bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 39: Slow-Flow in the Left Atrial Appendage on Cardiac CT in Patients With Acute Ischemic Stroke
Authors: Nio Shan Sui , Rinkel Leon A , Cramer Olivia N , Özata Z. B , Beemsterboer Chiel , Guglielmi Valeria , Bouma Berto , Boekholdt S , Lobé Nick H , Beenen Ludo , Marquering Henk , Majoie Charles B , Roos Yvo , van Randen Adrienne , Planken R. Nils , Coutinho Jonathan M
Published: February 2024

Background:
Slow-flow in the left atrial appendage (LAA) is thought to be associated with an increased risk of thrombus formation and stroke. We studied LAA slow-flow on cardiac CT in patients with acute ischemic stroke (AIS).

Method:
We used data from Mind the Heart, a prospective cohort study of AIS patients who underwent ECG-gated cardiac CT during the acute imaging protocol. We compared baseline characteristics, functional outcome (modified Rankin scale), stroke recurrence and major adverse cardiovascular events (MACE) after 2-year follow-up between patients with LAA thrombus (filling defect <100 Hounsfield Unit [HU]), slow-flow (filling defect, but with ≥100 HU) and normal filling. We performed a sensitivity analysis restricted to cryptogenic stroke patients.

Results:
Of 421 patients, 31 (7%) were classified as LAA thrombus, 69 (16%) as LAA slow-flow and 321 (76%) as normal LAA filling. Patients with LAA thrombus or slow-flow more often had atrial fibrillation compared to normal filling (45%, 39%, 9%, p<0.001, respectively). LAA thrombus patients had more severe strokes compared to slow-flow and normal filling (NIHSS 18 [IQR: 9-22], 6 [IQR: 3-17], 5 [IQR: 2-11], p<0.001). There was no significant difference between LAA slow-flow patients and normal LAA filling in functional outcome (acOR: 0.8, 95%CI 0.5-1.4), recurrent ischemic stroke (aHR 0.8, 95%CI: 0.3-1.9) or MACE (aHR 1.2, 95%CI 0.7-2.1). In cryptogenic stroke patients (n=156), LAA slow-flow was associated with a higher risk of recurrent stroke (aHR: 4.1, 95%CI: 1.1-15.7) compared to normal LAA filling (Figure 1).

Conclusion:
Patients with LAA slow-flow had similar characteristics compared to patients with a thrombus, including high rates of atrial fibrillation, but had less severe strokes. Compared to patients with normal filling, LAA slow-flow was not significantly associated with worse functional outcome or MACE, but was associated with recurrent stroke in patients with cryptogenic stroke.
Abstract 4: Unveiling the Economic Burden of Stroke in the European Union: Comparisons With the USA
Authors: Luengo-Fernandez Ramon , Walli-Attaei Marjan , Leal Jose
Published: February 2024

Introduction:
Stroke places a significant economic impact on health and social care systems, as well as indirect costs through premature retirement, and absenteeism, reducing productivity and economic output, and necessitating care for patients from friends and family. This study aims to provide novel and up- to-date evidence on the economic burden of stroke across 27 EU countries allowing to draw comparisons with the USA.

Methods:
Stroke-related costs were estimated for 27 EU countries in 2021. Country-specific resource use was estimated using aggregate data on morbidity, mortality, health, social and informal care, apportioned to stroke using patient-level data based on responses from 140,000 participants. Resource use was valued using country-specific unit costs. To allow for meaningful comparisons with the 2018 American Heart Association (AHA) estimates of stroke costs in the USA, costs are reported in US $ adjusted for price differentials and inflation.

Results:
In 2021, excluding long-term care costs as not included in AHA estimates, stroke cost the EU health care systems $39 billion (2% of health expenditure). Within this total, there was wide variation in per-capita healthcare costs (ranging from $30 in Malta to $177 in Austria), with that for the EU being $87. In the USA, comparable stroke-related healthcare costs accounted for 2% ($35 billion) of US health expenditure, and $108 per capita (comparable to Belgium - $103). In the EU-27, productivity losses due to early mortality were estimated at $8 billion ($19 per capita), compared to $21 billion in the USA ($65 per capita). Long-term nursing home care costs were є21 billion in the EU-27, driving the proportion of total healthcare expenditure due to stroke to 3%. Unpaid care for stroke patients accounted for $38 billion in the EU-27, with absence from work costing the EU economy an additional $4 billion. The total costs of stroke for the EU-27 were $110 billion.

Conclusions:
This study provides contemporary estimates of the wide-ranging impact of stroke on all aspects of 27 European countries’ economies, allowing for meaningful comparisons with the USA. The data help inform evidence based polices to reduce the impact of stroke, promoting care access and better health outcomes and economic sustainability.
Abstract 40: Relationship of Collateral Status With Clinical Outcomes in Endovascular Thrombectomy for Large Core Stroke:
A SELECT2 Subanalysis
Authors: Sarraj Amrou , Hassan Ameer E , Abraham Michael G , Chen Michael , Hussain Muhammad S , Kasner Scott E , Ortega-Gutierrez Santiago , Churilov Leonid , Pujara Deep , Shaker Faris , Johns Hannah , Al-Shaibi Faisal , Duncan Kelsey R , Mendes Pereira Vitor , Sitton Clark W , Lansberg Maarten G , Albers Gregory W , Davis Stephen M , Wechsler Lawrence R , Grotta James C , Hill Michael D , Ribo Marc , Campbell Bruce ,   The SELECT2 Investigators
Published: February 2024

Background:
Previous studies demonstrating association of collateral status with clinical outcomes after endovascular thrombectomy (EVT) excluded patients with large core infarcts. We analyzed the association of collateral status with clinical outcomes and EVT treatment effect in SELECT2.

Methods:
In SELECT2, a central core lab adjudicated CT-angiographic collateral status using collateral scores (CS) by Tan et al. Patients were stratified based on CS into poor (CS 0-1) vs good (CS 2-3) collaterals. The primary outcome was the distribution of modified Rankin Scale score at 90-day follow-up. Models were adjusted for core volume, ASPECTS in addition to age, stroke severity and time to randomization.

