bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 138: Cost-Effectiveness of Insertable Cardiac Monitors to Identify Atrial Fibrillation After Stroke Attributed to Large-Artery or Small-Vessel Disease
Authors: Yaghi Shadi , Pollitt Vicki , Bernstein Richard A , Rose David Z , Witte Klaus K , Reynolds Matthew R , Cudworth Sarah , Carpenter Julius , Rosemas Sarah C , Ziegler Paul D , Neisen Karah , Franco Noreli C , Margetta Jamie , Pouliot Erika , Schwamm Lee H
Published: February 2024

Introduction:
Identification of atrial fibrillation (AF) in patients with stroke is critical for secondary stroke prevention with guideline-recommended oral anticoagulation (OAC). The randomized STROKE AF trial evaluating patients with ischemic stroke attributed to large-artery or small-vessel disease (LAD/SVD) found that insertable cardiac monitors (ICMs) were more likely to detect AF than standard of care (SoC) using intermittent external ECG monitors. However, the cost-effectiveness of ICMs in this population is not known. This study aimed to evaluate the cost-effectiveness of ICMs to detect new AF in patients with LAD/SVD stroke in the U.S.

Methods:
Using patient data from STROKE AF (N=492, median CHA
2
DS
2
-VASc=5.0), a lifetime Markov model was developed to assess the cost-effectiveness of ICM vs. SoC from a payer perspective. SoC was based on the frequency of ECG/Holter monitoring observed in the trial. AF detection was assumed to result in a switch from aspirin to OAC, unless precluded by prior bleeds. Lifetime risks of stroke and bleeding events were based on underlying presence of AF and the safety and efficacy of the treatment received. Future costs/effects were discounted at 3% annually to adjust to present values. Sensitivity analyses were conducted to assess uncertainty.

Results:
ICM was associated with a gain of 0.17 quality-adjusted life years (QALYs) versus SoC (6.63 vs. 6.46), driven by higher incidence of OAC and consequent reduction in lifetime ischemic strokes, with 53 fewer strokes projected per 1,000 patients. Total lifetime per-patient costs were $65,989 and $59,703 in the ICM and SoC arms, respectively. The incremental cost-effectiveness ratio was $37,760 per QALY gained compared to SoC (under the $50,000/QALY threshold considered highly cost-effective in the U.S.). Cost-effectiveness improved further in the subset with CHA
2
DS
2
-VASc≥6. In the patients at highest risk of AF detection (left atrial enlargement, heart failure, obesity, or prolonged QRS), the cost/QALY was $22,016.

Conclusions:
ICMs are likely to be cost-effective in the U.S. for the diagnosis of AF in the population with stroke attributed to LVD or SVD. This strategy was most cost-effective in patients with high CHA
2
DS
2
-VASc scores and those at greatest risk of AF.
Abstract 14: Associations Between Measures of Structural Racism and Acute Ischemic Stroke Incidence in the US
Authors: Polineni Sai P , Polineni Praneet , Santos Daniel , Daniel David , Dhamoon Mandip S
Published: February 2024

Introduction:
Racial differences in socioeconomic characteristics are believed to be secondary to structural racism. While socioeconomic factors explain some of the racial disparity in stroke incidence at an individual level, little is known about the association between societal-level structural racism and the incidence of acute ischemic stroke (AIS).

Methods:
We conducted a national cross-sectional analysis of 71,078,619 adults aged >65 years enrolled in Medicare from January 1, 2016 to December 31, 2019. The primary exposure was a county-level composite structural racism score that was calculated from constituent measures of structural racism: segregation indices (delta index, dissimilarity index, isolation index), Gini index, housing discrimination, educational attainment ratio, employment ratio, income ratio. The primary outcome was AIS incidence.

Results:
The composite structural racism score identified significant geographic variation in structural racism across the U.S. (mean 0.818, SD 2.874, IQR 3.02). Among 844,406 Medicare beneficiaries with incident AIS, Black individuals had a 19% increased hazard of AIS compared to White individuals (HR 1.19, 95% CI 1.14-1.25, p<0.0001). Increasing segregation conferred increased incidence of AIS for both Black and White populations. Each standard deviation increase in the composite structural racism score was associated with an 18% increased incidence in AIS (HR 1.18, 95% CI 1.12-1.24) in the total population. This association interacted with race (p=0.03), with a greater magnitude of association for White (HR 1.19, 95% CI 1.13-1.25, p<0.0001) versus Black (HR 1.09 ,95% CI 1.03-1.16, p=0.0073) individuals.

Conclusions:
There is significant geographic variation in structural racism at the county level across the US, and increasing levels of structural racism are associated with increased incidence of AIS, regardless of race.
Abstract 142: Automated Text-Messaging System for Assessment of 90-day Modified Rankin Scale After Stroke
Authors: Abbasi Mohammad Hossein , Yuan Qingyang K , Kasner Scott E , Sloane Kelly L
Published: February 2024

Background:
The modified Rankin scale (mRS) is commonly used to measure disability after stroke, traditionally assessed through telephone or in-person evaluation. Here, we investigated the validity of mRS assessment through automated text-messaging as an alternative method to traditional assessments.

Methods:
Two hundred and fifty patients admitted to 3 hospitals within the University of Pennsylvania Health System with ischemic or hemorrhagic stroke were enrolled. Participants received automated text-messages 48 hours prior to their outpatient appointment at about 90-days post-stroke. The mRS scores were assigned based on participant responses to 2-4 yes/no questions, based on the simplified modified Rankin scale questionnaire (SmRSq). The mRS was then evaluated in-person or by telephone interview for comparison. Responses were compared with kappa(κ).

