bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WMP99: A Novel Network Analysis of County- and Individual-Level Factors Associated With Functional Outcomes After Stroke
Authors: Jones Andrea A , Zhou Lily W , Rutherford Alexander R , Panenka William J , Honer William G , Smith Eric E , Field Thalia S
Published: February 2024

Background:
Social circumstances may contribute to health disparities in patients with stroke through indirect and interdependent mechanisms that are not well understood.

Objective:
This study used complexity science methodology to examine the interplay between county- and individual-level social and clinical factors influencing stroke functional outcomes.

Methods:
As part of the Get With the Guidelines-Stroke (GWTG-S) Data Challenge, the GWTG-S Registry was merged with county-level Institute for Health Metrics and Evaluation data. Patients diagnosed with stroke (ischemic, subarachnoid, or intracerebral hemorrhage) were included. Multilayer networks were constructed by estimating mixed graphical models of 32 nodes across four layers, including social (county- and patient-level) and clinical (comorbidities and encounter) factors. Social determinant networks were estimated for patients with less favorable (ie., functional dependence or death, modified Rankin Score [mRS] 3-6) versus favorable outcomes (ie., functional independence, mRS 0-2). Network structure and node centrality were compared between mRS groups using bootstrap permutation analyses. Hub nodes were defined by betweenness centrality and facilitate effects across the network.

Results:
From 2013-2019, 990 721 (62.3%) stroke patients had mRS of 3-6 and 597 477 (37.6%) had mRS 0-2 at discharge. Compared to the mRS 0-2 group, the mRS 3-6 group’s social determinants network had greater global connectivity (p<0.001), and homelessness (p<0.001) and Black race (p<0.001) were hub nodes. Unique to the mRS 3-6 group, younger patients were more likely to identify as homeless (p=0.031), uninsured (p=0.001), and live in a county with lower per capita income (p<0.001).

Conclusions:
The effects of social determinants were significantly greater in patients with less favorable functional outcomes. Homelessness and race play critical roles in mediating the impacts of county- and individual-level social determinants on downstream disparities in stroke outcomes. Particularly among younger patients, housing, insurance status, and income may serve as a critical leverage point for county-level interventions to improve function after stroke.
Abstract WP103: The Role of Social Determinants in Aphasia Outcomes
Authors: Jacobs Molly , Evans Elizabeth , Ellis Charles
Published: February 2024

Introduction:
Aphasia is a post-stroke communication disorder that negatively impacts quality of life and life satisfaction even in its mildest form. Traditionally predictors of aphasia outcomes have emphasized neurological factors and little is known about the role that the social, cultural, environmental, and economic determinants of aphasia outcomes.

Hypothesis:
We hypothesize that non-neurological social factors (social determinants) are linked to post-stroke aphasia outcomes in a large, diverse population of individuals with aphasia.

Methods:
Merged data from the AphasiaBank—a large database designed to explore aphasia outcomes using data collected from aphasia studies based on standardized protocols were matched with data from the National Health Interview Survey (NHIS) based on range of sociodemographic and clinical outcomes to create an integrated dataset to examine the association between social determinants and aphasia outcomes. Generalized log-linear regression models were utilized to examine the association between scores on the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R AQ) and sociodemographic, economic, and environmental characteristics. Regression models accounted for geographic clustering of respondents and the stratification of data collection to ensure the robustness of estimates.

Results:
Blacks had 6.1% (SE=0.009) lower WAB-AQ scores compared to Whites as did those who were married (β-0.030, SE=0.004) and living in the Southern US (β=-0.013, SE=0.003) even after controlling forage, environment, and aphasia type. Individuals with aphasia and living in larger families (β=0.031,SE=0.004) and those who visited their medical provider regularly (β=0.051, SE=0.002) had higher scores compared to the reference group. Income-to-poverty ratio and home ownership were significantly correlated with impairment level. The analysis indicated that having available transportation did not influence observed outcomes. Finally racial disparities did not persist at the highest income levels.

Conclusion:
The findings of this study suggest researcher should look beyond neurologic correlates when exploring aphasia outcomes..
Abstract WP108: Predictive Accuracy of Multivariable Models for 30-day and 1-year All Cause Readmission After Stroke Using Different Combinations of Registry, Hospital and Claims Based Data Sources
Authors: Hailat Raed , Thompson Michael P , Nickles Adrienne , Oostema J. Adam , de los Campos Gustavo , Reeves Mathew J
Published: February 2024

Introduction:
Hospital readmissions are often used as an indicator of quality of care. However, identifying patients at risk of readmission after stroke is challenging and predictive models have historically not performed well, in part because they often rely on single data sources. Data linkage might offer a solution.

Methods:
We probabilistically linked data from the Michigan’s Get With The Guidelines Stroke registry and Michigan Value Collaborative multipayer claims database from Medicare and Blue Cross Blue Shield beneficiaries discharged alive following acute stroke (ICD-10 I61-I63) between 2016-2020. The registry dataset included 64 variables covering demographics, stroke presentation, medical history, procedures, and complications. The hospital dataset included 20 variables from the American Hospital Association’s database. The claims dataset included payer and 79 HCC comorbidity codes. Using combinations of the 3 data sources, we examined the performance of multivariable LASSO logistic regression models to predict all cause readmission at 30-days and 1-year post discharge. We generated hospital-specific testing and training models and reported the mean model discrimination (AUC) of all combinations of the 3 datasets.

