bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WMP57: Existing Imaging Studies in Acute Ischemic Stroke Hospitalizations with Nonspecific ICD-10 Codes Could Specify the Vascular Distribution of the Lesion: A Descriptive Study
Authors: Hirsch Jason , Burke James , Hailat Raed , Kerber Kevin
Published: January 2025

Background:
The vascular region of a stroke is reported in International Classification of Diseases-10 (ICD10) subcodes as either a specific or nonspecific/unspecified location. The coding has been shown to be accurate for specific ischemic stroke regions but has not been assessed for nonspecific/unspecified coding. The overall accuracy has implications for research. We aimed to describe the imaging characteristics in strokes coded with nonspecific/unspecified region subcodes and to assess for associations with their use.

Methods:
From a single comprehensive stroke center, we randomly selected 200 stroke hospitalizations with a primary discharge I63 ICD10 code; 100 had non-specific/unspecified vascular location subcodes, and 100 had specific vascular location subcodes oversampled for posterior circulation strokes. Gold-standard scoring of the vascular region was performed using the imaging studies and reports blinded to the subcode. The NIHSS was categorized using R29 codes (i.e. missing, mild, moderate, severe). We used logistic regression to assess the association of potential predictors with nonspecific/unspecified ICD10 vascular region subcodes weighted for the sampling.

Results:
In the 100 strokes with nonspecific/unspecified region subcodes, mean NIHSS was 4.0 (SD 4.2), 88% had a head CT and 93% had a MRI. The most commonly used non-specific/unspecified codes were I63.9 (48%), I63.89 (20%), and I63.81 (11%). The gold standard classification of vascular region identified an acute infarct in a defined location in 85 of the 100 cases that had non-specific/unspecified subcodes: 45 anterior circulation strokes (27 MCA, 9 ACA , 9 carotid), 40 posterior circulation strokes (17 PCA, 11 basilar, 6 cerebellar, 6 vertebral), and 15 with no infarct on imaging. In the model (c-statistic 0.63), NIHSS category (severe stroke vs missing: OR 0.08; 95% CI:0.01-0.49), no gold standard acute lesion (OR 10.8; 95% CI:1.0-115.9), and MRI performed (OR 3.25; 95% CI:1.0-10.4) were associated with nonspecific/unspecified ICD10 subcodes but posterior versus anterior circulation location of infarct was not (OR 0.88; 95% CI: 0.41-1.8).

Conclusions:
We found that most stroke hospitalizations with a nonspecific/unspecified vascular region subcode have acute lesions of a specific region on imaging and were more likely to have low NIHSS. These findings suggest that selecting for specific stroke locations based on ICD10 codes could bias studies toward more severe strokes in that region.
Abstract WMP73: Evolution of Ischemic Stroke Etiology Diagnosis During Stroke Hospitalization
Authors: Ellsworth Patrick , Lee Ho-Joon , Sansing Lauren , Schwamm Lee , Thottempudi Neeharika , Sharma Richa
Published: January 2025

Background:
During the course of an ischemic stroke hospitalization, the initial diagnosis of the causative mechanism or etiology of stroke may evolve. We aimed to quantify the degree to which patients with initial etiologic diagnosis are reclassified during the hospitalization and frequencies of reclassified diagnoses.

Methods:
This retrospective cohort consisted of all patients from a single center recorded in the institutional Get-with-the-guidelines Stroke registry from September 2015-December 2020 with a stroke etiology entered who were evaluated by at least 1 vascular neurologist. The stroke etiologies documented were mapped to one of the 5 TOAST classifications: 1-large artery atherosclerosis, 2-cardioembolism, 3-small vessel disease, 4-other determined etiology, 5-undetermined etiology. Spline models and a Sankey diagram were employed to visualize the trends in etiology diagnosis reclassification by subsequent vascular neurologists during the hospitalization.

Results:
A total of 709 patients were included in the analytic cohort. Initial TOAST classifications were the following: TOAST 1 (n= 132, 19%), TOAST 2 (n= 168, 24%), TOAST 3 (n=88, 12%), TOAST 4 (n=50, 7%), TOAST 5 (n= 271, 38%). There were 132 (19%) patients who were reclassified with a different etiologic diagnosis by the time of hospital discharge. The number of patients who were reclassified from their initial etiologic diagnosis were: TOAST 1 (n=11), 2 (n=9), 3 (n=4), 4 (n=4), and 5 (n=104). The spline plots in the
Fig. 1
demonstrate that an increasing number of impressions by subsequent vascular neurologists was associated with increasing likelihood of reclassification for subtypes 4 and 5. For each subtype, the most common reclassifications were TOAST 1 to 5 (54.5%), 2 to 1 (33.3%), 3 to 5 (50.0%), 4 to 5 (50.0%), and 5 to 2 (58.7%). Distributions of initial and final etiologic diagnoses among patients who had diagnostic reclassification are displayed in the Sankey diagram in
Fig. 2
.

