bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP290: Glyburide Reduces Cytotoxic Edema within the Cerebral Peduncles in Acute Ischemic Stroke
Authors: Edlow Brian L , Wu Ona , Singhal Aneesh B , Chaudhry Zeshan A , Yoo Albert J , Stern Barney J , Sheth Kevin N , Kimberly W T
Published: March 2022

Introduction:
Diffusion tensor imaging (DTI) measurements of fractional anisotropy (FA) and apparent diffusion coefficient (ADC) within the cerebral peduncle (CP) and corticospinal tract (CST) correlate with functional outcomes in ischemic stroke. We evaluated the utility of FA and ADC as quantitative biomarkers of cytotoxic edema in acute stroke subjects treated with intravenous glyburide (RP-1127), which may prevent brain swelling after ischemia.

Methods:
Nine acute hemispheric stroke subjects enrolled in the Glyburide Advantage in Malignant Edema and Stroke (GAMES) Pilot study were compared to a cohort of seven stroke patients not treated with RP-1127. GAMES subjects received an intravenous bolus of RP-1127 within 10 hours of symptom onset, followed by an intravenous drip for 72 hours. The cohorts were matched for admission NIHSS score, infarct volume, and time from infarct to DTI data acquisition. CPs were manually traced on color FA maps and used as seed regions to identify CST fiber tracts using deterministic, streamline tractography. Ipsilesional FA and ADC values were normalized to contralesional values, yielding four quantitative metrics: CP FA ratio, CP ADC ratio, CST FA ratio, and CST ADC ratio.

Results:
Median NIHSS score was 19 in both cohorts. Mean time to DTI data acquisition was 2.5 ± 0.4 and 2.4 ± 0.6 days, and mean infarct volume was 170 ± 49 and 188 ± 13 cc in the GAMES and control cohorts, respectively. CP ADC ratios were significantly higher in patients treated with RP-1127 compared to the control cohort (1.05 vs. 0.98, p=0.045). No difference between the GAMES and control cohorts was observed for the CP FA ratio (1.02 vs. 0.98, p=0.30), CST FA ratio (1.0 vs. 0.99, p=0.78), or CST ADC ratio (0.92 vs. 0.93, p=0.75).

Conclusions:
CP ADC ratio may provide a quantitative imaging biomarker of response to RP-1127 in acute stroke. Higher CP ADC ratios reflect a reduction of cytotoxic edema within CST axons at the level of the CP, consistent with RP-1127’s proposed mechanism of preventing cellular edema.
Abstract TP295: Different Patterns of Subcortical White Matter Disease in Patients with Cerebral Amyloid Angiopathy and Hypertensive Intracerebral Hemorrhage
Authors: Haley Kellen , van Etten Ellis S , Auriel Eitan , Ayres Alison , Vashkevich Anastasia , Reed Anne K , Dipucchio Zora Y , Schwab Kristin M , Rosand Jonathan , Viswanathan Anand , Greenberg Steven M , Gurol Mahmut E
Published: March 2022

Objective:
We aimed to identify the potential contributions of cerebral amyloid angiopathy (CAA) and hypertensive microvasculopathy on periventricular (PV) and subcortical (SC) white matter disease (WMD).

Methods:
Total, SC and PV WMD volumes of 359 CAA patients and 102 patients with hypertensive intracerebral hemorrhage (htn-ICH) were quantitatively measured on FLAIR MRI. The presence of 6 different subcortical WMD patterns (detailed under Results and Figure 1) was recorded. The independent predictors of each of these WMD variables were explored using multivariate models that included the diagnosis (CAA vs htn-ICH), age, gender, ApoE genotype, vascular risk factors, total WMD volume as well as lobar and deep microbleed (MB) counts from T2*MRI.

Results:
CAA patients were older (mean 74 vs 68, p<0.001) with a higher WMD burden (p<0.05 for total, PV and SC WMD) than htn-ICH cases. Older age, higher lobar and deep MB counts were independent predictors of both total and PV WMH (p<0.01 for all predictors) whereas only high lobar MB count was independently associated with SC WMD (p<0.001). CAA-related covariates (CAA diagnosis and/or lobar MB counts) were independently associated with large posterior SC WMD (Fig 1a, frequency 16% in CAA vs 5% in htn-ICH, p<0.001) and anterior SC WMD (Fig 1b, 46% vs 24%, p<0.01). Peri-basal ganglia WMD (Fig 1c) pattern was more frequent in htn-ICH (29% vs 10%, p<0.001) and independently associated with deep MB count. The SC spots (Fig 1d, p=0.16), U-shaped SC WMD pattern (Fig 1e, p=0.17) and severe-coalescent WMD (Fig 1f, p=0.5) were not independently related to CAA or htn-ICH.

Conclusions:
Our results show that CAA pathology is associated with the severity of both PV and SC WMD as well as presence of severe posterior and anterior SC disease. A pattern of deep peri-basal ganglia WMD is mostly associated with hypertensive disease. Recognition of these patterns might help understand the dominant type of microvasculopathy in older individuals with WMD.
Abstract TP302: Brain Natriuretic Peptide Upon Admission Should Predict Patients Mortality Within 1 Year After Onset Of Intracerebral Hemorrhage
Authors: goya yoshino
Published: March 2022

Background and Purpose:
A recent study demonstrated that the plasma level of BNP is an independent predictor of long-term mortality after ischemic stroke. Furthermore, BNP also increases in patients with acute intracerebral hemorrhage (ICH). However, the relationship between BNP and long-term mortality after ICH is not clear. We investigated the relationship between BNP and mortality within 1 year after onset of ICH.

