bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP335: Comparative Impact of Timing From Ictus to Intracerebral Hemorrhage Evacuation on Outcome in MISTIE III, STICH I & II Trials
Authors: Polster Sean P , Carrion-Penagos Julian , Gregson Barbara A , Cao Ying , Thompson Richard E , Stadnik Agnieszka , Money Patricia Lynn , Koskimaki Janne , Lyne Sean , Fam Maged D , Girard Romuald , Lane Karen , McBee Nichol , Ziai Wendy , Hao Yi , Dodd Robert , Carlson Andrew P , Camarata Paul J , Caron Jean-Louis , Harrigan Mark R , Dawson Jesse , Mendelow A. David , Zuccarello Mario , Hanley Daniel F , Awad Issam A ,   On behalf of the MISTIE III and STICH I and II investigators
Published: June 2021

Introduction:
Completion of the MISTIE procedure requires a period of hematoma stability before and during hematoma removal and, if necessary, dosing of rtPA which can take days to complete. Early surgery was intended in the STICH I and II trials, yet was performed after varying delays. No previous analysis has evaluated the timing for hematoma removal on outcomes in these trials.

Objective:
Determine if time from ictus to completion of hematoma removal may have affected patient outcome in three large surgical clinical trials of ICH evacuation.

Methods:
Patients randomized to surgery in the MISTIE III (n=242), STICH I (n=464) and STICH II (n=266) trials who received the procedure were analyzed, excluding cases crossing over to surgery. Time from ictus to end of treatment, defined as 24 hours after last dose in (MISTIE III) or time to craniotomy (STICH I and II), was analyzed in relation to likelihood of survival and functional outcome at 180 days. Cubic spline models with dichotomized outcomes were used.

Results:
The probability of achieving an mRS 0-3 increased significantly with longer time until completion of the procedure, up to 83 hours post-ictus, and worsened with longer delays thereafter (p=0.05). Better mRS was also achieved in STICH I patients with longer time until surgical removal, up to 60 hours post-ictus (p=0.0002), but not with longer delays (p=0.49). In STICH II (lobar cases), there was greater likelihood of mRS 0-3 with longer delay after 22 hours post-ictus (p=0.004), but not with earlier surgery (p=0.19). There was no significant benefit in survival, with earlier intervention across modalities and trials. Adjustment by initial hematoma volume further validated that early procedures do not favor survival or achieving a mRS 0-3.

Conclusion:
Early hematoma evacuation up to 60-80 hours post-ictus does not increase the probability of survival nor a good functional outcome in non-herniating ICH patients included in clinical trials, likely in view of bleeding instability. This was true in minimally invasive intervention as well as open surgeries.
Abstract TP338: The Dynamic CT Angiography Spot Sign: Prevalence, Predictive Value, and Rate of Contrast Extravasation
Authors: Dowlatshahi Dar , Chung Hee Sahng , Momoli Franco , Stotts Grant , Aviv Richard I , Hogan Matthew , Demchuk Andrew , Chakraborty Santanu
Published: June 2021

Introduction:
Hematoma expansion is a predictor of poor clinical outcome in intracerebral hemorrhage (ICH). The CT angiography (CTA) spot sign is a validated predictor of hematoma expansion, but its predictive performance is modest. This is in part because traditional “static” CTA can miss delayed spot signs, depending on the timing of image acquisition. Dynamic CTA (dCTA) can detect delayed spot sign formation and allows calculation of contrast extravasation rate. However, the predictive performance of a delayed “dynamic spot” and the relationship between rate of extravasation and hematoma expansion are not known. Our primary objective was to calculate the prevalence and predictive performance of the dynamic spot sign with dCTA. Our secondary objective was to determine whether the rate of contrast extravasation predicts significant hematoma expansion.

Methods:
We prospectively enrolled 79 patients who presented with primary ICH and underwent dCTA within 6 hours from onset. Primary outcomes were the prevalence of dCTA spot sign and its predictive performance for significant hematoma expansion (increase in hematoma by 6mL or 33% from baseline). For the secondary objective, we calculated the rate of contrast extravasation as the slope of the time curve from the first appearance of contrast at a spot sign to the maximal volume of contrast in 19 acquisitions over 60 seconds. We assessed the relationship between rate of extravasation and hematoma expansion using Mann-Whitney U test and logistic regression.

Results:
The prevalence of the dCTA spot sign was 45.6% (95% CI, 34.5-56.6%). Significant HE was seen in 58.1% (18/31) of spot-positive patients versus 29.0% (9/31) of spot-negative patients (P=0.04). The sensitivity and specificity of the dCTA spot sign in predicting significant HE was 67% and 63%, respectively. Median rate of extravasation was 0.0022 mL/min in patients with hematoma expansion vs 0.0013 mL/min in those without (p=0.05).

