bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP206: Scrnaseq Revealed Increased Microglial Expression Of Interferon-induced Transmembrane 3 (ifitm3) In Stroke And Other Inflammatory Conditions In The Brain.
Authors: Harmon Elisabeth , Doan Andrea , Bautista-Garrido Jesus , Jung Joo Eun , Marrelli Sean P , Kim Gab Seok
Published: February 2023

Microglia (MG) play critical roles in modulating inflammation and interferon signaling is a driver of neuroinflammation in various neurodegenerative diseases. Recently, Ifitm3 (a member of the “interferon-inducible transmembrane” family) has been revealed as a molecular mediator between neuroinflammation and neurodegeneration. However, expression of Ifitm3 in MG under inflammatory conditions, is not well described.

Methods:
To define the expression of Ifitm3 following stroke, permanent distal middle cerebral artery occlusion was performed with aged mice (18-22 mos). Brains were isolated at post-stroke day (PSD) 14 for single-cell RNAseq (scRNAseq), and at PSD 3, 7, and 14 for immunostaining and qRT-PCR. Primary microglial culture was established to evaluate mRNA levels of
Ifitm3
and other pro-inflammatory genes to cytokine treatment.

Results:
Our scRNAseq revealed that
Ifitm3
is among the top 10 genes upregulated in MG following stroke in aged brains. To validate these findings, we utilized a stroke model in aged mice and primary cell culture. We found that ischemic injury causes an induction of Ifitm3 in the striatum and peri-infarcted area following stroke, with peak induction PSD 7 (n=3-5, p<0.01). We also examined the induction of other Ifitm gene mRNA in brains following stroke. Interestingly, among Ifitm family members, only
Ifitm3
was markedly induced in the damaged cortex of PSD 3 brains (n=4-6). We found that
Ifitm3
expression is induced in primary MG following treatment with proinflammatory mediators (TNFα/IFNγ) for 6 hours (n=5-6, p<0.05) or for 24 hours (n=7-8, p<0.01). TNFα/IFNγ treatment also induced increased expression of inflammasome component gene,
Il1b
and
Casp1
. There was a close correlation between
Ifitm3
and
Casp1
expression, suggesting a potential of Ifitm3 in inflammasome activation.

Conclusions:
We demonstrated the profound induction of
Ifitm3
in activated MG within the stroke brain in aged mice and in response to inflammatory factors in primary microglia culture. These studies identify
Ifitm3
as a novel player involved in microglial modulation in response to a variety of inflammatory conditions. Future studies are warranted to determine if Ifitm3 deletion or inhibition can reduce neuroinflammation in the stroke brain.
Abstract TP211: Recombinant Growth Differentiation Factor 11 Treatment Improves Functional Outcome In A Rat Permanent Ischemia Model Of Subacute Stroke
Authors: Paskavitz James , Wang Yongting , Sinha Manisha , Cohen Ori , Daman Tyler , Deatherage Catherine , Jordan Samuel , Li Pi-Chun , Allen Mark , Sandrasagra Anthony
Published: February 2023

Introduction:
GDF11 is a pleiotropic circulating blood factor and member of the transforming growth factor β (TGFβ) superfamily. In animal models of stroke, GDF11 is linked to regeneration and recovery through neovascularization, neurogenesis, and anti-inflammatory effects, among other potential mechanisms.

Methods:
Focal cerebral infarcts were made by permanent occlusion of the proximal right middle cerebral artery (MCA) by microbipolar coagulation, following a modification of the method of Tamura et al. rGDF11 or vehicle was delivered via multiple routes of administration to male Sprague Dawley Rats at single and multiple doses ranging from 0.1 - 4 mg/kg per dose. Dosing started ~24 hours following injury. Behavioral assessments (e.g., limb placement and body swing) were captured at days 3, 5, 7, 14, 21, and 28 post-injury.

Results:
Dose-dependent improvements in all behavioral assessments were seen at all animals receiving any dose level or frequency of rGDF11. Vehicle vs. rGDF11 comparisons yielded statistically significant improvements (p < 0.05) in all 3 behavioral assessments at several post-injury timepoints, including follow-up days 14 & 28. No major tolerability events were observed, and no animals were lost during the study. Histologic and serum markers indicated rGDF11’s beneficial effects on neovascularization, neurogenesis, and inflammation.

Conclusions:
Treatment of pMCAO rats with rGDF11 ~24hrs post-injury resulted in dose-dependent, durable improvements in motor function-focused behavioral assessments. These data support continued development of the potential clinical therapeutic application of rGDF11 in stroke and related disorders.
Abstract TP212: Robust Neuroprotection With PAF-R Antagonist Plus AT-NPD1 In Experimental Ischemic Stroke: Dose-response And Therapeutic Window
Authors: Belayev Ludmila , Reid Madigan , Obenaus Andre , Mukherjee Pranab , Khoutorova Larissa , Oria Reinaldo , Roque Cassia R , Bazan Nicolas G
Published: February 2023

Objective:
We examined the neuroprotective efficacy, including dose-responses and therapeutic window of 1) LAU-0901, receptor antagonist of the bioactive phospholipid mediator platelet-activating factor (PAF-R) that downregulates pro-inflammatory signaling and has been shown efficacy in a stroke model and, 2) AT-NPD1 (Aspirin- triggered NPD1), its synthesis in the brain was discovered upon aspirin + DHA administration (Bazan et al. Exp Neurol., 2012) and induced cell-survival pathways, anti-inflammatory and neuroprotective activity in focal cerebral ischemia.

