bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P306: The Association Between Treatments and Hematoma Expansion in Thrombolysis Related Hemorrhage: A Multicenter Retrospective Study
Authors: Yaghi Shadi , Leon-Guerrero Christopher R , Dibu Jamil , Ali Syed , Noorian Ali Reza , Boehme Amelia K , Keyrouz Salah G , Hinduja Archana , Bianchi Nicolas A , Marshall Randolph S , Liebeskind David S , Schwamm Lee , Willey Joshua Z
Published: March 2022

Background:
Symptomatic intracerebral hemorrhage (sICH) is the most feared complication of thrombolytic therapy in acute ischemic stroke. There is limited data on efficacy of treatments to prevent hematoma expansion (HE). We hypothesized that treatment for sICH would reduce HE.

Methods:
This study was a collaboration from 5 stroke centers (Columbia University, Massachusetts General Hospital, University of Arkansas, Washington University, and UCLA). Outcome was HE, defined as 33% increase in hematoma volume in the first 24 hours.

Results:
We identified 87 patients with sICH between 1/2009-4/2014 and analyzed the 70 patients (80%) with follow up scans after sICH; those without a follow-up scan were all made comfort care in the first 24 hours and expired. HE occurred in 18 patients (26%); mean duration to diagnosis of sICH was 13±10 hours and mean duration to treatment after detection was 2.4±1.8 hours. On univariate analysis, the only factor associated with increased risk of HE was platelet transfusion (50% vs. 15%,p<0.008). Providing any treatment for sICH vs. none was not associated with reduced HE. There was a trend towards HE with cryoprecipitate treatment (44% vs 23%,p=0.1), time to sICH < 12 hours (42% vs. 19%,p=0.1), and post-thrombolysis fibrinogen < 150 mg/dL (75% vs. 31%,p=0.1). After adjusting for code status, the odds of a patient being treated was increased if the time to diagnosis was <12 hours (OR 5.73, 95%CI 1.46-22.6). After adjusting for time to sICH diagnosis, there was no longer an association between HE and cryoprecipitate use (OR 0.94, 95%CI 0.20-4.46), however, there remained a non-significant association between platelet transfusion and HE(OR 2.93, 95%CI 0.56-15.3). In multi-variable models, none of the treatments given or pretreatment characteristics were associated with reduced HE.

Conclusion:
Although our study is underpowered to detect treatment effect, the treatments used to reverse coagulopathy in sICH were not associated with reduced rate of HE across multiple centers. Larger studies are needed to establish an algorithm to diagnose and treat sICH early enough to prevent HE.
Abstract T P319: Patient Characteristics and Outcomes in Pregnancy-Related Intracerebral Hemorrhage
Authors: Leffert Lisa , Clancy Caitlin , Bateman Brian , Cox Margueritte , Schulte Phillip , Smith Eric , Fonarow Gregg , Schwamm Lee , George Mary , Kuklina Elena
Published: March 2022

Background:
Mortality rates as high as 20% have been reported for pregnant patients with intracerebral hemorrhage (ICH). The aim of this study is to describe the risk factors, management and outcomes of pregnant compared to non-pregnant patients with ICH in the Get With The Guidelines (GWTG) Stroke Registry.

Methods:
Using medical history or ICD-9 codes, we identified 178 pregnant and 4817 non-pregnant female patients aged 18-44 with ICH in GWTG from 2008-2013. Differences in patient and care characteristics were compared by Chi-square tests for categorical variables and Wilcoxon Rank-Sum tests for continuous variables. Stratified logistic regression assessed the effect of pregnancy on outcomes conditional on age and adjusted for patient and hospital characteristics.

Results:
Pregnant ICH patients were younger, had fewer preexisting stroke risk factors and used fewer associated medications. Median initial blood pressures, initial neurologic exam findings and measures of guideline-based care were similar between groups (Table). Stroke onset did not occur in a healthcare setting for >85% of all patients, but pregnant patients took longer to arrive (median 268 vs. 186 min), used EMS less often (29% vs. 39%) and went to larger hospitals with higher annual ICH admissions than non-pregnant patients. Risk adjusted odds of in-hospital death in pregnant women were about half that of non-pregnant women (aOR 0.57, 95% CI 0.34-0.94), but length of stay >6 days (aOR 1.39, 95% CI 0.86-2.27), independent ambulation at discharge (aOR 1.12, 95% CI 0.81-1.54) and discharge to home (aOR 1.10, 95% CI 0.81-1.51) outcomes were similar.

