bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP234: Process Improvement Drives Improved Time to Treatment in a Teleneurology Partnership
Authors: Jolly B. Tilman , Largoza Shan
Published: October 2018

Introduction:
Door-to-needle time (DTN) is a primary metric of operational success in the provision of thrombolytic therapy in cases of acute ischemic stroke (AIS). A telemedicine provider and a multihospital system collaborated to improve notification of the need for consultation by introducing an online consult request system for teleneurology consultations. A simplified user interface allowed for notification from any device with an active Internet connection, and provided user capability with minimal training.

Hypothesis:
An online directed consult request system will reduce DTN.

Methods:
This observational study assessed changes in DTN before and after institution of an updated consult process. Prior to institution of the process change all consults were identified through a phone call to a consult coordination center with required information as part of the interaction. After the process change all acute stroke consults were requested through on online automated methodology. Sample mean DTN times among thrombolytic cases were compared using one-way ANOVA. Other related variables are reported.

Results:
Five hospitals in a single hospital system participated in the conversion from the original to the updated communications method, with staggered conversion dates. The sample includes 220 total cases pre-conversion and 128 total cases post-conversion over a total time of 18 months. Among thrombolytic cases, the DTN pre-conversion was 65.3 minutes and 51.3 minutes post-conversion (p=0.0003). There were no significant differences among the samples related to age, gender, NIHSS or other premorbid conditions. There were no significant differences found related to length of stay (LOS) or disposition.

Conclusion:
The study demonstrates a significant and immediate effect on DTN related to an isolated change in the methodology of consult request between a hospital system and a telemedicine provider. Future study will examine effects on clinical outcome, LOS, and financial performance.
Abstract TP237: Improving Door to Needle (dtn) Times and Culture of Treating AIS Using a Stroke Alert RN (SA-RN)
Authors: Pisarra Christine R , Robison Trudy B
Published: October 2018

Background and Purpose:
In 2012 Saint Francis Hospital, a community hospital was challenged with extended DTN times, low treatment rates of AIS, and no formal inpatient stroke process. In 2012, primary stroke diagnosis volume was 614, only 13 patients were treated with Alteplase for AIS, with a DTN median of 92 minutes. Leaders were concerned with culture of not treating with Alteplase and desired improvement.

Methods:
Equip key clinical leaders for both Emergency and Inpatient stroke alerts, using a Neuro ICU nurse in the role of
Stroke Alert Nurse (SA-RN)
. 2012 SA-RN role was created to standardize assessments, NIHSS, administration of Alteplase, and monitoring post-procedure. Efforts were focused on improving time sensitive outcomes, i.e. DTN, LVO assessment, and BP control to mitigate s-ICH. The SA-RN role includes intensive training regarding care of the AIS patient. Audits were used to assure expected outcomes. Education included neuro anatomy and monthly case reviews allowing SA-RN Q&A.

Results:
Positive trends seen were (1) increased stroke alert volume, (2) decreased DTN, (3) increased Alteplase administrations. Stroke alert volume, both from the ER and the inpatient units, grew as the staff became more comfortable with stroke identification. Stroke Alerts: 2012 (179), 2013 (322), 2014 (405), 2015 (840), 2016 (1312) Alteplase Administrations: 2012 (13), 2013 (19), 2014 (17), 2015 (73), 2016 (156) DTN median: 2012 (92m), 2013 (76m), 2014 (62m), 2015 (56m), 2016 (44m)

Conclusion:
The addition of a clinical leader in the role of SA-RN is recommended for a stroke program with limited resources. The SA-RN allows for consistency of assessment, Alteplase administration, decreased DTN, increased compliance with post-Alteplase monitoring standards, and therefore decreased risk of s-ICH. The SA-RN is for Saint Francis Hospital as a valuable, trusted and consistent member of the stroke team.
Abstract TP239: Initial Results From a Community Emergency Medical System Based Bypass Protocol Using Rapid Arterial Occlusion Scale to Screen for Emergent Large Vessel Occlusion
Authors: Ramakrishnan Pankajavalli , Gossage M. O’Brien , Leesch Wolfgang , Sanderson J. Frank , Kostov Dean , Vermette Tonya
Published: October 2018

Introduction:
Although mechanical thrombectomy (MT) is the standard of care for patients with acute ischemic stroke due to emergent large vessel occlusion (ELVO), few patients remain eligible for MT due to pre-hospital delays and presentation to non-MT capable hospitals. Emergence of in field screening tools have allowed EMS to reliably identify patients with likely ELVO, thus facilitating their direct triage to MT capable hospitals for prompt thrombectomy.

Methods:
In collaboration with the Peninsulas EMS Council (PEMS), we implemented a community based pilot program in the Hampton Roads region of Southeastern Virginia to identify patients with ELVO by utilizing the Rapid Arterial oCclusion Evaluation (RACE) scale, a validated in field screening tool. Under this protocol, since March 1
st
, 2017, patients with a RACE score of ≥ 5, presenting within 6 hours of last known well would be transported directly to a Comprehensive Stroke Center (CSC) rather than a Primary Stroke Center (PSC), provided the bypass does not prolong the trip by more than 15 minutes. We present the initial results of this study including iv tPA and MT treatment rates, time metrics, and patient outcomes, in comparison to the pre-RACE protocol data.

