bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP106: Bridging the Gap: System of Care Partnerships to Improve Prehospital Diagnostic Error
Authors: Dorsett Maia , Silco Riley , Leonhardt-Caprio Ann , Hodge Devorah , Spatuzzi Janese , Wronski Angelina , evans melissa , Kiehle Katherine , polvino nanette , Sensenbach Benjamin , Johnson Trent , Parker Shelby , Montano-Brooks Melanie , Cushman Jeremy
Published: January 2025

Introduction:
Emergency Medical Services (EMS) play a key role in stroke systems of care. Prehospital stroke recognition is critical, but limited data exchange between prehospital and hospital entities hinders the ability to measure and improve this aspect of stroke care. To measure baseline prehospital stroke recognition and inform quality improvement efforts, we developed a regional collaboration for sharing Get with the Guidelines (GTWG) data with regional EMS leadership.

Methods:
This was a retrospective analysis of GWTG registry data from all hospitals in a single county, including two comprehensive stroke centers (CSC) and two primary stroke centers (PSC) spanning two health systems for quality improvement. Patients were included if they had a diagnosis of ischemic stroke, developed stroke symptoms before hospital admission and arrived by EMS. Percent prehospital stroke recognition was measured across all hospitals. A subset of missed strokes were analyzed for dispatch code, primary impression and assessments performed.

Results:
In 2022-23,1848 ischemic stroke patients were transported by EMS to four hospitals in a single county. 17%(348) of GWTG entries were missing prehospital information and excluded from analysis. Amongst the remaining 1503 patients, stroke was recognized prehospital 75% of the time. Prehospital stroke recognition varied by destination hospital with CSCs having the highest prehospital stroke recognition. Missed strokes brought to one PSC were reviewed to identify common themes. The most common primary impressions were Generalized Weakness (39%), Fall (15%), Altered Mental Status (15%), Nausea/Vomiting (10%) and Dizziness (10%). 41% of patients had a prehospital stroke scale documented (CPSS). The most common prehospital dispatch codes were stroke (23%), fall (16%) and generalized illness (16%). Missed strokes were predominantly localized to the posterior (57%) and frontal (20%) regions. Results have been used to develop regional symptom-based EMS care bundles, standardize EMS feedback, and inform initial and continuing education for EMS clinicians.

Conclusion:
Prehospital stroke recognition varies greatly between destination hospitals with PSCs more likely to receive patients with prehospital diagnostic error. Measuring and improving prehospital stroke recognition requires a regional approach involving bidirectional information sharing and collaboration between hospitals, health systems, and regional EMS leadership.
Abstract WP108: Implementation of a rural severity-based EMS stroke destination protocol improves destination selection for EMS suspected strokes
Authors: Oostema John , Miller Malgorzata , Khan Nadeem , Khan Muhib , Reeves Mathew
Published: January 2025

Background:
Emergency medical services (EMS) routing of stroke patients is challenging in rural settings. To address this, the American Stroke Association (ASA) has developed a template severity-based EMS triage algorithm to direct EMS to either the nearest stroke-ready versus the nearest Comprehensive Stroke Center (CSC) hospital, but its real-world impact is uncertain.

Methods:
This is an interim analysis of a before-and-after quality improvement study examining the impact of implementation of a severity-based EMS stroke destination protocol by three medical control authorities (MCAs) covering 4 rural counties in western Michigan. We defined optimal destination according to the ASA algorithm, which recommends bypass for patients within 24 of last known well if large vessel occlusion suspected and bypass will not delay thrombolysis. Chi square tests were used to compare optimal destination selection before and after implementation among EMS suspected stroke cases originating from the target counties. We also compared the time from EMS scene arrival to ischemic stroke (IS) treatment (thrombolysis or endovascular therapy [EVT]) before and after implementation using Wilcoxon Rank Sum tests.

Results:
From November 2021 to May 2024, EMS transported 616 suspected stroke cases, 272 (44.2%) of which ultimately received a diagnosis of ischemic stroke (IS) or transient ischemic attack. The protocol was implemented by each MCA in random order at months 21, 23, and 29, resulting in 73 MCA-months before and 17 after implementation, excluding a one-month washout for each MCA. Optimal hospital destinations were selected for 310/499 (62.1%) patients prior to the protocol and 86/117 (73.5%) after (p=0.021). Thrombolytics were administered to 57 patients (48 before and 9 after) and 46 (42 before and 4 after) received EVT. Median times from first EMS contact to needle decreased from 98 (interquartile range [IQR]: 79-107) to 77 (IQR: 75-85) minutes (p=0.012); median times from EMS contact to groin puncture increased nonsignificantly from 165 (IQR: 132-216) to 196 (IQR: 191-228) minutes (p=0.110).

Conclusions:
Interim analysis of implementation of a rural EMS severity-based triage algorithm for suspected stroke cases resulted in improved destination selection and faster thrombolysis but did not improve EVT treatment times. This analysis will be repeated once follow-up is completed in 7 months.
Abstract WP115: Influence of Cognitive Factors on Motor Performance Early After Stroke
Authors: Cardoso Ferreira Isabel , Song Min-Keun , Feldman Marc , Brinkman Lorie , Holl Christina , Nguyen Tiffany , Schwarz Anne , Soleimani Nina , Stehman Andrea , Young Brittany , Cramer Steven
Published: January 2025

Background:
Cognitive factors influence motor performance, but often this is not considered when testing motor function. Here we examined this issue using 3 versions of the Box and Blocks Test (BBT), a measure of arm motor function. First, we developed 2 new, briefer versions of BBT and then tested their validity. Second, we hypothesized that cognitive factors would be more strongly related to versions of the BBT that require a longer period of testing.

