American Stroke Research Articles

Vertigo and dizziness due to vertebrobasilar TIA: a prospective study

PurposeProspective studies on vascular vertigo and dizziness (VVD) due to vertebrobasilar transient ischemic attack (VBTIA) have been sparse. This study aimed to characterize clinical features, response to treatments, and prognostic factors of VVD due to VBTIA using a cohort established in 2021.MethodsWe recruited 103 patients (58 female individuals, 56.3%), with a mean age of 70.9 ± 9.3 years (range = 37–85), between January 2021 and January 2024. All patients met the diagnostic criteria of “Probable transient VVD” published by the Bárány Society. The mean interval from symptom onset to recruitment was 11.8 months (range = 0.5–72). Treatments followed the current American Heart Association–American Stroke Association's Guidelines for Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack. Patients with recurrent strokes among TIAs, and patients who were already taking an antithrombotic agent and should maintain the same regimen were excluded.ResultsImbalance (46.7%) and vertigo (39.8%) were the most frequent symptoms. The duration of attacks was <1 min in 35 patients (33.9%), 1–10 min in 34 patients (33.0%), 10–60 min in 15 patients (14.6%), and >60 min in 19 patients (18.5%). Trigger factors were reported in 20 patients (19.4%), which included eccentric neck position in 12 patients (11.7%), physical exercise in four patients (3.9%), positional changes in three patients (2.9%), and eccentric neck position and physical exercise in the remaining patient (0.9%). The frequency of attacks before the medication was 1 or <1/month in 32 (31.0%) patients, 1–4/month in 44 (42.7%) patients, 4–8/month in 21 patients (20.4%), and daily in six patients (5.9%). The treatment regimens were aspirin in 57 patients (55.3%), clopidogrel in 19 patients (18.5%), aspirin plus clopidogrel in 25 patients (24.3%), and rivaroxaban in two patients (1.9%). The attacks were reduced by 93.2% [IC 95% (88.34, 98.06), number needed to treat: 1] during the median follow-up of 12 months (range = 2–36 months). Only seven (6.8%) patients experienced a new attack with the medication. No prognostic factors could be identified for the recurrences.ConclusionVVD due to VBTIA has a broad clinical spectrum. Secondary stroke prevention is effective in VVD due to VBTIA even though no prognostic factors could be identified for symptom recurrence.

International Initiatives of the American Heart Association: Original Concepts, Present Programs, and Future Focus: A Science Advisory From the American Heart Association.

The American Heart Association (AHA), founded in 1924, is anchored in the core belief that scientific research can lead the way to better prevention, treatment, recovery, and ultimately a cure for cardiovascular disease. Historically, the association's involvement in international efforts centered on scientific cooperation. Activities mostly involved AHA leadership presenting at international scientific meetings and leaders from other countries sharing scientific and medical information at AHA meetings. Although the AHA's and American Stroke Association's international efforts have expanded substantially since those early days, global knowledge exchange remains the bedrock of its international endeavors. As the AHA turns 100, we reflect on the successful global efforts in prevention, resuscitation, global advocacy, quality improvement, and health equity that have guided the organization to a place of readiness for "advancing health and hope, for everyone, everywhere." Motivated by the enormous potential for population health gains in an aging world, the AHA is entering its second century with redoubled commitment to improving global cardiovascular and cerebrovascular health for all.

Comparison of American and European Guideline Recommendations for Diagnostic Workup and Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack.

