bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP268: Associations Between Case Volume and Outcomes in the Subarachnoid Hemorrhage Patients With Clipping or Coiling: J-ASPECT Study
Authors: Kurogi Ryota , Kada Akiko , Nishimura Kunihiro , Kamitani Satoru , Ogasawara Kuniaki , Ono Junichi , Shiokawa Yoshiaki , Toyoda Kazunori , Nakagawara Jyoji , Miyachi Shigeru , Yoshimura Shinichi , Okuchi Kazuo , Nagata Izumi , Matsuda Shinya , Nakamura Fumiaki , Onozuka Daisuke , Hagihara Akihito , Suzuki Akifumi , Ido Keisuke , Kurogi Ai , Nishimura Ataru , Arimura Koichi , Iihara Koji
Published: October 2018

Background:
Many studies have reported that high-volume center was associated with the favorable outcomes in subarachnoid hemorrhage (SAH) patients with treatment. However, in Japan, the effect of the case volume of the hospital in SAH patients remains elusive. The aim of this study is to investigate the associations between case volume and outcomes of clipping or coiling using data obtained from the Japanese Diagnosis Procedure Combination [DPC]-based Payment System.

Methods:
Of the 847 certified training institutions of the Japan Neurosurgical Society, 327 institutions agreed to participate in this DPC discharge database study. Data on patients hospitalized for SAH between April 1, 2012 and March 31, 2013 were obtained from the DPC database. Patients hospitalized because of SAH were identified using International Classification of Diseases-10 diagnosis codes (I60.0-9). The case volumes of clipping and coiling in each hospital were divided into quintiles (Q1-Q4). Odd ratios (ORs) of in-hospital mortality and modified Rankin Scale (mRS) at discharge were estimated after adjustment for age, sex, comorbidities, and SAH severity. The category of Q1 was assigned a reference for OR.

Results:
A total of 5214 patients with SAH (3624 clipping, 1590 coiling) were analyzed. Mortality was 9.8%, and proportion of discharge mRS3-6 was 44.0%. No significant associations were found between case volume and in-hospital mortality in both the clipping (Q2, Q3, and Q4; OR = 0.97, 0.69, and 0.77; P = 0.902, 0.148, and 0.263) and coiling group (Q2, Q3, and Q4; OR = 0.94, 1.62, and 0.84; P = 0.864, 0.140, and 0.586). No significant associations were found between case volume and discharge mRS3-6 in both the clipping (Q2, Q3, and Q4; OR = 1.28, 1.27, and 1.09; P = 0.194, 0.189, and 0.619) and coiling group (Q2, Q3, and Q4; OR = 0.89, 1.15, and 0.78; P = 0.691, 0.599, and 0.315).

Conclusion:
In Japan, case volume did not show the correlation with outcomes in SAH patients. This nationwide database study reflects the real-world practice. 
Abstract WP272: Sleep-disordered Breathing is Associated With Worse Stroke Outcomes in Mexican Americans
Authors: Lisabeth Lynda D , Sanchez Brisa , Lim David , Chervin Ronald , Li Chengwei , Case Erin , Garcia Nelda , Morgenstern Lewis , Brown Devin
Published: October 2018

Objective:
Post-stroke sleep-disordered breathing (SDB) is prevalent and may be linked to poor stroke recovery but population-based studies in diverse populations are lacking. Our objective was to examine the association between SDB measured soon after stroke and stroke outcomes and to determine whether associations vary by ethnicity in the population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project.

Methods:
Ischemic stroke (IS) patients were offered SDB screening with the ApneaLink Plus™; SDB was defined as apnea-hypopnea index (AHI) ≥ 10 events per hour. Patient data were collected from interviews and medical records. Functional, neurologic, cognitive, and quality of life (QOL) outcomes were ascertained at 90-days by patient or proxy interviews. Regression models were used to examine associations between SDB and outcomes adjusted for confounders. Interaction terms were used to investigate differences by ethnicity.

Results:
232 NHW and 393 MA IS patients had a successful SDB screening and completed a 90-day interview. Median age was 65 years (IQR:58-75) among MAs and 67 (IQR:58-77) among NHWs. Post-stroke SDB was 68.7% in MAs [median AHI: 16 (IQR:8-26)] and 52.6% in NHWs [median AHI: 10 (IQR:6-23)]. Patients with SDB were more likely to be MA and to have diabetes, hypertension, and higher BMI but less likely to smoke than those without SDB. SDB was associated with worse functional, neurologic, cognitive, and QOL outcomes in MAs but not NHWs (Table).

Conclusions:
SDB is associated with worse stroke outcomes in MAs but not NHWs, the reasons for which should be explored. SDB treatment in MAs may improve outcomes in this subgroup and lessen ethnic stroke outcome disparities.
Abstract WP275: Cost-Effectiveness of Mechanical Thrombectomy of Ischemic Stroke
Authors: Pan Yuesong , Cai Xueli , Wang Yongjun , Miao Zhongrong , Wang Yilong
Published: October 2018

Background and Purpose:
Endovascular mechanical thrombectomy is an effective but expensive therapy for acute ischemic stroke with proximal anterior circulation occlusion. This study aimed to determine the cost-effectiveness of mechanical thrombectomy in China, the largest developing country.

