bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP239: Vitamin D and Post-Stroke Depression: A Systematic Review and Meta-Analysis
Authors: Kurra Nithin , Sudireddy Kavya , Ramakrishna Manju , Boorle Naga Vijaya Lakshmi Divya , Irfan Shayan Ali , Jillella Dinesh V , Gandrakota Nikhila
Published: February 2024

Objective:
Low vitamin D levels have often been associated with depression as well as worsen stroke outcomes. With post-stroke depression (PSD) being an important factor contributing to poor recovery and rehabilitation and thereby poor functional outcomes, this study was undertaken to explore the role of vitamin D deficiency in PSD and their correlation with stroke prognosis and outcomes.

Methods:
A systematic search of eligible studies from PubMed, MEDLINE, Cochrane CENTRAL, and Google Scholar were identified. Selected studies were those that met the inclusion criteria. Statistical analysis was conducted using Review Manager 5.4.1. A random-effects model was used to pool the data when heterogeneity was seen and so,results were reported in the standard mean differences within their corresponding 95% confidence interval.

Results:
Our analysis showed statistically significant clinical depression in the Vitamin D deficient group on the BDIII (SMD= 6.90 [3.32, 10.48]; p= 0.0002) and PHQ-9 (SMD= 3.20 [1.84, 4.56]; p< 0.00001) scales. Of the seven studies, four showed significantly poorer prognosis in PSD patients with respect to NIHSS (SMD=1.54; [0.34, 2.74]; p< 0.0001) and MMSE (SMD= -2.53 [3.79, 1.27]; p< 0.0001).

Conclusion:
This study shows a significant association between serum Vitamin D levels and PSD. Further studies are needed to explore causal relationships and the effect of vitamin supplementation on stroke prognosis and outcomes in relation to PSD
Abstract TP245: Identifying Ischemic Stroke Etiology Through Cytokine Biomarkers
Authors: Tolcher Heather , Finger Carson A , Dongarwar Deepa , Anhstedt Hilda , Manwani Bharti
Published: February 2024

Background:
Ischemic stroke can arise from various etiologies, such as cardioembolism, atherosclerosis, small vessel disease or cryptogenic. Accurate identification of stroke etiology is vital for secondary stroke prevention. Accumulating evidence suggests that an imbalance of neuroprotective and neuroinflammatory cytokines may contribute to stroke outcomes. Interleukin-2 receptor subunit α (IL-2Rα), a cell surface protein that regulates lymphocyte activation, has been shown to have either pro-atherosclerotic or atheroprotective roles through activation of lymphocytes or regulatory T cells, respectively. We hypothesized that distinct cytokine profiles, and in particular IL-2Rα, may correlate with specific stroke etiology.

Methods:
Plasma samples were collected from patients with ischemic stroke that were admitted to Memorial Hermann Hospital, Houston by UTHealth biobank. ELISA was used to analyze the plasma samples for levels of IL-2Rα. The relationship between stroke etiology (TOAST criteria) and IL-2Rα was assessed using ANOVA and then adjusted for co-morbidities using multilinear regression models.

Results:
The mean age of patients was 63.4 years, 35.2% were women, 87% had hypertension, 48.1% had diabetes mellitus, and 53.7% had hyperlipidemia. IL-2Rα levels were significantly elevated in patients with ischemic stroke due to large-artery atherosclerosis (53.5±4.7 pg/ml) as compared to cardioembolic (35.6±6.5 pg/ml), small vessel disease (38.2±7.4pg/ml) or cryptogenic etiology 32±7.8; p<0.01).

Conclusions:
Our study suggests that IL-2Rα is significantly elevated in ischemic strokes caused by atherosclerosis compared to other ischemic etiologies. This suggests the role of lymphocytic activation in strokes from intracranial and extracranial atherosclerotic disease, which may be used as a therapeutic target. It also identifies a novel biomarker for ischemic strokes from atherosclerosis. Future studies identifying the upstream and downstream pathways that lead to IL-2Rα activation and stroke in atherosclerotic lesions, will further add to our understanding of the characteristics of atherosclerotic lesions that lead to ischemic strokes.
Abstract TP246: Circadian Variability of the Clot Burden Score in Acute Anterior Circulation Ischemic Stroke
Authors: Lin Sidney , Raince Avtar , Byrns Kory
Published: February 2024

Background/Purpose:
Fibrinolytic activity in blood plasma displays a circadian rhythm with a drop in the morning hours that may predispose to acute thrombotic events. The Clot Burden Score (CBS) is a semiquantitative measure on CT angiography (CTA) of thrombus extent in proximal anterior circulation strokes that has been correlated with functional outcome. Higher clot burden has also been shown to have lower recanalization rates with intravenous thrombolytics. We aimed to investigate whether CBS is a parameter that displays circadian variability.

Methods:
We performed a retrospective analysis on consecutive stroke patients presenting <24 hours from symptom onset or last known well (LKW) with an occlusion in the anterior circulation confirmed on CTA. CBS was scored on a 10-point
negative
ordinal scale with 2-points subtracted for occlusion of the supraclinoid ICA, proximal M1, or distal M1, and 1-point subtracted for occlusion of the infraclinoid ICA, A1, or either M2 branches. No points were subtracted for occlusion distal to A1 or M2. Subjects were grouped into four 6-hour intervals, MORNING: 6:00-11:59, DAY: 12:00-17:59, EVENING: 18:00-23:59, and NIGHT: 0:00-5:59, based on the time of onset/LKW. CBS values were compared between groups using the Kruskal-Wallis test with pairwise comparisons.