Discussion:
Identifying stroke etiology is important for ensuring that patients receive targeted secondary stroke prevention. Strokes with initial subtypes of 4 and 5 were more likely to receive a different diagnosis with an increasing number of impressions by subsequent vascular neurologists. The treatment profiles of the initial and reclassified subtypes are distinct, highlighting the value of inpatient diagnostic evaluation, particularly cardiac testing, during an acute stroke hospitalization.
Abstract WMP81: A ChatGLM-based stroke diagnosis and prediction tool
Authors: Song Xiaowei , Wang Jiayi , Ma Weizhi , Wu Jian , Wang Yueming , Gao Ceshu , Wei Chenming , Pi Jingtao
Published: January 2025

Background and purpose:
Stroke as a world-wide prevalent disease, has brought a huge burden to health care and the national economy, accurate and fast stroke diagnosis can significantly increase reperfusion rate, mitigate disability, and reduce deaths. However, there exists a great discrepancy in acute stroke diagnosis and treatment due to the diverse medical information for making decisions. This study aims to develop a stroke diagnosis and prediction tool based on Large Language Models (LLM) to combine heterogeneous information for reasoning.

Methods:
By taking the electronic health record's (EHR) free-text information combined with non-contrast computed tomography (NCCT) to improve stroke discovery and treatment, We randomly included 1885 stroke and non-stroke subjects admitted at neurology ER in a comprehensive stroke center as a training set. We developed an LLM based on ChatGLM3-6B by selecting optimal entry combinations, using external tools, Instruction Tuning, and Low-Rank Adaptation (LoRA) techniques to enhance the performance of key procedures in stroke diagnosis flow-chart, and finally validating the results at both internal and external datasets.

Results:
The multimodal LLM based on clinical notes and NCCT has very high accuracy in stroke diagnosis (99.0% in the internal validation dataset, 95.5% and 79.1% in other 2 external test cohorts), distinguish ischemia and hemorrhage (100.0% in validation dataset, 99.1% and 97.1% in other test cohorts), LVO identification (80.0% in validation dataset, 88.6% and 83.3% in other test cohorts), and screening patients eligible for IVT (89.4% in validation dataset, 60.0% and 80.0% in other test cohorts).

Conclusion:
We derived an LLM that utilizes clinical text and NCCT to identify stroke and guide recanalization therapy. Our results require wide-scale deployment validation but can potentially improve stroke identification and narrow reperfusion time.
Abstract WMP82: Stroke Transitional Care Model: An Advanced Practice Provider Led Initiative
Authors: Mealey Rachael , Nobles Kristen , Burdett Rebecca , George Donna , Sloane Kelly , Stein Laura
Published: January 2025

Background and Purpose:
Stroke patients discharged home face significant vulnerabilities in the immediate post-discharge period. Our Comprehensive Stroke Center identified critical gaps in post-discharge care, including inconsistent follow-up timing and a high rate of missed appointments. This initiative, led by Advanced Practice Providers (APPs), aimed to refine the post-discharge process to enhance care quality and reduce missed follow-ups.

Methods:
We introduced a streamlined follow-up process for stroke patients discharged home, adhering to the Centers for Medicaid and Medicare (CMS) Transitional Care Management (TCM) model. An Advanced Practice Provider, specifically a Nurse Practitioner (NP), conducted inpatient rounds, coordinated follow-up appointments prior to discharge, and initiated contact with patients within 24-48 hours. Follow-up visits were scheduled with the outpatient stroke NP within 7 to 14 days, either in the clinic or via telemedicine. This approach, compliant with CMS TCM requirements and billable under TCM codes, was evaluated over a seven-month period, with a focus on clinic no-show rates and reimbursement compared to traditional discharge practices.

Results:
The TCM model, managed by APPs, resulted in a 3% no-show rate, significantly lower than the 14% rate for patients discharged without TCM. All patients under the TCM model had a scheduled post-discharge follow-up appointment, compared to only 9% of those discharged without TCM who lacked a scheduled stroke follow-up. Additionally, appropriate use of CMS TCM codes led to higher reimbursement and increased departmental revenue.

Conclusions:
The APP-led initiative aligned our discharge process with the CMS-recognized TCM model, improving the scheduling of post-discharge follow-up appointments, reducing clinic no-show rates, enhanced departmental revenue, and strengthening collaboration between inpatient and outpatient APPs.
Abstract WMP94: Trends in Co-morbidities and Mortality in Rescue Stenting and Elective Stenting for Intracranial Atherosclerotic Disease: National Inpatient Sample Data Analysis
Authors: Alexander Michael , SHEN YI , Zhou Tianzan , Nuno Miriam
Published: January 2025

Introduction:
Medical therapy and endovascular therapy for intracranial atherosclerotic disease (ICAD) have evolved over the past two decades with improved medical therapy benchmarks, and improved techniques and patient selection for stenting. This study investigated patient co-morbidity trends to determine if these factors have led to better national patient outcomes.

Methods:
We performed a data search from the U.S. National Inpatient Sample (NIS) database from 2009 to 2020, evaluating patients who presented with stroke from ICAD and were treated with angioplasty and stenting and analyzed presenting co-morbidities and patient outcomes. The sample included patients who presented with stroke due to severe stenosis and underwent elective stenting, and those who presented with large vessel occlusion (LVO) with underlying ICAD who underwent rescue stenting following thrombectomy. We analyzed Elixhauser co-morbidity groups to look for trends and looked at all-cause in-hospital mortality.