Guidelines help to facilitate treatment decisions based on available evidence, and also to provide recommendations in areas of uncertainty. In this paper, we compare the recommendations for stroke workup and secondary prevention of ischemic stroke and transient ischemic attack of the American Heart Association (AHA)/American Stroke Association (ASA) with the European Stroke Organization (ESO) guidelines. The primary aim of this paper is to offer clinicians guidance by identifying areas where there is consensus and where consensus is lacking, in the absence or presence of high-level evidence. We compared AHA/ASA with the ESO guideline recommendations for 7 different topics related to diagnostic stroke workup and secondary prevention. We categorized the recommendations based on class and level of evidence to determine whether there were relevant differences in the ratings of evidence that the guidelines used for its recommendations. Finally, we summarized major topics of agreement and disagreement, while also prominent knowledge gaps were identified. In total, we found 63 ESO and 82 AHA/ASA recommendations, of which 38 were on the same subject. Most recommendations are largely similar, but not all are based on high-level evidence. For many recommendations, AHA/ASA and ESO assigned different levels of evidence. For the 10 recommendations with Level A evidence (high quality) in AHA/ASA, ESO only labeled 4 of these as high quality. There are many remaining issues with either no or insufficient evidence, and some topics that are not covered by both guidelines. Most ESO and AHA/ASA Guideline recommendations for stroke workup and secondary prevention were similar. However not all were based on high-level evidence and the appointed level of evidence often differed. Clinicians should not blindly follow all guideline recommendations; the accompanying level of evidence informs which recommendations are based on robust evidence. Topics with lower levels of evidence, or those with recommendations that disagree or are missing, may be an incentive for further clinical research.

Outcomes Among Mexican American and Non-Hispanic White Informal Stroke Caregivers.

Informal home care is prevalent among Mexican American stroke survivors, but data on the impact on caregivers are not available. The aim was to assess ethnic differences in informal stroke caregiving and caregiver outcomes at 90 days poststroke. Informal caregivers were recruited from the population-based Brain Attack Surveillance in Corpus Christi Project (2019-2023), conducted in a bi-ethnic community in Texas. Caregivers of community-dwelling stroke survivors who were not cognitively impaired and not employed by a formal caregiving agency were interviewed. Interviews included sociodemographics, dyad characteristics, Modified Caregiver Strain Index (range 0-26, higher more positive), Positive Aspects of Caregiving scale (range, 5-45, higher more), Patient Health Questionnaire-8 (range, 0-30, higher worse), and PROMIS (Patient-Reported Outcomes Measurement Information System)-10 physical (range, 16.2-67.7, higher better) and mental health (range, 21.2-67.6, higher better) summary scores. Stroke survivor data was from interviews and medical records. Propensity score methods were used to balance caregiver and patient factors among Mexican American and Non-Hispanic White caregivers by fitting a model with ethnicity of caregiver as the outcome and predictors being caregiver sociodemographics, patient-caregiver dyad characteristics, and patient sociodemographics and functional disability. Propensity scores were included as a covariate in regression models, considering the association between ethnicity and outcomes. Mexican American caregivers were younger, more likely female, and more likely a child of the stroke survivor than Non-Hispanic White caregivers. Mexican American caregiver ethnicity was associated with less caregiver strain (β, -1.87 [95% CI, -3.51 to -0.22]) and depressive symptoms (β, -2.02 [95% CI, -3.41 to -0.64]) and more favorable mental health (β, 4.90 [95% CI, 2.49-7.31]) and positive aspects of caregiving (β, 3.29 [95% CI, 1.35-5.23]) but not associated with physical health. Understanding the mechanisms behind more favorable caregiver outcomes in Mexican American people may aid in the design of culturally sensitive interventions to improve both caregiver and stroke survivor outcomes, potentially across all race and ethnic groups.

Evaluating the strength and quality of evidence in American heart association/American stroke association's guidelines for aneurysmal subarachnoid hemorrhage and spontaneous intracerebral hemorrhage