Results:
240 subjects were included with median age of 75 (IQR 65-84), NIHSS score of 17 (IQR 10-24), and time from onset/LKW to CTA of 5 hours (IQR 2-11). 73 subjects had onset during the MORNING, 56 during the DAY, 86 during the EVENING, and 25 during the NIGHT. The median CBS from MORNING time onset was 6 (IQR 5-9), compared to 7 (IQR 6-9) from the DAY, 7.5 (IQR 6-9) from the EVENING, and 7 (IQR 5-8.5) from the NIGHT. CBS was significantly lower in the MORNING compared to the EVENING, p=0.037. CBS was not significantly different between all other pairwise comparisons, p>0.107.

Conclusion:
CBS as a measure of thrombus extent in proximal anterior circulation strokes on CTA appears to show circadian variability, with lower scores (higher clot burden) during MORNING onset (6:00-11:59) than the EVENING (18:00-23:59). This may have implications for future studies of chronotherapeutic protocols.
Abstract TP249: A Real World Study of PFO Closure in Young Patients With Ischemic Stroke
Authors: Emmerson Danison , Li Ya-Huei , Tunguturi Ajay , Nouh Amre M , Hou Yan
Published: February 2024

Introduction:
Over the past decade, the concept of Patent Foreman Ovale (PFO)-related stroke has been evolving. Current guidelines recommend PFO closure in young patients who had a non-lacunar ischemic stroke of undetermined cause and related to a high-risk PFO. Whereas there remains a discrepancy in patient selection for PFO closure among providers and institutions in real-world practice. The retrospective study comprehensively examined patient characteristics, clinical assessments, and outcomes among young stroke patients who underwent PFO closure to gauge the current clinical process in selecting PFO candidates.

Methods:
Adult ischemic stroke patients (age >18) who underwent PFO closure from 1/2018 to 12/2022 at the single center were identified from the cardiology PFO closure database. Patients were characterized into PFO-Associated Stroke Causal Likelihood (PASCAL)-probable; PASCAL-possible, and PASCAL-unlikely categories for comparison. Descriptive statistics was conducted due to the small sample size.

Results:
The mean age of qualified 78 patients was 47 years old when receiving PFO closure; the majority were males (64%) and Caucasians (75%). High risk PFO was identified in 55% of patients, and 63% of patients had high Risk of Paradoxical Embolism score ≥7. The patients were determined as PASCAL- probable (53%); PASCAL-possible (33%), and PASCAL-unlikely (15%), respectively. Among all the patients, the rate of successful device implantation was 96.0%, rate of closure related adverse events were 15.8% with post closure atrial fibrillation rate of 7.9%. Compared to PASCAL possible and unlikely patients, PASCAL-probable patients had the highest rate of successful device implantation and the lowest closure-related adverse events rate, including post-procedure atrial fibrillation. During a median follow-up of 3.4 years after PFO closure, three patients (one PASCAL-unlikely and two PASCAL-possible) had a recurrent stroke.

Conclusions:
The findings of real-world data confirmed that PASCAL-probable patient most likely benefit from PFO closure with the least procedure-related adverse events.
Abstract TP25: Model-Free Dynamic Contrast-Enhanced MRI in Cerebral Small Vessel Disease: Test-Retest Reliability and Association With WMH Lesion Burden
Authors: Astafiev Serguei V , Ying Chunwei , Chen Yasheng , Astafyev Maxwell , Kang Peter , Dai Xing , Wang Yan , Lee Jin-moo , Ford Andria L , An Hongyu
Published: February 2024

Introduction:
Dynamic contrast enhanced (DCE)-MRI has been used to study blood-brain barrier (BBB) disruption in cerebral small vessel disease (CSVD), but complex kinetic modeling of DCE MRI is sensitive to noise and is not robust in detecting subtle BBB impairments. In contrast, model-free DCE is simple and does not require arterial input function and complex computation. In this study, we aimed to evaluate the test-retest repeatability of model-free DCE and its association with white matter hyperintensity (WMH) burden.

Methods:
Patients with CSVD were recruited. DCE-MRI, FLAIR, and T1 MPRage scans were acquired. A subgroup of patients had two repeated DCE MRI scans with an average interval of 41 days. WMH segmentation was performed to obtain the relative volume of WMH (rVwmh). Ten subjects had DCE-MRI data in two sessions for test-retest repeatability analysis. DCE-MRI were acquired using a Siemens volumetric interpolated breath-hold examination (VIBE) gradient echo sequence with a temporal resolution of 49 seconds and an acquisition time of ~20 minutes. The wash-out slope (WOS), which indicates the rate of contrast agent leaving the tissue, was computed.

Results:
64 patients (mean (SD) age = 68.6 (8.51), 37 females) with CSVD were studied. WOS demonstrated good test-retest repeatability for WM and GM with an intra-class correlation coefficient (ICC) of 0.626 and 0.671 in cerebrum WM and GM, respectively. WMH WOS has a significant negative correlation with rVwmh (r=-0.31; p<0.02).

Conclusions:
A slow contrast wash-out (small WOS) is expected in the presence of BBB impairment. WMH burdens are associated with BBB impairments manifested by decreased WOS. WOS is computationally less intense and demonstrates good repeatability. It may offer an alternative to model-based DCE in evaluating BBB dysfunction in patients with CSVD.
Abstract TP269: Determining Differences in the Association Between Atrial Fibrillation and Ischemic Stroke Outcomes by Acute Therapy Received
Authors: Lopez Ana , Wang Jing , Prashant Manasi , Johansen Michelle C
Published: February 2024

Introduction:
Whether the association between atrial fibrillation (AF) and ischemic stroke (IS) outcomes differs by IS therapy is unknown.

Hypothesis:
AF IS patients will have a worse discharge NIH Stroke Scale (NIHSS) and 90-day modified Rankin Scale (mRS) scores than non-AF, with differences by IS therapy.

