bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP27: Aspiration Success With Adapt Technique: Rate, Predictors, and Outcome
Authors: Anadani Mohammad , Alawieh Ali , Turk Aquilla S , Chaudry Mohammad I , Machaj Jan V , Turner Raymond D , Spiotta Alejandro M
Published: January 2019

Introduction:
First Aspiration Pass Technique (ADAPT) was shown to be effective, safe and cost effective. However, around third of patients treated with aspiration technique require rescue therapy.

Objective:
report the rate of aspiration success (AS), investigate the predictors of aspiration success and the effect of aspiration success on the functional and hemorrhagic outcome.

Methods:
We interrogated our prospectively collected database which included all patients who presented with large vessel occlusion between 1/2013 and 12/2017 and were treated with ADAPT technique. Baseline characteristics, procedural and outcome variables were collected. Functional outcome was assessed using modified rankin scale (mRS). Hemorrhagic transformation was classified based on ECASS radiological criteria. Logistic regression was used to determine predictors of AS and investigate the effect of AS on outcomes.

Results:
A total of 510 patients were included in analysis. 333 patients (65%) achieved successful recanalization using only aspiration technique. On multivariate analysis, pretreatment tPA and ICA occlusion were associated with AS. mRS 0-2 was achieved in higher proportion of patients in AS group (42 % vs. 31%; p<0.001) and mortality was lower in AS group (14.7% vs. 29%, p<0.001). The difference remained significant after controlling for potential confounders.

Conclusion:
AS was associated with better functional outcome and lower mortality rate. Both IV tPA and ICA occlusion were predictors of aspiration success.
Abstract TP270: When Telestroke Programs Work, Bed Size Really Doesn’t Matter
Authors: Joiner Renee , Brown Aliza T , Onteddu Sanjeeva , Nalleballe Krishna , Benton Tina , Lowery Curtis
Published: January 2019

Background:
Telestroke rural networks are comprised of micro>small>medium>large sized hospitals without specialized neurology support. Many times the micro hospitals are
<
25 beds. In an examination of spoke hospitals in the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telestroke program, we determined program efficacy correlating bed number. Efficacy was determined by the mean Door-to-ED physician (D2MD) time and door-to-needle (D2N) Alteplase time, and numbers of Alteplase administrations (#Alteplase), mock scenario sessions (#Mocks) and consults (#Consults).

Hypothesis:
All hospitals would perform equally well with the larger hospitals with slight tendencies to outperform the smaller hospital sites in the #Consults and #Alteplase.

Methods:
We retrospectively reviewed 2015-2017 spoke hospital data from AR SAVES, the largest statewide telestroke program. The #Mocks and #beds were comparatively analyzed using regression analysis for D2MD, D2N, #Consults and #Alteplase. Spoke sites were categorized by bed numbers; 0-25, 26-50, 51-100, 101-150, 151-200 and
>
200.

Results:
Data from 53 spokes encompassing 2,555 consults over three years indicated that sites
>
151 beds were significantly higher in #Alteplase (p
<
0.01) and #Consults (p
<
0.002). Although the #Mocks were not different among the smaller vs. larger hospitals (p
>
0.19), nor was the D2MD time (p=0.82). However, the hospitals
<
50 beds had significantly shorter D2N mean time (p
<
0.03). The micro (0-25 beds) vs the largest hospitals (
>
200 beds) D2N mean times, were significantly less (76.0±2.5 vs 87.5±4.0 min, p=0.01, respectively).

Conclusions:
Although the smaller hospitals receive less volume of consults and #Alteplase, with training they perform equally if not better than their larger counterparts.
Abstract TP271: Long-term Results of an EMS-driven Rapid Arterial oCclusion Evaluation (RACE) Protocol for Triage of Acute Strokes
Authors: Afreen Ehad , Castonguay Alicia C , Shawver Julie , Salahuddin Hisham , Korsnack Andrea , Dawod Giana , Zaidi Syed F , Jumaa Mouhammad A
Published: January 2019

Background and Purpose:
We previously reported on the successful implementation of a EMS-driven bypass protocol using the Rapid Arterial oCclusion Evaluation (RACE) score for triage of acute strokes. Here, we describe the long-term results of our RACE alert protocol.

Methods:
Patients with a RACE score
>
5, who are last seen normal within 12 hours, wakeup with stroke symptoms, or have unknown time of symptoms onset were directly transferred as RACE alerts (RA) to our two stroke centers (one primary with interventional capabilities and one comprehensive) with interventional capacity in Lucas County, Ohio. Data including baseline demographics, RACE score, diagnosis, treatments and procedures, and clinical and angiographic outcomes were captured in a prospective database.

Results:
From July 2015 to July 2018, 511 RAs were triaged. Median age of RA patients was 73 (IQR 63-82), 55.8% were female, and median RACE score was 7 (IQR 5-8). Median time from 911 dispatch to ER was 31 minutes (IQR 22-38) and onset to arrival was 85 minutes (IQR 47-307). Of the 511 RAs, 52.3% were diagnosed with an ischemic stroke, 13.5% intracerebral hemorrhage, 6.5% transient ischemic attack, 12.9% seizure, and 7.8% encephalopathy. The rate of IV-tPA use was 24.5% and median door to needle time was 33 min (IQR 24-48). The rate of mechanical thrombectomy (MT) was 24.3%, with median door to puncture and door to revascularization times of 64 (IQR 48.5-78.5) and 91 minutes (IQR 79.3-114.8), respectively. The majority of occlusions were MCA (73.2%). Successful revascularization (TICI≥2b) was achieved in 84.7%. Ninety-day favorable outcome (mRS 0-2) and mortality was 47.2% and 25.4% in patients who underwent MT.

