bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP219: Can Pre-hospital Intervention Improve Rural Stroke Care?
Authors: Brown Aliza T , Vrudny David , Adolph Sharada S , Culp William , Balamurugan Appathurai
Published: October 2018

Background:
In the stroke belt, local rural hospitals have reported 29 - 32% tissue plasminogen activator (tPA) treatment within 60 minutes for ischemic strokes. Since 2008, telemedicine has improved the door to treatment time from 120+ minutes to 70 minutes. A six month pilot program was initiated to determine the feasibility of a pre-hospital intervention to reach the American Stroke Association (ASA) target of 50% treatment within 60 minutes. Nine rural hospital sites were designated as Stroke Ready Hospitals (SRHs). Local emergency medical service (EMS) providers to these sites received additional education to evaluate and transport suspected stroke patients to the SRH in their area. The study also evaluated the early acute hospital patient care for improvements in treatment rates and data reporting at each SRH site.

Hypothesis:
Within six months, the SRHs will have 30-50% improvement rates in pre-notification by their local EMS providers and these will correspond to decreased triage time.

Methods:
This study assessed the benefit of early pre-notification by local EMS providers on decreased time to treatment and improved triage time as an improved process of care after implementation in nine SRH designated sites. To measure improvements in time to treatment and treatment rates, we compared time and treatment rates before (baseline was 11 months pre-study) and after study implementation in the same hospital sites.

Results:
A total of 6,049 transports were made by the EMS services with 117 patients suspected as strokes. A medical public safety answering point (PSAP) communication network provided stability in EMS data acquisition and stroke code notification to SRHs. The study showed improvements in mean triage and transport time vs. baseline (30.7 vs. 74 min, n=48 and n=22, respectively), Door to CT time vs. baseline (21 vs. 26 min, n=151 and =218, respectively) and Door to tPA time vs. baseline (65 vs. 78 min, n=13 and =22, respectively). While the ASA goal of 50% was not met, the % of treated ≤ 60 min increased from baseline at 24.8 to 38%. Pilot study code stroke % pre-notification increased from 38 to 69%.

Conclusions:
Pre-hospital intervention with local EMS providers improved pre-notification, first medical contact to CT time and the arrival time to treatment.
Abstract TP220: TIA Referral Influences Delay of Evaluation in TIA Clinic
Authors: Raposo Nicolas , Albucher Jean Francois , Rousseau Vanessa , Sommet Agnes , Calviere Lionel , Viguier Alain , nasr nathalie , Bonneville Fabrice , Chollet Francois , Olivot Jean Marc
Published: October 2018

Background:
Transient ischemic attacks and minor stroke are vascular emergencies associated with a high risk of brain infarction within the first hours after onset. When available those patients may be evaluated and managed in a TIA clinic. Several therapeutic strategies are currently tested within 12 hrs after TIA/minor stroke onset. We aim to investigate the factors associated with a delay of evaluation longer than 12 hours in our TIA clinic.

Subjects and Methods:
Subjects are consecutive patients evaluated in an academic center TIA clinic during 2 years. Briefly patients were evaluated by a certified stroke neurologist according to 2009 AHA recommendations including MRI, vessel imaging, blood tests, EKG and when needed TTE/TEE. Referring pathways were dichotomized between office based physicians (General practitioners, others:cardiologists, ophtalmologists, ...) and Emergency medical service (local and from other hospital with no neurologists). Univariate and multivariate logistic regression were performed.

Results:
354 patients were evaluated in 2 years. Mean (+/- SD) age was 61 YO (18), Median (IQR) ABCD2 score was 3 (2-4); median (IQR) delay from onset to evaluation was 8 hours (4-48), 59% of patients did arrive in TIA clinic within 12 hours after onset. 52% were referred by an office based physician (36% general practitioner and 16% others) vs. 48% by ED (32%,local ED and EMS 16% other ED) Univariate analysis showed that ABCD2 score<4 and office based physician referral were associated with a delay>12 hrs. There was no relationships with other factors such as risk factors, previous history of stroke or recurrent TIA. Office based physician referral was the only independent factor associated with a delay of evaluation > 12 hrs OR 5.7, (95%CI:3.5-9.3, p<0.0001) after multivariate logistic regression.

Conclusion:
Direct referral from ED increases the rate of patients starting their evaluation in TIA clinic within 12 hrs after onset.
Abstract TP226: Vision, Aphasia, Neglect Assessment for Predicting Large Intracranial Hemorrhages requiring Neurosurgical Intervention
Authors: Navalkele Digvijaya , Martin-Schild Sheryl
Published: October 2018

Introduction:
Vision, aphasia, and neglect (VAN) assessment is a novel screening tool for identifying large vessel occlusion (LVO) in acute ischemic stroke (AIS) patients. We hypothesize that this tool will also aid in predicting large intracranial hemorrhages (ICH) that require neurosurgical (NS) intervention.

Methods:
Retrospective data from a prospectively collected dataset was reviewed for all the ICH patients from year 2008 to 2015. ICH presenting more than 24-hrs after symptom onset and missing NIHSS at arrival were excluded. VAN assessment was calculated based on the components of NIHSS. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of VAN for identifying any NS procedure (including ventriculostomy) and open NS procedure (craniectomy and/or clot evacuation) were calculated.

Results:
Of the 228 ICH patients, 176 (77%) were VAN positive, 65 patients (28.5%) required any NS procedure, and 24 patients (10.5%) had open NS procedure. VAN had a sensitivity of 88% and a low specificity of 27%. Although a low PPV 32%, VAN had a high NNP 85%. Odds of neurosurgical intervention were 2.6 times higher if patients were VAN positive (OR 2.6 (1.102-6.509); p = 0.022). For open NS procedure, the sensitivity, and NPV were 100%; specificity 25.5% and PPV 13.6%.

