bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP327: Nihss Proxy Using Administrative Data From the Us and Uk
Authors: Bottle Alex , Bogdanovskaya Maria , Rinkel Gabriel J , Shaw Louise , Lee Jin-Moo , Hemmen Thomas M
Published: June 2021

Introduction:
Comparing outcomes between hospitals for quality improvement needs risk adjustment for the severity of the stroke. The NIHSS is the standard instrument for this but has difficulties in collection and integration into administrative and other electronic databases. A proxy derived from existing data items would be useful.

Methods:
We derived a proxy using the 2014 national hospital administrative data for England and the 2012 US Nationwide Inpatient Sample. Diagnosis codes and procedures (performed on admission day) with a prevalence in ischaemic stroke admissions of at least 1% were tabulated and their potential for inclusion into a proxy independently assessed by members of a physician panel. Classification and regression trees helped inform the development of a logistic regression model that was used to finalise and evaluate the performance of the proxy when predicting in-hospital mortality. The proxy was also compared against the actual NIHSS in a sample of 282 US administrative records and 265 English records linked to those patients’ NIHSS from a separate study.

Results:
For England, there were 69,125 admissions and 9,130 in-hospital deaths; for the NIS there were 86,478 admissions and 3,795 in-hospital deaths. The physician panel agreed on 19 candidate variables, which included intubation, aspiration pneumonitis, dysphasia and aphasia, coma, and others. The models in England and the US retained most variables. The relative importance of each variable was similar in each database, with intubation, aspiration pneumonitis, and coma the most important. The c statistic for discrimination was 0.82 for the NIS and 0.69 for England; adding age, sex and admission source gave 0.84 for NIS and 0.78 for England. The adjusted odds ratio per unit increase in the proxy in the NIS was 1.16 (p<0.001). The correlation between our proxy and the actual NIHSS in our separate sample was 0.52 in England and 0.47 in the US.

Conclusions:
An NIHSS proxy can be derived using administrative data with either ICD9 or ICD10 and has reasonable prediction for in-hospital mortality.
Abstract WP333: Utilizing Data to Drive Stroke Program Management
Authors: Shah Ruchir , Catalano Peter , Heck Susan , Devlin Thomas , Jennings Traci , Butler Jennifer
Published: June 2021

Introduction:
There is a lack of standard data management tools for neurovascular service lines and stroke programs. Many hospitals use “home grown” spreadsheets or upload to various registries which are designed more toward research initiatives than daily operations.

Hypothesis:
Installation of a dedicated Neurovascular Information System (NVIS), especially when electronically interfaced with other systems, will result in improved efficiency in operating a stroke program and/or neurovascular service line.

Methods:
A large health system in Tennessee has installed an NVIS for daily use within its Comprehensive Stroke Center. The system has been interfaced with other information systems in the hospital to support automated data entry. The service line directors and physician leaders have monitored data related to time spent in various aspects of program management (e.g. data entry/management, interaction with staff, interaction with patients, etc.) to understand how the use of a system can impact resource allocation. The system is being utilized through mobile technology, such as tablets, and static monitoring units in identified key locations.

Results:
The data collection time required has been reduced by more than 50% because of the system’s automated collection and reporting features. The leaders of the service line have also developed more detailed, data-driven dashboards which are being used for management decisions. Education is also data-driven as any process fall-outs are revealed through program dashboards.

Conclusion:
Utilization of a dedicated NVIS reverses the narrative related to stroke program management. It has allowed the program leaders to use data to drive programmatic decisions and development, rather than being tied to data entry requirements and struggling to enter post-dated information. This novel approach continues to support research endeavors and registry participation, while increasing efficiency and improving access to meaningful analytics.
Abstract WP334: Standardized Language Reduces Symptom Discovery to CT Times: “Code Stroke - Inpatient”
Authors: Cox Kailey L , Baraban Elizabeth
Published: June 2021

Introduction:
Inpatient stroke represents up to 17% of all strokes and should receive the same timely care as patients arriving to the ER, especially in a Joint Commission Certified Comprehensive Stroke Center (CSC). However, evidence suggests there is greater in-hospital delay in evaluation and treatment of inpatient strokes compared with stroke patients in the ER. To reduce symptom discovery to CT time, we implemented standardized language and a single pager for inpatient stroke alerts in a CSC hospital.

Hypothesis:
Using standard language to activate the stroke team and a one-call system will reduce symptom discovery to CT times for patients with stroke in the inpatient setting.

Methods:
A baseline evaluation revealed a lack of standard language for activating the stroke team (e.g. “Activate Stroke Team”, “Acute Stroke”, “Stroke Consult”, “Internal Alert”) and that the Rapid Response Team (RRT) nurse had to call multiple people to initiate the stroke evaluation process. Key stakeholders formed a workgroup and implemented a hospital-wide education initiative that included the use of standardized language for inpatient activation of the stroke team (“Code Stroke - Inpatient”) and the creation of a pager group with all responders (Stroke MD, RRT nurse, Transport, CT tech, Pharmacy, IV therapy, Chaplain, and NCCU Charge RN). Symptom discovery time to CT was measured pre- (January 2015-February 2016) and post-implementation (March 2016-August 2016). Data were reported as mean ± standard deviation and median [interquartile range], and results were analyzed using an unpaired t-test.

Results:
Implementation of standardized language and a single pager reduced the symptom discovery to CT times from 260 ± 421.9 minutes (median = 98 [59,277], n=22) pre-implementation to 39.8 ± 16.5 minutes (median = 36.0 [28, 47], n=20) post-implementation.