Results:
Data from 2009 to 2020 showed no significant difference in patient mortality over the study period for patients who presented with LVO and underlying ICAD who underwent thrombectomy and rescue stenting, but there was a trend towards increased baseline co-morbidities. There was a significant decrease in mortality over the study period in patients who presented with stroke and severe stenosis who underwent elective angioplasty and stenting alone (p = 0.0103). Interestingly, there was a trend towards increased co-morbidities in patients during this period, despite the improved outcomes. There were significantly higher incidences in uncontrolled hypertension (28.2% vs 7.9%), diabetes (33.6% vs 4.6%), obesity (26.4% vs 10.2%) in the 2020 patient group compared to the 2009 patients. Hypercholesterolemia data is not captured in the Elixhauser co-morbidity analysis.

Conclusions:
Despite SAMMPRIS aggressive medical therapy guidelines published in 2011, over the study period there was a trend towards worse co-morbidity profiles in both the thrombectomy plus stent and stent only cohorts. While there was no change in mortality in the thrombectomy plus stent group over time, there was a significant trend towards better outcomes with lower mortality in the stenting only cohort, suggesting improved outcomes with best practice techniques and better patient selection criteria for endovascular therapy
Abstract WMP95: Endovascular Therapy Vs. Medical Management In Isolated Anterior Cerebral Artery Acute Ischemic Stroke: A Multinational Multicenter Propensity Score-Weighted Study
Authors: Salim Hamza , Koneru Manisha , Pulli Benjamin , Abushehab Nimer , Lakhani Dhairya , Musmar Basel , Faizy Tobias , Heit Jeremy , Wintermark Max , Guenego Adrien , Dmytriw Adam , Yedavalli Vivek
Published: January 2025

Introduction:
Isolated anterior cerebral artery occlusions (iACAo) in acute ischemic stroke (AIS) patients present significant challenges due to their rarity and complex symptomatology. The efficacy of endovascular therapy (EVT) versus best medical management (BMM) for iACAo remains unclear. In light of context we aim in this investigation to assess the outcomes of these treatments.

Methods:
This multinational, multicenter study analyzed data from the Multicenter Analysis of Distal Medium Vessel Occlusions: Effect of Mechanical Thrombectomy (MAD-MT) registry. We included 108 patients with iACAo, who underwent either EVT or BMM. Data were collected retrospectively from 37 sites across North America, Asia, and Europe. Inverse Probability of Treatment Weighting (IPTW) was applied to balance confounding variables between treatment groups. The primary outcome was functional independence at 90 days. Secondary outcomes included excellent outcomes (mRS 0-1), mortality, and NIHSS score on day one post-EVT. Safety outcomes assessed hemorrhagic complications.

Results:
Of the 108 patients, 36 received BMM and 72 underwent EVT. The median age was 75 years (IQR 67-87), with 60 (56%) male patients overall. The primary outcome of 90-day mRS 0-2 was achieved in 40% of the cohort, with no significant difference between the EVT and BMM groups (38% vs. 45%, p=0.46). Procedural success (TICI 2b-3) was high in EVT patients at 91%, with a low sICH rate of 2.9%. The IPTW-adjusted analysis showed no significant association between EVT and improved functional outcomes (OR 1.17, 95% CI 0.23-6.02, p=0.85) or reduced mortality (23% overall; 25% EVT vs. 21% BMM, p=0.71). However, EVT was associated with higher NIHSS scores on day one post-stroke in crude analyses (OR 4.8, 95% CI 1.2-8.5, p=0.012), though this was not significant in the IPTW model (OR 2.2, 95% CI -0.51 to 4.8, p=0.11).

Conclusions:
In this propensity score-weighted analysis, EVT did not demonstrate superior functional outcomes compared to BMM in patients with iACAo. Nonetheless, EVT achieved high procedural success and low rates of symptomatic hemorrhage, indicating its safety. These findings highlight the need for randomized controlled trials to further explore EVT's potential role as a first-line or rescue therapy in iACAo patients, especially given the low recanalization rates with IV thrombolysis alone.
Abstract WP100: Temporal trends in acute ischemic stroke care in a community without an academic medical center
Authors: Malingagio Amanda , Miller Robert , Royan Regina , Stamm Brian , Meurer William , Lisabeth Lynda , Morgenstern Lewis
Published: January 2025

Introduction:
Novel therapies have changed the landscape of acute ischemic stroke (AIS) treatment over the past decade. Timely identification and treatment of AIS is imperative, which makes swift action by emergency departments (ED) critical. Most research on AIS comes from academic medical centers. We sought to report the temporal trends of ED-based AIS treatment from 2012-2022 in a community without an academic medical center.

Methods:
As part of the community-based Brain Attack Surveillance in Corpus Christi (BASIC) project, ischemic strokes treated in an emergency department were identified via active and passive surveillance. Logistic regression was used to model the temporal trends for overall neurology consult, tele-stroke consult, NIHSS documentation by provider, transfer to an out of area facility for mechanical thrombectomy, and tPA utilization. All predictions were adjusted for age, race/ethnicity, sex, NIHSS, and history of stroke/TIA. Mechanical thrombectomy candidates were also identified, and frequencies were calculated.

