bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP260: Reducing Time From Pre-Hospital to Arterial Puncture in Acute Ischemic Stroke
Authors: Ohara Nobuyuki , Imamura Hirotoshi , Fujiwara Satoru , Murakami Yasutaka , Ishiyama Hiroyuki , Kohara Nobuo , Sakai Nobuyuki
Published: June 2021

Background and Purpose:
Efficacy of mechanical thrombectomy for acute cerebral large vessel occlusion depends on time from symptom onset to reperfusion. While time to treatment in hospital has been optimized in these days, it is not well-known about improving time in pre-hospital when suspected stroke. We sought to analyze time from emergency medical services (EMS) dispatch to arterial puncture in stroke patients eligible for mechanical thrombectomy.

Methods:
We analyzed time components from EMS dispatch to puncture in patients with acute large vessel occlusion within 6 hours from onset treated with mechanical thrombectomy between April 2015 and December 2018. We assessed the associated factors with each time component and patient outcomes.

Results:
Consecutive 195 patients were included in this analysis. The median EMS dispatch-to-scene, on-scene, transport, door-to-puncture (DTP), and scene-to-puncture (STP) times were 4, 16, 12, 40, and 70 minutes, respectively. Percentage of favorable outcomes were significantly higher in patients with STP within 60 minutes (57.5% vs 35.8%, p<0.05). Direct call from EMS, lower number of acceptance request times, shorter transport distance, and out-of-home onset were significantly associated with STP within 60 minutes (P<0.01). EMS education program shortened STP times and increased use of direct call which significantly reduced on-scene (15.9 vs 20.2), DTP (40.4 vs 57.8), and STP (68.9 vs 91.5) times (P<0.001).

Conclusions:
Reducing time in pre-hospital and in-hospital interact with each other. Education program and use of direct call from EMS contributed to reducing these times.
Abstract TP264: Analysis of Emergency Department Code Stroke Activations at a Large County Hospital: Real World Experience
Authors: Cheung Ryan , Magadan Alejandro A
Published: June 2021

Introduction:
Code strokes are activated to rapidly mobilize hospital resources directed at stroke care. Activations for non-strokes and stroke mimics can divert attention away from patients with acute stroke or delay care of other medical emergencies. There is a drive to reduce door to treatment times in acute ischemic stroke (AIS) without a universal triage method to accurately recognize stroke. We looked at the most common reasons for activation of a code stroke in a quality improvement effort to increase the yield of correctly identifying AIS treatment.

Methods:
Retrospective review of prospectively collected emergency department (ED) code stroke activations between January - December 2018 at our institution. Reasons for code stroke activations, patient demographics, exam and MRI findings, and discharge and neurologist diagnoses were reviewed.

Results:
A total of 523 patients were activated as an ED code stroke. One hundred forty (26.8%) were discharged with a cerebrovascular-related diagnosis (20.1% AIS, 1.2% TIA, and 5.6% ICH). The average age of all acute cerebrovascular pathology is 61.5 years and the gender were found to be 57.1% male. The non-stroke group had an average age of 51.8 years and were 44.1% male. The average NIHSS of the entire cerebrovascular cohort was 9.1 (7.8 in AIS, 15.1 in ICH) compared with 4.6 in the non-stroke group. The most frequent non-stroke diagnosis was related to non-neurologic medical emergencies (25.3%), headaches and migraine (14.6%), psychiatric diagnoses (14.1%), recrudescence of prior symptoms (9.1%), and other neurologic emergencies (8.4%).

Conclusion:
In an era of increased treatment expectations, accurate detection of AIS is key. Current activation criteria and screening tools have a low sensitivity and specificity for AIS. They are often complex for the non-neurologist and inconsistently applied during a code stroke. In conclusion, an overwhelming majority of code strokes are not related to AIS and represent other non-neurologic medical emergencies. A simpler more accurate triage method is needed.
Abstract TP269: Lncrna-u90926 Aggravates Ischemic Brain Injury via Promoting Neutrophils Infiltration After Experimental Stroke
Authors: Chen Jian , Xu Yun
Published: June 2021

Background:
Long non-coding RNAs (LncRNAs) are expressed at high levels in the brain in a variety of neuropathologic conditions, including stroke. However, the potential role of LncRNAs in ischemic stroke-associated microglial biological function and neurological injury remains largely unknown.

Methods:
Oxygen-glucose deprivation and transient middle cerebral artery occlusion (MCAO) in C57BL/6 mice were used as in
vitro
and in
vivo
ischemic stroke models. Microarray analysis was performed to explore the overall expression level changes of LncRNAs. Real-time polymerase chain reaction (RT-qPCR) was used to detect expression level of LncU90926 in brain, plasma and microglia. ShRNA-LncU90926 in lentivirus and microglia specific Adeno-associated virus (AAV) were used to knockdown LncU90926 in
vitro
and in
vivo
separately. Infarct volumes and neurological impairments were assessed by 2,3,5-triphenyltetrazolium chloride (TTC) staining, Neurological Severity Scores (NSS), rotarod test and grip strength respectively. Immunofluorescence staining and flow cytometry were performed to detect the number of neutrophils recruited to brain. RT-qPCR was used to detect the level of chemokines (CXCL, CCL2) and inflammatory mediators associated with neutrophils (MPO, MMP3 and TIMP1).

Results:
(1). LncU90926 was markedly up-regulated in the infarcted brain and plasma after MCAO. Both MCAO and OGD treatment induced remarkable up-regulation of LncU90926 in microglia.