Conclusions:
Pregnant women with ICH are younger and healthier than their non-pregnant counterparts but have similar presenting symptoms. Despite later arrival times, in-hospital mortality is lower, suggesting differences in underlying disease pathophysiology.
Abstract T P32: Infarct Volume as a Potential Prognostic Biomarker for Acute Ischemic Stroke after Intravenous Recombinant Tissue-Type Plasminogen Activator Therapy
Authors: Tateishi Yohei , Hamabe Jumpei , Morofuji Yoichi , Horie Nobutaka , Izumo Tsuyoshi , Hayashi Kentaro , Tsujino Akira
Published: March 2022

Background:
Pretreatment infarct volume has been known as a predictor of outcome in patients with acute ischemic stroke after intravenous recombinant tissue-type plasminogen activator (IV rt-PA) therapy. To confirm the importance of infarct volume in patients with undergoing IV rt-PA therapy, we sought to characterize the relationship between final infarct volume and long-term outcome.

Method:
We retrospectively reviewed outcomes of acute ischemic stroke patients who had treated with IV rt-PA. Patients underwent magnetic resonance imaging at baseline and 7 days after IV rt-PA. Baseline characteristics, stroke features, time from onset to treatment, initial National Institutes of Health Stroke Scale (NIHSS) score, the presence of major artery occlusion, and laboratory findings were recorded. Outcomes included complete independence (mRS of 0 to 1), unfavorable outcome (mRS of 4 to 6) at 90-day, and mortality within 90-day. Multivariate regression analysis was used to identify predictors of the outcomes.

Results:
Of 116 patients, 47 (41%) patients achieved complete independence. At univariate analysis, they were younger (median age, 71 versus 77, p=0.008), had a lower prevalence of diabetes mellitus (23% versus 43%, p=0.040), had a lower initial NIHSS score (median, 8 versus 16, p<0.001), had a lower prevalence of internal carotid artery occlusion (9 versus 29%, p=0.010), had no occlusion (36 versus 10%, p=0.001), had a lower prevalence of parenchymal hemorrhage (2 versus 20%, p=0.004), had smaller diffusion-weighted imaging lesion volume at baseline (median, 2.6 versus 8.0ml, p=0.008) and final infarct volume at 7-day (median, 3.8 versus 42.2ml, p<0.001). Age (Odds ratio [OR], 0.943, 95% confidence interval [CI], 0.896 to 0.992; p=0.024) and final infarct volume (OR, 0.952; 95%CI, 0.992 to 0.982; p=0.002) were identified as independent predictors of complete independence. They also predicted unfavorable outcome (p=0.036 and p<0.001) and mortality (p=0.036 and p=0.035).

Conclusion:
Among patients with acute stroke patients who undergo IV rt-PA therapy, final infarct volume is a critical determinant of 90-day functional outcome and mortality.
Abstract T P323: Corticospinal Tract Disruption in Acute Intracerebral Hemorrhage is Unrelated to Baseline Hematoma Volume
Authors: McCourt Rebecca , Gioia Laura , Kate Mahesh , Treit Sarah , Beaulieu Christian , Butcher Kenneth
Published: March 2022

Background:
Acute hematoma volume is the most powerful predictor of poor functional outcome after intracerebral hemorrhage (ICH). Putative reasons for functional deficits include disruption of white matter (WM) tracts. Fractional anisotropy (FA), as assessed with Diffusion Tensor Imaging (DTI), can be used to assess WM integrity. We tested the hypothesis that larger hematoma volumes are associated with lower FA values in the corticospinal tract (CST).

Methods:
We conducted a prospective cross-sectional imaging study in ICH patients with DTI scans within 7 days of symptom onset. Mean relative FA (rFA) was measured in the entire CST. Hematoma volume was measured using planimetric techniques on acute and follow-up CT scans. Motor function was assessed using a composite of the upper and lower extremity NIHSS subscale (0=normal, 8=hemiplegia) at day 7.