Methods:
Male SD rats underwent 2 hours of MCAo. Behavior testing (days 1-7) and
ex vivo
MRI on day 7 were conducted. In dose-response, rats were treated with LAU-0901 (45 and 60 mg/kg; IP), AT-NPD1 (111, 222, 333 μg/kg; IV), LAU-0901+AT-NPD1 (LAU-0901 at 3h and AT-NPD1 at 3.15h) or vehicle. In the therapeutic window, vehicle LAU-0901 (60 mg/kg), AT-NPD1 (222 μg/kg), and LAU-0901+AT-NPD1 were administered at 3, 4, 5, and 6h after onset of MCAo. Rats were perfused on day 7, and an
ex vivo
brain MRI was conducted using 11.7 T MRI. Hierarchal region splitting was used to distinguish the core from the penumbra.

Results:
LAU-0901 and AT-NPD1 treatments alone improved behavior by 40-42% and 20-30%, respectively, and LAU-0901+AT-NPD1 by 40% compared to the vehicle group. T2-weighted imaging (T2WI) volumes were reduced with all doses of LAU-0901 and AT-NPD1 by 73-90% and 67-83% and LAU-0901+AT-NPD1 by 94% compared to vehicle. In the therapeutic window, treatment with LAU-0901 and AT-NPD1 alone, when administered at 3h, improved behavior on day 7 by 35 and 28%. In contrast, LAU-0901+AT-NPD1, when administered at 3, 4, 5, and 6 hours, improved behavior by 50, 56, 33, and 26%. Ischemic core, penumbra, and total lesion volumes were dramatically reduced with LAU-0901+AT-NPD1 when administered at 3, 4, 5, and 6h by 93, 90, 82, and 84% compared to the vehicle.

Conclusion:
These data suggest that LAU-0901 and AT-NPD1 alone in low doses provide high-grade neuroprotection in the MCAo model. Combination therapy with LAU-0901 and AT-NPD1 is more effective than the single therapy, affording synergistic neuroprotection with improved neurological recovery when administered up to 6 h after focal cerebral ischemia in rats.
Abstract TP215: Prenatal Alcohol Exposure Impairs Long-term Behavioral Recovery Following Ischemic Stroke In Sprague Dawley Rats
Authors: Bake Shameena , Hurst David , Samiya Nadia T , Miranda Rajesh , Sohrabji Farida
Published: February 2023

Background and Purpose:
Early life adversity is an important risk factor for cardiometabolic diseases in adulthood. There is very little information on prenatal insults and adult stroke outcomes. The present study tested the hypothesis that prenatal alcohol exposure (PAE) impedes long-term recovery from ischemic stroke in rats.

Methods:
Pregnant Sprague Dawley rats (in-house bred) were exposed to 10% alcohol or air, for 1 hour from gestational day 8 through 18 using the rodent alcohol inhalation system. Adult offspring (5-6 mo old) were subjected to endothelin-1 induced MCAo and outcomes were evaluated after 180 days. Long-term cognitive outcomes were determined using the Barnes maze and fear conditioning/extinction test.

Results:
In the Barnes maze test, control males showed shorter latency to reach the goal box over 3-day learning period (p=0.002), as assessed by the slope of the curve (-27.66, significantly different from 0; p=0.005). In contrast, the latency over the 3-day learning period did not improve in PAE males (-9.674, not significantly different from 0; p=0.22). In females, the latency to escape box during the learning trials was not different between the control and PAE. The fear conditioning data indicate that percent freezing over trials was similar in control and PAE-males. However, the PAE females exhibited a diminished freezing response as compared to control females (p=0.01). In the context of fear extinction, control males showed a reduction in freezing response to repeated tones over the trial blocks (p=0.004) compared to PAE-males. The control and PAE females showed similar freezing responses with repeated tones.

Conclusions:
The present findings support the hypothesis that PAE modifies long-term cognitive changes after stroke, and further show that different cognitive domains are affected by PAE in males and females.
Abstract TP225: Cell-type-based Pathway Analysis In Experimental Subarachnoid Hemorrhage
Authors: Wong George K , Chen Evan
Published: February 2023

Introduction:
Recently, increasing evidence points to a pivotal role of neuroinflammation in the pathogenesis of Subarachnoid hemorrhage (SAH). However, the pattern of cell interaction after SAH is not clear.

Methods:
Endovascular perforation (EVP) murine SAH model was established to reproduce experimental SAH. Post-SAH CD11b+ single-cell suspension was harvested at day 3 and sequenced using 10X single-cell RNA-sequencing platform. Then, the detailed single-cell information of post-SAH cells was analyzed with bioinformatics. The same pathways and related ligand-receptors in microglia and other cells were compared.

Results:
More than 51 pathways were found in the crosstalk of brain cells after SAH, these cells including: microglia (microglia worked in 25 pathways), CNS-associated macrophage, astrocyte, neuron, monocyte and macrophage and Oligodendrocyte. In the microglia subsets’ interaction, 15 pathways upregulated, of which four pathways were specific to microglia subsets, including amyloid-β precursor protein (APP), Tumor necrosis factor (TNF), growth differentiation factor (GDF) and oncostatin M (OSM) signaling pathways. We precisely distinguished the ligand-receptor pattern in which microglia differ with other cells in 7 pathways, including chemokine ligands (CCL), colony-stimulating factor (CSF), GALECTIN, growth arrest-specific (GAS), intercellular adhesion molecule (ICAM), junction adhesion molecule (JAM) and secreted phosphoprotein 1 (SPP1) signaling pathways. Gene ontology (GO) results showed that compared with non-microglia cells, post-SAH microglia with upregulated function like leukocyte, glia cell activation and migration, while have downregulated functions of protein-lipid complex remodeling.