Results:
Sample size varied between 3912 and 5156 depending on the outcome and its number of observations with complete covariate data. NIHSS documentation by provider increased by 17.5% (95% CI: 0.135, 0.215) (Figure 1A). Overall neurology consultation rate increased by 25.6% (95% CI: 0.211, 0.302) (Figure 1B). Tele-stroke consult rate increased by 35.7% (95% CI: 0.307, 0.407) (Figure 1C). Patient transfer to an out of area facility for mechanical thrombectomy saw a peak around 2019 (3%) that subsequently declined by 2022 (0.2%) as this expertise became more available in the community (Figure 1D). tPA utilization increased by 6.7% (95% CI: 0.036, 0.098) (Figure 1E). The frequencies of mechanical thrombectomy in 2020, 2021, and 2022 were 2.00%, 4.14%, and 6.68% respectively.

Conclusions:
There have been remarkable changes in AIS treatment from the emergency medicine perspective in the last decade. Dramatic increases in neurology and tele-stroke consults, transfers for mechanical thrombectomy, and tPA usage suggests assertive treatment protocols in this “real-world” community without an academic medical center.
Abstract WP101: Rural-Urban Differences in Whether Stroke Thrombectomy is Performed at the Nearest or More Distant Thrombectomy-Capable Centers in Florida
Authors: Fleming Nathaniel , Solovey Liza , Hsia Renee , Shen Yu-Chu , Kim Anthony
Published: January 2025

Introduction:
Stroke thrombectomy (ST), an effective but time-sensitive intervention for acute large-vessel occlusion (LVO) stroke, is not available at all centers, so transport to a nearby ST-capable facility is often required. To characterize the regionalization of ST, we determined the proportion of ST patients in Florida that were treated at the nearest ST-capable facility, the predicted EMS driving time delay associated with bypassing the nearest facility when ST was performed at a more distant facility, and whether these measures differed for patients in urban and non-urban areas.

Methods:
Using data from the 2019 Florida Healthcare Cost&Utilization Project, we identified all hospitalizations of adult Florida residents at non-federal facilities with a primary diagnosis of acute ischemic stroke who received ST. Then we identified the nearest ST-capable facility (defined as a facility that performs ≥15 STs per year) based on the driving distance from the centroid of each patient’s residence zip code. We calculated the proportion of ST cases treated at the nearest ST-capable facility and the expected additional EMS drive time for those treated at a more distant facility. We then stratified our analyses by USDA rural-urban area codes.

Results:
Among 2728 acute ischemic stroke patients treated with ST at ST-capable facilities in Florida in 2019, 1663 (61.0%) were treated at the nearest ST-capable facility, with a mean expected EMS drive time of 17.6 minutes. A further 496 (18.2%) were treated at the second-nearest facility, with a mean expected additional drive time of 5.9 minutes. Non-urban residents were less likely to be treated at the nearest ST-capable facility than urban residents (53.2% vs 61.6%, p=0.014) but were equally likely to be treated at one of the two nearest ST-capable facilities (80.0% vs 79.1%, p=0.744). The expected mean additional drive time when treated at the second nearest facility was greater for non-urban residents than urban residents (+10.9 minutes vs +5.3 minutes, p=0.021).

Conclusions:
Most Florida residents received ST at the nearest or second-nearest ST-capable center, with small differences in expected travel times. However, residents outside of urban areas were more likely to bypass the nearest ST-capable center to receive treatment at a more distant center and had longer additional drive times as a result, consistent with a potential disparity in geographic access to ST between urban and non-urban populations.
Abstract WP109: Outcomes of patients with in-hospital onset stroke and cancer is similar to those without cancer
Authors: Kawano Hiroyuki , Sakurai Ayumi , Takizawa Yuuki , Toyota Risa , Miwa Reona , Onuki Hayate , Kawatake Ayane , Yamamichi Atsushi , Saito Mikito , Nakanishi Kaoru , Tsuji Eisaku , Tomari Shinya , Yuko Honda , Unno Yoshiko , Uchida Mayumi , Hirano Teruyuki
Published: January 2025

Introduction:
Comorbid active cancer among in-hospital onset acute ischemic stroke (IHS) is increasing. We aimed to clarify the differences in the initial management and clinical outcome of IHS patients between with and without active cancer.

Methods:
During the period from August 2016 to July 2023, 200 IHS patients (58% male, median age 78 years, median NIHSS score 9) at a single institution were divided into two groups: 70 IHS patients with active cancer (IHS-AC group, 35%) and 130 IHS patients without active cancer (IHS-nonAC group, 65%). Patients’ characteristics, time course, of initial management and clinical outcome were compared in both groups. A good functional outcome was defined as modified Rankin Scale score 0-3. AC was defined as diagnosis of cancer within 6 months of stroke onset, any treatment for cancer within the previous 6 months, or recurrent or metastatic cancer.

Results:
IHS was identified most frequently by a nurse in both groups (67% in the IHS-AC group and 71% in the IHS-nonAC group). The time from last known well to recognition (median, 112 min vs. 165 min, p=0.178) and time from recognition to stroke physician assessment (37 min vs. 90 min, p=0.008) were shorter in the IHS-AC group than the IHS-nonAC group. Good functional outcome at discharge (31% in each group, p=1.000) and the in-hospital mortality (29% in the IHS-AC group, 21% in the IHS-nonAC group, p=0.225) were similar in both groups. The rates of reperfusion therapy (intravenous rt-PA and/or mechanical thrombectomy) were 16% in the IHS-AC group and 15% in the IHS-nonAC group, with no significant difference (p=1.000). The rates of good functional outcome and mortality at discharge in patients with reperfusion therapy were 36%, respectively.

