bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP206: Effects of Smoking Status on the Onset Age of the First-Ever Stroke: Data From Korean Stroke Registry
Authors: Jeong Han-yeong , Mo Heejung , Lee Chan-Hyuk , Kang Min Kyoung , Lee Eung-Joon , Jeong Hae-Bong , Kim Tae Jung , Kim Yerim , Park Jong-Moo , Oh Mi Sun , Lee Ji Sung , Kim Beom Joon , Kim Joon-Tae , Kim Jinkwon , Seo Woo-Keun , Lee Jun , Cha Jae-Kwan , Jung Keun-Hwa , Ko Sang-Bae , Bae Hee-Joon , Yoon Byung-Woo
Published: June 2021

Background:
There is evidence that smoking increases stroke risk. However, the impact of smoking status on age at onset of ischemic stroke has not been studied. The aim of this study is to explore the effect of smoking status on the age at onset of first-ever ischemic stroke using the Korean Stroke Registry(KSR), the nation-wide, multicenter, hospital-based stroke registry in Republic of Korea.

Methods:
This study used individual data of first-ever ischemic stroke patients from the KSR, between 2014 and 2018. We divided the patients into four groups according to their smoking status; current smokers, past-smokers - quit in recent 5 years, past smokers - quit over than 5 years, and never-smokers.

Results:
A total of 27,942 patients were included in the analysis. The mean age at onset of the first-ever stroke were 60.0±11.9 in current smokers, 65.9±11.9 past-smokers - quit in recent 5 years, 70.1±10.8 in past smoker - quit over than 5 years, and 70.5±12.8 in never-smokers (p<0.001). In the stroke subtypes analysis, the mean age at onset of the first-ever stroke were 60.9±12.5, 66.7±11.2, 70.7±10.8, and 71.1±11.9 in large artery atherosclerosis group, 58.8±10.8, 63.8±11.1, 68.2±10.4, and 68.6±12.0 in small vessel occlusion group, and 64.1±11.9, 67.7±11.6, 71.8±10.3, and 73.8±11.4 in cardioembolism group, respectively (all p<0.001).

Conclusions:
The smoking status of patients was associated with an earlier onset age of the first-ever stroke. The onset age tends to be delayed with the longer duration of cessation period.
Abstract TP208: Fazekas Scores Correspond With Specific Volumes of White Matter Hyperintensity
Authors: Andere Ariana , Boyanpally Anusha , Collins Scott , Reznik Michael , Mahta Ali , Jindal Gaurav , Burton Tina , Mac Grory Brian , El Jamal Sleiman , Sacchetti Daniel , Stretz Hanns Christoph , Saad Ali , Yaghi Shadi , Furie Karen , Cutting Shawna M
Published: June 2021

Background:
White matter hyperintensity (WMH), also known as leukoaraiosis, is commonly visualized as abnormal T2 signal in the deep and subcortical white matter on Magnetic Resonance Imaging (MRI). It is also commonly associated with aging, diabetes, hypertension and cerebrovascular disease. The Fazekas (F) scoring system is a subjective tool commonly used to assess WMH, but no volumetric analysis has been published showing how the scores correspond to true quantities of white matter disease.

Methods:
MRIs performed on inpatients and outpatients at our tertiary care institution between 2015 and 2017 were reviewed and their relative WMH was scored by one author trained in using the Fazekas scale. Using 3D Slicer 4.9, manual segmentations of WMH were completed and a 3D model was created to quantify the amount of WMH. Univariate analysis and ANOVA tests were run to determine the association of each Fazekas score with volume of WMH.

Results:
Among the 198 patients in our study (53% female), 163 had WMH (F1 n=66, F2 n=49, F3 n=48). Ranges of WMH in each group were 0.1-8.3 mL in Fazekas 1 (mean = 3.7, SD = 2.3), 6.0-17.7 mL in Fazekas 2 (mean = 10.8, SD = 3.1), and 14.2-77.2 mL in Fazekas 3 (mean = 35.2, SD = 17.9); if 11 outliers above 50 mL were excluded, the range for Fazekas 3 was 14.2-47.0 mL (mean = 27.1, SD = 8.9). When comparing data between groups, both the comparison between F1+2 (t-value = 14.1, p<0.001) and F2+F3 (t-value = 9.62, p<0.001) were significant. Moreover, when comparing between the three groups, each range of values was found to be significant from one another (F = 151.3, p<0.001).

Conclusion:
When accurately trained in assigning Fazekas scores to patient’s WMH, each of the scores appears to represent an approximate range of distinct volumes for WMH. Studies have shown that the presence and extent of WMH is a predictor for future development of stroke. These results should be validated in subsequent studies.
Abstract TP209: Effect of Chemotherapy on Stroke Risk in Cancer Patients
Authors: Kitano Takaya , Sasaki Tsutomu , Gon Yasufumi , Todo Kenichi , Okazaki Shuhei , Kitamura Tetsuhisa , Kitamura Yuri , Sakaguchi Manabu , Sobue Tomotaka , Matsumura Yasushi , Hattori Satoshi , Mochizuki Hideki
Published: June 2021

Introduction:
Chemotherapy may be a cause of cancer-associated stroke, but whether it increases stroke risk remains uncertain. We aimed to clarify the impact of chemotherapy on stroke risk in cancer patients.

Methods:
We investigated 27,932 patients enrolled in a hospital-based cancer registry at Osaka University Hospital between 2007 and 2015. The registry collects clinical data, including cancer status (site and stage), on all patients treated for cancer. Of them, 19,006 patients with complete data were included. A validated algorithm was used to identify stroke events within 2 years of cancer diagnosis. Patients were divided based on whether their initial treatment plan included chemotherapy. The association between chemotherapy and stroke was analyzed using the Kaplan-Meier method and stratified Cox regression.

