bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract HUP8: Mobile Stroke Unit Management Associated With Reduction In Racial Disparities In Stroke Treatment Metrics
Authors: Czap Alexandra L , Rajan Suja S , Yamal Jose-Miguel , Jacob Asha , Wang Mengxi , Parker Stephanie , Sambursky Jacob , Bowry Ritvij , Grotta James C , Sharrief Anjail Z , Gonzales Nicole R
Published: February 2024

Background:
Racial and ethnic disparities in stroke exist across the continuum of care, including prehospital care. The impact of Mobile Stroke Units (MSUs) on racial disparities in thrombolytic treatment metrics is not reported.

Methods:
A pre-specified sub-study of ischemic stroke patients enrolled in BEST-MSU was conducted. MSU and standard management (SM) groups were divided into Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic (H) cohorts. Other racial groups were excluded (small n). Primary outcome was last seen normal to tPA time . Secondary outcomes included 90-day utility-weighted modified Rankin Scale (uw-mRS), functional independence (mRS 0-1), and mortality.

Results:
A total of 1420 patients were included: 557 NHW, 586 NHB, and 277 H. NHB and H groups were younger, had lower education, and higher proportions uninsured. In SM, NHB and H patients received slower care and less frequent tPA compared to NHW (Table 1). In contrast, MSU management reduced time to treatment (19 min NHW vs 46.5 min NHB vs 46 min H; p=<0.001) in NHB and H, and led to more frequent tPA (13% more NHW, 11% more NHB, 25% more H) in H. MSU management was associated with better uw-mRS across all groups (Figure 1). More functional independence was seen in NHW and NHB (adjusted OR NHW 1.79 [1.10-2.95] p=0.019; NHB 2.13 [1.38-3.33] p=0.0007). Mortality benefit was seen in H (p=0.03).

Conclusion:
MSUs overcome known disparities in thrombolytic utilization and treatment metrics in Non-Hispanic Black and Hispanic groups. Further studies are needed to evaluate care inequities that are overcome through integration of a MSU into the prehospital setting.
Abstract HUP9: Assessing Adaptations of a Complex Secondary Stroke Prevention Intervention
Authors: Scott Lisa , Galatovich Michele , Ayala-Rivera Monica , Mittman Brian , Rodman John , Vickrey Barbara G , Towfighi Amytis
Published: February 2024

Introduction:
S
econdary stroke prevention by
U
niting
C
ommunity and
C
hronic care model teams
E
arly to
E
nd
D
isparities (SUCCEED) was a randomized trial of a multilevel complex intervention to enhance risk factor control after stroke. Subjects randomized to intervention were managed by an advanced practice clinician (APC)-community health worker (CHW) team. Within the framework of ≥3 clinic and ≥3 home visits, and Chronic Disease Self-Management Program (CDSMP) workshops, the team tailored the intervention to meet participants’ needs. To describe how the intervention was implemented and adapted, we used the form/function framework.

Methods:
We identified key domains (overall goals of intervention), motivating needs (importance of targeting each domain), functions (methods for addressing motivating needs), and forms (tools, resources, methods for accomplishing each function). Two study leaders conducted semi-structured interviews with 4 APCs and 4 CHWs to identify forms used. APCs and CHWs described how frequently they used each form and usefulness via a RedCap survey. Descriptive statistics were subsequently run with R version 4.2.3.

Results:
SUCCEED targeted 7 domains: medication adherence, stroke literacy, self-management skills, care coordination, healthcare system navigation, social support, and addressing barriers. Each domain had 1-7 motivating needs and 4-13 functions. Each function had 5-23 forms, resulting in a total of 365 forms for addressing all domains. Most providers (85%) reviewed medication bottles to assess medication adherence, strongly agreeing this was useful. Pill organizers and stickers were used 53% of the time to ensure patients knew what medications they should be taking; 71% strongly agreed this was useful. Providers identified physical/environmental/social/literacy barriers during both home visits and CDSMP workshops (71%); all providers found this combination helpful.

Conclusion:
The form/function framework is useful for describing real-world adaptations of complex interventions. We identified key aspects of the intervention that providers used frequently and found useful, to inform future development of secondary stroke prevention interventions.
Abstract NS7: Improving Emergency Department Hemorrhagic Stroke Management
Authors: Miller Lesley , Call Kevin D
Published: February 2024

Background and Issues:
The Emergency Department lacked a formal hemorrhagic stroke process for the management and care of non-traumatic hemorrhagic patients which resulted in increased length of stay in the department and poor patient outcomes.

Purpose:
The purpose of this quality improvement project was to develop and implement a standard process of care for hemorrhagic stroke in our emergency department.

Methods:
This project was aimed at improving the overall emergency department management of hemorrhagic stroke patients by developing a standard process of care for this patient population. Project analysis began by identifying care opportunities. Our action plan was aimed at: developing a hemorrhagic stroke algorithm of care, implementing a hemorrhagic stroke paging process, implement best practice care for hemorrhagic stroke, develop a consulting services process, develop a power plan for hemorrhagic stroke, develop a data gathering method for tracking, and develop a hemorrhagic stroke feedback method.

Results:
Lessons learned from this project were that developing a standard process of care around this patient population led to better adherence to hemorrhagic stroke goals, management, and patient care.

