Acute Stroke Care Research Articles

The Pitfalls of NIHSS: Time for a New Clinical Acute Stroke Severity Scoring System in the Emergency?

Stroke is the second leading cause of death and a major cause of disability worldwide. Stroke severity scales serve as reliable means to track a patient's neurological deficit, predict outcome, and guide treatment decisions in clinical practice. The National Institute of Health Stroke Scale (NIHSS) was introduced over 30 years ago, marking a significant milestone in the field of stroke. Over the years, there have been notable advancements in acute stroke care. Despite several modifications made to NIHSS, none has yet succeeded in effectively capturing all the complex effects of a stroke. This review focuses on the pitfalls of NIHSS and emphasizes the need for a quick and comprehensive clinical and upgraded version of the stroke severity rating scale.

Trends and Progress in Neuroendovascular Treatment in Japan: Japanese Registry of Neuroendovascular Therapy (JR-NET) 4. Main Report.

We reported the main results of the Japanese Registry of Neuroendovascular Therapy (JR-NET) 4, a nationwide surveillance of therapy (NET) in Japan from January 2015 to December 2019. JR-NET 4 registered consecutive patients who underwent NETs by Japan Society of Neuroendovascular Therapy (JSNET) -certified specialists. The primary endpoint was functional independence (mRS score of 0-2) at 30 days post-NET, with secondary endpoints focusing on technical success and major adverse events within 30 days.A total of 63,230 patients and 60,354 NET procedures from 166 participating centers were analyzed. During the study period, NET cases have consistently increased, with an increase in the proportion of elderly patients. A significant trend shift was observed in the distribution of NET procedures, with endovascular treatment for acute ischemic stroke that showed a dramatic increase in 5 years. This trend aligns with key randomized clinical trials from 2015 that presented the efficacy of this treatment. Clinical outcomes at 30 days posttreatment revealed that endovascular treatment for acute ischemic stroke and other NETs maintained safety and effectiveness despite varying prevalence of functional independence between target diseases. The study also observed a steady increase in emergency treatment cases, reflecting the increase in acute ischemic stroke, a time-sensitive medical condition.This comprehensive surveillance highlights the trend of NET practices in Japan, driven by clinical evidence and advancements in treatment devices. Although these findings were specific to Japan, they offer valuable insights into the broader trends in NETs and acute stroke care.

The impact of artificial intelligence on large vessel occlusion stroke detection and management: A systematic review meta-analysis

IntroductionStroke remains the second leading cause of death worldwide, with many survivors facing significant disabilities. In acute stroke care, the timeless adage 'Time is brain' underscores the vital need for quick action. Innovative Artificial Intelligence (AI) technology potentially enables swift detection and management of acute ischemic strokes, revolutionizing acute stroke care towards enhanced automation. MethodsThe study is registered with Prospero under CRD42024496716 and adheres to the Problem, Intervention, Comparison, and Outcomes framework (PICO). The analysis used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched Embase, PubMed, DBLP, Google Scholar, IEEE Xplore, Cochrane database, IEEE, Web of Science, ArXiv, MedRxiv, and Semantic Scholar. The articles included were published between 2019 and 2023. Out of 1528 articles identified, thirty-seven met the inclusion criteria. ResultsWe compared AI-augmented Large Vessel Occlusion (LVO) detection and non-AI LVO detection in various patient processing times related to emergent endovascular therapy in acute ischemic strokes. Triage Time, Door-to-Intervention Notification Time (INR), and Door-to -Arterial Puncture Time revealed an odds ratio (OR) of 0.39 (95 % CI: 0.29–0.54, p < 0.001), 0.30 (95 % CI: 0.21–0.42, p < 0.001), and 0.50 (95 % CI: 0detection 0.30–0.82, p = 0.007), respectively -- all of which had negligible heterogeneity (I^2 = 0). CT-to-Puncture-Time and Door-to-CTA-Time yielded an OR of 0.57 (95 % CI: 0.31–1.04, p = 0.065) and 0.77 (95 % CI: 0.37–1.60, p = 0.489), respectively -- both of which had negligible heterogeneity (I^2 = 0). The Last Known Well (LWK) to Time of Arrival resulted in an OR of 1.15 (95 % CI: 0.83–1.59, p = 0.409, I^2 = 0). AI stroke detection sensitivity OR of 0.91 (95 % CI: 0.88–0.95, p < 0.001) should be interpreted with potential heterogeneity in mind (I^2 = 69.3). National Institute of Health score (NIHSS) mean of 16.20 (95 % CI: 14.96–17.45, p = 0.001, I^2 = 0). Patient Transfer-Times between primary and comprehensive stroke centers generated an OR of 0.98 (95 % CI: 0.73–1.32, p = 893, I^2 = 0). Similarly, Door-in-Door-Out Time (DIDO) had an OR of 1.19 (95 % CI: 0.21–6.88, p = 0.848) and low heterogeneity (I^2 = 5.1). The results indicated significant differences across several parameters between the AI augmentation and non-AI groups. ConclusionOur findings highlight how AI augments healthcare providers' ability to detect and manage strokes swiftly and accurately within acute care settings. As these technologies progress, healthcare organizations mature, and AI becomes more integrated into healthcare systems, longitudinal studies are critical in evaluating its impact on workflow efficiency, cost-effectiveness, and clinical outcomes.