Conclusion:
One-third of IHS were comorbid active cancer. The rates of reperfusion therapy and good functional outcome were similar in both groups. Because one-third of IHS-AC patients with reperfusion therapy regained independent gait, acute stroke management for IHS should not be withheld solely based on cancer.
Abstract WP112: Genomic Insights into Stroke Recovery: Cross-Phenotype Associations and Biological Pathways
Authors: Aldridge Chad , Braun Robynne , Parodi Livia , Rosand Jonathan , Holman Alison , Cramer Steven
Published: January 2025

Background:
Stroke is a major cause of long-term disability and has widely varying recovery outcomes. While clinical factors like stroke severity play a role, genetic factors are increasingly recognized as important contributors to stroke recovery. This study aims to identify genetic variants associated with recovery phenotypes through genome-wide association studies (GWAS) and protein-protein interaction (PPI) networks.

Methods:
DNA from STRONG study participants was genotyped using the Infinium Global Screening Array, resulting in 565 samples and 9,814,610 variants after quality control. GWAS were conducted on 11 recovery phenotypes using plink v1.9, including motor (Grip Strength), cognition (tMoCA), functional performance (SIS-ADL), mental health (PHQ-8 and PTSD), and disability (mRS). Models adjusted for age, sex, stroke severity acutely, and ancestry. To further examine how the identified genetic variants may relate to biological mechanisms of recovery, PPI networks and gene ontology enrichment analyses were conducted.

Results:
Participants’ stroke severity was mild to moderate (acute NIHSS median score 4, IQR 2 – 9). Several cross-phenotype associations were identified for genes of biological interest: Grip strength, PHQ8, and PTSD were associated with the rs138829971-C variant near DCLK2 (involved in hippocampal organization). Grip strength and tMoCA were associated with the rs149456987-T variant near UNK (crucial for cortical neuron development). The PPI networks for multiple phenotypes (including SIS ADL and mRS at 3 months, change in Grip Strength from 1-3 months, PHQ8 and PTSD measures at 12 months) were significantly enriched in protein-protein interactions, and for GO terms including Nervous System Development (SIS ADL), Post-synaptic Density (PHQ8), Neuron Projection (tMOCA) and Axon Guidance (Grip Strength).

Conclusions:
While some genetic variations affect specific domains of recovery, others have cross-phenotype associations that affect recovery more broadly. Our analyses identified several gene associations and biological pathways active during development, suggesting a potential shared biology with reparative processes post-stroke. Other associated genes affecting axon guidance that we identified remain expressed in adult brain tissue and could offer targets for developing drug therapies.
Abstract WP116: Lesion Volume and Location Correlate with Picture Description using the New NIH Stroke Scale Stimuli
Authors: Stockbridge Melissa , Neal Voss , Liu Shun , Diaz-Carr Isidora , Kang Joseph , Faria Andreia , Hillis Argye
Published: January 2025

Introduction:
In January 2024, the picture stimuli used to elicit language on the NIH Stroke Scale were updated. Descriptions elicited using the now-retired
Cookie Theft
picture are informative regarding the size and location of stroke. An important dimension of validation for the new stimuli is to demonstrate that the language patients produce when describing the new
Precarious Painter
picture that is now part of the NIH Stroke Scale is similarly informative.

Methods:
Participants included 62 patients with acute ischemic stroke (24 left and 38 right) compared with 10 control participants with transient ischemic attack. Descriptions of the
Precarious Painter
image were analyzed for content and structure. Bilateral regions of interest were selected based on their role in language processing, and lesion volume and location were measured on diffusion-weighted imaging. Analyses of variance were used to contrast discourse performance across groups, and correlations between discourse characteristics and proportion of region lesioned were calculated.

Results:
Patients with left hemisphere strokes included less content from the right side of the picture, F(2) = 4.5, p = 0.02, η
2
P
= 0.12, than those in the other groups. Patients with right hemisphere stroke produced similar samples to controls across all dimensions examined, though there was evidence of a trend in including less content from the left side of the image, similarly consistent with contralesional spatial neglect (
Figure 1
). Correlations between discourse variables and lesion locations were grossly consistent with those previously reported (
Figure 2
) and provided evidence of a relationship between lesions to the left middle temporal pole and a greater use of holistic description.

Conclusion:
Features of picture description that may be appraised without specialized training in communication, such as how many things a patient includes, their location, and the inclusion of inferences or summarizing statements in the description, provide insight into stroke location and severity. The samples elicited using the new
Precarious Painter
stimulus perform similarly to those elicited using the retired
Cookie Theft
stimulus.
Abstract WP120: Real-world Canadian experiences from therapy staff implementing an intensive rehabilitation protocol in stroke inpatient rehabilitation settings: a survey study
Authors: Hung Stanley , Ackerley Suzanne , Connell Louise , Bayley Mark , Best Krista , Corriveau Helene , Donkers Sarah , Dukelow Sean , Ezeugwu Victor , Milot Marie-Helene , Peters Sue , Sakakibara Brodie , Sheehy Lisa , Yao Jennifer , Eng Janice
Published: January 2025

Objective:
Despite guidelines recommending intensive rehabilitation for walking recovery after stroke, its implementation remains challenging. Our understanding of barriers and facilitators in real-world settings remains minimal. We aimed to understand the implementation factors for intensive rehabilitation within real-world inpatient rehabilitation settings.