Methods:
In 71 patients <=30 days post-stroke, 3 BBT versions were scored. BBT60 is the standard one; subjects move as many blocks as possible over a divider in 60 sec. We also counted # blocks moved in the first 10 sec (BBT10) and time to move the first 3 blocks (3-BBT). Other testing included 2 motor scores, Fugl Meyer (FM) and 9-Hole Peg (9HP); and 2 cognitive scores, Trail Making Test-A (TMT-A) and Montreal Cognitive Assessment (MoCA). First, we tested the validity of the briefer BBT versions (3-BBT and BBT10) against BBT60 and FM. Second, we compared all BBT versions to measures of sustained attention (TMT-A) and cognitive function (MoCA). Comparisons used Spearman’s rank correlation coefficient (threshold p<0.05).

Results:
Mean time post-stroke was 13.1±5.9 days; age, 66.9±14.9 yrs; 40.8% female. Median BBT scores: 3-BBT, 17.4 sec; BBT10, 2 blocks; and BBT60, 10 blocks. Other median scores: FM, 36 points, MoCA, 21 points; 9HP, 1 peg in 60 sec; TMT-A, 49.5 sec for 25 targets. Scores on 3-BBT (r=-0.93, p<0.0001) and BBT10 (r=0.95, p<0.0001) showed strong validity with BBT60 scores. Each BBT version, respectively, was related to FM score (r=-0.81, r=0.77, r=0.82; all p<0.0001) and to 9HP score (r=-0.77, r=0.82, r=0.82; all p<0.0001). TMT-A was not significantly related to 3-BBT (r=0.20, p=0.09), but was related to BBT10 (r=-0.24, p=0.04) and BBT60 (r=-0.24, p=0.04). MoCA was not significantly related to 3-BBT (r=-0.15, p=0.21) or BBT60 (r=0.20, p=0.09), but was to BBT10 (r=0.26, p=0.03).

Conclusions:
The 3-BBT and BBT10 are both valid measures of arm motor function in subacute stroke. Each is quicker and more easily assessed than BBT60. The BBT10 and BBT60 were more strongly related to TMT-A, and BBT60 to MoCA, suggesting that these 2 BBT versions are more influenced by attention or cognition compared to 3-BBT. All 3 BBT measures are valid; choice of which to use depends on whether the goal is to measure motor function with less (3-BBT) or more (BBT10 and BBT60) influence of attention or cognitive factors.
Abstract WP122: Readmission to Acute Care from Inpatient Rehabilitation Among Patients with Acute Ischemic Stroke
Authors: Potter Thomas , Borei Karim , Khan Osman , Bako Abdulaziz , Pan Alan , Vahidy Farhaan
Published: January 2025

Introduction:
Inpatient rehabilitation (IR) for patients with Acute Ischemic Stroke (AIS) offers improved functional recovery and quality of life. Readmission (RA) to acute care during IR may compromise this favorable recovery trajectory. We seek to define the factors associated discharge to IR, and RA from IR, after AIS.

Methods:
Data for adult (>18) AIS patients admitted from May 2016-May 2024 were retrieved from the Registry of Neurological Endpoint Assessment among Patients with Ischemic and Hemorrhagic Stroke (REINAH), including demographics, comorbidities, clinical scores, use of endovascular thrombectomy (EVT) and intravenous tissue plasminogen activator (IV-tPA), and discharge dispositions. Separate multivariable logistic regression models were fit to determine factors associated with discharge to IR vs. home (model 1) and IR vs. unfavorable discharge (UD; long-term acute care, skilled nursing facility, hospice, expired, other; model 2). Adjusted odds ratios (aOR) and 95% confidence intervals (CI) are reported. Cox proportional hazard models were fit to determine the hazard of 30-day RA for patients discharged to IR, with adjusted hazard ratios (aHR) and 95% CI reported.

Results:
A total of 18,645 AIS patients were included, comprising 51.2% female and15.7% Hispanic patients with a racial distribution of 65.1% White, 26.0% Black, 5.4% Asian, and 3.5% Other. A total of 3,743 (20.0%) patients discharged to IR, 11,052 (59.3%) discharged home, and 3859 (20.7%) had UD. Of patients discharged to IR, 389 (10.4%) readmitted within 30 days. Across both IR discharge models, patients who were male (aORs: 1.17 [1.08-1.26]; 1.30 [1.18-1.43]), [FV2] had a history of antihypertensive use (1.18 [1.04-1.34]; 1.27 [1.08-1.51]), and received EVT (2.02 [1.70-2.40]; 2.05 [1.70-2.46]) were more likely to discharge to IR (vs. home or UD) (Figure 1). Consequently, patients who were self-pay (vs. Medicare, 1.17 [1.08-1.26]; 1.30 [1.18-1.43]) or on Medicaid (1.17 [1.08-1.26]; 1.30 [1.18-1.43]) had lower odds of discharge to IR (vs. home or UD). Among patients discharged to IR, those aged 60-69 years (vs. < 60) (aHR: 1.55 [1.04-2.32]), 70-79 years (1.70 [1.09-2.63]), with peptic ulcer disease (1.76 [1.18-2.62]) and atrial fibrillation (1.52 [1.17-1.97]) had higher odds of RA (Figure 2).

Discussion:
Males and patients receiving EVT were more likely to discharge to IR, while those with peptic ulcer disease and atrial fibrillation who discharged to IR faced a greater risk of RA.
Abstract WP130: Sexual Dysfunction Education and Treatment Post Stroke
Authors: Sudduth Heather
Published: January 2025

Introduction:
Over half of stroke patients experience sexual dysfunction as a result of an ischemic or hemorrhagic stroke. Stroke survivors establish that sexual activity and sexual expression are fundamental activities of daily living. Yet, sex education and treatment are not a primary component of post-stroke treatment and rehabilitation. The purpose of this research is to validate the need for sexual dysfunction education and treatment following a stroke and to identify and address barriers to receiving the needed education.

