of care was associated with reduced all-cause readmission rates without increasing hospital length of stay or mortality. Our findings require external validation.
Abstract TMP57: User Engagement is Associated With Clinical Impacts of Automated LVO Detection Software
Authors: Azeem Hussain , Kim Hyun Woo , Ballekere Anjan Nagesh , Ali Iman , Salazar-Marioni Sergio , Abdelkhaleq Rania , Le Ngoc Mai , Niktabe Arash , Iyyangar Ananya , Segev Omri , bibas orin , Paz Dan , J. Love Christopher , Giancardo Luca , Sheth Sunil
Published: February 2024

Introduction:
Machine learning (ML)-based acute ischemic stroke (AIS) large vessel occlusion (LVO) detection algorithms can reduce door to groin time (DTG). Here, we examine whether the dependency of these benefits on end user engagement and interaction.

Methods:
This analysis was conducted as a pre-planned
post hoc
analysis of our multicenter, prospective randomized clinical trial (NCT05838456). ML-based LVO detection software was implemented at 4 comprehensive stroke centers in the greater Houston area in a stepped fashion between Jan 2021 and March 2022. Patients were included in this analysis if they underwent EVT for LVO AIS. Exclusion criteria included inter-hospital transfers or inpatient stroke alerts. ML-software utilization was quantified as the number of software interactions including imaging viewing and/or HIPAA-compliant text messaging and was trichotomized at the hospital level into low/medium/high. Primary outcome was the reduction in DTG relation to pre-ML implementation by hospital utilization level. Secondary outcomes included CT to groin puncture time, and sensitivity analyses in subsets of patients who did and did not have an LVO alert sent.

Results:
Among 243 patients that met inclusion criteria, median age was 70 (IQR 58-79), 50% were female and median NIHSS was 17 (IQR 11-22). There were 2 high-utilization centers interacting with the ML software mean 160 times, one medium center that interacted 64 times and one low center interacting 42 times during the study period. We observed a reduction on DTG of 11 minutes in the high-interaction center (p<0.01) but no significant reduction in DTG in the medium or low-interaction centers. Similarly, time from CT scan initiation to groin puncture fell in the high-utilization centers by 32 minutes (p<0.05) but no significant change in others. Without adjusting for hospital-level software utilization, there was no statistically significant reduction in DTG for patients analyzed by the ML software versus those that were not (p=0.35).

Conclusion:
The benefit of ML-enhanced LVO AIS workflows are dependent on user engagement.
Abstract TMP59: Automated Analysis of Dynamic Computed Tomographic Angiography Perfusion Maps Accurately Identifies Regional Hypoperfusion in Minor Stroke Patients
Authors: Tadros George S , Sheronick Raneem , McDougall Connor C , Barber Philip A
Published: February 2024

Background:
Multi-phase computed tomographic angiography (mCTA) perfusion maps can help confirm the diagnosis of stroke which can be especially challenging when the symptoms are minor. The current study proposes an automated stroke detection method for identifying patient stroke status based on volumetric analysis of mCTA perfusion maps applied to minor stroke patient populations.

Methods:
Minor stroke patients were acutely imaged with mCTA and CTP. mCTA perfusion maps were created using an extreme gradient boosting trees classifier with a CTP TMAX>6s ground truth. Volumes for each patient for each hemisphere were calculated from ten perfusion thresholds equally spaced from the minimum and maximum of the scaled perfusion map. The ten volumes form the variables in a logistic regression algorithm trained on the known stroke status of the hemisphere. 10-fold cross validation was implemented in addition to receiver-operating characteristic (ROC) analysis to produce accuracy, sensitivity, specificity, and area-under-curve (AUC).

Results:
In total 82 minor stroke patients (median age: 71, 48% female, median NIHSS: 3). 78% had identifiable intracranial occlusions. The analysis generated an ROC curve with an AUC of 81%. Cross-validation produced accuracy, specificity, and sensitivity of 76%, 87%, and 65%, respectively.

Conclusion:
The stroke detection model developed in the current study accurately categorized stroke and healthy hemispheres in minor stroke. Based on these results dynamic CTA perfusion could help diagnose stroke when the symptoms are mild thus providing accessible and accurate stroke diagnosis in primary stroke centres.
Abstract TMP62: The Delayed Seizure CVT Score Predicts Delayed Seizure After Cerebral Venous Thrombosis - A Secondary Analysis of ACTION-CVT
Authors: Stretz Christoph , Shu Liqi , Kala Narendra S , El JAMAL SLEIMAN , Heldner Mirjam , Bakradze Ekaterina , Sharma Richa , Zubair Adeel , Henninger Nils , Rothstein Aaron , Salehi Omran Setareh , Klein Piers , Nguyen Thanh , Kuohn Lindsey , Frontera Jennifer , Kerrigan Deborah , Al Kasab Sami , Aziz Yasmin , Wu Teddy , Siegler James E , Asad Syed Daniyal , Furie Karen L , Yaghi Shadi
Published: February 2024

Introduction:
Seizures are a common initial manifestation of cerebral venous thrombosis (CVT). We sought to establish predictive factors for delayed seizures to stratify risk and guide clinical management.

Methods:
We analyzed data from the Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT) study of consecutive patients with CVT from 2015 - 2020. The primary outcome was delayed seizure(s), occurring after 7 days from CVT diagnosis. Patients with outcome data for late seizures and follow-up of at least 7 days from time of diagnosis were included. Univariate analysis was performed using Chi-square, rank-sum, and t-tests. Variables with P-value < 0.2 were included in the backward stepwise regression model with 0.2 as cutoff, based on which we constructed the Delayed Seizure CVT (Delayed Seizures after CVT) score.

