bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP94: Reducing (CT) Assessment Time Improves Inpatient Ischemic Stroke Care with Telestroke
Authors: Modrzynski John , Kaki Sahith
Published: January 2025

Introduction:
Inpatient stroke alerts requiring an in-person neurologist to assess and evaluate patients for thrombolytic therapy may contribute to delays in evaluation and treatment. A new inpatient stroke alert process was developed to improve assessment and treatment of stroke. Timeliness of stroke evaluation and treatment was assessed before and after change in processes.

Methods:
A retrospective study on patients with stroke alerts called between January 2023 and July 2024 at a 375-bed regional hospital. Patients without complete data were excluded. A new inhouse stroke alert process was implemented in two phases. Phase one (March 2023) utilized telestroke instead of in-person neurology and phase two (November 2023) refined the process by replacing phone-call paging with secure-text communication. The pre-rollout periods involved interdepartmental and interdisciplinary planning, education and communication about appending the Rapid Response Team process in the facility. Primary outcome examined the time from alert to CT using a quantile (median) regression analysis. Secondary analysis evaluated the proportion of alert to CT within 20-minute target using chi-square analysis. Subgroup analysis evaluated paging time from phone-call to secure-text page using a quantile (median) regression.

Results:
A total of 135 patients were identified and after exclusions, 130 were included. Mean age was 72.75 ± 12.46 years, 65 patients (50%) were female and median NIHSS was 6.5 [interquartile range (IQR) 2 – 15]. Stroke alerts increased from before phase one to after phase one, 5.36±1.49 versus 7.24±2.95, but difference was not statistically significant, p = 0.30. One patient was treated with IV thrombolysis before phase one compared to five after with median alert to needle (ATN) time of 84 versus 81 minutes. One case (20%) after implementation of phase one achieved ATN time of less than 60 minutes. Alert to CT scan decreased by 18 minutes [95%CI 10.98, 25,02] after phase one, p < 0.001. The proportion of stroke alerts achieving CT target times increased after phase one, 13% versus 60%, OR = 9.75 [95% CI, 2.10, 45.24], p=0.001. Paging time decreased by 2 minutes [95%CI 0.86, 3.14] after phase two compared to prior, p=0.001.

Conclusions:
The new in-house process resulted in faster imaging, communication and improved assessment times. Continued process improvement is needed to decrease alert to needle times and further improve patient outcomes.
Abstract TP96: Aerobic Physical Activity, Resistance Exercise, and Sedentary Times of Stroke Survivors
Authors: Lee Eung-Joon , Kim Seung Jae , Bae Jeonghoon , Jeong HaeBong
Published: January 2025

Background and Purpose:
Stroke survivors are at a higher risk of having long sedentary time (ST) and low physical activity (PA). We investigated the factors associated with aerobic PA, resistance exercise (RE) and long ST in stroke survivors in a community setting.

Methods:
A cross-sectional study was performed using data from the Korea National Health and Nutrition Surveys from 2016 to 2020. We compared the level of moderate to vigorous aerobic PA, RE, and ST between stroke survivors and controls. Furthermore, we performed a multivariate logistic regression analysis to investigate the factors associated with aerobic physical inactivity, insufficient RE, and long ST above 8 hours.

Results:
Of the total 28,146 participants, 633 had a history of stroke. Among stroke survivors, aerobic physical inactivity was much more common, they did RE less often, and their ST was longer. Older age ≥80 years (adjusted odds ratio [aOR]=5.45, 95% confidence interval [CI] 1.96–15.15, p=0.001), lower education level ≤9 years (aOR=2.18, 95%CI 1.13–4.18, p=0.019), and living in rural areas (aOR=1.91, 95% CI 1.11–3.29, p=0.020) were associated with aerobic physical inactivity. Female sex (OR=2.36, 95%CI 1.28–4.35, p=0.006) and lower education level ≤9 years (aOR=2.31, 95%CI 1.01–5.34, p=0.048) were associated with an insufficient amount of RE. Finally, living with no economic activity (aOR=1.9. 95% CI 1.21–2.96, p=0.001), being single (aOR=1.68, 95%CI 1.21–1.96, p=0.049), and being subjectively unhealthy (OR=1.59, 95%CI 1.01–2.49, p=0.027) were independent predictors for long ST.

Conclusions:
This study highlights the need for targeted strategies to reduce ST and promote PA and RE among stroke survivors. Further, multifaceted research and policy studies are needed.
Abstract TP98: Post-Acute Inpatient Rehabilitation Care and Long-Term Major Adverse Cardiovascular Events among Patients with Spontaneous Intracerebral Hemorrhage: Population-Based Analysis of Data From 5 US States
Authors: Bako Abdulaziz , Potter Thomas , Li Chih-Ying , Hay Catherine-Cooper , Abbott Rhonda , Reeves Mathew , Vahidy Farhaan
Published: January 2025

Objectives:
We evaluate the potential link between post-acute care, particularly care provided at inpatient rehabilitation facilities (IRF) (vs. home discharge or discharge to a skilled nursing facility [SNF]), and major adverse cardiovascular events (MACE) among ICH survivors.

