bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP294: Sex Differences in Thrombin Generation in Patients With Acute Ischemic Stroke
Authors: Falcione Sarina , Spronk Elena , Munsterman Danielle , Joy Twinkle , Boghozian Roobina , Jickling Glen
Published: February 2024

Background and Purpose:
Sex differences in stroke exist, including variation in stroke risk and outcome. Differences in thrombin generation may contribute to this variation between females and males. To examine this, we assessed sex differences in thrombin generation between females and males with acute ischemic stroke and the relationship to blood cell gene expression.

Methods:
In 97 patients with acute ischemic stroke thrombin generation was measured by thrombin generation assay. Blood cell gene expression was measured by microarray. Differences in thrombin generation between sexes were identified and the relationship to blood cell gene expression examined. Genes associated with sex differences in thrombin generation were analysed by functional pathway analysis.

Results:
Females and males had similar overall capacity to generate thrombin. The peak thrombin generated in females was 468.8nM (SD 91.6), comparable to males 479.3 (SD 90.8; p=0.58). Lag time, time to peak thrombin, and endogenous thrombin potential were also similar between females and males. While overall thrombin generation was comparable between females and males with stroke, differences in genes that promote this thrombin generation exist. Females with high peak thrombin had an increase in genes that promote thrombosis, and platelet activation. In contrast, males with high peak thrombin had a decrease in genes involved in thrombus degradation.

Conclusion:
Females and males with acute ischemic stroke have similar capacity to generate thrombin. However, differences may exist in how this thrombin generation is achieved, with females having increased thrombin signaling, and platelet activation, and males having decreased thrombus degradation. This suggests regulatory differences in thrombosis may exist between females and males that may contribute to sex differences in stroke.
Abstract TP3: Predicting Rupture Risk of Intracranial Aneurysms Through Radiomics Analysis
Authors: Sagues Elena , Saleem Arshaq , Ojeda Diego , Gudino Andres S , Veeturi Sricharan , Tutino Vicent , Samaniego Edgar A
Published: February 2024

Background:
Intracranial aneurysm rupture is a devastating event. Accurate estimation of their rupture risk can help guide management decisions. However, existing prediction methods remain subjective and have limited accuracy. This study is aimed at using clinical and imaging data to create an accurate predictive clinical tool for identification of aneurysms at a higher risk of rupturing.

Methods:
A prospectively acquired database of patients scanned with 3T high-resolution MRI between 2018 to 2023 was analyzed. Symptomatic status was defined as aneurysms that caused a cranial nerve neuropathy due to compression, and/or presented with a sentinel headache. Saccular aneurysms were segmented within 3D Slicer using co-registered T1 and T1+Gd 3T images. Morphological and aneurysm wall enhancement (AWE) metrics were obtained from the 3D models. Radiomic features (RFs) were extracted using pyRadiomics extension of 3D Slicer. This database was utilized for training and testing different machine learning prediction models. Finally, a Naïve bayes model was then employed for constructing clinical nomograms (Figure).

Results:
A total of one hundred and four aneurysms were analyzed. Twenty-nine were symptomatic. There were 87 RFs significantly different between symptomatic and asymptomatic aneurysms. Four machine learning prediction models were created based on clinical, morphological, AWE and RFs data. The best predictive model was based on RFs, achieving an accuracy of 74%.

Conclusion:
RFs combined with clinical, morphological and AWE metrics could potentially be a valuable clinical tool to predict intracranial aneurysms rupture risk.
Abstract TP302: Circular RNAs Methylation Patterns Positively Correlated With Their Expression Level in the Post-Stroke Brain
Authors: Mehta Suresh L , Vemuganti Raghu
Published: February 2024

Circular RNAs (circRNAs), a novel subgroup of noncoding RNAs derived from reverse splicing of various genes, have emerged as potential regulators of transcription and translation. Recent findings indicate that methylation of adenosine (m
6
A; N6-methyladenosine) in various RNA types might govern their levels by modulating their degradation as well as functional roles. This study investigated the spatiotemporal correlation of methylation patterns of circRNAs with their abundance in the post-stroke brain. Adult male C57BL/6J mice were subjected to transient middle cerebral artery occlusion, and m
6
A methylation in circRNAs was profiled using immunoprecipitated methylated RNAs with microarrays in the peri-infarct cortex at 6h, 12h, and 24h of post-reperfusion. Computational analysis was employed to identify the change in m
6
A levels and evaluate the correlation between expression and methylation patterns. We noted that most circRNAs that alter their levels following ischemic stroke are transcribed from the exonic regions of all chromosomes. While most genes generate a single circRNA, a unique situation occurs with the gene Rn45s, giving rise to a minimum of 30 circRNAs within the brain. Interestingly, following the stroke, the overall m
6
A levels of circRNAs displayed notable alterations. Moreover, the percentage shift in circRNA m
6
A levels increased from 6h to 24h of reperfusion, with some circRNAs, including mmu_circRNA_32433, demonstrating an increase of >40% at the 24h reperfusion. More significantly, many cerebral circRNAs that displayed increased expression also showed elevated m
6
A methylation following stroke. The increased m
6
A methylation suggests potential stabilization and altered function of circRNAs in the post-stroke brain.
Abstract TP305: microRNA-182 Preserves Oxidative Phosphorylation During Substrate Limitation in Both Male and Female Primary Astrocyte Cultures
Authors: Sun Xiaoyun , Russo Isabella , Manis Lizzie , Robbins Cassidy , Smith Nathanael , Montague-Alamin Lillen , Stary Creed M
Published: February 2024