Results:
We identified 599 patients who met inclusion criteria: mean age 44.9(± 16.6) years, 62.9% female. Delayed seizures occurred in 37 (6.1%) patients. Risk factors included intracranial hemorrhage (OR 2.0 95% CI 0.7-5.74 p=0.196), alcohol abuse (OR 3.88 95% CI 1.45-10.38 p=0.007), focal neurologic deficit (OR 2.05 95% CI 0.95-4.44 p=0.067), seizure on presentation (OR 2.88 95% CI 1.32-6.29 p=0.008), hormonal birth control (OR 2.38 95% CI 1.06-5.37 p=0.0036), endovascular therapy (OR 2.86 95% CI 1.16-7.07 p=0.023) and decompressive hemicraniectomy (OR 3.357 95% CI 1.02-10.99 p=0.046), respectively. Based on coefficients of these variables, a 7-item score was created with acceptable performance for seizure prediction (AUC 0.796, 95% CI 0.72 - 0.86) (Table 1).

Conclusions:
Delayed seizure CVT score is a clinical tool to identify risk of delayed seizure in CVT. Further research is needed to validate these findings in an external cohort.
Abstract TMP63: Blood Pressure (BP) Protocol Violations in IV Tenecteplase Treated Ischemic Stroke Patients is Associated With Early Neurologic Deterioration and Symptomatic Intracranial Hemorrhage
Authors: Frenchman Jacob A , Aldridge Chad , Johnston Karen C , Bhole Rohini
Published: February 2024

Background:
The American Heart Association guidelines recommend BP goal of <180/105 mmHg for the first 24 hours in acute ischemic stroke (AIS) patients treated with IV Alteplase and now adopted for IV Tenecteplase (TNK). Studies suggest increased hemorrhage risk in patients with BP ≥170 mmHg and greater BP variability.

Methods:
We performed a retrospective study with data from the Get with The Guidelines database and electronic medical record of all adult AIS patients treated with TNK at a Comprehensive Stroke Center from 6/2021 to 6/2023. All BP readings from ED arrival to 24 hours post TNK were queried. We analyzed the temporal trends of BP characteristics and their association with early neurological deterioration (END) and symptomatic intracranial hemorrhage (sICH). The BP characteristics included mean and standard deviation of systolic (SBP) and diastolic (DBP) measurements, intra-patient BP variability and frequency of excessive BP (SBP > 180 mmHg and DBP > 105 mmHg) at each time point.

Results:
There were 132 TNK treated patients: mean age 68 ± 15 years, 54% male, 73% Caucasian, median admission NIHSS 9, IQR 4-15, 42 (32%) underwent mechanical thrombectomy, 72 (54.5%) treated with IV antihypertensive(s). Of these, 6 (4.5%) developed END and another 6 (4.5%) sICH. Of the 5901 BP measurements, 217 (3.7%) and 99 (1.7%) exceeded systolic of >180 mmHg and diastolic of >105 mmHg respectively. All END and sICH patients had excessive BP within 4 hours post TNK (Figure 1) and during this time there was a strong association of END with excessive SBP (14% vs 4.8%; p=0.05) and DBP (14% vs 1.2%; p < 0.001). sICH had a similar but weaker association: excessive SBP (7.7% vs 4.9%; p=0.3) and excessive DBP (3.8% vs 1.4%; p=0.2).

Conclusion:
Our findings suggest that excessive BPs within 4 hours of TNK may be associated with patients developing END and sICH. Further exploration of moderate BP parameters deserve further study post thrombolysis, like the BEST II study in post thrombectomy patients.
Abstract TMP69: Impaired Cognitive Function and Cerebral Hemodynamics Associated With
APOE4
in Asymptomatic Carotid Artery Stenosis/Occlusion
Authors: Kakino Yoshinori , Hattori Yorito , Iida Hidehiro , Ihara Masafumi
Published: February 2024

Introduction:
Cerebral hypoperfusion even in asymptomatic CASO may cause cognitive impairment. We reported
APOE4
induces neurovascular dysfunction and cognitive impairment in a mouse model of CASO. However, it has not been clinically investigated in patients with asymptomatic CASO.

Methods:
A cross-sectional observational study was conducted between January 2017 and March 2022. In a primary analysis, 91 patients with asymptomatic moderate or severe CASO who underwent cognitive tests, including the Alzheimer’s Disease Assessment Scale-Cognitive Subscale 13 (ADAS-Cog), and
15
O-gas positron-emission tomography (PET) were included to examine associations of cognitive impairment and cerebral hemodynamic disruption with
APOE4
. To investigate hemodynamic disruption, a sensitivity analysis in 70 additional patients who underwent only
15
O-gas PET was performed.

Results:
Among the 91 patients with asymptomatic moderate or severe CASO, 20 (22.0%) were
APOE4
carriers. In a multivariable linear regression analysis,
APOE4
was an independent risk factor for a worse ADAS-Cog delayed word recall score, indicating short-term memory impairment (β = 0.21, 95% confidence interval (CI) 0.026–2.30,
p
= 0.045). The
15
O-gas PET showed that
APOE4
was an independent risk factor for lower cerebral blood flow (CBF) in the anterior circulation territory (β = –0.31, 95%CI –0.091 to –0.015,
p
= 0.007), without changes in cerebral metabolic rate of oxygen (CMRO
2
) or oxygen extraction fraction. Of 161 patients in the sensitivity analysis, 31 (19.3%) carried
APOE4
, which was an independent predictor of lower CBF (β = –0.23, 95%CI –0.072 to –0.014,
p
= 0.004) in the anterior circulation territory.