Methods:
Using inpatient and emergency department data from Florida, New York, Maryland, Washington, and Georgia, we identified adult (≥18 years) spontaneous ICH survivors discharged to home (with or without home health), IRF, or SNF between April 2016 and December 2018. We fit multivariable logistic regression models and report the adjusted odds ratio (aOR) and 95% confidence intervals (CI) for the independent association of discharge disposition (IRF versus home, and IRF versus SNF) with MACE (a composite outcome of stroke, acute myocardial infarction [AMI], systemic embolism, or vascular death), recurrent primary ICH [rICH], acute ischemic stroke (AIS), AMI, and all-cause mortality within 1-year of initial ICH admission. We assessed for interaction between age and discharge disposition and performed stratified analysis among patients aged < 65 years and older patients ≥ 65 years.

Results:
A total of 17 647 ICH patients alive at discharge (median age [IQR]: 69[57-79]; 45.2% female; 55.5% non-Hispanic White; 23.2% non-Hispanic Black; 10.4% Hispanic; 4.9% Asian) were included, of which 8 194(46.4%), 4 506 (25.5%), and 4 947(28%) were discharged to home, IRF, and SNF, respectively. Within 1-year of follow-up, 7.4% of ICH survivors experienced MACE, while 2.5%, 3.2%, 0.6%, and 3.5%, respectively, experienced rICH, AIS, AMI, and mortality. Overall, patients discharged to IRF had lower odds of MACE (vs. home [aOR, CI: 0.79, 0.68-0.92]; vs. SNF [0.82, 0.70-0.97]; Table 1), rICH (vs. home [0.68, 0.52-0.89]; and vs. SNF [0.66, 0.49-0.88]), AMI (vs. home [0.57, 0.35-0.94]) and mortality (vs. SNF [0.57, 0.45-0.72]). A significant interaction between age and discharge destination was observed (P<0.01) for MACE. Patients <65 years had a similar pattern of associations as the combined data but among those aged ≥ 65 years, IRF discharge was only associated with lower mortality (vs SNF: 0.63, 0.48-0.81).

Conclusions:
Post-acute care at an IRF (vs. home or SNF discharge) was associated with lower rates of MACE and recurrent ICH; however, this protective effect was not significant in patients ≥ 65 years. Specific aspects of IRF care driving better vascular outcomes need further evaluation.
Abstract TP99: Relationship between muscle mass and masseter muscle in hyperacute stroke.
Authors: Irisawa Hiroshi
Published: January 2025

Introduction:
In acute stroke treatment, it is known that complications of muscle mass loss, such as sarcopenia, increase mortality and delay functional recovery. However, it is often difficult to measure muscle mass in the acute stroke phase. On the other hand, it has been reported that masseter muscle thickness reflects the total body muscle mass. We therefore investigated whether it is possible to determine muscle mass loss by measuring the masseter muscle volume on computed tomography (CT) images, which are taken at the same time as the stroke diagnosis.

Objective:
To compare the relationship between muscle mass (Skeletal Muscle mass Index: SMI) measured by body composition in patients in the acute phase of stroke and the masseter muscle area captured by head CT images.

Methods:
The relationship between the masseter muscle area measured from the first head CT image taken for stroke diagnosis and body composition data within 24 hours after admission was investigated in 385 patients (119 women and 266 men) admitted to the Stroke Care Unit of our hospital.

Results:
The correlation coefficient between SMI and masseter muscle area was 0.46 in women and 0.44 in men. In women, SMI <5.7kg/m
2
, a diagnostic criterion for sarcopenia, was detectable when the masseter muscle area was <145 mm
2
. (Sensitivity 89%, specificity 85%, AUC 0.929) In men, SMI <7.0kg/m
2
was detectable with a masseter muscle area <180 mm
2
. (Sensitivity 86%, specificity 83%, AUC 0.912) [Conclusion] It is possible to determine the risk of muscle mass loss from head CT images taken in the acute phase of stroke. This method may assist in determining the rehabilitation treatment strategy and nutritional dosage for stroke patients.
Abstract WMP15: Association Between Electrocardiographic Age and Cognitive Performance
Authors: Ofosuhene Bernard , Lin Honghuang , Ding Huitong
Published: January 2025

Introduction:
Stroke can contribute to age-related cognitive decline, directly affecting the quality of life and post-stroke functioning. While cognitive impairment is usually associated with chronological age, the association between biological/electrocardiographic age (ECG-age) and cognition is unclear. We used a machine learning model to predict the ECG-age of participants directly from their ECG waveform data in the UK Biobank. We determined the association between participants’ ECG-age and their scores on various digital cognitive tests.

Methods:
In the UK Biobank, about 500,000 participants aged between 40 and 69 were recruited from across the United Kingdom. Electrocardiogram data was collected using a 12-lead ECG at rest. Deep neural network (DNN) was used to predict the ECG-age of participants from their raw ECG waveform data. In our main analysis, participants with available ECG data and cognitive test scores were selected (n=63800). Δage was defined as the difference between ECG-age and reported age. We used a multivariable linear regression model to evaluate the association between Δage and digital cognitive tests adjusted for reported age, sex, and education. Additionally, we defined aging according to these 3 categories: decelerated aging: participants with Δage below -5, normal aging: participants with an absolute value of Δage below mean absolute error, and accelerated aging: participants with Δage above 5.

Results:
Compared to the normal aging group, the accelerated aging group (Δage>5) showed a significant decline in cognitive performance, whereas the decelerated aging group (Δage<-5) performed better on various cognitive assessments. The accelerated aging group showed negative β values in 6 out of the 8 cognitive tests analyzed, implying a negative change in performance in those tests compared to the normal aging group. On the other hand, the decelerated aging group outperformed the normal aging group in 6 out of 8 tests, showing positive β values in those tests. β and SE values describe the change in effect sizes and standard error following a 10-year change in the Δage. The risk of cognitive decline was higher in the accelerated aging group (p<0.016).

