bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP27: Sex-Related Differences in Disability Adjusted Life Years After Mechanical Thrombectomy for Acute Ischemic Stroke
Authors: Sheth Sunil A , Warach Steven , Gralla Jan , Jahan Reza , Goyal Mayank , Nogueira Raul , Zaidat Osama , Pereira Vitor , Siddiqui Adnan , Lutsep Helmi , Liebeskind David S , McCullough Louise D , Saver Jeffrey L
Published: October 2018

Background:
Randomized trials have shown that mechanical thrombectomy improves 3-month disability outcomes after acute ischemic stroke for both women and men. However post-stroke disability and reduced life expectancy (LE) persists beyond 3 months, and lifetime effects of thrombectomy might differ between men and women.

Methods:
We analyzed patients treated with the Solitaire stent retriever in the TripleS database (pooled patient-level data from the SWIFT, STAR, and SWIFT-PRIME trials). Years of optimum life after thrombectomy were defined as disability adjusted life-year (DALYs), using the methodology of the World Health Organization Global Burden of Disease Project. For each patient, LE was calculated based on age and sex-specific values, and known degree of modification of LE by modified Rankin Scale (mRS) status at 3 months post-stroke. Years of optimum life lost due to disability were calculated by projecting mRS status at 3 months through the remaining LE.

Results:
Among 389 patients treated with ET, 55% were female, and median NIHSS was 17 [8-28]. There were no differences between females vs. males in presenting deficit severity (NIHSS 17 vs. 17, p=0.21), occlusion location (69% vs. 64% M1, p=0.62), presenting infarct extent (ASPECTS 9 vs. 8, p=0.24), rate of substantial reperfusion (TICI 2b/3, 87% vs. 83%, p=0.37), onset to reperfusion time (277 vs. 306 mins, p=0.46). Women presented at advanced mean age compared to men (69 vs 64, p<0.001). Rates of functional independence at 90 days (53% vs. 56%, p=0.54) were similar in men and women. Without adjusting for age at presentation, years of optimal life (DALYs) following thrombectomy were similar between women and men (9.3 vs 9.6 years, p=0.48). After adjusting for differing ages at presentation, women had more years of optimal life (DALYs) following thrombectomy, 10.6 vs 8.5 years (p<0.001).

Conclusions:
In age-standardized comparisons, women experience two more optimal years than men following mechanical thrombectomy for acute ischemic stroke. Greater life expectancies of women, coupled with similar disability outcome distributions, yield substantially greater years of optimal life after intervention.
Abstract WP271: Incidence of Diagnostic Error in Cerebral Vein Thrombosis at a Single Urban Center
Authors: Bakradze Ekaterina , Patel Miten , McHugh Daryl , Liberman Ava L
Published: October 2018

Introduction:
An estimated 150,000 cerebrovascular events are misdiagnosed in US emergency departments each year. Cerebral vein thrombosis (CVT) is a rare cerebrovascular disease caused by a thrombus formed in the cerebral sinuses or veins that can result in intracerebral hemorrhage and ischemia. Early treatment of CVT may improve patient outcomes, but diagnostic errors leading to delayed or missed CVT diagnosis have received limited attention.

Hypothesis:
CVT misdiagnosis rate in emergency department (ED) and outpatient settings would be high and associated with adverse outcome.

Methods:
We performed a retrospective cohort study at Montefiore Medical Center using electronic medical records. We identified all CVT patients hospitalized between 9/1/2005 to 9/1/2015 using validated
International Classification of Diseases, Ninth Revision
codes and detailed chart review. Misdiagnosis of CVT was defined as any instance when a patient sought medical attention for headache or seizure within 30 days of initial CVT diagnosis in any care setting that resulted in discharge to home. We tested whether patients’ demographic and clinical features were associated with CVT misdiagnosis. Outcomes at hospital discharge were reported. Categorical variables were compared using chi-squared and continuous variables using student t-test. P-value of <0.05 was considered statistically significance.

Results:
We identified 74 CVT patients. Mean age was 46 years (SD: 18) and 44 were female (67%). A total of 15 patients (20%) had a CVT misdiagnosis; 12 initially presented to the ED and 3 to outpatient clinics. Patients with CVT misdiagnosis were younger (35 vs. 48 years of age, P=0.02), and more often Spanish speaking (n=3 vs. n=0, P = 0.02). There was no difference in clinical characteristics, radiographic features, or outcomes between misdiagnosed and accurately diagnosed CVT patients.

Conclusion:
Misdiagnosis of CVT occurred in a fifth of CVT patients and was more common in younger and non-English speaking patients. Interventions to improve diagnostic accuracy among patients with CVT should be explored, particularly in high-risk patient subgroups.
Abstract WP274: Impact of Discontinuation of Telestroke
Authors: Ranta Annemarei , Busch Suzanne
Published: October 2018

Introduction:
Telestroke can improve access to experts at smaller hospitals to assist with thrombolysis decision making. We trialled a regional telestroke ‘hub’ and ‘spoke’ model that was associated with a substantial increase in thrombolysis rates at ‘spoke’ hospitals. One ‘spoke’ hospital, however, elected to discontinue the telestroke service and returned to providing thrombolysis solely under the guidance of local general physicians. The rationale being that the transient telestroke service helped to upskill local doctors and that the boost in rate was partially or even mainly due to other changes in the local services.

Methods:
This is a sequential comparison of three periods: 6 months pre-telestroke, 6-months during telestroke, and 6-months post telestroke. Main outcomes were thrombolysis rate and door-to-needle time with versus without telestroke support.