Methods:
We prospectively enrolled ICH patients who were admitted within 24 hours of onset from April 2007 to December 2010 and measured plasma BNP upon admission. Follow up was performed at 12 month from enrollment and patients were divided into two groups: the survival group and the death group. The factors associated with mortality were determined by multiple logistic regression analysis.

Results:
A total of 304 patients ( median age, 72 years , 112 female) were enrolled in the present study. The locations of the hematoma were: the putamen in 102 (34%)patients, the thalamus in 93 (30%), the lobar in 40 (13%), the brainstem in 28 (9%), the cerebellum in 20 (7%), and other location in 21 (7%). 86 patients (28%) died during 12 month from enrollment. The mean±SD admission BNP level for all patients was 123.1±320.8 pg/ml. The median of age, NIHSS score on admission, frequency of preadmission warfarin use, preadmission antiplatelet use, a past history of diabetes mellitus, atrial fibrillation, ICH, coronary artery disease, hemoglobin, glucose level, ICH volume and BNP level were significantly higher in the death group than in the survival group. In multivariate logistic regression analysis, age >71years (odds ratio [OR], 2.3; 95%CI, 1.080-5.054,
P
=0.03112), NIHSS score on admission >16 (OR, 2.9; 95%CI, 1.407-6.053,
P
=0.00400), past history of diabetes mellitus (OR, 2.5; 95%CI, 1.139-5.567,
P
=0.02246), glucose level >145 mg/dl (OR, 2.0; 95%CI, 1.005-4.136,
P
=0.04831), ICH volume >10 cc (OR, 4.1; 95%CI, 1.963-8.503,
P
=0.00017), and a plasma BNP level >50 pg/ml (OR, 2.9; 95%CI, 1.457-5.931,
P
=0.00260) were found to be independently associated with mortality within 1 year after onset.

Conclusions:
BNP level (>50 pg/ml) upon admission should predict patients mortality within 1 year after onset of ICH.
Abstract TP31: Resting State Functional MR Connectivity In Acute And Sub-acute Stroke
Authors: Nair Veena A , La Christian , Song Jie , Reiter Peter , Nadkarni Tanvi , Jensen Mathew , Chacon Marcus , Sattin Justin , Prabhakaran Vivek
Published: March 2022

Objective:
Stroke can have important effects on widespread brain regions resulting in network disruption. This study investigates the changes in spontaneous activity in the brain after stroke using resting-state functional connectivity(FC) MRI.

Methods:
Acute ischemic stroke patients (N=22, 11 cortical, mean age=60, 10F) were recruited within 7 days of stroke onset(timepoint 1, V1). Eleven of these patients were also scanned at timepoint 2(V2), approximately 3 months later. Age-matched healthy controls (N=17, mean age = 56, 7F) and 7 patients with risk factors for stroke (mean age=67, 1F) were also recruited in the study. Ten minute eyes-closed resting-state fMRI scans were collected along with a high resolution anatomical scan. We examined FC in the language network consisting of ten regions extracted based on functional activations on a phonemic fluency task performed during a separate scan. We also examined the correlation of brain FC with behavioral performance on the task outside the scanner.

Results:
We examined correlation between every seed region and every other region in the network(45 seed region-pairs). Compared to age-matched controls, acute strokes showed significantly reduced inter-hemispheric connectivity, specifically between inferior frontal and temporal regions(p<.001 corrected). This difference however was not significant in the sub-acute stage(Figure 1 left panel). Additionally, although both acute and sub-acute patients showed significant differences in performance compared to normals on phonemic fluency(Fig 1 right), there were no significant correlations between brain FC measures and behavior and no differences in the correlation between brain FC and behavior among the groups.

Conclusions:
These results suggest that acute strokes show reduced brain connectivity between contralateral regions in the language network; however, this connectivity pattern is restored in the sub-acute stage.
Abstract TP313: Early Supported Discharge after Stroke in Bergen, Norway: No Significant Difference from In-Patient Treatment, but Home Rehabilitation may be Better
Authors: Hofstad Håkon , Eide Geir Egil , Moe-Nilssen Rolf , Næss Halvor , Skouen Jan Sture
Published: March 2022

Background:
Both incidence and prevalence of stroke will increase in the coming decades, due to demographic changes with a more aged population and increased stroke survival. An optimized rehabilitation outcome is therefore essential from both the individual and societal point of view. Early discharge from hospital is cost-effective. In Early Supported Discharge (ESD) stroke patients are discharged home as soon as possible, but with support from a multidisciplinary team and rehabilitative treatment in the community. Studies conducted 10-15 years ago indicate that this is equal to or better than traditional in-hospital treatment, but the essential components are mostly unclarified.

Methods:
We conducted an RCT with 306 acute stroke patients randomized into one of two different ESD arms or a control arm. The ESD arms differed in the location for the rehabilitative treatment after discharge: either in a day unit or in the patients’ homes. The control patients were treated according to ordinary procedures. The main outcome was modified Rankin Scale (mRS), in addition to several secondary outcomes. Patient data were collected at 0, 3 and 6 months after stroke and analysed using regression statistics.

Results:
Baseline characteristics were not different between the groups. 55.2 % of the patients were male and 44.8 % female, with a mean age of 69.8 years (males) and 75.5 years (females). On follow-up all the groups performed well with mean mRS of 2.36/2.32 (3/6 months), mean Barthel Index of 86.7/87.5, and mean NIHSS of 3.05/2.55. There were only minor differences between the groups, but the home treatment-group did a little better at both time points. Detailed results will be presented at the conference.

