bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP266: EMS/Hospital Combined Education Decreased Primary Stroke Center Bypass
Authors: Stopyra Jason P , Waddell Myron , Parks Emily B
Published: June 2021

Introduction:
Historically, community hospitals have had few options for meaningful treatment of patients presenting with acute stroke. As expertise grows in the administration of thrombolytics, primary stroke centers (PSC) fulfill an important role in the reduction of morbidity and mortality related to stroke. It is important for the PSC to partner with Emergency Medical Services (EMS) to change historical perceptions of the quality of PSC care. Education may improve teamwork and increase awareness of the PSC, thereby increasing their utilization in EMS disposition decisions.

Objective:
The objective of this study is to report the impact of an education intervention on PSC bypass decisions.

Methods:
The electronic patient care record database from a North Carolina county EMS system was queried as a quality improvement analysis from January 1, 2012 to February 28, 2016. This included 19 months prior to the education intervention, the year during the education intervention, and 19 months after the education intervention. All primary patient transports with Stroke/CVA, or suspected TIA as the primary or secondary impression were included. Interfacility transports were excluded. The recorded call location was determined to either be inside or outside the PSC service area. The hospital the patient was transported to was also recorded.

Results:
During the pre-intervention phase 222 patients were identified, 48 of which originated in the PSC service area. Of those 48 patients, 16 bypassed the PSC (33.3%). In the post-intervention phase, 94 of 269 total patients were in PSC service area. Only 12 bypasses occurred (12.8%) which is a reduction of 61.7% in PSC bypass compared to the pre-intervention phase.

Conclusion:
The period following a combined hospital/EMS educational intervention showed significant reduction in PSC bypass.
Abstract WP267: Clinical Simulation-based Usability Testing of a Mobile Telestroke System
Authors: Chapman Smith Sherita N , Mehndiratta Prachi , Ricks Jamie , Heath Jamie , Bennam Poanna , Toqeer Qaiser , Heath Kaitlynne , Ruiz Andres , Feldman Moshe , Hekmatdoost Kevon , Blankson Baaba , Bhatti Muhammad , Henry Jeneane , Rahim Basit , Madu Theandra , Decker Richard , Fellows Daniel , Whitt Dempsey , Lavrentyev Vladimir , Wong Jason , Brown Pamela , Warren Felton , Ornato Joseph
Published: June 2021

Background:
Mobile prehospital telestroke presents a novel solution to improve stroke diagnosis and reduce treatment times. This study aims to 1) understand perceptions of a mobile ambulance-based telestroke system from all users and 2) evaluate system usability during ambulance transport.

Methods:
A Critical Care ambulance was equipped with a mobile telemedicine system to perform remote stroke assessments. Scripted scenarios were performed by trained actors during transport and evaluated by physicians using the NIH stroke scale (NIHSS). Scores obtained during transport were compared with independent bedside and original scripted NIHSS scores. Participants completed the System Usability Scale (SUS), NASA task load index (NASA TLX), audio-video quality scale and a modified Acceptability of Technology survey after completing the NIHSS evaluations. In addition, interviews were conducted to evaluate user’s experience and perceptions. Descriptive analysis was used for all surveys. Weighted kappa was used to compare the agreement in NIHSS scores. A regression model was used to further account for variations.

Results:
Ten scripted scenarios were simulated twice during the mobile transport and once at bedside. All simulations were completed except for one. NIHSS scores between mobile, bedside and original scripted scenarios revealed good agreement [weighted kappa=0.76 (95% CI: 0.63-0.9, p=0.63)]. There were no statistically significant differences in NIHSS scores between mobile and bedside evaluations. The results were independent of stroke scenarios, physicians, and actors. Overall, 92% and 81% raters deemed video and audio quality as “good” or “excellent” (rating
<
3) respectively. The overall mean SUS score was 69.1 (13.3). Content analysis identified strengths, usability issues (i.e. audibility and equipment stability during transport), and safety concerns.

Conclusion:
This study used in-situ simulation to evaluate the viability of a mobile telestroke system. Simulating stroke scenarios using actors during a real ambulance transport allowed us to assess a health technology without risking patient safety while capturing realistic environmental factors.
Abstract WP268: Evaluation and Validation of Prehospital Acute Stroke Severity Scale to Predict Large Vessel Occlusion in Patients with Proven Large Vessel Occlusion; Single Center Study in US
Authors: Niazi Muhammad H , El-Ghanem Mohammad , Richardson Alicia , Morrison Kathy , Raymond Reichwein , Ermak David
Published: June 2021

Background:
In 2015 guidelines regarding endovascular treatment (ET) of Large Vessel Occlusion (LVO) in acute ischemic stroke (AIS) were changed, leading to more patients being transferred to comprehensive stroke centers (CSC) for ET in selected patients, sometimes bypassing primary stroke centers. In the era of ET, there is a need for a simple yet sensitive pre-hospital tool to triage appropriate patients to CSCs. Many prehospital stroke scales predicting LVO are not in widespread clinical use because they are complex and not reliable. A recently published Denmark study demonstrated the PASS tool (Score range 0-3) for detecting LVO where a score of ≥2 was considered to be optimal in predicting LVO with sensitivity of 0.66.

Methods:
A retrospective analysis of AIS patients with confirmed anterior circulation LVO by catheter-based cerebral angiography between January 2015 and June 2016 was conducted. PASS scores were calculated and correlated with NIHSS to assess for severity of the stroke.

