bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP47: Brain iron metabolism impairment differs between aged mouse models of cerebral hypoperfusion and iron overload
Authors: Ashraf Areej , Monga Sheelu , Moruno-Manchon Jose
Published: January 2025

Introduction:
Iron is the most abundant metal in the brain and plays an important role in cellular processes. Thus, an imbalance of iron metabolism in the brain negatively affects brain function. Iron accumulates in the brain with aging, which contributes to the progression of different neurological disorders. In two previous independent studies in our lab using an iron overload model and a chronic cerebral hypoperfusion (CCH) model (bilateral carotid artery stenosis, BCAS) in aged mice, we observed that mice of both models showed enhanced brain iron deposition and cognitive deficits, compared with control mice. Here, we investigate if these two models share the same molecular mechanisms in brain iron metabolism, and whether the combination of iron overload and CCH exacerbates the phenotype.

Methodology:
18-month-old C57BL/6 mice of both sexes were subjected to survival surgery to implant 0.18 mm diameter micro-coils in both common carotid arteries to induce CCH (BCAS mice). Sham mice underwent the same procedure without coil implantation. Two weeks after surgery, mice were administered 5% ferric citrate (FC, 3 alternate days/week for 6 weeks) by oral gavage as a model of iron overload or were given saline solution. Two months after surgery, mice were tested for open field, elevated plus maze, and fear conditioning. We analyzed their brains to determine the expression of genes involved in iron metabolism by qPCR.

Results:
Iron overload and/or BCAS did not affect body weight, nor velocity and distance moved of mice. However, FC mice showed reduced freezing time (p=0.002) in fear conditioning, and BCAS mice spent more time in the open arms (p=0.04) in the elevated plus maze, compared with control mice. We did not find differences between BCAS+FC mice and control mice. Interestingly, CCH reduced the levels of ferrous iron (p=0.049) in the serum of BCAS mice. We also found that BCAS, but not iron overload, increased the expression of both
Gss
(glutathione synthetase, an antioxidant enzyme; p=0.01) and
Ncoa4
(nuclear coactivator 4, a mediator of ferritinophagy; p=0.005).

Conclusions:
BCAS and FC affect brain function via different mechanisms, and the combination of both does not worsen the phenotype. BCAS, but not FC, increased the expression of
Gss
and
Ncoa4
. Next, we will determine whether ferritinophagy is activated in the brains of BCAS mice and whether the higher expression of
Gss
is a response to mitigate the oxidative stress induced by CCH.
Abstract TP49: Establishing a Cell Type-Specific Extracellular Vesicle Isolation Workflow For Improved Biomarker Discovery
Authors: Wang David , Pullabhotla Venkata , Thi Thuy Duong Van , Jin Lee-Way , Elahi Fanny , Wang Aijun , DeCarli Charles
Published: January 2025

Background:
Small vessel cerebral vascular disease (sCVD) is common to older individuals, often asymptomatic, but associated with incident stroke and future mortality. Multiple mechanisms for sCVD have been postulated, all of which include injury to the neurovascular unit. Analysis of extracellular vesicles (EVs), important constituents of the intercellular communication pathway, may offer new ways to evaluate pathological processes of sCVD as well as serve as novel biomarkers or identify new avenues for therapy. This abstract summarizes work by our group to subtype EVs and measure cargo proteins from the various cell types of the neurovascular unit from a group of cognitively normal individuals with a spectrum of sCVD.

Method:
Study participants consisted of 14 individuals, 50 % female, 76
+
7 years of age, having 17.6
+
1.9 years of education. White matter hyperintensities varied from 0.73 – 38.8 cc. EV isolation used an Exodus ultrafiltration system on platelet depleted plasma. EVs were further fractionated into EV subtypes with resin-conjugated antibodies against cell type-specific markers. Five EV subtypes were isolated by two rounds of immunoprecipitation with the following markers: NCAM1/ATP1A3 (excitatory neuron EV), CD49f/LRP1 (astrocyte EV), CD11b/LCP1 (activated microglia EV), LAMP2/FTH1 (oligodendrocyte EV), CD31/CD146 (activated endothelial EV). Following isolation of EV subtypes, samples were characterized for purity and yield by nanoparticle tracking analysis, imaged for protein expression by super resolution microscopy, and sequenced for biomarker identification by quantitative proteomics.

Results:
Nanoparticle tracking analysis confirmed high yields of all 5 EV subtypes, > 2E9 EVs/mL, along with identical size and surface charge profiles. Super resolution microscopy showed consistent canonical EV marker distributions on all EVs while EV subtypes expressed unique markers based off their cell type of origin. Quantitative proteomics identified 400 unique and differentially expressed proteins present amongst the various EV subtypes as compared to mean plasma EVs concentrations. Protein abundance varied widely across EV subpopulations, indicating distinct protein profiles.

Conclusion:
Preliminary results confirm the potential for biomarker discovery from novel EV subpopulations through identification of differentially expressed cargo proteins from the neurovascular unit. Future work will associate these findings with sCVD phenotypes.
Abstract TP51: Uniting Forces: A Collaborative Approach to Enhancing Door-to-Needle Efficiency for Acute Stroke
Authors: Fisher Kristen , Porcelli Amie , Slocum Giles , Cozzi Nicholas , Vargas Alejandro , Patwari Rahul , Cherian Laurel
Published: January 2025

Background:
The medical center is a participant of American Heart Association's Get with the Guidelines, and monitors performance compared to other comprehensive stroke centers. The stroke performance improvement committee noted a trend of increasing door-to-needle times overall, achieving the center's goal of <60 minutes only 69.2% of the time.