Interpretation:
Although differences between groups did not reach statistical significance, ESD performed at least as well as ordinary treatment and best with the home rehabilitation group. This demonstrates that early discharge is safe in the present context. Most previous studies were conducted 1-2 decades ago when thrombolysis had not been introduced and prophylactic treatment was less developed than today, and this may partly explain the more uniformly good results now.
Abstract TP32: ‘ABC/2’ Method for Stroke Measurement has Excellent Intra-Class Correlation for Different Modalities and Raters
Authors: Janjua Nazli , Smolak Alex , Bulic Sebina , Diaz Kardelina , Tan Kay Sin , Linden Craig
Published: March 2022

BACKGROUND:
The ‘Revascularization in Stroke Based on Clinical-Diffusion Mismatch’ study will evaluate the safety of endovascular therapy for stroke patients beyond 8 hours from onset. The inclusion criteria include diffusion weighted magnetic resonance imaging (DW-MRI) stroke lesion volume </=25 mL3. To apply this criterion in practice, measurement techniques easily performed by any clinician, such as the ‘ABC/2’ formula for intracerebral hemorrhage (ICH), are needed. This has been validated against planimetry for middle cerebral artery (MCA) infarction on DW-MRI. We sought to evaluate the inter-rater reliability between raters and the correlation between different ABC/2 formulas for lesions on DWI-MRI and CT.

METHODS:
CTs and DWI-MRIs of stroke and hemorrhage patients were screened to select a sample of lesions in the cerebral cortex, subcortex, basal ganglia, brainstem, and cerebellum for each group (CT hemorrhage, CT stroke, DW-MRI stroke). Three raters then measured lesion volume as follows: (AxBxC)/2, where A= largest linear lesion diameter in centimeters (cm) on a single slice; B=largest linear diameter perpendicular to A (cm); C=counts between lesion slices multiplied by slice thickness in cm. The ‘adjusted ABC/2’ formula for ICH weights each scan slice by proportion of hemorrhage to the index slice. To evaluate differences between these techniques, a single rater evaluated each lesion using each of the formulas. Measurements were examined through the intraclass correlation (ICC) statistic, to give a composite score of intra-observer and inter-observer variability. The ICC was tested for being significantly different from 0 yielding the reported p-value (1 indicates good ICC).

RESULTS:

CONCLUSION:
The ABC/2 method has excellent ICC on DW-MRI and CT for different examiners, lesions, and locations as well as minimal variability between different formulas. This may be an alternative to computer planimetry for triage of stroke patients in future studies.
Abstract TP320: Do Aspects Or Profiles Of The NIHSS Predict Post Stroke Spasticity?
Authors: Wein Theodore , Sucharew Heidi , Gillard Patrick , Manack Aubrey , Alwell Kathleen , Moomaw Charles , Woo Daniel , Khatri Pooja , Flaherty Matthew , Adeoye Opeolu , Ferioli Simona , Kleindorfer Dawn , Kissela Brett
Published: March 2022

Introduction:
Post stroke spasticity (PSS) is a debilitating complication after stroke. Despite its significant impact, little is known regarding predictors of PSS. We explored the predictive value of aspects of the NIHSS after ischemic stroke (IS).

Methods:
A cohort of IS subjects from2005 was prospectively enrolled in an outcomes study. For each patient, we extracted baseline retrospective NIHSS values. Presence/absence of PSS was assessed at 3 months, 1 and 2 years(yrs). Each NIHSS item was dichotomized to any abnormal symptoms vs normal. Baseline demographics & previously identified risk factors for PSS were extracted from the database. Multiple logistic regression analysis with generalized estimating equations to account for repeated measures over the follow up period was used to examine associations between PSS and NIHSS items. Potential covariates - age, race, gender, smoking status, history of depression, & total NIHSS score- remained in the final model if significant at p<0.05. Models were run separately for each NIHSS item.

Results:
Of 460 IS patient’s, 365 (79%) had PSS data & were included in this analysis; 274 patients (75%) did not report PSS status during follow up. Of 91 patients with PSS, 54 reported PSS at 3 months, 43 at 1 yr, & 31 at 2 yrs. The NIHSS items most predictive of PSS were abnormal motor function present in: left arm (OR= 1.68, 95%CI 1.04, 2.70); left leg (OR=1.72, 95%CI 1.07, 2.75), & sensory loss (OR=1.75, 95%CI 1.07, 2.85). Multivariable models adjusting for age & total NIHSS score, left leg (adj OR=1.67, 95% CI 1.02, 2.71) remained significant; with a trend for left arm (adj OR=1.61 95% 0.99, 2.62). Age was associated with PSS (OR=0.97 95%CI 0.96, 0.99), & patients with sensory loss were younger (mean age± (SD) yrs= 62 (13) vs 69 ± (14), p <0.01). After adjusting for age, sensory loss was no longer a predictor of PSS (adj OR: 1.54, 95%CI 0.93, 2.54).

