Hyperacute Stroke Research Articles

Pre-hospital telestroke and expanded hyper-acute telestroke network solutions to reduce geographic inequities: a brief review from the South Pacific

Hyper-acute stroke treatments are time sensitive, and decision-making is complex. Telemedicine has been highly effective in breaking down regional access barriers by providing front line rural hospital clinicians with remote telemedicine decision support by remote stroke experts. With the advent of mechanical thrombectomy, hyper-acute stroke care has grown even more complex from both a decision-making and logistical perspective. Mobile Stroke Units (MSU) have been deployed in a few urban settings globally but are unlikely to address all global access issues due to geographical and logistical factors. This paper reviews the feasibility and benefit of extending telestroke into the pre-hospital setting as an adjunct or alternative to MSUs. It will discuss how this service model can fit into existing stroke networks and potential deployment strategies. Finally, the paper also considers potential scalability of pre- and in-hospital telestroke support across regional and international boundaries to further reduce global hyper-acute access inequities.

Renal disease is not associated with delays in hyperacute stroke management in South Australia.

The aims of the present study were to determine how renal disease is associated with the time to receive hyperacute stroke care. The present study involved a 5-year cohort of all patients admitted to stroke units in South Australia. In those with pre-existing renal disease there were no significant differences in the time taken to receive a scan, thrombolysis or endovascular thrombectomy. The present study shows that in protocolised settings there were no significant delays in hyperacute stroke management for patients with renal disease.

Hospital-to-Hospital Transfer Delays in Hyperacute Stroke: Known Causes and Gaps in Knowledge

Background Transfer challenges from primary stroke centers and acute stroke ready hospitals (PSC/ASRH) to a higher level of care are excessive. This narrative review examines the published literature for factors within and external to PSC/ASRH emergency departments that contribute to delays in the transfer of large vessel occlusion (LVO) patients to a higher level of care for thrombectomy.Methods A review of the literature was conducted incorporating findings from January 1996 to April 2020. Reference software was utilized to organize and track references. Retrieved papers were screened first by abstract to eliminate non-pertinent studies; papers selected for full review were then fully examined for relevance, and those retained were subsequently divided into thematic groups based on content. Results Guideline standardization of intrahospital practices and associated performance metrics, along with prehospital provider education and training have contributed to improved acute stroke service efficiency. Factors associated with transfer delays have not been identified nor quantified, yet delays contribute to significantly worse patient outcomes. Calls for bypass of lower levels of care with direct transport to CSC are fueled primarily by assumptions of poor PSC/ASRH internal performance. Conclusions Although transport delay times have been quantified as excessive, the reasons for delays are not fully understood. Additional research is warranted to fully understand why delays occur

Abstract TMP44: Widening Sex Disparity in Thrombolysis Amid Worsening Stroke Care Quality in Korea

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 89: Portable, Low-Field Magnetic Resonance Imaging: Determining Mismatch Following Acute Ischemic Stroke

Background and Aims: Treatment options for acute ischemic stroke (AIS) are uniquely dependent on the time of stroke onset. Intravenous thrombolysis must be administered within 4.5 hours of symptoms commencing, yet a subset of patients wake-up with symptoms and time of onset is unknown. Mismatch between fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) MRI can be used to qualify wake-up strokes for thrombolysis. This has been shown to lead to improved functional outcomes in multicenter trials (WAKE-UP, MR-WITNESS). However, access to MRI is a barrier to differential diagnosis and subsequent treatment. Recent advances in portable, low-field MRI (LF-MRI) offer a solution to increase access to MRI technologies and circumvent the limitations of conventional systems. As such, in this pilot study, we sought to establish the utility of portable LF-MRI to identify DWI-FLAIR mismatch following AIS. Methods: Patients with a diagnosis of AIS presenting to Emergency Department or Intensive Care Unit of the Yale New Haven Hospital or Massachusetts General Hospital from January 2020 to June 2023 underwent DWI and FLAIR acquisition on a 0.064T MRI (Hyperfine Research Inc.) at <4.5 hours ( n =7), 4.5-6 hours ( n =7), and 6-48 hours ( n =110) since last known well (LKW). Conventional high-field (HF) MR images were acquired within 72 hours of LF-MRI. HF-DWI images were co-registered to LF-FLAIR and the hyperintense DWI stroke lesion segmented and superimposed on the FLAIR. The segmentation was mirrored to the contralateral hemisphere of the LF-FLAIR to establish a FLAIR signal intensity ratio (SIR). Results: The FLAIR SIR on images <4.5 hours since LKW was 0.98±0.08. The SIR for cases 4.5-6 hours was 1.34±0.33. Cases 6-48 hours produced a SIR of 1.56±0.36. The SIR at <4.5 hours was significantly less than that observed >6 hours since LKW ( p =0.03). Conclusion: This pilot study demonstrates that a 0.064T portable MRI is capable of distinguishing hyperacute stroke from later stroke onset using FLAIR SIR. Future research is needed in a larger cohort to determine if this imaging technology can be used to guide thrombolysis in the setting of wake-up stroke.

