bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP78: Team-based Resident Training For Stroke Code Simulations Decreases Variations In Thrombolytic Door To Needle Times
Authors: Seol Hyeyoung , Smith Peri , Azher Aidan I , Keser Zafer , Kumar Aditya , Chandra Shivika , Jagolino-cole Amanda L , Zha Alicia
Published: February 2022

Introduction:
Stroke code simulation training is effective at reducing door to needle times (DTNT) for tPA administration. We aimed to evaluate the effect on DTNT from simulation training specifically for Neurology residents.

Method:
Stroke code simulation was implemented at our comprehensive stroke center in July 2017, targeting PGY2 adult neurology residents and PGY3 pediatric neurology residents who were first responders at stroke codes during off-hours. Training was completed at the beginning of the residents’ respective training years. An interrupted time series analysis of DTNT for tPA before and after the implementation of simulation training from July 2016 to July 2019 was performed. Demographics, tPA metrics, and safety and hospital metrics were compared pre and post intervention among the residents. No other quality improvement projects targeting DTNT were implemented during this time.

Results:
Between July 2016 and July 2019, 305 patients received thrombolysis from a resident first responder - 118 (39%) of whom were treated pre-simulation and 187 (61.3%) treated during the simulation period. There was no significant difference in patient baseline characteristics between the two groups (Table 1). Median DTNT was 49.5 (IQR 40-71) min during the pre-simulation period and 48 (IQR 37-60) min during the post-simulation period (p= 0.04). Compared to pre-simulation, there were no months in which the median DTNT exceeded 60 min post-simulation. IQR for the DTNT appeared both clinically and statistically different. Pre and post simulation, there was no difference in incidence of symptomatic intracranial hemorrhage nor in 90-day outcomes.

Conclusion:
In our analysis of the effect of stroke code simulation training among neurology residents, improvement in DTNT after simulation training appears more driven by improvement in the variation in times rather than a clinically significant decrease in median times.
Abstract TP87: Discrete-event Simulation Of The Prehospital Stage Of The Acute Ischemic Stroke
Authors: Koca Gizem , Kamal Noreen
Published: February 2022

Introduction:
It is critical to treat Acute Ischemic Stroke (AIS) patients quickly; however, treatment eligibility is dependent on the arrival time to the nearest stroke center by Private Vehicle (PV) or Emergency Medical Services (EMS). The duration in the prehospital stage is defined as the period from stroke onset to arrival at a non-stroke center, primary stroke center or comprehensive stroke center. This study aims to detail the prehospital stage of suspected AIS patients in order to identify opportunities for process improvements.

Methods:
Discrete-event simulation (DES) is a powerful decision-making tool and robust methodology for evaluating treatment processes and allows for improvements to be tested before implementing changes using real resources. A DES is developed using ARENA software to model the prehospital stage of suspected AIS patients. The process steps include two treatment pathways, PV and EMS. The pathways differ because those patients arriving via EMS allow for the activation of the code stroke protocol prior to hospital arrival. The drive times from the stroke scene to the hospital were kept constant at 40 min assuming a suburban transport. The model assumes 60% recognition of ischemic stroke using EMS stroke screening tools and large vessel occlusion screening tools and a 90% probability that the paramedics correctly screen for a potential stroke and bypass to a stroke center. The primary outcome measure is median onset-to-door time, defined as the time from onset of stroke symptoms to arrival to the hospital. The Mann-Whitney U test is used for evaluating statistical significance among the outputted median onset-to-door time for all scenarios.

Results:
The following process improvement scenarios were run: reducing the waiting time for EMS on average from 7 min to 5 min and reducing delays on-scene on average from 20 min to 15 min, and the median onset-to-door time reductions were from a median of 57.53 min to a median of 51.41 min (p<0.0001).

Conclusions:
Reduction in onset to arrival times is possible by reducing waiting time for the EMS and delay on-scene of the stoke.
Abstract TP88: Advance Care Planning In Stroke Survivors: A Survey Of Patient Goals And Preferences
Authors: Chu Kristie M , miller shawanda , Abdulrazzak Mohammad A , Seol Hyeyoung , Gomez Juliana B , Leech Ana L , Gonzales Nicole R , Sharrief Anjail Z , Zha Alicia M
Published: February 2022

Introduction:
The AHA 2014 statement on palliative and end-of-life (EOL) care in stroke recommended patient- and family-centered care and goals of care discussions. Despite a recurrent stroke risk of up to 39% at 10 years, stroke survivors have low advance directive completion rates. We conducted a survey characterizing the advance care planning (ACP) attitudes in our population of stroke clinic patients.

Methods:
We developed a survey based on validated surveys assessing ACP behaviors and engagement. The survey was provided to all TIA, ischemic and hemorrhagic stroke patients in our clinic between February and August 2021. Non-English-speaking patients and those unable to express preferences were excluded.

Results:
Surveys were provided to 88 stroke survivors with a 68.2% response rate (N=60). Patient characteristics reported in Table 1. Patients were racially and ethnically diverse and 54.2% had greater than high school education. Patients were also fairly independent, most living at home (96.7%) and ambulatory (63.3%). Most patients completed the survey a median of 43 days after their first stroke (63.3%). Less than half (48.3%) of patients had designated a medical decision maker but many (63.3%) had had conversations with family/decision makers about preferences for future medical care if they were to become very sick or near the EOL. However, only 46.7% felt ready to talk with a doctor about these preferences. More than half (53.3%) of patients indicated that they would like their stroke doctor’s participation if/when they were to have such a conversation.