Conclusion:
This analysis demonstrated that among items of the NIHSS, left leg and left arm motor dysfunction were predictive of later PSS. This may reflect anatomical differences between the hemispheres or a potential enrollment bias. Sensory loss alone was also associated with later PSS but is also highly associated with age.
Abstract TP326: Incremental Cost of an Individualized Telephone Intervention for Stroke Caregivers
Authors: Morrison Gwendolyn C , Jessup Nenette , Bakas Tamilyn
Published: March 2022

Background/Purpose:
Informal care represents a substantial part of total lifetime care costs for stroke patients; yet, the literature has focused on the costs of tertiary care for stroke patients. The purpose of this study was to estimate the cost of a nurse-led individualized Telephone Assessment and Skill-building Kit (TASK) intervention compared to one in which a nurse actively listened, and paraphrased the ASA pamphlet on caregiving.

Methods:
A sample of stroke caregivers were randomly assigned to one of two phone interventions: the individualized TASK intervention or information, Support and Referral (ISR). This analysis uses the first 50 caregivers assigned to each of the two interventions. Following a template designed in the pilot study, we included the costs of training and supervising nurse interveners, intervention (preparation, delivery and wrap-up), materials for caregivers and caregiver time (for phone calls and material review).

Results:
Average cost for the intervention was $173 for the TASK group and $110 for the ISR group; materials for caregivers and caregiver time costs were $116 for TASK and $42 for ISR. Training and supervising nurse interveners cost $144 per care giver in the TASK group and $75 for the ISR group. We estimate that, for 9 calls to caregivers, the TASK intervention cost was $433 per caregiver while the ISR cost $227 per caregiver_$48 and $25 on a per call basis, respectively.

Conclusions:
For 50 caregivers, the incremental cost per caregiver for TASK relative to ISR was $206, of which, $69 was for training and supervising nurse interveners. Average costs (ie, costs per caregiver) associated with training and supervising, can be expected to decrease as the number of caregivers served increases, unless there is high attrition among nurse interveners. Consequently we expect that the incremental cost per caregiver will decrease as more caregivers are served. The estimated costs can be used in a future cost-effectiveness analysis, and also provide insight into the extent to which average costs can be reduced.
Abstract TP329: Patient Transfer Check Off Decreases Fall Rate on Stroke Unit
Authors: Ashcraft Susan , Coon Linda , Bussey Cindy , Cargal Jamie , Allred Ashley
Published: March 2022

Background and Issues:
Protecting stroke patients from falls and injury is fundamental to providing exceptional care. An increased risk for falls has been recognized among persons with diagnoses of stroke and other neurological disorders. Our Stroke Unit’s comprehensive fall prevention program, while helpful, did not adequately identify stroke patients who would fall. While instituting video monitoring of patients at high risk for falls provided a 20% reduction in fall rate, stroke patients evaluated at low and moderate risk continued to fall.

Purpose:
The purpose of our practice change was to determine if implementing high risk measures on all patients admitted to a stroke unit until demonstration of five safe transfers would decrease the number of patient falls.

Methods:
Utilizing a shared responsibility model, our Stroke Unit engaged all staff members in the falls prevention program. Each patient was evaluated using the current falls risk assessment tool. If the patient was scored high risk, full falls prevention measures were maintained. For patients scoring low to moderate risk, a safe patient transfer check off procedure was implemented. Each patient was monitored five times to ensure independent demonstration of all aspects of transfer without support. Upon five safe transfers, the patient’s bed alarm could be shut off and general fall preventative measures maintained. Unit secretaries checked the bed alarm system twice a day to monitor proper activation of alarms. A report was created representing the retrieved information for the charge nurse. The charge nurse followed up with nurses whose patient alarms were not on and ensured proper activation.

Results:
Since implementation of the safe patient transfer check off, we have seen an additional 33% reduction in fall rate compared to our post-implementation of video monitoring rate (3.48/1000 patient days compared to 5.20/1000 patient days). There were zero falls for patients who were successfully checked off on safe transfers.

Conclusion:
Implementing a safe transfer check off for mild to moderate fall risk patients on a Stroke Unit may be a successful strategy to prevent falls and fall related injuries. Engaging all staff members in the program increased awareness of the importance of falls prevention.
Abstract TP336: Sustaining Excellence in Alteplase Administration in the Emergency Department: Staying Lean
Authors: Williams Jennifer , Panagos Peter , McCammon Craig , Ford Andria , Heitsch Laura , Tan David , Khoury Naim
Published: March 2022

Background:
Identification and treatment of acute ischemic stroke (AIS) patients in the emergency department (ED) was reorganized in January 2011 using Lean Methodologies. The team achieved initial success post implementation in March 2011 of median time to treatment of 34 minutes. Sustaining the improvements required a shift in paradigm of the ED Acute Stroke Committee (EDASC) and the front line staff caring for the patients. Pre-Lean door to treatment time was 60 minutes (N=132).

Methods:
Lean methodologies were chosen as a process improvement strategy. Initial implementation demonstrated immediate success of reaching 34 minutes; however in the first quarter following the implementation, the team identified drift in the process and increased numbers of stroke activation evaluations. Individual case review at monthly meetings demonstrated intermittent role confusion, complex patient presentations, inconsistency in process for alteplase preparation and patient preparation. While the team historically discussed these issues, the expectations had been raised to sustain the critical changes. Identification of individuals in each case for role clarification, general nursing education regarding alteplase preparation, reinforcement of bolus administration as a priority and the addition of point of care testing to decrease barriers enabled the front line staff to receive timely feedback and rapid practice corrections.

Results:
The initial protocol changes were implemented in March 2011. Team reviews with rapid (less than 48 hour) feedback were implemented in April 2011. Point of care testing was implemented in September 2011 for PT/INR testing. Median time to treatment increased to 51 and 48 minutes in April and May 2011. Through drill down review, communication of expectations and progress, and addition of point of care testing the post implementation median time is currently 39 minutes (N=120) for 2011 and 2012.

