bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract DP28: NLRC5 Mediates Microglial Autophagy to Regulate Post-Stroke Neuroinflammation and its Mechanisms Study.
Authors: Xu Siyi , Cao Xiang , Xu Yun
Published: January 2025

Background:
Microglia-mediated inflammatory response directly affects ischemic stroke outcome. Autophagy is crucial in inflammatory response after cerebral ischemia. NLRC5 can be a positive or negative regulator of inflammatory signaling cascades, but its role after ischemic stroke is unstudied.

Methods:
Single-cell RNA sequencing and immunofluorescence staining were used to explore the expression and localization of NLRC5 in mice brain. Conditional (microglia-specific) NLRC5-knockout mice (TMEM119
CreERT
NLRC5
f/f
) and their littermate control mice (
NLRC5
f/f
) were subjected to MCAO. Histopathological and behavioral methods were performed to assess ischemic injury in mice. In vitro, oxygen-glucose deprivation (OGD) and OGD neuronal supernatant were used to stimulate microglia to simulate post-stroke inflammatory microenvironment. Primary microglia were extracted from litters of wide type and NLRC5-global-KO mice for proteomic detection after OGD. Mass spectrometry was used to investigate the interaction of NLRC5 with other proteins. A series of cellular and molecular biological techniques were used to evaluate the proinflammatory response, autophagy activity and protein–protein interactions etc.

Results:
mRNA and protein expression of NLRC5 were increased after MCAO from 1 to 7 days. NLRC5 was mainly expressed in microglia rather than neurons and astrocytes. After MCAO, the cerebral infarction volume of TMEM119
CreERT
NLRC5
f/f
mice was smaller than that of
NLRC5
f/f
mice, and neurological impairment was slighter. In the ischemic penumbra tissue of TMEM119
CreERT
NLRC5
f/f
mice, autophagy level increased, microglia activation decreased, and inflammation decreased. In vitro experiments, NLRC5 knockdown promoted autophagy level of primary microglia and BV2 in the inflammatory environment, and the inflammatory response was reduced. Proteomic results showed that after OGD, the autophagy levels of NLRC5-global-KO primary microglia were increased compared to that of wide type mice. Additionally, the protein levels of EIF5A, EIF5A hypusination and ATG3 increased in NLRC5-KO primary microglia after OGD. Mass spectrometry revealed that NLRC5 could bind to EIF5A. Specific binding sites and mechanisms need further study.

Conclusions:
Down-regulation of microglia NLRC5 can increase hypusination level of EIF5A, increase ATG3 transcription, thus promote autophagy, inhibit neuroinflammation, and protect brain injury after ischemic stroke.
Abstract DP31: Effect of Hemoglobin and Blood Glucose Levels on CTP Ischemic Core Underestimation: a post-hoc analysis of the ESCAPE-NA1 trial
Authors: Pensato Umberto , Bosshart Salome , Stebner Alexander , Rohr Axel , Kleinig Timothy , Gupta Rishi , Thomalla Gotz , Heo Ji , Goyal Mayank , Demchuk Andrew , Hill Michael , Ospel Johanna
Published: January 2025

Introduction:
CT perfusion maps (CTP) can estimate the ischemic core in acute ischemic stroke based on distinctive cerebral blood flow (CBF) thresholds. However, metabolic factors beyond perfusion influence the tissue tolerance to ischemia and the infarct growth rate.

Hypothesis:
We hypothesize that patients with lower hemoglobin and higher blood glucose levels exhibit reduced cerebral tissue resilience to hypoperfusion and will show larger ischemic core underestimation volume (ICuV) compared to other patients with normal hemoglobin and blood glucose levels.

Methods:
Large vessel occlusion stroke patients investigated with baseline CTP undergoing thrombectomy with near-complete reperfusion and without parenchymal hemorrhage from the ESCAPE-NA1 trial were included. Patients were subdivided into anemic (Hgb <130g/L for men and <120g/L for women) and non-anemic groups, and hyperglycemic (blood glucose level >7mmol/L) and normoglycemic groups. The primary outcome was the presence of “perfusion scotoma” defined as ICuV ≥10mL. The presence of “perfusion scotoma” and median ICuV were compared between anemic vs. non-anemic and hyperglycemic vs. normoglycemic patients using non-parametric tests and multivariable binary logistic regression with adjustment for baseline variables.

Results:
One-hundred-sixty-two/1105 (15%) patients were included (
Figure 1
). The median ICuV was 7.26mL (IQR=0-25.63). Seventy-eight (48%) patients demonstrated perfusion scotoma. Forty-two (25.7%) patients were anemic, and 65 (40.1%) were hyperglycemic. In univariable analysis, the hyperglycemic group had a higher prevalence of perfusion scotoma (65% [n=40] vs. 39% [n=38], p=0.006) and larger ICuV (17.79 mL [IQR=1.57-42.75] vs. 6 mL [-0.31, 12.51], p=0.003) compared to normoglycemic patients (
Figure 2
). No significant ICuV differences between patients with and without anemia were seen. Multivariable regression analysis revealed an association between perfusion scotoma and hyperglycemia, adjusted odds ratio (OR) 2.37 (95%CI=1.22-4.61), and between perfusion scotoma and blood glucose levels, adjusted OR 1.19 (95%CI= 1.02-1.37) per 1 mmol/L increase (
Figure 3
).