Conclusions:
In our study group of diverse, younger and more independent stroke survivors, we found that many had had ACP conversations with surrogate decision makers and more than half wanted their stroke doctor to participate in future discussions. More work is needed to assess the generalizability of our findings and how ACP can be improved for stroke survivors who are at high risk for recurrent events.
Abstract TP91: Incidence Of Long-term Acute Medical Events In Treated Patients With Acute Ischemic Stroke From A United States Administrative Database
Authors: Oleske Denise , Boiser Joey C , Fan Yunhua , Wong Emily , Fayad Pierre B
Published: February 2022

There is limited information on long-term risk of acute medical events after acute ischemic stroke (AIS) treatment with tissue plasminogen activator (tPA) or mechanical thrombectomy (MT). We sought to determine the incidence of seven acute medical events at 1 and 5 years after AIS treatment using an administrative database. The Optum Clinformatics Data Mart database was used to construct the cohort of patients aged 30+ years with AIS diagnosis (ICD-10 I63 or ICD-9 433.x1, 434.x1, 436 or DRG 061-063) during the period: 01/01/2015-06/30/2020 with at least 1-year observation prior to cohort entry. Using procedure coding (CPT or ICD-9/10), patients were grouped as tPA only, MT only, tPA+MT, or untreated. Excluded were patients with an acute event in year preceding first AIS treatment, or first AIS diagnosis for untreated patients. Acute medical events were assessed at 1 and 5 years. The denominator was calculated as the person-years (PY) (per 100) from AIS diagnosis date or treatment, until event occurrence date or database end. The Charlson-comorbidity score (CCS) was used to measure concomitant illness severity.The 313,756-patient AIS cohort was mostly male, had a mean age of 72 years, with 8% receiving intervention. In the first year, cardiovascular event rates were highest in the tPA+MT group for recurrent AIS (10.9/100 PY), myocardial infarction (4.8/100 PY), and venous thromboembolism (4.3/100 PY). All-cause mortality (35.2/100 PY) and urinary tract infections (31.4/100 PY) were highest in the tPA+MT group. The tPA group had the highest rate for pneumonia (18.6/100 PY). The untreated group had the lowest rate for all events. All event rates decreased at 5 years, with the largest decline (-34%) in recurrent AIS.Stroke patients remain at significant risk of morbidity in the first year after stroke, in spite of treatment, but rates of acute medical events decrease over time possibly related to prevention strategies.
Abstract TP98: Diagnostic Utility Of Transcranial Color Flow Imaging Identifying High Risk Patent Foramen Ovale
Authors: Mitsumura Hidetaka , Nakata Ryoji , Kitagawa Tomomichi , Tanabe Maki , Sato Takeo , Takatsu Hiroki , Komatsu Teppei , Sakuta Kenichi , Sakai Kenichiro , Umehara Tadashi , MURAKAMI HIDETOMO , Iguchi Yasuyuki
Published: February 2022

Background and Purpose:
Recent several studies demonstrated that percutaneous patent foramen ovale (PFO) closure reduced the risk of stroke recurrence for patients with cryptogenic stroke and PFO. Our aim of this retrospective study is to evaluate the usefulness of transcranial color flow imaging (TC-CFI) in the diagnosis of anatomically high risk PFO, in which percutaneous PFO closure is expected to be more effective in preventing embolism.

Methods:
Subjects were ischemic stroke patients who were investigated the presence of right-to-left shunt (RLS) using TC-CFI and transesophageal echocardiography (TEE). Anatomically high risk PFO evaluated by TEE were defined as satisfying one or more of the following findings: 1) large shunt (more than 20 microbubbles (MB) identified in the left ventricular system), 2) atrial septal aneurism, and 3) the presence of shunt without Valsalva maneuver (VM). TC-CFI was performed in the middle cerebral artery and/or intracranial vertebral artery once without VM and three times with VM, respectively. The number of microembolic signals from MB was determined using international Consensus Criteria (ICC). The accuracy of TC-CFI for high risk PFO diagnosed by TEE was calculated, and then the positive rate of TC-CFI in detecting high risk PFO was also analyzed by TC-CFI’s findings (A: ICC grade II or higher, B: positive without VM, and C: positive on multiple times or in multiple vessels).

Results:
We analyzed 176 patients (41 females, mean age 64 years) admitted to our facility from July 2019 to July 2021. Of them, 44 patients (25%) had PFO, and 29 patients (16%) were high risk. The diagnostic power of TC-CFI was sufficient, with sensitivity of 93%, specificity of 80%, and accuracy of 89%. The positive rate of each finding was significantly higher in C than in A and B (A: 23%, B: 39%, and C: 55%. P=0.04).

Conclusions:
To perform the TC-CFI procedure frequently in multiple vessels is useful for screening of high risk PFO.
Abstract WMP10: Sex Difference In Imaging-based Intravenous Thrombolysisfor Ischemic Stroke With Unknown Onset Time: A Pooled Analysis Of Clinical Trials
Authors: Fukuda-doi Mayumi , Koga Masatoshi , Thomalla Götz , Jensen Märit , Inoue Manabu , Yoshimura Sohei , Miwa Kaori , Gerloff Christian P , Davis Stephen , Donnan Geoffrey A , Ma Henry , Hacke Werner , Ringleb Peter , Wu Ona , Schwamm Lee H , Warach Steven J , Boutitie Florent , Toyoda Kazunori ,   Evaluation of unknown Onset Stroke thrombolysis trials (EOS) investigators
Published: February 2022

Introduction:
Our prior meta-analysis reported that imaging-based intravenous thrombolysis (IVT) was safe and effective for patients who have had a stroke with an unknown onset time. The aim of this study is to investigate whether sex differences exist in clinical outcomes among this population.