Results:
Over the 18-month period, 25 patients of 195 admitted ischemic stroke patients were thrombolyzed at this small centre. The thromboloysis rate was 8.5% (6/71) during the 6-months pre, 23.0% (14/61) during the 6-months of, and 7.9% (5/63) during the 6-months post the use of telestroke support from the tertiary centre (with telestroke odds (95% CI) of being thrombolyzed 3.33 (1.41-7.86); p=0.006). Patients receiving thrombolysis within 60 minutes of arrival were 50% before, 64% during, and 20% after telestroke (with telestroke OR (95%CI) 3.15 (0.61-16.3); p=0.16). Careful review of patients not treated after discontinuation of telestroke revealed that nine additional patients would have likely been treated had a stroke specialist been involved in the decision-making process raising treatment rate to 22% (14/63).

Conclusion:
These finding indicate that the transient implementation of telestroke was insufficient to upskill provincial hospital generalist clinicians to sustain a high thrombolysis rate. It also supports the conclusion that telestroke itself contributed strongly to the increase in treatment rate rather than the rate increase being primarily attributable to other factors. The numbers are small and need to be interpreted with caution. However, interestingly, the rates at centres who have opted to continue with telestroke have been maintained at the much higher level.
Abstract WP276: Trends in Acute Stroke Treatment Among Rural Hospitals in Minnesota: Utility of Acute Stroke Ready Hospital Designation
Authors: Tsai Albert W , Lindgren Paula G , Asaithambi Ganesh
Published: October 2018

Background:
The Minnesota Stroke System was launched in 2013 to organize and recognize hospitals able to deliver acute stroke treatment. The goal of the system is to increase access to acute stroke treatment and improve outcomes for stroke patients. The Minnesota Department of Health designates Acute Stroke Ready Hospitals (ASRHs) according to ten criteria corresponding to the 2013 Brain Attack Coalition recommendations. This analysis explores whether implementation of the Minnesota Stroke System and the corresponding adoption of standards by ASRHs corresponded to an increase in intravenous (IV) alteplase utilization among rural Minnesota hospitals between 2012 and 2017.

Methods:
Stroke patient care data were submitted by hospitals into the Minnesota Stroke Registry. Rural Minnesota hospitals were grouped into three categories: early adopters that became designated between 2014-2015; late adopters (designated between 2016-2017); and never-designated hospitals. Trends in IV alteplase use from 2012 to 2017 were examined in each group.

Results:
Among 103 rural Minnesota hospitals, 21 never received designation, 21 were designated in 2016-2017, and 61 were designated between 2014-2015. Treatment of stroke patients with IV alteplase among all rural hospitals increased in Minnesota between 2012 and 2017 from 12.9% to 15.9% (p<0.01). Among never-designated hospitals, IV alteplase use increased from 12.5% to 15.4% (p=0.13), and among late-adopting ASRHs use increased from 10.1% to 12.7% (p=0.22). In contrast, IV alteplase use significantly increased among early adopting ASRHs from 14.6% to 20.5% (p<0.0001). A significant trend was noted with IV alteplase use within the ≤3-hour window in the early adopting group (p<0.0001) and the late adopting group (p=0.02), but the trend was not significant in the never-designated group (p=0.09).

Conclusions:
Trends in treatment with IV alteplase was highest among early adopting ASRHs. Sustained increases in treatment rates among early adopters suggests that similar increases may be seen in late-adopting ASRHs in the future. This analysis suggests that the implementation of a statewide system of care, namely adoption of standards and hospital designation, is a driver for sustained increases in treatment rates.
Abstract WP281: Multicenter Analysis of Stroke Risk Factor Treatment
Authors: Rao Neal M , Wu Matthew J , Nguyen Viet-Huong V , Dergalust Sunita , Aramian Alenoush , Minassian Grace , Siddiqui Uzair , McCreary Michael , Neil William P , Wallis Roi Ann , Saver Jeffrey L
Published: October 2018

The majority of the 800,000 strokes occurring in the US each year are first-time strokes. To understand how these can be prevented, our study assessed primary care (PC) treatment of common stroke risk factors (RF) in the year prior to a first-time stroke. We compared hospitals in three major health systems – a California County (OVMC), VA (WLAVA), and Kaiser HMO (KSD), both before and after the Affordable Health Care Act (ACA).

Methods:
We identified patients who suffered a first-time stroke in 2013 and 2015 at all three sites. We then assessed the three most recent PC visits for these patients in the year before their stroke for “missed opportunities” (MO) in stroke preventative care. MOs included: Systolic blood pressure (SBP) >140 not addressed, elevated A1C not addressed, LDL never checked or >100 but not addressed, antiplatelet medication not refilled, and no RF counseling (smoking, alcohol, obesity, or physical activity). MOs were compared between sites, before (2013) and after the ACA (2015).

Results:
85 patients from OMVC, 88 patients from KSD and 64 patients from WLAVA met entry criteria. All sites had an increase in the number of patients who had PC visits prior to first-time stroke between 2013 and 2015 (OVMC 2013: 1/26, 2015 15/59 (25.4%). KSD 2013: 50/67 (74.6%), 2015 16/21 (76.2%). VA 2013: 24/33 (72.7%) 2015 28/31 (90.3%). In 2013, only one OVMC patient had primary care. In 2013, the WLAVA had significantly less MO than Kaiser (23.6% vs 59.0%, p<0.001). In 2015, there was no significant difference in MO between the three sites (p=0.21). The most common MOs were in addressing hypertension, elevated LDL, and lack of RF counseling.