Methods:
Interviewed local stroke survivors and their significant others. Interviewed interdisciplinary in-patient and out-patient treatment team members including physicians, nurses, occupational therapists and physical therapists. Compared the stroke survivors’ post-stroke deficits to the education received from healthcare providers. Researched sexual dysfunction educational resources available for both healthcare providers and stroke survivors. Researched importance of sexual activity and sexual expression to a person’s quality of life.

Results:
Seventy-six percent of people age 57 - 80 believe that sex is an important aspect of a romantic relationship. Greater than 50% of stroke survivors experience sexual dysfunction. Healthcare providers seldom provide education on sexual dysfunction following a stroke because of limited resources, prioritizing other functional limitations (feeding, dressing, mobility) and a reluctance to discuss.

Conclusions:
In conclusion, sexual dysfunction education and treatment are essential to the quality of life of stroke survivors and their significant others. Despite sexual activity and sexual expression being a fundamental activity of daily living, education and treatment for sexual dysfunction following a stroke is very limited. Effective educational materials and training will empower healthcare providers to successfully address sexual dysfunction and improve their patients’ quality of life.
Abstract WP133: Mapping the cerebral structural changes related to the multi-dimensional neuropsychiatric deficits in patients with ischemic thalamic stroke
Authors: li congjun , Ye Chen , Pan Ruosu , Yan Yuying , Jiang Shuai , Cao Le , Wu Bo
Published: January 2025

Background:
Ischemic thalamic stroke often leads to cognitive and emotional dysfunctions, yet the link between these deficits and structural brain changes remains unclear. This study explores the association between gray matter volume alterations and neuropsychological assessments in ischemic thalamic stroke patients, aiming to elucidate the structural basis of neuropsychiatric deficits.

Methods:
Patients with first-time unilateral ischemic thalamic stroke were recruited from West China Hospital, Sichuan University (October 2021 - December 2023). Inclusion criteria included MRI-confirmed diagnosis, subacute phase (7 days to 1 month), completion of cognitive and structural MRI evaluations, and informed consent. MRI scans were processed using CAT12 and SPM12. Cognitive assessments included MoCA-BJ, STT, Stroop, and CAVLT tests; psychological status was evaluated using HAMA and HAMD scales. Partial Least Squares (PLS) regression analyzed the relationship between gray matter volume (170 ROIs) and neuropsychological scores (11 indicators). Data were standardized, with the optimal number of components determined by MSE using 5-fold cross-validation. Model performance was assessed using R2.

Results:
PLS regression revealed significant associations between gray matter volume and neuropsychological outcomes. The optimal number of components was determined to be two through 5-fold cross-validation, with the model showing good fit as indicated by the R2 and residual plots. Specific brain regions, including the Left Inferior Parietal Gyrus (lIPG), Right Cerebellar Lobule VI (rCER6), and Right Cerebellar Crus I (rCERCRU1), were significantly associated with cognitive and emotional assessment scores. VIP scores and loading matrix analyses highlighted these regions as key areas.

Conclusions:
This study, using PLS regression, identifies significant relationships between gray matter volume changes and neuropsychological assessments in ischemic thalamic stroke patients. Key regions such as lIPG, rCER6, and rCERCRU1 are closely linked to cognitive and emotional functions, including attention, spatial cognition, memory, and emotional regulation. These findings provide critical insights into the structural basis of neuropsychiatric deficits post-stroke and support the development of personalized rehabilitation strategies. Future research should validate these regions' roles across rehabilitation stages and explore targeted interventions.
Abstract WP139: Telestroke service for Endovascular Stroke Treatment in Canada: Results from the OPTIMISE Registry
Authors: Tarek Mohamed , Catanese Luciana , Mandzia Jennifer , Shankar Jai , Tkach Aleksander , Shoamanesh Ashkan , Sharma Mukul , Stotts Grant , Katsanos Aristeidis
Published: January 2025

Background:
Telestroke allows rapid assessment of patients presenting with acute stroke symptoms for intravenous thrombolysis or endovascular thrombectomy (EVT). Although the safety and efficacy of telestroke services for the delivery of intravenous thrombolysis has been well established, evidence on EVT decision-making is scarce.

Methods:
We analysed data from OPTIMISE, a quality improvement registry to support EVT implementation in Canada. We assessed for unadjusted differences in baseline characteristics, time metrics, and procedural outcomes between patients transferred for EVT who received telestroke consultation and those who didn’t receive the service. We used mixed-effects logistic regression models to compare the likelihood for symptomatic intracerebral hemorrhage (SICH), good functional outcome (defined as a modified Ranking Scale score of 0-2), or all-cause mortality at 90 days between the two groups. All models were adjusted for predefined confounders and participating centre.

Results:
Patients receiving telestroke consultation (n=997; 15%) had higher rates of carotid terminus occlusion (23.9% vs. 14.3%), but similar rates of M1-MCA and basilar occlusion compared to patients not receiving telestroke consultation (n=5,561). Patients receiving telestroke consultation had longer onset-to-door time (300.5 vs. 175 minutes) and onset-to-groin puncture time (344 vs. 233 minutes), but shorter door-to-groin puncture time (40 vs.70 minutes) compared to those not receiving telestroke consultation. No differences in groin puncture to reperfusion times, successful reperfusion rates, or adverse periprocedural events were found between the two groups. In the unadjusted analyses patients receiving telestroke consultation had higher rate of SICH (6.5% vs 3.1%), a lower rate for good functional outcome at 90-days (35.6% vs. 40.6%) and higher rate for all-cause mortality at 90 days (39.9% vs. 27.5%) compared to those not receiving telestroke consultation. Those differences were eliminated in the adjusted analyses.