Results:
Among the one hundred and forty-two patients (57%) who completed the study: mean age 62 years; 45% female; 48% white, 45% black; 84% ischemic stroke; median baseline NIHSS 4. The patient was the responder in 63%, surrogate in 37%. Spontaneous response rate to text messages was 46% and up to 72% with an additional direct in-person or phone call reminder. Agreement (Figure) was substantial (quadratic-weighted κ=0.87) between responses derived from the automated text messaging and traditional interviews. Agreement for distinguishing functional independence (mRS 0-2) from dependence (mRS 3-5) was substantial (unweighted κ=0.79).

Conclusion:
An automated text messaging system is a feasible and highly reliable tool for determining mRS and can serve as an alternative to traditional in-person or telephone assessment.
Abstract 148: Increased Systolic Blood Pressure Variability During the First 24-hours of Hospitalization Associates With Poor 90-day Outcome After Intracerebral Hemorrhage
Authors: Potter Thomas B , Bako Abdulaziz , Pan Alan P , Borei Karim , Prince Taya , Khan Osman , Garg Tanu , Gadhia Rajan R , Volpi John J , Chiu David , Britz Gavin W , Vahidy Farhaan
Published: February 2024

Introduction:
Prospective studies and secondary analyses from clinical trials have identified increased systolic blood pressure variability (SBPV) as a risk factor for poor outcomes. Evidence of this association in real-world intracerebral hemorrhage (ICH) hospitalization is lacking, however.

Methods:
Data for adult (≥18) patients with primary ICH were retrieved from the REINAH cerebrovascular research database. Systolic blood pressure measurements from the first 24 hours of admission were retrieved and SBPV was calculated as the Coefficient of Variation (CV) = (standard deviation/mean)*100. Socioeconomic deprivation was assessed using the state Area Deprivation Index (ADI), with high deprivation assessed at ADI ≥ 8. The primary outcome was severe disability or death (SDD; modified Rankin Scale ≥4) at 90-days after discharge. Differences in SBPV across SDD were assessed using the Mann-Whitney U test. Associations between SBPV and SDD were assessed using multivariable logistic regression models adjusted for patient characteristics. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) are reported.

Results:
Final cohort included 807 patients (median [IQR]: 66 [54-77], 45.6% female), with an ethno-racial distribution of 41.9% White, 25.9% Black, 23.9% Hispanic, 5.7% Asian, and 2.6% Other. The median CV was 12.07 [9.50-15.59] and 485 (60.1%) patients experienced SDD. Patients with SDD showed significantly higher SBPV than non-SDD patients (12.90 [10.33-17.11] vs 10.99 [8.72-13.72]; p<0.001). Patients with 24-hour SBPV in the 3
rd
(1.86 [1.16-2.96]) and 4
th
quartile (3.10 [1.89-5.09]) had higher independent odds of SDD (vs. 1
st
quartile) (Figure 1).

Discussion:
Patients with high SBPV during the first 24 hours of admission have higher odds of severe disability or death at 90-days after discharge.
Abstract 17: SARS-CoV-2 Spike Protein Exacerbates Thromboembolic Cerebrovascular Complications in Humanized ACE2 Mouse Model
Authors: Heath Stan P , hermanns Veronica C , Coucha Maha , Abdelsaid Mohammed A
Published: February 2024

COVID-19 doubles the risk for acute ischemic stroke in patients with cardiovascular disorders, yet, the molecular mechanisms are unclear and remain unresolved medical challenges. We hypothesize that SARS-CoV-2 spike protein exacerbates stroke and neurovascular complications via increasing coagulation and decreasing fibrinolysis by disrupting the renin-angiotensin-aldosterone system (RAAS) balance.

Methods:
MCA/FeCl
3
thromboembolic model was induced in humanized ACE2 knock-in mice. hACE2 mice were treated with Losartan, an angiotensin receptor blocker, after one day of SARS-CoV-2 spike protein injection. Cerebral blood flow was measured using a Laser speckle imager. Infarct size was compared using TTC stain. Vascular-induced cognitive function and dementia (VCID) were assessed using a Novel object recognition test. D-dimmer, Tissue factor -3 (TF-3), and Plasminogen activator inhibitor-1 (PAI-1) were measured using ELISA and Western blot to assess coagulation and fibrinolysis. Human brain microvascular endothelial cells (HBMEC) were exposed to hypoxia with/without SARS-Co-V2 spike protein and were assessed for coagulation factors, inflammation, and RAAS balance.

Results:
SARS-CoV-2 spike protein increased neuronal death and decreased cognitive function after MCA/FeCl
3
thromboembolic occlusion. hACE2 mice subjected to SARS-CoV-2 spike protein showed diminished cerebral blood flow compared to control groups. SARS-CoV-2 spike protein increased coagulation factors (increased TF-3, P<0.05) and decreased fibrinolysis (increased PAI-1, P<0.05) in hACE2 and HBMVEC. Losartan reduced spike protein-induced infarction and improved cognitive function in hACE2 mice. SARS-CoV-2 spike protein caused RAAS system imbalances in hACE2 mice by increasing AT
1
R and downstream inflammatory signal. Moreover, spike protein decreased the protective RAAS arm by decreasing AT
2
R and Mas receptors in hACE2 mice and HBMVEC.