Conclusions:
Our results show the long-term feasibility and efficiency of an EMS-driven early stroke triage protocol using the RACE score.
Abstract TP272: Air versus Ground Transport for Interhospital Transfer Prior to Endovascular Stroke Treatment
Authors: Froehler Michael T , Fusco Matthew R , Chitale Rohan , Liebeskind David S , Zaidat Osama O , Jahan Reza , Aziz-Sultan Mohammad A , Klucznik Richard P , Saver Jeffrey L , Hellinger Frank R , Yavagal Dileep R , Yao Tom L , Haussen Diogo C , Mueller-Kronast Nils H
Published: January 2019

Introduction:
Interhospital transfer for endovascular treatment of large vessel occlusion (LVO) stroke results in significant delays and worse outcomes. We hypothesized that interhospital patient transfer using air transport would result in shorter transit times compared to ground ambulance.

Methods:
Subjects from the STRATIS registry that underwent interhospital transfer for endovascular treatment were separated by air transport vs. ground ambulance transport and analyzed by transfer distance. The primary endpoint was transfer-time, calculated as the time from imaging at the initial hospital to arrival at the treating hospital. Also assessed was travel-time, calculated as time of departure from the initial hospital to arrival at the treating hospital.

Results:
There were 232 subjects from 41 sites. Mean transfer-time for all air subjects (n=118) was 147.1 min, and for all ground subjects (n=114) was 130.0 min (p=0.019). Mean travel-time was 45.0 min for air transport and 40.2 min for ground transport (p=0.239); though the average travel distance was longer for air (65.5 miles) vs. ground (27.6 miles; p<0.001). When analyzed by distance, there was no difference between air and ground transfer-time except transfers less than 20 miles, which favored ground transportation (154.4 min vs. 119.5 min; p=0.015; see table). The lack of advantage for air transport may be accounted for by the time between imaging and departure from the initial hospital (mean 89.4 vs. 101.6 min; p=0.075), reflecting additional logistics and/or reduced availability of air transport.

Conclusions:
In this large, real-world study, interhospital transfer via air transport did not result in faster transfer times compared to ground ambulance. In fact, there was an advantage to ground transportation for distances of less than 20 miles. These results suggest that ground ambulance should routinely be used for interhospital transfer of stroke patients for travel less than 20 miles.
Abstract TP275: Impact of a Direct to Computed Tomography Protocol on Tissue Plasminogen Activator Door-to-Needle Time in Acute Ischemic Stroke
Authors: Kim Sunghyun , Sanchez Sarah , Brunetti Luigi , Wei Juanqin , Smith Laura , Sun Nellie , Thorn Neil , Wieczorek Mary , Milano Marc , Dhanaliwala Fatema , Nguyen May T
Published: January 2019

Background:
Current American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend brain imaging with computed tomography (CT) within 20 minutes of emergency department (ED) arrival and treatment with tissue plasminogen activator (tPA) in eligible patients with acute ischemic stroke within 60 minutes of arrival. In January 2017, we implemented a direct-to-CT protocol which consisted of direct patient transportation by emergency medical services (EMS) personnel from ambulance to CT scanner. Patients were then transported to the ED for evaluation and treatment as appropriate via telemedicine and ED staff.

Objective:
To determine if a direct-to-CT protocol would improve the percentage of patients with door-to-needle (DTN) time ≤ 60 minutes.

Methods:
This was a single center retrospective cohort study of patients who received tPA for acute ischemic stroke in the ED between October 2016 and May 2018. Patients were grouped based on the use of a direct-to-CT protocol.

Results:
Of 64 included patients, 23 patients (36%) were transported via the direct-to-CT protocol and 41 patients (64%) arrived via private vehicle or EMS without use of the protocol. Goal DTN time ≤ 60 minutes was achieved in 78% of patients when the protocol was used compared to 44% when it was not (p=0.0078). The mean DTN time was significantly shorter when the protocol was used (52.83±13.8 vs 70.98±32.6, p=0.003). Following adjustments for time of day and the need for blood pressure management with intravenous anti-hypertensives, a greater percentage of patients in the direct-to-CT protocol group achieved DTN ≤ 60 minutes (OR=8.09;95%CI=1.99-32.91, p=0.003).

Conclusions:
An EMS activated direct-to-CT protocol improved the percentage of patients achieving DTN ≤ 60 minutes and significantly reduced mean DTN time.
Abstract TP276: Comparative Performance of for Paramedic Stroke Severity Assessment Scales of Stroke Severity in Assessing Stroke Severity and Predicting Long-Term Functional Outcome
Authors: Shkirkova Kristina , Chueng Shauna , McMullan Jason , Saver Jeffrey L , Liebeskind David , Conwit Robin , Eckstein Marc , Pratt Frank , Hamilton Scott , Starkman Sidney , Sanossian Nerses
Published: January 2019

Background:
Brief prehospital stroke severity scales have several uses, but their comparative performance has generally been evaluated only in screening for patients likely harboring large vessel occlusion. An additional application is in providing a baseline deficit assessment to enable severity adjustment in clinical trials of prehospital stroke treatments.

Objective:
To assess the convergent, divergent, and predictive validity of LAMS, C-STAT, FAST-ED, and RACE for stroke severity and 90-day outcome (freedom from disability - mRS 0-1).

Methods:
We analyzed data prospectively gathered in the FAST-MAG trial (Field Administration of Stroke Therapy-Magnesium phase 3) among patients with acute cerebrovascular disease (cerebral ischemia and intracranial hemorrhage) within 2 hours of onset, transported by 315 ambulances to 60 receiving hospitals.