Conclusions:
APOE4
may confer an increased risk of memory impairment accompanied by cerebral hemodynamic disruption in asymptomatic CASO. The present study indicated that identifying
APOE4
in such patients may be useful in early detection of disease severity.
Abstract TMP74: Association Between Hematoma Volume After Risk of Subsequent Ischemic Stroke: A MISTIE III and ATACH-2 Analysis
Authors: Harris William , Kaiser Jed , Avadhani Radhika , Iadecola Costantino , Sheth Kevin N , Awad Issam , Goldstein Joshua N , Qureshi Adnan I , Hanley Daniel F , Kamel Hooman , Ziai Wendy C , Murthy Santosh B
Published: February 2024

Background:
Non-traumatic intracerebral hemorrhage (ICH) is independently associated with long-term increased risk of major arterial ischemic events. Whether hematoma volume influences this risk is poorly understood.

Methods:
We pooled individual patient data from the MISTIE III (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3) and the ATACH-2 (Antihypertensive Treatment of Acute Cerebral Hemorrhage) trials. The exposure was hematoma volume. In the primary analysis, hematoma volume was treated as a continuous measure after natural logarithmic transformation to approximate linearity, and in the secondary analysis, it was dichotomized by the median. The outcome was an ischemic stroke, adjudicated centrally within each trial. We evaluated the association between hematoma volume and the risk of an ischemic stroke using Cox regression analyses after adjustment for demographics, vascular comorbidities, and ICH characteristics.

Results:
Of 1,499 ICH patients, the mean age was 61.7 (SD, 12.8) years and 574 (38.3%) were female. The median hematoma volume was 17.3 mL (IQR, 7.2-35.7). During a median follow up of 107 days (IQR, 91-140), 30 ischemic strokes occurred of which 22 were in patients with median ICH volume
>
17.3 mL with a cumulative incidence of 4.6% (95% CI, 3.1-7.1). Among patients with median ICH volume < 17.3 mL, there were 8 ischemic strokes with a cumulative incidence of 3.1% (95% CI, 1.7-6.0). Using adjusted Cox regression models, log-transformed ICH volume (continuous measure) was associated with an increased risk of ischemic stroke (HR, 1.5 per log-unit increase; 95% CI, 1.1-2.8). Similarly, ICH volume
>
17.3 mL was associated with an increased risk of ischemic stroke (HR, 2.5; 95% CI, 1.1-7.2), compared to those with an ICH volume < 17.3 mL.

Conclusions:
In a heterogeneous cohort of ICH patients, initial hematoma volume was associated with a heightened risk of subsequent ischemic stroke.
Abstract TMP97: Temporal Trends in Black-White Differences of Antihypertensive Treatment in Individuals With and Without History of Stroke: Reasons for Geographic and Racial Differences in Stroke (REGARDS)
Authors: Stamm Brian , Royan Regina , Cui Jinhong , Long Leann , Lineback Christina , Akinyelure Oluwasegun P , Plante Timothy B , Levine Deborah A , Howard Virginia J , Howard George , Gorelick Philip B
Published: February 2024

Introduction:
In 2014, the Eighth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC8) included race-specific recommendations for antihypertensive treatments (e.g. calcium channel blockers [CCBs] for Black persons). The impact of these guidelines on anti-hypertensive regimen changes over time, and if this varied by prevalent stroke status, is unclear.

Methods:
REGARDS participants reporting anti-hypertensive medications with and without history of stroke who completed an in-home examination in 2003-2007 (Visit 1) or 2013-2016 (Visit 2) were included. Logistic regression mixed models estimated odds ratios (OR) and 95% confidence intervals (CI) for use of each antihypertensive class for Visit 2 vs. Visit 1 and Black vs. White with interaction by prevalent stroke status, adjusted for demographic and socioeconomic status.

Results:
Of 17,222 participants without prevalent stroke at Visit 1, Black participants had greater odds of ACE-inhibitor usage relative to White participants (OR 1.68, 95% CI 1.44-1.95). This difference remained but was smaller in 7,476 participants without stroke at Visit 2 (OR 1.29, CI 1.20-1.38). In participants without prevalent stroke, lower odds of CCB usage among Black compared to White participants was observed at Visit 1 (OR 0.47, CI 0.41-0.55) but there was no difference at Visit 2 (OR 1.00, CI 0.94-1.07). Among 1,436 participants with prevalent stroke at Visit 1, Black participants had lower odds of CCB use compared to White participants (OR 0.48, CI 0.29-0.82) but similar odds in 689 participants with prevalent stroke at Visit 2 (OR 1.15, CI 0.91-1.44).

Conclusions:
Consistent with JNC8 recommendations for first-line medication administration in Black persons with hypertension, there was a higher likelihood of CCB use over time among Black participants in REGARDS. Adherence to race-based guidance for antihypertensive medication may be increasing over time.
Abstract TP111: Attitudes and Perceptions Regarding Patient Engagement and Knowledge Translation in Stroke Research: Results From the PERSPECT Qualitative Study
Authors: Drozdowska Bogna A , Cristall Nora , Fladt Joachim , Tanaporn Jaroenngarmsamer , Sehgal Arshia , McDonough Rosalie V , Goyal Mayank , Ganesh Aravind
Published: February 2024

Background:
Patient engagement and knowledge translation are increasingly recognized as critical components of stroke research. However, it is unclear how these components are currently perceived by interested parties.