Conclusion:
In conclusion, developing an emergency department hemorrhagic stroke process of care led to decreased length of stay in our emergency department, better adherence to hemorrhagic stroke goals, better management of blood pressure in this patient population, early recognition and awareness by caregivers and stroke team, and clearly defined consultation guidelines for streamlined patient care. Development of such a process raised the standard of care for this patient population and leads to overall improvement in patient management.
Abstract TMP10: Children With Sickle Cell Anemia Have Impaired Cerebrovascular Reactivity
Authors: Lewis Josiah B , Binkley Michael , Rutlin Jerrel , Ying Chunwei , Fields Melanie , Dedkov Igor , Quartuccio Heather , Mirro Amy , Fellah Slim , Ford Andria L , An Hongyu , Lee Jin-moo , Shimony Joshua , Guilliams Kristin
Published: February 2024

Introduction:
Sickle Cell Anemia (SCA) causes lower hemoglobin, leading to increased cerebral blood flow (CBF) to maintain cerebral oxygen metabolism (CMRO
2
). Although CBF rises in childhood to meet higher CMRO
2
demands, further compensatory increases in CBF in children with SCA may tap into a limited hemodynamic reserve, increasing risk for infarct. Cerebrovascular reactivity (CVR) reflects hemodynamic reserve by measuring the vasculature’s response to vasoactive stimuli, particularly in the gray matter (GM). We hypothesized that children with SCA have lower GM CVR, regardless of CMRO
2
.

Methods:
We used magnetic resonance imaging of children with and without SCA to collect pseudocontinuous arterial spin labeling (pCASL) for CBF, asymmetric spin echo for oxygen extraction fraction (OEF) and blood oxygen level dependent (BOLD) data correlated with hypercapnic challenges for CVR. Lab draws confirmed Hemoglobin (Hb) values. CMRO
2
was calculated as CBF x OEF x Arterial Oxygen Content (1.36 x Hb x SpO
2
). Continuous variable differences between groups were analyzed using the Mann-Whitney
U
test, and categorical variables using the Fisher’s exact test. Linear regression assessed the relationship between CVR and Hb. Reported significant relationships survived multiple comparisons correction.

Results:
A total of 35 participants, ages 8–22 years had quality CVR data [9 SCA subjects (5 male) and 26 controls (9 male)]. Of these, 8 SCA and 20 controls had adequate quality metabolic data. The groups are matched by age (p=0.56) and sex (p=0.43). Children with SCA had higher GM CBF (62.0 v 49.3 mL/100g/min; p=0.03), but similar GM CMRO
2
(1.81 v 1.42 mL/100g/min; p=0.07) than controls. GM CVR was significantly lower in SCA than controls (0.17 v 0.27 %/mmHg; p=0.0003). Lower CVR was associated with lower Hb (Figure) after adjusting for age and sex (p <0.0001).

Conclusion:
Lower GM CVR in children with SCA indicates a lower hemodynamic reserve, likely related to the degree of anemia.
Abstract TMP104: Timing of Recurrence After Ischemic Stroke by Subtype: A Population-Based Study
Authors: Cortes Juan C , Aziz Yasmin N , Robinson David J , Stanton Robert J , Sucharew Heidi , Jasne Adam S , Ferioli Simona , Demel Stacie , Mistry Eva , Walsh Kyle , Haverbusch Mary , Alwell Kathleen S , Star Michael , De Los Rios La Rosa Felipe , Mackey Jason , Coleman Elisheva , Slavin Sabreena J , Woo Daniel , Kleindorfer Dawn O , Kissela Brett M
Published: February 2024

Introduction:
Prior work suggests stroke recurrence timing may vary by subtype, with large vessel disease being associated with earlier recurrence; however, these studies were conducted prior to the current era of secondary stroke prevention strategies. We examined whether the timing of recurrence after ischemic stroke varied by subtype in a large population-based study.

Methods:
In 2015, we identified all acute ischemic stroke events from hospitals in the Greater Cincinnati and Northern Kentucky area. Events in the last 6 months of 2014 were oversampled for black patients. Trained nurses extracted clinical data, and stroke specialists subtyped and adjudicated cases. We tracked events for 3 years, considering only ischemic strokes after day 14 as a recurrence. To assess recurrence timing variations, we stratified strokes by subtype and analyzed their restricted mean survival times (RMST) at 1, 3, 12, 24, and 36 months. RMST is the area under the survival curve up to a specific follow up point, denoting the average event-free time during that interval.

Results:
Of 2577 patients with index stroke, 332 recurrent strokes were seen over the ensuing 3 years. Half of the recurrences occurred within 8 months from the index event. At 12 months, large vessel (LV), undetermined, and other identified cause showed a statistically significant smaller RMST compared to small vessel (SV). This difference was nonsignificant at later time points, suggesting later recurrence for SV. There were no statistically significant differences in RMST between cardioembolic, LV, undetermined, and other identified at any time point.

Conclusions:
Recurrence after initial SV stroke was less likely to occur in the first year when compared to LV, undetermined etiology, or other identified causes of stroke. There was no evidence of difference in recurrence timing between cardioembolic, LV, other identified, and undetermined etiology.
Abstract TMP112: Von Willebrand Factor (VWF) Modulates Smooth Muscle Cell Proliferation During the Outward Remodeling of Leptomeningeal Collateral Arterioles Following Stroke
Authors: WU TING , Ahn John , Doan Andrea , Andersohn Alexander , Cruz Miguel A , Yee Andrew , Kim Gab , Marrelli Sean P
Published: February 2024

Introduction:
The leptomeningeal collaterals (LMCs) undergo outward remodeling after stroke to increase rescue flow toward the occluded region. We previously showed increased VWF in remodeled LMCs and others have shown that VWF can act as a smooth muscle cell (SMC) mitogen. Here we test the hypothesis that VWF modulates vascular remodeling of LMCs in the post-stroke brain.

Methods:
Permanent distal middle cerebral artery occlusion (pdMCAO) was performed in C57BL6 WT mice (cohort 1; 4 mos), aged (cohort 2; 24 mos) or VWF KO and WT male mice (cohort 3; 4 mos). At 3, 7, and 14 days after pdMCAO, the pial vessels were processed for VWF/Ki67/SMA immunofluorescence and morphometric analysis. Lastly, distribution of VWF was evaluated in LMCs from human and pig brains.