Conclusions:
Collectively, we first systematically report the interaction patterns of seven brain cells after SAH. Further the cell type based ligand-receptor analysis of microglia and other cells in the same pathway was comparatively conducted. These results revealed the cellular mechanisms for neuroinflammation after SAH, and the ligand-receptor results provided a theoretical basis and opportunities for accurate monitoring and modulation of SAH in the future.
Abstract TP236: Temporal Metabolomic Profiling Exposed Affiliated Metabolites Altered And Associations To Outcome After Different Acute Brain Injuries
Authors: Hellström Santtu , Sajanti Antti , Girard Romuald , Frantzen Janek , Umemori Juzoh , Koskimaki Fredrika , Lyne Sean B. , Falter Johannes , Rantamäki Tomi , Nazir Kenneth , Gajera Bharat , Posti Jussi , Roine Susanna , Takala Riikka , Kolehmainen Sulo , Cao Ying , Li Yan , Heino Iiro , Rahi Melissa , Rinne Jaakko , Nieminen Anni , Castren Eero , Koskimaki Janne
Published: February 2023

Background:
Neuronal recovering processes after acute brain injuries such as aneurysmal subarachnoid hemorrhage (aSAH), ischemic stroke (IS) and traumatic brain injury (TBI) are complex including brain plasticity and synaptic regeneration mechanisms.

Hypotheses:
Transient changes in metabolome after different acute brain injuries may reveal affiliated metabolites, metabolic pathways and associations that can also reflect important biological mechanisms. Measurable temporal changes in serum metabolomic profile may be similar irrespective of the type of the brain injury. These metabolomic commonalities may be associated to outcome.

Methods:
Prospective cohort (n=74) consisted of IS (n=30), aSAH (n=31) and TBI (n=13) patients. Serum samples were collected in two time points after the insult (early 24-48h and late 120-192h). Orbitrap Profiling of 462 metabolites was used to measure metabolites. Outcome was measured 90 days after injury (mRS favorable 0-3, unfavorable 4-6). The metabolomics data was imputed for missing value using KNN with 20% cut off for missing value, log-transformed and autoscaled. For statistics, t-test and ANOVA was performed and FDR-corrected p-value 0.05 was considered to be statistically significant.

Results:
We identified four similarly temporally increased metabolite levels across all acute brain injury types (p<0.05, FDR corrected). Twenty-eight metabolites were shown to have similar trend when only IS and TBI groups were compared. Whereas outcome analysis showed three metabolites associating both favorable and unfavorable outcome across all acute brain injury types (p<0,05, FDR corrected). IS and TBI groups combined twenty common metabolites were identified to associate favorable and twenty-three with unfavorable outcome (p<0,05, FDR corrected).

Conclusion:
Similar metabolic changes across time were identified with apparent associations to outcome. This suggests important common metabolic characteristics irrespective of the type of brain insult and encourage further studies and validation. Identified metabolites may be further developed as a prognostic biomarker and may indicate new metabolic pathways active irrespective the type of brain injury reflecting biological mechanisms.
Abstract TP25: Implementing Stroke Systems Of Care Within A New Hospital
Authors: Ronosky Kristen , Hackett Chris , Wood Mary , Cerejo Russell , Pasquella Julie , Latouf Kathleen
Published: February 2023

Background:
Stroke programs are often developed and implemented in well-established health care facilities. Stroke coordinators and nurse navigators are essential leaders to ensure success of a stroke program. We aimed to establish strong culture of engagement in the care of stroke patients from day one of a new 160-bed hospital, by hiring a stroke coordinator and navigator to assist with developing a stroke program prior to opening the hospital.

Methods:
Five months prior to opening a stroke coordinator was hired and navigator was assigned to coordinate post-acute stroke care. A multidisciplinary stroke oversight committee was formed, which guided development of the stroke program and integrated leaders from all areas involved with direct or indirect stroke patient care. In the months preceding go-live; policies and order sets were implemented, stroke alert processes, specific to each unit, with scenarios were reviewed. All nursing staff completed eight hours of stroke education, including NIHSS certification prior to go-live. Additionally, six mock stroke alerts were completed with the assistance of our simulation and training center.

Results:
One hundred twenty-two patients presented and were diagnosed with stroke between hospital opening on 09/30/2021 and 06/30/2022. The majority of patients were diagnosed with acute ischemic stroke (AIS) or transient ischemic attack 115 (94.3%), age was 69.1±14.8 years and median NIHSS was 1 [IQR, 0 - 2]. Two patients were recommended for and received AIS treatment; one IV thrombolysis and one endovascular stroke thrombectomy. Thirty four patients were added to the stroke care pathway and closely followed for 90 days. The hospital was 100% compliant with all Get with the Guidelines (GWTG) STK measures, with the exception of CSTK-01 NIHSS at 78%. Additionally, all GWTG achievement measures and quality measures achieved at least 93%, except for dysphagia screening which was at 86% compliance.

Conclusions:
Developing a stroke program by integrating a stroke coordinator and navigator prior to hospital opening facilitated best practices for stroke systems of care from day one. This allowed a brand-new hospital to achieve similar levels of compliance on key GWTG measures compared to other stroke certified hospitals.
Abstract TP32: Continuous Quality Improvement Implementation Across A Stroke Network
Authors: Zielke Shelly , Brown Harold E , Elkins Kelley , Okong'o Casey , Bellamy Lisa M
Published: February 2023

Background and Purpose:
One of the network missions is to improve quality of care through an evidence-based, standardized approach. In 2014 with 24 affiliate hospitals (25% certified stroke centers), a formalized continuous quality improvement process began and it continues through today with 37 affiliate hospitals (51% certified stroke centers).