Results:
Among 1632 acute cerebrovascular disease patients, (age was 69±13 years, female 42.6%, and final diagnoses were cerebral ischemia in 73.3% and intracranial hemorrhage in 22.8%. Time from onset to hospital arrival assessment was 145 minutes (IQR 119-180). Correlation with a concurrently performed, “gold standard” full hospital arrival NIHSS was: LAMS 0.89, FAST-ED 0.95, RACED 0.89, and C-STAT 0.89. All scales were divergent with a concurrently performed GCS. Predictive accuracy (C statistics) for excellent 3-month outcome among acute cerebrovascular disease patients was: hospital arrival LAMS 0.78 (95%CI 0.76-0.81); FAST-ED 0.80 (95%CI 0.78-0.82); RACE 0.79 (95%CI 0.77-0.82); C-STATS 0.77 (95%CI 0.75-0.80), among cerebral ischemia patients was: LAMS 0.75 (95%CI 0.72-0.78); FAST-ED 0.77 (95%CI 0.74-0.79); RACE 0.77 (0.74-0.79); C-STATS 0/74 (0.71-0.77), and among intracranial hemorrhage patients was: LAMS 0.81 (95%CI 0.73-0.89); FAST-ED 0.86 (95%CI 0.81-0.92); RACE 0.82 (95%CI 0.75-0.91); C-STATS 0.83 (95%CI 0.78-0.90).

Conclusions:
The four brief stroke severity measures, LAMS, C-STAT, FAST-ED, and RACE, showed comparable, moderate to excellent, convergent, divergent, and predictive validity in assessing stroke severity and forecasting long-term outcome, further supporting their appropriateness for use by prehospital personnel.
Abstract TP277: A Hospital’s Perspective: Economic Evaluation of Hospitalization vs Rapid Outpatient Evaluation for TIA and Minor Strokes
Authors: Shapiro Steven D , Luna Jorge , Mehendale Rachel , Navi Babak B , Kummer Benjamin , Rostanski Sara , Rosen Claudia , Vawdrey David , Chang Bernard P , Miller Eliza , Elkind Mitchell S , Willey Joshua
Published: January 2019

Introduction:
Patients presenting to emergency departments (ED) with TIA and minor strokes (TIAMS) are often admitted for expedited evaluation, though outpatient care models have been proposed. We piloted a rapid outpatient evaluation protocol for patients presenting with TIAMS within 24 hours of ED discharge. We hypothesized that this approach would reduce hospital costs and length of stay (LOS).

Methods:
This analysis looked at patients presenting to our institution’s ED with TIAMS (NIHSS
<
5) in calendar year 2017. We compared hospitalization LOS, costs and expected revenues between admitted patients and those referred for rapid outpatient evaluation. Patients eligible for outpatient evaluation were without disabling deficits, recurrent symptoms, new-onset atrial fibrillation, prior carotid imaging with >50% stenosis, and not receiving thrombolysis. Disabling deficits were defined as new gait impairments, significant motor weakness, hemianopia, dysphagia or severe aphasia. Cost data was obtained from our finance department and expected revenue was estimated using Medicare reimbursement data, assuming Medicare-Fee for Service as the primary payer for all patients.

Results:
We identified 92 patients referred to our rapid outpatient clinic and 90 admitted patients (mean NIHSS 0.8 vs 1.8 respectively). In comparison to patients who were admitted, patients referred to outpatient evaluation had shorter hospital stays, lower total hospitalization costs, and decreased net-losses after accounting for expected revenue (Table). Only one patient in the outpatient cohort was readmitted for further management. Overall, the one-year pilot cohort averted approximately 138 bed-days and $950,000 in hospitalization costs.

Conclusions:
For patients who presented to our ED with TIAMS without disabling deficits, rapid outpatient evaluation reduced hospital LOS and total costs. Further research is needed to incorporate costs to payers and patients.
Abstract TP28: Recurrent Thrombectomy in Patients With Prior Mechanical Endovascular Revascularization: A Single Center Experience
Authors: Mohamed Ghada A , Arshad Khadeja , Affan Muhammad , Alsrouji Owais , Miller Daniel , Kole Max , Horia Marin
Published: January 2019

Background:
Mechanical endovascular reperfusion therapy (MER) has become standard of care for treatment of large vessel occlusion (LVO) acute ischemic strokes (AIS) within 24 hrs of last known well. Nearly 25% of all stroke patients have a recurrent event in 5 years. Intravenous alteplase use in AIS patients with recent ischemic stroke history is avoided due to the risk of intracranial hemorrhage, but this may not be the case for MER. Bouslama et al found no statistically significant differences in reperfusion rates, hemorrhagic complications, clinical outcomes, and mortality between patients who had repeated thrombectomy (RT) and those who had a single thrombectomy.

Methods:
This is a retrospective case series study of endovascular database for patients who underwent RT in our institution from March 2016 till March 2018. Demographic, clinical, procedural date, imaging and clinical outcomes were evaluated.

Results:
Total 145 patients with AIS received MER, 8 (5.5%) RT occurred in 5 patients. Mean age was 67 ± 21 years. Four of the five patients were females. All patients achieved successful reperfusion (TICI 2b-3). Three patients underwent one RT, one had two RT, and one had three RT. The average time between consecutive MER (8 total periods) was 106 days. The time between the first to last MER for each patient ranged from 3 days to 2 years. All patients were optimized on their medical therapy after the first stroke. Four of the five patients (80%) had RT in the same vascular territory. One patient had post procedure focal high grade stenosis after the 3
rd
intervention in the same artery that was treated with elective angioplasty. One RT was complicated with fatal intracranial hemorrhage due to late presentation despite presence of large area of penumbra. Average MRS was 2.4.

