bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract NS1: Thrombolytic Door to Needle Times: Impact of Additional Multimodal Neuroimaging With Initial Imaging for All Patients versus Large Vessel Occlusion Screen Triage
Authors: Patterson Michele J , MOORE TRACY , Blanchard Bonnie , Sanchez Briana , Mascitelli Justin , Tully John
Published: February 2024

Background:
Comprehensive Stroke Program identified increased thrombolytic door to needle times [DTN-t] for stroke alert patients [SA]. To increase numbers treated with [w/] mechanical thrombectomy [MT], the decision was made to perform additional multimodal neuroimaging [AMN] w/initial imaging for all SA & before thrombolytic. Prior to this, the Vision, Aphasia, Neglect [VAN] Large Vessel Occlusion [LVO] screening tool was used to triage for AMN. When compared to LVO screen triage, AMN for all SA demonstrated an overall increase in neuroimaging without increasing sensitivity of MT triage [Patterson et al, 2023].

Purpose:
Evaluate impact of AMN w/initial imaging for all SA on timely administration of thrombolytic.

Method:
Retrospective review of 220 SA receiving thrombolytic over 24-months was conducted, w/38 excluded for documented valid delay reasons & 156 receiving AMN before thrombolytic. The NIHSS was evaluated for components of the LVO screening tool to determine VAN [+] or [-]. For VAN [-] SA time required for AMN was subtracted from DTN-t & adjusted times assigned [A-DTN-t]. The group was divided into all SA, NIHSS 0-5 & NIHSS ≥6 & compared to determine impact on DTN-t.

Results:
A-DTN-t using LVO screen triage resulted in fewer AMN prior to DTN-t with a 5% increase in DTN-t ≤45 minutes [m] in all groups. For DTN-t ≤30m there was a 5% increase in all SA & in NIHSS ≥6, w/a 2% increase in NIHSS 0-5.

Conclusion:
Clinical Practice Guidelines state thrombolytic therapy is time-dependent & most beneficial when not delayed for AMN. Performing AMN w/initial imaging & before thrombolytic for all SA resulted in delayed administration of thrombolytic without increasing sensitivity of MT triage when compared to utilizing LVO screen triage.
Abstract NS3: Nurse Led Interventions Improve the Timeliness of Blood Pressure Reduction in Patients Presenting With Acute Nontraumatic Intracerebral Hemorrhage
Authors: Strait Yvette , Taleb Shayandokht , Jacobson Prashanta , Tomala Nadine , Salinas Jackalyn , Thorsen Tawnae , Mkrtumyan Alvina , Gaffney Denise , Santosa Rhendyanno , Cheng Pamela , Ajani Zahra , Le Duy , Sangha Navdeep S , Gupta Atul , Bernardino Tina
Published: February 2024

Introduction:
The 2022 AHA/ASA Guidelines for Intracerebral Hemorrhage (ICH) recommend initiating treatment and lowering blood pressure (BP) within 2 hours of ICH onset and reaching the target systolic BP of 130-150mmHg within one hour of treatment initiation. This study evaluates the effectiveness of nursing education at a Comprehensive Stroke Center (CSC) on improving the timeliness of BP medication administration and BP reduction in ICH patients.

Methods:
Emergency Department (ED) code stroke patients with a diagnosis of ICH were included in the analysis from 6/2022-12/2022 (pre-intervention) and 1/2023-6/2023 (post-intervention). Guideline based education regarding the importance of timely medication administration was provided in nursing huddles. Nurse to patient ratios were changed to 1:1 until goal BP achieved. BP medications were also placed in the CT scanner pyxis for immediate access. Baseline demographics, NIHSS, ICH score, and door to blood pressure reduction related time metrics were collected. Data were analyzed using R package.

Results:
34 patients were analyzed, 12 (35%) pre and 22 (65%) post-intervention. Patient demographics and characteristics were not different between both groups (Table 1). Time from first BP medication order to BP in range improved: 62(46.7-80) vs 43(33-52.3) mins p=0.02. In addition, the time from door to Systolic BP 130-150mmHg improved 81 (68.5-91.3) vs 56 (37.38-73.5) mins p=0.02 (Table 2).

Conclusion:
Guideline based education is effective in promoting nursing-led interventions to achieve timely BP reduction of ICH patients to the target goal of 130-150 mmHg.
Abstract TMP102: Association of Lipoprotein(a) With Stroke and Cerebral Injury: Insights From the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) and Investigation of Neurocognitive Aging-MRI (SOL-INCA MRI)
Authors: Chandra Akhil Avunoori , Duran Luciano Priscilla , Swett Katrina , Kaplan Robert , Talavera Gregory A , Lamar Melissa , Tarraf Wassim , Marquez Freddie , Joshi Parag H , Gallo Linda , Zeng Donglin , Gianola Morgan D , Daviglus Martha L , Labovitz Daniel L , Gonzalez Hector , DeCarli Charles , Rodriguez Carlos J
Published: February 2024

Introduction:
Lipoprotein(a) [Lp(a)] is a known risk factor for cardiovascular disease; however, its association with cerebrovascular disease is not as well established.

Methods:
Data from HCHS/SOL, a population-based cohort of Hispanics/Latinos, was utilized. We included 16,039 participants with measured Lp(a) levels (nmol/L) and self-reported history of prevalent stroke or transient-ischemic attack (TIA) from Visit 1. Data from SOL-INCA MRI (ancillary study conducted after Visit 2) was utilized to identify a subset of 2,668 HCHS/SOL participants with brain MRI. Linear and logistic regression was used to study the association of Lp(a) with 1. Self-reported stroke or TIA; 2. Cerebral injury defined as self-reported stroke or TIA or evidence of a stroke on brain MRI; and 3. White matter hyperintensity (WMH) volume modeled as log (WMH/total cranial volume). Lp(a) was modeled as a continuous variable and as quintiles. Sampling weights and surveys methods were used to account for the complex HCHS/SOL design.