Methods:
Over the years, the quality process has been enhanced to include additional abstraction training/support, individual data points for improved data analysis and a newly developed data report with built in logic and automatically populated graphs. Data is aggregated for network analysis and an annual scorecard is published that is utilized for benchmarking. Performance improvement (PI) goals are established as a network.

Results:
In 2014, 88% (21 of 24) affiliates submitted stroke data, compared to 91% (32 of 35) in 2022 fiscal year (Note: two affiliates are pending training). In 2022, 80% of non-certified stroke centers submitted data, compared to 100% for certified stroke centers. For Thrombolytic Therapy (STK-4), 79% compliance rate in 2014, compared to 89% in 2022; Thrombolytic Therapy (ASR-OP-1), 66% compliance rate in 2021, compared to 88% in 2022. For Dysphagia Screening (STK[PM]-7), 58% of the affiliates submitted data in 2014 with average of 92% compliance, compared to 89% in 2022 with an average of 87%. For Order Set Usage, in 2018 61% of the affiliates submitted data with an 87% compliance rate, compared to 89% of the affiliates submitted data with an 87% compliance rate in 2022. From 2018 to FY2022, the network had a 10% improvement in Door to Needle (≤ 60 minutes) from 66% compliance to 76%.

Conclusions:
The network showed improvement with the CQI program in: data submission rates, Door to Needle Time, and Thrombolytic Therapy. This is a success overall, particularly with the non-certified stroke centers. Though there are many confounding factors, this is in correlation with our focused improvement efforts such as individual follow-ups, data abstraction training, quarterly review of data, sharing best practices, updating program documents, monthly quality insights and education with affiliates.
Abstract TP36: Communication Error: Does Primary Language Slow Down Stroke Activations?
Authors: Glidden Michele
Published: February 2023

Racial equity is different from racial equality. Racial equality is achieved when race no longer factors into or determines one’s socioeconomic outcomes. Since the spring of 2020, racial equality and equity have been brought to the attention of health care organizations. A stand-alone academic, safety-net, urban hospital in the Midwest looked at if race and primary language were a factor in our emergent treatments for stroke. Being a safety net hospital, the languages used by our patients, families, and caregivers are very diverse. In 2021, there were over 170 languages supported at this facility. This facility looked at their emergent stroke interventions to see if there was an impact on the situation's urgency and if there were differences in getting the patient started on thrombolytics and/or to the NeuroInterventional Lab for an emergent mechanical thrombectomy. From 2018 through 2022, 250 cases were reviewed for times for the initiation of emergent treatment. These cases were patients that presented to the Emergency Department, either by private vehicle or Emergency Medical Services with acute stroke symptoms. Patients that received thrombolytic or thrombectomy from an outside hospital or an inpatient unit were excluded. Treatment times were defined by door-to-drug and door-to-puncture for each procedure. These patients were also defined by age, race, and primary language. It was also differentiated if these patients were subject to emergency 2 physician consent based on the inability to communicate because of their stroke symptoms. Our conclusion is that when emergent stroke treatments were involved, there was no distinction between language, race, or the ability to consent for either thrombolytic therapy or emergent mechanical thrombectomy.
Abstract TP39: Impact Of Silent Liver Fibrosis To Cerebral Microbleeds In Patients With Acute Ischemic Stroke
Authors: Takahashi Junichiro , Komatsu Teppei , Okumura Motohiro , Kida Hiroyuki , Maku Takahiro , Nakata Ryoji , Kitagawa Tomomichi , Sato Takeo , Takatsu Hiroki , Sakuta Kenichi , Sakai Kenichiro , Mitsumura Hidetaka , Iguchi Yasuyuki
Published: February 2023

Background:
Liver fibrosis (LF) is reported to affect the development of cerebral small vessel disease (SVDs) including cerebral microbleeds (CMBs). The Fibrosis-4 (Fib4) index is a simple and non-invasive scoring method for detecting LF. Herein, we investigated the association between the severity of LF and the presence or distribution of CMBs.

Methods:
From October 2012 to May 2022, patients with acute ischemic stroke within 24 hours from onset were retrospectively enrolled. Exclusion criteria were those associated with malignancy or missing clinical data including MRI findings before treatment started, or functional outcome at 3 months after discharge. The distribution of CMBs were classified on MRI as strictly lobar, or not (deep/ infratentorial or mixed area). FIB-4 index is calculated as follows: FIB-4 = [age (years)*aspartate aminotransferase (U/L)] / [platelet count (10
9
/L) *√alanine aminotransferase (U/L)]. We analyzed the association between the severity of LF, according to the tertile of Fib4 index; mild-LF (Fib4 index < 1.30), moderate-LF (1.30 ≤ Fib4 index < 2.67), severe-LF (2.67 ≤ Fib4 index), and the presence and distribution of CMBs.

Results:
614 subjects (median age 69 years, 435 men) were retrospectively enrolled. Fib4 index were higher in order of only lobar, deep/ infratentorial or mixed area, and none CMBs (
p
< 0.001). Also, severe LF group showed the highest number of CMBs (p < 0.001). Age on admission (OR 1.040, 95% CI 1.020-1.050, p < 0.001), hypertension (OR 1.840, 95%CI 1.260-2.690,
p
= 0.002), and anti-thrombotic drugs using (OR 1.500, 95% CI 1.020-2.190,
p
= 0.038) were independently associated with the presence of CMBs. In anatomical distribution of CMBs, Fib4 index (OR 0.701, 95%CI 0.505-0.974, p = 0.034) were only independent predictive factor of the CMBs on D/I or mixed area.

