bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P200: Transcranial Direct Current Stimulation in Post-Stroke Chronic Aphasia: A Double Blind Randomized Controlled Study
Authors: Schnakers Caroline , Zheng Zhong Sheng , Millan Henry , Lee Sharon , Howard Melissa , Rosario Emily
Published: March 2021

Background:
There is growing evidence even amongst those with chronic aphasia that transcranial direct current stimulation (tDCS) combined with behavioral speech therapy could boost language. However, current findings do not allow making strong recommendations for using tDCS in order to improve language in post-stroke aphasia. The efficacy of tDCS therefore still needs to be established using double-blind controlled randomized trials in large samples.

Intervention:
In this ongoing double-blind randomized placebo controlled trial study, participants were randomly assigned either to the tDCS group or to the sham group. Both groups had five consecutive days of 20 minutes session, using a FDA approved tDCS device (soterixmedical.com). Behavioral and neuroimaging data were performed the week before/after tDCS/sham intervention and again 3 months following treatment.

Participants:
42 post-stroke patients with chronic aphasia (32 males; age: 61±11y; 0.9-18years post-injury; 32 ischemic stroke; 19 non-fluent aphasia). Eighteen patients were in the tDCS group.

Main Outcome Measures:
The Western Aphasia Battery-Revised (WAB-R), Communication Outcomes after Stroke, patient and family report (COAST). MRI Diffusion Tensor Imaging data (64 dir) were also collected.

Statistical Analyses:
Anova with repeated measures was used on the behavioral outcome measures with aphasia severity, age and time since injury as covariates in SPSS. The average fractional anisotropy (FA) and mean diffusivity (MD) were extracted per ROI from each participant and timepoint.

Main Results:
a) Behavioral. Groups differed, pre/post intervention, on the WAB-R total score, for the Auditory-Verbal Comprehension and Repetition subscores; b) Neuroimaging. Change in Spontaneous Speech and Auditory Verbal Comprehension negatively correlated with change in mean MD and FA, respectively, in Superior Cerebellar Peduncle for tDCS, but not sham.

Conclusion:
Our preliminary findings show a higher improvement in language functions (for both receptive and expressive language skills) in response to treatment (vs. sham). Neuroplasticity was observed in superior cerebellar peduncle in response to tDCS mediated language improvement.
Abstract P204: Stroke Topography Impacts Sleep Architecture in Post-Acute Stroke
Authors: Howell Stefanie N , Robinson Stephanie E , Griesbach Grace S
Published: March 2021

Introduction/Objective:
Sleep-wake disturbances (SWDs) are common amongst stroke patients; however, little work has been done on the effect of stroke location on sleep architecture. The aim of this study was to investigate the impact of stroke topography on prevalence and severity of SWDs in the post-acute phase of ischemic stroke recovery.

Methods:
Ischemic stroke patients (n=55) were assessed for SWDs via overnight attended polysomnography in a post-acute rehabilitation setting. The mean age was 55 ± 1.4 years and mean latency from injury was 106 ± 11 days. Sleep measures included total sleep time (TST), sleep and REM latency, sleep efficiency, percent time in sleep stages, apnea/hypopnea index (AHI), wake after sleep onset (WASO), and arousal index. Patients who did not have at least four hours of TST were excluded. Stroke patients were identified as having supratentorial or infratentorial injuries.

Results:
Results showed a significant difference between supratentorial and infratentorial stroke in regards to sleep efficiency, REM sleep, and sleep apnea. Patients with infratentorial stroke (n=15) displayed significantly poorer sleep efficiency (F(1,53)=12.386, p<.001), decreased REM sleep (F(1,53)=5.944), p<.05) and higher AHI (F(1,53)=4.698, p<.05). In addition to displaying a decreased amount of REM, infratentorial stroke patients displayed significantly shorter bouts of REM (F(1,52)=7.482, p<.01). Neither age nor AHI were significantly correlated with the amount or duration of REM (p>.05).

Conclusion:
Infratentorial ischemic stroke patients display significant disruptions in sleep and may require close monitoring for sleep-wake disturbances in the post-acute period. REM sleep is particularly effected when compared to supratentorial ischemic stroke.
Abstract P205: Rehabilitation With Brain Computer Interface to Improve Hand Function After Stroke
Authors: Rodríguez Barragán Marlene Alejandra , Cantillo Negrete Jessica , Carrillo Mora Paul , Cariño Escobar Ruben , Quinzaños Fresnedo Jimena , Hernández Arenas Claudia
Published: March 2021

Background:
Stroke is the third cause of disability and the first cause of motor impairment of the upper limb, which significantly reduces independence in activities of daily living. Therefore, the development and use of new therapeutic approaches is needed. Brain-computer interfaces (BCI) based on movement intention (MI) have the potential to improve hand function and brain plasticity after stroke.

Purpose:
Improve hand function after stroke with BCI with MI.

Methods:
8 patients with subacute stroke, left or right hemiparesis was divided in two groups. The first received conventional therapy followed by BCI-MI therapy and the second was given BCI-MI therapy and then conventional therapy. The outcome variables were sensory-motor recovery, hand function, spasticity, level of disability, grip strength, change in motor threshold and amplitude of motor evoked potentials (MEP) and changes in desynchronization/synchronization event-related (EDR/EDS).