Point-Of-Care low-field MRI in acute Stroke (POCS): protocol for a multicentric prospective open-label study evaluating diagnostic accuracy

IntroductionFast and accurate diagnosis of acute stroke is crucial to timely initiate reperfusion therapies. Conventional high-field (HF) MRI yields the highest accuracy in discriminating early ischaemia from haemorrhages and mimics....

Endovascular thrombectomy is cost-saving in patients with acute ischemic stroke with large infarct.

Endovascular thrombectomy (EVT) is the standard of care for acute large vessel occlusion stroke. Recently, the ANGEL-ASPECT and SELECT 2 trials showed improved outcomes in patients with acute ischemic Stroke presenting with large infarcts. The cost-effectiveness of EVT for this subpopulation of stroke patients has only been calculated using data from the previously published RESCUE-Japan LIMIT trial. It is, therefore, limited in its generalizability to an international population. With this study we primarily simulated patient-level costs to analyze the economic potential of EVT for patients with large ischemic stroke from a public health payer perspective based on the recently published data and secondarily identified determinants of cost-effectiveness. Costs and outcome of patients treated with EVT or only with the best medical care based on the recent prospective clinical trials ANGEL-ASPECT, SELECT2 and RESCUE-Japan LIMIT. A A Markov model was developed using treamtment outcomes derived from the most recent available literature. Deterministic and probabilistic sensitivity analyses addressed uncertainty. Endovascular treatment resulted in an incremental gain of 1.32 QALYs per procedure with cost savings of $17,318 per patient. Lifetime costs resulted to be most sensitive to the costs of the endovascular procedure. EVT is a cost-saving (i.e., dominant) strategy for patients presenting with large ischemic cores defined by inclusion criteria of the recently published ANGEL-ASPECT, SELECT2, and RESCUE-Japan LIMIT trials in comparison to best medical care in our simulation. Prospective data of individual patients need to be collected to validate these results.

Hub-and-Spoke Stroke System: Enhancing Acute Ischemic Stroke Care in the Philippines.

The Hub-and-Spoke stroke system seeks to enhance the efficiency of stroke care by establishing a cohesive network between healthcare facilities providing quality stroke care to patients. This study endeavors to evaluate the effectiveness and characterize the outcomes of acute ischemic stroke patients treated within the Hub-and-Spoke hospital system over 2 years. The assessment focused on thrombolysis rates, mortality, and disability at 3-month follow-up. We conducted a retrospective single-center review to assess the service delivery and outcomes of acute ischemic stroke patients within the Hub-and-Spoke framework which was implemented in Q3 2021. The Hub-and-Spoke model aimed to provide appropriate neurological care for stroke patients, growing from four to eight spoke hospitals in 2 years. The study consisted of 132 stroke patients transferred to the hub hospital, and 42 (31.8%) of them had acute ischemic stroke. Among these 42 ischemic stroke patients, 76% of them were candidates for thrombolysis with a mean NIHSS of 12 (6-22). Among the subset of 32 patients eligible for intervention within the specified time window, a total of 23 individuals, constituting 72% received r-TPA. Regarding patients administered r-TPA, 91.2% demonstrated favorable functional outcomes with an mRS score of 0-1, while 8.7% exhibited a score of 2-3. Among those not given r-TPA, the mean NIHSS was 17 (ranging from 2 to 32). Their functional outcomes after 3 months revealed 52.5% with an mRS score of 0-1, 16% with a score of 2-3, 21.2% with a score of 4-5, and 10.5% with an mRS score of 6. Hub-and-Spoke networks represent a crucial advancement in stroke treatment, particularly for facilities lacking the capacity to manage strokes effectively. By leveraging added expertise and reducing the time from onset to diagnosis to treatment, these networks have significantly enhanced patient care. This enhancement is particularly evident in the increased rate of thrombolysis, resulting in reduced morbidity and prevention of mortality.