Conclusions:
Rapid process improvement using lean tools creates opportunities to radically alter a process of care. Sustaining the changes requires rapid attention to process defects, identification of additional opportunities for improvement and individual accountability to the process.
Abstract TP348: Crytogenic Stroke and Paroxysmal Atrial Fibrillation: Criteria for Long Term Cardiac Monitoring
Authors: Yarbrough Karen , Matthews Joyce
Published: March 2022

Background:
Cryptogenic stroke represents 30% of all ischemic strokes. Undetected atrial fibrillation may be a cause of cryptogenic stroke and may lead to ineffective secondary stroke prevention. Long term cardiac monitoring assists in identifying atrial fibrillation. The purpose of this performance improvement project was to develop a protocol for long term cardiac monitoring for patients with cryptogenic stroke.

Methods:
Stroke faculty, cardiology and stroke nurses developed a protocol for long term cardiac monitoring. A 14 day “event monitor” is placed electronically on day of discharge. Inclusion and exclusion criteria were identified. Inclusion: diagnosis stroke/TIA; EKG has not shown atrial fibrillation/flutter; vascular imaging of the extracranial and intracranial circulation excludes significant large vessel occlusive disease; evidence of abdominal or pelvic embolic on CT scan; echocardiography excludes thrombus or structural heart disease. Exclusion: documented atrial fibrillation/flutter; etiological diagnosis for the qualifying stroke/TIA event has been determined, i.e. probable small-vessel disease, probable large vessel disease, arterial dissection, venous sinus thrombosis, hypercoagulable states; echocardiography reveals indication for long-term anticoagulation; absolute indication for oral anticoagulation therapy; contraindications to oral anticoagulation therapy.

Results:
This protocol was effective in providing patients with long term cardiac monitoring. Patients are scheduled in the stroke discharge clinic for diagnostic review.

Conclusions:
This protocol assists in identifying patients who have paroxysmal atrial fibrillation and need anticoagulation for secondary prevention. The following process improvements are needed: 1) process for follow up, 2) improve communication with PMD, 3) improve transition of care when patients are transferred to rehabilitation, 4) costs can be prohibitive and, 5) 14 days may not be effective in detecting atrial fibrillation.
Abstract TP354: Inpatient Code Stroke Team Improves IV-tPA Treatment Rates and Decreases Time to IV-tPA
Authors: Rucho Mary E
Published: March 2022

Background and Purpose:
It is thought that with an in-hospital stroke the care would be better and quicker than if not in-hospital. Cumbler et al, suggests that in-hospital strokes are under recognized or under reported and that the evaluation times are twice that of the recommended 25 mins.(1) . The purpose of the present study was to assess whether this observation was valid with a defined care protocol for inpatient ischemic stroke.

Methods:
Retrospective analysis comparing 12 months of in-hospital stroke care as compared to 12 months following initiation of Inpatient Code Stroke Team of inpatient Code Strokes at a University teaching hospital. 2010-2011 had 31 activations with 10 diagnosed strokes. 17 diagnosed strokes. 2011-2012 had 72 activations. Areas of analysis were; number of Code Stroke activations, activation of Code Stroke to CT times, rates of IV-tPA administration and time of activation of Code Stroke to time of IV-tPA.

Results:
There was a 132 % increase in Code Stroke activations. Administration of IV-tPA increased by 5%. The median time of activation to CT increased by 5 minutes and the median time of activation to IV-tPA decreased by 7.5 minutes.

Conclusions:
Utilizing a multidisciplinary, multimodal approach. increased the rate of IV-tPA and decreased the median time to IV-tPA administration. Through continuous assessment and follow-up we continue to fine tune the Inpatient Code Stroke Team. Larger prospective studies are needed to assess patient outcome as well as decreasing time to Thrombolysis. l 1. Cumber
et al
Stroke. 2011 Jan;42(1):207-10. Epub 2010 Dec 2.
Abstract TP355: Supporting and Sustaining Systems Change Through the Development of Common Standards of Stroke Care
Authors: Quant Sylvia , McKellar Jocelyne , Cheung Donna , Linkewich Elizabeth
Published: March 2022

Background/Issues:
The Stroke Flow initiative is a system-wide redesign of stroke services to enhance access to stroke best practices. Specifically, its focus is to ensure access to acute stroke units and timely and appropriate rehabilitation. To support this work, the Toronto Stroke Networks (TSNs) held forums with stroke nursing leaders (SNLs) within the Greater Toronto Area (GTA).

Purpose:
Through these forums, the purpose of this work was to develop evidenced-informed common standards of stroke care across the continuum and set priorities for implementation within the GTA.

Methods:
Six forums (from December 2011 to June 2012) were held for 43 SNLs from 16 acute and rehabilitation hospitals within the GTA. Using an appreciative inquiry approach, meetings focused on: 1) identifying common core elements (CCEs) for stroke care; 2) validating CCEs through consultation with interprofessional stroke teams; 3) forming consensus on CCEs; 4) identifying organizational priorities for implementation planning using thematic analysis; 5) integrating CCEs into existing processes of care; and 6) sustaining this work through the establishment of a stroke community of practice.

Results:
Through collaborative planning, CCEs were developed and reflect current and emerging best practices. Preliminary results from thematic analysis identified priorities related to: transitions of care, improved team communication processes, patient/family education, and integration of outcome measures across the care continuum.