Methods:
A cross-sectional online survey design was used. We invited 85 therapy staff (physiotherapists + therapy assistants) who delivered the structured, progressive intensive rehabilitation protocol (>2000 steps, 40-60% heart rate reserve, >30 minutes/session) as usual care from 12 sites (7 Canadian provinces) within the Walk ’n Watch implementation trial (NCT04238260). Fitbit step counters and Garmin heart rate monitors were provided. The survey was developed by a multidisciplinary team (clinicians, scientists, and a stroke patient), including close-ended (Likert agreement scale) and open-ended questions regarding protocol practicalities, workplace structure, and support. Close-ended responses were descriptively summarized. Open-ended responses were thematically analyzed using the Consolidated Framework for Implementation Research (CFIR).

Results:
Forty-seven therapy staff (85% female; mean 13 ± 10 years clinical experience) completed the survey. Most therapy staff agreed that they delivered the protocol safely and successfully (87%) and that the step and heart rate targets were helpful (72%). However, only about one-third agreed that they had enough time to deliver the protocol (36%); 26% and 47% agreed that they achieved the prescribed step count and heart rate targets, respectively. The major time-related factor was insufficient therapy time to accommodate the 30-minute protocol, besides other required therapy activities (CFIR Work Infrastructure). For example, discharge planning often took priority near the end of the stay. Most agreed to future use of the protocol (87%). However, only about half agreed to future use of the trial-assigned devices (49% step counters, 64% heart rate monitors), likely due to perceptions of device inaccuracies (CFIR Materials&Equipment).

Conclusions:
Therapy staff reported successfully delivering an intensive rehabilitation protocol as usual care under real-world conditions. Strategies identified to facilitate implementation included building in discharge planning considerations within the protocol and acquiring more accurate step counters and heart rate monitors.
Abstract WP123: Exploring Myasthenia Gravis as a Potential Contributor to Post-Stroke Fatigue: A Prospective Case-Control Study
Authors: NAMBIAR VIVEK , PT Karthika , kannoth Sudheeran , Mathai Annamma , V U Anaghakrishna , Chandran Divyasree , S Midhun , TU Athira
Published: January 2025

Background:
Post-stroke fatigue is a common and debilitating issue, often linked to depression or neural damage. Emerging evidence suggests that myasthenia gravis (MG) may also play a role in post-stroke fatigue, offering a new perspective on patient management and long-term disability reduction.

Objectives:
This study aims to assess the incidence of de novo MG in stroke survivors following motor recovery over 18 to 24 months and compare findings with a healthy control group.

Methods:
Conducted at a tertiary care institution over two years, this prospective case-control study included ischemic and hemorrhagic stroke patients. Participants were recruited during the acute stroke phase and underwent evaluations for neuromuscular weakness and autoimmune disorders. They were monitored in a specialized stroke clinic for two years. Key variables included demographics, comorbidities, autoimmune disorders, stroke subtype, time since onset of stroke, and muscle fatigability. Age and sex-matched controls were assessed concurrently. Baseline and two-year follow-up measurements of acetylcholine receptor (AChR) antibodies were performed, and new antibodies were monitored. Participants with significant fatigability were tested for MG, and if confirmed, treated with cholinergic drugs.

Results:
The study involved 96 participants with a mean age of 60.45 years, predominantly male (63.86%). Ischemic stroke was most common (93.75%). Major risk factors included hypertension (12.5%), diabetes (5.20%), and dyslipidemia (3.12%), with 11.45% having autoimmune disorders. Of the 96 participants, 74 (77.08%) reported fatigability an average of 23.2 months post-stroke. Types of fatigability included neck (34.37%), proximal arm (11.46%), grip (19.80%), speech (5.21%), and eye (6.25%). Among 36 stroke patients with post-stroke fatigability and 36 controls re-evaluated at follow-up, 7 stroke patients tested positive for AChR antibodies compared to 1 control. Fisher’s Exact test showed a significant association between stroke and AChR-Ab positivity (p = 0.001), with an odds ratio of 7, suggesting a potential link between post-stroke fatigue and MG.

Conclusion:
The study highlights MG as a potential underrecognized factor in post-stroke fatigue. These findings may improve diagnostic and therapeutic strategies for stroke survivors and pave the way for further research into post-stroke immune alterations and MG development.
Abstract WP14: Objective Scoring to Reduce Excess Thrombolysis Utilization in Acute Ischemic Stroke Patients with NIHSS ≤ 5
Authors: Matta Sofia , Hillis Emma , Jordan Hannah , Zweifler Richard , Tarsia Joseph
Published: January 2025

Introduction:
The use of IV thrombolysis (IVT) in acute ischemic stroke patients presenting with an NIHSS of ≤ 5 has failed to demonstrate benefit, particularly when the symptoms are considered non-disabling. This critical disability distinction, however, is often made subjectively by the treating physician at the bedside. This may complicate and delay decision-making or lead to unnecessary dosing of thrombolytic agents, especially when symptoms such as paresis, visual field loss (VFL), or aphasia are present, despite having no impact on clinical outcome.

Hypothesis
The implementation of an objective scoring system, as used in the ARAMIS Trial, utilizing non-disabling NIHSS individual sub-score cut-offs (NdSSC) [≤ 1 for single limb weakness, aphasia, VFL and neglect] will reduce excess utilization of IVT in this patient population.