Conclusion:
Dynamic CTA had a higher spot sign prevalence than conventional CTA. While the sensitivity in predicting expansion was higher with dCTA, the specificity was lower, possibly due to a lower risk of expansion with delayed spot signs. The rate of extravasation was roughly double in patients with hematoma expansion.
Abstract TP341: Yield of Interval Magnetic Resonance Imaging in Determining Cryptogenic Etiologies of Spontaneous Intracerebral Hemorrhage
Authors: Mac Grory Brian C , Stretz Christoph , El Jamal Sleiman , Burton Tina , Cutting Shawna , Boyanpally Anusha , Madsen Tracy , Mahta Ali , Wendell Linda E , Thompson Bradford , Rao Shyam , Jayaraman Mahesh , McTaggart Ryan , Schrag Matthew , Yaghi Shadi , Furie Karen , Reznik Michael
Published: June 2021

Introduction:
Spontaneous intracerebral hemorrhage (ICH) most commonly arises due to primary etiologies such as hypertensive or cerebral amyloid angiopathy (CAA), but may also occur due to underlying secondary causes such as vascular malformations or intracranial neoplasms. However, focal mass effect may potentially obscure underlying lesions on neuroimaging performed during the acute phase of ICH, and follow-up imaging is often recommended. We sought to determine the yield of interval magnetic resonance imaging (MRI) in identifying cryptogenic ICH etiologies.

Methods:
We performed a single-center descriptive cohort study of consecutive patients enrolled in an institutional ICH registry over 12 months. ICH features including etiology and acute neuroimaging were prospectively adjudicated, while planned interval follow-up imaging was retrospectively reviewed. We determined the frequency of newly-discovered findings on interval MRI, and classified new findings according to whether or not they contributed meaningfully to patient management.

Results:
There were 241 ICH patients in our cohort who survived to discharge and did not have MRI-incompatible devices; 44 had planned follow-up imaging and 33 ultimately completed a follow-up MRI. Mean interval between initial and follow-up MRI was 61 (±34) days. New findings were identified in 33% of follow-up cases (11/33), with changes in patient management occurring in 12% (4/33). Age (59.4 vs. 61.5, p=0.74), sex (45% vs. 45% male, p>0.99), and secondary ICH score (median 3 [IQR 2-3] vs. 3 [1-4], p=0.87) were not significantly different between patients who had new findings and those who did not. New findings included cavernoma (n=4; 1 underwent resection), CAA-related changes (n=3), intracranial malignancy (n=2; 1 transitioned to hospice care, 1 led to cancer workup), new embolic stroke (n=1, underwent extended cardiac monitoring), and demyelination (n=1).

Conclusions:
Interval MRI aided in diagnosing ICH etiology in one-third of patients who received one, though few cases led to direct actionable changes in patient management.
Abstract TP344: Human pcMSCs Improved Neurological Deficits in Intracerebral Hemorrhage Rats
Authors: Huang Abel
Published: June 2021

Introduction:
Stem cell therapy is one of the most promising strategies for treating intracerebral hemorrhage (ICH). Human mesenchymal stem cell (MSC) is a frequently used cell source, however, it is not perfect. The main weakness of MSCs is that they gradually lose the stemness during in vitro expansion (usually fewer than P10 in subculture), which limits their availability in clinical application. We developed a method to isolate MSCs from human term placenta in a serum-free selective culture condition and named these cells as placenta choriodecidual membrane-derived MSCs (pcMSCs). According to our in vitro data, pcMSCs expressed standard MSC cellular markers more than P20 during in vitro expansion.

Objective:
To evaluate whether pcMSC improves neurological deficits in a rat model of ICH and study the underlying mechanisms.

Methods:
The ICH rat model was induced by striatal injection of collagenase type VII. One day after ICH induction, pcMSCs were directly injected into the hematoma site. Behavior tests such as rotarod test were repeatedly performed for four weeks. [18F]FEPPA positron emission tomography (PET) and magnetic resonance imaging (MRI) were applied to reveal neuroinflammation and brain atrophy, respectively.

Results:
The rats in situ injected with pcMSCs showed better performance in the rotarod test which assesses the motor coordination and balance (see Figure). Such neurological recoveries occurred four weeks after treatment. MRI data showed reduced brain atrophy in pcMSC-treated rats at the end of study, while preliminary data of PET suggested smaller signals within one week.

Conclusion:
Human pcMSCs improved the neurological deficits in ICH rats. The underlying mechanisms may be the reduced neuronal loss (indicated by reduced brain atrophy) associated with the regulated neuroinflammation (indicated by smaller signals). Currently, the therapeutic effects of pcMSCs to ICH rat model are intensively studied.
Abstract TP350: Escin Attenuates the Impairment of Neurological Function by Ameliorating Systemic Inflammation in Intracerebral Hemorrhagic Mice
Authors: Fu Fenghua , Wang Tian
Published: June 2021

Background and Purpose:
Escin could attenuate cerebral ischemia-induced brain injury. The present study aimed to investigate whether Escin may attenuate the impairment of neurological function by ameliorating systemic inflammation in ICH mice.

Methods:
The ICH model was prepared by intrastriatal injection of collagenase. At 0.5 h, 2 h, 6 h and 12 h after Escin injection, the concentration of Escin in the serum and brain were detected. The effects of Escin on the Garcia test were evaluated. Brain water content was observed via a wet/dry weight method. Evans blue extravasation in the cerebrums were also assayed. The serum IL-1β level was detected with the ELISA kit. The ICH mice were further treated with Escin plus IL-1β. At 24 h of the ICH, Garcia test, and brain water content, the Evans blue extravasation and serum IL-1β levels were evaluated. Additionally, the expression of RhoA, ROCK1, IκBα, nuclear NF-κB, cytosolic NF-κB, Occludin and Claudin-5 in mice brain tissue were investigated with the Western blot.