Methods:
We studied a cohort of AF and non-AF IS patients from Johns Hopkins (2020-2023) with IS characteristics and demographics who received acute IS therapy (intravenous tissue plasminogen activator (IVtPA), mechanical thrombectomy (MT), or both). Multivariable regression models were used to examine the association between AF and either NIHSS (continuous or dichotomized at the mean (5)) or mRS (ordinal) separately, with interaction terms for IS therapy as appropriate.

Results:
Of the 240 patients (mean age 67, 52.5% female, 56.2% Black), 26.2% received IVtPA, 45.8% MT, and 27.9% both. There was no association between AF and NIHSS (β 1.53, 95% CI 0.38-3.4) in the final model, but there were higher odds of an NIHSS > 5 among AF patients (OR 3.46, 95% CI 1.16-10.30). AF patients had an increased odds of a worse mRS (Ordinal OR 2.05, 95% CI 1.14-3.71), but not after adjustment (Ordinal OR 1.07, 95% CI 0.52-2.20). The association between AF and IS outcomes differed by IS therapy (Table 1). AF patients who did not receive MT had a worse NIHSS and higher odds of a one unit increase in mRS, compared to AF patients who received MT (p-interaction 0.07, 0.01 respectively). Conversely, AF patients who received IVtPA had a worse NIHSS, compared to those who did not receive IVtPA (p-interaction 0.07), with essentially no difference in the association between AF and mRS in the final model when considering IVtPA use (p-interaction 0.09).

Conclusion:
In this study, AF patients had a higher mRS and worse discharge NIHSS versus non-AF, with differences by treatment; not receiving MT was detrimental for AF patients while our found worse outcome with IVtPA may reflect AF-associated treatment delays.
Abstract TP292: Chronic Kidney Disease Exacerbates Post-Stroke Cell Death and Inflammatory Mechanisms
Authors: Chelluboina Bharath , Mehta Suresh L , Vemuganti Raghu
Published: February 2024

Chronic kidney disease (CKD) is an important independent risk factor for stroke. To understand the mechanisms of CKD that exacerbates stroke pathogenesis, we developed a rodent CKD model by feeding adult C57BL/6 mice with adenine. There was a gradual progression of CKD from mild to severe stages between days 7 and 28 identified by a combination of hematological (creatinine, blood urea nitrogen, and total protein) and imaging (MRI, μCT, dual-energy X-ray absorptiometry, and ultrasound) markers. The CKD cohort showed significant vascular fibrosis, collagen deposition, microvascular rarefaction, and tubulointerstitial abnormalities in the kidneys compared to the control. Induction of transient focal ischemia (by MCA occlusion) on day 28 of adenine treatment led to bigger infarcts (estimated by MRI on day 1 of reperfusion) and worsened motor function (assessed by rotarod test and beam walk test on days 1, 3, 7 and 14 of reperfusion) compared with non-CKD control cohort. The CKD group also showed twice higher mortality by day 14 of reperfusion after transient MCAO compared to control. Proteomic profiling showed that pro cell death and inflammatory mechanisms were directly induced in the brain by CKD pathogenesis. Overall, these studies conclude that CKD-induced cell death and inflammatory mechanisms in the brain contribute to severe and disabling stroke.
Abstract TP315: The Role of Sirt1 in Nuclear Cytoplasmic Translocation After Ischemic Stroke
Authors: Lee Seeun , Jun Yonghyun , Cho Suin , Lee Kyungjin , Lim Chiyeon , Lim Sehyun , Kim Nain , You Zerong , Kim Daeki , Mao Jianren , Kashiwagi Satoshi , Atochin Dmitriy N. , Kim Hyung-Hwan
Published: February 2024

Background and rationale:
Sirtuin 1, NAD-dependent deacetylase sirtuin-1 (Sirt1), plays a role in the regulation of mammalian metabolism that regulates transcription of factors, modulates the chromatin, and improves motor function. Here, we investigated rapid nuclear-cytoplasmic translocation of Sirt1 in ischemic stroke both neuron-specific Sirt1 knock-in (nSirt1 KI) and wild-type mice and demonstrated that Sirt1-specific inhibition by sirtinol affected the cGK1/2 signaling pathway within 6 h reperfusion an ischemia-reperfusion injury model.

Methods:
Both nSirt1 KI and WT mice were subjected to 1 h of ischemia, followed by 6 h of reperfusion. All mice measured rCBF by Laser Doppler. Sirtinol (10 mg/kg) was injected intraperitoneally as a single dose on 1 day. To assess the Sirt1, cGK1, and cGK2 protein expression, brain sample specimens were divided into the cerebral cortex, hippocampus, and striatum, and then protein expressions from brain lysates were studied by western blotting.

Results:
The conditions described above, i) The result of cerebral cortex obtained from total protein lysate was degraded the fastest by I/R injury, but no significant difference was found in Sirt1 and cGK1/2. ii) neuronal lysate from the hippocampus confirmed the degradation of Sirt1, cGK1, and cGK2. iii) On the TTC staining, within 6 h of reperfusion, the striatum does not appear to be damaged by sirtinol treatment, but it was confirmed that rapid Sirt1 translocation occurred on the intracellular mechanism. It was also demonstrated that subphase cGK1 and cGK2 were reduced in the striatum.