(2). LncU90926 knockdown definitely attenuated brain infarct size and neurological deficits after ischemic stroke.

(3). LncU90926 knockdown in microglia reduced the number of neutrophils recruited to brain, and CXCL1 and CCL2 were down-regulated in both MCAO and OGD models. LncU90926 knockdown also induced reduction of MPO, MMP3 and TIMP1 in the infarcted brain.

Conclusions:
LncU90926 was up-regulated in microglia after experimental stroke, and aggravates ischemic brain injury through facilitating neutrophils infiltration via up-regulating microglial chemokine.
Abstract TP27: Time-window of Endovascular Therapy for Elvo Patients Will be Extended Beyond 24 Hours After Onset
?
Authors: Kimura Ryutaro , Aoki Junya , Kanamaru Takuya , Suzuki Kentaro , Sakamoto Yuki , Katano Takehiro , Numao Shinichiro , Suda Satoshi , Nishiyama Yasuhiro , Kimura Kazumi
Published: June 2021

Background and Purpose:
Eendovascular thrombectomy(EVT) had a clinical benefit when it was performed within 6 hours after onset symptom in the emergent large vessel occlusion(ELVO) patients. Recently, it is proved that EVT 6 to 24 hours after stroke onset with mismatch between deficit and infarct is benefit. However, it is not unclear whether EVT is effective more than 24 hours after stroke onset.

Method:
We enrolled ELVO patients treated with EVT more than 24 hours after stroke onset from our prospective registry. We investigated clinical background including onset to puncture time, clinical stroke type, and recanalization rate. We evaluated patient outcome at 3 months after onset and classified patients into two group; good outcome group as modified Rankin Scale (mRS) 0-2 and poor outcome group as mRS 3-6, respectively. We compared clinical background between two groups.

Result:
In our stroke registry, 443 patients were treated with EVT from January 2011 to July 2019. Among them, 21 patients(5.4%, age was 69(55-72) years old, and male was 16(76%)) were treated with EVT more than 24 hours after stroke onset. All patients had ELVO and clinical and DWI mismatch, which might be thought to be benefit from EVT. Onset to puncture time was median 2632 (1605-6116) minutes and NIHSS scale was 6(2.5-15), and DWI-ASPECTS were 9(7-10). ICA, M1 and BA occlusion were 8(38%), 4 (19%), and 1(4%) patients, respectively. Symptomatic hemorrhage was none. Regarding to patient outcome at 3 months, good and poor outcome were 14(66.7%) and 7(33.3%) patients, respectively. Among the 19 patients with premorbid mRS 0-2, 14(73%) patients achieved good outcome at 3 months. Age, gender, onset to puncture time, DWI-ASPECTS, and ICA occlusion were not different between good and poor outcome groups. However, good outcome patients less frequently had NIHSS score (3.5(2-7) vs. 15(12-23), P=0.006), and cardioembolic stroke (0% vs. 14%, P=0.333).

Conclusion:
More than a half of ELVO patients with clinical DWI mismatch more than 24 hours after stroke onset had good outcome from EVT. There is possibility that time window of EVT for ELVO patients is extended beyond 24 hours after stroke onset.
Abstract TP276: Identification of Potential Key Genes and Pathways in Ischemic Stroke by Analysis of Human High Throughput Sequencing Data
Authors: Li Yufeng , Lu Dan , Xu Anding
Published: June 2021

Background and Purpose:
Ischemic stroke (IS) is one of the most common causes of human death worldwide, but the molecular mechanisms of IS are still unclear. To explore the key genes and pathways involved in the pathogenic process of IS, we did a bioinformatics analysis of high throughput sequencing data of IS for the first time, which compared the expression profiles of brain tissues in IS patients and health controls.

Methods:
The dataset SRP040622 analyzed of expression profiling in 13 samples by deep sequencing in the platform of Illumina HiSeq 2000, including seven cortical ischemic stroke tissues and six control cortex tissues. These data from SRP040622 were downloaded from Sequence Read Archive (SRA) by using Prefech. We adopted fastq-dump, Hisat2, samtools, HTseq and DEseq2 to get the quantification of gene expression from raw data. The differentially expressed genes (DEGs) were identified by limma package, and function enrichment analyses were performed in DAVID website. In addition, the protein-protein interaction (PPI) network was constructed by using STRING and Cytoscape.

Results:
A total 880 DEGs were identified, including 350 up-regulated genes and 530 down-regulated genes. These DEGs enriched in biological processes(BP) mainly associated with signal transduction, multicellular organism development, positive regulation of cell proliferation, protein phosphorylation, cell-cell adhesion and angiogenesis. And KEGG pathway which DEGS were mainly enriched in is PI3K-Akt signaling pathway, Focal adhesion and Ras signaling pathway. In addition, 34 hub genes were selected by using CytoHubba with degrees >10.

Conclusions:
Our data reflects that PI3K-Akt signaling pathway, Focal adhesion and Ras signaling pathway may play significant roles in IS, and the hub genes among DEGs(including KDR, ESR1, MMP2, CAV1, PTK2, VWF) may be the potential targets for diagnosis and treatment of IS.
Abstract TP278: Gradually-Induced Hypoxic Conditioning Attenuates Blood-Brain-Barrier Disruption via Fatty Acid β-Oxidation of Cerebrovascular Endothelial Cells After Cerebral Ischemia/Reperfusion in Mice
Authors: Ren Changhong , Li Sijie , Li Haiyan , Ji Xunming
Published: June 2021

Background:
Hypoxic conditioning protects against ischemic brain injury, while the mechanisms on BBB disruption remains unknown. To date, no study has examined the role of FAO in hypoxic conditioning-afforded
blood-brain-barrier
(BBB) protection. We explored the hypoxia conditioning-induced protection and related molecular mechanism with FAO in BBB against ischemia/reperfusion injury.

