bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP37: The Relationship Between Long-Term Neuropsychiatric Symptoms and Cognitive Performances in Intracerebral Hemorrhage Survivors
Authors: Tsai Hsin-Hsi C , Lin Sheng-Sian , Tsai Li-Kai , Jeng Jiann-Shing S
Published: February 2024

Introduction:
Neuropsychiatric (NP) symptoms have substantial influence on patients surviving with intracerebral hemorrhage (ICH), but their impact to cognitive impairment and life quality are poorly understood. We aim to investigate the subtypes of long-term NP symptoms, and their correlation to neurocognitive profiles and quality of life (QoL) in ICH survivors.

Methods:
Fifty-six patients survived with spontaneous ICH for at least 12 months were prospectively recruited to participate in this study. Each patient received comprehensive neurocognitive and NP assessment as well as a questionnaire for their QoL. We reported the prevalence and types of NP symptoms, and compared the demographic and neuroimaging findings between patients with and without NP symptoms. Multivariable linear regression models were applied to investigate the association between NP symptoms and cognitive domains after adjustment for age, sex, educational years, hematoma location and small vessel disease (SVD) scores.

Results:
NP symptoms were present in 24 (42.9%) of the recruited patients, in which affective symptoms were most common (35.7%), followed by apathy/vegetative symptoms (26.8%), hyperactivity (17.9%), and psychosis (1.8%). Patients with NP symptoms showed more cerebral SVD changes and they were associated with worse general cognitive abilities (p<0.05). In our analysis regarding each NP subtype, the presence of apathy/vegetative symptoms was associated with slower processing speed (p=0.015) and worse category fluency (p=0.042) while the affective or hyperactivity symptoms were neither associated any domain-specific neurocognitive functions. Additionally, the presence of these NP symptoms except for psychosis independently predicts worse QoL.

Conclusions:
Long-term NP symptoms are frequent in ICH survivors and is independently related to cognitive dysfunction and worse life quality. The NP subtype, especially apathy/vegetative symptoms, should be well-characterized for their contribution to neurocognitive domains.
Abstract TP41: Racial Differences in Cumulative Blood Pressure Exposure and Hippocampal Subvolumes
Authors: Kaprielian Hagop , Mahinrad Simin , Milstead Andrew , Tan Can Ozan , Sorond Farzaneh A
Published: February 2024

Introduction:
We previously showed that a higher cumulative systolic blood pressure (cSBP) burden from young adulthood to midlife was associated with lower hippocampal volumes in Black but not White individuals independent of other vascular risk factors (VRF). And this difference was particularly evident in those with highest cSBP. In this study, we further explored these relationships by examining the impact of cSBP exposure on different hippocampal subvolumes.

Methods:
Thirty-four participants (18 black, 16 white) in the highest quartile of cSBP and longitudinal VRF exposure over 30 years with available brain MRI at the year 30 visit of the Coronary Artery Risk Development in Young Adults (CARDIA) cohort were used for this analysis. We measured the hippocampal subvolumes (CA1, CA2/3, and CA4) standardized as a percentage of total intracranial volume. T1 MRI images were processed using FreeSurfer (7.3.2) recon-all and the hippocampal sub-regions were segmented based on the computational atlas available in FreeSurfer.

Results:
Among the three regions, cSBP was only associated with CA1 subvolume in Black but not White participants. Racial differences were most evident in the CA1 hippocampal subvolume (p=0.099) and this difference remained even when other VRF were accounted for.

Conclusion:
Blacks with higher cSBP exposure over young adulthood to midlife, have smaller hippocampal CA1 subvolumes, which parallels the disparities in cSBP we previously reported. Our findings further highlight the anatomic vulnerability of the CA1 region to cSBP exposure and underscore the importance of early blood pressure control, particularly in minority populations where early screening for VRF may be limited.
Abstract TP53: Above Par on the Back Nine: Improving Triage of Posterior Circulation Stroke
Authors: Beavis James , Lewis Maya
Published: February 2024

Background and Purpose:
Notoriously difficult to recognize, posterior circulation strokes (PCS) can be some of the most devastating. It is incumbent on the triage nurse to recognize these signs and symptoms. This project was developed to educate frontline ED staff on early identification of posterior strokes, decrease time to recognition, and improve outcomes.

Methods:
The community Primary Stroke Center (PSC) identified the need to improve recognition of PCS after a series of treatment-eligible patients were missed. A team was created including the directors of the PSC and associated Comprehensive Stroke Center (CSC), emergency room physicians, and nurses. A triage algorithm was created to capture as many strokes as possible without a glut of false positives. This included focal and non-focal signs of stroke. ANY sign of stroke should initiate the code stroke (CS) process provided that the presentation was within 24 hours of last known well, the presentation was sudden, and the symptoms were disabling to the patient. Once approved, the algorithm and education were provided to all patient-facing ED staff. Updates were added to huddle notes and a copy of the algorithm was made available at all triage areas. Data was collected retroactively for a total of 16 months, 8 months prior to the intervention and 8 months after.