Abstract 1: Overcoming Clinical Trial Enrollment Challenges by Monitoring EMS Radio Transmissions: Pre-Hospital Screening of Acute Ischemic Stroke Patients

Background: Enrollment into hyperacute stroke trials may be constrained since candidates are usually not identified until they arrive in the emergency department. Pre-hospital identification may increase and speed study enrollment. Methods: Midway through the Multi-Arm Optimization of Stroke Thrombolysis (MOST) trial, our mobile stroke unit research personnel monitored EMS radio for potential stroke patients en route to our study hospital. Time of onset, symptoms, and expected arrival time were relayed to the MOST research team, who met the patient upon ED arrival. Expected site enrollment was 1 patient per month. Results: The rate of trial enrollment before intervention (10/2019 - 11/2021) was 0.8 patients per month compared to 2.4 after intervention (12/2021 - 07/2023), 2.43, 95% CI: 1.48-4.10, p<0.01 - see figure. In addition, there was a 17.5-minute reduction in ED arrival to trial randomization (88 vs. 70.5 minutes). Conclusion: Pre-hospital screening tripled the rate of trial recruitment and can help overcome challenges when enrolling participants in hyperacute clinical trials.

Alterations of Hemostatic Molecular Markers During Acute Large Vessel Occlusion Stroke.

This study aimed to investigate regional levels of TAT (thrombin-antithrombin complex), PIC (plasmin-α2 plasmin inhibitor complex), t-PAIC (tissue plasminogen activator-plasminogen activator inhibitor complex), sTM (soluble thrombomodulin), and D-dimer, along with their associations with clinical and procedural characteristics in patients with acute ischemic stroke undergoing endovascular thrombectomy. We retrospectively analyzed 166 consecutive patients with acute ischemic stroke (62±11.54 years of age, 34.3% women) using prospectively maintained clinical databases and blood samples from local ischemic (proximal to thrombus) and systemic (femoral artery, self-control) arterial compartments. Levels of TAT, PIC, t-PAIC, and D-dimer were significantly elevated, whereas sTM was significantly reduced, in local ischemic regions compared with their systemic levels. Each 1-unit increase in ischemic TAT (adjusted odds ratio [aOR], 1.086 [95% CI, 1.03-1.145]; P=0.002; area under the curve [AUC], 0.833) and PIC (aOR, 1.337 [95% CI, 1.087-1.644]; P=0.006; AUC, 0.771) correlated significantly with higher symptomatic intracranial hemorrhage risk. Additionally, each 1-unit increase in ischemic TAT (aOR, 1.076 [95% CI, 1.016-1.139]; P=0.013; AUC, 0.797), PIC (aOR, 1.554 [95% CI, 1.194-2.022]; P=0.001; AUC, 0.798), and sTM (aOR, 0.769 [95% CI, 0.615-0.961]; P=0.021; AUC, 0.756) was significantly associated with an increased risk of an unfavorable 90-day outcome (modified Rankin scale of 3-6). These hemostatic molecules, individually or combined, significantly improved the predictive power of conventional risk factors, as evidenced by significant increases in net reclassification improvement and integrated discrimination improvement (all P<0.01). We observed a hyperactive state of the coagulation-fibrinolysis system within the local ischemic region during hyperacute stroke. Rapid automated measurement of hemostatic molecular markers, particularly TAT, PIC, and sTM, during intra-arterial procedures may provide additional information for stroke risk stratification and therapeutic decision-making, and warrants further investigation.