Results:
4 patients were female, the average age 56 ± 12.7 years, and 87% were ischemic stroke. No differences were found between post-conventional therapy and postBCI-MI in the sensorimotor recovery, the spasticity, and the degree of deficiency in the strength. Only in hand function measured with the Action Research Arm Test (ARAT), a statistically significant difference was found in the BCI-MI therapy group (p= 0.0247). Dynamometry grip strength had a tendency to increase the Post-BCI group. A MEP was obtained in the ipsilesional primary motor cortex of 3 patients. A higher EDR was found in the injured hemisphere in favor of the post-BCI group (p= 0.0165).

Conclusions:
This study shows that BCI-MI rehabilitation, which combines MI with a robotic hand orthosis as feedback, has a significant improvement in hand function and a greater ERD in the ipsilesional primary motor cortex. It is necessary to carry out controlled clinical trials with a larger sample and with a greater frequency and duration of intervention to measure hand motor and functional improvement of patients after stroke.
Abstract P210: Cognitive Testing During Mild Acute Ischemic Stroke Predicts Return to Work, Driving, and Good Functional Outcome at 3 Months
Authors: SLAVIN Sabreena J , Richardson Lindsay , Moore Justin , Ecklund-Johnson Eric , Gronseth Gary S , Akinwuntan Abiodun
Published: March 2021

Introduction:
Many patients after a mild ischemic stroke (IS) do not return to work or driving. Cognitive testing is commonly done to assess long-term cognitive impairment after IS. However, inpatient cognitive testing during the acute period of mild IS may also be a predictor for workforce reengagement and functional outcome.

Methods:
At our comprehensive stroke center, we prospectively enrolled previously working adults age <65 years who were diagnosed with first-ever IS, had a prestroke modified Rankin Scale (mRS) ≤1 and NIHSS ≤3. Testing performed within 1 week of IS included the Montreal Cognitive Assessment (MOCA), Clock Drawing Test, Trail Making Tests A and B, Backward Digit Span Test, and Hospital Anxiety and Depression Scale (HADS). Other data obtained included age, gender, years of education, occupation (blue collar or white collar), stroke location (cortical, subcortical, or posterior fossa), stroke laterality, and presence of white matter disease on imaging. Outcome measures assessed at 3 months post stroke included return to work, return to driving, and mRS ≤1. In a logistic regression analysis, we performed both univariate and multivariate analyses. Multivariate analysis was completed on variables p ≤0.05 in the univariate analysis.

Results:
Of 40 total IS patients enrolled (median [IQR] age 55 [46-60] years; 22.5% female), 36 completed 3-month follow up. 58% returned to work, 78% returned to driving, and 72% had mRS of 0-1 at 3 months. In multivariate analysis, a single point increase in the Clock Drawing Test score increased the odds of return to work by 3.79 (95% CI, 1.10-14.14) and return to driving by 6.74 (95% CI, 1.22-37.23). MOCA and HADS were both associated with mRS ≤1.

Conclusion:
Clock Drawing Test in the acute period after mild IS may predict early return to work and driving at 3 months. MOCA and HADS may also predict good functional outcome. These tools can potentially be used for prognosis and identifying those who may benefit from further interventions.
Abstract P224: Management of TIA Over Time in the Greater Cincinnati Northern Kentucky Stroke Study
Authors: Madsen Tracy E , Khoury Jane C , Alwell Kathleen S , Adeoye Opeolu M , Coleman Elisheva R , Demel Stacie L , De Los Rios La Rosa Felipe , Flaherty Matthew L , Khatri Pooja , Jasne Adam , Haverbusch Mary , Ferioli Simona , Martini Sharyl R , Mackey Jason , Mistry Eva , Slavin Sabreena , Star Michael , Walsh Kyle B , Woo Daniel , Broderick Joseph P , Kissela Brett M , Kleindorfer Dawn
Published: March 2021

Introduction:
The availability of rapid tissue and vessel imaging for TIA has increased, but the utilization rates of these and other diagnostic and management strategies for TIA over time are unknown.

Objective:
To investigate trends in TIA diagnostic and management strategies over time in the Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS).

Methods:
The GCNKSS is a population-based study of 1.3 million people living in a 5-county area of southern Ohio and Northern Kentucky. For this study, all physician-adjudicated, first-ever cases of TIA (defined clinically as sudden onset of focal symptoms lasting < 24 hours) presenting to an emergency department over five study periods (1993/4, 1999, 2005, 2010, 2015) were included. Use of AHA-recommended aspects of TIA management as well as disposition of TIA patients (admission to hospital or discharge from ED) and length of stay were compared across study periods. Rates of acute infarct on MRI were also reported. Trends were examined using the Cochran-Armitage test for trend.

Results:
In total, over all study periods, there were 2251 first-ever TIAs. Overall, 14% (n=311) occurred in Black individuals, and 57% (n=1275) occurred in women. Utilization of diagnostic modalities [non-contrast CT brain, vascular imaging (CTA, MRA, or carotid dopplers), tissue imaging (MRI), and echocardiogram] increased significantly over time (all p<0.0001). In terms of management, both admission to the hospital and discharge from the hospital on an antiplatelet agent increased over time (both p<0.0001; Table).