Telestroke network to robotic telestroke network: How to upgrade regional stroke care to include remote robotics?

Selected patients with large vessel occlusion (LVO) strokes can benefit from endovascular therapy (EVT). However, the effectiveness of EVT is largely dependent on how quickly the patient receives treatment. Recent technological developments have led to the first neurointerventional treatments using robotic assistance, opening up the possibility of performing remote stroke interventions. Existing telestroke networks provide acute stroke care, including remote administration of intravenous thrombolysis (IVT). Therefore, the introduction of remote EVT in distant stroke centers requires an adaptation of the existing telestroke networks. The aim of this work was to propose a framework for centers that are potential candidates for telerobotics according to the resources currently available in these centers. In this paper, we highlight the future challenges for including remote robotics in telestroke networks. A literature review provides potential solutions. Existing telestroke networks need to determine which centers to prioritize for remote robotic technologies based on objective criteria and cost-effectiveness analysis. Organizational challenges include regional coordination and specific protocols. Technological challenges mainly concern telecommunication networks. Specific adaptations will be necessary if regional telestroke networks are to include remote robotics. Some of these can already be put in place, which could greatly help the future implementation of the technology.

Effectiveness of the acute stroke care map program in reducing in-hospital delay for acute ischemic stroke in a Chinese urban area: an interrupted time series analysis.

Timely intravenous thrombolysis (IVT) is crucial for improving outcomes in acute ischemic stroke (AIS) patients. This study evaluates the effectiveness of the Acute Stroke Care Map (ASCaM) initiative in Shenyang, aimed at reducing door-to-needle times (DNT) and thus improving the timeliness of care for AIS patients. An retrospective cohort study was conducted from April 2019 to December 2021 in 30 hospitals participating in the ASCaM initiative in Shenyang. The ASCaM bundle included strategies such as EMS prenotification, rapid stroke triage, on-call stroke neurologists, immediate neuroimaging interpretation, and the innovative Pre-hospital Emergency Call and Location Identification feature. An interrupted time series analysis (ITSA) was used to assess the impact of ASCaM on DNT, comparing 9 months pre-intervention with 24 months post-intervention. Data from 9,680 IVT-treated ischemic stroke patients were analyzed, including 2,401 in the pre-intervention phase and 7,279 post-intervention. The ITSA revealed a significant reduction in monthly DNT by -1.12 min and a level change of -5.727 min post-ASCaM implementation. The ASCaM initiative significantly reduced in-hospital delays for AIS patients, demonstrating its effectiveness as a comprehensive stroke care improvement strategy in urban settings. These findings highlight the potential of coordinated care interventions to enhance timely access to reperfusion therapies and overall stroke prognosis.

Comparing acute hospital outcomes for people with post-stroke aphasia who do and do not require an interpreter

ABSTRACT Background People with communication differences are known to have poorer hospital outcomes than their peers. However, the combined impact of aphasia and cultural/linguistic differences on care and outcomes after stroke remains unknown. Objectives To investigate the association between cultural/linguistic differences, defined as those requiring an interpreter, and the provision of acute evidence-based stroke care and in-hospital outcomes for people with aphasia. Methods Cross-sectional, observational data collected in the Stroke Foundation National Audit of Acute Services (2017, 2019, 2021) were used. Multivariable regression models compared evidence-based care and in-hospital outcomes (e.g., length of stay) by interpreter status. Models were adjusted for sex, hospital location, stroke type and severity, with clustering by hospital. Results Among 3122 people with aphasia (median age 78, 49% female) from 126 hospitals, 193 (6%) required an interpreter (median age 78, 55% female). Compared to people with aphasia not requiring an interpreter, those requiring an interpreter had similar care access but less often had their mood assessed (OR 0.50, 95% CI 0.32, 0.76), were more likely to have physiotherapy assessments (96% vs 90% p = 0.011) and carer training (OR 4.83, 95% CI 1.70, 13.70), had a 2 day longer median length of stay (8 days vs 6 days, p = 0.003), and were less likely to be independent on discharge (OR 0.54, 95% CI 0.33, 0.89). Conclusions Some differences exist in the management and outcomes for people with post-stroke aphasia who require an interpreter. Further research to explore their needs and the practical issues underpinning their clinical care pathways is required.