Results:
Between March 1
st
and June 30
th
, 2017, of the 75 brain attacks received in our CSC, 45 patients were screened using the RACE scale by the EMS. 30 patients scored ≥ 5 on the RACE scale (RACE +) and 21 of those bypassed PSCs on their way. RACE + patients had a higher median NIHSS (16 vs. 6,
p
< .0
5
), and ischemic strokes (70% vs. 58%), compared to the non-RACE + patients in the preceding 4 months. Improved time metrics (median) were observed for symptom onset to arrival (54 min vs. 81 min), arrival to CT (8.5 min vs. 12 min,
p
< .05), DTN (36 min vs. 47 min), DTG (94 min vs. 105 min), and arrival to recanalization with MT (142 min vs. 185 min). IV tPA (27% vs. 11%) and MT treatments rates (33% vs. 11%) with TICI ≥ 2b (90% vs. 77%) were higher in the RACE + patients compared to the non-RACE + cohort.

Conslusion:
Our pilot program employing RACE as an in field screening tool for ELVO and using it to bypass PSCs in favor of CSCs is feasible in the community setting, and demonstrates improved metrics in key domains known to be associated with better outcomes for these patients.
Abstract TP24: Outcomes in Patients With Acute M2 Occlusions Undergoing Endovascular Reperfusion Therapy
Authors: Lee James , Rybinnik Igor , Mehta Deviyani
Published: October 2018

Introduction:
Acute ischemic stroke remains a devastating disease that portends a high rate of morbidity and early mortality without intervention. Although significant advances have been made with tissue plasminogen activator and mechanical thrombectomy in M1 occlusions, the effect in patients with M2 occlusions is poorly understood. The aim of this study is to determine if M2 revascularization is associated with improved functional outcome and severity of stroke.

Hypothesis:
We hypothesize that endovascular therapy in patients with M2 occlusions will portend better functional outcomes and improvement in severity of stroke.

Methods:
We generated a retrospective database of stroke patients who received endovascular intervention over a 5-year period. We identified suspected M2 occlusions on CT angiography and confirmed these findings with cerebral angiograms. Demographic information, including age, sex, side of occlusion, as well as functional outcome and stroke severity were assessed via initial and discharge modified Rankin (mRS) and National Institutes of Health Stroke Scale (NIHSS).

Results:
We identified 224 patients who received endovascular intervention at our institution over the study period. From this group, 53 candidates with suspected M2 occlusions on initial CT angiography were identified, of which 36 patients (15 female, 21 male) were confirmed to have M2 occlusions on cerebral angiogram. The average age for patients was 71.0 (female= 72.9 ± 14.6; male= 69.7 ± 14.1). NIHSS showed dramatic improvement from admission to discharge, while mRS showed mild-to-moderate benefits (Table 1).

Conclusion:
Endovascular therapy in M2 occlusions showed marked improvement in severity of stroke symptoms and mild benefits in functional outcome. Although further studies will be needed to analyze the magnitude of this effect, endovascular therapy does seem to be a useful intervention to improve the functional outcome and severity of stroke in M2 patients.
Abstract TP242: Factors Influencing Timeliness of Stroke Transfer From the Emergency Department
Authors: Hayes Mitchell , Schlundt David , Bonnet Kemberlee , Vogus Timothy , Kripalani Sunil , Froehler Michael , Ward Michael
Published: October 2018

Background:
The emergency department (ED) plays a pivotal role in the care of patients with acute ischemic stroke, particularly when transferred to another facility for definitive treatment. Our objective was to identify potential factors that influence the timeliness of interfacility transfer for ED patients with an acute ischemic stroke.

Methods:
We conducted semi-structured interviews with 39 staff at three EDs that routinely transfer acute ischemic stroke patients. A structured interview guide was developed and piloted prior to use. It included the following topics: staff roles, admission and transfer processes, communication, and facilitators/barriers to timely care. Interviews were recorded, transcribed, and analyzed using an iterative inductive-deductive approach to build a list of subthemes, and supporting quotes using prespecified themes: 1) resources, 2) processes and protocols, and 3) organizational behavior (e.g., communication and coordination).

Results:
Timely care of acute stroke patients requires a highly coordinated effort within the ED and between facilities (Table). We found that existing ED-based protocols were viewed as facilitating timely tPA treatment but might ignore more severe, potential thrombectomy candidates. Lack of protocolized guidance on imaging (i.e., angiographic) selection and eligibility for treatment options creates uncertainty for emergency physicians forcing reliance on neurology consultation for decision-making. Further, enhanced coordination between organizations such as autoaccept policies and teleneurology services were seen as facilitators to timeliness of care and transfers.

Conclusions:
Lack of ED-based protocols to guide angiographic imaging in suspected stroke patients may hinder identification and treatment of acute large vessel ischemic strokes and may be a source of intervention. Further, enhancing organizational coordination is a novel direction to enhance timeliness of transfers.
Abstract TP243: SpeedPass: A Pilot Project Utilizing an Online Tool Reduced Door-to-Needle Time in a Community-Based Telestroke Program
Authors: Mateen Pamir , Jung Syung , Baig Mirza , Halligan Jennifer , Saadat Mohsen
Published: October 2018

Background:
Through application of the American Stroke Association Target Stroke Best Practice Strategies, our telestroke program led by internal medicine has dramatically improved door-to-needle (DTN) time for thrombolysis. However, a persistent delay was noted in the time interval between patient arrival and on-screen evaluation by a teleneurologist. We collaborated with a telestroke vendor on a pilot project, “SpeedPass”, in order to reduce the delay.