Conclusions:
The management of TIA has changed significantly over time. Utilization of tissue and vessel imaging as well as echocardiogram during the hospital stay has increased; in 2015, the vast majority of patients with TIA in this population-based study received each of these testing modalities and were admitted to a hospital for TIA work-up. Further work is needed to understand the best practices for work-up of suspected TIA.
Abstract P233: Descriptions of the Meaning of Modified Rankin Scale Outcomes in Acute Stroke Clinical Trials: Meta-Analysis and Call to Corrective Action
Authors: Chaisinanunkul Napasri , Saver Jeffrey L
Published: March 2021

Background:
The modified Rankin scale, a 7-level, clinician-reported, measure of global disability, is the most widely employed outcome scale in acute stroke trials. As the meaning of technical mRS scores (e.g. mRS 1, mRS 4) is not well-known among general clinicians, patients, and policy-makers, trialists sometimes apply valence (e.g. “excellent”, “good”) and health-state (e.g. “disabled”, “dependent”) terms to convey the clinical meaning of trial findings. The terms employed have not been well-delineated.

Methods:
Systematic meta-analysis assessing mRS descriptive terms across all large (n ≥ 100) RCTs for acute ischemic or hemorrhagic stroke reported 2000 - 2020, following PRISMA guidelines.

Results:
Among the 60 RCTs meeting study entry criteria, patient populations were acute ischemic stroke (AIS) in 88%, intracerebral hemorrhage in 8%, both in 3%. Among the 55 AIS trials, tested agents included: antiplatelet - 28%, endovascular thrombectomy - 20%, IV lytics - 20%, neuroprotective - 11%. The mRS was a major endpoint measure in 82% of trials (primary in 60%, secondary in 22%). Table 1 shows frequency of different valence terms (1A) and health state terms (1B) for 9 types of mRS analysis. Trials often used mutually contradictory terms for particular mRS outcomes. e.g. “good outcome” was applied to outcomes mRS 0-1 (2 trials), mRS 0-2 (2 trials), mRS 0-3 (1 trial), and ordinal mRS (3 trials); “favorable” was applied to mRS 0-1 (5 trials), mRS 0-2 (6 trials), and ordinal mRS (6 trials). Also many trials provided no meaningful descriptor (no valence descriptor in 82%, no health state descriptor in 58%).

Conclusion:
Across major acute stroke trials of the past 20 years, the valence and health state terms for different mRS outcomes have been often mutually contradictory or not provided at all. A standardized nomenclature for mRS outcome description would improve clinician and policy-maker understanding of trial results
Abstract P236: Impact of Covid-19 Outbreak on the Quality of Care and Outcomes for In-Hospital Patients With Acute Ischemic Stroke in China
Authors: Wang Meng , Wang Chun-Juan , Gu Hong-Qiu , Yang Xin , Yang Kai-Xuan , Li Zi-Xiao , Wang Yong-Jun
Published: March 2021

Background:
It is unclear the impact of the COVID-19 pandemic on the health care and outcomes for in-hospital patients with acute ischemic stroke (AIS). We aimed to evaluate the influence of COVID-19 on the quality of care for in-hospital patients with AIS.

Methods:
This is an observational registry study between November 23rd, 2019 and March 22nd, 2020. 408 hospital from 29 provinces in China were enrolled from Chinese Stroke Center Alliance (CSCA). Patients with AIS were extracted with demographic, clinical and previous history information. We focus on the time period before and after January 23rd, 2020, when the public health interventions were carried out in China. The primary outcome was adherence to 11 performance measures, with co-primary outcomes of a composite of percentage of performance measures adhered to. Secondary outcomes included were time measures and in-hospital outcomes.

Results:
42056 patients with AIS was enrolled (mean age 66.5±12.1, male 61.3%). The overall in-hospital patients decreased slightly from 14323 to 14204 before the COVID-19 outbreak and went down sharply by 31.4% and 61.1% after the outbreak and the public conducted interventions in China. A remarkable reduction was shown in patients with NIHSS score ≤ 3 from 57.7% to 55.7% after the outbreak (p<.001). Adherence to performance kept steady and grew slightly overall, for the composite measure (0.78±0.19 vs. 0.79±0.18, p<.001) increased after the COVID-19 outbreak. Discharged against medical advice increased from 5.9% to 7.3% after the outbreak (p<.001). The length of stay fell as expected after the public health interventions (10.0 (7.0-13.0) vs. 9.0 (7.0-13.0), p<.001).

Conclusions:
The admission number of patients with AIS declined significantly after the COVID-19 outbreak, but the quality of care and outcomes kept stable. Hospitals should admit AIS patients to the fullest extent of ability and provide tailored treatment strategies under the premise of no the cross-infection of COVID-19.
Abstract P254: Decompressive Hemicraniectomy and Functional Outcomes After Malignant Cerebral Infarction: Real World Experience From a Comprehensive Stroke Center
Authors: Park Christine , Weiss Martin , Le Scott , Shah Shreyansh , Guhwe Mary , Mac Grory Brian , Gonzalez L. Fernando , Feng Wayne
Published: March 2021

Background:
Decompressive hemicraniectomy (DHC), performed in select patients with malignant infarction (MCI), reduces mortality. However, there is conflicting evidence surrounding the use of DHC in improving disability outcomes in this patient population. This is in part due to differing definitions of functional recovery in prior studies. The purpose of this study is to characterize a cohort of patients with ischemic stroke who underwent DHC and compare the outcomes data with pooled data from three major trials published for DHC (DECIMAL, DESTINY, and HAMLET).

Methods:
This was a retrospective, observational cohort study of consecutive patients who underwent DHC as part of best clinical care during 2015-2020. We report our cohort using descriptive statistics.

Results:
Of the 44 patients underwent DHC at our institution, 33 were included for analysis after applying the inclusion and exclusion criteria based on the three major trials. Our DHC cohort tended to have higher rates of comorbidities including hypertension and diabetes
(Table 1).
A greater number of our DHC patients had unfavorable modified Rankin Scale (mRS) scores of 4 or 5 at 6-month follow-up compared to those who underwent DHC or received conservative therapy at 12-month follow-up in the three prospective trials
(Figure 1).