Conclusion:
SARS-CoV-2 spike protein exacerbates hypercoagulation and inflammation leading to increased cerebrovascular damage and cognitive dysfunction. However, the AT
1
R blocker, Losartan, restored the RAAS balance and reduced COVID-19-induced thromboembolic cerebrovascular complications.
Abstract 24: Differences in Door to Needle and Door In Door Out Times for Tenecteplase vs Alteplase in Acute Ischemic Stroke: Findings From Get With the Guidelines Stroke
Authors: Warach Steven J , Weber Jeremy , Alhanti Brooke , Messe Steven , Schwamm Lee H , Fonarow Gregg C , Sheth Kevin N , Smith Eric E , Mullen Michael T , Sampaio Silva Gisele , Mac Grory Brian C , Xian Ying , Saver Jeffrey L
Published: February 2024

Introduction:
Tenecteplase (TNK) has arisen as an alternative to alteplase (ALT) for emergent treatment of acute ischemic stroke. Shorter times to prepare and administer TNK raises the possibility that TNK use leads to faster treatment and transfer times.

Hypothesis:
We hypothesized that treatment with TNK is associated with shorter door-to-needle (DTN) and door-in-door-out (DIDO) times.

Methods:
Using the US Get With The Guidelines-Stroke registry, we performed a retrospective, observational cohort study of consecutive patients treated with either TNK or ALT between July 1, 2020 and June 30, 2022. The exposure was treatment with TNK vs ALT. The primary endpoints were DTN and DIDO. We fit generalized linear mixed models to determine the association between TNK (vs ALT) and endpoints after adjustment for key demographic, clinical, and hospital-level variables. A secondary analysis compared changes in DTN among hospitals that switched to TNK in 2021 with at least 10 cases per year pre and post switch.

Results:
From 2092 sites, 133,228 patients received intravenous thrombolysis. Among the 13,988 (10%) treated with TNK, median age was 70 yrs, median NIHSS 7, 47% female, 21% received endovascular thrombectomy (EVT), and 9% were transferred from the hospital emergency department after receiving lytic. Among 119,240 (90%) treated with ALT, median age was 69 yrs, median NIHSS 7, 48% female; 17% received EVT, and 12% were transferred after lytic. In the primary DTN analysis, time to treatment was shorter with TNK, with mean 47.0 vs 52.7 minutes and DTN ≤60 mins in 77.5% vs 70.7% (TABLE). In the primary DIDO analysis, time to departure was shorter with TNK, 108.3 vs 114.1 minutes. In centers that changed from ALT to TNK during this period DTN times were significantly lower after switching.

Conclusions:
In this largest study of TNK vs ALT workflow time intervals in ischemic stroke using population-based data, TNK use was associated with more favorable DTN and DIDO times relative to ALT use.
Abstract 26: Regional Inequities in Access to Stroke Facilities in India - Estimating Travel Distance and Times for Thrombolysis and Thrombectomy
Authors: Mitra Arun , Asif Kaiz S , huded Vikram , Ortega-Gutierrez Santiago , Herial Nabeel A , Jadhav Ashutosh P , Yavagal Dileep , soman biju , Sylaja PN N
Published: February 2024

Introduction:
Stroke is a global health concern, with its impact more pronounced in low- and middle-income countries like India. The access to acute stroke treatments, especially intravenour thrombolysis and mechanical thrombectomy, is limited. This research dives into the regional variations in the distribution and accessibility of stroke centers in India.

Methods:
Data on stroke centers, including those capable of intravenous thrombolysis (IVT) and endovascular treatment (EVT), was gathered from pertinent medication and device providers and geocoded. We estimated driving distances and travel durations between population centers and their proximate IVT and EVT stroke facilities using Google Distance Matrix API, which provided gross estimations. We then compared the estimates across different zones to look at regional disparities in access to stroke facilities.

Results:
Of the 566 IVT-capable centers spread across 26 states/UTs, 361 (63%) were equipped for EVT. The average stroke centres per million (SCPM) population was 0.41 and 0.26 for IVT-C and EVT-C, respectively. Majority of stroke centres were located in the south zone (>35%), followed by the western and central zones, while the north, east and northeast zones collectively accounted for just 15% of stroke facilities. Median travel distances to IVT and EVT centers were 114 km and 140 km, respectively. Median travel durations to access IVT and EVT facilities stood at 3.04 and 3.46 hours, respectively. The median duration in the south zone for IVT-C and EVT-C centers was 2 and 2.5

Conclusions:
The findings of this gross estimations a comprehensive view of stroke care infrastructure in India, highlighting significant regional disparities. The substantial travel times and distinct inconsistencies in stroke care facility availability underscore the need for strategic policy interventions and focused interventions, particularly in underserved regions.
Abstract 44: Portable Optical Blood Flow Monitor for the Detection of Large Vessel Occlusion
Authors: Favilla Christopher G , Grama Kedar , Carter Sarah , baird grayson , Gitlevich Rebecca , Smith Wendy , Lebron-Cruz Alexa , Konecky Soren , McTaggart Ryan
Published: February 2024

Introduction:
Early detection of large vessel occlusion (LVO) facilitates triage to appropriate stroke centers and reduces treatment times. Prehospital stroke scales are insensitive, so we investigated the ability of the Openwater Headset, a portable optical blood flow monitor, to detect LVO in patients undergoing acute stroke evaluation.

Hypothesis:
We hypothesized that the Openwater Headset would detect LVO with greater sensitivity and specificity than prehospital scales.

Methods:
At two comprehensive stroke centers, eligible patients presented to the emergency department or were transferred from another facility for acute stroke evaluation within 24 hours of symptom onset and NIHSS ≥2. Eligible patients underwent emergent vascular imaging as per routine care. LVO was defined as occlusion of the ICA or the first/second segment of the MCA. Each patient underwent a 70-second bedside optical blood flow evaluation with the Openwater Headset (prior to endovascular therapy, if applicable). The Openwater Headset generated blood flow waveforms based on the relative change in the speckle contrast, acquired at 40 Hz. A deep neural network was trained to identify waveform features that discriminate LVO status (
Figure 1a
), withholding a validation set to test model performance. ROC analysis compared Openwater Headset performance with that of prehospital stroke scales.

