bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WMP64: Association between ipsilateral stroke and non-stenotic (<50%) carotid disease – Analysis from the Alteplase compared to Tenecteplase Trial
Authors: Ignacio Katrina , Nagendra Shashank , Bala Fouzi , Alhabli Ibrahim , Baguley Elizabeth , Poulin Therese , Sjonessen Kirsten , Swartz Richard , Catanese Luciana , Tkach Aleksander , Sajobi Tolulope , Buck Brian , Menon Bijoy , Almekhlafi Mohammed , Ganesh Aravind , Singh Nishita
Published: January 2025

Background and Objectives:
Emerging literature suggests that non-stenotic carotid disease (<50% stenosis), especially in the presence of high-risk plaque features, can be a possible etiology for ischemic stroke. We aimed to evaluate the odds of concordant stroke among individuals with non-stenotic carotid arteries with various plaque features.

Methods:
This is a secondary analysis from the Alteplase compared to Tenecteplase (AcT) trial. We evaluated carotid arteries on baseline CT Angiogram (CTA) to assess the degree of stenosis, plaque features such as ulceration, thickness, irregularity, hypodensity and presence of intraluminal thrombi, carotid web and dissection. 24hour follow-up imaging was used to evaluate stroke location. At a carotid level, we performed mixed effects logistic regression analysis adjusted for age and sex, with patient ID as a random effects variable, to determine the association between each high-risk plaque feature and the presence of concordant stroke (ipsilateral acute stroke in the territory of the carotid artery).

Results:
Of 1577 patients in the trial, 1407 (89.2%) had interpretable baseline imaging.

Of these, 329 (23.4%) had no carotid disease, 869 (61.8%) had non-stenotic (<50%) carotid disease and 209 (14.9%) had stenotic (>50%) carotid disease. At a carotid level,

2519 (89.5%) had non-stenotic carotid disease. Of these, 689 (27.4%) had concordant stroke. Intraluminal thrombi and carotid webs were significantly associated with concordant stroke (aOR 8.11, 95% CI 1.6 – 41.08 and aOR 3.58, 95% CI 1.53 – 8.35, respectively). None of the other plaque features were significantly associated with concordant stroke.

Conclusions:
Among patients with non-stenotic carotid disease, only the presence of intraluminal thrombi and carotid webs were found to be associated with increased odds of concordant stroke. Further CTA-based studies on larger populations are required to identify plaque features associated with concordant ischemic stroke.
Abstract WMP65: Machine-learning Approach To Classify Vulnerable Calcified Plaque In Embolic Stroke Of Undetermined Source
Authors: Sakai Yu , Kim JieHyun , Phi Huy , Hu Andrew , Balali Pargol , Guggenberger Konstanze , Woo John , Kasner Scott , Cucchiara Brett , Saba Luca , Huang Zhi , Haehn Daniel , Song Jae
Published: January 2025

Introduction:
Embolic stroke of undetermined source (ESUS) may be associated with nonstenotic carotid artery plaques. Noncalcified plaque components such as intraplaque hemorrhage (IPH) as well as perivascular adipose tissue (PVAT) are associated with increased stroke risk, but the role of plaque calcifications is unclear. We examine a machine-learning approach using eXtreme Gradient Boosting (XGBoost) to classify carotid plaques as vulnerable or stable using non-calcified plaque features and calcification morphology.

Methods:
Patients with neck CT angiography and unilateral anterior circulation ESUS with calcific carotid plaque were retrospectively analyzed. Derived by a combination of manual scoring by a neuroradiologist blinded to stroke side and semi-automated plaque composition segmentation software (Elucid), plaque-level features included plaque thickness, ulceration, composition volumes (IPH, lipid-rich necrotic core, matrix) and PVAT. Calcification-level features, segmented/scored manually with 3D Slicer, included spotty calcification (arc <90 degrees, thickness <3 mm), rim-sign (adventitial site, >90 degrees arc, and 2 mm non-calcified plaque), volume, surface area, roundness, flatness and density. Plaques ipsilateral to stroke side were defined as vulnerable and stable if contralateral. XGBoost models were trained to classify plaques as vulnerable/stable using 1) plaque-level, 2) calcification-level and 3) combination of both features. Data were split into training (80%) and test (20%) sets with 5-fold cross-validation (CV) to ensure consistency. Performance was measured by ROC AUC and accuracy.

Results:
71 patients were included [116 calcific carotid plaques; 60 ipsi-, 56 contralateral to stroke; 270 calcifications (146 ipsi-, 124 contralateral)]. 11 plaque-level and 16 calcification-level metrics were extracted. Plaque-level model achieved AUC 0.38 and accuracy 0.38. Calcification-level model achieved AUC 0.60 and accuracy 0.56. Combined model achieved AUC 0.97 and accuracy 0.93, with 5-fold CV score range 0.70-0.93 and mean 0.80. Five most important features for the Combined model were plaque ulceration, calcification surface area, ratio of PVAT to total plaque volume, plaque thickness and PVAT volume.

Conclusions:
XGBoost model trained with a combination of noncalcified plaque and calcification features can classify plaque as vulnerable with > 90% accuracy, superior to models exclusively trained with plaque-level or calcification-level features.
Abstract WMP71: Brain Frailty location is an independent predictor of functional outcome in patients undergoing recanalization treatment for Large Vessel Occlusion Stroke.
Authors: Carone Davide , Garrard James , Brinjikji Waleed , Al Halak Abdulrahman , Rai Ansaar , Kallmes David F , Harston George
Published: January 2025

Background:
There is an unmet need to better understand the likelihood of a good functional outcome in older and frailer populations undergoing endovascular therapy (EVT) following large-vessel occlusion (LVO) ischemic stroke. One approach is to improve the understanding of pre-morbid brain health (“brain frailty”) as a predictor of functional outcome. This study explored the relationship between the spatial pattern of brain atrophy and functional outcome to determine whether this is a predictor of outcomes following EVT.