Methods:
A combination of decision tree and Markov model was developed to determine the cost-effectiveness of mechanical thrombectomy within 6 hours with IV tPA treatment within 4.5 hours versus IV tPA treatment alone. Outcomes and costs data were derived from the published literature and claims database. Efficacy data were derived from the patient-level pooled analyses of the 5 trials in 2015. Benefit was assessed by calculating the cost per quality-adjusted life-year (QALY) gained in the long term (30 years). One-way and probabilistic sensitivity analyses were performed to assess the uncertainty of the results.

Results:
The addition of mechanical thrombectomy compared with standard treatment alone yielded a lifetime gain of 0.934 QALYs at an additional cost of CNY 61,760 (US$ 9,500), resulting in a cost of CNY 66,100 (US$ 10,170) per QALY gained. Probabilistic sensitivity analysis showed that mechanical thrombectomy is cost-effective in 91.9% of the simulation runs at a willingness-to-pay threshold of CNY 125,700 (US$ 19,300) per QALY.

Conclusions:
Mechanical thrombectomy for acute ischemic stroke caused by proximal anterior circulation occlusion within 6 hours was cost-effective in China. This may be a reference to medical resources allocation for stroke treatment in low- and middle-income countries and the remote areas in the developing countries.
Abstract WP295: Improving Resident Confidence and Efficiency During Stroke Alerts Through Simulation Training
Authors: Margiotta Megan , Wilhour Danielle , D’Ambrosio Robin , Pineda Carissa , Rincon Fred
Published: October 2018

Background:
While most institutions have mock simulations for a code blue or rapid response, there is no standard practice for stroke alert simulations to train neurology residents. This causes residents to feel less confident and take longer when responding to stroke alerts and giving tPA.

Objectives:
The first objective was to teach incoming neurology residents how to respond efficiently and appropriately to a stroke alert. Second, we wanted to improve the confidence level of residents during stroke alerts.

Methods:
The training session began with a one hour didactic session on how to respond to stroke alerts and when to appropriately administer tPA. A second hour of training focused on how to perform the NIH stroke scale (NIHSS). The following day, nine residents each participated in two stroke simulations utilizing standardized patients. They were observed by an attending, fellow, or resident via video monitoring to ensure accurate history taking and correct NIHSS performance. The residents reviewed head CT imaging and determined if tPA would be given. If tPA was deemed appropriate, the residents notified pharmacy and explained the risks and benefits of the medication to the standardized patient. There was then an immediate feedback session to review particular areas for improvement. The residents completed pre- and post- simulation tests to assess stroke knowledge and to determine confidence in responding to stroke alerts.

Results:
Prior to the stroke lecture and simulation, 44% of residents reported confidence responding to a stroke alert. After the simulation, 78% of residents felt confident. Only 44% of residents felt confident performing an NIHSS prior to the simulation versus 100% after the simulation. The number of residents who felt confident in their decision-making ability to give tPA increased from 22% to 56% after the simulation.

Conclusion:
In conclusion, residents were more confident responding to stroke alerts, performing an NIHSS, and deciding to give tPA after completing both the didactic stroke training and simulation cases. Data is also being analyzed to determine if the simulations had an effect on resident efficiency during stroke alerts by comparing door to needle time before and after the simulations.
Abstract WP30: Role of Solitaire in Endovascular treatment for Acute Serious Stroke Due to Intracranial In Situ Thrombosis (ROSE ASSIST study)
Authors: Lee Jin Soo , Sohn Sung-Il , Hwang Yang-Ha , Hong Ji Man , Lee Seong-Joon , Choi Jin Wook , Kang Dong-Hun , Kim Yong-Won , Kim Yong-Sun , Hong Jeong-Ho , Chang Hyuk Won , Kim Chang-Hyun , Demchuk Andrew , Ovbiagele Bruce
Published: October 2018

Background:
Solitaire, a representative stent retriever, shows high performance in removing embolic clots; however, its reperfusion potential in intracranial atherosclerotic disease (ICAD)-related occlusions is rarely reported. In this ROSE ASSIST study, we hypothesized that Solitaire is as effective for removing in-situ thrombi in ICAD-related occlusions as much as its performance in cardiogenic or cryptogenic embolism.

Methods:
ASIAN KR, an observational multicenter registry (n=721) enrolling patients who underwent endovascular treatment for acute cervicocephalic artery occlusions, was retrospectively reviewed. Through blinded evaluations, ICAD-related (significant fixed focal stenosis observed at the occlusion site during endovascular treatment) and embolic (no or minimal stenosis observed) occlusions were classified. Among patients treated with Solitaire stent (n=373), exclusion criteria were as follows: onset to puncture time >720 min; occlusion etiology neither ICAD-related nor embolic; both ICAD-related occlusion and atrial fibrillation. Primary endpoint was successful reperfusion (modified Treatment In Cerebral Ischemia 2b-3) immediately after Solitaire stent retrieval. Comparative analyses were performed between embolic and ICAD-related occlusions (2:1 matched by propensity score; age, sex, onset to puncture time and primary endovascular method adjusted).

Results:
In total, 270 patients (embolic, 216; ICAD-related, 54) were included in the analyses. After propensity score matching, successful reperfusion rate following Solitaire stent treatment did not differ between etiologic groups (embolic, 77.8% vs. 68.5%, p=0.201). Although final successful reperfusion grade was similarly achieved between groups (83.3% vs. 75.9%, p=0.259), median number of endovascular methods was higher in ICAD-related occlusions (2 [interquartile range, 1-2] vs. 2 [2-3], p<0.001). The grade and frequency of intracerebral hemorrhagic transformation and subarachnoid hemorrhage did not differ between groups.