Conclusion:
The novel association between silent LF and the distribution of CMBs as located in only lobar were established.
Abstract TP4: Freezing Tenecteplase Aliquots Reduces Waste And Achieves Similar Door To Needle Times And Reperfusion Rates
Authors: Kaur Harsimran , Merkel Alison , Hackett Chris , Finoli Lauren , Seidl Edward , Reardon Caitlin , Cerejo Russell
Published: February 2023

Objective:
To determine the feasibility of using previously frozen tenecteplase (TNK) to treat acute ischemic stroke (AIS) due to large vessel occlusion (LVO).

Methods:
This is a single-center proof of concept prospective study that was retrospectively analyzed. We began using freshly reconstituted TNK to treat AIS due to LVO in May 2020. In March 2022 we began dividing the 50mg vial of TNK into two frozen 25mg aliquots based on a previously published stability and bioactivity study comparing thawed TNK to freshly reconstituted samples. Our primary outcome was door-to-needle time (DTN) which was analyzed with a quantile regression specifying the median, which was adjusted for age, NIHSS and delays related to treating hypertension. Binomial logistic regression analyses were used to assess secondary outcomes of TNK recanalization rate prior to mechanical stroke thrombectomy (MST) and excellent reperfusion scores (≥TICI 2C) after MST in the fresh and previously frozen TNK groups.

Results:
Five frozen TNK vials (ten aliquots) had been created since implementation of freezing TNK. Seven previously frozen aliquots were thawed and used, while three aliquots expired and were discarded. We analyzed the seven previously frozen TNK aliquots against the sixty eight freshly reconstituted TNK vials used to treat acute ischemic stroke patients. Median DTN was similar between previously frozen, 41 (IQR, 27 - 53) and fresh TNK, 46 (IQR, 37 - 60), p = 0.12. There was no difference in the LVO recanalization rate prior to MST in previously frozen, 0 (0.0%) and fresh TNK, 2 (2.9%), p = 0.99. Patients undergoing MST achieved similar rates of excellent reperfusion in previously frozen, 4 (66.7%) and fresh, 30 (56.6%) TNK treated patients, Odds Ratio = 1.55 [95%CI, 0.25, 9.70], p = 0.64

Conclusions:
It is feasible to freeze 50mg vials of TNK into two 25mg aliquots to use to treat acute ischemic stroke. We found similar DTN times, indicating that thawing the previously frozen TNK did not delay IV thrombolysis administration. Additionally, we found similar reperfusion rates prior to and after MST with freshly reconstituted and previously frozen TNK.
Abstract TP44: No Differences In Outcomes For Stroke Patients Presenting To A Comprehensive Stroke Center And Treated Using Telestroke Vs. In-person Assessments During The Covid-19 Pandemic.
Authors: Fawcett Adrian , Ho Wilson
Published: February 2023

Introduction:
Telestroke is the use of videoconferencing technology by a stroke specialist to assess and treat acute ischemic stroke patients who present elsewhere. It has been well-studied previously in a “Hub-and-Spoke” model. In 2021, Telestroke was used to assess and treat acute ischemic stroke patients who presented primarily after-hours to our comprehensive stroke center because we were concerned the COVID-19 pandemic could affect the timeliness of in-person code stroke assessments. After implementation, we determined the efficacy and safety outcomes for patients treated with Telestroke versus in-person assessments.

Hypothesis:
We hypothesized that there will be no difference in the efficacy or safety outcomes between patients treated using Telestroke vs. in-person assessments.

Methods:
A retrospective chart review identified acute ischemic stroke patients who presented to our center in 2021, who were assessed and treated using either Telestroke or an in-person assessment. The primary outcomes for efficacy were door-to-needle (DTN) time for alteplase administration and door to puncture (DTP) time for endovascular thrombectomy. The primary safety outcomes were 3-month mortality and symptomatic intracranial hemorrhage rates (sICH).

Results:
We treated 302 acute stroke patients in 2021, with 18.2% (n=55/302) of patients treated using Telestroke. There were no differences in clinical outcomes between patients treated using Telestroke vs. in-person assessments: median DTN (35.5min (n=42) vs. 33min (n=182), p<0.76), median DTP (86.5min (n=30) vs. 85min (n=134), p<0.97), sICH (0% (n=0/55) vs. 1.6% (n=4/245, p<0.59) or 3 month mortality (20.6% (n=7/34) vs. 22.1% (n=40/181), p<0.29).

Conclusion:
This is the first study to our knowledge that reports on using Telestroke at a comprehensive stroke center. In this study, there were no differences in the clinical outcomes between stroke patients treated with Telestroke vs. in-person assessments. These results support using Telestroke to meet the increasing demands for acute stroke assessments at other comprehensive stroke centers.
Abstract TP47: Impact Of Prehospital Care And Patient Presentation On In-hospital Treatment Of Acute Ischemic Stroke
Authors: DYLLA LAYNE , Higgins Hannah M , Ravare Brandy , Jeppson Kerri , Bina Heather , Rice John D , Herson Paco S , Monte Andrew A , Poisson Sharon N
Published: February 2023

Background:
Emergency Medicine Service (EMS) provider compliance with American Heart Association (AHA) guidelines for acute stroke care is low. While early recognition improves in-hospital quality of care, including door-to-computed tomography (CT) time, the impact of compliance with individual recommendations on in-hospital outcomes is unknown.