Methods:
Patients with LVO from four hospitals in Europe and the USA were included. Three cohorts were used as a derivation cohort, and the fourth served for validation. Presenting CT imaging was processed using Brainomix in-house software to automatically localize and quantify atrophy (frailty-index). Masks from the derivation cohort were used to localize regions of atrophy significantly associated with poorer functional outcome (modified Ranking Scale 3-6) using a voxel-based, multivariate method (Sparse Canonical-Correlation-Analysis) (see Figure 1). For both derivation and validation cohorts, the degrees of overlap between each patient’s atrophy mask and the regions associated at a group level with poor outcome were calculated. This was used as an independent predictor of functional outcome in multivariate analysis adjusting for overall brain frailty-index, recanalization status, and ASPECT score

Results:
The derivation cohort consisted of 658 patients (mean age 69.6±15.0, median ASPECTS 9 [7-10]), while the validation cohort consisted of 447 patients (mean age 64.7 ±15.5, median ASPECTS 8 [5-10] ). Atrophy localized to the lateral ventricles and sylvian fissure was significantly associated with poorer outcomes (Figure 1). In both derivation and validation cohort, the presence of this spatial pattern of brain frailty (quantified using the degree of overlap) was an independent predictor of poor functional outcome (Table 1).

Conclusion:
A better understanding of pre-stroke brain health, such as the distribution of atrophy, may provide additional information to inform the prediction of outcome following LVO. This could improve patient selection for treatment following ischemic stroke through better prognostication and a more personalized approach to decision making.
Abstract WMP79: Biologic mechanisms of Early Exercise After Acute Ischemic Stroke and Intracerebral Hemorrhage (BEACH): A Pilot Randomized Controlled Trial of Cycle Ergometry after Stroke
Authors: Zink Elizabeth , Bahouth Mona , Ziai Wendy , Budhathoki Chakra
Published: January 2025

Background and Purpose:
The inflammatory response after ischemic and hemorrhagic stroke is associated with worse clinical outcomes through immune mediated production of pro- inflammatory cytokines. Repair proteins such as brain derived neurotrophic factor (BDNF) are expressed as part of the adaptive immune response. We assessed safety of moderate intensity exercise in the acute phase and its association with pro-inflammatory cytokines and BDNF expression.

Methods:
This was a prospective, single center, randomized, pilot of prescribed exercise for patients hospitalized with stroke. The intervention group was randomized to standard care plus two 20-minute in-bed cycle ergometry sessions per day during the first week after stroke. We measured serum concentrations of BDNF as primary outcome and interleukin(IL)-1β IL-6, IL-10, tumor necrosis factor(TNF)-α and National Institutes of Health Stroke Scale (NIHSS) score as secondary outcomes at days 1(T1), 3(T2) and 7(T3). Cerebrospinal fluid was collected in 4 patients with an external ventricular drain. We used Spearman’s Rho to assess associations of biomarker levels with treatment group.

Results:
A total of 15 patients with acute spontaneous intracerebral hemorrhage (ICH) and nine patients with acute ischemic stroke (AIS) were enrolled. Of 25 enrolled patients, mean age was 65.8 (SD, 16.3) years, and 10 (40%) were female. Median admission NIHSS score was 12 (interquartile range 6-17) in the intervention group (n=14) compared to 19 (14-24) in the control group (n=11). Seventy-four cycling sessions were performed in the intervention group for a mean of 98.9 (sd, 59.1) total minutes of cycling per patient. In the combined AIS/ICH cohort, a trend association of increased BDNF was observed at T2 in the intervention group compared to the control group (p=0.05). No serious adverse events were recorded.

Conclusions:
This is one of the first human trials to investigate exercise-induced modulation of inflammatory cytokine and trophic factor expression in the first week after stroke. Early moderate intense exercise was safe and showed small but promising changes in BDNF despite imbalances in clinical factors in this small study.
Abstract WMP87: Determinants of proceduralist-associated differences in angiographic outcomes following stroke thrombectomy
Authors: Chen Huanwen , Njonkou Tchoquessi Rosy Linda , Iyyangar Ananya , Skorseth Paige , Rewinkel Scott , Majmundar Shyam , Cherian Jacob , miller tim , Sheth Sunil , Gandhi Dheeraj , Colasurdo Marco
Published: January 2025

Background:
Complete recanalization, defined as modified Treatment in Cerebral Ischemia (mTICI) score of 2c or better, has been shown to be superior to mTICI 2b in terms of patient outcomes following stroke thrombectomy. While some proceduralists achieve higher rates of complete recanalization than others, the driving factors underlying provider-specific differences are not well understood.

Methods:
This was a retrospective study of stroke thrombectomy cases at three large comprehensive stroke centers. Patients treated by high-volume proceduralists (50 cases or more per proceduralist) were included. The rate of complete recanalization for each proceduralist was calculated and inter-proceduralist variability was assessed; proceduralists were then divided into tertiles based on these rates. First pass effect (FPE, defined as complete recanalization after one pass) and the number of passes for patients treated by the top tertile of proceduralists were compared to those treated by the bottom tertile using multivariable regression models. Mediation analyses were conducted to assess causal links with FPE and number of passes.