Results:
HCHS/SOL mean age ± SE was 41.1 ± 0.3 years, 52.0% female, and median (IQR) Lp(a) level 19.7 (7.3-60.6) nmol/L. SOL-INCA MRI mean age ± SE was 49.9 ± 0.4 years, 56.4% female, and median (IQR) Lp(a) level 21.7 (8.1-62.9). A ten nmol/L unit increase in Lp(a) was significantly associated with a higher risk of self-reported prevalent stroke or TIA (OR 1.03, 95% CI: 1.02-1.05, p = 0.0002). Lp(a)>77 nmol/L (5
th
quintile) was significantly associated with higher risk of self-reported prevalent stroke or TIA (OR 1.8, 95% CI: 1.2-2.8, p = 0.009) compared to Lp(a) <6 nmol/L (1
st
quintile) as reference. A ten unit increase in Lp(a) was significantly associated with higher odds of cerebral injury (OR 1.03, 95% CI: 1.02-1.05, p<0.0001). Lp(a)>77 nmol/L was significantly associated with cerebral injury (OR 1.8, 95% CI 1.3- 2.6, p=0.002) as compared to Lp(a) <6 nmol/L. A ten unit increase in Lp(a) was also significantly associated with increasing WMH volume (β 0.02, p=0.0002).

Conclusions:
Lp(a) is significantly associated with self-reported prevalent stroke or TIA, brain MRI evidence of cerebral injury, and WMH, in a large diverse population of Hispanics/Latinos, suggesting that Lp(a) may be a modifiable risk factor for cerebrovascular disease.
Abstract TMP109: Elovanoid Precursors Are Neuroprotective in Experimental Ischemic Stroke
Authors: Belayev Ludmila , Reid Madigan M , Obenaus Andre , Khoutorova Larissa , Mukherjee Pranab K , Hong Sung-Ha , Bazan Nicolas G
Published: February 2024

Objective:
Ischemic stroke triggers oxidative and biochemical responses that disrupt cell homeostasis. We previously demonstrated that Elovanoids (ELVs), a novel class of homeostatic lipid mediators, reduced infarct volumes and improved neurologic function when administered IV following middle cerebral artery occlusion (MCAo). The present study defines neuroprotection by very long-chain polyunsaturated fatty acid (VLC-PUFA) ELV precursors (C-32:6 and C-34:6) delivered intranasally following experimental ischemic stroke.

Methods:
Male SD rats underwent 2 hours of MCAo. Treatments with C-32:6, C-34:6 (1μg/μl, 20 μg per rat), or vehicle were administered at 1, 24, and 48h after onset of MCAo. Behavior testing was performed on days 1, 2, 3, and 7. Ischemic core and penumbra were computed from T2WI on day 7 followed by immunohistochemistry.
RT-qPCR gene expression
was investigated in a separate cohort of rats treated as above at 72 h.

Results:
C-32:6 and C-34:6 improved behavioral function on days three by (41% and 20%) and seven by (45% and 24%); T2WI total lesion volumes were reduced by (87% and 61%), respectively, compared to the vehicle. In the ischemic penumbra, C-32:6 and C-34:6 reduced TMEM119
+
microglia by (38% and 29%), increased NeuN
+
neurons by (87% and 110%), reduced IgG staining by (54% and 25%), and increased the number of SMI-71
+
vessels by (50% and 26%). In the core, C-32:6 and C-34:6 reduced TMEM119
+
microglia by (12% and 15%), increased NeuN
+
neurons by (251% and 89%) and increased the number of SMI-71
+
vessels by (31% and 70%). Anti-inflammatory marker genes for protective microglia and astrocyte phenotypes
Tm4sf1, Thbs1, Ptx3, Gpc4, Fizz1, Cd14, Msr1, Manf
, and
Osmr
were upregulated with C-32:6 and genes
Fcrls, S1pr3,
and
Vim
were downregulated with C-34:6.

Conclusion:
These data suggest that IN administered C-32:6 C-34:6 improved behavior, protected the ischemic penumbra, increased neurogenesis and angiogenesis, and reduced the number of microglia cells. The overall gene expression changes observed from free fatty acid C-32:6 indicate that its modulatory effects promote the biological activity of astrocytes, microglia, and cerebrovascular cells involved in plasticity.
Abstract TMP111: Selective Activation of Peritoneal TRPV1-Containing Vagal Afferents Promotes Sustained Mild Hypothermia and Neuroprotection Following Stroke
Authors: Andersohn Alexander , Jarret Bob , Cantrell Charles , Marrelli Sean P
Published: February 2024

Intro:
Mild hypothermia has been clinically effective at improving outcomes in cardiac arrest patients for decades. Similarly, mild hypothermia has been shown to neuroprotective in experimental stroke models. Unfortunately, hypothermia protocols in awake subjects are hampered by inconsistent temperature management due to incomplete suppression of cold defense mechanisms (e.g. shiver response). To address a need for better strategies for cooling conscious subjects, we sought to promote mild hypothermia by pharmacological activation of heat-sensing nerve fibers in the thermoregulatory system. We hypothesize that selective activation of TRPV1-containing vagal afferents in the peritoneal cavity can promote sustained hypothermia and protection following stroke.

Methods:
Aged (18-20 mo) and young (11 weeks) C57BL6 mice of both sexes were given a capsinoid mixture consisting of capsiate and dihydrocapsiate. Mice from both the aged and young cohorts underwent permanent distal middle cerebral artery occlusion (pdMCAO) or sham before recovering for 2hrs in warming cages to maintain normal body temperatures during post-stroke recovery. At 2 hours after stroke, mice were given capsinoids or vehicle (4 IP injections, 90 min interval) to produce 6 hours of mild hypothermia (or normothermic control). After 3 days brains were collected for histological analysis.