Conclusion:
In our study, CTP-based ischemic core underestimation was common and associated with higher baseline blood glucose levels. Individual metabolic factors beyond perfusion that critically influence the infarct growth rate should be considered when interpreting baseline CTP estimations of the ischemic core volume.
Abstract DP43: Assessment of initial National Institute of Health Stroke Scale score’s impact on the likelihood of receiving acute treatment in the community setting before transfer to a comprehensive stroke center.
Authors: Saidi Yazid , Opaskar Amanda , Al-Shaibi Faisal
Published: January 2025

Objective:
Most patients with concern for an acute stroke are transported by Emergency Medical Services (EMS) or a Mobile Stroke Unit (MSU) from community hospitals to a Comprehensive Stroke Center (CSC). Some receive intravenous thrombolysis (IVT) before transfer, while others are transferred for further evaluation and possibly treatment at the CSC. This project aims to assess whether the initial National Institute of Health Stroke Scale (NIHSS) score influences the likelihood of receiving IVT in a community setting, and the likelihood of transfer to the CSC, particularly for patients with low initial NIHSS scores..

Methods:
We utilized Get with the Guidelines Data from a large academic hospital in Northeast Ohio including 21 regional hospitals and 1 CSC. An initial NIHSS score is assigned upon initial evaluation by by NIHSS-certified EMS and MSU first responders, or emergency department providers. Patient data was analyzed between January 1, 2022 and August 31, 2024 and stratified based on initial NIHSS score into very low (0-3), low (4-7), moderate (8-14) and high (≥ 15). The primary outcome group was patients who didn't receive IVT before transfer and received it after transfer to the CSC.

Results:
326/359 (90.8%) of patients with very low NIHSS score (0-4) didn't receive IVT prior to transfer to CSC. Out of those patients, 6/326 (1.8%) received IVT upon arrival to the CSC. In those patients with low NIHSS score (4-7), 182/223 (81.6%) didn’t get IVT prior to transfer to CSC. Of those patients, 17/182 (9.3%) received IVT upon arrival to the CSC. Patients with moderate NIHSS score (8-14), 241/293 (82.25%) didn’t receive IVT prior to transfer to CSC. Out of those patients, 15/241 (6.22%) received IVT at the CSC. Finally, 300/387 (77.5%) of patients with high NIHSS score (>15) didn’t get IVT prior to transfer to CSC, and 5% (15/300) out of those patients received IVT at the CSC.

Conclusion:
A significant proportion of patients with low initial NIHSS scores (4-7) didn't receive IVT before transfer to a CSC, despite being deemed candidates for thrombolysis and receiving treatment after transfer. This raises the question of whether a low initial NIHSS score acts as a barrier to acute treatment in community settings. These preliminary findings highlight the need for prospective studies to better understand the prognostic impact of the initial NIHSS score, potentially improving assessment quality and educational efforts for optimal initial patient evaluation.
Abstract DP47: The Role of Chronic Kidney Disease and Brain Iron Deposition in Intracerebral Hemorrhage
Authors: Chang Peter , Troutt Hayden , Kim Seung Min , Tang Crystal , Paganini Hill Annlia , Lau Wei Ling , Fisher Mark
Published: January 2025

Introduction:
Chronic kidney disease (CKD) is a risk factor for intracerebral hemorrhage (ICH) and for worse outcomes following ICH. In this study, we examined the relationship between kidney function, ICH, and brain iron deposition, using quantitative susceptibility mapping (QSM) and cerebral microbleeds (CMB) as intermediate biomarkers. We hypothesized that kidney function is an independent risk factor for QSM/CMB, and that high QSM/CMB burden is an independent risk factor for ICH.

Methods:
A retrospective cohort of spontaneous ICH and non-ICH patients with CT/MR imaging was identified. For each patient, eGFR along with age, sex, race, ethnicity, hypertension, diabetes (DM), heart disease, and hyperlipidemia were abstracted. CMB volume as well as intracranial arterial calcification (IAC) volume were extracted using custom convolutional neural networks. QSM was derived using the Graz total generalized variation method. All results were visually verified for accuracy by an expert neuroradiologist. Univariate analysis for QSM/CMB risk factors was assessed using Pearson correlation and t-test, while multivariate analysis was assessed using linear regression. Univariate analysis of ICH risk factors was assessed using t-test and Chi-square, while multivariate analysis was assessed using logistic regression.

Results:
Among 155 patients in this study, 39 were ICH patients. In all patients, eGFR was significantly inversely correlated with QSM (r=-0.30, p=0.02) and CMB (r=-0.24, p=0.04); significant differences were also observed across CKD stages for both QSM/CMB (ANOVA; p<0.01). Univariate analysis for QSM risk factors yielded additional statistically significant associations for DM (p=0.01), heart disease (p=0.03), Caucasian race (p=0.01) as well as IAC (p=0.048). In multivariate analysis, eGFR (p=0.04) and Caucasian race (p<0.01) remained significant independent predictors of QSM, while eGFR (p=0.02) remained the only independent predictor of CMB. Furthermore, both QSM (p=0.02) and CMB (p<0.01) were significantly higher in ICH patients. In multivariate analysis, QSM remained a significant independent predictor of ICH (p=0.03) while CMB did not reach significance.