Results:
Of 19,382 linked stroke discharges, 2,724 (14.1%) and 8,169 (42.2%) were readmitted within 30-days and 1-year, respectively. For 30-day readmission, the model based on only registry data produced the best performance (M1, Table). However, for prediction of 1-year readmission, the combination of registry and claims data produced the best performing model (M13, Table). Hospital level characteristics did not have any significant impact on prediction accuracy.

Conclusions:
Clinical registry data was the best data source for predicting 30-day readmission. However, claims based data were additive when predicting readmission within 1-year, probably because HCC codes add information about total comorbidity burden.
Abstract WP114: Texas Stroke Program Assessment: Infrastructure, Turnover, and Burnout Implications
Authors: Goff Arielle , Hussain Uzma , Bauer Jody L , Prasad Sidarrth , Olson Daiwai M , Novakovic-White Robin
Published: February 2024

Introduction:
Unlike state designation for trauma centers, there are no Texas State rules on certain infrastructure requirements for stroke designation and independent stroke center accreditation. To assess the current state of program manager impact, a Texas Stroke Program Survey was administered.

Hypothesis:
Lack of requirements results in overburdened programs, high turnover, poor mentorship, and burnout.

Methods:
Electronic survey contained program assessment with link to validated instrument (MBI-HSS), administered by Mind Garden Inc, to assess burnout, well-being, and work-related dimensions for medical personnel. Of the 181 Texas designated stroke facilities, 98% were contacted with each site having one anonymous senior program staff member complete the survey.

Results:
Survey responses were 105 among which 78 completed MBI-HSS (26% CSC, 1% TCS, 59.6% PSC, 17.3% ASRH). Respondents: 66.7% stroke coordinators, 23.8% stroke program managers/directors, and 9.5% identified as other. Majority (41%) were in current role for 1-2 yrs (19% <1 yr, 20% 3-5 yrs, 13.3% 6-9 yrs, 6.7%
>
10 yrs) and 42.9% did not consider resigning. Over 5 yr period, 49.5% reported 2 or more turnovers of their position (none 26.7%, once 21.9%, twice 20%, > twice 29.5%, new role 1.9%). Majority (57.1%) reported serving more than one major role at facility. Reported 67.3% had dedicated stroke coordinators and 49% data collectors. Only 53.3% reported adequate resources and 15.2% felt program was priority with sufficient hospital support. Role on-boarding was reported by 16.2% and 61.9% reported no mentorship. MBI-HSS revealed 74.4% had burnout profile of ineffective, overextended, or burnout.

Conclusion:
Survey demonstrates variability in infrastructure, reduced support and mentorship, high rates of turnover and burnout in Texas stroke programs. Nearly all respondents (91.4%) felt requirements for infrastructure and support for stroke program development and growth were needed.
Abstract WP116: Plaque Features and Infarct Pattern in Ischemic Stroke With Bilateral Carotid Artery Atherosclerosis
Authors: Song Xiaowei , Wu Jian , Zhang Siyuan , Zhao Xihai , Xu Yilan , Pengmao Zhuoma
Published: February 2024

Objective:
to compare the carotid artery plaque characteristics between ipsilateral and contralateral infarct in ischemic stroke with bilateral carotid artery atherosclerosis, and explore the association between plaque characteristics and infarct pattern.

Methods:
a total of 186 ischemic stroke patients with bilateral carotid artery atherosclerosis were included, carotid artery plaque burden (the degree of stenosis, maximum wall thickness, lumen area, wall area, normalized wall index (NWI=wall area/[lumen area+ wall area]), and eccentricity index), and vulnerability (intraplaque hemorrhage [IPH], calcification, irregular surface, thin or ruptured fibrous cap[TRFC], and lipid-rich necrotic core[LRNC]) were obtained by MR vessel wall imaging, infarct pattern was divided as single and multiple/recurrent infarcts in infarct ipsilateral carotid artery. Ipsilateral and contralateral carotid artery plaque features were compared, then the carotid artery plaque characteristics on the infarct side were correlated with the infarct pattern.

Results:
the mean age of subjects included was 68 years old, 79.6% of them were male. Compared with contralateral carotid artery plaque, plaque burden at the ipsilateral carotid artery was much heavy, presented with a higher degree of stenosis, smaller lumen area (0.22±0.15 vs. 0.28±0.15), larger wall area (0.50±0.19 vs.0.42±0.17), and higher eccentricity index (0.67±0.13 vs. 0.58±0.23), all p values<0.05. The vulnerable plaques were also more prevalent at ipsilateral infarct, with a high percentage of IPH (47.8% vs. 19.8%), irregular surface (36.3% vs. 17.5%), TRFC (38.5% vs.12.3%), and LRNC (38.1% vs. 15.9%), all p values were <0.05. After adjusting for covariates, the degree of stenosis (OR=1.590, 95% CI 1.048-2.410) and LRNC (OR=0.259, 95% CI 0.087-0.769) were associated with multiple or recurrent infarcts independently.

Conclusion:
in ischemic stroke with bilateral carotid atherosclerosis, the atherosclerotic plaque burden at ipsilateral infarct was much heavier and more vulnerable. Both lumen stenosis and plaque components were correlated with multiple or recurrent infarcts in this population.
Abstract WP122: Statins May Increase White Matter Hyperintensity Burden in Older Adults: A Systematic Review and Meta-Analysis
Authors: Goldstein Eric D , Chahien Dalia , Muppa Jayachandra , Shu Liqi , Tanzer J. R , Yaghi Shadi
Published: February 2024

Introduction:
White matter hyperintensities (WMH) are a hallmark radiographic finding of cerebral microangiopathy. Longitudinal studies have shown varying effects of statins on accrual of WMH over time. We aimed to understand the impact of statins on WMH volume over time through a systematic review and meta-analysis.

