bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP208: Increased Brachial Ankle Pulse Wave Velocity is Associated with Perivascular Space
Authors: Zhai Fei-Fei , Ye Yi-Cong , Chen Si-Yu , Han Fei , Ni Jun , Yao Ming , Zhou Li-Xing , Li Ming-Li , Jin Zheng-yu , Cui Li-Ying , Zhang Shu-Yang , Zhu Yi-Cheng
Published: June 2021

Background and Purpose:
To investigate the association between arterial stiffness, measured by brachial-ankle pulse wave velocity (baPWV), and severity of dilated perivascular space (PVS) in a population-based sample.

Methods:
Participants were recruited from an ongoing Chinese community-based cohort study. Stroke-free participants, who completed baPWV and brain MRI, were included. Severity of PVS was rated in the basal ganglia (PVS-BG) and white matter (PVS-WM) in high-resolution 3D T1-weighted images. We used logistic regression model to evaluate the association between baPWV and MRI markers. Subsequently, we explored associations in strata of age.

Results:
A total of 953 participants were included (mean age, 55.7 years, 37.6% male). Age and mean arterial blood pressure were major determinants of baPWV. BaPWV was independently associated with the severity of PVS in white matter (OR per SD,1.39; 95%CI, 1.07-1.81), with periventricular hyperintensities (OR per SD,1.44, 95%CI, 1.10-1.87) and deep white matter hyperintensities (OR per SD,1.44, 95%CI, 1.05-1.97), but not with lacunes. When stratifying by age, baPWV was significantly associated with PVS-WM and PVS-BG only in younger group (age<60), while the association between baPWV and WMH or lacunes was more evident in older group (age≥60).

Conclusions:
BaPWV was independently associated with severity of PVS, especially in younger individuals. This finding provided further evidences of the relationship between arterial stiffness and cerebral small vessel disease.
Abstract WP209: Plasma Brain Natriuretic Peptide Should be a Predictor for 3-Month Mortality in Non-Cardioembolic Stroke
Authors: Arakawa Masafumi , Shimoyama Takashi , Suda Satoshi , Takayama Yohei , Ouchi Takahiro , Suzuki Shizuka , Okubo Seiji , Mishina Masahiro , Kimura Kazumi
Published: June 2021

Background:
Plasma brain natriuretic peptide (BNP) is primarily released from the ventricular myocardium and is a biomarker of cardioembolic stroke. Previous studies have shown that elevated plasma BNP level predicts short and long term mortality in cardioembolic stroke. However, the relationship between BNP and mortality in non-cardioembolic stroke has not been fully examined. The present study tested the hypothesis that admission plasma BNP level can serve as a marker of 3-month mortality in non-cardioembolic stroke.

Methods:
From a prospective stroke registry, we examined acute non-cardioembolic stroke patients within 7 days after symptom onset who measured plasma BNP on admission from September 2014 to March 2016. We divided all patients into the non-survivors and the survivors within 3 month of non-cardioembolic stroke, and compared clinical characteristics between the two groups. The factors associated with 3-month mortality were investigated by multivariate logistic regression analysis.

Results:
Three hundred and one patients (198 males, 71 [61-80] years old) were enrolled in the study. Thirteen patients (3.8%) died within 3 month of non-cardioembolic stroke. There were no significant differences in male (61.5% vs. 66.0%, P=0.769), age (71 years old vs. 68 years old, P=0.450), hypertension (61.5% vs. 65.6%, P=0.771), diabetes (15.4% vs. 28.7%, P=0.525), dyslipidemia (30.8% vs. 43.4%, P=0.409), and smoking (61.5% vs. 50.0%, P=0.573) between the non-survivors and the survivors. The NIHSS score was significantly higher in the non-survivors than in the survivors (15 vs. 2, P<0.001). The plasma BNP was significantly higher in the group of non-survivors than in the group of survivors (85 pg/ml vs. 31 pg/ml, p =0.005). A cut off plasma BNP level of 65.0 pg/ml could predict death within 3 month of non-cardioembolic stroke. Multivariate logistic regression analysis showed that a plasma BNP level of >65.0 pg/ml (odds ratio [OR] 6.49; 95% confidence interval [CI], 1.79-23.56, P=0.04) was independently associated with 3-month mortality in non-cardioembolic stroke.

Conclusions:
A high plasma BNP level on admission should be a predictor for 3-month mortality in non-cadioembolic stroke.
Abstract WP21: Extracranial Carotid Revascularization May Have Higher Mortality Rate in Acute Stroke Intervention
Authors: Janjua Nazli , Tse-Chang Karen , Jones Kimberly , Woolfolk Katrina , Panichpisal Kessarin , Keaslier Debbie , Desai Bhupat
Published: June 2021

Background:
The endovascular management of acute extracranial carotid artery (EcCA) occlusion is unclear, as hypotension, a known phenomenon with carotid revascularization (CR), may exacerbate stroke symptoms. Most studiesinclude patients with tandem intracranial occlusions requiring thrombectomy, and even in those cases, there remains variability in regards to the order and manner of endovascular therapy (e.g. extra- vs intracranial revascularization first.

Objective:
We sought to compare the clinical and radiographic differences in EcCA patients who did or did not undergo proximal CR.

Methods:
We identified patients screened for possible intervention with acute EcCA occlusion from our prospective stroke database from 1/2014-8/2016and abstracted their demographic, clinical, and radiographic data. We compared differences between groups using chi-square analysis.