Conclusion:
This is the first demonstration that eGFR predicts strictly quantified QSM and CMB, which then predicts ICH. These findings offer novel insights into determinants of brain iron deposition and microbleeds as mechanisms underlying the CKD-ICH relationship.
Abstract DP50: Angiotensin inhibition reduces the risk of subarachnoid hemorrhage in patients with hypertension
Authors: Abbasi Mohammad Hossein , Brensinger Colleen , Acton Emily , Favilla Christopher , Burkhardt Jan-Karl , Kasner Scott
Published: January 2025

Background:
Local angiotensin activity is thought to play a critical role in arterial wall homeostasis and remodeling, which contributes to the pathogenesis of subarachnoid hemorrhage (SAH). Here we aimed to assess the association between pharmacologic inhibition of angiotensin-converting enzyme and subsequent non-traumatic SAH

Methods:
In a retrospective cohort study based on Optum’s Clinformatics® Datamart de-identified Database records (2000-2021), patients with hypertension were included. We collected medication history and assessed the risk of non-traumatic subarachnoid hemorrhage (SAH) associated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARB). Cox proportional hazard regression models were used to compare the time to SAH by type of antihypertensive treatment. Analyses were adjusted for baseline demographic and clinical characteristics

Results:
7.5 million patients with hypertension were assessed. Patients on ACEI/ARBs with or without other antihypertensives (n=4.8 million,follow-up:6.3 years, average age 61.9, 50.4% female) had lower rates of SAH compared to those on alternative antihypertensive regimens (n=1.3 million, follow-up:5.7 years,average age 61.9, 60.3%female) [HR:0.94(0.91-0.97), p<0.0001] and compared to those on no antihypertensive medications (n=1.4 million,follow-up: 5.3 years, average age 61.0, 50.8% female) [HR:0.94 (0.91-0.97), p=0.0002]. However, patients on non-ACEI/ARBs anti-hypertensive medications had a similar risk of SAH risk compared to those not on any antihypertensives [HR:1.00(0.97-1.04), p=0.83]. Uninterrupted ACEI/ARBs use for ≥3 years reduced the risk of SAH by 23%, compared to treatment by only other hypertensives (HR:0.77[0.73-0.80], p<0.001). Among the subgroup of patients with known unruptured intracerebral aneurysms (n=8034), no difference in SAH with ACEI/ARBs was observed compared to alternative antihypertensive regimens [HR:1.04(0.95-1.13), p=0.39] or no antihypertensive therapy [HR:1.06(0.97-1.16), p=0.20]. No difference in rate of SAH was observed in patients with intracerebral aneurysms who were treated by only ACEI antihypertensives [HR:1.03(0.93-1.13),p=0.59] or by only ARB antihypertensives [HR: 1.01 (0.90-1.13),p=0.87] compared to patients on only antihypertensives other than ACEI or ARBs

Conclusion:
Treatment of hypertension with ACEI/ARBs was associated with a lower risk of SAH compared to other antihypertensive agents, particularly with longer courses of therapy
Abstract DP58: Frequent EEG Captures Neuroplasticity In Patients With Subacute Stroke.
Authors: Delcamp Celia , Sobel Emily , Settle Maeve , Hansen Matthew , Sunil Kyra , Schwarz Anne , Yang Xinyue , Song Min-Keun , Lee Rebecca , Srinivasan Ramesh , Cramer Steven
Published: January 2025

Introduction:
Neuroplasticity is highest during the first weeks after stroke and can be studied at the bedside using EEG. However, brain mapping studies during this time are uncommon and longitudinal data are spaced weeks or months apart, which is insufficient to capture neuroplasticity and respond therapeutically. Towards this goal, a longitudinal study of frequent EEG was performed in subacute stroke patients to deeply understand neuroplasticity during this time period.

Methods:
Post-stroke patients were included 16 days after stroke onset and were seen four times every 2.1±0.3 days (n=2). They performed paretic hand grip contractions while 32-lead EEG and paretic flexor digitorum communis electromyography (EMG) were recorded. In the EEG beta frequency band, event-related desynchronization (ERD) was calculated as well as cortico-muscular coherence (CMC) with paretic flexor digitorum communis EMG. Cortical coherence (CC) was calculated between EEG electrodes. Longitudinal variation was quantified as % change between visits.

Results:
The contralesional hemisphere showed maximum plasticity between days 16 and 18. A 24% increase in ERD amplitude and a 30% decrease in CMC were seen between day 16 and 18, compared with respective variations of 0% and 4% between subsequent visits. The ipsilesional hemisphere showed maximum plasticity between days 21 and 23. A 26% decrease in ERD amplitude and a 54% increase in inter-hemispheric connectivity were seen, compared with, respectively, 12% and 11% variation between the other visits.

Discussion:
Findings suggest two-stage neuroplasticity, first involving the contralesional, and then the ipsilesional, hemisphere. Recruitment of the contralesional hemisphere increases, while its communication with the paretic flexor muscle decreases, suggesting its indirect involvement in motor control. Subsequently, ipsilesional hemisphere activity decreases, while its connectivity with the contralesional hemisphere increases, reinforcing the contralesional hemisphere role in movement programming early post-stroke. Frequent bedside EEG provides precise measures of sequential stages of neuroplasticity early post-stroke, finding that may ultimately inform sub-acute post-stroke rehabilitation.
Abstract HUP1: Drivers of Disparities in Stroke Outcomes by Neighborhood Socioeconomic Status: A Causal Mediation Analysis
Authors: Stulberg Eric , Miller Robert , Hartman Nicholas , de Havenon Adam , Lisabeth Lynda
Published: January 2025

Introduction:
Identification of modifiable drivers of the disparity between neighborhood socioeconomic status (nSES) and stroke outcomes remains elusive. Using a causal inference framework, we evaluate the degree of mediation by modifiable individual- and neighborhood-level characteristics in the association between worse nSES and worse 90-day stroke outcomes.