BackgroundClinical practice recommendations guide healthcare decisions. This study aims to evaluate the strength and quality of evidence supporting the American Heart Association (AHA)/American Stroke Association (ASA) guidelines for aneurysmal subarachnoid hemorrhage (aSAH) and spontaneous intracerebral hemorrhage (ICH). MethodsWe reviewed the current AHA/ASA guidelines for aSAH and spontaneous ICH and compared with previous guidelines. Guidelines were classified based on the Class of recommendation (COR) and Level of evidence (LOE). COR signifies recommendation strength (COR 1: Strong; COR 2a: Moderate; COR 2b: Weak; COR 3: No Benefit/Harm), while LOE denotes evidence quality (LOE A: High-Quality; LOE B-NR: Moderate-Quality, Not Randomized; LOE B-R: Moderate-Quality, Randomized; LOE C-EO: Expert Opinion; LOE C-LD: Limited Data). ResultsFor aSAH, we identified 84 recommendations across 15 guideline categories. Of these, 31% were classified as COR I, 30% as COR 2a, 17% as COR 2b, and 18% as COR 3. In terms of LOE, 7% were based on LOE A, 10% on LOE B-R, 65% on LOE B-NR, 14% on LOE C-LD, and 5% on LOE C-EO. Compared to previous guidelines, there was a 46% decrease in LOE A, a 45% increase in LOE B, and an 11% decrease in LOE C. For spontaneous ICH, 124 guidelines were identified across 31 guideline categories. Of these, 28% were COR I, 32% COR 2b, and 9% COR 3. For LOE, 4% were based on LOE A, 35% on LOE B-NR, and 42% on LOE C-LD. Compared to previous guidelines, there was a 78% decrease in LOE A, an 82% increase in LOE B, and a 14% increase in LOE C. This analysis highlights that less than a third of AHA/ASA guidelines are classified as the highest class of recommendation, with less than 10% based on the highest LOE. ConclusionLess than a third of AHA/ASA guidelines on aSAH and spontaneous ICH are classified as the highest class of recommendation with less than 10% based on highest LOE. There appears to be a decrease in proportion of guidelines based on highest LOE in most recent guidelines.

Self-Management among Stroke Survivors in the United States, 2016 to 2021.

Background: Self-management among stroke survivors is effective in mitigating the risk of a recurrent stroke. This study aims to determine the prevalence of self-management and its associated factors among stroke survivors in the United States. Methods: We analyzed the Behavioral Risk Factor Surveillance System (BRFSS) data from 2016 to 2021, a nationally representative health survey. A new outcome variable, stroke self-management (SSM = low or SSM = high), was defined based on five AHA guideline-recommended self-management practices, including regular physical activity, maintaining body mass index, regular doctor checkups, smoking cessation, and limiting alcohol consumption. A low level of self-management was defined as adherence to three or fewer practices. Results: Among 95,645 American stroke survivors, 46.7% have low self-management. Stroke survivors aged less than 65 are less likely to self-manage (low SSM: 56.8% vs. 42.3%; p < 0.0001). Blacks are less likely to self-manage than non-Hispanic Whites (low SSM: 52.0% vs. 48.6%; p < 0.0001); however, when adjusted for demographic and clinical factors, the difference was dissipated. Higher education and income levels are associated with better self-management (OR: 2.49, [95%CI: 2.16-2.88] and OR: 1.45, [95%CI: 1.26-1.67], respectively). Further sub-analysis revealed that women are less likely to be physically active (OR: 0.88, [95%CI: 0.81-0.95]) but more likely to manage their alcohol consumption (OR: 1.57, [95%CI: 1.29-1.92]). Stroke survivors residing in the Stroke Belt did not self-manage as well as their counterparts (low-SSM: 53.1% vs. 48.0%; p < 0.001). Conclusions: The substantial diversity in self-management practices emphasizes the need for tailored interventions. Particularly, multi-modal interventions should be targeted toward specific populations, including younger stroke survivors with lower education and income.

Neighborhood Resources and Health Outcomes Among Stroke Survivors in a Population-Based Cohort.

Stroke survivors believe neighborhood resources such as community centers are beneficial; however, little is known about the influence of these resources on stroke outcomes. We evaluated whether residing in neighborhoods with greater resource density is associated with favorable post-stroke outcomes. We included Mexican American and non-Hispanic White stroke survivors from the Brain Attack Surveillance in Corpus Christi project (2009-2019). The exposure was density of neighborhood resources (eg, community centers, restaurants, stores) within a residential census tract at stroke onset. Outcomes included time to death and recurrence, and at 3 months following stroke: disability (activities of daily living/instrumental activities of daily living), cognition (Modified Mini-Mental State Exam), depression (Patient Health Questionnaire-8), and quality of life (abbreviated Stroke-Specific Quality of Life scale). We fit multivariable Cox regression and mixed linear models. We considered interactions with stroke severity, ethnicity, and sex. Among 1786 stroke survivors, median age was 64 years (interquartile range, 56-73), 55% men, and 62% Mexican American. Resource density was not associated with death, recurrence, or depression. Greater resource density (75th versus 25th percentile) was associated with more favorable cognition (Modified Mini-Mental State Exam mean difference=0.838, 95% CI=0.092, 1.584) and among moderate-severe stroke survivors, with more favorable functioning (activities of daily living/instrumental activities of daily living=-0.156 [95% CI, -0.284 to 0.027]) and quality of life (abbreviated Stroke-Specific Quality of Life scale=0.194 [95% CI, 0.029-0.359]). We observed associations between greater resource density and cognition overall and with functioning and quality of life among moderate-severe stroke survivors. Further research is needed to confirm these findings and determine if neighborhood resources may be a tool for recovery.