Results:
135 patients completed the optical evaluation a median of 6 hours after symptom onset (IQR: 3-14). The median NIHSS was 9 (IQR: 4-18). 52 patients (39%) had a LVO. The Openwater LVO stroke alert algorithm had 81% sensitivity and 80% specificity for the presence of LVO (AUC 0.85 by ROC analysis), exceeding that of prehospital stroke scales (
Figure 1b
).

Conclusions:
The Openwater Headset outperformed prehospital stoke scales for LVO detection in patients who underwent acute stroke evaluation, but further investigation is needed to assess performance in pre-hospital settings.
Abstract 46: Minimally Invasive Surgery is Associated With Lower Mortality After Spontaneous Intracerebral Hemorrhage in the Get With the Guidelines Registry
Authors: Murthy Santosh B , Zhang Cenai , Garton Andew , Mac Grory Brian , Shah Shreyansh , Fonarow Gregg C , Schwamm Lee H , Bhatt Deepak L , Smith Eric E , Falcone Guido J , Knopman Jared , Ziai Wendy C , Kamel Hooman , Sheth Kevin N
Published: February 2024

Introduction:
The efficacy of emergent minimally invasive surgery (MIS) in improving outcomes after non-traumatic intracerebral hemorrhage (ICH) is unclear, with two randomized clinical trials (MISTIE III and ENRICH) showing conflicting results. We therefore sought to evaluate the association of MIS for ICH with outcomes in a real-world, nationally representative cohort.

Methods:
We performed a retrospective cohort study of patients with ICH in the Get With The Guidelines-Stroke registry, between 2011 and 2021. Patients who underwent open craniotomy/craniectomy and those transferred to another hospital were excluded. The study exposure was MIS, defined as a composite of stereotactic surgical evacuation and endoscopic surgical evacuation. The primary outcome was in-hospital mortality. In the primary analysis, we matched patients who underwent MIS with medically managed patients in a 1:1 manner on age, sex, race, NIH Stroke Scale, prior antithrombotic therapy, and external ventricular drain use. Logistic regression was used while adjusting for withdrawal of care. In secondary analyses, stereotactic and endoscopic surgical approaches were analyzed separately.

Results:
Among 555,964 patients with ICH, MIS was performed in 703 patients (330 had stereotactic surgery; 391 had endoscopic surgery). The matched cohort included 485 patients in each group. Median time to surgery was 1 day (IQR, 1-2). In-hospital deaths occurred in 63 (13%) with MIS and 96 (20%) without surgery. Medically managed patients had more vascular comorbidities such as hypertension, diabetes, and prior stroke than those who underwent MIS. In regression analyses adjusted for withdrawal of care, MIS was associated with lower in-hospital mortality at discharge (aOR, 0.4; CI, 0.3-0.6). In secondary analyses, stereotactic surgery (aOR, 0.3; CI, 0.2-0.6) and endoscopic surgery (aOR, 0.6; CI, 0.3-0.9) were also independently associated with lower mortality.

Conclusions:
In a large heterogeneous US cohort of ICH patients, emergent MIS was associated with lower in-hospital mortality. Longer-term follow up data with ascertainment of functional outcomes may shed more light on the benefit of surgery after ICH.
Abstract 53: Patients With Tandem Lesions Undergoing Thrombectomy Have Increased In-Hospital Stroke Recurrence Risk
Authors: Torabi Radmehr , Moldovan Krisztina , Shu Liqi , Khan Farhan , Mohammadzeh Nahid , Snow Ethan , Chang Kelvin , Furie Karen L , Yaghi Shadi , Jayaraman Mahesh
Published: February 2024

Introduction:
Mechanical Thrombectomy improves outcomes in patients with acute ischemic stroke due to large vessel occlusion. Nearly 15% of patients have a tandem extracranial and intracranial occlusion. There is limited data on in-hospital outcomes in patients with acute tandem lesions undergoing thrombectomy.

Methods:
We included patients hospitalized with acute ischemic stroke and large vessel occlusion undergoing thrombectomy at our comprehensive stroke center over a 7-year period. Data on demographics and baseline risk factors, occlusion site, and acute treatment was pulled from the stroke registry. Records were reviewed for the study outcome which was recurrent ischemic stroke during the in-hospital period, defined as new or worsening neurological symptoms due to new infarct or extension of the infarct. All outcomes were confirmed by a second neurologist. Patients were followed for 90-days and received a 90-day call to determine their modified rankin scale. We defined good functional outcome as 90-day mRS 0-2. We used fisher’s exact test and t-tests to compare categorical and continuous variables and built binary logistic regression model to compare 90-day mRS across the two groups (tandem vs. non-tandem lesions), adjusting for age and NIHSS scale.

Results:
We identified a total of 1347 patients (mean age 72 years, 51% women) who underwent thrombectomy and 226 (16.7%) had tandem lesions and 108/226 (47.8%) underwent acute stenting. Patients with tandem lesions were more likely to be men (60.6% vs. 46.6%,), have hyperlipidemia (60.9% vs. 52.1%), coronary artery disease (25.3% vs. 19.0%), smokers (35.9% vs. 20.5%) and less likely to have atrial fibrillation (20.0% vs. 46.2%) and history of congestive heart failure (8.0% vs. 16.8%), all p<0.05. Patients tandem occlusions were more likely to have in-hospital recurrent ischemic stroke (8.0% vs. 4.1%, p = 0.012). Acute stenting was not associated with improved functional outcome at 90-days (aOR 0.86, 95% CI 0.41-1.82, p = 0.703).