Results:
During the 3-14 days post-stroke, WT mice of cohort 1 demonstrated significantly increased VWF in ipsilateral LMCs as well as increased Ki67 positive cells. In ECs, Ki67-positive cells were 10.68 ± 1.48 and 10.73 ± 1.26 per mm of vessel at 3 and 7 days, respectively. In SMCs, Ki67-positive cells were 0.049 ± 0.22 and 4.546 ± 0.95 per mm vessel at 3 and 7 days, respectively. By 14 days, LMC no longer showed Ki67-positive ECs or SMCs. In aged cohort 2, along with attenuated VWF expression and remodeling, the Ki67-positive ECs and SMCs were significantly decreased in the aged mice compared to young mice (Ki67-positive ECs were reduced by 40% and 50% at 3 and 7 days, respectively; Ki67-positive SMCs were reduced by 75% at 7 days). In cohort 3, Ki67-positive SMCs were absent in the VWF-KOs at 3 days post-stroke. However, by 7 days, Ki67-positive SMCs were equivalent between WT and VWF-KOs (4.8-5.0 per mm vessel). Lastly, the presence of VWF was detected in the smooth muscle layer of LMCs of human and pig brains.

Conclusions:
Our study revealed increased VWF in the mural layer of remodeled LMCs and both EC and SMC proliferation. The remodeling response, VWF expression, and number of proliferative cells were attenuated in LMCs from aged brains. Knockout of VWF resulted in reduced LMC remodeling and delayed SMC proliferation. Our findings also provide evidence for VWF within the smooth muscle layer of pig and human brain arterioles, supporting the broader potential role of VWF as a molecular player in vascular remodeling.
Abstract TMP120: Contralesional Corticospinal Tract Reinnervates Cervical Spinal Anatomical Regions With Highest Pre-Lesion Synapse Density After Unilateral M1 Stroke in Mice
Authors: Kenwood Matthew , Poinsatte Katie , Ajay Aporva , Nawaby Ariana , Betz Dene , Plautz Erik , Ramirez Denise , Goldberg Mark
Published: February 2024

Introduction:
Stroke leaves many patients with significant motor impairment. Following ischemic lesions of the rodent primary motor cortex, sprouting of the contralesional corticospinal tract (cCST) into the injured hemicord is associated with improved motor recovery. In adult mice, most corticospinal neurons project to spinal interneurons, and few synapse directly on alpha motor neurons. We examined the distribution of newly formed corticospinal synapses in the mouse spinal cord, using genetically encoded tracers, 3D microscopy, and a spinal atlas with machine learning-based automated classification and registration.

Hypothesis:
We tested the hypothesis that cCST neurons innervate homotopic regions in the injured hemicord after unilateral motor cortex stroke in adult mice.

Method:
We induced a photothrombotic motor cortex stroke or performed sham surgery (n=4 per group) in 8-11 week old male C57/B6 mice and administered a contralesional motor cortex injection of an anterograde adeno-associated virus expressing both membrane-targeted tdTomato and synaptically-targeted eGFP. Cervical spinal cords were subjected to volumetric imaging via serial two-photon tomography (TissueCyte 1000) to characterize synaptic and axonal density of cCST collaterals in whole cervical spinal cords in both stroke and sham mice. Unbiased, global quantification of axonal and synaptic density across the entire cervical cord was accomplished by the development of a custom automated image analysis pipeline, incorporating a novel 3D spinal cord reference volume, published spinal cord annotations comprising 47 distinct anatomical regions (SpinalJ), and machine learning based pixel classification.

Results:
We observed cCST synapses in the 6-week post-stroke injured hemicord innervating lamina IV & IX most densely at C7 & C8 (See Figure).

Conclusions:
Contralesional CST reinnervation of the denervated hemicord is targeted to both lamina and cervical level specific.
Abstract TMP2: Longitudinal Risk of Seizures in Patients With Brain Arteriovenous Malformations
Authors: Chowdhury Samyami S , Nelson Jeffrey , Weinsheimer Shantel , Schollenberger Jonas , Fullerton Heather J , Fox Christine K , Kim Helen ,   The UCSF AHA Bugher Hemorrhagic Stroke Rsch Group
Published: February 2024

Objective:
To examine longitudinal risk of seizures following diagnosis of brain arteriovenous malformations (bAVM).

Methodology:
A total of 1178 patients diagnosed with bAVM and enrolled into a prospective cohort study at our institution from 2000-2023 were included. We calculated the incidence rate (IR) of seizures pre- and post-bAVM treatment, censoring at either treatment, death, or last follow-up. Cox regression models tested whether treatment was associated with seizures during follow-up using treatment as a time-varying covariate (no treatment, radiosurgery only, and surgical resection),adjusting for age at diagnosis, prior seizure, prior hemorrhage, bAVM size, and lobar location.

Results:
The bAVM cohort was 51% female, 29% children (median age 9.5y, range 0-19y), and 71% adults (median age 44.5y, range 20-89y). 290 (25%) presented with seizures that led to bAVM diagnosis; of these, 52 had both acute seizures and hemorrhage at presentation. A total of 72 patients had seizure after diagnosis but before treatment over 2296 patient-years (PY) of follow-up (IR 3.1 per 100 PY, 95% CI: 2.5-4.0). Post-treatment, there were 167 seizures during 4712 PY of follow-up (4.8 per 100 PY, 95% CI: 4.2-5.5). Compared to untreated patients, treated patients were at 2-fold higher risk of seizures during follow-up (Figure) with either radiosurgery (HR=2.3, 95% CI: 1.6-3.2, P<0.001) or surgical resection (HR=1.9, 95% CI: 1.4-2.7, P<0.001). Prior seizures (HR=2.2, 95% CI: 1.6-3.0), lobar location (HR=1.9, 95% CI: 1.2-3.0), and AVM size (HR=1.11, 95% CI: 1.0-1.2) were independent predictors of seizures while prior hemorrhage (P=0.451) and age at diagnosis (P=0.481) were not.