Conclusions:
Stroke RFs were often not addressed during PC visits at all 3 sites. All sites had an increase in PC visits among first-time stroke patients after the ACA, particularly within the LA County system. It is unclear if this resulted in increased stroke RF counseling and intervention. Efforts to promote primary stroke prevention are still needed.
Abstract WP282: Moyamoya Disease and Pregnancy: A Single Institutional Experience in the USA
Authors: Qaiser Rabia , Bell-Stephens Teresa E , Girsen Anna , El-Sayed Yasser Y , Steinberg Gary K
Published: October 2018

Introduction:
Moyamoya disease is a progressive bilateral steno-occlusive disease of the terminal internal carotid arteries accompanied by development of collateral moyamoya vessels. It affects a younger population and thus, women in their reproductive years. We aim to define the practices, comorbidities and outcomes of pregnancies in women with moyamoya disease.

Method:
We conducted a retrospective review of 33 patients and 49 successful pregnancies between 1992 and 2017 at Stanford Health Care/Lucile Packard Children’s Hospital from our institutional database by surveys and chart review.

Results:
To date we have completed 1483 revascularization procedures in 930 patients. Out of these 930 patients we identified 45 patients who had pregnancies immediately prior to the diagnosis of moyamoya disease and some after being diagnosed with moyamoya. 33 out of these 45 patients’ charts and consents were available for review. These 33 patients had 49 successful pregnancies. There were 20 single pregnancies, 10 women had 2 pregnancies each and 3 woman had 3 successful pregnancies. 22 pregnancies were NVD (normal vaginal deliveries), 2 were assisted vaginal and 25 were C-sections. Maternal age varied from 19 years to 40 years. Gestational age ranged between 32 weeks to 40 weeks. 8/49(16.3%) pregnancies were associated with transient ischemic attacks or stroke. 44 pregnancies had a history of revascularization before or during pregnancy, and 5 pregnancies occurred prior to any revascularization. 8/49(16.3%) pregnancies were associated with eclampcia and pre-eclampcia and 9/49(18%) with hypertension. Neonatal complications included low birth weight 2/49 (4%), Mild jaundice 2/49 (4%), Tachypnea 1/49 (2%), Acid reflux 1/49 (2%), NICU stay 3/49 (6%).

Conclusion:
Our study shows that the trend in the USA is towards vaginal delivery in patients with moyamoya disease: 51.1%, is less than whein compared with studies in Asia. We also show that both the patients and babies do well. The complication rate is minimal, including no strokes in the peripartum period in patients who have been treated. We would advocate vaginal deliveries in the absence of any other contraindications along with peripartum blood pressure control.
Abstract WP284: Modelling Hospital-Level Costs of Thrombolysis to Strokes and Stroke Mimics
Authors: Choi Ho-Jun , Liberman Ava L , Mendelson Scott , Ruff Ilana , Prabhakaran Shyam
Published: October 2018

Introduction:
When the diagnosis of stroke is not completely certain, the benefits of rapid treatment with tPA are widely thought to outweigh the minimal risk of complication associated with thrombolysis of stroke mimics (SM). However, acceptable rates of hospital-level SM treatment have not been well established.

Hypothesis:
A cost-reimbursement (CR) analysis will identify a threshold of SM treatment with tPA above which the CR ratio is unacceptably high.

Methods:
We used stochastic modeling with probability distributions to mathematically examine various tPA treatment scenarios. The main hospital-level variables used were: (1) case-mix or rate of SM and (2) percent of all eligible cases treated with tPA. For each case, a hospital cost was assigned based on whether or not tPA was given, onset to treatment time (OTT), length of stay based on severity distribution and expected clinical outcome, and whether the case was a true stroke or SM. The costs associated with index hospitalization, treatment complications, and non-treatment of true stroke patients were estimated from published rates and data. Reimbursement for stroke with and without thrombolysis as well as treated SM were estimated from Medicare rates. We calculated a CR ratio and identified thresholds of hospital SM treatment rates above which CR ratios are >1.0 and >1.5.

Results:
Assuming that 75% of true eligible stroke patients are treated with tPA with median OTT of 120 minutes, we found an increase in CR ratio from 0.97 (0% SM rate) to 1.61 (100% SM rate). The SM rate of <10% was associated with CR of <1; the SM rate of >10% was associated with CR ratio >1.0 while SM rate >80% was required for a CR ratio >1.5. For each OTT interval (0-90 minutes, 90-180 minutes, 180-270 minutes), the CR ratio was on average 0.1 lower for a hospital with a 5% SM rate compared to a hospital with a 20% SM rate.

Conclusions:
In a simulation study, we found the CR ratio increased with increasing OTT and hospital SM treatment rate. As other researchers have suggested, hospitals may need to carefully monitor rates of SM patients treated with tPA and establish performance metrics to lower costs and reduce patient harm.
Abstract WP287: Differences in Outcome and Cost Between Patients Admitted to Intensive Care versus the Neuroscience Unit Post Neuroendovascular Procedure
Authors: Kabbani Mouhammed R , Smith Angela L , Borgert Andrew J , Carlisle Allison G
Published: October 2018