Results:

- For all PCS the median time from arrival to initiation of CS improved from 9 minutes to 1 minute

- For all PCS the median time from arrival to confirmation of stroke improved from 597 minutes to 249 minutes

- Prior to intervention, only 60% of CS-eligible patients had a CS initiated, compared to 92% after

- Ninety-day Rankin was from 0-2 in 86% of PCS patients prior to intervention compared to 100% after

Conclusions:
A clear triage process can maximize identification of PCS, increase capture of treatment-eligible patients, and decrease disability. A PSC with tele-stroke coverage and ongoing education improved identification of posterior circulation strokes and outcomes. Key takeaways for success include clear and concise code stroke algorithm, support from providers, and ongoing educational interventions. While this data is preliminary, we will continue to track and trend. Next steps should include education directed to EMS personnel in the field.
Abstract TP6: Identification of Circulating Epigenetic Biomarkers for Seizure in Brain Arteriovenous Malformation by Methylome Profiling
Authors: Park Peter , Nelson Jeffrey , Fox Christine K , Numis Adam , Ko Nerissa , Winkler Ethan , McCulloch Charles , Kim Helen , Weinsheimer Shantel
Published: February 2024

Background:
Brain arteriovenous malformations (bAVMs) are an important cause of intracranial hemorrhage, seizure, or other neurological deficits. Clinical heterogeneity of bAVM suggests a role for genetic modifiers that may associate with seizure risk. DNA methylation is a reversible epigenetic mechanism that regulates gene expression in development and disease. We hypothesized that DNA methylation in epilepsy-related genes is associated with seizure at presentation in bAVM patients.

Methods:
We performed a literature review in PubMed to identify epilepsy-related genes with potential epigenetic regulation using the search terms: epigenetics, DNA methylation, seizure, epilepsy. We selected 19 unruptured bAVM cases (mean age 44.9 y) enrolled in the bAVM study at UCSF, including 10 presenting with seizure. We performed methylome sequencing of genomic DNA extracted from whole blood using bisulfite sequencing services at Psomagen with ~20X coverage. Differentially Methylated Regions (DMR) mapping to or nearby the candidate seizure genes were identified by comparing the average methylation ratio in bAVM cases presenting with and without seizure by t-test. DMRs with a delta average methylation ratio between the two groups ≥
Abstract TP66: Decreased Order to Administration Times Following Transition to Tenecteplase for Acute Ischemic Stroke
Authors: Johnson Leonard E , Michael Catherine , Lycan Sarah L , Guzik Amy K
Published: February 2024

Introduction:
Alteplase was the first approved tissue plasminogen activator and standard of care for acute ischemic stroke (AIS). The utilization of Tenecteplase as a thrombolytic agent in AIS has offered many organizations several advantages over Alteplase, including ease of preparation and administration. Both thrombolytic agents require a Physician's order and reconstitution by a certified Pharmacist or Registered Nurse prior to administration. Our academic comprehensive stroke center transitioned from Alteplase to Tenecteplase as standard thrombolysis for acute ischemic stroke in November 2022. Treatment times were monitored to explore the benefits of a single bolus administration.

Methods:
A retrospective chart review was conducted at a single academic comprehensive stroke center. Patients were included if they received thrombolytic therapy in the Emergency Department for a diagnosis of AIS. Patients prior to November 2022 received Alteplase, and those after November 2022 received Tenecteplase. We evaluated the time frame for the medication bolus order for Alteplase and Tenecteplase to the administration time.

Results:
Of 140 patients screened, 108 were included in the study, with 51 in the alteplase group and 57 in the Tenecteplase group. Mean order to administration times were 10.9 minutes in the alteplase group and 7.37 minutes in the Tenecteplase group, with statistical significance (P=0.0052). There was no significant difference in mean door-to-needle time (59.27 Alteplase vs 53.09 Tenecteplase, P= 0.1803).

Conclusions:
In a single CSC, the transition from Alteplase to Tenecteplase reduced the order to administration time by 3.53 minutes. The decreased administration time highlights one of Tenecteplase’s potential advantages. Further review is necessary to evaluate additional stroke metrics and clinical outcomes.
Abstract TP67: Know Your Numbers: Refining the Stroke Alert Process for Hospitalized Patients
Authors: Sheehan Tiffany O , Schroeder Tracie , Kramer Wendy , Warga-Lopez Wendy , Reynolds Ina , Williams Audra , Plueger Madona
Published: February 2024

Background and Issues:
Patients who experience an in-hospital stroke often have delayed treatment compared with patients presenting to the ED. AHA Scientific Statement on Best Practices to Improve Management of In-Hospital Stroke recommends a targeted QI team to address barriers to treatment.

Purpose:
To establish a targeted QI team to evaluate in-hospital stroke alert (SA) response times, identify performance opportunities and develop an improvement plan.

Methods:
A QI team was formed in Jan 2023. Data were collected from the EHR and analyzed (i.e., symptom discovery to SA, SA to response team arrival, arrival of response team to imaging, imaging to treatment). Barriers to timely treatment were identified through the use of case timelines and stroke nurse champion focus groups. One barrier identified was the use of a non-emergent operator vs. the emergency hotline to activate a SA. Use of the non-emergent line left staff placed on hold, resulting in a delay of SA activation. In March 2023, PDSA cycle #1, use of the emergent hotline, was implemented and house wide staff education were administered addressing the process change.