Methods:
This is a pooled analysis of individual patient-level data acquired from the EOS project, a meta-analysis of clinical trials (PROSPERO, CRD42020166903). Patients treated with imaging-based IVT for stroke with an unknown time of onset were included. The primary outcome was a favorable functional outcome (mRS 0-1) at 90 days. Secondary outcomes were mRS shift towards a better functional outcome and death within 90 days. Sex differences were investigated using mixed-effect logistic or ordinal regression models adjusted for covariates, considering potential heterogeneity across trials.

Results:
Among 509 patients treated with imaging-based IVT, 204 (40.1%) were women. Compared to men, women were older (70
±
12 vs. 67
±
13, p=0.003), more frequently had atrial fibrillation (27.6% vs. 17.2%, p=0.005), and were taking antiplatelets prior to the onset (45.5% vs. 36.4%, p=0.045). Baseline NIHSS score was higher (8.0 (IQR 5-15) vs.6 (4-11), p<0.001), and hours from last-known-well to treatment were longer (11.2 (9.3-12.9) vs. 10.3 (8.1-11.9), p<0.001) in women than men. Favorable outcomes occurred in 80 (40.6%) women and in 150 (49.7%) men (p=0.047). Among women, 19 (9.6%) patients died, compared with 15 (5.0%) patients in men (p=0.042). After multivariate adjustment, female sex was not significantly associated with favorable functional outcome (adjusted odds ratio (OR) 1.01[95% confidential intervals (CI) 0.66-1.54]; p=0.97) nor death (adjusted OR 1.28 [95%CI 0.59-2.76]; p=0.59). Female sex was not associated with a significant shift towards the better functional outcome (common OR 1.07 [95%CI 0.77-1.49]; p=0.70).

Conclusions:
Pooled data from clinical trials show that in univariate analysis, women had numerically less good functional outcomes following imaging-based IVT among ischemic stroke patients with unknown onset time. However, this sex difference can be explained by higher age and more severe clinical status in women at stroke onset.
Abstract WMP101: Potential Causes Of Anticoagulant Underuse In Patients With Atrial Fibrillation Presenting With Ischemic Strokes
Authors: Gurol Edip M , Das Alvin S , Daoud Nader , Gokcal Elif , Horn Mitchell , Abramovitz Avia , Smith Eric E , Yaghi Shadi ,   on behalf of The Neuro-AFib Study Group
Published: February 2022

Background:
Underuse of FDA-approved stroke prevention methods in atrial fibrillation (AF) remains a major problem. We aimed to explore the potential causes of oral anticoagulant (OAC) non-use and compare the frequency of these factors between AF patients with acute ischemic stroke (AIS) off and on oral anticoagulant (OAC).

Methods:
The Neuro-AFib study is a multicenter observational study aiming to clarify the causes of different stroke types in a contemporary AF cohort. Potential causes of OAC non-use were systematically collected from all enrolled patients based on the exclusion criteria of the Direct OAC (DOAC) studies. The frequency of potential causes of OAC non-use (AIS-off-OAC) are explored in AF patients consecutively admitted to 22 US academic stroke centers with an AIS between 1/2018-12/2019, and these rates are compared to AIS-on-OAC.

Results:
Among 4898 patients with known AF who had IS, 2694 (55%) were not using any OAC, and 45% were AIS-on-OAC. CHA2DS2-VASc <2, the cutoff representing low embolic risk until late 2019, was found in 7% of AIS-off-OAC group compared to 3.8% in AIS-on-OAC (p<0.0001). The most common factor in OAC non-use group was history of falls (26%) vs 18% in AIS-on-OAC group (p=0.004). History of bleeding [intracranial (2.3%) and extracranial (18.5%)] was found in 20.8% of AIS-off-OAC vs 10.4% of AIS-on-OAC group (p<0.0001). 82.6% of these hemorrhages were classified as major bleeds. Pre-stroke cognitive impairment was also common in AIS-off-OAC (21.7%). Renal failure (creatinine >2mg/dl) was found in 13% of AIS-off-OAC. Gait problems leading to limited mobility (10%) and excessive alcohol use (3.8%) were other potential factors for OAC non-use. Among OAC non-users, 64% had at least one risk factor defined above.

Conclusions:
In a large multicenter contemporary IS cohort with known AF, 55% of patients were not on OAC, and about two thirds of them had a reason that would exclude them from the phase 3 DOAC studies. Other than improving the accuracy of risk prediction algorithms, research should focus on identifying optimal management approaches for this large AF population who present challenges to lifelong OAC use. FDA-approved left atrial appendage closure procedures can be considered in such AF patients.
Abstract WMP115: Developing A New Drug For Ischemic Stroke
Authors: Zheng Yi , Holman Theodore , Van Leyen Klaus
Published: February 2022

Introduction:
Since 1996, no new drugs to treat ischemic stroke have gained approval by the FDA, leading to a perception in the private sector that developing a stroke drug is too risky to be worthwhile. Recognizing this Catch-22 situation, the NIH has instituted programs designed to bridge the gap that prevents successful translation from the bench to the clinic. With support through the NIH Blueprint Neurotherapeutics (BPN) program, we have focused our efforts on targeting the lipoxygenase ALOX15, which is increased following ischemic injury and contributes to both neuronal cell death, as well as vascular leakage and hemorrhagic transformation.