Conclusion:
In a large population-based cohort, a strong association was observed between ECG-age and cognitive performance. Given the wide availability of ECG in cardiovascular diagnosis, including stroke, accelerated ECG aging could serve as a risk indicator for cognitive impairment.
Abstract WMP49: A machine learning approach to classifying ischemic stroke etiology using variables available in the Get-with-the-Guidelines Stroke Registry
Authors: Lee Ho-Joon , Schwamm Lee , Turner Ashby , de Havenon Adam , Kamel Hooman , brandt cynthia , Zhao Hongyu , Krumholz Harlan , Sharma Richa
Published: January 2025

Background:
There is a scarcity of US data about the epidemiology of ischemic stroke etiologies. The stroke etiology data field in the Get-with-the-Guidelines (GWTG) Stroke Registry has a 43% missing rate. We sought to develop a scalable machine-learning model to predict ischemic stroke etiology using variables already collected in the GWTG Stroke registry.

Methods:
We linked data from two GWTG Stroke registries from YNHH and MGH from 2015-2020 with non-missing, non-cryptogenic stroke etiology inputs adjudicated by the agreement of at least 2 board-certified vascular neurologists’ review of the EHR data from the acute ischemic stroke hospitalization. We trained machine-learning classifiers using XGBoost to predict non-cryptogenic stroke etiology per 4-level TOAST classification using sequentially increasing number of features along with imputation of missing values: (1) Model-1 with age and sex, (2) Model-2 with all GWTG variables excluding ICD codes, and (3) Model-3 with all GWTG variables including ICD codes. Each model underwent Bayesian hyperparameter optimization with 1,000 trials and 5-fold cross-validation. Model performance was evaluated by the following metrics: AUCROC, accuracy, and Cohen’s kappa.

Results:
The cohort included 2,724 patients (median age 70; males = 53%). The number of features was 80 in Model 2 and 2,733 in Model 3. In Model-1, the cross-validation mean AUCROC was 0.64, accuracy 0.45, F1 0.30, and kappa 0.063. Model-2's mean AUCROC was 0.78, accuracy 0.57, F1 0.56, and kappa 0.36. Model-3's mean AUCROC was 0.83, accuracy 0.62, F1 0.62, and kappa 0.44. The performance of the three models with respect to diagnosing each etiology is presented in
Figure 1
.

Conclusion:
We developed and validated a proof-of-concept machine-learning model built using variables available in the GWTG Stroke Registry including embedded ICD codes that yield a predicted ischemic stroke etiology in moderate agreement with board-certified vascular neurologists. Upon further improvement, its application to the National GWTG Stroke Registry could allow automatic population of the stroke etiology variable and facilitate etiologic-specific quality evaluation and epidemiologic studies.
Abstract WMP53: Pre-hospital Arrival Times in 25 countries across regions: A Cross-Country Analysis from Registry of Stroke Care Quality (RES-Q)
Authors: Mikulik Robert , Neto Geraldo , Sedani Rupal , Asif Kaiz , Bornstein Natan , Hill Michael , Lavados Pablo , Martins Sheila , Middleton Sandy , Sohn Sung-il , Suwanwela Nijasri , Sylaja PN , Nguyen Huy Thang , Tsivgoulis Georgios , Van Der Worp H
Published: January 2025

Background:
Treatment options and outcomes in stroke also depends on pre-hospital delays. The goal of this study is to describe onset-to-door times (ODT) across many countries and also investigate how the mode of arrival affects ODT.

Methods:
This is an analysis of the data from the Registry of Stroke Care Quality (RES-Q), years 2022&2023. RES-Q is used across the world for audit of clinical care. Data were stratified by the mode of arrival (EMS vs. non-EMS). Median ODT were analyzed, and 95% confidence intervals (CI) were calculated for each country and arrival mode.

Results:
Of 334,184 patients from 1,130 hospitals in 70 countries, 155,532 patients from 25 countries were diagnosed with acute ischemic stroke after excluding secondary transfers (n=32,349), cases from countries with fewer than 1,000 cases (n=128,660), and those with missing data or typing errors (n=17,643). The median ODT was 193 mins (95% CI: 164-223) for patients arriving by EMS and 309 mins (95% CI: 274-360) for those arriving by non-EMS. The percentage of EMS arrival by region was 34% (Africa), 30% (Asia), 39% (Latin America), and 87% (Europe). The percentage of EMS arrivals is shown in Figure 1. Compared to the patients who reached by non-EMS mode, patients who reached by EMS mode were more likely to receive intravenous thrombolysis (16% vs 44%,). The ODTs by mode of arrival and country are detailed in Figure 2.