Methods:
Our analytic sample was composed of 90-day community-dwelling stroke survivors with non-missing data between 2010-2020 from the Brain Attack Surveillance in Corpus Christi (BASIC) cohort. Variables were derived from BASIC, Redfin and the National Neighborhood Data Archive (NaNDA). The census-derived nSES index was our exposure. 90-day outcomes were functional status via the average of the 22-item ADL/IADL Scale, post-stroke depression symptoms via the PHQ-8, and quality-of-life via the average of the Stroke Specific QoL Scale (SS-QOL). Confounder-adjusted multi-level Bayesian G-computation causal mediation analysis was used to determine to what extent hypothetical interventions on individual level (receipt of thrombolysis or thrombectomy) and neighborhood level (density of home health services, walkability, transportation access, density of recreation centers, and density of rehabilitation providers) characteristics would reduce the disparity of 90-day outcomes by nSES. We repeated the analyses stratified by stroke severity (NIHSS ≤ 5 or >5).

Results:
Among the 2,118 stroke survivors in 68 census tracts, 47% were female and 59% were Mexican-American. The respective median (IQR) values of nSES, PHQ-8, IADL/ADL score, and SS-QOL were: -0.7 (-1.2 – -0.2), 5.0 (1.0 – 11.0), 2 (1.3 – 3.0), and 3.5 (2.6 – 4.3). Figure 1 displays the total, direct and decomposed mediated indirect effects by groupings of correlated mediators. Figure 2 displays the results stratified by stroke severity. Table 1 displays the indirect effects mediated by each specific characteristic in our total and stratified samples.

Discussion:
Lower nSES portends worse stroke outcomes. However, this disparity was not significantly driven by receipt of hyperacute treatment, neighborhood walkability, transportation access, density of rehabilitation providers, density of home health services, or density of recreation centers irrespective of stroke severity. Future work should explore other potential intervenable drivers of the disparity such as time-to-treatment and discharge destination using a similarly rigorous framework.
Abstract HUP13: Trends in Mortality from Intracerebral Hemorrhage in the Elderly in Brazil
Authors: Rossi Yohanna , Bolner Gabriel , Vincenzi Zacaria Lucas , Engster Pedro Henrique , Denicol Taís Luise
Published: January 2025

Introduction:
Intracerebral Hemorrhage (ICH) is a significant type of stroke, being the second most common and with a higher risk of mortality and morbidity compared to ischemic stroke. The objective of this study is analyzing trends in the mortality rate of ICH in Brazil over a decade.

Methods:
This was an ecological time-series analysis. Mortality data of ICH from January 2014 to June 2024 were extracted from the database system of Brazil's Ministry of Health (DATASUS) and analyzed for all age elderly groups, 60-69, 70-79, and 80 years and older. Joinpoint Trend Analysis Software version 5.2.0 was used to perform joinpoint regression and calculate the annual percent change (APC) and the average annual percent change (AAPC).

Results:
A total of 41,213 deaths were reported during the analyzed period among individuals aged 60 years or older. Most patients were female (50.62%), white (37.83%), and within the 60 to 69 age group (39.16%). In the whole period, the mortality did not change significantly (AAPC -0.34 [CI -1.09 to 0.39], p > 0.05). However, mortality trends showed great fluctuations over time, with an increase from 2014 to 2020 (APC 1.61 [CI 0.63 to 3.70], p < 0.01), followed by a decrease from 2020 to 2024 (APC −3.19 [CI −6.65 to −1.45], p < 0.01). The 60–69 age cohort presented an estimated joinpoint in 2019 (2014–2019: APC 1.75 [CI 0.01 to 9.07], p < 0.05; 2019–2024: APC −1.97 [CI −8.07 to −0.30], p < 0.05). Meanwhile, the 70–79 age cohort's estimated joinpoint was in 2020 (2014–2020: APC 2.28 [CI 0.91 to 5.01], p < 0.01; 2020–2024: APC −4.15 [CI −8.29 to −1.74], p < 0.01). Finally, the age group over 80 years old had an estimated joinpoint in 2021 (2014–2021: APC 1.08 [CI 0.36 to 2.16], p < 0.01; 2021–2024: APC −4.73 [CI −8.13 to −2.38], p < 0.01), being the only group with an decrease in mortality when considering the whole period (AAPC -0.70 [CI -1.2691 to -0.1457], p < 0.05).

Conclusion:
The fluctuation in mortality rates from ICH among the elderly may reflect broader trends in healthcare access and stroke risk management in Brazil. Moreover, the COVID-19 pandemic may have influenced these rates by contributing to premature deaths among the elderly before they could develop ICH and promoting improved medical care for patients with hypertension and other risk factors. Understanding these dynamics is important for maintaining the decline in mortality rates within this population through the development of targeted public health strategies.
Abstract HUP19: Stroke Knowledge Trends Along Income Lines: A Community Survey on Awareness of Stroke Prevention and Emergency Response Tactics in a Region of Connecticut with Economic Diversity
Authors: Wang Isabel , Ellsworth Patrick , Sharma Richa , Forman Rachel
Published: January 2025

Introduction:
Every 40 seconds, someone in the U.S. experiences a stroke, yet research shows that as few as 53% of survey respondents have known to call 911 in response. Despite the high incidence of strokes, awareness has remained low, as the proportion of respondents who can name one symptom has been as low as one-in-four. Recent studies have found that communities at a financial disadvantage are more likely to have lower levels of stroke knowledge, higher prevalence of modifiable risk factors, and significantly elevated rates of strokes—which can lead to death, economic burdens, and the need for lifelong assistance. Our study seeks to explore how ZIP-code-level income is associated with variability in stroke knowledge.