Conclusion:
In patients presented with recurrent LVO, RT appears to be effective and relatively safe. Based on the available literature, prior MER should not discourage aggressive treatment that might lead to a good clinical outcome. It is unclear if prior MER therapy causes endothelial injury with risk for in situ de-novo stenosis or thrombus formation. Reperfusion injury risk in a recently infarcted territory should be weighted carefully when considering as hemorrhagic complications remain possible.
Abstract TP280: Triage and Outpatient Evaluation of Emergency Department Patients With TIA and Minor Stroke: Rapid Access Vascular Evaluation-Neurology (RAVEN)
Authors: Chang Bernard P , Willey Joshua , Miller Eliza , Mehendale Rachel , Rostanski Sara , Shapiro Steven D , Kummer Benjamin , Elkind Mitchell S
Published: January 2019

Introduction:
The timely evaluation of TIA and minor stroke (TIAMS) is important, but whether TIAMS patients with no debilitating deficits should be admitted or not remains unsettled. We piloted a clinical protocol to assess the feasibility and safety of discharging selected TIAMS patients without disabling deficits from the Emergency Department (ED) to a rapid outpatient stroke clinic: Rapid Access Vascular Evaluation-Neurology (RAVEN).

Methods:
RAVEN was created as a specialized outpatient neurology clinic for TIAMS patients discharged within 24 hours from the ED at an urban quaternary academic medical center. Patients were first screened in the ED by a neurologist and selected using a decision tool identifying presumed low-risk TIAMS seen in the ED. Criteria included medical (e.g. National Institute of Health Stroke Scale of 5 or less, no disabling deficit, no fluctuating or recurrent symptoms over past month, no thrombolytic agent given, negative CT for hemorrhagic stroke, no new onset atrial fibrillation, blood pressure not over 180/110), as well as social criteria (e.g. patient ability to follow-up within 24 hours). Doppler ultrasound to exclude intracranial and extracranial stenosis, along with neurology re-evaluation was performed as part of RAVEN follow-up. Sample population was evaluated for rates of noncompliance with post-ED follow-up and need for hospitalization from clinic. Final diagnosis was also tabulated.

Results:
Between December 2016 and June 2018, 162 TIAMS patients seen in the ED were recommended for RAVEN utilizing the decision tool. Of these patients, 153 (94.4%) were evaluated within 24 hours of ED discharge. Two patients (1.3%) who received outpatient evaluation required hospitalization; 101 (66%) of these patients had a final diagnosis of TIAMS. Other common diagnoses included peripheral neuropathy (15%), migraine (12.5%) and seizure/recrudescence (4%).

Conclusions:
Our pilot data suggests that for a subset of TIAMS patients, rapid outpatient evaluation may be a feasible and safe strategy for TIAMS management. Future work exploring such strategies may improve TIAMS outcomes, reduce ED and inpatient crowding, and offer reductions in healthcare costs associated with TIAMS care.
Abstract TP282: Prehospital Acute Stroke Treatment by Critical Care Physicians in a Mobile Stroke Unit
Authors: Larsen Karianne , Tveit Lars H , Jæger Henriette S , Hov Maren R , Røislien Jo , Solyga Volker , Lund Christian G , Bache Kristi C
Published: January 2019

Background:
Mobile Stroke Units (MSU) diagnose and treat stroke prehospitally to reduce time from symptom onset-to-treatment (OTT). Several MSU-models exist world wide, but the best framework for MSUs are still unknown. Many models depend on in-hospital personnel working in the prehospital field. The MSU in Treat-NASPP (Norwegian Acute Stroke Prehospital Project) mimics the Norwegian Helicopter Emergency Medical Services and adds diagnostics and treatment of acute stroke to the existing prehospital emergency system.

Objective:
To investigate if the Treat-NASPP MSU-model is timesaving and safe.

Methods:
Treat-NASPP started 15th of May 2017 and is an ongoing, prospective, controlled intervention study. The inclusion criteria are: age over 18 years, not pregnant and clinical stroke symptoms with onset within the last 4 hours. The MSU is manned with an anesthesiologist trained in prehospital critical care, a nurse and a paramedic, and it is active 8 a.m. to 8 p.m. on weekdays 2 weeks per month. The control group is dispatch with ordinary ambulance and in-hospital treatment. The emergency medical communication center dispatches the MSU and/or ordinary ambulance whenever acute stroke is suspected.

Results:
By 1st of July 2018, 74 patients are included in the study. In the intervention group (N=49) 23 (46%) received thrombolysis, and in the control group (N=25), 10 (40%) received thrombolysis. Median (quartiles) OTT time was 98 minutes (72-184) in the MSU-group and 120,5 (107-169) in the control group, p=0,211. Median (quartiles) emergency call-to-treatment time was 29,5 minutes shorter in the MSU group compared with the control group (62 (52-71) vs 91,5 (75-97), p=0.006). Median (quartiles) mRS day 30 was 0 (0-1) in the MSU group and 0,5 (0-1,75) in the control group. No serious adverse events or symptomatic intracranial hemorrhages have occurred.

Conclusion:
The preliminary results indicate that adding diagnostics and treatment of acute stroke to the work-list of prehospital critical care physicians in an MSU-system, is timesaving and safe.
Abstract TP284: Mobile Stroke Unit Site Experience in Diagnosis and Management of Extraparenchymal Intracranial Hemorrhage in the Prehospital Setting
Authors: Nour May , Bahr Hosseini Mersedeh , Brown Kevin , Lynn Edward , Shiraishi Rinka , Harrell Kenny , Parker Stephanie , Bowry Ritvij , Shimbo Daisuke , Hussain Muhammad Shazam , Uchino Ken , Grotta James , Saver Jeffrey L
Published: January 2019

Background:
Mobile stroke units (MSUs) permit advanced cerebrovascular diagnosis, triage, and treatment to be delivered in the field. While the range of acute cerebral ischemia and intraparenchymal hemorrhage patients encountered by MSUs has been described, the frequency, determinants, and outcomes of patients presenting with extraparenchymal intracranial hemorrhages (subdurals/subarachnoid/epidural) has not been well delineated.

Methods:
We analyzed consecutive transports among MSU programs in 3 cites, Los Angeles, Houston and Cleveland from program inception through August 2018 in the two former and through 2015 in the latter. Frequency and demographic, presenting, and treatment features of patients with subdural hematoma (SDH) and subarachnoid hemorrhage (SAH) were quantified.