Conclusion:
Patients receiving telestroke consultation prior to EVT have prolonged treatment times and worse outcomes, compared to patients that did not receive telestroke consultation prior to EVT. The higher risk for unfavorable outcomes was eliminated after adjustment for confounders, including treatment time. There is a need for quality improvement initiatives to optimize the workflow of patients receiving telestroke consultation prior to EVT.
Abstract WP142: A Framework for Developing Prehospital Intracerebral Hemorrhage Recognition Scales and Technologies
Authors: Taleb Shayandokht , Hsu Jamie , Saver Jeffrey
Published: January 2025

Introduction:
INTEREACT 4 demonstrated lowering blood pressure in the prehospital setting improves outcomes for patients with intracerebral hemorrhage (ICH) but worsens outcomes for acute cerebral ischemia (ACI). Consequently, hyperacute antihypertensive therapy could potentially aid prehospital patients identified as likely having ICH by clinical scales and helmet technologies. The diagnostic performance characteristics needed to yield net benefit have not been well-delineated.

Methods:
We modeled net treatment benefit and harm using magnitude of beneficial and adverse effects of BP lowering in INTERACT 4 with a 2-stage algorithm. In stage 1, we continuously varied prehospital diagnostic test sensitivity, specificity, disease prevalence, with output of positive predictive values (PPVs) for ICH. In stage 2, PPVs were converted to net treatment effect using INTERACT 4 outcomes.

Results:
The results of the stage 1 PPV module are shown in Figures 1 and 2, with continuous variation of specificity (1) and sensitivity (2) at different biologically plausible levels of ICH prevalence for Western and Asian populations. PPV is more strongly influenced by test specificity than test sensitivity. At sensitivity 80% and specificity of 80%, as prevalence varied from 20%, 30%, 40%, 50%, PPVs were 50%, 63%, 73%, and 80%. The results of the stage 2 mRS outcomes module are shown in Figure 3 for the endpoint of functional independence (mRS 0-2). With PPVs below 30%, treating test-positive patients with BP lowering resulted in net decrease in mRS 0-2 outcome but with PPVs above 30%, treating test positive patients results in net increase in mRS 0-2 outcome, with benefit magnitude increasing as PPV increased. To achieve the minimally clinically important difference (MCID) in mRS 0-2 increase of value to patients of 1.3%, test PPV is 39% or higher. To achieve the MCID that would be practice-changing of 5%, test PPV is 67% or higher. At test PPV of 90%, the mRS 0-2 increase would be 8.2%.

Conclusion:
This model provides a framework for developing prehospital ICH recognition instruments by profiling BP-lowering treatment effects associated with test performance and biologically plausible disease prevalence. Prehospital tests that yield PPVs for ICH of 67% or higher would be associated with treatment benefit magnitudes traditionally considered sufficient to change practice.
Abstract WP150: Gender Differences in Acute Ischemic Stroke Outcomes within a Tele-Stroke Network: A Retrospective Cohort Study
Authors: Musmar Basel , Roy Joanna , Abdalrazeq Hammam , Sizdahkhani Saman , Koduri Sravanthi , Atallah Elias , Karadimas Spyridon , Gooch M. Reid , Rosenwasser Robert , Jabbour Pascal , Tjoumakaris Stavropoula
Published: January 2025

Background:
Stroke is a leading cause of death and disability globally, with timely intervention being critical to improving patient outcomes. Tele-stroke networks have been developed to bridge the gap in stroke expertise, particularly in rural areas where multidisciplinary stroke care is scarce. This study aims to compare stroke outcomes between male and female patients within a large tele-stroke network.

Methods:
We conducted a retrospective analysis of 7,947 patients who were evaluated for acute ischemic stroke symptoms via a tele-stroke network encompassing a hub and 38 spoke centers. Baseline characteristics, treatment details, and outcomes were compared between male (n=3,513) and female (n=4,434) patients. Statistical analyses included Chi-square tests for categorical data and Mann-Whitney U tests for continuous variables, with a significance threshold of p < 0.05.

Results:
The median age was significantly higher in females (70 years, IQR: 55-82) compared to males (66 years, IQR: 56-78) (p < 0.001). True stroke diagnosis was more prevalent in males (82.4%) than females (80.2%) (p = 0.01). The recommendation for tissue plasminogen activator (tPA) was similar between genders (p = 0.08), but males were more likely to receive tPA (14.7%) compared to females (13%) (p = 0.05). Mechanical thrombectomy was performed in 2.3% of patients with no significant difference between genders (p = 0.96). The median time from last known normal to tPA administration was slightly longer in males (120 minutes) compared to females (107.5 minutes) (p = 0.17). Hemorrhagic transformation occurred in 8.2% of patients, with no significant gender differences. The median length of hospital stay was 4 days for both genders, and the NIHSS score at discharge showed no significant difference (p = 0.93).

