bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 158: Rescue Strategy for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: An Analysis of the SVIN Registry
Authors: Rodriguez-Calienes Aaron , Vivanco-Suarez Juan , Haussen Diogo C , Mohammaden Mahmoud , Nogueira Raul G , Al-Bayati Alhamza , Hassan Ameer E , Tekle Wondwossen , Desai Sohum , Saei Hamzah , Johanna Fifi , Majidi Shahram , Matsoukas Stavros , Siegler James E , Patel Pratit , Jovin Tudor G , Sheth Sunil , Salazar-Marioni Sergio , Iyyangar Ananya , Nguyen Thanh , AbdalKader Mohamad , Linfante Italo , Dabus Guilherme , Mehta Brijesh P , Sessa Joy , Jumaa Mouhammad A , Sugg Rebecca M , Saleemi Adeel , Linares Guillermo , Siddiqui Fazeel M , Ortega-Gutierrez Santiago
Published: February 2024

Background:
Mechanical thrombectomy (MT) fails to achieve successful reperfusion in up to 20% of large vessel occlusions (LVOs). Rescue strategies (RS) have shown promise in multicenter studies and meta-analyses. We aimed to evaluate the association between RS with functional outcomes compared to medical management (MM) in patients who underwent failed MT.

Methods:
This is a cross-sectional study using prospectively collected data from the Society of Vascular and Interventional Neurology (SVIN) Registry from 2018 to 2021. We included all adult patients with anterior circulation LVOs who experienced a failed MT (mTICI 0-2a after multiple attempts to clot retrieval) at the 14 participating centers. The patients were divided into two groups: those who received RS (including balloon angioplasty alone, intracranial stenting with or without balloon angioplasty) and those who only received MM. The primary outcome was the shift in the degree of disability, as measured by the mRS at 90 days. Additional outcomes included functional independence (90-day mRS score of 0-2), sICH, and mortality at 90 days.

Results:
A total of 642 patients were included in the analysis. The RS group consisted of 294 (45.8%) patients, while the MM group comprised 348 (54.2%) patients. A mTICI score of 2b-3 was achieved in 242/293 (82.6%) patients in the RS group. After adjusting for confounders, the RS group showed a favorable shift in the overall 90-day mRS distribution (acOR=1.97, 95%CI 1.36-2.85,
p
=<0.001) and higher rates of functional independence (RS: 30.7% vs. MM: 12%, aOR=2.39, 95%CI 1.34-4.26,
p
=0.003) (
Figure
) compared to the MM group. RS also showed lower rates of sICH (RS: 2.7% vs. MM: 9%, aOR=0.32, 95%CI 0.14-0.71,
p
=0.005) and 90-day mortality (RS: 29.5% vs. MM: 49.7%, aOR=0.49, 95%CI 0.33-0.74,
p
=<0.001).

Conclusion:
Our findings support the use of RS as a potential alternative for stroke patients with failed MT. Further prospective studies are needed to validate these observations.
Abstract 18: Toll-Like Receptor 4 Knockout Attenuates Microglia-Mediated Oxidative Stress and White Matter Toxicity
Authors: Demetriou Alexandra N , Shkirkova Kristina , Zhang Hongqiao , Sizdahkhani Saman , Morales Manuel , De La Isla Alberto , Zhao Lifu , Diaz Arnold , Thorwald Max , Godoy-Lugo Jose A , Zhou Beryl , Zhang Nathan , Li Andrew , Mack Wendy J , Sioutas Constantinos , Pike Christian , Mack William J
Published: February 2024

Background:
Exposure to ambient air pollution causes neuroinflammation and white matter (WM) damage. In patients with preexisting cerebrovascular disease, pollution exposure can compound underlying pathology and may accelerate functional decline. Major mechanisms of this toxicity are microglial reactivity and oxidative stress. We therefore hypothesized that attenuation of the Toll-like receptor 4 (TLR4)-dependent microglial response would significantly decrease oxidative WM damage in a joint experimental model of pollutant exposure and chronic cerebral hypoperfusion modeled by surgical bilateral carotid artery stenosis (BCAS).

Methods:
Inducible microglial/macrophage-specific TLR4 deletion was achieved using a Tamoxifen-induced Cx3cr1CreER+/- mouse model. Male and female Cx3cr1CreER+/- mice treated with tamoxifen (i-mTLR4-ko) or corn oil (control) were exposed to 120 hours of filtered air (FA) or aerosolized diesel exhaust particulate (DEP), and 30 days of BCAS or sham surgery using a factorial design. The 8 experimental groups were: 1) control/FA (n=10), 2) control/DEP (n=10), 3) control/FA + BCAS (n=9), 4) control/DEP+BCAS (n=10), 5) i-mTLR4-ko/FA (n=9), 6) i-mTLR4-ko/DEP (n=8), 7) i-mTLR4-ko/FA + BCAS (n=8), and 8) i-mTLR4-ko/DEP+BCAS (n=10). Immunofluorescence was used to identify 4-HNE and 8-OHdG expression in the corpus callosum (CC).

Results:
While control mice showed elevations of 4-HNE in the CC after DEP (p<0.01) and DEP+BCAS (p<0.0001), i-mTLR4-ko prevented this change (Figure 1). While control mice exhibited a rise in 8-OHdG in the CC after DEP+BCAS (p<0.05), i-mTLR4-ko prevented this rise.