Results:
Among 850 overall transports, extraparenchymal intracranial hemorrhages accounted for 18 (2.1%), and included 11 (1.3%) SDH and 7 (0.8%) SAH. Among the SDH patients, age was mean 70/median 77 (range 28 to 85). Special features of SDH cases included: acute on chronic blood on CT in 36%, seizures in 9%, and isolated head trauma in 9%. Among SAH patients, mean age was 57 (range 41-75). Special features of SDH/SAH cases included accompanying intraparenchymal hemorrhage in 17%. Of the 18 combined SDH/SAH patients (67% women), 4 (22%) required field intubation, 1 (5%) was actively treated in the field with KCentra to reverse anticoagulation, and 5 (28%) were treated in the field with antihypertensives. (See Figure for exemplar cases.)

Conclusions:
Extraparenchymal intracranial hemorrhages account for about 1 in 50 cases managed in Mobile Stroke Units. MSU response permits immediate definitive diagnosis by CT imaging, earlier start of indicated medical therapies, and direct routing to neurosurgically-capable stroke centers.
Abstract TP285: Ongoing Clinical Trial: Treatment With Exenatide in Acute Ischaemic Stroke (TEXAIS) Trial: Prospective, Randomised, Open Label, Blinded End-point Study of Exenatide vs. Standard Care in Post Stroke Hyperglycaemia
Authors: Bladin Christopher , Cheung Wah , Dewey Helen , Churilov Leonid , Middleton Sandy , Thijs Vincent , Levi Chris , Lindley Richard , Donnan Geoff , Parsons Mark , Muller Claire
Published: January 2019

Background and Aims:
Post-stroke hyperglycaemia (PSH) occurs in up to 50% of patients presenting with acute ischaemic stroke (AIS). It reduces the efficacy of thrombolysis, increases infarct size, and worsens clinical outcomes. Insulin-based therapies have generally not been beneficial in treating PSH as they are difficult to implement, may cause hypoglycaemia, possibly increase mortality and worse clinical outcomes. Exenatide may be a safer, simple, and more effective alternative to insulin in AIS.

Methods:
TEXAIS is a 3-year, Phase 2, multi-centre, prospective, randomised, open label, blinded end-point (PROBE) trial comparing Exenatide to Standard of Care. It aims to recruit 528 patients with a primary end point of major neurological improvement1 at 7 days defined as a ≥8-point improvement in NIHSS score, or NIHSS 0-1. Secondary outcomes of hyper- and hypoglycaemia at 5 days and NIHSS and mRS at 90 days will be measured. The treatment arm will receive Exenatide 5μg subcutaneously twice daily. The control arm will receive standard stroke unit care. Continuous glucose monitors will track the dynamic variability of glucose.

Results:
Recruitment in TEXAIS is continuing with over 40 patients enrolled to date.

Conclusion:
TEXAIS aims to show that Exenatide is safe and effective in the treatment of PSH. It has been designed to be highly generalisable with an ability to enroll a large percentage of patients with AIS, regardless of admission blood glucose level, diabetes status, or stroke severity, with very low risk of hypoglycaemia.
Abstract TP288: Emergency Department Nursing Stroke Champions Improve Door to Needle Times at a Comprehensive Stroke Center
Authors: Griffith Tawnae C , Gupta Atul , Gaffney Denise C , McCartney David L , Mkrtumyan Alvina , Punsalang Lorina Y , Le Duy , Ajani Zahra A , Sangha Navdeep S
Published: January 2019

Introduction:
Intravenous tissue plasminogen activator (IV tPA), for acute ischemic stroke, has a more robust effect if given early. Improving Door-to-Needle (DTN) times in order to allow quicker administration of IV tPA continues to be the primary aim of TARGET:STROKE. The Stroke Champion (SC) Program, an American Heart Association’s Get with the Guidelines recommendation, was implemented in our emergency department (ED) in 2018.

Purpose:
The purpose of this study was assess if an ED Nurse SC would help to improve DTN, with a specific goal to increase the percentage of patient’s receiving IV tPA ≤30 minutes.

Methods:
The SC program was initiated in our ED in January 2018. The ED Nurse SC carries the following responsibilities: respond to all stroke alerts, weekly audit of all stroke alert charts, peer to peer follow up for any fallouts to determine if there was a system error or if there was an educational opportunity, weekly update of ED staff virtual communication board, weekly meeting with ED director for any challenges or expected changes, development of a relevant stroke education topic to be delivered at the biweekly ED nursing huddle, participate at the weekly code stroke huddle to collaborate with the stroke team, and attend relevant stroke conferences or stroke-related educational opportunities. A weekly “Stroke Shout Out” was also initiated by the ED Nurse SC to recognize a high performing member of the ED team. Data was compared 6 months pre and post-intervention, and analyzed using a Wilcoxon Rank Sum Test.

Results:
More patients received IV tPA after the initiation of the ED Nursing SC program than before (38 vs. 23 p=0.03). The median DTN was 36 (IQR 23-49) mins after implementation vs. 47 (IQR 40-56) mins before implementation (p=0.004). A higher percentage of patients received IV tPA less than 30 minutes post intervention vs. pre-intervention (42.1% vs. 17.4% , p <0.001)

Conclusion:
Implementation of an ED Nurse SC can increase the number of patients who receive IV tPA, improve DTN, and increase the percentage of patients who receive IV tPA less than 30 minutes from door time.
Abstract TP291: Melbourne Mobile Stroke Unit Increases Stroke Treatment Rates and Treatment Opportunities
Authors: Coote Skye , Zhao Henry , Pesavento Lauren , Langenberg Francesca , Desmond Patricia , Easton Damien , Bent Lindsay , Foster Shane , Stephenson Michael , Smith Karen , Bernard Stephen , Bladin Christopher , Cadilhac Dominique , Yan Bernard , Campbell Bruce , Parsons Mark , Donnan Geoffrey , Davis Stephen
Published: January 2019

Background:
The Melbourne Mobile Stroke Unit (MSU) is the first stroke ambulance in Australia. The MSU aims to provide rapid access to time critical treatments to acute stroke patients in the pre-hospital setting, thereby increasing the number of patients eligible for treatment. This is achieved by providing immediate access to expert stroke and ambulance personnel and the use of a mobile CT scanner.