Results:
Fifty-four patients received ET during the study period. Those who had posterior circulation LVO were excluded, leaving 44 patients for final analysis. Only 5 (11.4%) patients had PASS score of <2 while 39 patients (88.6 %) had a score of ≥2 showing sensitivity of 0.89 for those patients with LVO. Average NIHSS scores were 11 (95% CI 6.6-15) for PASS <2 and 20 (95% CI 18.5-22.5) for PASS ≥2 (p value 0.005).

Conclusion:
The PASS tool is simple, quick, and easy to perform and has high sensitivity in AIS patients with LVO. To assess its value and efficacy in real time it should be implemented into EMS systems and be performed in the pre-hospital setting.
Abstract WP269: Shift Towards Earlier Time to Presentation of Ischemic Strokes at a Regional Tele-Stroke Network After Endovascular Stroke Trials
Authors: Anand Aashish , Nalluri Suman , Shams Tanzila , Pierre-Louis Naregnia , Chugh Chandril , Guthmann Anita , Janardhan Vallabh
Published: June 2021

Introduction:
The presentation of results of endovascular stroke treatment trials at the International Stroke Conference (ISC) in February 2015 was a landmark event in the treatment of acute ischemic strokes. Time to treatment remains the main limiting factor in the success of both endovascular and pharmacological treatment of acute ischemic strokes. This study aims to evaluate if publication of these trials has positively impacted the time to presentation for acute ischemic strokes at a regional tele-stroke network.

Methods:
Clinical data of all stroke consults from 17 months (October 2013 to February 2015) before, and 17 months (March 2015 to July 2016) after presentation of endovascular trials at ISC 2015 was collected from a prospective regional tele-stroke registry. Trends in time to presentation of acute ischemic strokes in the pre-trials and post-trials period were compared.

Results:
Prospective data of 7176 consecutive tele-stroke consults is presented. There was a significant increase in proportion of tele-stroke calls for acute ischemic stroke referrals in the post-trials period compared to pre-trials period [2792 (84%) versus 2297 (69%), p=0.002]. On sub-group analysis, this trend was seen in the referrals from urban “in-network” hospitals [p=0.02]. There was no change in the referral pattern from rural “out-of-network” hospitals [p=0.2]. In the post-trials period, there was an increase in the proportion of stroke presentations within 4 1/2 hours “window period” and 4.5 to 12 hours, and a decrease in presentation beyond 12 hours [ 4 ½ hrs: 16% vs. 14%; 4 ½-12 hrs: 36% vs. 33%; >12 hrs: 48% vs. 53%, p=0.009]

Conclusions:
The advent of landmark stroke trials appears to have increased awareness towards stroke treatment, resulting in higher referrals and earlier time to presentation from urban centers, but not rural centers.
Abstract WP270: Using County Stroke Receiving System Data to Identify Areas in Need of Public Health Intervention
Authors: Olson-Mack Lindsay , Kenner-Brininger Amelia , Royer Diane , Haynes Bruce , Hemmen Thomas M
Published: June 2021

Background:
Patients who alert the Emergency Medical Services (EMS) system arrive to the hospital sooner and receive faster and more appropriate care after stroke. We investigated the regional distribution of EMS alerts in stroke patients throughout San Diego County. Our aim is to document regional difference that may provide opportunities for improvement in community outreach.

Methods:
We included all patients with principle discharge diagnosis of stroke in the San Diego County Stroke Registry from 01/2015 to 12/2015. We analyzed stroke incidence by ZIP code in cases per 100,000 and use of EMS in percent of all stroke discharges by ZIP code. Each ZIP code was characterized by race/ethnicity, age, use of prescriptions for high blood pressure, diabetes and smoking from ESRI Community Analyst. ZIP codes with fewer than 10 stroke cases were excluded. We used Pearson correlation with significance level of p<0.05.

Results:
In total we found 5,302 stroke discharges, 4,163 (78.5%) matched to one of 77 ZIP codes in San Diego County. The rate of stroke incidence ranged from 42.9 to 263.9 cases per 100,000 residents. Frequency of EMS use ranged from 26.3% to 83.3%. Rate of stroke was positively correlated with older age, use of prescription drugs for high blood pressure and diabetes. EMS use was higher in ZIP codes with increased smoking (p=0.02). No other variable correlated with EMS use within ZIP codes.

Conclusion:
The rate of EMS alert after stroke varies considerably across our region. We did not identify a robust predictor for higher EMS use within a ZIP code. Our data suggests that further studies are needed to best understand the variance in EMS use. The regional difference, however, justify a targeted community outreach program to improve EMS utilization after stroke.
Abstract WP276: Simplification of a Prehospital Short NIHSS Scale Does not Increase Interrater Agreement Between Emergency Medical Services and Stroke Specialists
Authors: Demeestere Jelle , Garcia-Esperon Carlos , Lin Longting , Loudfoot Allan , Bivard Andrew , Parsons Mark , Levi Christopher
Published: June 2021

Objective:
To assess if simplifying a prehospital 8-item NIHSS scale (NIHSS-8, fig 1) to a 0 (symptom absent) – 1 (symptom present) scoring system increases interrater agreement between emergency medical services (EMS) and stroke specialists.

Methods:
We analysed interrater agreement between EMS and stroke specialists of a single centre on a prospectively collected cohort of 64 suspected acute ischemic stroke patients. EMS performed NIHSS-8 score upon patient arrival at the emergency department. The stroke specialist scored the full 15-item NIHSS blind to the EMS scores and within 5 minutes of patient arrival. Linear-weighted Cohen’s kappa statistics was used to assess agreement between EMS and stroke specialist on the total NIHSS-8 score and each NIHSS-8 scale item. We then simplified each item to a 0-1 score and reassessed interrater agreement for the overall NIHSS-8 scale using linear-weighted Cohen’s kappa statistics and for each NIHSS-8 item using Cohen’s kappa statistics. We used Cohen’s kappa statistics to assess agreement for original and simplified NIHSS-8 cut-off scores.