Conclusion:
Risk of seizure persisted for decades after bAVM diagnosis, but highest in the years following bAVM treatment, independent of prior seizures, age at diagnosis, lobar location, AVM size or prior hemorrhage. This suggests greater attention is needed for seizure management after bAVM treatment.
Abstract TMP24: Thrombolytics With ≤30 Minutes Door-to-Needle Time in Acute Ischemic Stroke: How Fast is Too Fast?
Authors: Bicen Metin , Afzal Saira , Orlando Mark , Dengri Chetna , Reinoso Dixie , Koriesh Ahmed , Nouh Amre M
Published: February 2024

Introduction:
Current Phase III of the American Heart Association Target Initiative aims to achieve secondary goals of door to-needle-times within 30 minutes in ≥50% of acute ischemic stroke patients. We sought to evaluate the influence of non-institutional factors (namely presenting patient characteristics) on administration times, safety, and feasibility of thrombolytics within ≤30 minutes of presentation.

Method:
A single center, retrospective study from March 2018 to March 2023 was conducted yielding 179 patients who received IV thrombolytic for suspected acute ischemic stroke. Patients were dichotomized into those treated within 30 minutes and >30 minutes. A univariate analysis using Chi-squared test of proportions (or Fisher exact when appropriate) was used to compare the patient characteristics on presentation and a multivariate logistic regression was utilized to explore independent predictors.

Results:
Of a total of 176 patients (after excluding patients with missing data), 60% (n=105) were ≤30 minutes. Age, gender, past medical history, last known well time and admission modified ranking score did not influence thrombolytic administration time (table 1). However, a presenting NIH stroke score of >4 was associated with a 2.5 OR (1.19-5.23) (p=0.0151) of achieving < 30min times. Although a higher rate of intracerebral hemorrhage was noted in the >30 minutes group, this was not statistically significant (11% vs 6.6%; p=0.283).

Conclusion:
In our study, acute thrombolytic within 30 minutes was feasible, safe, and only influenced by higher NIHSS. Institutional processes remain the mainstay of achieving this target.
Abstract TMP25: Common Molecular Biomarkers in Different Types of Acute Brain Injuries Predicting Outcome
Authors: Hellstrom Santtu , Sajanti Antti , Cao Ying , Girard Romuald , FRANTZEN JANEK , Koskimaki Fredrika , Umemori Juzoh , Falter Johannes , Lyne Sean , Rantamäki Tomi , Nazir Kenneth , Gajera Bharat , Posti Jussi , Roine Susanna , Takala Riikka , Kolehmainen Sulo , Jänkälä Miro , Puolitaival Jukka , Kauppinen Mikko , Rahi Melissa , Rinne Jaakko , Nieminen Anni , Castren Eero , Koskimaki Janne
Published: February 2024

Background:
Acute brain injuries, including aneurysmal subarachnoid hemorrhage (aSAH), ischemic stroke (IS), and traumatic brain injury (TBI), entail complex recovery processes involving brain plasticity and synaptic regeneration mechanisms. Exploring lipidomic profiles, microRNA expression, and metabolomic changes can yield insights into recovery mechanisms, unveil conserved molecular associations, and identify potential biomarkers.

Hypotheses:
We hypothesized that regardless of injury type, variations in lipidomic and metabolomic profiles, along with differentially expressed microRNAs, share common characteristics. These changes likely mirror essential biological mechanisms and may correlate with outcomes.

Methods:
We studied a prospective cohort of patients with IS, aSAH, and TBI (N=71). Serum samples were collected once, followed by comprehensive profiling: lipidomics (Lipidyzer™ Platform), metabolomics (Orbitrap Profiling), and microRNA sequencing (DESeq2).

Results:
Univariate analysis unveiled candidate molecules predictive of outcomes. Multivariate combinatory linear discriminant analysis (LDA) demonstrated significant prognostic potential for favorable outcomes. The LDA equation combining eight biomarkers was: -0.239[LPC17:0] - 1.125[TAG51:2:FA15:0] + [TAG51:2:FA18:1] + [D-glucuronic Acid] + 0.416[hsa-miR-146b-3p] + 0.082[hsa-miR-485-3p] + 0.433[hsa-miR-5010-5p] + 0.727[hsa-miR-485-5p], effectively predicting favorable outcomes. The AUC was 95.8%, 95% CI (0.88 - 1.00), p-value 0.023, indicating strong discriminatory power of the combinatory biomarker (OR 8.7, 95% CI 1.35-56.9).

Conclusion:
Findings reveal a shared pattern of lipidomic, metabolomic, and microRNA changes across distinct acute brain injuries. This warrants further investigation and validation, offering prospects for biomarker development, mechanistic validation, and therapeutic interventions in brain recovery. These shared features underscore the importance of interdisciplinary research for targeted, personalized interventions in diverse acute brain injuries.
Abstract TMP35: Short Interval Intracortical Inhibition is Associated With Leg Motor Function in Chronic Stroke
Authors: Anderson Trenley , Iyengar Pragnya , Salameh Ahlam , Duncan Kelsey R , McCabe Jessica , Skelly Margaret , Hisel Terri , Grabinski Sarah , Zhang Liangliang , Pundik Svetlana
Published: February 2024

Objective:
Stroke disrupts inhibitory and excitatory networks in the brain. To develop better therapies, we need to understand the role of inhibitory and excitatory systems. Paired-pulse transcranial magnetic stimulation (ppTMS) allows for evaluation of these inhibitory and excitatory systems. Our objective was to explore the relationship between Short Interval Intracortical Inhibition (SICI) and Intracortical Facilitation (ICF) ppTMS measures for tibialis anterior (TA) and measures of lower limb motor function in chronic stroke.