Methods:
We performed a systematic review using standard search and risk of bias assessment practices. We included statin-exposed and statin-naive adults with longitudinal brain MRIs with computer-generated WMH volumetric analyses. The primary outcome was change in WMH volume (mL). Allowing for curvilinear change, a mixed-effects model was applied to capture the dynamic change over time. Model forecasts were used to visualize results, comparing changes over time among younger cohorts (60 years) and older cohorts (75 years) based on the the cohort mean age standard deviation. A
p
value ≤ 0.05 was considered significant.

Results:
We identified 6 studies enrolling 1911 participants from China, Europe, and North America (2 studies each); mean age 67.5 (± 7.5). The maximal study duration was 60-months. All studies had a least some degree of bias. Control groups had steady increase in WMH volume over time, Figures. The younger statin-exposed cohort developed statistically less WMH after 40 months of use. Older statin exposed patients had an increase in WMH volume compared with naïve patients which remained over the study duration.

Conclusion:
The impact of statins on WMH volume may be age dependent whereby older patients may have an accelerated accumulation. Further studies are warranted to confirm this data and investigate underlying mechanisms leading to this finding.
Abstract WP123: Accuracy of Cisternal Score in Predicting Cerebral Vasospasm Risk in Aneurysmal Subarachnoid Hemorrhage: A Post Hoc Analysis of a Single Center Study
Authors: Moody Scott A , Haripottawekul Ariyaporn , Potter Nicholas S , Stretz Christoph , Furie Karen L , Mahta Ali
Published: February 2024

Background:
Cisternal score (CISCO), which is calculated based on quantification of blood clot in basal cisterns, has been shown to have good accuracy in predicting ventriculoperitoneal shunt requirement in patients with aneurysmal subarachnoid hemorrhage (aSAH). We hypothesized that CISCO is superior to modified Fisher score (mFS) in predicting vasospasm, a common complication associated with worse outcomes in aSAH, as it better quantifies blood clot burden in the basal cisterns.

Design/Methods:
We performed a post hoc analysis of a retrospective study of a cohort of consecutive patients with aSAH admitted to an academic center from 2016 through 2021. Data was collected prospectively as part of a quality improvement project. Cerebral vasospasm was defined based on transcranial Doppler criteria. CISCO, as previously described, was constructed based on quantification of blood clot thickness in the basal cisterns (interpeduncular, ambient, crural, prepontine, interhemispheric cisterns, and bilateral Sylvian fissures) on admission head CT scans. Receiver operating characteristics (ROC) curve analysis was performed to compare accuracy of CISCO with mFS in predicting vasospasm.

Results:
We included 176 patients with aSAH who had radiographic assessments with complete clinical data. Mean age was 54.9 years [SD 12.8] and 57% were female. Cerebral vasospasm was observed in 30% of patients. CISCO ranged from 0 to 10 with a median of 3 [IQR 1-5]. Higher CISCO was associated with higher risk of vasospasm (odds ratio 1.29 per point increase, 95% CI 1.17-1.49; p=0.001). ROC curve analysis revealed that CISCO had higher accuracy in predicting vasospasm compared to mFS but the difference was not significant (AUC 0.67, 95% CI 0.59-0.76 vs 0.60, 95% CI 0.52-0.68; p=0.10).

Conclusions:
CISCO has comparable accuracy with mFS score in predicting vasospasm in aSAH. Improvement in quantification methods using fully automated volumetric measurement techniques may further enhance its accuracy in predicting vasospasm in aSAH in future. Larger studies are needed to test this hypothesis and to explore the utility of using CISCO in clinical practice.
Abstract WP128: Using Clinical Data to Reclassify ESUS Patients to Either Large Artery Atherosclerotic or Cardioembolic Stroke Mechanisms
Authors: Klein Lauren R , Tirschwell David L , Hippe Daniel , Haines Brooke , Balu Niranjan , Hatsukami Thomas S , Yuan Chun , Kharaji Mona , Akoum Nazem W , Lila Eardi , Mossa-basha Mahmud
Published: February 2024

Introduction:
Defining the specific underlying pathophysiology of ischemic stroke is critical for minimizing the risk of recurrent events with personalized secondary prevention treatments. A notable portion of ischemic strokes are classified as embolic stroke of undetermined source (ESUS), leaving these patients without optimal treatment tailored to their pathophysiology.

Hypothesis:
Standard clinically collected data can reliably reclassify a substantial portion of ESUS patients into either a large artery atherosclerotic (LAA) or cardioembolic (CE) cause.

Methods:
A statistical model was developed to discriminate LAA from CE using a retrospective cohort of ischemic stroke patients treated at the University of Washington. A total of 189 patients were included (79 CE and 61 LAA to train the model, 49 ESUS patients to assess reclassification). Sixteen candidate predictors were collected across several sources: clinical risk factors, blood tests, echocardiography, ECG, and neurovascular imaging (Table 1). The LASSO (least absolute shrinkage and selection operator) was used to select important predictors in a penalized logistic regression model with stroke etiology (LAA vs. CE) as the outcome. ESUS patients were considered reclassified if the model-based probability of CE or LAA was at least 75%.

Results:
Of 189 patients, the mean (SD) age was 68 (14) years and 40% were women. The LASSO selected 12 predictors to discriminate CE vs. LAA (Table 1), with a corresponding cross-validated C-statistic = 0.87 (95% CI: 0.82-0.94). When the model was applied to the 49 ESUS patients, 23 (47%) were reclassified to LAA and 6 (12%) to CE.