Methods:
This single-center, retrospective cohort study included IVT candidates with an NIHSS ≤ 5, either in-person or via tele-stroke, from 2019 to 2023. Baseline characteristics were compared between those treated and not treated based solely on an exclusion of "mild non-disabling symptoms." A logistic regression analysis was performed to identify any variables influencing this treatment decision. Potential excess utilization of IVT was determined by applying objective NdSSC criteria to patients who received IVT, and the Kappa statistic was calculated to evaluate agreement.

Results:
A total of 2,565 patients were included in the analysis, with 47.2% (n = 1210) receiving IVT. 72.4% (876/1210) of these patients who received IVT would not have been recommended for therapy under the NdSSC Criteria. In the overall population, a net total 32.8% more patients received lytic therapy than would have been recommended under the NdSSC Criteria. (Kappa = 0.26 [95% CI 0.23 – 0.29]) (Table 1). Adjusted analyses did not show any significant effect on treatment decision for age, race, time of day, tele-stroke vs. in-house, paresis, aphasia, visual loss, and neglect (Table 2).

Conclusion:
In acute ischemic stroke patients with an NIHSS ≤ 5, using standard of care, subjective decision-making, compared to objective criteria, led to a potential excess use of IVT in over 30% of cases.
Abstract WP146: Racial Differences in Percutaneous Endoscopic Gastrostomy (PEG) Placement in Post-Stroke Dysphagia
Authors: Krekeler Brittany , Ding Lili , Haverbusch Mary , Ferioli Simona , David Robinson , Stanton Robert , Aziz Yasmin , Laporta Joseph , Wechsler Paul , Menzies Lauren , Wright Shea , Nobel Lisa , Slavin Sabreena , Walsh Kyle , DeLosRiosLaRosa Felipe , Stamm Brian , Mackey Jason , Mistry Eva , Demel Stacie , Coleman Elisheva , Jasne Adam , Star Michael , Martini Sharyl , Adeoye Opeolu , Flaherty Matthew , Woo Daniel , Kleindorfer Dawn , Kissela Brett
Published: January 2025

Background:
Prior literature has reported patterns of racial differences in percutaneous endoscopic gastrostomy (PEG) placement for patients with post-stroke dysphagia. Reasons for this disproportion are not well understood, but critical for clinical decision making. Long-term implications for PEG placement are considerable, given complication rates and that reducing oral intake can significantly impact recovery of swallow function. In this population-based study, we evaluated the influence of patient-related factors and stroke characteristics on PEG placement.

Methods:
All patients, 18 years or older, hospitalized with either ischemic or hemorrhagic stroke in Greater Cincinnati in 2010, 2015, and 2020 were considered for this study. Patients who died within 3 days or transferred to hospice care were not included. Demographics and clinical characteristics of Black and White individuals were compared. Multivariable logistic regression was then used to examine the association between Black race and PEG placement after adjustment for potential confounders. Univariable and multivariable logistic regression analysis (dependent = PEG) was used to determine influential factors for PEG placement. Patient and stroke characteristics between Black and Non-Black patients were compared using Chi-square tests, two-sample t-tests, or Wilcoxon rank-sum tests.

Results:
The final sample included 2315 cases, of whom 28.2% were Black (653/2315) and 54.1% were women (1254/2315). Black individuals with stroke were younger (p<0.0001), more likely to have a prior stroke (p=0.0003), had more severe strokes based upon NIHSS (p<.0001), were less likely to be treated at an academic center (p<0.0001), and were more likely to have a PEG placed (p>0.0001).Multivariable analysis revealed that Black race remained associated with PEG placement even after adjustment for potential confounders (aOR 1.47, 95% CI 1.15-1.87).

Discussion:
Black stroke patients are more likely to receive PEG, even after adjustment for potential confounders. Additional analyses are underway looking at potential influence of socioeconomic characteristics, patient comorbidities, and lesion location. Given the importance of clinical decision making for alternative access to nutrition and hydration, with the goal of recovery of swallowing function, future studies should examine influence of patient-specific factors including health literacy, familial support, and cultural/patient preferences.
Abstract WP148: Assessment of the modified Rankin Scale in Electronic Health Records with Deep Learning
Authors: Milani Marcus , Silva Luis , Bindra Sohum , Kumar Kompal , Jagtap Pramit , Chakravarthula Nitin Ramanujam , Ergen Halil , Frederickson Kaylee , Datta Abhigyan , Tessmer Megan , Cooper Dawson , Guo Yugene , Stangebye Alex , Valcinord Carl-Lewis , Yeung Jeremy , Lakshminarayan Kamakshi , Streib Christopher
Published: January 2025

The modified Rankin Scale (mRS) is a commonly used functional outcome assessment in stroke clinical trials and has become an essential metric for stroke research. However, the mRS is not routinely obtained in clinical practice. When necessary, the mRS can be derived retrospectively from electronic health record (EHR) documentation review, but this process is labor-intensive and subjective. Large language models, such as GPT-4, have shown promise in automating chart review for various health outcomes. We developed and tested the ability of a large language model to extract an mRS score from EHR text.