Methods:
Lower limb motor function was evaluated with Fugl-Meyer for Lower Limb (FM), gait speed (max and preferred), Timed-up-and-go (TUG), Functional Gait Assessment (FGA) and Gait Assessment and Intervention Tool (GAIT). SICI was collected with interstimulus interval of 2ms and ICF with 10ms. The conditioning stimulus was 90% and test stimulus was 120% of active motor threshold. Motor evoked potentials (MEPs) were collected for both paretic or non-paretic TAs while volitionally activated to 20% of maximum effort. SICI and ICF were calculated as percent of test stimulus (TS) amplitude. Analysis included descriptive statistics and linear models controlling for age, months post-stroke, and gender. TUG test time was log-transformed.

Results:
Study participants (n=34) were 66±8 years old, 4.9±4 years after stroke and 76% male. Mean±SD FM was 25.1±3.7 and preferred gait speed was 0.52±0.30 m/s. Relative to TS amplitude, SICI was 107±27% and ICF was 175±71% for paretic leg and, for non-paretic leg, SICI was 108±42% and ICF was 159±66%. For paretic leg after controlling for ICF, a 10% lower SICI was associated with the following: 0.89 point better FM (95% CI: 0.37-1.42), 14% better TUG (95% CI: 3-23%), 0.08 m/s faster max speed (95% CI: 0.02-0.14), and 0.05 m/s faster preferred walking speed (95% CI: 0.01-0.10). For non-paretic limb, a 10% lower SICI was associated with a 0.43 point better FGA (95% CI: 0.11-0.76) while a 10% lower ICF was associated with a 0.73 point better GAIT (95% CI: 0.37-1.10).

Conclusion:
Greater inhibition with paired pulse of both paretic and non-paretic limbs was predictive better motor abilities. These findings are related to previous work and warrant future investigations.
Abstract TMP36: Anatomical Predictors of Gastrostomy Tube Placement After Large Vessel Occlusion Ischemic Stroke
Authors: Ikramuddin Salman , McCullough-Hicks Margy E , Christensen Soren , Ruiz-Betancourt Daniel , Mlynash Michael , Albers Gregory W
Published: February 2024

Dysphagia is a common neurologic deficit after ischemic stroke; as a result, patients often require percutaneous endoscopic gastrostomy (PEG) tube placement for safe maintenance of sufficient caloric intake. Right hemispheric strokes have previously been associated with post-stroke dysphagia. We examined whether topographic locations of post-stroke diffusion-weighted MRI (DWI) lesions associated with the need for placement of PEG tube. A registry of 898 patients evaluated for acute treatment of suspected large vessel occlusion (LVO) stroke was used. 65 patients underwent post-stroke PEG placement, and 65 additional patients were selected as propensity matches based on age, baseline NIH Stroke Scale score, and recanalization status. Binary masks of 24-to-72-hour post-stroke DWI lesions were co-registered to standard template space. Voxel-based lesion symptom mapping (V2.6), rewritten to perform logistic regression at each voxel, was used to generate statistical maps of lesion contribution to PEG placement. Uncorrected t-statistic maps demonstrated voxels in the right frontal, parietal, and temporal regions were associated with post-stroke PEG placement. Upon controlling for age and/or recanalization status, lesions in the right parietal lobe were associated with need for PEG. After controlling for lesion volume, this association weakened; once all variables were controlled for, there were no topographical regions associated with PEG placement. In this limited series, there is not a topographic region on post-stroke diffusion MRI that is significantly associated with need for PEG placement in patients with LVO stroke after controlling for appropriate covariates. PEG tube requirement may be a composite outcome, dependent on various inputs notably including lesion volume.
Abstract TMP38: Enhancing Door-In-Door-Out Time in a Rural Primary Stroke Center: Early Activation of a Large Vessel Occlusion Alert/Bundle of Care Utilizing EMS Pre-Alert, Parallel System Processing and Auto-Launch of Transfer Resources
Authors: Liberati-Kipphut Brittany , Berry Christopher , Cannoy Austin
Published: February 2024

Background:
Thrombectomy has become the primary treatment in the management of acute stroke Large Vessel Occlusions (LVO). For a rural primary stroke center that does not have in house thrombectomy services, expedited transfer to a Comprehensive Stroke Center is imperative. The purpose of this quality improvement initiative is aimed at optimizing the Door-In-Door-Out (DIDO) time for stroke patients at a Rural Primary Stroke Center, with a specific goal of DIDO time of <90 minutes, 50% of the time and <120 minutes, 75% of the time.

Methods:
System inefficiencies in serial event processing, radiology interpretation, teleneurology application and activation of transferring Emergency Medical Services (EMS) were identified. We implemented several systematic changes utilizing multiple Plan Do Study Act cycles. The final implementation was an “LVO-Alert” process, which utilized parallel event processing of emergency medicine, teleneurology, radiology, and transfer center auto-lance of EMS transfer resources. This process is activated based on a positive prehospital modified Rapid Arterial Occlusion Evaluation score prior to the patient’s hospital arrival rather than a positive Computed Tomography Angiogram and can be cancelled in the case of negative imaging or declination of transfer. Pre and post metrics were compared.

Results:
Pre LVO-Alert implementation, DIDO time averaged 184 minutes (n=21) over 2 years, and anterior circulation LVO’s achieved a <90-minute DIDO time 5% of the time. Post implementation, DIDO averaged 109 minutes (n=21) and anterior circulation LVOs achieved a <90-minute DIDO 48% of the time. Post implementation, anterior circulation LVOs went from 19% to 90% transferred in <120 minutes. Pre implementation, posterior circulation LVO’s achieved a <120-minute DIDO time 0% (n= 2) of the time while post implementation, posterior circulation LVOs achieved a <120-minute DIDO 50% (n=4) of the time. Among LVO alert activations over the post-implementation period, 27.4% resulted in transfer for thrombectomy.