Methods:
The PERSPECT (Priorities and Expectations of Researchers, Donors, Patients, and the Public Regarding the Funding and Conduct of Stroke Research) qualitative study involved in-depth, semi-structured interviews with patients, members of the general public, researchers, and donors, including board members of funding organizations and philanthropists. Participants were asked to discuss their thoughts about the role of patient and public engagement in stroke research and on the translation/dissemination of research findings. Collected data were analyzed through constant comparison and theme identification, followed by grounded theory content analysis.

Results:
Forty-one interviews were completed (11 with researchers and 10 for each patients, public and donors). An important theme that emerged was a need to re-evaluate and broaden conventional definitions of “expertise” in the context of selecting grant application review panels, recognizing the value of lived experience alongside that of education and professional experience. Whereas participants identified an important role for patient voices in guiding research direction and design; concerns were raised about the limited public awareness and understanding of medical research, which may hinder meaningful, advantageous involvement in the research process, as well as trust in evidence-based recommendations. In this regard, lay participants highlighted media-driven misinformation and a lack of credible lay-language resources as impeding effective dissemination of research findings.

Conclusions:
All four participant groups recognized the importance of knowledge end-users being engaged in research from its early stages, including decision-making about funding allocation. Impactful involvement seems however hindered by knowledge and communication gaps between the research and lay communities. Our results underscore the importance of efforts to make ongoing research and study findings more visible, accessible, and comprehensible.
Abstract TP115: Stroke Metrics Reporting to Hospital Leadership Advances Thrombolysis and Thrombectomy Rates in a Competitive Region: Analysis of SETRAC Registry
Authors: Venkatasubba Chethan P , Farquhar Grace , Ramachandran Lintu ,   SETRAC Stroke Committee
Published: February 2024

Background:
The SouthEast Texas Regional Advisory Council (SETRAC) has actively engaged representatives from regional healthcare systems who collectively work towards advancing stroke care delivery. SETRAC has demonstrated its efficacy in improving thrombolysis rates in patients with acute ischemic stroke. We analyzed our regional data from 2014-2023 to evaluate the continued efficacy of acute stroke care.

Hypothesis:
We hypothesized that consistently and periodically reporting acute stoke metrics to the hospital leaders in a competitive environment improves acute stroke care as measured by: a) Percentage of patients receiving thrombolysisb) Time to receive thrombolysisc) Percentage of patients receiving thrombectomy

Methods:
We analyzed the stroke care metrics of our regional centers from the Get With The Guidelines (GWTG)®-Stroke registry. SETRAC stroke committee compiled and shared this data with the coordinators and hospital administrators on a quarterly basis. Blinded metrics were shared utilizing visual tools such as bar graphs. We performed linear analyses to evaluate the increase in the percentage of patients receiving thrombolysis, and those treated within 45 minutes.

Results:
31 hospitals reported treating a total of 93,688 patients from 2014-2023. The rates of thrombolysis increased from 7.10% in 2014 to 11.8% in 2023 (p<0.001). We also observed that the mean time to thrombolysis decreased from 66 minutes in 2014 to 48 minutes in 2023 (p-value <0.001). We also observed that the percentage of patients who received endovascular intervention significantly increased from 0.02% to 6.2% (p-value<0.001).

Conclusion:
In our community-facing approach, we demonstrated that engaging hospital leadership and utilizing structured GWTG metrics and consistent reporting resulted in higher proportions of patients receiving thrombolysis and thrombectomy.
Abstract TP118: Development and Integration of a Dedicated Neurorehabilitation Space Within a Hospital-Based Stroke Unit
Authors: Polly Megan , Johnson Allison , Thomas Angela , Reckner Katie
Published: February 2024

Background:
It is well documented that rehabilitation post-stroke is associated with better functional outcomes, however, in the United States access to post-acute care rehabilitation is becoming increasingly limited. The Office of the Inspector General recently reported that 13% of Medicare beneficiaries were denied access by some Medicare Advantage Organizations to medically necessary care, including admission to inpatient rehabilitation facilities (IRF). Further, the Centers for Medicare and Medicaid Services have initiated the Review Choice Demonstration (RCD) for IRF Services in several states which is anticipated to further reduce access to post-acute care rehabilitation. In response, when our institution began planning for a new neuroscience unit, the decision was made to build a dedicated neurorehabilitation space. The purpose of this project was to design a space that would increase patient access to high quality, intensive neurorehabilitation in the hospital setting.

Methods:
To maximize utilization and effectiveness of the space, the neurorehabilitation staff were involved in the design of the layout and the selection of appropriate equipment, and participated in several training sessions. One year after opening, the neurorehabilitation staff were surveyed about their access to necessary equipment, and their perception of the effects different features of the space had on the quality of their treatment sessions.

Results:
Of the 20 surveys completed, the percentage of staff who reported they had the necessary equipment increased from 35% to 100%, and 90% of the space’s features had a favorable effect on the quality of the treatment sessions. Additionally, 95% of staff reported that the overall time spent with each patient increased and overall job satisfaction improved from 60% to 85%.