Results:
Escin was detected in the serum of the Control group and ICH group at 0.5 h, 2 h, 6 h and 12 h after Escin administration. Escin was not detected in brain tissues at any time points in the animals. At 24 h and 72 h of ICH, the Garcia test scores in the Escin groups were significantly increased (
P
< 0.05 or
P
< 0.01). Brain water contents and Evans blue extravasation of the right basal ganglia in the Escin groups were significantly reduced (
P
< 0.05 or
P
< 0.01). Escin abated the increase of IL-1β induced by ICH (
P
< 0.05 or
P
< 0.01). IL-1β administration reversed the effect of Escin on Garcia test scores, the brain water contents, and the Evans blue extravasation (
P
< 0.01). In the ICH group, the levels of RhoA, ROCK1, nuclear NF-κB were increased while the expression of IκBα, cytosolic NF-κB, Occludin, Claudin-5 were reduced (
P
< 0.05 or
P
< 0.01). However, Escin abated RhoA, ROCK1, nuclear NF-κB and augmented IκBα, cytosolic NF-κB, Occludin, and Claudin-5. IL-1β administration partially blocked the Escin-mediated regulation of IL-1β/RhoA/NF-κB signaling pathway.

Conclusion:
Escin cannot penetrate the blood brain barrier (BBB). Escin improves neurological function and by inhibiting systemic inflammation, and then regulating IL-1β/RhoA/NF-κB signaling pathway in BBB.
Abstract TP355: A Valiant Effort to Improve Stroke Education
Authors: Meighan Melissa M , Mojares Joseph C , Snow Kathryn M
Published: June 2021

Background and Purpose:
Increasing knowledge of pertinent aspects of stroke disease may improve outcomes for stroke survivors and family members. Patients and families are educated in a large integrated health system on Joint Commission required elements of stroke education which include: importance of calling 911, stroke signs and symptoms, disease processes, risk factor management, and follow up. In 2018, despite 95% documented rates of education, 40 to 50% of stroke survivors in the health system replied “No” to three Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPs) "staff explained stroke..." questions. The purpose of this project was to improve stroke education as measured by an increase in HCAHPs scores.

Methods:
Current literature was reviewed. Stroke survivors spoke to a regional stroke coordinator group about their experiences. Staff nurses were surveyed on barriers to stroke education. Based on information from the literature, stroke survivors, staff nurses and neuroscience nursing, neurology and education experts, two interventions were undertaken. A flyer was designed using a well-spaced layout with required stroke education elements written at fourth grade reading level and translated into four common languages in the patient population. Community feedback was integrated after the initial design. A training module for teaching stroke education was completed by 886 nurses in eight facilities. The pre and post intervention HCAHPs scores were aggregated from the eight hospitals. The results were analyzed using a Chi2 statistical tool.

Results:
Unfortunately, a statistically significant increase in HCAHPs scores was not achieved. For question #1; “staff explained stroke diagnosis”, the percentage yes went from %53 (n=49) to %59 (n=59). Question #2; “staff explained risk factors” went from %52 (n=50) to %43 (n=58). Question #3 “staff explained stroke signs/symptoms” went from %47 (n=48) to %53 (n=69).

Conclusion:
This work supports literature and local stroke survivor feedback indicating stroke survivors and their families are too overwhelmed in the hospital to absorb education. Resources should be put into follow-up phone calls or other modalities after trauma from the stroke event has subsided.
Abstract TP359: Rapid Access Stroke Unit - A Virtual Clinic to Assess Minor Stroke Admissions, Expedite Investigations and Implement Timely Treatments
Authors: Morgan Deborah M
Published: June 2021

Background:
The current Stroke service is seeing more than 200 patients per month admitted to our acute tertiary hospital. Acute major stroke patients are admitted to the stroke ward but many of the minor strokes or mimics are admitted to an acute medical assessment unit (AMAU) waiting on average 3 days for completion of investigations.

TIA clinics are an established element of a stroke service in other countries. We established a similar service, the Rapid Access Stroke Unit (RASU), opened daily in July 2018 aiming to reduce admission rates by expediting investigations and treatments for patients presenting with minor or resolved symptoms.

The referral criteria for RASU is a CT scan with no evidence of hyperacute stroke and the Patient is independent in ADL’s. If the patient is in hospital the clinical nurse specialist will triage patients for suitability for transfer to RASU. Out of hours suitable patients can be discharged from ED with instructions to attend RASU the following morning. The clinical nurse specialist, supported by the Stroke Consultant, will coordinate the investigations, track results, organise reviews and ensure the patients are fully educated of diagnosis, treatment and risk factor management.

Results:
The first year’s figures show a decrease in the inpatient admissions with 496 patients attending RASU, saving 1749 bed days.

There is also an increase in the number of patients discharged directly home from the Emergency Department (ED), with the option of attending RASU if required.

The diagnosis of patients admitted to RASU are 102 ischemic, 145 TIA, 247 Mimics and 1 ICH.

Conclusion:
One-year results have shown a significant benefit in patient care, early discharge and improved use of the hospital resources. One unexpected result was the increase in discharges from ED and this may be attributed to the ED physicians discharging patients confident that there is a rapid access service available. Another consequence of the service is that patients will ‘walk in’ to RASU if they have any further concerns or require clarification of treatments.
Abstract TP363: A Successful Nurse-Driven Acute Stroke Code Algorithm to Reduce Door-to-Needle Time at a Telestroke Site
Authors: Moran Jennifer L , Kim Lydia E , Nakagawa Kazuma
Published: June 2021

Background and Issues:
In Hawaii, where stroke remains the 3
rd
leading cause of death, a large comprehensive stroke center serves as the telestroke hub site for multiple telestroke spoke sites. Among these spoke sites, an 80-bed suburban community hospital within the same healthcare system has the highest number of IV alteplase administrations in Hawaii. Although both hospitals share similar resources and clinical expertise, the median “door-to-needle” (DTN) time at the spoke site was significantly longer compared to the hub site (by ~13-15 minutes). The main difference between the two sites was the traditional acute stroke (in person) vs. telestroke (telemedicine) workflow.