Conclusions:
The immediate reperfusion performance of Solitaire for ICAD-related occlusions was as substantial as for embolic occlusions although these occlusions more often needed other treatment methods.
Abstract WP301: Does Stroke Conference Attendance Affect Patient Outcomes?
Authors: Bogdanovskaya Maria , Talbott Jessica , Aslop Rachel , Barclay Lorna , Lee Jin-Moo , Shaw Louise , Alberts Mark J , Rinkel Gabriel J , Hemmen Thomas M
Published: October 2018

Background:
Reduced hospital staffing out of hours and at weekends has been associated with adverse patient outcomes. Following recent study showing reduced adjusted mortality after acute heart disease during large cardiology conferences, we explored acute ischemic stroke (AIS) outcomes and practice patterns during stroke conferences.

Method:
We compared 7-day in-hospital mortality, all in-hospital mortality, and number of stroke admissions per day, baseline demographics, and length of stay (LOS) for patients admitted on stroke conferences days (SCD) and matched non-conference days (NCD) in the three weeks before and after. The
table
shows which countries’ data were used for each of the three conferences. Conferences were chosen if a large portion of stroke providers attended from each country under study. We used the Global Comparators data set that represents predominantly academic teaching hospitals from across Europe, Australia and the US. Outcomes were adjusted for country, age, sex, and comorbidity score, whether a patient was transferred into the hospital or had an emergency admission to the hospital in the previous 30 days.

Results:
We identified 6684 patients (SCD 940, NCD 5744), and found no difference in raw and adjusted outcomes between groups. The frequency of stroke admissions and LOS were similar. Mortality was 7.77% during SDC, 8.2% on NDC and 7-day in-hospital mortality was 4.04% during SDC and 4.65% on NDC. Using regression analysis, admission on a conference day was not a predictor for in-hospital mortality or 7-day in-hospital mortality.

Discussion:
We found no differences in practice pattern and outcomes for patients admitted with AIS during stroke conferences in this international dataset. Future monitoring of outcomes during large medical conferences using larger samples should focus on exact staffing ratio changes during conference times to assure robust patient care at all times.
Abstract WP312: Using Qualitative Analysis to Explore the Themes of Follow-Up Calls to Discharged Stroke Patients
Authors: Braune Isadora , Kudrin Bertina , Wysota Christina , Humayun Aaima , Goldmann Emily , Parikh Nina S , Appleton Noa , Boden-Albala Bernadette
Published: October 2018

Introduction:
Few studies have explored unscripted conversations with stroke survivors during the post-discharge period to determine areas of need and concern. Additional contact during the transition period may provide a better understanding of patient needs once home.

Methods:
Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) was an RCT of a skills-based educational intervention among mild stroke/TIA patients, which included follow-up calls from a research coordinator at 72 hours, 1 month and 3 months post discharge. Follow-up forms (N=651, 242 patients) were reviewed and a codebook, consisting of 30 unique codes, was created to capture conversational themes. Two coders independently conducted systematic-content-analysis on the textual data. Discrepancies were examined and adjudicated by a third coder. Frequencies were calculated to determine the most prevalent conversational themes. Associations between themes and patient demographics were then assessed using chi-square tests.

Results:
The most frequent conversation topics identified were: 1) setting up medical and neurological appointments (70.97%), 2) good medication adherence (16.28%) and 3) complaints of post-stroke symptoms (12.29%). Additionally, we found a significantly higher prevalence of non-Hispanic blacks and Hispanics complaining of post-stroke symptom to the health coordinator (54.4% and 49.2%, respectively) compared to non-Hispanic whites (25.0%, P=0.008). Although not statistically significant, we observed a higher prevalence of complaints of post-stroke symptoms among unmarried individuals (51.2% vs 40.2%, P=0.149) and people who live alone (53.2% vs 41.0%, P=0.248).

Conclusions:
In this sample of mild stroke/TIA patients from the DESERVE study, we found that stroke survivors’ main concerns during the post-discharge period include setting up medical appointments, medication adherence, and post-stroke symptoms. Furthermore, these concerns varied by race-ethnic group, marital status and living arrangement. Future interventions should be tailored to address these concerns, especially once the patient has transitioned home.
Abstract WP331: Intracranial Hemorrhage in Infective Endocarditis: Underlying Arterial and Parenchymal Disease
Authors: Khoury Jean , Cho Sung Min , Rice Cory , Zhang Lucy , Wisco Dolora , Uchino Ken
Published: October 2018

Introduction:
Intracranial hemorrhage (ICH) is a known complication of infective endocarditis (IE). We aimed to explore radiologic findings that may explain the cause of ICH and the prognosis of these patients.

Methods:
We reviewed records of infective endocarditis cases with intraparenchymal hemorrhage (IPH) and subarachnoid hemorrhage (SAH) who underwent magnetic resonance imaging (MRI) and cerebral angiography at a single tertiary center from 2010 to 2014. All patients fulfilled modified Duke’s criteria for infective endocarditis.