Results:
Of the 19,006 patients, 5,887 (31%) patients were in the chemotherapy group. Non-targeted chemotherapy was used in 5,371 patients. Stroke occurred in 44 patients (0.75%) in the chemotherapy group and 51 patients (0.39%) in the no-chemotherapy group. Kaplan-Meier curve analysis showed that patients in the chemotherapy group had a higher stroke risk than patients in the no-chemotherapy group (HR 1.84; 95% CI 1.23-2.75; Figure [A]). However, this difference was insignificant after adjustment for cancer status using inverse probability of treatment weighting with propensity scores (HR 1.20; 95% CI 0.76-1.91; Figure [B]). Similarly, in the stratified Cox regression model, chemotherapy was not associated with stroke after adjustment for cancer status (HR 1.26; 95% CI 0.78-2.03). These findings were consistent with analysis wherein the effect of chemotherapy was treated as a time-dependent covariate (HR 1.02; 95% CI 0.55-1.88).

Conclusions:
In this population, the elevated stroke risk in cancer patients who received chemotherapy was presumably due to advanced cancer stage; chemotherapy was not associated with the increased risk of stroke.
Abstract TP210: Examining the Role of Context: Neighborhood Socioeconomic Status Shaping Post-Stroke Outcomes
Authors: Stulberg Eric , Twardzik Erica , Hsu Chia-Wei , Kim Sehee , Clarke Philippa , Morgenstern Lewis , Lisabeth Lynda
Published: June 2021

Introduction:
Neighborhoods may influence post-stroke recovery. We examined the association between neighborhood socioeconomic status (nSES) and 90-day post-stroke function, depression, cognition, and quality of life (QoL).

Methods:
Stroke survivors (N=782) were identified from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project. An nSES index – composite of 2010 census-tract level income, wealth, education, employment – was the exposure; higher values indicate higher nSES (median -4.56; IQR: -7.48 to -0.46). Function was measured with 22 self-reported activities of daily living/instrumental activities of daily living, depression with Patient Health Questionnaire-8, QoL with the Stroke Specific QoL Scale, and cognition with the Modified Mini Mental State Examination. Confounder-adjusted generalized estimating equations were used to estimate associations between nSES (comparing 75
th
to 25
th
percentile) and 90-day outcomes. We tested for effect modification by initial stroke severity (NIH Stroke Scale (NIHSS) ≤ 5 or >5) by including interaction terms in adjusted models.

Results:
Higher nSES was associated with significantly better function, better QoL, and less depression after adjusting for person-level confounders in those with NIHSS >5. Higher nSES was associated with better cognition, but this result was not significant. In those with NIHSS ≤5, higher nSES had a statistically significant (though attenuated) association with function and cognition.

Conclusions:
Future research should identify features of higher nSES neighborhoods that contribute to more favorable stroke outcomes. Our findings highlight the need for examining the individual and joint influence of neighborhood context and stroke severity on post-stroke recovery.
Abstract TP211: Long-Term Trends in Ischemic Stroke Risk Factors and Outcomes in a Multiethnic Population
Authors: Tan Benjamin Y , Tan Joshua TC , Cheah Dawn , Pek Pin Pin , Zheng Huili , De Silva Deidre Anne , Ahmad Aftab , Chan Bernard PL , Chang Hui Meng , Kong Keng He , Young Sherry H , Tang Kok Foo , Yeo Leonard LL , Venketasubramanian Narayanaswamy , Ho Andrew FW , Ong Marcus Eng Hock
Published: June 2021

Introduction:
Stroke medicine has evolved over time, with changing demographics and improving outcomes. We aimed to evaluate trends in incidence, risk factors, treatment and case fatality of acute ischemic stroke (AIS) in a multiethnic population.

Methods:
Data was obtained from the Singapore Stroke Registry. 60,325 AIS cases that presented to Singapore’s public hospitals from 2005-16 were studied. Trends were analyzed with Poisson regression, logistic regression and Cox regression.

Results:
The AIS age-standardized incidence rate has decreased by 11.6% (126.5 to 111.8 per 100,000 person-years from 2005-07 to 2014-16, p < 0.001). This was observed in all gender and ethnic groups except in those younger than 65, which saw a 2.5% increase (51.0 to 52.4 per 100,000 person-years, p = 0.017). In terms of risk factors, hypertension, hyperlipidemia, and atrial fibrillation have increased in prevalence, while history of stroke, ischemic heart disease, diabetes, and smoking have decreased (Figure A). Treatment-wise, thrombolysis utilization rates have increased significantly from 0.8% in 2005-2007 to 6.7% in 2014-2016 (p < 0.001). While atrial fibrillation (AF) has become more prevalent (15.8% to 25.2%, p < 0.001), anticoagulant prescription has not increased by the same magnitude (13.2% to 14.4%, p = 0.014). Case fatality has reduced by 25.6% (8.2% to 6.1%, p < 0.001).

Conclusion:
In a multi-ethnic population, whilst we found that AIS age-standardized incidence rate has been declining, we demonstrate a temporal trend of changing risk factors. Further research is needed to investigate the causes and implications of these trends, so as to better strategize prevention efforts.
Abstract TP213: Diagnostic Score to Differentiate the Etiology of Cortical Microinfarcts on 3-Tesla MRI
Authors: Ishikawa Hidehiro , Ii Yuichiro , Shindo Akihiro , Niwa Atsushi , Tomimoto Hidekazu
Published: June 2021

Background and Purpose:
Cortical microinfarcts (CMIs) are small ischemic lesions found in cerebral amyloid angiopathy (CAA) patients, which are also associated with embolic stroke. This study aimed to differentiate cortical microinfarcts caused by CAA from those caused by microembolism, using 3-tesla magnetic resonance imaging.

Methods:
We retrospectively investigated 119 patients with at least 1 cortical infarct <10 mm on 3D double inversion recovery imaging. Forty-three patients with an embolic stroke history were included as the emboli group (Emboli-G) and 27 patients with CAA were included as the CAA group (CAA-G), based on the modified Boston criteria. We compared the size, number, location, and distribution of CMIs between groups to assess CMI etiology. Using this information, we designed a radiological diagnostic score, which incorporated data on the location, size, distribution, and numbers of CMIs.