Conclusions:
A multivariate model based on standard clinical data can separate LAA from CE with a high degree of discrimination. Applying this model led to reclassification to either LAA or CE in 59% of ESUS patients. Such approaches may enable more personalized secondary prevention strategies, but need to be tested in future trials.
Abstract WP13: Derivation and Validation of Utility Weights for the Modified Rankin Scale From the AcT Thrombolysis Trial
Authors: Okikiolu Ayooluwanimi , Arimoro Olayinka , Singh Nishita , Bala Fouzi , Ademola Ayoola , Almekhlafi Mohammed A , Ganesh Aravind , Buck Brian H , Swartz Richard H , Hill Michael D , Menon Bijoy K , Sajobi Tolulope
Published: February 2024

Introduction:
Utility-weighted mRS (UW-mRS) is increasingly being adopted as an important clinical endpoint in stroke trials as it offers some gains in statistical efficiency and power when estimating treatment effects. The widely used utility weights for estimating UW-mRS, derived from a systematic review of acute stroke trials, are prone to substantial variability across and between mRS categories. This study aims to derive utility weights for UW-mRS by directly mapping 5-item EuroQoL (EQ-5D-5L) responses to mRS scores.

Methods:
Data were collected from all patients included in Alteplase compared to Tenecteplase (AcT) trial. Quality of life at 90 days post-randomization was assessed using EQ-5D-5L. Health utilities (EQ-5D index) were estimated using the time trade-off approach based on Canadian norms and imputed as zero for patients who died. Using a predictive linear model, utility weights were derived by regressing the ordinal mRS on the utilities. Model performance was measured using R
2
and root mean square error (RMSE) after 5-fold cross-validation. We compared the distribution of the UW-mRS scores using the systematic review and model-based weights.

Results:
Of the 1503 acute stroke patients who completed the EQ-5D-5L questionnaire at 90 days, 717 (47.7%) were female, and the median (interquartile range [IQR]) age was 74.0 (20.0). The median (IQR) estimated health utility was 0.81 (0.52). The utility weights for mRS categories 0-6 were 0.93, 0.90, 0.80, 0.67, 0.41, 0.24, and 0.00. The model performed well after 5-fold cross-validation (R
2
= 0.89; RMSE = 0.12). The model-based weights had higher mean and median UW-mRS scores but smaller variability across mRS levels than those from the systematic review-based weights. There was no statistically significant difference in the median UW-mRS scores across both treatment groups for each utility weight type.

Conclusion:
The estimation of UW-mRS scores largely depends on the choice of weights used, which depends on sample heterogeneity in treatment interventions and stroke severity of the cohorts. Model-based approaches result in reduced variability between and across mRS levels. Future research will seek to validate these utility weights externally in an independent cohort of patients with stroke.
Abstract WP132: The Significance of Fluid-Attenuated Inversion Recovery Vascular Hyperintensity in Combination With Occlusion Site and Reperfusion Status by Mechanical Thrombectomy for Proximal and Distal Middle Cerebral Artery Occlusion
Authors: Maruyama Daisuke , Nanto Masataka , Murakami Nobukuni , Nagakane Yoshinari , Nakata Mitsuko , Hashimoto Naoya
Published: February 2024

Introduction:
In patients with acute ischemic stroke, FLAIR vascular hyperintensity (FVH) is a reliable indicator of large vessel occlusion and salvageable tissue requiring mechanical thrombectomy (MT). However, its significance in distal arterial occlusion has not been established. This study aimed to investigate the significance of FVH in DWI-negative areas, in combination with occlusion site and reperfusion status, by MT for regional tissue outcomes in proximal and distal middle cerebral artery (MCA) occlusion.

Methods:
The clinical records of patients admitted to a single institute between April 2017 and June 2022, who presented with MCA occlusion with initial NIHSS ≥ 5 and underwent MT within 24 h of onset were retrospectively analyzed. Proximal occlusion was defined as M1 segment occlusion, and distal occlusion as M2 or M3 segment based on initial MRA. Each cortical MCA area in Alberta Stroke Program Early CT Score (ASPECTS) ipsilateral to the occluded vessel was categorized into group A (DWI-, FVH-) or B (DWI-, FVH+) based on initial MRI. Regional collateral status on initial angiogram, expanded Thrombolysis in Cerebral Infarction (eTICI) grade on final angiogram, and regional unfavorable tissue outcome with the appearance of low or high density on CT 24 h after MT were recorded. Univariate and multivariate analyses using mixed-effects models for regional unfavorable tissue outcome were performed.

Results:
A total of 103 patients (56 with proximal and 47 with distal occlusion) were included. Categorizing cortical areas resulted in 256 areas in group A and 171 in group B. The rate of unfavorable tissue outcome in order of eTICI 0-2a, 2b50-67, and 2c-3 reperfusion status in group A were 14.3%, 11.3%, and 6.0%, respectively (p=0.06) while those in group B were 47.1%, 34.0%, and 12.9%, respectively (p<0.01). In multivariate analysis, eTICI 0-2b67 vs. eTICI 2c-3 in group B of distal occlusion was an independent predictor for unfavorable regional tissue outcome (OR 7.8, 95% CI 1.1-55.6, p=0.04), along with ASPECTS M2 or M5 and poor angiographical collaterals.

Conclusions:
FVH in DWI-negative areas can reveal penumbra tissue secondary to both proximal and distal MCA occlusions. However, salvage requires fairly reliable reperfusion in distal occlusion.
Abstract WP14: Photobiomodulation Treatment Enhancesand Sustains Neurogenesis Following Acute Ischemic Stroke
Authors: Zong Xuemei , Feng Yu , Huang Zhihai , Ma Xiaohui , Zhang Quanguang
Published: February 2024

Rationale:
Previous work has indicated that photobiomodulation (PBM), may provide neuroprotection and improve neurological function after acute ischemic stroke. However, the underlying mechanism remains unclear. The present study was performed to examine whether PBM, a noninvasive neurostimulation technique, promotes neurogenesis in a middle cerebral artery occlusion (MCAO) stroke rat model.