Results:
Of 352 patients, 180 received EVT. Median collateral status was 2(IQR 1-2). Patients presenting <6h after last known well (LKW) (n=100) had poorer collaterals than those presenting at 6-24 hours (n=252), median 1 (1-2) vs 2 (1-2), p<0.001. Collateral status inversely correlated with CTP core volume (Rho=-0.32, p<0.0001), but not with CT ASPECTS (Rho=0.07, p=0.16). Overall, point estimates favored EVT in patients with poor (CS 0-1) [aGenOR: 1.32, 95% CI: 0.98-1.79, p=0.068] and good (CS 2-3) collaterals [aGenOR: 1.97, 95% CI: 1.43-2.72, p<0.001] without significant heterogeneity [p-interaction=0.094]. However, in the earlier 0-6h time window, there was evidence of treatment effect hetermogeneity with a larger treatment effect when good collaterals were present [aGenOR: 4.10, 95% CI: 1.81-9.29] and an absent treatment effect when only poor collaterals were observed [aGenOR: 1.26, 95% CI: 0.79-1.99], p-interaction=0.023. In the late time window, (6-12h), the EVT treatment effect did not differ significantly between poor collaterals (aGenOR: 1.35, 95% CI: 0.91-2.01) and good collaterals (aGenOR: 1.78, 95% CI: 1.24-2.56, p-interaction=0.50).

Conclusion:
Collateral status was worse in large core patients presenting in early (<6 hours) window; and correlated with ischemic core volume but not ASPECTS. Collaterals status modified EVT treatment effect in the early but not the late time window, in which both good and poor collaterals still benefited from EVT.

Clinicaltrials.gov registration:
NCT03876457
Abstract 42: Validation of a New Plaque-RADS Classification System to a Cohort of Embolic Stroke of Undetermined Source Patients
Authors: Koneru Manisha , Sakai Yu , Pandey Shraddha , Woo John , Kasner Scott E , Cucchiara Brett L , Saba Luca , Song Jae W
Published: February 2024

Introduction:
A new Plaque-RADS classification (I-IV) is proposed to categorize the degree of carotid plaque instability and risk of embolic ischemic stroke. We tested the Plaque-RADS classification in a cohort of patients with embolic stroke of undetermined source (ESUS) and imaged with neck CTAs.

Methods:
Patients with unilateral anterior circulation ischemic stroke due to ESUS and neck CTAs showing <50% carotid stenosis were retrospectively identified. Carotid total plaque thickness and ulceration were scored by a neuroradiologist blinded to stroke side. A semiautomated segmentation software measured intraplaque hemorrhage (IPH) volumes. The Plaque-RADS classification is defined as: I: no plaque; II: plaque thickness <3mm ; III: plaque thickness
≥
3mm or ulcerated; and IV: plaque with IPH>50mL irrespective of thickness. Prevalence of Plaque-RADS subtypes was analyzed ipsilateral versus contralateral to stroke side. The proportion of low (subtypes I/II) versus high-risk (III/IV) carotid plaques on the ipsilateral versus contralateral stroke-side was tested using a McNemar’s test.

Results:
Ninety-four patients (N=52 female, mean age 65.4; N=188 plaques) met criteria. Plaque-RADS distribution was classified as: Plaque-RADS I: 18.1%; II: 44.7%; III: 36.7% (III
ulc
: 1.6%); IV: 0.5%. High-risk Plaque-RADS subtypes were significantly more prevalent on the ipsilateral (42.6%) compared to the contralateral side of stroke (31.9%, p=0.008).

Conclusions:
Carotid plaque ipsilateral to stroke side showed a higher proportion of Plaque-RADS III/IV subtypes. The Plaque-RADS classification may be used to risk-stratify carotid plaque phenotypes in patients with ESUS.
Abstract 43: Race-Ethnic Specific Trends in Stroke Thrombolysis Care Metrics in Relation to U.S. Target: Stroke Nationwide Quality Improvement Program 2003-2021
Authors: Man Shumei , Solomon Nicole C , Mac Grory Brian , Alhanti Brooke , Saver Jeffrey L , Smith Eric E , Xian Ying , Bhatt Deepak , Schwamm Lee H , Uchino Ken , Fonarow Gregg C
Published: February 2024

Objectives:
To examine whether thrombolysis care metrics have improved in all races and ethnicities with the launch and advance of Target: Stroke (TS) national quality initiatives.

Methods:
This cohort study included patients presenting to Get With The Guidelines (GWTG)-Stroke participating hospitals within 4.5 hours of ischemic stroke onset from 2003 to 2021. Thrombolysis rates and speed of treatment during TS phase I (2010-2013), II (2014-2018), and III (2019-2021) were compared with the pre-TS period (2003-2009).

Results:
Among all the patients with ischemic stroke, Asian, Black, and Hispanic individuals, compared with White, were significantly more likely to present after the 4.5-hour thrombolysis treatment window (Figure/Panel A and B). Among the 1,182,182 patients arriving within 4.5 hours, 33,375 were Asian, 180,315 Black, 86,831 Hispanic, and 881,661 White. Unadjusted rates of thrombolysis treatment increased in all race-ethnic groups from 2003 to 2021 (Figure/Panel C) with no significant disparities. Disparities were evident in adjusted analyses (Figure/Panel D) and persisted in TS:III when, compared with White patients, Asian, Black, and Hispanic patients had significantly lower odds of receiving thrombolysis (0.85, 0.76, and 0.86) (all p values<0.05). Door-to-needle (DTN) times significantly improved in all race-ethnic groups during TS (Figure/Panel E). However, compared with White patients, Asian, Black, and Hispanic patients had significantly lower odds of DTN≤60 minutes (Figure/Panel F) which persisted in TS:III (adjusted OR 0.91, 0.78, and 0.87) (all p values<0.05).