Results:
CAA-G patients showed significantly more lesions <5 mm, which were restricted to the cortex (p<0.01). Cortical lesion number was significantly higher in Emboli-G than in CAA-G patients (4 vs 2; p<0.01). The diameter of cortical lesions was significantly larger in Emboli-G than in CAA-G patients (3.8 mm vs 3.0 mm; p<0.01). Lesions in CAA-G and Emboli-G patients were disproportionately located in the occipital lobe (p<0.01) and frontal or parietal lobe (p=0.04), respectively. In diagnostic scoring, a score of ≥3 points strongly predicted microembolism (sensitivity, 63%; specificity, 92%) or CAA (sensitivity, 63%; specificity, 91%). The area under the curve was 0.85 and 0.87 for microembolism and CAA, respectively.

Conclusions:
Our radiological diagnostic score may be a powerful tool for differentiating the etiology of CMIs.
Abstract TP214: 3D-Electron Microscopy for the Analysis of the Microstructure of Acute Ischemic Stroke Clots
Authors: Fitzgerald Seán , Dai Daying , Rizvi Asim , Doyle Karen M , Kadirvel Ramanathan , Kallmes David F , Jaspersen Adam L , Christensen Trace A , Brinjikji Waleed
Published: June 2021

Introduction:
Characterization of acute ischemic stroke thrombi has typically focused on the two dimensional (2D) histological characterization of the thrombus. Little is known about the three dimensional (3D) structure of these occlusive thrombi. Electron Microscopy (EM) can be used to obtain 3D information about the organization of clot components. Individual structures can be segmented and qualitative and quantitative information obtained from the clots.

Methods:
Following IRB approval from Mayo Clinic, acute ischemic stroke clot samples were collected from 10 patients treated at Mayo Clinic. Samples were immediately fixed in fresh modified Trumps fixative solution. A representative fragment of clot was taken and split longitudinally into two pieces; one piece was sent for 3D-EM analysis and the other for histological processing and analysis. Hematoxylin and eosin stain (H&E) and Martius Scarlett Blue (MSB) histological stains were used for conventional histopathology evaluation and components analysis. Immunohistochemical (IHC) staining using anti-CD42b (Platelets) was applied to confirm the presence of platelets in each clot. Serial block-face scanning electron microscopy was used to generate high-resolution three-dimensional images.

Results:
The 2D morphological features of the clot were identified using H&E, MSB and anti-CD42b staining. The 3D organization of thrombi varies greatly, both within and between clots depending on the constituents. Red Blood Cell-rich areas are mainly composed of Red Blood Cells packaged tightly together, with a small number of Fibrin strands interwoven between the cells. Fibrin-rich areas are characterized by dense networks of fibrin strands along with platelets and White Blood Cells with some sparse Red Blood Cells present. Platelet-rich areas are composed of large volumes of de-granulated platelets, some fibrin stands and white blood cells and an absence of Red Blood Cells.

Conclusions:
3D electron microscopy can provide important information on the organization of components within thrombi. This could provide key information on the age and etiology of the thrombus. In addition, it may help to inform thrombolytic treatment and medical device design.
Abstract TP22: Longer Procedure Time in General Anesthesia versus Conscious Sedation During Mechanical Thrombectomy for Large Vessel Occlusion Ischemic Stroke
Authors: Saini Vasu , Chen Stephanie H , McCarthy David J , Brunet Marie C , Khandelwal Priyank , Peterson Eric C , Starke Robert M , Asdaghi Negar , Yavagal Dileep R
Published: June 2021

Introduction:
There is no definitive evidence currently to guide the choice between general anesthesia (GA) over conscious sedation (CS) for patients undergoing mechanical thrombectomy (MT). As MT outcomes are highly time-sensitive especially in the early time window, we aim to evaluate work-flow metrics and outcome differences between the two approaches in routine clinical practice at a Comprehensive Stroke Center (CSC).

Methods:
From 2/2015-9/2018, 329 consecutive MT patients were included from a large retrospective CSC database. In late 2017, we implemented a first-choice GA protocol at our CSC from a first choice CS for MT. Baseline characteristics, work-flow metrics and outcomes measures: mRS at discharge, mRS last follow-up (median, IQR 184 days, 37.25-202.5), radiological hemorrhagic conversion (rHT) and symptomatic intracranial hemorrhage (sICH) defined as rHT with post-MT (4-24 hours) NIHSS worsening ≥4, were examined. Multivariate logistic regression model was used to compare workflow and outcomes in GA vs. CS patients.

Results:
82 (25.2%) patients received GA and 246 (74.8%) received CS. Baseline characteristics show significantly higher baseline HTN (p .043) and posterior circulation strokes (p .02) in GA patients. Compared to CS, patients undergoing GA had significantly longer procedure times 54±35 vs. 37±22min (OR .98, 95%CI .97-.996) but no difference in onset- or door-to-puncture times. Both had similar first pass success ~57% vs. 53% (p .59), number of attempts 1(1-2) vs. 1(1-2) (p .94) and rate of TICI 2b-3 ~87% vs. 84% (p .85). On multivariate regression, there was no significant difference in outcome measures between GA and CS: rHT (OR 1.1, 95%CI .64-1.9), sICH (OR 1.15, 95%CI .41-3.2), mRS at discharge (OR .75, 95%CI .176-3.22) and mRS at last follow-up (OR 1.05, 95%CI .53-2.08).