Results:
We identified 36 patients our inclusion criteria. Eleven (30%) had IPH only, 10 (28%) had SAH, and 15 (42%) had both. The most common presenting symptoms were focal neurological deficit (39%, n=14), encephalopathy (25%, n=9), followed by headache (19%, n=7). The hemorrhage was silent in (19%, n=7) cases. Twelve patients (33%) had mycotic aneurysms but only 4 had evidence of rupture (11%). Ten (28%) had distal arterial irregularities on angiography suggestive of vasculitis. Thirteen (36%) had evidence of microabscesses on MRI, and 22 (61%) had cerebral ischemia on MRI, of which 6 had a hemorrhagic transformation. In 24 out of 25 SAH cases cortical sulcal hemorrhage was seen and only one SAH was in the basal cistern. In 14 (56%) of these cortical SAHs had adjacent restricted diffusion lesion on the MRI. Among 21 patients undergoing valvular repair, only 2 (1%) were complicated with new intracranial hemorrhage that had no relation to the presence of microhemorrhages on MRI (p=0.42).

Conclusion:
Intracranial hemorrhage in infective endocarditis is rarely related to mycotic aneurysms. Parenchymal involvement of infection or vascular inflammation may be the underlying causes for IPH and SAH in these patients.
Abstract WP334: In-hospital Systolic Blood Pressure Variability in Elderly Patients With Primary Intracerebral Hemorrhage
Authors: Meeks Jennifer R , Bambhroliya Arvind B , Meyer Ellie G , Slaughter Kristen B , Fraher Christopher J , Bowry Ritvij , Ahmed Wamda O , McCullough Louise D , Tyson Jon E , Miller Charles C , Warach Steven , Sharrief Anjail Z , Savitz Sean I , Vahidy Farhaan S
Published: October 2018

Introduction:
Systolic blood pressure (SBP) regulation is the cornerstone of intracerebral hemorrhage (ICH) management, and SBP variability (SBPV) is associated with poor outcomes. We aimed to determine SBPV patterns and associated factors in a prospective cohort of ICH patients.

Methods:
Primary ICH patients are consented, assessed in-hospital and followed up at 30 and 90 days. All SBP values and BP management details for the hospital stay were collected from electronic medical records. Day and night intervals were defined as 0601 - 2159hrs and 2200 - 0600hrs, respectively. Mean and standard deviation (SD) were calculated for all intervals in each patient. Overall, between and within patient SBPV for day and night was characterized by generalized estimating equation (GEE)-based methods. We identified patients with a high SBPV (HSBPV) and built logistic regression models to determine associated factors.

Results:
Thus far, 158 patients have been enrolled, with detailed SBP data was available for 126. Total in-hospital follow-up period is 1,446 days [Median (IQR): 8 (4.25 - 15)]. We analyzed 34,740 SBP readings, yielding 3,010 day/night intervals. The in-hospital mean (SD) SBP was 138.2 (15.6) mmHg. GEE-based estimates for mean night SBP were significantly lower compared to day (137.2 v 139.1 mmHg, p < 0.01). Mean SBP SD was 9.1 mmHg between patients while 13.4 mmHg within patients’ individual readings. HSBPV was defined as SD > 13 mmHg. Age and high admission SBP were independently associated with HSBPV after controlling for sex, race, admission NIHSS, ICH score, hemorrhage volume and Nicardipine infusion use (Figure). Enrollments are continuing and updated data with outcomes will be presented.

Conclusion:
Characterization of patients with HSBPV can help in triage and management decisions based on risk-stratification. Elderly patients may be at a higher risk of SBPV, warranting exploration of possible SBPV contribution to poor outcomes in the elderly.
Abstract WP338: Effect of Thalamic Hemorrhage Localization on Level of Consciousness and Functional Outcomes in the CLEAR III Trial
Authors: Tahsili-Fahadan Pouya , Eslami Vahid , Rivera-Lara Lucia , Thompson Carol B , Dlugash Rachel , McBee Nichol , Awad Issam , Hanley Daniel F , Ziai Wendy C ,   for the CLEAR III Trial Investigators
Published: October 2018

Introduction:
Thalamic hemorrhages account for 10-15% of intracerebral hemorrhages (ICH) and have a variety of clinical manifestations. We investigated the relationship between injury to thalamus and intra-thalamic regions with level of consciousness and functional outcomes among CLEAR-III trial participants.

Methods:
We analyzed diagnostic CT scans of 500 patients from CLEAR-III trial prior to randomization and identified the anatomic localization of ICH. Thalamic hemorrhages were further divided into 5 groups: dorsal, anterior, medial, central, and posterolateral. Blinded level of consciousness measures (Glasgow Coma Score (GCS) and question 1a of the National Institutes of Health Stroke Scale (NIHSS)) and stroke severity indices (including mortality and modified Rankin Scale (mRS)) were analyzed. We assessed association of each region with level of consciousness and stroke severity measures using multivariate logistic regression models. Major disability was defined as mRS 4-5. Outcome models were adjusted for ICH volume, IVH (intraventricular hemorrhage) volume, and age.

Results:
Thalamic ICH was present in 332 patients (71%, 33 with primary IVH were excluded). Initial median GCS was similar in patients with (10, IQR 7-14) and without (10, IQR 6-14) thalamic lesion (P=0.72). At day 30 and 180, thalamic ICH was associated with increased mortality (OR 2.48, CI 0.92-6.63 and OR 2.03, CI 1.02-4.06), major disability (OR 2.44, CI 0.87-6.81 and OR 2.50, CI 1.08-5.75), and death or major disability (OR 2.57, CI 0.91-7.19 and OR 2.71, CI 1.37-5.38), respectively. Thalamic ICH involved medial, central, posterolateral, dorsal, and anterior regions in 51.8%, 48.8%, 48.6%, 56.8%, and 47% of cases, respectively. On day 7, only involvement of the medial thalamus was associated with decreased consciousness defined as GCS <=8 and NIHSS question 1a>=2 (P=0.024 and 0.043, respectively). While all thalamic regions were associated with worse mRS, none were associated with decreased consciousness at day 180.