Rapid advancements in endovascular technologies over the past decade have increased the number of patients successfully treated with this minimally invasive technique. Consequently, utilization of hospital resources and costs has both risen. A process change at our institution allowed neuroendovascular patients hemodynamically stable and extubated to be admitted directly to the neuroscience unit (NSU) as opposed to the intensive care unit (ICU). The NSU nursing staff is specifically trained to care for neuroendovascular intervention patients and some hold advanced certification in stroke or neurosciences. This study is the first to our knowledge that compares post-operative complications and costs between groups admitted to the ICU versus the NSU after neuroendovascular treatment. Retrospective chart review of elective and emergent neuroendovascular procedures requiring inpatient admission from 01/01/2013- 06/01/2017 was conducted. Procedures included for review were carotid artery stenting, intracranial or extracranial stenting, embolization of intracranial vascular malformation, dural AV fistula, thrombectomy for stroke, or unruptured aneurysm. Patient demographics, clinical characteristics, hospitalization data and follow-up data were extracted from the electronic medical record. Procedures between 2013 and 02/28/2016 were analyzed as the pre-process change group and compared to the post-process change group after 02/28/2016. There was a transitional period of approximately 6 months in which staff was trained and patients were gradually accepted to the NSU. Of the 209 procedures reviewed, we found no significant difference in perioperative (p= 0.18) and 30 day complications (P=0.99) or in overall survival (p=0.88) between the pre (n=111) and post (n=98) process change eras. The change in admission location resulted in cost savings of approximately $670 to the institution per patient for the first day and $2466 for each additional day. These results suggest that ICU admission is not necessary for patients that are hemodynamically stable and extubated post neuroendovascular treatment. Admission to the NSU did not negatively impact patient outcomes, yet it decreased patient hospital stay costs and institutional expenses.
Abstract WP290: A Resident-Driven Intervention to Decrease Door-to-Needle Time and Increase Resident Satisfaction in a Resource-Limited Setting
Authors: Fara Michael G , Lloyd-Smith Alexandra J , McMenamy John , Chan Monica , Ishida Koto , Torres Jose , Zhang Cen , Favate Albert , Singh Anuradha , Zhou Ting , Rostanski Sara K
Published: October 2018

Introduction:
Neurology residents are often the first-line responders to emergency department (ED) stroke codes, however their role in initiating stroke systems changes is not well established. At a large, resource-limited public hospital, neurology residents developed a protocol for acute stroke codes focused on improved interdisciplinary communication.

Methods:
Process mapping was used to identify current state deficiencies. Poor communication between neurology residents and ED physicians, nurses, and radiology techs and role redundancy were identified as core deficiencies. Ideal and future state maps were used to create a stroke code workflow diagram (the “protocol”). Changes included assigning specific responsibilities to each team member, and forcing interdisciplinary communication at specific points in the process (i.e. ED physician calls tech when patient goes to CT). The protocol was implemented in May 2016. Median door-to-needle (DTN) times were compared in the pre-intervention (January 1, 2014 - April 30, 2016) and post-intervention (May 1, 2016 - June 15, 2017) periods using non-parametric tests. Resident satisfaction with communication during stroke codes was measured using pre- and post-intervention surveys; responses were compared with t-test.

Results:
A total of 66 patients received tPA, 20 (30%) in the post-intervention period. Baseline demographics and NIHSS did not differ in the pre- and post-intervention periods, however median DTN decreased (58 vs. 40 min, p=0.02) and proportion of DTN≤45 minutes doubled (30% vs. 60%, p=0.03) in the post-intervention period. Twenty-three residents (79%) completed pre-intervention surveys; 19 residents (64%) completed post-intervention surveys. Resident satisfaction was greater in the post-intervention period with respect to stroke team communication (2.8 vs. 3.6, p=0.01), understanding multidisciplinary roles (3.8 vs. 4.3, p=0.03), and interaction between team members (3.2 vs. 3.8, p=0.03) measured using a five-point scale (higher being better).

Conclusion:
In a resource-limited setting, neurology residents are capable of implementing acute stroke workflow changes using basic process improvement methods that have a measurable impact on DTN and resident satisfaction.
Abstract WP292: Changing Landscape of Stroke Systems of Care: Increase in Inter Hospital Transfer in the United States
Authors: Shah Shreyansh , Sheng Shubin , Xian Ying , Zachrison Kori S , Sheth Kevin N , Saver Jeffrey L , Smith Eric E , Fonarow Gregg C , Schwamm Lee H
Published: October 2018

Purpose:
Interhospital transfer is necessary to facilitate endovascular therapy (EVT) for patients with emergent large vessel occlusion (ELVO) who present to nonendovascular centers. We hypothesized that interhospital transfer would accelerate following 2014 pivotal randomized controlled trials (RCTs) demonstrating benefits of EVT.

Methods:
We analyzed trend of interhospital transfer for EVT using Get With The Guideline (GWTG)-Stroke from January 2012 to September 2016. Analyses of transfer-in trend for the hospitals consistently providing EVT were restricted to hospitals with >1 EVT/quarter in last 4 study quarters (250 sites). We analyzed trend of interhospital transfer for all ischemic stroke (IS) patients and following subgroup: NIHSS ≥6 and arrival to the EVT-providing hospital within 7 hours of last known well.

Results:
During the study period 31425 patients received EVT. Transfer-in EVT cases increased from 334 to 912 from Q3 2014 to Q3 2016 (p<0.001 for change in linear trend, Figure 1A). Interhospital transfer for EVT is common (44% in Q3 2016) and increasing proportion of IS patients are arriving to EVT-providing hospitals as transfers, especially among the subgroup of NIHSS ≥6 and arrival to the EVT-providing hospital within 7 hours of last known well (Figure 1B). Since RCT announcement, transfer-in patients receive EVT at a significantly higher rate (5.2% in Q3 2014 vs. 10.8% in Q3 2016, Figure 1C). Hospitals with a higher % transfer-in EVT (comparing top quartile to bottom quartile) were more likely to have more beds and be in an urban location, with comprehensive stroke center certification and higher annual EVT volumes.