Conclusion:
A multidisciplinary approach is essential to improving symptom discovery to CT times for inpatient strokes; even high performing CSC’s may lack timely care for this population. Continued research is needed to understand successful methods for equalizing the disparity of stroke care in the ER versus inpatient units.
Abstract WP336: Impact of Anti-Hypertensive Interventions for Treatment of Acute Ischemic Stroke in Patients Receiving Tissue Plasminogen Activator
Authors: Leya Jeffrey , Donahey Elisabeth , Rech Megan
Published: June 2021

Introduction:
Early treatment of acute ischemic stroke (AIS) with recombinant tissue plasminogen activator (rtPA) within 4.5 hours of symptom onset is associated with neurologic improvement. A risk of rtPA is hemorrhagic conversion, which has a higher incidence in patients with elevated blood pressure at presentation. Current literature supports the use of blood pressure goals (<185/110 mm Hg) in patients qualifying for rtPA, but the effects of anti-hypertensive (anti-HTN) medications within the first 24 hours of AIS on outcomes has not been evaluated.

Hypothesis:
AIS patients requiring anti-HTN medications (anti-HTN group) before rtPA have a poorer outcome at 90 days compared to those that do not need anti-HTN medications (control group).

Methods:
This was a retrospective cohort study of patients >18 years diagnosed with AIS from January 2011 through December 2015 who received one or multiple anti-HTN medication(s) prior to rtPA administration, compared to control patients who did not. Primary endpoint was poor outcome at 90 days, defined as a modified Rankin Scale (mRS) of ≥3. Univariate analysis with Chi-square, Fisher’s exact test or t-test was performed. Multivariate analysis was conducted.

Results:
Of 235 patients evaluated for AIS, 145 (61.7%) were included. Baseline demographics were well matched, though more patients in the anti-HTN group had a history of HTN (86.7% vs. 62.5%, p<0.01), diabetes (33.3% vs. 17.5%, p=0.04) and chronic kidney disease (20% vs. 7.5%, p=0.04). There was no difference in the primary endpoint of poor outcome (mRS ≥3) between groups who received blood pressure medication versus those who did not (37% anti-HTN group vs. 30% control, p=.374). There was no difference in hemorrhagic conversion (13.3% anti-HTN group vs. 6.3% control, p=.187). Mortality at 90 days did not differ between groups (11% who received anti-HTN vs. 7.5%, p=.508).

Conclusion:
No difference was observed in poor outcomes, hemorrhagic conversion, or 90-day mortality in patients receiving anti-HTN medications prior to rtPA compared to those that did not. These results suggest that aggressive blood pressure management should be used to control hypertension in AIS who may qualify for rtPA, though larger, randomized trials are needed to confirm this finding.
Abstract WP344: Lower Hemoglobin A1c is Associated With Higher In-Hospital Mortality in Intracerebral Hemorrhage
Authors: Dandapat Sudeepta , Siddiqui Fazeel M , Fonarow Gregg C , Bhatt Deepak L , Xu Haolin , Matsouaka Roland , Heidenreich Paul , Xian Ying , Schwamm Lee H , Smith Eric E
Published: June 2021

Introduction:
Relationship of prior glycemic status to outcomes in intracerebral hemorrhage (ICH) is not established.

Hypothesis:
Higher hemoglobin (Hb) A1c is associated with worse outcomes in ICH.

Methods:
Data harvested from GWTG-Stroke registry on patients with ICH between April 1, 2003 and September 30, 2015. Four ordinal groups made based on HbA1c values of <5.7%, 5.7-6.4%, 6.5-8.0% and >8.0%. Outcomes analyzed overall and separately for patients with or without history of diabetes using unadjusted and adjusted multivariable regression models.

Results:
Among 75,455 patients with ICH from 1,336 sites, the prevalence of diabetes was 36.2% and prediabetes (no prior history of diabetes and HbA1c between 5.7-6.4%) was 41.9%. An increasing trend in the median BMI values was noted across the groups, with worse HbA1c associated with higher BMI. Lower HbA1c was associated with higher in-hospital mortality (3947/25473 {15.5%} overall, 542/2852 {19.0%} in patients with history of diabetes, and 3405/22621{15.1%} in patients without history of diabetes) (Table), higher mRS, less chance of going home, and lower likelihood of having independent ambulatory status, also seen in unadjusted and adjusted outcomes (Figure). Only in patients with no prior diabetes history, both higher HbA1c and lower HBA1c were associated with higher in-hospital mortality.

Conclusions:
In this large cohort of ICH patients, contrary to our original hypothesis, lower HbA1c (rather than higher HbA1c) was associated with higher in-hospital mortality. Further studies are needed to better define the relationship between HbA1c and outcomes, for it may have important implications for care of ICH patients.
Abstract WP347: Early Achievement of Blood Pressure Lowering on Hematoma Growth in Hyperacute Intracerebral Hemorrhage: the SAMURAI-ICH Study
Authors: Yamaguchi Yoshitaka , Koga Masatoshi , Todo Kenichi , Sato Shoichiro , Yamagami Hiroshi , Kamiyama Kenji , Okuda Satoshi , Okada Yasushi , Kimura Kazumi , Shiokawa Yoshiaki , Furui Eisuke , Hasegawa Yasuhiro , Kario Kazuomi , Yoshimura Sohei , Ide Toshihiro , Yoshimoto Takeshi , Nagatsuka Kazuyuki , Toyoda Kazunori
Published: June 2021

Background:
Little has been investigated about associations between timing of blood pressure lowering and clinical outcome of intracerebral hemorrhage (ICH).