Methods:
Surveys were provided to participants who attended stroke education workshops provided by our institution’s Stamp Out Stroke group. We divided our population by event ZIP code and labeled cohorts according to median annual income levels as reported in the most recent American Community Survey, conducted by the U.S. Census Bureau. A two-sided t-test was performed, and ZIP Code 4, the cohort with the lowest level of stroke knowledge, served as the reference cohort.

Results:
A total of 65 participants were included in the analyses: 3 at ZIP Code 1, 7 at ZIP Code 2, 31 at ZIP Code 3, and 24 at ZIP Code 4. Participants, on average, demonstrated the most knowledge about actions to take after a stroke and where a stroke occurs in the body, and the least knowledge about stroke pathophysiology and awareness of non-modifiable risk factors, such as family history (Figure 1). ZIP Code 3 (highest median annual income) had significantly more correct answers when compared to ZIP Code 4 (second-lowest median annual income) (Figure 2). While other cohort comparisons were not significant, perhaps due to smaller sample sizes, stroke knowledge and income trended together overall (Figure 2).

Conclusions:
Given that differences in stroke knowledge may correlate with ZIP code income levels, stroke education should be prioritized for communities with lower median annual income estimates. These outreach initiatives should emphasize health literacy in stroke prevention, fostering an awareness personal risk factors and the pathophysiology behind strokes. Such information provided to low-income communities may promote health equity, in particular, by raising awareness about when to seek emergency care in order to be eligible for acute stroke therapies.
Abstract HUP3: Determining genetic contributions in young stroke from TAPESTRY whole exome sequencing data
Authors: Kumar Gyanendra , Brown Samantha , Lazaridis Konstantinos , Swanson Alexandria , Egan Jan , Schroeder Mariah , Libling William , Beezhold Brenna , Vierkant Robert , Luehrs Tony , Sicotte Hugues , Kaiwar Charu , Kocher Jean-Pierre
Published: January 2025

Introduction:
The lack of understanding about the genetic and molecular basis of young stroke (<55 years of age) has hindered development of diagnostic, management, and therapeutic approaches. Whole exome sequencing (WES) can be leveraged as a tool for studying etiological processes underlying stroke. At the time of study inception, this is the single largest WES study in this unique young stroke population to uncover elusive stroke etiologies.

Methods:
The Mayo Clinic TAPESTRY database is a research program conducting whole exome sequencing of 100,000 participants. Of these, 406 participants met the criteria for young stroke (18-54 years of age) based on ICD-9 and ICD-10 diagnostic codes. Controls were TAPESTRY participants without a stroke-related ICD diagnosis. Cases were matched for age, gender, and race for a 1:4 case-control ratio. Ischemic stroke etiology was classified using TOAST classification. To uncover genetic mechanisms, a gene centric approach was used to identify variants in our cohort. A list of 66 genes known to be associated with young stroke was curated based on existing genetic databases. Various filtration strategies were used to identify potentially damaging variants (graphic 1).

Results:
There were 406 cases (363 ischemic and 43 hemorrhagic; 291 female; age at stroke onset 39.8±10.4; 368 were White) and 3,857 controls. TOAST classification yielded 20 patients with large artery atherosclerosis, 58 cardioembolic, 10 small vessel disease, 148 other determined (58 patent foramen ovale, 50 dissection, 48 hypercoagulable state, 11 Moyamoya, 11 vasculitis, 10 fibromuscular dysplasia), and 165 undetermined etiologies. Several individuals had multiple competing etiologies. Of cerebral hemorrhages, there were 6 aneurysmal, 6 arteriovenous malformation, 5 hypertensive, 2 substance abuse, 3 trauma, and 21 other etiologies. Across the entire cohort, 35,054 variants were found within the 66 genes identified from the literature. Filtration identified 48 potentially damaging variants across 30 genes in 44 patients (20 cryptogenic and 21 other: 12 patent foramen ovale, 5 vasculitis, 4 dissection, 4 cardioembolic) that were absent in controls.

Conclusion:
WES is a powerful tool that can be used to uncover potential genetic mechanisms in the young stroke population. An improved understanding of etiologies would improve diagnostics and pave the way for new preventive and therapeutic approaches, thus improving the overall care of young stroke patients.
Abstract NS2: Enhancing Door-In-Door-Out Times to Achieve Top Third Percentile Ranking for Large Vessel Occlusions Ischemic Stroke at a Primary Stroke Center Through Quality Improvement Initiatives
Authors: Melgar Carolina , Arroyo Michelle , Templin Jennifer , Martinez Linda , Zrelak Patricia
Published: January 2025

Background:
Patients with acute ischemic stroke (AIS) due to a large vessel occlusion (LVO) who present to a Primary Stroke Center and are eligible for endovascular stroke therapy (EVT) require rapid transfer to a facility capable of EVT. Nationwide 2023 Get with the Guidelines data suggest that only 20 percent of LVO patients are transferred for EVT within 90 minutes.

Purpose:
To increase the proportion of cases with Door-In-Door-Out (DIDO) times less than 76 minutes from 30% (baseline performance) to over 50% (a goal set by leadership) by designing and implementing a multifaceted quality improvement initiative. Given that reduced transfer times correlate with enhanced cognitive efficiency, we aimed to reduce our median transfer time from 88 minutes to less than 76 minutes.