Methods:
We generated new candidate molecules through medicinal chemistry approaches, starting with a previously identified ALOX15 inhibitor as scaffold. Human and mouse ALOX15 were expressed as recombinant proteins and used for in vitro assays of ALOX15 inhibition. HEK293 cells were transfected to express human ALOX15 and used to measure intracellular inhibition of ALOX15. Mouse HT22 cells and primary rat neurons were used to show protective efficacy of inhibitors in cellular oxidative stress assays. Male and female C57Bl6J mice were subjected to 60 minute transient middle cerebral artery occlusion (tMCAO). TTC staining was used to determine infarct sizes. To measure long-term efficacy of protection, mice were subjected to a battery of behavioral tests including Garcia Score, Corner Test, Grid Walk Test, Adhesive Removal Test, and Y Maze.

Results:
Out of more than 400 novel compounds synthesized, 142 showed submicromolar IC50 values when assayed against recombinant human ALOX15. After successive screening rounds in in vitro assays, we advanced 5 compounds for testing in the MCAO model, where 3 compounds reduced infarct size by more than 25% when injected intraperitoneally. With intravenous administration at 40 mg/kg 3 hours after onset of ischemia, our lead compound reduced the infarct size by 34%. One month after the experimental stroke, mice showed significant improvement in 4 out of 5 behavioral tests.

Conclusions:
We have developed promising new candidate drugs that show efficacy in rodent models of stroke and favorable pharmacological properties. We intend to further develop our compounds for clinical use.
Abstract WMP21: Blood Biomarkers Of Endothelial And Macrocytic Activation Are Associated With Brain White Matter Microstructure In People Living With Hiv On Antiretroviral Treatment.
Authors: Spagnolo-Allende Antonio , Schnall Rebecca , Liu Minghua , Laing Krystal K , Igwe Kay C , Brickman Adam , Gutierrez Jose
Published: February 2022

Objective:
To identify associations between specific serum inflammatory markers and structural white matter integrity as measured on brain diffusion tensor imaging (DTI) in middle-aged people living with HIV (PLWH).

Methods:
PLWH over 50 years of age residing in New York, NY participated in a cross-sectional study between January and July 2019. Demographic and magnetic resonance imaging data, along with blood samples, were collected. Least absolute shrinkage and selection operator (LASSO) regression was used to identify the most relevant variables associated with brain white matter fractional anisotropy (FA) and mean diffusivity (MD), among seventeen serum inflammatory markers, and control variables (listed in Table 1).

Results:
A total of 85 PLWH were included in the analysis. Mean age (SD) was 60 (6) years, 48% were men and 78% non-Hispanic black. All were taking antiretroviral therapy at enrollment. Among them, 75% had CD4 count ≥200 cell/mm
3
and viral load <400 copies/mL near the time of their MRI scans. We observed that, as the penalty factor (λ) increased in the LASSO regression, vascular endothelial growth factor (VEGF) (β=-0.052), monocyte chemoattractant protein 1 (MCP-1) (β=-0.001) and macrophage inflammatory proteins 1α (MIP-1α) (β=-0.007) and 1β (MIP-1β) (β=-0.074) remained in the LASSO model for FA. Similarly, VEGF (β=1.01x10
-4
), MIP-1α (β=3.67x10
-6
) and MIP-1β (β=7.12x10
-5
) remained in the LASSO model for MD (Table 1).

Conclusion:
Prior research has linked VEGF to HIV-associated encephalopathy and MCP-1 to HIV-associated dementia, while both MIP-1α and MIP-1β have been associated with asymptomatic HIV infection. Our findings therefore may offer a mechanistic framework for those associations, indicating that chronic inflammation in the context of HIV infection may alter brain white matter microstructure. Such alterations may contribute to the development of HIV-associated central nervous system disorders.
Abstract WMP25: Incidence Of Access Site Complications In Patients Receiving Tenecteplase As Bridging Therapy To Endovascular Treatment
Authors: Percival Brigitte , Le Yenna , Ali Nasar , sahitu sindhu , Amireh Abdallah , Suhan Laura B , panezai spozhmy , Mehta Siddhart , Zacharatos Haralabos , Mehta Siddhart , Fourcand Farah , Kirmani Jawad F
Published: February 2022

Introduction:
Mechanical thrombectomy (EVT) is the standard of endovascular care for acute ischemic stroke secondary to large vessel occlusion. Alteplase in conjunction with EVT has a strong safety profile with low incidence of complications including groin hematoma. Our objective was to evaluate the incidence of groin hematoma in EVT following bridging therapy tenecteplase (TNK) as this is not well-described in the literature.

Methods:
Retrospective review of prospectively collected data for patients with acute ischemic stroke who underwent mechanical thrombectomy at a University Hospital. Incidence of access site complication including groin hematoma, retroperitoneal hematoma, blood loss and femoral artery pseudoaneurysm with or without the need for surgical intervention were reviewed. Rates of use of other antithrombotic agents were also noted. Social Science Statistics was used for data analysis.

Results:
From October of 2020 to April of 2021, of 348 ischemic stroke patients, 16 had LVO identified on CT and received TNK prior to mechanical thrombectomy (Females = 6; age, 63.25 95% CI [54.9207, 71.5793]); Mean weight =78kg, 95% CI [67.68, 88.32]). Five subjects (31.25%) received intra-arterial non-thrombolytics. None received intra-arterial thrombolytics. Three patients (18.75%) received therapeutic heparin during the procedure. Four patients (25%) were started on non-thrombolytic infusion during the periprocedural period. One subject (6.25%) was started on stroke nomogram heparin infusion less than 24 hours post-intervention. One subject (6.25%) developed groin hematoma that did not require intervention. This subject received intra-arterial non-thrombolytics during procedure and IV non-thrombolytics during the peri-procedural period.