Conclusion:
Our study highlights subtle yet important differences in stroke treatment outcomes between male and female patients within a tele-stroke network. While tPA administration was more common in males, the overall outcomes, including the length of stay and NIHSS at discharge, were similar between genders. These findings highlight the importance of individualized treatment approaches in stroke care, particularly in the context of telemedicine, where rapid decision-making is vital.
Abstract WP158: Socioeconomic Influences on Stroke Outcomes: A Comprehensive Zip Code-Based Hospital Analysis
Authors: Musmar Basel , Roy Joanna , Abdalrazeq Hammam , El Hajj Victor Gabriel , Atallah Elias , Tjoumakaris Stavropoula , Gooch M. Reid , Rosenwasser Robert , Tzeng Diana , Dharia Robin , Jabbour Pascal
Published: January 2025

Objective:
Socioeconomic disparities significantly affect the treatment and outcomes of cardiovascular and cerebrovascular diseases, including acute ischemic stroke. This study evaluates the impact of socioeconomic status (SES), determined by residential ZIP codes, on stroke outcomes in patients undergoing mechanical thrombectomy.

Methods:
This study is a retrospective analysis based on a prospectively maintained database of 697 patients who underwent mechanical thrombectomy between 2016 and 2023. ZIP codes were retrospectively added to the database to determine socioeconomic status (SES). SES was assessed by matching patient ZIP codes to median household income data from the Census for the years 2016-2022. Baseline characteristics, stroke characteristics, procedural details, and outcomes were collected. Patients were stratified into income quintiles (Q1: $14,658–$52,635; Q2: $52,905–$64,046; Q3: $64,140–$77,737; Q4: $78,449–$95,128; Q5: $95,231–$217,674). Multivariate regression was conducted to identify predictors of good functional outcomes (mRS 0-2).

Results:
The study included 697 patients representing 270 zip codes mostly from the states of Pennsylvania and New Jersey, distributed across income quintiles as follows: Q1 (n = 140), Q2 (n = 142), Q3 (n = 138), Q4 (n = 138), and Q5 (n = 139). Significant racial differences were observed between income quintiles, with a higher proportion of African-American patients in Q1 (40.7%) compared to Q5 (19.9%; p < 0.001), and more white patients in Q5 (82.7%) compared to Q1 (47.1%; p < 0.001). The Onset to arterial puncture time was longer in Q1 (369 minutes) compared to Q5 (258 minutes; p = 0.004). There were no significant differences in stroke outcomes such as successful recanalization (TICI 2b-3), hemorrhagic transformation, median NIHSS score on discharge, 30-day readmission, disposition to home, or length of stay between Q1 and Q5. SES was not a significant predictor of good functional outcomes (mRS 0-2).

Conclusion:
This study found no significant differences in stroke outcomes between low SES and high SES patients undergoing mechanical thrombectomy for acute ischemic stroke. Patients from higher SES had a shorter duration from stroke onset to arterial puncture, and there was a tendency though not significant for higher SES patients to have a higher rate of 30-day readmission, and higher rate of discharge to home. Further research is needed to confirm.
Abstract WP167: Posterior Circulation Stroke is Associated with Increased Risk of Misdiagnosis as Compared to Anterior Circulation Stroke in a Multistate Cohort
Authors: Farnes Kara , Zhang Cenai , Navi Babak , Razzak Junaid , Kamel Hooman , Liberman Ava
Published: January 2025

Background:
Small studies have found that patients presenting with posterior circulation ischemic strokes are more likely than patients with anterior circulation strokes to suffer a missed or delayed diagnosis in the ED. We evaluated whether probable ED stroke misdiagnosis was more common among patients subsequently hospitalized with anterior versus posterior circulation acute ischemic strokes using a large, multistate cohort.

Methods:
We conducted a retrospective cohort study using administrative claims data from the Healthcare Cost and Utilization Project on all hospital admissions and ED visits across 11 states from 2016-2021. To identify patients with a probable ED misdiagnosis, we identified stroke patients with an ED visit for a neurological complaint resulting in discharge to home (treat-and-release visit) in the 7 days preceding hospitalization for ischemic stroke. We used validated International Classification of Disease, Tenth Revision, Clinical Modification codes to identify stroke patients with anterior or posterior circulation strokes. We used logistic regression to determine the odds of misdiagnosis depending on stroke location adjusting for demographics and vascular risk factors.

Results:
We identified 264,705 ischemic stroke patients with a documented territory of brain infarction; 191,689 (72%) had anterior circulation stroke, 63,697 (24%) had posterior circulation stroke, and 11,319 (4%) had stroke involving both territories. Based on preceding ED treat-and-release visits, 1,116 (0.58%) patients with anterior circulation stroke, 944 (1.48%) patients with posterior circulation stroke, and 82 (0.72%) with stroke involving both territories had a probable ED misdiagnosis. After adjusting for demographic and vascular risk factors, posterior circulation strokes had a higher odds of probable ED misdiagnosis relative to both anterior (adjusted OR, 2.44; 95% CI, 2.23-2.66) and mixed territory cases (adjusted OR, 2.03; 95% CI, 1.62-2.55).

Conclusions:
Patients with posterior circulation stroke are over two times as likely to have a probable misdiagnosis in the week preceding their hospital admission relative to patients with anterior circulation stroke. These data highlight a disease of high diagnostic uncertainty and an opportunity for stroke quality improvement.
Abstract WP180: Carotid Web Diagnostic Pitfalls
Authors: Balali Pargol , Guggenberger Konstanze , Shakibajahromi Banafsheh , Sakai Yu , Voleti Sriharsha , Song Jae , Kasner Scott , Messe Steven
Published: January 2025

Introduction:
Carotid webs (CW) are rare shelf-like filling defects arising from the posterior wall of the internal carotid artery (ICA) bulb and are reportedly associated with a high risk of recurrent stroke, particularly in young patients. Limited awareness and understanding of CW make diagnosis and clinical research challenging.