Conclusions:
We demonstrate that i-mTLR4-ko is sufficient to abate major elevations in oxidative stress markers in WM after DEP and BCAS exposures. This suggests a potential role for therapies targeting TLR4 signaling to minimize pollution-associated neurotoxicity, particularly in the setting of cerebral hypoperfusion.
Abstract 20: Axonal Neuropathy and Inflammatory Response in Peripheral Nerves of a Murine Cerebral Amyloid Angiopathy Model
Authors: Patel Dillan A , Sprenger-Svacina Alina , Svacina Martin K , Maniskas Michael E , Sheikh Kazim A , Zhang Gang , Lee Juneyoung
Published: February 2024

Introduction:
Cerebral amyloid angiopathy (CAA) induces intracerebral hemorrhages, small vessel disease, and cognitive decline in elderly individuals. CAA is also associated with slower walking speed and abnormal gait rhythms compared to healthy controls. Little is known regarding the impact of peripheral nervous system abnormalities on CAA-associated gait disturbance. Furthermore, it is unknown whether peripheral nerves pose extracerebral targets of amyloid-related endoneurial inflammation.

Hypothesis:
Gait disturbance in a CAA model is associated with peripheral neuropathy through endoneurial inflammation related to amyloid accumulation.

Methods:
Aged (19-24 months) Tg-SwDI mice (CAA mice) of both sexes harboring mutations of human amyloid precursor protein (APP) were used as a CAA model. Age-matched C57BL/6 wild-type (WT) mice were used as controls (n=6-11/grp). Gait disturbance and sensorimotor function were assessed via DigiGait and grip strength testing. Flow cytometry was used to analyze immune cells in the sciatic nerve. Tibial nerve morphometry was performed to assess for neuropathy.

Results:
CAA mice had weaker grip strength (
CAA: 97.7 ± 17.6 g, WT 111.5 ± 8.1 g,
p=0.039
) and evidence of neuropathic gait disturbances, reflected by increased paw angles (
CAA: 21.1 ± 4.8°, WT 11.7 ± 3.4°,
p=0.0002
) and reduced paw areas (

CAA: 0.4 ± 0.05 cm
2
, WT 0.5 ± 0.06 cm
2
,

p=0.013
) impacting the ground when walking compared to WT mice. Tibial nerve morphometry showed a reduced number of myelinated nerve fibers (
CAA: 1023
±
230.1, WT 1318
±
45.8, p=0.0047
) suggesting potential axonal degeneration in CAA mice. Flow cytometry showed an increase in the count of macrophage (both M1 and M2 subtypes) lineage cells (
M1 CAA: 102.3 ± 29.2, WT 57.9 ± 36.3,
p=0.009
) as well as M1 macrophage associated pro-inflammatory cytokine TNF-α (
CAA:
99.7 ± 28.3, WT 53.8 ± 12.2,
p=0.009
) in sciatic nerves of CAA mice compared to WT mice.

Conclusions:
CAA mice display an enhanced inflammatory response within the endoneurium which may contribute to observed axonal degeneration, ultimately impairing sensorimotor function and gait. Further studies are needed to unravel the mechanistic interplay between amyloid pathology, endoneurial inflammation, and axonal neuropathy in this CAA model.
Abstract 21: Similarity in the Changes of Brain Myeloid Transcriptome Signature is Shared Between Ischemic Stroke and Chronic Inflammation Caused by Diabetes Mellitus
Authors: Kato Yuya , Yu Kailin , Falcone-Juengert Jaime , Liu Jialing
Published: February 2024

Introduction:
Ischemic stroke (IS) is a pressing global health concern. Diabetes mellitus not only heightens the risk of IS but also aggravates its outcomes. There is established evidence that neutrophil infiltration is involved in inflammation after stroke through various mechanisms, such as activating neutrophil extracellular traps. We aimed to examine the factors that contribute to the deterioration of IS in diabetic mice focusing on mechanisms underlying immune cell infiltration by single cell RNA sequencing (scRNAseq) of brain before and after stroke.

Methods:
Experimental stroke was induced using the distal middle cerebral artery occlusion (dMCAO) model. db/db mice were used to model type 2 diabetes and obesity, while db/+ mice served as euglycemic controls. Mononuclear cells from ipsilateral mouse brains were isolated 3 days post-dMCAO or sham surgery with the Percoll gradient following enzymatic digestion. Transcriptomic analysis was performed using scRNAseq from db/+ sham, db/db sham, db/+ stroke, and db/db stroke. Fluorescence-activated cell sorting (FACS) and immunofluorescence (IF) staining were conducted to validate the changes detected in the transcriptome results.

Results:
Prior to the onset of stroke, db/db mice exhibited changes in gene expression in endothelial cells and myeloid cells including macrophages, monocytes, and microglia, mirroring patterns of changes after stroke. Among the macrophage subpopulation in particular, db/db sham and db/+ stroke mice shared an overlap of 638/901 (70.8%) differentially expressed genes compared to db/+ sham. Gene enrichment analysis indicated predominant upregulation of genes linked to leukocyte migration and neutrophil chemotaxis. FACS revealed a heightened neutrophil presence in the brain parenchyma of diabetic mice before stroke, and further elevated after stroke compared to control mice. Specifically, the increased expression of anaphylatoxin receptor C3aR and complement C3 shown by IF corroborated with the transcriptomic signature, supporting a role of complement activation and myeloid cell transmigration.

Conclusions:
Our findings provide valuable insights into the mechanisms whereby diabetes potentially escalates neutrophil infiltration post-stroke.
Abstract 22: Time to Treatment and the Effect of Intravenous Thrombolysis Before Thrombectomy: An Individual Participant Data Meta-Analysis
Authors: Kaesmacher Johannes , Cavalcante Fabiano , Kappelhof Manon , Treurniet Kilian , Rinkel Leon A , Liu Jianmin , Yan Bernard , Zi Wenjie , Kimura Kazumi , Eker Omer , Zhang Yongwei , Piechowiak Eike , van Zwam Wim , Liu Sheng , Strbian Daniel , Uyttenboogaart Maarten , Dobrocky Tomas , Zhongrong Miao , Suzuki Kentaro , Lei Zhang , Oostenbrugge Robert Van V , Meinel Thomas , Guo Changwei , Seiffge David , Ying Congguo , Bütikofer Lukas , Lingsma Hester , Mitchell Peter J , Yang Pengfei , Majoie Charles B , Roos Yvo , Fischer Urs M , Gralla Jan
Published: February 2024

Introduction:
The benefit of intravenous thrombolysis for acute ischemic stroke declines with longer time from symptom onset. It is not known whether a similar time-dependent treatment effect modification of intravenous thrombolysis (IVT) is present in patients undergoing thrombectomy.