Results:
Thirty-four patients had EcCA: (10, 29% sole EcCA; 24, 71% tandem occlusions; these included 19 of our 143 (13%) patients undergoing acute stroke intervention (16 with tandem lesions, 3 without). Nine of the 16 tandem occlusion patients underwent specific CR, whereas in four we were unable to cross the EcCA, and in 3 only targeted the intracranial occlusion. The mean age was 69±14 years among 19 males and 15 females, with no intergroup differences. Most (19, 56%) received IV tPA in the whole group as well as the CR subset (7, 58%), who were loaded with antiplatelet agents afterwards; 11 underwent stent placement and 1 angioplasty alone. Although there were trends towards higher baseline and discharge National Institutes of Health Stroke scale scores (NIHSSS) among the CR group (19 vs 16 and 21 vs 18) and median discharge modified Rankin scales (5 vs 4), these were not significant (p>0.05). There were 5 deaths in both groups. As a comparison to the rest of our thrombectomy cohort, there was no significant difference in discharge NIHSSS (11 vs 13) among patients undergoing CR though there proportionately more deaths (25, 18%, no CRvs 5, 42%, CR, p<0.05).

Conclusion:
These data suggest that EcCA patients should be informed of possible greater risk of mortality during acute stroke intervention. Further analyses may better identify practice standards to improve outcomes in this population.
Abstract WP212: Association Between Within-visit Blood Pressure Variability and Stroke
Authors: Lin Michelle P , Ovbiagele Bruce , Gottesman Rebecca F , Sanossian Nerses , Markovic Daniela , Towfighi Amytis
Published: June 2021

Introduction:
Long-term variability in systolic blood pressure (SBP) is associated with higher risk of cardiovascular events. Little is known about the association between within-visit SBP variability and stroke.

Hypothesis:
Higher within-visit SBP variability is associated with higher odds of stroke.

Methods:
Participants included adults ≥18 years who participated in the US National Health and Nutrition Examination Surveys from 1999 to 2010. Stroke was self-reported. SBP was obtained up to four times by a physician, using a manual sphygmomanometer according standardized procedures. Within-visit SBP variability was defined as standard deviation of the BP measurements, stratified into quartiles. We evaluated the relationship between within-visit SBP variability and odds of having had a stroke using multivariable logistic regression.

Results:
Of the 27,987 adults, 16.4% were aged ≥ 65 years, 51.3% were female, 71.2% were White, 10.7% were Black and 7.9% were Mexican American. Factors associated with higher mean SBP variability included older age, hypertension, chronic kidney disease, peripheral artery disease, and smoking (all P<0.05). The prevalence of stroke significantly increased across SBP variability quartiles from 2.1% for quartile 1 to 3.7% for quartile 4. High SBP variability was associated with higher odds of stroke (OR 1.8, 95% CI 1.4-2.2). After adjustment for covariates, the odds ratio of stroke comparing highest vs. lowest quartile of SBP variability was 0.9 (p=0.400).

Conclusions:
Within-visit variability in SBP is associated with increased odds of stroke but the relationship is confounded by age and covariates.
Abstract WP213: Comparison of Clinical and Imaging Characteristic of Cryptogenic Stroke to Known Ischemic Subtypes
Authors: Behymer Tyler P , Vagal Achala , Sucharew Heidi , Yeluru Vineeth , Minhas Arjun , Hazenfield J. M , Reddy Mahati , Frey Courtney , Alwell Kathleen , Moomaw Charles J , Flaherty Matthew , Ferioli Simona , Mackey Jason , De Los Rios La Rosa Felipe , Martini Sharyl , Adeoye Opeolu , Kleindorfer Dawn O , Kissela Brett M , Khatri Pooja , Woo Daniel
Published: June 2021

Introduction:
Cryptogenic stroke is defined as not attributable to an identified source despite standard evaluation. The absence of small vessel or large artery disease in such evaluation suggests that cryptogenic stroke may be largely cardioembolic. We hypothesized that cryptogenic stroke would be similar to cardioembolic stroke in clinical and imaging characteristics.

Methods:
The Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) is a population-based study that tracks the regional incidence of stroke. A convenient subsample from the 2010 GCNKSS ischemic stroke cohort (N= 368) was selected for detailed neuroimaging analysis. The study physician subtyped cases based on clinical, radiographic and laboratory findings (carotid ultrasound, echocardiography, vascular imaging). Subtypes included cryptogenic, cardioembolic, large-vessel, small-vessel, undetermined, and other. Three radiologists performed imaging analysis including number of acute infarcts, location and white matter hyperintensity (WMH). Infarct volume was segmented using manual tracing.

Results:
Of 368 ischemic stroke cases with imaging data, subtypes were 26.4% cryptogenic, 16.3% large vessel, 15.5% small vessel, 24.7% cardioembolic, 5.4% undetermined, and 11.7% other. Compared to cardioembolic, cryptogenic stroke patients were younger, had less hypertension, higher alcohol use, smaller infarct volume and differed in location of stroke. Cryptogenic stroke had more clinical and radiological features in common with large and small-vessel stroke (Table). Undetermined and other had no significant differences to cryptogenic.

Conclusion:
Contrary to our hypothesis, cryptogenic stroke was different from cardioembolic stroke and appeared more similar to large vessel stroke in clinical and radiological characteristics. Further testing on a larger sample size to evaluate the impact of cardiac event monitoring on subtype distribution is needed.
Abstract WP215: Patients with Acute Ischemic Stroke Admitted to the Hospital Closest to the Epicenter of 2016 Kumamoto Earthquake
Authors: Nagao Yoichiro , Nakajima Makoto , Shindo Seigo , Namitome Satoshi , Wada Kuniyasu , Terasaki Tadashi , Ando Yukio
Published: June 2021

Background:
2016 Kumamoto Earthquake in 2016 is characterized by a huge foreshock of magnitude-6.5, a magnitude-7.3 mainshock, and numerous, sustained aftershocks.