Conclusion:
A dedicated rehabilitation space was developed to better meet the needs of the neurorehabilitation staff, and to improve patient access to neurorehabilitation in the hospital setting. Survey results suggested that job satisfaction and staff’s perception of therapy quality improved after opening the new space.
Abstract TP125: Retina and Optic Nerve Diffusion Restriction in Acute Central Retinal Artery Occlusion: A Case-Control Study
Authors: Harahsheh Ehab , Zhang Nan , Gomez Daneil R , Elshaigi Omer , Parikh Parth , Rath Tanya , Hoxworth Joseph , Dumitrascu Oana M
Published: February 2024

Objective:
To assess whether diffusion restriction (DR) of the retina and optic nerve (ON) can be accurately and reliably identified on standard stroke protocol brain magnetic resonance diffusion-weighted imaging (DWI-MRI) in patients presenting with acute non-arteritic central retinal artery occlusion (CRAO).

Background:
Retinal DR (RDR) and ONDR in patients with acute non-arteritic CRAO have been described with various diagnostic accuracies and often identified by experienced neuroradiologists with fair inter-rater agreement.

Methods:
This retrospective case-control study included patients that presented to our academic center from 2013-2021 with acute non-arteritic CRAO or acute cerebral ischemia (controls, age and gender-matched) and had brain MRI performed within 14 days from symptom onset. Two neuroradiologists, blinded to the site of CRAO and diagnosis, independently reviewed MRI of CRAO cases and controls to assess for the presence of RDR and ONDR. Their inter-rater agreement was calculated (prevalence and bias- adjusted kappa coefficient) and their final consensus was used to perform sensitivity and specificity analyses.

Results:
We included 128 patients with CRAO (mean age 69 years; 50% males; median time from CRAO to MRI 2 days (IQR 1-5)) and 128 matched controls with acute cerebral ischemia (mean age 68 years; 51% males). After neuroradiologists’ consensus, DR was correctly identified in the retina or ON in 51/128 (39.8%), retina alone 35/128 (27.3%), ON alone 31/128 (24.2%), both retina and ON 15/128 (11.7%), with excellent inter-rater agreement for retina (K=0.91) and ON (K=0.83). There were no cases of RDR or ONDR in the control group. After neuroradiologists’ consensus, sensitivity, specificity, PPV and NPV were 28.1%, 100%, 100%, and 58.2% for RDR and 27.3%, 100%, 100%, and 57.9% for ONDR.

Conclusion:
Though RDR and ONDR can be identified with excellent interrater reliability, they are infrequent findings and their role in diagnosing acute CRAO is unclear. Observational prospective studies with large cohort of patients, optimization of dedicated and standardized orbit DWI-MRI protocols, and education of neurology and neuroradiology providers are needed to facilitate more accurate identification of RDR and ONDR in hyperacute CRAO.
Abstract TP131: Computed Tomography Perfusion Imaging Patterns Are Similar Before and After Interfacility Transfer of Ischemic Stroke Patients
Authors: Oostema John A , Miller Malgorzata , Wideman Brian , Reeves Mathew J , Khan Nadeem I , Khan Muhib
Published: February 2024

Background:
Large vessel occlusion (LVO) stroke patients are often transferred from regional hospitals to comprehensive stroke centers (CSC) for thrombectomy. The need for repeat imaging at CSCs prior to intervention is unclear. We compared regional hospital and CSC perfusion imaging results for interfacility transfers in a single health system.

Methods:
We analyzed a cohort of patients in western Michigan who received CT perfusion imaging before and after transfer to a CSC. Perfusion mismatch (MM), core infarct volume (CIV), and favorability of imaging for mechanical thrombectomy (MT) candidacy were compared between the regional and CSC studies. A favorable imaging profile was defined as the presence of LVO, MM volume >10 mL, and MM/CIV ratio of >1.2. Linear regression was used to examine predictors of infarct growth during transfer.

Results:
Over a 10-month period, 25 patients met inclusion criteria. The median age was 76 (IQR 66-81), 60% were male, median NIHSS was 11 (IQR 2-18), and most patients had occlusion of the internal carotid or middle cerebral arteries (72%). The median time from last known well to initial CT was 250 minutes (IQR 85-620). Regional median MM volume was 52 mL (IQR 8-97), CIV was 0 mL (IQR 0-13), and hypoperfusion intensity ratio (HIR) was 0.25 (IQR 0-0.34). The median time between CTs was 152 minutes (IQR 139-226). The median change in MM volume was -3 mL (IQR -27-3) and median CIV growth rate was 0 mL/hr (IQR 0-2.0). In a multivariable regression model, higher HIR (β=23.2, p=0.012) and minutes between imaging studies (β=0.10, p=0.021) were associated with CIV growth. Sixteen patients (64%) had favorable imaging profiles for MT at the regional hospital. Of these, 15 (93.8%) continued to have a favorable CSC imaging profiles and 9 (56.2%) underwent MT. Of the 9 patients without favorable regional imaging profiles, 1 (11.1%) had a favorable CSC imaging profile and 2 (22.2%) underwent MT.

Conclusion:
In our sample, regional and CSC perfusion imaging patterns were similar and patients infrequently crossed thresholds for MT candidacy between studies. Initial HIR and longer delays between were independently associated with infarct growth during transfers, however overall infarct growth was very small.
Abstract TP133: Clot Burden Score Correlates Best With Hypoperfusion Volume and Predicts Final Infarct ASPECTS<=3 in Anterior Circulation Ischemic Strokes
Authors: Lin Sidney , Raince Avtar , Byrns Kory
Published: February 2024

Purpose:
Clot Burden Score (CBS) is a semiquantitative measure of thrombus extent on CTA for proximal anterior circulation strokes whose relationship with perfusion metrics has not been fully explored. CBS has potential added value during stroke triage if perfusion imaging is not available or suboptimal. We aimed to investigate if CBS is (1) correlated to perfusion estimates of infarct core volume, hypoperfusion volume, or collateral status, and (2) a predictor of final infarct extent without reperfusion therapy.