Introduction:
Stroke remains the leading cause of long-term disability in the United States, with therapy remaining limited to early reperfusion interventions. Adjuvants that aim to preserve neuronal survival could provide functional benefits to stroke survivors. Astrocytes promote neuronal survival by providing metabolic support to neurons in the absence of glucose availability, a critical substrate required for neuronal metabolism and survival. MicroRNAs (miRs) are non-coding RNAs that suppress translation of target genes. Our prior work identified miR-182 as a critical modulator of stroke by targeting genes that preserve astrocyte mitochondrial function. In the present study we assessed the role of miR-182 inhibition on oxygen consumption rate (OCR) during glucose deprivation (GD) injury. As stroke-induced mitochondrial dysfunction occurs mechanistically differently between males and females, we compared the effect of miR-182 inhibition between male and female astrocytes.

Methods:
Primary male and female cortical astrocyte cultures were generated from neonatal male and female C57BL/6 mice. Cultures were maintained at ambient O
2
tension and 5% CO
2
until day-in-vitro 12. Cultures were randomized to transfection with miR-182 inhibitor, or mismatch control RNA, 24h prior to 72h of GD injury. OCR was measured using the Lucid Scientific Recipher
TM
. Cell plating density was assessed using the nuclear stain DAPI.

Results:
No significant differences between treatments or between sexes in cell density were observed. GD injury resulted in a progressive decrease in OCR, requiring 12.5+7.8h to become significantly (p<0.05) lower in male astrocyte cultures, and 12.5+6.4h in females, with no difference between sexes. Comparatively, time-to-reach a lower OCR with miR-182 inhibitor required 38+7.1h in male cultures and 47+12.7h in females. The time-to-reach a lower OCR with miR-182 inhibition was significantly greater in both sexes versus control transfection, but not between sexes with miR-182 inhibition.

Conclusions:
These results suggest that inhibition of miR-182 represents a novel target to indirectly support neuronal metabolism during stroke that could be applied to both men and women survivors of stroke to improve functional outcomes.
Abstract TP309: Cortical Extravasation of Neutrophils and Unexpected Persistence Following Ischemia/Reperfusion in a Murine Ischemic Stroke Model
Authors: Arias Erika , Nadkarni Neil A , Haynes Maureen , Muller William A , Batra Ayush , Sullivan David P
Published: February 2024

Background and Purpose:
Neutrophils are the first recruited leukocytes following ischemia/reperfusion injury in the brain; however, when and where neutrophils enter the brain parenchyma to exert their effects is controversial. Understanding the spatiotemporal underpinnings of leukocyte extravasation is required to advance therapeutic interventions. Here we describe the complex evolution of neutrophil recruitment and extravasation following ischemic stroke.

Methods:
Circulating neutrophils were pulse-labeled with EdU to track specific cells recruited post stroke. The transient middle cerebral artery occlusion (tMCAO) model was used to simulate large vessel occlusion and reperfusion. Coronal sections were examined at various timepoints and the position of EdU-labeled neutrophils was precisely determined by fluorescence microscopy. PECAM antibody treatment was used to disrupt neutrophil extravasation at the cortical surface and alter migration kinetics.

Results:
At early timepoints, 12 h and 24 h, neutrophil recruitment was unexpectedly superficial. Over 120 h, neutrophils were found increasingly deeper into the subcortex. Timing of tMCAO surgery with EdU labeling allowed for specific labeling of the initial wave of neutrophils. Surprisingly, many EdU positive neutrophils were still observed at 72 h, indicating they had survived for several days. The number and distribution of EdU positive neutrophils confirms the majority of neutrophil recruitment occurs before 24 h across the infarct. Disrupting leukocyte extravasation with PECAM function-blocking antibodies restricted neutrophils to the cortical surface.

Conclusions:
Our findings demonstrate that neutrophil infiltration post stroke evolves over several days. This data suggests neutrophils are recruited to the infarct within the first 24 h, enter the brain at the cortical surface, distribute throughout the infarct, and persist over 72 h. Furthermore, disrupting extravasation with PECAM antibodies modulates neutrophil progression into the infarct. A better understanding of leukocyte spatiotemporal infiltration and its regulators will help inform future therapeutic interventions targeting leukocytes.
Abstract TP39: Multi-Marker Cerebral Small Vessel Disease Score and Risk of Incident Depression: The Framingham Heart Study
Authors: Araujo Contreras Robert , Pinheiro Adlin , Ekenze Oluchi , Aparicio Hugo J , Beiser Alexa , Himali Jayandra J , Lioutas Vasileios , De Carli Charles , Seshadri Sudha , Demissie Serkalem , Romero Jose R
Published: February 2024

Introduction:
The vascular depression hypothesis postulates that cerebral small vessel disease (CSVD) contributes to the development of depression. A multi-marker CSVD score based on brain magnetic resonance imaging (MRI) could serve as a valuable tool for predicting the risk of developing vascular depression. This is important as depression can mimic cognitive impairment, dementia and is treatable. This study aimed to determine the relation of a MRI multi-marker CSVD score with incident depression in community-dwelling individuals.