Conclusion:
VAN negative ICH patients are unlikely to undergo neurosurgical intervention. Although the PPV is low, the odds of requiring a neurosurgical intervention is significantly higher if VAN positive. Triaging VAN positive patients in the field to high level centers not only captures LVOs in AIS but also large ICH requiring neurosurgical intervention. Prospective study to validate this tool in ICH patients is recommended.
Abstract TP241: Information and Communication Technology Revolutionizes Acute Ischemic Stroke Care
Authors: Yonemori Terutake
Published: October 2018

Background:
Tissue plasminogen activator (t-PA) treatment for patients with acute ischemic stroke requires a considerable number of medical tasks after arriving at the hospital. We designed and developed an Information and Communication Technology (ICT) system to support the processing of these tasks. Our aim was to introduce this system, called “Task Calc. Stroke”.

Methods and System Overview:
“Task Calc. Stroke” consists of ICT technology, such as cloud environments and smart devices. By clicking one button, it broadcasts messages to medical staff in the hospital, and it immediately activates many departments before the patient’s arrival. Required tasks appear on the screen, and the progress of tasks is indicated by color changes. Medical staff can prepare their own tasks before the patient’s arrival.

Results:
We compared the number of times that emergency room (ER) nurses called for computed tomography (CT) or magnetic resonance imaging (MRI) between before and after the introduction of this system. Before this system, ER nurses called for CT or MRI an average 3.8 and 4.2 times, respectively; after this system was introduced, the average number of times decreased to 1.2 and 1.8, respectively. Therefore, this system can improve the efficiency of task management, and the stroke physician can monitor the progress of all tasks and decide when to use intravenous (IV) t-PA.

Conclusion:
“Task Calc. Stroke” could improve treatment times for IV t-PA in many stroke centers worldwide owing to early preparation, cooperation among staff, and recognition of task progression.
Abstract TP249: Sensitivity of “Best Language”,item 9, of the National Institutes of Health Stroke Scale
Authors: Gronberg Angelina , Henriksson Ingrid , Lindgren Arne
Published: October 2018

Background:
The National Institutes of Health Stroke Scale (NIHSS) is a well-known and validated scale to measure the severity of symptoms associated with stroke. NIHSS item 9, “Best Language”, is often used to ascertain initial aphasia, however, data on how well NIHSS item 9 can discriminate aphasia in stroke patients is incomplete. We investigated if NIHSS item 9 is a reliable tool to diagnose patients with aphasia in the acute phase of first-ever ischemic stroke.

Methods:
56 patients with first-ever acute ischemic stroke were included prospectively and consecutively in the Lund Stroke Register Study. Patients were excluded if they had any of the following characteristics: 1) diagnosed dementia or psychiatric disorders; 2) non-native Swedish language; 3) altered consciousness. Patients were assessed within 7 days after stroke onset by a trained research nurse with the NIHSS item 9 followed by a language evaluation with the Language Screening Test (LAST, range 0-15, where 0-14 indicate aphasia) within 24 hours of the NIHSS item 9 assessment, by a licensed speech and language pathologist. Data were analyzed using LAST as a ‘gold standard.’

Results:
Of 56 first-ever ischemic stroke patients (median age 79 years; n=37 female, n= 19 male) 9 patients (16%) had aphasia according to NIHSS item 9 (the distribution of scores 1-3 were n=6, n=1, and n=2, respectively). When using LAST 17 patients (30%) had aphasia (score ≤14) with a median LAST score of 13 (IQR 10-14). The median LAST score for patients with NIHSS item 9 with a score of 0, but LAST ≤ 14 (n= 10) was 14 (IQR 13-14). Assuming LAST as gold standard, NIHSS item 9 gave 10 false negatives for aphasia (LAST scores ranging from 12 to 14) and 2 false positives (both with NIHSS item 9 score of 1) for aphasia, translating into a sensitivity of 34% and a specificity of 95%.

Conclusions:
Our results indicate that the sensitivity of NIHSS item 9 is low compared to more in depth testing by a speech and language pathologist. Using NIHSS item 9 as a diagnostic tool for aphasia after stroke can misclassify patients with mild to moderate aphasia.
Abstract TP257: Fasl Enhances Cytotoxicity of CD8
+
T Cells After Ischemic Stroke
Authors: Zhao Haoran , Meng Hailan , He Dongsheng , Wan Lihua , Xu Yun
Published: October 2018

Introduction:
After the onset of stroke, infiltrated CD8
+
T cells aggravate brain injury through FasL or cytotoxic granules. We previously reported that FasL mutation could attenuate brain inflammation in experimental stroke, however, the exact mechanisms were undefined. Thus, this study tested the hypothesis whether FasL could modulate the cytotoxicity of CD8
+
T cells or not.

Methods:
Middle cerebral artery occlusion was induced in both wide-type (WT) and FasL-mutant (
gld
) mice. Magnetic activated cell sorting was used to isolate CD8
+
T cells from the spleen.
In vitro
, CD8
+
T cells were cocultured with neurons or microglia for 24 hours. In some experiments, FasL neutralizing antibody were used to block FasL on CD8
+
T cells. Flow cytometry and q-PCR were performed to measure the cytotoxicity of CD8
+
T cells and polarization of microglia. Cytometric Bead Array was used to evaluate the inflammatory cytokines in the coculture supernatant. The cell viability of oxygen glucose deprivation (OGD) neurons was measured by lactate dehydrogenase assay and propidium iodide and calcein AM staining.