Methods:
Focal ischemia/reperfusion model was induced in C57Bl/6J mice by transient middle cerebral artery occlusion (MCAO) for 60 min. Mice were placed in hypoxia chamber, in which the oxygen concentration were reduced from 21% to 5% at a constant rate within 50 min at 10 min after MCAO surgery. BBB permeability was determened by IgG immunohistochemical stain at 24 h after reperfusion.
In vitro
BBB permeability was determined by measuring leakage of 3kDa-dextran and 55 kDa-dextran in oxygen glucose deprivation (OGD). Tight junction proteins (occludin and claudin-5) and
fatty acid β-oxidation
(FAO) rate-limiting enzyme, CPT1A, were measured by Western blot for protein and real time PCR for mRNA, in the isolated cerebral microvessels.

Results:
The hypoxic conditioning (HC) reduced mortality from 33.3% to 0% and improved neurological outcomes (scores?) after 35 days of reperfusion. HC mitigated BBB leakage and reduced the loss of tight junction proteins in cerebral microvessels at 24 h after reperfusion. RNA sequence of the endothelial cells showed that HC enhanced the expression of CPT1A and increased the FAO level. Co-stained microvessels
in situ
with CAPT1 and endothelium cell marker (CD31) showed that HC increased the expression of CPT1A. CPT1A expression in microvessels was decreased after ischemia/reperfusion, while HC restored the protein to the non-ischemic control levels.
In vitro
BBB model, HC reduced OGD-induced dye leakage. HC significantly increased the mRNA and protein expression of CPT1A. FAO inhibitor, etomoxir, or siRNA-mediated CPT1A knockdown diminished the protection of GHT on the BBB integration-by 80.7% and 76.9%. Supplementation of acetate (a downstream product of FAO) enhanced the protection of HC.

Conclusions:
Our results suggest that FAO and signaling play an important role in BBB protection of HC against ischemia/reperfusion injury.
Abstract TP280: A Bland-new Rat Model of Embolic Cerebral Ischemia Using Micro Catheter Under Fluoroscopic Guide
Authors: Komatsu Teppei , Ohta Hiroki , Hata Junichi , Motegi Haruhiko , Terawaki Koshiro , Koizumi Makoto , Muta Kanako , Okano Hirotaka J , Iguchi Yasuyuki
Published: June 2021

Background:
The failure of clinical trials on neuroprotective treatment may be partially caused by unestablished animal models. To verify a trans-arterial regeneration therapy, our project is aimed at developing a brand-new focal stroke model using micro catheter.

Methods:
Using Sprague-Dawley rats (n=8), a micro catheter (ID 0.26mm, OD 0.35mm) was navigated from the caudal ventral artery to the middle cerebral artery in order to establish local occlusion under digital subtraction angiography apparatus.

Results:
We succeeded in brain angiography by percutaneous tail artery puncture and occlusion of the middle cerebral artery by a radiopaque micro bead with 6 rats (75%). Ischemic stroke lesion volume is 480.3 mm3±84.2 mm3 on sustained 1% TTC solution after 24 hours occlusion.

Conclusion:
We present a new rat model for focal stroke using micro catheter under fluoroscopic control. The model is capable of repeated super selective administration of therapeutics directly to cerebral artery, and practice the 3Rs principles in experimental animals because of minimal invasive.Figure Legend- A: A sheath is inserted through the ventral midline, approximately 5 cm from the root of the tail of the rat, with a sharp angle. B: Cerebral angiography of rats. Arrowhead pointe middle cerebral artery. C: Occlusion of the middle cerebral artery by a radiopaque micro bead (arrowhead). D: Brain is sliced and stained 1% TTC solution after 24 hours occlusion.
Abstract TP289: Diagnostic Evaluation of Patients Admitted to Emergency Department Observation Unit for Suspected TIA
Authors: Kumar Arooshi , Ishida Koto , Zhang Cen , Liberman Ava , Torres Jose , Yaghi Shadi , Rostanski Sara
Published: June 2021

Introduction:
Emergency department observation units (ED-OU) allow patients with a suspected transient ischemic attack (TIA) an expedited workup without the need for a prolonged inpatient admission. Despite risk stratification scores and physician evaluation, however, the reliability in diagnosis of TIA remains poor, which may lead to unnecessary testing. This study aimed to identify and compare the diagnostic workup between patients with final diagnosis of true vascular events (TIA or minor stroke, TIAMS) versus nonischemic transient neurological attacks (NI-TNA) in suspected TIA patients admitted to an ED observation unit.

Methods:
A retrospective analysis was performed on consecutive patients who were admitted to an ED-OU at a single center for suspected TIA. All diagnostic testing obtained during observation stay was abstracted from chart review. Final discharge diagnosis was dichotomized to either TIAMS or NI-TNA. Standard statistical tests were used for comparison testing between the two groups with significance defined as p<0.05.