Conclusions:
Interhospital transfer of IS patients has accelerated markedly in the past two years, highlighting the need to develop protocols and quality metrics to ensure efficient systems of care for this subset of patients.
Abstract WP299: Patient-centered Quality of Life Utility Values Are Superior to Modified Rankin Scale Outcomes in Stroke- Experience From the Artss-2 Trial (Randomized, Multi-center Trial of Argatroban With Recombinant Tissue Plasminogen Activator for Acute Stroke)
Authors: Barreto Andrew D , Ford Gary A , Shen Loren , Pedroza Claudia , Tyson Jon E , Cai Chunyan , Rahbar Mohammad , Grotta James C ,   on behalf of the ARTSS-2 Investigators
Published: October 2018

Background and Purpose:
Although the modified Rankin Score (
mRS
) is broadly used as a measure of stroke outcome, patients’ valuation of each mRS category has been understudied. Stroke patient/caregiver quality of life (
QOL
), expressed in 0-1 numerical
utility
scores, more accurately reflect patient-centered health states. We hypothesized that QOL utility values would
not
be linearly associated with mRS. Rather, clinically-meaningful transitions with large utility differences would occur among certain mRS scores.

Methods:
Utilities were obtained from ischemic stroke patients or proxy family members in the ARTSS-2 randomized trial; clinicaltrials.gov/NCT01464788. A societal perspective for health-state assessments was performed using Time-Trade-Off methodology (EuroQol-5D). Utilities were converted using country-specific tariffs as ARTSS-2 had US & UK sites. Death was assigned a utility=0. Certified raters blinded to utility data assessed 90-day mRS. Mean (SD) utilities were mapped across mRS categories. mRS 5 & 6 were collapsed as 5, bedbound and dependent for all bodily needs, is accepted to be equal or worse than death (mRS=6).

Results:
86 of 90 (96%) patients had utilities at 90-days. Excluding missing and deaths, 70 patients had utilities generated by either the patient (N=48; 70%) or the proxy (N=22; 30%). Of the 22 proxy assessments, 20 (91%) were aphasic, 1 had severe neglect, and 1 remained mechanically ventilated. Utility vales declined in a non-linear fashion with increasing mRS; the largest difference between 3-4 and 4-5+6 (Figure).

Conclusions:
Although the mRS is analyzed under a linear assumption that each numerical transition is equal, stroke patient QOL utilities demonstrate important transitions between mRS scores. Future stroke trials should consider replacing mRS with direct patient utilities or convert mRS into utility-weighted scores established by patient-generated values that reflect clinically important health states.
Abstract WP304: Clinician-User Satisfaction With Compass-cp for Stroke
Authors: Duncan Pamela W , Abbott Rica M , Rushing Scott , Gesell Sabina B , Lutz Barbara J , Coleman Sylvia W , Sissine Mysha E , Lycan Sarah , Condon Christina , Stafford Jeanette M , Johnson Anna , Jones Berkeley Sara B , Psioda Matthew A , Bushnell Cheryl D
Published: October 2018

Introduction:
COMPASS-CP is a patient-centered electronic application that includes real-time, patient-reported measures of functional and social determinants of health (PROMs). Algorithms assess PROMS and immediately generate actionable, individualized care plans. Algorithms may also trigger a caregiver assessment. COMPASS-CP identifies relevant local community resources tailored to the needs identified on the care plan. COMPASS-CP is administered by a nurse during a 7 to 14 day post-stroke transitional care clinic visit which meets CMS requirements for transitional care management codes. COMPASS-CP is being evaluated in a PCORI-funded pragmatic trial of COMprehensive Post-Acute Stroke Services (COMPASS). Scalability and sustainability of COMPASS-CP will require high user satisfaction. The purpose of this study was to evaluate clinician/user satisfaction with the COMPASS-CP application.

Methods:
We surveyed 56 clinicians (nurses, NPs or PAs) from 20 hospitals utilizing COMPASS-CP to assess satisfaction with the application in (1) efficiency in care plan development, (2) identifying factors impacting patient self-management and caregiver needs, (3) patient/provider communication, (4) patient/caregiver engagement, and (5) patient satisfaction with care. Clinicians rated their satisfaction on a 5-point Likert scale as either
Strongly Agree
,
Agree
,
Neither Agree Nor Disagree
,
Disagree
,
Strongly Disagree
.

Results:
Forty-four clinicians (79%) from 19 hospitals (95%) responded. Thirty-nine responders (89%) had used COMPASS-CP for 3 months or more.

Conclusions:
Successful implementation of electronic applications requires high levels of clinician/user satisfaction. The majority (66 %) of users agreed that they were satisfied with the COMPASS-CP application and 58% reported it made their job easier. Future analyses will determine if individualized care plans improve patient satisfaction and outcomes.
Abstract WP306: Race-Ethnic Disparities in 30-Day Readmission After Ischemic Stroke Among Medicare Beneficiaries in the Florida Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study
Authors: Gardener Hannah , Leifheit Erica C , Lichtman Judith , Wang Kefeng , Wang Yun , Gutierrez Carolina M , Ciliberti-Vargas Maria A , Dong Chuanhui , Robichaux Mary , Romano Jose G , Sacco Ralph L , Rundek Tatjana ,   FL-PR CReSD Investigators and Collaborators
Published: October 2018

Background:
30-day readmission after ischemic stroke is an important health quality of care metric, but little is known about potential race-ethnic disparities for this outcome. We examined 30-day rates and causes for readmission among Medicare beneficiaries in the NINDS-funded Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (CReSD) Study.