Methods:
Framingham Heart Study participants from the Original and Offspring cohorts free of stroke, dementia and depression with available data on depression and CSVD ratings on MRI were included. Depression was defined as Center for Epidemiological Studies Depression scale score ≥16 or use of antidepressant medication. The multi-marker CSVD score was calculated by summing 1 point for individual CSVD markers present (covert brain infarcts, cerebral microbleeds, extensive white matter hyperintensities, high burden perivascular spaces, cortical superficial siderosis), ranging 0-5. Multivariable logistic regression models were used to relate the MRI-multi-marker CSVD score and incident depression in a primary analysis and individual CSVD biomarkers and depression in an exploratory analysis. Models were adjusted for age, sex, FHS cohort, time interval between MRI and clinic exam, body mass index, smoking, prevalent hypertension and diabetes.

Results:
In 1768 participants included (mean age 54.4±12.4 years, 54% male), the incidence of depression was 11% (median follow-up 6.0 years, IQR: 5.3-6.7). No CSVD score group had a statistically significant association with incident depression, however a CSVD score 3+ showed a trend towards increased odds of developing incident depression (OR 2.65 [0.87, 8.06],
p
=0.09). Among the individual CSVD markers, visible perivascular spaces had the highest odds for incident depression (OR 1.55 [0.96, 2.51]
p
=0.07).

Conclusion:
A higher multi-marker CSVD score might be associated with increased odds of incident depression. Further studies with a larger sample may help elucidate a potential association between this CSVD burden and onset of depression.
Abstract TP42: Single Stem Cell Modification With Biomaterials and Oligopeptide for Stroke Targeting and Recovery
Authors: Shan Dingying , George Paul
Published: February 2024

Stem cell transplantation enhances stroke recovery. A primary mechanism is the release of trophic factors, such as VEGF, BDNF, and CNTF, which are thought to stimulate brain plasticity and recovery mechanisms. While promising, the treatment efficacy of stem cell transplantation is restricted by inadequate stem cell survival and insufficient trophic factor release at the stroke site. To address this, we have developed a single stem cell encapsulation method (SingleStem) using the naturally occurring glycolysis process and click chemistry strategy to modify individual neural progenitor cells (NPCs) with polymeric materials and the stroke targeting oligopeptide (E-selectin binding oligopeptide (Esbp)). Our data demonstrate that the polymeric biomaterial coating provided uniform cell protection and control of individual NPC, which increased transplanted NPC survival and enabled trophic factor release modulation (such as VEGFA and VEGFB). Additionally, the stroke targeting oligopeptide Esbp is able to bind to components on activated endothelial cells to facilitated NPC homing to the stroke region and improve stroke recovery efficacy. These advantages enable SingleStem to be an effective stroke recovery tool to improve stem cell efficacy and understand stroke recovery mechanisms.
Abstract TP45: A Nurse-Driven Pre-hospital Telemedicine Program Supports Care of Patients With Suspected Stroke
Authors: Cruz Nina , Bolling Ashley , Belnap Starlie , Vallone O , DeLosRiosLa Rosa Felipe
Published: February 2024

Background:
Because of the time-sensitive nature of stroke treatment, extensive efforts focus on reducing treatment time in the hospital and prehospital setting. Recent studies exploring the use of telemedicine within the ambulance setting report positive results. Non-recordable paramedic-assisted videos allowed patients to be examined by an ED physician while in route to the receiving hospital, improving stroke treatment times. Ambulance teleconsultations are reported to be reliable and a good method to aide emergency triage facilitating accurate diagnosis. To the best of our knowledge, these studies have used EMS tele-health services to connect with a physician. In this study we assessed the treatment benefits of a nurse-driven pre-hospital telemedicine program in a community comprehensive stroke center (CSC).

Methods:
Telemedicine services was installed in 4 ambulance units. A tablet was supplied to highly specialized stroke nurses. Using the current dispatch notification system, the stroke nurse was alerted to an incoming suspected stroke patient and prepared to receive the telemedicine video connection. During the telemedicine video call a paramedic-assisted assessment occurred, patient history, contact information, and pre-thrombolytic consent was obtained. Upon arrival, the stroke alert proceeded as normal. Telemedicine data was retrospectively matched with data extracted from the medical record to evaluate treatment volume (thrombolytics (TNK), endovascular procedure (EP), or both), treatment times [door to CT(D2CT), door to needle (D2N), door to puncture(D2P), door to device(D2D)], and coded stroke volume for all EMS-telemedicine cases between Jan 2020-May 2022.

Results:
Over the course of the pilot, 41 cases were successfully matched, and pre-hospital video assessments occurred for 17 (41%) cases. Treatment rates were 20% (n=8), 15% (n=6), and 10% (n=4) for TNK, EP, and both respectfully. Median times were 7 min (4-21), 20min (12-32), 58min (48-124), and 82 min (64-140) for D2CT, D2N, D2P, D2D respectively. Lastly, 71% (n=29) received a stroke diagnosis.