Artificial intelligence-based decision support software to improve the efficacy of acute stroke pathway in the NHS: an observational study.

In a drip-and-ship model for endovascular thrombectomy (EVT), early identification of large vessel occlusion (LVO) and timely referral to a comprehensive center (CSC) are crucial when patients are admitted to an acute stroke center (ASC). Several artificial intelligence (AI) decision-aid tools are increasingly being used to facilitate the rapid identification of LVO. This retrospective cohort study aimed to evaluate the impact of deploying e-Stroke AI decision support software in the hyperacute stroke pathway on process metrics and patient outcomes at an ASC in the United Kingdom. Except for the deployment of e-Stroke on 01 March 2020, there were no significant changes made to the stroke pathway at the ASC. The data were obtained from a prospective stroke registry between 01 January 2019 and 31 March 2021. The outcomes were compared between the 14 months before and 12 months after the deployment of AI (pre-e-Stroke cohort vs. post-e-Stroke cohort) on 01 March 2020. Time window analyses were performed using Welch's t-test. Cochran-Mantel-Haenszel test was used to compare changes in disability at 3 months assessed by modified Rankin Score (mRS) ordinal shift analysis, and Fisher's exact test was used for dichotomised mRS analysis. In the pre-e-Stroke cohort, 19 of 22 patients referred received EVT. In the post-e-Stroke cohort, 21 of the 25 patients referred were treated. The mean door-in-door-out (DIDO) and door-to-referral times in pre-e-Stroke vs. post-e-Stroke cohorts were 141 vs. 79 min (difference 62 min, 95% CI 96.9-26.8 min, p < 0.001) and 71 vs. 44 min (difference 27 min, 95% CI 47.4-5.4 min, p = 0.01), respectively. The adjusted odds ratio (age and NIHSS) for mRS ordinal shift analysis at 3 months was 3.14 (95% CI 0.99-10.51, p = 0.06) and the dichotomized mRS 0-2 at 3 months was 16% vs. 48% (p = 0.04) in the pre- vs. post-e-Stroke cohorts, respectively. In this single-center study in the United Kingdom, the DIDO time significantly decreased since the introduction of e-Stroke decision support software into an ASC hyperacute stroke pathway. The reduction in door-in to referral time indicates faster image interpretation and referral for EVT. There was an indication of an increased proportion of patients regaining independent function after EVT. However, this should be interpreted with caution given the small sample size. Larger, prospective studies and further systematic real-world evaluation are needed to demonstrate the widespread generalisability of these findings.

Safety of Antithrombotic Therapy within 24 Hours after Recombinant Tissue-Plasminogen Activator Treatment for Large-Artery Atherosclerosis Stroke: Insights from Emergent PTA/CAS Cases.

Antithrombotic therapy (AT) should generally be avoided within 24 hours after recombinant tissue-plasminogen activator (rt-PA) treatment but should be considered in patients with large-artery atherosclerosis (LAA) who undergo concomitant emergent endovascular treatment (EVT). The aim of the present study was to assess the safety of AT within 24 hours after rt-PA treatment in patients with hyperacute ischemic stroke due to LAA who received concomitant EVT. From January 2013 through July 2019, consecutive patients with acute ischemic cerebrovascular disease due to LAA who were admitted within 6 hours from symptom onset were recruited. The patients were classified into six groups based on the reperfusion treatment and early (within 24 hours) AT from rt-PA treatment. Safety outcomes were compared among the groups. A total of 155 patients (35 women [23%], median age 74 [IQR 66-79] years; NIHSS score 3 [1-10]) were included in the present study. Of these, 73 (47%) received no reperfusion therapy, 24 (15%) received rt-PA treatment and early AT, seven (6%) received rt-PA without early AT, 26 (17%) received EVT only, six (4%) received both rt-PA and EVT without early AT, and 19 (12%) received rt-PA and EVT with early AT. AT was administered a median of 3.9 (1.6-8.0) hours after rt-PA in patients with rt-PA+EVT with early AT. AT within 24 hours after rt-PA and EVT treatment did not increase hemorrhagic complications (p > 0.05 for all). In this retrospective analyses, early AT administration for patients with hyperacute stroke due to LAA treated with rt-PA plus EVT did not increase hemorrhagic events.