Methods:
Individual participant data meta-analysis from six randomized controlled trials comparing IVT plus thrombectomy vs thrombectomy alone. Primary analysis was performed testing for heterogeneity of the treatment effect. We estimated the effect of onset-to-expected-IVT times on the association between allocated treatment (intravenous thrombolysis plus thrombectomy vs thrombectomy alone) and disability at 3 months (modified Rankin scale, mRS).

Results:
In 2313 participants (IVT plus thrombectomy [n = 1160]; thrombectomy alone [n = 1153]; median age, 71 years, IQR 62-78 years; 44.3% female), the median onset-to-expected-IVT time was 2h 28min (IQR, 1h 46min to 3h 17min). We observed a statistically significant interaction between onset-to-expected-IVT times and treatment group effect (pinteraction=0.02), with the treatment effect of IVT plus thrombectomy vs thrombectomy alone declining over time (e.g., common adjusted Odds Ratio for a one-step mRS shift toward improvement 1.49, 95%CI 1.13-1.96 at 1h; 1.25, 95% CI 1.04-1.49 at 2h; 1.04, 95% CI 0.88-1.23 at 3h). If treated before 2h 20min after symptom onset, participants allocated to IVT plus thrombectomy were significantly less disabled at 90 days than participants allocated to thrombectomy alone.

Conclusions:
This individual participant data meta-analysis of patients with ischemic stroke presenting at thrombectomy-capable stroke centers demonstrated time-dependence of the treatment effect of IVT plus thrombectomy vs thrombectomy alone. Intravenous thrombolysis showed clinical benefit if it was administered within 2h 20min after symptom onset.
Abstract 25: Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Recent Direct Oral Anticoagulant Use: A Systematic Review and Meta-Analysis
Authors: Ghannam Malik , Almajali Mohammad , Khasiyev Farid , Galecio-Castillo Milagros , Al Qudah Abdullah , Ghazaleh Dana , Dibas Mahmoud , Vivanco-Suarez Juan , Rodriguez Aaron , Farooqui Mudassir , Ortega-Gutierrez Santiago
Published: February 2024

Introduction:
Intravenous thrombolysis (IVT) is efficacious treatment of acute ischemic stroke (AIS). However, certain circumstances associated with increased bleeding risk, such as recent direct oral anticoagulation (DOAC) intake limits its use. Nonetheless, emerging evidence has shown promising results in this patient group. We investigated the safety and efficacy of IVT in patients with AIS and recent DOAC use.

Methods:
We conducted systematic review and meta-analysis of proportions evaluating IVT with recent DOAC use. Outcomes of interest were symptomatic intracranial hemorrhage (sICH), any ICH, serious systemic bleeding (SSB), and 90-day functional independence (mRS 0-2). Moreover, we calculated pooled odds ratios (OR) for each outcome using a random effect meta-analysis to compare the rates between the patients with DOAC and non-DOAC upon IVT. Ultimately, we completed a sensitivity analysis for idarucizumab, NIHSS, and the timing of DOAC administration.

Results:
Our meta-analysis included 14 studies with 247079 patients (3610 in DOAC and 243469 in non-DOAC). In the DOAC group, the rate of sICH was 3% (95%CI 3 - 4%), any ICH was 12% (95%CI 7 - 19%), SSB 0.7% (95%CI 0 - 1%), and 90-day mRS 0-2 was 57% (95%CI 43 - 70%). No difference in the rates of sICH (3.4vs.3.5%; OR=0.95; 95%CI 0.67 - 1.36), any ICH (17.7vs.17.3%; OR=1.23; 95%CI 0.61 - 2.48), SSB (0.7vs.0.6%; OR=1.27; 95%CI 0.79 - 2.02), and 90-day mRS 0-2 (46.4vs.56.8%; OR=1.21; 95%CI 0.400 - 3.67) was found between DOAC and non-DOAC groups. Subgroup analysis revealed no significant difference in the sICH rate between idaricuzumab and no idaricizumab administration prior to IVT [Figure 1].

Conclusions:
Our analysis demonstrated no significant difference in functional independence and hemorrhagic complication rates in AIS patients treated with IVT with recent DOAC compared to the no-DOAC group. Further prospective randomized clinical trials are needed to shed more light on this topic.
Abstract 3: A Randomized Clinical Trial Evaluating the Impact of a Personalized Video-Based Educational Platform After Discharge
Authors: Favilla Christopher G , Stein Laura A , Reehal Navpreet , Cummings Stephanie , Burdett Rebecca , Kasner Scott
Published: February 2024

Introduction:
Stroke knowledge, risk factor awareness, and medication adherence are critical to post-stroke outcomes. Here, we aimed to quantify the impact of a personalized video-based educational platform that facilitates ongoing engagement after discharge.

Hypothesis:
We hypothesize that a personalized educational platform improves patient satisfaction and stroke knowledge.

Methods:
In a single-center randomized trial, stroke patients and caregivers were randomized to receive standard stroke education during the hospitalization or access to MyStroke, a personalized educational platform with brief videos about their stroke etiology, risk factors, medications, and post-stroke lifestyle. Satisfaction, quality of life, and stroke knowledge were assessed 90 days after discharge.