Conclusion:
Target: Stroke was associated with substantial improvement in thrombolysis frequency and timeliness for all races and ethnicities, but disparities persisted after risk adjustment. Further stroke system of care and health equity interventions should focus on early hospital arrival and quality reporting of risk-adjusted care metrics by race-ethnicity.
Abstract 48: Early Carotid Endarterectomy and Carotid Artery Stent Placement in Symptomatic Patients With Internal Carotid Artery Stenosis
Authors: Qureshi Adnan I , Ma Xiaoyu , Ahmed Rehan , Gillani Syed A , Maqsood Hamza , Siddiq Farhan , Gomez Camilo R , Suri Fareed K
Published: February 2024

Background:
The American Heart Association/American Stroke Association (AHA/ASA) 2021 guidelines state that in patients in whom revascularization is planned within 1 week of the index stroke, it is reasonable to choose carotid endarterectomy (CEA) over carotid artery stent placement (CAS) to reduce the periprocedural stroke rate (level of evidence 2A, weak evidence, [B-R] moderate quality data).

Objective:
To compare the 1-month stroke, myocardial infarction (MI), and/or death rates among symptomatic patients undergoing either CAS or CEA according to the timing of the procedure in Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).

Methods:
We analyzed the effect of CAS and CEA on the rates of 1-month stroke, MI, and/or death after adjusting age, gender, presenting symptom (transient ischemic attack [TIA], retinal ischemia, or minor ischemic stroke), severity of stenosis (50-69% and 70-99%), and timing of procedure (≤7 days and >7 days post qualifying event) using multivariate analysis.

Results:
The rate of 1-month stroke, MI, and/or death was higher (non-significant) in patients who underwent CAS compared with those who underwent CEA within ≤7 days post-qualifying event (8 of 157 [5.1%] versus 3 of 124 [2.4%], p=0.251). In the multivariate analysis, there was no difference in the odds of 1-month stroke, MI, and/or death in patients who underwent CEA compared with those who underwent CAS (odds ratio [OR] 0.57, 95% CI 0.26-1.20, p=0.15). There was no effect of the timing of the procedure (OR 1.19,95% CI 0.48-3.47, p=0.72). The interaction term between CEA versus CAS and the timing of the procedure was not significant (OR 1.69, 95% 0.21-36.31 CI p=0.66). The only significant factors associated with decreased odds of 1-month stroke, MI, and/or death were the qualifying event of TIA (OR 0.13, 95% CI 0.02-0.57, p=0.02) and retinal ischemic event (OR 0.13, 95% CI 0.01-0.63, p=0.02).

Conclusions:
In our analysis, we did not identify any increase in odds of a 1-month stroke, MI, and/or death rate with CAS compared with CEA according to the timing of the procedure. Qualifying event characteristics rather than the timing of procedure appeared to be the most determinant, highlighting the need to revisit the recommendations in the AHA/ASA guidelines.
Abstract 54: Investigating the Relationship Between Reperfusion and Cerebral Edema Using Novel Cerebrospinal Fluid and Net Water Uptake Biomarkers
Authors: Olexa Madelynne , Begunova Yelyzaveta , Dhar Rajat , Matouk Charles C , Sheth Kevin N , Ortega-Gutierrez Santiago , de Havenon Adam H , Petersen Nils H
Published: February 2024

Introduction:
Studies show that successful reperfusion after large-vessel occlusion (LVO) stroke can lead to reduced mass effect and midline shift (MLS). However, MLS typically occurs late in the edema cascade and only develops in approximately half of patients treated with endovascular thrombectomy (EVT). This study aimed to explore the connection between reperfusion and cerebral edema in more detail, utilizing CSF volumetrics and tissue water concentration.

Methods:
Using a deep-learning algorithm, we measured cerebrospinal fluid (CSF) volumes and their interhemispheric ratio on CT images at baseline, 24 hours, and 72 hours following a stroke. Automated segmentation of infarct regions on follow-up scans was used to measure net water uptake (NWU), the ratio of density within infarcted tissue relative to the mirrored contralateral region. The change in edema markers from baseline to 24 hours, as well as 72-hour NWU, were dichotomized at the median into significant edema growth and low/moderate edema growth. Reperfusion status was assessed by the modified thrombolysis in cerebral infarction score.

Results:
This study included 137 patients (mean age 69 ± 15, mean NIHSS 14) with LVO stroke who underwent EVT. There was a gradual decrease in the CSF ratio change at 24 and 72 hours with lower (worse) TICI scores (p=0.023 and p<0.001, respectively, Figure 1A). After adjusting for age, admission NIHSS, and ASPECT score, successful reperfusion was associated with lower odds of significant edema by CSF ratio change at 24 hours (aOR 0.25, 95% CI 0.1-0.6, p=0.002) and NWU at 72 hours (aOR 0.26, 95% CI 0.1-0.7, p=0.01) when compared with unsuccessful reperfusion. Lower CSF ratio growth and NWU at 24 hours were significantly associated with lower global disability measured by the modified Rankin Scale at 90 days (p<0.001 and p=.008, respectively, Figure 1B).

Conclusions:
Successful reperfusion is associated with reduced edema and better functional outcomes following thrombectomy.
Abstract 61: The Effect of Remote Ischemic Conditioning in Stroke Subtypes: A Subgroup Analysis From the RESIST Trial
Authors: Blauenfeldt Rolf , Mortensen Janne K , Valentin Jan , Hess David C , Johnsen Soeren , Simonsen Claus , Hjort Niels , Andersen Grethe
Published: February 2024

Introduction:
Remote ischemic conditioning (RIC) is a simple and non-invasive procedure that has proved safe and feasible in numerous smaller clinical trials. Still, mixed results have been found in recent large randomized controlled trials. Here we present a predefined subgroup analysis of the RESIST trial on the effect of RIC in subgroups of acute ischemic stroke (AIS) and whether this effect is modified by adherence to RIC.

Methods:
The subgroups were defined as large artery atherosclerotic disease (LAA), small vessel disease (SVD), cardioembolic, and unknown/other/multiple/rare, and were based on ICD-10 discharge diagnoses assigned by the treating physician to define stroke etiology. Acceptable treatment adherence was defined as at least 80% received out of planned cycles. The outcome analysis used the entire range (‘shift analysis’) of the 90-day modified Rankin Scale score (ordinal logistic regression). ClinicalTrials.gov:NCT03481777.