Results:
Data were collected between Dec 2022-June 2023. There were a total of 64 SA activations, 53% were activated on a non-neuroscience unit, and 33% were diagnosed with a stroke. Three patients were treated with a thrombolytic (n=2, avg. 47 min) or thrombectomy (n=1, 55 min). Prior to implementation (Dec-Feb 2023) symptom discovery to SA averaged 8 minutes (n=28) and remained unchanged post implementation (April-June 2023, avg. 8 min, n=36).

Conclusion:
A targeted QI team focused on in-hospital SA processes showed benefit by identifying opportunities to decrease time to treatment. No change was seen in the avg time from symptom discovery to activation. Future areas of opportunity include focused education on non-neuroscience units and strategies aimed at decreasing the time from SA to imaging interpreted.
Abstract TP68: Nina Campbell MSN BSN RN
Authors: campbell Nina , LINDNER ALEXANDRA
Published: February 2024

Many of the American Heart Association’s Get with the Guidelines metrics for stroke are medication-related, including appropriate utilization of antithrombotics, statins, and anticoagulation. Furthermore, for the subpopulation of patients with type 2 diabetes, an antihyperglycemic medication with proven cardiovascular benefit is indicated. Abstraction to the American Heart Association Get with the Guidelines has clear but complex guidelines on criteria for meeting these metrics. Our goal was to improve adherence to the guidelines via pharmacist assessment, discussion, and documentation. Prior to December 2022, clinical pharmacists had been reviewing the use of antithrombotics, statins, and anticoagulation in stroke patients and reaching out to the provider with concerns. However, they were not yet reviewing the use of antihyperglycemic medications with proven cardiovascular benefit nor documenting assessments/rationale in the patient’s chart. In December 2022, pharmacists started evaluating antihyperglycemic medications with proven CVD benefits in addition to the above, with assessments taking place Monday through Friday. The pharmacist would reach out to the provider when necessary and also document rationale for appropriate avoidance of usual recommended therapy, if indicated. The most notable intervention was the creation of pre-formatted note with the various specific ways to meet each medication-related metric in accordance with Get with the Guidelines abstraction criteria. Baseline data from January to November 2022 indicated good adherence to the stroke metrics involving the use of antithrombotics, statins, and anticoagulation that pharmacy was already following at that time, ranging from 97.7-100% adherence. However, the metric of addressing an antihyperglycemic medication with proven CVD benefit was only met 47.1% of the time. After the above intervention, data collected from March to July of 2023 demonstrated a stable effect on the metrics that were already above goal, ranging 96.5% to 100%, but there was a significant increase in adherence to the antihyperglycemic medication with proven CVD benefit, which went from 47.1% to 83.3%.
Abstract TP7: A Case Series of Spontaneous Thrombosis With a Conservative Approach to Posterior Spinal Artery Aneurysm Management
Authors: Pirahanchi Yasaman , Atchie Benjamin , Dao Athena , Rodriguez-Brizuela Richard , Izaguirre Simon , Kaminsky Ian
Published: February 2024

Ruptured spinal artery aneurysms, <1% of SAH, pose challenges in understanding and management. In contrast to intracranial aneurysms, they often manifest with symptoms like back pain and possibly myelopathy. While morbidity and mortality seem low, limited data makes generalizations difficult. Fatalities have resulted from re-ruptures. Management options—surgical clipping, endovascular treatment, and conservative care—lack consensus. Surgical clipping appears to be most common, recommended for rebleeding prevention. However, some advocate conservative care due to spontaneous regression and low rebleeding risk. Our study presents five cases of spinal SAH from posterior spinal artery aneurysms. Patients aged 58-81, with three males and two females, who underwent spinal angiography and a repeat angiogram in 1-9 days between 2018 and 2022 at two Denver institutions. Notably, our study is the largest single practice case series to date. All patients initially reported back pain, with three experiencing leg paresthesias. One patient had confusion and a seizure. Four of the five were hypertensive. Crucially, all five patients achieved resolution and aneurysm occlusion on repeat angiograms. Our findings highlight the potential of conservative care for ruptured spinal artery aneurysms, with spontaneous thrombosis demonstrated on short-term follow-up angiograms. Based on our results, we propose a “hybrid” approach: starting with conservative management and angiographic follow-up in 3 to 7 days, typically when most aneurysms occlude. Clinical deterioration or persistent/worsening angiographic features at one week would prompt endovascular or surgical intervention as needed.
Abstract TP80: Differences in Access to Post Acute Care Services Between Traditional Medicare and Medicare Advantage Beneficiaries in Michigan
Authors: Hailat Raed , Thompson Mike P , Nickles Adrienne , Oostema J. Adam , de los Campos Gustavo , Reeves Mathew J
Published: February 2024

Introduction:
In recent years, Medicare Advantage (MA) enrollment in the US has increased dramatically relative to traditional Medicare (TM). There is evidence to suggest that MA stroke patients are less likely to receive inpatient rehabilitation facility (IRF) based care in favor of home health. To evaluate potential gaps in quality of care, we compared post-acute care use patterns following hospitalization for acute stroke between TM and MA populations.

Methods:
We probabilistically linked data from Michigan’s Get With The Guidelines-Stroke registry and Michigan Value Collaborative multipayer claims data registry for 16,231 TM and MA beneficiaries discharged alive following acute stroke (ICD-10 I61-I63) between 2016-2020. We used discharge claims to identify the initial discharge destination classified as home, home health, IRF, skilled nursing facility (SNF) or other. Unadjusted differences in proportions and time trends between TM and MA populations were assessed using chi square statistical tests.