Results:
120 subjects (96 patients and 24 caregivers) were randomized to receive MyStroke (n=61) or standard education (n=59). Satisfaction with stroke education was higher among those who received MyStroke (
Figure 1
). Participants who received MyStroke were more likely to correctly identify their stroke etiology, but no effect was observed with respect to risk factor recognition, medication awareness, or quality of life (
Table 1
). Participants without a college degree experienced a larger educational benefit and improved in quality of life (
Table 1
).

Conclusions:
The MyStroke personalized video-based education platform improved stroke knowledge, and then impact was augmented in subjects with less formal education. A multicenter trial is needed to confirm these results, clarify generalizability, and target clinically relevant metrics such as stroke recurrence or adherence.
Abstract 36: Association Between High-Resolution Magnetic Resonance Imaging Characteristics and Recurrent Stroke in Patients With Symptomatic Intracranial Atherosclerotic Steno-Occlusive Disease: A Prospective Multicenter Study
Authors: Yuan Weizhuang , Xiaoyun Liu , Yan Zhongrui , Wu Bo , Lu Baoquan , Chen Beilei , Tian Daishi , Du Ailian , Li Litao , Liu Changyun , Liu Guangzhi , Tao Gong , Shi Zhimin , Feng Feng , Liu Caiyan , Yao Meng , Lin Qianqian , Li Mingli , Wei-hai Xu ,   Stroke Imaging Package Study of Intracranial Atherosclerosis (SIPS-ICAS) study group
Published: February 2024

Background and Objectives:
This study aimed to investigate the association between high-resolution magnetic resonance imaging (HR-MRI) characteristics and recurrent ipsilateral stroke in patients with symptomatic intracranial atherosclerotic steno-occlusive disease (ICAS).

Methods:
This multicenter, observational study recruited first-ever acute ischemic stroke patients attributed to ICAS (>50% stenosis or occlusion) within 7 days after onset. Participants were assessed by multi-parametric MRI including diffusion-weighted imaging, three-dimension time-of-flight magnetic resonance angiography, and three-dimensional T1-weighted HR-MRI. The patients were recommended to receive best medical therapy and were systematically followed up for 12 months. The association between HR-MRI characteristics and the time to recurrent ipsilateral stroke was investigated by univariable and multivariable analysis.

Results:
Two hundred and fifty-five consecutive patients were enrolled from 15 centers. The cumulative 12-month ipsilateral recurrence incidence was 4.1% (95% confidence interval [CI]: 1.6-6.6%). The plaque length (5.69±2.21 mm vs. 6.67±4.16 mm), plaque burden (78.40±7.37% vs. 78.22±8.32%), degree of stenosis (60.25±18.95% vs. 67.50±22.09%) and remodeling index (1.07±0.27 vs. 1.03±0.35) on HR-MRI did not exhibit discernible difference between patients with and without recurrent ipsilateral stroke. Patients with recurrent ipsilateral stroke exhibited higher rates of intraplaque hemorrhage (IPH) (30.0% vs. 6.5%) and eccentric plaque (90.0% vs. 48.2%), and lower occurrence of occlusive thrombus (10.0% vs. 23.7%). In the multivariable Cox regression analysis, IPH (hazard ratio: 7.05, 95% CI: 1.53-32.41, p=0.012) was significantly associated with recurrent ipsilateral stroke after adjustment.

Discussion:
We found IPH is significantly associated with recurrent ipsilateral stroke. Our results suggest IPH has potential value in the selection of patients for aggressive treatment strategies.
Abstract 51: Impact of Cerebral Autoregulation on the Relationship Between Blood Pressure Variability and Functional Outcome Following Endovascular Thrombectomy
Authors: Petersen Nils H , Olexa Madelynne , Jayasundara Sithmi , Falcone Guido J , Gilmore Emily , Kim Jennifer , Matouk Charles C , Alian Aymen , Sheth Kevin N , Miller Eliza C , Ortega-Gutierrez Santiago , de Havenon Adam H
Published: February 2024

Background:
Both increased blood pressure (BP) variability and impaired autoregulation have been linked to worse outcome after endovascular thrombectomy (EVT). This study examined the combined effect of these variables on the risk of poor outcome in patients with large-vessel occlusion (LVO) stroke.

Methods:
Autoregulation was continuously measured for up to 24 hours after EVT and quantified as a moving correlation coefficient between arterial BP and the near-infrared spectroscopy-derived cerebral oxygen saturation. Systolic BP variability was assessed using the standard deviation of the mean. Values were averaged for the entire recording period and dichotomized at the lowest tertile for both variables. Functional outcome was assessed using the modified Rankin scale (mRS) at 90 days and dichotomized into good (mRS 0-2) and poor outcome (mRS 3-6).

Results:
We included 195 patients (mean age 70
+
16, 45% female, mean NIHSS 14, mean monitoring time 15
+
7 hours). After adjusting for age, NIHSS, ASPECTS, and TICI score, patients with low BP variability and intact autoregulation were significantly more likely to achieve a good outcome than those with high BP variability and impaired autoregulation (OR 3.7, 95% CI 1.2-12.1, p=0.028, Figure 1A). We found an interaction between BP variability and autoregulation (p=0.067). Patients with high BP variability showed a gradual decrease in the probability of a good outcome with worsening autoregulation. However, for patients with low BPV, autoregulation had minimal impact. (Figure 1B). No significant correlation was seen between autoregulatory function and BP variability (r=0.07, p=0.33).