Results:
A total of 1,137 thrombectomy cases performed by 11 high-volume proceduralists were identified. Overall, there was significant variability in complete recanalization rates across providers (range 44.0% to 75.8%, p<0.001; Figure 1). Patients treated by the top tertile of proceduralists in terms of complete recanalization rates were significantly more likely to experience FPE (OR 2.17 [95%CI 1.55 to 3.06], p<0.001; Figure 2), and they did not undergo more EVT passes (rate ratio 1.02 [95% 0.93 to 1.12], p=0.72; Figure 2) compared those treated by the bottom tertile. The higher rates of FPE among patients treated by the top tertile partially explained their higher odds of complete recanalization (46% mediation [95%CI 27% to 66%], p<0.001), whereas the number of passes did not (5% mediation [95%CI -5% to 20%], p=0.23).

Conclusions:
Complete recanalization rates among high-volume thrombectomy proceduralists are highly variable. Proceduralists who achieve higher rates of complete recanalization are doing so in large part due to higher rates of FPE, not additional attempts. Future efforts are needed to identify factors associated with FPE, such as patient characteristics, device choice, procedural technique, and proceduralist training.
Abstract WP1: Intravenous Thrombolysis for Central Retinal Artery Occlusion in Routine Clinical Practice
Authors: Cernik David , Neumann Jiri , Vondrackova Simona , Vachova Marta , Macko Jan , Havlicek Roman , bikova sona
Published: January 2025

Background and aims:
Central retinal artery occlusion (CRAO) is a rare but significantly underestimated form of ischemic stroke. There is still no definite recommendation for treatment. One of the considered and currently increasingly preferred options is intravenous thrombolysis. We present the results of a multicenter retrospective study to assess the safety and effectiveness of thrombolytic treatment in CRAO.

Methods:
All patients with CRAO from six centers who received intravenous thrombolysis were included in the retrospective study. The effectiveness of the intervention was evaluated in two stages. The first stage was when the residual vision in the affected eye was achieved at least to the level of the ability to orientate in space (recognizing contours). The second stage was the improvement of vision to recognize objects and faces. The effectiveness was further evaluated depending on the duration of the difficulties before the intervention. Safety was assessed based on the symptomatic intracerebral hemorrhage.

Results:
In the years 2016-2024, 32 patients (age 67.5 ± 12.9 years, 46.9% men) were treated for CRAO with intravenous thrombolysis.The median time from onset of symptoms to treatment was 6.5 hours. Within one year, 28% of patients had an ischemic stroke. Improvement after treatment occurred in 56.3% (1st degree - recognition of contours) and significant improvement in 34.4% (recognition of faces, ability to read). In patients treated within 4.5 hours, there was a significant improvement in 46%. In the case of treatment over 4.5 hours, there was a significant improvement in 26.3%. When symptoms lasted for more than eight hours, only 20% improved (at least partial improvement occurred in 46.7% of cases). Overall, intracerebral hemorrhage occurred in 6.3%. However, none of them were symptomatic. One patient had vitreous hemorrhage with subsequent correction of vision.

Conclusion:
CRAO is a significantly neglected subgroup of ischemic stroke. According to our data, intravenous thrombolysis is also an effective and safe therapy here.
Abstract WP124: Three-year Follow-up Quantitative MRI And Recovery Assessment After Endovascular Treatment In Acute Ischemic Stroke
Authors: Konduri Praneeta , Karkalousos Dimitrios , Roosendaal Stefan , Lahr Maarten , Nguyen Chi , Marquering Henk , Majoie Charles , Liebrand Luka , Caan Matthan
Published: January 2025

Introduction:
Long term (>36 months) recovery after endovascular treatment (EVT) remains largely understudied in acute ischemic stroke (AIS) patients. Previously, we have shown that long-term white matter microstructure damage, iron deposition and atrophy within/remote to the 24-hour stroke lesion could influence long term quality of life. However, the role of baseline and 24-hour lesion characteristics on long term lesion characteristics and the influence of lesion status on recovery to perform daily activities is unknown.

Methods:
We executed a quantitative 3T MRI protocol (FLAIR, diffusion MRI, R1, R2*, Quantitative Susceptibility Mapping, Arterial Spin Labeling) after 37 (IQR: 28-38) months in patients from the MR CLEAN No-IV trial who received a 24-hour post-EVT MRI (DWI, FLAIR, SWI). Lateral ventricular volume difference was computed at both time-points to quantify atrophy. Long term MRI was also used to quantify iron deposition (R2*) and volume difference in subcortical nuclei relative to the contralateral nuclei. Long term recovery was defined using daily activity scores from EQ5D5 questionnaire. A Bayesian paired T-test of ventricular lateral atrophy between 24-hour and long term MRI was performed, and a Bayesian correlation of baseline clinical and 24-hour lesion characteristics with long term MRI outcomes (Bayes Factor (BF)<3: no/weak; BF>3: moderate; BF>20: strong evidence).

Results:
We included 24 patients with a 24-hour and long-term MRI protocol. Median age was 64 (51-75) years, 11 (46%) patients were randomized to receive intravenous thrombolysis (IVT) prior to EVT, and 19 (79%) patients had an MCA occlusion. Functional independence (mRS 0-2) at 90 days (21 (88%) patients) and long term (20 (83%) patients) was comparable. Ventricular lateral atrophy was observed (BF=4.10
5
), and higher baseline blood pressure and poorer collaterals were associated with larger long term lateral ventricular atrophy (BF: 11, 11, 4.3 respectively). Lower ASPECTS and poorer collaterals were associated with higher thalamic volume difference (BF=111, 11 respectively). Lastly, lower hippocampal volume and iron deposition were associated with reduced long term daily activity (BF=26, BF=4).