Objective:
To elucidate the influence of the Kumamoto Earthquake to ischemic stroke by investigating acute stroke patients who were admitted to the acute hospital located closest to the epicenter of the foreshock and mainshock during 1 month.

Methods:
Acute ischemic stroke patients within 7 days of onset who were admitted during April 14 and May 13, 2016, and those admitted in the same period in 2015 were investigated. Patients’ characteristics, stroke severity, subtype, onset-admission time, and laboratory data were compared between 2015 and 2016.

Results:
A number of acute ischemic stroke patients increased by 1.2 times from 43 (14 women) to 69 (27 women), and age was younger in 2016 (median, 72 years; interquartile range, 65-81) than in 2015 (78; 67-85; p = 0.042). No differences were observed in background characteristics, vital signs, stroke severity, or stroke subtype between the two years. Onset-to-admission time was longer in 2016 than in 2015 (951 vs. 441 minutes, p = 0.023). Among laboratory data, platelet count was higher after the earthquake, whereas other data were similar in the two years.

Conclusions:
Number of ischemic stroke admitted to the closest to the epicenter increased than the previous year and the time from onset to admission prolonged. These data indicate that patients were transferred from wider area after huge earthquakes. An increment of platelet was the only change observed in laboratory data after the earthquake. Multicenter, longitudinal observation would be needed to clarify the effect of the earthquake to cerebrovascular events.
Abstract WP218: Brain Reserve: A Protective Mechanism for Stroke Outcome
Authors: Schirmer Markus D , Etherton Mark R , Dalca Adrian V , Giese Anne-Katrin , Cloonan Lisa , Wu Ona , Golland Polina , Rost Natalia S
Published: June 2021

Introduction:
Stroke is a leading cause of disability worldwide. Mechanisms of post-stroke recovery are complex, and conventional outcome prediction models are limited. “Brain reserve” (BR) has been proposed as a construct to model the brain’s capacity to withstand insults. BR has been shown to co-vary with white matter hyperintensity volume (WMHv) using structural equation modeling (SEM), a technique to test models with latent variables.

Hypothesis:
We hypothesize that BR is a protective mechanism that improves functional outcome after acute ischemic stroke (AIS).

Methods:
We define an effective brain reserve (eBR), the remaining brain reserve after other influences have been accounted for. Using SEM, we characterize eBR through intra-cranial volume (ICV), age and systolic blood pressure (SBP). Our model incorporates known relationships between age, SBP, WMHv, acute infarct volume on diffusion-weighted imaging (DWIv) and 90-day functional post-stroke outcome (modified Rankin Scale; mRS), as shown in Figure 1. Path analysis was performed (R; package lavaan) to estimate the relations within the model in a dataset of 451 AIS patients. No priors were used for the path coefficients.

Results:
The estimated model coefficients (Figure 1) show that eBR is negatively associated with age and SBP, but positively with ICV, while association between age, SBP and WMHv are positive. Outcome is positively associated with WMHv and DWIv and negatively with eBR, suggesting that eBR acts as a protective mechanism. All path coefficients are statistically significant, except for WMHv and mRS.

Conclusion:
Our analysis shows that eBR is negatively associated with post-stroke outcome (the higher eBR, the lower mRS), suggesting that eBR acts as a protective mechanism. Additionally we reproduced known relationships between WMHv, SBP, age, DWIv and mRS.
Abstract WP220: The Effect of Self-Reported Optimism on the Incidence of Stroke
Authors: Malik Ahmed , Rahman Haseeb , Qureshi Adnan , Wojtowycz Martha A
Published: June 2021

Purpose:
The purpose of this study is to determine whether having an optimistic outlook on life decreases the risk of developing incident stroke.

Methods:
Participants who developed incident stroke in Americans’ Changing Lives study, and participants who did not develop incident stroke (dependent variable) in were compared for demographics, baseline characteristics, comorbidities, and optimistic outlook on life. Numbers and proportions of respondents in both groups were reported for all categorical variables, while mean and standard deviation were reported for age. All statistically significant variables from the above analyses were entered into a logistic regression analysis to ascertain the association between optimistic outlook on life and stroke.

Results:
Of the 98,577,928 participants, 73,040,055 did not have stroke at baseline. There were 599,190 who developed incident stroke and 1,104,751 who did not develop incident stroke. The mean age (standard deviation) was lower in those who developed incident stroke compared to those who did not [45.9 (13.8) vs. 46.4 (9.9) p<.0001], and participants with an optimistic outlook on life, were 0.20 times less likely to develop stroke as those who did not have an optimistic outlook on life [OR (Odds ratio) 0.20 95% CI (95% confidence interval) 0.20,0.21], after adjusting for confounders.

Conclusions:
People who have an optimistic outlook on life are less likely to develop incident stroke. The protective value of optimism lends credence to the value of targeting unconventional risk factors in stroke prevention.
Abstract WP228: Clinical Characteristics of Hmong Patients Presenting with Acute Ischemic Stroke
Authors: Hussein Haitham M , Kashyap Bhavani , Erickson Lauren O , Droegemueller Carol , Hanson Leah
Published: June 2021

Introduction:
Hmong people are originally from the mountainous areas of Southeastern China, Northern Vietnam, Laos, and Thailand. Large numbers have migrated to the USA. In response to a request from leaders of the Hmong community and given the lack of literature, this study was conducted to describe ischemic stroke in the Hmong patients at our comprehensive stroke center.

Methods:
Institutional GWTG database and charts for years 2010-2015 were retrospectively reviewed. Hmong patients were identified by their last names (18 clans) provided by the Hmong community leaders. Different demographic, social, and clinical aspects were reported and compared to white patients in a univariate analysis.