Conclusion:
DHC in patient cohorts with significant comorbid data is associated with reduced mortality but a worsened functional outcome in survivors. The treating practitioner should consider this procedure only in the context of a lengthy discussion regarding the patient’s baseline functional and health status as well as competing benefits and risks associated with this procedure.
Abstract P255: Inpatient and Emergency Department Utilization for Herpes Zoster Infection After Stroke
Authors: Parikh Neal S , Zhang Cenai , Hwang Mu Ji , Mir Saad , Merkler Alexander E , Kamel Hooman , Navi Babak B
Published: March 2021

Introduction:
Patients with acute ischemic stroke (AIS) are generally vulnerable to subsequent infection, but there are few population-based data on the risk of herpes zoster infection after AIS. We tested the hypothesis that AIS is associated with an increased risk of zoster.

Methods:
We performed a retrospective cohort study using statewide administrative claims data from all emergency department (ED) visits and admissions at nonfederal hospitals in Florida from 2005 to 2015 and New York from 2006 to 2015. These Healthcare Cost and Utilization Project data are well suited for longitudinal analyses of acute care utilization. The primary exposure was AIS, and the outcome was subsequent zoster; diagnoses were ascertained using validated ICD-9-CM codes. We excluded people with zoster before AIS. Survival statistics were used to calculate incidence rates, and Cox proportional hazards analysis was used to determine the association between AIS and subsequent ED visit or admission with zoster. In addition to demographics and comorbidities, models were adjusted for conditions associated with zoster (cancer and HIV/AIDS). In a secondary analysis, we limited the population to people under 50 years old, because current guidelines recommend zoster vaccination for only those at least 50 years old.

Results:
Among 19,675,854 beneficiaries, 421,940 (2.1%) had AIS; their mean age was 70.8 (SD, 14.5) years. Follow-up duration was a mean of 4.1 (SD, 3.0) years. The incidence of zoster was 4.1 per 1000 patient-years in those with AIS and 2.1 per 1000 patient-years in those without. After AIS, the median time to zoster was 1.7 years (IQR, 0.4-4.1). In unadjusted models, patients with AIS had a two-fold higher risk of zoster (HR, 2.1; 95% CI, 2.0-2.1). AIS remained associated with zoster after adjusting for cardiopulmonary comorbidities and risk factors, medical comorbidities, tobacco and alcohol use, cancer, and HIV/AIDS (HR, 1.34; 95% CI, 1.30-1.39). This association was also observed in people under 50 years old (HR, 1.55; 95% CI, 1.31-1.84).

Conclusions:
AIS is associated with an increased risk of subsequent ED and inpatient visit with zoster infection. Preventive strategies, including with currently available vaccinations, should be investigated.
Abstract P256: Association Between Antidepressants Use and Intracerebral Hemorrhage: Florida Stroke Registry
Authors: Siddu Mithilesh , Bustillo Antonio , Gutierrez Carolina M , Wang Kefeng , Gardener Hannah , Koch Sebastian , Marulanda-Londoño Erika , Dong Chuanhui , Rundek Tatjana , Romano Jose G , Sacco Ralph L , Asdaghi Negar
Published: March 2021

Introduction:
SSRIs, the most commonly prescribed antidepressants (AD) in the US, are linked to an increased intracerebral hemorrhage (ICH) risk possibly related to impaired platelet function. In the Florida Stroke Registry (FSR), we studied the proportion of cases presenting with ICH amongst AD users and the rate of SSRI prescription amongst stroke patients discharged on AD.

Methods:
From Jan 2010 to Dec 2019 we included 127,915 cases from FSR in whom information on AD use was available. Multivariable logistic regression was used to evaluate ICH proportions amongst AD and non-AD users and rates of prescribed SSRIs at discharge.

Results:
The rate of ICH amongst prior AD users (n=17,009, median age 74, IQR=19) and non-AD users (n=110,906, median age 72, IQR=21) were 11% and 14% respectively. Prior AD users were more likely to be female (17% vs. 10% male), non-Hispanic White (16% vs. 8% non-Hispanic Black vs. 12% Florida Hispanic vs. 6% Puerto Rican Hispanic), have hypertension (HTN) (14.% vs. 10%), diabetes mellitus (DM) (16% vs.12%), use oral anticoagulants (OAC) (17 % vs. 13%), antiplatelets (AP; 17% vs. 11%), and statins (17% vs. 10%) prior to hospital presentation. In multivariable analysis adjusting for age, race, prior history of HTN, DM, prior OAC, AP and statin use, AD users just as likely to present with spontaneous ICH as compared to non-AD users (OR=0.92, 95% CI 0.85, 1.01). A total of 3.4% of all ICH patients and 9% of those in whom AD information was available were discharged home on an AD (74 % SSRI, 24% other AD).

Conclusion:
In this large population-based study, we did not find an association between prior AD use and an increased rate of ICH. Importantly AD (mostly SSRIs) are commonly prescribed to patients with ICH in routine clinical practice. The association between types, duration, and safety of antidepressant use in ICH patients deserves further studies.
Abstract P265: Identifying Factors Associated With Early Transfer Death of Stroke Patients Can Improve Transfer Criteria
Authors: Toumbs Randi R , Dao Thanh , Zhu Liang , Savitz Sean I
Published: March 2021

Introduction:
Mortality is an important performance metric monitored by CMS, US News and World Report, and Vizient UHC. Large academic medical centers have high mortality given higher severity of disease and volume. We analyzed mortality of stroke patients transferred to our university hospital from community EDs. Transferring patients who die within 48 hours raises questions about resources, financial burden, and unrealistic expectations from families. We analyzed our transfer early death (TED) population to improve identification of patients who likely do not benefit from transfer out of a community hospital.