Conclusion:
The application of a parallel process bundle of care model with early activation from a prehospital positive LVO scale may help to improve DIDO times in this patient population.
Abstract TMP41: Mapping Accessibility Differences of Acute Stroke Centers in the United States
Authors: Dugan Jacob , Hinman Jason D , Liebeskind David S , Scalzo Fabien
Published: February 2024

Background:
One of the keys to mitigating adverse outcomes of an ischemic or hemorrhagic stroke is timely access to a stroke center. Every minute of a large vessel occlusion results in the mean loss rate of 2 million neurons. Every 20-minute reduction in time to reperfusion increases disability-free lifespan by 3 months. For intracerebral hemorrhage, early intensive blood pressure lowering within 2 hours of onset improved outcomes
. For aneurysmal subarachnoid hemorrhage, more than one-third of rebleeds occur within 3 hours. Accessibility of acute stroke centers varies drastically across the United States, both between states and between localities. There is a need to characterize accessibility not only based on the population and distance to the nearest center but also using average travel time per area.

Methods:
To understand the accessibility of the 2,446 stroke centers in the US we performed geospatial mapping by combining distance and average travel time as part of an interactive map. The map can be used to visually identify regions lacking timely access to a stroke center. Through linking highly granular demographic and socio-economic census data, we can better understand populations effected by long travel times. To identify the nearest stroke center for every census tract in the US, the distance between centroids and the KNN algorithm was used. By adding the average commute times of the counties that intersected the straight line, travel time to the nearest stroke center was estimated.

Results:
Approximately 45 million people live over 90 minutes away from a stroke center. Increasing stroke center access should be prioritized for populations over 1.5 hours from the nearest stroke center. The map highlights regions of particular concern with 2.5 - 4+ hour travel times (Fig. 1).

Conclusion:
We demonstrate that accessibility differences of stroke centers can be better understood using an interactive map. Our map highlights regions and populations in need of a stroke center.
Abstract TMP45: Assessing Adaptations of a Complex Secondary Stroke Prevention Intervention
Authors: Scott Lisa M , Galatovich Michele , Mittman Brian , Ayala-Rivera Monica , Vickrey Barbara G , Rodman John , Towfighi Amytis
Published: February 2024

Introduction:
S
econdary stroke prevention by
U
niting
C
ommunity and
C
hronic care model teams
E
arly to
E
nd
D
isparities (SUCCEED) was a randomized trial of a multilevel complex intervention to enhance risk factor control after stroke. Subjects randomized to intervention were managed by an advanced practice clinician (APC)-community health worker (CHW) team. Within the framework of ≥3 clinic and ≥3 home visits, and Chronic Disease Self-Management Program (CDSMP) workshops, the team tailored the intervention to meet participants’ needs. To describe how the intervention was implemented and adapted, we used the form/function framework.

Methods:
We identified key domains (overall goals of intervention), motivating needs (importance of targeting each domain), functions (methods for addressing motivating needs), and forms (tools, resources, methods for accomplishing each function). Two study leaders conducted semi-structured interviews with 4 APCs and 4 CHWs to identify forms used. APCs and CHWs described how frequently they used each form and usefulness via a RedCap survey. Descriptive statistics were subsequently run with R version 4.2.3.

Results:
SUCCEED targeted 7 domains: medication adherence, stroke literacy, self-management skills, care coordination, healthcare system navigation, social support, and addressing barriers. Each domain had 1-7 motivating needs and 4-13 functions. Each function had 5-23 forms, resulting in a total of 365 forms for addressing all domains. Most providers (85%) reviewed medication bottles to assess medication adherence, strongly agreeing this was useful. Pill organizers and stickers were used 53% of the time to ensure patients knew what medications they should be taking; 71% strongly agreed this was useful. Providers identified physical/environmental/social/literacy barriers during both home visits and CDSMP workshops (71%); all providers found this combination helpful.

Conclusion:
The form/function framework is useful for describing real-world adaptations of complex interventions. We identified key aspects of the intervention that providers used frequently and found useful, to inform future development of secondary stroke prevention interventions.
Abstract TMP52: Modern Thin-Slice CT Perfusion Has High Sensitivity for Supratentorial Lacunar Stroke
Authors: Thomas James O , Visser Milanka , Cordato Dennis , Cappelen-Smith Cecilia , Garcia Esperon Carlos , Spratt Neil , Lin Longting , Bivard Andrew , Parsons Mark W
Published: February 2024

Background:
Lacunar stroke is a common form of ischaemic stroke with mechanisms poorly understood compared to large vessel stroke. Access to gold standard MRI is often limited in the acute setting. Acute diagnosis of lacunar stroke is difficult with conventional CT, as non-contrast CT and CT angiography have poor sensitivity. Previous studies have demonstrated only low to moderate sensitivity of CT perfusion (CTP).

Aims:
To test the accuracy of thin-slice CTP to detect lacunar stroke and compare the clinical and radiological characteristics to better understand the limitations of CTP for diagnosis of lacunar stroke.

Methods:
We reviewed thin-slice CTP (slice thickness <=3mm) of cases presenting with an acute lacunar syndrome without large/medium vessel occlusion, or perfusion lesion detected by automated analysis. Cases presented to two comprehensive stroke centres in Sydney and Newcastle, NSW, Australia, between 2019 and 2022. CTP was reviewed by two independent reviewers, blinded to follow-up MRI but not the clinical syndrome. CTP and DWI were registered to a standard template and DWI lesions were manually segmented. CTP was further reviewed adjacent to DWI, and raw CTP values within the lesion was calculated.

Results:
We reviewed 394 cases of acute lacunar syndrome including 82 stroke mimics, 48 infratentorial and 250 supratentorial infarcts. Overall sensitivity was 76% and varied by infarct location. Sensitivity was lowest for brainstem (46%), moderate for thalamic (69%) and high for infarcts within the lenticulostriate perforator territory (84%). Factors associated with reduced sensitivity include small infarct volume, increased noise, or artefact, and infratentorial location.