Results:
CD8
+
T cells were activated and expressed more cytotoxic cytokines when cocultured with microglia. Nevertheless, this induction was attenuated when CD8
+
T cells were pretreated with FasL neutralizing antibody. Meanwhile, FasL mutation or functional block abrogated CD8
+
T cell-mediated killing of neurons and M1 microglia polarization. In addition, the CD8
+
T cell-microglia coculture supernatant contained less pro-inflammatory cytokines and resulted in enhanced cell viability of post-OGD neuron when FasL on CD8
+
T cells was mutant or blocked.

Conclusions:
FasL enhances cytotoxicity of CD8
+
T cells after ischemic stroke.
Abstract TP264: Actin Reorganization is a Rapid and Reversible Adaptive Response by Neurons Exposed to Ischemic and Excitotoxic Injury
in vitro
and
in vivo
Authors: Halpain Shelley , Shih Andrew , Calabrese Barbara
Published: October 2018

In initial stages of ischemic injury, glutamate receptor hyperactivation mediates extensive neuronal cell death. Most of this initial death is due to cytotoxic edema, whereby sodium and chloride entry cause cell swelling. Early subcellular responses to neuronal edema are poorly understood. We observed that actin filaments (F-actin) undergo a dramatic reorganization within the somatodendritic domain of neurons exposed to ischemia and/or sublethal excitotoxicity in vivo and in vitro. Fluorescence imaging was performed on embryonic rat hippocampal neurons cultured for 21-days in vitro. “Ministrokes” were induced in vivo by photothrombosis of a single penetrating vessel in mouse sensorimotor cortex. Animals were fixed 4 or 6 hours after vessel occlusion. Fluorescence images were analyzed in infarct, peri-infarct, and contralateral regions. All experiments were repeated 3-4 times, and quantified in a blinded fashion In control tissue F-actin is concentrated within dendritic spines, with little F-actin in the dendrite shaft. Within 5 min of applying 50μM NMDA, F-actin is lost from spines (inducing spine shrinkage) and polymerizes into long filament bundles within the dendrite shaft and soma. A similar redistribution of actin occurs after oxygen/glucose deprivation in vitro and after stroke in vivo. In vitro these actin changes are reversible within 1-3 hours of transient NMDA exposure. Increased Ca2+ is necessary but not sufficient for iniduction. Conditions that reduce cytotoxic edema prevent actinification; conditions that promote cytotoxic edema induce actinfication. The actin nucleator inverted formin-2 (INF2) was found to mediate dendrite actinification. Pharmacological inhibition of formins but not Arp2/3, completely prevented actinification. Moreover, silencing of endogenous INF2 using shRNA prevented NMDA-induced actinification; overexpression of wildtype INF2 sensitized neurons to actinification. Silencing of INF2 rendered neurons more vulnerable to NMDA-induced cell death. Results indicate that ischemia-induced actin filament accumulation within the somatodendritic compartment is a pro-survival response that protects neurons from death induced by cell swelling.
Abstract TP27: ADAPT Reperfusion With ACE64 and ACE68 is Safe and Effective in Large Vessel Occlusions of the Anterior Circulation - The PROMISE Registry Results
Authors: Schramm Peter , Navia Pedro , Papa Rosario , Zamarro Parra Joaquin , Tomasello Weitz Alejandro , Weber Werner , Fiehler Jens , Michel Patrik , Mendes Pereira Vitor , Krings Timo , Pierot Laurent , Gralla Jan , Santalucia Paola , Lo T.H. ,   PROMISE Trial Investigators
Published: October 2018

Introduction:
Safe and complete recanalization is important to reduce clot burden and determines functional prognosis of patients with cerebral infarction from large vessel occlusions (LVO). The aim of PROMISE is to evaluate the safe and effective use of the aspiration-based Penumbra System with the latest generation of ACE Reperfusion Catheters in a real world population with acute ischemic stroke from anterior circulation LVO, treated with the ADAPT technique in routine practice.

Methods:
The prospective, single-arm, multicenter PROMISE registry evaluated the Penumbra System with ACE64 and ACE68 catheters across 20 European centers. Criteria for inclusion include presentation of anterior circulation LVO within 6 hours of ictus, NIHSS ≥ 2, ASPECTS ≥ 6 and wherein intervention was proceeded with ADAPT as frontline. Primary endpoints include angiographic revascularization to TICI 2b-3, and clinical independence (mRS 0-2) at 90 days. Secondary endpoints include safety events, functional improvement at 7-10 days, procedural metrics and quality of life.

Results:
A total of 202 patients were enrolled for evaluation of this interim analysis. Table I details patient history and baseline characteristics. Prior to endovascular procedure, IV rtPA was administered in 61.9% of patients. A final revascularization mTICI 2b-3 was achieved in 96.5% (194/201), per investigator assessment. Of these, mTICI 3 was achieved in 68.2% (137/201). Mortality was observed in 15 of the 141 (10.6%) patients at this interim analysis. Patient follow-up data collection, including clinical outcome, will be completed by the end of 2017. Core lab adjudicated results will be available at time of presentation.

Conclusion:
Interim analysis of the PROMISE registry demonstrated safe and effective utility of the Penumbra System with the novel ACE64 and ACE68 Reperfusion Catheters using ADAPT as frontline treatment. All follow up visits and final results will be presented at the ISC conference.
Abstract TP272: Effect of the Affordable Care Act on Direct Medical Expenditures Among US Adults With Stroke: 2003-2014
Authors: Lekoubou Alain , Bishu Kinfe , Ovbiagele Bruce
Published: October 2018

Background:
Healthcare expenditures among stroke patients are high and expected to rise over time as the population in the United States ages. However, there are limited contemporary data on the nationwide economic impact of stroke especially in the era of the Affordable Care Act (ACA).