Results:
Of 186 suspected TIA patients admitted to an ED-OU, median ABCD2 score was 4 [IQR 3-4]. Final diagnosis was TIAMS in 85 (46%) patients and NI-TNA in 101 (54%) patients. A total of 182 (98%) patients had non-contrast head CT (NCHCT); 160 (86%) brain MRI; 117 (63%) extracranial vessel imaging; 116 (62%) transthoracic echocardiogram (TTE); and 108 (58%) intracranial vessel imaging. Assessing diagnostic work-up by final diagnosis, TTE (78% vs 40%, p<0.01), and extracranial imaging (75% vs 55%, p<0.01) were more common in patients with TIAMS. Restricted diffusion on MRI (27% vs. 2%, p<0.01) and abnormality on TTE (50% vs. 28% p=0.02) were more common in TIAMS patients. The overall rate of symptomatic stenosis was low: 1 patient had a symptomatic carotid and 4 patients had symptomatic intracranial stenosis.

Conclusion:
Extensive diagnostic testing is done on patients with suspected TIA admitted to ED-OU, with more studies acquired on patients with true ischemic events as compared to NI-TNA. As the use of ED-OUs increases, refinement of current diagnostic testing algorithms to reduce workup for cerebrovascular disease among patients with NI-TIA and among different ischemic stroke subtypes is warranted.
Abstract TP294: Can Stroke Systems of Care Improve Measure Compliance and Outcomes Through Statewide Hospital Collaboration?
Authors: Moore Kari , Hundley Lynn , Hunt Polly , Singletary Bill , Bobo Bonita , Merritt Allison , Graham Amy , Block Starr
Published: June 2021

Background:
The Stroke Encounter Quality Improvement Project (SEQIP) launched in 2009 as a statewide voluntary initiative and collaboration between the American Heart Association, the Kentucky Department for Public Health and 16 acute care hospitals interested in improving stroke care in their communities. The mission is to advance acute stroke care and reduce disparities in Kentucky by: establishing a network that encourages and supports collaboration; increases access to stroke care by targeting underserved areas; provides opportunities to share resources related to program development and proficiency across the continuum of care; and promotes quality outcomes and standardization of care through collegiality and use of evidence-based guidelines and research collaboration.

Purpose:
The goal of this unfunded initiative (now in its tenth year) has been to increase adherence to evidence-based guidelines for stroke patients by implementing a unified statewide effort.

Methods:
Get With The Guidelines-Stroke data were reviewed with the founding 16 SEQIP hospitals and adherence to evidence-based guidelines was measured and analyzed over a 10-year period.

Results:
SEQIP has grown to a network of 35 hospitals with 23 submitting data; patient records increased from 4358 (2008) to 10015 (2018); hospitals achieving Gold GWTG award status increased from 4 to 16; certified stroke centers grew from 4 to 32 decreasing geographic barriers to the nearest certified center; and, SEQIP hospitals achieved statistically significant improvement in all stroke measures.

Conclusions:
With deployment of strategically targeted action plans and expected accountability, competing hospitals can collaborate on a statewide level. Sharing of best practices across organizations can empower stroke teams to implement effective strategies within the confines of their resources to achieve collective goals.
Abstract TP296: Telestroke Associated With Increased Levels of Acute Stroke Care
Authors: Graham Glenn D , Anderson Jane A , Murphy Katherine E , Plue Laurie , Williams Linda , Martini Sharyl R
Published: June 2021

Introduction/Hypothesis:
Telestroke may be used to augment hospitals’ acute stroke services. The Department of Veterans Affairs launched a National TeleStroke Program (NTSP) in September 2017 that provides emergency stroke consultative services at 30 VA hospitals as of August 2019. NTSP uses a virtual hub/spoke model, with transfer to community hospitals when required. We examined the hypothesis that NTSP sites would be overrepresented among VA medical centers increasing their level of acute stroke care between 2012 and 2019.

Methods:
All VA hospitals with an emergency department or urgent care center were required to submit their stroke policies in 2012 certifying the level of acute stroke care offered: VA primary stroke centers provide alteplase evaluation and treatment 24/7/365, limited hours stroke facilities provide alteplase evaluation and treatment typically during business hours, or supporting stroke facilities which transfer all stroke patients for acute care. Re-attestation was required in 2019, with an additional category of comprehensive stroke center added, reflecting availability of both alteplase and endovascular thrombectomy 24/7/365. All submitted documents were reviewed by a single stroke neurologist and the level of acute stroke services was tabulated.

Results:
Of the 115 VA hospitals submitting complete documents, 25 increased their level of acute stroke care, and only 2 decreased their level of acute stroke care between 2012 and 2019. Sixteen of 30 NTSP sites (53%) enhanced acute stroke care in 2019 vs. 2012, compared to 9 of 85 hospitals (11%) not using telestroke. The difference was highly significant (p < 0.0001, Chi-square test).

Conclusions:
In a large, national health care system less driven by financial incentives than most US medical care, adoption of telestroke services was successful in enhancing local VA hospital stroke care. This difference was especially apparent at smaller, rural VA hospitals with limited access to VA neurology services and (in some cases) non-VA care options.
Abstract TP297: Does Use of Telestroke Negatively Impact Family Perceptions of the Local Hospital?
Authors: Lank Rebecca J , Hsu Chia-Wei , Kim Sehee , Ortiz Carmen , Case Erin , Morgenstern Lewis B , Zahuranec Darin B
Published: June 2021

Introduction:
While telestroke use is increasing, little is known about its effect on the patient and family perceptions of quality of stroke care. We hypothesized that use of telestroke may negatively impact perceptions of the quality of communication with local physicians.