Conclusion:
These results confirm that Sirt1 inhibition by sirtinol treatment is involved in nuclear-cytoplasmic translocation in the striatum with an inhibitory mechanism of Sirt1. In addition, cGK1/2 is inhibited by sirtinol in the striatum, suggesting that cGK1/2 is also involved in inhibitors and that cGK1/2 responds as a subphase of Sirt1. These processes are expected to lead to toxic protein aggregates, inefficient transcription, and defective nuclear-cytoplasmic translocation via nuclear pore complex damage.
Abstract TP317: The Neuroprotective Effect of Dipyridamole in Ischemia-Reperfusion Injury via Neuronal cGK1/2 Activation
Authors: Lee Seeun , Cho Suin , Lee Kyungjin , Jun Yonghyun , Lim Chiyeon , Lim Sehyun , Kim Daeki , Kashiwagi Satoshi , Atochin Dmitriy N. , Kim Hyung-Hwan
Published: February 2024

Background and rationale:
Smooth muscle cell-specific cGK1 knock-out mice (SMKO) due to impaired blood vessel motility is a leading cause of reduced blood flow in ischemic stroke. This study investigated relative cerebral blood flow (rCBF), neuronal cGK1/2, and vessels cGK1/2 activity in smooth muscle cGK1 littermate control (SMLC), and SMKO mice with and without PDE5 inhibitor, dipyridamole.

Methods:
Middle cerebral artery occlusion (MCAO)-reperfusion was performed in SMLC and SMKO. All mice were measured for the rCBF by laser Doppler flowmetry and investigated the behaviors after ischemic stroke. To confirm the time-kinetics of cGK1/2 changes, brain samples were divided ischemia-reperfusion period in SMLC and SMKO mice with and without dipyridamole (60 mg/kg, p.o.).

Results:
Infarction volumes were larger in SMKO compared to that of SMLC mice and neurological deficit score was worsening in SMKO compared to that of SMLC mice. The rCBF values during MCAO and at reperfusion were significantly decreased in the SMKO group. During the ischemia and reperfusion period, neuronal cGK1 was sustained without protein degradation. Not only SMLC but also SMKO were the same. However, neuronal cGK2 was decreased time-dependent manner. In contrast, infarction volume was decreased in SMKO by dipyridamole treatment and NDS was improved in SMKO with dipyridamole. The changes of cGK1 and cGK2 were reversed in the reperfusion period in the cerebral cortex and hippocampus with dipyridamole.

Conclusion:
We conclude that the neuroprotective effect of dipyridamole in ischemic stroke is not only dependent on smooth muscle cell-specific cGK1 function but also related to the neuronal cGK1/2 activation via PDE5 inhibition.
Abstract TP320: The Novel Potent Complement C3a Receptor (C3aR) Antagonist JR14a Confers Robust Neuroprotection in Stroke
Authors: Ahmad Saif , Contreras Jessica , Bhatia Kanchan , Fairlie David P , Waters Michael F , Ducruet Andrew F
Published: February 2024

Background:
The complement C3a receptor (C3aR) plays a prominent role in deleterious post-stroke neuroinflammation. We and others have shown that either genetic deficiency of C3aR or its pharmacological inhibition in rodents protects against ischemic brain injury. Several limitations of the existing C3aR antagonist (SB290157) limit its translational potential. We therefore sought to evaluate a novel C3aR inhibitor in experimental stroke.

Hypothesis:
The novel C3aR inhibitor JR14a will confer more robust neuroprotection than SB290157 in experimental models of stroke.

Methods:
Mouse primary cortical neurons and primary endothelial cells were seeded at a density of 5000 cells/well in 96-well plates. Oxygen-glucose deprivation (OGD) followed by reperfusion was used to compare JR14a and SB290157 in terms of neuronal/endothelial cytotoxicity evaluated using MTT assay. We also compared JR14a and SB290157 by evaluating infarct volume using MRI/TTC in both photothrombotic (PT) and embolic stroke models in C57Bl6 mice.

Results:
JR14a-treated cortical neurons/endothelial cells demonstrated reduced cell death following OGD. JR14a treatment reduced phosphorylation of ERK/STAT3 in cortical neurons following OGD/R relative to SB290157. JR14a also significantly reduced brain infarction relative to SB290157 following PT and embolic stroke.

Conclusion:
Here, we conclude that JR14a attenuates neuroinflammation in stroke and may be more potent than existing C3aR antagonists. Additional work is warranted to investigate the neuroprotective properties of JR14a in stroke.
Abstract TP38: Cognitive Decline After Stroke Correlates With Small Vessel Disease and Race
Authors: Pikel Karly , Logue Lawson , Germroth Matthew , Parrish Michael , McCain Caylee , Martin Chylee , Sen Souvik
Published: February 2024

Introduction:
An Asian study found 30% of patients showed a cognitive decline measured by Montreal Cognitive Assessment (MoCA) score one year after stroke. There is limited US data on this subject. We investigated 1) decline rate in MoCA one year post-stroke 2) racial differences in baseline MoCA post-stroke and 3) if racial differences in small vessel disease (SVD) correlated with the decline in MoCA.

Methods:
MoCA was assessed in the PREMIERS trial (NCT#02541032) at baseline and one year after index stroke. Sub-scores for each MoCA domain were combined into a total score. The Fazekas scale was used to rate white matter signal abnormalities on patient MRI FLAIR images at baseline. Patients were categorized by total, deep white matter (DWM), and periventricular white matter scores. They were then sub-categorized into none/mild or moderate/severe groups. A one year cognitive decline was defined as a decline in MoCA scores by ≥2 points.