Results:
Capsinoids are particularly suited for region selective activation of TRPV1 targets, as they are degraded by ubiquitous esterases, and thus limited in biodistribution to distant targets. This regionally restricted activation was demonstrated through induction of mild hypothermia with IP capsinoid administration, but not with oral or subcutaneous delivery. We demonstrated that the hypothermic effect is TRPV1 dependent and that IP capsinoid delivery increases activity of the cervical vagus (hook electrode). We applied this capsinoid-mediated hypothermia approach to the pdMCAO model and demonstrated a significant reduction of brain infarct at 3 days post-stroke in both young and aged mice of both sexes.

Conclusion:
Selective activation of TRPV1-containing peritoneal vagal afferents is sufficient to promote sustained mild hypothermia and protection following ischemic stroke.
Abstract TMP22: Removing Disparities Related to Thrombectomy Transfers Within an Integrated Healthcare System Across Fourteen Primary Stroke Centers
Authors: Wong Eric , Cheng Pamela , Rho Howard J , Ly An , Li Qiaowu , Gaffney Denise , Taleb Shayandokht , Ajani Zahra , Le Duy , Sangha Navdeep S
Published: February 2024

Introduction:
Patients who present to a PSC with a large vessel occlusion are often transferred to hospitals with thrombectomy capability. Inequities in rates of hospital transfer amongst patients across various gender, racial background, and socioeconomic status are well established. A common metric used to determine quality of care in such transfers is the Door In Door Out (DIDO) time. We hypothesized that there would be no difference in the DIDO using an established systematic approach to transfers in our 14-hospital integrated healthcare system.

Methods:
All interhospital transfers for thrombectomy across our 14 PSCs were examined from 10/2020 - 4/2023. Age, gender, race/ethnicity, and insurance status were abstracted and used to assess if disparities in DIDO were present. ANOVA and Chi-Square were used for statistical analysis.

Results:
307 patients were identified over a 3-year period across all our sites. 48.9% were female with a mean age of 69.7 (±16.2). The median NIHSS was 13 (IQR 7 - 20) and the median DIDO was 96 mins (IQR 74 - 131 mins). There was no difference in median DIDO between females 94 mins (IQR 74 - 132 mins) and males 98 mins (IQR 73 - 98 mins) (p = 0.2). When compared to White patients, there was no difference in median DIDO for Asian American/Pacific Islander (AAPI) (12.6 mins, p = 0.6), Black (-2.1 mins, p = 1.0), or Hispanic patients (7.6 mins, p = 0.7). The insurance status of our patient population was predominantly Medicare (56.4%), followed by Commercial (26.4%), Medicaid (8.1%), and Self- Pay (2.9%). The remainder were classified as Other/Missing (6.2%). When compared to the remainder of the population, we found no difference in median DIDO for patients on Medicare (-2.0 mins, p = 0.7) or Medicaid (10.8 mins, p = 0.3).

Conclusions:
A Southern California integrated healthcare system’s approach to thrombectomy transfers enables the removal of disparities in DIDO regardless of gender, racial background, and insurance status.
Abstract TMP23: Mobile Stroke Unit to Mitigate Disparities in Stroke Treatment
Authors: Ro Jennifer , Taiwo Oludamilola , Bianchi Nicolas A , Robinson Elijah , Frankel Michael , Fleming Carol , Navalkele Digvijaya
Published: February 2024

Background:
Studies have reported longer emergency department (ED) wait times and delayed stroke treatment for Black versus White patients. Minority patients also have severe stroke symptoms compared to White patients. We hypothesize that patients with acute stroke living in distressed communities will be treated faster in the Mobile Stroke Unit (MSU) than in the ED.

Methods:
This is a retrospective analysis of all patients who presented to Grady Memorial Hospital from January 1 2022-December 31, 2022, and received alteplase (tPA) either in the ED (by arrival of Emergency Medical Services) or the MSU. Patients evaluated in the MSU but received tPA in the ED were excluded from the study. Stroke treatment time metrics were compared for patients from the same zip codes between the two groups.

Results:
169 patients treated with IV tPA in the ED or MSU were screened. 39 patients qualified for the study (11 MSU and 28 ED) with matching zip codes (8 zip codes were matched). 82% (32/39) were from at-risk or distressed communities. 87% (34/39) were Black, 44% male (17/39) and mean age was 63 years. The median alarm to CT time (minutes) was significantly shorter in MSU compared to ED (41 vs 79, p <0.0001). The median alarm to thrombolysis time (minutes) was significantly shorter in the MSU compared to the ED (76 vs. 115, p < 0.0001) (Figure 1).

Conclusions:
Patients from distressed communities get evaluated and treated faster in the MSU compared to ED. Our results suggest that having a MSU in distressed communities that include patients at high risk of stroke can help reduce disparities in stroke care by allowing for faster diagnosis and treatment. A larger sample size is required to compare functional outcomes.
Abstract TMP26: Density of Physical Activity Resources is Associated With Post-Stroke Physical Activity
Authors: Wing Jeffrey J , Strominger Julie , Rajczyk Jenna , Gibbs Brooke , Drum Emily , Boden-Albala Bernadette
Published: February 2024

Background:
Exercise post-stroke can improve health-related quality of life and promote physical fitness, walking, and balance. Physical activity (PA) is important in post-stroke rehabilitation and recovery through the reduction of cardiovascular risk factors and lowering the risk of recurrent stroke and mortality.

Objective:
To assess if area PA resources influence the change in PA 12-months post-stroke.

Methods:
Addresses of 546 mild stroke survivors from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) study were geocoded to the census tract level and merged with the density of physical activity resources from the National Neighborhood Data Archive (NaNDA). We modeled the odds of perceived change in PA at 12-months post-stroke (more active vs. about the same vs. less active) and number of fitness and recreational sports centers per square mile using multinomial logistic regression. Selection bias due to loss-to-follow-up was accounted for using stablized inverse probability weights with robust standard errors. Models were adjusted for age, gender, race/ethnicity, education, insurance, BMI, and intervention.