Conclusion:
This study shows that a nurse-driven prehospital telemedicine system can be successfully implemented in a community CRC with excellent treatment time metrics.
Abstract TP47: When Folks Stroke at a Freestand: Building Successful Stroke Workflows for Freestanding Emergency Departments
Authors: Werner Amanda , Scheideman Kory
Published: February 2024

Background:
Services offered at freestanding emergency departments (FSED) vary and often have inconsistent clinical education and workflow standardization. Delivery of clinical education and implementation of hospital-based emergency department (ED) workflows to FSEDs contributes to a successful system of care. All sites in a mostly rural region are held to PSC standards with 24/7 ED physician coverage from a local, contracted group. All sites have 24/7 neurology provider coverage from an internal Neurohospitalist group that responds to stroke alerts in person or via telestroke. Nursing, radiology, and pharmacy leadership across the region participate in regional stroke and quality committees.

Methods:
Clinical education for FSED staff aligns with hospital-based EDs but includes competencies related to lack of ancillary services at the FSEDs. NIHSS certification is required and renewed every two years. Quarterly stroke education posters team are at all sites and new hire training is standardized. Availability of thrombolytics is maintained by pharmacy even though they are not on site at FSEDs. Volume and accuracy of 2022 stroke alert activations were reviewed as were door to CT first slice times, total thrombolytic cases, and median D2N times. FSED data was compared to local hospital-based ED outcomes and national stroke standards.

Results:
There were 27 total FSED stroke alert activations in 2022; 13 had a final coded stroke diagnosis. This 48% accuracy rate is above the range of 35-40% across the region’s hospital-based EDs and meets national standards for alert accuracy. Median door to CT time was 20 minutes and is among the best for the region though slightly longer than national standards. There were 5 FSED thrombolytic cases with a median D2N time of 55 minutes—below the 60-minute national recommendation for treatment time.

Conclusion:
Providing clinical education and standardizing workflows in the FSEDs resulted in stroke metrics aligning with (or exceeding) regional and national standards. leading to a positive impact patient care when stroke patients present for emergent evaluation and treatment at a FSED.
Abstract TP48: Rebuilding Sustainable Stroke Support Group: Strategies and Impact
Authors: Patterson Michele J , MOORE TRACY , Blanchard Bonnie , Sanchez Briana
Published: February 2024

Background:
Comprehensive Stroke Program identified decreased monthly Stroke Support Group [SSG] participants [P] months after pandemic, when safe to meet. November 2022, the Neuroscience Nurse Navigator [NNN] took responsibility to rebuild the SSG by enhancing communication [EC], value [V], & consistency [C] for stroke survivors & caregivers [SS/CG].

Purpose:
Evaluate strategies to rebuild a sustainable SSG & impact of EC, V, & C.

Methods:
NNN EC by coordinating with [w/] marketing to post events & SS stories, & updating the SSG brochure with “Life After Stroke” [LAS] verbiage & an RSVP QR code. SS/CG received emails 1-week before SSG & 1 day after w/information shared. NNN added SSG to discharge [DC] instructions & encouraged attendance during inpatient rounding & post DC follow-up calls. The annual Stroke Reunion, October 2023, highlighted SSG. NNN added V by making SS/CG feel heard & understood, while reminding SS of LAS purpose. SS/CG feedback was used to develop a recovery topic calendar w/speakers & healthy snacks. Evidence-based AHA/ASA resources were used to facilitate discussion. SS/CG engagement was encouraged to share experiences & SS were recognized & celebrated during their stroke anniversary month. NNN ensured C by holding SSG monthly regardless of RSVPs & arranged to cover the event when unavailable. Number of SSG-P & new P were monitored w/surveys completed in June & July.

Results:
SSG-P increased in February [220%] & April [320%] from October. SSG-P decreased during Spring Break & summer vacations. New P began attending in November w/highest number in April [9]. Surveys showed 95% found the topic helpful & likely to make LC. All SSG-P reported SSG helped LAS adjustment, planned to attend monthly & would encourage others to attend.

Conclusion:
Key strategies, EC, V, & C, helped build a sustainable SSG and improved SS/CG satisfaction. The NNN was able to streamline processes, build meaningful connections, attract new P & improved SS/CG participation.
Abstract TP51: Improving Prescriptions of Cardiovascular-Effective Anti-Diabetic Medications in Patients With Stroke and Type 2 Diabetes
Authors: Libby Jill , Couts Linda , Rockwell Jean , Burley Jessica , Appenzeller Otica
Published: February 2024

Background and Issue:
Type 2 diabetes (DM2) and cardiovascular (CV) disease pose significant risks for ischemic stroke, with a heightened impact on marginalized and under-resourced communities. Despite known CV benefits of newer anti-diabetic medications like glucagonlike peptide 1 receptor agonists (GLP-1 RA) and sodium-glucose co-transporter-2 (SGLT2) inhibitors, these medications are under prescribed. To improve utilization, we conducted a quality improvement (QI) project to enhance prescription rates for these medications. The QI initiative focused on improving diabetes education and ensuring appropriate hypoglycemic medications were provided at discharge, with an aim of reducing the incidence of recurrent strokes.

Purpose:
The goal of this QI initiative was to improve prescription rates of GLP-1 R or SGLT2 inhibitors in eligible patients with stroke.

Method:
An assessment of current diabetic referral practices and medical therapy management were conducted, and an algorithm aimed at streamlining referrals for diabetic consults for patients with stroke developed. A diabetic educator or advanced practice nurse was consulted for patients with stroke and elevated A1c. Patients were then evaluated for qualification and use of GLP-1 RA or SGLT2 inhibitors, and discharge recommendations provided. A stroke registry was used to conduct a retrospective analysis of cases with stroke and DM2 for discharged prescriptions of GLP-1 R or SGLT2 inhibitors. Pre-implementation data from October 2021 to March 2022 were compared to post-implementation data from October 2022 to March 2023.