Conclusions:
Common core elements of stroke care were collectively developed by the TSNs, stroke nursing leaders, and interprofessional teams to promote a standardization of stroke care that integrates best practices and identifies areas for improvement. Impact of this work has led to the development of CCE documents to support the integration and standardization of stroke care and the establishment of a stroke nursing community of practice. Final thematic analysis is currently underway to further identify priorities for implementation.
Abstract TP366: Implementation of an Interdisciplinary Code Stroke Protocol to Facilitate Consistent Evidence Based Assessment and Treatment of Stroke Patients
Authors: Gentry Candace , Baptista Joy , Brown Kevin , Chesney Shannon , Dickerson Bonnie , Couch Barbara , Lamay Edward , Linens Gale , Mentler Philippe , Stell Tracy , Whitney David , Woody Regina
Published: March 2022

Introduction:
A shorter door-to-TPA time reduces stroke mortality and risk of hemorrhagic conversion. Although the Brain Attack Coalition recommends a goal of door-to-TPA in 60 minutes for 80% of ischemic stroke patients, the Joint Commission reported less than 29% of TPA eligible patients met this goal in CY2010. To meet these targets without 24 hour neurology coverage, we examined and changed processes, developed a team-oriented Code Stroke protocol, and compared FY2010 baseline to 9 consecutive months of door-to-TPA times for eligible patients and “ideal” TPA candidates.

Methods:
Our Stroke Taskforce, of more than six departments, used the Six Sigma DMAIC methodology to map acute stroke processes and look at delays in assessment, testing, medication dispensing and through-put. Stroke symptom education was provided to EMS, hospital security, triage technicians, nursing and nursing assistants. Each department had a list of responsibilities to facilitate the protocol. De-briefings occurred after each code stroke to examine process deficiencies. Data was reviewed monthly.

Results:
Process evaluation identified inefficiencies (e.g., lab notified of “Code Stroke” blood samples; replaced an old centrifuge in the laboratory which decreased spin times of coagulation studies and processing time). Protocol implementation included EMS advanced notification and an ED physician-initiated “Code Stroke” algorithm involving the House Supervisor, IV room pharmacy, CCU charge nurse, CT charge technician, On-call Neurologist, and the care nurse. Implementation phase (11/2010-07/2011) mean door-to-TPA time was 74.6 ± 24.6 minutes (range 35-119) for 13 patients compared to baseline (07/2009-06/2010) mean of 105.4 ± 28.6 minutes (range 59-151) for 10 patients. Mean door-to-TPA time for the nine ideal” patients (obvious stroke symptoms on admission; no intubation, sutures, or IV drip for blood pressure control) was 61.3 minutes. Improved stroke symptom recognition and expedited test results were also found for non-TPA candidates.

Discussion:
Our systematic team approach with delineation of responsibilities decreased door-to-needle times for our stroke population and improved timeliness of results for all acute stroke patients.
Abstract TP367: Enhancing Patient Safety with Improved Monitoring following Cerebral Angiography
Authors: Donnelly Rose M , Burns Jo-ann
Published: March 2022

Background and Issues:
In a Primary Stroke Center, which admits 1200-1300 stroke patients annually, cerebral angiography is a frequently performed diagnostic test. Frequent monitoring is important to evaluate for complications following the procedure. In 2009, the documentation compliance with site checks and vital sign monitoring was 58% and 78% respectively. Poor communication was occurring at change of shift regarding status of monitoring which resulted in lack of continuation with monitoring.

Purpose:
The goal of this project was to increase compliance with monitoring and documentation in order to enhance patient safety.

Methods:
In 3rd Quarter of 2009, education was rolled out to all RNs and Patient Care Technicians regarding the importance of monitoring and compliance with physician orders. A worksheet was developed to assist in determining the times when monitoring was due. This worksheet was handed off to the next shift and discussed in bedside shift report. All monitoring was to be documented in the electronic medical record. In 2010, a signature requirement was added to the worksheet for accountability.

Results:
Compliance rates in 2010 were 81% for site checks and 91% for vital signs. Compliance rates in 2011 increased to 92% for site checks and 93% for vital signs.

Conclusions:
A simple worksheet, for nurses to use with monitoring, improved the communication and handoff from nurse to nurse. Post cerebral angiography patient monitoring increased which improved patient safety.
Abstract TP372: Stroke Patients Transported To A Primary Stroke Center More Likely To Receive Intravenous Tissue Plasminogen Activator
Authors: Sen Souvik , Hawsey Kelly , Burdine Joselyn , Kowalczyk Hannah E , Sumner Roxanne , Finney Chris , Brown Jordan , Heidari Khosrow
Published: March 2022

Background:
South Carolina (SC) is located in the “buckle” of the stroke belt with one of the highest stroke death rates in the country. In 2010, SC had 66 acute care hospitals caring for strokes, nine of which were certified primary stroke centers (PSC). The rate of intravenous tissue plasminogen activator (IV-tPA) use and its correlates have not been investigated in the state.

Objectives:
To study the rate of IV-tPA use and its correlates using the statewide hospital discharge records stored at SC Department of Health and Environmental Control (DHEC), for the calendar year 2010.

Methods:
A retrospective analysis was conducted of the statewide hospital discharge records stored at SC DHEC, for the calendar year 2010. Patients with a discharge diagnosis of ischemic stroke were included in the analysis. Variables considered included patient demographics, insurance status, location/type of destination hospital, and treatment with IV-tPA.