Neuroimaging in Cerebrovascular Accidents

Introduction: The incidence rate and the death rate from stroke increase dramatically with age. The one who survive are usually left with permanent disability. Thus, stroke has become a great medical and social problem. Accurate and early diagnosis may improve the morbidity and mortality rates in the future as newer and more effective therapies are currently being instituted. Neuroimaging in stroke patients, especially in acute ischemic stroke patients, plays an essential role. It helps to differentiate other causes of stroke (i.e., stroke mimics such as migraine headache, tumors, seizure, metabolic disturbance, and peripheral or cranial nerve disorders), early detection of hemorrhagic stroke, distinguish irreversible infarcted tissues from salvageable tissue, identify vascular malformations, treatment planning for intravenous thrombolysis and intra-arterial thrombectomy, and outcomes prediction. The aim of the study is to characterize type of stroke hemorrhagic vs. ischemic on neuroimaging. Radiological evaluation of stroke regarding –site, size, volume and duration. Correlation of neuroimaging findings with clinical findings and patient demographics. Materials and Methods: In 100 patient single-center, prospective observational study was conducted in the department of radiology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly and adult patients with suspected stroke on computed tomography (CT) and magnetic resonance imaging (MRI) and characterization and correlation with clinical findings were done from the study. Infarcts were grouped into hyperacute (0–24 hours), (acute 1–7 days), early subacute (7–10 days), late subacute (10–21 days) Results: Out of 100 patients, the study showed male predominance. The majority of cases had a history of weakness. Comorbidities like diabetes, hypertension, and dyslipidemia increase the risk of stroke On the basis of GCS score the majority of the cases were, having GCS score greater than 10 (72.0%). Cranial nerve palsies and LOC were also common among patients of stroke. Out of a total 69 ischemic stroke cases, CT was positive in 55 patients, while MRI was positive in all the cases. Arterial infarcts (89.8%) are much more common than the venous infarcts 7 cases (10.2%). The majority of cases that reached our department were in the acute stage (56 cases, 81.2%), and the majority had MCA territory involvedThe basal ganglia complex was the most common location for the hemorrhage and was seen in 15 cases (48.3%). The mean volume of bleeding was large in cases of lobar bleeding. There was a strong positive correlation between altered sensorium (Phi value .64) and vomiting (.60), while the symptoms showed a positive correlation. The correlation of cerebrovascular accidents with age was seen more in patients aged &gt; 60 as compared to those age &lt; 60 (Phi value .1). Conclusion: This study depicts the predominance of the older age group (&gt; 40 years). The ischemic stroke was more common than the hemorrhagic stroke, the commonest cause being the MCA territory infarcts. In the cases of hemorrhagic stroke, the ganglion-capsular bleed was the commonest. Stroke imaging has undergone significant advances over last decade. It remains very crucial for the management of hyperacute stroke in the first few hours, where aim is to recognize patients eligible for thrombolytic therapy and expected to have good outcomes. Both CT, and MRI are useful for a comprehensive assessment of acute stroke MRI is sensitive for ischemic infarct detection and can provide important and necessary information for therapy planning. Both clinical examination and early diagnosis of stroke by imaging can lead to better patient outcomes.

Real-world evaluation of Brainomix e-Stroke software.