Results:
A review of 273 cases was completed. Prior to the QI implementation, 14.2% (19 of 134) of cases admitted for stroke with a secondary diagnosis of DM2 and elevated A1c were discharged home on a GLP-1 RA or SGLT2 inhibitor compared with 28.8% (40 of 139) of cases post implementation.

Conclusion:
Implementation of a QI process aimed at increasing the number of written discharge prescriptions for DM2 medications with proven CV benefits demonstrated a substantial increase in the number of written prescriptions for these medications at discharge.
Abstract TP52: Reducing Door-to-Imaging Times in Acute Stroke Patients Presenting to the Emergency Department by Private Vehicle: Triage Hallway versus Room Evaluation
Authors: Victor Patricia , Burris Shelley , Bost Patricia , Miller Kenneth , Lyons Cobb Genevieve , Mishra Shovan , Nahab Fadi B
Published: February 2024

Background:
Delays in IV thrombolytic and thrombectomy treatments are associated with worse outcomes after ischemic stroke. The objective of our study was to compare door-to-CT imaging times among Code Stroke patients who presented by private vehicle and were evaluated by a physician in the emergency department (ED) either in the triage hallway or the emergency department room.

Methods:
We prospectively collected real-time data on Code Stroke patients presenting by private vehicle to a primary stroke center from May 1, 2022 through September 18, 2022. A Code Stroke was activated for all patients presenting to the emergency room with positive BE-FAST symptoms occurring within 24 hours from last known normal time. Patients were evaluated by a physician either in the triage hallway or an ED room prior to CT imaging. We compared baseline demographic data, NIHSS scores and door-to-CT times in patients evaluated by the physician in the ED triage hallway versus the ED room.

Results:
Of 55 patients who presented to the ED by private vehicle during the study period, the mean age was 54 ± 15 years, 53% were female and 45% non-white. The median NIHSS score was 1 [IQR 0-4]. There were 27 (49%) patients who underwent physician evaluation in the triage hallway and the remaining went into a patient room before going to CT. The median NIHSS scores for evaluations in the room were higher than in the triage hallway (2 vs 0, p=0.037). Overall, median time from door-to-CT was 11 minutes for patients who went directly from the triage hallway to CT and 21 minutes for patients who were roomed prior to CT (p=0.005).

Conclusions:
This study found that Code Stroke patients presenting by private vehicle and evaluated by an emergency physician in the triage hallway saved 10 minutes in door-to-CT time compared with physician evaluation in a room.
Abstract TP60: Utilization of Rapid Response Team Nurses to Improve In-Hospital Stroke Response
Authors: Kelly Suzanne , French Mindy , Fields Jeremy , Campbell Rebecca , Calarco Andrea , Jones Andy , Santoro Michell
Published: February 2024

Introduction:
In-hospital strokes are estimated to account for 2-17% of all strokes. These patients typically have higher mortality, longer length of stay, and higher disability rates than strokes that initiate within the community. In addition, in-hospital strokes often result in delayed symptom recognition and slower coordination of stroke team response. To address this, Rapid Response Team (RRT) nurses have been empowered to lead the Inpatient Stroke Alert process to improve response time.

Methods:
Beginning in 2016, stroke program leadership in conjunction with frontline RRT nurses worked together to improve the Inpatient Stroke Alert response. A standardized Inpatient Stroke Alert pathway was created and simulated that included empowering RRT nurses to initiate stroke alerts. Quality drilldown emails of each patient receiving thrombolytics began to be sent to frontline teams including RRT to debrief each event. In 2017, a neurohospitalist team and overnight tele-stroke capability was introduced to work alongside the RRT nurse to quickly assess and provide direction on care. Finally, in 2020, a streamlined RRT stroke alert order set was introduced along with an updated nurse-specific stroke alert badge buddy. RRT nurses were integral to these efforts as a small but highly skilled and unassigned team dedicated to response to all critical events within the hospital.

Results:
Every in-hospital (n=38) and ED stroke alert patient (n=377) that received thrombolytics from 2016 to June 2023 was included in the data. Mean discovery-to-thrombolytic times for in-hospital stroke patients in 2016 was 116.7 minutes (n=3) compared to 71.7 minutes (n=35) for ED stroke alerts. As of June 2023, mean discovery-to-thrombolytic times for in-hospital stroke patients have steadily improved to 52.8 minutes (n=6; vs. ED 38.7 minutes, n=57) in 2022 and 45 minutes (n=1; vs. ED 34.3 minutes, n=47) in 2023. This resulted in an improvement of greater than 60% in discovery-to-thrombolytic times.

Conclusions:
Development of a nurse-led in-hospital stroke alert process utilizing the RRT nurses has led to vast improvement in discovery-to-thrombolytic times.
Abstract TP61: 15 Minutes Can Save Lives: An EMS Direct to CT Protocol for Stroke Patients in the Emergency Department
Authors: Pisacka Christine , Bartman Maria
Published: February 2024

Purpose:
To evaluate an Emergency Medical Services (EMS) Direct-to-CT Protocol developed and implemented to reduce diagnostic and treatment times in eligible adult patients presenting to the Emergency Department (ED) with an acute ischemic stroke (AIS).