Methods:
Beginning 6 h after MCAO, once-daily 2-min PBM treatments(808 nm) were applied to the infarcted hemisphere for 7 consecutive days. Samples were collected 7 days and 14 days after MCAO stroke. Fluorescent labeling, Western blotting, and behavioral tests were performed accordingly.

Results:
We found that PBM-treated animals displayed improved motor and sensory functions. PBM treatment significantly expanded the pool of neural progenitor cell (NPC) and newly generated immature neurons in the cortical peri-infarct region after acute ischemic stroke. Application of PBM strikingly diminished the MCAO-induced loss of NPCs and newly-formed neurons. In addition, the amount of newly generated mature neurons in the peri-infarct zone was significantly promoted by PBM treatment. Intriguingly, PBM reduced reactive gliogenesis significantly while promoting oligodendrogenesis and preserving myelination. Mechanistic studies uncovered that PBM enhances the expression of brain-derived neurotrophic factor (BDNF) and initiates the activation of the BDNF/TrkB signaling pathway.

Conclusions:
Our findings indicate that PBM promotes neurogenesis and functional recovery through stimulating NPC proliferation, reducing NPC and immature neuron cell death, and tamping excessive gliogenesis. These effects were due, in part, to the upregulated release of trophic factors. These findings support PBM as an effective neuroregenerative treatment for acute ischemic stroke.
Keywords:
Ischemic stroke, Photobiomodulation (PBM), Neurogenesis, Functional recovery, Neurotrophic factors
Abstract WP147: Utilization of Rapid Response Nurses to Improve In-Hospital Stroke Response
Authors: Kelly Suzanne , French Mindy , Fields Jeremy , Campbell Rebecca , Calarco Andrea , Jones Andy , Santoro Michell
Published: February 2024

Introduction:
In-hospital strokes are estimated to account for 2-17% of all strokes. These patients typically have higher mortality, longer length of stay, and higher disability rates than strokes that initiate within the community. In addition, in-hospital strokes often result in delayed symptom recognition and slower coordination of stroke team response. To address this, Rapid Response Team (RRT) nurses have been empowered to lead the Inpatient Stroke Alert process to improve response time.

Methods:
Beginning in 2016, stroke program leadership in conjunction with frontline RRT nurses worked together to improve the Inpatient Stroke Alert response. A standardized Inpatient Stroke Alert pathway was created and simulated that included empowering RRT nurses to initiate stroke alerts. Quality drilldown emails of each patient receiving thrombolytics began to be sent to frontline teams including RRT to debrief each event. In 2017, a neurohospitalist team and overnight tele-stroke capability was introduced to work alongside the RRT nurse to quickly assess and provide direction on care. Finally, in 2020, a streamlined RRT stroke alert order set was introduced along with an updated nurse-specific stroke alert badge buddy. RRT nurses were integral to these efforts as a small but highly skilled and unassigned team dedicated to response to all critical events within the hospital.

Results:
Every in-hospital (n=38) and ED stroke alert patient (n=377) that received thrombolytics from 2016 to June 2023 was included in the data. Mean discovery-to-thrombolytic times for in-hospital stroke patients in 2016 was 116.7 minutes (n=3) compared to 71.7 minutes (n=35) for ED stroke alerts. As of June 2023, mean discovery-to-thrombolytic times for in-hospital stroke patients have steadily improved to 52.8 minutes (n=6; vs. ED 38.7 minutes, n=57) in 2022 and 45 minutes (n=1; vs. ED 34.3 minutes, n=47) in 2023. This resulted in an improvement of greater than 60% in discovery-to-thrombolytic times.

Conclusions:
Development of a nurse-led in-hospital stroke alert process utilizing the RRT nurses has led to vast improvement in discovery-to-thrombolytic times.
Abstract WP151: Prevailing Income-Based Disparities in Acute Ischemic Stroke and Cardiovascular Events in Young Hospitalized Adults With Cannabis Use Disorder: Insights From a Population-Based Analysis
Authors: Mohammed Adil S , Manne Suvidha , Ahmed Hafeezuddin , Polamarasetty Harshavardhan , Siddiqui Muneeb , Vanukuru Sravya Gayatri , Devarala Bhagya Lakshmi , Kohli Muskan , Ganampet Narendranath Reddy , Arastu Azeem , Jayaprakash Sanmayi , Singh Sandeep , Desai Rupak
Published: February 2024

Introduction:
Cannabis use and low socioeconomic status are recognized as distinct risk factors for stroke and cardiovascular pathologies. This observational study aims to investigate the association between income status in acute ischemic stroke (AIS) and cardiovascular events among young, hospitalized adults with dependent cannabis use or cannabis use disorder (CUD).

Methods:
We analyzed young adult hospitalizations (18-44 years) with known CUD from the 2020 National Inpatient Sample. Propensity score-matched analysis (1:1) was used to compare comorbidities, including AIS and cardiovascular events, between the high-income quartile (HIQ) and low-income quartile (LIQ) within the CUD cohort.