Results:
TM and MA-insured patients constituted 75.1% and 24.9% of the 16,231 stroke discharges, respectively. Compared with TM, MA beneficiaries were older (77.4 vs 75.8,
P
<0.001), less likely to be female (50.3% vs 55.3%,
P
<0.001), and more likely to be white (87.0% vs 82.4%,
P
<0.001). Over the study period, the proportion of MA patients increased from 21.2% in 2016 to 32.4% in 2020 (
P
<0.001) (Table). Overall, significant differences in discharge destination were due to more MA patients discharged to home and home health (
P
<0.001). Despite significant differences between MA and TM populations, there were no consistent time trends in discharge patterns. However, the exception was in 2020 where increased utilization of home health was accompanied by decreases in IRF and SNF discharge.

Conclusions:
We did not find clinically meaningful differences in discharge patterns between TM and MA populations. Changes in 2020 were likely attributed to COVID-19.
Abstract TP88: The Role of Tele-Occupational Therapy to Facilitate Occupational Performance in Stroke Survivors Selected by Patient Reported Outcomes
Authors: Cristina Guirao , Sanchez-Gabilan Ester , Baladas Maria , Montiel Estefania , Paredes Carolina , Rizzo Federica , Molina Carlos A , Ribo Marc , Rubiera Marta
Published: February 2024

After a stroke, coming back home is difficult for most stroke patients. Occupational Therapy (OT) promotes coping with this situation, but in-home intervention is scarce. Through patient reported outcomes (PROMs), an OT can detect possible needs in the areas of occupational performance (OP), and then provide the appropriate tools to facilitate occupation in areas of self-care, productivity and leisure. We aimed to evaluate a tele-OT intervention through a holistic app to provide OT after discharge from a comprehensive stroke center.

Methods:
Consecutive stroke patients discharged home were included in a multimodal digital follow-up program (NORA) through a mobile application validated for communication, education, adherence, risk factors control and PROMs/PREMs recollection. Patients with OT needs are offered a telematic visit to solve stroke-related doubts, everyday activities, home modifications promoting patient’s autonomy and self-care. A tele-OT satisfaction questionnaire (teleOT-PREM) was recollected.

Results:
Over two years, 993 patients were included in NORA follow-up and reported PROMs at 7-30 days. 147 (14.8%) patients presented OT needs and were included in our tele-OT intervention. Sixty-one were men, with a mean age of 68.5y and a median mRS of 2 at hospital discharge. Tele-OT patients reported worse PROMs than the global series: in HADS, 40.8% anxiety and 34.2% depression and in PROMIS-10 89.3% altered mental health and 82.1% altered physical health, as compared with 13.1%, 17.7%, 64.7%, and 54.8% respectively (p<0.001) 108 patients answered the teleOT-PREM. The median usefulness of intervention (in a scale from 0-10) was 8.2 and 65% reported being “very satisfied” with the visit.

Conclusion:
Stroke has a direct impact on a person’s occupational performance. Follow-up by an expert of the occupation (OT) could help to identify the post-stroke patient’s needs and poor PROMs can be used as a selection tool. Tele-OT intervention may promote a better OP, facilitating the daily life activities and improving the quality of life. Tele-OT intervention was feasible and considered useful for most of our stroke patients with OT requirements.
Abstract TP90: Feasibility of Robotic Exoskeleton Intervention in the Stroke Population During Acute Hospitalization
Authors: Bowen Alyssa , Power Karen , Walls Iva , Weis Kaitlin
Published: February 2024

Introduction:
Patients hospitalized with a stroke have limited mobility during the acute recovery phase. Those requiring significant assistance to mobilize often experience greater periods of immobility. Research in subacute rehabilitation demonstrates safe and feasible use of robotic exoskeletons for upright positioning and reciprocal motions similar to gait kinematics post stroke. This study explores the feasibility and frequency of adverse events with robotic exoskeleton during acute hospitalization post stroke.

Methods:
Retrospective design using the electronic health record to identify patients hospitalized with a stroke between 1/1/19 and 12/31/22. Patients that completed a single session of robotic exoskeleton in conjunction with traditional physical therapy met criteria. All participants met the manufacturer’s criteria for device use. Those who did not complete robotic intervention were excluded. Thirty-four patients were included and data obtained from physical therapy documentation of the initial session in the robotic device. Data collected included adverse events atypical of physiologic responses found with traditional physical therapy movement strategies including fracture, cardiac event, skin tear, dislocation and declining neurologic function. Further data collected includes stroke etiology, location, post stroke day intervention completed, steps taken and duration of upright weight bearing in the device.

Results:
Data revealed 0 patients had an adverse event with a total of 5 sessions terminated, all in patients with ischemic infarcts. Reasons for termination included orthostatic hypotension, pain in stance and fatigue. The mean step count was 106 with standard deviation (SD)of 102. The mean upright time was 19 minutes with SD of 8 minutes. Intervention was initiated on average at day 8 with SD of 7 days.