Methods:
In the “SpeedPass” pilot project, initiation of teleneurology consultation was converted from a traditional phone process to an online format. SpeedPass was applied to all patients presenting to the hospital with acute ischemic stroke symptoms within the window period for thrombolysis. The online format was completed by a senior internal medicine resident or an attending physician with specific information such as patient identification, arrival time to the emergency room, last well known well time and use of an anticoagulant. Retrospective chart review was performed comparing Door-to-Video (DTV) and Consultation-to-Video (CTV) times between the pre-implementation period (1/1/15-12/31/15) and post-implementation period (1/1/16-4/30/17).

Results:
Data on a total of 47 patients who received thrombolysis was compared. Mean DTV time decreased from 31.86 minutes in the pre-implementation group to 23.96 minutes in the post-implementation group. Mean CTV time decreased from 22.31 minutes to 9.92 minutes respectively. In the pre-implementation group, 6 of 22 patients (27.3%) received thrombolysis within 45 minutes compared to 12 of 25 patients (48%) in the post-implementation group.

Conclusion:
Our streamlined collaborative approach with SpeedPass has significantly reduced triage and teleneurology consultation time. The reduction in CTV and DTV time has resulted in a greater percentage of qualified patients receiving thrombolysis within 45 minutes and being transferred to a comprehensive stroke center. Similar measures could benefit rural and community hospitals that lack 24/7 in-house neurology coverage.
Abstract TP246: Evaluating Thrombolysis Decision Making in Minor Stroke Using Adaptive Discrete Choice Experimentation
Authors: Liberman Ava L , Pinto Daniel , Labovitz Daniel , Naidech Andrew , Prabhakaran Shyam , Prabhakaran Shyam
Published: October 2018

Introduction:
Historically, physicians have been less likely to give intravenous tPA to patients with minor symptoms but evidence that mild stroke carries significant risk of permanent disability may be influencing practice.

Hypothesis:
Important factors in minor stroke thrombolytic treatment decision making will be type of neurological deficit, patient age, and risk of complication.

Methods:
We circulated an online survey to physicians treating acute stroke patients. We used the potentially all pairwise rankings of all possible alternatives (PAPRIKA) methodology via the 1,000Minds platform to calculate point values for six clinical criteria: communication, motor, and sensory deficits from index stroke as well as relevant history (non-ST-segment myocardial infarction within 3 months and genitourinary bleeding within 21 days), age, and premorbid disability. Survey participants were asked to choose between multiple pairs of clinical attributes in two thrombolysis treatment scenarios (e.g., 92 year old with mild hemiparesis versus 75 year old with mild aphasia) that adapted based on their prior responses. We report participant characteristics and mean part-worth utilities representing the relative importance of each criterion.

Results:
Fifty-three participants completed our survey. Most participants were male (32/53), in practice >5 years (37/53), and were vascular neurologists (37/53). Overall (Figure), motor deficits were weighted most heavily (31.8%, SD 9.5) followed by communication (24.1%, SD 9.6) and sensory (16.6%, SD 6.4) deficits. Relevant history was the least heavily weighted of all criteria (4.5%, SD 4.2) while age (10.2%, SD 6.3) was assigned a similar weight as premorbid status (12.8%, SD 6.7).

Conclusions:
In thrombolysis decision-making for patients with minor stroke, participants assigned more weight to patients’ motor and communication deficits than sensory deficits; age, premorbid status, and history did not play a major role.
Abstract TP252: MicroRNA-376a-5p Improves Outcome for Acute Ischemic Stroke After Endovascular Mechanical Reperfusion in Rat Model
Authors: Tuo Yong-Hua , Liu Zhong , Feng Lei , Shi Zhongsong
Published: October 2018

Background:
MicroRNAs are involved in regulating cerebral ischemia process, but its underlying mechanism is unclear. The removal of intraluminal filament in the transient middle cerebral artery occlusion (tMCAO) model resulted in instantaneous recanalization, similar to endovascular thrombectomy in stroke. We previously showed microRNA-376a down-regulation in the ischemic brain in rat tMCAO model with hemorrhagic transformation. This study investigated the role of miR-376a-5p in cerebral ischemia and reperfusion injury after mechanical reperfusion.

Methods:
The intraluminal filament tMCAO model was established in rats with 2 hour ischemia followed by reperfusion. The expression of miR-376a-5p in the ischemic brain and blood were quantified. Intravenous miR-376a-5p agomir was delivered before reperfusion or after reperfusion. Infarct volume, brain water content, neurological score, blood-brain barrier (BBB) damage, and levels of miR-376a-5p, NADPH oxidase (NOX) 4, Caspase-3 and aquaporin-4 were determined at 24-hour after ischemia.

Results:
MiR-376a-5p levels in the infarction core and peri-infarct cortex were decreased at 3 hours after reperfusion in tMCAO model. The decreased levels of miR-376a in ischemic brain and blood lasted for 24 hours after ischemia. Intravenous miR-376a-5p agomir before and after reperfusion increased the expression of miR-376a and suppressed the up-regulation of NOX4, Caspase-3 and AQP-4 in the infarction core and peri-infarct cortex compared with the tMCAO group (p<0.01). Dual-luciferase reporter system showed that NOX4, Caspase-3, and AQP-4 were the direct target genes of miR-376a-5p. MiR-376a overexpression inhibited the up-regulation of reactive oxygen species and neuronal apoptosis in the peri-infarct cortex. Intravenous miR-376a agomir reduced infarct volume, brain edema and reperfusion-induced BBB breakdown at 24-hour after ischemia, resulting in improved neurological outcome (p<0.01).