Methods:
The Stroke Acute Management with Urgent Risk-factor Assessment and Improvement (SAMURAI)-ICH Study is a multicenter, prospective, observational study investigating the safety and feasibility of early (within 3 hours from symptom onset) systolic blood pressure (SBP) reduction to less than 160 mmHg with intravenous nicardipine for acute hypertension in patients with spontaneous ICH. We retrospectively examined the relationship between time from onset, CT imaging, and initiation of antihypertensive treatment to target SBP achievement and hematoma growth in ICH patients. Hematoma growth was defined as an absolute growth of ≥ 6 ml from baseline to second imaging at 24 (±6) hours after the initiation of antihypertensive treatment.

Results:
Among 211 patients (81 women (38.4%), mean age 66 years), mean baseline hematoma volume was 13 ml and hematoma growth was seen in 36 (17.1%) patients. Time from image to target SBP and time from treatment to target SBP were significantly shorter in patients without hematoma growth than those with (
P
= 0.043 and
P
= 0.032, respectively), whereas there was not significant difference in time from onset to target SBP between the two groups (
P
= 0.177). Lower quartiles of time from image to target SBP and time from treatment to target SBP had lower incidences of hematoma growth (P trend = 0.023 and 0.037, respectively, Cochran-Armitage test), whereas there was not significant trend in time from onset to target SBP (
P
= 0.074). The lowest quartile of time from image to target SBP was negatively associated with hematoma growth on multivariate logistic regression (odds ratio 0.182, 95% confidential interval 0.038-0.867,
P
= 0.032).

Conclusions:
Early achievement to target SBP <160 mmHg was negatively associated with hematoma growth in ICH patients.
Abstract WP351: No Effect of Mannitol on the Course of Perihemorrhagic Edema After Intracerebral Hemorrhage
Authors: Volbers Bastian , Herrmann Sabrina , Willfarth Wolfgang , Huttner Hagen B , Lang Stefan , Giede-Jeppe Antje , Knott Michael , Kuramatsu Joji B , Staykov Dimitre
Published: June 2021

Introduction:
In patients with intracerebral hemorrhage (ICH) perihemorrhagic edema (PHE) seems to play a predictive role besides initial hematoma size, clinical status and intraventricular bleeding (IVH). PHE may exceed the initial hematoma volume by up to 600% thereby leading to increased intracranial pressure (ICP) which may cause severe clinical deterioration. EUSI and ASA guidelines recommend the use of intravenous mannitol or hypertonic saline (HS) in order to reduce elevated ICP. However, clinical data suggest that HS may be superior to mannitol in lowering ICP and clinical data concerning the effect of mannitol on PHE as a cause of elevated ICP is limited. We aimed to investigate the effect of mannitol on PHE after ICH.

Methods:
Patients with supratentorial spontaneous ICH treated with 20% intravenous mannitol solution (125-250ml every 6h) for 5-10 days and controls matched for ICH volume, age and IVH who did not receive any osmotic agents during the course of treatment were identified retrospectively from our institutional ICH database. PHE volume was calculated on diagnostic CT scans performed on days 1, 2-3, 4-6, 7-9 and 10-12 using a validated volumetric algorithm. Frequency of elevated ICP up to day 12 (ICP burden), modified Rankin Scale (mRS) after rehabilitation (approx. day 90) and PHE evolution were assessed as outcome variables.

Results:
44 ICH patients treated with mannitol and 43 controls were included. Basic characteristics did not differ between groups (median ICH volume day 1: 32.9 mL (IQR 16.3 - 54.0) and 27.7 mL (IQR 22.4 - 37.1), p=0.786; median age 71 y (IQR 61.5 - 77) and 72 y (IQR 66 - 81), p=0.269; median PHE volume day 1: 24.3 mL (IQR 16.0 - 38.8) and 24.3 mL (IQR 17.1 - 32.1), p=0.592, respectively). In the mannitol group PHE volume exceeded to a greater extent than in controls (PHE on day 10-12: 60.1 mL (SD 33.6) vs. 36.8 mL (SD 23.2), p=0.005). Median ICP burden was higher in the mannitol group (0 (IQR 0 - 7.75) vs. 0 (IQR 0), p=0.016). Median mRS did not differ between both groups (4 (IQR 4-6) vs. 4 (IQR 3-6), p=0.321).

Conclusions:
We found no effect of mannitol use on the general evolution of PHE and ICP. Other underlying mechanisms may explain the short-term effect of mannitol bolus administration on ICP in patients with spontaneous supratentorial ICH.
Abstract WP360: Race and Ethnicity Are Associated with Intracerebral Hemorrhage Recurrence Risk
Authors: Biffi Alessandro , Osborne Jennifer , Moomaw Charles , Langefeld Carl D , Woo Daniel , Rosand Jonathan
Published: June 2021

Introduction:
Intracerebral Hemorrhage (ICH) has previously been shown to disproportionately affect African-American (AA) and Hispanic-American (HA) patients compared to White (W). ICH recurrence risk, while a critical determinant of long-term disability and mortality, has not been extensively studies among minority individuals.

Hypothesis:
We sought to clarify whether AA and HA patients are at higher risk for ICH recurrence, and whether etiological differences exist for rebleeding events in different racial / ethnic groups.

Methods:
We analyzed data for 1542 ICH survivors enrolled in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, who survived at least three months post-ICH and were followed for at least one year. Participants underwent scheduled follow-up at 10-16, 22-28 and 50-60 weeks after index ICH to identify recurrence events. ICH etiology (primarily hypertensive vs. primarily amyloid related) was determined on the basis of index hemorrhage location, i.e. lobar for amyloid and non-lobar for hypertensive bleeds.