Results:
A total of 333 participants had 12-month PA data with 17.2% reporting being more physically active and 48.0% being about the same at 12 months. The adjusted odds of being more active compared to less active were 1.57 times larger when comparing the 90
th
percentile of PA resources to the 10
th
percentile (range: 58 resources; 95% CI: 0.99, 2.48). Similarly, adjusted odds of reporting the same level of PA compared to less active were 1.47 times larger when the 90
th
and 10
th
percentiles of PA resources are compared (95% CI: 0.99, 2.17).

Conclusion:
Stroke survivors report higher odds of both maintaining the same level of PA and being more physically active when there are more PA resources in the area. This study demonstrates the potentially important role of the physical and built environment on physical fitness post-stroke.
Abstract TMP29: Plasma Proteomics Demonstrates Immune Dysregulation in Chronic Post-Stroke Fatigue
Authors: Aslan Alperen , Xue Lei , Mlynash Michael , Zera Kristy , Drag Lauren , Aghaeepour Nima , Buckwalter Marion S
Published: February 2024

Introduction:
Post-stroke fatigue is a common and impactful complaint of stroke survivors. As with fatigue from other causes, our understanding of the biological underpinnings of post-stroke fatigue is poor. Here we used plasma proteomics to better understand post-stroke fatigue.

Methods:
We report here on 97 participants 5 months to 10 years after ischemic stroke. Functional Assessment of Chronic Illness-Fatigue (FACIT) scale was used to assess fatigue. Disability and self-reported mood was measured using the modified Rankin Scale (mRS) and the Stroke Impact Scale’s mood subset (SIS3), respectively. We dichotomized participants into non-fatigued (FACIT >41) and fatigued (FACIT ≤41) groups and employed a binary logistic regression to examine associations with clinical variables. Aptamer-based proteomics (Somalogic) was used to quantify 7288 plasma proteins, after which we performed pathway analyses.

Results:
Fatigue was present in 49.4% of our cohort. 39.2% was female and the mean age was 64.2±12.8. When adjusted for age and sex, a prior diagnosis of hypertension (OR=2.7, 95% CI 1.09-6.75, p=0.032) or any psychiatric disorder (OR=8.8, 95% CI 2.54-31, p<0.001) was associated with fatigue. Adjustment for time since stroke did not affect these associations. Higher mRS (rho=-0.49) and worse SIS3 (rho=0.59) were associated with more fatigue. 215 proteins had an absolute correlation coefficient greater than 0.3 and differed between fatigued and non-fatigued patients (p<0.001). Pathway analysis revealed dysregulation of both innate and adaptive immune responses and cytoskeletal regulation. The JAK/STAT pathway was highly dysregulated. In fatigued patients, plasma levels of several components were significantly elevated (log2Fc); CCL5 (0.81), JAK2 (0.73), and STAT3(0.53). The largest downregulation was in fetuin (AHSG, log2Fc -5.5), which contributes to the most down regulated pathway, regulation of ossification, and is an immunosuppressant.

Conclusion:
Immune dysregulation after stroke may be associated with fatigue, particularly upregulation of the JAK/STAT pathway and downregulation of fetuin. More studies are needed to replicate these findings and to probe mechanisms.
Abstract TMP30: The Impact of Social Influences on Rehabilitation Services Utilization After Stroke
Authors: Bonilha Heather , Ma Tianwen , Prabhakaran Shyam , Bhadsavle Lori J , Belagaje Samir R , Blanke Debra , Henriquez Laura , Starnes Danielle , Christopher Hannah , Cabral Jacqueline , Walczak Teri , Nahab Fadi B
Published: February 2024

Introduction:
Evidence supports that early initiation of rehabilitation is important for patient outcomes after stroke. Thus, determination of patients needing rehabilitation during their acute hospitalization is critical. We assessed the impact of demographic, clinical, and county-level social influences on rate of transfer to a rehabilitation facility after acute stroke hospitalizations.

Methods:
Using Get with the Guidelines-Stroke registry data and Institute for Health Metrics and Evaluation data, we fitted univariate and multivariate generalized linear mixed models (GLMM) with demographic, clinical, and social variables to determine how social influences of health impacted variances in transfers to rehabilitation facilities. Specific county-level variables assessed were related to education, income, employment, home ownership, and being foreign born.

Results:
Among 912,488 patients who were assessed or received rehabilitation services due to acute ischemic or intracerebral hemorrhagic stroke, 33.4% of them were transferred to rehabilitation facilities. Multivariate analyses of patient-level demographic and clinical variables achieved an Akaike Information Criterion (AIC) of 925780 (21.0% reduction from the base model) largely driven by clinical factors (mRS at discharge, initial NIHSS, and initial exam findings). When county-level variables related to social influences of health were incorporated, AIC decreased by 23.4% to 871806, indicating a better model fit largely driven by education level.

Conclusions:
Social influences of health impact transfer to rehabilitation facilities after acute stroke hospitalization. Future studies should focus on individual (versus county-level) metrics of social influences of health and their impact on access to rehabilitation. This information should be used to develop interventions to improve the equity of rehabilitation utilization after stroke.
Abstract TMP34: Lower Limb Motor Performance is Proportional to Corticospinal Tract Integrity in Chronic Stroke
Authors: Duncan Kelsey R , Carr Sarah , Salameh Ahlam , Anderson Trenley , Iyengar Pragnya , McCabe Jessica , Skelly margaret , Leonhardt Lisa , Hisel Terri , Pundik Svetlana
Published: February 2024

Introduction:
Gait is a complex behavior characterized by an array of measures, each contributing to our understanding of gait performance. To improve gait recovery after stroke, we need to connect complex clinical function and brain structure. Here, our purpose is to evaluate the relationship between lower limb performance and structural integrity of corticospinal tract (CST) in ambulatory chronic stroke survivors.