Methods:
This retrospective cohort study was undertaken from 01/2021 to 06/2024 at a large community medical center in Northern California, part of an integrated health system with a system-wide tele-stroke program. Annual ED visits exceed 140,000 (second busiest in the state). We chartered a multidisciplinary work group and developed a bundle of interventions to address critical processes of care delivery (Figure 1).We implemented the bundle 07/2022. We reported DIDO times quarterly.

Results:
The study included 80 patients from 1/2021-6/2024: 45 were women, 35 men, median age 75. The percentage of cases that met our target time objectives improved significantly across the study period (Figure 3). Following the initiative's implementation we met target DIDO metrics 80% of the time from 9/2022-12/2022 (n=8). We continued to exceed our 50% goal through 6/2024. Benchmarked against national performance metrics, we are at the top third percentile based on The Joint Commission first quarter 2024 reports.

Conclusion:
Achieving more efficient patient transfers to comprehensive stroke centers for patients with an LVO requiring an EVT is feasible. It requires an interdisciplinary and coordinated approach, dissecting the processes at each intervention point from patient arrival to emergency medical services transport. Although having 911 services for transport is beneficial, decreasing patient arrival to teleneurology contact, improved communication through standardized documentation, handoffs, and implementation of checklists and debriefs have resulted in decreased delays and improved patient outcomes.
Abstract NS8: Enhancing Post-Stroke Care: Implementing the Transitional Care Model
Authors: Mealey Rachael , Nobles Kristen , Burdett Rebecca , George Donna , Sloane Kelly , Stein Laura
Published: January 2025

Background and Purpose:
Patients discharged home after a stroke are particularly vulnerable during the immediate post-discharge period. We identified significant gaps in post-discharge care for stroke patients at our Comprehensive Stroke Center, including inconsistent follow-up timing and a high rate of missed appointments. This initiative aimed to enhance the post-discharge process to improve care quality and reduce missed follow-ups.

Methods:
We implemented a streamlined follow-up process for stroke patients discharged home, aligning with the Centers for Medicaid and Medicare (CMS) definition of the Transitional Care Management (TCM). A Nurse Practitioner (NP) conducted inpatient rounds, coordinated follow-up appointments before discharge, and contacted patients within 24-48 hours. Patients were seen by the outpatient stroke NP within 7 to 14 days, either in clinic or via telemedicine. This process, compliant with CMS requirements and billable under TCM, was evaluated over seven months, focusing on clinic no-show rates and reimbursement compared to standard discharge practices.

Results:
Patients discharged home under our TCM model had a 3% no-show rate, significantly lower than the 14% observed in those discharged without TCM. All patients discharged home with TCM had a post-discharge follow-up appointment scheduled compared to 9% of patients discharged home without TCM who had no scheduled stroke follow-up. Additionally, using the appropriate CMS codes for TCM resulted in higher reimbursement and increased revenue compared to standard follow-up billing.

Conclusions:
Implementing this initiative aligned our discharge process with the CMS-recognized TCM model, improved scheduling of post-discharge follow-up appointments, reduced post-discharge clinic no-show rates, and increased departmental revenue.
Abstract NS9: Community Based Stroke Self-Management Program for Rural African American Aging Population: A Needs Assessment and Initial Development
Authors: Andrabi Mudasir
Published: January 2025

Background:
High Blood Pressure (HBP) issue is high among African American aging populations living in rural areas. There is a lack of programs for self-management of HBP and post-stroke life for these individuals living in rural Stroke belt areas.

Purpose: Develop the need-based Community Stroke and Hypertension Self-management Program (CSSP) and test its feasibility among rural-dwelling African American stroke survivors 50 and above.

Methods:
Study Design:

Mixed methods study with a sequential design.

Study Population: African American stroke survivors with HBP aged 50 years or above (N=25) and caregivers (N=15) residing in rural counties of Alabama.

Study Procedures:

I)
Needs assessment:
We assessed needs and cultural preferences by using surveys and interviews. The surveys included a) the demographic survey, b) the Hypertension Knowledge-Level Scale, c) the Hypertension Self-Care Activity Level Effects, and d) the Southampton Stroke Self-Management Questionnaire.

II)
Intervention development
: Multicomponent intervention includes a) educational component, b) home visiting, c) problem-solving, d) telephonic follow-ups, e) text reminders, and f) social groups.

III)
Intervention delivery phase:
A 12-week CSSP will be delivered to groups of 8 to 10 participants in a hybrid format. Data
will be collected
before, at midpoint, and after the intervention is completed.

Results:
Results from Needs assessment:

Themes evolved from Qualitative data:

- Lack of information, lack of rehabilitation services, and lack of assistance with daily life activities. Multiple barriers to care and challenges during post-stroke, including lack of transportation and affordability of care. These communities have some facilitators for health programs, including the existing conference call system and social groups.

Results from Quantitative Data:

All participants (100%) had low knowledge related to HBP management. The majority of them had low levels of adherence with HBP medications (52%), a low-salt diet (92%), physical activity (56%), weight management (81%), and alcohol avoidance (91%). All (100%) of the participants had low to moderate competencies to manage post-stroke conditions.