Methods:
We searched the radiology database from 6 hospitals within a health system between January 2021 and June 2024 for reports that included “web” in the diagnostic impression. These were reviewed by two experienced raters to determine whether a CW was present based on previously published criteria. Discrepancies were resolved by consensus with a third rater (a neuroradiologist or a stroke neurologist). Cases were categorized as confirmed, possible, or no CW (Figure 1). Confirmed CWs were defined as a shelf-like, thin, linear filling defect on the posterior wall of the ICA bulb within 3cm of the bifurcation, visible as a septum on axial view, and without calcification/atherosclerotic plaque adjacent to the filling defect on multiplanar reconstruction view. Possible CWs were defined as filling defects 3-4.5cm from the bifurcation, not on the posterior wall, not seen on the axial view, or accompanied by atherosclerotic plaque/calcification in the proximity of the suspected web. The remaining cases were classified as no CW. Baseline characteristics of those with confirmed CWs were compared to the remainder.

Results:
Of the 373 patients screened, 233 were reviewed. Of these, 102 (44%) were classified as confirmed CW, 66 (28%) as possible CW, and 65 (28%) as no CW (Figure 2). Patients with confirmed CW were younger, predominantly female, and they were less likely to have history of hypertension and diabetes mellitus compared to those in the possible CW and no CW groups (Table 1). Confirmed webs were numerically most commonly associated with Black/African American race.

Conclusions:
Our findings underscore the need for standardized definitions for the diagnosis of carotid webs, as less than half of the webs suspected on radiology reports met the criteria established in the literature. Establishing consistent criteria is essential for further investigating the natural history and designing clinical trials for this reportedly high-risk disorder.
Abstract WP21: The novel target and mechanism of clinically used Edaravone dexborneol for ischemic stroke in China
Authors: Zhang Huiling , Cao Ruiqi , Chen Wei , zhou hui , Du Huaping , Xu Yuan , LIU YUAN
Published: January 2025

Background and Purpose：
Increasing evidence has shown that lipid metabolism disorder and oxidative stress play crucial roles in pathogenesis of ischemic stroke, both of which are closely related to ferroptosis. Edaravone dexboneol (Eda.B) is clinically used in China for acute ischemic stroke management as a brain protectant. It consists of two ingredients, edaravone and (+)-dexborneol, exerting antioxidant, free radical scavenging, and anti-inflammation. This study aimed to identify their respective specific targets and to elucidate molecular mechanisms underlying their synergistically anti-ischemic stroke effects.

Methods:
Ischemic stroke was induced in Male C57BL/6 mice by transient middle cerebral artery occlusion (tMCAO). Mice was injected intravenously with Eda.B upon reperfusion and then each day for consecutive 14 days. Neuroprotective effect, glial scar formation and pro-inflammatory factors levels, lipid droplets (LDs), lysosomal and mitochondrial damage were assessed. The click chemistry was applied for lysosomal heat shock protein (Hsp70) and mitochondrial voltage-dependent anion channel 2 (VDAC2) palmitoylation. The surface plasmon resonance (SPR) and biotin probe labelling and computer molecular docking were used to detect the respective target for Edaravone and dexboneol.

Results:
Eda.B protects neuronal cell death, and inhibits glial scar and neuroinflammation. Mechanistically, edaravone and dexboneol synergistically suppress astrocytic ferroptosis pathway and lipid metabolism disorder. Among these two components: edaravone reverses OGD/Re-induced astrocytic lipid disorder via targeting activation of mitochondrial carnitine o-palmitoyltransferase 1A (CPT1A), thereby reducing LDs accumulation and LDs-mediated Hsp70 and VDAC2 palmitoylation, protecting lysosomal and mitochondrial damage; Dexborneol targets activation of antioxidant enzyme PRDX1, which can suppress the OGD/Re-induced NLRP3 inflammasome activation and inflammation. We unexpectedly found that CPT1A can bind to and activate PRDX1. Edaravone activating CPT1A promotes the interaction between CPT1A and PRDX1, further enhancing PRDX1 activation, producing synergistically effect with dexborneol in antioxidant and anti-inflammation.

Conclusions:
This study demonstrates for the first time that CPT1A and PRDX1 are the key targets for edaravone and dexboneol, respectively. These two drugs enhance the interaction between CPT1A and PRDX1, causing synergistically anti-ischemic stroke effects.
Abstract WP22: Shift to Tenecteplase: One Year Real World Experience Of Rural South Carolina Tele-Stroke Network
Authors: Vorobyev Alexander , Buciuc Marina , Jacks Kevin , Blake Christina , Cobiella Marrissa , Al Kasab Sami , Holmstedt Christine , Mohamed Ghada
Published: January 2025

Background:
While alteplase (tPA) remains the only FDA-approved thrombolytic for acute ischemic stroke (AIS), emerging data suggest that tenecteplase (TNK) offers similar safety and efficacy, with potential superiority in large vessel occlusion (LVO) cases. Our academic institution is a statewide telestroke network hub which implemented system-wide shift from tPA to TNK in August 2023. This study reports on the real-world experience of this transition in rural South Carolina within primary and telestroke centers.

Methods:
This retrospective study analyzed prospectively collected data from our institution’s telestroke network (1 Hub, 16 spoke centers) for confirmed AIS patients treated with thrombolytics between 2022 and 2024. We compared outcomes between patients treated with tPA or TNK, with subgroup analyses for LVO and spoke center patients. The analysis focused on treatment times, safety, and functional outcomes. Data are presented as n (%) or median (IQR) for categorical and continuous variables, with p-values calculated using the Wilcoxon and Fisher’s exact tests.