Conclusions:
Transport via EMS was associated with a reduced arrival time nearly by 2 hours and tripled the chance of receiving thrombolysis as compared to non-EMS transportation. The percentage of patients arriving by EMS was higher in European countries as compared to Africa, Asia and Latin America and this is reflected by shorter ODT in many EU countries. Improvements in EMS infrastructure could improve stroke outcomes globally.
Abstract WMP77: Assessing Effects of Nimodipine-Associated Blood Pressure Reductions on Cerebral Autoregulation and Cortical Activity in Aneurysmal Subarachnoid Hemorrhage
Authors: Jayasundara Sithmi , Choi Rachel , Rapuano Amedeo , Chen Yilun , Top Ilayda , Olexa Madelynne , Maarek Rafael , Yan Jennifer , Vargas David , Magid-Bernstein Jessica , Amllay Abdelaziz , OKeefe Lena , Hebert Ryan , Bahrassa Farhad , Sheth Kevin , Beekman Rachel , Gilmore Emily , Matouk Charles , Kim Jennifer , Petersen Nils
Published: January 2025

Introduction:
Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition after which patients are at risk for vasospasm and delayed cerebral ischemia (DCI). Nimodipine, a calcium channel blocker, is used to reduce the risk of DCI. Despite its widespread application, the specific effects on cerebral hemodynamics and cortical activity are poorly characterized. It remains unknown whether this potent therapy may have unintended harmful consequences in some patients, which could potentially be mitigated or avoided. This study aims to characterize the effects of nimodipine on cerebral autoregulation, brain blood flow, and quantitative electroencephalography (qEEG).

Methods:
Nimodipine-associated blood pressure (BP) reductions were quantified as percent change between median BP in the hour before nimodipine administration and the minimum BP in the hour following nimodipine. Autoregulatory function was measured by analyzing changes in near-infrared spectroscopy-derived tissue oxygenation (a surrogate for cerebral blood flow) in response to changes in mean arterial pressure (MAP). The resulting autoregulatory index was utilized to determine the limits of autoregulation in each patient. Cortical EEG activity was measured by computing percent changes in each qEEG frequency band in the anterior and middle cerebral vascular regions after artifact reduction and feature extraction.

Results:
We identified 124 occurrences of nimodipine administration with simultaneous recording of continuous EEG and physiologic data among 13 aSAH patients (median age 59 ± 11 years, Hunt Hess 3.0 ± 1.0, modified Fisher 4.0 ± 0.6). Of these, 89 episodes (71.7%) showed a BP drop of 10% or greater, with a median MAP reduction of 25.6 mmHg. Blood pressure reductions were correlated with an increased time below the lower limit of autoregulation (p < 0.001). Nimodipine-associated BP reductions led to an average increase in time below the lower limit of autoregulation of 19.5 ± 24.1% (p < 0.001); a >5% increase was seen in 58.9% (56/89) of episodes. However, only 28 out of 89 episodes (31%) showed a >5% change in alpha-delta ratio.

Conclusions:
Nimodipine-associated BP reductions are common and frequently lead to cerebral hypoperfusion with BP reduction below the lower limit of autoregulation. These episodes did not exhibit a consistent qEEG signature, suggesting that other factors may interact with or compensate for the decline in BP. Further exploratory analyses are on-going.
Abstract WMP83: Stroke Simulation for Emergency Department Advanced Practice Providers
Authors: Turick Nicole , Tarasaria Karan
Published: January 2025

Background:
Acute stroke management requires rapid triage and a highly efficient team to work together for prompt diagnosis and acute reperfusion therapy. An emerging practice is incorporating Advanced Practice Providers (APPs) into the stroke response teams, a model that has been shown to be successful in delivering thrombolytic therapy to patients with ST elevation MI as well. Simulation-based training has been shown to be a beneficial part of education for neurology residents and APPs. Emergency Department APPs have limited experience with Stroke Code training which leads to lack of provider confidence and could presumably be a factor contributing to suboptimal triage and stroke management in the emergency room setting.

Hypothesis:
Simulation-based training would improve confidence, comfort level and preparedness in emergency department APPs for acute management during stroke codes.

Methods:
A prospective quasi-experimental pre-test/post-test study was conducted. Participants included 13 emergency department advanced practice providers at a Comprehensive Stroke Center, including advanced practice nurses (APRNs) and physician assistants (PAs) who attended a case-based acute stroke simulation session involving 6 cases supervised by a vascular neurologist and APP followed by a debriefing session. Questionnaire included items on comfort and confidence surrounding clinical evaluation and acute reperfusion therapy in stroke management. Responses were analyzed using the Mann-Whitney U test.

Results:
On a 5-point Likert scale, median score for participant comfort in leading a Stroke Code increased from 3 (neutral) to 4 (agree) (p ≤ 0.008). Median score also increased from 3 to 4 in respect to feeling prepared for their next stroke code and 2 to 4 in comfort assessing for Large Vessel Occlusion (p ≤ 0.008) and administering IV Thrombolysis (P<0.001).

Conclusion:
There was notable improvement in knowledge and comfort surround stroke code management among advanced practice providers based on simulation training. Stroke code simulation training can be a valuable modality in improving skill and comfort for advanced practice providers practicing in the emergency department setting; and simulation-based training can be expanded to enhance training and improve stroke management involving additional team members. Further research is needed to determine impact of simulation training on treatment times and outcomes of acute stroke patients.
Abstract WP107: Standardized Inpatient Telestroke to Improve Access to Stroke Specialists
Authors: Pereira Rios Beatriz , Jagtap Pramit , Lathiya Maulik , Boes Samuel , Ramezani Hashtjin Solmaz , Stalin Karen , Mehta Tanvi , Pestka Deborah , Usher Michael , Botsford Chloe , Koopmeiners Joe , Beebe Timothy , Melton-Meaux Genevieve , Streib Christopher
Published: January 2025

Introduction:
Of the 800,000 strokes per year in the United States, approximately 25% are recurrent. A stroke specialist evaluation with targeted secondary prevention reduces the risk of recurrent stroke, but access to specialist stroke care remains limited, especially in rural areas. We evaluated the feasibility of standard-of-care inpatient telestroke consultation to reduce the rate of transfers and increase the rate of stroke specialist evaluation for hospitalized acute ischemic stroke (AIS) patients within our telestroke network.