Conclusion:
In this large cohort of thrombectomy patients, patients with tandem lesions had increased in-hospital recurrent stroke and acute stenting in this sub-group was not associated with improved functional outcome at 90-days.
Abstract 62: Effect of Ginkgo Diterpene Lactone Meglumine on Cognitive Function in Patients With Acute Ischemic Stroke
Authors: Wang Anxin , Zhang Qian , Xu Qin , Xia Xue , Tian Xue , Zhang Yijun , Meng Xia , Zhao Xianquan
Published: February 2024

Objective:
To investigate the effect of ginkgo diterpene lactone meglumine injection on cognitive function in patients with acute ischemic stroke.

Methods:
This was a randomized, double-blind, placebo parallel-controlled, multicenter clinical trial. Patients with acute ischemic stroke within 48 hours of onset were enrolled. Patients were divided ginkgo diterpene group and placebo control group receive a 14-day treatment, the ginkgo diterpene group was treated with ginkgo diterpene lactone glucamine, and the placebo control group was treated with mimic ginkgo diterpene lactone glucamine injection. The evaluation index was the change of Montreal Cognitive Assessment scale (MoCA) score of at Day 14 and Day 90.

Results:
A total of 3452 patients from 100 centers were randomized, of which 3163 patients with complete data on MoCA at baseline, day 14, and day 90 were included in analysis set, with 1588 patients received ginkgo diterpene lactone glucamine injection and 1575 patients received mimic ginkgo diterpene lactone glucamine injection. The MoCA scores of the two groups increased after treatment, the average change of MoCA scores at Day 14 and Day 90 in ginkgo diterpene group was 3.93[95% confidence interval (CI), 3.77-4.09] and 5.51 (5.34-5.69), respectively, which was significantly higher than that in the in the placebo control group (
P
< 0.05). MoCA subentry analysis showed that the scores of visual space and execution and language in the ginkgo diterpene group were significantly higher than those in the placebo control group at Day 14, and the scores in visual space and execution, attention, language and abstract in the ginkgo diterpene group were significantly higher than those in the placebo control group at Day 90.

Conclusions:
Ginkgo biloba diterpene lactone meglumine can effectively improve the cognitive function of patients with acute ischemic stroke.
Abstract 75: Validation of Vascular Location Subcodes for Acute Ischemic Stroke by the International Classification of Diseases-10
Authors: Hirsch Jason L , Burke James F , Kerber Kevin A
Published: February 2024

Background:
The affected vascular region is included in the International Classification of Diseases-10 (ICD-10) coding scheme for stroke. These data have the potential to enable studies of vascular and regional location. For example, differentiating anterior versus posterior circulation stroke. However, the coding in real world practice has not been validated. The purpose of this study was to evaluate the validity of these subcodes.

Methods:
We identified all hospitalizations for ischemic stroke at a single center from 2018-2022. We selected a random sample of 100 hospitalizations with vascular region subcoding specifying 50 with anterior circulation subcodes (carotid, anterior cerebral artery [CA], middle CA) and 50 with posterior circulation subcodes (vertebral, basilar, cerebellar, posterior CA). The gold standard classification for the primary infarct vascular distribution was made by the study team, blinded to the subcode, after review of the available imaging studies and the medical record. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the administrative data posterior circulation subcodes versus anterior circulation subcodes with the gold standard classification. We also calculated the kappa statistic for overall agreement of the 7 vascular regions.

Results:
The final study population was 50 ICD-10 anterior circulation ischemic stroke hospitalizations and 50 ICD-10 posterior circulation ischemic stroke hospitalizations. Mean age was 68 (SD, 15) and 44% (44/100) were female. Mean NIHSS was 8 (SD, 8). Neuroimaging was performed in 100% (100/100): Head CT, 95% (95/100); MRI brain, 77% (77/100). The accuracy of the ICD-10 classification for primary posterior circulation stroke was as follows: sensitivity 89% (49/55); specificity 98% (44/45); PPV 98% (49/50); NPV 88% (44/50), respectively. The reliability of the 7-region classification was excellent (kappa statistic, 0.85).

Conclusions:
We found that the ICD-10 subcode classification for vascular location used in clinical practice had excellent agreement with our gold standard based on medical review. These data validate the use of these subcodes for anterior versus posterior circulation stroke studies.
Abstract 76: Expediting Intracerebral Hemorrhage Patients to the NeuroICU and Improving Emergency Department Length of Stay
Authors: Davis Nicolle W , Hester Jeannette M , Allen Brandon , Robinson Christopher , Wilson Christina A , Khanna Anna , Polifka Adam , syer Saradiya , Walker John W , Libunao Rommel , Marker Peggy , Singh Amita , Busl Katharina M
Published: February 2024

Introduction:
Emergency Department Length of Stay (EDLOS) impacts outcomes of critically ill intracerebral hemorrhage (ICH) patients with the risk of dying while hospitalized increasing 40% when an intensive care unit (ICU) bed is delayed beyond 4h. The NINDS recommends admission to the destination unit within 3 hours of hospital arrival; however, EDLOS for ICH patients spans about 5 hours with a wide variation. To expedite patient admission, we developed a standardized triage pathway (NeuroICU-FastTrack). In this study, we evaluated whether NeuroICU-FastTrack decreased EDLOS and whether this decreased time reduced hospital length of stay or improved patient outcomes.