Methods:
We identified 410 acute ischemic stroke patients who presented to a Comprehensive Stroke Center via EMS between January 1, 2018, and December 31, 2019. Guideline concordant care was defined as encounters in which EMS documented: a blood glucose, a 12-lead electrocardiogram, a stroke scale result, and time of the last known well; were enroute within less than 2 minutes from dispatch and spent less than 15 minutes on scene. We used a multivariable linear regression model to determine the effect of individual metrics, race/ethnicity, sex, and age on door-to-CT times.

Results:
There was low compliance with all quality-of-care metrics (37/410 encounters, 9%), but most encounters met at least 4 metrics (60.3%). Compliance with recommendations to maintain short dispatch-to-enroute times and to obtain a blood glucose were the highest (88.1% and 74.5%, respectively). Only 44.5% of encounters documented a stroke scale, but 95.9% documented a neurological exam. A linear regression model identified documentation of classic symptoms (unilateral weakness, facial droop, or speech changes) (parameter estimate -16.6, 95% CI -21.8 to -11.5) and documentation of the last known well time (parameter estimate -15.9, 95% CI -21.6 to -10.1) as significant predictors of door-to-CT times. However, documentation of a last known well occurred only in 59.9% encounters.

Conclusions:
Like prior studies, this study finds similarly low compliance with AHA stroke guideline and also identifies two key EMS actions that are associated with shorter door-to-CT times - documentation of last known well and recognition and documentation of classic stroke symptoms. Further education is needed to reinforce the importance of individual recommendations such as documentation of last known well and its impact on in-hospital care. Broader analysis of EMS practices is needed to fully understand the impact on additional patient outcomes.
Abstract TP50: Exception From Informed Consent (EFIC) In Emergency Research: Developing A Community Consultation Plan
Authors: Zarrieneh Ashkan , Amidei Christina , Jahromi Babak
Published: February 2023

Background:
In emergent situations where patients are neurologically impaired, obtaining informed consent is a challenge. Research-related interventions that may optimize patient outcomes may be delayed or not given. Under the Final Rule, emergency research studies can proceed without informed consent granted that certain criteria are first met. One criteria is that researchers must conduct community consultation activities.

Objective:
We share the various mechanisms used in outreach to our catchment area and their respective views of EFIC research.

Methods:
As part of community consultation efforts for an emergent hemorrhagic stroke trial, our research team first developed a comprehensive plan to seek out the best platforms to disseminate study information and obtain diverse input (all while recognizing the heterogeneity of the community). A survey tool developed by the study’s sponsor National Institute of Health StrokeNet team was used to elicit feedback related to the value of the trial, participants’ understanding of EFIC, and trust in physician-investigators.

Results:
A total of 700 individuals participated across all the proposed community consultation events (e.g. focus groups, local support groups, forums). Two-hundred five participants completed the survey, with 96% agreeing that the trial is an important study to do; 80% were in favor of themselves or a loved one being included in the trial without consent. Community members responding included seniors, those at higher risk of suffering a stroke, and medical providers. Minority communities (i.e. Hispanic & African American populations) were contacted to ensure that their voice was heard. We used public disclosure to assist in reaching minority groups. Despite receiving only 22% turnout from these community members, the feedback received demonstrated the need to continue to make a collective effort in gaining the trust of these populations through community liaisons.

Conclusion:
Overall, community members expressed high levels of support for this EFIC trial. By incorporating a wide variety of mechanisms into a community consultation and public disclosure plan, maximal support for EFIC can be achieved.
Abstract TP57: Understanding Ethnic Differences In Post-stroke Informal Caregiver Needs
Authors: Mehdipanah Roshanak , Morgenstern Lewis B , Prvu-Bettger Janet , Kwicklis Madeline , Almendarez Elizabeth , Lisabeth Lynda D
Published: February 2023

Introduction:
Stroke is the leading cause of adult disability in the U.S. Mexican Americans (MAs) have worse 90-day neurologic, functional, cognitive and quality of life outcomes and a higher prevalence of post-stroke depression compared to non-Hispanic whites (NHWs). MAs receive more help through informal, unpaid caregiving than NHWs. Little is known about caregivers’ needs and whether they differ by ethnicity. We examine ethnic differences in the number and type of needs identified by MA and NHW caregivers.

Methods:
Caregivers were identified from the population-based Basic Attack Surveillance in Corpus Christi Project from October 2019 to November 2021 in Nueces County, Texas. Responses to the 32-item Caregiver Needs and Concerns Checklist (CNCC) were collected at 90-days post stroke and were used to assess needs and concerns of stroke caregivers within 5 domains: information, emotions and behaviors, physical care, instrumental care, and personal responses to caregiving. Bivariate analyses were used to examine differences between CNCC items by ethnicity. Linear regressions were used to examine adjusted associations of ethnicity with the total average of needs for each domain.

Results:
187 caregivers were included; 74.3% MAs and 25.7% NHWs. MA caregivers had lower education and income, and more had other jobs while providing care. Significant ethnic differences were only observed in the average frequency of the “finding information on stroke” domain (B=0.17; 99.17%CI: 0.02-0.32) after adjusting for various caregiver and patient characteristics. Within the information domain, MAs reported an overall greater need and some individual needs differed by ethnicity (Table 1).