Purpose:
Implementation of a bundle with a goal of reducing DTN times and improving interdisciplinary communication and collaboration at a single comprehensive stroke center.

Methods/Design:
A multidisciplinary stakeholder group including representatives from nursing, emergency medicine, vascular neurology, pharmacy, patient registration, radiology, emergency medical services, and the stroke program, developed an action plan. Due to the urgent need to address the issue, several initiatives were introduced simultaneously as a bundled approach. All interventions were at no cost to the institution. The bundle included: an interdisciplinary huddle for every Code Stroke alert; clock to travel with the patient; BP monitor/IV equipment in the CT area; streamlining the registration process; reinstating a unit-based stroke committee; increased communication, transparency, and recognition of performance with ED staff. A post-implementation survey was disseminated to the ED and stroke teams. Data was compared 6 months pre-implementation of the bundle to 6 months post-implementation. Patients that received tenecteplase were included, regardless of final diagnosis. If patients met valid exclusion criteria for time-based goals according to GWTG, they were excluded. Pre-implementation n = 21, post-implementation n =20.

Results:
Pre-implementation: median DTN: 53 minutes, mean DTN: 56 minutes. Post-implementation: median DTN: 47 minutes, mean: 47 minutes. This demonstrated a 10% decrease in median DTN, and a 15% decrease in mean DTN. The center is currently achieving their goal DTN 100% of the time for GWTG cases, improved from 69.2%. When looking at each level of GWTG Honor Roll status, pre-implementation was: 15% of cases <30 minutes, 46% <45 minutes, and 62% < 60 minutes. Post-implementation was: 20% of cases <30 minutes,60% <45 minutes, 100% <60 minutes. Better communication was reported by 100% of survey respondents.

Conclusion:
The implementation of the bundle significantly reduced DTN times and improved interdisciplinary communication. Staff feedback has been positive, and all components of the bundle are sustainable.
Abstract TP53: Optimal Time Frame for Post Stroke Hospitalization Follow-Up Phone Calls
Authors: Mkrtumyan Alvina , Santosa Rhendy , Aguilera Christopher , Sangha Navi , Gaffney Denise , Ajani Zahra , Cheng Pamela , Le Duy , Taleb Shayandokht
Published: January 2025

Background:
Post-discharge phone calls to stroke patients are a valuable tool to assess medication compliance, stroke education retention and prevention of emergency room visits. However, there is no optimal time frame defined by The Joint Commission for post-discharge follow-up calls. The purpose of this study was to determine if there is an optimal time frame to call patients and whether call fatigue affects call completion rate.

Methods:
Ischemic and hemorrhagic stroke patients discharged to home with and without home health from 2/2024 to 6/2024 were included. Participants received phone calls from a Stroke Certified Registered Nurse at 7 days (Group 1), 14 days (Group 2), and 21 days (Group 3) post-discharge. Two call attempts were made. Data collected included baseline demographics, call completion rates, stroke education and validation of knowledge retention. Call fatigue was assessed by capturing the number of times patient was contacted after discharge by health care team. Patients received a Knowledge Score of 0-6 based on recall of knowledge of diagnosis, stroke type, signs and symptoms of stroke, risk factors, medication knowledge and stroke prevention. R *** was used for data analysis.

Results:
178 patients were called, 64 (36%) Group 1, 61 (34%) Group 2, 53 (30%) Group 3. There were no differences in baseline demographics. 74% (131) of patients were reached successfully. There were no differences in completion among each group (49 {75%} Group 1, 42 {69%} Group 2, 40 {75%} Group 3) p=0.6 despite more calls being made by healthcare team members early on (7.09±4.55 in Group 1, 4.12±3.27 in Group 2, 3±2.89 in Group 3). There were no differences in Knowledge Score regardless of time phone call was made. Patients who were discharged home with home health had better Knowledge Score than those discharged home without home health (5.87(±0.61) vs 5.48(±1.36)) p=0.03.

Conclusion:
Implementing a post-discharge phone call program up to 21 days is feasible. There was no difference in call completion rates and retention of stroke knowledge despite a heavier call burden earlier on suggesting no call fatigue.
Abstract TP57: A Retrospective Study to Determine Opportunities to Improve Earlier EMS Activation for Transport of Patients with Large Vessel Occlusion to Thrombectomy Centers
Authors: Maria Shannon , Mojares Joseph , Zrelak Patricia
Published: January 2025

Background and Purpose:
Early and accurate identification of large vessel occlusion (LVO) stroke is critical to optimizing patient outcomes, particularly in timely endovascular thrombectomy (EVT). Despite existing protocols, challenges remain in ensuring that patients are rapidly identified and appropriately transferred to neurovascular centers. This study aims to review suspected LVO stroke cases to identify patterns in emergency medical services (EMS) activation for transport and subsequent transfer decisions by considering a stand-by EMS approach.