Methods:
Diffusion weighted images (DWIs) and lower limb performance measures were acquired from 36 chronic (>6 months) stroke survivors with lower limb deficits. Clinical measures included Fugl-Meyer(FM), Gait Assessment and Intervention Tool (GAIT), timed-up-and-go (TUG) and fastest gait speed (GS). Lesions were manually outlined on the MRIs, and left hemisphere lesions were flipped. DWIs were preprocessed using standard denoising techniques before calculating fractional anisotropy (FA), mean diffusivity (MD) and radial diffusivity (RD). Tract-based spatial statistics (TBSS) was used to normalize all data to MNI space and project it onto a skeleton of white matter tracts. CSTs were isolated. Voxel-wise analysis was performed with permutation testing (5000 permutations). A regression model was created for each clinical variable using lesion masks as a regressor.

Results:
Participants were 64±8.9 y/o, 83% male and 53% left hemisphere lesion. FM was 24.1±4.1. Mild correlations were present for FM with GAIT (Pearson, r = -0.33, p = 0.045) and GS (r = 0.34, p = 0.038), and GS with GAIT (r = -0.35, p = 0.036). TUG was highly correlated with GS (r = -0.93, p = 0.000). In exploratory analysis, findings for ipsilesional CST were as follows: 1) better FM was associated with higher FA, MD and RD, p = 0.001, 0.002 and 0.006 respectively; 2) better GS with higher FA, p = 0.034,3) better TUG scores with lower RD, p = 0.041 and 4) a trend of GAIT with RD, p=0.054. Location of statistically significant voxels varied for different clinical measures. No associations were found for contralesional CST.

Conclusion:
Structural correlates of lower limb performance can be detected using diffusion weighted tractography. FM, an impairment measure of paretic limb, has a stronger association with CST integrity than the measures of global gait function (TUG and GS).
Abstract TMP44: Widening Sex Disparity in Thrombolysis Amid Worsening Stroke Care Quality in Korea
Authors: Ko Yoona , Kim Beom Joon , Kim Youngran , Kim Nakhoon , Kang Dong-wan , Cha Jeongmin , Lee Dongje , Paik Sang Min , Kang Hye-Min , Kim Giryun , Lee Seongtaek , Choi Hyungchan , Han Moon-Ku , Bae Hee-Joon
Published: February 2024

Introduction:
The difference in the use of intravenous thrombolysis (IVT) between females and males has been recognized. Nevertheless, there has been a lack of comprehensive investigation into the sex disparity in South Korea, where the stroke care system has experienced a government-initiated reform recently.

Method:
A prospective, multicenter, nationwide stroke registry (CRCS-K) was utilized to analyze acute stroke admissions during the years 2008 to 2022. IVT candidates were defined as patients with an NIHSS score of 4 or greater and who arrived at the hospital within 4.5 hours from the time last known well. The stroke care quality was measured by the 90th percentile of door-to-needle (DTN) time for IVT. The joinpoint regression model was applied to detect changes in trends of IVT utilization among the candidates.

Results:
A total of 96,855 admissions, of which 43% were female, were recorded during the period. IVT candidates were identified to be 15,732 (16%). The proportion of IVT among the candidates showed an increasing trend after 2008 (Phase 1), followed by a notable decline from 2013 to 2016 (Phase 2) and no significant change afterward (Phase 3, Panel A). During Phase 2, a significant decrease in IVT utilization was observed with an annual percent change (APC) of -5.40, with a greater downward trend in females (APC, -8.71) compared to males (APC, -1.99, Panel B). The 90th percentile of DTN time improved during Phase 1 (APC, -10.28), and worsened after the year 2013 (APC, 4.82, Panel C). IVT utilization was comparable between sexes in Phase 1 (adjusted OR [95% CI], 0.88 [0.76 - 1.03]), but a significant difference was noted in Phase 2 (0.77 [0.66 - 0.91]) and in Phase 3 (0.82 [0.30 - 0.91]), after the year 2013.

Conclusion:
A sex disparity in the use of IVT for ischemic stroke was documented in South Korea. In line with the deterioration in the hyperacute stroke care quality, the gender disparities in the utilization of IVT were also worsening.
Abstract TMP46: Barriers and Facilitators to Tenecteplase Implementation: A Mixed-Methods Study
Authors: Prasad Sidarrth , Jones Erica M , Gebreyohanns Mehari , Aguilera Veronica , Olson Daiwai M , Anderson Jane A , Savitz Sean I , Cruz-Flores Salvador , Warach Steven J , Rhodes Charlotte E , Goldberg Mark P , Ifejika Nneka L
Published: February 2024

Introduction:
Tenecteplase (TNK) has potential advantages over alteplase for treating acute ischemic stroke (AIS). Yet, TNK adoption is not universal. This mixed-methods study identifies common barriers and facilitators to TNK implementation.

Methods:
We surveyed 40 Texas hospitals using qualitative interview and a Likert questionnaire. Hospitals ranged from Acute Stroke Ready Hospitals that had not implemented TNK to Comprehensive Stroke Centers using TNK. Qualitative themes were identified using a phenomenological approach with hermeneutic cycling. Quantitative data were examined using SAS v9.4.

Results:
Thematic analysis identified 3 themes (Evidence, Process flow, and Consensus) and 8 sub-themes which were mapped to barriers and facilitators identified through quantitative analysis (Table 1). Hospitals that implemented TNK differed significantly from non-adopters in their perceptions of barriers related to clinical evidence, TNK delivery times, and legal issues (P<.05). However, both groups shared similar views on key barriers of having a TNK policy, buy-in from administration, TNK cost, and pharmacy approval (
P
>.05).

Conclusion:
The study provides insight into the barriers and facilitators perceived by stroke clinicians when implementing TNK for AIS patients. The results provide a foundation for developing an implementation science study to facilitate successful TNK implementation via a TNK Toolkit to assist with known barriers by leveraging identified facilitators. The toolkit will be validated in a future prospective interventional block randomized study.
Abstract TMP49: Radiomics Model Predicts Histological Thrombus Composition on Admission CT Imaging
Authors: Hernandez-Perez Maria , García Rey Alba , Dorado Laura , Juega Jesus M , Salvia Punsoda Víctor , Camacho Jessica , Marti Cristian , Pagola Jorge
Published: February 2024

Background:
Red blood cells (RBC)-rich thrombus are more easily retrieved via endovascular procedures while platelet-rich thrombus are more resistant to recanalization. Our aim was to generate a radiomics model able to identify both RBC and platelet-rich thrombus at CT admission in patients undergoing mechanical thrombectomy.