Methods:
Stroke patients aged 45 years and older and their surrogate medical decision makers were identified (April 2016-August 2018). Surrogates were asked to rate the main physician in charge of the patient’s care using a validated scale for quality of communication (QOC, range 0-10). Using Tobit regression models, we assessed the relationship of telestroke and in-person neurology consultation with surrogate-rated QOC, adjusted for confounders (with a family-specific random intercept term to account for clustering in families). A subset of surrogates also participated in qualitative interviews about the stroke hospitalization; unprompted discussion of telestroke were summarized.

Results:
197 surrogates for 157 patients were included. Surrogates were a median age of 56, 74% female, and 58% Mexican American. 51 patients received telestroke. The mean overall QOC score was 6.7/10. Neither telestroke nor in-person consultation were associated with QOC. However, the direction of the effects suggested a positive association with QOC for in-person consultation and a negative association for telestroke (Table). 32 surrogates underwent qualitative interviews with 3 individuals spontaneously discussing telestroke. In 2 cases, use of telestroke may have highlighted concerns about the competence or lack of resources of the local hospital. The other surrogate felt surprised and “stupid” for not knowing telestroke was possible (Table).

Conclusions:
We did not identify any association of telestroke use with QOC in the local hospital. However, the direction of the observed effect and unprompted reports of negative feelings about telestroke in qualitative interviews may warrant further study.
Abstract TP30: Effect of General Anesthesia versus Conscious Sedation on Achievement of Substantial Reperfusion for Different Target Occlusions - Analysis of the Goliath Randomized Trial
Authors: Raychev Radoslav I , Liebeskind David , Saver Jeffrey , Brown Scott , Yoo Albert , Rasmussen Mads , Simonsen Claus Ziegler
Published: June 2021

Background:
Achievement of successful reperfusion during endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) may affected by patient motion, especially in more difficult to access, technically challenging targets, such as tandem and distal occlusions. General anesthesia (GA) may be particularly beneficial as compared to conscious sedation (CS) in such patients.

Methods:
We evaluated target occlusion subtypes in the GOLIATH randomized trial comparing GA and CS. Patients were divided in 2 groups based on target arterial occlusion: 1) single, proximal occlusion (ICA T/M1), and 2) tandem or distal (M2) occlusion. Technical success was defined as substantial reperfusion (TICI 2B/3). Clinical outcome measures at 90 days included disability level (mRS ordinal), functional independence (mRS 0-2), and mortality. Multivariable analysis adjusted for age, baseline NIHSS, baseline ischemic core volume, and IV TPA was conducted in each group to assess the impact on technical and clinical outcome. Interaction test for heterogeneity was conducted to assess the difference in outcomes across the subrgoups.

Results:
Among 128 analyzed patients, 80 (62.5%) had single, proximal occlusions and 48 (37.5%) had tandem (22.7%) or distal (14.8%). The absolute difference in substantial reperfusion was higher for both tandem occlusion (83.3% vs 36.4%) and distal occlusion (75% vs 57.1%) than for single, proximal occlusion (74.3% vs 66.7%). The combined distal and tandem occlusion group showed magnified reperfusion success with GA vs CS (80.0% vs 44.4%) compared with the single, proximal occlusion group, (p=0.048, interaction test for heterogeneity). The single and proximal occlusion group showed improved 3m functional independence with GA vs PS (p=0.030), although the heterogeneity between groups was not significant (proximal and single: 71.4% vs 44.4%; tandem or distal: 63.3% vs 72.2%, heterogeneity p=0.12). There was no heterogeneity in the effect of method of sedation on mortality across analyzed groups.

Conclusions:
Achievement of substantial reperfusion during endovascular thrombectomy may differentially be aided by general anesthesia in patients with technically more challenging distal and tandem occlusions
Abstract TP302: Health Insurance-Related Disparities in Management Patterns and In-Hospital Outcomes for Ischemic Cerebrovascular Disease: A Nationwide Trends Analysis of 2005-2015
Authors: Gu Hongqiu , Wang Chunjuan , Jiang Yong , Zhang Xinmaio , Zhao Xingquan , Meng Xia , Wang Yilong , Li Hao , Li Zixiao , Wang Yongjun
Published: June 2021

Background and Purpose:
China has made an impressive achievement in both the scale of coverage and the speed of expansion of its health insurance system, yet data regarding health insurance-related disparities in managements patents and in-hospital outcomes for ischemic stroke/transient ischemic attack (IS/TIA) are still limited.

Methods:
We used a two-stage random sampling method to create a nationally representative sample of patients in China hospitalized with IS/TIA in 2005, 2010, and 2015. Health insurance was limited in Urban Employee Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI), New Rural Cooperative Medical Scheme (NRCMS), and self-payment. We used three composite measures to summarize the treatment and management for assessment tests, in-hospital treatments, and medication at discharge. In-hospital outcomes, including death, discharge against medical advice (DAMA), and a composite outcome of death or DAMA, were assessed.

Results:
Of the 23,389 analyzed patients, the percentage of self-payment patients decreased from 56.3% in 2005 to 9.4% in 2015. Composite measures showed no significant difference between insurance status for in-hospital treatments and medication at discharge, except for assessment tests. Compared to UEBMI, other insurance groups had a higher risk of DAMA and in-hospital mortality or DAMA. Nevertheless, the discrepancies become smaller from 2005 to 2015 (P for interaction < 0.0001) (Figure 1).