Results:
Forty-one Hmong and 1510 White were included in the analysis. Compared to Whites, Hmong patients were significantly younger (60±2.16 vs. 70±0.39 years
#
), predominantly women (66% vs. 48%; p=0.03), less frequently covered by medical insurance (68% vs. 87%
#
) and less frequently brought by ambulance (44% vs. 54%
#
). Onset-to-door time, door-to-needle time, NIHSS at admission, and incidence of vascular risk factors was similar between the two groups; however, Hmong patients seemed to have poorly controlled risk factors with mean A1C 11±0.9% in diabetics (n=13) and mean LDL 116±6.4 mg/dL in hyperlipidemics (n=16). The most common stroke mechanisms were small vessel (31%) and intracranial atherosclerotic diseases (27%). Based on imaging in Hmong patients; 56% had intracranial arterial calcification, 53% had microaniopathic disease, 46% had intracranial stenosis, and 18% extracranial stenosis. On echocardiogram, 68% of Hmong had left ventricular hypertrophy, 54% had dilated left atrium, one patient had hypokinesis, and none had low ejection fraction. The length of stay and the rate of independent ambulation on discharge were not different between Hmong and Whites, however, a larger proportion of Hmong were discharged home (59% vs. 46%; p=0.05).
#
p≤0.0005

Conclusion:
In this study population, Hmong patients suffered from poorly controlled risk factors, had high incidence of small vessel and intracranial atherosclerotic disease, low incidence of carotid disease and heart failure and utilized fewer resources than Whites.
Abstract WP229: Randomised Clinical Trial of Early Prolonged Ambulatory Cardiac monitoring After Stroke (EPACS): Interim Analysis
Authors: Teo James T , Lenane Judith , Sztriha Laszlo , Chan Fong K , Aeron-Thomas John , Gall Nicholas , Kaura Amit , Piechowski-Jozwiak Bartlomiej
Published: June 2021

Introduction:
Cardioembolism in paroxysmal atrial fibrillation (PAF) is a preventable cause of ischaemic stroke or transient ischaemic attack (TIA), but the transient nature of PAF means that a short-duration Holter monitor misses a significant proportion of cases. Systems for recording beyond 3-7 days have significant limitations: event-triggered loop recorders are cumbersome while implanted loop recorders require a minor surgical procedure. There is a need for a patient-friendly long-duration cardiac monitoring system for stroke patients which can be performed without significant delay from the index event and with superior yield to Holter ECG’s.

Methods:
We conducted a pragmatic randomised controlled trial of cardiac monitoring after an ischaemic stroke or TIA to increase detection of paroxysmal atrial fibrillation (recruited within 72 hours of index event) using a wearable water-proof adhesive cardiac monitoring patch (Zio® Patch, iRhythm Technologies) that can be fitted immediately by the clinician early after the index event for up to 14 days or a standard Holter ECG. The trial aimed to recruit 120 patients across two locations - urban teaching hospital (Kings College Hospital, London) and suburban district hospital (Princess Royal University Hospital, Orpington). ISCRTN Registration 50253271.

Results:
In August 2016, the interim analysis detected PAF in 4/17 cases in the active arm and 0/16 cases in the control arm. The commonest arrhythmias detected were atrial tachyarrhythmias followed by PAF. Those in the control arm of Holter ECG’s had significant delays to initiate cardiac monitoring due to scheduling delays and patient non-attendance. There were no device-attributable serious adverse events. Further late-breaking results will be available in February 2017.

Conclusion:
The convenience of the Zio® Patch cardiac monitor substantially increased the uptake and efficiency of cardiac monitoring early after ischaemic strokes and TIA.
Abstract WP238: Utility of the Bubble Test With Cervical Triplex Ultrasound in Diagnosis of Patent Foramen Ovale in Patients With Inadequate Transtemporal Sonic Window
Authors: Topcuoglu Mehmet Akif , Arsava Ethem Murat
Published: June 2021

Introduction:
Transcranial Doppler (TCD) detection of microbubble signals in the middle cerebral artery (MCA) after agitated saline injection, known as the bubble test, is a dependable method to detect right-to-left shunts (RLS) such as patent foramen ovale (PFO). In patients with inadequate temporal bone windows, cervical internal carotid or vertebral arteries (ICA and VA) are suggested to be alternatives of MCA. However, utility of the bubble test with cervical arteries has never been documented in this population.

Methods:
Using contrast transesophageal echocardiography (cTEE) as gold standard, the sensitivity (Se) and specificity (Sp) of unilateral hand-held cervical triplex ultrasound bubble test technique was computed and compared with other available TCD methods. RLS volume was graded per the International Consensus Criteria (ICC).

Results:
Of 796 patients who underwent the bubble test in 3 years, 41 (5.3%) patients had no adequate temporal bone windows for MCA insonation. cTEE was available for 184 patients. Se and Sp of cervical bubble test was excellent in patients without adequate bone windows (n=36, Se: 88% (57-98) and Sp: 91% (71-99) for ICA; n=33, Se: 85% (55-98) and Sp: 90% (68-98) for VA), and was to comparable to those with adequate bone windows (n=78, Se: 93% (95%CI: 82-99) and Sp: 79% (61-91) for ICA; n=48, Se: 92% (74-99) and Sp: 91% (72-99) for VA). Diagnostic yield is comparable to standard bubble test with bilateral MCA Doppler monitoring (n=56, Se: 74% (55-88) and Sp: 56% (35-76) for spectral Doppler and M-mode). Of note, unilateral hand-held transcranial Doppler (n=26, Se: 93% (66-99) and Sp: 58% (28-85) for spectral Doppler: Se: 93% (66-99) and Sp: 50% (21-79) for M-mode) and color-coded (n=125, Se: 88% (78-94) and Sp: 64% (48-78) for color-coded MCA) techniques are also acceptable and apparently more practical methods for RLS detection.