Results:
EMS and stroke specialist reached substantial agreement on overall NIHSS-8 scoring (linear-weighted kappa 0.69). Optimum agreement was reached for right arm weakness (linear-weighted kappa 0.79; Table 1) and a cut-off score of 2 and 5 (Cohen’s kappa 0.78; Table 2). When the score was simplified to a 0-1, overall agreement between EMS and stroke specialists was substantial (linear-weighted kappa 0.65). Optimum agreement was seen for LOC questions (Cohen’s kappa 0.78; Table 1) and a cut-off score of 2 (Cohen’s kappa 0.77; Table 2).

Conclusion:
Simplifying an 8-item prehospital NIHSS stroke scale does not increase interrater agreement between emergency medical services and stroke specialists.
Abstract WP278: Demographic Disparities in Extended Use of Tissue Plasminogen Activase in Acute Stroke Patients Treated via Telestroke
Authors: Bozorgui Shima , Wu Tzu-Ching , Bambhroliya Arvind B , Ankrom Christy M , Cossey Tiffany D , Trevino Alyssa D , Savitz Sean I , Jagolino Amanda L
Published: June 2021

Introduction:
Disparities have been demonstrated in acute ischemic stroke (AIS) treatment between age, gender, and racial/ethnic groups. Telestroke (TS) has been noted to decrease disparities in AIS care. As AIS management via TS increases and the inclusion criteria for tPA expands, it is crucial to evaluate differences among patients of various age, gender, and race/ethnicity with extended use of tPA (EU-tPA). EU-tPA was defined as patients with relative contraindications as per 2016 AHA/ASA scientific statement, and who have consented to receive EU-tPA.

Hypothesis:
We hypothesized that EU-tPA is administered at similar frequencies among patients of different age, gender, and racial/ethnic groups via TS.

Methods:
From 9/2015-3/2016, we identified 136 suspected AIS patients with reported relative contraindications to tPA in our TS registry who were evaluated by video consultation at one of 17 spoke hospitals. We compared the likelihood of receiving EU-tPA among patients of different age, gender, and racial/ethnic groups.

Results:
Of 136 suspected AIS patients with reported contraindications to tPA in our TS registry, 35 (25.7%) received EU-tPA. Demographic characteristics are presented in Table 1. There was no significant difference between gender and race/ethnicity in receiving EU-tPA. Patients who were older were less likely to receive EU-tPA and the difference persisted in the multivariate analysis (p=0.026). Similarly, patients with mild or rapidly improving symptoms were less likely to receive EU-tPA (p=0.001).

Conclusion:
Our study suggests that older patients receive EU-tPA less frequently. Although there was no significant difference between gender and racial/ethnic groups, there was a trend that Hispanics might receive EU-tPA less frequently than non-Hispanic whites. Additional prospective study is needed to evaluate reasons why older patients are less likely to receive EU-tPA.
Abstract WP28: Symptom Recognition-to Door Time is Associated With Outcomes from Endovascular Recanalization in Wake-up Stroke
Authors: Sung Sang Min , Kang Yoon Jung , Choi You Jin , Shin Jae Yong , Cho Han Jin
Published: June 2021

Background and Purpose:
Patients who have acute stroke symptoms present on awakening are ineligible for standard intravenous thrombolysis due to the unclear onset time of symptoms. Some of these wake-up stroke (WUS) patients may benefit from endovascular recanalization. This study aimed to evaluate clinical predictors of outcomes from endovascular recanalization in WUS patients.

Methods:
Forty-one WUS patients with internal carotid (ICA) or middle cerebral artery (MCA) occlusion treated with endovascular recanalization were reviewed. Regression analysis was performed to measure clinical predictors of outcomes from endovascular recanalization in WUS patients.

Results:
The mean initial NIHSS score was 16.41 ± 4.96 (5-24). The mean symptom recognition-to-door time (SRDT) was 108.85 ± 65.80 (19-230) minutes. Successful recanalization (TICI 2b-3) was achieved in 29 patients (70.7%). Thirty-four patients improved on NIHSS (amount 7.59 ± 4.84, range; 1-17) at 7 days after recanalization. At 90 days after recanalization, a mRS of ≤ 2 was achieved in 19 patients (46.3%) and a mRS of ≤ 3 was achieved in 24 patients (58.5%). No symptomatic intracerebral hemorrhage occurred. Multivariate regression analysis identified SRDT (P=0.019), successful recanalization (P=0.005), and hypertension (P=0.013) were factors associated with an improvement of the NIHSS score. For a good functional outcome at 90 days, SRDT (P=0.036) and initial NIHSS score (P=0.016) were found to be significant predictors.

Conclusions:
The results of this study suggest that the SRDT is an independent predictor of both an improvement of NIHSS score and a good functional outcome after endovascular recanalization in WUS patients.
Abstract WP285: tPA Variant tPA-A296-299 Prevents Impairment of Cerebral Autoregulation and Hippocampal Neuronal Necrosis After Stroke Through Inhibition of ET-1 Upregulation
Authors: Armstead William , Hekierski Hugh , Yarovoi Serge , Higazi Abd Al-Roof , Cines Douglas
Published: June 2021

Introduction:
The sole FDA approved treatment for acute stroke is tissue type plasminogen activator (tPA). However, its brief therapeutic window and post-treatment complications markedly constrain its use. The limited efficacy of tPA may be explained in part by our finding that it potentiates impairment of cerebral autoregulation after stroke in pigs. Upregulation of JNK MAPK after thrombotic stroke contributes to tPA mediated impairment of autoregulation. However, the role of ET-1, and its relationship to JNK, in impairment of autoregulation is unknown. Impairment of autoregulation is linked to Glasgow Coma Scale after brain injury, but unknown if autoregulation correlates with hippocampal histopathology after stroke.