Discussion:
There exists differences in the needs of MA caregivers compared to NHWs. Understanding these differences can help develop or improve resources needed to help with post-stroke recovery, improve caregiver well-being in this population and strengthen health equity.
Abstract TP6: Recanalization Of Large Vessel Occlusion After Intravenous Alteplase Therapy In Acute Ischemic Stroke Patients Transferred From Primary Stroke Centers
Authors: Wong Serena , Russo Brittany , Bornovski Yarden , Viswanathan Divya , Chong Ji , Kurian Christeena , Al-Mufti Fawaz , Patel Neisha , Geraci Suzanne , Kaur Gurmeen
Published: February 2023

Background and Purpose:
Early recanalization of occluded intracranial arteries predicts favorable outcome in acute ischemic stroke (AIS) patients treated with intravenous alteplase therapy within 4.5 hours from stroke onset. Prior studies have shown recanalization of large vessel occlusion (LVO) with alteplase ranging from 0% for internal carotid artery and 33% for distal blood vessels. We performed an analysis to examine the characteristics of stroke patients and the location of LVO that predicts early recanalization in patients treated with intravenous alteplase alone.

Methods:
This single-center, retrospective study solely included AIS patients with LVO who were transferred to our institution for mechanical thrombectomy evaluation after treated with alteplase at a primary stroke center between January 2019 and January 2021. Recanalization was identified by repeated computed tomographic angiography (CTA) or digital subtraction angiography (DSA) at our institution upon arrival.

Results:
One hundred and six patients were included in the analysis, 15 (14.1%) patients had partial or complete recanalization of LVO. Cardioembolic was the most common cause of ischemic stroke (46%), followed by large vessel atherosclerosis (33%) in this group. They were more likely to have a medical history of hypertension (73.3% vs. 59.3%), better baseline function as measured by pre-modified Rankin Score 0-2 (73.3% vs. 68.1%), and receive early treatment (105 minutes vs. 135 minutes), compared to their counterparts with no recanalization. Proximal and distal middle cerebral artery had the same rate of recanalization in this cohort.

Conclusion:
The highest incidence of early recanalization of occluded intracranial arteries was found in cardioembolic strokes with middle cerebral artery being the most common location of recanalization. Early recanalization with intravenous alteplase was also associated with improved functional recovery at discharge.
Abstract TP64: Characterization Of Stroke Mimics Treated With Thrombolytics
Authors: Schmitt Barrie L , O'Banion Darcy R , Jeppson Kerri A , Ravare Brandy C , Poisson Sharon N
Published: February 2023

Background:
Stroke is a medical emergency. The effectiveness of stroke treatment is time dependent. Due to the urgency of treatment and the challenge of rapidly assessing stroke-like symptoms, patients with stroke mimics (non-stroke etiologies of focal neurologic symptoms) may be treated with thrombolysis. We aimed to understand characteristics of patients treated with IV tPA with a final diagnosis of stroke versus a stroke mimic.

Methods:
This retrospective cohort study identified patients who received tPA for stroke-like symptoms in the emergency department at a single urban Comprehensive Stroke Center over 26 months. Final diagnosis was based on ICD-10 codes. Demographic data, medical history and presenting symptoms were obtained through electronic medical record review. Characteristics of patients with strokes and mimics were compared using Chi-squared and t-tests.

Results:
Of 202 patients presenting with stroke-like symptoms who received tPA, final diagnosis was ischemic stroke in 166 (82%) and mimic in 36 (18%). A statistically significant difference was noted between the stroke and mimic groups in age (64 ±16.9 vs 57 ±13.8 years, p=0.015) and neared significance in sex (38% vs 56% female, p=0.052). There was no difference in initial NIHSS (7.8 ±7.2 vs 5.8 ±5.2, p=0.109), Hispanic ethnicity (13% vs 22%, p=0.170), presence of stroke risk factors (79% vs 78%, p=0.880), or race distribution (white 54% vs 61%, Black 28% vs 14%, multiple/other 18% vs 25%, p=0.199). The most common mimic symptoms included unilateral weakness (61%), unilateral numbness (53%), dysarthria (33%), ataxia (28%), vertigo (22%), and gait impairment (17%). The most common clinical diagnoses in mimics were headache, functional neurologic disorder, and toxic/metabolic disturbances (17% each).

Conclusion:
Of patients receiving tPA at our facility, stroke mimics comprised 18% and were significantly younger than patients with ischemic stroke. Further analysis of demographics within these two groups could identify characteristics that distinguish strokes from mimics, which may lower the rate of tPA administration to non-stroke presentations.
Abstract TP75: Waking Up To A New Wake-Up Stroke Protocol Is Feasible And Safe
Authors: Rana Maheen , Burton Tina M , Jayaraman Mahesh , Mandel Daniel , Shu Liqi , Goldstein Eric D , Kala Narendra , Stretz Christoph , Perelstein Elizabeth , El Jamal Sleiman , Moldovan Krisztina , Rogg Jeffrey , Jindal Gaurav , Alvin Matthew , Boxerman Jerrold , Madsen Tracy , Karb Rebecca , Fussell-Louie David , Buksar Andrew , Harmon Melissa , Furie Karen L , Yaghi Shadi
Published: February 2023

Introduction:
Up to 25% of strokes are recognized upon awakening. Recent studies have demonstrated that a “tissue clock” rather than a time clock can be used to identify patients who may benefit from intravenous thrombolytics (IVT) beyond 4.5 hours from last known well (LKW). Consistent access to hyperacute MRI limits many centers from treating wake-up stroke patients. We created a formal protocol of clinical and imaging criteria to standardize evaluation and management of wake-up strokes.