Purpose:
To transform the process and experience of a telemedicine stroke code into those similar to that of an in-person stroke code, with the aim to reduce the median IV alteplase DTN time to 20 minutes at the telestroke spoke site.

Methods:
Upon case review, the telestroke neurologist was seen as ineffective in running the stroke code remotely, an on-site stroke code leader was necessary to efficiently guide the team through the stroke code. The stroke code leader did not need to be an expert in stroke neurology, thus it was decided to have the primary nurse or charge nurse be the code leader. The code leader followed a simple Acute Stroke Code Checklist similar to that of the ACLS algorithm. The checklist included time targets to focus on the 20 minute DTN goal. In addition, the neurological exam was standardized into a primary and secondary assessment; imaging studies were also separated into primary and secondary neuro-imaging. The DTN times between pre- and post- period were compared by non-parametric Wilcoxon test.

Results:
The ED Acute Stroke Code Checklist was implemented on October 16, 2017. Following implementation DTN times decreased; the first 5 cases after the intervention were under the pre-intervention median time. DTN time decreased from a median DTN: Pre vs. Post 42.5 to 33.0 min (p = 0.0012) with data through March 2019 analyzed.

Conclusions:
The nurse-driven acute stroke code algorithm significantly improved the DTN times and reduced variation in outcomes in a community hospital telestroke site.
Abstract TP364: Developing a Pediatric Ischemic Stroke Code Protocol at a Comprehensive Stroke Center: The Georgetown Experience
Authors: Leutbecker Jacqueline , Carlson-Chalifoux Ashley , Monacci Kelsey , Pergami Paola
Published: June 2021

Background/ Issue:
Epidemiologically, pediatric strokes are rare; therefore, index of suspicion is low and many cases are not recognized early enough to qualify for acute treatment. With this small patient population, many regions have yet to develop protocols and policies for acute pediatric stroke response. In the District of Columbia, MedStar Georgetown University Hospital (MGUH) is the only Joint Commission Accredited Comprehensive Stroke Center with a pediatric intensive care unit.

Purpose:
The purpose of our program was to develop institutional protocols for pediatric stroke patients who are candidates for hyper-acute treatment. Protocols focused on pediatric patients who presented through our emergency department or were transferred from other facilities within the time window for acute treatment. The protocols were established to ensure a clear process for physicians and staff to follow.

Methods:
An interdisciplinary group met to discuss modification of our current Adult Ischemic Stroke Code Protocol needed for a coordinated approach to pediatric stroke patients. The team members included the Stroke Coordinator, Stroke Nurse Navigator, Stroke Nurse Practitioner, Pediatric Neurologist, Medical Director of the Pediatric ICU, Manager of the Pediatric ICU, Pediatric Anesthesia, Medical Director of the Stroke Program, and the Emergency Department Team.

Results:
The interdisciplinary team was able to adapt a protocol using the Adult Ischemic Stroke Code Protocol. Key differences between the adult and pediatric stroke code work-flow consisted of including pediatric neurologists early in the decision process, pediatric nurses to assist with monitoring children, and pediatric anesthesia for assistance with imaging and/or endovascular intervention. The order sets were adjusted to include weight- based calculations for medications, age-based monitoring parameters, and specific pediatric needs.

Conclusion:
It is possible to develop a Pediatric Stroke Code Protocol based on the Adult Ischemic Stroke Code Protocol to include all modifications appropriate for pediatric care and still maintain the rapid work-flow that everyone is familiar with. It is essential to include all key stakeholders to ensure a smooth and safe process.
Abstract TP367: Dimensions of Social Support and Post-Stroke Depressive Symptoms in Saudi Arabia: A Mixed Methods Approach
Authors: Babkair Lisa A , Chyun Deborah , Dickson Victoria V , Almekhlafi Mohammed
Published: June 2021

Stroke is the second leading cause of death and a major cause of serious long-term disability worldwide. Post stroke depressive symptoms (PSDS) affect one third of stroke survivors. The prevalence of PSDS ranges from 17%–63.3% in Saudi stroke survivors. Stroke survivors use social support as a coping mechanism and as a protective factor against the adverse effects of stroke outcomes.

The purpose of this study was to describe the nature of PSDS and to compare the influence of perceived and received social support among stroke survivors in Saudi Arabia. The aims were: (1) to examine the influence of perceived social support on PSDS, (2) to explore the nature of PSDS and received social support, and (3) to characterize the contribution of perceived social support and received social support and PSDS.

A convergent embedded mixed methods design was used. 135 participants were recruited for the quantitative purpose from outpatient clinics and inpatient rehabilitation facilities in Saudi Arabia and 34 participants were selected from the original sample for qualitative purposes. The data were gathered using structured instruments and interviews.

The findings were: (a) 54% had depressive symptoms (DS); (b) DS were negatively associated with perceived social support (
r
= -.65,
p
< .001) and the functional independency (
r
= -.45,
p
< .001), whereas perceived stress was positively associated (
r
= .71,
p
< .001); (c) social support, stress level, and literacy were associated with DS (β = -.31,
p
< .001; β = .45,
p
< .001; β = .16,
p
= .01, respectively) and partially mediate the association of DS with functional independence; (d) there is a typology of experiencing DS and receiving social support,
Satisfied
and
Deprived
, and those with DS and social support,
Discrepancies
.