Conclusions:
For LVO stroke patients with high BP variability after EVT, worse 90-day functional outcome may be exacerbated by impaired autoregulation. These results suggest that autoregulatory status should be considered in the management of BP after EVT to identify high-risk patients and develop individualized treatment strategies.
Abstract 60: Utilization, Workflow, and Outcomes of Endovascular Thrombectomy in Patients With versus Without Pre-Morbid Disability in a National Stroke Registry
Authors: Ganesh Aravind , Volny Ondrej , Kovacova Ingrid , Tomek Ales , Bar Michal , Rocek Miloslav , Padr Radek , Cihlar Filip , Nevsimalova Miroslava , Kocí Lubomír , Havlicek Roman , Kovar Martin , Sevcik Petr , Rohan Vladimir , Fiksa Jan , Cernik David , Jura Rene , Vaclavik Daniel , Hill Michael D , Mikulik Robert
Published: February 2024

Background:
Given the paucity of high-quality data on acute stroke therapies in patients with pre-morbid disability, they risk being routinely excluded from such therapies. We examined utilization of endovascular thrombectomy (EVT), workflow, and outcomes among ischemic stroke patients with vs without pre-morbid disability in a national registry.

Methods:
We used data for the Czech Republic from 1-January-2016 to 31-December-2020. Pre-morbid disability was defined as pre-stroke modified Rankin Scale score (mRS) >2. We compared receipt of EVT, workflow times, ΔmRS (change from pre-stroke to 3-months), intracerebral hemorrhage (ICH), mortality, and discharge NIHSS among patients with vs without pre-morbid disability, adjusting for age, sex, baseline NIHSS, and comorbidities, and verified using propensity score-weighting (PSW) for differences in treatment assignment.

Results:
Among 22,405 patients, 1,712 (7.6%) had pre-stroke mRS >2. Patients with pre-morbid disability were less likely to receive EVT (10.1% vs 20.7%, aOR:0.30, 95%CI:0.24-0.36) and had longer door-to-puncture times (median:75-minutes, IQR:58-100 vs 54, IQR:27-77, adjusted-difference:12.5, 95%CI:2.68-22.3), worse ΔmRS (adjusted rate-ratio, aIRR on PSW:1.57, 1.43-1.72), rates of 3-month mRS 5-6, discharge NIHSS, and mortality (aOR-PSW[mortality]:2.54, 1.92-3.34); ICH rates did not differ. Among those with pre-morbid disability, 32.1% returned to pre-stroke state; this ranged from 19.6% for those >85-years to 66.0% for <65-years. EVT was associated with better outcomes including lower ΔmRS (aIRR-PSW:0.87, 0.83-0.91) and mortality, with no interaction of treatment effect by pre-morbid disability (e.g. mortality p
interaction
=0.73). EVT recipients with pre-morbid disability did not differ significantly for several key outcomes including ΔmRS (aIRR:0.99, 0.84-1.17), but were more likely to have mRS 5-6 (70.1% vs 39.5%, aOR:1.85, 1.12-3.04).

Conclusions:
Patients with pre-morbid disability were less likely to receive EVT and had slower treatment and worse outcomes than those without disability. However, patients fared better with EVT versus medical care, and one-third with pre-stroke disability returned to their pre-stroke state.
Abstract 77: A Regional Transfer Center Pilot Improves Door-in-Door-out Time in a Large Integrated Healthcare System
Authors: Klingman Jeff , Hatton Joeffrey , Reader Kyle E , Weil Joshua , Sudhalkar Hemali , Dove Karin , Alexander Janet , Nguyen-Huynh Mai N
Published: February 2024

Background:
Successful treatment of patients with large vessel occlusions (LVO) is time dependent, yet timely transfers between hospitals for endovascular therapy (EVT) can be challenging. At Kaiser Permanente Northern California (KPNC) a wide variety of ambulance and EMS agencies may be involved in Urgent interfacility transfers. We evaluated a region-wide pilot utilizing a central transfer center to facilitate these transfers within a large integrated healthcare system.

Methods:
KPNC implemented a regional transfer center (TC) in March 2023, which arranged transfers for 17 of 19 primary stroke centers (PSC) from 8am to 9pm. Two centers were excluded as they were utilizing 911 transport rather than interfacility ambulance hub transfers. The study cohort included all stroke patients arriving to a PSC with LVO who were transferred to one of our Comprehensive Stroke Centers for EVT from 3/6/23 through 8/4/23. Data were compared to a similar cohort 10/6/23 through 3/5/23 (pre-TC). All patients were evaluated by teleneurologists on arrival, who requested initiation of ambulance transfer. Before TC, the ambulance request was made by the local ED facility; after the implementation of the TC, ambulance was arranged by the TC and communicated with teleneurology and the local ED. Door in door out (DIDO) times were measured for all transfers.

Results:
The pre-TC group had 81 transfers. The post-TC group had 68 patients. After TC, median DIDO dropped from 105 minutes to 83.5 minutes (p=0.02). The percent of patients transferred within 90 minutes rose from 41% to 57% (p=0.04) and the percent transferred with 75 minutes rose from 25% to 35% (p=0.14). Similar improvements were seen regardless of sex or ethnicity [Table].

Conclusions:
Preliminary results show a significant improvement in DIDO times with initiation of a centralized TC to facilitate LVO transfers in a large integrated delivery system. Systems wishing to improve DIDO performance should consider implementing a similar TC.
Abstract 83: Early Notification Using a Novel Three-Tiered Code Stroke System Reduces Neurointerventional Team Activation Times
Authors: Tariq Muhammad Bilal , Sharma Latisha K , Jahan Reza , Chatfield Fiona , Bahr-Hosseini Mersedeh , Colby Geoffrey , Duckwiler Gary , Hinman Jason D , Kaneko Naoki , Liebeskind David S , Mun Katherine T , Nour May , Szeder Viktor , Tateshima Satoshi , Alfonso Rodel C , Saver Jeffrey L
Published: February 2024

Background:
Although Code Stroke group page systems are essential to accelerate endovascular therapy (EVT), their design and implementation has not been well-studied. We assessed a novel 3-tiered system crafted to facilitate prompt, stepped activation.