Methods:
A retrospective chart review was conducted for all patients with suspected LVO stroke presenting to the Emergency Department (ED) within 24 hours of last known normal and with the National Institute of Stroke Scale (NIHSS) score of greater than 6 and modified Rankin Scale (mRS) of 0-1 from June 2023 to June 2024.

Results:
Of 48 cases initially identified for potential transfer to a thrombectomy center, only 16 cases had a final diagnosis of LVO stroke. Of these, only 43% (N=7) or 14.5% of the original number of cases were transferred for thrombectomy. Reasons for non-transfer for the nine cases with LVO included no meaningful recovery due to stroke severity, perfusion study mismatch, and the area of clot being too distal for thrombectomy. The median time from patient arrival to ED to EMS activation for transport was 39 minutes. The average EMS arrival time is 32 minutes. For the 32 non-LVO cases. 43% (N=14) did not have an LVO on imaging with cortical signs and symptoms, 38% (N=12) had an intracranial hemorrhage, and 19% (N=6) were stroke mimics. Based on these results, pre-ordering EMS based on initial assessment (NIHSS and mRS) would result in overcalling EMS 85% of the time.

Conclusion:
While re-ordering EMS based on initial assessment (NIHSS, mRS, and opinion of tele-neurologist) has the potential to greatly improve transfer times for patients with LVO stroke, it is not feasible based on the large number of misclassified cases. Additional ED screening tools are required.
Abstract TP61: National Hemorrhagic Stroke Initiative: Ensuring Every Patient Receives Optimal Care
Authors: Abelt Susan , Serdynski Lynn , Luciano Jeanie , Congdon Michelle , Sheth Kevin
Published: January 2025

Background:
Intracerebral hemorrhage (ICH) constitutes 10% of all strokes and is the most fatal and debilitating subtype. Unlike ischemic stroke, treatment strategies for ICH have not advanced as rapidly, resulting in limited adoption of specialized care metrics. Translating current guidelines into actionable performance measures is central to enhancing care delivery and improving ICH patient outcomes.

Objective:
Establish a three-year national initiative focused on promoting ICH data collection and analysis with specific ICH education, model share events, and protocol contribution which is built on existing hospital quality improvement work.

Methods:
In February 2023, expanded data elements and sixteen measures for ICH care adopted from the
Clinical Performance Measures for Adults Hospitalized with Intracerebral Hemorrhage
were added to the American Heart Association's Get With The Guidelines® (GWTG)-Stroke registries. This allowed hospitals to identify gaps and barriers in care with support from AHA staff through training, model sharing, and resource development.

Findings:
The initiative led to a significant increase in data collection entered into GWTG-Stroke registry during 2023. It also identified gaps in care, particularly in
Last Known Well, Baseline Severity Score
documentation
and Time to Anticoagulation Reversal.

Conclusions:
This national initiative allows for hospitals to analyze data, exchange challenges, develop strategies and resources, all aimed at fostering continuous quality improvement in ICH guideline adherence. Enhanced data collection established during the initiative timeframe will prove to strengthen insights into ICH care for years to come.
Abstract TP63: Combining Stress First Aid And The 4-As Models To Improve Resiliency
Authors: Beels Suzanne , McCaffrey Sara , Evans Troy
Published: January 2025

Background and Issues:
A neurovascular intensive care unit (ICU) had a large volume of employee turnover associated with burnout and moral distress. Literature suggested nurses caring for stroke patients experienced significant moral distress and secondary traumatic stress injuries. ICU leadership implemented a combined approach of Schwartz Center Rounds (SCR) Stress First Aid (SFA) and American Association of Critical-Care Nurses (AACN) 4-As methodology to support and improve staff resiliency.

Purpose:
Would employees experience decreased moral distress, improved sense of resiliency, decreased burnout, and decreased turnover through a combined implementation of the SCR SFA and AACN 4-A’s process?

Methods:
SFA and 4-As models were selected because they both aligned with project goals. They guided support for and educated on how to support one another. Models were launched one month apart via computerized learning modules. All employees were educated, but the measures focused on nursing. Techniques used for ongoing educational support included:

-Monthly newsletters

-Self-care and stress reduction tactics

-Awareness of hospital resources, including crisis resources

-Quarterly Mobile Town Hall: Unit rounding with therapy dogs, education, snacks, senior directors, chaplaincy, and employee assistance program director

Results:
The annual employee engagement survey used a numeric rating scale of 0-5. The statement specific to this project was “This facility helps me deal with stress and burnout”. In fiscal year (FY)2021, the ICU scored 2.43. In FY2022, the score improved to 2.53. Unfortunately, the survey question changed in 2023 to “The amount of job stress I feel is reasonable”, so an equal comparison could not be made. The score for FY2023 was 3.06.

Turnover rates decreased from a high of 32.76% to a low of 26.87% one year following implementation.

Conclusions:
Implementation of SFA and 4-As skills improved resiliency and the unit benefited in decreased turnover. Lessons learned included implementing both programs during the onboarding process and leadership role-modeling to support enculturation.

Initially, staff felt awkward approaching one another. Use of case studies would have improved confidence and comfort in approaching peers about their stress level.

A comprehensive list of hospital resources was essential.