Results:
Out of the young adult admissions, a total of 286,855 individuals were identified as dependent cannabis users. After propensity matching, we divided the CUD cohort into 63,355 patients with HIQ (41.1% female) and LIQ (41.4% female). While both cohorts exhibited comparable ages and racial distribution (>65% white), the individuals from LIQ cohort were predominantly from South (45.7% vs. 27.9%), visiting rural hospitals (13.9% vs. 1.3%), with Medicaid (56.3% vs. 41.1%) as the predominant payer. Additionally, LIQ cohort had a higher prevalence of drug abuse (65.5% vs. 58.4%), tobacco use (24.9% vs. 22.6%), HTN (17% vs. 14.7%), chronic pulmonary disease (13.2% vs. 12.7%), DM (8% vs. 6.6%), and obesity (10.9% vs. 10.0%). Additionally, in-hospital outcomes like AIS (0.5% vs. 0.3%) and MACCE (2% vs. 0.8%) were higher in the LIQ cohort. After adjusting for confounding factors, the risk of AIS in the HIQ cohort was 37% lower than in the LIQ cohort (OR: 0.63 [95% CI: 0.42-0.96]). (all-p<0.05).

Conclusion:
Higher prevalence of CVD risk factors in the LIQ-CUD group and lower odds of AIS-related admissions in the HIQ-CUD group warrant targeted interventions and policy measures to understand and address behavioral risk of cannabis use by economic status and disparities in MACCE.
Abstract WP157: Withdrawing and Withholding of Life Sustaining Treatment After Stroke: Understanding the Content of Discussion With Families & Review of Symptoms at End of Life
Authors: Romba Meghan , Khan Sumayyah , Willert Anna-Christin , Creutzfeldt Claire J
Published: February 2024

Background:
Stroke kills 160,000 patients every year in the US. Most patients who die with stroke do so in hospital. Little is known about the acute dying process or experience of patients with stroke and their families.

Objectives:
The goal of this quality improvement project is to better understand the end-of-life process in patients dying with stroke at our institution, focusing on patients who were awake at end of life.

Methods:
Of patients admitted to our academic medical center in 2022 with stroke who died, we collected basic characteristics and information about reasoning behind WLST and the patient’s condition immediately after WLST. Among those who showed signs of wakefulness (tracking examiner or better), we searched the chart for any documentation of broadly defined goals of care conversations and patient or family symptoms assessed at end of life.

Results:
Of 525 patients, 118 patients (22.5%) died in hospital. Basic characteristics are listed in Table 1. WLST occurred in 99 patients (84% of decedents), of whom 33 (27.8%) showed signs of wakefulness at time of WLST. None of the patients participated in conversations, and a documented advance directive was followed in 5 (15%). After WLST, patient symptoms most frequently documented by clinicians included dyspnea (n=29), pain (n=18), and restlessness (n=12), but no non-physical symptoms (see Table 2). Family symptoms were not documented.

Discussion:
At least one quarter of hospital decedents after stroke showed signs of wakefulness, with patient-centered symptoms rarely documented. A standardized, systematic symptom assessment is needed to truly understand signs and symptoms during end-of life for patients with stroke.
Abstract WP160: Mechanisms of Brain Hemorrhage in Chronic Kidney Disease
Authors: Chang Peter D , Tang Cynthia Crystal , Paganini-Hill Annlia , Lau Wei Ling , Fisher Mark
Published: February 2024

Introduction:
Chronic kidney disease (CKD) is a risk factor for intracerebral hemorrhage (ICH) and for worse outcomes following ICH. In this study, we examined the relationship between ICH and CKD, as well as intracranial arterial calcification (IAC) as an intermediate biomarker. We hypothesized that CKD is an independent risk factor for IAC burden, and that high IAC burden is an independent risk factor for ICH.

Methods:
A retrospective cohort of spontaneous ICH and non-ICH patients with non-contrast head CT imaging was identified. For each patient, eGFR (estimated glomerular filtration rate) along with age, sex, race, ethnicity, hypertension (HTN), diabetes (DM), heart disease, and hyperlipidemia were abstracted. A convolutional neural network was developed to automate quantification of IAC burden within the anterior and posterior circulation, and all results were visually verified for accuracy by an expert neuroradiologist. The relationship between eGFR and IAC was assessed with Pearson correlation and one-way ANOVA. Univariate analysis of ICH risk factors was evaluated using t-test and Chi-square, while multivariate models were analyzed using logistic regression.

Results:
Among the 717 patients in this study, 98 were ICH patients. In all patients, mean IAC burden increased significantly with CKD stage (p < 0.01). Univariate analysis for IAC risk factors yielded statistically significant associations for eGFR (p < 0.01) as well as age (p < 0.01), HTN (p = 0.01), and African-American race (p = 0.02). In multivariate analysis, eGFR remained a significant independent predictor of IAC (p < 0.01) along with HTN (p < 0.01), DM (p < 0.01), and race (p < 0.01). Furthermore, IAC burden was significantly higher in ICH patients (15.4 mL vs. 8.7 mL, p = 0.02). In multivariate analysis, IAC remained a significant independent predictor of ICH (p < 0.01) along with HTN (p < 0.01), DM (p = 0.03), sex (p < 0.01), and race (p < 0.01).

Conclusion:
This is the first demonstration that eGFR predicts strictly quantified IAC, which then predicts ICH. These findings offer novel insights into determinants of IAC and mechanisms underlying the CKD-ICH relationship.
Abstract WP17: Best Practices for Optimizing Door-to-Needle Times: Road to Target Stroke Phase III
Authors: Gannon Kimberly P , Sivapatham Thinesh , Nomura Jason T , Huisenga Douglas P , Ciechanowski Mary C , McAndrew Reina W
Published: February 2024

Introduction:
The launch of AHA’s Target: Stroke Phase III in 2019 challenged stroke centers to achieve DTN times ≤ 30 min of arrival to ≥ 50% of AIS patients treated with IV thrombolytics. At the time of Phase III launch, we were achieving the DTN ≤ 30 min goal in 43% of patients (median DTN 34 min) at our CSC (> 1300 ischemic stroke discharges/year).