Evolving Role of Imaging in Acute Ischemic Stroke Care.

Evolving Role of Imaging in Acute Ischemic Stroke Care.

Regionalization of stroke systems of care in the stroke belt states: The IMPROVE stroke care quality improvement program

Despite guidelines and strong evidence supporting intravenous thrombolysis and endovascular thrombectomy for acute stroke, access to these interventions remains a challenge. The objective of the IMPROVE stroke care program was to accelerate acute stroke care delivery by implementing best practices and improving the regional systems of care within comprehensive stroke networks. The IMPROVE Stroke Care program was a prospective quality improvement program based on established models used in acute coronary care. Nine hub hospitals (comprehensive stroke centers), 52 regional/community referral hospitals (spokes), and over 100 emergency medical service agencies participated. Through 6 regional meetings, 49 best practices were chosen for improvement by the participating sites. Over 2 years, progress was tracked and discussed weekly and performance reviews were disseminated quarterly. Data were collected on 21,647 stroke code activations of which 8,502 (39.3%) activations had a final diagnosis of stroke. There were 7,226 (85.0%) ischemic strokes, and thrombolytic therapy was administered 2,814 times (38.9%). There was significant overall improvement in the proportion that received lytic therapy within 45 minutes (baseline of 44.6%-60.4%). The hubs were more frequently achieving this at baseline, but both site types improved. A total of 1,455 (17.1%) thrombectomies were included in the data of which 401 (27.6%) were transferred from a spoke. There was no clinically significant change in door-to-groin times for hub-presenting thrombectomy patients, however, significant improvement occurred for transferred cases, 46 minutes (interquartile range [IQR] 36, 115.5) at baseline to 27 minutes (IQR 10, 59). The IMPROVE program approach was successful at improving the delivery of thrombolytic intervention across the consortium at both spoke and hub sites through collaborative efforts to operationalize guideline-based care through iterative sharing of performance and best practices for implementation. Our approach allowed identification of both opportunities for improvement and operational best practices providing guidance on how best to create a regional stroke care network and operationalize the published acute stroke care guidelines.

Epidemiology, pathogenesis, and management of Coronavirus disease 2019-associated stroke.

The Coronavirus disease 2019 (COVID-19) epidemic has triggered a huge impact on healthcare, socioeconomics, and other aspects of the world over the past three years. An increasing number of studies have identified a complex relationship between COVID-19 and stroke, although active measures are being implemented to prevent disease transmission. Severe COVID-19 may be associated with an increased risk of stroke and increase the rates of disability and mortality, posing a serious challenge to acute stroke diagnosis, treatment, and care. This review aims to provide an update on the influence of COVID-19 itself or vaccines on stroke, including arterial stroke (ischemic stroke and hemorrhagic stroke) and venous stroke (cerebral venous thrombosis). Additionally, the neurovascular mechanisms involved in SARS-CoV-2 infection and the clinical characteristics of stroke in the COVID-19 setting are presented. Evidence on vaccinations, potential therapeutic approaches, and effective strategies for stroke management has been highlighted.

Safety and effectiveness of emergency stenting for acute anterior circulation large artery disease