Methods:
We examined 30-day all-cause readmission for Medicare fee-for-service beneficiaries treated for ischemic stroke (ICD-9 433,434, 436) in FL CReSD hospitals from 2010-2013. We fit a Cox proportional hazards model that censored for death and adjusted for age, sex, and comorbidities to assess race-ethnic differences in readmission, and identified reasons for readmissions.

Results:
Among 16,952 unique ischemic stroke patients (54% women, 75% white, 8% black, 15% Hispanic), all-cause 30-day readmission was 15%. Readmission rates were 17.2% for Blacks, 16.7% for Hispanics, 14.4% for Whites, and 14.7% for Others (p=0.003). There was a median of 11 days between discharge and first readmission. In risk-adjusted analyses, there was no significant difference in 30-day readmission for Blacks (hazard ratio 1.15, 95% confidence interval 0.99-1.33), Hispanics (1.00, 0.90-1.13), and those of other race (0.91, 0.71-1.16) compared to Whites. Nearly 1 in 4 readmissions were attributable to an acute cerebrovascular event: 16.6% ischemic stroke or transient ischemic attack, 1.5% hemorrhagic stroke, and 5.2% cerebral artery intervention (carotid endarterectomy or stenting, endovascular). Interventions were more common among Whites (6.0%) and those of other race (7.5%) than among Blacks (1.8%) and Hispanics (3.8%; p=0.029). Readmission due to pneumonia or urinary tract infection was 8.2%.

Conclusions:
Readmissions varied by race/ethnicity, but generally occurred within two weeks of hospital discharge. Our results underscore the importance of post-discharge transition of care and the need for better secondary stroke prevention strategies early after ischemic stroke. Implementation of effective transition of care after acute stroke hospitalization may reduce potentially preventable readmissions, particularly among minority populations.
Abstract WP308: Low Volume of Acute Stroke Intervention in Aurora Health Care System Analysis
Authors: Panichpisal Kessarin , Chohan Adil , Singh Maharaj , Villar Paul , Hook Mary , Matyas Sharon , Grenier Becky , Kojis Nathaniel , Babygirija Reji , Sajjad Rehan , Wolfe Thomas , Rovin Richard A
Published: October 2018

Introduction:
Thrombectomy for acute ischemic stroke (AIS) is an important intervention, though the majority of eligible patients do not receive it. Drawing upon data from our high volume comprehensive stroke center, we identified barriers to recognizing patients with large vessel occlusion and subsequent impediments to treatment.

Methods:
This is a retrospective chart review of patients presenting with AIS within 24 hours to the 14 hospitals within the AHCS between January 2015 and December 2016. Demographic, National Institutes of Health Stroke Scale (NIHSS) score, vascular imaging, and thrombectomy data were collected and analyzed. Large vessel occlusion (LVO) involved the distal internal carotid artery (ICA), middle cerebral artery (M1), or basilar artery (BA).

Results:
Three thousand five hundred ninety- five AIS patients were identified. The median age was 61 years and 1863 (52%) were female. Two thousand one hundred eighty-three patients presented within 24 hours (61%): 1105 ≤ 6 hours. More than one third of AIS patients (773) did not have acute intracranial vascular imaging. Of 1410 patients with vascular imaging, 171 patients (12 %) had LVO. The site of occlusion was: M1, 86 patients (50.3%); distal ICA, 51 (30%); and BA, 27 (16%). Only 75 LVO patients (44%) had acute stroke intervention of whom 57 (77%) had mechanical thrombectomy, additional intra-arterial thrombolysis was given in 14 (19%) and 4 (5%) had intra-arterial thrombolysis as monotherapy. Successful revascularization (mTICI 2b-3) was achieved in 53 patients (70%). The main reasons that LVO patients did not receive acute stroke intervention include: late onset or unknown onset in 32 (35%), large core infarction 25 (27%), rapid improving NIHSS in 6 (7%), and unclear reason in 25 (17%),

Conclusion:
There are several reasons that LVO is under recognized: a non neurologist often evaluates the patient in the ER first and they might not be familiar with stroke protocol guidelines; some LVO patients have an atypical presentation; and some patients refuse intervention. Based on our data, there is a need for continuing education of stroke care providers, particularly in this period of changing interventional guidelines.
Abstract WP31: Mechanical Thrombectomy Performs Similarly in Real-World Clinical Practise as in Randomized Trials: Nationwide Study From the Czech Republic
Authors: Volny Ondrej , Belaskova Silvie , Krajina Antonin , Bar Michal , Cimflova Petra , Herzig Roman , Sanak Daniel , Tomek Ales , Kocher Martin , Rocek Miloslav , Padr Radek , Cihlar Filip , Nevšímalovã Miroslava , Jurak Lubomir , Havlicek Roman , Kovar Martin , Rohan Vladimir , Fiksa Jan , Mikulik Robert
Published: October 2018

Background:
In randomized clinical trials (RCTs) mechanical thrombectomy (MT) was proved to be a highly effective and safe treatment in acute ischemic stroke. Its efficacy and safety in routine practice needs to be documented.

Methods:
Available nationwide 2016 data for the Czech Republic (CR) from SITS-TBY registry of patients with terminal internal carotid artery (ICA) and/or middle cerebral artery (MCA) occlusion were compared with data from HERMES meta-analysis. Categorical variables were compared by Pearson′s Chi-squared test, ordinal/continuous variables by Mann-Whitney test.