Methods:
Our stroke team, in collaboration with the ED and other relevant departments, analyzed the stroke alert process and implemented incremental changes (listed below, 1 change per month to allow focus) to improve DTN times.

• Vascular neurologist (VN) arriving to ED before EMS for pre-hospital stroke alerts

• Assigning specific roles to each stroke team member

• Calling out time since arrival every 5 minutes

• Minimizing time in ED prior to CT (ie, not changing patient into gown, bypassing EKG)

• Premixing alteplase (prior to TNK transition)

• Giving IV thrombolytic in CT prior to CTA

• Implementing video stroke alerts to allow VN to have virtual presence 24/7 DTN times were collected at launch of Phase III in 2019, and after changes were implemented.

Objectives were to improve DTN times from baseline, in order to optimize care and achieve Phase III goals.

Results:
DTN times improved from a median of 34 min in FY19 to 25 min in FY21, corresponding to an increase in achievement of the Target: Stroke Phase III goal from 43% to 95% (Figure 1).

Conclusion:
By implementing collaborative and focused interventions, our CSC was able to improve and optimize the workflow of stroke patients receiving IV thrombolytics, allowing us to achieve the rigorous Target: Stroke Phase III goals and optimize patient outcomes.
Abstract WP184: Intravenous Thrombolysis Improves Outcomes in Stroke Patients With Unsuccessful Mechanical Thrombectomy
Authors: Elawady Sameh S , Nawabi Noah , Matsukawa Hidetoshi , Cunningham Conor , Sowlat Mohammad Mahdi , Orscelik Atakan , Zandpazandi Sara , Maier Ilko , Al Kasab Sami , Jabbour Pascal M , Kim Joon-Tae , Quintero Stacey C , rai ansaar , Starke Robert , Psychogios Marios , Samaniego Edgar A , Arthur Adam S , Yoshimura Shinichi , Cuellar Hugo , Howard Brian , Alawieh Ali , Romano Daniele G. , Tanweer Omar , Mascitelli Justin , Fragata Isabel , Polifka Adam , Osbun Joshua , Crosa Roberto , Matouk Charles C , Park Min S , Levitt Michael , Brinjikji Waleed , Moss Mark , Dumont Travis , Williamson Richard , Navia Pedro , Kan Peter , De Leacy Reade A , Chowdhry Shakeel A , Ezzeldin Mohamad , Spiotta Alejandro M
Published: February 2024

Introduction:
The benefits of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients with unsuccessful mechanical thrombectomy (MT) are not well established.

Methods:
This study included patients from the Stroke Thrombectomy and Aneurysm Registry (STAR) who underwent MT for ICA, M1, or M2 occlusions with unsuccessful MT (mTICI score ≤ 2a). Patients who received IVT prior to MT were compared to those who received MT alone. Propensity score (PS) matching was performed using age, sex, premorbid modified Rankin Scale (mRS), admission National Institute of Health Stroke Scale (NIHSS), occluded vessel, ASPECTS score, mTICI score, and symptom onset to groin puncture time. The primary outcome was favorable 90-day outcomes (mRS 0-2).

Results:
Of 610 patients with unsuccessful MT, 219 were matched in each group. Median ages were 70 [IQR: 61 - 80] and 73 [IQR: 62 - 81] in the IVT + MT and MT alone groups, respectively. In the IVT + MT group. Final TICI scores of 0, 1, and 2a were achieved in 92 (42.0%), 33 (15.1%), and 94 (42.9%) patients, respectively, compared to 76 (34.7%), 29 (13.2%), and 114 (52.1%) in the MT alone group. The IVT + MT group showed a significantly. higher 90-day mRS of 0-2 (aOR: 2.54, 95% CI: 1.53-4.32) and mRS of 0-3 (aOR: 2.05, 95% CI: 1.36-3.12). There were no significant differences between the groups in intracranial hemorrhage (ICH), symptomatic ICH, or 90-day mortality rates.

Conclusions:
IVT is associated with improved functional outcomes in patients with unsuccessful MT. Ensuring that IVT is provided to all eligible stroke patients should remain a priority.
Abstract WP187: Association of Renin Angiotensin Aldosterone Blockade and Hypotension After Carotid Artery Stenting
Authors: Cao Le , Zhang Xuening , Hu Fayun , Wu Bo
Published: February 2024

Background:
Persistent hypotension after carotid artery stenting (CAS) can lead to adverse outcomes, prolong length of stay (LOS), and increase hospital costs. As catecholamine plays a critical role in blood pressure (BP) regulation, we aimed to determine the relationship between the use of renin-angiotensin-aldosterone inhibitor (RASI) drugs and post-CAS hypotension.

Methods:
A multicenter prospective study of patients with extracranial internal carotid artery stenosis and history of hypertension requiring CAS at two hospitals in China between January 2020 to May 2023. BP was recorded at frequent intervals for at least 24 hours post-CAS. Blood catecholamine concentrations were assessed in the morning of, and day immediately after, CAS in a subset of patients. Persistent hypotension was defined as systolic BP <90 mmHg or requiring vasopressor treatment for at least 6 hours. Logistic regression models assessed differences in the rates of post-CAS hypotension between RASI and non-RASI patients with adjustment for known confounding variables.