Methods:
Retrospective analysis included consecutive patients (1) arriving <24 hours from onset, (2) with occlusion in the intracranial ICA, M1, M2, or A1 or combination, (3) with concurrent CTP, and (4) had followup CT or DWI during hospitalization. CBS is a 10-point
negative
ordinal scale: 2-points subtracted for occlusion of supraclinoid ICA, proximal M1, or distal M1, and 1-point subtracted for occlusion of infraclinoid ICA, A1, or M2. Correlation of CBS with perfusion metrics was evaluated using Spearman's rank test. Final infarct ASPECTS were scored for those without thrombolysis or thrombectomy. Multivariate logistic regression was used to identify predictors of final ASPECTS<=3 (approximating >=100mL). ROC analysis was evaluated to assess performance and optimal thresholds.

Results:
222 patients included with median (IQR) age of 75 (65-84) and NIHSS of 18 (11-24). Median CBS was 7 (6-9) and best correlated to Tmax>6s r=-0.579 (hypoperfusion volume), followed by HIR r=-0.401 (collateral status) and rCBF<30% r=-0.306 (core volume), all p<0.001. 71 (32.0%) untreated patients also had median CBS of 7 (6-9). CBS and Tmax>6s had the strongest correlation to final ASPECTS in this subgroup, r=0.637 and r=-0.686 (both p<0.001). 22 of these (30.1%) had final ASPECTS<=3. Multivariate logistic regression including CBS, Tmax>6s, HIR, baseline ASPECTS, and NIHSS showed only CBS as independent predictor of final ASPECTS<=3 (p<0.001). ROC AUC for CBS was 0.902 [95% CI: 0.819-0.985] with optimal threshold of <=6 for sensitivity 86.4% and specificity 81.6%.

Conclusion:
CBS as a measure of thrombus extent correlates best with baseline hypoperfusion volume on CTP and independently predicts very large final infarcts (ASPECTS<=3) without treatment.
Abstract TP139: Revascularization Improves Vascular Hemodynamics in Pediatric Moyamoya Patients
Authors: Zhao Moss , Steinberg Gary , Moseley Michael E , TONG Elizabeth
Published: February 2024

Introduction:
Cerebrovascular reactivity (CVR) reflects the change in cerebral blood flow (CBF) in response to vasodilation. Studies have demonstrated that impaired CVR was associated with a higher risk of acute stroke in patients with intracranial vasculopathy and that bypass surgeries can reduce the risk of strokes. Moyamoya disease is a progress cerebrovascular disorder that begins during childhood. Arterial spin labeling (ASL) is a quantitative MRI technique for non-invasive CBF and CVR measurement; ASL with multiple delays can also measure arterial transit time (ATT). Here, we compare the CBF, CVR, and ATT in pediatric Moyamoya patients before and after bypass using multi-delay ASL.

Hypothesis:
CVR will increase significantly after bypass surgeries.

Methods:
Imaging data were acquired from 22 Moyamoya patients (11 months - 18 years, 14 females) using a 3T MRI system. All patients had unilateral or bilateral occlusion at ACA, MCA and/or PCA. Multi-delay ASL data (7 delays) were acquired at baseline and 15 minutes after acetazolamide administration. CBF and ATT were computed using the general kinetic model. CVR was computed as the percentage of CBF change compared with baseline CBF. Flow territories (right and left ACA, MCA, and PCA) were defined using the Harvard-Oxford atlases. Paired t-tests were conducted to compare the mean CVR, CBF, and ATT changes before and after bypass surgeries.

Results:
The figure shows the hemodynamic maps of an example patients. Overall, CVR and CBF in the affected regions increased after bypass; ATT in these regions decreased after bypass. For this cohort, our analysis showed that CVR of the affected regions increased significantly by 68% and ATT reduced significantly by 10.7% measured by multi-delay ASL, implying improved circulation and lower risk for strokes.

Discussion:
Multi-delay ASL was effective to detect improved CVR and reduced ATT in pediatric Moyamoya patients after bypass surgeries.
Abstract TP147: Assessment of Inter-Rater Reliability of Fazekas Scoring on Magnetic Resonance Imaging in Patients With Sickle Cell Disease
Authors: Haughey Aoife M , O'Cearbhaill Roisin M , Schaafsma Joanna D , Kuo Kevin H , Padilha Igor G , Forté Stéphanie
Published: February 2024

Background:
White matter disease is a common phenomenon in patients with sickle cell disease, that has been linked to cognitive impairment. However, there is no standardized approach for quantification of the cerebral disease burden. The Fazekas score is widely used to quantify the burden of white matter disease in chronic small vessel disease. However, its utility in sickle cell disease has not yet been established. We aimed to assess its, interrater reliability in this patient population.

Methods:
A patient cohort was compiled for the purpose of a research ethics board (REB) approved retrospective study of consecutive adult patients with sickle cell disease, each of whom underwent MRI/MRA between the year 2017 and 2019. All MRI/MRA studies were performed on 3-Tesla MRI. Two neuroradiologists independently assessed the axial FLAIR MRI brain sequence, for all patients, with the sole focus of assigning a Fazekas score (0-3) to each study, as a means of quantifying the burden of ischemic white matter lesions. The neuroradiologists were blinded to the scoring assigned by their counterpart and to the clinical information. Cohen’s weighted Kappa was used as a measure of agreement between readers.