Objective:
To evaluate temporal trends of stroke-related healthcare expenditures before and after the ACA, which was signed into law on March 23, 2010.

Methods:
We identified 9,351(4.2%) adults with stroke aged ≥18 years from 2003-2014 Medical Expenditure Panel Survey (MEPS) data. Stroke was identified using ICD-9 code of 431, 433, 434, 436 and 438 as well as self-reported surveys. We used ‘margins’ post estimation command following the adjusted GLM to estimate the predicted mean of healthcare expenditure for Pre ACA vs Post ACA among adults with stroke.

Results:
Prevalence of stroke in the United States increased from 3.60% in the pre-ACA era to 4.39% in the post-ACA era (P<0.0001). The adjusted predicted mean of healthcare expenditures per year during the Pre-ACA period was $9,653 (95% CI $8,627-$10,679) compared with the Post-ACA period of $9,339 (95% CI $8,153-$10,525) among adults with stroke, which corresponded to a non-significant $317 (95% CI: -$1,161-$525) decrease in healthcare expenditure. On the other hand, pre-ACA vs. post-ACA overall mean healthcare expenditure in the US significantly increased from $5,339 (95% CI: $5,211-5,466) to $5,750 (95% CI: 5,598-5902).

Conclusions:
Direct healthcare expenditures for stroke patients were reduced after the introduction of the ACA, but not to a significant degree. The lack of a significant effect of the ACA on direct stroke expenditures from 2010-2014 may have been due to an increase in the prevalence of stroke, a background increase in overall healthcare expenditures, more time needed to see an effect, or weaknesses in the law itself. Further study is warranted.
Abstract TP284: The Risk of Venous Thromboembolism Among Patients Hospitalized for Acute Ischemic Stroke in the US
Authors: Amin Alpesh , Neuman Richey , Lingohr-Smith Melissa , Menges Brandy , Lin Jay
Published: October 2018

Introduction:
There is a high risk for venous thromboembolism (VTE) among patients hospitalized for acute ischemic stroke. Prophylactic anticoagulant therapy may reduce such risk. The aim of this study was to evaluate the receipt of VTE prophylaxis and VTE risk among patients hospitalized in the US for acute ischemic stroke.

Methods:
Patients hospitalized with acute ischemic stroke from 1/1/2012 to 6/30/2015 were identified from the MarketScan Commercial and Medicare databases. The first of such hospitalization to occur was defined as the index hospitalization. Patients were required to have continuous insurance coverage for the 6 months before (baseline period) and after (follow-up period) the index hospitalization. The proportion of patients who received VTE prophylaxis was determined. Additionally, Kaplan-Meier analysis was used to evaluate VTE risk following the index hospitalization.

Results:
Among patients hospitalized for acute ischemic stroke (n=1,148; mean age 69 years), 54.1% were female. During the index hospitalization, 48.4% (n=556) of patients received inpatient VTE prophylaxis. During the follow-up period, 15.9% (n=183) of patients received outpatient prophylaxis. Among these patients, 48.3% (n=554) did not receive any VTE prophylaxis and 12.6% (n=145) received both inpatient and outpatient VTE prophylaxis. Among this patient population, 1.1% (n=12) had a VTE event during the index hospitalization and 2.0% (n=23) had a VTE event after hospital discharge. The risk for VTE among such patients remained high for up to approximately 30-40 days after the index hospitalization (Figure).

Conclusions:
Despite a high risk for VTE, nearly half of patients hospitalized for acute ischemic stroke received no VTE prophylaxis therapy. Increased prophylaxis therapy may improve patient outcomes in this population.
Abstract TP291: Frequency of Neurological Evaluation and Neuroimaging in Patients With Infective Endocarditis
Authors: Sacchetti Daniel C , Mir Saad , Wu Xian , Segal Alan Z , Navi Babak B , Kamel Hooman , Merkler Alexander E
Published: October 2018

Introduction:
Stroke is a frequent complication of infective endocarditis, but there are few data and guidelines to inform appropriate neurological evaluation and imaging in this setting. We sought to determine how often patients with endocarditis undergo neuroimaging and evaluation by a neurologist.

Methods:
Using claims between 2009-2015 from a 5% sample of Medicare beneficiaries, we identified all patients ≥66 years of age who were hospitalized with infective endocarditis, as defined by previously validated
ICD-9-CM
codes. Using
CPT
codes and Medicare provider specialty codes from claims submitted during the hospitalization, we ascertained our outcomes of brain imaging (CT or MRI), intracranial vessel imaging (CTA, MRA, or catheter angiography), and evaluation by a neurologist. We first assessed these outcomes in all patients hospitalized with infective endocarditis, and then in the subset of patients who had a concurrent diagnosis of stroke. Stroke was ascertained using a validated
ICD-9-CM
code algorithm and defined as the composite of ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. We used descriptive statistics with Wald confidence intervals (CI) to report crude rates.

Results:
Among 3,200 patients with infective endocarditis, brain imaging was performed in 34.5% (95% CI, 32.8-36.1%) of patients, intracranial vessel imaging in 4.7% (95% CI, 4.0-5.5%), and evaluation by a neurologist in 18.1% (95% CI, 16.8-19.5%). In this overall cohort, 343 (10.7%) patients had a concurrent diagnosis of stroke, 292 (85.1%) of which were ischemic. Among the 343 patients with both endocarditis and stroke, brain imaging was performed in 89.5% (95% CI, 86.3-92.7%) of cases, intracranial vessel imaging in 35.0% (95% CI, 30.0-40.0%), and neurologist evaluation in 74.6% (95% CI, 69.7-79.2%).