Results:
Fourteen/15 comprehensive stroke centres reported data to SITS-TBY. From 1,053 MTs performed in the CR, 845 (80%) patients were reported to SITS-TBY. From these patients, 605 (72%) patients were involved in analyses (available outcome data in Tab.). CR and HERMES patients were comparable in: age, sex, baseline NIHSS. Occlusion locations were as follows (CR vs. HERMES): ICA 22% vs. 21% (p=0.16), M1 MCA 62% vs. 69% (p=0.004), M2 MCA 16% vs. 8% (p<0.0001). Intravenous thrombolysis was given in 76% vs. 83% patients (p=0.003). Median onset-to-reperfusion times were comparable: 232 vs. 285 min (p=0.66); median groin-to-reperfusion times were 58 vs. 63 min. Modified TICI 2b/3 was achieved in 74% (433/584) vs. 71% (390/549), p=0.24. There was no difference in percentage of PH type 2 (5.7 vs. 5.1%). Modified Rankin scale 0-2 at 3 months achieved 44% (103/235) vs. 46% (291/633) patients, p=0.57.

Conclusions:
This nationwide experience on mechanical thrombectomy in acute ischemic stroke documents safety, efficacy and logistics comparable with HERMES data. Tab. Comparison on available demographic characteristics, past medical history, clinical and radiological characteristics, treatment details and outcomes in SITS-TBY versus HERMES.
Abstract WP310: Timing of Comfort Care Decisions in Ischemic Stroke Patients: Implications for Publicly Reported Outcomes
Authors: Donohue Megan M , Hafen Heidi , Knight Stacey , Min David B , Chatwin Stephen , Foster Gaye , Hoesch Robert
Published: October 2018

Introduction:
Risk-adjusted stroke mortality is a publicly-reported CMS quality measure. Patients (pts) admitted with stroke who are discharged to hospice prior to the first midnight are excluded in reported metrics. It is difficult to prognosticate outcomes early in ischemic stroke; additionally, the sudden nature of the disease makes it difficult for families to make rapid decisions. We hypothesized that the decision to proceed to comfort care in ischemic stroke pts takes longer than 24 hours.

Methods:
This was an observational study of all ischemic stroke pts seen at Intermountain Medical Center in 2016 (n=581) who were discharged to hospice (n=27) or died in hospital on comfort care (n=27). A Wilcoxon sign rank test was used to compare time to decision regarding comfort care to the CMS standard of 24 hours. Differences in the time to decision or death for the pt characteristics were also compared using Wilcoxon-Mann-Whitney test.

Results:
The average age was 80 years old ± 13 (range 44 - 98), 59% were female, all were Caucasian Non-Hispanic, and 65% reported a religious affiliation. NIH stroke score was reported in 42 subjects with an average of 15.9±7.9 (range 2-31). The mean time from admission to initiation of comfort care orders was 3.12 days (±3.6) with a median of 1.8 days and a range from 12.5 hours to 14.1 days. The time was significantly greater than 24 hours (p<0.0001) with only a third (n=18) having the time less than 24 hours and with only a fifth (n=11) having the time before the first midnight. The table below contains the differences in the times based on pt characteristics and none of these were significantly associated with time differences.

Conclusions:
The decision to transition to comfort care or hospice often takes greater than 24 hours. If the stroke mortality metric is meant to exclude hospice pts or those that prefer comfort measures only, the time window for initiation of those orders should be extended beyond the first midnight.
Abstract WP316: Efficacy and Safety of Usage of Tirofiban for Patients With Acute Ischemic Stroke- A Meta-Analysis
Authors: Lowe Forrest J , Liu Shimeng , Dong Yi , Feng Wuwei
Published: October 2018

Background:
Tirofiban, a Glycoprotein IIb/IIIa inhibitor, has been used as an adjunctive therapy (adjunct to alteplase or antiplatelet) for patients with acute ischemic stroke. We aimed to conduct a systematic review and meta-analysis assessing both the efficacy and safety of tirofiban usage in ischemic stroke patients.

Methods:
We searched PubMED with the terms “tirofiban", and" ischemic stroke". Inclusion criteria were 1) randomized or non-randomized studies with two study arms; 2) inclusion data on mortality and/or symptomatic intracerebral hematoma (sICH); 3) modified Rankin Scale (mRS) used as an outcome measurement at 90 days; and 4) publication in the English language. We extracted data and calculated a summary odds ratio for sICH, mortality, and favorable outcomes (defined as mRS of 0 ≤1).

Results:
Five studies with 617 subjects suffering acute ischemic stroke were included in the analysis. Three studies included mRS data at 3 months which demonstrated that the trend of non-significant favorable outcomes in the Tirofiban group were non-significant (ORs=1.29; 95% CI=0.55-3.31; P=0.56). Two studies included data on sICH and there was no difference in risk of sICH. (ORs=0.52; 95% CI=0.09-3.-3; p=0.46). Four studies contained data on patients who died after treatment and there was no difference in the risk of mortality (ORs=1.06; 95% CI: 0.28-3.97; p=0.94).

Conclusion:
Our meta-analysis suggests that Tirofiban as an adjunct therapy to acute ischemic stroke does not increase the risk of sICH or death in stroke patients, but also does not increase the rate of favorable outcomes.
Abstract WP319: Continued Nationwide Decline in Stroke Related In-hospital Mortality in United States
Authors: Afzal Mohammad Rauf , Maud Alberto , Cruz-Flores Salvador , Qureshi Mohtashin A , Qureshi Ihtesham A , Vellipuram Anantha R , Piriyawat Paisith , Rodriguez Gustavo J , Khatri Rakesh
Published: October 2018

Background and Purpose:
Previously a downward trend in stroke related in-hospital mortality was noted from 1996 to 2006 reflecting advancements in acute stroke care. Given ongoing improvement in acute stroke care models and therapies, our study assessed nationwide patterns in in-hospital mortality related to acute stroke for next decade.