Methods:
We assessed AIS care at five “spoke” hospitals between 1/1/21–12/31/23. Prior to the intervention, all hospitals had telestroke coverage in the emergency department, a protocolized stroke admission order set, and stroke specialists at the “hub” available to provide guidance 24/7 via telephone consultation and chart review. Standard-of-care inpatient telestroke consultation by stroke specialists at the hub site was then implemented sequentially at each spoke hospital in a phased rollout. The telestroke specialist recommended the necessary diagnostic stroke evaluation and secondary stroke prevention. A stepped-wedge cluster design and multivariable logistic regression model was used to compare the likelihood of transfer and stroke specialist consultation pre-and post intervention.

Results:
A total of 1,295 patients with AIS were included (537 pre-inpatient telestroke implementation and 758 post-inpatient telestroke implementation, median age 75.24 [IQR: 64.45-86.11], 47.7% female, 92.2% white, and median NIHSS 2 [IQR:0-5] [Table 1]). The transfer rate pre-and post-inpatient telestroke implementation was 58.5% and 37.5%, (adjusted p-value < 0.01). Of the specific transfer indications, the need for stroke specialist evaluation (7.4% vs 0.9%) and need for a higher level stroke center (27.6% vs 18.3%) showed the most absolute reduction (Table 2). The rate of stroke specialist consultation increased from 80.2% to 96.4% post-inpatient telestroke (adjusted p-value < 0.01); similarly, stroke consultation became increasingly comprehensive (full telestroke consultation 1.4% versus 94.1%) (Table 3).

Conclusions:
Standard-of-care inpatient telestroke consultation significantly increased access to stroke specialist consultation and decreased the AIS transfer rate in spoke hospitals. This stroke care delivery model was feasible and may help address persistent stroke healthcare disparities in underserved areas.
Abstract WP118: Lost to Follow-Up in Randomized Clinical Trials on Longer-Term Patient Management Following Stroke
Authors: Du Peipei , Xu Ziwen , Li Yixuan , Zhang Chi
Published: January 2025

Background:
Although long-term management following a stroke is crucial, many patients do not adhere to follow-up appointments, which pose a risk to the integrity of clinical trials. This systematic survey aimed to identify factors and potential impacts linked to lost to follow-up (LTFU) in stroke patients participating in long-term management trials, to enhance trial quality. Understanding LTFU is essential for informing patients, clinicians, and researchers for both clinical and research purposes.

Methods:
An information specialist completed a comprehensive search of available data sources, including studies published up to June 15, 2024. Eligible articles included randomized trials that involved multimodal post-stroke care programs, initiated within one year after the stroke, with specified and assessed follow-up outcomes. We collected data on general trial characteristics and methodological characteristics for each study. Multiple linear regression analyses were conducted to identify factors associated with LTFU. Additionally, we evaluated the relative risk of several assumptions about the outcomes of participants LTFU on the estimate of effect for the significant binary primary outcome.

Results:
Of the 57 eligible reports identified, 6 (10.5%) did not specify whether LTFU occurred. The duration of follow-up ranged from 1 to 60 months. The median proportion of subjects LTFU was 7.9% (interquartile range, 0–12.9%). Factors of LTFU increase on regression analysis were more study centers (beta=0.003 per center,
P
=0.017), higher proportion of females (beta=0.027 per percentage of 10,
P
=0.006), and non-protocol available (beta=-0.06,
P
=0.021) (Table 1, Fig.1). Patients were also more likely not to be lost if their providers were therapists (beta=-0.14,
P
=0.016) or rehabilitation team (beta=-0.12,
P
=0.038) compared to physician alone. In the trials that provided relevant data, results of 14.3% of trials were no longer significant if we assumed no participants LTFU had the event of interest, and 42.9% of trials were no longer significant if we assumed a worst-case scenario (Table 2).

Conclusion:
Overall, nearly one-tenth of contemporary stroke trials on longer-term patient management still did not report LTFU. Identified modifiable risk factors may provide targets to improve the continuity of stroke management within these trial settings. Neurologists should pay close attention to how the participants are managed which may change the direction of the entire study.
Abstract WP119: Sex differences in longitudinal functional, neurological, cognitive, and quality of life outcomes in the year after first-ever ischemic stroke
Authors: Chen Chen , Kwicklis Madeline , Morgenstern Lewis , Lisabeth Lynda
Published: January 2025

Background:
Given the growing number of stroke survivors in the US, especially among women, understanding contemporary sex-specific trajectories of outcomes after stroke is crucial. Yet, such data are rare. We estimated sex-specific functional, neurological, cognitive, and quality of life outcomes at 3, 6, and 12 months post-stroke in a population-based study.

Methods:
First-ever ischemic strokes (IS) were ascertained between January 1, 2014 and December 31, 2019 from the Brain Attack Surveillance in Corpus Christi (BASIC) Project in South Texas. Data were collected from medical records and patient or proxy interviews (baseline, 3, 6, and 12 months after stroke). Sex-specific trajectories in functional (activities of daily living/instrumental activities of daily living score, ADL/IADL), neurological (National Institutes of Health Stroke Scale, NIHSS), cognitive (Modified Mini-Mental State Examination), and quality of life (QOL) outcomes (12-domain Stroke-specific Quality of Life scale) were estimated using multivariable-adjusted linear mixed effect models accounting for within-subject correlations. Interactions between sex and time were included to examine sex differences at each time point.