Conclusion:
Thalamic hemorrhages are associated with poor functional outcomes. Medial thalamus involvement affects consciousness acutely but not in the long term. The mechanism by which medial thalamus alters consciousness merits investigation.
Abstract WP344: Basal Ganglia Atrophy in Cerebral Amyloid Angiopathy
Authors: Fotiadis Panagiotis , Pasi Marco , Charidimou Andreas ,   Alzheimer’s Disease Neuroimaging Initiative, Lee Myung J , Schwab Kristin , Rosand Jonathan , Viswanathan Anand , Gurol M. Edip , Greenberg Steven M
Published: October 2018

Background/Purpose:
Cerebral Amyloid Angiopathy (CAA) is associated with cortical and white matter atrophy. We hypothesized that atrophy in CAA extended into the subcortical gray matter as well and might explain previously observed alterations in subcortical gray matter diffusion-tensor properties.

Methods:
We compared multimodal MRIs from 80 prospectively enrolled non-demented patients with probable CAA, to two other cohorts: 80 Healthy Controls (HC) and 80 patients with Alzheimer’s Disease (AD) from the AD Neuroimaging Initiative. Validated
FreeSurfer
algorithms were used to calculate Gray Matter (GMV) and Basal Ganglia Volumes (BGV), expressed as percentage of intracranial volume (ICV). High-resolution diffusion scans were used to calculate the fractional anisotropy (FA) and apparent diffusion coefficient (ADC) within the basal ganglia. A visual basal ganglia atrophy scale was also developed to compare atrophy between 93 patients with CAA-related intracerebral hemorrhage (CAA-ICH) and 93 age-matched patients diagnosed with Hypertensive Arteriopathy and ICH (HTN-ICH).

Results:
CAA patients (mean age: 70.3 ± 8.5) were age-matched to HC (71.8 ± 3.7) and AD patients (70.4 ± 6.8). Patients with CAA had significantly lower BGV (1.16% ± 0.14) when compared to both HC (1.30% ± 0.13, p<0.0001) and AD (1.23% ± 0.12, p=0.003). Within the CAA cohort, there was a positive association between BGV and GMV (r=0.45, p<0.0001) and negative association between BGV and FA (r=-0.36, p=0.001). All associations remained independent after correcting for age, sex, and presence of hypertension. For the clinical ICH cohorts, patients diagnosed with CAA-ICH displayed significantly lower visually rated BGV when compared to similar aged patients with HTN-ICH (mean age: 68.5 for both groups, basal ganglia atrophy scale: 7.31 ± 1.03 vs 8.24 ± 1.14, p<0.0001).

Conclusions:
Patients with CAA displayed substantial atrophy in the basal ganglia when compared to HC, AD, and HTN-ICH patients. Within the CAA cohort, greater basal ganglia atrophy was independently correlated with greater cortical atrophy and previously observed increases in basal ganglia anisotropy. The mechanisms for and clinical manifestations of CAA-related basal ganglia atrophy remain to be determined.
Abstract WP348: Stroke Nurse Navigator: Feasibility, Implementation and Early Impact at a Comprehensive Stroke Center
Authors: Larsen Darren T , Cox Kailey , Swearingen Natalie , Kansara Amit
Published: October 2018

Background:
Stroke nurse navigator (SNN), modeled after other proven disease specific navigator roles, may be an effective way to positively impact patient experience and improve outcomes. There is a paucity of data on the feasibility and effectiveness of stroke nurse navigator role. We want to present descriptive analysis of first six months experience with SNN at our Comprehensive Stroke Center (CSC).

Methods:
The SNN was implemented in January 2017. Population includes patients discharging home and or discharged to rehab or skilled nursing facility with complex follow up needs. The SNN also follows up on an as-needed basis for issues such as extended cardiac monitoring, imaging and anticoagulation. Seven day phone follow up is performed for home discharges and 90 day phone follow up for selected patients using a standardized questionnaire developed collaboratively with stroke experts spanning the continuum of patient care. Other tools utilized by the SNN include use of EHR (electronic health record) inbox for streamlined communication between SNN and stroke clinic administration staff as well as EHR template letters with a standard risk factor assessment and education. Shared patient lists, and a database for long term patient outcome tracking were also used.

Result:
Information collected at the seven day phone call includes review of symptoms, review of medications, follow up plan, lifestyle modification, stroke signs and symptoms, patient experience and at 90 days also includes modified Rankin Scale (mRS). Between February and June, 118 patients were seen by SNN prior to discharge, 86 of which were home discharges and 48% of all home discharges during the same period. 85% of all home discharges were successfully reached within seven days by phone to complete the post-discharge assessment. There have been instances of new symptom recognition by SNN during follow up that prompted some emergent readmissions.