Conclusion:
Robotic exoskeleton is feasible during acute hospitalization with patients post stroke and yields no adverse events. Adjunct use of this device allows patients to participate in weight bearing, upright posture and neuromuscular facilitation for reciprocal motion allowing movement which otherwise may not be possible at this acute stage given the burden of mobility and level of neurologic impairment.
Abstract TP93: A Bayesian Hierarchical Time Series Model to Forecast Patient Recovery Outcomes After an Acute Stroke When Activity Monitor Data is Incomplete
Authors: Fulk George D , Peterson Emily N , Klingman Karen J
Published: February 2024

Background:
Activity monitor data is a useful tool in clinical trials to monitor patient recovery after stroke. These data offer important information on activity, sedentary and sleep behaviors throughout recovery. However, not all participants wear activity monitors, or their activity data may be incomplete. The purpose of this study was to develop a model-based approach to obtain individual patient-level longitudinal forecast estimates of activity and sleep behaviors for both those with and without complete activity data.

Methods:
Participants wore an ActivPal (steps/day) and Actigraph (total sleep/day) monitors for 3-7 days at 10-60-90 days post stroke. We developed a Bayesian hierarchical time series model to forecast daily steps and sleep time by participant. We included a logistic growth curve in which we use predictors comprising age, sex, race, marital status, smoking, BMI, cognition, gait speed, depression, self-reported sleep, and patients’ previous time trends to forecast patient specific future time trends during the first 90 days following stroke.

Results:
Data were collected on a total sample of 114 participants. Out of the 114 participants, 73 participants had recorded sleep data, and 76 participants had step data reported, which are not mutually exclusive groups. Out of 114 total participants, 41 participants did not have any sleep or step data recorded. We obtained patient-specific time trends for both patients with and without monitor data. To assess model predictive performance, we compared predicted estimates to observed data using a validation study and found that on average, there was a difference of 0.52 daily steps (counts). Additionally, on average, there was a difference of 0.46 between observed and estimated daily sleep count (minutes).

Discussion:
The contribution of our study is a model-based approach to accurately predict patient-specific longitudinal step and sleep behaviors based on predictor variables and previous time trends for patients in the subacute stroke recovery phase. Our approach may be extended to other applications using activity monitor data. A limitation of this study is the increased uncertainty surrounding forecast estimates for periods/days without data, which will be addressed in future work.
Abstract WMP106: The Impact of Social Determinants of Health on Ambulatory Status at Discharge Following Acute Ischemic Stroke: Findings From the Get With the Guidelines-Stroke Registry
Authors: Aboul-Nour Hassan O , Bhadsavle Lori J , Ido Moges S , Bayakly Rana , Nahab Fadi B
Published: February 2024

Background:
Medical comorbidities and stroke risk factors only explain a proportion of stroke incidence and outcomes in different populations. Social determinants of health(SDOH)have been associated with incident stroke. The objective of our analysis was to determine if SDOH are associated with ambulatory status at discharge following acute ischemic stroke(IS) hospitalization.

Methods:
We included IS patients hospitalized from January 1, 2015-December 31, 2019 who were ambulating at baseline and had known county of residence in the GWTG registry. The primary outcome measure was ambulatory status at discharge, defined as ability to ambulate with or without the assistance of a device or person. Estimates of SDOH including education status, income, employment status, poverty and foreign-born residents at patients’ residence county were the main predictors. Baseline demographics, clinical comorbidities, stroke center certification status among other logistic and event-related factors were analyzed. Covariates included demographic, clinical factors and hospital-related factors. Estimates of county level SDOH were classified into quartiles and the relative odds of outcome were assessed using a multivariable logistic regression.

Results:
Of 1,171,519 observations included in our final analysis, median age was 71 years, 49% were female, 78% were of white ethnicity and 45% were insured through Medicaid/Medicare. In multivariable logistic regression analysis adjusting for baseline characteristics, counties with the lowest quartile education level had a lower likelihood of being ambulatory at discharge than the highest quartile (OR0.91[95%CI 0.86-0.96],p=0.001).Patients from counties with the lowest quartile of foreign-born residents were more likely to be ambulatory at discharge than the highest quartile (OR1.11[95%CI 1.05-1.18];P=0.001). Income, employment status, and poverty were not associated with ambulatory status at discharge.

Conclusion:
County level SDOH including education and percentage of foreign born population were associated with ambulatory status at discharge after ischemic stroke hospitalization. Our findings can be used to develop interventions that reduce inequity in ischemic stroke outcomes at discharge.
Abstract WMP14: Cerebrospinal Fluid Beta-Amyloid Concentration and MRI Manifestations of Cerebral Amyloid Angiopathy
Authors: Alten Baris , Gokcal Elif , Warren Andrew , van Veluw Susanne , Kozberg Mariel , Gurol Edip M , Viswanathan Anand , Greenberg Steven
Published: February 2024

Background:
Cerebral amyloid angiopathy (CAA) is associated with reduced cerebrospinal fluid (CSF) levels of the beta-amyloid (Aβ) 40- and 42-amino acid species, thought to reflect the burden of vascular Aβ deposition in the brain. Little is known regarding the association of CSF Aβ reduction with specific MRI manifestations of CAA.