Results:
Ninety patients with a median age of 31 and 45/90 (50%) women were included. The expected agreement was 74.65%, with an observed agreement of 94.44% between readers, with a weighted Kappa of 0.7808.

Conclusion:
On the basis of this study, there is good inter-rater reliability of Fazekas scoring on axial FLAIR MRI brain sequence in patients with sickle cell disease, even though the underlying pathophysiology of white matter lesions in this patient population might vary compared to individuals with chronic small vessel disease. The Fazekas is a promising measure that could easily be integrated in systematic evaluation of cerebrovascular lesions of adults with sickle cell disease.
Abstract TP152: Systolic Blood Pressure Variability Characteristics Increase With Severity Among Intracerebral Hemorrhage Patients
Authors: Potter Thomas B , Bako Abdulaziz , Pan Alan P , Borei Karim , Prince Taya , Khan Osman , Britz Gavin W , Vahidy Farhaan
Published: February 2024

Introduction:
Selected studies link high systolic blood pressure variability (SBPV) to poor patient outcome after intracerebral hemorrhage (ICH). SBPV levels during real-world ICH admission remain unknown, however. We profile SBPV across ICH patient characteristics.

Methods:
Clinical data for adult patients (≥18) with primary non-traumatic ICH were retrieved from the electronic medical records. Patient SBPV was calculated as the Coefficient of Variation (CV; CV = (Standard Deviation/Mean)*100) during the first 24 hours of admission and across whole hospitalization. Hemorrhage characteristics and cerebral small vessel disease burden (CSVD; STRIVE 2.0 criteria) were assessed from neuroimaging during admission. Severe CSVD was assessed at summary scores ≥3. Cerebral Amyloid Angiopathy (CAA) was graded via Modified Boston Criteria. Descriptive statistics are provided for SBPV during first 24 hours of admission and whole-stay. Population differences are assessed using Mann Whitney Rank Sum and Kruskal Wallis tests of hypothesis.

Results:
Patient cohort included 2,020 primary ICH patients (median age: 67, IQR: [55-77]; 45.2% female), with an ethno-racial distribution of 43.6% White, 23.3% Black, 22.5% Hispanic, 8.2% Asian, and 2.5% Other. Median hemorrhage volume was 12.1 [1.9-36.3] cm
3
; SBPVs over the first 24-hours and whole-stay were 12.6 [9.9-16.2] (Mean: 13.7; Skewness: 1.9; Kurtosis; 11.3) and 12.5 [10.7-15.0] (Mean: 13.4; Skewness: 3.05; Kurtosis; 21.3), respectively. SBPV significantly increased with female sex, worsening discharge disposition, increasing Glasgow Coma Scale severity, hemorrhage volume, intraventricular hemorrhage presence, and severe CSVD. Increasing CAA tiers showed reductions in SBPV. (Figure 1)

Discussion:
Levels of SBPV during ICH vary across patient characteristics and are elevated in those with more severe hemorrhage characteristics and worse hospital outcomes.
Abstract TP154: Association of Left Ventricular Hypertrophy With Ischemic Lesions After Intracerebral Hemorrhage
Authors: Ridha Mohamed , Simonetto Marialaura , Carvalho Poyraz Fernanda , Hess Evan , Kumar Aditya , Agarwal Sachin , Ghoshal Shivani , Claassen Jan , Connolly Edward , Park Soojin , Roh David
Published: February 2024

Background:
Ischemic lesions on diffusion weighted imaging (DWI) occur in one-third of intracerebral hemorrhage (ICH). Due to conflicting prior studies, it is uncertain if the degree of systolic blood pressure reduction increases the risk. Patients with severe, chronic hypertension may be more vulnerable to the development of ischemia after ICH due to altered cerebral autoregulatory limits. Using cardiac remodeling as a biomarker for severe chronic hypertension, we hypothesized that the presence of left ventricular hypertrophy (LVH) is associated with DWI lesions.

Methods:
Patients with spontaneous ICH enrolled in the Intracerebral Hemorrhage Outcomes Project who underwent DWI imaging and transthoracic echocardiography (TTE) during hospitalization were included. Lesions were identified as hyperintensities >10mm remote from the hematoma with corresponding low ADC signal. LVH presence was identified using clinically obtained TTE reports with imaging evidence of moderate-severe left ventricular wall thickness. The relationship between LVH and DWI ischemic lesions was assessed with logistic regression modeling after adjusting for age, ICH volume, intraventricular hemorrhage, hypertension history, and blood pressure change within 24 hours. A secondary analysis using linear regression assessed the association with the number of DWI lesions adjusting for similar covariates.

Results:
Of 187 patients analyzed, DWI lesions were observed in 30.5% and LVH was seen in 23.5%. In our logistic regression analyses, we identified that LVH was associated with DWI lesions (adjusted OR 2.77, CI: 1.19-6.40). Separate sensitivity analyses adjusting for sex (OR 2.47, CI 1.05-5.83) and race (OR 2.52, CI 1.08-5.91) did not change these relationships. In secondary analysis, we identified that LVH was associated with increased DWI lesion number (B 1.018, CI 0.40-1.63 ).