Methodology:
A pre-and post-implementation design at a primary stroke center in a New Jersey small-scale urban city. The chart review consisted of 54 records of patients presenting to the adult ED by EMS with a stroke activation from September 2022 to November 2022 and was measured to determine the time of provider evaluation, door-to-Code Stroke time, door-to-CT (DTCT) time, and door-to-needle (DTN) time.

Results:
50/101 (49.5%) pre-and 4/17 (23.5%) post-implementation charts met inclusion criteria. Statistically significant decreases occurred in the post-implementation period for door-toprovider evaluation time (median, 11.5 minutes vs 3 minutes; P = .026), door-to-Code Stroke activation time (median, 18.5 minutes vs 3.5 minutes; P = .002), and DTCT time (median, 21 minutes vs 7.5 minutes; P = < .001). Although median DTN time was reduced, it was not statistically significant (median 72 minutes vs 53 minutes, P = .060). The rate of patients with a DTN time of
<
60 minutes was 50% higher in the post-implementation group.

Implications for Practice:
This project demonstrates improvement in the knowledge of the current American Heart Association and American Stroke Association recommended guidelines in stroke management and treatment. This program evaluation identifies improvements in DTCT and DTN times with the future integration of this protocol into a policy. The most cost-effective intervention for an acute ischemic stroke is early treatment with thrombolytics.
Abstract TP63: Eliminate Delays: Utility of a Cross-Trained Nurse Responder Team in Acute Stroke
Authors: Ray Ashleigh J , Moriarty Karen , Heinrichs Dorothy W , McCabe Patricia A
Published: February 2024

Background:
Over the past year, it was noted that having two separate teams (Rapid Response (RRT) and Code Stroke) delayed the care of multiple stroke patients. Challenges encountered included: waiting for the Code Stroke Team to arrive, delays in essential stroke care metrics (door to needle, door to groin, & door to start of device), and waiting for Interventional Radiology (IR) personnel to begin IR procedures.

Purpose:
The purpose of this project was to determine if a cross-trained Nurse Responder Team would decrease the time to essential nursing stroke care interventions and wait times to neuro-interventional acute stroke treatment.

Methods:
Utilizing the Plan-Do-Check-Act quality improvement method, we cross-trained our Rapid Response Nurses to various types of emergency responses including Code Stroke. Thus, the evolution a Rapid Response Team to a Nurse Responder Team. Training consisted of on-line learning management system courses, preceptorship, and simulation training. Data was collected and analyzed at various times throughout the Code Stroke process. Time markers collected included: time RRT call was changed to Code Stroke, time the Stroke Team arrived, and time between when a Code Stroke patient arrived in IR without an available IR nurse to initial groin puncture.

Results:
Implementing a multiple code cross-trained Nurse Responder Team reduced the need to call another nursing response team to begin the Code Stroke process. This resulted in a decrease in treatment times, the number of patient hand-offs, wait times for IR endovascular procedures, door to needle time, door to groin time and door to start of device time. The median door to needle time before the nurse responder team was 90 minutes and after the nurse responder team the median was 52.5. The before median door to groin time was 104 minutes and after door to groin time was 91.3. The percentage of time, the door to start of device within 60 minutes for patients transferred from outside hospital or 90 minutes in presented directly, was increased from 16.7 to 53.8% with initiation of the Nurse Responder Team.

Conclusions:
A cross-trained Nurse Responder Team improved stroke quality indicators.
Abstract TP71: Creative Methods Utilized to Improve Stroke Education at an Academic Medical Center
Authors: Rosenberg Antonieta , froehlich anne , Anderson Marret , george josephine , Kabacinski Andrea A , Wankmuller Gabriela , Suri-Finn Jillian
Published: February 2024

Background:
Stroke patients admitted to a hospital can be cared for in several different settings requiring hospital clinical staff to have a strong knowledge base of signs and symptoms of a stroke as well as the care and management of patients after a stroke. Stroke patients may present with other co-morbidities which may take precedence over their stroke diagnosis causing them to be admitted to non-stroke units. In addition, patients may also have an acute stroke during their hospitalization for a non-related admission. Therefore, hospital systems must continue to expose all staff to education regarding stroke recognition, care and management.

Purpose:
To increase the knowledge of stroke recognition, prevention, care, and treatment options of clinical staff at one academic medical center.

Methods:
Members of the stroke clinical team and unit nurse specialists provide educational opportunities through a mobile education program which brings interactive games to the unit staff to test and reinforce their stroke knowledge. They provide brain themed prizes and provide direct staff feedback on stroke codes that occurred on the unit. This team also provides in-person educational in-services to units where gaps in our data metrics have occurred. They are a resource that all clinical staff can reach out to for additional education on stroke management.

Results:
Feedback from the clinical staff after receiving education either from interactive games, in-services or direct feedback has been positive. We have seen increased confidence with our inpatient units nursing staff in activating the stroke code immediately as soon as signs and symptoms of stroke are observed. They also have a stronger understanding of the importance of meeting our time targets to improve patient outcomes.