Brainomix e-Stroke is an artificial intelligence-based decision support tool that aids the interpretation of CT imaging in the context of acute stroke. While e-Stroke has the potential to improve the speed and accuracy of diagnosis, real-world validation is essential. The aim of this study was to prospectively evaluate the performance of Brainomix e-Stroke in an unselected cohort of patients with suspected acute ischaemic stroke. The study cohort included all patients admitted to the University College London Hospital Hyperacute Stroke Unit between October 2021 and April 2022. For e-ASPECTS and e-CTA, the ground truth was determined by a neuroradiologist with access to all clinical and imaging data. For e-CTP, the values of the core infarct and ischaemic penumbra were compared with those derived from syngo.via, an alternate software used at our institution. 1163 studies were performed in 551 patients admitted during the study period. Of these, 1130 (97.2%) were successfully processed by e-Stroke in an average of 4 min. For identifying acute middle cerebral artery territory ischaemia, e-ASPECTS had an accuracy of 77.0% and was more specific (83.5%) than sensitive (58.6%). The accuracy for identifying hyperdense thrombus was lower (69.1%), which was mainly due to many false positives (positive predictive value of 22.9%). Identification of acute haemorrhage was highly accurate (97.8%) with a sensitivity of 100% and a specificity of 97.6%; false positives were typically caused by areas of calcification. The accuracy of e-CTA for large vessel occlusions was 91.5%. The core infarct and ischaemic penumbra volumes provided by e-CTP strongly correlated with those provided by syngo.via (ρ=0.804-0.979). Brainomix e-Stroke software provides rapid and reliable analysis of CT imaging in the acute stroke setting although, in line with the manufacturer's guidance, it should be used as an adjunct to expert interpretation rather than a standalone decision-making tool.

Update on the INTEnsive ambulance-delivered blood pressure Reduction in hyper-ACute stroke Trial (INTERACT4): progress and baseline features in 2053 participants

Background and aimsUncertainty persists over the effects of blood pressure (BP) lowering in acute stroke. The INTEnsive ambulance-delivered blood pressure Reduction in hyper-Acute stroke Trial (INTERACT4) aims to determine efficacy and safety of hyperacute intensive BP lowering in patients with suspected acute stroke. Given concerns over the safety of this treatment in the pre-hospital setting, particularly in relation to patients with intracerebral hemorrhage, we provide an update on progress of the study and profile of participants to date.MethodsINTERACT4 is an ongoing multicentre, ambulance-delivered, randomized, open-label, blinded endpoint trial of pre-hospital BP lowering in patients with suspected acute stroke and elevated BP in China. Patients are randomized via a mobile phone digital system to intensive (target systolic BP [SBP] <140mmHg within 30 min) or guideline-recommended BP management. Primary outcome is an ordinal analysis of the full range of scores on the modified Rankin scale scores at 90 days.ResultsBetween March 2020 and April 2023, 2053 patients (mean age 70 years, female 39%) were recruited with a mean BP 178/98 mmHg in whom 45% have a diagnosis of primary intracerebral hemorrhage upon arrival at hospital. At the time of presentation to hospital, the mean SBP was 160 and 170mmHg in the intensive and control groups (Δ10 mmHg), respectively. The independent data and safety monitoring board has not identified any safety concerns and recommended continuation of the trial. The sample size was reduced from 3116 to 2320 after meetings in August 2022 as the stroke mimic rate was persistently lower than initially estimated (6% vs 30%). The study is expected to be completed in late 2023 and the results announced in May 2024.ConclusionsINTERACT4 is on track to provide reliable evidence of the effectiveness of ambulance-delivered intensive BP lowering in patients with suspected acute stroke.Trial registrationClinicalTrials.gov NCT03790800; registered on 2 January 2019. Chinese Trial Registry ChCTR1900020534, registered on 7 January 2019.