Conclusion:
Thin-slice CTP has high sensitivity for detection of supratentorial lacunar infarcts however is more susceptible to noise and imaging artefact than larger infarcts. Advanced processing techniques show promise to improve overall diagnosis of lacunar stroke.
Abstract TMP58: Neuroimaging Markers of Patient-Reported Outcomes in Acute Ischemic Stroke
Authors: Carvalho De Oliveira Lara , Bonkhoff Anna , Regenhardt Robert , Alhadid Kenda , Tuozzo Carissa , Etherton Mark , Rost Natalia S , Schirmer Markus D
Published: February 2024

Objectives:
To determine the relationship between patient-reported outcome measures (PROMs) and volumetric biomarkers assessed on clinical imaging in acute ischemic stroke (AIS).

Background:
AIS is a leading cause of long-term disability. White matter hyperintensity (V_WMH), brain (V_Brain) and stroke lesion volume (V_Lesion) have been linked as potential determinants of functional outcomes after stroke. Recently, there has been surging attention to PROMs, which allow for direct, patient-centered health assessments of stroke victims. However, the link between neuroimaging biomarkers and PROMs is not well studied.

Methods:
Patients presenting to the Emergency Department at Massachusetts General Hospital between February 2017 and February 2020 with a confirmed AIS on MRI were eligible and underwent a follow-up telephone interview, including PROM-10 questionnaires. V_WMH and V_Brain were automatically determined from clinical MRI. V_Lesion was manually segmented. Regression analyses were performed to identify associations of brain volumetrics and clinical variables with PROM-10 subscores and global mental and physical summary scores.

Results:
Utilizing data from 150 patients (mean age: 64.7; 41.9% female), higher V_WMH was associated with worse global mental (β = -0.65), global physical (β = -0.60), social activities (OR = 0.59), physical health (OR = 0.68), fatigue (OR = 0.69) and social satisfaction (OR = 0.66) scores. V_Lesions were associated with poorer global mental (β = -0.79), social (OR = 0.55) and physical (OR = 0.66) activities, mental health (OR = 0.68) and emotional distress (OR = 0.68) scores. Higher V_Brain was linked to better global mental (β = 0.93), global physical (β = 0.79), physical activities (OR = 1.72) and mental health (OR = 1.54) scores.

Conclusions:
Imaging biomarkers were significantly associated with PROMs. The inclusion of these markers with PROMs in routine post-stroke assessment can enhance our understanding of recovery.
Abstract TMP65: Sex Differences in Outcomes of Acute Myocardial Injury After Stroke
Authors: Rosso Michela , Stengl Helena , Ganeshan Ramanan , Hellwig Simon , Klammer Markus G , von Rennenberg Regina , Böhme Sophie , Audebert Heinrich J , Nolte Christian H , Endres Matthias , Kasner Scott E , Scheitz Jan F
Published: February 2024

Introduction:
Sex differences in presentation, treatment, and prognosis of cardiovascular disorders are well recognized. Although an association between acute myocardial injury and mortality after ischemic stroke has been demonstrated, it is unclear whether prevalence and outcome of post-stroke acute myocardial injury differ between women and men.

Methods:
We prospectively screened consecutive patients with acute ischemic stroke and serial high-sensitivity cardiac troponin T (hs-cTnT) measurements admitted to our center (January 2019-December 2020). Acute myocardial injury was defined as at least one hs-cTnT value above the upper reference limit (URL=14 ng/L) with a rise/fall of >20%. Additionally, rates of acute myocardial injury were calculated with sex-specific hs-cTnT cut-offs (women URL=9ng/L; men URL=16ng/L).

Results:
Of 1,067 patients included, 494 were women (46%). Women were older, had higher rate of known atrial fibrillation, were more likely to be functional dependent before admission, and had higher stroke severity (all p-values <0.05). The prevalence of acute myocardial injury differed by sex (29% women vs 23% men,
P
=0.024). In multivariate analysis, statistically significant associations between acute myocardial injury and outcomes were observed in women (7-day mortality: aOR=3.2 [1.07-9.3]; in-hospital mortality: aOR=3.3 [1.4-7.6]; mRS at discharge: aOR=1.6 [1.1-2.4]), but not in men (Fig.1). The implementation of sex-specific cut-offs did not increase the prognostic value of acute myocardial injury for unfavorable outcomes. The ROC-derived optimal cut-offs of hs-cTnT peak values for predicting of early mortality was higher than current URLs and sex-specific (women=29.5 ng/L vs men=66 ng/L; negative predictive value: 98.46% and 99.23%) (Fig.2).

Conclusions:
The prevalence of acute myocardial injury after ischemic stroke and its association with mortality and unfavorable functional outcome might be sex-dependent.
Abstract TMP76: Outcomes in Large Mostly Intraventricular Hemorrhage: From the Clear III Trial Public Use Dataset
Authors: Haines Brooke , Tirschwell David L , de Havenon Adam H , Klein Lauren , Asirot Mary Grace , Creutzfeldt Claire J
Published: February 2024

Introduction:
Intraventricular hemorrhage (IVH), a common complication of intracerebral hemorrhage (ICH), can occur with little or no associated ICH (mostly IVH, mIVH). mIVH is reported to have better outcomes than IVH associated with substantial ICH. Few data exist describing outcomes from mIVH, especially more severe cases.

Hypothesis:
Using the CLEAR III public use dataset, outcomes from large mIVH can be described and may be useful to providers and families making decisions about goals of care.

Methods:
Large mIVH was defined as CLEAR III patients with ICH volume < 5 cc and IVH volume > 30 cc. A backward stepwise logistic regression model identified baseline predictors of 180 day modified Rankin score 0-3 (good outcome), and a post-estimation probability was calculated for each patient. Descriptive nonparametric statistics are provided, including medians with interquartile range (IQR). Patients were divided into prognostic tertiles based on probability of a good outcome with corresponding 180 day modified Rankin scores (mRS) are displayed via a Sankey diagram.