Methods:
Data are prospectively collected on all MSU dispatches and compared to our local hospital database and Australian national standards.

Results:
The Melbourne MSU launched November 20
th
2017. It has been dispatched to 970 cases, of which 400 patients (41%) were attended by the MSU. Forty-two patients were thrombolysed (28% of all ischemic stroke versus the Australian average of 13% in-hospital thrombolysis), with a median scene-needle time of 40 mins (23-80mins). The median Australian door-needle time is 72 mins, with only 30% of patients treated within the internationally recommended 60 mins. Of the MSU thrombolysed patients, 12% were treated 3.5-4.5 hours from symptom onset; given ambulance transport and standard door-to-needle times, these patients would have been excluded from hospital-based lysis due to time. Additionally, the number of “golden hour” (onset-needle <60mins) thrombolysis patients has increased from 2% within our hospital to 12% on the MSU. Three patients had their anticoagulation reversed on the MSU with idarucizumab prior to thrombolysis and 1 patient received prothrombinex to manage a warfarin-related ICH. Nicardipine, labetalol and hydralazine are routinely used to manage BP. The MSU also provides a unique platform for hyperacute research trials, enrolling 10 patients into both ischemic and hemorrhagic stroke trials (utilising tenecteplase and tranexamic acid respectively).

Conclusion:
The Melbourne MSU more than doubles the rate of thrombolysis compared to in-hospital treatment and provides a comprehensive range of other novel treatments and opportunities. Consequently, the MSU allows more patients to be treated than the standard ambulance-hospital paradigm.
Abstract TP293: Door to Needle Time Over Telestroke for Primary Stroke Center Spokes versus Non Primary Stroke Center Spokes
Authors: Al kasab Sami , Almallouhi Eyad , Harvey Jillian , Girotra Tarun , Debenham Ellen , Turner Nancy , Holmstedt Christine
Published: January 2019

Background:
Faster door to needle (DTN) times has been shown to lead to better functional outcome in patients with acute ischemic stroke. The implementation of telestroke networks has improved access to intravenous alteplase (tPA). In this study, we aim to compare DTN time between of tPA administered through telestroke in primary stroke center (PSC) spokes versus non-PSC spokes.

Methods:
A retrospective review of prospectively collected data on patients who received tPA through the Medical University of South Carolina telestroke program between July 2016 and March 2018. Collected data included baseline characteristics, baseline NIH stroke scale, door to CT times, door to telestroke consult time, symptom-onset to needle time, time between tPA decision and tPA administration, door to needle time, and 90-day modified Rankin scale (mRS). Wilcoxon Rank-sum (Mann-Whitney) test was used to compare median times between different groups.

Results:
During the study period, 399 patients received tPA through our telestroke network (314 received tPA at PSC spokes, and 85 received tPA at non-PSC spokes). PSC patients had more females (61.2%) compared to non-PSC patients (48.2%) (P=0.032). Other baseline characteristics including age and race were similar between both groups. Median NIHSS was 6 for both groups (IQR 4-9) (P=0.59). Mean times for all procedure measures were longer in non-PSC spokes; Door to CT: 8 min Vs. 5 min (P=0.029), Door to telestroke consult: 24 min Vs. 20.5 min (P=0.017), Symptom-onset to needle: 150 min Vs. 122 min (P=0.001), tPA decision to tPA administration: 20 min Vs. 10 min (<0.001), and Door to needle: 65 min Vs. 54 min (P<0.001). There was a trend towards having good functional outcome (90-day mRS
2
) in the PSC group (79.1% and 75.7% of patients in PSC and non-PSC respectively, P=0.054)

Conclusion:
In our study, PSC spokes had better performance in the procedural measures for tPA administration than non-PSC spokes. Further research is needed to study the trend of these measures over time and to study the effect on the long-term functional outcome.
Abstract TP296: Predicting Cincinnati Prehospital Stroke Scale Components in Emergency Medical Services Patient Care Reports Using Natural Language Processing and Machine Learning
Authors: Garg Ravi , Richards Christopher T , Naidech Andrew , Prabhakaran Shyam
Published: January 2019

Introduction:
Prehospital stroke data is often not included in hospital records and quality improvement registries. However, manual data abstraction from free-text emergency medical services (EMS) patient care records is time-intensive and often incomplete. We sought to test the accuracy of natural language processing (NLP) and machine learning (ML) analysis in identifying the Cincinnati Prehospital Stroke Scale (CPSS) components - arm drift, facial droop, and slurred speech - in EMS free text patient care report narratives.

Methods:
We performed a retrospective analysis of de-identified records of EMS-suspected stroke patients in Chicago between January 2013 and December 2016. Using Gensim and Spacy, Python packages for NLP, we pre-processed and transformed the free text by extracting “bag of words,” “term frequency inverse document frequency,” “principal component,” and “mean embedding vectors” features and then trained ML models to predict whether each CPSS component documented by paramedics using a drop-down list was described in the free text. Several ML algorithms were tested (Logistic Regression, Random Forests, XGBoost, and Stacking) to calculate the area under the curve and accuracy for each model. To avoid overfitting and to test the generalizability of the results, we performed 10-fold cross-validation by cyclically dividing the dataset, training on 9 parts and testing on 1.

Results:
6,204 data points were obtained for arm drift (3,195 negatives and 3,009 positives), 7,487 data points for facial droop (3,851 negatives and 3,636 positives), and 6,874 data points for slurred speech (2,498 negatives and 4,376 positives). Stacking using Random Forests provided the best results for each CPSS component (Table).