Conclusions:
MiR-376a-5p overexpression protects against cerebral ischemia and reperfusion injury via downregulating NOX4, Caspase-3 and AQP-4. Infusion of miR-376a-5p agomir represents a novel adjunctive therapeutic strategy to improve outcome after mechanical reperfusion for acute stroke.
Abstract TP255: Calcium Release-activated Calcium Channel Inhibition Protects Against Inflammation in Ischemic Stroke
Authors: Mizuma Atsushi , Kacimi Rachid , Stauderman Ken , Dunn Michael J , Hebbar Sudarshan , Yenari Midori A
Published: October 2018

Purpose:
Inflammatory responses after ischemic stroke contribute to worsening of ischemic brain injury. Calcium release-activated calcium (CRAC) channels are known to be involved in the activation of immune responses in microglia, and have been studied indirectly through non-specific calcineurin inhibitors such as cyclosporine and FK506. Since these compounds have many off-target effects and unacceptable side effects, we studied a novel CRAC channel inhibitor which is specific to the CRAC channel and appears safe in preclinical studies in anticipation of human clinical trials for other indications. We explored whether this inhibitor might improve outcome in experimental stroke by inhibiting microglial activation.

Subjects and Methods:
2-3 month old C57/BL6 male mice, were exposed to transient middle cerebral artery occlusion (tMCAO, filament model) for 2h followed by reperfusion. Some were treated with the CRAC channel inhibitor (CM-EX-137, 5mg/kg IP; tMCAO-CM) or vehicle control (tMCAO) daily beginning immediately after occlusion and the following two days. Brains were collected 3d post-stroke. Neurological function was evaluated using a Bederson score, elevated body swing test, adhesive removal test, and corner test at baseline, at 3, 24 and 72 h. Relative cerebral blood flow (rCBF) was studied in some mice using laser Doppler flowmetry. Ischemic lesion size was evaluated by 2,3,5-triphenyl tetrazolium chloride (TTC) staining. Microglial/monocyte activation was assessed by isolectin B4 histochemistry.

Results:
A total of 18 mice were studied (tMCAO-CM: 8; tMCAO: 8, sham:2). rCBF was no different between experimental groups, and is consistent with the notion that the compound should not alter blood flow. Neurological function at 1 & 3d after ischemia was significantly improved in tMCAO-CM group compared to tMCAO (p<0.001). The CM compound also significantly reduced infarct volume by ~60% (p<0.05). Isolectin B4 staining was markedly reduced in the tMCAO-CM group compared to tMCAO 3d post ischemia (p<0.01).

Conclusion:
CRAC channel inhibition protects against experimental stroke by decreasing lesion size, improving neurological outcomes and decreasing microglial activation.
Abstract TP26: Endovascular Therapy in Patients With Low NIHSS Score on Presentation
Authors: Nogueira Raul G , Haussen Diogo , Veznedaroglu Erol , Budzik Ronald , Gupta Rishi , Grossberg Jonathan , Barreira Clara M , Bouslama Mehdi , English Joey , Baxter Blaise , Bartolini Bruno , Frankel Michael , Liebeskind David ,   Trevo Retriever Registry Investigators
Published: October 2018

Introduction:
Approximately 2/3 of all AIS present with NIHSS 0-5. While it has been demonstrated that LVO can be found in ~10-20% of all low NIHSS patients, outcome data in this population remains scarce. Indeed, only 14/1766 patients in the recent endovascular RCTs had baseline (b) NIHSS in the 0-5 range. Yet, the presence of LVO in the setting of low NIHSS is associated with ~10-fold increase in subsequent deterioration. We aim to describe the outcomes in a large cohort of low NIHSS patients undergoing thrombectomy.

Methods:
Patients derived from a large prospective multicenter international stent-retriever registry (Trevo Registry, n=2,010). Baseline and outcome variables were compared according to bNIHSS 0-8 vs >8 and bNIHSS 0-5 vs >5. The primary and secondary efficacy endpoints were the rates of 90-day mRS 0-2 and mTICI 2b-3, respectively. Safety endpoints included sICH and 90-day mortality.

Results:
A total of 1,985 patients were included. As compared with patients with higher baseline NIHSS, low baseline NIHSS (0-8, n=342; 0-5, n=160) patients were younger, had less comorbidities and better functional status, more frequently had MCA-M2 or vertebrobasilar occlusions, less frequently received IV tpa, and underwent thrombectomy at later times (Table 1). The reperfusion outcomes were nearly the same. There were no significant differences in procedure-related complications, which were overall low (Table 2). The rates of 90-day mRS 0-2 were significantly higher in the lower NIHSS patients (p<0.001); however, ~20% of those patients were not independent and ~7% were dead at 90 days despite presenting with low clinical severity.

Conclusion:
Despite safe and efficacious endovascular reperfusion, low-NIHSS LVO patients have a relatively high proportion of bad outcomes. This supports the notion that many of "mildly" presenting patients do not fare well. A randomized clinical trial including immediate endovascular treatment in this patient population is warranted.
Abstract TP265: Confidence in Stroke Abstraction Increases After Focused Training
Authors: Hess Maureen , Bluma Dot , Mallas-Serdynski Lynn
Published: October 2018

Background and Purpose:
Abstractors of stroke records are at various levels of expertise in their role. Many have not received formal training and lack total confidence in the reliability of data entry. The purpose of this study was to engage participants in a 4-hour educational session to determine changes in confidence in performing stroke data abstraction and methods of interpretation.