Hypothesis:
Wild type (wt) tPA can bind to either the lipoprotein-related receptor (LRP), which mediates vasodilation, or NMDA-Rs. We propose that wt tPA given after stroke primarily binds to NMDA-Rs, upregulates ET-1 in a JNK dependent manner, which impairs autoregulation, causing histopathology. tPA-A
296-299
, a variant that is fibrinolytic but cannot bind to NMDA-Rs, preferentially binds LRP, which blocks ET-1 and JNK upregulation and limits impairment of autoregulation and histopathology after stroke.

Methods:
Anesthetized pigs equipped with a closed cranial window were used. Stroke was induced by photothrombosis, CBF determined by radiolabeled microspheres, CSF ET-1 and JNK determined by ELISA and histopathology determined with H + E stain.

Results:
CBF was unchanged during hypotension (mean arterial pressure decreased by 45%) in sham animals. CBF was reduced in brain tissue surrounding the infarct and was reduced further during hypotension, indicating impairment of autoregulation. CA1 and CA3 neuronal cell necrosis and autoregulation were further impaired by wt tPA which was prevented by BQ 123 and tPA-A
296-299
. Cerebral ET-1 was increased by stroke, potentiated by wt tPA, but returned to sham baseline value by tPA-A
296-299
and the JNK antagonist SP600125.

Conclusions:
JNK contributes to ET-1 release after stroke. tPA-A
296-299
prevents impairment of cerebral autoregulation and histopathology after stroke through inhibition of ET-1 upregulation.
Abstract WP289: Interaction Between Stroke and Amyloid-β Deposition in Cognitive Function ~Possible Involvement of Antagonist Effect of AT
2
Receptor Activation~
Authors: Min Li-Juan , Mogi Masaki , Tsukuda Kana , Higaki Akinori , Kukida Masanori , Yamauchi Toshifumi , Wang Xiao-Li , Bai Hui-Yu , Shan Bao-Shuai , Iwanami Jun , Horiuchi Masatsugu
Published: June 2021

Background and Aim:
Stroke is known to be causally related with Alzheimer’s disease pathology and amyloid-β (Aβ) deposition has been suggested to induce cerebral amyloid angiopathy resulting in stroke-associated cognitive decline. Angiotensin (Ang) type 1 (AT
1
) receptor activation impairs cognitive performance, whereas Ang II type 2 (AT
2
) receptor stimulation has been reported to improve cognitive impairment. We examined the interaction between stroke and Aβ deposition in cognitive function, and the possible antagonist effect of AT
2
receptor in vascular smooth muscle cells (VSMC) on this cognitive decline.

Methods:
Adult (10-12 weeks old) male wild-type (WT) mice (C57BL/6J mice) or the mice with AT
2
receptor overexpression in VSMC (SMAT2) were used. Mice were subjected to intracerebroventricular (ICV) injection of Aβ1-40 following 15 minutes global brain ischemia operation. Three weeks after Aβ1-40 ICV injection, cognitive function of spatial learning memory was evaluated by the Morris water maze test. Brain samples were obtained after behavioral testing, and the expression of inflammatory cytokines and NADPH oxidase subunits were measured by real-time quantitative RT-PCR.

Results:
ICV injection of Aβ1-40 in WT mice showed impaired cognitive function. On the other hand, WT mice with transient global brain ischemia did not decline significantly cognitive function. In contrast, WT mice with Aβ1-40 ICV injection with global brain ischemia exhibited more marked cognitive impairment compared with control mice. These results suggested that transient brain ischemia and amyloid-β deposition exerted at least additive effects on cognitive impairment. This cognitive decline was accompanied with increased expressions of inflammatory cytokines such as monocyte chemoattractant protein-1 and NADPH oxidase subunits including p22
phox
. On the other hand, SMAT
2
mice did not show cognitive impairment by global brain ischemia with/without Aβ1-40 ICV injection.

Conclusion:
Brain ischemia and amyloid-β deposition induced additive or synergistic effect on cognitive impairment. AT
2
receptor activation in VSMC could play an inhibitory role in the cognitive decline induced by brain ischemia and amyloid-β deposition.
Abstract WP290: AT2 Receptor Stimulation Reduces Stroke Size in Concert With AT2 Receptor-Interacting Protein
Authors: Iwanami Jun , Mogi Masaki , Wang Xiao-Li , Tsukuda Kana , Higaki Akinori , Kukida Masanori , Nakaoka Hirotomo , Yamauchi Toshifumi , Bai Hui-Yu , Shan Bao-Shuai , Min Li-Juan , Horiuchi Masatsugu
Published: June 2021

Objective:
We previously reported that the ischemic brain area was significantly larger in angiotensin II type 2 (AT
2
) receptor-deficient mice after middle cerebral artery (MCA) occlusion compared to wild-type mice. We have cloned ATIP (AT
2
receptor interacting protein) as a protein interacting specifically with the C-terminal tail of the AT
2
receptor, and suggest that ATIP might play key roles in diverse mechanisms of AT
2
receptor signaling. However, the effect of ATIP on brain damage has not been clarified. We investigated the possibility that ATIP could enhance the protective effects of compound 21 (C21), a selective direct non-peptidic AT
2
receptor agonist, on focal cerebral ischemia.