Conclusion:
While functional independence in our cohort remains comparable over time, baseline, clinical, and treatment characteristics point to long-term brain degradation, which in turn impacts the ability of patients to perform daily activities.
Abstract WP128: A Comparative Meta-Analysis of Functional Outcomes Following Various Exercise Intensities in Stroke Rehabilitation.
Authors: Rizwan Ahmed Aisha , Restrepo Natalia , koppanatham aishwarya , Chochol Pawel , Varkey Thomas
Published: January 2025

Introduction:
Stroke patients often experience varying degrees of locomotor deficits. Research has shown that physical rehabilitation can help improve these deficits to different extents. Our analysis aims to compare functional outcomes in stroke patients after high-intensity training (HIT) with those achieved through various other exercise intensities.

Methods:
A comprehensive search of PubMed, Cochrane, Embase, and Scopus databases were performed for studies comparing HIT with low and moderate intensity training (LIT, MIT), or usual activity (UA) in stroke patients. We evaluated changes from baseline in the 6-minute walking test (6MWT), fastest speed, and comfortable speed. Subgroup analyses were performed by exercise intensity and stroke onset, as well as separate analyses according to follow-up periods.

Results:
12 studies were included, encompassing 1,019 patients, with 54% undergoing HIT. An analysis of ten studies with 860 patients showed that control group had a 49m greater improvement in 6MWT than HIT group (95%CI 21.62-76.38; p<0.01). Subgroup analysis showed a 44m and 59m greater improvement in subacute (95%CI 3.55-86.37; p=0.03) and chronic stroke (95%CI 2.57-116.58; p=0.04) in control, respectively. MIT and UA also showed a 28.7m (95%CI 16.04-41.43; p<0.01) and 63m (95%CI 21.55-104.76; p<0.01) greater improvement in 6MWT compared to HIT. A separate analysis of three studies showed that chronic stroke patients in control group achieved greater improvement in 6MWT (MD 29.34m;95%CI 4.57-54.11;p=0.02) with follow-up periods of less than three months. Analysis of eight studies involving 414 patients found significantly higher fastest speed (MD 0.16m/s;95%CI 0.08-0.23;p<0.01) and comfortable speed (MD 0.11m/s; 95%CI 0.07-0.15; p<0.01) in control group compared to HIT group. Subgroup analysis indicated MIT (MD 0.16m/s;95%CI 0.07-0.26;p<0.01) and UA (MD 0.25m/s; 95%CI 0.10-0.39; p<0.01) significantly increased fastest speed compared to HIT. Additionally, comfortable speed showed a significant increase after LIT (MD 0.13m/s;95%CI 0.03-0.24;p=0.02), MIT (MD 0.10m/s;95%CI 0.04-0.15;p<0.01), and UA (MD 0.16m/s;95%CI 0.04-0.28;p=0.01).

Conclusion:
Moderate-intensity training and usual activity yield better functional outcomes than high-intensity training in stroke patients, particularly benefiting chronic stroke patients within three months. Further studies should determine the impact levels and optimal daily duration for long-term benefits.
Abstract WP13: Determining Eligible Thrombolysis Candidates for Isolated Dizziness
Authors: Wasserstrom Briana , Mallick Dania , Furie Karen , Stretz Christoph , Burton Tina , Perelstein Elizabeth , Khan Farhan , Yaghi Shadi
Published: January 2025

Introduction:
Strokes affecting the posterior circulation (PCS) account for 20% of all ischemic strokes. In the emergency department, patients with PCS will often present with nonspecific symptoms such as dizziness, blurry vision, headache, nausea/vomiting, and altered mentation, leading to lower NIHSS scores. These also make PCS more prone to delayed recognition, missed diagnoses and delays in acute treatment. Recent studies indicate that PCS are half as likely to receive thrombolytic therapy and threefold less likely to receive intervention with mechanical thrombectomy compared to anterior circulation strokes (ACS). We aimed to create a protocol that identifies thrombolysis candidates for patients presenting with isolated dizziness.

Methods:
A code stroke activation protocol was implemented by the Rhode Island Hospital Stroke Committee in 08/2021. In addition to focal neurological symptoms typically associated with ACS, the protocol included objective criteria for a chief complaint of sustained isolated dizziness, including evidence of localizing examination findings and <24 hrs since last known well (LKW), or new balance issues and <4.5 hrs since LKW. A retrospective chart review was conducted for patients between 01/2021-06/2024 with a chief complaint of isolated dizziness. We compared the patients’ discharge diagnoses, decision for thrombolytic administration, door to activation times, and door to needle times.

Results:
In the years 2021 and 2022, there were 3 missed thrombolysis opportunities per year for patients presenting with isolated dizziness. From 01/2023-06/2024 there were 0 misses. The number of stroke mimics presenting with isolated dizziness who received thrombolysis was 11 in 2021, 16 in 2022, 9 in 2023, and 11 in 2024. The average door to needle time (in min) for patients with isolated dizziness and a diagnosis of acute ischemic stroke were 48.5 in 2021, 37.5 in 2022, 48 in 2023, and 62 in 2024. All delays in door to needle times were related to delayed activation, though all cases should have met criteria for the protocol.