Senior Directors played a valuable role in modeling new behaviors, increasing frontline visibility, budgeting, and supporting efforts.
Abstract TP65: Increasing Stroke Symptom Awareness Improves Patient Outcomes
Authors: Prevatte Brooke , Dean Amanda , Hill Carrie , Wilt Erica , Michael Catherine , Guzik Amy , Lycan Sarah
Published: January 2025

Background and Purpose:
In 2023, High Point Medical Center implemented a quality improvement initiative to enhance outcomes for hospitalized patients experiencing strokes. This initiative was created after review of cases entered in a patient event reporting system. Root cause analyses of the reported events identified multiple opportunities for improvement. An interdisciplinary initiative was launched that engaged stakeholders from patient safety, the stroke team, and nursing education. The project team concentrated on implementing hospital-wide strategies aimed at preventing harm by enhancing stroke symptom recognition, stroke alert activations, and the execution of the code stroke protocol for inpatient stroke alerts. The purpose of this quality improvement initiative was to increase the quantity and quality of code stroke activations among hospitalized patients.

Methods:
Patient volumes from 2022 and 2023 were trended in Get with The Guidelines and compared to the Stroke Data Bank. Our intervention consisted of comprehensive education for all clinical staff including symptom recognition, stroke simulations, and empowering nurses to activate stroke alerts immediately upon suspicion of stroke. Interventions were initiated in quarter two of 2023 and continued throughout the year.

Results:
Initial analysis of patient volumes determined that our hospital had fewer recognized inpatient strokes than anticipated for our size. Reported safety events concluded that stroke events were not consistently recognized or implemented in a timely manner. After the intervention, surveys indicated that staff experienced a heightened awareness of signs of stroke and knowledge of their roles in the code stroke process. Inpatient code stroke activations tripled from quarter one to quarter four after the interventions. The number of patients receiving intervention quadrupled by the end of quarter four. Nurses identified stroke symptoms and had gained the confidence to independently activate a code stroke. A culture of stroke advocacy and reporting of events was formed.

Conclusions:
Increasing stroke symptom awareness through symptom recognition, stroke simulation, and empowering nurses to activate stroke alerts improved patient care and outcomes for those who experienced a stroke while hospitalized. Staff recognition of stroke symptoms increased, resulting in more inpatient stroke alerts, thrombolytic administrations, and thrombectomies for acute ischemic strokes.
Abstract TP66: Learning from Dropouts in a Multicenter Stroke Clinical Trial: Experience from the C3FIT (Coordinated, Collaborative, Comprehensive Family-Based, Integrated, Technology-enabled Care) Study
Authors: Cardenas Sandra , Braunlin Jeri , Howard Virginia , Bell Desiree , Commiskey Patricia , Trevino Lisa , Ramirez Amy , Zhang Yu , Rael Erin , Gaines Kenneth
Published: January 2025

Background:
A successful clinical trial requires retention as well as recruitment of subjects. Exploring reasons for dropout can provide insights for application to the design and methods of future long-term stroke trials. The aim of this study is to understand reasons for dropout in a stroke trial.

Methods:
The C3FIT (Coordinated, Collaborative, Comprehensive Family-Based, Integrated, Technology-enabled Care) (NCT04000971) is a multicenter, randomized, single-blinded, Phase III, cluster randomized trial assessing if an Integrated Stroke Practice Unit (ISPU) system of care with 12 monthly home/virtual visits will improve quality of life for stroke survivors compared to standard of care. There are 22 Comprehensive/Primary Stroke Center (CSC/PSC) sites; 12 ISPU and 10 CSC/PSC arm. The ISPU arm provides coordinated care by a nurse and lay health educator. The control arm receives standard of care at 3, 6, and 12 months. Enrollment began 03.03.2020 and monthly visits will end 10.31.2024. Participants who dropped out prior to the 12-month follow-up were asked to give reasons that were classified into themes.

Results:
Of the 1,196 participants enrolled, 67 died, 85 were lost to follow-up, 5 moved away. A total of 105 withdrew, 14 left for other reasons, and 91 dropped out. Those who dropped out did not give a reason (n=52). Of those who did, the most common reason for dropping out was “feeling overwhelmed” (n=27), describing reasons as overwhelmed due to time commitments (n=8) or health reasons (n=14). Two participants reported competing external priorities, while 12 provided various reasons for dropping out, and 12 felt the study did not meet their expectations, Table 1.

Conclusions:
The majority of participants who dropped out of this trial did not provide a reason. Information from those who did provide suggestions indicates improvements could be made in communicating study expectations during the informed consent process along with strategies for minimizing study burden. Protocols should implement a plan to capture reasons for dropout from conversations with participants. Such data could assist personnel across multiple sites in supporting participants to continue in a trial and identify potential study changes to facilitate continued involvement. This information could also assist in recruitment and retention strategies for future clinical trials. Further research is needed to fully address stroke survivors’ reasons for prematurely leaving a clinical trial.
Abstract TP67: Stroke Education in Motion: Education-on-the-Go Posters for Healthcare Professionals
Authors: Okongo Casey , Elkins Kelley , Brown Harold , Sumner Jessica , Zielke Shelly
Published: January 2025

Introduction:
Ongoing staff stroke education is crucial to ensure that stroke knowledge remains current and at the forefront of everyone's minds and is also required for stroke certification. The challenge often is how to continue to meet the education requirements in an effective and timely format. After hearing of a similar initiative shared at a conference, a stroke network in a Midwestern state tried disseminating this education quarterly in a format that would be quick to read and easily digested by the target audience. The goal was to reach as many individuals as possible with valuable education about stroke and improve the quality of care given to stroke patients.