Method:
Ten week-old male ATIP-transgenic (ATIP-Tg) and littermate (WT) mice were subjected to permanent MCA occlusion with silicon-coated micro-filament. C21 (10 μg/kg/day) was administered 2 weeks before MCA occlusion. Twenty-four hours after MCA occlusion, ischemic area and neurological deficit was assessed. Cerebral blood flow (CBF) was measured by laser speckle flowmetry. Expression of methyl methanesulfonate sensitive 2 (MMS2) as a neuroprotective factor were measured by real-time RT-PCR. Collateral circulation was evaluated by the perfusion of India ink.

Results:
Systolic blood pressure did not differ between ATIP-Tg and WT mice with or without C21. There was no significant difference in ischemic size without C21 treatment between two strains. Treatment with C21 decreased ischemic size and improved neurological deficit in both strains. These protective effects by C21 were more marked in ATIP-Tg mice compared with WT mice. Treatment of C21 did not affect CBF in the core region of ischemic area after MCA occlusion in both strains; however, the reduction of CBF in penumbra region was markedly attenuated in ATIP-Tg mice treated with C21. MMS2 expression increased in ipsilateral hemisphere of ATIP-Tg mice compared with contralateral hemisphere. C21 treatment tended to increase collateral number in ATIP-Tg mice.

Conclusions:
These results suggested that ATIP could enhance the cerebral protective effects of AT
2
receptor stimulation at least in part due to the improvement of CBF and increase of MMS2 expression.
Abstract WP291: Diabetes Impairs Long-term Functional Recovery in an Embolic Stroke Model in Sex Independent Manner
Authors: Li Weiguo , Hafez Sherif , Valenzuela John Paul , Ward Rebecca , Dong Guangkuo , El-Shafey Sally , Fagan Susan C , Ergul Adviye
Published: June 2021

Ischemic stroke is a leading cause of death and disability. Diabetes not only increases the risk of stroke, it also worsens the outcomes, increases the risk of hemorrhagic transformation (HT) and impairs recovery after stroke. It is well established that young females are more protected and show better outcomes than males after stroke. However, the impact of diabetes on long term recovery after stroke in both sexes was not clear. Accordingly, this study tested the hypothesis that diabetes impairs long term functional recovery after ischemic stroke in a sex independent manner.

Methods:
Diabetes was induced in male and female Wistar rats using high fat diet and low dose streptozotocin (30 mg/Kg). After 8 weeks of diabetes, animals were subjected to embolic stroke. Male and female Wistar normoglycemic age matched rats were used as controls. Motor (composite score: 14 best outcome and adhesive removal-ART) and cognitive (novel object recognition, NOR) deficits were assessed at day1, 3, 7 and 14.

Results:
Female control animals had better outcomes compared to the males. Mortality was higher in diabetic animals, especially in males. The neurological deficits were greater in diabetic animals with no difference between males and females.

Conclusion:
Diabetes impaired functional and cognitive outcome and recovery after ischemic stroke in a sex independent manner.
Abstract WP30: Trends and Outcomes of Endovascular Revascularization Therapy for the ASIAN KR Registry
Authors: Hwang Yang-Ha , Kim Yong-Won , Hong Jeong-Ho , Kim Chang-Hyun , Chang Hyuk Won , Yi Sung Eun , Choi Jin Wook , Hong Ji Man , Kang Dong-Hun , Kim Yong-Sun , Sohn Sung-Il , Lee Jin Soo
Published: June 2021

Background and Purpose:
The rapid evolution of endovascular therapy (EVT) in acute ischemic stroke has benefited its performance in real clinical practice. The aim of this study is to describe the annual trends of EVT performance after the introduction of the stentriever in Korea.

Methods:
Data were retrospectively collected from the ASIAN KR (Acute Stroke due to Intracranial Atherosclerotic occlusion and Neurointervention - Korean Retrospective) registry between January 2011 and December 2015. The ASIAN KR registry is an observational multicenter registry of consecutive patients treated with EVT for acute ischemic stroke. Trends in EVT performance were described and analyzed.

Results:
A total of 649 patients were included for analysis. The target arterial occlusive lesions included 584 in the anterior circulation (including 158 ICA terminuses and 293 MCA M1s) and 65 in the posterior circulation. Overall, successful reperfusion (mTICI 2b-3, post-procedure) and favorable outcome (mRS 0-2 or equal to prestroke mRS, at 3-month) was achieved in 500 patients (77.0%) and 332 patients (51.2%), respectively. A trend for increase in successful reperfusion and favorable outcome over time was observed (73.9% in 2011 vs. 83.1% in 2015,
p
=0.040; 48.7% in 2011 vs. 58.1% in 2015,
p
=0.074). Utilization of a stentriever as a first-chosen device for EVT increased over time from 12.8% in 2011 to 46.9% in 2015 (
p
<0.001). This was accompanied by a significant trend for shorter time regarding arrival to groin puncture and groin puncture to end of EVT procedure (median 119 minutes in 2011 vs. 86 minutes in 2015,
p
<0.001; 68 minutes in 2011 vs. 54.5 minutes in 2015,
p
<0.001). After adjustment for age, onset to groin puncture time, and successful reperfusion, a trend for better clinical outcome over time following EVT remained statistically significant (odds ratio 1.13, 95% CI 1.01-1.27;
p
=0.033)

Conclusions:
A upward trend in successful reperfusion and better clinical outcome was observed along with improvement in intra-hospital workflow and utilization of up-to-date thrombectomy devices over time, which emphasizes the role of EVT experience, quality improvement of workflow, and use of newer EVT devices.
Abstract WP300: Early Palliative Care Consultation Decreases Length of Stay in Severe Stroke Patients
Authors: Schloss Evan R , Tversky Steven , Katz Jeffrey M , Wright Paul
Published: June 2021

Introduction:
Palliative care consultation (PCC) decreases patient suffering and clarifies goals of care. It also has the potential to decrease length of stay (LOS) and hospitalization costs. Recently, the American Heart Association released a statement stressing the importance of PCC in stroke patients. We sought to evaluate the usage of PCC in acute stroke patients at a comprehensive stroke center and to determine the effect of early PCC on LOS.