The results of this mixed methods study show that a lack of social support was associated with DS. The integration of quantitative and qualitative data provided a broad, in-depth perspective on the nature of DS and social support influenced by individual’s life changes after stroke. Future research is needed to examine the interventions to improve social support among caregivers and to reduce DS in stroke survivors.

2
Abstract TP37: Ten-Year Single Center Experience of Intra-Hospital Triage for Endovascular Treatment: The Hardest Hurdle During Late Off-Duty Hours
Authors: Shim Dong-Hyun , Kim Yong-Won , Gwak Dong Seok , Kwon Jung-A , Hwang Yang-Ha
Published: June 2021

Background and Purpose:
Intra-hospital time delays can affect the outcome following endovascular treatment (EVT). To overcome these hurdles, multidisciplinary quality improvement (QI) program could be helpful in that it can improve intra-hospital time-related factors with subsequent better clinical outcome. We aimed to describe our ten-year experience of endovascular triage via the multidisciplinary QI program with emphasis on time-related factors.

Methods:
Based on our prospectively maintained EVT registry (n=602), three consecutive periods were defined based on the implementation of QI program and the changes in the primary modality of first angiographic imaging: (1) period 1 (May 2006 to December 2009); (2) period 2 (January 2010 to August 2012); and (3) period 3 (September 2012 to April 2016). Definitions of working hours: On-duty was defined as regular working hour from AM 8:00 to PM 6:00, and off-duty was defined as night shift from PM 6:00 to AM 8:00 the following day. Off-duty was classified into two groups by early off-duty as PM 6:00 to midnight and late off-duty as midnight to AM 08:00 the next day. Also, regular working hours in holidays were considered same as early off-duty.

Results:
Overall, successful reperfusion (mTICI 2b-3, post-procedure) and favorable outcome (mRS 0-2 or equal to pre-stroke mRS, at 3-month) was achieved in 395 patients (65.6%) and 311 patients (51.6%), respectively. A trend for increase in successful reperfusion and favorable outcome over periods was observed (
p<0.001
, respectively). Also, significant trends for shorter door-to-picture and door-to-puncture (DtoP) times over periods were observed (
p<0.001
, respectively). Inside each period, late off-duty hours were the hardest time period for improvement. In period 3, the DtoP time was 98.0 (IQR 79.0 - 118.0) minutes in late off-duty hours compared to 77.0 (IQR 60.5 - 88.5) minutes in on-duty hours (
p<0.001
).

Conclusions:
Upward trend in successful reperfusion and better outcome were observed along with improvement in intra-hospital workflow to decrease door-to-puncture time, which emphasizes the importance of incessant QI program of EVT workflow. However, late-off duty hours were the hardest time point for improvement.
Abstract TP376: Director, Comprehensive Stroke Program
Authors: Patterson Michele J , Moore Tracy , Cline Paula
Published: June 2021

Background:
Hospital system identified decline in Emergency Medical Services arrivals [EMS-A] and increased Private Vehicle arrivals [PVA].

Purpose:
Understand community response and PVA for focused education to increase EMS-A in order to improve treatment rates and decrease disability.

Methods:
Retrospective chart review to evaluate age, gender, race, poverty levels, stroke type, severity, treatment rates, and outcomes of the Target Population [TP].

Results:
Review of 4,264 records [2015-2018] identified 1,612 PVA and 2,652 EMS-A. The largest PVA age group, identified as TP, was age 46-65. The TP was 60% male. Hispanics comprised 59% PVA versus [v] 54% EMS-A. All other races had higher EMS-A. Those with PVA were more likely to have private insurance [39% PVA v 23% EMS-A] and more likely to have zip codes with less than 10% poverty [8% PVA v 1% EMS-A]. Those below poverty had lower PVA [6% PVA v 12% EMS-A]. Stroke type was 90% Ischemic. Eighty-nine percent of PVA had NIHSS 0-7 [NIHSS: 0=24%, 1-5=57%, 6-7=8%]. Time last known well [TLKW] for PVA NIHSS 0-7 was less than or equal to 3.5 hours in 15% and greater than 3.5 hours in 33%. Alteplase treatment rate for NIHSS 0-7 was 4% PVA v 9% EMS-A. Mechanical Endovascular Reperfusion [MER] treatment rate for NIHSS 0-7 was 0% PVA v 1% EMS-A. Discharge [DC] disposition for PVA NIHSS 0-7 showed 21% rehabilitation and 2% death or hospice. DC Modified Rankin Scale [mRS] for PVA NIHSS 0-7 was mRS 2-3 in 17% and mRS 4-5 in 10%.