Conclusions:
Hand-held cervical artery bubble test has high Se/Sp enough for routine use for PFO screening. Yield is good in the setting of impermeable transtemporal bone windows.
Abstract WP243: Prehospital Scales Derived From NIHSS Items May Not Accurately Reflect Performance in the Prehospital Setting
Authors: Borges Claire , Gazi Melissa , Gropen Toby
Published: June 2021

Introduction:
The widely used Cincinnati Prehospital Stroke Scale (CPSS) has a sensitivity for stroke identification of only about 50%. A previous study suggested that stroke was missed more frequently by EMS using the CPSS in patients without motor signs. The purpose of this study was to compare the elements of the CPSS to the corresponding items of the gold standard National Institutes of Health Stroke Scale (NIHSS).

Hypothesis:
Speech and language components of the NIHSS are more sensitive than the corresponding speech component of the CPSS.

Methods:
We retrospectively studied patients transported to University of Alabama at Birmingham by EMS with suspected stroke from January to May of 2016. We excluded patients who did not have the CPSS performed by EMS in the field or admission NIHSS performed by neurology residents and those without a discharge diagnosis of stroke. We compared the sensitivity of abnormal facial droop, arm drift, and speech of the CPSS to the corresponding NIHSS items (facial palsy ≥ 1, left or right motor arm ≥ 1, best language or dysarthria ≥ 1) for a discharge diagnosis of stroke by vascular neurologists.

Results:
There were 232 subjects (White, 52%; Black, 44%; men, 51%: age=66, sd=16) There was no difference in the sensitivity of arm drift for discharge diagnosis of stroke between the CPSS (77.6%, 95% CI 70-85) and NIHSS (79.2%, 71-87), p=0.13. Compared to the NIHSS, the CPSS had significantly lower sensitivities on tests of facial weakness (51.2%, 42-60 vs. 65.3%, 55-75, p=0.006) and speech and language abnormalities (63.2%, 54-72 vs.71.6%, 61-80, p<0.0001).

Conclusions:
CPSS items testing facial weakness and speech/language are significantly less sensitive compared to corresponding NIHSS items. This may relate to more rigorous testing of these items on the NIHSS, but may also relate to different examiners or settings. Prehospital scales derived from NIHSS items may not accurately reflect performance in the prehospital setting.
Abstract WP247: Facilitating Pre-hospital Communication between Neurology and Witness Reduces IV Alteplase Initiation Times
Authors: Elshire Cortlyn J , Olson-Mack Lindsay , Rockwell Jean , Deskin Sara , Berger Lynn , Richetts Renee , Kalafut Mary , Wells Christine M.
Published: June 2021

Introduction:
American Stroke Association guidelines recommend pre-hospital stroke code notification via EMS to facilitate prompt treatment decision for acute ischemic stroke (AIS) patients. Despite pre-notification to the stroke team, treatment decisions are often delayed until medical history and last known well times are established.

Hypothesis:
We hypothesized that screening for IV Alteplase candidacy and obtaining pertinent medical history from a witness or patient during a pre-hospital stroke code activation prior to hospital arrival would decrease door to needle (DTN) times.

Methods:
A retrospective analysis was conducted on 193 patients presenting to the emergency department (ED) at a Comprehensive Stroke Center (CSC) from February 2016 through July 2016. A process improvement (PI) event was initiated between the CSC and two fire stations with a catchment time of > 10 minutes. For pre-hospital activated stroke codes, the witness or patient was provided the contact card and encouraged to call the centralized number to the Neurologist. Inclusion criteria: All patients presenting to the ED with EMS pre-hospital stroke code activation. Exclusion criteria: Patients presenting to the ED with stroke code initiated after arrival, or medic response events which did not lead to a pre-hospital stroke code activation.

Results:
After applying criteria, 126 met inclusion and exclusion criteria. A total of 19 patients arrived via the 2 fire stations with pre-hospital stroke code initiations and serve as our intervention group, while 107 patients underwent standard of care. Contact cards were provided to 11 patients (58%) in the intervention group prior to arrival. IV Alteplase was initiated for 3 of 11 patients (27.3%) in the intervention group vs. 19 of 107 patients (17.8%) in the standard of care group. Mean and median DTN times in the intervention group was 36 minutes as compared to a mean of 46.1 minutes and median time of 40 minutes receiving standard of care.

Conclusions:
Preliminary data suggest that DTN times can be decreased when medical history is obtained prior to hospital arrival to screen for IV Alteplase eligibility. This study warrants further investigation in pre-acquisition of history for pre-hospital stroke code patients.
Abstract WP248: Pre-treatment Perfusion CT in Stroke Thrombolysis Can Predict Disability-free Life
Authors: Kawano Hiroyuki , Bivard Andrew , Lin Longting , Ma Henry , Cheng Xin , Aviv Richard , O’Brien Billy , Butcher Kenneth , Lou Min , Zhang Jingfen , Jannes Jim , Dong Qiang , Levi Christopher R , Parsons Mark W
Published: June 2021

Introduction:
Stroke shortens an individual’s disability-free life. We aimed to assess the relative prognostic influence of pre- and post-treatment perfusion CT imaging variables (e.g. ischemic core and penumbral volumes) compared to standard clinical predictors (such as onset-to-treatment time) on long-term stroke disability in patients undergoing thrombolysis.