Results:
Of 280 patients, 30.4% had a ≥2 decline in MoCA score, with no significant difference between AA and white (29.4% vs. 32.9%, p=0.57). However, AA patients had lower baseline total MoCA scores (20.4±4.6 vs. 22.6±3.9, p<0.001), visuospatial/executive (3.1±1.5 vs. 3.7±1.3, p<0.001), naming (2.5±0.7 vs. 2.8±0.4, p=0.001), and attention (4.2±2.1 vs. 4.9±1.9, p<0.001) sub-scores. Overall, baseline MoCA was lower in patients with moderate/severe total Fazekas scores (20.1±5.0 vs. 21.6±4.2, p=0.015) and DWM sub-scores (20.1±5.2 vs. 21.4±4.2, p=0.048). In AA, baseline MoCA remained lower in patients with moderate/severe total Fazekas scores (19.6±5.1 vs. 21.0±4.2, p=0.039) and DWM sub-scores (19.4±5.5 vs. 21.0±4.1, p=0.055). This was contrary to White patients with moderate/severe total Fazekas scores (22.3. ±4.4 vs. 23.0±3.9, p=0.50) and DWM sub-scores (23.1±2.3 vs. 22.7±4.4, p=0.73).

Conclusion:
We report that 30.4% of patients in this US-based study showed a decline in MoCA score one year post-stroke, which aligns with a similar study conducted in Asia. A significant association was found between the AA race and lower baseline total MoCA score compared to white patients. Moderate/severe total and DWM Fazekas scores are also significantly associated with lower baseline MoCA scores, a finding specific to AA patients.
Abstract TP44: Door In-Door Out Times: A Comprehensive Stroke Center Review
Authors: Schrier Chad , Palmisano Caitlin , Phipps Michael S
Published: February 2024

Expeditious transfer of patients with acute ischemic stroke (AIS) and LVO presenting to a primary stroke center (PSC) and within the window for mechanical thrombectomy (MT) is vital to optimize their functional outcome. Door-in-door-out (DIDO) represents the time of patient arrival to the PSC to the time of discharge from the PSC for transfer to a comprehensive stroke center (CSC). The goal for this metric is 90 minutes. At a large urban academic and CSC with a high volume of patient transfers, we examined our DIDO metrics to identify trends and opportunities for improvement.

Methods:
The CSC MT database was queried to analyze DIDO times. Inclusion criteria included AIS cases with LVO transferred to the CSC for MT from fiscal year 2022-2023. Hospitals transferring less than 5 cases during that timeframe, inpatient cases, and unavailable times were excluded. Hospital DIDO times and their components (i.e. each step in the process) were grouped into quartiles and analyzed. A survey to PSC stakeholders was sent to identify themes for possible barriers.

Results:
Among 8 hospitals, the top quartile with the fastest DIDO times had a mean of 132 minutes and median of 122 (N = 22 patients). The hospitals with the longest DIDO had a mean of 205 and a median of 193 (N=17). The components of DIDO times that separated the fastest from the slowest were

PSC arrival to 1
st
call to CSC

and

1
st
call of PSC to acceptance at CSC

. The PSCs with the highest DIDOs took double the time in these components (40 vs 81, 22 vs 53 minutes). Distance from the CSC does not appear to be a factor in DIDO times, with the fastest being 13 to 68 miles away vs. 11 to 30 miles for the slowest. In the survey results, 81% of participants had CSC bed availability as the top barrier, whereas 69% reported delays in transport time to PSC.

Conclusion:
DIDO times from PSCs continues to be an opportunity for process improvement. Only 5% in our sample met the DIDO metric goal of 90 minutes. Two areas of potential improvement include decreasing PSC time to 1
st
call and improving time of CSC acceptance. PSCs believe that a “ready” bed at the CSC would decrease DIDO times, but there are additional opportunities among the components.
Abstract TP46: Improving Efficiency of Interfacility Transfer for Mechanical Thrombectomy: Delaware Stroke System Experience
Authors: Ciechanowski Mary C , Gannon Kim , Sivapatham Thinesh , McAndrew Reina , Holmes Kimberly K , Sheharyar Ali , Shehzad Usman , Brown Amber , Dopler Bruce M
Published: February 2024

Introduction:
Delaware (DE) created a stroke system with a primary objective to improve the interfacility transfer process between DE PSCs and its only CSC to improve efficiency and outcomes for mechanical thrombectomy (MT) transfer patients.

Methods:
The DE stroke system, including stroke coordinators/medical directors and EMS, defined criteria for MT eligibility, identified barriers to transfer, and implemented the interventions listed below. Data on transfer volumes, thrombectomy rates, and outcomes were collected. Objectives were to improve early detection of MT eligible patients, improve rate of thrombectomy on MT transfers, and track patient outcomes (mRS 0-2 at 90 days).

• MT eligibility defined as any patient with a significant/disabling deficit with target lesion identified on CTA.

• Implementation of “EZ” button in PSC EDs for early activation of flight team for suspected MT candidates upon initial clinical evaluation.

• Time goal of 30 min for PSC arrival to call out to CSC for MT candidates.

• Implementation of RAPID.AI platform at PSCs to allow CSC immediate access to imaging.

• Revision of CSC transfer process: conference call with transfer center, PSC physician, and CSC stroke team physicians to discuss case.

• Transport expedited for MT eligible patients; ineligible patients stay at PSC.

• CSC provides outcome feedback and time goals to PSC on each transfer.

• Variant cases reviewed by CSC and DE Stroke System Quality & Data committee as needed.

Results:
From FY22 to FY23, there was a 39% increase in MT transfers, 20% increase from 52% to 72% in rate of thrombectomy, and 15% increase in # patients in mRS 0-2 category at 90d (figure 1).