Conclusion:
Our single center experience with TNK outside of the clinical trial setting with concomitant use of other antithrombotics suggests safety of bridging strategy. Larger prospective ‘real-life’ studies are required to validate our findings.
Abstract WMP26: Performance Improvement During A Pandemic: Implementing Weekly Case Review To Decrease Door-to-CT And Door-to-Needle Times For Code Stroke Patients
Authors: Rhoten Jeremy B , Strong Edwin , James Daniella , Asimos Andrew W
Published: February 2022

Background and Purpose:
When reviewing Code Stroke workflow data early in the COVID pandemic, a delay in obtaining CT brain imaging for stroke patients was identified. This study was aimed at improving Door-to-CT and Door-to-IVtPA bolus times by developing an Emergency Department (ED) led process improvement (PI) team to identify and track root causes for delays, provide feedback after fallouts, and recognize care teams after successful cases. Our primary goal was to demonstrate improved trends for performance metrics utilizing a novel method of process improvement, data collection, analysis, and dissemination.

Methods:
All ED patients activated as a Code Stroke were included in a weekly workflow review conducted by the PI team. Patients with a Door-to-CT of > 20 minutes were analyzed by the team via an in-depth chart review to identify the root cause of the delay. Specific metrics analyzed included Door-to-CT times and Door-to-IVtPA bolus times, along with the percentage of cases that met process metric time goals. Implementation of the weekly review began September 31, 2020, with the pre-implementation period corresponding to the prior nine months and the post-implementation period being the ensuing nine months. Metrics were analyzed using a control chart based on monthly metric averages, standard deviations (SD), and both an upper and lower control limit defined as 1 sigma level of variability from the average.

Results:
The average Door-to-CT time pre-implementation was 30.6 minutes versus 22.8 minutes post-implementation, with a percentage goal within 20 minutes pre- and post-implementation of 47% and 66%.The average Door-to-IVtPA Bolus time pre-implementation was 40.1 minutes versus 31.5 minutes post-implementation, with a percentage goal <30 minutes pre and post-implementation of 42% and 56%.The SD for Door-to-CT average improved from 4.81 to 3.76, while the Door-to-IVtPA Bolus average SD decreased from 9.26 to 8.53.

Conclusion:
Reviewing identification, activation, and treatment times for all ED Code Stroke patients during the COVID pandemic was associated with significantly reduced imaging and treatment times.
Abstract WMP38: The Functional Significance Of Distal Arm Motor Deficits After Stroke
Authors: Cramer Steven C , McGee Breann , Cao Madelyn , Jubb Ashley , Holman Alison ,   The STRONG Study Team
Published: February 2022

Background:
Much of human behavior revolves around use of the hand, yet distal arm motor deficits are not part of the NIH Stroke Scale (NIHSS), and so their measurement is omitted from many guidelines and care pathways. We examined the frequency of distal arm motor deficits and their functional implications.

Methods:
Patients in the STRONG Study were examined 1-10d and again 90 d post-stroke. Grip force, expressed as the ratio of paretic/nonparetic hands, and the NIHSS were measured serially. The modified Rankin (mRS) and Fugl-Meyer arm motor (FM) scales were measured at d90.

Results:
There were 763 patients, with age = 62.5±15.0 (mean±SD), acute NIHSS = 4 [2-9] (median [IQR]), and day 90 mRS median = 2 [1-3]. Grip force was available in 748 acutely and in 439 at d90. Weakness in grip strength was present in 60.2% acutely and 52.2% at d90. Acutely, grip force was not related to NIHSS total score (r=.04, p=.3) after accounting for proximal motor deficits (NIHSS Q5); at d90, there was a weak relationship (r= -0.15, p<.0001). Proximal weakness was only partially related to distal motor deficits at both timepoints (r = -0.48 to -0.53, p<.0001). At d90, grip force explained 24.6% of the variance in mRS score (p<.0001). D90 grip force showed convergent validity, correlating strongly with the distal arm motor FM score (r=.64, p<.0001).

Conclusions:
In this mild-moderate stroke population, distal arm motor deficits were common, were poorly captured by the NIHSS total score, and did not simply echo proximal arm motor deficits. Distal arm motor deficits were strongly related to level of global disability at d90. These findings argue that measurement of distal arm motor deficits should be included in guidelines and care pathways after stroke.
Abstract WMP45: Feasibility, Acceptability, And Accuracy Of A Text-messaging Program For Outcomes Data Collection In Patients After Stroke
Authors: DiCarlo Julie A , Petrilli Marina , Emerson Kristi , Erler Kimberly S , Schwamm Lee H , Lin David J
Published: February 2022

Introduction:
Robust outcome data collection is critical for stroke care and clinical trials. However, reaching patients after discharge from acute care is challenging. This study examined the feasibility, acceptability, and accuracy of collecting outcomes through a text message-based program after stroke.

Methods:
Patients discharged between June 8
th
, 2020 and February 1
st
, 2021 from Massachusetts General Hospital with an ICD-10 Code of stroke who consented to receiving messages, were enrolled in a message-based program upon acute stroke discharge. Participants received weekly brain health tips and assessments of the Modified Rankin Scale (mRS) and PROMIS Global-10 at 30, 60, and 90 days post-stroke via text message prompts. Participants were sent a satisfaction survey upon program conclusion. Data from routine 90-day follow-up phone calls were extracted from clinical charts of patients discharged during a representative 3 month period for comparison. Descriptive statistics, group comparisons, and inter-modal reliability (text message versus phone) were performed.