Objective: To explore the safety and effectiveness of early stent implantation in patients with acute anterior circulation large artery disease. Methods: Patients were recruited from the RESCUE-RE study (a registration study for Critical Care of Acute Ischemic Stroke After Recanalization). Patients who were diagnosed with acute ischemic stroke within 24 hours of onset and given endovascular treatment after consultation from July 2018 to May 2019 from 18 sub-centers nationwide were retrospectively enrolled. According to whether the stents were placed during the operation, the patients were divided into two groups: stenting group and non-stenting group. The baseline between the two groups was matched by propensity score. The matching variables included age, sex, baseline National Institutes of Health Stroke Scale (NIHSS) score, baseline Glasgow Coma Scale (GCS) score, history of stroke, smoking and onset to hospital time. The primary clinical outcome was 90-day good neurological outcome [defined as modified Rankin score (mRS) 0-2]. Secondary outcomes include 90-day mortality, 24-hour re-occlusion of the responsible artery, and symptomatic intracranial hemorrhage. The differences in clinical endpoints between the two groups were compared. Result: A total of 899 patients with acute anterior circulation artery stenosis or occlusion were included in the study, with a mean age of(66±12)years,and 532(59.18%) were male. There were 193 patients in the stenting group and 706 patients in the non-stenting group. After the baseline data between the two groups were matched by propensity score, 169 patients were enrolled in each of two groups respectively. After matching, the proportion of patients in the stenting group with etiological diagnosis of large atherosclerosis [82.53% (137/166) vs 55.69% (93/167)] and the proportion of patients with previous history of hypertension [63.31% (107/169) vs 47.93% (81/169)] in the stenting group were higher than those in the non-stenting group (both P<0.05). While the proportion of patients in the non-stenting group with cardiogenic embolism [37.73%(63/167) vs 11.45%(19/166)]and the proportion of patients with atrial fibrillation [18.93% (32/169) vs 10.65%(18/169)]was higher(all P<0.05). In the stenting group, the time from onset to recanalization was longer[519 (408, 620)min vs 469 (365, 690)min], and the proportion of general anesthesia [50.89% (86/169) vs 35.50% (60/169)] was higher in the stenting group(both P<0.05). In addition, in the stenting group, the proportion of patients receiving mechanical thrombectomy[67.46% (114/169) vs 88.76% (150/169)] and arterial thrombolysis [2.37% (4/169) vs 18.93% (32/169)] was lower than non-stenting group during the operation, while the proportion of patients receiving balloon dilation [53.85% (91/169) vs 13.61% (23/169)]was higher(both P<0.05). The proportion of patients in stent group receiving antiplatelet drugs before operation was higher [13.46% (21/169) vs 8.70% (14/169)](both P<0.05). In terms of clinical outcome, compared with the non-stenting group, the proportion of patients in the stenting group with good neurological function in 90 days was lower [44.79% (73/169) vs 56.36% (93/169)], and the proportion of death at 90 days was higher[15.98% (27/169) vs 8.88% (15/169)] (both P<0.05). There was no significant difference between the two groups in 24-hour re-occlusion[8.88% (15/169) vs 9.47% (16/169)] and symptomatic intracranial hemorrhage[5.92% (10/169) vs 4.76% (8/169)](both P>0.05). Conclusion: For patients with acute anterior circulation artery disease, early stent therapy may increase the proportion of patients with adverse neurological outcomes.

Improving communicative access and patient experience in acute stroke care: An implementation journey

IntroductionPatient experience for people with aphasia/families in acute care is frequently reported as negative, with communication barriers contributing to adverse events and significant long-term physical and psychosocial sequelae. Although the effectiveness of providing supported communication training and resources for health care providers in the stroke system is well documented, there is less evidence of implementation strategies for sustainable system change. This paper describes an implementation process targeting two specific areas: 1) improving Stroke Team communication with patients with aphasia, and 2) helping the Stroke Team provide support to families. The project aimed for practical sustainable solutions with potential contribution toward the development of an implementation practice model adaptable for other acute stroke contexts. MethodsThe project was designed to create a communicatively accessible acute care hospital unit for people with aphasia. The process involved a collaboration between a Stroke Team covering two units/wards led by nurse managers (19 participants), and a community-based Aphasia Team with expertise in Supported Conversation for Adults with Aphasia (SCA™) – an evidence-based method to reduce language barriers and increase communicative access for people with aphasia. Development was loosely guided by the integrated knowledge translation (iKT) model, and information regarding the implementation process was gathered in developmental fashion over several years. OutcomesExamples of outcomes related to the two target areas include provision of accessible information about aphasia to patients as well as development of two new products – a short virtual SCA™ eLearning module relevant to acute care, and a pamphlet for families on how to keep conversation alive. Potential strategies for sustaining a focus on aphasia and communicative access emerged as part of the implementation process. ConclusionsThis implementation journey allowed for a deeper understanding of the competing demands of the acute care context and highlighted the need for further work on sustainability of communicative access interventions for stroke patients with aphasia and their families.