Methods:
We included consecutive patients that received mechanical thrombectomy due to a large vessel occlusion in which thrombi was obtained. Thrombi obtained during the procedure were hematoxiline-eosine processed and proportions of RBC were determined. Relative proportion of the platelets in the thrombi was quantified by using a immunohistochemical staining recognizing CD61. We considered RBC-rich thrombi those with a content of RBC>30% and platelet-rich thrombi those with a content of CD61>70%. Thrombi were segmented manually on co-registered non-contrast CT (NCCT) and CT angiography (CTA) at admission (<1mm thickness). 804 quantitative radiological features were extracted from the NCCT and CTA images. The most relevant features were selected with a genetic algorithm. Xgboost models were trained and one-versus-all cross-validated on the selected features to classify RBC and platelet-rich thrombi.

Results:
From 97 patients with histologically and radiologically available thrombi, 43% were female and mean age was 71(±12) years. The area under the curve for detecting RBC>30% was 0.938 (sensitivity 86%, specificity 86%, PPV 84%). Regarding platelet-rich thrombus, the area under the curve for detecting CD61>70% was 0.89 (sensitivity 83%, specificity 84%, PPV 74%). Feature importance by imaging type for RBC-rich and platelet rich thrombus was 70.33% and 69.8% for NCCT and 29.67% and 30% for CTA, respectively. The most important feature types for RBC-rich thrombus were histograms (51%) and first order (27%) while the most important features for platelet rich-thrombus were histograms (94%) followed by texture (5.94%). No information about shape improved any model.

Conclusion:
Our radiomics model can reliably identify RBC and platelet-rich thrombi. Fast identification of thrombus histological components on CT at arrival can help to design the preferred therapeutic strategy
Abstract TMP55: Arterial Spin Labeling Study Immediately After Thrombectomy: A Mechanism of Poor Prognosis Despite Recanalization
Authors: Yamamoto Ryoo , Amano Yu , Kamimura Naoya , Amari Kazumitsu , Johkura Ken , Tanaka Fumiaki
Published: February 2024

Introduction:
In thrombectomy, the mechanism of poor prognosis despite complete recanalization is still unclear. Hyperperfusion may be a such poor prognostic mechanism. Residual microcirculatory dysfunction after restored large artery blood flow (no-reflow phenomenon) may also be a potential mechanism. MRI with arterial spin labeling (ASL) can easily assess cerebral perfusion. We here investigated the mechanism of poor prognosis despite recanalization by analyzing ASL images immediately after thrombus retrieval.

Methods:
This study included 41 consecutive cases (July 2019 to July 2023) with ICA or M1 embolic occlusions who underwent successful thrombectomy (mTICI3) and immediate post-operative ASL-MRI. Regional cerebral blood flow (CBF) on the ASL images were automatically quantified by means of 3DSRT software using 318 constant ROIs classified into 12 segments in each hemisphere. We evaluated the contralesional CBF ratio not only for the entire middle cerebral artery area and each of its segments, but also for each 3DSRT ROIs around the central sulcus (central arterial segment including 28 ROIs). These results of the post-operative ASL evaluation were compared between the favorable prognosis group (mRS 0-2 at 3 months) and the poor prognosis group (mRS 3-6).

Results:
There was no difference between the poor prognosis group (n=14) and the favorable prognosis group (n=27) in the comparison of the contralesional CBF ratio for the entire middle cerebral artery area or for each segment. However, the number of ROIs in the central segment decreased by 10% CBF or more and by 20% CBF or more compared to the contralesional side were significantly higher (both p<0.01) in the poor prognosis group (19.1% against 11.8%, 3.1% against 0%, respectively). There was no difference in comparing the number of ROIs with increased CBF.

Conclusions:
This study showed that a high number of small-area (ROI) circulatory dysfunction (suggesting no-reflow phenomenon) was associated with a poor prognosis despite complete recanalization.
Abstract TMP64: Time-Trends and Determinants of Dual Antiplatelet Therapy Prescription After Acute Moderate-to-Severe Non-Cardioembolic Ischemic Stroke
Authors: Del Brutto Victor J , Yin Ruijie , Gardener Hannah , YING HAO , Gutierrez Carolina M , Jameson Angus , Alkhachroum Ayham , Foster Dianne , Zhou Lili , Ancheta Selina , Sur Nicole B , Gordon Perue Gillian L , Rundek Tatjana , Asdaghi Negar , Romano Jose G
Published: February 2024

Introduction:
Short-term dual antiplatelet therapy (DAPT) lowers the risk of early stroke recurrence after mild non-cardioembolic ischemic stroke (NCIS) and high-risk transient ischemic attack. However, DAPT benefit in moderate-to-severe NCIS is unknown. We sought to investigate time-trends and determinants of DAPT prescription after moderate-to-severe NCIS in the Florida Stroke Registry (FSR).

Methods:
Within 168 FSR-participating hospitals, between January 2010 and September 2022, we analyzed NCIS patients with NIHSS score >3, without other indication(s) for DAPT (e.g., carotid stenting) or systemic anticoagulation, hemorrhagic complications, and whom received at least one antiplatelet agent upon discharge. Using single antiplatelet therapy (SAPT) as comparison, we assessed DAPT determinants through logistic regression models adjusted for demographics, hospital characteristics, clinical presentation, vascular risk factors and stroke subtype.

Results:
Out of 283,264 ischemic stroke patients during the study period, 53,282 had moderate-to-severe NCIS (mean age 68 +/-14 years, 50% women, median presenting NIHSS score 7 [interquartile range 6]). DAPT was prescribed in 15,107 (28.4%) and SAPT in 38,175 (71.6%). DAPT prescription increased from 24.2% in 2010 to 44.8% in 2022 (Figure 1). Independent determinants of DAPT prescription are shown in Table 1.