Conclusions:
Making learning fun and rewarding staff for their understanding and impact on patient care creates an incentive to continue to learn more about stroke care, management, and improves their recognition of stroke among all patients. We continue to develop creative and alternative methods to provide education to the clinical staff throughout the health care system.
Abstract TP76: Step by Step: Implementing Post-Acute Stroke Standards
Authors: Pawloski Madeline , Pietrzak Janna , Stein Joel , Anders David , Goldman Amy , Kopp Peggy , Logan Daniel , Malouf Jessica , Root Hannah , Schmidt Joelle , Malina Beth L
Published: February 2024

Introduction:
Certification programs and quality improvement initiatives improve outcomes among patient populations. Stroke rehab expertise, care processes, and educational resources vary among sites where post-acute care (PAC) is delivered. The Misson: Lifeline Stroke PAC Initiatives are recruiting sites in four states to implement the AHA PAC Stroke Program Standards.
Purpose
Developed from evidence-based rehab and proven secondary prevention interventions, the American Heart Association (AHA) created quality standards based on the AHA 2016 Guidelines for Adult Stroke Rehabilitation and Recovery to address gaps in PAC care.

Methods:
Nursing facilities (SNFs), critical access hospitals (CAHs) with swing beds, and inpatient rehab facilities (IRFs) in Iowa, Montana, Nebraska, and North Dakota were recruited to participate in the Initiative. Sites received education on the PAC Stroke Program standards and individualized quality improvement support. Sites were enrolled in the Healthcare Network, a collaborative tool to start discussions, share resources, and discuss patient care processes, and the Quality and Certification Tool, used to track clinical measures and outcome metrics. Monthly virtual learning collaboratives were held to share educational materials, community resources, and processes for patient care.Statewide AHA conferences and workshops facilitated in-person collaboration across settings. A pre-implementation survey was utilized to identify gaps in existing practices. A post-implementation survey will be used to assess the effectiveness of these initiatives.

Results:
Forty-seven facilities were recruited including 10 IRFs, 17 CAHs and 20 SNFs. Additional sites will be added throughout the project. 100% of facilities completed orientation. Nine learning collaboratives have been hosted and 26 facilities completed the pre-implementation survey. Data submissions and review are ongoing through 2025.

Conclusions:
Future evaluation of implementation of standards is needed to assess improvements in patient outcomes. The participation of 47 facilities shows a need for more organized initiatives that help health care professionals incorporate research proven standards for stroke rehab.
Abstract TP82: Effect of Stroke Etiology and Treatment Intervention for Young Adults With Large Vessel Occlusion- Acute Ischemic Stroke: Results From the Cleveland Clinic Young Adult Retrospective Cohort Study
Authors: Bhayana Kriti , Handshoe Jonathan , Coors Benjamin , Li Yadi , Thompson Nicolas , Schuster Andrew , Hussain M. Shazam , Kharal Abbas
Published: February 2024

Introduction:
The incidence of Large Vessel Occlusion-Acute Ischemic Stroke (LVO-AIS) continues to increase in young adults. Although young adults who undergo mechanical thrombectomy have favorable outcomes, it is unclear if stroke etiology affects rehabilitation outcomes & discharge destination for these patients.

Hypothesis:
Large artery atherosclerosis (LAA) results in worse outcomes as compared to other etiologies in terms of discharge destination.

Methods:
This retrospective study cohort comprised of patients 18-50 years of age, presenting to the Cleveland Clinic Stroke Enterprise, with LVO-AIS from January 2017 to December 2021. Patients with LVO on CTA or MRA at presentation were included. We then assessed patients with LAA and compared their discharge destination to patients with other etiologies.

Results:
Out of 1210 patients with AIS, 172 with LVO were included. 31 patients (18%) had stroke etiology as Large Artery Atherosclerosis (per TOAST criteria). Among patients with LAA, the median initial NIHSS was 6 and median discharge NIHSS 4. 16.2% of these patients received IV thrombolysis and 32.4% underwent mechanical thrombectomy (MT). 48.4% patients were discharged to acute rehabilitation, 32.3% went home, 12.9% SNF, and 6.5% deceased. In contrast, patients for whom TOAST criteria was not “Large Artery Atherosclerosis”, had a median initial NIHSS 9 and median discharge NIHSS 2. 31.2% received IV thrombolysis and 43.9% underwent MT. Their discharge destination was home for 56%, acute rehabilitation for 27.7%, LTAC for 5%, 2.8% SNF, and 8.5% deceased. Both these groups had similar initial mRS.

Conclusions:
Young adults with LVO-AIS had good outcomes irrespective of stroke etiology, however LAA patients were less likely to be discharged home compared to other etiologies, likely owing to less functional recovery as compared to other etiologies. Further studies are needed to determine why young adults with LVO with LAA have worse outcomes.
Abstract TP87: Trending the Impact of Non-Body Weight Supported Treadmill Training on Physical Functioning and Depressive Symptoms in Chronic Stroke Survivors
Authors: Xia Christina , Drury Colin , Awosika Oluwole
Published: February 2024

Introduction:
Stroke is the most common cause of adult-onset disability and is often associated with chronic limitations in activities of daily living (ADLs). Relatedly, the loss of functional independence has been suggested in increasing the likelihood of post-stroke depression, yet limited strategies are available to mitigate these risks. The objective of this secondary analysis study was to determine the immediate and residual impact of non- body weight supported treadmill training (NBWTT) on ADL and PHQ-9 in chronic stroke survivors. We hypothesized that training would result in improvement in ADL and depressive symptoms.