Methods:
ICH patients presenting to UFHealth Shands between 1/1/22-6/30/22 were evaluated to establish baseline EDLOS, length of hospitalization, and functional outcomes defined as modified Rankin Score (mRS). On 7/1/22 NeuroICU-FastTrack was implemented and patients admitted through 6/30/23 were evaluated to establish post-intervention characteristics. To avoid bias, data was extrapolated from medical records. Statistical analyses were performed on R (v4.3.1).

Results:
Compared to the pre-intervention group (n=48), the post-intervention group (n=129) had a significantly lower EDLOS (mean 7.3h vs 4.4h, p<0.001), but no difference in functional outcomes. During the intervention period, there was a trend toward decreasing EDLOS (F(1,126)=3.91, p=0.050) and a significant decrease in the length of hospitalization by two days (F(1,123)= 4.38, p=0.038). Based on correlation analysis, the success of the NeuroICU-FastTrack is due to expedited timing of the bed request order, allocation of a pre-assigned bed, and speed of the final bed assignment (Pearson’s r= 0.307, 0.493 and 0.645 respectively; p<0.001).

Conclusion:
There is an urgent need for expedited disposition of patients with ICH to an ICU due to significant variability in stroke care provided in an ED. The NeuroICU-FastTrack process significantly decreased the EDLOS from a median time of 6.2h to 2.8h. With this decreased EDLOS, there is an associated overall decreased hospital length of stay by two days. Additional studies are being conducted to evaluate whether our intervention impacted long-term functional outcomes.
Abstract 88: Mobile Stroke Unit Management Associated With Reduction in Racial Disparities in Stroke Treatment Metrics
Authors: Czap Alexandra L , Rajan Suja S , Yamal Jose-Miguel , Jacob Asha , Wang Mengxi , Parker Stephanie , Sambursky Jacob , Bowry Ritvij , Grotta James C , Sharrief Anjail Z , Gonzales Nicole R
Published: February 2024

Background:
Racial and ethnic disparities in stroke exist across the continuum of care, including prehospital care. The impact of Mobile Stroke Units (MSUs) on racial disparities in thrombolytic treatment metrics is not reported.

Methods:
A pre-specified sub-study of ischemic stroke patients enrolled in BEST-MSU was conducted. MSU and standard management (SM) groups were divided into Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic (H) cohorts. Other racial groups were excluded (small n). Primary outcome was last seen normal to tPA time[GJ1] . Secondary outcomes included 90-day utility-weighted modified Rankin Scale (uw-mRS), functional independence (mRS 0-1), and mortality.

Results:
A total of 1420 patients were included: 557 NHW, 586 NHB, and 277 H. NHB and H groups were younger, had lower education, and higher proportions uninsured. In SM, NHB and H patients received slower care and less frequent tPA compared to NHW (Table 1). In contrast, MSU management reduced time to treatment (19 min NHW vs 46.5 min NHB vs 46 min H; p=<0.001) in NHB and H, and led to more frequent tPA (13% more NHW, 11% more NHB, 25% more H) in H. MSU management was associated with better uw-mRS across all groups (Figure 1). More functional independence was seen in NHW and NHB (adjusted OR NHW 1.79 [1.10-2.95] p=0.019; NHB 2.13 [1.38-3.33] p=0.0007). Mortality benefit was seen in H (p=0.03).

Conclusion:
MSUs overcome known disparities in thrombolytic utilization and treatment metrics in Non-Hispanic Black and Hispanic groups. Further studies are needed to evaluate care inequities that are overcome through integration of a MSU into the prehospital setting.
Abstract 90: Optimizing Triage Assessments for Large and Medium Vessel Occlusions
Authors: Nanavati Parin P , Albright Karen , Wee Claribel , Anderson Jane A , Lyerly Michael J
Published: February 2024

Introduction:
Stroke symptom assessment tools are used in various settings, including telestroke triage, to identify patients who may be candidates for endovascular therapy (EVT). EVT is now being offered to more patients including those with medium vessel occlusions (MeVOs). We hypothesize that triage screening tools have differing rates of detection for large vessel occlusions (LVOs) versus medium vessel occlusions (MeVOs).

Methods:
Using our 2021 stroke registry, we created a retrospective cohort of ischemic stroke patients with LVO, MeVO or no occlusion. Patients were treated with the standard of care (e.g., thrombolytics, EVT). Clinical and radiographic data were abstracted for each case. Patients were evaluated for hemiparesis (HP) and vision, aphasia, or neglect (VAN) using the documented presenting exam. ROC analysis was conducted to evaluate the ability of the HP + VAN screening tool to detect LVOs and MeVOs.

Results:
The cohort consisted of 299 patients (median age 66 years, 48% female, 36% Black, median NIHSS score 9). Among the 175 patients with recorded HP + one of the VAN signs, 81% (n=141) had an occlusion (LVO or MeVO). HP+VAN criteria was not met by 11% of LVOs and 33% of MeVOs. HP + VAN tool performed best for the combined endpoint of LVO or MeVO (sensitivity 0.83, specificity 0.74, AUC 0.786, Figure). Variations of this tool did not significantly improve performance (additional models with AUCs will be presented) with the exception of changing the score to from HP+VAN to “HP
or
VAN” (sensitivity 1.00, specificity 0.25).