Methods:
We identified 31 patients with CAA per Boston criteria v2.0 (1 definite, 27 probable, and 3 possible), who underwent CSF sampling for measurement of Aβ42, total tau (t-tau), and phospho-tau (p-tau) as part of their evaluation with ADmark (Athena Diagnostics). We assessed the following MRI manifestations of CAA while blinded to CSF biomarkers: the presence of cortical superficial siderosis (cSS), number of lobar cerebral microbleeds (CMBs), pattern and severity of white matter hyperintensities (WMH), and number of enlarged perivascular spaces in centrum semiovale (CSO-EPVS).

Results:
Median age of presentation was 69 years (range 56-89). Out of 31 patients, 19 were female (61.3%), 20 (64.5%) presented with cognitive impairment, 9 (29%) with intracerebral hemorrhage, and 2 (6.5%) with transient focal neurologic events. Mean (±SD) CSF Aβ42 concentration in our cohort was 359.3±126.7 pg/ml, substantially reduced relative to that reported in healthy controls. MRI manifestations associated with reduced Aβ42 without altered tau were presence of cSS (310±136 vs. 406±101, p=0.03) and higher burden of CSO-EPVS (307±101 vs. 431±127, p=0.005). Patients presented with cognitive impairment had higher tau levels (t-tau: 551±320 vs. 317±141, p=0.03; p-tau: 75.7±39.8 vs. 49.2±22.4, p=0.05) without altered Aβ42. Similar results were obtained when patients with possible CAA were excluded.

Discussion:
Our results suggest that presence of cSS and higher burden of CSO-EPVS are associated with lower Aβ42 concentration in CSF, potentially reflecting higher overall burden of vascular Aβ deposition in the brain. We found that higher tau concentrations in CSF are associated with cognitive impairment, presumably reflecting concomitant Alzheimer’s disease pathology. These results help inform interpretation of this clinically accessible test in practice and suggest potential mechanisms for specific CAA-related pathologies.
Abstract WMP19: A Brain Care Score for Risk of Late-Life Depression: Data From the UK Biobank Cohort
Authors: Singh Sanjula D , Rivier Cyprien , Oreskovic Tin , Carr Sinclair , Papier Keren , Chemali Zeina , Guiterrez-Martinez Leidys , Mallick Akashleena , Parodi Livia , Mayerhofer Ernst , Senff Jasper , Kourkoulis Christina , Marini Sandro , Clocchiatti-Tuozzo Santiago , Nunley Courtney , Newhouse Amy , Ouyang An , Westover Michael B , Tanzi Rudolph , Lazar Ronald M , Pikula Aleksandra , Ibrahim Sarah , Brouwers H , Howard Virginia J , Howard George , Yechoor Nirupama , van Duijn Cornelia , Littlejohns Thomas , Sheth Kevin N , Rosand Jonathan , Fricchione Gregory , Anderson Christopher D , Falcone Guido J
Published: February 2024

Introduction:
The 21-point Brain Care Score (BCS), developed via a modified Delphi process with practitioners and patients, is a novel instrument designed to motivate behavioral and lifestyle changes, ultimately aiming to decrease incidence of dementia and stroke (Fig 1). Whether or not BCS components are associated with longitudinal changes in mood disorders is not clear. For this study, we tested the hypothesis that the BCS also significantly correlates to late-life depression incidence in the UK Biobank (UKB).

Design / Methods:
The BCS was derived from UKB participants (using both the hospital and general practitioners cohort) aged 40-69 years, at baseline (2006-2010). After excluding patients with prevalent psychiatric disorders, we performed multivariable Cox proportional hazard regression models between the BCS and risk of incident late-life depression, adjusting for sex and stratified by age groups (<50, 50-59, >59 years).

Results:
The total BCS (median: 12; IQR:11-14) was derived for 416,370/502,408 (83%) UKB participants with complete data (mean age: 57; females: 54%). After exclusion of 50,395 participants who had mood or psychiatric disorders other than depression, a total of 365,975 participants were included in our analysis. In total, 6,628 incident cases of late-life depression were documented during the median follow-up period of 13 years. Each five-point increase in BCS was associated with a 59% (HR: 0.41, 95% CI: -0.03-0.85) decreased incidence of late-life depression among UKB participants aged <50, 35% (HR: 0.65, 95% CI: 0.57-0.74) among those aged 50-59; and 28% (HR: 0.72, 95% CI: 0.65-0.79) lower risk among those aged >59).

Conclusions:
In addition to its associations with dementia and stroke incidence, the BCS strongly correlates with late-life depression incidence in the UK Biobank. Additional research is needed to understand the association between BCS elements and late life depression in additional, diverse cohorts.
Abstract WMP20: Deep Learning Radiomics Identifies White Matter Hyperintensity-Related Cognitive Decline Based on T2-FLAIR
Authors: Huang Lili , Zhu Xiaolei , Zhao Hui , Mo Yuting , Yang Dan , Mao Chenglu , Ke Zhihong , Xu Yun
Published: February 2024

Introduction:
Early identification of white matter hyperintensity-related cognitive impairment (WMH-CI) through normal MRI images is of great significance for early clinical intervention to reduce the occurrence of dementia. The aim of this study was to develop a generalizable and interpretable deep learning model for screening WMH-related CI using radiomic features (RFs) from T2 fluid-attenuated inversion recovery (T2-FLAIR) images.