Results:
Of 530 patients with stroke discharged during the study period, 350 enrolled in the message program. Forty-one percent of the patients answered one or more of the assessment prompts. The 90-day mRS collected by messaging was 1[0-3] and the PROMIS Global Physical and Mental Health were 15[12.5-17] and 13[11-16], respectively. We reached 104/169 (61.54%) patients by phone. There were no statistically significant differences on 90-day outcome scores between those who responded via messages or phone. Inter-modal reliability (message versus phone) was moderate for mRS (κ=.521) but poor for PROMIS scores (κ<.1). Nearly all participants (90%) felt it was helpful to receive information about stroke via messages and found the program adequate (63%) and not burdensome (94%).

Discussion:
Post-stroke outcomes data collection via text-messaging is feasible, acceptable, and moderately accurate compared to phone-based methods. Inter-modal reliability was higher for functional outcomes as compared to PROMs. Further validation of specific measures is required; yet, these findings suggest that future programs could use messaging to identify patients at risk for poor outcome.
Abstract WMP46: Quantitative Electroencephalogram To Assess Neurovascular Coupling Post Endovascular Thrombectomy
Authors: Ishaque Noman , Thangeswaran Jeyaram , Burrell Jennifer , Wilkinson Cassandra , Buck Brian H , Mathewson Kyle , Kate Mahesh P
Published: February 2022

Introduction:
Persistent neurovascular uncoupling may be associated with poor outcome in patients with ischemic stroke after successful recanalization. Quantitative electroencephalography (EEG) can be used to assess neuronal function. We assessed relation between degree of recanalization post-endovascular thrombectomy (EVT), quantitative EEG based parameters and severity of neurological deficits.

Methods:
Patients with acute ischemic stroke with large vessel occlusion in anterior circulation were enrolled. EEG was recorded using a modified Muse headband (InteraXon) before, immediately after and at 24 hours post-EVT. Pairwise-derived brain symmetry index (pdBSI) and delta-to-alpha ratio (DAR) were computed using Fitting Oscillation & one-over F (FOOOF) MATLAB wrapper.

Results:
A total of six patients with mean age 73.6±11.6 years and baseline median (IQR) NIHSS of 13.5 (11-15) were included. Expanded thrombolysis in cerebral infarction (eTICI) scores were 2b67 in one, 2c in two and 3 in three cases. Baseline EEG was recorded at 75 minutes (60-100) from arrival, second at 255 minutes (90-420) after recanalization and third at 28.5 hours (27-31) after recanalization. Four patients with improvement in NIHSS of >10 had 46.6±31.7% change in pdBSI at 24 h. One patient with NIHSS <10 improvement had -25.3% change in pdBSI. One patient with low baseline NIHSS (9) had 90.9% change in pdBSI. There was linear correlation between baseline infarct volume on perfusion studies and change in pdBSI at 24 h (r=0.86, p<0.0001, Figure 1). There was no difference in the DAR in the ipsilateral hemisphere pre-EVT, immediately post-EVT (p=0.6) and 24 h post-EVT (p=0.8).

Conclusion:
Preliminary data suggest return of neuronal function and clinical recovery may lag after successful recanalization, due to persistent neurovascular uncoupling. Higher baseline infarct volume may predict lower pdBSI change. Portable EEG may help characterise this novel treatment target.
Abstract WMP5: Non-invasive Vagus Nerve Stimulation For The Acute Treatment Of Ischemic Or Hemorrhagic Stroke
Authors: Arsava Ethem M , Topcuoglu Mehmet Akif , Ay Ilknur , Liebler Eric , Ay Hakan
Published: February 2022

Background:
This first-in-human randomized, blinded, sham-controlled, multicenter study assessed the safety and feasibility of non-invasive vagus nerve stimulation (nVNS) for the acute treatment of ischemic and hemorrhagic stroke. Potential efficacy was also assessed.

Methods:
Eligible participants admitted to nine clinical sites received standard care for acute stroke and were randomly assigned to low-dose nVNS, sham (2-minute stimulation applied to the skin overlying the vagus nerve every 10 minutes for an hour; 7 stimulations) or high-dose nVNS (2-minute stimulation every 10 minutes during hour 1 and hour 5; 14 stimulations) within 6 hours of stroke onset. Safety endpoints included severe bradycardia (≤50 beats/min) or significant hypotension (≥20-mm Hg reduction in arterial blood pressure) evaluated at 2 and 5 minutes after each stimulation and 30 minutes after the final stimulation. Feasibility was measured as the proportion of eligible patients in whom nVNS could be initiated within 6 hours of stroke onset and the ability to deliver scheduled stimulations per protocol. Efficacy measurements included absolute and relative infarct growth 24 hours poststroke compared to baseline and the proportion of patients with an NIH Stroke Scale (NIHSS) score of ≤4 or a ≥8-point improvement at 24 hours.

Results:
Sixty-eight patients with ischemic (n=60) or hemorrhagic (n=8) stroke completed the study. Baseline characteristics did not differ between sham (n=24) and nVNS (n=44). No significant bradycardia (2.9% of sham vs 3.1% of nVNS;
p
=0.965) or hypotension (1.1% of sham vs 2.5% of nVNS;
p
=0.145) occurred with nVNS. No deaths, acute coronary syndrome, symptomatic intracerebral hemorrhage, or stimulation site reactions were noted. All patients received 100% of intended stimulations per protocol. Clinical efficacy measures were similar between sham and total nVNS. Relative infarct growth, measured by diffusion weighted imaging, in the high dose nVNS group (63.3%) was lower than in the sham group (185.8%;
p
=0.05).