Methods:
Patients with DRG codes for ischemic and hemorrhagic strokes admitted from July 2018-June 2020 were identified. Transfer patients were isolated and grouped as outside hospital (OSH) or intra-system transfers. Data were analyzed for overall hospital mortality and TED mortalities and characteristics. Demographic and clinic variables were compared between intra-system and outside transfers by chi-square test, Fisher’s exact test, t test or Wilcoxon rank sum test.

Results:
The total stroke mortality rate was 13% with 276 deaths out of 2,145 patients. There were 171 early deaths out of 276 deaths (62%). There were a total of 923 transfer patients in the 2-year period; 76 were TED (8%) and TED accounted for 27% of all in-hospital mortality at our center. Median age of TED was 67, median NIHSS was 27, 39% were >70, and 80% were ICH with a median ICH score 4. The mean volume of ICH was 68mL (SD=55.2). There were no significant associations between age, sex and ethnicity with TED compared with patients who survived beyond 48 hrs. Among TED, 31 (41%) were from within our health system and 45 (59%) were OHS transfers. There were no significant differences among stroke type, severity (GCS, NIHSS, ICH score, MRS), or demographics between intra-system and OSH transfers.

Conclusions:
TED patients are more likely to have severe ICH where medical care may be futile. Strategies are needed to work with community hospitals to establish goals of care and implement approaches to provide end-of-life services at these facilities. Identification and implementation of such strategies may also reduce intra-system transfers of patients with high mortality.
Abstract P266: The Implementation of Artificial Intelligence Significantly Reduces Door-In Door-Out Times in Primary Care Center Prior to Transfer
Authors: Hassan Ameer E , Ringheanu Victor M , Preston Laurie , TEKLE WONDWOSSEN
Published: March 2021

Introduction:
Viz.ai artificial intelligence (AI) software utilizes AI powered large vessel occlusion (LVO) detection technology which automatically identifies suspected LVO through CT angiogram (CTA) imaging and alerts on-call stroke teams. We performed this analysis to determine if utilization of AI software can reduce the door-in door-out (DIDO) time interval within the primary care center (PSC) prior to transfer to the comprehensive care center (CSC).

Methods:
We compared the time interval between door-in and door-out for all LVO transfer patients from a single spoke PSC to our CSC prior to (Feb. 2017 to Nov. 2018) and after (Nov. 2018 to June 2020) incorporating Viz.ai. Using a prospectively collected stroke database at a CSC, demographics, DIDO time at PSC, modified Rankin Scale at discharge (mRS dc), mortality rate at discharge, length of stay (LOS) in hospital and neurological ICU, and intracranial hemorrhage rates were examined.

Results:
There were a total of 63 patients during the study period (average age 69.99 ± 13.72, 55.56% women). We analyzed 28 patients from the pre-AI (average age 71.64 ± 12.28, 46.4%), and 35 patients from the post-AI (average age 68.67 ± 14.88, 62.9% women); see Table 1 for comparison of baseline characteristics and outcomes. Following the implementation of the AI software, the mean DIDO time interval within the PSC significantly improved by 102.3 minutes (226.7 versus 124.4 minutes; p=0.0374); significant reductions were not noted in mRS at discharge, rates of hemorrhage, or mortality.

Conclusion:
The incorporation of the AI software was associated with a significant improvement in DIDO times within the PSC and may lead to significant improvements in functional outcome and mortality in transfer patients. More extensive studies are warranted to expand on the ability of AI technology to improve transfer times and outcomes for LVO patients.
Abstract P268: Community Wide Real-Time Stroke Code Capture to Better Identify Changes in Health Care Utilization During Covid-19
Authors: Kenner Brininger Amelia , Olson-Mack Lindsay L , Chmielowski Lorraine , Koenig Kristi L , Kalafut Mary A , Hemmen Thomas
Published: March 2021

Introduction:
Many healthcare systems reported a decline in stroke admissions in the early months of the COVID-19 pandemic. We used real-time hospital admission data from Stroke Receiving Centers (SRCs) across San Diego County to quantify changes in stroke patients accessing healthcare with the onset of the COVID-19 pandemic. Rather than waiting for months-delayed discharge data, real-time stroke code data was used to understand the impact on healthcare utilization which may better inform mitigation strategies to encourage accessing care for acute stroke.

Methods:
We analyzed the total number of patients presenting to any of the 18 San Diego County SRCs for which a stroke code was activated between January 1, 2019 and July 31, 2020; and separated the times into: pre-pandemic (PP) as January 2019 thru February 2020, early-pandemic (EP) as March and April 2020, and mid-pandemic (MP) as May-July 2020. Patients arriving via emergency medical services or private transport were included. A public messaging campaign regarding the safety of accessing care for acute stroke started in early May 2020.

Results:
A total of 14,028 stroke codes were initiated between January 2019 and July 2020. An average of 43.2 stroke codes were activated per stroke center per month (range=39.6 to 46.7 activations per stroke center per month) during PP, 30.6 during EP and 37.7 during MP (p=.019). Overall, 30% fewer stroke code activations occurred during EP compared to the same months in the PP (p=.012). Mid-pandemic, there were 14.6% fewer stroke code activations compared to the same months pre-pandemic (p=.095).