Results:
Among 1644 patients diagnosed with AIS, 302 patients (18%) received thrombolytic therapy; 144 (47.7%) received TNK and 158 (52.3%) received tPA. There was no statistical difference in baseline characteristics between both groups. Door-to-needle times were similar: 45 min IQR (32-66) vs. 42 min (30-66), p=0.6. There were no significant differences in symptomatic hemorrhagic transformation (4.2% vs. 1.9%, p=0.32), discharge NIHSS scores, or hospital length of stay. Subgroup analysis of spoke center patients showed comparable safety, treatment times, and outcomes. Among LVO patients treated at the institution’s Hub, there was no difference in door-to-groin time for MT: 78 min (55-106) vs. 79 min (52-103), p=0.9. TNK patients had fewer MT passes (1[1-2] vs. 2 [1-3], p=0.04) and similar successful reperfusion rates TICI 2b-3 (96.1% vs 91.3%, p=0.4) and pre-MT spontaneous recanalization rates (p=0.6). TNK-treated LVO patients were more likely to be discharged with mRS ≤3 (75.4% vs. 54.4%, p=0.02).

Conclusions:
The transition to TNK in the South Carolina Telestroke network was associated with similar safety profiles and treatment times with notable improvements in procedural efficiency and functional outcomes for patients with LVO. These findings support the broader adoption of TNK as a viable alternative to tPA in acute ischemic stroke management, particularly in telestroke networks.
Abstract WP231: The Temporal Trends in the Burden of Intracerebral Hemorrhage in a Developing Middle Eastern Country Over 3 Decades
Authors: Abdulelah Zaid , Abdulelah Ahmed , Al-Dqour Mohammad , Al Husni Abdel-Rahman
Published: January 2025

Introduction:
Intracerebral hemorrhage (ICH) imposes a significant health burden due to the associated morbidity and mortality. Evaluation of the burden of ICH, and the temporal trends of this burden, is of paramount significance in determining the shifting paradigms and in the introduction of effective measures at both, preventative and therapeutic levels, particularly in developing Middle Eastern nations with limited resources such as Jordan.

Methods:
The burden of ICH in Jordan over the period 1990-2019 was evaluated by initially retrieving relevant data, including age-standardized rates per 100,000 persons, regarding the mortality, incidence, prevalence, disability-adjusted life years (DALYs), and years lived with disability (YLDs) from the Global Burden of Disease database. Temporal trends were evaluated by calculating the Annual Percent Change (APC) and Average Annual Percent Change (AAPC) using Joinpoint Analysis software.

Results:
An estimated total of 20,294 ICH-related mortalities with a female predominance of approximately 52.7% were reported in Jordan over a span of around 30 years. There is an overall decline in ICH-related age-standardized mortality rate with an AAPC of -3.36 (95CI% -3.45 to -3.26; p<0.0001). Stratification by sex demonstrated a statistically significant decline in both males and females, with the latter having a more prominent decline in age-standardized mortality rates with an AAPC of -3.59 (95CI% -3.88 to -3.27; p<0.0001), whereas males had an AAPC of -2.82 (95%CI -2.87 to -2.77; p<0.0001). In terms of age-standardized prevalence and incidence rates, statistically significant declines were also noted with the age-standardized incidence rate witnessing an AAPC of -2.31 (95%CI -2.33 to -2.29; p<0.0001) and the age-standardized prevalence rate witnessing an AAPC of -1.57 (95CI% -1.59 to -1.56; p<0.0001). A total of 739 thousand DALYs were attributable to ICH in Jordan over the 30 years. However, A statistically significant decline in age-standardized DALY rate was noted with an AAPC of -3.76 (95%CI -3.83 to -3.68; p<0.0001). A significant decline was noted in the age-standardized YLD rate with an AAPC of -1.54 (95%CI -1.56 to -1.52; p<0.0001).

Conclusion:
In conclusion, the burden of ICH in Jordan has been witnessing a progressive decline over the period of 3 decades. This can be attributed to better access to care, but comparison to neighboring countries is warranted to identify the driving factors behind this decline.
Abstract WP248: Endovascular Thrombectomy for Acute Ischemic Stroke in Anticoagulated Patients
Authors: Adachi Kaho , Raymundo Allison , Sanchez Anthony , Sadeh Morteza , Mehta Ankit
Published: January 2025

Introduction:
Endovascular thrombectomy (EVT) is effective in treating acute ischemic stroke, with research showing improved functional outcomes compared to medical treatment alone. Oral anticoagulants (OAC) are often prescribed for stroke prevention. In such a population, the safety and efficacy of EVT remain uncertain, with emphasis on the risk of intracranial hemorrhage (ICH).

Method:
We searched Pubmed, Cochrane, and Embase from 2015 to August 2024, which compared EVT in OAC and Non-OAC patients with acute ischemic stroke. Safety outcomes included ICH and 90 days mortality. Efficacy outcomes included successful reperfusion rate and 90 days functional outcome. Subgroup analysis included comparing Vitamin K antagonist (VKA) and direct oral anticoagulant (DOAC); any OAC with intravenous thrombolysis (IVT), for patients deemed appropriate, and without IVT.