Methods:
A total of 783 subjects were enrolled from three medical centres. RFs for WMH lesions were extracted from T2-FLAIR images in each subject. A deep learning model with a hierarchical transformer architecture was used to leverage all extracted RFs, instead of feature selection, to develop and cross-validate the diagnostic model for cognitive dysfunction. Unsupervised domain adaptation was used to address the cross-centre data inconsistencies without labelling the outer centre data. A gradient-weighted class activation mapping approach was adopted to identify the RFs that contributed most to the diagnosis. Subgroup analysis, correlation analysis and mediation analysis were performed to confirm the clinical relevance of the model. Besides, we also verify the clinical importance of the model by microstructural pathology of WMH detected by diffusion tensor imaging.

Results:
The deep learning model showed robust diagnostic power for WMH related CI, with an area under the receiver operating curve (AUC) of 0.841±0.016 in the development cohort. The prediction accuracy, sensitivity, specificity, precision and recall were 0.793 ± 0.108, 0.798 ± 0.021, 0.800 ± 0.065, 0.716±0.055 and 0.793 ± 0.108, respectively. The model generalized well across different subgroups. It also performed well in other two external verification cohorts, with an AUC of 0.859 and 0.749, respectively. The visual representation showed that the most important features were textural features, which were also significantly correlated with clinical assessment scale and diffusion parameters.

Conclusions:
This study presents a non-invasive imaging biomarker that can identify WMH-CI patients and is applicable to all levels of hospitals since only conventional MRI images are needed.
Abstract WMP29: Effects of Mind-Body Intervention on Fall-Related Outcomes for Stroke Survivors: A Systematic Review and Meta-Analysis
Authors: Mou Huanyu , Wan Xiaojuan , Chien Wai Tong
Published: February 2024

Introduction:
Fall is a common clinical problem for people after stroke, which can impact their functional recovery and cause physical and psychosocial disturbances. Mind-body intervention may be beneficial for fall management. This review aimed to assess the effects of mind-body intervention on fall-related outcomes for stroke survivors.

Methods:
Seven English databases and four Chinese databases were searched from inception to August 2023. Two reviewers independently conducted study screening, risk of bias assessment and data extraction. Cochrane Risk of Bias Tool 2.0 and Grading of Recommendations Assessment, Development and Evaluation were adopted to assess the risk of bias and certainty of evidence. Meta-analyses were performed using Review Manager 5.4 and narrative syntheses were adopted if necessary.

Results:
Twenty-two randomised controlled trials were included. The included interventions consisted of meditative exercise (e.g., Tai Chi, yoga), imagery and biofeedback approaches. The pooled results showed that mind-body intervention reduced the incidence of falls (RR = 0.28, 95% CI: 0.15 to 0.54, I
2
= 0%) and the number of fallers (RR = 0.43, 95% CI: 0.22 to 0.85, I
2
= 0%) over the study period. Despite not reducing the number of survivors having fear of falling, it could significantly increase fall efficacy at short- (<1 month: SMD = 0.84, 95% CI: 0.38 to 1.30, I
2
= 88%) and medium-term post-intervention (1 to < 6 months: SMD = 0.37, 95% CI: 0.05 to 0.69, I
2
= 0%). Mind-body intervention could significantly improve balance (SMD = 1.56, 95% CI: 0.85 to 2.28, I
2
= 95%), but had non-significant effects on mobility, functional independence and quality of life. Besides, meditative exercise and imagery showed greater effects on fall efficacy and balance than biofeedback intervention. For all outcomes, we judged the evidence as very low or low certainty.

Conclusions:
Low- to very low-certainty evidence suggests that mind-body intervention, especially meditative and imagery approaches, can be effective in improving fall-related outcomes for stroke survivors, e.g., reducing fall incidence and fallers, and increasing fall efficacy and balance. Further rigorous large-scale randomised controlled trials are recommended to strengthen the existing evidence.
Abstract WMP32: Effect of Immersive Motor-Cognitive Training on Executive Function in Patients With Vascular Mild Cognitive Impairment: Aquasi-Experimental Study
Authors: Chang Hong , Tian Siying , Zhao Jie , Li Suai , Li Mengrao
Published: February 2024

Background:
Cerebrovascular disease is a common cause of vascular cognitive impairment (VCI) and may progress to vascular dementia at a relatively fast rate. Strengthening intervention in patients with mild VCI can delay cognitive decline and prevent vascular dementia.

Purpose:
To investigate the effect of an immersive motor-cognitive training program on executive function in patients with mild VCI.

Methods:
A total of 60 patients with mild VCI were divided into two groups: the intervention group (n=30) and control group (n=30). The participants were recruited from an outpatient Neurology clinic between May 2021 and January 2022. The intervention group was received immersive motor-cognitive training for 2 months, while the control group was received traditional motor-cognitive training during the same duration. Before the intervention and at the end of the first and second months of the intervention, executive function was assessed as the primary outcome using the Trail-Making Test (TMT)-A/B. General cognitive, speech function and balance function were evaluated as secondary outcomes using the Mini-Mental State Examination (MMSE)/Montreal Cognitive Assessment (MoCA), Boston Naming Test, and Berg Balance Scale, respectively. Data analysis was performed using independent sample t-test, Chi-Square test, nonparametric test, and generalized estimation equation model.