Methods:
An educational poster series was developed, focusing on key aspects of stroke care. Topics covered included early recognition, acute management, hemorrhagic stroke, cerebral venous sinus thrombosis (CVST), etc. Each poster was designed to be visually engaging and included a QR code to lead the participant to an interactive quiz with five content-related questions. After the interactive quiz was attempted, the participant received an email with either a certificate of completion and instruction for obtaining continuing credits or an email with a link to retake the quiz if a passing grade was not achieved.

The posters were developed and sent out once a quarter for the following three disciplines: RN, MD, and EMS. Each poster was designed to take the participant around 30 minutes to digest the information and take the quiz. They were distributed broadly via email, social media posts, and word of mouth.

Results:
From the inception of the posters in the fall of 2023 to the end of the summer of 2024, the Education-on-the-Go offerings have had 619 completed tests from 18 states. The feedback received throughout has been overwhelmingly positive and suggestions for future topics have been beneficial in the planning of ongoing posters.

Conclusions:
In conclusion, interactive stroke education posters with integrated quizzes have proven to be a popular method of distributing stroke education. Future efforts should focus on expanding this education method to other clinical education areas. Research is needed to determine if this method is effective in increasing knowledge and confidence in caring for stroke patients.
Abstract TP68: Streamlining Innovation: A Stroke of Genius in Education
Authors: Kozakowski Kathryn , Okonkwo Natasha
Published: January 2025

Background:
A mandatory educational requirement for nurses and staff at designated stroke centers existed within a health system, but the process varied across sites. Staff selected their own educational content, leading to minimal engagement and irrelevant content. The transition of the electronic health record (EHR) to Within Defined Limits (WDL) further complicated documentation. To address these issues, the Clinical Nurse Specialist (CNS) and the Critical Care Nurse Professional Development Specialist (CC NPDS) collaborated with stakeholders to overhaul stroke education, nursing documentation, and patient care at two hospitals.

Purpose:
The goal was to standardize and streamline stroke education and EHR documentation system-wide, enhance nursing knowledge and improve patient care and outcomes for stroke patients.

Methods:
The NPDS and CNS conducted a current state analysis and gathered feedback about the need for meaningful education and streamlined processes. They developed and refined four core educational modules, incorporated into a back-to-the-basics campaign, and uploaded them to the online platform. They also created over 11 bundles of targeted education, ranging from 2 to 8 hours, specific to various specialties. The core modules were automatically assigned to units based on cost centers, aligning with annual education requirements. A Stroke Symposium in 2/2024, attended by over 100 participants, fulfilled annual stroke education requirements. Concurrently, the CNS worked with informatics to optimize EHR systems and update the Risk Factor activation process for individualization.

Results:
EHR optimizations reduced missed documentation and improved rounding efficiency. The streamlined education process and updated documentation requirements led to a reduction in time spent on documentation and clicks in the EHR. Compliance with stroke documentation improved, as evidenced by randomized chart audits, and stroke identification increased across the health system. Feedback from nurses and unit leadership highlighted the new content's relevance and engagement.

Conclusions:
The successful implementation of standardized stroke education and streamlined documentation has led to its expansion and continuous annual evaluation. The improvements have reduced documentation burdens, optimized the EHR, and allowed nurses to dedicate more time to patient care, enhancing patient outcomes through increased nurse confidence and competence in managing complex stroke cases.
Abstract TP7: Comparison of inflammatory clot markers in higher and lower shear stress environments: is there really that big of a difference?
Authors: Yacoub Simon , Piracha Zain , Suresh Shakthivarrun , Holthaus Blake , Carfora Arianna , Densel Nash , Ilangovan Sowndarya , Wheeler Debra , Cataland Spero , Gumina Richard , Visovatti Scott , Nimjee Shahid
Published: January 2025

Introduction:
Venous thromboembolism (VTE
)
manifesting as deep vein thrombosis (DVT) and pulmonary embolus (PE) and arterial thromboembolism (ATE) manifesting as acute ischemic stroke (AIS) result in ~1 million US deaths annually. Increased levels of circulating inflammatory markers, particularly von Willebrand factor (VWF), may indicate poor outcomes in ATE, but previous studies limit this response to high shear stress milieu. We compared VTE and AIS thrombi inflammatory markers at time of intervention.

Methods:
Clots were harvested from 20 PE, 9 DVT, and 74 AIS patients and immunofluorescent staining completed in duplicate with VWF, plasminogen activator inhibitor 1 (PAI-1), glycophorin A (RBCs), CD42b (platelets), fibrinogen, and neutrophil endothelial trap constituents (NETs). NETs were defined as citrullinated histones (CitH3), neutrophil elastase (NE) and myeloperoxidase (MPO). Clot sections were analyzed with Image J.