Method:
Data from 40-community-dwelling stroke survivors with mild-moderate walking impairment were used for this analysis. All participants underwent nine training sessions (3 per week x 3 weeks) of backward (BLTT/n=19) or forward (FLTT/n=21) NBWTT. The Stroke Impact Scale -16 (ADL-measure) and PHQ-9 (depression screen) were collected at baseline, post-training, at 30- and 90-day follow-up.

Results:
Both BLTT and FLTT resulted in an improvement in SIS-16 (p<0.01) and PHQ9 <0.01); however, there were no significant differences between groups. Post-training improvements in SIS and PHQ-9 were minimally inversely correlated (p<0.01, R2=0.2). While the impact of training on SIS-16 and PHQ-9 were still present at 30 and 90-days post-training, these differences were no longer significant.

Conclusion:
Our preliminary findings suggest that NBWTT resulted transient improvements in both ADL and symptoms of depression. Future studies should investigate ways to extend the effects of training on these and similar quality of life measures.
Abstract WMP104: Influence of Living Arrangements and Within Household Communications on Blood Pressure Control Among Stroke Patients
Authors: Ding Xueting , Wing Jeffrey J , Drum Emily , Albala Bruce , Boden Albala Bernadette
Published: February 2024

Introduction:
Social support plays a vital role in shaping health behaviors and may impact disease outcomes such as blood pressure (BP) control. We aim to study the association between household living arrangements and BP control for stroke patients, over time and by household communication type.

Methods:
Discharge Educational Strategies for Reduction of Vascular Events (DESERVE), which aimed to improve post-stroke BP, randomized stroke survivors to skills-based intervention or usual care. Baseline, 6- and 12-month BP was measured according to AHA guidelines with BP control defined as no hypertension present or if follow-up BP was within normal range. We grouped baseline household arrangements as nuclear, multigeneration, spouse, alone, or other and household communication as engaging in conversations about stroke or not. We estimated adjusted odds of BP control by living arrangements and within household communication controlled for age, gender, race/ethnicity, education, Medicaid, and intervention status.

Results:
Among 540 participants with baseline BP data (72% with hypertension), 361 and 478 had 6- and 12-month data, respectively. Most patients lived in nuclear households (31%), followed by living alone (25%). About 36% participants achieved well-controlled BP after 6 months, increasing to 37% after 12 months. Living in a nuclear arrangement was associated with 2.59 (95% CI: 1.13-5.94) times higher odds of BP control at 6 months. Among participants with multigenerational families, those engaged in conversations about stroke within household showed 5.52 (1.25-24.3) times higher odds of BP control at 12 months.

Conclusions:
Our findings suggest that living arrangements are positively related to BP control outcomes in stroke patients, and communication with household members on health topics modifies this association. Within household social support to stroke patients may offer an opportunity for targeted secondary stroke prevention strategies.
Abstract WMP110: Endogenous Angiogenic Cerebral Endothelial Cell Derived Small Extracellular Vesicles Actively Communicate to Neurons and Astrocytes After Stroke
Authors: Luo Hao , Zhang Yi , Liu Xianshuang , Chopp Michael , Zhang Zheng Gang , Zhang Li
Published: February 2024

While ex-vivo studies have shown that small extracellular vesicles (sEVs) isolated from cerebral endothelial cells (CEC-sEVs) can be internalized by neurons leading to enhancement of neurite remodeling, whether such communication are present in ischemic brain is not known. Using CEC-sEV reporter mice, we investigated whether endogenous CEC-sEV mediate communication between CECs and neural cells after stroke. A CEC-specific/sEV reporter mouse line was generated by crossing Slco1c1-
CreERT2
mice with CD63-GFP
loxP/loxP
mice. The adult reporter mice were subjected to middle cerebral artery occlusion or sham operation after tamoxifen injection (n=4/group). 3D confocal microscopic analysis revealed that GFP signals in sham operated reporter mice were primarily localized within cerebral vessels, while extravascular GFP signals were also detected throughout the entire brain, suggesting that endogenous sEVs are specific to CECs and CEC-sEVs are released into brain parenchyma. Compared to the sham mice, ischemia induced robust angiogenesis in the peri-infarct areas assessed by increasing vascular density at day 7 and 42 post stroke, where the GFP signals within endothelium increased by 56% and 28%, respectively. The GFP signals within parenchyma (outside of vessels) of the peri-infarct areas were augmented by 21% and 24% at day 7 and 42 post stroke, respectively, suggesting that stroke increases CEC-sEVs secretion at peri-infarct angiogenic sites. Immunofluorescent staining showed that the increased parenchymal GFP signals in peri-infarct areas were localized within GFAP
+
astrocytes by 36% and 21% of total parenchymal GFP signals at day 7 and 42 post stroke, respectively. Moreover, the GFP signals within the peri-infarct MAP2
+
neurons were significantly augmented by 22% at day 42 but not at day 7 after stroke compared to the sham group. Stroke did not alter GFP signals within IBA1
+
microglia in the reporter mice. In conclusion, our in vivo data for the first time demonstrate that stroke increases the release of CEC-sEVs at peri-infarct angiogenic sites, where they actively communicate with astrocytes and neurons during stroke recovery. These data suggest that endogenous CEC-sEVs may regulate neurovascular function contributing to stroke recovery.