Conclusion:
NLP and ML performed very well in predicting documented CPSS scores from free text in EMS patient care records. Future studies may investigate the applications of NLP and ML in assisting data abstraction from EMS patient care records.
Abstract TP297: Predictors of Acute Ischemic Stroke in Patients Presenting to the Emergency Department With Dizziness, Imbalance, and Vertigo
Authors: Kim Yongwoo , Faysel Mohammad , Balucani Clotilde , Yu Daohai , Gilles Nadege , Levine Steven R
Published: January 2019

Objectives:
To identify predictors of acute ischemic stroke (AIS) among patients presenting to the Emergency Department (ED) with dizziness, imbalance, or vertigo (DIV) based on demographic and clinical characteristics.

Methods:
We identified patients admitted to the hospital after presenting to the ED with DIV from the Statewide Planning and Research Cooperative System database of New York from 2010 through 2014. ICD-9-CM codes were used to identify patient's clinical characteristics. Demographic and clinical characteristics were systematically collected. Multivariable logistic regression was used to determine predictors of a discharge diagnosis of AIS.

Results:
Among 77,993 patients with DIV, 3,857 (4.9%) had a discharge diagnosis of AIS. Admission presentation of imbalance (Odd ratio [OR] 1.64 95% confidence interval [CI] 1.51-1.77 p<0.001), African-American race (OR 1.15, 95% CI 1.05-1.25, p=0.002), history of hypertension (OR 1.60, 95% CI 1.49-1.72, p<0.001), diabetes mellitus (OR 1.39, 95% CI 1.29-1.49, p<0.001), hypercholesterolemia (OR 1.52, 95% CI 1.42-1.62, p<0.001), tobacco use (OR 1.70, 95% CI 1.53-1.88, p<0.001), atrial fibrillation (OR 1.41, 95% CI 1.28-1.56, p<0.001), and prior AIS due to extracranial artery atherosclerosis (OR 4.47, 95% CI 4.00-5.01, p<0.001) were each positively associated with an AIS diagnosis independently. Factors negatively associated with an AIS discharge diagnosis included: admission presentation of vertigo (OR 0.56, 95% CI 0.41-0.75, p<0.001), female sex (OR 0.64, 95% CI 0.60-0.69, p<0.001), age>81 (OR 0.86, 95% CI 0.77-0.96, p=0.01), history of anemia (OR 0.65, 95% CI 0.58-0.73, p<0.001), coronary artery disease (OR 0.84, 95% CI 0.78-0.91, p<0.001), asthma (OR 0.68, 95% CI 0.59-0.76, p<0.001), depressive disorders (OR 0.74, 95% CI 0.64-0.84, p<0.001), and anxiety disorders (OR 0.70, 95% CI 0.59-0.82, p<0.001).

Conclusions:
Multiple potential positive and negative predictive AIS risk factors were identified. Combining with currently available centrally-caused dizziness prediction tools, these newly identified factors could provide more accurate AIS risk stratifying method for DIV patients.
Abstract TP298: Early and Extended Time Window Prehospital Large Vessel Occlusion Scale Application: A Retrospective Analysis
Authors: Yallapragada Anil , Prier Jillian , Redd Kolby T , Kulkarni Ronit , LaValley Elizabeth , Shaw Allison , Saver Jeffrey L , Sen Souvik
Published: January 2019

Introduction:
Multiple trials have validated thrombectomy as a viable option in acute stroke patients with Anterior Large Vessel Occlusion (LVO). As a consequence, there has been a dire need for proper routing of patients. Currently, there are established prehospital scales but limited evidence for late window LVO screening.

Methods:
We assessed 748 patients, from June 2016 to June 2018, who presented within a 24 hour last known well time (LKWT) and were assessed with RAPID neuroimaging and CT angiography. An analysis was completed of patients with LVOs versus those without a LVO. Patient’s medical records were reviewed to obtain their baseline presenting NIHSS, which was used to derive 14 corresponding LVO stroke scale values. Patients excluded had absent NIHSS values and unknown LKWT. LVO stroke scales excluded evaluated history of seizures, seizure at onset, grip strength, or age > 45 as criteria.

Results:
A total of 748 consecutive patients (67 years, 51% male, 49% African American) were analyzed with 110 confirmed anterior LVO, 476 patients in the 0-6-hour (hr) window, and 272 in the 6-24-hr window. In the 0-6-hr window, the top three scales in sensitivity were ranked in order of C-STAT (0.83) > MaPSS (0.81) > VAN (0.80). In the 6-24-hr window, the top three scales that ranked equally in sensitivity were MaPSS (0.75), VAN (0.75), and C-STAT (0.75). In the 0-6-hr window, the top three scales in specificity were ranked in order of 3-ISS (0.88) > MiPSS (0.76) > FPSS (0.72) = sNIHSS-8 (0.72). In the 6-24-hr window, the top three scales in specificity were ranked in order of 3-ISS (0.90) > MiPSS (0.84) > FPSS (0.83). (See Table 1).

Conclusion:
To correctly identify as many patients as possible in the pre-hospital setting with the available scales, the data suggests that C-STAT, VAN, and MaPSS are effective within the early and late windows. To reduce routing of incorrect prehospital LVO identification, the data suggests that 3-ISS, MiPSS, and FPSS are effective in the early and late windows
Abstract TP300: Is Stroke Code Activation for Stroke Mimics Decreasing With Stroke Center Certification
Authors: Duda Julian , Ali Syed F , Meyer Brett , Meyer Dawn
Published: January 2019

Introduction:
There has been extensive education required as part of the Joint Commission (TJC) stroke center certification to rapidly identify acute stroke patients. One study found from 1998 to 2001, 25.3% of stroke codes (SC) were deemed stroke mimics (SM). The purpose of this study was to assess if SC activation in true stroke (TS) patients has improved as part of TJC certification.