Results:
VWF
levels were lower in AIS clots (21.02 +/- 12.02%) compared to DVT (24.87 +/- 12.98%, p=0.0212) and higher in PE (12.21 +/- 5.96%, p=0.0001).
PAI-1
levels were higher in AIS clots (42.80 +/- 16.28%) compared to DVT (27.43 +/- 15.61%, p=0.0001) and lower in PE (51.23 +/- 10.89%, p=0.0016). Although
RBCs
were not significantly different in AIS (35.34 +/- 15.32%) compared to DVT, they were more prevalent in PE (52.93 +/- 8.31%, p=0.0001). Surprisingly, although
platelets
were lower in DVT thrombi (15.30 +/- 12.33%, p=0.0105) compared to AIS (23.06 +/- 13.71%), they were increased in PE (32.70 +/- 8.46%, p=0.0001. Lastly, although there was no difference in DVT thrombi compared to AIS clots,
fibrinogen
(21.307 +/- 8.75%) was lower in PE clots (14.85 +/- 7.56%, p=0.0001), as was
CitH3
(8.42 +/- 10.42% vs 7.03 +/- 4.18%, p=0.0001, and
NE
(31.10 +/- 18.31% vs 37.18 +/- 14.31% in PE, p=0.0025).
MPO
was unremarkable.

Conclusion:
Inflammatory marker levels in AIS vs VTE have a complexity beyond shear stress and offer insights into targeting thrombolytics.
Abstract TP74: Trends in extracranial-intracranial bypass procedure from 2016-2019
Authors: Razavi Seyed Mostafa , Kasper Rachel , Manchanda Monika
Published: January 2025

Introduction:
Extracranial-intracranial (EC-IC) bypass has evolved in recent years with more focus on indications, selection criteria, surgical methods, and postop management. Recent studies observed decreased utilization of EC-IC bypass and increased complications leading up to year 2015. In this study, we aim to study trends in EC-IC bypass throughout the years.

Methods:
Using the National Inpatient Sample 2016-2019, hospital admissions with carotid occlusive disease (COD), moyamoya, subarachnoid hemorrhage (SAH), unruptured intracranial aneurysm (UIA) were identified using ICD-10 diagnosis codes. Trends in ECIC-Bypass utilization, demographic and hospital characteristics, and unfavorable outcome were evaluated for each condition.

Results:
From 2016 to 2019, total number of EC-IC procedures increased significantly by 43% from 740 to 1060 weighted cases. Year after year, an increasing number of procedures were performed in urban teaching hospitals compared to rural or non-teaching hospitals for all indications. The most common indication was moyamoya, accounting for 58.1% in 2016, increasing to 60.8% in 2019. COD was the next common indication, comprising 26.4% in 2016, but slightly decreasing to 25.9% in 2019. Similarly, UIA accounted for 10.8% in 2016, declining to 8.5% in 2019. SAH remained stable at 4.7% in both 2016 and 2019 (Figure 1). Percentage of unfavorable outcome, including death, slightly increased for procedures in moyamoya and SAH cases and slightly decreased for COD and UIA.

Conclusion:
Overall number of EC-IC procedures increased significantly from 2016 to 2019. Urban teaching hospitals performed the increasing majority. Moyamoya was the primary indication for more than half of the procedures, exhibiting an increasing trend over the study period. While SAH did not show any significant changes, the percentage of procedures for COD and UIA decreased. The prevalence of unfavorable outcomes varied among different indications.
Abstract TP75: Trends in Stroke Symptom Onset to Emergency Department Arrival Time in the Greater Cincinnati and Northern Kentucky Stroke Study
Authors: Royan Regina , Stamm Brian , Sucharew Heidi , Robinson David , Haverbusch Mary , Ferioli Simona , Stanton Robert , Aziz Yasmin , LaPorta Joseph , Woo Daniel , Wechsler Paul , Menzies Lauren , Wright Shea , Nobel Lisa , Slavin Sabreena , Walsh Kyle , DeLosRiosLaRosa Felipe , Mackey Jason , Mistry Eva , Demel Stacie , Coleman Elisheva , Jasne Adam , Star Michael , Martini Sharyl , Adeoye Opeolu , Madsen Tracy , Kissela Brett , Kleindorfer Dawn
Published: January 2025

Introduction:
Time from stroke symptom onset to emergency department (ED) arrival (OTA) is an important driver of acute stroke functional outcomes and mortality for both acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH). Acute therapies for AIS are time-sensitive, and there are several recently published time-dependent therapeutic trials for ICH, yet little is known about the patterns of symptom onset to ED presentation over time. We sought to analyze trends and predictors of arrival times for AIS and ICH within the Greater Cincinnati/Northern Kentucky Stroke Study.

Methods:
Patients included those ≥20 years old with physician-adjudicated acute ischemic stroke (AIS) or intracerebral hemorrhage (ICH) from 2010, 2015 and 2020. Study nurses abstracted relevant information from the medical record, including symptom onset and ED arrival times. Median OTA time trends were analyzed for both AIS and ICH using quantile regression and the likelihood ratio test for year. Associations between demographic-, clinical-, and system-factors with early OTA times (less than 4.5 hours) were assessed using logistic regression, stratified by AIS and ICH stroke subtype.