Results:
We analyzed data for 1542 ICH survivors (W: n=514, AA: n=453, HA: n=565), and identified a total of 42 recurrent ICH events (2.72%). AA patients were at higher risk for ICH recurrence compared to W (3.75% vs. 2.10%, p = 0.012), while HA were not (2.20% vs. 2.10%, p=0.78). Self-identified AA race/ethnicity was associated with greater risk for non-lobar ICH (Hazard Ratio [HR]=2.77, p=0.008) than lobar ICH (HR=1.43, p=0.048).

Conclusions:
AA ICH survivors are at higher risk for recurrent bleeding, and particularly for non-lobar hypertensive hemorrhages. These findings highlight the need for dedicated studies investigating the biological determinants of ICH recurrence in different racial/ethnic patient populations.
Abstract WP366: Quantitative Diffusion Tensor Tractography of the Corticospinal Tract as a Predictive Outcome Parameter in Patients With Intracerebral Hemorrhage
Authors: Volbers Bastian , Mennecke Angelika , Kästle Nicola , Huttner Hagen B , Schwab Stefan , Schmidt Manuel , Engelhorn Tobias , Doerfler Arnd
Published: June 2021

Introduction:
Intracerebral hemorrhage (ICH) is a devastating disease with poor outcome. Established predictive markers include initial hematoma size, clinical status, intraventricular bleeding and age. However, prognostic assessment is often difficult which additionally burdens patients and caregivers and complicates rehabilitation. Functional outcome especially relies on motor function which is correlated with the integrity of the Corticospinal Tract (CST). Diffusion Tensor (DT) Tractography allows visualization of the CST. However, sufficient data about the prognostic impact of quantitative CST assessment is lacking.

Methods:
We prospectively enrolled patients with spontaneous supratentorial ICH admitted between 08/2012 und 08/2015. Informed consent and ethical approval was obtained. MRI scan was performed on day 5±1. DT data was normalized to MNI Space and Q-Space diffeomorphic reconstruction was performed using DSI-studio. CST was reconstructed based on quantitative anisotropy (QA) using the CST region (JHU white matter atlas) as seeding region and cerebral peduncle as region of interest (ROI). Fractional Anisotropy (FA) and QA were analyzed in the seeding and ROI region and in the posterior limb of the internal capsule (PLIC). Dichotomized modified Rankin Scale on day 90 (favorable outcome = mRS 0-2) was assessed as primary outcome variable.

Results:
33 patients, mean age 70.7 y (standard deviation (SD) 12.9), 12 male, 21 with lobar hemorrhage, mean ICH volume on admission 16.5 (SD 11.3) cm
3
were included. 16 patients had a favorable outcome on day 90 (median mRS 3 (IQR 1-3.5). Mean number of reconstructed CST fiber pathways ipsilateral to ICH was higher in patients with favorable outcome (11343 (SD 8201)) than in patients with unfavorable outcome (4868 (SD 3221), p=0.008). Median QA and FA values in the PLIC ipsilateral to ICH were also higher in patients with favorable outcome (QA: 18.9 (IQR 16.2-23.3) vs. 14.6 (IQR 11.7 - 17.7), p=0.016, FA: 0.49 (IQR 0.45-0.53) vs. 0.41 (IQR 0.38-0.49), p=0.026).

Conclusion:
Higher FA- and QA-values in the PLIC and higher numbers of CST fiber pathways ipsilateral to ICH seem to be associated with a favorable outcome. DT Imaging may turn out as a useful quantitative predictive marker in the acute phase of ICH.
Abstract WP368: The Association of Prior Use of Antiplatelet Agents and Increased Mortality and Morbidity in Intracerebral Hemorrhage Patients
Authors: Khan Nadeem , Siddiqui Fazeel , Goldstein Joshua , Xian Ying , Cox Margueritte , Matsouaka Roland , Heidenreich Paul , Peterson Eric , Bhatt Deepak L , Fonarow Gregg , Schwamm Lee , Smith Eric E
Published: June 2021

Introduction:
Use of anti-platelet therapy is common among patients presenting with intracerebral hemorrhage (ICH). There are limited data regarding pre-stroke antiplatelet therapy (APT) and outcomes in patients presenting with spontaneous ICH. We hypothesized that prior use of antiplatelet agents increases mortality and discharge morbidity in ICH patients.

Methods:
We analyzed data of 82,576 ICH patients not on anticoagulation from 2185 GWTG-Stroke hospitals between Oct 2012 and March 2016. Patients were categorized as no APT, single antiplatelet therapy (SAPT) and dual antiplatelet therapy (DAPT). Logistic regression using generalized estimating equations to account for within-site correlations were used to assess the relationship between outcomes and prior-APT use.

Results:
No pre-ICH APT was used in 65.8%, SAPT in 29.5%, and DAPT in 4.8%. The median age of the cohort was 69 years and prevalence of females in the cohort was 48.6%, with preponderance of white race (58.9%). Overall onset of symptoms to arrival time was 131 minutes with a median NIHSS of 9. A total of 23.7% had history of previous stroke/transient ischemic attack, 15.3% had prior myocardial infarction/coronary artery disease and 73.4% had known hypertension. There was no significant difference in in-hospital mortality among patients not on any APT vs patients on SAPT. However, in-hospital mortality was higher among ICH patients on DAPT compared with no therapy (adjusted OR 1.41, 95 % CI 1.31-1.51, P<0.0001).