Conclusions:
This study suggests that nVNS is safe and feasible for the acute treatment for ischemic and hemorrhagic stroke. Possible efficacy is suggested by a decrease in relative infarct growth.
Abstract WMP50: Saving Lives And Saving Money With Tele-stroke: Population Health Economics In South Carolina
Authors: Abdul Rahman Line , Almallouhi Eyad , Al Kasab Sami , Holmstedt Christine A , Simpson Kit N , Simpson Annie N
Published: February 2022

Background:
Over the past decade, tele-stroke networks have been shown to remarkably improve our ability to provide timely treatments for stroke patients. Data on the economic impact of tele-stroke networks are scarce. Our aim is to assess the economic impact associated with the adoption of tele-stroke in local, geographically defined areas in the state of South Carolina (SC).

Methods:
Data were extracted from SC All-payer hospital discharges database from 2014-1017. Patients included were admitted with primary diagnosis ICD-9 codes for acute ischemic stroke. SC tele-stroke tracking data was used to assign county exposure. Data was analyzed using multivariable logistic, Poisson and gamma regression models with robust error variance in Proc Genmod to estimate effects. Multiple variables were assessed including tPA treatment, mechanical thrombectomy, and cost of in-hospital and follow up care for readmissions or ED visits in patients that had tele-stroke available in-county compared to those that did not.

Results:
A total of 33,603 patients were included in these analyses. A total of 2,799 patients received tPA and 695 patients received mechanical thrombectomy. Estimated mean hospital payments were $13,715 (SD $15,742) for patients with tele-stroke available compared to $14,065 (SD $15,477) where tele-stroke was not available (P=0.0002). Total mean payments were significantly higher for patients without tele-stroke availability ($34,560 SD $51,049) compared to patients with tele-stroke available ($31,744, SD $45,517) (P<0.0001). Mean total follow up payments were also calculated and found to be significantly different for patients with tele-stroke available ($30,451, SD $50,367) compared to patients without tele-stroke ($34,258, SD $57,921) (P<0.0001).

Conclusion:
Our results indicate that tele-stroke presence in geographic locations improves treatment and outcomes in patients with acute ischemic stroke and may be expected to have an economic benefit. We observed a significant population-level association between availability of tele-stroke and mean hospital payments, follow up payments, and follow up ER visit payments.
Abstract WMP54: Stroke Secondary Prevention Care In Persons With Schizophrenia
Authors: Matheson Emilie N , Porter Joan , Kurdyak Paul , Yu Amy Y , Fang Jiming , Sheehan Kathleen A , Casaubon Leanne K , Kapral Moira K
Published: February 2022

Introduction:
Schizophrenia is associated with stroke incidence and case-fatality but the causes of this are not well-understood. We evaluated the association between comorbid schizophrenia and the quality of secondary prevention care after ischemic stroke.

Methods:
We used linked health administrative data to identify adults discharged alive from acute care hospitals in Ontario, Canada between 2004 and 2017 following an incident ischemic stroke and identified those with a history of schizophrenia using a validated algorithm. Outcomes were screening, treatment among those with the risk factor, control of vascular risk factors, and receipt of outpatient physician services. We used modified Poisson regression to model the relative risk of each indicator outcome among persons with and without schizophrenia who were alive one year after discharge, adjusting for age, sex, income, comorbidity and rural residence.

Results:
Among 85,046 persons with ischemic stroke, 886 (1.04%) had a diagnosis of schizophrenia. Those with schizophrenia were younger (median age 64 vs 72), more likely to be female (50.1% vs 44.6%), live in the lowest neighbourhood income quintile (41.1% vs 23.0%) and have diabetes (42.8% vs 32.3%). Of those alive 1 year after stroke, those with schizophrenia were less likely to be screened for hyperlipidemia (adjusted relative risk (aRR) 0.89; 95% confidence interval (CI) 0.84 to 0.94) or diabetes (aRR 0.93; 95% CI 0.89 to 0.97), be prescribed antihypertensive agents (aRR 0.96; 95% CI 0.93 to 0.99), or achieve target lipid levels (LDL < 2 mml/L) (aRR 0.87; 95% CI 0.78 to 0.96). There were no differences in prescription of antilipemic (aRR 0.96; 95% CI 0.91 to 1.01) or antiglycemic (aRR 0.95; 95% CI 0.87 to 1.03) agents or in achievement of target HbA1c ≤ 7% (aRR 0.89; 95% CI 0.78 to 1.02). Outpatient stroke specialist care in the 3 months after discharge was less likely among those with schizophrenia (aRR 0.72; 95% CI 0.65 to 0.78) as were visits to primary care physicians (aRR 0.93; 95% CI 0.91 to 0.96).

Conclusions:
People with schizophrenia and stroke are less likely to receive secondary preventive care across many indicators measured. This information may be useful for targeted interventions to improve post-stroke care in those with schizophrenia.
Abstract WMP55: Short-term Stroke Risk After Emergency Department Treat-and-release Headache Visit
Authors: Liberman Ava L , Zhang Cenai , Lipton Richard , Kamel Hooman , Parikh Neal S , Newman-toker David E , Merkler Alexander E
Published: February 2022

Introduction:
When a stroke hospitalization follows soon after an Emergency Department (ED) treat-and-release visit for non-specific neurological complaints, a diagnostic error may have occurred. In this study, we sought to evaluate potential stroke misdiagnoses after ED treat-and-release headache visits.

Methods:
We conducted a retrospective cohort study using state-wide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005-2018 and New York 2005-2016. Using standard
ICD
codes, we identified adult patients discharged home from the ED with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of back pain or renal colic (negative control cohorts). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic), defined using validated
ICD
codes. We used Cox proportional hazards modeling to assess the relationship between the index ED visit reason and stroke hospitalization adjusting for demographics and vascular risk factors.