Results:
There were 6466 AIS events and 950 ICH events among patients ≥20 years old who presented to an ED in the time periods studied. Among all patients with AIS, median age was 70 (IQR 59-82), 23% were black and 54% female, and median NIHSS was 3 (IQR 1-7). Median OTA time for all patients with AIS and onset time known was 483 minutes (IQR 105-1170), 30% arrived with an OTA time ≤4.5 hours, although median OTA times significantly increased over time (Figure 1). Among all patients with ICH, median age was 72 (IQR 58-82), 27% were black and 52% female, and median NIHSS was 7 (IQR 1-22). Median OTA time for patients with ICH and onset time known was 248 minutes (IQR 68-685), 42% arrived with an OTA time ≤4.5 hours, and median OTA times did not significantly change over time. EMS use, presenting symptoms of stroke, and greater stroke severity were associated with better arrival times whereas living alone was associated with worse times (Table 2).

Discussion:
Only 33% of AIS and 42% of ICH patients arrive to an emergency department within 4.5 hours of a known symptom onset. Several systems-level factors were associated with onset to arrival times. Understanding why symptom onset to ED arrival times are increasing over time is an important area for quality improvement.
Abstract TP76: Enhancing Thrombolysis Times in Acute Ischemic Stroke with Regional Dashboards: Results from the Florida Stroke Registry
Authors: Del Brutto Victor , Gutierrez Carolina , YING HAO , Gardener Hannah , Veledar Emir , Jameson Angus , Scheppke Kenneth , Sand Charles , Antevy Peter , Hylton Tara , Perue Gillian Gordon , Asdaghi Negar , Rundek Tatjana , Mehta Brijesh , Romano Jose
Published: January 2025

Background:
Reducing the time between ischemic stroke onset and intravenous thrombolysis (IVT) is crucial for treatment effectiveness. Through a grassroots effort, the Florida Stroke Registry (FSR) developed regional dashboards (RDs) displaying reperfusion treatment metrics from hospitals participating voluntarily in local Stroke Coalitions with the goal of improving quality of acute stroke care. We sought to evaluate whether RD utilization is associated with faster IVT treatment times, as well as with improved hospitalization outcomes.

Methods:
We conducted a cross-sectional analysis across the FSR, a statewide registry across Get With the Guidelines-Stroke participating hospitals. We included ischemic stroke cases receiving IVT from January 2016 to December 2023. Cases were categorized by whether they received IVT at hospitals actively participating in the RD initiative or not at their time of treatment. Primary study endpoints were door-to-treatment (DTT) time <20 minutes and onset-to-treatment (OTT) time <60 minutes, while secondary endpoints comprised hospitalization outcomes. Logistic regression models, adjusted for calendar year, patient characteristics, and hospital factors, were used to examine the association between RD utilization and study endpoints.

Results:
Ninety-two out of 172 FSR hospitals participated in Stroke Coalitions and RD by the end of the study period. The analysis included 32,320 IVT-treated cases (mean age 69 ±15 years, 48.4% female). Of these, 10,666 (33%) were treated at hospitals participating in the RD initiative. Regional Dashboards utilization was independently associated with DTT <20 minutes (12.7% vs. 7.3%; aOR=1.48, 95%CI 1.35-1.63) and OTT <60 minutes (13.9% vs. 9.0%; aOR=1.63, 95%CI 1.49-1.80), as well as increased likelihood of being discharged directly to home (aOR=1.15; 95%CI 1.07-1.23) and functional independence at discharge (aOR=1.49; 95%CI 1.39-1.59). Hospitals using RD had better thrombolysis times than non-participating hospitals from their first year in Stroke Coalitions, with further improvements after 3 to 4 years of participation (Figure).

Conclusion:
The FSR RD initiative applied within Stroke Coalitions was associated with faster IVT treatment times and improved hospitalization outcomes. This quality improvement initiative, adaptable to local needs, could emerge as a valuable tool for enhancing stroke systems of care.
Abstract TP77: Evaluating the Efficacy of EMS Integration and CSC Triage in Improving Stroke Patient Outcomes
Authors: Ramage Michael
Published: January 2025

Background and Issues:
Timely diagnosis and treatment are essential for optimal outcomes in acute stroke care. The lack of EMS integration into the stroke system of care is leading to delays in treatment resulting in poor outcomes. The absence of centralized resources at the Comprehensive Stroke Center (CSC) results in delayed patient care and worsened outcomes.

Purpose:
This project aimed to enhance EMS stroke recognition and improve triage to appropriate stroke centers, thereby reducing treatment times. The successful integration of EMS with an optimized CSC triage protocol seeks to reduce hospital stays, mortality rates, direct costs, and long term disability.

Method:
Effective integration of EMS into the stroke system of care was achieved by developing triage protocols with local EMS leaders. Adoption of a standardized stroke triage assessment tool was implemented. Centralizing resources at the CSC was a multidisciplinary approach to streamline the identification and treatment of stroke patients in a definitive location near CT scan. Stroke triage education and mock drills were provided to local EMS agencies and the acute stroke team. Outcomes were measured using pre and post intervention data for TNK administrations and endovascular therapy.

Results:
Outcomes were measured in two groups of acute stroke patients who received TNK, mechanical thrombectomy, or both. 115 patients from 2022 prior to project initiation and 131 patients from 2023 after its initiation. TNK door-to-needle time decreased from 37 to 32 minutes. Thrombectomy door-to-revascularization time dropped from 118 to 85 minutes. Average hospital stay reduced from 8 to 7 days. Mortality rates fell from 13.04% to 3.94%. Direct costs decreased from $27,989 to $24,109. Thrombectomy mortality decreased from 17.14% to 6.06%. 90-day modified Rankin score 2 or less improved from 45% to 49%. Average EMS first contact to revascularization went from 152 minutes to 120 minutes. Average EMS first contact to TNK administration went from 70 minutes to 67 minutes.