Methods:
We reviewed the charts of acute ischemic and hemorrhagic stroke patients (n=319) with a hospital stay of ≥ 6 days admitted over a 1-year period. Student’s t-test and Fisher’s exact test were used for continuous and categorical variables, respectively.

Results:
Overall, 54/319 (16.9%) patients had PCC. Mean age, mean National Institute of Health Stroke Scale, and median pre-hospital Modified Rankin Scale were 79, 19.9, and 3, respectively, for the PCC subgroup. In general, patients who did not receive PCC trended towards lower mean LOS (No PCC 9.46 days vs PCC 10.22 days; p=0.12). A statistically significant decrease in mean LOS was observed among patients with early PCC (≤3 days, n=28) versus late PCC (≥4 days, n=26; 8.71 days vs 11.85 days; p=0.02). In-hospital mortality (3.6% vs 11.5%), hospice deaths (64.2% vs 65.2%), and discharges to home or rehabilitation (32.1% vs 23.1%) were similar between groups (p=0.52).

Conclusions:
Early PCC in severe stroke patients decreased hospital LOS by 3 days. This may be due to prompt clarification of goals of care and hastened discharge to hospice. Advanced age, poor pre-stroke functional status, and severe post-stroke deficits and disability warrant early PCC. In addition to decreasing LOS, further study is needed to determine whether early PCC also limits futile tests, procedures, and iatrogenic complications. Ultimately, timely identification of PCC candidates may produce higher satisfaction and decreased hospital costs.
Abstract WP308: Impact of Ethnicity on Access to Sleep Apnea Screening and Testing In Stroke Survivors
Authors: Sozener Cemal B , Brown Devin L , Jiang Xiaqing , Li Chengwei , Case Erin , Garcia Nelda M , Lisabeth Lynda D
Published: June 2021

Introduction:
Sleep apnea (SA) following stroke is present in approximately 72% of patients. SA leads to increased stroke risk and is associated with poorer prognosis. Aggressive risk factor modification after stroke is widely accepted, yet evaluation for SA is not routine practice. We hypothesized that fewer Mexican-Americans (MA) are screened for and offered SA testing following stroke than non-Hispanic whites (NHW).

Methods:
Between July 2011 and May 2016, MAs and NHWs with ischemic stroke or intracerebral hemorrhage in the Brain Attack Surveillance in Corpus Christi (BASIC) project were asked during a baseline interview (a median 8 days (interquartile range=16) after presentation), if they had reported symptoms of SA to their doctor, had been asked by their doctor about SA symptoms, and if their doctor had offered formal SA testing. Logistic regression was used to test the association between ethnicity and these three outcomes unadjusted and adjusted for potential confounders such as sex, age, insurance status, and BMI.

Results:
Of the 1,086 MA and 621 NHW participants, median age was 68 and 49% were women. Two hundred nineteen (20.2%) MAs self-reported symptoms of SA compared with 114 (18.4%) NHW (p=0.36). One hundred forty-seven (13.5%) MAs were asked about symptoms of SA by their doctors compared with 76 (12.2%) NHWs (p=0.44). One hundred ninety-two (17.7%) MAs were offered a SA test compared with 112 (18.0%) NHWs (p=0.86). MA ethnicity was associated with a lower odds of reporting being offered SA testing in the fully adjusted model (odds ratio 0.751 (95% CI: 0.567, 0.995)), but was not associated with the other two outcomes.

Conclusions:
Screening for SA in post-stroke patients is poor overall, and worse for MAs. Given the important relationship between SA and stroke, educational interventions are needed to improve provider awareness surrounding SA screening in stroke survivors.
Abstract WP312: Identifying Acute Ischemic Stroke by Analyzing Icd-10 Claims Data Using Machine Learning Models
Authors: Esenwa Charles , Luna Jorge , Kummer Benjamin , Salmasian Hojjat , Vawdrey David , Kamel Hooman , Elkind Mitchell
Published: June 2021

Introduction:
Retrospective identification of patients hospitalized with new diagnosis of acute ischemic stroke is important for administrative quality assurance, post-discharge clinical management, and stroke research. The benefit of using administrative claims data is its widespread availability, but the disadvantage is in the inability to accurately and consistently identify the clinical diagnosis of interest.

Hypothesis:
We hypothesized that decision tree and logistic regression models could be applied to administrative claims data coded using International Classification of Diseases, version 10 (ICD-10) to create algorithms that could accurately identify patients with acute ischemic stroke.

Methods:
We used hospital records from our institution to develop a gold standard list of 243 patients, continuously hospitalized with a new diagnosis of stroke from 10/1/2015 to 3/31/2016. We used 1,393 neurological patients without a diagnosis of stroke as negative controls. This list was used to train and test two machine learning methods of diagnosis and procedure codes analysis, for the purpose of ischemic stroke identification: one using classification and regression tree (CART) and another using regularized logistic regression. We trained the models using 75% of the data and performed the evaluation using the remaining 25%.