Conclusion:
In routine clinical practice, compared to CS, patients who underwent GA for MT had no difference in clinical outcomes, despite longer procedure times.
Abstract TP226: Aging and Smoking Exacerbates Post-Stroke Complement Driven Neuroinflammation
Authors: Alawieh Ali M , Toutonji Amer , Atkinson Carl , Tomlinson Stephen
Published: June 2021

Introduction:
Mechanical thrombectomy for acute ischemic stroke (AIS) is the current standard of care based on level 1 evidence from multiple randomized controlled trials. Recently, real-world indications for mechanical thrombectomy (MT) has extended beyond the inclusion criteria used in the majority of trials including elderly patients. We have recently developed a machine-learning based tool, SPOT, to optimize selection of elderly patients for MT based on single-center data. Here, we use a large cohort of international multicenter patients who underwent MT for AIS to externally validate SPOT.

Methods:
Patients who underwent MT for AIS at 12 comprehensive stroke centers in the US and Europe between 01/2013 and 12/2018 were reviewed. Patients age 80 years or older were included for validation of SPOT. SPOT is designed based on a combination of decision trees and linear regression models to provide binary output of predicted good (mRS 0-2) or poor outcome (mRS 3-6) after MT. SPOT uses admission variables: age, gender, comorbidities, admission NIHSS, baseline mRS score, ASPECT score and whether IV-tPA was administered. Predicted outcome was compared to actual outcome recorded at 90-days after treatment. A receiver operating characteristic curve was used to evaluate the accuracy of SPOT, and the negative predictive value was computed. The rate of post-procedural hemorrhage and mortality were compared between patients predicted by SPOT to have good versus poor outcome.

Results:
A total of 3,228 patients underwent MT for AIS during the study duration, of which 647 patients were at least 80 years of age or older and were included in the study. The average age was 85±5 years, and 65% were females. The median mRS score at 90 days was 4, and 21.3% had a good outcome (mRS 0-2). Of patients predicted by SPOT to have a poor outcome, 90% had a poor outcome. The area under the ROC curve was 0.7. The mortality rate in patients predicted by SPOT to have poor outcome had twice higher mortality than those predicted to have good outcome (55% vs 27%, p <0.001).

Conclusions:
Based on multicenter validation, SPOT presents a clinical decision in aid in assisting for exclusion of elderly patients unlikely to benefit from MT for AIS with a 90% negative predictive value.
Abstract TP228: The Overlap of Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome
Authors: Purohit Meghan , Scarsella Monica , Mullaguri Naresh , Jillella Dinesh , Wisco Dolora , Uchino Ken
Published: June 2021

Introduction:
Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome with typical neuroimaging findings of vasogenic cerebral edema in posterior brain regions. Reversible cerebral vasoconstriction syndrome (RCVS) is diagnosed when there is reversible cerebral vessel narrowing and often with thunderclap headache. The two diseases have overlap in clinical and radiographic features.

Objective:
To compare clinical presentation, vascular abnormalities and imaging findings among PRES and RCVS.

Methods:
We searched patients in electronic health record at a single tertiary center from January 2008 to December 2018. Inclusion criteria was 18 years or older with clinical and radiographic evidence of PRES or RCVS. PRES was diagnosed by clinical presentation and presence of vasogenic edema on radiographic imaging. RCVS was determined by clinical presentation and transient arterial stenosis. Patient demographics, presenting symptoms, comorbid conditions, and imaging findings were compared between PRES and RCVS populations. Analysis was performed using Fisher’s exact test

Results:
Seventy-four patients with PRES and 24 patients with RCVS met inclusion criteria. The median age and presenting blood pressure did not differ between PRES and RCVS groups. PRES population consisted of fewer females (70%) compared to RCVS (92%, p=0.05). There was no significant difference in frequency of DWI lesions in PRES (37%) and RCVS (24%, p=0.308). Among patients who had arterial imaging, arterial stenosis was seen in 28% (13/46) of PRES. The occurrence of > 50% FLAIR reversibility was more common in PRES (67%) and seen less frequently in RCVS (27%, p=0.008).

Conclusion:
There is radiographic overlap between PRES and RCVS. About a quarter of PRES have arterial stenosis, while about a quarter of the RCVS group had FLAIR reversibility.
Abstract TP236: Eval to Groin Puncture Times: Efficiencies and Deficiencies of Live Physician vs Telemedicine Triage
Authors: Rosenbaum-Halevi David , Reddy Sujan T , Trevino Alyssa D , Bilal Tariq Muhammad , Shahrivari Mahan , Ankrom Christy , Zhu Liang , Sheth Sunil A , Sarraj Amrou , Savitz Sean I , Wu Tzu-Ching
Published: June 2021

Introduction:
Telemedicine (TM) is increasingly implemented in community hospitals acute ischemic stroke (AIS). The efficiency of TM to facilitate thrombectomy (IAT) is unknown. We addressed this question by studying our spoke hospitals which are staffed by both in-person (IP) consultation (Day: 8am-5pm) and TM (Night: 5pm-8am) to analyze differences between TM and IP and comparing to our university hub which has IP staffing day and night.

Methods:
We performed a retrospective analysis from 3/2016 to 3/2019 of all IAT cases directly admitted to 4 IAT capable centers (1 hub + 3 spokes) in our system. Demographic, clinical, and time metrics were analyzed. Primary outcome was door to groin (DTG) time. Continuous variables were analyzed with Wilcoxon rank sum test, and categorical variables with chi-square or Fischer’s exact test.

Results:
Table 1 summarizes the cohort. Eval to tPA (ETPA) time was faster at spokes vs hub (p < 0.0001), with no significant difference in DTG between spoke and hub (p= 0.444). At spokes, while DTPA times were no different between IP and TM at spokes, IP achieved faster DTG times (p<0.0001) (Fig.1A). DTG was equal during day vs. night at the hub. At the spokes, day (IP) DTG times were faster than night (TM) at some but not all spokes (Fig.1B). TPA administration did not delay DTG at either the hub or the spokes (Fig. 1C). At spokes, TM-TPA cases were associated with faster DTG than TM-noTPA (Fig. 1D).