Findings:
There were 329 patients included: 160 in the RASI group and 169 in the non-RASI group. The RASI group had a higher rate of persistent hypotension (relative risk 1.52, P=0.031). The RASI group showed a greater decline in norepinephrine concentration after CAS compared with the non-RASI group (P=0.008). Patients with persistent post-CAS hypotension showed a similar decline in norepinephrine concentration (P=0.004) when compared with patients without persistent hypotension. Persistent hypotension prolonged LOS (P=0.014).

Conclusion:
Prior use of RASI for the treatment of hypertension is associated with persistent hypotension after CAS. A relation between decline of norepinephrine after stenting and persistent hypotension supports the role of catecholamine in BP control.
Abstract WP199: Outcomes Following Posterior Cerebral Artery Thrombolysis vs Medical Management in those with Atrial Fibrillation
Authors: Dasgupta Savanna , Patel Karan , Jafri Neda , Shu Liqi , Koneru Manisha , Taneja Kamil , Shaikh Hamza , Tonetti Daniel , Khalife Jane , Schumacher Hermann , Thon Jesse , Nguyen Thanh , Yaghi Shadi , Siegler James E
Published: February 2024

Background:
The benefits of endovascular thrombectomy (EVT) for posterior cerebral artery (PCA) occlusion remain controversial, but intravenous thrombolysis (IVT) has proven benefit across nearly all ischemic stroke types. We isolated a cohort of patients with likely embolic PCA occlusions (those with atrial fibrillation) and compared outcomes associated with IVT and EVT versus medical management (MM).

Methods:
The National Inpatient Sample (2015-2020) was retrospectively queried for patients with a primary diagnosis of a PCA occlusion (without a concomitant basilar occlusion, BAO) with a secondary diagnosis of atrial fibrillation. Descriptive statistics and propensity score matching for IVT with multivariable logistic regression were used to determine the odds of routine discharge, hospital length of stay, and death between those treated with IVT and EVT versus MM.

Results:
Of the 107,525 screened patients with a primary diagnosis of a PCA occlusion, 27730(25.7%) had a secondary diagnosis of atrial fibrillation, of whom 3010 underwent IVT. In a 1:1 matched cohort(n=3010 per group), patients treated with IVT had greater odds of discharge to home (adjusted OR 1.87,95% CI 1.22 to 2.87) with no difference in length of hospital stay (adjusted β 0.26, 95% -0.71 to 1.22) or in-hospital death (adjusted OR 0.81, 95% CI 0.27 to 2.47) as compared to patients treated with MM. These trends were preserved in a secondary analysis of unmatched patients in multi variable regression models, and no significant benefit of EVT for these outcomes (OR 1.75, 95%CI 0.62-4.93). Patterns were also similar when patients with a concomitant BAO were included (routine discharge adjusted OR for IVT: 1.57, 95% CI:1.03-2.38).

Conclusion:
Our findings show a potential real-world benefit for IVT in patients with a PCA occlusion secondary to presumed cardio embolism, but no significant advantage with EVT.
Abstract WP20: Hemorrhagic Conversion Patterns After Stroke Thrombolysis With Alteplase versus Tenecteplase Real-World Experience
Authors: Hill Courtney , Ezzeldin Rime , Percenti Eryn , Kerro Ali , Delora Adam , Santos Juan , Saei Hamzah , Greco Lisa , Elghanem Mohammad , Alderazi Yazan J , Kim Yana , Poitevint Cathleen M , Mir Osman , Ezzeldin Mohamad
Published: February 2024

Importance:
Tenecteplase use is more prevalent as the thrombolytic drug of choice for acute ischemic stroke, with results demonstrating its non-inferiority compared to alteplase. However, there is conflicting data regarding intracranial hemorrhage risk.

Objective:
To determine the rate of symptomatic intracranial hemorrhage in ischemic stroke patients after thrombolysis with either tenecteplase or alteplase.

Design:
Retrospective cohort study.
Setting:
15 Texas stroke centers.

Participants:
431 patients that were eligible for thrombolytic therapy, and received either tenecteplase or alteplase.

Exposure:
Data was collected 90 days before and after the stroke center changed from alteplase to tenecteplase.
Main Outcomes:
Primary endpoint was to compare the incidence of sICH according to SITS-MOST/ECASS-3 criteria in the alteplase and tenecteplase groups. Secondary endpoint included the radiographic pattern of hemorrhagic conversion according to the Heidelberg bleeding classification (HBC).

Results:
Median age was 62.94 for alteplase and 64.45 for tenecteplase, females represented half of each cohort:110 for alteplase and 117 for tenecteplase. Half of patients received alteplase (n=216), 174 (81%) received alteplase within 3 hours versus 176 (82%) for tenecteplase. Endovascular thrombectomy was attempted in 34 patients (15%) receiving alteplase versus 26 patients (12%) receiving tenecteplase. 7 patients in the alteplase group (3.2%) and 14 (6.5%) in the tenecteplase group had sICH, with an odds ratio of 1.44 (95% CI 0.60-3.43; P=0.41). A higher NIHSS score on arrival (1.06; 95% CI 1.0004-1.131; P=0.04) was a statistically significant predictor of sICH. A two-sample proportion test on tenecteplase produced a statistically significant increase in HBC class 3 (P=0.040) over alteplase.

Conclusions and Relevance:
An increased rate of sICH was observed with a statistically significant increase in HBC class 3 with tenecteplase administration compared to alteplase. Suggested mechanisms of bleeding are hemorrhagic conversion in clinically silent infarcts and contusions underlying the lesions. This suggests a potential need to reevaluate the criteria for tenecteplase administration. Larger studies are required to confirm this data.