Conclusion:
In conclusion, the role of SNN is feasible at a CSC and early data suggests improved patient experience, education, and follow up. Data collection requires manual maintenance of patient lists and a large database separate from the EHR. Further research is needed on standardized tools for management of long term stroke patient follow up.
Abstract WP358: Lightning Fast Stroke Treatment: Recognition Makes a Difference
Authors: Hundt Beth , Turner Heather
Published: October 2018

Background:
For acute ischemic stroke patients, reduced door-to-needle (DTN) times are associated with better clinical outcomes. Our Stroke Center evaluated DTN time for thrombolysis cases since 2004 to identify opportunities to reduce time to treatment. In October 2014, the American Heart Association/American Stroke Association introduced Target: Stroke Phase II to challenge Get With the Guidelines-Stroke participating hospitals to reduce time to tPA. In January 2015 our center adopted the goal DTN time of 45 minutes. Many best practice strategies outlined in Target: Stroke Phase II were previously implemented, including: EMS pre-notification, single call activation, rapid evaluation by the Stroke Team, and rapid completion and interpretation of brain imaging. In 2015, our stroke center was able to administer tPA within 45 minutes of Emergency Department (ED) arrival in 29% of cases (n=35).

Purpose:
The purpose of this project is reduce DTN times by recognizing the efforts of the interdisciplinary team in cases of timely thrombolysis.

Methods:
A team-based approach is used for all ED Stroke Alerts. Starting January 2016, for each case of tPA administration within 45 minutes of arrival, every team member was recognized for their contribution in providing “Lightning Fast Stroke Care.” A flyer was developed highlighting details of the case, clinical outcome, and recognizing every team member who participated in the care of the patient. Persons recognized include: EMS, ED nurses, techs and physicians, registration, radiology techs, laboratory staff, pharmacists, Stroke Team physicians and trainees. Flyers were distributed and displayed publically. Each team member recognized received a lightning bolt pin, in addition to a copy of the flyer.

Results:
In 2016, over 500 pins were awarded for Lightning Fast Stroke Treatment, and the lightning bolt pin became a badge of honor recognized throughout the medical center. Our Stroke Center was able to administer tPA within 45 minutes of ED arrival in 58% of cases (n=40). Without making other changes to the process our percent of cases achieving DTN within 45 minutes doubled.

Conclusion:
Recognition and feedback are important to providing team-based care and have made a significant sustainable impact on DTN times.
Abstract WP362: Nothing Is Going To Stop Us Now: Expediting Care For The Stroke Patient In The Emergency Department
Authors: Clark Ashley , Zimmermann Mary
Published: October 2018

Background:
Between July 1, 2016 and July 31, 2016, there was a significant delay in the initiation of care for patients presenting to the Emergency Department with signs and symptoms of stroke. Applicable metrics for this population include; arrival time to triage complete, arrival time to provider, arrival time to code stroke activated, dysphagia screen completed, reason for no Alteplase documented, and National Institutes of Health Stroke Scale documented. Overall goals for these metrics were being met 76.67% of the time.

Purpose:
The purpose of this process improvement project was to improve outcomes and metrics related to patients arriving to the Emergency Department through triage with signs and symptoms of stroke.

Methods:
The Stroke Program Manager, Emergency Department Leadership, and the Emergency Department Shared Governance Council, worked together to propose a change to the triage process. Goals were established for; arrival to triage complete, arrival to provider, and arrival to activation. Education on stroke signs and symptoms was provided to all ED staff. A “First Look Nurse” position was introduced in the lobby of the Emergency Department and nursing activation of “Code Stroke” with overhead paging was initiated at time of triage. All metrics were reported out on a weekly and monthly basis to all department staff including physicians.

Results:
Between September 1, 2016 and December 31, 2016 goal attainment improved to 93.33% and has been sustained over 90% over the last 6 months. Average arrival to triage time decreased from 7.75 minutes to 4.6 minutes, and arrival to “Code Stroke” activation decreased from an average of 33 minutes in July of 2016 to 13.5 minutes in December of 2016.

Conclusion:
This process improvement led to a timelier triage process and increased competence in identifying stroke patients who may be eligible for thrombolytic therapy and endovascular treatment.
Abstract WP368: Stroke: Identifying the Educational Gap for Nurses in Argentina
Authors: Calvillo Claudia S , Goldenberg Fernando
Published: October 2018

Background and Issues:
Providing nurses with stroke pathology, prevention and management training is essential to diminish the devastating outcomes that this pathology can have on a patient and family. After an overwhelming response to medical education, we identified the possible need for nursing stroke education in Argentina.

Purpose:
The purpose is to define the status of stroke education among acute care nurses in Argentina and determine the need for stroke educational programs.

Methods:
For customer discovery, 32 semi-structured interviews were conducted in person, via Skype and via telephone calls with Argentinean nurses, nurse managers, nurse administrators and government officials. Interview questions were guided towards methods of nursing education, evaluations of skills, professional development, means of personal education and opportunities for growth in nursing educational courses regarding stroke pathology, prevention, and management. Responses given by the interviewees were documented and recurring themes were noted.

Results:
We discovered that there are very few opportunities for nursing continuing education without formal pursuit of a graduate degree. Bedside acute care nurses must seek out conferences or symposiums for topics of educational interest that are directed to physicians. All of our interviewees were in agreement that there is a need and desire toward stroke educational programs, including pathology, prevention and management. One of the recurring themes that was noted was the desire and need for nursing tailored education.