Conclusion:
DAPT prescription after moderate-to-severe NCIS is common now, and has nearly doubled over the past decade. Major DAPT determinants were premorbid SAPT and large-artery atherosclerosis. Further research may determine DAPT efficacy and safety in this population.
Abstract TMP66: Ipsilateral Carotid Web is Associated With Higher Risk of Recurrent Stroke in Patients With Large Vessel Occlusion Undergoing Thrombectomy
Authors: Khan Farhan , Yaghi Shadi , Torabi Radmehr , Moldovan Krisztina , Goldstein Eric , Furie Karen L , Kala Narendra S , Mohammadzadeh Nahid , Prabhakaran Shyam , Shu Liqi
Published: February 2024

Introduction:
Carotid artery webs are a rare cause of embolic stroke of undetermined source, especially among the young without conventional risk factors. However, despite its detriment, the rate of stroke recurrence is not well studied. We aimed to understand the likelihood of stroke recurrence in patients with a confirmed symptomatic carotid web.

Methods:
We analyzed data from adult patients admitted with anterior large vessel occlusion at Rhode Island Hospital from July 2015 to March 2023. The assessment of carotid webs was conducted by a group of endovascular neurosurgeons and vascular neurologists by reviewing the vessel imaging. Any identified carotid webs on vascular imaging were reviewed by an independent vascular neurologist for adjudication. Chi square and fisher’s exact tests were used for the comparison of groups. After adjusting for age, admission NIHSS, known atrial fibrillation, and site of occlusion, multivariate logistic regression modeling was performed for in-hospital recurrence ischemic stroke.

Results:
Of the 1225 patients with anterior circulation large vessel occlusion, 22(1.80%) had ipsilateral carotid artery web. Patients with carotid web were younger than those without carotid web (73% <65 years). Patients with ipsilateral carotid web had a higher risk of recurrent stroke compared to those without ipsilateral carotid web (OR 3.35, 95% CI,1.043373-10.7041, p = 0.042).

Conclusion:
Carotid webs are an under recognized cause of acute large vessel occlusion and are associated with higher risk of early recurrence. Studies are needed to validate our findings and test early revascularization strategies in patients with symptomatic carotid artery webs.
Abstract TMP68: Proximal Balloon Occlusion With Forced Aspiration (POWER) Technique Should Be Effective in Preventing Distal Microembolization During Carotid Artery Stenting With the Filter Protection Device
Authors: Saito Tomonari , Suzuki Kentaro , Shoda Sotaro , Yoshimura Junki , Numao Shinichiro , nishi yuji , Katano Takehiro , Kanamaru Takuya , Matsumoto Noriko , Nishiyama Yasuhiro , Kimura Kazumi
Published: February 2024

Purpose:
Since the balloon protection device became unavailable in Japan three years ago, the DWI-positive rate after carotid artery stenting (CAS) has increased. We have developed a Proximal balloon Occlusion With forcEd aspiRation (POWER) technique to prevent distal embolization in CAS with the filter protection device. The concept of this technique was to standardize the three points: (1) aspiration force, (2) timing of aspiration and (3) use of balloon guiding. To standardize (1), a VACLOK (vacuum pressure) syringe-like system was used instead of manual aspiration, so that the same aspiration force was applied. To standardize (2), aspiration was to be initiated just before PTA balloon deflation during pre- and post-dilatation.

Methods:
From June 2020 to the present, CAS cases using the Filter protection device were enrolled and divided into two groups before and after the introduction of the POWER technique. Patient backgrounds, carotid artery characteristics (symptomatic, stenosis rate and length, MRI and echographic findings), PTA balloon size, stent type, the postoperative DWI positive rate and the number of DWI spots, and the symptomatic stroke rate were compared between the two groups, respectively.

Results:
Of the 55 CAS cases, 36 were enrolled in the without-POWER group and 19 in the with-POWER group. Between the two groups, postoperative DWI positivity was 32 (88.9%) vs. 9 (47.4%) (p<0.001), DWI spot lesions (n, median (quartiles)) was 9 (3-20) vs. 0 (0-2) (p<0.001), and symptomatic stroke was 6 (16.7%) vs. 0 (0%) (p=0.06), all with-POWER group were less common. Symptomatic stenosis (63.9% vs. 94.7%, p<0.05) was more common in the with-POWER group. There were no differences in age, gender, stenosis rate and length, open cell stent, PTA balloon size, MRA TOF high, MRI T1BB high, hypoechoic plaque, HT, DL, DM, CKD, smoking or DAPT use.

Conclusion:
POWER technique was associated with lower postoperative DWI positivity and lesion counts in CAS with filter protection device.
Abstract TMP71: The Association Between Improvement of Headache and Cerebrovascular Reactivity After Revascularization Surgery in Moyamoya Arteriopathy
Authors: Janssen Helena , Gallego Moyano Daniela , Venkatraghavan Lakshmikumar , Mikulis David , Andrade Barazarte Hugo , Radovanovic Ivan , Hendriks Everardus , Schaafsma Joanna D
Published: February 2024

Background and aim:
Significant headache is often reported by patients with moyamoya arteriopathy (MMA) but has a poorly understood pathophysiology. To decide on management, physicians often focus on stroke-like symptoms while the impact on quality of life and economic burden of chronic headache is often overlooked. We aimed to investigate the effect of revascularization surgery on headache in MMA and potential association with cerebrovascular reactivity (CVR).

Methods:
This was a single-center retrospective study in adult patients with MMA, who underwent extracranial-intracranial (EC-IC) bypass surgery between Jan 2010 - Sept 2022 and had CVR-MRI performed. Clinical and imaging data were collected through systematic chart review complemented by structured headache questionnaires. We assessed the association between headache and CVR before and after revascularization surgery along with potential predictors using logistic regression analysis.