Effect of Blood Pressure Augmentation on CVA Patients who are out of Injection TPA (Tissue Plasminogen Activator) and Mechanical Thrombectomy Window

Background: Ischemic stroke is a leading cause of morbidity and mortality worldwide, prompting an urgent need for effective treatments outside the standard therapeutic window. With an estimated 6.5 million stroke-related deaths annually and a particular prevalence in the 18-49 age demographic, there is a substantial burden on healthcare systems. Intravenous thrombolysis and mechanical thrombectomy are time-sensitive treatments that are not universally accessible, highlighting the need for alternative strategies. Objective: The study aimed to evaluate the efficacy of induced hypertension as a therapeutic intervention for ischemic stroke patients who are beyond the window for conventional reperfusion therapies. Methods: This cross-sectional observational study was conducted at the Hyper Acute Stroke Unit (HASU) of PEMH, Rawalpindi. Over four months, 50 male patients who had suffered an ischemic stroke and were outside the therapeutic window for TPA and mechanical thrombectomy were recruited. Induced hypertension was achieved through intravenous administration of norepinephrine, titrated to maintain systolic blood pressure between 180-200 mmHg. Blood pressure was recorded at baseline, immediately before norepinephrine administration, and every 12 hours thereafter. Muscle power was assessed using the Medical Research Council (MRC) scale at 24-hour intervals over a 3-day observational period. Results: The mean systolic blood pressure was 140±5.07 mmHg, and the mean diastolic blood pressure was 94.16±4.71 mmHg, with a mean patient age of 55±4.4 years. Following induced hypertension, 30 out of the 50 patients (60%) showed improvement in muscle power. Specifically, in Group 1 (6 patients with leg muscle weakness), 3 patients improved from an MRC scale of 2 to 3, and 1 patient improved from an MRC scale of 3 to 4. In Group 2 (15 patients with upper and lower limb weakness), 7 patients improved from an MRC scale of 2 to 3, and 4 patients improved from an MRC scale of 3 to 4. Similar improvements were observed in other groups, with overall improvements ranging from 37.5% to 80% within individual subgroups. Conclusion: Induced hypertension via norepinephrine infusion appears to be a promising therapeutic strategy to improve muscle power in ischemic stroke patients who cannot receive standard reperfusion treatments. This intervention could potentially bridge the treatment gap for patients who present outside of the traditional therapeutic time frame.

Klebsiella pneumoniae cerebritis with symptoms of hyperacute middle cerebral artery stroke

Klebsiella pneumoniae cerebritis with symptoms of hyperacute middle cerebral artery stroke

Role of cardiac computed tomography in hyperacute stroke assessment

BackgroundIncorporating cardiac CT with hyperacute stroke imaging may increase the yield for cardioembolic sources. It is not clarified whether stroke severity influences on rates of intracardiac thrombus. We aimed to investigate a National Institutes of Health Stroke Scale (NIHSS) threshold below which acute cardiac CT was unnecessary. MethodsConsecutive patients with suspected stroke who underwent multimodal brain imaging and concurrent non-gated cardiac CT with delayed timing were prospectively recruited from 1st December 2020 to 30th November 2021. We performed receiver operating characteristics analysis of the NIHSS and intracardiac thrombus on hyperacute cardiac CT. ResultsA total of 314 patients were assessed (median age 69 years, 61% male). Final diagnoses were ischemic stroke (n=205; 132 etiology-confirmed stroke, independent of cardiac CT and 73 cryptogenic), transient ischemic attack (TIA) (n=21) and stroke-mimic syndromes (n=88). The total yield of cardiac CT was 8 intracardiac thrombus and 1 dissection. Cardiac CT identified an intracardiac thrombus in 6 (4.5%) with etiology-confirmed stroke, 2 (2.7%) with cryptogenic stroke, and none in patients with TIA or stroke-mimic. All of those with intracardiac thrombus had NIHSS ≥4 and this was the threshold below which hyperacute cardiac CT was not justified (sensitivity 100%, specificity 38%, positive predictive value 4.0%, negative predictive value 100%). ConclusionsA cutoff NIHSS ≥4 may be useful to stratify patients for cardiac CT in the hyperacute stroke setting to optimize its diagnostic yield and reduce additional radiation exposure.