Methods:
Pre and post-session surveys that contained six identical questions were utilized. The questions, reflected in the graph below, were utilized to measure changes in confidence when performing several tasks related to stroke record abstraction and data interpretation. Participants were asked to self-identify confidence level in performing the tasks on a scale of 1-4 at pre-session and again at post-session, where 1 is not at all confident, 2 is not very confident, 3 is somewhat confident and 4 is very confident.

Results:
Three abstraction trainings from April 2016 to April 2017 found a robust confidence level increase in all surveyed items. The chart displays each element’s mean based on the 1-4 scale. An overall confidence score was calculated at pre-session and at post-session. Internal reliability was measured using Cronbach’s alpha, and alpha coefficient for the six items is .924 indicating high internal consistency.

Conclusions:
The respondents had a mean of 2.37 pre-session compared to 3.28 post-session. This demonstrates an increase of 0.91 points from pre- to post-session, indicating a significant increase in confidence of data entry following the four-hour training course.
Abstract TP266: Linking Inpatient Coverdell Stroke Program Registry to Commercial Claims Data in the United States: Assessing Feasibility and Representativeness Among Adults With Ischemic Stroke
Authors: Patorno Elisabetta , Schneeweiss Sebastian , Lee Moa , George Mary G. , Barberio Julie A. , Mogun Helen , Schwamm Lee H.
Published: October 2018

Background:
Linking inpatient stroke registries to commercial claims data can provide a unique data source with detailed in-hospital data and long-term information on patient history, post-stroke care, and health outcomes, to answer clinical and pharmacoepidemiological research questions. Such linked data can offer a broader picture than the solely linkage to Medicare Fee-for-Service data.

Objectives:
To assess the feasibility of linking the Paul Coverdell National Acute Stroke Program registry (PCNASP) to commercial claims data and to evaluate the representativeness of the identified linked population.

Methods:
All stroke admission records entered in PCNASP between 2008-2015 were considered for linkage to longitudinal patient claims records from a large U.S. commercial health insurer using an algorithm based on age, gender, admission date, discharge date, primary diagnosis, and state. We assessed the linkage quality via the uniqueness level, i.e., the percentage of unique records among the linked subset. The representativeness of the claims-PCNASP-linked population was assessed via absolute standardized differences (SD) for a range of patient and hospital characteristics among linked and unlinked patients with a hospital discharge diagnosis of ischemic stroke.

Results:
From a claims-based population of 105,033 stroke hospitalizations, a total of 5,975 records (5.7%) were linked to PCNASP with a 99.1% uniqueness. Baseline patient characteristics and in-hospital information between linked and unlinked patients were overall balanced, as assessed by SD<0.1, despite minor imbalances (0.1<SD<0.3). (Table)

Conclusions:
A high-quality linkage between PCNASP and commercial claims data using indirect identifiers is feasible allowing to combine detailed disease markers of the acute stroke care episode with long-term follow-up. Despite minor imbalances, the linked subset appeared to be representative of the overall claims-based population with stroke.
Abstract TP270: Stroke Code Simulation for Neurology and Emergency Medicine Residents
Authors: Kaur Gurmeen , Shah Vishal , Kapur Puneet , Stein Laura , Dhamoon Mandip S , Masoud Hesham
Published: October 2018

Background:
Simulation-based learning has improved medical knowledge, proficiency and performance. The treatment window for acute stroke is limited, making preparedness exceedingly critical. We aimed to assess improvement in performance in first responders to ‘stroke codes’, namely junior Neurology and Emergency Medicine (EM) residents. EM residents were included because EM physicians often make tPA decisions at peripheral and non-academic hospitals.

Methods:
14 Neurology and 10 EM residents participated at Upstate Medical University, Syracuse, New York. The simulation consisted of senior Neurology residents playing the roles of stroke patient, CT technician and radiologist, nurse, pharmacist and the stroke fellow on-call. The simulation included the time from patient arrival to acute stroke treatment. Each junior Neurology and EM resident completed this simulation, while the rest of the group observed. Cases included stroke mimics, strokes with large vessel occlusions, dissections, cases ineligible for acute intervention, intracerebral and subarachnoid hemorrhages, basilar thrombosis, wake-up strokes, seizure at onset and dissections. Participants reviewed non-contrast CT head, EKG and CT angiography of the head and neck to make decisions about tPA administration and endovascular interventions. This was followed by a debriefing session by the attending and chief residents. Participants filled a pre-and post-simulation graded questionnaire on medical knowledge and confidence (range 0-25, with higher scores reflecting higher performance).

Results:
The mean score was 18 (range 14-23) pre-simulation and 22 (range 18-25) post-simulation for Neurology residents and 14 (range 8-24) pre-simulation and 18 (range 10-23) post-simulation for EM residents. For all residents, pre-and post-median score was 17 and 19 (Wilcoxon signed-rank test p<0.0001).