Results:
Fifty-nine patients were included (mean age 44±13 years, 42 women (71%)). Thirty-seven patients (63%) had bilateral MMA of whom 19 (51%) had bilateral EC-IC bypass surgery. Thirty-eight patients (64%) reported headache pre-surgery with mostly migraine-like features. More than a third of patients (37%) lost workdays or quit their job because of headache. Headache improved in 26/38 (68%) patients post-surgery with a reduction in pain severity (median VAS 6 to 3; p = 0.005) and sick leave (37% to 8%; p<0.001). CVR improved in 33/43 (77%) patients who had pre- and post-surgery CVR-MRI, which was associated with headache improvement (OR:14; 95% CI:1.4-131). Pre-operative headache severity (VAS-score) was an independent predictor for headache improvement post-surgery (OR:1.7; 95% CI:1.2-2.5).

Conclusions:
Results of this study showed improvement of headache in most patients with MMA after revascularization surgery and association with improvement in CVR, supporting the hypothesis of a vascular origin. Future larger cohort studies should confirm this hypothesis, improve understanding of underlying pathophysiology and identify potential future treatment targets to guide management for this underappreciated yet disabling aspect of MMA.
Abstract TMP73: Incidence and Outcomes for Aneurysmal Subarachnoid Hemorrhage During Pregnancy: A 20-year Analysis of the National Inpatient Sample From 2000-2019
Authors: Mehta Amol , Hardigan Trevor , Kellner Christopher P , Johanna Fifi , Mocco J D , Majidi Shahram
Published: February 2024

Introduction:
Pregnancy is a risk factor for subarachnoid hemorrhage (SAH). Albeit rare, it can be a devastating condition with high rates of mortality and morbidity. We aim to better understand this risk and its impact on in-hospital outcomes over a longitudinal time period in a large population based sample.

Methods:
We analyzed the 2000-2019 National Inpatient Sample, selecting for aneurysmal SAH (aSAH). Pregnant patients were identified. Demographics, comorbidities, and outcomes were compared between pregnant and not pregnant groups. We used T-tests and chi-squared tests , and created a 1:1 propensity score matched cohort. Variables with notable differences (>0.1 standardized mean) were used for multivariable regression, determining adjusted odds ratios (AOR) and beta coefficients for the impact of pregnancy on outcomes.

Results:
Of the 662,981 SAH patients identified, 0.82% were pregnant. SAH incidence in these patients increased over our study period. Pregnant patients were more often African American (34.9% vs 15.2%) and were more likely to have Medicaid insurance (43.4% vs 12.5%). They had a lower Elixhauser Comorbidity Score (6.01 vs 8.52). They had less hydrocephalus (8.7% vs 23.0), coma (5.4% vs 11.5%), and ventilator use (16.3% vs 28.4%). However, they experienced seizures more often (18.1% vs 12.3). Their rate of in-hospital mortality was lower (7.3% vs 24.2%), and they were more frequently discharged to home or short term hospitals (72.9% vs 38.8%). After propensity matching, pregnant patients had a reduced risk of in-hospital mortality (AOR 0.47, p<0.001). They were also more likely to be discharged home or to short term hospital although these were not statistically significant to our pre-specified alpha.

Conclusion:
sSAH in pregnancy appears to be very rare and is associated with better outcome compared to the general population, as the majority of pregnant patients with aSAH present with favorable neurological status.
Abstract TMP78: Disparities in Experiencing Major Adverse Cardiovascular Events Among Survivors of Spontaneous Intracerebral Hemorrhage by Hematoma Location
Authors: Bako Abdulaziz T , Potter Thomas B , Pan Alan P , Borei Karim , Prince Taya , Britz Gavin W , Vahidy Farhaan
Published: February 2024

Background:
Large studies evaluating the association of hematoma location with the risk of developing major adverse cardiovascular events (MACE) among survivors of intracerebral hemorrhage (ICH) in the United States are lacking.

Methods:
We identified adult (>=18 years) ICH survivors from the state inpatient and the state emergency department databases of Florida, New York, Maryland, Washington, and Georgia (2016 - 2019). We fit a series of multivariable Fine-Gray sub-distribution hazard models, with the competing risk of death, and report the sub-distribution hazard ratio (SHR) and 95% confidence interval (CI) of the independent associations of hematoma location (lobar vs. non-lobar) with recurrent ICH (r-ICH), acute ischemic stroke (AIS), acute myocardial infarction (AMI), and MACE (any stroke, AMI, systemic embolism, or vascular death).

Results:
Among 10,652 ICH patients (median age [IQR]: 70 [58 - 80] years; 47.7% female; 43.2% lobar ICH), 3.3%, 3.1%, 0.5%, and 8.1%, respectively, experienced r-ICH, AIS, AMI, and MACE. Patients with lobar ICH (vs. non-lobar ICH) had a higher risk of r-ICH (SHR, CI: 1.67, 1.35 - 2.07) and MACE (1.28, 1.14 - 1.44). Blacks (vs. Whites) have a higher risk of AIS (1.64, 1.32 - 2.03) and MACE (1.42, 1.22 - 1.65). Also, privately insured patients (vs. Medicare) have a lower risk of r-ICH (0.45, 0.31 - 0.67), AIS (0.71, 0.53 - 0.95), and MACE (0.58, 0.47 - 0.71). Patients from low-income zip codes have a higher risk of AMI (1.83, 1.23 - 2.15) and MACE (1.16, 1.02 - 1.32). Patients with atrial fibrillation had a higher risk of AIS (1.47, 1.18 - 1.84) and MACE (1.26, 1.07 - 1.49). Patients with a high risk of metabolic syndrome (>= 2 of the following: hypertension, diabetes, hyperlipidemia, or obesity) have a higher risk of AIS (1.37, 1.13 - 1.65), AMI (1.81, 1.19 - 2.75), and MACE (1.28, 1.13 - 1.44).

Conclusions:
Developing targeted secondary prevention strategies tailored to the specific sociodemographic and clinical profiles of ICH survivors is warranted.