Abstract 142: Safety and Efficacy of PCSK9 inhibitor injection in Pathients immediately before mechanical thrombectomy

Introduction Statins are lipid‐lowering agents and have beneficial effects in patients with acute ischemic stroke, including in the hyperacute period around mechanical thrombectomy.Evolucumab, a PCSK9 inhibitor, is a fast‐acting drug that lowers serum LDL with beneficial effects during chronic stroke period. During an hyperacute ischemic stroke, the brain can be vulnerable, especially around reperfusion therapy. However, the clinical effect of PCSK9 inhibitor injection around mechanical thrombectomy is still unknown. Here we showed the efficacy and safety of PCSK9 inhibitor injection immediately prior to mechanical thrombectomy for these patients. Methods The subjects were stroke patients who underwent mechanical thrombectomy at Inha University Hospital from April 2019 to March 2023. Clinical profiles between the evolucumab group and the non‐user group were analyzed. Results Of the 263 patients enrolled, 112 (42.6%) were male and the mean age was 69.1 years. Of these, 42 patients received a single dose of a PCSK9 inhibitor immediately prior to intervention and additional injections were not made due to insurance issues. Evolukumab injection was determined according to physician preference. There were no significant differences between the two groups in age, gender ratio, major risk factors, stroke etiology, or prior statin treatment. Evolucumab group had a higher stent recovery rate than the non‐user group (70.7 vs 53.4%, p = 0.04). However, there were no significant difference in TICI grade, or symptomatic hemorrhage. Compared with non‐user group, Evolucumab group had the lower NIHSS score on discharge (12.41 vs 8.83, p=0.03) and seemed to have the lower in‐hopital mortality(12.2 vs 2.4% p=0.06) Mean LDL‐C levels at admission and 3 months after stroke did not differ between the two groups. Cardiovascular and other adverse events within 3 months were similar in both groups. Conclusion Evolocumab added to conventional high‐intensity statin therapy was well tolerated and appeared to be associated with lower in‐hospital mortality and lower NIHSS scores at discharge without additional side effects. Further large randomized clinical trials might be needed to investigate the beneficial effects of PCSK9i during hyperacute stroke period.

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.

Abstract 270: Evaluating the Knowledge of Stroke Management among Nigerian Medical Doctors

Introduction According to the World Health Organization, Stroke is the 2nd leading cause of death, responsible for approximately 11% of total deaths worldwide (1). In Nigeria, stroke accounts for 4% ‐ 17% of medical deaths (2).Effective stroke management is essential to reduce morbidity and mortality. Few trained neurologists in Nigeria who are mostly concentrated in the cities, making non‐specialists the backbone of initial acute stroke assessment and management in Nigeria. Physician‐related factors have been identified as one of the factors leading to suboptimal stroke care. There is limited literature analysing the proficiency of non‐specialists in the optimal management of stroke in Nigeria. This study was vital for the evaluation of the knowledge of acute stroke care among medical doctors and the factors responsible for the disparity in their skills. Methods A descriptive cross‐sectional survey was conducted among 404 medical doctors across all six geopolitical zones in Nigeria using the Acute Stroke Management Questionnaire (ASMaQ). Data were analysed using descriptive statistics and simple logistic regression to predict the relationship between independent variables and the outcome variable (good knowledge vs poor knowledge). Results 39.1 % of respondents encounter stroke patients a few times a month, 52% work without a neurologist ,and 88.4% work in hospitals without stroke units. 67% (95% CI =63% – 72%) of respondents had good overall knowledge of stroke management. General Stroke Knowledge (GSK) domain had the largest percentage of good knowledge (88.6%, 95% CI= 85‐92%), followed by Hyperacute Stroke Management (HSM), (52.5%, 95% CI=47.3% – 57.7%) and Advanced Stroke Management (ASM), (49.5%, 95%CI= 49.5% –54.4%).Most participants (&gt;85%) demonstrated good knowledge of stroke signs and symptoms. Only 21.8% and 4.2% of respondents work in facilities equipped with intravenous thrombolysis and mechanical thrombectomy respectively. 92% erroneously believe that a full neurological examination is essential in acute stroke while 33.4% demonstrated poor knowledge of blood pressure control in patients with acute stroke .Working in Primary Healthcare Centre (PHCs) and Government Hospital was a significant predictor of overall poor knowledge of stroke. Compared to Private Hospitals, working in Government Hospitals had 1.98 times the odds of poor knowledge (P = 0.011) and medical doctors in Primary Healthcare Practice had 2.29 times the odds of poor knowledge than those in Tertiary Hospitals (P = 0.045). Conclusion Despite the fact that the majority demonstrated good knowledge of stroke management, there is a significant knowledge deficit in the ASM domain. This study highlights the need for regular retraining and professional development of medical doctors in acute stroke management in Nigeria. There is an urgent need to address the critical shortage of neurologists in the country and improve access to thrombolysis care in order to reduce the burden of stroke related‐morbidity and mortality.