Conclusion:
Our study suggests that patients on DAPT, but not on SAPT, have higher mortality rates after ICH compared with patients on no APT.
Abstract WP369: Case-Fatality of Cortical Superficial Siderosis in Intracerebral Hemorrhage
Authors: Mackey Jason , Gagesch Kelsey , Blatsioris Ashley D , Moser Elizabeth A , Saha Chandan , Carter Ravan J , Williams Linda S
Published: June 2021

Introduction:
Cortical superficial siderosis (CSS) is a neuroimaging biomarker of interest in intracerebral hemorrhage (ICH) and represents hemosiderin deposition in the supratentorial sulci. CSS increases risk for recurrent ICH and is associated with cognitive impairment, but the long-term outcomes of ICH patients with CSS are unknown. We sought to characterize the long-term case-fatality of ICH patients with CSS.

Methods:
We performed a retrospective convenience study of primary ICH patients who underwent MRI during the index admission. We evaluated each hemisphere for presence of CSS, as well as other SVD markers, and performed Kaplan-Meier analysis to compare the survival curves of those with and without CSS. Vital status was ascertained via chart review and a National Death Index query when necessary.

Results:
Of 121 patients who underwent an MRI in our cohort, 95 had usable GRE or SWI sequences. Overall CSS prevalence was 11.6% (11/95): 18.2% (10/55) in lobar ICH and 2.5% (1/40) in deep ICH. Univariate predictors of CSS presence included older age (75.6 vs. 63.8, p=.01), larger hematoma volume (10.5mL vs. 4.6, p=.02), and prior ICH (54.5% vs. 10.7%, p=.002). There were no differences between the groups in MBs, EPVS, WMD scores, or DWI lesions. Patients with CSS had a significantly different survival history than those without CSS (log-rank p=.034). Twenty-five percent of the patients with CSS died by 4.4 months after index admission, compared with 45.1 months for those without CSS. The risk of death for the patients with CSS was 2.6 times (95% CI: 1.06-6.41) higher than those without. Four of 11 (36.4%) CSS patients lived at least 4 years after index ICH.

Conclusions:
Characterization of CSS in ICH patients may improve disease subtyping and clinical trial design. Future studies with larger and more generalizable cohorts are needed to assess how CSS focality vs. dissemination affects case-fatality and whether CSS is an independent predictor of case-fatality.
Abstract WP374: Implementation of the Stroke Transition Discharge Center Improves 30-day Readmission Rate
Authors: Quimby Susan , Peterson-Cole Javicia
Published: June 2021

Background:
Stroke patients and their caregivers require formalized education, medications, testing and rehabilitation to assist in prevention of recurrence and of post-stroke complications for optimal outcomes.

Objective:
The purpose of this program was to evaluate the effect of the Stroke Transition Discharge Center (STDC) on stroke readmission.

Methods:
The Advanced Practice Nurses (APN) see all stroke and TIA patients one week after discharge from hospital to home or one week after discharge from rehab to home. During the hour encounter, the APN reviews medications, test results, signs and symptoms of stroke, complete education including patient specific risk factors and ensure appropriate follow up. The APN coordinates and facilitates multiple services and disciplines impacting the patient, assuring the most efficient and effective goal-directed activities are provided at the right time and in partnership with all other disciplines providing care.

Results:
Implementation of the STDC enhances patient outcomes and improves 30-day readmission rates. Prior to our intervention, the readmission rate was 15.3%. After the implementation of the STDC, there was a 61% reduction in 30-day readmission rates to 6%, which is significantly below the hospital system benchmark of 11%. There was an increase in the readmission rate in the first two quarters of 2016 noted. There is an inverse correlation with the number of patients seen in the STDC during the same time period. Further analysis demonstrates that only one readmission in this time period had been seen prior in the STDC.

Conclusion:
Implementing the Stroke Transition Discharge Center demonstrated a dramatic reduction in 30-day readmission rates. Our data suggests that utilization of the clinic and participation by the patients has a direct and inverse effect on readmissions. Further data will need to be collected to determine if this is a sustained response.
Abstract WP376: Stress-Mediated Hyperglycemia or Undiagnosed Diabetes?
Authors: Grove Mary A , Biby Sharon , Dusenbury Wendy , Doerr Abbigayle , Lindstrom Anne , Grove Samuel B , Middleton Sandy , Alexandrov Anne W
Published: June 2021

Background:
“Stress mediated” hyperglycemia is often assumed to drive initial hyperglycemia during stroke admission. We sought to examine hemoglobin A1c (HbA1c) in relation to initial serum glucose.

Methods:
An observational design was used to examine glucose data from prospectively admitted acute stroke patients at 4 Comprehensive Stroke Centers. Data were entered and analyzed in SPSS using descriptive statistics, student t-tests, and Mann Whitney U.

Results:
1226 patients were studied; 50% male, 63% White, 34% African American (AA); age averaged 69±13.5 years, and 93% were ischemic strokes. DM was known on admission in 37%. Admission HbA1c was 5.8±.7 in non-DM patients, compared to 7.8±1.8 in known DM patients (p<0.001; 95% CI=1.7-2.1). Patients with admission glucose >180mg/dL had significantly higher HbA1c (9.0±1.9) compared to lower glucose values (6.1±1.1, median 5.9; p<0.001; 95% CI=2.5-3.2). Importantly, of those with an admission glucose >180mg/dL, 94% met the diagnosis of DM by HbA1c, although 13% had not been previously diagnosed. Discharge mRS was significantly worse at a median of 4 (unable to walk independently) vs. 3 (p=0.001) in patients with admission glucose >180mg/dL, despite having equivalent median admission NIHSS of 3 in each group (p=NS).