Conclusion:
Stroke code activations decreased by 30% across San Diego County SRCs in the EP period compared to the previous year. It is unclear if this is primarily due to decreased healthcare utilization at the start of the COVID-19 pandemic or if there were changes in stroke incidence. MP showed stroke code activations increased compared to EP. This may be partially due to the public messaging campaign initiated after an analysis of PP to EP stroke code activations. We will continue to analyze stroke code data to better understand the impact of public messaging campaigns and determine when activations have returned to PP levels.
Abstract P277: The Impact of Implementing the SNIS Recommendations for the Care of Emergent Neurointerventional Patients in the Setting of COVID-19 on Patients Undergoing Mechanical Thrombectomy
Authors: Atchie Benjamin , Jarvis Stephanie , Salottolo Kristin , Bennett Alicia , Burrell Christian , McCarthy Kathryn L , Nieberlein Amy , Bartt Russell , Bar-Or David
Published: March 2021

Introduction:
As a result of the novel coronavirus 2019 (COVID-19) pandemic, the Society for Neurointerventional Surgery (SNIS) issued guidelines for patient management during COVID-19. Specifically, they suggested intubating COVID-19 positive or those with unknown COVID-19 status prior to emergent endovascular thrombectomy, cohorting by COVID-19 status, early ICU discharge, and postponing elective cases. We sought to determine how the implementation of SNIS guidelines affected outcomes for patients with ischemic stroke.

Methods:
This was a retrospective cohort study comparing ischemic stroke patients who were treated with thrombectomy admitted during the COVID-19 pandemic 4/1/20-6/30/20 “COVID-19 peak” to patients admitted 4/1/19-6/30/19 “2019”. Statistical tests used for analysis included Kruskal-Wallis, chi-squared and Fisher’s exact test.

Results:
The proportion of patients treated with thrombectomy was not significantly different, 23% in 2019 vs. 24% during the COVID-19 peak, p=0.67. There were 112 patients treated with thrombectomy: 57 (51%) in 2019, 55 (49%) during the COVID-19 peak. No patients treated with thrombectomy were positive for COVID-19, but 27 (49%) were tested. The median age was 69 for those treated in 2019 and 69 for those during the COVID-19 peak, p=0.44. Patients were similar in sex, race, and comorbidities. The time from onset to arrival was also statistically similar, p=0.19. In 2019, 16% received tPA compared to 9% during the COVID-19 peak, p=0.28. The median time to groin puncture was significantly shorter in 2019, 38 minutes, than during the COVID-19 peak, 44 minutes, p=0.01. The recanalization rate and mRS were similar between groups, p=0.06, and p=0.91, respectively.

Conclusions:
After implementing the SNIS guidelines, including pre-treatment intubation, we observed a significantly longer time to groin puncture. Anecdotally, the increased observed was remarkably small given the changes to care and did not negatively impact patient outcomes. This suggests that hospitals managing patients efficiently can implement changes in response to COVID-19 and continue high level of care without impacting outcomes. Therefore, we recommend following the SNIS guidelines to prevent the spread of COVID-19.
Abstract P279: Using Systems Redesign to Develop, Implement, and Evaluate the Effectiveness of a Care Transitions and Hypertension Management Program for Veterans With Ischemic Stroke
Authors: Sico Jason J , Burrone Laura , Phadke Manali , Ragunton Jan-Michael , Hurd Paul , Fenton Brenda
Published: March 2021

Introduction:
Patients are routinely discharged after an ischemic stroke with uncontrolled hypertension; blood pressure (BP) at discharge predicts BP 6-months post-discharge.

Hypothesis:
Systems Redesign approaches can develop and implement effective interventions using existing infrastructure more efficiently to improve care transitions and hypertension management for Veterans 6-months post-stroke.

Methods:
Two external facilitators with expertise in clinical stroke care and Systems Redesign conducted a rapid process improvement workshop with local healthcare personnel and hospital leadership within a large VA medical center providing suboptimal post-stroke BP control. The team process mapped out the current state of BP control post-stroke and conceptualized a future state with enhanced care coordination between inpatient and outpatient providers and increased engagement of underutilized talent within clinical pharmacy and telehealth. The CAre Transitions and Hypertension (CATcH) management program was created and implemented. Chart review was conducted to collect data related to BP and healthcare utilization. Categorical variables were examined by calculating frequency distributions and using chi-square or fisher’s exact tests.

Results:
A total of 76 Veterans were the recipient of the CATcH program. Compared to Veterans admitted in the 6-months prior to program implementation, utilization of clinical pharmacy (68.4% versus 33.3%;
P
=0.0002) and telehealth services (48.7% versus 4.2%;
P
<0.0001). CATcH patients were also more likely to return home/home with services than historical controls (86.6% versus 60.4%;
P
=0.003). Mean (SD) systolic BP reduction from discharge to 6-month follow-up these CATcH patients was 8.9 (5.3) mmHg. Rates of readmission to the hospital and presenting to the emergency room within the 6-months post-discharge period were not significantly different between groups.