Methods:
We used data from a prospectively collected international, multicenter, observational registry of acute ischemic stroke patients who had perfusion CT and CT angiography before treatment with intravenous alteplase. Baseline perfusion CT and follow-up MRI were analysed to derive the baseline penumbra volume, baseline ischemic core volume, and penumbra salvaged from infarction. The primary outcome measure was the effect of imaging and clinical variables on disability-adjusted life years (DALY). Clinical variables were age, sex, NIHSS score, and onset-to-treatment time. Age, sex, country, and 3-month modified Rankin Scale were extracted from the registry to calculate DALY due to stroke, such that one year of DALY equates to 1 year of healthy life lost due to stroke.

Results:
Seven hundred seventy two patients were treated with alteplase therapy. 17.5 DALY-days were lost per 1 mL of baseline ischemic core volume (95%CI, 13.2 - 21.9 days, p < 0.001). For every mL of penumbra salvaged, 7.2 days of DALY-days were saved (95%CI, 4.1 - 10.4 days, p < 0.001). Each minute of earlier onset-to-treatment time resulted in a saving of 4.4 disability-free days after stroke (1.3 - 7.5 days, p = 0.006). However, after adjustment for imaging variables, onset-to-treatment time was not significantly associated with savings in DALY-days.

Conclusions:
Pre-treatment perfusion CT scan defined penumbra (independently of clinical variables) predict significant gains, or loss, of disability-free life in patients undergoing reperfusion therapy for stroke. The effect of earlier treatment on disability-free life appears explained by salvage of penumbra.
Abstract WP250: Transport Times and Door to Needle Times for Stroke Patients Transported by EMS
Authors: Ramirez Lucas , Bosson Nichole , Gausche-Hill Marianne , Saver Jeffery L , Starkman Sid , Liebeskind David S , Lyden Patrick , Sanossian Nerses
Published: June 2021

Background:
Treatment of acute ischemic stroke with intravenous thrombolytics (IV tPA) within the therapeutic window is more likely achieved when there is rapid activation of emergency medical services (EMS), identification of stroke, direct transport to Acute Stroke-Ready Hospitals, and expedited ED evaluation.

Objective:
To characterize the relation between EMS treatment interval and door to needle times in a regional stroke system of care.

Methods:
This is a retrospective analysis of consecutive patients with positive prehospital stroke screens transported to an approved stroke center in a large metropolitan system from January 2011 to December 2014. Data, including EMS on scene time, ED arrival time, and time of IV tPA administration, was abstracted from the regional EMS Agency stroke database. The median times from EMS arrival on scene to ED arrival (scene to door) and from ED arrival to IV tPA (door to needle) were calculated along with the total scene to needle time. The correlation coefficient was calculated between scene to door and door to needle time.

Results:
Among 16,317 patients transported for suspected stroke, the median age was 75 (Interquartile range [IQR] 62-85) years, 53% were women, 66% White, 11% Asian, 10% Black and 24% Hispanic. 84% had a cerebrovascular final diagnosis, ischemic stroke (IS) being the most common (n=8606, 53%). 16% had a non-stroke-related diagnosis. The median NIHSS was 9 (IQR 4 to 19). Median scene to door time was 29mins (IQR 23-38). IV tPA was administered to 1655 patients (19% with final diagnosis of IS), with 84% treated within 3hrs of LWKT (median=128mins, IQR 99-165). Among patients receiving IV tPA, the median scene to door time was 28mins (IQR 22-36), door to needle time 92mins (IQR 68-98) and scene to needle time 116mins (IQR 89-126). There was no correlation between scene to door and door to needle time (r=-0.0014).

Conclusions:
In this large metropolitan region, scene to door times for stroke transports averaged just under 30mins and scene to needle times just under 2hrs. There was no correlation between scene to door and door to needle times. These findings provide data to guide efforts to reduce first responder to final treatment intervals throughout regional EMS stroke systems.
Abstract WP252: The Effect and Associated Factors of Dispatcher Recognition of Stroke: A Multicenter Observational Cohort Study
Authors: Hsieh Ming-Ju , Sun Jen-Tang , Chiang Wen-Chu , Chien Kuo-Liong , Ma Matthew Huei-Ming
Published: June 2021

Introduction:
Stroke patients recognized by dispatchers have an increased chance of receiving prehospital care with advanced life support and arrive at hospital earlier. There is limited research on factors associated with dispatcher recognition of stroke. This study aimed to: (1) understand the details of the dispatcher-caller communication among the calls for stroke patients, (2) identify factors associated with stroke recognition by dispatchers, and (3) evaluate the association between stroke recognition by dispatchers and stroke management.

Methods:
We conducted a multicenter retrospective study involving patients with stroke or transient ischemic stroke transported by the emergency medical service, and arriving at 9 hospitals in Taipei within 3 hours of symptom onset from January 1, 2013 to February 28, 2014. Patients were excluded if tape-recording data or prehospital management information were not available. Data of the enrolled patients were reviewed, including the tape recording of the dispatcher-caller communication, the type of dispatch determination, and patient characteristics. We used stroke dispatch determination as the surrogate for stroke recognition by dispatchers. Multivariable logistic regression was used to identify the factors associated with stroke dispatch determination.

Results:
A total of 507 patients were included. In approximately 50% of cases, callers were close family members. Ninety-one patients (17.9%) had stroke dispatch determination. After adjustment, stroke reported spontaneously, any one symptom included in the Cincinnati Prehospital Stroke Scale reported spontaneously, and dispatcher adherence to the protocol, were associated with stroke dispatch determination independently. Stroke dispatch determination was associated with receiving pre-arrival notification, shorter door-to-computed tomography time, and thrombolytic therapy.