Abstract 19136: Barriers to Equitable Access to Acute Stroke Care in Hawaii: Logistical and Socioeconomic Effects on Stroke Care in an Island Chain

Introduction: Stroke is the leading cause of chronic disability and third-leading cause of mortality in Hawaii. State incidence of stroke is lower (2.9% to 3.4%) but mortality is higher (70.3:100,000) compared to the rest of the country (58.1:100,000). Access to comprehensive acute stroke care is complicated by geographical restrictions including topography and isolation between islands and also socioeconomic factors such as cost of living. The Queen’s Medical Center (QMC, Honolulu, Oahu, HI) is the sole comprehensive stroke center in the state. Hypothesis: Access to comprehensive stroke care and thrombectomies will be negatively correlated with both travel time and increased geographical barriers. Methods: Retrospective review of records from QMC between January 2021 to June 2023 identified 405 patients with an acute stroke and underwent thrombectomy. Patient zip codes were used to create a heat map identifying locations of patients receiving thrombectomy. Another heat map was made for all acute stroke cases using public health data. An index was created to determine travel time from zip code to QMC. Thrombectomy and acute stroke versus travel time was performed using generalized linear models. Results: GIS-generated heat maps demonstrate a difference in care opportunities between zip codes, identifying areas with highest incidence of acute stroke associate with lower rates of thrombectomy procedures. Island barriers create the highest differences in acute stroke cases versus thrombectomy procedure. Regression analysis demonstrated marked negative correlation in comparison between thrombectomies versus acute stroke cases with respect to travel time. Conclusions: Healthcare providers in Hawaii face an increased challenge with respect to providing care due to natural geography that extending the time to comprehensive stroke treatment. Hawaii is acutely aware of the unique challenges and the results of this study are an initial phase in providing a framework for modified statewide acute stroke protocols that can further be utilized by other communities with similar barriers to access to care.

43 Application of the Moroccan Arabic Bedside Western Aphasia battery-Revised in Acute Stroke Care

Objective:Despite the prevalence of aphasia in Morocco, standardized quick assessment tools are not available for use with patients in acute stroke care. The present study set out to (1) describe the processes of linguistic adaptation of a Moroccan Arabic (MA) version of the Bedside Western Aphasia Battery-Revised (WAB-R), (2) examine the test’s sensitivity to the detection of aphasia in an acute clinical setting, and (3) measure the instrument’s ability to detect improvement in language ability in the acute period.Participants and Methods:To achieve the first objective, the English Bedside WAB-R was adapted to Moroccan Arabic by a group of linguists. The instrument’s psychometric properties were established by (1) ascertaining the test’s sensitivity to the presence of aphasia, and (2) verifying the tool’s validity and reliability. Participants included a group of age- and education-matched non-brain-damaged individuals (N = 106), a group of right hemisphere brain-lesioned patients (N = 20), and a group of left hemisphere aphasic patients (N = 52). To accomplish the second and third objectives, the Bedside MA-WAB-R was administered to a group of aphasic participants in the acute period (less than three months post-stroke), and a group of age- and education-matched participants (N = 20). Aphasic patients in the acute stage were tested twice on a seven-day interval (3 days and 10 days post-onset). All data were collected from the Neurology department at the University Medical Hospital Hassan II, and the study received approval from the ethics committee of the Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah.Results:Regarding the first objective, the results indicated that the MA-WAB-R is sensitive to the presence of aphasia, as revealed by the significantly worse performance of the aphasic group on all subtests relative to matched normal and right-hemisphere participants (p = .000). Analyses revealed excellent content and construct validity (correlations between subtests and AQ ranging from .5 to .8) as well as high inter-rater reliability, intra-rater reliability and test-retest reliability (ICC (2,1) &gt; .9). For the second and third objectives, the results supported the test’s sensitivity to the detection of aphasia in the acute phase, as confirmed by the significantly worse performance of aphasic patients relative to matched normal controls (p = .000). The instrument also proved as a reliable measure of language improvement in the acute period, as supported by better scores on the second testing point relative to the first across all subtests.Conclusions:The MA-WAB-R is the first standardized assessment tool that can be used for a quick but reliable screening of aphasia in both chronic and acute clinical settings. The test can inform the initial diagnosis of aphasia, and guide a more comprehensive assessment of patients’ spared and impaired linguistic abilities within a context receiving little attention in the aphasia literature.