The impact of telemedicine enabled pre-hospital triage in acute stroke - a protocol for a mixed methods systematic review.

Increasing access to thrombolysis and thrombectomy through improved pathway organisation remains a health service challenge that requires contextualisation to the geographic, demographic and resourcing status of any regional stroke service. Pre-hospital delays or delays during inter-hospital transfers can result in patients being outside the window for one or both interventions. Pre-hospital triage using technology-enabled interdisciplinary communication networks may facilitate rapid individualized care decisions, permitting streamlined care pathways to hospital sites most appropriate to their clinical presentation and history in the first instance. Understanding the experience of those involved in efforts to improve or reorganise care may help to explain the impact observed. 1. To review the impact of pre-hospital telemedicine enabled workflow intervention strategies on patient outcomes and on service process metrics in hyper-acute stroke care2. To examine how the experience of those involved in providing or receiving such interventions might identify key characteristics of effective interventions. Quantitative, qualitative and primary mixed methods studies will be included. Quantitative studies will assess effectiveness of telemedicine-enabled interventions that facilitate pre-hospital acute stroke triage. Intervention effects on functional outcomes of patients, on intervention rates and on key time metrics in hyperacute stroke care will be assessed. Qualitative studies will explore the experiences of people involved in or impacted by these interventions. A convergent segregated mixed methods systematic review will synthesise and integrate primary qualitative, quantitative and mixed methods studies using the Joanna Briggs Institute methodology. Database searches will include OVID (MEDLINE), EMBASE, The Cochrane Library, CINAHL and Web of Science. Critical appraisal will include the Mixed Methods Assessment Tool. Results of quantitative studies and findings of qualitative studies will be integrated and configured to explore and contextualize each single method synthesis. This protocol has been submitted for registration with PROSPERO.

Mechanical thrombectomy in low Alberta stroke program early CT score (ASPECTS) in hyperacute stroke-a systematic review and meta-analysis.

Major randomized controlled trials of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) failed to include a substantial number of patients presenting with low baseline Alberta Stroke Program Early CT Score (ASPECTS:0-5). Patients experiencing hyperacute strokes (last known well ≤ 6 h) can potentially benefit most from MT. We conducted a systematic review and meta-analysis to report presentation severity and radiographic and clinical outcomes for hyperacute stroke patients presenting with low-ASPECTS. Our comprehensive literature search of PubMed, Embase, and Cochrane databases up to August 31, 2022 included articles reporting patients presenting hyperacutely who underwent MT for anterior circulation large vessel occlusion AIS with an ASPECTS ≤ 5 on baseline imaging. Pooled averages were calculated for age and presenting National Institutes of Health Stroke Scale (NIHSS). Fixed- and random-effects meta-analyses for weighted estimation of overall rates were performed. Forest plots were generated for proportions and estimated overall outcome rates. 18 studies (1958 patients) were included (mean age = 64.1 years; presenting NIHSS = 18.4). Final modified thrombolysis in cerebral infarction 2b-3 grade was achieved in 76.4%, with symptomatic intracranial hemorrhage in 12.1%. Good (modified Rankin Scale [mRS] 0-2) and ambulatory (mRS 0-3) 3-month outcomes were achieved by 27.4 and 46.7%, respectively; 90-day mortality was 26.4%. MT in low-ASPECTS hyperacute stroke patients may result in ambulatory clinical outcomes with acceptable hemorrhage risk. Recanalization rates achieved were similar to those in patients presenting with ASPECTS ≥ 6; this did not fully translate to better clinical outcomes. MT should be considered for hyperacute strokes with low presenting ASPECTS.