Conclusions:
In a nationally representative cohort of Medicare beneficiaries, we found that approximately one-third of patients with infective endocarditis underwent brain imaging and few were evaluated by a neurologist or received intracranial vessel imaging. Most patients with endocarditis complicated by stroke underwent head imaging and were seen by a neurologist, but a minority received intracranial vessel imaging.
Abstract TP292: Discrepancies in Arrival Time for Acute Ischemic Stroke Patients
Authors: Mendelson Scott J , Richards Christopher T , Prabhakaran Shyam
Published: October 2018

Background:
Current best-practice guidelines and national quality improvement efforts emphasize reduction in door-to-needle (DTN) time. Stroke center certifying bodies depend on hospital-reported DTN to appraise compliance and award designations. However, the validation of hospital reported arrival times against ambulance arrival times has not been previously reported.

Objective:
To determine differences in Emergency Medical Services (EMS) reported arrival time of stroke patients versus hospital documented arrival times at 10 primary and comprehensive stroke centers in Chicago.

Methods:
We performed a retrospective analysis of stroke admissions using the Get With The Guidelines (GWTG) Stroke registries of 10 hospitals in Chicago between July 1 and December 31, 2013. We matched ambulance run numbers from EMS records to those in the GWTG-Stroke EMS special initiative tab. GWTG-Stroke data included arrival time, age, sex, race, initial NIHSS score, and whether tPA was administered. EMS data include hospital arrival time in addition to age, sex, hospital name, and clinical impression. We compared GWTG-Stroke and EMS reported arrival times overall and whether any clinical factors were associated with time discrepancy.

Results:
There were 308 matched EMS to GWTG-Stroke records over the study period and of those, 51 (16.6%) received tPA. Overall, EMS documented arrival time was a median 5 minutes earlier than hospital documented arrival time (range -14 to +35m). There was no significant difference in time discrepancy by tPA administration, stroke type, NIHSS score, age, sex, race, insurance status, or hospital. Median DTN based on EMS data was 88m versus 82m for hospital-reported data (p>0.05). The proportion with DTN times <60 minutes was 22% based on EMS versus 29% based on hospital arrival times.

Conclusions:
EMS reported arrival time is on average 5 minutes earlier than hospital documented arrival time at 10 Chicago stroke centers. These data suggest that current hospital reported DTN times may be lower than DTN times had EMS arrival been recorded as door time. Further quality improvement should ensure using EMS source data for more accurate documentation of arrival times.
Abstract TP294: Improving the Prospect of Diagnosing Paroxysmal Atrial Fibrillation After Cryptogenic Stroke to Prevent Recurrent Strokes by Appropriate Counseling, Cardiology Referral and Telephone Follow-Up: a Quality Improvement Initiative From Neurology Residents
Authors: Prasad Apoorv , Sanders Amy , Latorre Julius , Masoud Hesham , Anwer Sanam
Published: October 2018

Introduction:
25% of all strokes are Cryptogenic; paroxysmal atrial fibrillation is frequently the underlying cause. Patients with cryptogenic stroke require cardiac event monitoring (CEM) after hospital discharge in order to diagnose paroxysmal atrial fibrillation and switch to anticoagulant therapy from antiplatelet therapy. Very important question remains regarding who is responsible for CEM among healthcare providers. The objectives of our quality improvement project were to understand the barriers and ensure all patients receive CEM after cryptogenic stroke.

Methods:
All patients with MRI evidence of ischemic stroke and documented transient ischemic attack during a two-month period at an academic comprehensive stroke center were included. Data were recorded and compared for one month prior to (Group A) and one month after (Group B) implementation of the QI project. The QI project included patient counseling about importance of CEM and dual-verification of orders for CEM and cardiology referral. Two members of the stroke team independently verified placement of the CEM order and the referral to cardiology. One month after discharge, patients in the QI project were contacted by telephone to ensure CEM placement.

Results:
48 patients suffered ischemic stroke or TIA before and 54 patients after implementation of the QI project. The incidence of cryptogenic stroke was 20.83% (10/48) in group A and 16.66% (9/54) in group B. In Group A, only 2 of 10 patients with cryptogenic stroke received CEM. Major barriers were (1) patient ignorance and concern (2)unapproachable patient (3) lack of follow-up with primary care provider/neurologist. In Group B, after implementation of the QI project, 8 of 9 patients received CEM. One patient in Group B refused cardiac event monitoring. CEM diagnosed paroxysmal atrial fibrillation in one patient in group B and anticoagulation was initiated. Our quality improvement initiative increased the incidence of cardiac event monitoring from 20% in group A to 88.88% in group B.

Conclusion:
This project highlights that patient’s with cryptogenic stroke face barriers towards receiving cardiac event monitoring which can be improved by proper counseling, ensuring cardiology referral and a telephone follow-up by neurologist.
Abstract TP298: Examining the Relationship Between Continuing Education in Communication and Stroke Patient Outcomes
Authors: Frank Sheri , Thomas Kathie
Published: October 2018

Background and Objectives:
Successful physician-patient meetings require effective communication between both the patient and the physician, which is linked to improved patient outcomes and increased patient satisfaction. Yet, communication is often not a focus of continuing education (CE). The objective of this study was to examine the relationship between physician CE and stroke patient outcomes.

Methods:
Archival data for the 2015 and 2016 calendar years was collected from two American Heart Association databases: The Professional Education Center (PEC) and Get With The Guidelines (GWTG) Stroke. Relative to the PEC, courses with communication competency as a learning objective were reviewed, and 284 Midwest (IL, IN, IA, KS, MI, MN, MO, NE, ND, SD, and WI) hospitals with attendees in these courses were analyzed. The GWTG Stroke database was used to collect stroke patient outcomes data on in-hospital mortality rate (MR), disability rate (DR), treatment related complication rate (TRCR), and average length of stay (ALOS). Readmission rate (RR) data as part of stroke patient outcomes was collected via Centers for Medicare and Medicaid database.