Methods:
An escalating 3-tiered system was designed to provide salient services with both an a) alert-be ready page, and a b) go-go-go page while minimizing false alarms. Group page levels are: 1) pre-arrival notification of possible stroke by EMS to Neurology; 2) notification of possible large vessel occlusion (LVO) by Neurology (based on cortical signs) to Neurointerventional+/Anesthesia; and 3) post-imaging notification of confirmed LVO and angiosuite decision to all services. System performance was assessed over a 1 year period September 2022 to August 2023.

Results:
Among 798 Code Strokes, 75 (9.4%) patients received EVT, including 45 who were EMS-arriving. Among the 45 LVO strokes treated with EVT, 26 (58%) had an early notification (EN) Level 2 page pre-imaging and 19 (42%) only a late notification (LN) Level 2 page post-imaging. Patients in the EN vs LN group were nominally older (84 vs 74), more often female (61.5% vs 47.3%), and more severely affected (NIHSS 16 vs 13). Time metrics are presented in Table 1 and Figure 1. The EN group had a near 40 minute decrease in door-to-puncture (DTP) and 50 minute decrease in door-to-reperfusion (DTR) times.

Conclusion:
All levels of a 3-tier (pre-arrival, pre-imaging, and post-imaging) Code Stroke group page system were activated frequently in EVT patients and pre-imaging early notification of neurointerventional and anesthesia teams was associated with markedly reduced DTP and DTR times.
Abstract 89: Portable, Low-Field Magnetic Resonance Imaging: Determining Mismatch Following Acute Ischemic Stroke
Authors: Sorby-Adams Annabel , Guo Jennifer , Schleicher Riana , Mazurek Mercy , Baldassano Steven , Payavbash Sam , Sze Gordon , Schindler Joseph , de Havenon Adam , Goldstein Joshua , Schaefer Pamela , Zabinska Julia , Lalwani Dheeraj , Wira Charles , Matouk Charles , Lee Vivien , Muir Keith , Nimjee Shahid , Pinter Nandor , Siddiqui Adnan , Kirsch John , Iglesias Juan Eugenio , Rosen Matthew , Sheth Kevin , Kimberly W. Taylor
Published: February 2024

Background and Aims:
Treatment options for acute ischemic stroke (AIS) are uniquely dependent on the time of stroke onset. Intravenous thrombolysis must be administered within 4.5 hours of symptoms commencing, yet a subset of patients wake-up with symptoms and time of onset is unknown. Mismatch between fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) MRI can be used to qualify wake-up strokes for thrombolysis. This has been shown to lead to improved functional outcomes in multicenter trials (WAKE-UP, MR-WITNESS). However, access to MRI is a barrier to differential diagnosis and subsequent treatment. Recent advances in portable, low-field MRI (LF-MRI) offer a solution to increase access to MRI technologies and circumvent the limitations of conventional systems. As such, in this pilot study, we sought to establish the utility of portable LF-MRI to identify DWI-FLAIR mismatch following AIS.

Methods:
Patients with a diagnosis of AIS presenting to Emergency Department or Intensive Care Unit of the Yale New Haven Hospital or Massachusetts General Hospital from January 2020 to June 2023 underwent DWI and FLAIR acquisition on a 0.064T MRI (Hyperfine Research Inc.) at <4.5 hours (
n
=7), 4.5-6 hours (
n
=7), and 6-48 hours (
n
=110) since last known well (LKW). Conventional high-field (HF) MR images were acquired within 72 hours of LF-MRI. HF-DWI images were co-registered to LF-FLAIR and the hyperintense DWI stroke lesion segmented and superimposed on the FLAIR. The segmentation was mirrored to the contralateral hemisphere of the LF-FLAIR to establish a FLAIR signal intensity ratio (SIR).

Results:
The FLAIR SIR on images <4.5 hours since LKW was 0.98±0.08. The SIR for cases 4.5-6 hours was 1.34±0.33. Cases 6-48 hours produced a SIR of 1.56±0.36. The SIR at <4.5 hours was significantly less than that observed >6 hours since LKW (
p
=0.03).

Conclusion:
This pilot study demonstrates that a 0.064T portable MRI is capable of distinguishing hyperacute stroke from later stroke onset using FLAIR SIR. Future research is needed in a larger cohort to determine if this imaging technology can be used to guide thrombolysis in the setting of wake-up stroke.
Abstract HUP13: Participants With Complex Impairment Profiles Are Systematically Excluded From Stroke Psychosocial Support Research: A Scoping Review
Authors: Lin Nancy X
Published: February 2024

Introduction:
Disability after stroke often requires mental health treatment, but contradictorily, also restricts access to it. People with cognitive, motor, language, and perceptual impairments have been excluded from research on psychosocial supports like psychotherapy, support groups, and meaningful life activities. This exclusion adds to the inequitable distribution of benefits, including fewer treatment options and less knowledgeable providers. Very little is known about
who
is excluded from stroke psychosocial support research,
why
they are excluded, and
how
exclusion occurs.

Methods:
Exclusionary practices were investigated using a Johanna Briggs Institute-method scoping review. Independent reviewers screened searches of CINAHL, Embase, MEDLINE, and PsychInfo, resulting in 101 included studies. Content analysis was used to analyze studies following an
a priori
coding framework, which included: Design, inclusion/exclusion criteria, stroke impairment, psychiatric comorbidity, and psychosocial support type.

Results:
Samples were commonly limited to mild cognitive impairment, with other subpopulations under-represented. Moderate-to-severe cognitive and language impairments were systematically excluded from psychotherapy studies. In contrast, support group and meaningful life activity studies more often included a range of impairments, but also more often excluded psychiatric comorbidity. Studies with rigorous designs rarely included complex impairment profiles. Reasons for exclusion were seldom provided, and participant characteristics were routinely underreported.