African American patients have a higher probability of cognitive impairment after incident stroke: An analysis of national electronic health record data

BackgroundCognitive impairment (CI) and stroke are diseases with significant disparities in race and geography. Post stroke cognitive impairment (PSCI) can be as high as 15–70 % but few studies have utilized large administrative or electronic health records (EHR) to evaluate trends in PSCI. We utilized an EHR database to evaluate for disparities in PSCI in a large sample of patients after first recorded stroke to evaluate for disparities in race. MethodsThis is a retrospective cohort analysis of Cerner Health Facts® EHR database, which is comprised of EHR data from hundreds of hospitals/clinics in the US from 2009–2018. We evaluated patients ≥40 years of age with a first time ischemic stroke (IS) diagnosis for PSCI using ICD9/10 codes for both conditions. Patients with first stroke in the Cerner database and no pre-existing cognitive impairment were included, we compared hazard ratios for developing PSCI for patient characteristics ResultsA total of 150,142 IS patients with follow-up data and no pre-existing evidence of CI were evaluated. Traditional risk factors of age, female sex, kidney injury, hypertension, and hyperlipidemia were associated with PSCI. Only African American stroke survivors had a higher probability of developing PSCI compared to White survivors (HR 1.347, 95 % CI (1.270, 1.428)) and this difference was most prominent in the South. Among those to develop PSCI, median time to documentation was 1.8 years in African American survivors. ConclusionIn a large national database, African American stroke survivors had a higher probability of PSCI five years after stroke than White survivors.

Treatment Delays for Patients With Acute Ischemic Stroke in a Rural Arkansas Emergency Department: A Retrospective Chart Review.

Objective The goal of this study is to evaluate treatment times regarding acute ischemic stroke and identify barriers to implementing stroke care at the Ouachita County Medical Center Emergency Department. Methods A retrospective review of medical records was conducted of patients who presented with acute ischemic stroke to the Ouachita County Medical Center Emergency Department between 2020 and 2023 and received intravenous (IV) r-tPA. The primary focus of this study was to analyze door-to-needle time withIV r-tPA. To determine areas of improvement, this studyexamined door-to-initial physician evaluation, door-to-CT, door-to-tele neurologist evaluation, and door-to-IV r-tPA administration. Results A total of 26 patients who received treatment with IV r-tPA for acute ischemic stroke were included in this study. Twenty-three patients (88%; n=26)received IV- r-tPA within the recommended 60-minute window with a mean treatment time of 44.5 minutes. The mean door-to-physician evaluation time for patients presenting with acute ischemic stroke was 1.81 minutes. All patients received CT scans within 28 minutes of arrival with the mean time being 5.08 minutes. Teleneurologist evaluation was initiated within 59 minutes of presentation with a mean time of 25.19 minutes. Conclusion Evaluation of treatment times at the Ouachita County Medical Center Emergency Department confirms that stroke care received at this facility adheres to the recommendations outlined by the American Stroke Association. Nevertheless, clinicians should always strive for improvement. Through extensive evaluation of the treatment process, we were able to provide recommendations to further decrease treatment times and improve overall clinical outcomes.