Conclusions:
While no difference is noted between TM and IP in rapid TPA treatment, our data show delayed DTG at spokes during the TM day and night service. While DTG in TM was prolonged, differences in spoke metrics imply that availability of staff and resources play a significant role. Further analysis is needed to identify factors that prolong DTG at a site-specific level.
Abstract TP245: Variance in Ems Run Times by Receiving Hospital for Stroke Patients in San Diego County
Authors: Kenner-brininger Amelia , Olson-Mack Lindsay , Calzone Lorraine , Koenig Kristi L , Hemmen Thomas M
Published: June 2021

Background:
Emergency Medical Services (EMS) play an important role as initial providers after stroke. Few data are available that capture Stroke Receiving System and EMS response and transport data. We used a stroke registry from a community of 3.3 million residents, 18 stroke receiving centers, and 19 ground transporting advanced life support EMS agencies to evaluate EMS response time, scene time, and transport times. Our aim was to inform the stroke community about duration of EMS care and guide future prehospital interventions.

Methods:
We included all cases from the San Diego County Stroke Registry arriving by EMS with associated computer automated dispatch (CAD) record and base hospital record (BHR) from July 2017 through December 2018. Records were linked on the EMS incident number, reviewed for accuracy. We analyzed EMS response, scene, transport and total run times (enroute to arrival) by receiving hospital.

Results:
Between July 2017 and December 2018 2,376 EMS patients were transported to 18 hospitals. Volume per hospital ranged from 11 to 483 patients over the study period. Mean (±SD) response time was 7.0 (±3.7) minutes, range: 5.3 to 9.3 minutes between hospitals. Mean (±SD) scene time was 13.1 (±5.2) minutes, range: 10.5 to 15.0 minutes between hospitals. Transport time averaged 13.8 (±7.7) minutes, range: 8.3 to 23.8 minutes between hospitals (IQR=8.5-17.9). The mean (±SD) total EMS run time was 33.8 (±10.8) minutes, range: 26.4 to 44.9 minutes between hospitals (IQR=26.4-39.9).

Conclusion:
Only minor variations in EMS response and scene times were observed across the Stroke Receiving Centers. However, transport time showed greater variation and contributed to the differences in total EMS run times. Many systems had short transport times, limiting prehospital interventions. Next steps include studying factors contributing to transport time variation to inform prehospital care and triage decisions of possible stroke patients to optimize transport times.
Abstract TP248: Reduced Door-in-Door-Out Time Increases the Likelihood of Endovascular Thrombectomy for Large Vessel Occlusion Patients
Authors: Shah Kavit , Desai Shashvat , Morrow Benjamin , Patel Pratit , Ziayee Habibullah , Bradley Klein , Dolia Jay , Rocha Marcelo , Starr Matthew , Jovin Tudor , Jadhav Ashutosh P
Published: June 2021

Introduction:
Endovascular thrombectomy (EVT) is recommended for patients with large vessel occlusion (LVO) presenting within 24 hours of last seen well (LSW). Unfortunately, patients transferred from spoke hospitals to receive EVT have poorer outcomes compared to those presenting directly to the hub, underscoring the importance of rapid transfer timing - door-in-door-out (DIDO).

Methods:
Data were analyzed from consecutive acute ischemic stroke patients with proximal large vessel occlusions (LVO) transferred to our comprehensive stroke center for EVT. The following variable were studied: DIDO, baseline NIHSS/mRS, presentation CT ASPECTs, site of LVO, treatment, and clinical outcome.

Results:
Ninety patients with internal carotid or middle cerebral artery (M1) occlusion at the spoke hospital were included in the study. At the hub hospital, 75% (68) underwent emergent cerebral angiography (DSA) with intent to perform EVT. Reasons for not undergoing angiography at hub hospital included large stroke burden (59%) and improvement in NIHSS score (41%). Overall, DIDO time was 184 (130-285) minutes. Mean DIDO time was significantly lower for patients who underwent DSA at hub hospital compared to patients who did not (207 versus 272 minutes, p=0.031). 92% (12) of patients with DIDO <=120 minutes (n=13) underwent EVT compared to 73% (56) of patients with DIDO >120 minutes (n=77). Every 30-minute delay after 120 minutes lead to a 6% reduction in the likelihood of EVT. Lower DIDO time [OR-0.92 (0.9-0.96), p=0.04] and higher ASPECTS score [OR-1.4 (1.1-1.9), p=0.013] at spoke hospital are predictors of EVT at hub hospital.

Conclusion:
Reduced DIDO times are associated with higher likelihood of receiving EVT. DIDO should be treated on par as in-hospital time metrics and methods should be in place to optimize transfer times.
Abstract TP249: Collaborative In-Person Bedside Handover Improves Emergency Department Nurses’ Confidence in and Compliance With Documentation of Frequent Post Alteplase Neurological Assessments
Authors: Cox Kailey L , Lobell Jessica , Champagne Xavier , Lesko Alyx , Corless Leslie , Baraban Elizabeth
Published: June 2021

Introduction:
Stroke centers are often cited for poor compliance with post alteplase (tPA) neurological assessment documentation (SNAP DOC). Emergency department nurses (ED RNs) have less exposure to patients receiving tPA than neurocritical care nurses (NCCU RNs) and are less compliant with SNAP. In this project we sought to improve compliance of SNAP DOC in the ED.

Methods:
Data included retrospective chart review of SNAP DOC compliance for patients in ED treated with tPA age 18 and over from 03/2018 to 07/2019. In phase 1, ED RNs were trained in-person on SNAP three separate times between 02/2018 and 09/2018 (PRE). After seeing no improvement with SNAP in ED after the in-person education interventions, ED and NCCU collaborated to form a new strategy. In phase 2, beginning 12/14/2018 NCCU RNs retrieved their tPA patients from ED, performed a bedside SNAP and coached ED RNs on any missing SNAP DOC (POST). ED SNAP DOC were evaluated by finding the total number completed among the total possible opportunities combined across the four components of SNAP and vital signs. Three Likert scale questions were administered to assess ED RN confidence in SNAP practices for both PRE and POST timeframe with answers from 1 (strongly disagree) to 5 (strongly agree). PRE and POST responses were then dichotomized into agree (4-5) or disagree (1-3) and compared using Pearson’s chi square test. Descriptive analyses were performed to assess SNAP DOC compliance for the PRE and POST periods.