Results:
Quantitative analysis demonstrated that CE in communication and RR as an indicator of stroke patient outcomes were statistically significantly negatively correlated and the strength of the relationship doubled over the two-year study period. Hospital type influenced these findings, with non-profit hospitals having lower RR. This result suggests the number of CE classes offered at a hospital is an independent predictor of RR. There was no significant relationship between CE in communication and MR, DR, TRCR, and ALOS.

Conclusions:
This study was among the early investigations aimed at examining the relationship between CE in communication and stroke patient outcomes. These findings are important to improving leadership development of physicians, engagement and retention of physicians, engagement of patients, and enhancement of medical curricula. Finally, these findings may also inform healthcare policy makers, strategic decision makers, those providing direct clinical care, as well as academic program directors and course developers at universities with medical or healthcare programs.
Abstract TP299: Early Mortality Prediction in Ischemic Stroke
Authors: Akca Ozan , Ziegler Craig , Liu Ruolan , Stewart Benjamin , Lenhardt Rainer , Remmel Kerri
Published: October 2018

Introduction:
Ischemic stroke (IS) is a medical emergency with a high risk of morbidity, leading to disability, and mortality. IS’s impact on our patients’ lives and healthcare system make it essential to optimize its immediate management, triage requirements, and plans for transfer to comprehensive stroke centers. In this study, we hypothesized that it is possible to predict the mortality of IS patients within the first hour of hospital admission.

Methods:
With the approval of the Human Studies Committee (IRB #: 13.0396), we performed a retrospective analysis from the Stroke Quality Database. Patients who were admitted between 2007-2012 were included. In-hospital mortality was the main outcome of the study. Patients’ demographics, baseline illnesses, home medications, baseline neurological assessment scores, and basic laboratory values on admission were included in the analysis as potential factors. Multivariate analysis was performed to assess the independent contributing factors. Data is presented as odds ratio and 95% confidence intervals.

Results:
IS in-hospital mortality was about 10% in our study population. Multivariate analysis was performed in 2,131 patients. NIH Stroke Scale on admission, recurrent stroke, high WBC levels (>11K), elderly age, AHA Stage II hypertension, baseline use of Ca-channel blockers, and beta-blockers, admission glucose levels and albumin levels independently contributed to in-hospital mortality (Table).

Conclusions:
IS patients’ baseline characteristics, hospital admission assessment scales, and laboratory values on admission contributed to prediction of in-hospital mortality. Therefore, it is essential to rapidly initiate acute care for high-risk and complex stroke patients. Additionally, focusing on the modifiable factors such as blood pressure management, treating acute infections, and managing glucose levels may help to decrease acute IS mortality.
Abstract TP306: Mobile Application, “WeTrain911” to Decrease Stroke Mortality by Enhancing Emergency Dispatcher Training
Authors: Brown Aliza T , Im Jay , Hall Richard W , Garcia-Rill Edgar
Published: October 2018

Background:
In rural states there are shortages of medically trained public safety answering point (PSAP) 911 answering stations. Dispatchers in these rural states risk leaving out vital Medical Priority Dispatch System (MPDS) determinants on patient stability and location to emergency medical systems (EMS) paramedics. We developed a smart phone medical education application for PSAP operators in underserved rural areas with a high deficiency of medical training. In Arkansas, as a rural stroke belt state there are 120 PSAP locations and 75 do not require any medical information training from state agencies. Twenty-six of these sites have limited medical training in cardio-pulmonary training. Only five counties have medically trained dispatchers and use MPDS. Following training, certification of dispatchers in any of the remaining underserved 70 counties that provide medical information will be regarded as a success.

Hypothesis:
The PSAP personnel serving as dispatch operators who utilize a medical dispatch training application will provide training based medical information, and reduce mortality due to stroke, trauma, and ST-elevation myocardial infarction (STEMI).

Methods:
In our data analysis, we are identifying whether the app intervention training influences telecommunication transition of information such as patient condition and caller location information to emergency medical service (EMS) providers. Other variables include paramedic impression/observation coding and response time to the scene. Baseline data from 2012 to 2014 will be used to compare pre- and post-training and state mortality data for stroke, trauma, and STEMI. Dispatcher to EMS agencies for dispatcher/caller information pre- and post-training will be compared for stroke, trauma, and STEMI mortality data.

Results:
App downloads have been noted in states across the US and as far as South Africa. At this time, we are still acquiring data for app downloads and user completed course training. Baseline mortality in 2012 to 2014 due to stroke, trauma, and STEMI were 140, 234, and 277 per 100,000, respectively.

Conclusion:
Currently, non-trained PSAP operators do not provide medical information on 911 calls and risk delayed EMS response time, jeopardizing patient safety.
Abstract TP316: Epidemiology of Neurologic Deterioration in Acute Stage of Ischemic Stroke or Transient Ischemic Attack
Authors: Lee Jung-Gon , Park Tai Hwan , Kang Kyusik , Lee Sang-Hwa , Park Jong-Moo , Cho Yong-Jin , Lee Kyung Bok , Lee Soo Joo , Kim Beom Joon , Lee Jun , Cha Jae-Kwan , Kim Dong-Eog , Kim Joon-Tae , Choi Jay Chol , Lee Byung-Chul , Kim Wook-Joo , Shin Dong-Ick , Sohn Sung Il , Lee Ji Sung , Lee Juneyoung , Bae Hee-Joon
Published: October 2018

Objective:
Neurologic Deterioration (ND) is known to be related to disability and poor outcomes. However, no large epidemiologic study on ND has been reported.