Abstract 274: Mechanical Thrombectomy for Ischemic Stroke in Elderly Population

Introduction Stroke is a leading cause of mortality and morbidity worldwide and the risk increases with age. Mechanical thrombectomy (MT) in eligible patients is proven to improve outcomes and is ow standard of care for acute ischemic stroke. Clinical trials evaluating MT often exclude patients older than 80 and available scientific evidence supporting MT in elderly is limited and varied. Purpose of this systematic review is to examine current literature on efficacy and outcomes of MT in octogenarian and nonagenarian stroke patients. Methods A literature search was conducted using PubMed and Scopus from 2013‐2023. All studies that included patients 80 yrs and older with acute ischemic stroke who underwent MT and provided 90‐day clinical outcomes and rates of complications were reviewed. Results Review identified 25 publications and the median age of study populations ranged from 82 to 93.3 years with proportion of female patients higher in all studies. Success rate of MT ranged from 66.7% to 97%. Symptomatic intracranial hemorrhage was the common complication ranging from 3% to 28%. The 90‐day mortality rate ranged from 7% to 70%. No differences were noted between octogenarians and nonagenarians. Conclusion MT in elderly patients had high reperfusion rates indicating procedural success, and variable clinical outcomes with wide range of complication and mortality rates. Factors influencing MT outcomes in elderly are discussed and the need for randomized control trials providing the highest level of scientific evidence for MT in this population is emphasized.

Abstract 207: Clinical Outcomes After Endovascular Thrombectomy in Large Vessel Occlusion: A Philippine Single Center Experience

Introduction Endovascular thrombectomy (EVT) has emerged in the last decade to be the gold standard of care for acute ischemic stroke. The use of EVT is known internationally, mostly in the western hemisphere. Its application and accessibility differ in the Asian countries, especially in the Philippines. The only Philippine data on EVT use was a retrospective study conducted in the same institution as this paper. It included 31 subjects and showed the emerging utility of EVT in the Philippines. However its limitations are varying functional outcomes, as their point of evaluation was at the time of discharge as well as it lacking a long‐term outcome follow up. Methods In this single center retrospective study, subjects included were all patients who underwent EVT during the period of September 2018 to April 2023. The following variables were collected from medical charts: demographic data (age and sex), admitting MRS, NIHSS score upon admission and discharge, underlying co‐morbidities (hypertension, diabetes, history of previous stroke), use of anti‐thrombotics/anti‐coagulants as maintenance medications, CT (ASPECTS) or MR ASPECTS, history of rTPA administration prior to EVT, technique, ictus to groin time, post‐EVT recanalization score (TICI), site of occlusion, discharge MRS, and 90‐day MRS. Results In 2018‐2023, there were 1,595 patients admitted for acute ischemic strokes, 57 (3%) cases underwent EVT and 20 (1%) of which underwent combined EVT and IVT. The mean age was 65 with a male to female ratio of 6:5. Hypertension was a common co‐morbidity in half of the population, also diabetes and atrial fibrillation were existing in 1/3 of cases. During their admission, majority of patients (90%, n=54) presented with moderate to severe disability (MRS 3‐5) with a mean NIHSS of 16, indicating a moderate stroke severity. The identified site of occlusion is mainly in the anterior circulation (89%, n=51) and with 6 cases of posterior circulation strokes. Stentriever technique is primarily utilized in 59% (n=34), aspiration in 10% (n=6), and combined stentriever and aspiration in 17% (n=10) with a 77% (n=44) recanalization rate. Early neurologic improvement (ENI) defined as a difference of 8 points in NIHSS or a score of 0 at day 1 post‐EVT were found in 7% (n=4), 2 of which translated to a favorable outcome using the 90‐day MRS. In‐hospital mortality occurred in 24% (n=14) of cases, 6 from brain herniation and the rest were due to complications of prolonged hospitalization such as septic shock. On long term follow‐up at 90 days post ictus, 24% (n=14) had favorable outcome of MRS 0‐2. Among those grouped in the unfavorable outcome, 53% (n=23) were MRS 3, still showing marked improvement of quality of life. Conclusion Long‐term clinical outcome of EVT in this retrospective study is at par with the landmark trials which exhibited a number needed to treat of 2.8‐7.4. This is the single local data on the long‐term clinical outcomes of EVT in the Philippines and it aims to spread awareness that EVT is a possible and effective treatment for large vessel strokes despite wide gap in accessibility and use in the country.