Conclusion:
A simplified protocol is feasible to identify stroke patients with isolated dizziness eligible for thrombolysis. Use of the protocol reduced the number of missed PCS, however it also increased the number of stroke mimic patients who received thrombolysis for isolated dizziness. Continued education of the protocol is required to reduce the door to needle times in patients with isolated dizziness.
Abstract WP132: A Novel Approach of Monitoring Stroke Recovery: Contactless Sensor for Gait Speed and Fugl-Meyer Action Duration Estimation
Authors: Gu Zhuangzhuang , Titus Ryan , Regmi Hem , Tavasoli Reza , Sur Sanjib , Sen Souvik
Published: January 2025

Objectives:
Gait speed and motor deficits are key determinants of functional recovery, dependence, and disability in stroke survivors. Traditional methods of assessing these involve in-person observation and measurements by a healthcare provider. The objective of this study was to evaluate the accuracy of a contactless sensor to estimate gait speed and the duration of actions in a Fugl-Meyer (FM) assessment.

Methods:
A contactless sensor with a processing unit was developed to estimate gait speed and FM action duration. The device transmits low-power radio-frequency signals (similar frequency used in 5G smartphones) and analyzes reflections from the subject's body. By filtering spatial and temporal frequencies, an algorithm identifies 3D body structure, separates walking periods, and calculates gait speed from time and distance. For FM actions, the algorithm identifies features associated with 3D movements of arms and legs, extracting segments with the highest feature template matching. We compared the contactless sensor measurements with the standard manual measurements (Figures).

Results:
Ten stroke survivors (mean age 62.4 years, standard deviation or SD = 11.8) with self-selected gait speeds of 0.18 to 0.85 m/s and ten control subjects (mean age 31.6 years, SD = 17.7) with gait speeds of 0.80 to 1.31 m/s were evaluated. For stroke survivors, the sensor showed a high correlation (R = 0.99) with manual gait speed measurements, with error mean and SD of 0.03 and 0.02 m/s. For control subjects, the correlation was moderate (R = 0.68), with error mean and SD of 0.14 and 0.10 m/s. So, the sensor is better suited for automatic estimation of low to moderate gait speeds (0.18 m/s to 0.85 m/s). In FM assessments, the sensor accurately estimated lower-extremity action duration with mean errors of 0.60 s and 0.53 s for stroke survivors and controls. Upper-extremity action duration estimates were less accurate than the lower-extremity, but the errors are still less than 2.21 s and 1.89 s for stroke survivors and controls.

Conclusions:
In conclusion, the contactless sensor demonstrated high accuracy in estimating gait speed and showed promising results in estimating the duration of lower- and upper-extremity actions in FM assessments for stroke survivors. This technology could facilitate personalized recovery monitoring in variable environments, including home/health care facilities, potentially triggering rehabilitation needs to improve patient outcomes.
Abstract WP134: Stroke Subtype is Associated with Diagnostic Delays in Pregnancy and Postpartum: A Retrospective Study
Authors: Haghighi Noora , Bourscheid Raeann Marie , shang catherine , Romo Elida , Seitz Alison , Shapouran Sara , Mamer Lauren , Meurer William , Liberman Ava , Shields Andrea , Holl Jane , Prabhakaran Shyam , Miller Eliza
Published: January 2025

Introduction:
Stroke is a leading cause of maternal morbidity and mortality, and hemorrhagic strokes account for up to half of these cases. Prior studies in non-maternal populations demonstrated that 9% of strokes are missed at initial ED presentation. We hypothesized that pregnant or postpartum patients with acute hemorrhagic stroke would have higher odds of delayed or missed diagnosis at the time of their initial presentation, compared with those with thrombotic strokes (arterial ischemic stroke [AIS] or cerebral venous thrombosis [CVT]).

Methods:
We retrospectively identified female patients aged 18-50 years treated at 5 stroke centers between 1/1/2012 and 12/31/2021 with a confirmed diagnosis of AIS, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) or CVT. Patients who were pregnant or within 1 year of delivery at the time of stroke underwent medical chart review by vascular neurologists at each center. Medical encounters leading up to the stroke diagnosis were evaluated using the Safer Stroke-Dx instrument, a validated chart review tool to identify encounters with a missed opportunity to diagnose stroke. Encounters were categorized as “diagnostic delay” or “no diagnostic delay.” Patients with insufficient data for a determination were categorized as “no diagnostic delay.”

Results:
A total of 121 patients were identified, of whom 48% had hemorrhagic stroke. Overall, 29% of patients experienced diagnostic delays. Age and vascular risk factors did not differ significantly between those with diagnostic delays and those without (
Table
). More patients in the group with diagnostic delays were Black (49% vs 31%) or Hispanic (23% vs 12%). The proportions of stroke subtype for diagnostic delays and no diagnostic delays are shown in the
Figure
. The odds of diagnostic delays were higher for individuals with hemorrhagic stroke compared to those with thrombotic strokes (OR 2.35, 95% CI 1.05-5.28). Adjusting for race and ethnicity did not change the effect.

Conclusions:
The odds of experiencing a diagnostic delay were more than doubled for pregnant and postpartum patients with hemorrhagic strokes compared to those with thrombotic strokes. More research is needed to identify contributing factors to diagnostic delays in maternal stroke, and to develop tailored stroke screening tools to aid clinicians in diagnosing hemorrhagic stroke in the maternal population.
Abstract WP135: Race-Ethnic Specific Hospital Arrival Time of Acute Ischemic Stroke by State in the U.S.
Authors: Chen Bing Yu , Sun Jie-Lena , Fonarow Gregg , Alhanti Brooke , Mac Grory Brian , Smith Eric , Schwamm Lee , Bhatt Deepak , Saver Jeffrey , Xian Ying , Uchino Ken , Man Shumei
Published: January 2025

Introduction:
Arriving at the hospital after 4.5 hours of stroke onset makes a patient ineligible for intravenous thrombolytic therapy. In the U.S., pre-hospital triage is governed by each state. We aimed to understand hospital arrival times by state and race/ethnicity.