Methods:
Patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) admitted within 7 days of symptom onset were identified. Under a component of a quality assurance program of stroke care, we have captured ND during hospitalization prospectively with regular monitoring and systemic audits. ND was defined as any new neurological symptoms/signs or neurological worsening within 3 weeks of onset, satisfying one or more of the followings: increase of total NIHSS score ≥ 2, subscore 1a, 1b, or 1c (level of consciousness) ≥ 1, or subscore 5a, 5b, 6a, or 6b (motor)≥1, or any new neurological deficit (even unmeasurable by NIHSS scores). We investigated the incidence, timing, causes and outcomes of ND.

Results:
From December 2010 to September 2015, 29446 patients with AIS or TIA were admitted to 15 participating centers. Seventy-one percent of the patients were hospitalized within 24hours of onset. Deterioration occurred in 18.2% during median 10.1 days of hospitalization, its cumulative incidence was 5.6% at 1 day, 9.1% at 2 days, 10.9% at 3 days, 14.2% at one week. As causes of ND, progression was most common (73%), followed by recurrence (8.5%). Compared to those without ND, patients with ND were more likely to be older, be females, be hospitalized earlier, have stroke subtypes of large arterial disease or cardioembolism, have relevant steno-occlusion of major cerebral arteries, and have severer neurologic deficits. ND was independently associated with poorer functional outcome (modified Rankin scale 3 or more) at 3 months (adjusted odds ratio, 5.58; 95% confidence intervals (CI), 5.10-6.11) and one year (4.85; 4.43-5.32), and incidence of major vascular events (stroke, myocardial infarction, all-cause death) up to one year (adjusted hazards ratio, 1.64; 95% CI, 1.50-1.79).

Conclusions:
Our study reveals that about one fifths of AIS or TIA patients deteriorate neurologically during hospitalization and this deterioration is associated with poor functional outcome and subsequent major vascular events. Further researches for its prediction, detection and treatment are warranted.
Abstract TP319: Early Feeding Post G-tube Insertion is Safe in Stroke Patients
Authors: Smith Dale , Vaheesan Kirubahara , Erlinger Lisa , Kynion Jaime , Kumar Abhay
Published: October 2018

Introduction:
Initiation of tube feeding (TF) via gastrostomy tube (G-tube) after insertion in dysphagic stroke patients is often delayed per physician preference with delayed feeding (DF) initiated at 12-24 hours being a common practice. Guidelines suggest that initiation of G-tube feeding (EF) within 4 hours after insertion is safe and does not lead to more complications. The stroke and interventional radiology (IR) physicians at a comprehensive stroke center agreed to an EF guideline in April 2016 and changed the post-insertion G-tube feed initiation time in all stroke patients from 24 hours to 6 hours. A year after, we conducted this retrospective study to understand the impact of EF guideline on TF timings.

Methods:
All stroke patients that had G-tubes placed by IR between April 2015 and April 2017 were eligible for inclusion in the study. Patients with non-stroke diagnoses were excluded, as were those whose tube feeds were never initiated. In addition to TF timings, data regarding complications and reasons for guideline deviation were recorded. Descriptive analyses were done for continuous and categorical variables.

Results:
Compared to pre-protocol patients (n= 37), the TF initiation time in EF group (n= 47, range 5-51 hours) decreased by 11.5 hours after institution of EF guidelines (25.8 hrs vs 14.2 hrs,
p < 0.0001
). Only eight patients (17%) had TFs started by 6 hours, while twenty-one (44%) had TF started by 10 hours. There was a nonsignificant increase in complications after protocol initiation: 8 patients (17%) in the protocol group vs 4 (11%) in the pre-protocol group (OR = 1.69, 0.47 - 6.13, 95% CI). In five of eight patients in the protocol group who developed complications, TFs were initiated after 12 hours. No death was noted on account of EF. No significant difference in length of stay was noted. Delays in TF initiation were mostly due to failure to write appropriate orders (n=8) and less often for worsening in clinical status due to insertion related (n=2) or unrelated (n=2) complications.

Conclusions:
TF initiation time can be significantly improved with institution of an EF guideline without any significant increase in complications. With education, guideline compliance can be improved further.
Abstract TP326: Effect of Dysphagia Screening Strategies on Clinical Outcomes After Stroke a Systematic Review for the 2018 AHA/ASA Guidelines for the Early Management of Patients With Acute Ischemic Stroke
Authors: Smith Eric E , Kent David , Bulsara Ketan , Leung Lester Y , Lichtman Judith H , Reeves Mathew J , Towfighi Amytis , Towfighi Amytis , Whiteley William N , Zahuranec Darin B
Published: October 2018

Introduction:
Dysphagia screening protocols have been recommended to identify patients at risk for aspiration. The American Heart Association convened an Evidence Review Committee to systematically review evidence for the effectiveness of dysphagia screening protocols to reduce the risk of pneumonia, death, or dependency after stroke.

Methods:
The Medline, Embase, and Cochrane databases were searched on November 1, 2016, to identify randomized controlled trials (RCTs) comparing dysphagia screening protocols or quality interventions to increased dysphagia screening rates, and reporting outcomes of pneumonia, death or dependency.

Results:
Three RCTs were identified. One RCT (n=1,126) found that a combined nursing quality improvement intervention targeting fever and glucose management as well as dysphagia screening reduced death and dependency (42% vs. 58%, p=0.002), but without reducing the pneumonia rate (2.1% vs. 2.7%, p=0.82). Another RCT (n=311) failed to find evidence that pneumonia rates were reduced by adding the cough reflex test to routine dysphagia screening (26% vs. 21%, p=0.38). A smaller RCT (n=162) randomly assigned 2 hospital wards to a stroke care pathway including dysphagia screening or regular care, and found that patients on the stroke care pathway were less likely to require intubation and mechanical ventilation (7.8% vs. 20%, p=0.03 after adjustment); however, the study was small and at risk for bias.