Acute ischemic stroke patients hospitalized within the M Health Fairview system between August 2020 and June 2023 had their charts reviewed at discharge and 90 days post-hospitalization. The mRS score at each clinical encounter was assessed by two independent researchers with any disagreements resolved through case discussion; a third researcher’s assessment was utilized when consensus could not be met. Additionally, each reviewer collected critical EHR text for mRS determination. Extracted EHR text and the corresponding mRS score for each encounter were used for model training and evaluation.

Two separate models were trained on the data: the first received all seven classes of the mRS, and the second received binomial mRS scores reflecting functional independence versus non-independence (mRS 0-2 vs. 3-6). Four-fold cross-validation was conducted, using accuracy and Cohen's kappa as model performance metrics. The base language model employed was Gatortron.

A total of 1616 EHR texts and mRS scores were included in the analysis. The first model—considering all seven classes of the mRS—presented with an accuracy of 74% and a Cohen's Kappa of 0.69. The highest class specific accuracy was achieved on mRS 4 determination (90%). The lowest class specific accuracy was achieved on mRS 2 determination (28%). The second model—considering only 2 classes—achieved an accuracy of 93% and Cohen's Kappa of 0.84.

Our findings demonstrate that large language models can be successfully trained to determine mRS scores through EHR text analysis. The multi-class model had the lowest class specific precision when determining an mRS score of 2, but the outstanding accuracy of the two-class model suggests that this could be improved with more training examples. Validation of our findings in different institutions is warranted to ensure model generalizability.
Abstract WP160: Poststroke Guideline Concordant Care in an Urban Safety Net Hospital
Authors: Pena Shaney , Groves Christine , Parrott Devan , Williams Linda
Published: January 2025

Introduction:
Stroke patients with lower socioeconomic status (SES) have been found to experience worse functional outcomes, but few studies have examined the association between SES and quality of poststroke care. The primary aim of this follow-up study was to evaluate the relationship between SES and the poststroke guideline score (PGS) score (Table 1). Secondary aims explored other factors related to overall poststroke quality of care.

Methods:
We reviewed the electronic medical records of individuals with acute ischemic stroke (AIS) admitted to an urban safety net hospital from July to September 2022. Individuals were given a pass/fail or ineligible for each process. The PGS, calculated per individual, was passes/total number of eligible processes with a possible score of 0 – 1.0. Unknowns were coded as failures as this approach is more likely to reflect actual missed opportunities for care in this population.

Results:
47 individuals with AIS were eligible for PGS assessment. Mean PGS score was 0.554 (SD 0.245, range 0.111-1.000). Using the independent sample t-test we found no significant difference in PGS based on the presence of financial strain. Individuals with private insurance had a mean PGS of 0.954, compared to those without with a mean PGS of 0.526 (t = 10.30, p < 0.001), however, only three individuals among our cohort had private insurance. Females had significantly higher PGS scores compared to males (t = 4.08, p <.001), see Figure 1.

Conclusion:
In our study we found no significant difference in PGS based on the presence of financial strain, but we did identify a possible difference in score based on payor type. Females also scored significantly higher than males. We plan to qualitatively explore the poststroke care experience among this patient population as well as providers to identify barriers/facilitators to care and potential interventions to improve poststroke care among this patient population.
Abstract WP172: Invariant Pupil Reactivity (PuRe) Score: Robust Smartphone-based Pupillometry for Critical Care Across Lighting, Measurement Conditions, and Hardware Variations
Authors: Chrapkiewicz Radek , Wlodarski Michal , Chrost Hugo , Manohar Sanjay
Published: January 2025

Smartphone-based pupillometry offers potential for widespread neurological monitoring in critical care, including for stroke patients in both hospital and post-hospital rehabilitation settings. However, varying measurement conditions, operator-dependent differences, and device models affect result reliability [1]. We developed an AI-powered app with an invariant Pupil Reactivity (PuRe) score to enable standardized quantitative pupillometry across diverse settings, addressing the need for consistent neurological monitoring by different healthcare providers under varying conditions [2, 3].

We conducted two studies to validate PuRe score stability. At Nicolaus Copernicus University (Ethics ref: KB42712021), we collected 309 recordings under various lighting conditions (5-11,800 lux). Additionally, we performed 300 measurements on 2 volunteers using three iPhone models (SE2, 13, 15Pro) at phone-face distances of 50-210 mm in dim lighting (275-350 lux). We developed adaptive algorithms to recognize the scene, adjust flash intensity, and provide real-time guidance for positioning. We compared measurements using fixed vs. adaptive settings.

The lighting study showed no significant correlation between pupil reactivity and illumination (Pearson's r=0.064, p=0.26). In the hardware/distance study, a linear mixed effects model showed that adaptive settings significantly reduced parameter dependence on distance: constriction amplitude (F(1,198)=9.27, p=0.0026), ratio (F(1,198)=11.02, p=0.0011), and PuRe score (F(1,198)=10.15, p=0.0017). Without adaptive settings, parameters varied significantly with distance (p<0.001), while adaptive settings eliminated these effects (p>0.5) with no significant device-related differences (F(2,99)=1.47, p=0.235).

The AI-powered pupillometer app with the invariant PuRe score shows consistent performance across varied lighting, distances, and phone models. This reliability enables effective pupillary assessment in diverse critical care and rehabilitation settings, promoting adoption for standardized neurological monitoring. The system's adaptability supports centralized health record data collection and consistent evaluation across care environments, regardless of measurement conditions or device models.

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