Results:
Among the 1,440 IS (median age 68, 48.4% women), women had significantly worse functional outcomes (0.11 points higher in ADL/IADL score) but better neurological outcomes (0.33 points lower in NIHSS score) than men at 3 months (Table 1). There were no sex differences in quality of life and cognitive outcomes. Throughout the one year following stroke, functional and neurological outcomes among both sexes improved, primarily driven by the improvement between 3 to 6 months, with small changes in the outcomes on the absolute scale (Table 2). Improvement in quality of life was only seen among women between 3 to 6 months, while worsening of cognitive outcome between 6 to 12 months was seen among both sexes. There were no significant sex differences for all outcomes at 6 or 12 months and no significant interactions between sex and time.

Conclusions:
Functional and neurological outcomes were at their worst at 3 months after stroke for both sexes and sex differences were small throughout the one-year poststroke, suggesting early assessment and intervention to improve these outcomes in both sex groups. The considerable worsening of cognition after 6 months post-stroke in both sexes suggests that longer-term monitoring of cognitive outcome may be needed.
Abstract WP138: Contemporary Trends in Characteristics, Treatment, and Outcomes in Acute Ischemic Stroke: Data from The Florida Stroke Registry
Authors: Asdaghi Negar , YING HAO , Gardener Hannah , Jameson Angus , Rose David , Alkhachroum Ayham , Del Brutto Victor , Perue Gillian Gordon , Koch Sebastian , Gutierrez Carolina , Rundek Tatjana , Romano Jose
Published: January 2025

Introduction:
The evolving landscape of acute ischemic stroke (AIS) demands knowledge of the changing demographics, treatment status and stroke outcomes.

Methods:
Temporal trends in characteristics, presentation, guideline recommended therapies (defect free care-DFC), in-hospital mortality, and functional outcomes of AIS patients enrolled in GWTG-S, Florida Stroke Registry (FSR) were evaluated from 2012 to 2023 using multinomial temporal model adjusting for age, sex, race, severity, pre-morbid disability, time from onset to arrival and DFC.

Results:
A total of 311,471 AIS patients with available mortality data were included (mean age 70.7(14.2), 48.8% female, 63.6% white, 18.8% black, 13.5% Hispanic). The median onset to arrival (OTA) was 232 min [IQR=651], median NIHSS was 4 (1,9), 59% arrived by EMS, 15.3% received reperfusion therapies (11.8% IV thrombolysis, 5.4% thrombectomy, 1.9% both), 68.4% received DFC. Temporal analysis showed a trend for diminishing age (73 to 71yrs), increased median OTA (192 to 299 min), decreased median NIHSS (4 to 3), increased receipt of reperfusion therapies (9% to 17%) and DFC (18% to 83%) through the study period (p for trend <0.001). In-hospital mortality occurred in 3.2% (median presenting NIHSS 17 (8,24)), 6.2% were discharged to hospice, discharged mRS 4-5 was 40.1%, mRS 2-3 was 22.3% and mRS 0-1 was 34.4%. Multinomial adjusted temporal analysis showed stable in-hospital mortality over time (OR=1.01, 0.99,1.01, p=0.95), but increased rates of hospice admission (OR=1.036 [1.03, 1.04], p<.0001) and discharge mRS 4-5 (OR=1.01 (1.00, 1.01) P<0.0001).

Conclusion:
This real-world data shows a decline in age and stroke severity, and a rise in utilization of reperfusion and guideline recommended therapies in AIS patients over time. Despite improved stroke care and a stable mortality rate, a temporal increase in significant disability at discharge is observed. This data suggests an expected rise in functional burden from AIS.
Abstract WP151: Optimizing High-Value Echocardiography Practices in Older Adult Patients
Authors: Leonhardt-Caprio Ann , Manou Dimitrios , Roberts Debra
Published: January 2025

Background:
High-value practices (HVP) focus on optimal patient care with minimized costs and unnecessary interventions. At an academic comprehensive stroke center, echocardiography (echo) with bubble study was performed for all patients with ischemic stroke (IS) and transient ischemic attack (TIA) for patent foramen ovale (PFO) detection. This practice, especially in patients over age 65, could increase costs, resource use, and overtreatment, despite limited evidence for PFO closure in older adults where alternative stroke mechanisms are more likely.

Aim:
Enhance HVP with targeted PFO screening by reduction of echo with bubble study in IS/TIA patients over 65 from 87.7% to 50% within one year.

Methods:
In July 2023, vascular neurologists agreed on the limited utility of routine echo with bubble study in older adults. The Neuromedicine Intensive Care Unit revised standard practice, delaying echo orders until after rounds to assess necessity for bubble study on a case-by-case basis. Shorter length of stay (LOS) on inpatient units made delayed echo orders impractical; admission orders were modified to exclude bubble studies for patients over 65, except in cases of cryptogenic stroke. Changes were finalized in September 2023. Advanced practice providers and physicians monitored for adverse events (AEs) and process challenges. Hospital LOS was monitored as a balancing measure.