Conclusion:
By implementing collaborative and focused interventions, the DE stroke system increased rates of MT in transferred patients while reducing unnecessary transfers and improving patient outcomes.
Abstract TP5: Impact of Race on Outcomes in the Endovascular and Microsurgical Treatment in Patients With Intracranial Aneurysms: Analysis of the Stroke Thrombectomy and Aneurysm Registry
Authors: Matsukawa Hidetoshi , Uchida Kazutaka , Sowlat Mohammad-Mahdi , Elawady Sameh Samir , Cunningham Conor , Alawieh Ali , Al Kasab Sami , Jabbour Pascal , Mascitelli Justin , Levitt Michael , Cuellar Hugo , Brinjikji Waleed , Samaniego Edgar , Burkhardt Jan-Karl , Ezzeldin Mohamad , Kan Peter , Fox W. Christopher , Moss Mark , Grandhi Ramesh , Altschul David J , Spiotta Alejandro M , Yoshimura Shinichi
Published: February 2024

Introduction:
Impact of race on outcomes in the treatment of intracranial aneurysm (IA) remains unclear. We aimed to investigate the relationship between race classified into White, Black, Hispanic, and other ("other" includes Native American or Alaska Native, Asian or Pacific Islander, and other race) and treatment outcomes in patients with ruptured and unruptured IAs.

Methods:
Stroke Thrombectomy and Aneurysm Registry (STAR) was a retrospective observational study. Data from 9 centers in the United States, Europe, and Asia for IA patients who undertook endovascular treatment (EVT) or microsurgical treatment (MST) between January 2016 and December 2020 were included for analysis. The primary outcome was 90-day mRS 0-2. Secondary outcomes included periprocedural cerebral infarction and intracranial hemorrhage, perioperative symptomatic cerebral vasospasm in ruptured IA and mortality, and all causes of mortality within 90 days.

Results:
2,836 IA patients treated with EVT or MST were included. Among these 2,836 patients, 1,053 patients were White, 350 were Black, 264 were Hispanic, and 1,169 were other. The primary outcome in Hispanic patients was significantly lower than White patients (adjusted odds ratio [aOR] 0.36, 95% CI, 0.23-0.56,
P
< .001). The periprocedural cerebral infarction, perioperative mortality, and all causes of mortality in Hispanic patients were significantly higher than White patients (aOR 2.53, 95% CI, 1.40-4.58,
P
= .002, aOR 1.84, 95% CI, 1.00-3.38,
P
= .049, aOR 1.83, 95% CI, 1.06-3.17,
P
= .03, respectively). However, these outcomes were not significantly different in Black and other patients compared to White patients.

Conclusions:
This study demonstrates Hispanic IA patients are more likely to have a poor outcome at 90 days following EVT or MST than White patients.
Abstract TP70: EHR Based System Improves Stroke Alerting Process in the Emergency Department
Authors: Sellers Michele , Stein Laura A , Owens Karrima C , Blum Christina , Schmitt Catherine
Published: February 2024

Background and Issues:
Treatment decisions for patients experiencing acute ischemic stroke require complex imaging and evaluation. Specialized teams including Neurologists, pharmacists and CT technicians are alerted to the ED when a patient presents with signs or symptoms of acute ischemic stroke (AIS) to carry out these evaluations. At our facility, these alerts were delivered via a de-identified text message, preventing the collection of data needed for clinical effectiveness and quality improvement work.

Purpose:
This project's purpose was to improve the Stroke Alert process using Computerized Physician Order Entry (CPOE) to initiate the alert via a HIPAA Compliant Group Messaging (HCGM) application called Haiku.

Methods:
Haiku is an application available in the hospital’s electronic health record, which allows for retrieval of data unavailable when utilizing the de-identified alerting method. Data on 70 consecutive Stroke Alerts from 6 weeks prior to implementation of the Haiku Stroke Alert were compared to 80 consecutive Stroke Alerts 6 weeks after implementation. A comparison of Door to CT and Door to Needle times in those periods were also compared to ensure the new process did not cause any delays in these metrics.

Results:
Results showed the CPOE based Haiku Stroke Alert process was easily adopted and allowed for access to data necessary for clinical effectiveness and quality improvement work without causing delays in Door to CT (DTCT) or Door to Needle (DTN) times.

Conclusions:
In conclusion, this quality improvement project addressed the lack of data available to assess the Stroke Alert process. A new CPOE based alert process utilizing the HCGM app Haiku proved feasible, received positive feed-back from ED team who initiates the alert and the Neurology resident team who receives the alert. The Haiku alert did not appreciably add time to the DTCT or DTN times. This process allows access to comprehensive data that can be used to explore other avenues to improve the hyperacute phase of AIS triage and treatment. The availability of robust Stroke Alert data was the missing foundational element allowing for clinical effectiveness and quality improvement work.
Abstract TP74: MR-001 Improves Stride Length and Cadence in People With Chronic Stroke Walking Impairment
Authors: Smayda Kirsten , Jayaraman Arun , Nolan Karen J , Lewek Michael , Bonato Paolo , Newman Mark , Putrino David , Raghavan Preeti , Pohlig Ryan , Harris Brian , Parker Danielle , Taylor Sabrina , Awad Louis
Published: February 2024

Introduction:
Chronic stroke walking impairments impact approximately 3.5 million Americans and can lead to decreased quality of life, increased fall risk, and increased comorbidities. Stroke results in changes to spatiotemporal gait characteristics, including cadence, stride length, and speed, which can negatively impact walking stability and increase falls. In a multicenter randomized controlled trial, MR-001 was shown to increase comfortable walking speed more than Active Control (walking without MR-001). The purpose of this investigation is to characterize the spatiotemporal gait changes underlying MR-001's improvement in walking speed.

Methods:
Participants (n = 34) received the MR-001 (InTandem™) intervention for 30 minutes, 3 times a week for 5 weeks. MR-001 autonomously delivers an individualized and progressive intervention based on the principles of rhythmic auditory stimulation. The device algorithm uses input from foot-worn sensors to change the auditory stimuli in the form of embedded cues in time-shifted music. This secondary analysis from a larger clinical trial included change in stride length and cadence while walking without auditory stimuli, calculated as the change from before to after the intervention, as well as the relative contribution of changes in stride length and cadence to changes in walking speed.