Conclusion:
The implementation of standardized EMS triage protocols and centralized resources at the CSC led to significant improvements in acute stroke care. The interventions resulted in faster treatment times, reduced hospital days, lower mortality rates, decrease in direct costs, and improved long-term functional outcomes. These findings highlight the significance of EMS integration and resource centralization to improve patient outcomes.
Abstract TP79: Assessment of Limited English Proficiency on Door To Imaging Time
Authors: Cort Mark , Trang Ivan , Nguyen Courtney , Wang Mengxi , Flake-Rojas Mariel , Cooksey Gail , Carter Caitylnn , Okpala Munachi , Yamal Jose-Miguel , Sharrief Anjail
Published: January 2025

Background:
Ischemic stroke is a medical emergency necessitating prompt neurological evaluation and treatment. Standard of care is an initial CT Head within 25 minutes of patient arrival. Literature has shown that English language proficiency can lead to delays in evaluation by emergency medicine providers. In this study, we evaluate the effect of language preference on door to imaging (DIT) time for patients presenting with strokes symptoms.

Methods:
This was a retrospective study of patients enrolled in the Video-based Intervention to reduce Treatment and Outcome Disparities in Adults Living with Stroke or TIA (VIRTUAL) study from March 2022 to June 2023. Enrolled patients complete a 4-item language preference questionnaire which is used to assessed limited English proficiency (LEP). We used the question “Which language do you prefer for receiving verbal communication about health-related information?” to determine which patients had LEP. Door to CT time was used for DIT. Individual medical records were reviewed and “arrival time” and CT result time was abstracted to calculate DIT. We used Wilcoxon rank sum test to compare door to CT time between patients with and without LEP. We aimed to utilize a multiple linear regression model to evaluate the association between LEP and door to CT time after adjusting for age, sex, race, NIHSS and stroke type.

Results:
We included 152 patients with ischemic stroke, TIA, or hemorrhagic stroke who presented to our ED with stroke symptoms. LEP was found in 23 (15%) of patient. The median DIT for patients with LEP was 42 minutes (mean 100) vs 25 minutes (mean 67) for those without LEP. There was no significant difference between these two times in univariate analysis (p=0.21) or in adjusted analysis (P=0.59).

Conclusions:
This study did not demonstrate a statistically significant difference in median DIT between those who preferred to use English and those who preferred another language. However, this study was limited by small sample size and significant variance in the data set. The next step would be to include additional patients to determine if the signal seen here reflects a true difference in assessment according to language proficiency.
Abstract TP80: Direct Secure Messaging System in a Telestroke Network Streamlines Workflow and Reduces Door To Needle Time
Authors: Hackett Chris , Agostoni Nolan , kaziz hamza , Rana Sandeep , Quezada Timothy , Cerejo Russell , Malhotra Konark , Zulfiqar Maryam , Chandra Rahul
Published: January 2025

Introduction:
Delays in IV thrombolysis (IVT) via telestroke may occur because of limited access to direct communication between providers. A direct secure messaging system between requesting telestroke sites and telestroke physicians may streamline the process.

Methods:
Retrospective analysis of telestroke patients treated with IVT in the emergency department across twenty hospitals between June 2018 and June 2024. A direct secure messaging system was implemented in December 2023, which allowed requesting hospital staff the ability to directly page and message the telestroke physician obviating the need for phone calls to coordinate care. Summary statistics and outcomes compared telestroke notifications via a call center (phone) to a direct secure messaging system (direct message). Patients that developed disabling symptoms after arrival and with missing data were excluded. Primary outcome compared telestroke paging times and secondary outcomes compared page to video and door to needle (DTN) times with quantile (median) regression analyses adjusted for variables identified in univariate analyses: average telestroke volume, age, NIHSS and time of day. DTN time was also adjusted for door to telestroke request times and delays in treating IVT due to hypertension. Subgroup analysis evaluated differences in door in door out time between groups.

Results:
In the seven months after implementing a direct messaging system, 2435 (1739 initial telestroke requests and 696 follow-up communications) messages were sent directly to telestroke physicians from telestroke sites, reducing 3131 calls to and from the call center. A total of 829 patients were treated with IVT during the entire study period and after exclusions, 777 (93.7%) were included in the study. Median paging times via direct message were quicker than via phone by 1.86 minutes [95% Confidence Interval (CI) 1.47, 2.24], p<0.001. Page to video times were similar between groups, median difference was 1.48 minutes [95%CI -0.98, 3.94], p=0.24. Median DTN time in patients paged through direct message was quicker than phone paging by 10.03 minutes [95% CI 5.36, 14.70], p<0.001. The median difference in door in door out times was similar, -1.61 [95% -17.85, 14.63], p=0.85.

Conclusion:
Implementation of a direct messaging system reduced paging and door to needle times. Automating the telestroke paging process reduced call-center burden and facilitated a streamlined process in stroke care across telestroke sites.