Conclusion:
By including only people with mild and uncomplicated impairment profiles, the field risks neglecting the complex realities of others who arguably have even greater need for support. This scoping review offers recommendations for stroke research and practice, including: The inclusion of a range of stroke impairments in research samples, adapting procedures using compensatory strategies to facilitate inclusion, and greater cross-pollination between mental health and rehabilitation disciplines. This review serves as a call to action to make psychosocial supports equitable and accessible for all people, regardless of ability.
Abstract HUP18: Clinical Characteristic of a Haitian Stroke Cohort and a Scoping Review of the Literature of Stroke Among the Haitian Population
Authors: Jean Paul Axler , Charles Jude Hassan , Gedner Gandhi Marius Edwitch , Roche Richardson , Andre Wislet , Saint Croix Garly Rushler , Perue Gillian Gordon
Published: February 2024

Background:
There are significant disparities in stroke care and outcomes between low- and middle-income country like Haiti, which suffers from a lack of resources for acute stroke management. This study is the first to report the epidemiological profile of the Haitian population at the largest academic hospital in the nation.

Methods:
This is an observational study conducted over a period of 5 months from April 2021 to August 2021 in the Internal Medicine Department of the State University Hospital of Haiti. There were 51 included patients who were suspected to have had an acute stroke. A descriptive statistical analysis was conducted. A scoping review of the literature was also conducted.

Results:
Over 50% of included patients were between 19 and 65 years old. The mean age at presentation was 61 years, patients were predominantly female (64.7%). The prevalence of severe motor deficits was over 96%. The mean National Institutes of Health Stroke Scale was 12. Only 15.7% of patients (8/51) had a computed tomography (CT) scan during their hospitalization. The median time to CT scan was 84 h after symptom onset. About 80% of those with complications took more than 24 h to arrive at the hospital after the onset of symptoms. Eleven percent of patients had complications, and the mortality rate was 3.9%. There was a significant association between the Modified Rankin Scale and the occurrence of complications (p = 0.016). National Institutes of Health Stroke Scale (NIHSS) score had a significant association with the Glasgow score (F = 6.3; p < 0.001) where an inversely proportional correlation was observed between them (r = –0.7; p < 0.001) and a proportional correlation with the Rankin prediction score and the NIHSS (r = 0.3, p = 0.04). Little is known about the epidemiology of stroke patients in Haiti, and this limits the ability to develop targeted interventions to improve outcomes. In our scoping review, only three pertinent studies were identified over a 25-year period, this leads to a lack of data in regard to stroke care in Haiti mainly due to the absence of trained personnel.

Conclusion:
Urgent assistance is needed to strengthen personnel and infrastructure dedicated to stroke. Neurological assessment based on NIHSS and Rankin score should be systematic in stroke evaluation in Haiti.
Abstract HUP3: Neighborhood Deprivation and Functional Outcomes Following Ischemic Stroke
Authors: Kleinberg Leah M , Clocchiatti-Tuozzo Santiago , Rivier Cyprien , Torres Lopez Victor M , Kim Jisoo , Kitlen Eva , Kampp Michael C , Jasak Sara , Schindler Joseph L , Sansing Lauren H , Sheth Kevin N , Falcone Guido J
Published: February 2024

Introduction:
The association between neighborhood deprivation and risk of disease is well-documented. However, the role of neighborhood deprivation in long-term outcomes following acute brain injury remains understudied. We tested the hypothesis that neighborhood deprivation leads to unfavorable long-term functional outcomes following acute ischemic stroke (AIS).

Methods:
We conducted a nested study within the Yale Longitudinal Study of Acute Brain Injury, a prospective study which follows patients with acute brain injury admitted to the Yale Health System. The present study focused on AIS survivors and assessed neighborhood deprivation using the Area Deprivation Index (ADI), a metric that uses 9-digit zip codes to rank neighborhoods based on income, employment, education, and housing quality. Patients were stratified into tertiles based on their ADI, designated as low, intermediate, or high deprivation. Functional outcomes were evaluated using the modified Rankin Scale at one-year post-stroke, dichotomized into favorable (scores 0-2) and unfavorable (scores 3-6). Our analysis employed multivariable logistic regression for adjusted analyses.

Results:
Among 2,540 AIS patients enrolled between 2018 and 2021, 2,164 patients had zip code and outcomes data (mean age 69 years, 48% female, 7.5% Black, 7.7% Hispanic). The one-year unadjusted risk of poor outcomes was 35%, 40% and 46% for patients residing in neighborhoods with low, intermediate, and high deprivation, respectively (unadjusted p=0.001). These findings remained significant in multivariate analyses that controlled for confounding factors: compared to patients living in neighborhoods with low deprivation, those living in areas with intermediate and high deprivation had 44% (OR 1.44, 95% CI 1.11-1.86) and 107% (OR 2.07, 95% CI 1.58-2.72) greater risk of unfavorable outcomes (test-for-trend p<0.001).

Conclusion:
Our study, focusing on survivors of AIS participating in a prospective acute brain injury study, underscores the connection between neighborhood deprivation and an elevated risk of unfavorable outcomes. We validate the utility of the ADI as a valuable analytical tool for evaluating neighborhood deprivation as a composite for several social determinants of health.
Abstract HUP4: Can A Remote Telehealth-based Program Support Survivors With Varying Social Needs Post-stroke?
Authors: Sheehan Lauren , Winters Melanie , Wertheheimer Jeffrey , Tsai Nancey
Published: February 2024

Introduction:
There are significant and longstanding inequities in stroke prevalence and care as well as outcomes. Social determinants of health (SDOH) are known to be a risk factor in post-stroke recovery. SDOH also put individuals at higher risk for 90-day mortality. Social determinants are a significant contributor to disparities in health and specifically addressing SDOH needs may improve the health and outcomes of stroke survivors.