Conclusions:
The sensitivity of recognizing stroke patients by dispatchers is suboptimal. Dispatchers should spend more time identifying stroke patients from those with frequently reported problems, by following the dispatch protocol. Recognition of stroke by dispatchers was associated with improved stroke care.
Abstract WP253: Impact of a Stroke Coordinator on Improving Time to Treatment at Telestroke Sites.
Authors: Yamada Lidia B , Gurry Manuel C , Harvey Jillian B , Debenham Ellen , Holmstedt Christine A , Turan Tanya N
Published: June 2021

Background:
The implementation of Telestroke systems has made stroke expertise accessible to patients evaluated in hospitals located in rural areas. Yet, decreasing time from emergency department (ED) arrival to administration of intravenous tPA is still a challenge in many rural hospitals. Stroke coordinators can provide staff training on stroke recognition and implement strategies for faster assessment of acute stroke patients. We sought to determine if the presence of a stroke coordinator (SC) at Telestroke sites contributed to decreased door-to-registration (DTR) and door-to-needle (DTN) time in the ED.

Methods:
Data from Telestroke consultations at 22 different community hospitals in South Carolina (2008 - 2016) were analyzed. DTR and DTN were compared between consults when a SC was employed or not at the respective hospitals at the time of the consultation. T-tests and chi squared were used to examine differences in continuous and categorical variables, respectively. Estimates for each outcome were determined using a log link general linear model, with a gamma distribution, adjusting for patient age, sex, site, and stroke severity (NIH stroke scale) on admission.

Results:
Of 8441 Telestroke consultations performed, 5842 (69%) were included in the DTR analysis, with the remainder excluded due to incomplete data. DTN was available for 1056 consultations. Adjusted mean DTR time was 23.3 minutes shorter (31.6 vs. 54.9, p≤0.001) for consultations in sites that employ a SC vs. those without. Mean DTN time was 29.7 minutes shorter in sites with a SC (64.5 vs. 94.2, p≤0.001). The multivariable analysis showed that employment of a SC, site, patient age and NIHSS were significantly related to shorter DTR and DTN.

Conclusions:
Employment of a stroke coordinator at remote hospitals receiving Telestroke services can significantly decrease time to registration and time to treatment of patients presenting with acute stroke symptoms, which may improve outcomes for stroke patients.
Abstract WP258: Simulating the Impact of Direct Transport of Patients with Suspected Large Vessel Occlusion to Comprehensive Stroke Centers in a Large Urban Emergency Medical Services System
Authors: Richards Christopher T , Hong Tyler D , Lim Ashley , Myers Emma , Nie Yumeng , Khorzad Rebeca , Holl Jane , Smilowitz Karen , Prabhakaran Shyam
Published: June 2021

Introduction:
One strategy to facilitate timely endovascular revascularization therapy (ERT) is for emergency medical services (EMS) to transport patients with suspected acute ischemic stroke from large vessel occlusion (LVO) directly to comprehensive stroke centers (CSCs), a process that can potentially result in CSC over-triage and tPA delay.

Hypothesis:
We hypothesize that simulation modeling can identify optimal characteristics of an EMS protocol that directly transports patients with suspected LVO to CSCs.

Methods:
Simio (Simio LLC, Sewickely, PA) was used to develop and test a simulation model estimating tPA and ERT rates among EMS-transported patients if an EMS preferential triage policy were implemented in a large, urban EMS system with 23 primary stroke centers (PSC) and 7 CSCs. The process map included time from symptom onset to calling 911, stroke severity, accuracy of field LVO identification, scene and interfacility transport times, and time from hospital arrival to treatment. Current state estimates were obtained from the Get With the Guidelines-Stroke registry, into which the EMS system’s PSCs and CSCs report data.

Results:
Table 1 shows current treatment rates, theoretical maximum treatment rates (if CSC transport time = 0), and treatment and CSC transport rates in simulations varying symptom onset time as a cut-off criterion for direct transport to a CSC rather than a closer PSC. In sensitivity analysis, accuracy of field LVO identification and interfacility transfer time had the largest positive and negative effect, respectively, on the primary outcomes.

Conclusions:
Direct transport of patients with suspected LVO who have symptom onset greater than 2 hours prior to EMS arrival is predicted to result in high treatment rates with only a modest increase in the number of patients transported to CSCs and without delaying tPA. Accuracy of field LVO identification and interfacility transport processes may be targets for optimizing EMS stroke systems of care.
Abstract WP261: Non-English-preferring Patients Have No Differences in Stroke Symptom Recognition or Emergency Care Time Metrics
Authors: Natsui Shaw , Siddiqui Khawja A , Erfe Betty L , Mejia Nicte I , Schwamm Lee H , Sauser Zachrison Kori
Published: June 2021

Introduction:
The influence of patients’ language preference on the delivery of acute ischemic stroke (AIS) care in the pre-hospital and in-hospital emergency care settings is scarcely known. We hypothesize that stroke knowledge differences may be associated with non-English preferring (NEP) patients having slower time from symptom discovery to hospital presentation and less engagement of emergency medical services (EMS) than English preferring (EP) patients. Language barriers may also interfere with the delivery of time-sensitive emergency department care.

Objectives:
To identify whether language preference is associated with differences in patients’ time from stroke symptom discovery to hospital arrival, activation of emergency medical services, door-to-imaging time (DIT), and door-to-needle (DTN) time.

Methods:
We identified consecutive AIS patients presenting to a single urban, tertiary, academic center between 01/2003-04/2014. Data was abstracted from the institution’s Research Patient Data Registry and Get with the Guidelines-Stroke Registry. Bivariate and regression models evaluated the relationship between language preference and: 1) time from symptom onset to hospital arrival, 2) use of EMS, 3) DIT, and 4) DTN time.