Results:
The CART model had a κ=0.78, sensitivity of 96%, specificity of 90%, and a positive predictive value of 99%. The regularized logistic regression model had a κ=0.73, sensitivity of 97%, specificity of 81%, and a positive predictive value of 98%.

Conclusion:
Both the decision tree and logistic regression machine based learning models showed very high accuracy in identifying patients with a new diagnosis of ischemic stroke, using ICD-10 code claims data, when compared to our gold standard. Applying these machine learning models to identify patients with ischemic stroke has widespread applications, especially in this period where national billing data has transitioned from ICD-9 to ICD-10 codes.
Abstract WP313: Stroke Patient Characteristics Have Minimal Impact on Reliability of Teleswallow Evaluation
Authors: Yanase Lisa R , Hyers Megan , Stuchiner Tamela , Lucas Lindsay , Spinelli Kateri , Morrell Kathryn
Published: June 2021

Purpose:
To evaluate patient characteristics that may lead to inappropriate dietary texture recommendations by Teleswallow evaluation by Speech Language Pathologists (SLPs).

Background:
Following stroke, screening for dysphagia using a swallow evaluation is essential for patient safety. Liquid and solid diet recommendations are given per our standardized four-level scale, ranging from nothing by mouth (NPO) to regular for solid and thin for liquid. We have previously shown good agreement between tele- and bedside swallow evaluation by SLPs, for both liquid and solid dietary textures. In this study, we sought to determine whether patient characteristics account for slight differences in inter-rater reliability.

Methods:
Kendall’s tau-b and Wilcoxon Signed Rank test for related samples were used to look for significant differences between teleswallow and bedside swallow recommendations for patients with left and right stroke locations or varying levels of stroke severity measured by NIHSS. Evaluations for robot vs bedside swallow screens were categorized as in “agreement” or “disagreement”. Logistic regressions, with age and gender added as covariates, were then used to test the effects of NIHSS and stroke location on the odds of agreement of teleswallow and bedside swallow recommendations.

Results:
One hundred stroke patients received both evaluations with median 42.0 minutes between evaluations. The average patient age was 67.7 (±14.4) and 50% were female. Median NIHSS score was 4 (interquartile range (IQR) = 7), and 53% (n = 48) of patients had left-brain strokes and 47% (n = 42) had right-brain strokes. Our analysis showed no significant differences between recommendations for stroke location, for either liquid or solid textures. There was also no significant impact on the odds of agreement based on severity, by NIHSS score, for solid textures. However, the odds of agreement between recommendations for liquid textures were 13% less per NIHSS point (OR = 0.876, 95% CI 0.772 - 0.993,
p
= 0.04).

Conclusion:
Stroke severity had a small impact on the agreement between teleswallow and bedside recommendations for liquid, but not solid, diet textures.
Abstract WP314: Driving Stroke Care Within a Health System: The Impact of the
University Hospitals System Stroke Program Clinical Practice Guideline for the Emergency Management of Acute Stroke
Authors: Murty Pavan , Fussner Julie , Beilman Colin , Sila Cathy
Published: June 2021

Introduction:
With 18 University Hospitals at 12 locations, UH Case Medical Center is second in the University HealthSystem Consortium ranking for patient transfers at 24% of total volume. In 2009, the University Hospitals System Stroke Program developed a Clinical Practice Guideline (UHSSP-CPG) with the goal of providing the same, high quality stroke care throughout the health system that included a triage and transfer algorithm.

Methods:
From 2011-2q2016 (annualized), 5666 hospital discharges from MS-DRGs 61-66 representing medical management of cerebral infarction (CI) and intracerebral hemorrhage (ICH) were analyzed from 6 UH Legacy hospitals- UH-Case CSC, 4 PSCs and 2 Stroke Ready Facilities (SRF). Advanced expertise (AE) was developed at 2 PSCs for medical management of CI (2014) and low risk ICH (2015, 2016).

Results:
From 2011 to 2016, total stroke discharges increased across the UHSSP by 22%; total CI by 14%; and total ICH by 68%. Total IV-tPA cases increased by 174%, representing an increase in IV-tPA utilization from 6% to 15% of total CI. At UH-Case CSC, total stroke discharges increased by 15%, especially for ICH which increased by 63%. At the PSC-AE hospitals, total stroke discharges increased by 133%; IV-tPA Drip and Keep by 1300%; and total ICH by 700%. Total stroke discharges decreased by 28% at the other PSC hospitals.

Conclusions:
Implementation of the UHSSP-CPG triage and transfer algorithm resulted in an increase in total stroke volume across the health system but shifted more patients with lower risk ischemic and hemorrhagic stroke to PSC within their community. This strategy promotes enhanced access of more complex stroke patients to UH-Case CSC. As hospitals continue to coalesce into systems, robust triage and transfer algorithms will play an increasingly important role in systems stroke care.
Abstract WP318: Mortality Among Newly Certified Stroke Centers and Other Hospitals in the U.S.
Authors: Man Shumei , Schold Jesse D , Uchino Ken
Published: June 2021

Introduction:
Primary Stroke Center (PSC) certification was established to improve stroke care. The numbers of PSCs have significantly increased in the past decade. However, it remains unclear whether PSC certification has any impact on stroke mortality. We examined the short term mortality of hospitals that received initial PSC certification between 2009 and 2013 (new PSCs), compared to those received PSC certification before 2009 (existing PSCs) and those never received PSC certification (NSCs).

Method:
The inclusion criteria was Medicare beneficiaries aged ≥65 years who were hospitalized between January 1, 2009 to December 31, 2013 with a primary discharge diagnosis of ischemic stroke. The patient information were obtained from the Medicare Provider Analysis and Review (MEDPAR) file. The list and characteristics of hospitals were obtained from the American Hospital Association Annual Survey Database. This study included only those general hospitals with emergency departments. All statistical analyses were performed using SAS Version 9.4 software.