Results:
A total of 902 patients were included in the target population group, 466 in the sham group, and 436 in the RIC group. RIC did not significantly improve functional outcome in adherent patients with LAA, cardioembolic or multiple/unknown etiologies. In SVD patients (n=94), with good treatment adherence, RIC treatment was associated with a significantly improved 90-day functional outcome, unadjusted OR (95% CI): 2.47 (1.01-6.02), p= 0.047. In patients with SVD, 4 patients (8%) in the RIC group compared to 0 patients in the sham group had atrial fibrillation (AF), p=0.050. The association remained significant after adjusting for AF, adjusted OR (95% CI): 2.64 (1.07-6.54), p= 0.035.

Conclusions:
In patients with AIS due to SVD, who had good treatment adherence, RIC treatment was associated with improved functional outcome at 90 days. These results are encouraging but should only be hypothesis-generating for future studies.
Abstract 63: Ultra-Processed Food Intake Predicts Stroke Risk in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study
Authors: Bhave Varun M , Oladele Carol , Ament Zsuzsanna , Kijpaisalratana Naruchorn , Jones Alana , Couch Catharine , Patki Amit , Garcia Guarniz Ana-Lucia , Irvin M. R , Kimberly W T
Published: February 2024

Introduction:
Higher intake of ultra-processed foods (UPFs) is linked to cardiometabolic diseases and adverse neurological outcomes, such as stroke and cognitive decline. However, it is controversial whether food processing confers neurological risk independent of nutritive information. We explored associations between UPFs and incident stroke in the longitudinal REasons for Geographic and Racial Differences in Stroke (REGARDS) study.

Methods:
The NOVA system was used to classify items from a baseline food frequency questionnaire (FFQ) according to level of processing. Intake in grams for each NOVA category was normalized to total grams consumed. Scores quantifying adherence to other diets considered neuroprotective—including a Mediterranean, DASH, and Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet—were also derived from FFQ data. Multivariable Cox models were used to evaluate associations between diet patterns and stroke.

Results:
The cohort included 15,656 participants with reliable dietary intake data and without a previous stroke. Greater intake of UPFs (NOVA4) was associated with increased stroke risk (HR per SD: 1.10, 95% CI [1.03-1.18], p=4.77x10
-3
) in a model adjusted for demographic factors (age, race, sex, age-by-race interaction) and vascular risk factors (smoking, atrial fibrillation, hypertension, diabetes mellitus, cardiovascular disease, left ventricular hypertrophy). Intake of unprocessed or minimally processed foods (NOVA1) was associated with decreased stroke risk (HR: 0.87, 95% CI [0.81-0.93], p=5.56x10
-5
) as was adherence to the Mediterranean, DASH, and MIND diets. Adding intake of NOVA1 or NOVA4 items to multivariable models that included other diet patterns resulted in improved model fit (greater log-partial-likelihood). In contrast, adding other dietary patterns to models that included NOVA1 or NOVA4 intake did not improve model fit. While associations between NOVA1 and NOVA4 intake and stroke persisted in models that included the Mediterranean, DASH, or MIND diets, associations between other diet patterns and stroke were not significant.

Conclusion:
Intake of differentially processed foods is associated with stroke risk independent of adherence to other dietary patterns.
Abstract 72: Association Between Stroke Subtype and Post-Stroke Cognitive Decline: A Pooled Cohort Analysis of Four Cohorts
Authors: Levine Deborah A , Whitney Rachael T , Ye Wen , Briceño Emily M , Gross Alden L , Aparicio Hugo J , Beiser Alexa S , Elkind Mitchell S , Ferber Rebecca A , Giordani Bruno J , Gottesman Rebecca F , Howard Virginia J , Kollipara Adam S , Koton Silvia , Lazar Ronald M , Pendlebury Sarah T , Seshadri Sudha , Springer Mellanie V , Sussman Jeremy B , Burke James F , Hayward Rodney A
Published: February 2024

Introduction:
Associations between stroke subtype and post-stroke cognitive decline are unclear. We determined if post-stroke cognitive trajectories differed between 1) hemorrhagic vs. ischemic stroke and 2) ischemic stroke subtypes.

Methods:
We identified 1,150 eligible dementia-free individuals with incident stroke (93% ischemic, 7% hemorrhagic, 50% women, 31% Black, median age, 65) from 4 cohort studies from 1971-2019: Atherosclerosis Risk in Communities Study, Cardiovascular Health Study, Framingham Offspring Study, and Reasons for Geographic and Racial Differences in Stroke. Of the ischemic strokes, 22% were small-vessel occlusion, 8% large artery atherosclerosis, 21% cardioembolic, and 49% cryptogenic/other determined etiology. Linear mixed-effects models were used to estimate longitudinal changes in cognition after incident stroke. Global cognition (primary outcome), executive function, and memory were harmonized across studies and standardized as T-scores (mean [SD], 50 [10]); a 1-point difference represents a 0.1-SD difference in cognition. Median (IQR) follow-up was 5.9 (3.2, 9.2) years.

Results:
Survivors of ischemic stroke had significant declines in global cognition, executive function, and memory (Table). For example, global cognition declined -0.35 points/year (95%CI, -0.43, -0.26);
P
<0.001. Initial post-stroke cognitive scores and post-stroke cognitive trajectories did not differ between hemorrhagic and ischemic stroke, except for lower initial post-stroke memory scores (adjusted difference, -1.39 points; 95% CI, -2.77, -0.01;
P
=0.049). Survivors of small-vessel occlusions had significant declines in global cognition, executive function, and memory (Table). Initial post-stroke cognitive scores and post-stroke cognitive trajectories did not differ by ischemic stroke subtype.