Conclusion:
The majority of PVA were middle aged [46-65] and predominantly male. Hispanics were the only ethnic group with higher PVA v EMS-A. The TP majority lived in areas with less than 10% poverty, had private insurance, had ischemic strokes with milder deficits and presented outside the Alteplase treatment window. Treatment rates for Alteplase and MER were 50% greater for NIHSS 0-7 for EMS-A. At DC, 21% PVA with NIHSS 0-7 required rehabilitation and 27% had slight to severe disability. Identifying characteristics of the TP is helpful for focused public education to increase EMS-A and early presentation regardless of severity to increase treatment rates and decrease disability.
Abstract TP378: Can I Eat? Improving the Stroke Swallow Screen Process for Previously Lethargic Patients
Authors: Schaefer Karen , Daniels Joanne , Lobley Jennifer , Stone Mindy
Published: June 2021

For stroke patients at our facility, the stroke swallow screen is one of the initial assessments completed by the RN. This screen is typically completed in the Emergency Department prior to any oral intake. RNs on the stroke unit noticed some patients who failed the screening due to lethargy were kept NPO awaiting formal swallow evaluation by Speech Language Pathology (SLP). Some of these patients arrived on the stroke unit no longer lethargic and requesting something to eat or drink; however, due to policy, the patient would be kept NPO until evaluated by SLP. At times, patients admitted in the late evening/overnight remained NPO until morning causing frustration and, at times, agitation. An interdisciplinary team convened to review stroke swallow screen literature. A comprehensive review was completed, and no evidence was found against allowing the RN to repeat a screening if a patient failed due to lethargy. Due to this, policy was changed to allow the RN to repeat the swallow screen for patients that had an improvement in their mental status, only if the patient initially failed due to lethargy. If this patient were to fail the repeated screen, they would remain NPO until evaluated by SLP. Education was created for the RNs, including computer-based learning, tip sheet and face-to-face education. Data was gathered from a random sample of patients seen at our facility since this policy change was implemented in September 2018. Of 20 patients, 75% passed the repeated swallow screen completed by the RN and were able to begin oral intake; the remainder of the patients were referred for evaluation by SLP. A survey of RNs on the stroke unit revealed: 100% RNs feel comfortable repeating the swallow screen under the new policy, 100% RNs feel the new policy has improved patient/family and MD satisfaction, 72% RNs feel a reduced level of stress regarding patients’ ability to eat, drink, and take medications by mouth, prior to this policy change, 72% RNs had dealt with difficult situations in which a patient was kept NPO after failing a swallow screen due to lethargy.
Abstract TP383: Ischemic Stroke Patients With Diabetes Looking for Practices in Need of Improvement
Authors: Bautista Cynthia , Gerard Sally
Published: June 2021

Background/Purpose:
Stroke is the fifth leading cause of death and Diabetes is the seventh leading cause of death in the United States. Diabetes is an independent risk factor for stroke. Diabetes is a common co-morbidity in stroke patients and is associated with poor outcomes after stroke. Get with the Guidelines - Stroke (GWTG-S) Registry database provides a rich opportunity to look at disease-specific data and find opportunities for improving care. The purpose of this study was to examine specific elements of acute ischemic stroke care in patients with diabetes using the GWTG-S at Comprehensive and Primary Stroke Centers in Northeast of America.

Methods:
A retrospective, descriptive study at both a Comprehensive and Primary Stroke Center. The analysis focused on patients with ischemic stroke and diabetes entered in the GWTG-S from January 1, 2015, to December 31, 2017. Data were analyzed looking at measures specific to stroke and the presence of diabetes. General demographic data were examined to compare populations and quality outcome measures.

Results:
The sample of patients with ischemic stroke and diabetes was over 1,000 patient’s at the two sites (Comprehensive site N = 804, Primary site N = 203) Incidence of ischemic stroke with diabetes at the two sites were 32% and 26%, respectively. Demographic data were similar in most categories including age, race, and gender. Significant differences were found in regard to the type of insurance. Stroke care outcomes indicated thrombolytic administration rates were the same at 8%. Diabetes care outcomes indicated patients discharged on insulin occurred in 18% to 26% of the sample.

Conclusion/Implications for Practice:
Ischemic stroke patients with diabetes were shown to receive similar care at both a comprehensive and primary care stroke center. There were no differences between centers in thrombolysis treatment for ischemic stroke patients with diabetes. Several opportunities for improvement in diabetes-related care need to be addressed.
Abstract TP386: National Institute of Health Stroke Scale Completion Improved in Hyperacute Stroke Unit; Quality Improvement Strategy for Implementation of the Australian Stroke Foundation 2017 Clinical Guidelines for Stroke Management
Authors: Jaques Katherine R
Published: June 2021

Background and Purpose:
In September 2017, a new Hyperacute Stroke Unit (HASU) was opened in a metropolitan hospital with over 400 acute stroke admissions per year, offering endovascular clot retrieval (ECR) and IV thrombolysis; 185 ECR procedures completed in 2018. The HASU opening coincided with publication of the 2017 Australian Clinical Guidelines for Stroke Management. The Guidelines state stroke severity be assessed using a validated tool, such as the National Institute of Health Stroke Scale (NIHSS). A Quality Improvement workshop, March 2018, identified attendance of correct and reliable assessment for stroke severity as a service gap. Goal = Improve NIHSS completion on all stroke patients on presentation to hospital and 24hours post endovascular clot retrieval. This was to be achieved within 90 days of project implementation with the focus on nursing education; a new skill addition to the ward environment.

Methods:
Education workshops (August-September 18) were implemented with the goal of building knowledge, skills and confidence along with gaining NIHSS certification. All clinical and registered nurses were provided designated time to attend workshops. Workshops were also provided to Medical officers (January 2019) allocated to the Stroke team. Cognitive aids to assist with reducing variability in application of the NIHSS were created. These included NIHSS navigation aids to the electronic medical record, NIHSS app upload to mobile phones, paper based NIHSS assessment to assist the bedside nurses and ward round note templates with auto text for NIHSS completion. Data from three months pre and post implementation was collected and compared using the Australian Stroke Clinical Registry (AuSCR). All patients admitted with stroke were included in this analysis (Jan 18-April 19).