Conclusion:
Because running an effective stroke code requires coordination and rapid analysis, stroke simulation is an effective way of improving knowledge and confidence among residents and should be integrated into the Neurology and EM residency curriculum.
Abstract TP278: Decade-Long Trends in Recanalization Therapy at a Large Regional Comprehensive Stroke Center in Texas
Authors: Mirtchev Dimitre K , Bambhroliya Arvind B , Indupuru Hari K , Jagolino-Cole Amanda L , Wu Tzu Ching , Grotta James C , Sarraj Amrou , Savitz Sean I , Sharrief Anjail Z , Vahidy Farhaan S
Published: October 2018

Introduction:
Recanalization therapy (RT) is the cornerstone of acute ischemic stroke (AIS) management. We present 10-year trend in RT at our center, and explore effects of increasing telemedicine (TM) access and a Mobile Stroke Unit (MSU).

Methods:
We identified suspected AIS patients between 01/01/2007-12/31/2016 from our prospectively managed registry. Patients presented directly (DP), were transferred-in (TP) from a regional referring hospital with or without TM consultation, or via the MSU. Pre-established TM/MSU period was from 01/01/2007-12/31/2011. We used logistic regression to explore temporal trends among patient groups, report odds ratios (OR) with 95% confidence intervals, and quantile regression to determine the difference in median (DIM) treatment times.

Results:
We reviewed 9,464 suspected AIS cases. 44.8% were in pre-TM/MSU and 55.2% TM/MSU period. Over 10 years, the proportion of DP has significantly reduced [OR 0.84 (0.83-0.86)], whereas non-TM TP has increased [OR 1.05 (1.03-1.06)]. In TM/MSU period, the proportion of TM patients has significantly increased each year [OR 2.00 (1.85-2.16)]. Fig. 1 shows the proportional distribution. 29.3% of patients were treated with tPA; significantly higher during the TM/MSU period compared to pre-TM/MSU [(31.5% vs 21.5%, OR 1.21 (1.11 - 1.33)]. Median onset to needle time was significantly shorter for the TM/MSU period [140(99-193) vs 157(119-198), DIM -17(-10.7,-23.2)], as was the proportion of symptomatic intracranial hemorrhage (sICH) [(1.7% vs 4.2%), OR 0.40(0.25-0.64)]. With each increasing year, a significantly greater proportion of patients were discharged home after controlling for age and NIHSS [OR 1.12 (1.10-1.14)].

Conclusion:
Over a decade, we saw a steady increase in proportion of tPA treated cases. With the introduction of TM and the MSU at our institution, more AIS patients received RT, with faster onset to treatment, fewer sICH complications, and improved discharge disposition.
Abstract TP280: Factors Associated With Outpatient Follow-up in Stroke Clinic After Discharge From a Comprehensive Stroke Center
Authors: Butt Reema T , Miller Daniel , Malik Shaneela , Ismail Mohammed , Schultz Lonni , Gatt Justin
Published: October 2018

Introduction:
Outpatient follow-up after a stroke is crucial for decreasing hospital readmissions, managing complications secondary to stroke, and preventing future stroke. Poor stroke follow-up rates have prompted further investigation at our comprehensive stroke center.

Aim:
To identify factors associated with failed follow-up in stroke clinic after discharge from the Hospital.

Methods:
A retrospective analysis was conducted on patients discharged with a diagnosis of acute ischemic stroke or TIA from July 1, 2016 to Dec 31,2016. Patients who expired or were enrolled in hospice by discharge were excluded. Chi-squared tests and two sample t-tests tests were performed to assess the associations of 90-day follow-up visit with patient demographics, clinical factors and discharge variables. Multivariate analysis was performed on variables with p value <0.10.

Results:
In this 6 month period, 384 patients were identified, of which only 45% (174) followed up in the stroke clinic by 90 days. Differences were significant for insurance carrier [commercial (55%) vs Medicare (28%) and Medicaid (31%); p<0.001)], appointment scheduled at discharge (54% vs 32%, p<0.001), primary service [neurology (49%) vs medicine (13%); p<0.001)], mRS [less than 4 (52-58%) vs 4 (34%) vs 5 (0%); p=0.01], ambulatory status [independent (52%) vs assistance (44%) vs non-ambulatory; p=0.003], transition of care call [called-confirmed (79%) vs called-unreachable vs no documented call (41%)] and discharge disposition [Home (52%) vs acute care facility (38%) vs other (35%); p=0.006]. Insurance carrier, ambulation, transition of care call and appointment at discharge statuses remained significant in the multivariate analysis.

Conclusion:
Multiple factors can predict clinic follow-up in stroke patients. These factors can be used to identify patients at risk of not completing stroke preventative services, to structure stroke discharge clinics, and proactively improve stroke follow-up rates.
Abstract TP282: S
3
TOP for Stroke: Improving In-Hospital Stroke Alert Activation Criteria
Authors: Chojecka Pola A , Richards Jason , Burnett Nicole , Wilson Susan E , Waller Ann , Beckwith Anne , Barr Luke K , Huang David Y , Powers William J
Published: October 2018

Background and purpose:
The study aimed to assess the efficiency (percent treated) of existing in-hospital stroke alert activation criteria and to improve these criteria.

Methods:
209 patient records from in-hospital stroke alerts at an academic medical center between January 2015 and December 2016 were reviewed retrospectively. Patients were sorted into five categories by final diagnosis: cerebral ischemia, cerebral hemorrhage, seizure, delirium or toxic/metabolic encephalopathy, and other. Acute treatment result of any in-hospital stroke was recorded. The study team determined adherence to the institution’s existing in-hospital stroke alert activation criteria. To improve efficiency a new set of in-hospital stroke alert activation criteria called “S3TOP for Stroke” was then developed. The checklist for “S3TOP for Stroke” guides hospital staff to assess the following items: symptoms, sedation, sugar, time, oxygenation and pulse. The checklist was then retrospectively applied to the 209 records.