Results:
Participants showed a significant increase in both stride length [+8%, Δ 0.06 +/- 0.02 m, p < 0.004] and cadence [+4%, Δ 3.04 +/- 1.32 steps/min, p < 0.028]. The average increase in stride length was 2x the established minimal detectable change of 4%. Changes in stride length and cadence each independently predicted the change in speed [
R

2

= 0.99,
F
(2,31) = 1132.44,
p
< 0.001], with the change in stride length being the stronger contributor [stride length:
β
= .78,
p
< 0.001, cadence:
β
= .50,
p
< 0.001].

Conclusions:
Post-stroke reductions in stride length and cadence result in slower walking speed and negatively impact walking stability. In conclusion, results of this secondary analysis show that the previously reported increase in walking speed resulting from MR-001 is influenced by stride length more strongly than cadence for individuals with chronic stroke walking impairment.
Abstract TP75: Age at Time of Stroke Does Not Predict Post-Stroke Fatigue
Authors: Persaud Andrew , Weedon Jeremy , Gilles Nadege , Levine Steven R
Published: February 2024

Introduction:
Post-stroke fatigue (PSF) is a long-term sequelae of stroke that negatively impacts patients and their rehabilitation. Approximately 38% of people hospitalized for a stroke are less than 65 years old. Studies regarding PSF and age are sparse and vary in their results. We examined whether age at time of ischemic stroke correlates with the severity of PSF of ischemic stroke patients in a predominantly Afro-Caribbean population.

Methods:
An IRB-approved prospective, observational study. Patients above 18 years of age with a diagnosis of ischemic stroke in the past 3 years were enrolled after informed consent. Patients with treated depression, significant cognitive impairment, or active cancer were excluded. The Fatigue Assessment Scale (FAS) was used to measure the level of PSF. Linear regression analysis was used to examine the relationship between age at time of stroke and severity of FAS score, adjusted for sex, NIH Stroke Scale (NIHSS), Modified Rankin Scale (mRS), and Beck Depression Inventory (BDI) scores. A general linear model was used to predict log-log-transformed total FAS score from age at stroke, BDI score, mRS score, NIHSS score, and sex. First-order interactions among predictors were investigated; model residuals were examined for skew and for outliers.

Results:
Of the 121 patients included, 55.4% are female, the mean age is 65.3 +/- 12.1 years old, 93.4% have hypertension, and 60.3% have diabetes mellitus. The median FAS score is 19 (IQR 15-25), median NIHSS score is 3 (IQR 2-5), and median mRS score is 1 (IQR 0-2). Crude Spearman Correlation between age at stroke and total FAS score was -0.07. Age at stroke was not an independent predictor of FAS score (p=0.545). R
2
for the model was 0.38. Both BDI score (p<0.001) & mRS score (p=0.024) were positively associated with transformed FAS score.

Conclusion:
Our data suggests that age at time of stroke is not independently correlated with severity of PSF in a predominantly Afro-Caribbean population.
Abstract TP79: Vagal Nerve Stimulation for Enhanced Stroke Recovery: Real-World Application in a Multidisciplinary Program
Authors: Cummins Daniel D , Park Hyun Joo , Tosto Jenna , Putrino David , Panov Fedor E , Kellner Christopher P
Published: February 2024

Introduction:
Randomized-controlled trial (RCT) evidence has demonstrated the efficacy of vagal nerve stimulation (VNS) with paired rehabilitation for upper limb functional recovery after ischemic stroke. There remains a need to assess the generalizability of these findings to a broader population of stroke patients with chronic functional deficits.

Hypothesis:
VNS for upper limb recovery after stroke may be safely and effectively applied to diverse populations of patients in a multidisciplinary program.

Methods:
Patients at one center not included in the original RCT of VNS for stroke recovery were implanted with left-sided VNS, paired with six weeks of in-clinic therapy, as implemented in the original RCT. At the conclusion of in-clinic therapy, clinical benefit was assessed by improvement from baseline in the validated Fugl-Meyer Assessment-Upper Extremity (FMA-UE) score for stroke recovery (maximum score of 66 equating to normal function).

Results:
All four patients included had chronic, stable functional deficits >1.5 years after stroke when implanted with VNS at ages of 43, 61, 70, and 71. Three patients with ischemic stroke were included with FMA-UE improvements of 13 (baseline 45, left-sided deficits), 15 (baseline 36, right-sided deficits), and 6 (baseline 21, left-sided deficits). One patient was implanted 3.0 years after intracerebral hemorrhagic stroke, with an FMA-UE improvement of 14 (baseline 16, right-sided deficits). No procedural complications were seen.

Conclusions:
Vagal nerve stimulation paired with in-clinic therapy can have a profound impact on upper limb function in patients after stroke. All patients in this series achieved greater FMA-UE improvement than the mean improvement in the largest RCT of VNS for stroke recovery (5.0 ± 4.4 points). This pilot series of real world application of paired VNS for upper limb functional recovery after stroke demonstrates early feasibility, safety, and efficacy of this treatment.
Abstract TP84: Characteristics of Cerebellar Cognitive Affective Syndrome in Patients With Acute Cerebellar Stroke and Its Impact on Outcome
Authors: Shinya Tokuaki , Yamauchi Kota , Tanaka Shota , Goto Kei , Arakawa Shuji
Published: February 2024

Background:
Recently, cerebellar cognitive affective syndrome-scale (CCAS-S) was developed to assess CCAS in which cognitive impairment is caused by cerebellar lesions. However, very few studies have been conducted regarding CCAS in patients with stroke, and its impact on outcomes is unclear. This study aimed to evaluate CCAS in patients with acute cerebellar stroke and examine its association with outcome.