Results:
NIHSS completion on patient presentation increased by 12% (n=325). NIHSS completion at 24hrs for patients post ECR increased by 22% (n=163). 31 registered nurses trained; 8 medical officers trained.

Conclusions:
Targeted, multimodal strategies improved completion of NIHSS on presentation and particularly, 24hrs post ECR. Further implementation in the emergency department is required to gain improvements in NIHSS completion on presentation.
Abstract TP390: The Prognosis of Adverse Stroke Outcomes on the Post IV Alteplase Ischemic Stroke Patients: A Trajectory Groups of 24-Hour Systolic Blood Pressure (SBP) Measurement
Authors: Zhao Jie , Chang Hong , Fan Kaiting , Wang Xiaojuan , Yao Hui , Cao Wenya , Ruan Zheng , Yang Xin
Published: June 2021

Background:
To explore whether longitudinal 24-hour SBP trajectory patterns after thrombolysis could predict the risk of adverse stroke outcome.

Methods:
The total of 362 ischemic stroke patients, were selected with onset of within 4.5 hours and underwent intravenous(IV) thrombolysis with alteplase(rt-PA). Group-based trajectory models to identify SBP subgroups were used. The demographics, medical history, laboratory test results and the stroke outcome including early neurological deterioration (END), early neurological improvement (ENI), hemorrhage, Barthel index(BI), the modified Rankin Scale (mRS) score, recurrent stroke at 3 months after stroke were collected.

Results:
The stroke patients with IV thrombolysis were classified into six SBP trajectory groups: admission SBP, antihypertensive drugs before thrombolysis, history of hypertension, stroke, hemoglobin, glucose, and triglycerides. There was no difference in the incidence of hemorrhage, END, and recurrent stroke. The results of logistic analysis,when compared with the moderate-stable SBP group, there was a negative correlation between the risk of ENI and SBP trajectory patterns (OR=0.32; 95%CI: 0.15 to 0.67) , and the “J” correlation between the risk of the mRS score(OR=0.31; 95%CI: 1.50 to 7.30).

Conclusion:
The findings potentially help identify candidates for clinical blood pressure observation, blood pressure control and nursing care and management.
Abstract TP399: Case Study: How to Run Three Simultaneous Stroke Alerts That Require Endovascular Therapy
Authors: Pozo Jessilyn , De Armas Peter , Waisbrot Andrew , D'Amour Daniel , Starosciak Amy K , Strauss Jayme
Published: June 2021

Introduction:
Even experienced teams can become overwhelmed with multiple simultaneous stroke alerts, especially when all require endovascular therapy. We describe a recent situation where three acute stroke alerts arrived to our comprehensive center within 36 minutes of each other and all needed endovascular therapy. We strategically handled the situation to ensure all patients were assessed and treated in an organized and timely manner.

Methods:
The stroke team conducted a detailed review of the three cases after treatment to identify areas of success and areas to improve.

Results:
EMS alerted our center for Case 1 at 11:47 followed by Case 2 at 11:51, FAST-ED scores of 4 and 7, respectively. Based on these scores, the interventional team was on standby because of the high likelihood of large vessel occlusion. As the stroke responder RN awaited the EMS cases, Case 3 arrived via triage at 12:00. The triage nurse immediately called a stroke alert for right facial droop, right weakness, and expressive aphasia, which activated a second stroke responder. Case 1 arrived at 12:19 and Case 2 arrived at 12:36. A third responder was activated so that all patients had a dedicated responder to facilitate initial assessment, rapid imaging, and coordination of care up to endovascular procedure start. Case details can be found in the table below.

Discussion:
With three stroke alerts arriving within 36 minutes of each other and all needed endovascular intervention, there was an initial strain on our stroke alert process. However, our center’s standard is to have a primary and secondary stroke responder, as well as multiple other nurses trained in rapid stroke response. In this way, we ensured that all patients were assessed and treated rapidly and efficiently.
Abstract TP4: Age is an Important Effect Modifier of Mechanical Thrombectomy: A Subgroup Analysis of the Resilient Trial
Authors: Lima Fabricio O , Montalverne Francisco J , Carvalho João J , Bandeira Diego A , Frota Norberto A , Rebello Letícia C , Silva Gisele S , Frudit Michel , Pontes-Neto Octávio M , Abud Daniel G , Haussen Diogo C , Souza Ana C , Oliveira-filho Jamary , Liebeskind David , Wagner Mario B , Broderick Joseph , Nogueira Raul G , Martins Sheila O
Published: June 2021

Background:
Randomized trials performed in high income countries have shown similar effects of mechanical thrombectomy (MT) in elderly and non-elderly patients with large vessel ischemic strokes (LVO). We aimed to assess the effect of age on the clinical outcome of MT in RESILIENT (a randomized, prospective, multicenter, controlled, phase III, clinical trial with blinded outcome assessment performed in Brazil designed to assess the safety, efficacy, and cost-effectiveness of mechanical thrombectomy as compared to medical treatment alone).

Methods:
Patients were classified as elderly and non-elderly (≤ 70 vs. > 70 years). The end-points were the common odds ratio (cOR) of mRs (shift analysis) and the frequency of functional independence (mRS 0-2) at 90 days. Ordinal logistic regression analysis (unadjusted and adjusted for important potential confounders) with age group as an interaction term were performed. A p value < 0.05 was considered statistically significant.