Results:
In the calendar year 2010, 10,377 hospitalized patients in SC were assigned a primary discharge diagnosis of ischemic stroke. Of these, 4.2% (442) were treated with IV-tPA. Those who were treated with IV-tPA were younger (mean age ± standard deviation=66.7 ± 14.4, p=0.002) compared with those who did not receive IV-tPA (68.8±13.6). Patients treated at a PSC (49% of all ischemic stroke patients) were more likely to receive IV-tPA (Odds Ratio or OR 4.0, 95% CI 3.2-5.0).Patients treated in hospitals located in urban counties were more likely to receive IV-tPA compared to those treated in rural counties (OR 1.3, 95% CI 1.1-5.3). On multivariate logistic regression analysis, patients treated at a PSC (Adjusted OR 2.2, 95% CI 1.9-2.5) and those treated in urban counties (Adjusted OR 1.4, 95% CI 1.1-1.8) independently increased the likelihood of receiving IV-tPA. Gender, race and insurance status did not significantly change the likelihood of receiving IV-tPA.

Conclusions:
Younger stroke patients, treatment in a PSC and hospitals located in an urban county increased the likelihood of receiving IV-tPA. Increasing community awareness of PSCs, their location and designation may increase the rate of IV-tPA use.
Abstract TP379: The Relation Between Destination on Hospital Discharge and Final 3 Month Disability Outcome in Acute Ischemic Stroke
Authors: Zhang Qihui , Saver Jeffrey L
Published: March 2022

Background:
The cardinal outcome measure of acute stroke clinical trials is final global disability at 3 months post-stroke. However, in routine practice it is not possible to obtain a 3 month modified Rankin Scale score in all encountered patients. The most similar variable available in administrative datasets, for use in local, regional, and national quality improvement activities, is discharge destination at end of the acute hospitalization. The relation between discharge destination and final 3 month outcome has not been previously well delineated.

Methods:
We analyzed the public dataset of the two NINDS-TPA trials. Hospital discharge destination (HDCHG) was characterized as home, acute rehabilitation, skilled nursing facility, or in hospital death and handled as a 4 level ordinal variable. Hospital length of stay (LOS) was also analyzed. Final global disability at 3 months was assessed using the modified Rankin Scale (mRS). Correlation coefficients and multiple linear regression models were used to probe the relation between outcome measures.

Results:
Among the 624 acute ischemic stroke patients, hospital discharge destination was home in 42.1%, acute rehabilitation in 33.0%, skilled nursing facility in 9.8%, and in hospital-death in 15.1%. A strong correlation was noted between hospital discharge destination and 3 month mRS global disability scores, r=0.71, P<0.0001. Length of stay showed a weaker correlation with 3 month mRS, r = 0.29, p <0.0001. HDCHG performed well as a single variable in predicting dichotomized 3 month mRS (independent vs dead or disabled, 0-2 vs 3-6), with c-statistic of 0.86. The multivariate model identified 9 independent predictors of 3 month global disability outcome, with HDCHG as the strongest independent variable, and LOS and the interaction term HDCHG x LOS also selected.

Conclusion:
Discharge destination at the end of initial hospitalization for acute ischemic stroke is a potent predictor of final 3 month global disability outcomes. Multivariate models enable comparison of discharge destination outcomes in administrative datasets with final disability outcomes in pivotal clinical trials.
Abstract TP38: Improved Infarct Prediction After Acute Ischemic Stroke: A Priori Infarct Probability Defined By Site Of Vessel Occlusion Can Be Combined With Infarct Likelihood-ratios Based On Ct Perfusion Imaging
Authors: Kemmling Andre , Kamalian Shervin , Souza Leticia , Lev Michael H , Fiehler Jens , Forkert Nils
Published: March 2022

PURPOSE:
CT-perfusion (CTP) is frequently used in acute stroke imaging, however, there is need for further standardization for reliable quantification of tissue at risk. Using a global threshold to predict infarct is not precise. Proximal branch occlusion, is an important predictor for outcome. The purpose was to present a holistic stroke imaging approach by combining CTP maps with a priori infarct probability defined by site of vessel occlusion to improve prediction of infarct.

METHOD AND MATERIALS:
A novel method is presented to derive CTP based images displaying voxel-wise probability of infarction: 1) In 105 MCA occlusive stroke, voxel-wise sensitivity and specificity for infarction for incremental perfusion thresholds was measured with respect to tissue lesion maps at 48h. CT perfusion parameters in CTP images were converted to likelihood ratios defined by sensitivity/(1-specificity). Thus, the discriminative power for every perfusion value with respect to tissue outcome was directly encoded within the perfusion image. 2) A probabilistic a priori map in standard space based on 103 non-recanalized distal M1-MCA occlusive strokes at 48h after onset was generated. Lesion-masks were registered to standard MNI-152 space. 3) The pre-test probability map for M1-occlusive strokes was transformed to CTP space and multiplied by the CTP based likelihood ratio to obtain a post-test map displaying voxel-wise probability of infarction.

RESULTS:
In 10 sample cases, infarct probability in admission imaging was displayed and compared to follow up imaging at 48h. Areas of >95% infarct probability correlated very well with actual tissue outcome. In contrast to original CTP maps, the resulting probability map exclusively displays voxels at risk of infarction. Noise was significantly reduced.