Methods:
This cross-sectional observational study included adult patients with acute ischemic stroke treated at the Get With The Guidelines-Stroke (GWTG-Stroke) participating hospitals from January 2021 to August 2023. The primary outcome was the proportion of patients with onset-to-arrival (OTA)>4.5 hours. Multivariable logistic regression models were adjusted for patient- and hospital-level potential confounding factors.

Results:
This study included 691,689 patients (66.2% White, 17.1% Black, 8.8% Hispanic, 3.4% Asian, and 4.4% other / undetermined), 49.8% with OTA >4.5 hours. OTA>4.5 hours occurred in 55% of Asian patients, 54% of Black patients, 52% of Hispanic patients, and 48% of White patients. Compared to White patients, Asian [adjusted odds ratio (aOR), 1.24; 95% CI 1.20-1.28], Black (aOR, 1.18; 95% CI 1.16-1.19), and Hispanic patients (aOR, 1.10; 95% CI 1.07-1.12) were more likely to present after 4.5 hours of stroke onset. The percentages of patients with OTA>4.5 hours in each race and ethnicity by state are depicted in the Figure. States with the highest percentages of OTA>4.5 hours were North Dakota for Asian patients (83%); and Vermont for Black (90%), Hispanic (100%), and White (55%) patients. After risk adjustment, compared to Texas which had the highest diversity index, states with the highest odds of OTA>4.5 hours in all patients were Vermont (1.31; 95% CI, 1.13-1.52), Mississippi (1.15; 95% CI, 1.04-1.28), North Carolina (1.15; 95% CI, 1.06-1.24) and Kentucky (1.15; 95% CI, 1.06-1.25). For the combined group of underrepresented Asian, Black, and Hispanic patients, the adjusted analysis showed that the highest odds of OTA>4.5 hours were in Vermont (5.68, 95% CI 4.30-7.51), District of Columbia (1.39, 95% CI 1.06-1.83), Utah (1.37, 95% CI 1.08-1.75) and Rhode Island (1.36, 95% CI 1.15-1.60) compared to Texas.

Conclusions:
Asian, Black, and Hispanic patients are more likely to arrive after 4.5 hours of stroke onset than White patients, with a state-specific pattern. Further studies and interventions of these states and culturally tailored interventions are warranted to improve arrival times and time-dependent stroke treatment.
Abstract WP143: Comparative Analysis of Patient Reported Outcomes in Cerebral Venous Thrombosis and Ischemic Stroke
Authors: Ahn Hyunjun , Li Yadi , Lapin Brittany , McCune Maximos , Katzan Irene
Published: January 2025

Introduction:
The majority of patients with cerebral venous thrombosis (CVT) achieve functional independence (modified Rankin Score [mRS] 0-2), although many continue to experience residual symptoms that negatively impact quality of life. Patient-reported outcome measures (PROMs) provides a means to assess these symptoms, capturing aspects of health often missed by clinician-reported assessments. We evaluated differences in PROMs across several health domains between patients with CVT and ischemic stroke.

Methods:
This observational cohort study included patients hospitalized for ischemic stroke or CVT who had a follow-up visit in a cerebrovascular clinic January 1, 2019 to April 30, 2024 and completed at least one PROM within three months of their last cerebrovascular event. Routinely collected PROMs included Patient Health Questionnaire-9, PROMIS Global Health, NeuroQoL computer adaptive testing (CAT) cognitive function, and the following PROMIS CAT scales: pain interference, physical function, satisfaction with social roles, fatigue, self-efficacy and sleep disturbance. Propensity score matching was used to pair CVT patients with ischemic stroke patients in 1:3 ratio based on demographic characteristics, mRS, Charlson comorbidity index, and time since last cerebrovascular event.

Results:
Out of 72 CVT and 2,533 ischemic stroke patients who met study criteria, 69 CVT and 196 ischemic stroke patients were matched and analyzed (average age 47.5±17.0 yrs, 62.6% female, 74.7% white race). Evidence of brain tissue injury on MRI was present in 22 (30.6%) of CVT patients. The median mRS of both CVT and ischemic stroke patients was 1 [IQR 0,1]. Except for sleep disturbance, PROMIS scores for both groups were meaningfully worse than the general population mean of 50. Worst scores were seen with physical function followed by fatigue and satisfaction with social roles. Pain interference scores were significantly worse in patients with CVT than those with ischemic stroke (58.0±10.5 vs 53.8±10.4; p=0.008); domain scores were otherwise similar between groups (Table).

Conclusion:
Despite low rate of brain injury on MRI, CVT patients had worse pain interference and similar severity and pattern of other PROM scores compared to a matched sample of ischemic stroke patients. This suggests that a holistic care approach addressing pain and the broader spectrum of outcomes, in addition to the primary vascular pathology, could be beneficial in the management of patients with CVT.
Abstract WP156: 911 Stat Ambulance Transfer in Comparison with Contracted Ambulance Reduces Door In Door Out Time for Transfer Patients with Emergent Large Vessel Occlusion
Authors: Taleb Shayandokht , Ly An , Rho Howard , Shaw Robin , Fleming Cherryl , Liang Conrad , Saver Jeffrey , Sangha Navi
Published: January 2025

Introduction:
Inter-hospital transfer of stroke patients with large vessel occlusion (LVO) safely and timely from primary stroke centers to comprehensive stroke centers is needed to improve outcomes. In this study we aim at comparing use of simple 911 ambulance stat transfer with contracted ambulance pickup (CAP) used for interhospital transfer of stroke and its effect on Door In Door Out time (DIDO).