Contemporary Prestroke Dual Antiplatelet Use and Symptomatic Intracerebral Hemorrhage Risk After Thrombolysis

Intravenous alteplase (IV-tPA) can be administered to patients with acute ischemic stroke but is associated with symptomatic intracerebral hemorrhage (sICH). It is unclear if patients taking prestroke dual antiplatelet therapy (DAPT) are at higher risk of sICH. To determine the associated risk of sICH in patients taking prestroke dual antiplatelet therapy receiving alteplase for acute ischemic stroke using propensity score matching analysis. This cohort study used data from the American Heart Association and American Stroke Association Get With The Guidelines-Stroke (GWTG-Stroke) registry between 2013 and 2021. Data were obtained from hospitals in the GWTG-Stroke registry. This study included patients hospitalized with acute ischemic stroke and treated with IV-tPA. Data were analyzed from January 2013 to December 2021. Prestroke DAPT before treatment with IV-tPA for acute ischemic stroke. sICH, In-hospital death, discharge modified Rankin scale score, and other life-threatening systemic hemorrhages. Of 409 673 participants, 321 819 patients (mean [SD] age, 68.6 [15.1] years; 164 587 female [51.1%]) who were hospitalized with acute ischemic stroke and treated with IV-tPA were included in the analysis. The rate of sICH was 2.9% (5200 of 182 344), 3.8% (4457 of 117 670), and 4.1% (893 of 21 805) among patients treated with no antiplatelet therapy, single antiplatelet therapy (SAPT), and DAPT, respectively (P < .001). In adjusted analyses after propensity score subclassification, both SAPT (odds ratio [OR], 1.13; 95% CI, 1.07-1.19) and DAPT (OR, 1.28; 95% CI, 1.14-1.42) were associated with increased risks of sICH. Prestroke antiplatelet medications were associated with lower odds of discharge mRS score of 2 or less compared with no medication (SAPT OR, 0.92; 95% CI, 0.90-0.95; DAPT OR, 0.94; 95% CI, 0.88-0.98). Results of a subgroup analysis of patients taking DAPT exposed to aspirin-clopidogrel vs aspirin-ticagrelor combination therapy were not significant (OR, 1.35; 95% CI, 0.84-1.86). Prestroke DAPT was associated with a significantly elevated risk of sICH among patients with ischemic stroke who were treated with thrombolysis; however, the absolute increase in risk was small. Patients exposed to antiplatelet medications did not have excess sICH compared with landmark trials, which demonstrated overall clinical benefit of thrombolysis therapy for acute ischemic stroke.

Depression following small vessel stroke is common and more prevalent in women

ObjectivesWe sought to examine the frequency of depression after small vessel-type stroke (SVS) and associated risk factors. Materials and methodsWe conducted a retrospective analysis of a prospective cohort of patients enrolled in the American Stroke Association-Bugher SVS Study, which included 200 participants within 2-years of SVS and 79 controls without a history of stroke from 2007 to 2012 at four sites. The primary outcome was PHQ-8, with scores ≥10 consistent with post-stroke depression (PSD). A logistic regression adjusted for age, race, sex, history of diabetes and Short-Form Montreal Cognitive Assessment score (SF-MoCA) was used to compare the risk of having depression after SVS compared to controls. Another logistic regression, adjusted for age, sex, race, level of education, SF-MoCA, white matter disease (WMD) burden, stroke severity (NIHSS), time between stroke and depression screen, history of diabetes, and history of hypertension was used to identify factors independently associated with depression in participants with SVS. ResultsThe cohort included 161 participants with SVS (39 excluded due to missing data) and 79 controls. The mean interval between stroke and depression screening was 74 days. Among participants with SVS, 31.7% (n = 51) had PSD compared to 6.3% (n = 5) of controls (RR = 5.44, 95% CI = 2.21-13.38, p = 0.0002). The only two variables independently associated with PSD in participants with SVS were female sex (RR = 1.84, 95% CI = 1.09-3.09, p = 0.020) and diabetes (RR 1.69, 95% CI 1.03-2.79). ConclusionsAfter adjusting for several demographic and clinical variables, having a SVS was associated with an approximate 5-fold increased risk of depression and was more frequent in women and in those with diabetes. The extent of WMD was not independently associated with PSD, suggesting that small vessel disease in the setting of an overt SVS may not account for the increased prevalence of depression.