Conclusions:
Our results suggest that stroke survivors experience long-term post-stroke cognitive decline regardless of subtype.
Abstract 73: Wallerian Axon Degeneration is Required for Chronic Neuroinflammation and Infarct-Induced Neurodegeneration
Authors: Wang Jack T , Song Andrew , Buckwalter Marion S
Published: February 2024

Background:
Ischemic stroke triggers a chronic B-lymphocyte response in the stroke core that is required for delayed post-stroke cognitive decline in mice. Because immune cells primarily infiltrate into connected subcortical axonal tracts after stroke, we hypothesized that degenerating axons promulgate a persistent neuroinflammation that is critical for late cognitive decline. To test this, we utilized mice deficient in Sarm1 (
Sarm1-/-),
a molecular trigger of axon degeneration and the loss of which leads to axonal protection after injury.

Methods:
Wildtype and
Sarm1-/-
male mice (N=9 per condition) underwent distal MCA stroke followed by transient hypoxia, which reliably leads to infarct-induced neurodegeneration 7 weeks after injury. Innate (monocytes) and adaptive (T, B lymphocytes) immune cell infiltration were evaluated via immunohistochemistry 1 & 7 weeks after stroke. Cognition was assessed using the Barnes maze at both time points after stroke.

Results:
Absence of
Sarm1
resulted in robust axonal protection after ischemic stroke. In connected thalamic region, mean immunostained intensity of axons was 166 in wildtype vs. 267 in
Sarm1-/-
(p < 0.005) 1 week, and 106 vs. 201 (p < 0.005) 7 weeks after stroke. Compared to wildtype mice,
Sarm1-/-
mice had an attenuated innate immune response in connected subcortical white matter 1 week after stroke (% area of CD68+ reactivity was 35 ± 5% in WT vs. 19 ± 4% in
Sarm1-/-
(p < 0.01), while peri-infarct CD68 was not different. Moreover, loss of
Sarm1
reduced B220+ B-cell infiltration into the infarct 7 weeks after stroke. Percent area of B220+ reactivity was 30 ± 8% in WT vs 15 ± 7% in
Sarm1-/-
(p <0.05). Compared to wildtype littermates,
Sarm1-/-
mice were resistant to chronic post-stroke cognitive decline on the Barnes maze. There was no difference in cognition between cohorts 1 week after stroke but there was at 7 weeks. The mean escape latency was 97 ± 11 sec in wildtype vs 57 ± 9 sec in
Sarm1-/
- mice (P<0.05).

Conclusion:
We report that
Sarm1
-mediated axonal degeneration is critical for chronic neuroinflammation and delayed cognitive decline after ischemic stroke. Directly targeting axon degeneration by modulating Sarm1 activity provides a novel therapeutic approach to ameliorate infarct-induced neurodegeneration.
Abstract 78: Mobile Stroke Units Address Disparities in Stroke Care as Demonstrated by Zip Code Level Socioeconomic Status
Authors: Jalal Muhammad I , Akkipeddi Sajal Medha , Lally Jag , Burgett Jason L , Proper Diana , Pilcher Webster H , Kelly Adam G , Benesch Curtis G , Mattingly Thomas K , Bhalla Tarun , Bender Matthew T
Published: February 2024

Introduction:
Acute ischemic stroke (AIS) disproportionately affects minority populations with evidence showing black and Hispanic patients utilize traditional EMS less, have greater delay in arrival to the emergency department, are less likely to receive thrombolysis, and have lower odds for good functional outcomes.
1–3
Mobile Stroke Units (MSUs) bring diagnostic and treatment tools for AIS directly to patients, achieving faster thrombolytic administration and better outcomes.
4,5

Objective:
This study compared demographic data and used Census data to characterize the socioeconomics of patient zip codes served and transported by our MSU based in Rochester, NY relative to patients that arrived at our institution via traditional EMS and private vehicle.

Methods:
Data was extracted from the 2018 American Community Survey (ACS), a 5-year a rolling survey of the US population. Zip code level socioeconomic status (zSES) was calculated based on 5 key factors by assigning percentile ranks to each across all US zip codes and combined to create one index variable measuring zSES. zSES, its factors, and demographics were compared amongst MSU and non-MSU patients.

Results:
468 patients transported by our MSUs to our institution between October 2018 to January 2022 were compared to the 2,296 non-MSU patients for the same time-period. Patients transported by MSU lived in zip codes with significantly lower SES Index (0.482 versus 0.527, p=0.013). Component analysis showed that MSU patients came from zip codes with a higher percentage of households with single parents, higher percentage of individuals below the federal poverty line, higher percentage of unemployed individuals, and higher percentage of adults with less than a 12
th
grade education. Per capita income did not differ. In addition, patients transported by our MSU’s were significantly more female, black, and Hispanic. Age did not differ.

Conclusion:
Mobile Stroke Units (MSU) help address disparities in stroke care, by bringing care to patients who live in zip codes that have significantly lower SES and are of historically marginalized communities, compared to patients transported by EMS and private vehicle.
Abstract 79: Twelve-Year Trends in Ninety-Day Stroke Outcomes and Ethnic Differences From a Population-Based Study
Authors: Lisabeth Lynda D , Kwicklis Madeline , Cox Melinda , CASE Erin , Morgenstern Lewis B
Published: February 2024

Background:
Stroke outcomes may be changing over time with improved acute stroke therapy, secondary prevention, and post-acute care. At the same time, stroke mortality has declined suggesting more people are living with stroke disability. No US population-based data exists on trends in outcomes. The objective was to investigate trends and ethnic differences in 90-day stroke outcomes in a population-based study.

Methods:
First-ever ischemic strokes in the population-based Brain Attack Surveillance in Corpus Christi Project (2009-2020, n=1,449) were included. 90-day outcomes included function (activities of daily living (ADL)/instrumental ADL), cognition (modified mini-mental state exam), NIHSS, and quality of life (Stroke-Specific Quality of Life (SS-QoL)). Linear regression with multiple imputation and inverse probability weighting was used to model adjusted associations between time, ethnicity, the interaction of time and ethnicity and outcomes.