Conclusions:
Admission glucose >180mg/dL should be recognized as a strong indicator of DM diagnosis and not be assumed to be stress mediated. Stroke nurses are encouraged to lead the early diagnosis/management of diabetes.
Abstract WP377: Stroke Awareness in the Age of Social Media
Authors: Hundt Beth , Chen Kearby
Published: June 2021

Background:
May is recognized as Stroke Awareness month and many stroke programs design public awareness campaigns to provide education about the signs and symptoms of stroke and modifiable risk factors. An essential element of any stroke program includes the education of the community about stroke prevention, recognition, and early activation. Prior to 2016, community education consisted of blood pressure and risk factor screening by in various community settings. In 2016, the health system incorporated internet and social media components to education and community outreach during Stroke Awareness Month.

Purpose:
The purpose of this project was to analyze the added impact of incorporating interactive internet education and risk factor identification during Stroke Awareness Month.

Methods:
In 2016 we conducted a stroke awareness campaign of traditional screening and education events in the community. At these events, persons were offered a blood pressure measurement, asked about risk factors, and educated on the signs of stroke. Persons were also directed to a stroke risk profiler on the health system stroke center page that stratified their risk and possible interventions to reduce risk. Additional outreach and education efforts included an internet campaign directing persons to the risk profiler via internal health system media and social media. Paid social media, search and display ads for stroke signs and stroke risk also directed persons to the stroke risk profiler.

Results:
Traditional methods of education and screening yielded contact with 193 community members requiring approximately 50 hours of volunteer time. During May the web-based, interactive stroke risk assessment profiler was visited by 6,010 persons, and 1,570 fully completed the profiler. In subsequent months following the web-based community outreach campaign, traffic on the health system stroke center webpage remained at the high level of activity during May, and over 200% higher than traffic the previous year.

Conclusions:
Stroke awareness education and risk assessment is feasible and efficient via the internet and using social media. Using the internet and social media expands the size and increases the interaction of the community reached during Stroke Awareness Month.
Abstract WP379: What Informal Caregivers Want in a Mobile Application: Evidence-based Interventions
Authors: Girouard Shirley , Singer Jonathan , Stefanov dimitre , Gilles Nadege , Kunnakkat Saroj , Weingast Sarah , Faysel Mohammad , Jensen Amy , Fraser-White Marilyn , Burton Dee , Levine Steven
Published: June 2021

Background:
Nurses play a critical role supporting informal caregivers of stroke patients and thus need evidence of best, client centered interventions. Although there is a growing literature evaluating interventions, there is a paucity of research that begins with and engages caregiver stakeholders in identifying interventions, especially with the use of mobile health technologies.

Research Question:
What do stroke survivor informal caregivers want in a mobile application?

Methods:
A cross-sectional, descriptive study of informal stroke caregivers from a national convenience sample of the National Stroke Association database was conducted using a 17-item survey mailed to stroke survivors asking their caregivers to identify useful educational content/knowledge and resources. Descriptive statistics and logistic regressions were performed to analyze data and examine the relationships among demographic variables and caregiver needs.

Results:
Of 396 respondents, 76% were female (mean age 59 years +/-13.3; range 20-99); 53%, Caucasian; 24%, African-American; 11%, Hispanic/Latino. A majority (76% to 81%) of respondents wanted information about scheduling tasks and appointments, local resources, internet resources, fitness and diet tracking, and tools for communication with the stroke survivor; 81% of respondents wanted information about support groups. Ninety-six percent of caregivers owned a cell phone; 60% of which were smart phones. As age increased, reported usefulness of the app decreased (p = 0.05). There were no significant differences related to gender, race/ethnicity, or whether or not the caregiver owned a smartphone.

Conclusion:
Consistent responses across population groups suggest that nurses can use the findings to develop mobile applications for smartphone users, to use the content to develop written resource guides for discharge planning, and to customize care plans to support stroke caregivers with and without smartphones. Discharge plans for informal caregivers should include specific information about stroke survivor services, how to arrange healthcare appointments, educational materials about strokes, and guidance in best methods for communicating with the stroke survivor.
Abstract WP38: MR Imaging Based Paradigm for Early Anticoagulation After Acute Ischemic Stroke: A Pilot Study
Authors: Luby Marie , Gupta Nidhi , Benson Richard T , Burton Tina M , Hsia Amie W , Leigh Richard , Nadareishvili Zurab , Lynch John K
Published: June 2021

Background and objectives:
There is limited data on the optimal times to start anticoagulation (AC) in patients with a recent ischemic stroke. The objective of this pilot study was to investigate the safety of our institutional MR imaging based paradigm (MR-IBP, Figure) regarding initiation of AC in acute ischemic stroke patients, with and without large ischemic stroke.

Methods:
Patients admitted with acute ischemic stroke between July 1, 2014 and December 31, 2015 and consented to our natural history protocol were included in this study. Eligible patients had a discharge diagnosis of ischemic stroke and were started on AC during their acute hospitalization. We rated all incidences of hemorrhagic transformation (HT) using ECASS-II criteria during their acute hospitalization with the HT ratings performed at the time of discharge. We retrospectively evaluated all cases for large stroke based on baseline diffusion-weighted imaging (DWI) lesion diameter > 5 cm measurements.