Conclusion:
African American aging individuals living in the Deep South are at risk for HBP and recurrence of stroke. There is a need for a self-management program that would overcome contextual barriers related to rural areas and enable these populations to manage their HBP and post-stroke life.
Abstract TMP10: Impact of eicosapentaenoic acids and cilostazol in patients with intracranial arterial disease
Authors: Takeishi Yusuke , Watanabe Yosuke , Matsuda Shingo , Okada Yoshio , Dowaki Ryosuke , Kuroki Kazuhiko
Published: January 2025

Introduction:
An optimal strategy for the treatment of intracranial atherosclerotic disease (ICAD) has remained unclear, despite medical therapy (antiplatelet therapy and LDL control management) or endovascular therapy (angioplasty or stenting). Recently, cilostazol plus other antiplatelet agents combined therapy (CT) has been reported to reduce recurrent stroke, and eicosapentaenoic acid (EPA) has been reported to reduce the risk of cardiovascular events and plaque progression. Therefore, our hypothesis is that the addition of CT and EPA therapy may reduce stroke recurrence and further regression of stenosis.

Methods:
Patients with symptomatic and asymptomatic intracranial artery stenosis treated and followed at our institution from January 2009 to December 2023 were included in this study: 198 ICAD lesions in 155 patients (mean follow-up 11 months) were retrospectively evaluated. Each patient was divided into antiplatelet therapy alone (AA) (monotherapy (MT) or CT), antiplatelet therapy plus statin (AS), and antiplatelet therapy plus statin and EPA (AE). Antiplatelet drug monotherapy was aspirin, clopidogrel, or prasugrel and combination therapy was any of them plus cilostazol. ICAD was assessed by MRA and the stenosis rate was calculated by the warfarin-aspirin symptomatic intracranial disease (WASID) method.

Results:
The improvement in stenosis was significantly better with CT than with MT (Median% interquartile range(IQR)= CT: 21.71% (11.33-41.40) vs. MT: 9.15% (2.69-25.78), P<0.0001 Mann-Whitney test). Within the CT group, the AE group showed the greatest improvement in stenosis (Median% (IQR)= AA: 10.95% (5.55-30.45) vs AS: 20.41% (12.54-41.26) vs AE: 25.51% (14.11-42.55), Kruskal-Wallis test p:0.0181), while there were no significant differences between the MT groups (Kruskal-Wallis test p:0.7185). Stroke recurrence rates were 16.2% in the AA group, 13.8% in the AS group, and 5.9% in the AE group, with no significant difference, but a trend toward lower recurrence rates in the AE group was observed; in a comparison of the CT+AE group with the MT+AA group, the CT+AE group had significantly lower recurrence rates than the MT+AA group (Fisher's exact test P: 0.0455).

Conclusion:
Cilostazol and EPA added to the conventional therapy was associated with less stroke recurrence, and it also showed significant regression in ICAD. Larger studies should investigate the role of cilostazol and EPA in stroke recurrence and plaque regression.
Abstract TMP14: The Resus and Flow Nurse; Positioned to Save Lives
Authors: Garrett Misty
Published: January 2025

“
Time is of the essence
” - this is one phrase every emergency department (ED) nurse knows. This especially true for stroke where time is brain. The ED at Inspira Health recognized the need to develop solution-based workflows which enhance timely of care. The development and implementation of the Flow and Resuscitation (Resus) registered nurse (RN) roles supports our goal of getting the patient to the right place at the right time. The Flow nurse was made effective throughout the network in 2023. The Flow RN is an assignment that has a global view of real time departmental operations. This RN is responsible for rapid assessment, and all patient placement in the ED. The Flow RN is always one step ahead and prepared to facilitate physician rapid assessment and initiation of stroke pathway by bypassing a patient care room to be brought directly to computed tomography (CT). The flow RN role has helped with early recognition of stroke symptoms that may not have been obvious during transport to the ED. The Resus RN is an experienced RN well versed in managing higher acuity patient presentations such as stroke and serves as a resource to other RNs in the ED. The resus RN supports two dedicated bays for management of critical patients. The resus role is time limited. This RN assesses the patient, escorts them to CT, monitors vitals, begins the stroke workup, and collaborates with the ED physician and consulting tele-neurologist. Once the patient is stabilized and the initial stroke workup is completed, the resus RN then hands the patient off to the primary RN where care and monitoring will continue. If the patient requires thrombolytics, the Flow RN will facilitate a 1:1 assignment so the primary RN can deliver uninterrupted care, and the resus RN is available for the next critical patient’s arrival. Our progress over a thirty-six-month (2022-2024) period across the network showed an improvement of up to a 25% in the door to CT results, up to 25% in the door to needle within sixty minutes, up to 17% in the door to needle within 45 minutes and up to 47% in the door to stroke team activation. In conclusion, the creation and implementation of these positions has improved the overall response time to patients who require time sensitive care such as stroke in our EDs. The data collected over the span of thirty-six months shows a significant improvement in response time which can improve patient outcomes and offers potential continuous improvement for the years ahead.
Abstract TMP16: Is Lipoprotein(a) Being Measured in Ischemic Stroke Patients?
Authors: Rudolph Steven , Davy Connor , Walkin Carol , Morhaim Holly , Roche Tara , Holland Cinthia , clark erynn
Published: January 2025

Lipoprotein (a) [Lp(a)] is a type of lipoprotein that is genetically inherited. Elevated levels of Lp(a) are an independent and causal risk factor for atherosclerotic cardiovascular diseases through mechanisms associated with increased atherogenesis, inflammation, and thrombosis. Having elevated Lp(a) can increase risk of heart attack, stroke, and peripheral artery disease.

It is estimated that as many as 20% of the American population have elevated Lp(a) levels. There are currently no specific targeted treatments to lower Lp(a). There are currently no universal guidelines for diagnosing and providing risk assessment. There is a clinical need to understand variation in Lp(a) levels in various ancestry groups.