Results:
Among 221 randomized patients (117- 52.9% males), 89 (40.2%) were classified as elderly. Age had an important effect modification of MT on the mRS shift analysis (elderly - cOR 1.20 95% CI [0.57-2.51] vs. non-elderly cOR 3.9, 95% CI [1.65-5.80], p-interaction = 0.003) and on the frequency of functional independence at 90 days (elderly - OR 0.92 95% CI [0.33 - 2.59] vs. non-elderly OR 3.56, 95% CI [1.64 - 7.75], p-interaction = 0.04). A similar effect modification was observed after adjusting for IV rt-PA, occlusion site, baseline NIHSS and ASPECTS on the mRS shift analysis (elderly - cOR 1.34, 95% CI [0.63 - 2.86] vs. non-elderly cOR 3.26, 95% CI [1.73 - 6.13], p-interaction = 0.06) and on the frequency of functional independence at 90 days (elderly - OR 1.08 95% CI [0.36 - 3.21] vs. non-elderly OR 4.26, 95% CI [1.85 - 9.82], p-interaction = 0.04) .

Conclusion:
The large effect size of MT on LVO outcomes is significantly diminished in the elderly population of patients treated under the less than ideal conditions typically found in the public healthcare system of a developing country.
Abstract TP400: The Differences of Vessel Wall Features Between the Anterior and Posterior Brain Arteries Detected by High Resolution Magnetic Resonance Imaging in Patients With Acute Ischemic Stroke
Authors: Chen Xiangyan , Zheng Lu , LI Jia , Yang Wenjie
Published: June 2021

Backgrounds:
The purpose of this study was to investigate vessel wall features visualization by high resolution magnetic resonance imaging (HRMRI) in a series of ischemic stroke patients and to identify differences between lesions in the anterior and posterior circulation.

Methods:
We consecutively recruited Chinese patients with acute ischemic stroke or transient ischemic attack from 2016 to 2018. All patients were scanned at 3T magnetic resonance imaging. We evaluated pre-and post-contrast cross-sectional views of M1 and M2 segments of middle cerebral arteries (MCAs), basilar arteries (BA) and V4 segments of vertebral arteries (VAs).

Results:
A total of 74 patients (males 52.3%; median age 62 years old) were included in this study, among which, 234 lesions were identified on HRMRI, including 117 MCA lesions, 26 BA lesions, and 91 VA lesions. The sensitivity and specificity of MRA for diagnosing stenosis in anterior circulation were 89.3% (95% CI, 81.8%- 94.2%) and 50.0 (95% CI, 9.2%- 90.8%). The sensitivity and specificity of MRA for diagnosing stenosis in posterior circulation were 73.2% (95% CI, 63.9%- 80.9%) and 40.0 (95% CI, 7.3%- 83.0%). VA had a significantly higher contrast enhancement index (43.71± 7.74,
p
<0.016) than MCA (23.32± 2.46) or BA (22.69± 5.31) . Anterior circulation plaques had higher degree of stenosis (anterior versus posterior: 68.5% vs. 62.9%,
p
=0.036), more eccentric distribution (anterior versus posterior: 70.1% versus 53.8%,
p
=0.015) and higher rate of intraplaque hemorrhage (anterior versus posterior: 17.1% versus 7.7%,
p
=0.046). The plaques in posterior circulation had a thicker lesion wall (posterior versus anterior 16.58± 8.25 mm
2
vs. 9.10± 4.07 mm
2
,
p
<0.001) and higher enhancement index (posterior versus anterior 39.04± 8.50 vs. 23.32± 2.46,
p
<0.001) than the plaques in anterior circulation.

Conclusions:
The lesions in posterior circulations could be obscure on MRA. The area stenosis, intraplaque hemorrhage and enhancement index differed between circulations.
Abstract TP401: Impact of Vital Signs and Neurological Assessments After Alteplase for Acute Stroke
Authors: Drake Scott , Renati Swetha , Packer Wilson Karen , Hilker Nicholas , Slye Nicole , Chen Henian , Rose David Z , Burgin William S
Published: June 2021

Background:
Vital signs and neurologic assessments are currently performed using the schedule utilized during the clinical trials which led to the approval of alteplase for acute stroke. These assessments can be disruptive to patients and represent a considerable staffing and infrastructural demand. While the goal of this approach is to improve outcomes by rapidly detecting actionable changes, its impact has been questioned. Despite its widespread use there has been limited systematic review regarding its influence on outcomes.

Purpose:
This project’s aim was to determine the impact of these assessments by conducting a retrospective review at our large, urban, comprehensive stroke center. We sought to evaluate the rate of compliance with established guidelines, and assess its correlation with patient outcomes.

Methods:
This retrospective review of patients receiving alteplase for acute stroke was approved by our institutional review board. A total of 130 patients were identified during 2018. Data was collected from the electronic medical record and The Get with the Guidelines database.

Results:
Our institutional guideline includes a total of 36 vital signs and 24 neurological assessments during first 24-hours after alteplase administration, for a total of 60 assessments. 63% of patients had full compliance with all 60 assessments. The discharge modified Rankin scale (mRS) for those with full compliance was 2.35 versus 2.31 for patients without 100% compliance (p>0.05; NS). There was less compliance with vital signs compared to neurological assessments (73.8% versus 76.9%).

Conclusions:
The majority of patients were complaint with all assessments however a notable portion missed at least one assessment, occurring more frequently with vital signs. Full compliance with all assessments was not associated with improved mRS.