Results:
There were 111 charts audited for compliance that met inclusion criteria with 56 in the PRE and 55 in the POST. ED RNs were more compliant with SNAP in the POST (77.3%) compared to the PRE (65.6%). Confidence surveys were completed by 52 ED RNs in PRE and 72 RNs in POST. RNs were more confident in, “I understand the rationale behind each component of [SNAP]”, in the POST vs PRE timeframe (87.5% vs 68.6%, p=.010).

Conclusion:
ED RNs remained confident in their use of SNAP throughout the project despite compliance scores. However, in the POST period, ED RNs reported improvement in their understanding of SNAP. In-person handover process improves SNAP DOC compliance in ED more than in-person training.
Abstract TP251: It’s All in the Wrist - Integrating EMS, Telestroke and Stroke Registry Data Systems
Authors: Brown Aliza T , Vrudny David , Marshall Tammie , Onteddu Sanjeeva , Radvany Martin , Nalleballe Krishna , Brown Greg , Joiner Renee , Backus Marzella , Culp William , Adolph Sharada , Balamurugan Appathurai
Published: June 2021

Background:
States without a recognized directive for stroke care and transport risk the ability to monitor, assess and review stroke patient movement from first medical contact (FMC) to delivery/and/or transfer to hospitals. We are seeking to determine a new tracking program’s efficacy from emergency medical systems (EMS) to telestroke sites and other receiving hospitals utilizing Get-With-The-Guidelines (GWTG) in data reporting.

Hypothesis:
We hypothesized that all three entities (EMS, telestroke sites and other hospitals) would record suspected and positive strokes into their electronic databases and integrate the process into their standard of practice, protocols and guidelines.

Methods:
Statewide EMS agencies, receiving hospitals in the Arkansas Stroke Registry and telestroke sites received educational training about placing blue wristbands on all suspected strokes. Stroke bands were to be placed on all patients arriving via EMS or privately owned vehicle. The bands contained a unique number sequence for recording in both EMS and hospital GWTG electronic databases. We retrospectively reviewed all prospectively collected data from January 1, 2019 to May 31, 2019 for wristband placement by the EMS systems and determined the percentage match to hospital emergency department (ED) discharge data using the GWTG data and telestroke data.

Results:
From the five months of retrospective analysis of prospectively collected data for 5 months showed, 4,668 strokes were seen in hospitals complying with GWTG. Forty-two% of the positive strokes in hospital (EDs) had stroke bands placed. Of these 8.4% had matching stroke wristband numbers to the EMS database. The telestroke system reported 636 consultations with 95% band placement, 39% placed by EMS. Matching telestroke band ID’s to EMS records was 37%. Wristbands placed by EMS were associated with positive screen tests, pre-notification and shortened Door to CT time (p
<
0.0021).

Conclusions:
Wrist-bands were associated with improved EMS response and provided informed response to hospital care teams. For consistent tracking of positive stroke patient data from FMC to discharge both prehospital and hospital, systems must undergo additional training followed by surveys to determine informed training.
Abstract TP253: Ongoing Quality Improvement for Acute Ischemic Stroke at Comprehensive Stroke Center
Authors: Liu Shimeng , Zhu Zhu , Shafie Mohammad , Abcede Hermelinda , Shah Jay , Suzuki Shuichi , Lin Li-Mei , Golshani Kiarash , Stradling Dana , Yu Wengui
Published: June 2021

Background:
Ongoing quality improvement is essential for better outcomes and healthcare cost control. The aim of this study is to examine the progressive quality benchmarks for acute ischemic stroke (AIS) at an academic comprehensive stroke center (CSC).

Methods:
We retrospectively analyzed consecutive patients with AIS at University of California Irvine Medical Center from Jan 1
st
, 2013 to Dec 31
th
, 2018.Demographics and clinical data were collected from the
Get-With-The-Guideline (GWTG)
-Stroke registry and electronic medical records. Patients were stratified into 3 time periods according to their admission dates: 2013 to 2014; 2015 to 2016; and 2017 to 2018. Quality benchmarks for AIS, including door-to-needle (DTN) times, rates of receiving IV tPA and/or endovascular thrombectomy (EVT), rate of symptomatic intracerebral hemorrhage (sICH), and outcomes at hospital discharge were analyzed to identify trends of quality improvement in the last 6 years.

Results:
A total of 1369 patients were included in the study; 398 (29%) patients received acute reperfusion therapy, with 231 (17%) receiving IV tPA, 97 (7%) receiving both IV tPA and EVT, 70 (5%) receiving EVT only. There was no significant difference in baseline characteristics of the patients during the 3 time periods. IV tPA rates were 20% in 2013-2014, 30% in 2015-2016, and 22% in 2017-2018 (
p
=0.0005). The EVT rates in 2017-2018 (15% vs. 9%; OR: 1.77; 95% CI: 1.16 - 2.68;
p
= 0.008) and 2015-2016 (14% vs. 9%; OR: 1.70; 95% CI: 1.11 - 2.59;
p
= 0.01) were significantly higher than in 2013-2014. There were significant ongoing improvements in median DTN times, with 57 minutes in 2013-2014, 45 minutes in 2015-2016, and 39 minutes in 2017-2018. Among patients receiving IV tPA, significantly more patients had favorable outcomes (mRS score 0-3) at hospital discharge in 2015-2016 (67% vs. 42%; OR: 2.80; 95% CI: 1.46 - 5.40;
p
=0.002) than in 2013-2014.