Results:
Baseline (Jan-Jun 2023) rate of echo with bubble study in patients over 65 (n=212) was 87.7%. Following practice change, it decreased to 21.7% (n=544) from July 2023 through June 2024. Sustained reduction was observed after order revisions in September 2023 (Figure 1). No patients required repeat echo and none were reported to have an incomplete evaluation when seen by vascular neurology after discharge. While LOS did not appear to correlate with decrease in bubble studies, additional unrelated factors have impacted LOS. Initial challenges included confusion among echo schedulers, who applied the change universally regardless of order for bubble study. Early education resolved this issue.

Conclusions:
We effectively reduced unnecessary echo with bubble study in older adults with IS/TIA without AEs over a year of monitoring. Continued use of bubble study in 10-15% of these patients reflects appropriate targeting for cryptogenic stroke. Future research should assess actual cost savings and relevance of echo with bubble study in younger patients with clearly defined stroke etiologies.
Abstract WP157: Implementation of a Stroke/TIA e-consult Increases Outpatient Stroke Follow-up Care
Authors: Williams Linda , Myers Laura , Daggy Joanne , Tang Qing , Kirchgassner Jessica , Bastin Grace , chagwena fadzai , Taylor Stanley , Odrzywolski Karen , Nobel Lisa , Wilkinson Jayne
Published: January 2025

Background:
e-consults for outpatient stroke/TIA care can improve timeliness of neurologic care, however it is unknown whether active implementation of an e-consult impacts the overall volume of outpatient stroke care provided in one healthcare system vs another.

Methods:
We studied the implementation of an e-consult for outpatient stroke/TIA care in a stepped-wedge trial in 10 VA facilities in the VA National TeleNeurology Program (NTNP). Sites were randomized to one of three sequential 6-month active implementation waves (after 2 months of usual care where the e-consult was available) that included a stroke prevention lecture for primary care (PC) providers, as well as participation in monthly PC meetings to review cases and utilization of the consult. After the 6-month active implementation (sustainability period), no data were presented to PC teams. The primary outcome was whether a consult was placed in the VA versus community care neurology (CCN) for outpatient stroke/TIA care. A generalized linear mixed model (GLMM) with binomial distribution and log link fit to the primary outcome was used to estimate the effect of active implementation with baseline serving as the reference. Other effects in the model included
a priori
selected variables: demographics, site data (stroke volume, median consult wait time, rurality, availability of local neurology, indicator for sustainability), time block (as categorical 2-month blocks) and random site effect. A similar model was fit including 4 control sites, with an added site-level indicator for intervention vs control site.

Results:
Of the 1545 consults placed for stroke/TIA, 21% (322/1545) were NTNP (within VA). The GLMM model demonstrated that the odds of a stroke/TIA consult being placed within the VA increased during active implementation: OR 1.92 (1.17-3.16, p = 0.01, Table). Adding data from 4 NTNP control sites who had access to the e-consult but did not receive the active implementation showed no trend in consult location over time but added additional variability to the model, resulting in a decrease in the effect (N = 1680, OR 1.48, 95% CI 0.96-2.28, p = 0.07).

Conclusion:
Active implementation of a stroke/TIA e-consult may increase the likelihood of further outpatient care being provided in that healthcare system. This may be relevant to healthcare systems seeking to improve continuity of care for post-acute stroke follow-up through innovative care models and use of asynchronous telehealth modalities.
Abstract WP165: Standardizing the Emergent Brain Magnetic Resonance Imaging Process during Stroke Alerts by Implementing the Full-Body-Scout Computed Tomography Protocol
Authors: Singleton Kate , Stuart Zyanna , Gutierrez Cheyenne , Stark Courtney , Bonin Pinto Camila , Saleh Velez Faddi
Published: January 2025

Background:
Reperfusion therapies are highly time-sensitive, necessitating streamlined protocols to ensure that each step meets target times. This is especially critical for wake-up strokes where emergent brain magnetic resonance imaging (eMRI-brain) is included in the evaluation process. Stroke alerts, particularly for patients with aphasia or altered mental status, present additional challenges in confirming the absence of metal foreign bodies, leading to time-consuming additional imaging. Implementing protocols that integrate a full-body-scout (FBS) during the non-contrast computed tomography of the head (CT head) could reduce delays and enhance the safety and efficiency of eMRI clearance, thereby improving the likelihood of timely thrombolysis.

Objective:
To standardize the stroke alert process for eMRI-brain on wake-up stroke cases and reduce door-to-eMRI times in eligible patients by implementing a FBS during CT head (FBS-CT) protocol.

Methods:
We reviewed wake-up stroke alert metrics before and after implementing a FBS-CT protocol between August 01, 2022 and July 31, 2024. The protocol consisted of adding FBS imaging to assess whether the patient had any foreign metal bodies and to avoid the need for additional imaging.

Results:
We identified wake-up strokes eligible for thrombolysis from 2,300 stroke alerts reviewed at an academic comprehensive stroke center. We classified the identified cases into two groups: Pre-FBS-CT group (n=53; mean age 58.05± 15.34 ; 66% female; 58% White) and Post-FBS-CT group (n=72; mean age 60.44 ±13.70, 58% female, 72% white). Door-to-eMRI median time was 79 [IQR 50-116] for the Pre-FBS-CT group and 45 [IQR 36.75 -57] min for the Post-FBS-CT group. Thrombolytic was given to only 1 Pre-FBS-CT patient while 12 patients from the Post-FBS-CT group received it.