Results:
Fifty-seven patients were included with 44% (25/57) started on AC according to the MR-IBP, Figure. For the patients started on AC, 8% (2/25) had HT (1 had HI-1; 1 had PH-2) after AC was started while 8% (2/25) were started on AC 1 day after HT (both were HI-2). Both patients started on AC after HT had baseline DWI lesion volumes < 1/3 MCA. Overall 16% (4/25) had HT pre- or post-AC versus patients who were not started on AC who had HT 19% (6/32) (p=0.77). There were 14 patients (25%) with large ischemic stroke. Of these large stroke patients, 8 (57%) had no HT, 4 (67%) were not started on AC but had HT post stroke (3 had HI-2; 1 had PH-1) and 2 (33%) were started on AC within MR-IBP but had HT (1 had HI-1; 1 had PH-2).

Conclusion:
Based on our pilot study, starting AC in patients with acute ischemic stroke including those with large stroke per our institutional MR-IBP is safe based on the low incidence of HT, with a 4% incidence of PH-2 HT during the acute hospitalization.
Abstract WP386: Acute Catecholamine Surge in Patients with Aneurysmal Subarachnoid Hemorrhage: Characteristics and Prognostic Value
Authors: Uramaru Koichi , Kikkawa Yuichiro , Sato Hiroki , Yanagawa Taro , Suzuki Kaima , Okuma Masahiro , Nakajima Hiroyuki , Takeda Ririko , Kurita Hiroki
Published: June 2021

Objectives:
The characteristics of serum catecholamine concentration at the hyper-acute phase of aneurysmal subarachnoid hemorrhage (SAH) and its relationship between patient outcome and delayed vasospasm were investigated.

Methods:
Patients with aneurysmal SAH (170) were prospectively studied between August 2008 and June 2011. Baseline demographic data and physiological parameters, including plasma concentrations of adrenaline (AD), noradrenaline (NA) and dopamine (DP) were evaluated for all patients.

Results:
On admission, plasma AD, NA and DP levels were significantly higher in patients with a poor clinical grade on admission (Hunt & Kosnik: IV-V), compared to those with a good clinical grade on admission (Hunt & Kosnik: I-III). AD showed a markedly high concentration immediately after the onset of SAH and then rapidly decreased. NA levels peaked within 6 hours after onset, then significantly decreased. The increase of DP with time was not significant, but showed a similar trend to that of NA. The level of each catecholamine showed significant mutual correlation. Multivariate analyses demonstrated age, poor clinical grade, plasma AD and NA levels were predictors of poor patient outcome, and.poor clinical grade, Fisher scale and plasma AD level were predictors of the development of delayed vasospasm.

Conclusions:
The present findings suggest that sympathetic activation in patients in the acute phase of SAH reflects the severity of SAH, and is closely related to the development of delayed vasospasm, leading to the subsequent immune response and inflammatory reactions. Strategies for suppressing catecholamine at the hyperacute phase may contribute to vasospasm prevention and improve patient outcome.
Abstract WP39: Mechanical Embolectomy for Acute Ischemic Stroke Beyond Six Hours From Symptom Onset Using Advanced MR Imaging
Authors: McTaggart Ryan , Yaghi Shadi , Sacchetti Daniel C , Haas Richard , Cutting Shawna , Hemendinger Morgan , Arcuri Daniel , Rogg Jeffrey M , Furie Karen L , Jayaraman Mahesh V
Published: June 2021

Background:
There is very limited data on the use of advanced neuroimaging to select patients with acute ischemic stroke and large vessel occlusion for intraarterial therapy beyond 6 hours from onset. Our aim is to report the outcome of patients with acute ischemic stroke and large artery occlusion who presented beyond 6 hours from onset, had favorable MRI imaging profile, and underwent mechanical embolectomy.

Methods:
This is a single institution retrospective study between December 1st, 2015, and July 30
th
, 2016 with acute ischemic stroke and anterior circulation large vessel occlusion (LVO) with ASPECTS of 6 or more and beyond 6 hours from symptoms onset. Favorable imaging profile was defined as 1) DWI lesion volume (as defined as apparent diffusion coefficient < 620 X 10-6 mm2/s) of 70 mL or less AND 2) Penumbra volume (as defined by volume of tissue with Tmax >6 sec) of 15 mL or greater AND 3) A mismatch ratio of 1.8 or more AND 4) Volume of tissue with perfusion lesion with Tmax > 10 sec is less than 100 mL. Good outcome was defined as a 90 day mRS≤2.

Results:
In the study period, 41 patients met the inclusion criteria; 22 (53.6%) had favorable imaging profile and underwent mechanical embolectomy. The median age was 75 years (59-92), 68.2% were females; the median time from last known normal to groin puncture was 684.5 minutes (range 363-1628) and the median admission NIHSS score was 17.5 (range 4-28). The rate of good outcomes in this series was similar to that in a patient level pooled meta-analysis of the recent endovascular trials (68.2% vs. 46.0%, p=0.07). The rate of good outcome matches that of the EXTEND-IA trial that selected patients using perfusion imaging (68.2% vs. 71.0%, p = 1.00). None of the patients in our cohort had symptomatic intracereberal hemorrhage.

Conclusion:
Advanced MR imaging may help select patients with acute ischemic stroke and anterior circulation large vessel occlusion for embolectomy beyond the treatment window used in most endovascular trials.
Abstract WP396: Barriers to Stroke Coordinator Practice
Authors: Livesay Sarah L , Casper Christy , Graves Alex , Stradling Dana , Wilson Susan
Published: June 2021

Background:
Stroke coordinators (SC) are key stroke program personnel. However, little is known about the SC role or barriers to practice. We designed a role study to better understand barriers to SCs practice and contributors to burnout and and turnover.