Methods:
This retrospective, observational study reviewed consecutive patients admitted to our Comprehensive Stroke Center who qualified for the wake-up protocol between February 2022 and June 2022. The implemented protocol, based on clinical trials’ inclusion criteria, is comprised of the following: 1) arrival within 12 hours from LKW and within 4.5 hours from symptom discovery; 2) high suspicion for acute ischemic stroke; 3) no contraindication to MRI; 4) NIHSS of at least 4; 5) baseline mRS 0-3; 6) no absolute contraindications to IVT. For patients meeting above inclusion criteria, emergent MRI with perfusion was performed. Diffusion-FLAIR mismatch (signal intensity ratio) and diffusion-perfusion mismatch were reviewed to determine thrombolysis eligibility by a trained neuroradiologist or vascular neurologist.

Results:
Ten patients qualified for the wake-up protocol in the first five months of protocol implementation. Median NIHSS was 7, median LKW to arrival time was 8 hours, and median door to MRI time was 72.5 minutes. A final diagnosis of ischemic stroke was made in 80% of these cases. Overall, 50% were eligible for IVT based on our criteria, and 30% received thrombolysis. Median door to needle time was 92 minutes (range 75-117). There were no symptomatic intracranial hemorrhages. All patients treated with IVT were discharged home with no to minimal residual deficits with mRS 0-1 and median NIHSS at discharge of 2 (range 0-4).

Conclusion:
A formal protocol for wake-up stroke management allowed a streamlined approach to expand the number of IVT-eligible cases. Continued efforts are needed to improve door to needle times in such cases and to follow clinical courses of treated patients.
Abstract TP77: Point Of Care Inr And R-tpa Decision Making In Acute Ischemic Stroke
Authors: Johnson Paul , Hoversten Knut , Moores Todd Tamara , Van Duren Joe
Published: February 2023

Introduction:
IV r-tPA is the standard of care treatment in acute ischemic stroke presenting within 4.5 hours of last known well. Exclusion criteria for administering IV r-tPA include conditions that predispose to bleeding, including an INR of ≥ 1.7 . Point of care (POC) INR testing is significantly faster than laboratory derived INR results and can expedite IV r-tPA administration. However, POC INR testing is less accurate than laboratory-based testing with an acceptable variance range of +/- 0.4, which may lead to improper r-tPA exclusion or inclusion.

Objectives:
We demonstrate the utility of a protocolized approach to POC INR testing in acute ischemic stroke, in which known or suspected warfarin use requires a lab INR result to determine if r-tPA is contraindicated when POC INR is between 1.3-2.1. This approach prevents IV r-tPA from being inappropriately administered or withheld.

Methods:
We stratified a subset of real world paired POC and laboratory INR results (n=892) for stroke code patients at our institution from January 1st through July 4
th
, 2022 by known or suspected warfarin status and calculated a positive predictive value for POC INR > 1.7.

Results:
Fifty-four of 892 paired POC and laboratory INR results represented patients with known or suspected warfarin use. Twenty-five (46%) had a POC INR within 1.3-2.1 warranting a lab INR verification prior to safe administration of r-tPA. Thirteen of which had a POC INR < 1.7 but a lab INR of ≥ 1.7. In 5.25% of cases where the POC INR > 1.7 the laboratory INR was < 1.7. The positive predictive value for POC INR >= 1.7 among patients with known or suspected warfarin status is 88.2%.

Conclusions:
POC INR testing rapidly screens for coagulopathy in IV tPA eligible stroke patients, but due to inherent inaccuracy may inadvertently rule patients in or out for IV r-tPA treatment. Our institution has instituted a policy of requiring laboratory verified INR results when the POC INR is within +/- 0.4 of the laboratory based INR tPA cutoff. In our 892 patient sample, this policy would prevent 13 patients from inadvertently receiving IV tPA due to an inaccurate POC INR. Up to five percent of patients excluded from r-tPA based on POC INR may in-fact be treatment candidates.
Abstract TP79: Epic Smartblocks: Faster Note And Better Look
Authors: Tarique Salman , Gangadhara Shreyas
Published: February 2023

Introduction:
Electronic health records (EHRs) were introduced into healthcare in order to minimize errors and increase efficiency. Unfortunately, the use of EHRs have also resulted in note bloat (“notes that contain multiple pages of nonessential information, often leaving key aspects buried or lost”). SmartBlocks (figure 1) in Epic EHR can be utilized in the stroke note template in order to reduce the amount of time it takes to complete each note, reduce note bloat, and automate data capture.

Method:
We first introduced SmartBlocks in the ischemic stroke note template at University of Mississippi Medical Center (UMMC) in 2019 in order to capture patient timeline and NIHSS. However, majority of the note still comprised of SmartLists which were buried in paragraphs and were amenable to non-standardized modifications. Major changes to the note were then made in October 2021 with the introduction of SmartBlocks in the assessment and plan sections. This allowed for a click-through model with guideline-based choices, output to be more objective with bullet points and grouping, and auto-population of selected smart elements in the REDCap database. Pre-implementation surveys were given to 12 UMMC neurology residents (PGY II-IV) between August-September 2021. Post-implementation surveys of the same residents were carried out between May-June 2022. Each survey contained fifteen questions with Likert scale choices.

Results:
Of the 12 residents surveyed, 84% responded with excessive time to extract relevant information from the pre-implementation note (vs 17% post-implementation). Note completion time was decreased for 58% of the residents after SmartBlock implementation (vs 25% pre-implementation). Overall satisfaction with the look of the note increased from 25% to 66%. Overall satisfaction with the information contained in the note increased from 8% to 75%.

Conclusion:
Implementation of SmartBlocks in stroke notes can reduce note bloat and time to note completion.