Conclusions:
Systems Redesign could be used retool existing workflow and enhance care coordination and collaboration. Improving processes related to care transitions and post-stroke hypertension management increased the likelihood of returning to home/home with services and BP control for stroke survivors.
Abstract P286: The Effects of COVID-19 on the Reasons for Not Calling 911 for Acute Stroke
Authors: Ramirez Maygret , bedgio rodney a , Ramos Virginia , Gonzalez Ivis , Gonzalez Yaima , Belnap Starlie C , De Los Rios La Rosa Felipe
Published: March 2021

Objective:
Our Stroke Program regularly provides community outreach and stroke education. The stroke team educates on signs and symptoms of stroke, risks factors, and 911 activation. Within a few days of discharge, Neuroscience nurses call stroke patients to ensure patients have obtained their prescription medications, have follow-up appointments, inquire about their satisfaction with our services, and reinforce stroke education. As part of these calls, our team asked why patients/families did not call 911. The purpose of this study was to determine if the COVID-19 crisis influenced the reasons why 911 was not called for possible stroke to better plan for targeted stroke education.

Method:
Discharge phone survey data from our stroke network was collected from Feb-Jul 2019 and compared to Feb-Jul 2020. Our stroke network includes 1 comprehensive stroke center and 2 primary stroke centers. Emergency Department (ED) stroke activation data was gathered for the same time periods. Discharge phone calls data was based on discharge date, whereas ED stroke alert data was based on admission date.

Results:
There was a notable decline in stroke volume between 2019 to 2020 with the largest decline occurring during the first peak (Apr 2020) in COVID-19 cases within our state. This decline was driven by a 16% decline in walk-in ED stroke arrivals as compared to a 1% decline in EMS stroke arrivals. Of those who did not call 911 in 2020, there was a 7% increase in failing to recognize stroke symptoms as an emergency, a 6% increase in concern about EMS cost, and 6% decrease in hospital preference.

Conclusion:
The COVID-19 crisis negatively influenced stroke volumes within our system stroke program. Reductions in stroke walk-ins accounted for this decline. COVID-19 affected the reasons why 911 was not called. The largest increase was in not recognizing stroke symptoms as an emergency and increased concern about EMS associated costs. Surprisingly, COVID-19 was not listed as a reasons for avoiding 911. Targeted community educational efforts on these concerns may lead to improved 911 usage for suspected stroke during the COVID-19 pandemic.

Limitations:
Further research is needed to investigate why those with a stroke who would have been walk-ins decided not to seek urgent medical attention.
Abstract P291: Early Risk of Readmission Following Hospitalization for Reversible Cerebral Vasoconstriction Syndrome
Authors: Garg Aayushi , Ortega Santiago
Published: March 2021

Introduction:
Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by diffuse cerebral vasoconstriction that can last up to 3 months. While most patients have a benign clinical course, neurological complications are not uncommon, especially in the initial few weeks. The aim of this study was to describe the rate, reasons, risk factors, and outcomes of 90-day readmissions following hospitalization for RCVS.

Methods:
We utilized the Nationwide Readmissions Database 2016-2017 to identify all hospitalizations with the discharge diagnosis of RCVS. The primary outcome of interest was readmission within 90 days of index hospitalization discharge. Survival analysis was performed, and the predictors of readmission were analyzed using the Cox proportional hazards regression.

Results:
During the study period, there were 1,201 weighted hospitalizations for RCVS with survival to discharge and known discharge disposition (mean±SD age: 48.6±16.0 years; female 76.7%). Neurologic complications during the index hospitalization included hemorrhagic stroke (40.0%), ischemic stroke (19.4%), cerebral edema (11.1%), and new onset seizure (4.2%). Readmission within 90 days of discharge occurred in 176 (14.7%) patients. The most common reasons for readmissions included acute cerebrovascular events (20.5%), infections (11.9%), continued or recurrent symptoms of RCVS (11.4%), and headache (9.1%). Diabetes, history of tobacco use, opioid use, and longer length of index hospitalization were independently associated with increased hazards of 90-day readmission. For readmissions, the mean (SD) length of stay was 5.6 (6.3) days and the mean (SD) charges per hospitalization were $53,030 ($56,977). There was no in-hospital mortality, however, approximately 40% of patients had discharge disposition other than to home or inpatient rehabilitation facility.

Conclusion:
Nearly 15% of patients with RCVS get readmitted within 90 days of discharge and a significant proportion of these readmissions are due to the ongoing/recurrent symptoms or neurologic sequelae of RCVS. Knowing that these patients are at risk of early recurrence/worsening of their symptoms is important for patient counseling at discharge as well as post-discharge follow-up plan.
Abstract P294: Short-Term Outcome of Post-Stroke Fatigue During the Transition From Hospital to Home
Authors: Su Ya , Yuki Michiko , Hirayama Kengo
Published: March 2021

Background and Purpose:
Post-stroke fatigue (PSF) is a frequent complication that worsens the patient’s rehabilitation outcomes and quality of life. Many studies have demonstrated a robust relationship between PSF and post-stroke depression and insomnia. However, sarcopenia was usually not taken into account. As stroke survivors manage and adapt to their functional limitations, the rhythms, and routines of life poststroke changes. At 1 month after discharge home, frustration is a common response to these changes. Therefore, this study was aimed to investigate the impact of post-stroke fatigue from the acute phase to the first month after discharge and assess the possible contributions of sarcopenia to discharged PSF.

Design:
A single-center prospective observational study.

Participants:
94 patients with acute stroke were recruited between May 2019 and July 2020.

Methods:
Clinical and stroke characteristics were collected from electronic medical records. Pre and post-stroke factors were collected by questionnaire. The main outcomes were included fatigue, depression, insomnia, sarcopenia, and health-related quality of life (QOL) was assessed at admission, and one month after discharged home. Fatigue was measured using the Fatigue Assessment Scale. Sarcopenia was measured using the SARC-F questionnaire.