Conclusions:
There were insufficient RCT data to determine the effect of dysphagia screening protocols on reducing rates of pneumonia, death, or dependency after stroke. Additional trials are needed to compare the validity, feasibility, and clinical effectiveness of different screening methods for dysphagia.
Abstract TP333: Lactoferrin as Contributor to Beneficial Effect of Neutrophil After Intracerebral Hemorrhage
Authors: Zhao Xiurong , Sun Guanghua , Ting Shun-Ming , Garrido Juan J , Mobley Alexis S , Aronowski Jaroslaw
Published: October 2018

Background:
Lactoferrin (LTF) is an essential, high-affinity iron-binding protein that is abundant in the secondary granules of neutrophils. After intracerebral hemorrhage (ICH), circulating blood neutrophils (PMNs) enter the ICH-afflicted brain and secrete LTF into the damaged tissue. This LTF can bind to iron and hemoglobin (key toxic components of the hematoma) thereby neutralizing toxicity of the hematoma. Here we study the role of LTF in the rodent brain after ICH.

Methods and Results:
In an autologous blood injection model of ICH in rats using RT-PCR and Western blotting, we measured the expression of LTF in ICH-affected brain. We found that LTF mRNA is virtually undetectable in the naïve rats’ brains and brains of rats at 3h to 7d after ICH. These findings suggest that LTF is not synthesized in the brain. LTF protein was not detectable in the naïve rat brain; however, the LTF protein is increased starting 3-6h post-ICH in the hematoma-affected hemispheres, reached maximum by 24-48h, and remained elevated for about 7d. Double immunofluorescence for LTF and RP-1 antigen (a biomarker for PMNs) shows that most LTF
+
-cells in the ICH-affected brains are PMNs. The locations of LTF
+
-cells in the brain were primarily peri-hematoma and the hematomas, which are loci of PMNs infiltration. Also, the temporal profile of LTF level and the number of PMNs in the brain were similar. We also detected a similar progression of LTF changes in the peripheral blood after ICH. Finally, in the ICH model in rats, administration of the recombinant LTF (rLTF) after the onset of ICH significantly reduced brain edema, oxidative damage, and neurological deficits, as assessed on day 3. Interestingly, in neuron-glial co-culture, after exposing these cells to red blood cells (RBCs; to simulate ICH-mediated injury), rLTF reduced the neurotoxic effect of RBCs and accelerated the removal of RBCs by microglia. This suggests that the cytoprotective effect of LTF and the modulation of microglia’s phenotype could underlie the beneficial role of LTF, with neutrophils being a primary source of LTF production.

Conclusion:
We propose that LTF delivered to the ICH-affected brain by infiltrating activated PMNS could be beneficial for hematoma detoxification, which may be a potential target for ICH therapy.
Abstract TP334: Sex and Racial Disparities in Mortality for Patients With Intracerebral Hemorrhage
Authors: Daileda Taylor , Vahidy Farhaan S , Chen Peng Roc , Liang Conrad , Savitz Sean , Sheth Sunil A
Published: October 2018

Introduction:
Women and minorities are reported to have worse outcomes and higher in-hospital mortality (IHM) after ischemic stroke. However, sex and racial differences for IHM after intracerebral hemorrhage (ICH) are still uncertain.

Methods:
Using administrative data on all discharges from acute care hospitals in California (2005-2011) and Florida (2005-2014), we identified adult ICH patients (ICD-9 Code 431). We excluded patients who had a diagnosis of subarachnoid hemorrhage, arteriovenous malformation, trauma, or ischemic stroke. Logistic regression models were used to assess factors associated with IHM. We report odds ratios and 95% CIs.

Results:
Among 82,613 ICH patients, 40,124 (48.7%) were female. Median (IQR) age was 72 (58-82), 14% were black, and 15% were Hispanic. In univariate analysis, females were older (OR 1.37, CI 1.29-1.45, age>60), had fewer extraventricular drains (EVD, OR 0.83, CI 0.74-0.95), and were less often intubated (OR 0.86, CI 0.84-0.89). Blacks had more EVDs (OR 2.5, CI 2.14-2.89), hemicraniectomys (OR 1.40, CI 1.12-1.75), and intubations (OR 1.55, CI 1.48-1.62) than whites. Hispanics were also intubated more often than whites (OR 1.19, CI 1.14-1.24). IHM rate was 24.2%. In univariate analysis, IHM was associated with female sex (OR 1.06, CI 1.03-1.10), age > 45 (OR 1.24, CI 1.14-1.34), black vs white race (OR 0.81, CI 0.77-0.85), Hispanic vs white race (OR 0.80, CI 0.76-0.84), history of hypertension (OR 0.85, CI 0.82-0.88), obesity (OR 0.71, CI 0.67-0.76), use of EVD (OR 1.48, CI 1.29-1.69), and intubation (OR 11.6, CI 11.2-12.0). In multivariate analysis, women were more likely to suffer IHM (OR 1.09, CI 1.05-1.13) and minorities were less likely to suffer IHM (OR 0.74, CI 0.70-0.79, black, and OR 0.70, CI 0.66-0.74, Hispanic) after adjusting for age, hypertension, obesity, use of EVD and hemicraniectomy.

Conclusions:
In this large real-world cohort of ICH patients, female sex was associated with increased IHM, while black and Hispanic race were associated with lower rates of IHM compared to whites. These findings suggest disparities in the severity of this disease in these groups, or in the type of care provided to them.