In March 2023, a field to include measures for Lp(a) was added to the Get With The Guidelines® IQVIA Registry Platform™ (GWTG). This registry is utilized by each of the hospitals in a current six hospital system. A configurable measure report including Lp(a) measurement obtained and Lp(a) level was added in April 2024.

Methods:
Beginning in January 2024, Lp(a) levels obtained at six hospitals in our health system in New York City have been entered into GWTG. We used the newly developed measure reports for patients with ischemic stroke and TIA to determine whether Lp(a) levels were being obtained during hospitalization for stroke, and prior to these events. These hospitals are all certified by The Joint Commission®, and include one academic comprehensive stroke center, two thrombectomy centers, and three primary stroke centers.

Results:
In general, measurement of Lp(a) was low. Only one hospital had more than 10% of patients where Lp(a) was measured. One hospital, a primary stroke center had significantly more patients tested due to specific interest in Lp(a). The hospital with the highest percentage of measurement prior to the stroke was a tertiary care academic hospital.

Conclusion:
These results point out the need for initiatives across our health system to raise awareness of Lp(a) as an emerging stroke risk factor, and to improve on its measurement. This data will serve as a baseline to evaluate improvement in recognition and eventually treatment of elevated Lp(a) values.
Abstract TMP17: Cerebral Compass- Guiding Nurses and Neurologist to be Aligned in Care Finding their true North on 4 North with Multidisciplinary Stroke Rounds
Authors: Izzo Rachel
Published: January 2025

Background:
For optimal care and outcomes, patients must receive treatment from a multidisciplinary team approach at a comprehensive-stroke certified facility with stroke specialist units. The multidisciplinary approach increases bedside RNs engagement. The stroke team frequently performed their rounds on 4N without the bedside RN present. This does not foster trust and communication between RNs and MDs. We sought to improve the bedside RNs engagement by having multidisciplinary rounds including the bedside RN and stroke team during rounds.

Smart Aim:
Improve the bedside RNs team engagement with an increase of at least 1 point on the Likert scale.

Implementation:
We began using a simple Likert 5-point questionnaire completed by the nurses on 4N to evaluate their daily experience with stroke team rounds and their engagement with the team. The Likert questions were graded 1-5 from strongly disagree (1) to strongly agree (5). Then from April 2024 to July 2024 the nurses on 4N, joined in collaborative rounds with the stroke team daily. The RN was requested to join collaborative rounding whenever the stroke team was present on the unit. Rounding with the bedside RN included plan of care, overnight events and any issues the bedside RN wanted to inform the stroke team about. After a few months of multidisciplinary/collaborative rounding, the RNS were then asked to complete the same Likert 5-point questionnaire.

Results:
Looking at the Likert pretest versus the posttest the question “ I feel engaged with the stroke team during their rounds” had a pretest score of 2.7 and a post score of 4.0. Thus demonstrating, the bedside RNs felt more engagement since the implementation of rounding with the stroke team daily.

Conclusion:
Creating a standardized plan of care with a multidisciplinary team rounding approach for the stroke patients on 4N, increased the nurse’s engagement by at least 1 point on the Likert 5-point questionnaire. The RN felt more engaged and empowered to express patient’s needs, concerns, and felt greater collaboration with stroke team. Demonstrating that multidisciplinary rounding engages the bedside RN. Additionally, we will track&trend this data to include improved patient outcomes for stroke patients.
Abstract TMP19: Implementation of an Outpatient TIA Clinic
Authors: Bourassa Sharon , Worthington Michelle
Published: January 2025

Background:
Patients who arrive at the emergency department (ED) with transient ischemic attacks (TIA) are at an increased risk of experiencing a stroke. These patients must undergo appropriate medical assessment, receive treatment for risk factors, and be educated on how to reduce their risk for stroke. The conventional TIA evaluation process often results in long ED stays or preventable hospital admissions. A significant portion of the evaluation may be safely conducted on an outpatient basis, if urgent follow-up care is readily available. With hospitals frequently facing capacity challenges, the stroke team sought an alternative solution to the conventional TIA evaluation model.

Objective:
We aimed to decrease inpatient TIA admissions by implementing a process where patients can have outpatient evaluation within 48-72 hours of ED discharge. During the TIA clinic visit the patient meets with a vascular neurologist to formulate a treatment plan. This includes referrals to relevant experts, medications, and counseling for lifestyle modifications. If indicated, the patient will be scheduled for an MRI within 24 hours and/or an echocardiogram within 48 hours of the TIA clinic visit. Stroke nurses are available to reinforce lifestyle counseling by reviewing the signs and symptoms of stroke, and how to manage individual risk factors.

Methods:
Key stakeholders in multiple departments collaborated to optimize the workflow, utilizing dedicated order sets. ED providers evaluate patients presenting with TIA symptoms and identify suitable candidates for the TIA clinic. Eligible patients undergo diagnostic tests in the ED and receive baseline education. The outpatient neurology clinic allocates 14 appointments per week for urgent TIA referrals to a vascular neurologist. Radiology and cardiology have availability for urgent MRIs and echocardiograms. Comprehensive staff training has ensured effective implementation of the new TIA care model.

Results:
The TIA clinic has been successful in decreasing TIA admissions by 57% in the first 2 years of implementation, resulting in increased inpatient bed availability and patient satisfaction.

Conclusion:
Due to the successful implementation of this service, it was expanded to other system hospitals with less access to specialized neurological care. The organization aims to implement this care model across multiple service lines.