Abstract TP55: A Statewide Quality Improvement Project: Identifying Disparities in Dysphagia Screening for Stroke Patients

Objectives: One of the principal cornerstones of the Minnesota Department of Health’s Stroke Program is quality improvement. Minnesota Primary (PSC) and Comprehensive Stroke Center (CSC) hospitals have consistently demonstrated performance below the national benchmark (76%) for dysphagia screening. We formed a workgroup comprised of stroke coordinators from across the Minnesota Stroke System to stratify the data by race, ethnicity, and insurance status and collectively identify ways to improve dysphagia screening for stroke patients. Methods: In 2021, MN Stroke Registry data was analyzed for dysphagia screening performance and compliance. Data was stratified by race, ethnicity and insurance status to assess for variance in performance. Disparities by patient race/ethnicity and an overall underperformance on this measure in MN compared to hospitals nationwide was identified. Work group members developed an action plan to improve resources and increase dysphagia screening performance. Results: In Minnesota, Asian (63%) and African American (68%) stroke patients are less likely to be screened for dysphagia than stroke patients overall (76%). Patients on Medicaid were also slightly less likely to receive dysphagia screening. Statewide initiatives included: guidance on stratifying site-specific data; creation of Impaired Swallowing Education for medical providers accessible on YouTube, cultural considerations, and electronic health record best practices; facilitators and barriers were reported and shared. Conclusions: The overall percentage of dysphagia screening compliance has remained steady at 77%. Continuation of the QI project will focus on identifying group participants that are actively engaged and implementing programmatic changes to improve dysphagia screening and identify disparities within their organizations. Education was successfully disseminated to 136 hospitals across the Minnesota Stroke System with over 450 views on YouTube. The work group is exploring further development of data disaggregation standards, specific to the diverse and growing populations of Minnesota. This is a vital step to develop more effective strategies and interventions that directly address health disparities.

Abstract NS9: Nurse-Led Quality Improvement Initiative: Advancing Stroke Awareness in Communities Experiencing Racial and Ethnic Disparities

Background and Purpose: As a Joint Commission Comprehensive Stroke Center, the provision of community education is a priority goal of our program. The majority of our existing community education program takes place in locations where we receive requests to provide these sessions. Analysis of our Get With the Guidelines (GWTG) data reveals gaps in early arrival to the hospital and Emergency Medical Service (EMS) utilization among African American and Hispanic populations. Providing educational resources within these populations may help to close these gaps and foster trust in the healthcare system. The aim of this proposed nurse-led quality improvement project is to improve hospital arrival times of African American and Hispanic stroke patients living in zip codes where GWTG data have identified gaps, through provision of targeted community education. Methods: The top zip codes associated with our target outcomes for improvement will be identified using GWTG pre-data from 2022 and 2023. We will partner with our Community Outreach department. We will identify educational venues and stakeholders among African American and Hispanic populations in these zip codes. We will provide education tailored to our identified populations including early recognition of stroke signs and symptoms, activation of EMS, stroke risk factors, and opportunities for treatment. Post implementation, GWTG data will be reviewed for any changes. Results: Using GWTG data, arrival mode, last known well time, and symptom discovery time to Emergency Department arrival as it pertains to zip codes, race and ethnicity will be reviewed and analyzed. The target zip codes’ data will be compared pre- versus post-implementation of community education efforts. Discussion: Through community education and partnership with the Community Outreach department we hope to improve timeliness of arrival to hospital among disproportionately affected racial minorities in our community for early stroke evaluation and treatment consideration.

Abstract TP73: Outcomes in Mexican American Informal Stroke Caregivers and Differences by Ethnicity