Results:
Overall, 72/500 (14.4%) of CLEAR III patients had large mIVH. Among these 72, median (IQR) age was 59.5 (51-68) years, 39% were female, median (IQR) GCS 8 (6.5-10), IVH volume 48 cc (39-67) and 180 day mRS 4 (2-6). Age and IVH volume were final model independent predictors of good outcome. Baseline median (IQR) values for Age and IVH volume in each prognostic tertile with 180 day mRS distributions are shown in the Figure. Good outcome was possible despite large mIVH, especially with younger age and smaller IVH volumes.

Conclusion:
Focusing on the CLEAR III subset of patients with large mIVH, a simple regression model identified prognostic tertiles which combined with a Sankey diagram provide easily interpretable outcome distributions that may facilitate clinical decision-making.
Abstract TMP81: Effect of Post Thrombolytic Intracerebral Hemorrhage Volume on 90-day Outcomes in Acute Ischemic Stroke Patients
Authors: Gillani Syed A , Ma Xiaoyu , Ahmed Rehan , Maqsood Hamza , Bains Navpreet , Fakih Rami , Siddiq Farhan , French Brandi R , Gomez Camilo R
Published: February 2024

Background and Purpose:
Post thrombolytic intracerebral hemorrhage (ICH) is associated with higher rate of death or disability in acute ischemic stroke patients. We investigated the relationship between post thrombolytic ICH volume and change in volume and death or disability at 90 days in acute ischemic stroke patients.

Methods:
We analyzed 110 patents recruited in the Safety Evaluation of 3K3A-APC in Ischemic Stroke (RHAPSODY) trial who received intravenous tissue plasminogen activator (tPA) followed by mechanical thrombectomy (if indicated) and 3K3A-APC or placebo. ICH volume was measured at Day 2 and Day 7 using susceptibility weighted sequence (SWI) on magnetic resonance imaging (MRI). We also calculated the post thrombolytic ICH volume change between Day 2 and Day 7. Outcomes were determined by using utility weighted modified Rankin scale (UW-mRs) at 90-days. We adjusted for age, gender, National Institute of Health Stroke Scale (NIHSS) score (<10,10-19 and ≥20), location of hemorrhage (single basal ganglia hemorrhage, single lobar, single cerebellum, and multiple sites hemorrhage) in multivariate regression analysis.

Results:
A total of 88 (80%) of 110 patients had post thrombolytic ICH (mean volume 28.3 ml ± SD 62ml). The strata of ICH volume were not associated with UW-mRs at 90 days: <20 cc (regression coefficient-0.05, p= 0.58), 20-39 cc (-0.23, p=0.15), or 40 cc (-0.33, p= 0.086) compared with no ICH after adjusting for potential confounders. Change in ICH volume mean volume 27.43ml ±59.01, 52 had increase in volume) between Day 2 and day 7 was not associated with UW-mRS at 90 days (regression coefficient -11.87, p= 0.796).

Conclusions:
We did not observe any independent effect of post thrombolytic ICH volume on death or disability in acute ischemic stroke patients. Strategies to prevent ICH expansion such as antifibrinolytic medications and reduction in ICH volume such as surgical evacuation may not reduce death or disability in acute ischemic stroke patients with post thrombolytic ICH.
Abstract TMP82: How Well Do Prehospital Stroke Triage Scores Identify Patients With Intracerebral Hemorrhage?
Authors: Wechsler Paul M , Robinson David , Sucharew Heidi , Stanton Robert J , Demel Stacie , Mistry Eva , Ferioli Simona , Khatri Pooja , Walsh Kyle B , Flaherty Matthew L , Jasne Adam S , Haverbusch Mary , Slavin Sabreena , Mackey Jason , Star Michael , Coleman Elisheva R , Martini Sharyl R , DeLosRiosLa Rosa Felipe , Alwell Kathleen , Adeoye Opeolu M , Woo Daniel , Kleindorfer Dawn O , Kissela Brett M
Published: February 2024

Background:
Prehospital stroke triage scores aim to identify LVO patients who benefit from direct transport to high-level stroke centers for EVT by bypassing primary stroke centers. Patients with ICH may benefit from direct transport to high-level centers for neurologic intensive care and hematoma evacuation. Lobar ICH patients may particularly benefit as randomized clinical trial data suggest hematoma evacuation is more effective in these patients. We determined the ability of prehospital LVO triage scores to identify ICH patients and to discriminate lobar from non-lobar ICH.

Methods:
We identified ICH cases presenting to the ED in Greater Cincinnati/Northern Kentucky in 2005, 2010, and 2015. Cases were identified by ICD codes (ICD9 430-438, ICD10 G45-46, H34.11-12, I60-69), clinical data was extracted by a research nurse and adjudicated by physicians. The CSTAT and RACE scores were abstracted from the NIHSS. We calculated the proportion of ICH patients with a CSTAT ≥ 2 and a RACE ≥ 5, cut-offs used to bypass primary stroke centers, and the scores’ ability to distinguish lobar from non-lobar ICH.

Results:
We identified 904 ICH patients (median age 72, 54% female, 25% Black). CSTAT was ≥ 2 in 45% of all ICH patients while 27% had a RACE ≥ 5. These score cut-offs identified patients with more severe deficits (Table). Among patients with lobar ICH (n=391), 44% had a CSTAT ≥ 2 and 27% had a RACE ≥ 5. Results were similar for non-lobar ICH (n=473, 45% CSTAT ≥ 2 and 26% RACE ≥ 5). Both scores performed poorly in differentiating lobar from non-lobar ICH (CSTAT ≥ 2: sensitivity 0.44, specificity 0.55, AUC 0.52; RACE ≥ 5: sensitivity 0.27, specificity 0.74, AUC 0.53).

Conclusion:
Prehospital LVO triage scores identified fewer than half of all ICH patients and did not discriminate between lobar and non-lobar ICH. New prehospital triage scores are needed to identify all ICH patients, or perhaps ICH subgroups, along with LVO patients who benefit from direct transport to high-level stroke centers.