Methods:
This study was a retrospective, observational study of prospectively collected data from an IRB approved Stroke Registry. This includes all SC managed by the stroke team from June 2006-June 2018. Data collected includes initial diagnosis, final diagnosis, demographics, and treatment variables. Analysis included all patients in the registry. Final diagnosis was adjudicated by stroke faculty. Baseline demographics, medical history, treatments, and baseline NIHSS were assessed. Data was examined for frequencies and distribution. Baseline demographics and correlations were compared as appropriate.

Results:
Of all SC (n=4602), 2100 were SM (45.6%). SM were associated with lower age and blood pressure, history of seizure or dementia, female sex, and black race (Table 1). SM also had a lower median NIHSS (3 vs 6, p<0.0001). Of SM, 62/2100 (3%) received IV rt-PA. The most common SM final diagnoses were other, somatization, seizure, encephalopathy and migraine (Figure 1).

Conclusions:
In this large retrospective, study, 45.6% of SC activations were SM. This is a significant increase in the number of SM captured in previous studies. These results show healthcare professionals are overly cautious at alerting a stroke code as they do not want to miss an opportunity to provide thrombolytic treatment.
Abstract TP303: The Effect of Telemedicine in IV-tPA Time Metrics of Acute Ischemic Stroke on and After-hours at Medically Underserved versus Non-medically Underserved Areas
Authors: Trevino Alyssa D , Zhu Liang , Malazarte Rene M , Astudillo Cesar F , Bambhroliya Arvind , Cossey Tiffany , Jagolino-Cole Amanda , Ankrom Christy , Savitz Sean I , Wu Tzu-Ching
Published: January 2019

Introduction:
Telemedicine (TM) may alleviate disparities in patients with acute ischemic stroke (AIS) in rural or medically underserved areas (MUAs) by increasing access to specialists. AIS metrics may also differ between patients who present to emergency rooms during nonworking hours. We compared time metrics and outcomes of AIS patients who received intravenous tissue plasminogen activator (IV-tPA) via TM during on-hours and after-hours at hospitals in MUAs with those during on-hours and after-hours at hospitals in non-MUAs.

Methods:
We identified suspected AIS patients who received IV-tPA via TM from 9/2016 - 12/2017. We compared baseline characteristics, time metrics, and outcomes between the after-hours (5pm-7:59am) and on-hours (8am-4:59pm) patients in MUAs and non-MUAs. Wilcoxon rank-sum test, Chi-square test, or Fisher’s exact test were used for two-group comparisons.

Results:
Of 662 patients evaluated via TM, 297 were seen during on-hours, and 365 after-hours; with 462 patients seen at non-MUA sites and 200 at MUA sites. There were no significant differences in baseline characteristics aside from racial demographics (Table 1). There was no difference in door-to-needle-time between all groups, in spite of small differences of door to CT (non-MUA sites were 5 minutes longer after hours than MUA sites, p=0.002) and onset to door time (MUA being 10 minutes longer on hours than non-MUA, p=0.027). Outcomes were slightly poorer for MUA compared to non-MUA, including discharge disposition (home: 53.9% vs 63.7%, p=0.004) and modified Rankin Scale (mRS≥4: 43% vs 27%, p=0.001).

Conclusions:
TM can provide AIS patients at spoke hospitals with 24/7 access to stroke specialists and standard of care evaluation and treatment. Lack of resources in MUA could be the reason for poorer outcomes however further research is needed.
Abstract TP304: Emergent Therapeutic Interventions Beyond Thrombolysis in Patients Evaluated Through the In-Hospital Stroke Alert Protocol
Authors: Del Brutto Victor J , Goldenberg Fernando , Loggini Andrea , Bulwa Zachary , El-Ammar Faten , Martinez Raisa C , Brorson James R , Ardelt Agnieszka
Published: January 2019

Background:
In-Hospital Stroke Alert Protocols (IHSAPs) are designed to evaluate acute thrombolysis candidacy in patients who develop acute ischemic stroke (AIS) while hospitalized for other causes. However, co-existing medical illnesses may result in difficulty in symptom recognition, false positive alerts, and a high number of contraindications to reperfusion therapies.

Methods:
We analyzed data of all Stroke Alert Protocol cases evaluated by the vascular neurology team in an academic university hospital over 4 consecutive years. Patient demographics and location at the moment of activation were recorded. Clinical presentation, final diagnosis, and acute interventions were compared between inpatients and those presenting to the emergency department (ED).

Results:
Of 1,965 included cases, 489 (24.9%) Stroke Alerts were activated in already hospitalized patients and 1,476 (75.1%) in the emergency department. IHSAPs cases were more likely to present with non-localizing neurological deficits (46.2
%
vs. 32.4%, p<0.0001) and diagnosed with non-cerebrovascular disorders (62.4% vs. 47.5%, p<0.0001). Critical acute therapeutic interventions other than thrombolysis were delivered in 377 (77.1%) cases evaluated through the IHSAP. When compared to the ED, inpatients were more commonly managed with correction of metabolic abnormalities (21.5% vs. 13.7%, p<0.0001), suspension or pharmacological reversal of drugs (11% vs. 3.7%, p<0.0001), and initiation of respiratory support (13.5% vs. 9.3%, p=0.01). Inpatients diagnosed with AIS received intravenous thrombolysis less frequently (4.9% vs. 23.9%, p<0.0001), but the proportion of endovascular treatments was similar to those presenting to the ED (9.8% vs. 10.3%).

Conclusion:
Patients who developed in-hospital ischemic stroke rarely received intravenous thrombolysis, however, the rate of endovascular treatment was similar to those presenting from the community to the ED. The vascular neurology team commonly implemented emergent time-sensitive therapeutic interventions other than thrombolysis during the evaluation of inpatients with stroke-like symptoms.