Results:
Of 209 patients who received in-hospital stroke alerts according to existing activation criteria: 192 (91.9%) met existing criteria, and 14 (6.7%) received acute stroke treatment. Applying the “S3TOP for Stroke” checklist to the study group excluded 56 of these and included all 14 (14/153 =9.2%) who received acute stroke treatment.

Conclusions:
This study found good adherence with poor efficiency for existing institutional stroke alert activation criteria. Retrospectively, the “S3TOP for Stroke” checklist improved efficiency. Prospective testing of this algorithm is underway.
Abstract TP286: Efficacy of Quality Improvement Protocols Across Diverse Modes of Arrival for Thrombectomy Patients With Ischemic Stroke
Authors: Brandel Michael G , Wali Arvin R , Santiago-Dieppa David , Cheung Vincent , Steinberg Jeffrey , Rennert Robert , Jurf Julie , Porras Kevin , Abraham Peter , Modir Royya , Meyer Brett , Pannell Scott , Khalessi Alexander
Published: October 2018

Background:
Quality improvement protocols (QI) aim to reduce in-hospital delays that result in prolonged door-to-groin-puncture time (DGPT) for the endovascular treatment of ischemic stroke. At our institution, we implemented a comprehensive QI protocol to reduce DGPT from June 2015 to December 2016. Here we discuss the QI protocol on DGPT across diverse modes of arrival to our interventional suite.

Methods:
61 patients underwent mechanical thrombectomy for ischemic stroke during our QI period. Independent samples t-tests were used to investigate differences in DGPT early in the QI protocol (July 2015 to February 2016, n=30) versus late in the QI protocol (March 2016 to December 2016, n=31) for patients that presented via emergency medical services (EMS), inpatient, and hospital transfers.

Results:
Each mode of arrival demonstrated reductions in DGPT (Figure 1). The greatest reduction in DGPT was for the 23 patients within the emergency medical services (EMS) group with a mean reduction of 39 minutes which approached, but didn’t achieve, statistical significance (138 vs. 99; p=0.06).

Discussion:
QI interventions impact DGPT across different patient arrival methods. QI protocols accounting for patient presentation allow tailored approaches to institutional measures to reduce DGPT.
Abstract TP287: tPA Consent: The Role for Paternalism in the Golden Hour
Authors: Jacob Sneha , Amelia adcock , Murray Ann , Samadi Yasamin , Ranasinghe Tamra , Petrone Ashley , Seachrist Eric
Published: October 2018

Background:
The founding principles of medical ethics are Beneficence, Justice and respect of patient Autonomy. Medical care in the US has rapidly moved away from the paternalistic approach toward an emphasis on patient autonomy however, conditions with limited treatment options (eg ischemic stroke) necessarily impact autonomy. Adequate understanding of complex medical decisions is paramount to good medical care, however the factors swaying patients and their surrogates are under-studied.

Hypothesis:
Patients prefer a paternalistic approach when making acute medical decisions.

Methods:
A survey replicating surrogate decision making in an acute ischemic stroke scenario was conducted among adults. Descriptive statistics were used in the analysis. Participants were presented with three different descriptive consenting scenarios. All three scenarios contained the general statement ‘‘we would recommend IV t-PA’’. Scenario 1 also included a declaration of IV t-PA’s benefits and FDA status. Scenario 2 provided statistical details. Scenario 3 stated that acute treatment would be the decision the treating physician would make for their own loved one.

Results:
184 people completed the survey of which 66% were females. Among respondents, 4% did not complete high school, 31% were high school graduates, and 65% attained some additional education. Overall, there was no statistically significant difference in agreeableness to each of the scenarios, however 84% of respondents would choose to receive tPA if presented with scenario 3. Regardless of education, the trend was the same; Scenario 3 > Scenario 1 > Scenario 2.

Conclusion:
Based on the results of a hypothetical consenting scenario for IV tPA administration, the majority of respondents preferred a paternalistic approach. Educational status and gender did not influence the participants’ preference. Medical paternalism is discouraged, however this data indicates that an intense collaboration is needed between physicians and patients so that patients can autonomously make choices that are informed by both medical facts and physician experience. Further studies are warranted in order to identify the optimal approach while keeping in mind the ethical and legal aspects of medical decision-making.
Abstract TP300: Where Did They Go? Recruitment and Retention in the Michigan Stroke Transitions Trial (MISTT)
Authors: Fritz Michele C , Hughes Anne K , Woodward Amanda T , Freddolino Paul P , Reeves Mathew J
Published: October 2018

Background:
Poor transitions adversely affect stroke survivors and contribute to readmissions and poor quality of life. More randomized trials are needed to identify effective interventions to improve patient wellbeing during the transitional period. However, the post-discharge period is complex and presents many practical challenges for transition trials when patients move between different care settings. We report on recruitment and retention challenges in the Michigan Stroke Transitions Trial (MISTT) designed to improve the transition experience of stroke survivors.

Methods:
MISTT, a 3 group pragmatic randomized trial, tested the efficacy of an in-home social work case management (SWCM) program and SWCM with an informational website against usual care. Eligible subjects were acute stroke patients discharged directly home or who had an expected rehab stay <4 weeks. Randomization occurred the day subjects were discharged home. Patient-centered outcomes were collected by phone 90-days later.