Methods:
An app-based, virtual care model was used to impact survivor quality of life and outcomes for stroke survivors and their care partners. As a part of program onboarding, the clinical navigator utilized the CMS Accountable Health Communities Health-Related Social Needs Screening Tool to assess survivor needs in five core domains including housing instability, food insecurity, transportation problems, utility needs, and interpersonal safety. As needs were identified, they were cross-walked to pre-populated community resource maps to aid the survivor in their recovery and support subsequent stroke prevention.

Results:
Of the (n=50) stroke survivors (median age of 62) that completed the 12-week survivor-led Navigator support program, 35% had one SDOH need, 16% had 2 SDOH needs, 16% had 3 SDOH needs, 3% had 4 SDOH needs and 28% had 5 or more SDOH needs. The most regularly identified areas of social need in the cohort were mental health (20%), financial strain (15.7%), employment (13.6%) and transportation (12.9%). These SDOH were addressed throughout the 90-day program based on individual access considerations. The 30- and 90-day all-cause readmission rates for survivors were 5% and 10%, respectively, superior to recent publications reporting 30-day unplanned readmission rates after stroke ranging from 8.7%-12.5%, and 90-day readmissions ranging from 18.9% to 20.7%.

Conclusion:
By assessing SDOH and providing specifically tailored post-acute resources to meet those needs, a tech-enabled platform with clinical navigator support can improve outcomes for stroke survivors with a variety of SDOH needs. Additional post-acute stroke care and targeted programming are needed to address the ongoing inequalities in the healthcare system as they relate to post-stroke care and recovery in populations with high SDOH needs.
Abstract HUP5: Patient and Hospital Characteristics Associated With Disparities in Acute Stroke Treatment in Community and Academic Hospitals
Authors: Shen Jerry , Corlin Laura , Cote Kathryn , Pudlo Megan , Leung Lester
Published: February 2024

Introduction:
Expedited transportation, identification, and coordination of care are essential drivers of optimal outcomes in the management of acute ischemic stroke (AIS), but systemic biases and barriers may affect these processes. We assessed patient- and hospital-level factors that may be associated with differences in prehospital and emergency department care processes for patients with AIS at academic medical centers (AMC) and those at community hospitals (CH).

Methods:
We retrospectively collected data from the electronic health record at an academic medical center (Tufts Medical Center) for adults age ≥ 18 hospitalized with AIS between 1/1/2018-12/31/2020, including patients who presented directly to the AMC versus patients transferred from a CH for further care. We performed multivariate analyses to assess predictors of emergency medical service (EMS) use, stroke code activation, door-to-CT time, and door-to-needle time across all patients and in each group.

Results:
542 patients were included. AMC patients identifying as Asian (OR 0.25, 95% CI 0.13-0.47) and Hispanic (OR 0.19, 95% CI 0.05-0.72) and CH patients identifying as Black (OR 0.17, 95% CI 0.17-0.62) were less likely to use EMS compared to white patients. Patients with non-English primary language were less likely to use EMS (OR 0.38, 95% CI 0.23-0.63) compared to English-speaking patients in all hospitals. CH patients identifying as Hispanic were less likely to have stroke code activation (OR 0.24, 95% CI 0.05-0.86) compared to white patients. There were no differences in median door-to-CT or door-to-needle times between CH and AMC patients. In analyses including all patients, Asian race was associated with longer door-to-CT time (OR 1.25, 95% CI 1.03-1.49), and female sex was associated with longer door-to-needle time (OR 1.23, 95% CI 1.03-1.43).

Conclusion:
There are multiple potential sources of disparity in prehospital and hospital-based hyperacute care for patients with AIS including sex, race, ethnicity, and non-English primary language. These may represent opportunities for community outreach on EMS use, interventions to address systemic racism among healthcare providers, and interventions to alleviate language barriers.
Abstract NS5: Outcomes of Nursing Led Post-Stroke Anxiety and Depression Screening
Authors: Mkrtumyan Alvina , Gaffney Denise , Santosa Rhendyanno , Sangha Navdeep S , Le Duy , Cheng Pamela , Ajani Zahra , Taleb Shayandokht
Published: February 2024

Introduction:
Post-stroke anxiety (PSA) is common, but underestimated and can be distressing during stroke recovery. Health systems may fail to provide screening and follow up for PSA.

Methods:
Stroke survivors between 10/2022-3/2023 received a phone call from an SCRN to assess anxiety and depression within 30-45 days of discharge using General Anxiety Disorder (GAD-7) and Patient Health Questionnaire (PHQ-9) respectively. Two call attempts were made. Based on the GAD-7, scores of 1-4 (minimal), 5 and 9 (mild), 10 to 14 (moderate), and 15 to 21 were classified as severe. The patients were referred to depression care management (DCM) or psychiatry based on the severity score. Data were analyzed using R package.

Results:
Total of 269 patients were identified: 111 (41%) completed the phone screening. The demographics and patient characteristics of patients are shown in table 1. The NIHSS of patient who did not complete the survey was higher 5(IQR 2,13) vs 3 (IQR 1,6). Most patients who completed the survey were discharged home 92(83%) (±home health). The severity of GAD-7 and PHQ9 score correlated moderately (Pearson’s r=0.69; P=0.002). Evaluation of dichotomized GAD-7 anxiety scores (minimal/mild vs moderate/severe) showed patients’ age and NIHSS are negatively correlated with GAD-7 score (r=-0.18; P=0.002 and r=-0.10 P=0.1).

Conclusion:
PSA and depression screening after discharge in stroke survivors helps with early identification and treatment, and potentially improving the quality of life. Anxiety and depression scores correlated positively and were higher in younger patients and those with low NIHSS.