Methods:
Data were retrospectively abstracted for patients with an LVO from 10/2020 to 04/2024. Median DIDO times were calculated for patients who were transferred using AMR 911 vs CAP. Statistical analysis was performed using R.

Results:
There were total of 412 patients with acute ischemic stroke who were found to have LVO. 272 (66%) of patients were transferred using contracted ambulance pickup (CAP) while 140(34%) were transferred using 911 ambulance. There were no significant differences in baseline demographics between the CAP and 911 ambulance groups (Table1). DIDO (AMR911: median 74.50 min (IQR 57.7-96) vs CAP: 105.50 (85-133.2), p< 0.001 was significantly faster for 911 AMR cases compared to CAP cases. (graph1).

Conclusions:
Utilizing the widely available 911 stat ambulance process for stroke patients eligible for mechanical thrombectomy reduced DIDO time significantly, which may contribute to improved functional outcome.
Abstract WP169: Moving the Finish Line: Impact of Continually Evolving Goals for Transfer of Patients with Large Vessel Occlusion.
Authors: Burley Jessica , Ellis Tanya , Sanchez Sandra , Gualberto Gary
Published: January 2025

Background:
Rapid transfer of patients with large vessel occlusion (LVO) from primary stroke centers (PSCs) to comprehensive stroke centers (CSCs) is crucial for optimizing outcomes. Door-in door-out (DIDO) time, the interval from arrival at the PSC to discharge for the CSC, is a key determinant of treatment timeliness and patient prognosis. Stroke Programs often hone in on benchmark times as goals for quality improvement (QI) initiatives, however, completing an initiative may not always be the end of the process.

Methods:
This study evaluates the impact of a continuous process improvement initiative aimed at reducing DIDO times for LVO patients transferred between PSCs and CSCs. Four distinctive time periods were defined, 1) initial QI to meet benchmark, 2) No active QI, 3) Renewal of QI, 4) Advancement of QI. At each stage intervention focused on staff education and fostering collaboration between a central transfer center, critical care transport teams, and stroke program staff with the current phase introducing additional targets beyond the benchmark of under 90 minutes for 50% of the cases transferred for LVO.

Results:
Data collected over an 8-year period where the transfer process was continually refined were analyzed. Overall, the conceptualization of progress towards the goal of the QI, impacted both mean transfer times [F(3,104) = 4.01, p= .01)] and the rate of compliance to benchmark [χ
2
= (2, N = 107) = 19.19, p <.001]. The initial QI project targeting meeting the 90-minute benchmark resulted in a mean DIDO time of under 90 minutes with a compliance rate of 56%. During phase 2, mean DIDO time increased to 103 minutes with compliance dropping to 13%. A renewal of the QI improved transfer times and compliance rate back within acceptable limits (86 min. and 67%, respectively). During Phase 4, mean DIDO time dropped to 72 minutes and compliance increased to 90%.

Conclusion:
Continuous process improvement strategies focusing on staff education and interdepartmental collaboration effectively reduced DIDO times for LVO patients transferred from PSCs to CSCs. These findings highlight the importance of setting new goals once a QI has succeeded. Continual structured interventions are paramount in optimizing acute stroke care systems. Future research should explore additional factors influencing transfer times and further refine strategies to expedite care for stroke patients requiring specialized interventions at CSCs.
Abstract WP171: Antithrombotic Therapy for Secondary Stroke Prevention in Patients with Severe Chronic Kidney Disease and Atrial Fibrillation
Authors: Jones Erica , Ayodele Iyanuoluwa , Obrien Emily , Laskowitz Daniel , Fonarow Gregg , Matsouaka Roland , Schwamm Lee , Smith Eric , Bhatt Deepak , Peterson Eric , Xian Ying
Published: January 2025

Background:
The prevalence of renal disease is increasing in the U.S. Renal dysfunction increases risk of atrial fibrillation, ischemic stroke and systemic bleeding. Lack of randomized trial data in this population has led to conflicting recommendations on management. Our objective was to review a decade of practice in utilization of antithrombotics including oral anticoagulants (OACs) for secondary stroke prevention in patients with severe renal dysfunction.

Methods:
We analyzed all ischemic stroke patients with atrial fibrillation and impaired renal function (creatinine clearance < 30) who were discharged on antithrombotics in the Get with the Guidelines- Stroke registry from Jan 2013 – Dec 2023. Subjects with other indication for anticoagulation such as venous thromboembolism, pulmonary embolism, and prosthetic valve were excluded. For the analysis, subjects were categorized as advanced chronic kidney disease (CKD, CrCl 15-30) and end stage renal disease (ESRD, CrCl<15).

Results:
Of 67,209 patients meeting inclusion criteria, 55,501 (82.6%) were classified as CKD and 11,708 (17.4%) as ESRD. Apixaban was the most utilized antithrombotic in both groups (41% in CKD and 40% in ESRD) followed by warfarin in the ESRD group (24%) and aspirin monotherapy (20%) in the CKD group. Among those on apixaban 5mg dose, 24.5% met criteria for the lower 2.5mg dose, yet were treated with the standard dose. Many subjects were discharged on the same oral anticoagulant they were taking at admission: warfarin 26%, apixaban 85%, rivaroxaban 33%, and dabigatran 58%. From 2013 to 2023, Apixaban utilization increased the most in both groups from 1.1% to 63.5% in the CKD group and 0.6% to 66.9% in the ESRD group. Aspirin monotherapy decreased from 27% to 14% in the CKD group and 25% to 14% in the ESRD group.