Results:
Figure 1 shows recruitment and retention data during the first 15 months. Of 242 subjects enrolled, 40 (17%) were dropped pre-randomization largely due to extended rehab stays. Of 136 subjects randomized to SWCM or SWCM+website, the intervention was not started in 14 (10%) due to early withdrawals or unwillingness to participate. A total of 188 subjects were eligible for 90 day follow-up. Lost to follow-up (n=43) occurred in 20%, 24% and 21% of the usual care, SWCM, and SWCM+Website groups, respectively. Half of the LTFU was due to patient withdrawals (n=23); reasons included study demands (n=9), protocol deviations (n=6), and deteriorating health conditions (n=5).

Conclusion:
The complexity of stroke transitions creates challenges for recruiting and retaining study participants in transition trials. These issues are important to consider in future study design and are relevant to understanding the validity of study results.
Abstract TP310: Inter- Rater Reliability of Telephonic Modified Rankin Scale Obtained for a Telestroke Network
Authors: Trevino Alyssa D , Shannon Steve O , Bozorgui Shima , Savitz Sean I , Wu Tzu-Ching , Ankrom Christy M
Published: October 2018

Introduction:
The modified Rankin Scale (mRS) has been established as a standard measurement of stroke disability and is widely used in major stroke clinical trials. Previous studies compared inter-rater reliability between face-to-face and telephone assessments; we aimed to evaluate the reliability of the mRS between two rater’s assessments both conducted by telephone.

Objective:
Identify the inter-rater reliability of mRS of patients interviewed twice by mRS-certified raters over telephone.

Methods:
Patients seen by telemedicine (TM) between 03/2017-04/2017 at UTHealth Lone Star Stroke Consortium spoke sites with discharge diagnosis of ischemic or hemorrhagic stroke and contacted via telephone. They underwent a structured telephone interview conducted by two trained raters of the UTHealth TM research team. The 2 interviews were conducted within 2 weeks of each other. Scoring agreement was measured using the κ statistic.

Results:
Total of 65 patients were in-window for 90 day mRS telephone interviews; excluding deaths, mRS of 30 patients were collected by both interviewers. The overall agree ment between two raters was 43.3% (13 cases). It was most common to disagree by one category (10 cases, 33.3%). The unweighted kappa value (κ) for inter-rater agreement was 0.29 (p = 0.0006), and the weighted kappa value (κ
w
) was 0.50 (p = 0.0000).

Conclusion:
Unlike previous studies, we found reliability of mRS obtained via structured telephone interview in our TM population is uncertain. The inter-rater reliability of mRS assessed by telephone shows discrepancies between interviewers, as >50% of patients did not receive the same score. Our study is limited by small sample size and further studies are needed to confirm our findings. With clinical trials relying on telephone mRS for longitudinal measurement of patient outcome and some requiring mRS on the same patient multiple times during a study, it is important mRS be both reliable and reproducible between different raters.
Abstract TP311: Initial Stroke Severity is a Significant Predictor of All-Cause Mortality
Authors: Alberts Mark , Chen Yen-Wen , Lin Jennifer H , Deshmukh Siddhant , Kogan Emily , Twyman Kathryn , Milentijevic Dejan
Published: October 2018

Background:
The National Institutes of Health Stroke Scale (NIHSS) score has been used to measure initial stroke severity. However, limited data are available on the utility of NIHSS in predicting all-cause mortality risk.

Objective:
To assess the association between stroke severity and mortality in stroke patients, using NIHSS stroke severity scoring.

Methods:
This retrospective cohort study followed patients after first inpatient diagnosis of stroke using OPTUM de-identified Integrated Claims-Medical Database (2007-2016). The NIHSS score was imputed using 100 clinically relevant predictors selected by a random forest method. Patients were classified by NIHSS score into 5 severity groups: no impairment (<1, NI), minor (1-5, Min), moderate (>5-16, Mod), moderately severe (>16-21, MS) or severe (>21-42, S). Patients were followed from stroke diagnosis to the earliest occurrence of either death, end of data or lost to follow-up. Time to death was assessed by Cox proportional hazard regression, comparing more severe stroke patients vs the NI patients (reference group), adjusting for age, gender, comorbidity index, and region.

Results:
A total of 16,554 stroke patients were studied; 17%, 57%, 22%, 2%, and 2% were in None, Min, Mod, MS and S groups, respectively. Mean age was 68 years at stroke diagnosis (ranging 64 to 79 years). Overall, 4.3% had a history of atrial fibrillation and 3.1% received anticoagulants for stroke prevention. Median follow-up was 23, 18, 10, 0.9 and 0.6 months for the None, Min, Mod, MS and S cohorts, respectively. Following stroke diagnosis, 74% of MS and 89% S patients died within 30 days of stroke onset, whereas the NI and Min patients remained alive within 30 days. When compared with the NI patients, more severe patients had significantly increased mortality risk; hazard ratios (95% confidence intervals) were 2.8 (2.2-3.6), 9.7 (7.4-12.6), 116 (86-154), and 364 (270-491) for the Min, Mod, MS and S patients, respectively.

Conclusions:
Mortality rates increased significantly with more severe strokes, as determined by the initial NIHSS score. Over 75% of the patients with moderately severe and severe strokes died within 1 month following stroke diagnosis.