Methods:
Patients who experienced acute cerebellar stroke for the first time and were admitted to Steel Memorial Yawata Hospital, Japan within seven days of stroke onset between April 2021 and April 2023 were included in this observational study. CCAS-S, Mini-Mental State Examination (MMSE), and Scale for Assessment and Rating of Ataxia (SARA) scores were measured one week after stroke onset, and Functional Independence measure (FIM)/ Barthel Index (BI) at discharge, physical function, activities of daily living, length of hospital stay, and outcome (discharge destination) were evaluated. The Mann-Whitney U test was used to compare CCAS-S scores and other variables between patients with acute cerebellar stroke and healthy controls. Additionally, we compared these variables between patients discharged home and those discharged to a rehabilitation hospital. A significance level of less than 5%.

Results:
Thirteen consecutive patients with acute cerebellar stroke (9 women) and age-and sex-matched healthy controls (7 women) were included. The MMSE score was within the normal range in all patients; however, patients with stroke had a lower total CCAS-S score (median 72, interquartile range [IQR] 66-80) and a higher number of failed tests (median 4, IQR 3-5) than healthy controls. Significant deficits were observed in semantic fluency (p=0.008), category switching (p=0001), and similarity (p=009). Possible, probable, and definite CCAS were diagnosed in 2, 1, and 10 patients, respectively. Patients discharged home showed better SARA and FIM/BI scores but similar CCAS-S scores compared to those discharged to rehabilitation hospitals.

Conclusion:
CCAS along with impaired executive and language functions is frequently observed in patients with acute cerebellar stroke; however, impaired motor function, and not CCAS, influenced the outcome.
Abstract TP85: Neighborhood Built Environment May Not Influence Reintegration to Normal Living Post-Stroke
Authors: Wing Jeffrey J , Rajczyk Jenna , Strominger Julie , Gibbs Brooke , Drum Emily , Boden-Albala Bernadette
Published: February 2024

Introduction:
Reintegration to normal living post-stroke is important to foster peer support and recovery. Reintegration may be facilitated through neighborhood resources and out-of-home facilities.

Methods:
The Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) intervention randomized stroke survivors to skills-based intervention or usual care with the goal of improving post-stroke blood pressure. Three domains of reintegration to normal living (RINL) through daily functioning (community mobility, recreational, and social activity participation) at 12-months post-stroke were evaluated. Participants’ addresses were linked to census tract area density of community resources from the National Neighborhood Data Archive. Recreational, arts, entertainment, religious, social and civil, and personal care resources were assessed in separate linear regression models for related RINL domains first unadjusted and then adjusting for age, race-ethnicity, gender, education, insurance status, number of identified alters, intervention status, and stroke severity. Loss-to-follow-up was accounted for using inverse probability weights.

Results:
Of the 546 DESERVE participants, 342 responded to 12-month RINL elements. Respondents were 64.9 years on average (SD=12.1) with a median NIHSS of 2.0 (IQR=4.0). The median level of RINL for each domain was the maximum (10). Comparing high to low, resource densities were not associated with any of the RINL domains in unadjusted or adjusted models (
Figure
).

Conclusion:
In our novel exploration of neighborhood resources and RINL, the density of these built environment resources did not seem to influence individuals’ reintegration to normal living 12-months post-stroke. However, the metric of reintegration had a ceiling effect; future evaluations may need to consider different tools to better identify more sensitive metrics of reintegration post-stroke.
Abstract TP86: Stroke-Impaired Proprioception Limits Motor Recovery With BCI-FES Device
Authors: Remsik Alexander B , VAN KAN PETER L , Adluru Nagesh , Nair Veena A , PRABHAKARAN VIVEK
Published: February 2024

Introduction:
Non-invasive brain-computer interface (BCI) therapy with contingent (i.e., closed-loop) functional electrical stimulation (FES) shows efficacy improving motor function. However, it is not well understood why some stroke survivors respond better to closed-looped BCI-FES intervention than others. Contingent BCI-FES intervention drives neuroplastic change toward adaptive functional connectivity in stroke-impaired sensorimotor brain areas by enriching the afferent feedback environment. The interruption of afferent-efferent feedback circuits is a neural correlate of long-term acquired disability and intactness of functional connections predicts recovery capacity. Studies suggest that proprioception is essential for motor learning and performance. Therefore, we hypothesize that proprioceptive intactness is essential for recovery of motor performance when using a BCI-FES.

Methods:
Participants with upper extremity motor loss resulting from stroke (n=35) completed up to 30 hours of closed-loop BCI-FES.

Results:
Change in ARAT scores over the course of the control period were compared to ARAT change scores over the intervention period at a one-month follow up assessment. On average, participants in the intervention realized greater change in ARAT (M = 2.11, SD = 4.68) than during the control phase (M = 0.294, SD = 3.53). An independent-samples t-test indicated this difference, 1.82, 95%CI [-4.17, 0.534], was not statistically significant, t (40.901) = -1.56, p = 0.126. Preliminary results indicate that Proprioceptive sensory loss has a greater limiting effect on recovery than cutaneous somatosensory loss.

Discussion:
Rehabilitating motor capacity after stroke depends on the intactness of sensorimotor neural circuits. If afference signals are missing or degraded due to stroke, motor recovery is poor. When the stroke spares afferent connectivity to the peripheral muscles, the sensorimotor cortex can leverage plasticity-based motor rehab strategies such as BCI-FES.

Conclusion:
Intactness of sensorimotor circuits is related to baseline severity of motor impairment as well as recovery of motor function. Efficacious prescription of BCI-FES intervention is best suited for patients with stroke-spared proprioception.