Methods:
a role survey was developed using Dillman’s Tailored Design Methods and addressed orientation to role, mentoring and barriers to practice. The voluntary survey was distributed by email through three stroke organizations in Illinois and targeted SCs and advanced practice nurses (APN) with stroke program responsibilities.

Results:
40 participants from 33 different facilities responded to the role survey. 65% of respondents identified as SC, 30% as stroke program manager/director, 20% as an APN. 17% had worked at other facilities previously as a stroke coordinator or similar role. 46% of respondents reported not having adequate resources to perform duties as stroke coordinator. Top reported moderate or extreme barriers to success in the role were lack of time (78%), lack of role clarity by supervisor (32%), lack of role definition as stroke coordinator (30%), lack of mentorship (27%), lack of on-the-job training (22%), and lack of formal education (19%). SCs and APNs with program coordination responsibilities report to a variety of different supervisor roles, including nursing management (38%), quality department (27%), other hospital administration (14%), service line management (8%), a physician (5%), other (6%). 70% of respondents reported they had not been mentored by anyone at their facility once hired into the role and 16% of coordinators reported they were considering leaving their position in the next year.

Conclusions:
While stroke coordinators and APNs with programmatic oversight are viewed as integral to program success, many are struggling with lack of role clarity, time management, adequate resources, and lack of mentorship. These factors may be contributing to turnover and burnout.
Abstract WP397: Multidisciplinary Simulation of Stroke Alerts in Resident Education Leads to a 20% Decrease in Door to Needle Times
Authors: Richardson Alicia , Ermak David , Krishnaiah Balaji , Said-Said Sarita , El-Ghanem Mohammad
Published: June 2021

Introduction:
Neurology residents are primarily responsible for responding to stroke alerts within our institution. It is imperative that first year residents understand the process and role expectations are clearly defined. Historically, residents were expected to run a stroke alert without having formal education on the stroke alert process.

Hypothesis:
Giving residents timely education of the stroke alert process will lead to decreased door to needle times.

Methods:
In July 2015, the Clinical Nurse Specialist (CNS) identified that simulation based learning (SBL) would close this gap. Scenarios were developed in collaboration with a Vascular attending and fellow. Emergency department nurses, EMS, chaplains, and pharmacist all participated in the scenario to make it as realistic as possible. A mannequin was utilized and controlled by simulation lab personnel while participants were videotaped as they performed the scenario. Incorporated into the debriefing of the scenario was education of door to needle goals, stroke alert process, and a discussion of role expectations.

Results:
In FY2014, the average door to needle was 49.5 minutes. After providing simulation education to residents, the door to needle (DTN) average decreased to 39.8 minutes with a p-value of 0.0794. Before the education we met the goal of administering Alteplase in less than 60 minutes, 80% of the time. Following the education we met the goal 89% of the time. Improvement also occurred with the DTN goal of less than 45 minutes from FY2014 to FY2015, 51.5% and 59.2% respectively.

Conclusion:
Education of residents in a SBL environment prior to their stroke rotation led to a 20% decrease in door to needle times. Although results did not meet statistical significance, this reduction in DTN time is clinically significant as evidence has shown shorter DTN association with improved outcomes. Anecdotally, residents expressed increased confidence in running a stroke alert and understood the DTN goals.
Abstract WP398: Nursing Swallow Screen Validated for Detection of Dysphagia in Acute Stroke Patients
Authors: Carlson Janet , Hofmann Melissa
Published: June 2021

Background:
The importance of screening for dysphagia in stroke patients is well established, yet an optimal tool has not been identified. The CCW (cough on command, control of saliva and water swallow) Swallow Screen builds on existing data for item selection.

Purpose:
The purpose of the study was to compare the CCW Swallow Screen against the Gold Standard speech language pathology (SLP) swallow evaluation for detection of dysphagia in acute stroke patients.

Methods:
Using the CCW Swallow Screen and SLP swallow evaluation outcome measures, a prospective correlation study was performed on a sample of 88 acute stroke patients (SEM = 1.63). Inclusion required passing the CCW pre-screen component: be alert, follow commands and sit up. SLP swallow evaluation was completed within 3 hours after the nurse administered CCW screen, to support criterion-related validity. Data analysis included sensitivity and specificity, and positive (+LR) and negative (-LR) likelihood ratios. Specific statistics generated included chi-square (χ2), correlation (Phi ≥ .80). Inter-rater reliability (IRR) was supported by prior training, testing and competency validation of nurses, plus performance monitoring during data collection. IRR was computed with Cohen’s kappa.

Results:
The CCW Swallow Screen correctly detected the presence and absence of dysphagia, (Sensitivity = 84%; Specificity = 95%) and demonstrated a strong certainty that dysphagia was present or not present (+LR = 16.8; -LR = 0.17). A statistically significant association between the CCW Swallow Screen and the SLP evaluation (χ2 (1) = 56.66,
p
< .001) indicated that the CCW Swallow Screen and the SLP evaluation equally measured dysphagia in this stroke sample. The association between the two tests was found to be strong (Phi = .80). IRR results revealed zero variance as both raters observed and passed all nurses in perfect agreement (IRR = 1) for competency validation and data collection observation.

Conclusion:
The CCW Swallow Screen is a reliable, valid tool for detection of dysphagia in acute stroke patients. The simplicity of the tool supports feasibility in a variety of clinical settings. Further validation with a similar sample is warranted.