Results:
We identified 1,458,904 patients with an ED treat-and-release headache visit; mean age was 41 (SD: 17) and 70% were female. A total of 2,636 (0.18%) headache patients were hospitalized for stroke within 30 days. Stroke risk was higher among headache patients compared to patients diagnosed with renal colic (HR: 2.7; 95% CI, 2.3-3.1) or back pain (HR: 3.8; 95% CI, 3.6-4.1; Figure). Among patients <40 years of age, stroke risk was even higher among headache as compared to back pain (HR: 10; 95% CI, 7.7-13.1); no strokes occurred in renal colic patients <40 years of age.

Conclusion:
Approximately 1 in 500 patients discharged home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was 3-4 times higher after an ED visit for headache compared to back pain or renal colic. There may be opportunities to reduce diagnostic error among patients with ED visits for headache, particularly for those <40 years of age.
Abstract WMP56: Delay To Stroke Diagnosis In Patients That Require The Use Of An Interpreter
Authors: Melmed Kara R , Rossan-Raghunath Nirmala , Worley Sandie , Dessy Alexa , Bauman Kristie , Floyd Kyra , Palaychuk Natalie , Lewis Ariane , Ishida Koto , Frontera Jennifer , Lord Aaron , Torres Jose
Published: February 2022

Introduction:
Delay to stroke diagnosis can postpone appropriate treatment leading to worse outcomes. We hypothesize that interpreter use can contribute to a delay to treatment.

Methods:
We identified consecutive patients between January 2019 and June 2021 with acute stroke (hemorrhagic or ischemic) using the Get with the Guidelines Database (GWTG). We determined the requirement for interpreter via chart review. We assessed time from last known well (LKW) to CT. We also looked at time to treatment, defined as the time from LKW to tPA administration or groin puncture. Finally, we assessed the difference in outcomes in patients using discharge modified Rankin Score (mRS). We compared these values for patients that did and did not require the use of an interpreter.

Results:
We identified 2,576 patients from GWTG and found 1,306 patients (mean age 69±16, 48% female) with acute stroke notifications. The majority (78%) of these patients were diagnosed with ischemic stroke. For patients presenting with an acute stroke, 27% required interpreter use. For patients who required an interpreter, Spanish (28%), Russian (21%) and Cantonese (18%) were the most common primary language. Compared to patients who spoke English, patients with interpreter requirements were older (73±13 years vs 68±16 years) and had a higher median NIHSS admission score (8[3-18] vs 4[2-13]), p<.05 for both. There was no difference in arrival time to stroke code activation. However median time to CT [IQR] from LKW was longer for patients who required an interpreter (334 minutes [121-955] vs. 274 minutes [106-765], p=.03). Patients who required an interpreter were less likely to get tPA (15% vs 24%, p=.05), and had a longer time between LKW and treatment (60 minutes [36-85] vs 48 [31-75], p=.02). Patients who required an interpreter had a higher discharge mRS (3 [1-4] vs 2 [1-4], p=.02).

Discussion:
Interpreter requirement was associated with longer time to stroke diagnosis, reflecting a pre-hospital delay in the identification of stroke symptoms, despite the higher NIHSS. These patients were less likely to receive tPA and had a higher discharge mRS. Interpreter requirement merits consideration for systemic changes that might prevent this health care administration disparity.
Abstract WMP64: Multimodal Bayesian Modeling Of Stroke Severity
Authors: Bonkhoff Anna , Bretzner Martin , Hong Sungmin , Schirmer Markus D , Giese Anne-Katrin , Donahue Kathleen , Nardin Marco , Etherton Mark R , Regenhardt Robert , Wu Ona , Jern Christina , Lindgren Arne , Maguire Jane , Lin Christopher , Schaper Frederic , Ferguson Michael , Cohen Alexander , Fox Michael , Rost Natalia S ,   on behalf of the MRI-GENIE and GISCOME Investigators and International Stroke Genetics Consortium.
Published: February 2022

Introduction:
Understanding the relations between lesions and outcomes is a particularly promising avenue to support tailored stroke care. We here employed a novel Bayesian framework integrating lesion location and functional lesion connectivity, i.e., lesion network mapping data, aiming to augment the prediction of stroke severity and the interpretability of lesion-symptom associations in a multi-center cohort of acute ischemic stroke (AIS) patients.

Methods:
Analyses relied on 1,077 AIS patients of the MRI-GENIE study [age: 64.2(14.7), 38%women]. NIHSS-based stroke severity was modeled via Bayesian linear regression. Structural location and functional connectivity information was represented by ten unique patterns each. We compared the out-of-sample predictive performances of structural vs. structural-functional models in Bayesian model comparisons. In ancillary analyses, we extracted functional connectivity pattern relevant for stroke severity and repeated analyses after stratifying for lesion size (50% of patients with larger lesions). Models were generally adjusted for age, sex, comorbidities and total DWI lesion volume.

Results:
Model comparison indicated a benefit of the combined structural-functional stroke severity prediction model compared to the structural one (model weights: 82% vs. 18%). This benefit of the combined model became even more apparent in case of patients with large lesions (97% vs. 3%). Positive lesion connectivity to the bilateral ventral attention (VA) and somatomotor networks, as well as temporal default mode network (DMN) predicted higher severity, while positive connectivity to more medial parts of the DMN and the visual network predicted lower severity. Additionally, negative lesion connectivity to the bilateral DMN, somatomotor, dorsal attention, and control networks predicted higher, and negative connectivity to the right control and bilateral VA networks predicted lower severity.

Conclusions:
Model comparisons indicated a benefit of integrating structural and functional information for the prediction of stroke severity, especially in case of larger lesions. Lesion connectivity data can enhance our understanding of why specific lesion locations can lead to symptoms post-stroke.