Conclusions:
We demonstrate ongoing improvement in rates of IV tPA and EVT as well as DTN times for IV tPA in patients with AIS.
Abstract TP255: Tackling Door in-Door Out Through a Statewide Initiative
Authors: Martin-Schild Sheryl B , Spann Deborah , Legendre Yvette , Colligan Ted , Hargrove Paige
Published: June 2021

Background:
The AHA/ASA has determined thrombectomy is standard-of-care up to 24 hours after last seen normal (LSN) for ischemic stroke patients with anterior circulation large vessel occlusion (LVO), provided the perfusion imaging profile meets criteria. Many patients require secondary transfer to access thrombectomy centers. The door in-door out (DIDO) is a target for process improvement.

Methods:
The Louisiana Emergency Response Network (LERN)’s stroke system of care was initiated in 2010. Submission of quarterly emergency department stroke data to LERN was voluntary as of Q1 2014 and was mandated as of Q1 2018 for hospitals attesting to Acute Stroke Ready Hospital (ASRH) capability. Sites across the state were invited to pilot expanded variable in order to assess LVO screening and baseline DIDO for patients with LVO.

Results:
Of 56 ASRHs, 34 sites submitted one or more quarters of data during the pilot phase contributing a total of 1808 cases. LVO screening was performed in 992 (54.9%) cases; 172 (17.3%) were LVO screened positive. VAN was used in 75.6% of LVO positive patients and CTA was used in 20.3%. Most patients (71.3%) arrived via ambulance. The median NIHSS in LVO positive patients was 12 (IQR 5-20). Transfer time was available in 114 (66%) LVO positive patients; median DIDO was 146 minutes (IQR 89-243 minutes). Transfer request time was available in 30 (17.4%) of LVO positive patients; median interval from transfer request to departure was 47 minutes (IQR 31-65 minutes).

Discussion:
Given that most patients with ischemic stroke caused by LVO will not present initially to a thrombectomy center, DIDO must be minimized to preserve penumbra and maximize likelihood of eligibility for thrombectomy when the thrombectomy center is accessed. LERN’s pilot LVO screening study established a baseline from which DIDO is a necessary target for intervention. Only 25% of LVO positive patients were transferred with DIDO less than 90 minutes. LERN’s initial goal is to shift the median DIDO to 90 minutes. Participation in the expanded variables targeting LVO screening and DIDO was mandated by LERN effective Q3 2018.
Abstract TP256: Ems Run Times by Weekday vs. Weekend For Stroke Patients in San Diego County
Authors: Kenner-Brininger Amelia , Olson-Mack Lindsay , Calzone Lorraine , Koenig Kristi L , Hemmen Thomas M
Published: June 2021

Background:
Emergency Medical Services (EMS) is important as the initial responder, very little data examines EMS response and transport to hospital diagnosis. Understanding differences between weekday and weekend is informative for resource and staff planning. Using a countywide registry, we evaluated differences in EMS response times on weekdays and weekends and in-hospital treatment.

Methods:
We included EMS San Diego County Stroke Registry cases with a computer automated dispatch (CAD) and base hospital record (BHR) from July 2017 through December 2018; linked on EMS incident number. We analyzed EMS response, scene and transport time by weekday and weekend for all cases and cases with last known normal (LKN) to EMS enroute time < 6 hours. Hospital arrival to tPA and to embolectomy therapy (EVT) time was analyzed for this subgroup. Weekend was defined as Friday 1800 through Monday 0600.

Results:
Of 2,376 cases, 726 (30.6%) arrived during weekends. Weekend mean (±SD) response time was 6.7 (±3.4) minutes (min); 7.1 min (±3.9) on weekdays. Mean weekend scene time was 12.8 (±5.1) min, 13.2 (±5.3) min on weekdays (p=.18). Transport time was 13.2 (±7.6) min on weekends, 14.1 (±7.8) min on weekdays (p=.01). There were 1,190 cases with LKN to EMS enroute time < 6 hours, 379 arrived on weekends (31.8%). Mean (±SD) response time was 6.6 (±3.4) min on weekends, 7.2 (±3.9) min on weekdays; weekend scene time 12.1 (±4.5) min, weekday scene time 12.2 (±4.9); weekend transport time 12.2 (±6.6) min, weekday transport time 12.7 (±7.4) min. Of this group, 378 received tPA, 126 (33.3%) on the weekend. Mean (±SD) weekend arrival to tPA was 53.6 (±22.2) min; 56.0 (±32.1) min on weekdays (p=.39). 100 cases received EVT, 39 on a weekend. Mean (±SD) weekend arrival to EVT was 2.1 (±0.6) hours; weekdays 1.9 (±0.8) hours (p=.13).

Conclusion:
One in three patients arrived at the hospital on weekends. EMS response time and scene time did not differ, while transport time on the weekend was shorter, although this may not be clinically significant. This may be attributed to traffic volume and patterns during these times. However, among patients with shorter LKN time and patients receiving tPA no difference in EMS times was seen. Overall acute stroke transfer times did not differ across weekends and weekdays.
Abstract TP257: Is Non-English Language Correlated to Inaccurate Initial "Last Known Normal" Reports by Emergency Responders?
Authors: Bautista Alyssa , Saavedra-Chavez Christian , Rapp Karen , Meyer Brett C
Published: June 2021

Background:
Prior studies have looked into language and race disparities in receiving IV thrombolysis, however none into its correlation in obtaining accurate Last Known Normal (LKN) times that critically guide decision-making for acute stroke treatment. We sought to assess if non-English language preference was associated with inaccurate initial reporting of LKN time by emergency responders compared to LKN obtained by neurologists.

Methods:
Data was obtained from an IRB approved stroke registry in a single center from July 2013 to December 2018, for LKN time documented by a neurologist (“LKN2”). Manual chart review was done to document 1st reported LKN time as documented by EMS (or ED if no runsheets available) (“LKN1”). Inpatient stroke codes and hospital transfers were excluded. Differences in LKN1 and LKN2 were computed and stratified into Groups A (LKN1 is earlier in time than LKN2), B (LKN1 is the same as LKN2), and C (LKN1 is later in time than LKN2). Spearman correlation was used to analyze language differences; race between groups were compared using ANOVA.