Results:
Median age was 66; 61% Mexican American (MA). Trends in 90-day function overtime were roughly quadratic (Figure) and the change in the ethnic difference was significant among reference groups (p-value<0.01). Trends in NIHSS were linear with no change in the ethnic difference (p-value=0.51). Trends in cognition were approximately cubic and the change in the ethnic difference was significant within reference groups (p-value=0.03). Trends in QOL were stable with no change in the ethnic difference.

Conclusion:
Recent improvements in 90-day post-stroke functional and cognitive outcomes in MAs have resulted in reduced disparities. Factors contributing to favorable trends in outcomes in this group should be further studied.
Abstract 80: Predictors of Door-to-Needle Time in the Veterans Health Administration National Telestroke Program
Authors: Anderson Jane A , Albright Karen C , Lyerly Michael J , Larson Jason C , Ramsey David , Sonnenfeld Mandi , Plue Laurie , Williams Linda S , Martin Holly , Myers Laura , MARTINI SHARYL R , Graham Glenn D
Published: February 2024

Introduction:
The Veterans Administration (VA) National Telestroke Program (NTSP) increases access to stroke specialists across the VA enterprise. Unlike most telestroke networks, VA hospitals are not integrated into a hub-and-spoke model and most Veterans present to VA emergency departments by personal vehicle, rather than emergency medical services (EMS). Predictors of Door-To-Needle (DTN) time in Veterans receiving tPA via telestroke may differ from community telestroke systems.

Methods:
A logistic regression model was applied using operations data to identify patient and hospital characteristics predictive of DTN times
<
60 minutes. Predictors variables included patient demographics, National Institute of Health Stroke Scale score, Last Known Well time on arrival, rurality, integration with EMS routing systems, local neurology service, VA-designated facility complexity status, time from arrival to CT and time from CT to treatment.

Results:
Among (N=448) Veterans treated via Telestroke from 2017 to 2022, 32% (n=142) received tPA
<
60 minutes. No significant differences were observed between groups in terms of patient characteristics (Table). Significant differences were seen in hospital characteristics of complexity status (p=0.013), time from arrival to CT (p<0.001), and time from CT to treatment (p<0.001). The odds of receiving tPA
<
60 minutes were 12.4 times greater for patients with a door to CT time of
<
10 minutes (95% CI 6.7, 23.2) and 28.5 times greater for patients with a CT to treatment time
<
40 minutes (95% CI 14.5, 56.5).

Conclusions:
Our data clearly demonstrate that achieving target times of
<
10 minutes for arrival to CT and
<
40 minutes for CT to treatment increases the odds of receiving tPA in
<
60 minutes. This finding underscores the importance of improving stroke systems within VA hospitals to facilitate these key target times.
Abstract 81: Radial versus Femoral Access for Mechanical Thrombectomy in Patients With Large Vessel Occlusion: A Randomized Clinical Trial
Authors: Hernandez Morales David , Requena Manuel , de Dios Lascuevas Marta , Olive-Gadea Marta , Gramegna Laura L , Muchada Marian , Rivera Eila , Garcia-Tornel Alvaro , Rizzo Federica , Piñana Carlos , Rodriguez-Luna David , Pagola Jorge , Diana Francesco , Juega Jesus M , Rodriguez-Villatoro Noelia , Rubiera Marta , Molina Carlos A , Ribo Marc , tomasello alejandro
Published: February 2024

Introduction:
Femoral artery is the most used access for mechanical thrombectomy (MT) in stroke patients with a large vessel occlusion. Routine radial access has been proposed as an alternative following cardiology guidelines although its safety and efficacy remain controversial.

Hypothesis:
Radial access for MT is non-inferior to femoral access in terms of final recanalization.

Methods:
The study was an investigator-initiated, single-center, evaluator-blinded randomized clinical trial. Stroke patients undergoing MT, with femoral artery patency and radial artery diameter ≥2.5mm were randomly assigned (1:1) to either radial (60 patients) or femoral access (60 patients). The primary binary outcome was successful recanalization (final eTICI score 2b-3) assigned by blinded evaluators. In the per protocol analysis, patients with allocated access failure were considered non-recanalized. We established a non-inferiority margin of -13.2%, considering an acceptable reduction of 15% in the expected recanalization rates.

Results:
From September 2021 to July 2023, 120 patients were randomly assigned and 114 (57 radial access, 57 femoral access) with confirmed intracranial occlusion on initial angiogram were included in the primary analysis. In the intention to treat analysis, successful recanalization was achieved in 48/57 (84.2%) patients assigned to femoral access and in 54/57(94.7%) patients assigned to radial (adjusted risk difference 3.36%, 95% CI –6.47% to 13%; p<0.001). The lower limit of one-sided 95% CI was –4.8%, which did not cross our predefined margin of -13.2%. Median time from angiography suite arrival to first pass (femoral: 30 (IQR 25-37) minutes versus radial: 41 (IQR 33-62) minutes, p<0.001) and from suite arrival to recanalization (femoral: 42 (IQR 28-74) versus radial: 59.5 (IQR 44-81) minutes, p<0.050) were longer after radial access. Both groups presented one severe access complication and there was no difference in the rate of allocated access failure: radial 6 (10.5%) radial Vs femoral 5 (8.8%) (p=0.751).

Conclusion:
Among patients who underwent MT, radial access was non-inferior to femoral access in terms of final recanalization. Procedural delays may favor femoral access as default first approach.
Abstract 85: One-year Outcomes After Endovascular Treatment for Posterior Circulation Tandem Occlusions: A Multicenter Experience of 249 Patients
Authors: Dohiem Mohamed F , Li Wei , Sun Wen , Huang Jinbo , Qiu Zhongming , Han Zhongkui , Chen Zhonglun , Zhao Zhenqiang , Chen Zhibin , Zi Wenjie , Nogueira Raul G
Published: February 2024

Introduction:
Endovascular thrombectomy (EVT) in posterior circulation tandem occlusions can be challenging and the current evidence is limited to retrospective case series with small sample sizes.