Background: Informal home care is the most prevalent type of post-acute care (PAC) in Mexican American (MA) stroke survivors, but data on the impact on caregivers is not available. The objective was to investigate strain, positive aspects of caregiving, familial obligations/support, and depression in stroke caregivers and ethnic differences in a population-based study. Methods: Data are from Brain Attack Surveillance in Corpus Christi PAC Study. Community-dwelling stroke survivors and their caregivers were recruited (n=307). Caregiver eligibility included: 1) residence in study county, 2) not cognitively impaired, 3) not providing care pre-stroke. Caregiver interviews at ~90 days included sociodemographics, dyad characteristics, Modified Caregiver Strain Index (MCSI range 0-26, higher more), PAC scale by Tarlow et al (range 5-45, higher more), familial obligations/support scales by Sabogal et al (range 1-5, higher greater), and PHQ-8 (range 0-30, higher worse). Patient data were from interviews and medical records. Propensity score (PS) methods were used to balance caregiver and patient factors among MA and non-Hispanic white (NHW) caregivers by fitting a model with ethnicity of caregiver as the outcome and predictors being caregiver sociodemographics, patient-caregiver dyad characteristics, and patient sociodemographics and disability. PS were then included as a covariate in regression models considering the association between ethnicity and outcomes. Results: MA caregivers were younger, more likely female, and more likely a child than NHWs. Median MCSI, PAC scale, PHQ-8 were 11 (IQR:6-17), 36 (IQR:30-40), and 11 (IQR:9-15) in MAs and 13.5 (IQR:9-18.3), 30 (IQR:25-36.3) and 13 (IQR:10-16) in NHWS. MA ethnicity was associated with less caregiver strain (β=-2.22, 95% CI:-4.19, -0.26) and depression (β=-2.05, 95% CI:-3.48, -0.63) and more positive aspects of caregiving (β=2.96, 95% CI:0.91, 5.01), but not associated with familial obligations/support. Conclusions: Informal stroke caregivers report moderate levels of strain and depressive symptoms, with NHW caregivers reporting higher levels. MA caregivers report greater positive aspects of caregiving suggesting a possible intervention target to improve outcomes in MAs.

Abstract WP57: Who Needs to Compete When You Can Collaborate? Celebrating 25 Years of Successful Stroke Care

Background: In 2004, Kansas City nurses partnered with the American Stroke Association to provide stroke education to health care providers and the community. Over time, the goal shifted to stroke systems of care. Today this group is known as the Bistate Stroke Consortium, comprised of 34 hospitals and rehab facilities. The group continues to work together to facilitate their mission in a spirit of collegiality and collaboration throughout two states. The communities have also benefited as evidenced by an increase in Primary and Comprehensive Stroke Centers in the region. Methods: In 2021, this Consortium formed a community outreach and stroke leader development sub-committee. Multiple innovative projects were created for both community outreach and stroke leader development to help with educating our region about strokes, celebrating successes, and highlighting best practices from our group. The purpose of this research is to evaluate the effectiveness of these projects. Results: This group placed an emphasis on community and leader education. The group distributed over 10,000 resources in the region and gained substantial community viewership. The group members of the Bistate group provide over 130 hours of education each year including best practices and benchmarked data from GWTG. Notably, during this same period, these two states experienced improvements in stroke related mortality and hospitalizations. The increasing number of patients with stroke symptoms arriving at the hospital via EMS indicates a clear preference for calling 911 and the impact of community education. While the precise factors contributing to these improvements are multifaceted, it is likely that the efforts of this group have played a pivotal role in influencing these positive outcomes. Conclusion: The Bistate Stroke Consortium collaborates to improve patient care, community education, and supports Stroke Coordinators. Stroke mortality and hospitalizations are decreasing in the Consortium's region. Timely stroke recognition by non-healthcare providers and presentation to appropriate healthcare systems are essential to improve outcomes. Continued focus on community outreach and program development is crucial to the Consortium's success.

Abstract TP61: 15 Minutes Can Save Lives: An EMS Direct to CT Protocol for Stroke Patients in the Emergency Department

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 = &lt; .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 &lt; 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 TP247: Focused Approach to Tailor Native American Stroke Awareness Messaging in Montana

Overall, African Americans, Hispanics, and Native Americans have higher stroke risks, stroke occurrence at an earlier age, and for some people of color possibly more severe strokes than non-Hispanic whites. Native Americans make up approximately 6.5% of the population of Montana—equating to around 78,000 people. A focused objective of the Mission: Lifeline Stroke Montana initiative was to specifically engage with Native Americans through public awareness campaigns to improve stroke outcomes in Montana. Method: In 2021 a survey was deployed to Native Americans in Montana to evaluate knowledge, awareness, and understanding of stroke risk factors, signs and symptoms, and what to do in the event of a stroke. Surveys were collected from eight tribal nations. The results of this survey guided message development to create a tailored public awareness campaign. Results: Analysis of the 398 surveys collected showed a representative sampling of respondents by age, gender, education, and geographic area. The key findings were:· Less than 38% of respondents reported having ever talked with a healthcare provider about their risk of stroke, with men being less likely than women to have discussed their stroke risk.· Nearly 94% of respondents said they knew high blood pressure was a risk factor for stroke but have not discussed their personal risk with a healthcare provider.· When asked what action they would take in the event of a possible stroke, over 75% of respondents said they would call 911. Less than half of the respondents indicated the best mode of transportation, in the event of a possible stroke, was an ambulance. Conclusion: Based on survey findings, specific engagement strategies were centered around two main messages:-Know the risk factors for stroke and talk with a healthcare provider about your risk. -Stroke is a medical emergency that requires immediate attention. Call 9-1-1 at the first sign of stroke to access treatment through Montana’s Stroke System of Care. A post-campaign survey will be deployed in the fall of 2023. This survey will aim to assess the effectiveness of these tailored campaign initiatives.