CONCLUSION:
Infarct prediction can be improved combining CT perfusion maps with a priori infarct probability defined by site of vessel occlusion. Further studies are warranted.
Abstract TP394: Who Does It Better? Stroke Outcomes for Comprehensive versus Primary versus Stroke Support Facilities.
Authors: Censullo Joan , Chiu David
Published: March 2022

Background:
Tiered levels of stroke care have developed out of population need and have capabilities that range from centers with no specialized stroke care, to stroke care support centers (SSC), Primary Stroke Centers (PSC), and Comprehensive Stroke Centers (CSC). However, the stroke outcome advantages of Comprehensive Stroke Center care remain to be proven. This study is the first to investigate whether advanced stroke care capability translates to improved patient outcomes.

Methods:
51 months of regional hospital data (n=32,740) from the Solucients
®
data base was reviewed. Descriptive, univariate and multivariable techniques were used to analyze outcomes against stroke center designation on STATA 11.0 software.

Results:
For ischemic stroke, there were no statistically significant differences among stroke centers for mortality, complication, length of stay (LOS), and 30 day readmissions. CSCs and PSCs were 5.67 (p<0.001) and 2.15 (p<0.001) times more likely to administer thrombolytic treatment than stroke support and non designated centers. For hemorrhagic stroke, there were no statistically significant differences in complication and 30 day readmission rates among the different tiers. Hemorrhage mortality risk was higher at CSCs (OR=1.5, p= 0.037) and PSCs (OR=1.58, p= 0.016). Hemorrhagic stroke LOS was lower for all stroke center designations compared to non designated centers. CSCs and PSCs were associated with increasingly dependent discharge dispositions (coef= 0.227, p<0.001, coef=0.202, p<0.001, respectively).

Conclusions:
Ischemic stroke patients were more likely to receive thrombolytic treatment at Primary and Comprehensive stroke centers, but not more likely to die or experience complications or readmissions. The tertiary referral status that PSCs and CSCs serve for lower-tiered stroke treatment centers may explain the higher rate of discharge to long-term/ dependent care facilities from PSCs and CSCs.
Abstract TP402: TIA Evaluation - Is Hospitalization Really Necessary?
Authors: Sheta Mohamed A , Hwang Shirley S , Hwang Michael Y , Armour Florence , Holland Neil R
Published: March 2022

Objective:
A transient ischemic attack (TIA) is a major risk factor for a future disabling stroke. This risk can be lowered by the immediate evaluation of stroke risk factors and rapid intervention. TIA patients are generally admitted to the hospital for this evaluation, but this can take several days, and even then, their evaluation may be incomplete. We have started an outpatient open-access TIA rapid evaluation center at our medical center for comprehensive determination of stroke risk factors. We conducted a retrospective utilization and outcome review of all TIA patients hospitalized at our medical center over the last four years to help validate our new outpatient model.

Methods:
We identified 398 patients admitted with either an admission or discharge diagnosis of TIA, reviewed their charts to calculate an ABCD2 score, for diagnostic testing and treatment, and then checked for readmissions within the subsequent 90 days for further TIAs or stroke.

Results:
Only 5% of our patients admitted with TIA had recurrent cerebrovascular events within 90 days, none during their initial hospitalization. Despite a mean three-day length of stay, not all TIA patients underwent the complete diagnostic evaluation we are offering in our outpatient center. The ABCD2 score correlated with subsequent TIA and stroke, and in particular an ABCD2 score of 6-7 indicated a higher stroke risk.

Conclusion:
Recent TIA patients, particularly those with an ABCD2 score of 0-5, can be safely and more expeditiously evaluated as outpatients.
Abstract TP404: Applying ARISTOTLE Trial to Actual Practice
Authors: Amin Alpesh , Stokes Michael , Wu Ning , Gatt Elyse , Makenbaeva Dinara , Wiederkehr Daniel , Boulanger Luke
Published: March 2022

BACKGROUND:
Clinical event rates may differ among patients treated in real world (RW) clinical practice compared to patients enrolled in randomized controlled trials (RCTs).

OBJECTIVE:
To estimate the absolute effect of apixaban compared to warfarin on stroke and major bleed rates in a managed care, nonvalvular atrial fibrillation (NVAF) population.

METHODS:
We selected patients with a diagnosis of NVAF during 2007-2010 from Medco health plans. Pharmacy claims were used to define periods of warfarin exposure. Strokes and major bleeds were identified using diagnosis codes on the medical claims, and their rates were calculated during warfarin exposure. Estimated real world event rates for patients treated with apixaban were calculated by applying the ARISTOTLE relative risk reductions (RRRs) to the reference RW rates observed during warfarin exposure. Absolute risk reductions and associated number needed to treat (NNT) or number needed to harm (NNH) relative to warfarin were calculated using the estimated RW event rates.

RESULTS:
The RW population had a mean age of 74.9 years and mean CHADS
2
score of 2.8. Stroke and major bleeding event rates among NVAF patients treated with warfarin in RW were higher compared to those enrolled in ARISTOTLE clinical trial (Stroke: 5.61 vs. 1.51 per 100 PYs; Major Bleed: 11.14 vs. 3.09 per 100 PYs). Similarly, we estimate the absolute stroke and major bleed rates observed in the RW for apixaban would also be higher compared to the RCT (Stroke: 4.43 vs. 1.19 per 100 PYs; Major Bleed: 7.68 vs. 2.13 per 100 PYs). At the same time, the use of apixaban instead of warfarin would be associated with lower NNTs in order to prevent a stroke (85 vs. 313) and a major bleed (29 vs. 105) in the RW vs. RCT.

CONCLUSIONS:
The numbers needed to treat to avoid a stroke and major bleeding with apixaban instead of warfarin in the real world are likely to be substantially lower than in a randomized controlled trial setting.