Results:
Among 1165,960 Medicare beneficiaries included in this study, 28.9% were treated at 2640 NSCs, 24.6% were treated at 634 new PSCs, and 46.6% were treated at 785 existing PSCs. Higher percentages of patients at new and existing PSCs had complicated hypertension, myocardial infarction, congestive heart failure, atrial fibrillation, prior history of cerebrovascular disease, any malignancy, metastatic cancer, peripheral artery disease and smoking (p<0.0001). New PSCs had the lowest unadjusted in-hospital all-cause mortality, followed by NSCs and existing PSCs (4.2%, 4.6% and 5% respectively). Both New and existing PSC groups had lower unadjusted 30 day compared to NSCs (12.5%, 13.2% and 13.7%). New PSCs had lower unadjusted and adjusted 30 day mortality than existing PSCs (Hazard Ratio 0.981, 95% Confidence Interval (0.968, 0.993)).

Conclusion:
The PSCs that were newly certified between 2009 and 2013 had lower unadjusted in-hospital and 30 day mortality after stroke than existing PSCs and NSCs. It is important to further understand whether this difference results from change in patient population or quality of care.
Abstract WP322: The Use of a Dysphagia-gastrostomy-palliative Care Algorithm Increases Involvement of the Palliative Care Service
Authors: San Luis Christa , Stephens-Gibson Sherry , Chen Jian , Gunturu Manasa
Published: June 2021

Dysphagia is one of the most common reasons for a gastrostomy tube (GT) placement as a means of chronic nutrition as the patient transitions to rehabilitation. Discussion regarding artificial nutrition is one of the reasons palliative care service becomes involved in the care of an ischemic stroke patient. Recent recommendations state that palliative care involvement should be promoted as part of patient- and family- centered care. To provide timely palliative care involvement, dysphagia evaluations by speech and language pathologists (SLPs), GT placement in the in-patient setting, a Dysphagia-Gastrostomy-Palliative care (DG-Pal) multidisciplinary algorithm was created.

Hypothesis:
The authors hypothesize that the use of the DG-Pal algorithm will increase palliative care involvement, shorten the time to SLP dysphagia evaluation, and the time for GT placement without increase in in-patient mortality.

Methods:
The DG-Pal algorithm was created by a Stroke Gastrostomy Task Force of the University of Mississippi Medical Center Stroke. The patients admitted with acute ischemic strokes were grouped into “Before DG-Pal (June 2015) versus After DG-Pal (January 2016)”. Primary outcome included palliative care involvement and timing. Secondary outcome include time to first SLP dysphagia evaluation, GT placement, and in-hospital mortality rate.

Results:
A total of 78 patients were included for analysis. There were 45 (58%) patients included in the “before DG-Pal” cohort. Palliative care involvement was significantly higher in the “after DG-Pal” cohort (36% vs 4.5%, p=.001). The timing of palliative care involvement and time to first SLP dysphagia evaluation were similar in both groups. GTs were placed only among the “after DG-Pal” cohort (3, [9%]). In-hospital mortality rate was comparable between “before DG-Pal” and “after DG-Pal” groups respectively (2.3% vs 6.1%).

Conclusions:
This is the first report of the use of a multi-disciplinary Dysphagia-Gastrostomy-Palliative care (DG-Pal) algorithm to improve palliative care involvement and the coordination of care for ischemic stroke patients. Further prospective studies are needed to further analyze the effect on patient and family outcomes.
Abstract WP323: Association between Demographic Characteristics and Hospital Admission in Patients Presenting to the Emergency Department for Transient Neurological Attack
Authors: Kummer Benjamin R , Parikh Neal S , Merkler Alexander E , Kamel Hooman
Published: June 2021

Introduction:
Significant demographic differences in the management of ischemic stroke and transient ischemic attack exist in the United States. Transient neurological attack (TNA) is a common neurological diagnosis that can result from cerebral ischemia, and is associated with recurrent stroke. Demographic factors may be associated with differences in admission rates for patients that present to the emergency department (ED) with a diagnosis of TNA.

Methods:
In a population-based, retrospective, administrative claims-based cohort study, we identified patients who presented to a non-federal ED in Florida from 2005 through 2013 with a complaint consistent with TNA, which was defined as a poorly-localized, non-specific neurological symptom. Our predictor variables were race (white vs. non-white) and sex. Our outcome variable was admission to the hospital. We used multiple logistic regressions to characterize the relationship between the predictor variables and our chosen outcome while adjusting for age, insurance status, income, and vascular risk factors.

Results:
We identified 1,231,046 patients presenting to the ED with TNA. Female patients in this cohort were less often white, and had fewer vascular comorbidities than men, including alcohol abuse. Non-white patients were younger, more often had Medicaid or no insurance, less often had atrial fibrillation, coronary heart disease or alcohol abuse, and more commonly had diabetes. Among all patients, 22,300 (1.8%) were admitted. After adjustment for age, insurance status, income, and vascular comorbidities, we found lower odds of hospital admission in female patients (odds ratio [OR], 0.69; 95% confidence interval [CI]; 0.67-0.70) and non-white patients (OR, 0.65; 95% CI, 0.63-0.67).

Conclusions:
Among patients presenting to the ED with TNA, female sex and race are associated with decreased odds of admission, even after adjusting for age, income, insurance status, and vascular risk factors. Further studies are warranted to reproduce these findings in other states, and to determine the public health impact of our results.