Result:
We identified 998 potential records and 15 met the final inclusion criteria (n = 49, 272). Subgroup analysis revealed no significant difference in ICH rate comparing VKA to Non-OAC (RR 1.03, 95% CI [0.85, 1.25]) and DOAC to Non-OAC (RR 1.05, 95% CI [0.75, 1.46]). No significant differences were seen in reperfusion rate (RR, 1.01, 95% Cl [0.98, 1.05] and RR, 1.01, 95% Cl [0.98, 1.04]) and functional outcomes (RR, 0.88, 95% Cl [0.75, 1.03] and RR, 1.06, 95% Cl [0.99, 1.14]) for VKA and DOAC. 90 days mortality showed a significantly increased rate of mortality in VKA compared to Non-OAC (RR, 1.34, 95% Cl [1.03, 1.74]) while no difference was seen with DOAC (RR, 0.86, 95% Cl [0.45, 1.66]). For EVT with IVT compared to EVT alone, no difference was seen in ICH (RR, 1.03, 95% Cl [0.90, 1.18] and RR, 1.33, 95% Cl [0.84, 2.12]), reperfusion rate (RR, 0.99, 95% Cl [0.97, 1.02] and RR, 1.01, 95% Cl [0.94, 1.09]), or functional outcome (RR, 0.91, 95% Cl [0.79, 1.04] and RR, 0.87, 95% Cl [0.66, 1.14]). 90 days mortality was significantly greater in OAC compared to Non-OAC for the EVT + IVT; though not significant, the OAC mortality rate was higher than Non-OAC for EVT alone (RR, 1.23, 95% Cl [1.02, 1.48] and RR, 1.23, 95% Cl [0.94, 1.63]).

Conclusion:
EVT in OAC patients is generally safe and effective in treating acute ischemic stroke as no difference was seen in ICH rate or functional outcomes. However, VKA or IVT in OAC patients was associated with a higher rate of mortality after EVT. The future guidelines should focus on DOAC as the primary stroke prevention and avoid IVT in any anticoagulated patients.
Abstract WP25: Efficacy of Edaravone Dexborneol in Real-World Patients With Minor Acute Ischemic Stroke
Authors: Ma Gaoting , Zuo Yingting , Mo Ran , Wu Yifan , Lei Shaoyuan , Wu Yue , Jiang Ziying , Zhang Qian
Published: January 2025

Background:
Edaravone dexborneol is a novel cytoprotective agent widely used for acute ischemic stroke patients in clinical practice in China. It is unclear whether minor stroke patients benefit from edaravone dexborneol treatment.

Methods:
The present analysis was a post hoc analysis based on a prospective, multicenter EXPAND (The Effectiveness and Safety of Edaravone Dexborneol in Acute Ischemic Stroke) cohort study which conducted at 72 hospitals in China between December 2022 to October 2023. Inclusion criteria included patients diagnosed as acute ischemic stroke, aged 18 years or older, National Institutes of Health Stroke Scale [NIHSS] score ≤5, within 14 days of acute ischemic stroke, and modified Rankin Scale score of 0-1 prior to onset. Patients were divided into two groups (edaravone dexborneol or no edaravone dexborneol). The primary outcome was excellent functional outcome, defined as a modified Rankin Scale score of 0 or 1 at 90 days. The secondary outcome was the score on the modified Rankin Scale (range, 0 to 6 points, with higher scores indicating greater disability) at 90 days. Data were analyzed using multivariate regression after adjusting for the potential confounding factors. Furthermore, we performed a 1:1 propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) analysis to assess the robustness of the results.

Results:
A total 2 608 patients were included in this analysis. Overall, the median age of patients was 65 years old (interquartile, 56-72), and 1748 (67.7%) were men. Of these, 1838 were treated with edaravone dexborneol and 770 were not. At 90 days, 79.8% of patients in the edaravone dexborneol group and 74.4% of patients in the no edaravone dexborneol group had an excellent functional outcome (adjusted odds ratio, 1.31; 95% CI, 1.06-1.62). The median 90-day modified Rankin Scale score was 1 (interquartile, 0-1) in the edaravone dexborneol group and 1 (interquartile, 0-2) in the no edaravone dexborneol group (adjusted common odds ratio, 1.32; 95%CI, 1.12-1.54). The results were consistent in 1:1 PSM and IPTW analysis.

Conclusions:
Among patients with minor stroke, edaravone dexborneol was associated with higher odds for excellent functional outcome, as compared with no use.
Abstract WP250: Post-thrombectomy subarachnoid hemorrhage: incidence, predictors, clinical relevance, and effect modulators
Authors: Chen Huanwen , Colasurdo Marco , Khunte Mihir , Malhotra Ajay , Gandhi Dheeraj
Published: January 2025

Background:
Subarachnoid hemorrhage (SAH) following endovascular thrombectomy (EVT) is a poorly understood phenomenon, and whether it is associated with clinical detriment is unclear.

Methods:
This was an explorative analysis of a national database of real-world hospitalizations in the United States. Patients who underwent EVT were included. Patients were divided into SAH and non-SAH groups, and hospitalization outcomes were compared using multivariable logistic regression models. Regression models were also used to identify significant predictors for post-EVT SAH, and significant modulators of SAH’s association with hospitalization outcomes were also assessed.

Results:
99,219 EVT patients were identified; 6,174 (6.2%) had SAH. Overall, SAH was independently associated with increased odds of in-hospital mortality (21.5% vs. 10.6%, adjusted OR 2.53 [95%CI 2.23-2.87], p<0.001; Figure 1) and lower odds of routine discharge to home with self-care (18.2% vs. 28.0%, aOR 0.58 [95%CI 0.52-0.65], p<0.001; Figure 1). Distal/medium vessel occlusion (DMVO), coagulopathy, angioplasty or stenting, concurrent intraparenchymal hemorrhage (IPH), and female sex were associated with higher odds of SAH. DMVO was associated particularly heightened risk of death (31.8% vs. 7.9%, aOR 6.99 [95%CI 2.99 to 16.3], p<0.001; Figure 2), which was an effect size significantly larger than other sites of vascular occlusion (interaction p>0.05; Figure 2)

Conclusion:
SAH is an uncommon but likely clinically detrimental post-EVT complication. DMVO, coagulopathy, angioplasty or stenting, concurrent IPH, and female sex were independently associated with higher odds of post-EVT SAH. SAH associated with DMVO-EVT may be particularly harmful.