Methods:
Patients with acute stroke were identified from the nationwide in-patient sample database for the years 2007 to 2014 using International Classification of Diseases, Ninth Revision procedure codes. Time trends in the proportion of stroke hospitalizations that resulted in death were assessed.

Results:
Between 2007 and 2014, overall stroke hospitalizations increased from 1017 414 in 2007 to 2008 to 1114 960 in 2013 to 2014, whereas percentage stroke hospitalizations that resulted in death decreased from 8.98% in 2007-2008 to 7.34% in 2013-2014 (P<0.0001). Unadjusted Odds of mortality decreased regardless of stroke type: ischemic stroke (IS) (OR 0.798, 95% CI 0.762 to 0.835), subarachnoid hemorrhage (SAH) (OR 0.885, 95% CI 0.810 to 0.968), and intracerebral hemorrhage (ICH) (OR 0.865, 95% CI 0.824 to 0.908). In multivariate analysis these odds remained significant (IS: OR 0.813, 95% CI 0.770 to 0.859), SAH: OR 0.680, 95% CI 0.611 to 0.757, ICH: OR 0.707, 95% CI 0.664to 0.754) after adjusting with age, gender, race, medical comorbidities, in-hospital complications, insurance status and APRDRG Severity scale).

Conclusions:
There is continued decline in Nationwide In-Hospital Mortality among hospitalized acute stroke patients. This reflects ongoing improvement in stroke care models and advancement in therapies.
Abstract WP323: Using Telemedicine Eliminates the Weekend After-Hours Effect in Acute Ischemic Stroke Patients
Authors: Cossey Tc , Cai Chunyan , Bambhroliya Arvind , Jagolino Amanda , Ankrom Christy , Savitz Sean , Wu Tzu-Ching
Published: October 2018

Background:
Stroke outcomes have been shown to be worse for patients presenting overnight and on weekends (off-hours) to stroke centers compared with those presenting during business hours (on-hours). Not all stroke patients present to stroke centers. Telemedicine (TM) helps provide evaluation and safe management of stroke patients. The UT Teleneurology (UTT) hub provides acute neurological coverage by stroke specialists to 19 spoke centers. To our knowledge, variation in patient care and outcomes based on time of hospital presentation has not been thoroughly studied in stroke patients managed via TM.

Objective:
Compare time metrics and outcomes of stroke patients who were assessed and received IV-tPA via TM during off-hours with those during on-hours.

Methods:
In a retrospective query of the UTT registry from 9/15 - 12/16, we identified 425 stroke patients who were assessed via TM and received IV-tPA - 424 were included in our analysis, one was excluded after quality check. We compared baseline characteristics, clinical variables, time metrics, and outcomes between the off-hours (5pm-7:59am, weekends) and on-hours (weekdays 8am-4:59pm) patients (Table 1).

Result:
Of the 424 patients, 268 were managed via TM during off-hours, and 156 during on-hours. Baseline characteristics and clinical variables were similar between the groups. Importantly, there were no differences in all relevant time metrics including door to needle time. IV-tPA complications (including all ICH, any systemic bleeding, and angioedema), discharge disposition, and 90-day mRS were also similar in the groups.

Conclusion:
There was no difference in clinical outcomes between the patients treated off-hours vs on-hours. Unlike in-person neurology coverage at many centers, the coverage provided by UTT does not differ depending on the hour or day. Access to stroke specialists 24/7 via TM can ensure uniform and rapid clinical care for acute stroke patients regardless of the time of day or day of the week.
Abstract WP329: T2 Spotty Sign on Magnetic Resonance Imaging Should be Associated With Hematoma Expansion in Patients With Intracerebral Hemorrhage
Authors: Sato Takahiro , Suda Satoshi , Shimoyama Takashi , Aoki Junya , Suzuki Kentaro , Nisiyama Yasuhiro , Kimura Kazumi
Published: October 2018

Introduction:
The presence of spotty lesions in ICH on T2, which we determined as a spotty sign, is occasionally observed. Our study was aimed to determine whether the presence of spotty sign on T2 could be an independent prognostic marker for hematoma expansion in ICH patients.

Method:
Patients with spontaneous ICH were retrospectively identified and their MRI images were reviewed. The spotty sign was defined as “the small lesions don’t matter the size and shape in the hematoma on MRI T2-weighted images”. Significant hematoma expansion was defined as an absolute increase of hematoma volume of >6.0mL or an increase in hematoma volume of >33%. Neurological severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS) scores at admission. Univariate and multivariable logistic regression analyses were applied to assess the presence of the spotty sign and its association with hematoma expansion.

Results:
A total of 145 patients were enrolled, and 20 (14%) showed hematoma expansion, and 58(40%) had T2 spotty sign (Figure). Patients with hematoma expansion had a significantly larger hematoma volume (11.74ml vs 6.07ml, P<0.031), higher NIHSS score at admission (13 vs 7, P=0.002), and at discharge (8 vs 4, P=0.001) than those without expansion. Further, they had a higher yes findings rate of T2 spotty sign (65% vs 35%, P=0.002). Multivariate logistic regression analysis demonstrated that the spotty sign was an independent predictor of hematoma expansion (odds ratio [OR], 3.374; 95% confidence interval [CI], 1.110-10.256; P=0.032).

Conclusion:
The presence of a spotty sign on the initial MRI T2 scan should be associated with hematoma expansion in ICH patients.