Results:
The prevalence of PSF was 25.5% at admission and 29.8% at one month after discharged home. PSF at admission was associated with fatigue (p<0.01), insomnia (p<0.01), higher SARC-F scores (p=0.026), and lower QOL scores [Physical Component Score (p=0.029) and Mental Component Score (p=0.006)] at one month after discharged home.

Conclusions:
There is a really beginning that transition for stroke patients at discharge from hospital to home. In this study, PSF during hospitalization can affect sleep status and QOL after discharge, and which is consistent with previous studies. It is worth noting that patients with PSF at admission had higher SARC-F scores after discharged home. Muscle wasting is a common complication accompanying stroke, which may not only contribute to physical function reduction but also psychological function, it deserves more attention in clinical practice and scientific research.
Abstract P298: Redundant Imaging in TIA: Evidence From the Nationwide Emergency Department Sample (NEDS)
Authors: Timpone Vincent M , Jensen Alexandria , Poisson Sharon N , Salzberg Matthew , Reid Margaret , Trivedi Premal S
Published: March 2021

Introduction:
Multiple societal guidelines recommend patients with TIA be emergently imaged with brain-MRI and neurovascular screening-CTA, MRA or carotid ultrasound-to identify and treat risk factors for future stroke. Increased ED compliance with TIA imaging guidelines has previously been demonstrated, along with a substantial increase in imaging utilization over the past decade. The purpose of this study was to quantify prevalence of redundant imaging during ED work-up of TIA, and to identify imaging practices that could be targeted to reduce unnecessary expenditures.

Methods:
Utilizing the 2006-2017 Nationwide Emergency Department Sample, patients discharged with TIA from EDs in the US were identified using ICD-9/10 codes. Brain and neurovascular imaging obtained during the encounter was identified using CPT codes. Demographics, payor, patient income, and hospital characteristics were incorporated into a hierarchical multivariable logistic regression analysis to identify significant associations with redundant neuroimaging.

Results:
In 2017 there were 184,870 patients discharged from EDs with TIA. Redundant brain, brain vascular, and cervical vascular imaging was identified in 55,513(30%), 5,149(2.8%) and 1,325(0.7%) of encounters respectively. Decreased odds of obtaining redundant neuroimaging in a TIA encounter was observed in Medicaid patients(OR:0.72, 95%CI:0.64-0.81), non-trauma centers(OR:0.49, 95%CI:0.26-0.93), rural hospital locations(OR:0.18, 95%CI:0.11-0.29) and weekend encounters(OR:0.9, 95%CI:0.85-0.96). Trend analysis from 2006 to 2017 demonstrated a rise in redundant brain and neurovascular imaging from 2.3% and 0.2% of encounters respectively in 2006 to 30% and 3.5% of encounters in 2017. Using Medicare fee estimates, in 2017 redundant brain and neurovascular imaging for patients discharged from EDs with TIA resulted in additional charges of approximately 8,670,832 USD.

Conclusion:
Increasing utilization of imaging for workup of TIA across EDs in the US is also associated with substantial and increasing use of redundant imaging. We identify redundant brain and neurovascular imaging as areas that could be targeted to mitigate rising imaging expenditures.
Abstract P310: Impact of COVID-19 Pandemic on Stroke Care at the University of Rochester Medical Center
Authors: George Benjamin P , Boerman Christine , Papadakos Peter J , Benesch Curtis , Holloway Robert G , Kelly Adam G , Roberts Debra
Published: March 2021

Introduction:
The impact of the COVID-19 pandemic response on medical care for stroke is unknown.

Methods:
We used local “Get With The Guidelines” stroke data for patients with ischemic stroke (IS), transient ischemic attack (TIA), and intracerebral hemorrhage/subarachnoid hemorrhage (ICH/SAH) from March 20–April 14, 2020 (study period) and January 1–March 19, 2020 (control period #1) and March 20–April 14, 2019 (control period #2). We examined daily admission rates, transfers, tPA administration, thrombectomy, and time from last well to hospital arrival.

Results:
There were 349 patients (n=40 study period, n=225 control period #1, n=84 control period #2); 263 with IS, 37 with TIA, and 49 with ICH/SAH. Overall, 46% were female, 82% white, with median age 70 years (IQR 58-82 years).

Daily admission rates were 1.4 IS/day for the study period compared to 2.1 IS/day (Incident rate ratio [IRR] 1.49 95% CI 1.05-2.13, p=0.027) and 2.2 IS/day (IRR 1.57 1.04-2.37, p=0.033) for control periods #1 and #2 (
Table
), respectively. There was only one admission for TIA in the study period compared to approximately one every 4 days in control period #1 (IRR 7.2 95% CI 1.0-53.7, p=0.053) and one every 2 days in control period #2 (IRR 14.0 95% CI 1.8-106.5, p=0.011). ICH/SAH admissions were fewer in the study period. Transfers were less common with approximately one transfer every four days in the study period compared to one each day of the control periods. Rates of tPA, thrombectomy, and time from last well to first hospital contact did not differ across the epochs.

Conclusions:
Our data suggest the COVID-19 pandemic response has led to reduced admission volumes for all stroke types in the University of Rochester Medical Center catchment area, partly due to decreases in hospital transfers. These data raise the question whether fewer patients sought care for stroke symptoms at the height of the COVID-19 pandemic.