Abstract 122: Mechanical Thrombectomy for Acute Stroke in the Elderly: A Single‐Center Case Series in the Philippines

Introduction Mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke (AIS) caused by large‐vessel occlusion. However, the extent of its benefits in elderly populations remains uncertain, as most landmark trials on MT have focused on younger individuals. This single‐center case series aims to shed light on the advantages and disadvantages of MT in higher age groups, particularly within the context of low‐ or middle‐income countries. Methods Between January 2018 and June 2023, we conducted a chart review of five patients aged ≥80 years who underwent MT for stroke. The study analyzed the patients' premorbid comorbidities, time to treatment, revascularization rates, procedural complications, mortality, and 90‐day modified Rankin Scale (mRS) scores. Results The five cases included individuals aged between 81 and 94 years. Among them, two had mild baseline disability (mRS score 0‐1), and three had moderate baseline disability (mRS score 2‐4). Upon admission, the National Institutes of Health Stroke Scale (NIHSS) scores ranged from 14 to 24. Three of the patients received pre‐thrombectomy intravenous thrombolysis with Alteplase and subsequently underwent MT within 4 to 7 hours of symptom onset. Successful recanalization (TICI score 2b‐3) was achieved in all five patients. However, two patients developed symptomatic intracranial hemorrhage post‐thrombectomy, and one of them succumbed to the complication. Three out of the four discharged patients attained favorable clinical outcomes with a 90‐day mRS score of 0‐2 or equivalent to their prestroke disability. Conclusion Our case series suggests that elderly individuals can potentially achieve favorable functional outcomes after MT. Nevertheless, this potential is influenced by stroke severity and the success of the treatment. As the elderly population, including octogenarians, nonagenarians, and centenarians, is expected to grow in the future, cautious patient selection should be exercised when considering thrombectomy in this age group. Further research comparing endovascular and conventional treatments in the elderly is imperative to inform better clinical decisions.

Abstract 145: Hyperacute Virtual Reality Augmented Rehabilitation (VRAR) in the Neurological ICU: A Safety and Feasibility Study

Introduction Virtual reality (VR) has shown great promise in stroke rehabilitation, providing interactive exercises that target motor and cognitive impairments with minimal adverse events and positive outcomes in improving motor function, balance, and patient motivation. However, most post‐stroke rehabilitation focuses on recovery after discharge, emphasizing the need for efficient interventions like VR to make the most of limited hospital rehab time for stroke survivors. This study aimed to evaluate the safety and feasibility of incorporating hyperacute virtual reality augmented rehabilitation (VRAR) as part of acute stroke care. Methods A prospective, proof‐of‐concept study was conducted with 13 eligible patients who experienced hemorrhagic or ischemic stroke between July 1st, 2021, and January 1st, 2022. Enrolled patients received VRAR in addition to the standard‐of‐care rehabilitation. Patients with dementia, expressive aphasia, delirium, or were unable to participate in physical therapy/ utilize the virtual reality hardware were excluded. Demographic data, functional scores, and complications were collected. Results Of the 13 patients who used the VRAR rehabilitation program, ten completed up to three visits. The cohort consisted of 50% male patients with a mean age of 73.6 years. Half of the patients had a primary diagnosis of ischemic stroke, while the rest were diagnosed with either hemorrhagic stroke (30%) or transient ischemic attack (20%). The mean length of hospital stay was 11.1 days, and the median time from admission to rehabilitation was 4 days. Most patients (80%) were discharged to outpatient rehabilitation, while 20% were discharged home. The median number of sessions was one, with four patients using the VRAR program multiple times. Despite the withdrawal of two patients (15.4%) who expressed mild discontent, there were no adverse events reported during the use of the VRAR rehabilitation program. Conclusion The findings of this study offer evidence backing the safety and feasibility of integrating VRAR as a supplementary tool in hyperacute stroke care. These results underscore the potential of VR therapy as a promising addition to conventional stroke rehabilitation methods.