Method:
Consecutive patients from both PRESIST (ChiCTR2000033211) and BASILAR (ChiCTR1800014759) prospective registries between 2014 and 2022 were included with a total of 53 centers. Posterior circulation tandem occlusion was defined as stroke due to intracranial vertebral (V4), basilar, or posterior cerebral artery (PCA) occlusions, with tandem steno-occlusive lesion >70% of the extracranial vertebral artery and impaired distal flow or partial filling of the VA from collaterals. Outcomes included successful reperfusion defined as modified Thrombolysis in Cerebral Infarction (mTICI) of 2b-3, symptomatic intracerebral hemorrhage (sICH), favorable functional outcome defined as a modified Rankin Scale (mRS) score of 0-3, and mortality, at 90 day and 1-year.

Results:
After excluding 14 cases with failed access/penetration, a total of 249 patients (mean age of 63.9 years [SD 11.7], 208 [83.5%] male) were included. Basilar artery occlusions were recorded in 179 patients (71.9%) followed by V4 occlusions in 64 patients (25.7%) and PCA occlusions in 6 patients (2.4%). The median baseline NIHSS score was 23 (IQR 12-30) and median PC-ASPECTS was 9 (IQR 7-10). Intravenous thrombolysis was administered in 55 patients (22.1%) while general anesthesia was used in 94/248 patients (37.9%). The median time from onset to puncture time was 320 minutes (IQR 215-496), with a median procedure time of 130 minutes (IQR 89-170). A median number of passes was 1 (IQR 1-2) and successful reperfusion was achieved in 209/249 patients (83.9%). Favorable clinical outcome (90-day mRS 0-3) was achieved in 99/246 patients (40.2%), with mortality affecting 98/246 patients (39.8%). The 24 h post procedural sICH was found in 19/247 patients (7.7%). At 1-year, favorable clinical outcome (mRS 0-3) was achieved in 98/237 patients (41.4%), with mortality affecting 113/236 patients (47.9%).

Conclusion:
EVT seems to be a safe and effective approach for posterior circulation tandem occlusions. More comparative studies are needed to confirm these results.
Abstract 91: Patients With Intracranial Hemorrhage Have Greater Post-Stroke Mood Disturbance Than Those With Ischemic Stroke
Authors: Kim Min Sun , Hickman Leonard , Mun Katherine T , Sanossian Nerses , Starkman Sidney , Avila Gilda , Sharma Latisha K , Liebeskind David S , Conwit Robin A , Hamilton Scott , Saver Jeffrey L
Published: February 2024

Background:
Patients with stroke frequently suffer from post-stroke mood disturbances (PSMD) which decrease their quality of life. It remains unclear whether the prevalence of PSMD differs according to stroke subtype. The aim of our study was to investigate PSMD incidence among stroke subtypes in the large, prospective Field Administration of Stroke Therapy - Magnesium (FAST-MAG) Trial.

Methods:
In the publicly-available FAST-MAG database, we identified all patients with imaging-confirmed diagnoses of ischemic stroke (IS), transient ischemic attack (TIA), and intracerebral hemorrhage (ICH). Data on age, sex, NIHSS at presentation, stroke subtypes, and Stroke Impact Scale (SIS) 64 v3.0 at 90 days were collected. Differences in SIS Emotion Domain scores between IS, TIA, and ICH were assessed using the Mann-Witney U Test.

Results:
SIS Emotion Domain scores were available in 1239/1370 (90.4%) of patients. Mean age was 68.7 years (SD 13.4), and 41% were female. Median NIHSS was 7.0 (IQR 3-14). 65.3% had IS, 14.3% TIA, and 20.3% ICH. The preponderance of SIS-64 scores were patient-reported (86%) with the remainder completed by a patient proxy (14%). Emotion domain scores at 3 months were: lowest (most abnormal) in ICH patients (median 77.8, IQR 58.3-88.9); intermediate in IS patients (median 83.3, IQR 66.7-94.4); and highest in TIA patients (median 88.9, IQR 72.2-97.2), p<.01) (Figure). Neither age nor sex were strongly associated, but more abnormal mood scores were associated with greater presenting deficit severity (NIHSS 0-4: median SIS-64 mood score 88.9; NIHSS 5-14: 81.3; NIHSS ≥15: 75.0; Spearman’s rho: -0.30, p<.01).

Conclusions:
In this prospective study of a large population with broad enrollment criteria, mood disturbances at 90 days were most common among ICH patients and least common among TIA patients. Further work should investigate the driving factors of greater PSMD in patients with ICH compared to other patients with acute cerebrovascular disease.
Abstract 97: Acute Ischemic Stroke Despite Anticoagulant Use: The Neuro-AFib Study
Authors: Gurol Edip M , Das Alvin S , Gokcal Elif , Abramovitz Avia , Rotschild Ofer , Penadel Aguila Kim , Smith Eric E , Yaghi Shadi ,   The Neuro-AFib Study Group
Published: February 2024

Background:
Acute ischemic stroke (AIS) admissions in patients with atrial fibrillation (AF) using anticoagulants (AIS-despite-AC) are commonly seen in stroke units but data on their frequency, causes, and outcomes are scarce.

Methods:
The Neuro-AFib study is a multicenter effort geared toward elucidating the causes and consequences of strokes in a contemporary AF cohort. Detailed clinical, laboratory and multimodal imaging data from known AF patients consecutively admitted to 20 stroke centers with an IS between 1/2018-12/2019 were used to define characteristics of AIS-despite-AC and compared to AIS-off-AC.

Results:
Out of 4456 patients with known AF prior to the AIS, 2051 (46%) were using anticoagulants. Patients who had AIS-despite-AC were younger (76.8
+
11 vs 77.8
+
12, p=0.007), had higher mean CHA
2
DS
2
-VASc scores (4.57
+
1.7 vs 4.21
+
1.7, p<0.001), and they were more likely to have permanent AF (23.5% vs 19.6%, p=0.002) and a past-history of stroke/TIA (36% vs 25%, p<0.001) when compared to non-AC group. Chronic embolic (non-lacunar) infarcts on imaging were more common among AIS-despite-AC (34.5% vs 26.7%, p<0.001). Acute large vessel occlusion (LVO) was common among AIS-despite-AC (48%). The pattern of the acute infarcts (numbers, embolic features) was not different. The calculated acute infarct volume was large (34ml) and mean NIHSS was 10.4 for AIS-despite-AC. Intravenous thrombolysis was used much less commonly for AIS-despite-AC (10.5% vs 32.1%, p<0.001). Symptomatic carotid disease was suspected in 2.4%, a hypercoagulable condition in 5.7%, whereas acute lacunar infarct was found in 6.5% of all patients. Death or significant disability (mRS 3-5) at hospital discharge were common in AIS on vs off AC (70.6% vs 75.2%, p<0.001).