Survey of Potential Disparity Issues Among Minority Stroke Survivors in Central Brooklyn.

Medical data and information are ubiquitous due to internet availability. However, most people persist in using and trusting their healthcare professionals for health information. They are increasingly flooded with health information from diverse sources such as the internet, community-based organizations, and family or friends. It is crucial to understand where stroke patients vary in the use and trust of health information to improve their conditions. This pilot study aimed to better understand the nature of the problems confronted by stroke patients, such as the source of reliable health information, trust in the healthcare system, and technology trend awareness. African American and Afro-Caribbean stroke patients (n=64) residing in Central Brooklyn, New York, participated in a survey. The results showed that physicians remained the most highly trusted information sources for stroke patients, particularly among patients with higher education, irrespective of the available communication sources.

What have clinical trials taught us about brain health?

The Global Burden of Disease Study projects an almost tripling of dementia cases worldwide in the next 30 years making it important to recognize and understand modifiable risks and preventatives for cognitive impairment. Recent studies suggest that prevention or treatment of cardiovascular risks may be an important strategy to prevent or slow the progression of cognitive impairment. In 2017, the American Heart Association and American Stroke Association introduced metrics for "optimal brain health". These metrics defined brain health in terms of ideal health behaviors and factors.Since then and leading up to 2017, a number of clinical trials have been conducted to investigate the potential of modification of cardiovascular risks on prevention of dementia or cognitive impairment and thus, enhancement of brain health. This discussion is a review of findings from clinical trials focusing on interventions, including antihypertensive agents, glycemic control and lipid-lowering therapies, multidomain approaches, and antithrombotic medications. Notably, the results highlight the promise of intensive blood pressure lowering strategies and multidomain approaches, as evidenced by the FINGER trial. The review also discusses the potential of treatment or prevention of cerebral small vessel disease (cSVD) and the application of Mendelian randomization as a strategy to preserve brain structure and function.

SOCIAL CHARACTERISTICS OF RACIAL MINORITY STROKE SURVIVORS AND PERCEIVED DISCRIMINATION: A SECONDARY ANALYSIS

Abstract African American and Black persons experience significant disability after stroke. They also experience high external stressors, including discrimination, which may attenuate stroke recovery. Further understanding of the associations among external stressors, disability severity, and attenuated recovery are important to reduce healthcare disparities and improve patient outcomes. However, persons of the same race may not have the same lived experiences due to variations in social characteristics such as age or education. Associations between these social characteristics and perceived discrimination may offer insights into the recovery of older adult African American and Black stroke survivors. We conducted a secondary analysis of 11 poststroke patients who were recruited to participate in the Black Lived Experiences of Stroke Study (female=10, age=67±11, ≥2 years post-secondary education=63%) to assess the frequency of perceived discrimination. Perceived discrimination was measured with the Everyday Discrimination Scale survey. We examined correlations between age and education and perceived discrimination using Cramer’s V tests. Semi-structured participant interviews were also examined for examples of perceived discrimination during poststroke healthcare. Nine participants reported perceived discrimination post-stroke. Analyses revealed a clinically meaningful but not statistically significant relationship between chronological age and perceived discrimination (Cramer’s V=0.62, p=0.12). There was no meaningful relationship between educational level and perceived discrimination. All participants reported challenges with communication, missed diagnoses and poor delivery of care poststroke. Findings support the need for additional research to examine the relationships between participants’ social characteristics and perceived discrimination among Black and African American stroke survivors, and the impact on stroke recovery.