Results:
Among 60 patients, 54 were completed the 2 month-follow-up. Our results showed that there is a significant time effect (
F
=14.36,
P
=0.001) regarding the TMT-A score. In addition, significant time (F=7.28,
P
=0.001) and interaction effects (F=7.43,
P
=0.001) on the TMT-B score were noted. The MMSE score showed significant time (F=64.66,
P
=0.001) and interaction effects (F=12.01,
P
=0.002), and similar results were observed for the MoCA score with significant time (F=38.29, P=0.001) and interaction effects (F=22.89,
P
=0.001). The time effect of the Boston Naming Test score was also found to be statistically significant (
F
=2.92,
P
=0.003). However, no significant differences were observed in the Berg Balance Scale score.

Conclusion:
Immersive motor-cognitive training may improve the executive function and general cognitive function in patients with mild VCI.
Abstract WMP34: Impact of Complete Oral Feeding Resumption on Nutrition and Hydration in the Rehabilitation Inpatient With Stroke
Authors: Ye Ting , Zhou Huijun , Wenmin Wan , Xiaolei Fu , Suo Jianjun , Hongyan Ding , Dong Qiang
Published: February 2024

Objective:
Oral feeding resumption after feeding tube placement is an important therapeutic goal for stroke patients with dysphagia. Available information on nutrition and hydration status in stroke is limited after changing intake from commercial formula for tube feeding to dysphagia diet for oral. The aim is to explore the impact on nutrition and hydration after complete oral feeding.

Methods:
A total of 134 stroke patients who recovered from tube feeding to complete oral feeding were enrolled in rehabilitation hospital from Jan. 2020 to Jul. 2023. The swallow function was detected by the modified Volume-viscosity Swallow Test (V-VST). If a patient completed every viscosity more than 5 mL, feeding tube would be removed. We assessed the nutritional status of stroke patients and provided strategies of dysphagia diet for patients’ food and fluid intakes. Thickeners were used to prevent the risk of aspiration. Serum biochemical measures were obtained for nutrition (prealbumin) and hydration status (BUN/Cr ratio) at admission, before removing feeding tube and within the first week following oral feeding resumption.

Results:
48.51% patients could regain oral intake within 14 days from admission. Compared to admission and tube feeding phase, the level of prealbumin (mg/L) after oral feeding was significantly higher. (19.26±5.32. vs 22.57±5.03; P<0.001) (20.68±5.10 v 22.57±5.03; P=0.003). Based on prealbumin 20 mg/dL, 58.21 % of patients demonstrated poor nutrition at admission and 34.33 % after oral feeding resumption. BUN/Cr > 20:1 identified deficient hydration in 53.72 % of patients in tube feeding phase and 46.27 % of patients after oral intake. Differences in nutrition and hydration status were attributed to complete oral feeding resumption.

Conclusion:
Clinical practice of complete oral feeding resumption including evaluating swallow function of varying viscosities, dietary and fluid recommendations could achieve better nutrition and hydration status.
Abstract WMP39: Incorporation of Automated Robotic Transcranial Doppler to Screen for Patent Foramen Ovale and Quantify Right to Left Shunt Severity in the Evaluation of Ischemic Stroke Patients for Stroke Etiology at a Comprehensive Stroke Center
Authors: Pirahanchi Yasaman , Izaguirre Simon , Rodriguez-Brizuela Richard , Wicknick Alyssa , Chang Ira
Published: February 2024

Background:
Patent foramen ovale (PFO) as a source of right-left shunting (RLS) is a recognized risk factor for recurrent stroke in young patients. Current standard care for RLS diagnosis includes transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) and manual transcranial Doppler (TCD) which have disadvantages. The purpose of this retrospective review is to evaluate incorporation of an automated robotic TCD (rTCD) into the standard evaluation for RLS as cause of stroke, as prior studies have indicated higher sensitivity and quantification of RLS size to direct cardiology referral for potential PFO closure.

Methods:
Between Dec 2021-Oct 2022, 200 stroke patients age <65 were included in this retrospective review. Average age was 55.7 ± 11.1 yrs. All patients had standard TTE and an rTCD (NovaSignal) with saline bubble injection at rest and Valsalva strain for assessment of RLS performed by echo and ultrasound technicians. Neurologists read results, including RLS shunt severity using the Spencer Shunt Grading scale (0-5), where Grade 3-5 is considered large.

Results:
The rate of positive RLS shunt using rTCD was 55.5% (n=111), of which 23.5% (n=47) were Spencer grade 3+ or higher. No bone window rate was 8.5% (n=17), which is lower than reported manual TCD rates. There were no rTCD RLS shunt negative patients who had a positive TTE or TEE. Of patients who had positive rTCD (n=14) and TTE with bubble, only 5 TTE’s were positive (35.7% sensitivity). Of rTCD positive patients (n=23) who also had TEE with bubble, only 11 were positive (48% sensitivity). And of 15 rTCD Grade 3+ RLS, only 11 TEE with bubble were positive (73% sensitivity).

Conclusion:
We successfully replaced rTCD for TTE with bubble to screen for RLS on patients who were admitted with a stroke or TIA, with the following advantages. Non-TCD technicians could be trained to perform the tests with accuracy. rTCD was more sensitive in detecting RLS than TTE with bubble. Quantification of RLS severity identified stroke patients with potentially higher risk of recurrence, prioritized to more aggressive medical management and cardiology referral for TEE and potential PFO closure.