Conclusions:
In our sample from a tertiary care center, HP+VAN is a reasonable tool for the detection of LVOs or MeVOs. The only variation that improved sensitivity was screening for hemiparesis

or

VAN. While this prevented us from missing any LVOs or MeVOs, this approach comes at a heavy cost of reduced specificity.
Abstract 93: Upgrading to Endovascular Therapy-Performing Hospital Increases Acute Ischemic Stroke Admissions
Authors: Kumar Prateek , Salazar-Marioni Sergio , Lee Eunyoung , Abdelkhaleq Rania , Niktabe Arash , Ballekere Anjan Nagesh , Le Ngoc Mai , Azeem Hussain , McCullough Louise D , Sheth Sunil
Published: February 2024

Introduction:
Given the impact of endovascular therapy (EVT) on clinical outcomes and the use of pre-hospital bypass protocols to route acute ischemic stroke (AIS) patients to EVT-performing hospitals (EPHs), there is substantial interest in upgrading stroke center certification to become EPHs. Here, we assess trends in patient volumes of AIS admissions at three hospitals after upgrade, in comparison to one long-standing EPH and six non-EPHs within the same urban area.

Methods:
From our prospectively collected, multi-institutional registry, we identified consecutive AIS admissions at ten hospitals in the Houston metropolitan area from November 2017 through March 2022. One hospital had been an EPH throughout the study period (Group A: EPH 0), three transitioned to EPHs in November 2017 (Group B: EPH 1, EPH 2, EPH 3), and six were non-EPHs (Group C). Primary outcomes were trends in volume of total AIS admissions over time determined by linear regression. Secondary outcomes included trends in volumes of tPA usage, LVO admissions, and mechanical thrombectomy (MT) determined by linear regression.

Results:
Among 13,099 patients with AIS presenting to ten hospitals, median age was 67 [IQR 57-78], 45% were female, median NIHSS was 4 [IQR 1-11], 17.5% were given tPA, 22% had LVO, and 9.5% underwent mechanical thrombectomy. Centers that became EPH in 2017 experienced an overall increase in AIS admissions (p=0.0007) at rates of 8 per year for EPH 1 (p=0.005), 5 per year for EPH 2 (p<0.001) and 4 per year for EPH 3 (p=0.11). AIS admissions did not change significantly at the original EPH (p=0.13) nor at three of the non-EPHs (p=0.24, 0.39, 0.82), and volumes decreased at the other three non-EPHs (p=0.009, 0.02, 0.09). Changes in LVO volumes did not reach significance for any group. Volumes of tPA use and MT increased for group B (p<0.005) but did not change significantly for group A (p>0.18), and tPA use decreased for group C (p=0.03).

Conclusions:
In this observational cohort study, upgrading to EPH status resulted in increasing AIS admissions over time, as well as increases in tPA use and MT. Volumes at the previously established EPH did not change significantly over the study period, while AIS admissions decreased slightly at the non-EPHs in the surrounding area.
Abstract HUP1: Health Inequities in Preeclampsia and Maternal Ischemic Stroke: A Cross-Sectional Analysis of the National Inpatient Sample
Authors: Kaur Gunjanpreet , Rodriguez Wilson , Overberg Rachel , Edgell Randall C , Wang Fajun , Christopher Kara M
Published: February 2024

Introduction:
Maternal stroke affects 30 per 100,000 pregnancies, a 3-fold higher risk as compared to stroke rate in young adults. One study reported that preeclampsia (PE) or eclampsia was seen in 36% of pregnant patients with ischemic stroke. The objective of this study is to evaluate the odds of PE and maternal ischemic stroke (MIS) in a national sample.

Methods:
We utilized the National Inpatient Sample from Q4 2015 to 2020 to examine the rates of PE and MIS in women aged 20-44. To be included in the analysis, the primary Major Diagnostic Category (MDC) code on the record was for Pregnancy, Childbirth, and Puerperium (n=3,921,672) or Newborn and Other Neonates, Perinatal Period (n=178). Univariate analysis provided crude odds of relevant variables. Multivariate logistic regression models were fitted to determine the odds of PE based on known PE risk factors; a second model was fitted to determine the odds of maternal stroke in women who had PE. Covariates in both models were age, primary payer, gestational diabetes, and obesity.

Results:
Consistent with previous knowledge, univariate analysis showed that Black women had 69% higher odds of PE compared to white women (cOR=1.69, 95%CI=1.66-1.71), while Latinas had 8% higher odds of PE compared to white women (cOR=1.08, 95%Ci=1.06-1.11). Compared to white women, Black women had 42% increased odds of MIS (cOR=1.42, 95%CI=1.14-1.78), while Latinas had 24% decreased odds of MIS (cOR=0.76, 95%CI=0.59-0.99). In multivariate analysis, PE was associated with increased odds of MIS, aOR=1.74 (95% CI=1.31-2.31). When stratified by race, this result was only found among white women (aOR=1.85, 95% CI=1.26-2.75). Having PE was not associated with odds of MIS in Black women when compared to Black women without PE (aOR=1.52, 95% CI=0.90-2.56).

Conclusion:
This study found that preeclampsia increases the odds of MIS overall. These odds are higher if patients also have other risk factors such as gestational diabetes, history of hypertension, and history of stroke. Our results also found no significant difference in MIS among Black women or Latinas based on PE status. Future directions could address other potential contributing factors, including structural factors that contribute to health inequities.
Abstract HUP14: Racial And Ethnic Disparities In Neighborhood Socioeconomic Status Associated With Cardiovascular Disease And Stroke: The Women’s Health Initiative
Authors: Shropshire Jeremey N , Follis Shawna
Published: February 2024

Introduction:
The role of socioeconomic status (SES) across cardiovascular diseases (CVD) is well researched at the individual-level but fails to explain the greater CVD rates among Black and American Indian and Alaska Native (AIAN) groups at every level of SES. This research evaluated whether lower Neighborhood SES (NSES), a structural determinant of health, was associated with racial and ethnic disparities in CVD or stroke among aging women.