Conclusions:
Based on a large multicenter cohort, AF patients who have AIS-despite-AC have higher AF load and risk scores, most don't have a concurrent etiology and they are more likely to have recurrent embolic events. The stroke severity, common presence of LVO, infarct size, and poor outcomes are alarming features, and most patients are unable to receive thrombolysis because of AC use. Overall, detection of AF patients at risk of AIS-despite-AC and development of specific preventive modalities should be priorities.
Abstract 98: Direct-Acting Oral Anticoagulants and Antiseizure Medications for Atrial Fibrillation and Epilepsy: Risk of Thromboembolic and Major Bleeding Events
Authors: Acton Emily K , Hennessy Sean , Gelfand Michael A , Leonard Charles E , Bilker Warren B , Shu Di , Willis Allison W , Kasner Scott E
Published: February 2024

Rationale:
Direct-acting oral anticoagulants (DOACs) are commonly prescribed with antiseizure medications (ASMs) due to concurrency and causal links between atrial fibrillation (AF) and epilepsy. However, enzyme-inducing-ASMs (EI-ASMs) may reduce absorption and accelerate metabolism of DOACs, potentially lowering DOAC levels and elevating thromboembolism risk.

Methods:
We leveraged large-scale healthcare data to conduct an emulated target trial among a nationally representative cohort with AF and epilepsy. Thromboembolic and bleeding event rates were contrasted between adults on DOACs + EI-ASMs versus active comparators on DOACs + non-enzyme inducing ASMs. Data-adaptive high-dimensional propensity score matching was employed to control for observed confounders and proxies for unobserved confounders. Adjusted hazard ratios (aHRs) were estimated using Cox proportional hazard models with robust variance estimators to account for clustering within matched pairs.

Results:
Among incident ASM + DOAC users, we identified 14,078 and 14,158 episodes that met eligibility criteria for assessment of thromboembolic and bleeding outcomes, respectively. Incidence per 1,000 person-years was 88.5 for thromboembolic events and 68.3 for major bleeding events. Compared with use of non-enzyme inducing ASMs, use of EI-ASMs with DOACs was not associated with a difference in thromboembolic events (aHR=1.10, 95% CI: 0.82-1.46), but was associated with a reduction in major bleeding events (aHR=0.63, 95% CI: 0.44-0.89).

Conclusions:
EI-ASMs were not associated with alteration in DOAC efficacy. These real-world data are reassuring for the care of adults with epilepsy who require anticoagulation, particularly across a larger global community where EI-ASMs remain mainstays. Further research is needed on the reduction in bleeding risk with EI-ASMs, as this may be suggestive of pharmacokinetic interactions lowering DOAC levels without negating therapeutic effects.
Abstract HUP7: Impact of Social Determinants of Health and Academic Hospital Care on Outcomes After Non-Traumatic Subarachnoid Hemorrhage
Authors: Renedo Daniela , Rivier Cyprien , Clocchiatti-Tuozzo Santiago , Huo Shufan , Hebert Ryan , Gunel Murat , Matouk Charles C , Falcone Guido J , Sheth Kevin N
Published: February 2024

Background:
Growing evidence shows that SDOH and care setting affect ischemic stroke recovery. Impact on non-traumatic SAH is unclear. We studied SDOH and academic hospital influence on SAH outcomes.

Methods:
We conducted a retrospective study using data from the GWTG Stroke. All analyses were conducted using the Precision Medicine Platform. Hospitals partaking in this study obtained either human research approval for enrolment without patient consent or an IRB exemption. The exposures of interest were the Social Deprivation Index (SDI), the Adjusted Gross Income (AGI), and academic hospital care status. SDI and AGI were divided into three groups each, and care setting was labeled as academic or non-academic. Measured outcomes were: in-hospital death, length of stay (LOS), and discharge disposition (DD). We used regression with interaction terms to assess SDOH and care setting impact.

Results:
The study included 146,310 SAH patients (mean age 60, female sex 61%). Higher SDI was associated with longer LOS (unadjusted median days 11.1, 12.1 and 12.8) and worse DD (unadjusted risk 42.4%, 44%, 44.7%) (p < 0.001). Lower AGI was associated with increased in-hospital mortality (15.9%, 15.5%, 15.1%) and worse DD (44.2%, 43.9%, 43.1%) (p < 0.001). Academic hospital care demonstrated lower LOS (7.7±10.9 vs. 13.2±14.8, p < 0.001), reduced in-hospital mortality (13.8% vs. 16%, p < 0.001), and better DD (63.3% vs. 53.2%, p < 0.001). Adjusted multivariate analysis confirmed these findings. In comparison to the first, for the third tertile of the SDI, the odds for having a good outcome discharge were 0.87 (95% CI 0.82-0.92, p < 0.001). Additionally, SDI third tertile was associated with a significant increase in LOS (Beta 2.05; p=0.001). Higher AGI was correlated with reduced mortality (OR 0.90; 95% CI 0.83-0.96, p=0.004). Academic care was linked to lower in-hospital mortality (OR 0.89; 95% CI 0.81-0.98, p=0.029) and improved DD (OR 1.09; 95% CI 1.01-1.17, p=0.002). Interaction analysis revealed that academic care and higher AGI lead to synergistic reductions in LOS and better discharge outcomes (p<0.05).

Conclusion:
This analysis of GWTG-Stroke highlights the significant independent and synergistic influence of SDOH and academic hospital care on outcomes following SAH