Conclusions:
Trends in OAC utilization show increasing uptake in use of OACs, particularly apixaban, over antiplatelets in the renal dysfunction population. More data is needed to determine the risk/benefit of DOAC vs Vitamin K antagonists, the role of antiplatelets, the inappropriate dosing of DOACs and the management of OAC “failure” in renal patients.
Abstract WP175: Predicting Post-Stroke Cognitive Impairment (PSCI) Using Multiple Machine Learning Approaches
Authors: Xie Yuzhang , Nahab Fadi , Ge Yi , Wu Yuhua , Saurman Jessica , Yang Carl , Hu Xiao
Published: January 2025

Background:
Post-stroke cognitive impairment (PSCI) is a condition characterized by cognitive decline that occurs after a stroke. PSCI affects up to 60% of stroke survivors. Early detection of those at high risk for PSCI is essential for timely intervention and personalized care. Electronic health records (EHRs) contain valuable data that can be leveraged by machine learning to predict PSCI, potentially enhancing patient outcomes. This study focuses on developing and validating machine learning models to predict PSCI, aiming to enable earlier diagnosis and improve post-stroke care.

Methods:
7956 all-type stroke patients (including Ischemic&Hemorrhagic stroke) treated between 2012 and 2021 were extracted from Emory Healthcare system. We employed multiple methods to predict PSCI, using ICD codes and prescribed medications that were available up to the discharge of index strokes. First, we utilized traditional machine learning methods, including Logistic Regression, Support Vector Machine, and Random Forest to develop models. Then, we developed hypergraph models to enhance prediction performance. Unlike traditional graphs that only capture pair-wise relationships between pairs of entities, hypergraphs can model the more complex higher-order relationships among multiple entities, by allowing a hyperedge (encounter) to connect multiple vertices (ICD and medications) simultaneously among patient visits and EHR medical features. Finally, we compared the performance across different methods and selected the best one for the PSCI prediction task. We compared their performance on four metrics: ACC (Accuracy, the proportion of correct predictions), AUC (Area Under the ROC Curve, measuring the model's ability to distinguish between classes), AUPR (Area Under the Precision-Recall Curve, a comprehensive measure considering both precision and recall), and Macro-F1 (a balanced measure calculated by the harmonic mean of precision and recall).

Results:
We included 7956 all-type stroke patients (50% female, 56% non-white) in this analysis, where 1797 (23%) had diagnostic codes often used by clinicians at Emory to document PSCI. According to the performance, the hypergraph model was associated with higher ACC, AUC, AUPR, and Macro-F1 than other models.

Conclusion:
By comparing the results of various machine learning methods, we found that hypergraph model approaches outperform traditional machine learning methods in utilizing EHRs for predicting PSCI after a stroke.
Abstract WP179: Initial Core Volume Assessment-based Machine Learning on Non-Contrast CT could Discriminate Outcomes According to ASPECTS score and Stroke Elapsed Time in Reperfusion Treatment Patients
Authors: Flores Alan , SERO LAIA , Ustrell Xavier , Avivar Ylenia , Olive-Gadea Marta , Canals Pere , Ribo Marc
Published: January 2025

Background:
In reperfusion treatment, advanced neuroimaging can be used to indicate treatment or forecasting outcomes, however immediate access is not widely available. This study aims to explore the assessment of initial core volume (ICV) measured on NCCT by a machine learning-based algorithm on outcomes in overall and according to ASPECTS and stroke elapsed time.

Methods:
Consecutive patients who received reperfusion treatment were studied in two stroke-centers (Jan-2021 to Dec-2023). On admission, ICV was defined on NCCT (aICV) by an algorithm trained using UNet architecture with ResNet 34 encoder. Favorable ASPECTS was defined as score 9-10. Elapsed time from symptoms onset to admission was stratified as early (<240 min) and late (>240 min) temporal window. Good clinical outcome was defined as mRS 0-2 at 90 days. A statistical analysis was performed to evaluate the relation between aICV and clinical outcome in overall and pre-defined groups.

Results:
Among 595 consecutive patients included, mean age was 73.5(SD±14.4) and median baseline NIHSS 13(IQR:7-19). Mean aICV presented an inverse (r=-0.580, p<0.001) and direct (r=0.152, p=0.001) relation with ASPECTS and elapsed time respectively
(figure 1).

In overall, lower aICV was associated with good outcome (13.7 SD±23.4 vs 34.2 SD±25.6, p< 0.001). A logistic regression showed that lower aICV (OR:0.982, CI95%:0.931-0.974, p=0.001), baseline NIHSS and younger age were predictors of good outcome.

In favorable ASPECTS patients, lower aICV was associated with good outcome (10.2 SD±18.8 vs 17.4 SD±25.6, p=0.002). A logistic regression showed that lower aICV (OR:0.984, CI95%:0.970-0.999, p=0.043), baseline NIHSS and younger age were predictors of good outcome.

Lower aICV was associated with good outcome in both; early and late temporal window
(figure 2)
. Adjusted logistic regression showed that lower aICV (OR: 0.983, CI95%: 0.968-0.998, p=0.03) and age were predictors of good outcome in the early window. In the late window; aICV (OR: 0.977, CI95%: 0.960-0.994, p=0.007) and age were also predictors of good outcome.

Conclusion:
Among reperfusion treatment patients, ICV assessment-based machine learning logarithm on NCCT is capable to predict a favorable outcome even in patients with a favorable ASPECTS score and in both, the early and late time window. Furthers studies will determine the potential role of aICV to safely expand the indication of reperfusion treatments based on NCCT in different settings