Results:
Of 3,190 AIS patients who met inclusion/exclusion criteria, 9.4% were NEP (n=300). Time from symptom discovery to arrival, and EMS utilization were not significantly different between NEP and EP patients in unadjusted or adjusted analyses (overall median time 157 minutes, IQR 55-420; EMS utilization: 65% vs. 61.3% p=0.21). There was no significant difference between NEP and EP patients in DIT or in likelihood of DIT ≤ 25 minutes in unadjusted or adjusted analyses (overall median 59 minutes, IQR 29-127; DIT ≤ 25 minutes 24.3% vs. 21.3% p=0.29). There was also no significant different in DTN time or in likelihood of DTN ≤ 60 minutes in unadjusted or adjusted analyses (overall median 53 minutes, IQR 36-73; DTN ≤ 60 minutes 62.5% vs. 58.2% p=0.60).

Conclusion:
Non-English-preferring patients have similar response to stroke symptoms as reflected by EMS utilization and time from symptom discovery to hospital arrival. Similarly, NEP patients have no differences in in-hospital AIS care metrics of DIT and DTN time.
Abstract WP264:
Be Fast
- Redefined
Authors: Laroia Swati , Romero Charles , Deveikis Cynthia , Jovin Tudor , Jadhav Ashutosh , Esper Jeffrey , DeMatteis James
Published: June 2021

Introduction:
Simple prehospital assessment tools for identifying patients with large vessel occlusion remains a challenge. This study evaluated the mnemonic

BE FAST

with modified designations for the detection of large vessel occlusion by evaluation of select symptoms (

B

alance/Coordination,

E

ye Deviation,

F

acial Weakness,

A

rm/Leg Weakness,

S

lurred Speech/

S

ensory Deficits,

T

ime of Onset).

Methods:
Retrospective chart review for all patients (July 2014 to June 2015) with discharge diagnosis of ischemic stroke was performed excluding hemorrhagic stroke and TIAs. Presenting symptoms, physical findings and NIH score were used to determine a

BE FAST

score. Imaging was evaluated for presence of large vessel occlusion (LVO) and stroke. Comorbidities and interventions were recorded. A presumptive

BE FAST

cut-off value for identifying LVO was made and confirmed using Two-step Cluster Technique and data dichotomized based on the cut-off. Chi-Square Tests were then used to determine if an association existed between dichotomized

BE FAST

scores and rates of LVO. Diagnostic sensitivity, specificity, and accuracy were then calculated using this cut-off value.

Findings:
526 patient charts were identified and 455 patient charts remained after application of exclusion criteria. Of 108 patients with LVO, 18 patients had a

BE FAST

score <4 (16.7%) and 90 patients had a score ≥4 (83.3%). Of the 347 patients without LVO, 260 (74.9%) had a score <4 and 87 (25.1%) had a score of ≥ 4. Differences in the rates of LVO based on this cut-off were significant (p<0.001). Only atrial fibrillation and

BE FAST

score ≥4 were predictive of LVO, odds ratios of 1.89 (95% CI: 1.035 - 3.456; p=0.038) and 19.5 (95% CI: 10.474 - 36.293; p<0.001), respectively. The sensitivity for the

BE FAST

score in the detection of LVO was calculated as 83%. The diagnostic accuracy of the

BE FAST

score with a threshold of 4 was calculated as 77%.

Conclusion:
The modified
BE FAST
score, as defined here, may serve as a useful prehospital assessment tool for identifying patients with large vessel occlusion. The simplicity of the tool may reduce time to appropriate intervention. Prospective research is needed to confirm these findings and to determine inter- and intra-rater reliability of this modified

BE FAST

score.
Abstract WP265: Individual and System Contributions to Race and Sex Disparities in Thrombolysis Use for Stroke Patients
Authors: Faigle Roland , Urrutia Victor C , Cooper Lisa A , Gottesman Rebecca F
Published: June 2021

Background:
Intravenous thrombolysis (IVT) is the cornerstone of acute stroke therapy; however, is underutilized in minorities and women. In order to disentangle individual and system-based factors determining disparities in IVT use, we investigated race/sex differences in IVT utilization among hospitals serving varying proportions of minority patients.

Methods:
Inpatient admissions for ischemic stroke patients were identified from the Nationwide Inpatient Sample between 2007 and 2011. Hospitals were categorized based on the percentage of minority patients admitted with stroke (<25% minority patients [“white hospitals”], 25-50% minority patients [“mixed hospitals”], or >50% minority patients [“minority hospitals”]). Logistic regression was used to evaluate the association between race/sex and IVT use within and between the different hospital strata.

Results:
A total of 337,201 stroke admissions were examined. Compared to white women, minority men, and minority women, the odds of IVT were highest for white men in any hospital strata; the odds of IVT for white men did not differ by hospital strata. For white women and minority men the odds of IVT were significantly lower in minority hospitals compared to white hospitals (OR 0.83, 95% CI 0.71-0.97, for white women; and OR 0.82, 95% CI 0.69-0.99, for minority men). The odds of IVT for minority women did not significantly differ by hospital strata. Race disparities in IVT use among women were observed in white hospitals (OR 0.88, 95% CI 0.78-0.99, in minority compared to white women), but not in minority hospitals (OR 0.94, 95% CI 0.82-1.09). Sex disparities in IVT use were observed among whites, but not minorities.

Conclusion:
Minority men and white women have significantly lower odds of IVT in minority hospitals compared to white hospitals. IVT use in white men does not differ by hospital strata.