Methods:
The data came from the Women’s Health Initiative (WHI) cohort, consisting of 161,808 postmenopausal women with 30 years of data on stroke and CVD incidence. The NSES data were obtained from the US Census based on participant’s census tract of residence. We evaluated racial and ethnic disparities in the exposure and outcome prevalence using ANOVA. Associations between NSES and time to stroke and CVD were evaluated using multivariate adjusted Cox Regression models, and models were stratified by race and ethnicity to evaluate disparities.

Results:
NSES differed by race and ethnicity. Black, AIAN, and Latina groups were significantly (P<0.01) more likely to live in neighborhoods with NSES Z-scores below the population mean (Z-score=0) compared with White and Asian groups. The mean NSES Z-score among Black participants was -5.21 standard deviations below the population mean. Thirty-year CVD and stroke incidence followed the same trajectory of racial disparities. Preliminary analysis suggests results from Cox regression models will identify lower NSES to be longitudinally associated with greater stroke and CVD incidence overall, and greater effect sizes among groups experiencing structural racism.

Conclusion:
This research evaluates racial disparities in NSES as a structural determinant of stroke and CVD. These findings provide evidence emphasizing the need for neighborhood-level interventions to improve CVD disparities that coalesce in marginalized communities.
Abstract HUP15: An Exploring Qualitative Study of Real Life Experiences and Needs of Psychosocial Recovery Among Chinese Community Dwelling Stroke Survivors
Authors: Chan Mimi Wai Man , Lo Suzanne H , Sit Janet W
Published: February 2024

Introduction:
Stroke survivors may face challenges in managing their psychosocial functions. However, little is known about psychosocial experiences and needs of community-dwelling stroke survivors, particularly in China.

Purpose:
This study explored the experiences and needs of psychosocial recovery among Chinese community-dwelling stroke survivors.

Methods:
Semi-structured and individual interviews were conducted with participants in Macao from community healthcare centers and supported groups using convenience sampling. Participants were asked about their experiences, challenges, and strategies for managing post-stroke psychosocial functions, and desired support for psychosocial recovery. Interview data were transcribed verbatim and analyzed thematically.

Results:
Twenty-six participants (mean age: 69.96±14.06 years old; mean post-stroke duration: 83.88±66.8 months) were recruited to participate in interviews. Regarding the experiences and challenges, most participants faced obstacles in managing emotions and barriers to rebuilding social lives due to the impacts of physical disabilities. Generally, most participants recognized that they were a minority of people in society, and some experienced further invalidation by society. The majority of participants lost motivation and expectations to face challenges, hesitated to disclose their conditions to others, and had less confidence in social interactions as they felt that they were different from others. Meanwhile, some participants adopted strategies to improve their psychosocial functions, including appreciation for oneself and important persons or events supporting them, adjustments to the disparity between expectations and reality, and reinterpretations of unpleasant experiences. Furthermore, communal creative activities offered by health professionals and peer support were recommended.

Conclusion:
To promote post-stroke psychosocial recovery in communities, health professionals should consider designing meaningful group activities for stroke survivors to meet their psychosocial needs. These findings will guide the development of interventions for enhancing psychosocial functions among Chinese community-dwelling stroke survivors.
Abstract HUP16: Exploring Differences in Stroke Type and Stroke Risk Factors Between Young African Americans and Ghanaian Stroke Women
Authors: Rivas Cindy , Edwards Aniela , Rains Hannah G , Bruzzone Maria , SARFO Fred S , Simpkins Alexis
Published: February 2024

Introduction:
Recent reports demonstrate that stroke prevalence is expanding in young women, especially in diverse populations. Our goal was to compare the stroke type and stroke risk factors among patients with African Ancestral lineage, including African Americans (AA), West African (WA) descent from Ghana, a country in West Africa, and those without African Ancestral (WAA) lineage.

Methods:
Women aged 18- 45 from our institutional stroke databases and the Kumasi, Ghana Stroke Survivors Registry between January 2014 and November 2019 were included in this retrospective study. Non-parametric t-test and chi-square analysis was used for statistical analysis to identify significant differences between stroke type and stroke risk factors.

Results:
Among the 236 subjects, the median age was similar between groups (p-value 0.3940) [40 (IQR 35-43) Ghana, n= 91; 43 (IQR 34-43) in AA, n= 43, and 39 (IQR 31-43) WAA, n= 102). In the total population, 25% had an intracerebral hemorrhage, 56% had an ischemic stroke, and 19% had a subarachnoid hemorrhage. The proportion of patients with ischemic stroke was similar between groups (p-value 0.20). However, the frequency of subarachnoid hemorrhages was the lowest in the WA cohort (9%) in comparison to AA (33%) and those WAA lineage (22%), p-value 0.017. The incidence of intracerebral hemorrhage was lowest in those WAA lineage (15%) versus the AA cohort (33%) and the WA cohort (34%) p-value 0.0358. Prevalence of hypertension was highest in Ghanaians (87%) vs 60% AA, and 34% in those WAA lineage, p-value 0.0008. Patients from Ghana were less likely to smoke (1%) versus AA cohort (36%), and those WAA (31%) lineage, p-value 0.0001.

Conclusion:
Significant differences were found between stroke type and risk factors in young women with stroke (hypertension, DM, and smoking), race, and country of origin. These findings are important because behavioral interventions reducing smoking and controlling blood pressure are effective for the prevention of subarachnoid and intracerebral hemorrhage. Studying social and environmental influential factors between groups may identify points of intervention to reduce stroke in AA and West African young women.