Conclusions:
Currently no continuing stroke educational programs are provided to nurses in Argentina. Through our interview process we concluded that there is an unattended and substantial need and desire for such training. The findings of these interviews will help in the development of a neurological critical care course for nurses in Spanish. This course will include stroke pathology, prevention and management.
Abstract WP374: A Nurse Dyad Model for Collaborative Action Planning and Goal Attainment to Support Patient Self-Management of Stroke Risk Factors
Authors: Kimmel Barbara , Burns Joyce , George Shila , Roux Kelly , Mbue Ngozi , Shegog Ross , Anderson Jane
Published: October 2018

Background and Purpose:
Patient self-management (SM) of stroke risk factors is critical to prevent second stroke. Development of an action plan to reach behavior goals is established for chronic disease SM. In collaborative planning, patients identify a goal and then a healthcare provider helps develop action plan to attain the goal. We pilot-tested a model where nurses in stroke ward and in primary care worked as dyads to support stroke patients in setting goals. Nurses have been identified as front line health care providers for patient education and SM support. We conducted an IRB approved pilot of a nurse dyad model to determine feasibility of coaching patients in goal-setting and the Goal Attainment Measure for Stroke (GAM-S).

Methods:
A pre-experimental, pre/post design was applied. Ten registered nurses and 26 stroke patients were recruited from neurology at DeBakey VA Center. Nurses delivered one-on-one educational sessions to patients admitted with stroke and set goals and action plans in patients’ medical records. Nurses in primary care clinic called patients 2-weeks after discharge to evaluate goal attainment, which was documented and scored using GAM-S. The GAM-S components are scored as, 2 = attained, 1 = partially attained, and 0 = not attained.

Results:
Twenty six patients were enrolled: 24 males (92%) and 2 females (8%). Mean age was 67 years with 54% White, 34% African American, and 12% Hispanic. Of the 26 patients who completed GAM-S, 57% achieved a maximum total score of 8 for goal attainment. The mean GAM-S score was 6.7.

Conclusions:
Implementation of a nurse dyad model for collaborative action planning is feasible and shows promise for engaging patients in self-management of stroke risk factors. Findings will help design a self-management support intervention for stroke survivors using a nurse dyad delivery model.
Abstract WP381: NIHSS Training - Improving the Way We Learn
Authors: Richardson Melissa , Brown Dena , Oblak Meaghan
Published: October 2018

Background:
Training nurses to perform the National Institutes of Health Stroke Scale (NIHSS) exam can be expensive, as traditionally this involves going to an on-line training site and watching videos, then scoring patients in a test environment. Our organization pays nurses in the ICU and stroke unit for 3 hours of self-learning time annually in order to stay current with this certification. When the decision was made to expand this certification to the observation unit, there was concern about the additional costs of “unproductive time” to complete the learning. In addition, nurses have anecdotally expressed dissatisfaction with the on-line learning platform.

Purpose:
The purpose of this project was to develop a training program for nurses to learn the NIHSS exam in a manner that is both meaningful and cost effective. Our goal was to reduce the amount of time spent on training and provide an in-person experience that nurses would find more relevant to their everyday practice.

Methods:
We identified content experts already embedded in the stroke program to act as trainers. Subject nurses were then provided with three baseline training videos to provide an overview of the exam, followed by live education with tips to overcome common challenges. Finally, our content experts observed them performing the exam to determine their competence.

Results:
We designed a learning program that reduces the amount of time spent on training from 3 hours to 1 hour. Additionally, 92% of nurses interviewed as part of this project described a preference for learning through in-person training rather than the on-line version. This project is ongoing, but at the conclusion, we will collect data related to the nurses’ perception of and satisfaction with this style of learning. There is also a plan to model this training method in the ICU and stoke unit which will result in a two thirds cost savings over our current model.

Conclusion:
In the current healthcare climate where we need to be good stewards of our time and resources, redesigning a training program in a way that is efficient, cost effective, and perceived as a preferred style of learning will benefit our stroke program, as these nurses will have the skills and confidence they need in caring for stroke patients.
Abstract WP386: Age-Dependent Ultrasonographic Changes After Indirect Revascularization Surgery in Patients With Moyamoya Disease
Authors: Yeh Shin-joe , Tang Sung-Chun , Tsai Li-Kai , Jeng Jiann-Shing
Published: October 2018

Objective:
Pediatric patients with moyamoya disease (MMD) were supposed to have better neovascularization by indirect revascularization than adult patients with MMD, but the evidence was limited. The aim of this study was to assess age-dependent ultrasonographic changes after indirect revascularization in moyamoya patients.

Methods:
We prospectively enrolled moyamoya patients receiving indirect revascularization and ultrasonographic exams before and after surgery at 1, 3, and 6 months. The sonographic parameters included peak-systolic velocity (PSV), end-diastolic velocity (EDV), flow resistance, and flow volume (FV) in the superficial temporal artery (STA) and external carotid artery (ECA). The values and percentage changes of the sonographic parameter at the aforementioned time points were compared between pediatric and adult patients.

Results:
There were 47 hemispheres in pediatric and 16 hemispheres in adult patients with MMD receiving indirect revascularization. Before surgery, adult patients had higher EDV, lower resistance, and larger FV in the STA and ECA compared to pediatric patients (all p <0.05). After surgery, pediatric patients had higher PSV in the STA and ECA compared to adults, but the resistances of these 2 arteries remained higher in pediatric patients than that in adults (all p <0.05). The percentage changes of PSV in the STA at 3 and 6 months, FV in the STA at 3 months, as well as PSV and FV in the ECA at 6 months in pediatric patients were all larger than those in adult patients (all p <0.05).