Discussion:
LVH is associated with the presence and burden of DWI lesions. Further work is required to assess aggregate relationships of chronic hypertension/LVH, acute blood pressure change, ischemic lesions, and ICH outcomes to determine whether patients with LVH necessitate different acute blood pressure treatment goals.
Abstract TP158: Baseline Viscoelastic Hemostatic Assays and Associations With Poor Long-Term Intracerebral Hemorrhage Outcomes
Authors: Sieh Laura , Peasley Emma , Mao Eric , Mitchell Amanda , Heinonen Gregory , Ghoshal Shivani , Agarwal Sachin , Park Soojin , Connolly Sander , Hod Eldad , Roh David
Published: February 2024

Introduction:
Viscoelastic hemostatic assays can detect coagulopathy relevant for intracerebral hemorrhage (ICH) patients at risk for hematoma expansion. However, it is unclear whether these assays associate with long term ICH outcomes. We sought to assess whether baseline coagulopathy detectable via viscoelastic hemostatic assay associates with poor 6-month neurological outcomes after ICH.

Methods:
Spontaneous ICH patients enrolled in a single-center prospective observational study from 2013 to 2020 who received baseline viscoelastic hemostatic assay testing via Rotational Thromboelastometry (ROTEM) were included. Patients with prior anticoagulant use were excluded. ROTEM assessments of coagulation kinetics and clot strength were the primary exposure variables. Poor 6-month neurological outcome was defined as modified Rankin Scale (mRS) 4-6. Multivariable logistic regression analyses assessed the relationships of ROTEM parameters with 6-month outcomes after adjusting for ICH score, hemoglobin, and sex.

Results:
Of 44 patients included for analysis, the mean age was 64, 57% were female, 52% had deep ICH, and the median ICH volume was 23.3 mL. Poor 6-month outcome was seen in 61%. We identified that slower coagulation kinetics was associated with poor 6-month outcome as assessed in both extrinsic and intrinsic pathways (EXTEM CFT: adjusted OR 1.06, 95% CI: 1.02-1.12, p=0.02; INTEM CFT: adjusted OR 1.05, 95% CI: 1.01-1.10, p=0.05, respectively). Weaker clot strength was also associated with poor 6-month outcome (EXTEM MCF: adjusted OR 0.78, 95% CI: 0.59-0.93, p=0.03; INTEM MCF: adjusted OR 0.83, 95% CI: 0.68-0.97). We did not identify similar relationships using conventional coagulation assays (ie., PT/PTT/INR, platelet count).

Conclusions:
We identified that baseline impaired coagulation kinetics and weaker clot strength seen using ROTEM testing associate with poor 6-month ICH outcomes. Further work is needed to clarify the generalizability of these findings and the mechanisms driving these relationships to assess whether viscoelastic guided therapies can potentially be used to improve long-term ICH outcomes.
Abstract TP16: Dental Caries Associated With Cerebral Small Vessel Disease
Authors: Martin Chylee , McCain Caylee , Moore Shawn , Wasserman Bruce A , Rosamond Wayne D , Moss Kevin , Beck James D , Sen Souvik
Published: February 2024

Background:
Dental caries is a chronic oral infection distinct from periodontal disease in that it is associated with both ischemic stroke and intracerebral hemorrhage (ICH). Few studies have investigated the relationship between dental caries and cerebral small vessel disease (CSVD). White matter hyperintensities (WMH) and cerebral microbleeds (CMB) are manifestations of CSVD.

Methods:
Using the Atherosclerosis Risk in Communities (ARIC) database, we extracted data from 1112 participants assessed for dental caries and vascular risk factors. Of those, 203 (18.3%) had caries and 909 (81.7%) did not. Brain imaging was performed on 3T scanners. WMH was imaged by T2 fluid-attenuated inversion recovery, with volumes derived by a semiautomated algorithm. Multinomial logistic regression to test the association between caries and WMH volume categorized into quartiles. Quartiles (Q) were defined as Q1: <6.4 cm
3
, Q2: 6.4 - <11.6 cm
3
, Q3: 11.6 - <21.4 cm
3
, Q4: ≥21.4 cm
3
. CMBs were graded using a T2* gradient echo. We used binary logistic regression to test the association between caries and CMB dichotomized as >5 or ≤5.

Results:
Participants with caries were more likely to be African American than white (54% vs. 46%, p<.001), more likely to have hypertension (41% vs. 26%, p<.001) and diabetes (15% vs. 9%, p=.005). There were no differences detected in age (61 + 5 with caries vs. 62 + 5 without caries, p=0.08), gender (54% female vs. 46% male, p=0.66), and smoking history (48% vs. 52%, p=0.71). Dental caries were associated with WMH volume quartiles: Q1 (reference), Q2 OR 1.43 (95% 0.95 to 2.16), Q3 OR 1.78 (1.16 to 2.72), Q4 OR 1.80 (1.17 to 2.77). These associations remained after adjusting for age, gender, race, hypertension, diabetes, and smoking: Q1 (reference), Q2 Adj. OR 1.52 (95% 0.96 to 2.41), Q3 Adj. OR 1.76 (1.11 to 2.78), Q4 Adj. OR 1.63 (1.03 to 2.60). Caries were also associated with CMB>5 (Crude OR 2.78, 95% CI 1.12-6.44), the association strengthened after adjustment (Adj. OR 3.15, 95% CI 1.33-7.47).

Conclusion:
We report significant independent associations of caries with higher WMH quartiles and CMB>5. This suggests that ischemic stroke and ICH risk in participants with caries may be mediated by CSVD.