Conclusions:
Health insurance-related disparities exist in management patterns and in-hospital outcomes for ischemic cerebrovascular disease, nevertheless, the discrepancies become improved to some degree from 2005 to 2010.
Abstract TP306: The Problem With Transitions: An Evaluation of Appointment Compliance in the Transition of Care Clinic
Authors: Young Brittany A , Yousuf Fawad , Waheed Sadia , Lee Jessica
Published: June 2021

Background:
Stroke is the fifth leading cause of death in the US and a leading cost of disability. The National Transitions of Care (TOC) Coalition has developed a conceptual model of transitional care that defines TOC as an efficient transfer, verification, and clarification of information between communicating providers. The TOC model assumes that, not only are providers accountable in communicating and receiving pertinent information, but most important, that patients and families are engaged throughout the process. Post-stroke treatment non-adherence may impact morbidity and mortality, hospital readmission rates, recurrent stroke risk, and may lead to decreased quality of life. To improve post-acute stroke care, we developed an Advance Practice Provider (APP) driven Stroke TOC Clinic at our institution. We sought to compare rates of appointment adherence in this clinic with that of previously routine 90 day follow up, hypothesizing that a sooner appointment would be associated with greater appointment adherence, given the acuity of the diagnosis of stroke.

Methods:
A single center retrospective chart review was conducted for all stroke patients who were discharged home and scheduled for an appointment in the TOC Clinic between June 1, 2018 to August 31, 2018. TOC appointments were scheduled within 3-14 days. Adherence rates were compared to routine 90-day follow-up visits between March 1, 2014 to June 30, 2014.

Results:
During the study period, 143 patients were offered a TOC follow-up appointment. Each patient was contacted, via phone, within 48 hours of hospital discharge by an APP. 58% of patients (n=83) completed appointments; whereas, 24.5% (n=35) no-showed, and 17.5% (n=25) declined/cancelled the appointment. Compared to the 2014 routine stroke follow-up patients, 58% (n=204) completed appointments; whereas, 32% (n=113) no-showed, and 10% (n=36) declined/cancelled the appointment.

Conclusions:
The results were contrary to the hypothesis. No show rates were not different between the 2018 TOC follow-up group as compared to the 2014 routine follow-up group. The study is ongoing by evaluating other factors that may affect show rates (ie patient gender, geographic location, and insurance status) and how this affects post-acute stroke care.
Abstract TP321: Performance of R
2
Cha
2
Ds
2
Vasc, Cha
2
Ds
2
Vasc, R
2
Chads
2
, and Chads
2
Scores for Predicting Stroke One Year After Transcatheter Aortic Valve Replacement
Authors: Ndunda Paul M , Tadros Peter , Wiley Mark , Muehlebach Greg , Zorn George , Fanari Zaher
Published: June 2021

Introduction:
Stroke after transcatheter aortic valve replacement (TAVR) is a significant cause of morbidity and mortality. It increases the risk of mortality threefold, within one year of TAVR. It is also associated with significant disability and increased health care costs. A validated risk prediction tool for stroke one year after TAVR may be useful in risk stratification to guide decisions at the point of clinical care and in research. The objective of this study was to assess the calibration and discriminative ability of the R
2
CHA
2
DS
2
VASc, CHA
2
DS
2
VASc, R
2
CHADS
2
, and CHADS
2
scores for predicting stroke within one year of TAVR.

Methods:
This was a retrospective cohort study using data from a midwestern academic center TAVR program. Patients who underwent TAVR from 2012 to the first quarter of 2018 who had one-year follow-up data were included in the study. The model discrimination and calibration were assessed using the area under the receiver operating characteristic curve (c-statistic) and the Hosmer-Lemeshow test respectively.

Results:
Six hundred and sixty four patients met the inclusion criteria and 3.4% had stroke within one year of undergoing TAVR. They had a median age of 81 years and a mean STS score of 6.3. The R
2
CHA
2
DS
2
VASc, CHA
2
DS
2
VASc, R
2
CHADS
2
, and CHADS
2
scores had c-statistics of 0.591, 0.596, 0.607, and 0.622, respectively. The Hosmer-Lemeshow χ
2
p-values were 0.762, 0.422, 0.463 and 0.146 respectively.

Conclusion:
The CHADS
2
score had the best discriminative ability for stroke prediction one year after TAVR. All the four scores were well calibrated.
Abstract TP322: The Selection of Enteral Nutrition in Stroke Influence on In-Hospital Infection Control and Hospital Cost
Authors: Onodera Hidetaka , Mogamiya Takuma , Matsushima Shinya , Kawaguchi Kimiyuki , Sase Taigen , Nakamura Homare , Sakakibara Yohtaro
Published: June 2021

Background:
Infection is a common complication after stroke and is strongly associated with an unfavorable functional outcome of patients. Although nutritional intervention reduces the risk of post-operative infection, the impact of differences of products has not been clarified. Less examination of infection and use of antibiotics not only show a high-quality care. In DPC hospital (Japanese style of DRG / PPS), it is important from the hospital management point of view to reduce the comprehensive costs such as medicines and inspections as much as possible. The purpose of this study is to investigate whether the selection of enteral nutrition in the acute phase of stroke patients can contribute to inflectional control and hospital costs.

Methods:
Retrospective analysis in a single center was performed in 50 acute stroke patients who were received enteral nutrition from April 2017 to March 2019. Nutrients gradually over 7 days of hospitalization, the patients were classified into two groups: 1.0-group (general nutrition 1.0 kcal/mL, 25 patients) and 1.5+α-group (started with high protein whey peptide-digested liquid diet (1.5 kcal/mL) and were, later, switched to highly fermentable dietary fiber contained liquid diet (1.5 kcal/mL) after 4 days, 25 patients). Lengths of hospital stay, days of antibiotic use (except during intraoperative), serious infection including methicillin-resistant
Staphylococcus aureus
, Extended spectrum
β
-lactamase producing Enterobacteriaceae and Clostridium difficile infection, and total medical costs were analyzed.