Conclusion:
Pediatric patients with MMD had larger increase of PSV and FV in the STA and ECA after indirect revascularization than adult patients.
Abstract WP387: Diagnosis and Surgical Management of Rotational Vertebral Artery Occlusion in Children
Authors: Plummer Zachary , Taylor John M , Abruzzo Todd , Vadivelu Sudhakar
Published: October 2018

Background:
Rotational vertebral artery occlusion (RVAO) is associated with significant posterior circulation morbidity, recurrence, and lacks evidenced based treatment recommendations. Upper cervical spine abnormalities, lack of traumatic history, and dynamic vessel imaging aid in diagnosis and treatment options. Here, we evaluate our cohort of children with RVAO for associated musculoskeletal, angiographic, and arterial tortuosity factors in light of management strategies and outcomes.

Methods:
Five pediatric patients with RVAO were evaluated with dynamic arterial compression with either CT based angiography or digital subtraction angiography. Solitary factors such as ponticulous posticus, hypermobility comorbidities, 3D-print models and arterial tortuosity index were examined in relation to management strategies.

Results:
Musculoskeletal abnormalities were associated in all cases presenting with evidence of dynamic angiographic compression. Not all cases had evidence angiographic compression. A mild elevation in arterial tortuosity index was observed. All five patients were managed with treatment approaches including antiplatelet/coagulation therapies, vertebral artery decompression, and/or posterior cervical fusion.

Conclusion:
Treatment strategies relied on identifiable compression factors associated with the level of vertebral artery dissection. In children, upper cervical bony abnormalities and dynamic compression at the VA3 level are common to RVAO diagnosis. Further examination of arterial tortuosity as an index in understanding the susceptibility of children towards RVAO is required.
Abstract WP392: Ethnic Differences in Post-Stroke Medication Adherence
Authors: Lank Rebecca , Lisabeth Lynda , Li Chengwei , Kerber Kevin , Case Erin , Garcia Nelda , Morgenstern Lewis B
Published: October 2018

Background:
Post-stroke medication adherence reduces stroke recurrence risk. We assessed ethnic differences in medication adherence 3 months post-stroke in a population-based study, as possible explanation for the increased stroke recurrence risk in Mexican Americans (MAs) compared with non-Hispanic whites (NHWs).

Methods:
Stroke cases during 2008-2015 from the Brain Attack Surveillance in Corpus Christi (BASIC) project in Texas, USA were followed prospectively for three months post-stroke to assess medication adherence. Medications in five drug-classes were analyzed: statins, anti-platelets, anticoagulants, antihypertensives, and anti-depressants. For each drug class, patients were considered adherent if they reported never missing a dose in a typical week. Chi-square or Kruskal-wallis non-parametric tests were used for ethnic comparisons of demographics, risk factors and medication adherence. Multivariable logistic regression models were constructed for the association of ethnicity and medication adherence.

Results:
This study included 781 MAs and 477 NHWs. MAs were younger (median 66 years versus 70 years, p<0.001) and had more diabetes (p<0.001), and hypertension (p<0.001) and less atrial fibrillation (p <0.001) and smoking (p=0.002) than NHWs. Sex, insurance status, high cholesterol, previous stroke history, smoking status, excessive alcohol use, tPA treatment, NIHSS score, and comorbidity index did not significantly differ by ethnicity. There was no significant difference in medication adherence for any of the five drug classes between MAs and NHWs (table). The multivariable models showed only older age consistently associated as protective of non-adherence.

Conclusions:
Medication non-adherence is common and a potential important target for reducing stroke recurrence rates. This study did not find ethnic differences in medication adherence. Other reasons for the excessive stroke recurrence burden in MAs should be explored.
Abstract WP396: Prior Doac Therapy is Related to Small Infarct Size and No Major Artery Occlusion in Patients With Acute Stroke and Nvaf
Authors: Sakamoto Yuki , Okubo Seiji , Kimura Kazumi , Shimoyama Takashi
Published: October 2018

Background:
Anticoagulant treatment with a vitamin K antagonist (VKA) has been reported to be associated with no major artery occlusion and small infarct volume. However, the effect of direct oral anticoagulant (DOAC) therapy on stroke volume or the site of arterial occlusion in acute ischemic stroke (AIS) patients is not well known.

Methods:
From March 2011 through July 2016, consecutive patients with AIS in the middle cerebral artery territory and non-valvular atrial fibrillation (NVAF) who underwent MRI were recruited. The infarct size was assessed by ASPECTS score on DWI, and the arterial occlusion site was evaluated on MR angiography. The effect of prior DOAC treatment on the site of arterial occlusion was assessed by multivariate ordinal logistic regression analysis.

Results:
A total of 345 patients (160 women; median age 79 years; median NIHSS score 12) were enrolled. Of these, 248 were on no anticoagulant, 45 were undertreated with a VKA, 24 were sufficiently treated with a VKA, and 28 were on a DOAC prior to the AIS. The DWI-ASPECTS on admission differed among the groups (median 7 in patients with no anticoagulant, 8 in undertreated VKA, 9 in sufficient VKA, and 9 in DOAC, p=0.002). Multivariate analysis showed that prior DOAC treatment was independently and negatively associated with more proximal artery occlusion (OR 0.39, p=0.031), compared to no anticoagulant.

Conclusion:
DOAC treatment prior to the event was associated with decreased risk of more proximal artery occlusion in AIS patients with NVAF, compared to no anticoagulation.