Conclusions:
Implementing a FBS-CT protocol significantly decreased door-to-eMRI times and reduced the variability in those times. Although we cannot definitively attribute the increased eligibility and administration of thrombolysis solely to the improved imaging times in the Post-FBS-CT group, our data demonstrates a substantial reduction in door-to-eMRI times following protocol implementation. It is important to note that stroke onset may have influenced the presence of DWI-FLAIR mismatch. Nonetheless, any reduction in imaging times is crucial for improving the streamlined process of wake-up stroke alerts and impact patient eligibility for reperfusion therapies.
Abstract WP177: Impact of Imaging Acquisition Protocol on Automated ASPECTS Performance
Authors: Penn Lauren , Johnson Benjamin , Bruce Richard , Yu JP , Kennedy Tabassum
Published: January 2025

Introduction:
Automated imaging analysis tools are increasingly used in clinical decision-making for stroke. Rapid ASPECTS (iSchemaView, Menlo Park, CA) assists physicians by automatically calculating Alberta Stroke Program Early CT Scores (ASPECTS) and reducing inter-reader variability. To understand why the tool’s performance in real-world settings sometimes varies compared to published literature, we investigated how different imaging acquisition protocols affect its performance.

Materials&Methods:
Consecutive code stroke NCCT scans with thin (1.25 mm slice; 0.625 mm spacing) and thick (5.0 mm slice; 3 mm spacing) series were collected from a retrospective database between February 2020 and May 2021. Ground truth ASPECTS reads were collected from radiology reports, which neuroradiologists determined in real-time. Automated reads were obtained using Rapid ASPECTS 1.0 and 3.0 (iSchemaView, Menlo Park, CA). Agreement between automated and manual reads was defined as ASPECTS scores within two points.

Results:
A total of 682 cases were included in this analysis. 67 cases were excluded for technical inadequacy (hemorrhages, tumors, and artifacts). A review of the source imaging revealed that many cases had thick overlapping slices and incorrect head positioning (neck extended instead of the standard neutral position). These cases required significant tilt correction to align the patient data with the Rapid ASPECTS regions template. These corrections led to partial voluming artifacts, which caused lower Hounsfield unit (HU) values and ASPECTS scores. When adjusting protocols from thick to thin slices, agreement between ASPECTS V1 and manual reads improved from 85% (581/682) to 89% (606/682). ASPECTS V3 showed further improvement, with agreements of 91% (619/682) and 95% (648/682) for thick and thin slice scans, respectively.

Conclusion:
The combination of neck extension head positioning and thick overlapping slices caused partial voluming artifacts, resulting in artificially low ASPECTS scores on automated software. Our findings indicate that adjusting imaging protocols and working with the AI provider can enhance an algorithm's accuracy. To ensure that commercially available automated analysis tools deliver accurate results, it is crucial to follow the recommended imaging acquisition protocols.
Abstract WP194: Deep-learning Based Artefact Removal From Relative Non-contrast Computed Tomography Maps To Identify Early Hypodensity Changes After Acute Ischemic Stroke
Authors: Konduri Praneeta , Vandewalle Lieselotte , Christensen Soren , Seners Pierre , Marquering Henk , Wouters Anke , Demeestere Jelle , Lansberg Maarten , Lemmens Robin
Published: January 2025

Introduction:
A semi-automated method that compares voxel density with the contra-lateral hemisphere to generate ratio, or relative Non-Contrast CT (rNCCT) maps for identifying hypodensity changes was developed. In addition to being sensitive to stroke related hypodensities, these maps are also sensitive to motion artefacts and naturally occurring asymmetry in densities across hemispheres. We assessed the value of a deep-learning based model to segment and remove these artefacts and for identifying ischemic core of baseline NCCT.

Methods:
We included data from 268 acute ischemic stroke patients with a large vessel occlusion from the ongoing CT perfusion to Predict Response to Recanalization in Ischemic Stroke Project 2 study. NCCT scans acquired at the primary stroke center were used to create rNCCT maps. These maps detect regions with at least 1% relative hypodensity difference compared to the contralateral region. A trained observer who had insight of arterial occlusion location manually annotated artefacts. We trained a
no new UNet
using the NCCT, rNCCT, and flipped NCCT images to detect artefacts from the rNCCT maps. To assess the extent to which our model falsely identified ischemic regions as artefact, we determined the overlap between the automatically segmented artefact on the rNCCT map and the manually segmented ischemic core on diffusion-weighted imaging (DWI) acquired at the comprehensive stroke center before treatment.

Results:
The best performing model was the ensemble of the five cross-validation folds of 3d low- and high-resolution models based on dice similarity coefficient. Figure 1 provides an example of our model’s artefact segmentation and the processed rNCCT map after artefact removal. For the 54 patients (20% of study population) in our test set, our model achieved a median Dice similarity coefficient of 0.95 (IQR: 0.91-0.97) and a median false positive volume of 6.1 (3.2-11) ml. In the 30 patients with available DWI scans, 30% of patients had any overlap (>=1 voxel) between the segmented artefact and DWI ischemic core with a median overlap volume of 0.69 (IQR: 0.32-2.3) ml.

Conclusion:
We demonstrate the use of a deep-learning based model to automatically segment artefacts from rNCCT maps. Our model circumvents time-invasive manual removal of artefacts from the rNCCT map and thereby simplifies segmentation of the ischemic core on baseline NCCT. Validation with external datasets is necessary before use in routine stroke evaluation.