Results:
Of total 990 stroke codes, 59.9% had discrepancy in LKN1 and LKN2 (17.9% in Group A, 42% in Group C) whereas 40.1% had agreeable LKN1 and LKN2 (Group B). Data for preferred language and race was available in 985 and 950 stroke codes, respectively. Language preference for English versus non-English is listed in Table 1, where no difference was found when Groups A and C (discrepant LKN1 and LKN2) was compared to Group B (p=0.68). Race of each group is listed in Table 2, where no difference was noted among Groups A, B, C as well (p=0.68).

Conclusion:
Non-English language preference among patients did not correlate with inaccurate reporting of LKN times by emergency responders. There were no significant racial differences found as well between groups with discrepant and agreeable LKN1 and LKN2 times.
Abstract TP258: Increasing Emergency Medical Services Pre-Notification Results in Faster Alteplase Administration and Increased Thrombectomy Therapy
Authors: Bluma Dot , Bennett Nicole , Link Jessica
Published: June 2021

Background and Purpose:
EMS pre-notification of a suspected acute stroke patient assists the hospital in mobilizing the appropriate personnel and resources before the patient arrives. The pre-notification by EMS and mobilization of the hospitals stroke team will increase the probability of the appropriately screened acute stroke patient receiving thrombolytic therapy. The Wisconsin Coverdell Stroke Program (Coverdell) performed a multi-quarter analysis of the successes and barriers hospitals were experiencing with EMS pre-notifying, with an overarching goal to increase this percentage to >80%.

Methods:
Coverdell’s 66 participating hospitals represent 78% of annual stroke admissions to Wisconsin hospitals. Coverdell hospitals participate in the quarterly Coverdell Learning Collaborative (CLC) where they review several aggregated data points. Of these, EMS pre-notification times are analyzed and discussed. Stroke Coordinators at hospitals’ performing at a high level shared with the CLC their performance improvement activities and best practices related to EMS pre-notification. Methods used consisted of, educating and training EMS caregivers on improving pre-arrival notification by communicating in plain language stroke symptoms or verbalizing a “possible stroke”; educating and training emergency department caregivers on where to document the EMS pre-arrival report in the EHR; and educating the stroke data abstractor on where the EMS pre-hospital report is located in the EHR.

Findings:
In analyzing quarterly data from Q1 2017 to Q1 2019, our multi-disciplinary approach demonstrates impressive results. EMS pre-notification rose from 68.1% to 77.0%, with 82% reached in Q2 2018. Associated with this the median DTN time for those arriving by EMS decreased from 49 to 44 minutes, with the lowest median time in Q2 2018 of 42.5 minutes. Furthermore, thrombectomy therapy (alteplase and mechanical thrombectomy) administration rates increased from 21.5% to the highest in Q2 2018 at 26.8%.

Conclusion:
A multi-faceted approach focused on improving communication between EMS and hospitals by pre-notifying of a suspected stroke patients arrival, has led to remarkable improvements in Coverdell’s outcome data.
Abstract TP261: Beyond the Golden Hour: Treating Acute Stroke in the Platinum 30 Minutes
Authors: Randhawa Anantbir S , Starkman Sidney , Sanossian Nerses , Liebeskind David S , Avila Gilda , Stratton Samuel , Eckstein Marc , Pratt Franklin , Sharma Latisha , Restrepo-Jimenez Lucas , Valdes-Sueiras Miguel , Kim-Tenser May , Villablanca Pablo , Conwit Robin , Hamilton Scott , Saver Jeffrey L
Published: June 2021

Background:
As hemorrhagic and ischemic strokes progress, acute stroke therapy is time dependent. To emphasize treatment speed for time-sensitive conditions, emergency medicine has developed not only the concept of the “golden hour,” but also the “platinum thirty”. Acute stroke patients treated within the first half-hour of onset have not been previously characterized.

Methods:
We analyzed all patients with acute stroke symptoms enrolled in the multicenter NIH-funded FAST-MAG trial, testing paramedic prehospital start of neuroprotective agent within 2h of onset. The frequency, demographic, clinical, and outcome features of patients with treatment start within the platinum 30m were compared with later treated patients.

Results:
Among the 1700 enrolled patients, 180 (10.6%) received study agent within 30 minutes of last known well (LKW). In these platinum-30 patients, final diagnoses were: acute cerebral ischemia in 70.0% (ischemic stroke 59.4%, TIA 10.6%); intracranial hemorrhage in 26.7%; and mimic in 2.8%, similar to the overall study population. Mean age was 68.3 (±13.2) years, 46.1% were women, initial deficit in the field on the Los Angeles Motor Scale was mean 4.1 (±1.2) and early-post-arrival NIHSS deficit was 11.3 (±10.5). Time from LKW to 911 call was median 4m (IQR 2-6); from LKW to paramedic evaluation 10m (IQR 7-12); from LKW to study drug start 27m (IQR 25-29); and from LKW to ED arrival 36m (IQR 31-41). Outcomes at 3 months included freedom from disability (mRS 0-1) in 35.0%, functional independence (mRS 0-2) in 53.3%, and mortality in 17.2%. Demographic, medical history, presenting deficit severity, and 3m outcomes among the platinum-30 patients were largely similar to the 1415 patients treated between 31-120m after onset.

Conclusions:
Paramedic prehospital initiation of neuroprotection study agent permits treatment start within the platinum first 30 minutes in a substantial proportion of acute ischemic and hemorrhagic stroke patients, accounting for more than 1 in 10 patients enrolled in a multicenter trial. Hyperacute, <30m patients activated the 911 system sooner after onset but were otherwise similar to later patients and are a treatable target in prehospital stroke trials.