Results:
The baseline characteristics were similar in the both groups. The mean of lengths of hospital stay were 48.0 and 47.8 days in 1.0-group and 1.5+α-group, respectively. The mean of days of antibiotics use during hospitalization in 1.0-group (16.5 days (34.4%)) were larger than that in 1.5+α-group (11.3 days (23.6%)). The serious infections were developed in six and four cases in 1.0-group and 1.5+α-group, respectively. The total hospital costs were reduced by approximately 500 USD/patient in 1.5+α group as compared to 1.0 group.

Conclusions:
The selection of enteral nutrition in the acute phase of stroke patients affects the risk of in-hospital infection and reduces hospital costs.
Abstract TP331: The Effect of Intradialytic Blood Pressure Variability Prior to Intracerebral Hemorrhage on Outcomes
Authors: Ikenouchi Hajime , Miwa Kaori , Irie Kenichi , Ikeda Shuhei , Yi Kenichiro , Tanaka Kanta , Saito Satoshi , Yoshihara Fumiki , Ihara Masafumi , Toyoda Kazunori , Koga Masahoshi
Published: June 2021

Introduction:
Increased blood pressure variability (BPV) during chronic hemodialysis (HD) is associated with cardiovascular event and all-cause mortality. However, it is largely unknown whether pre-admission intradialytic BPV affects functional outcomes in patients with acute intracerebral hemorrhage (ICH).

Methods:
We examined consecutive patients with acute spontaneous ICH who had received HD from our prospective stroke registry between January 2012 and March 2019. Patients with premorbid modified Rankin Scale (mRS) score of 5 and patients who could not be obtained either pre-admission or post-admission blood pressure were excluded from the study. Pre-admission intradialytic BPV was quantified by systolic blood pressure successive variation (SBP-SV) from the last pre-admission dialysis record prior to ICH. Post-admission BPV during initial 24 hours was also quantified using SBP-SV. The clinical outcomes were hematoma expansion and unfavorable outcome at 3-months (mRS score of 5 to 6).

Results:
Of 54 ICH patients who had received HD, 45 patients were analyzed (median age, 68 years; male, 64%; non-lobar ICH, 93 %).Unfavorable outcome was observed in 26 (58%) patients.Increased pre-admission intradialytic SBP-SV was associated with only post-admission SBP-SV, but not associated with National Institute of Health Stroke Scale (NIHSS) score, hematoma volume, or hematoma expansion.In univariate analysis, both of pre- and post-admission SBP-SV were associated with unfavorable outcome. In analysis adjusting for age, NIHSS score, and hematoma volume, pre-admission SBP-SV (per SD; odds ratio, 3.70; 95% confidence interval, 1.01-13.6) was associated with unfavorable outcome, while post-admission SBP-SV was not independently associated with unfavorable outcome.

Conclusions:
In ICH patients who had received chronic HD, pre-admission intradialytic BPV was independently associated with unfavorable outcome after ICH, suggesting that BP control during HD may be a therapeutic target for avoiding further neurological aggravation even once ICH has occurred.
Abstract TP346: Quantitative Analysis of Intracranial Blood Volumes and Relationship With Stress Induced Hyperglycemia and Outcomes in Intracerebral Hemorrhage
Authors: Delpirou Nouh Claire , Ray Bappaditya , Xu Chao , Sidorov Evgeny
Published: June 2021

Introduction:
Stress-induced hyperglycemia (SIH) is independently associated with poor clinical outcome in intracerebral hemorrhage (ICH). It is unknown if quantitative radiological parameters determine SIH in ICH population.

Hypothesis:
Investigate whether SIH is associated with change in intracranial volume due to ICH using unbiased quantitative estimation, intraventricular hemorrhage (IVH) and ICH location.

Methods:
Retrospective cohort of 328 patients with spontaneous ICH over 5-year. Glycemic Gap (GG) is used to define SIH. Receiver Operator Curve (ROC) determined threshold for adverse outcomes (hospice or death). Blood volume was estimated in each intracranial compartment on admission head Computed Tomography (CT) using image segmentation software. Linear regression models and Pearson’s correlation analysis were used to study inter-relationship between SIH, ICH and IVH volume.

Results:
A GG of 29.5 mg/dL and higher defined SIH in this study cohort. Patients with SIH had significantly larger hemorrhage (30.5 mL vs 17.6 mL, p<0.005). ICH, IVH volumes and SIH showed positive correlation (r=0.185, p<0.005; r=0.233, p<0.005 respectively). Subcortically located ICH patients were more likely to have SIH as compared to other locations (ANOVA F-test p-value 0.011). ICH score also showed positive correlation with SIH (r =0.333, p<0.005). For each point increase in ICH score, GG increased by 10.6 mg/dL.

Conclusion:
Our single center retrospective study reports dose dependent SIH with ICH/IVH volumes and subcortical hemorrhage location. Such observation likely alludes to involvement of hypothalamo-pituitary endocrine axis in pathogenesis of SIH after ICH.
Abstract TP357: Use Your Stroke Clinic to Drive Process Improvement
Authors: Handler Diane L , Ross Michelle , Printy Kelly , Penn Cathy
Published: June 2021

Background:
Surveying of patients post stroke for quality of care is an accreditation and CMS requirement for Stroke Centers. However survey techniques can group responses, are often poorly returned and may not address specific concerns. Seeking original, meaningful information, we surveyed each stroke clinic patient with a simple two question survey to gain insight into the patient experience and understand how to make it better.

Methods:
From January 2017 to April 2019, patients and caregivers attended our Stroke Clinic 4-6 weeks post-discharge from our Joint Commission Primary Stroke Center. Two survey questions were asked. To insure 100% response, the discharge nurse encouraged and or assisted patients to complete. The questions were; 1. Do you know why you had a stroke? 2. What do you wish nurses, doctors or therapists had told you prior to going home after your stroke?

Results:
295 patients attended clinic during that time span of which 172 (58%) said they knew why they had a stroke. Of the group who thought they knew why they had a stroke, 41% were incorrect (answer compared to TOAST classification at discharge). Thus 65% of patients overall were not aware of why they had a stroke. When asked what do you wish you had been told prior to discharge, 223 (75 %) had no need for additional information, 73 (25%) needed more information. Responses were qualitative and categorized into; medication, diagnosis, transition of care, symptoms, prevention, diet, driving, and equipment.

Discussion:
Specific, qualitative, patient centered surveying can drive process improvements. Our hospital stroke team developed four process improvement projects to assist with patient transition to home; Return to Driving after Your Stroke; Cryptogenic Stroke - Why Cardiac Monitoring After Discharge; Discharge Readiness Program on the Stroke Unit; REST and REPETITION a Message to Patients About Recovery After Stroke.
Abstract TP36: Impact of Intracranial Hemorrhage After Endovascular Treatment on Long-Term Functional Outcomes in Patients With Acute Large Vessel Occlusion: Insights From RESCUE- Japan Registry-2
Authors: Kinjo Norito , Uchida Kazutaka , Yoshimura Shinichi , Sakai Nobuyuki , Yamagami Hiroshi , Morimoto Takeshi
Published: June 2021

Background and Purpose:
Endovascular therapy (EVT) for acute large vessel occlusion (LVO) is currently standard therapy, but it was associated with a higher incidence of intracranial hemorrhage (ICH) compared to conservative therapy. We investigated the impact of ICH within 72 hours on functional outcome at 90 days in patients with EVT for acute LVO.

Methods:
RESCUE-Japan Registry-2 was a multicenter registry enrolled 2420 consecutive patients with acute LVO within 24 hours of onset. We analyzed patients who received EVT and compared the functional outcomes between those with ICH (ICH group) and without ICH (No-ICH group) within 72 hours after onset. We estimated the adjusted odds ratio (OR) for good functional outcome as mRS 0-2 and mortality. We also explored the prognostic impact of symptomatic ICH (SICH) among those with ICH.

Results:
Among 2420 patients in the registry, 1281 received EVT and mean age was 75 years, and 759 (59.2%) were men. ICH occurred in 332 patients (25.9%). Good outcome was observed 80 patients (24.0%) and 454 patients (47.9%) in the ICH and No-ICH group, respectively, and the adjusted OR for good outcome of ICH group compared to No-ICH group was 0.30 (95% CI 0.22-0.42, p<0.0001). However, the mortalities within 90 days were not significantly different between groups (adjusted OR 1.13; 95% CI 0.72-1.76, p=0.59). SICH was observed in 35 patients (10.5%) among 332 patients with ICH, and the good outcomes were 8.6% and 25.9 % in patients with SICH and asymptomatic ICH (AICH), respectively (p=0.02). Mortality at 90 days were 31.4% and 7.0% in patients with SICH and AICH, respectively (p<0.0001).

Conclusion:
The functional outcomes at 90 days after onset was significantly worse in patients suffered ICH than the counterparts after EVT for acute LVO. However, the mortality rates were generally similar between those with and without ICH. Among patients with ICH, mortality was higher in patients with SICH, but mortality of the patients with AICH was similar to those without ICH.
Abstract TP360: Triage Nursing Intervention Improves Stroke Treatment Rate and Times for Walk-In Strokes
Authors: Quezada Nayive , Burke Ron , Miro Gonzalez Yaima , Ramirez Maygret , Gonzalez Ivis C , Ruiz Felix , D'Amour Daniel , Starosciak Amy K , Strauss Jayme
Published: June 2021

Introduction:
Our comprehensive stroke center provides community outreach and stroke education to patients, caregivers, and community members on the importance of calling 911 in the event of a stroke. However, approximately 1/3 of our center’s stroke alerts are walk-ins. With a walk-in stroke, rapid assessment is essential because the stroke response team has no information compared to information that otherwise would be provided by EMS. As such, our center developed a rapid assessment by the emergency triage nurse or technician, who can then activate a stroke alert.

Methods:
The change to rapid stroke assessment and stroke alert activation by triage nurses and technicians (rather than waiting for an emergency physician to assess and activate a stroke alert) was made in March 2018. Cases from one year prior to the intervention were compared to cases from the year after implementation. Differences in turnaround times (door to stroke alert activation, door to needle [DTN]) were calculated.

Results:
In the period before implementation, there were 1200 stroke alerts, of which 420 arrived via triage (35%). Median door to stroke alert was 0 min. Of those who arrived through triage, 8 received IV alteplase (8/420=2%). For those patients, median DTN was 39 min. In contrast, after implementation, there were 1401 stroke alerts, of which 342 arrived via triage (24%). Median door to stroke alert was 2 min. Of those, 15 received IV alteplase (15/342=4%), with a median DTN of 32 min.

Discussion:
A nursing driven initiative at Emergency Department triage was effective at improving stroke treatment rate and decreasing DTN for IV alteplase for walk-in stroke patients.