Results:
Twenty-one ICH patients (mean age 72±14) were imaged with DTI. Median hematoma volume was 9.6 (17.6) ml measured at the 1.8 (2.8) hour CT and 12.2 (35.2) ml at the 25.8 (28.9) hour CT. Median NIHSS motor score was 5 (7) at baseline and 3 (7) at day 7. DTI scans were grouped as acute (median time to imaging: 1.7 (0.78) days) and subacute (time to imaging: 6.9 (2.8) days). Mean acute FA was significantly lower in the CST ispsilateral to the hematoma (0.43±0.03) compared to the contralateral CST (0.48±0.03, p=0.002). Mean subacute FA was also lower in the ipsilateral (0.43 ± 0.04) vs. contralateral CST (0.60±0.15, p=0.002). Acute rFA (r= -0.33, p=0.68) and subacute rFA (r=-0.52, p=0.12) were not correlated with day 7 motor function. Acute hematoma volumes were not related to acute rFA (r= -0.33, p=0.35) or subacute rFA (r= -0.05, p=0.88). Patients with hematoma volumes <9ml had similar subacute rFA (0.96±0.05) to those with hematoma volumes >9ml (0.88±0.07, p=0.072). Acute rFA was similar between patients with hematomas directly adjacent to the CST (0.89±0.07) and those with hematomas separate from the CST (0.97±0.02, p=0.23).

Conclusion:
DTI demonstrates evidence of CST disruption in acute ICH. However, CST disruption appears to be independent of baseline hematoma volume. Serial assessment of rFA in ICH is required to further define the relationship between larger hematoma volume, rFA and functional outcome.
Abstract T P325: The Role Of A History Of Coronary Artery Disease, The Need For Transfusion And Outcomes In Patients With Intracerebral Hemorrhage
Authors: Khawaja Ayaz , Boehme Amelia K , George Alexander J , Hays Angela , Kumar Gyanendra , Alvi Muhammed , Miller David , Martin-Schild Sheryl , Harrigan Mark
Published: March 2022

Background and Purpose:
In patients with primary ICH, RBC transfusion (RBCT) may be detrimental and platelet transfusion effects are controversial. Different transfusion thresholds have been suggested in patients with coronary artery disease (CAD). We examined the relationship between transfusion and outcomes in ICH patients with and without CAD.

Methods:
A retrospective review of consecutive patients with primary ICH admitted to two academic stroke centers from 2008-2013 was conducted. Patients age<18 years, in-hospital strokes and outside hospital transfers were excluded. Primary outcome was discharge mRS of 5-6. Logistic regression was used to assess the association with outcomes.

Results:
Out of 456 patients identified, 50 (11.2%) had CAD on admission. CAD patients were older (68 vs. 61; p=0.001). There was no significant difference in frequency of RBCT between patients who had CAD compared to those without (6% vs. 9%; p=0.53). The frequency of platelet transfusion was higher in patients with CAD (26% vs. 7%; p<0.0001). This association was significant after adjusting for ICH score (OR 3.83; 95% CI 1.13-12.9; p=0.031). Patients with RBCT were at greater odds of having a mRS of 5-6 (OR 5.60, 95% CI 2.42-12.9, p<0.001) compared to those without. After adjusting for admission hematocrit, ICH score, and CAD the association between RBCT and mRS remained significant (OR 16.3, 95% CI 2.11-125.9, p=0.007). Patients with platelet transfusion were at greater odds of having a mRS of 5-6 on univariable analysis (OR 2.85; 95% CI 1.42-5.71; p=0.003). This association is no longer significant after adjusting for ICH score, CAD and admission hematocrit (OR 2.88; 95%CI 0.67-12.3; p=0.15). In patients with ICH score 0-2, platelet transfusion is significantly associated with a mRS of 5-6 after adjusting for CAD (OR 2.48; 95%CI 1.16-5.35; p=0.02).

Conclusions:
A history of CAD is not associated with increased frequency of RBCT in ICH compared to patients without CAD, but it is significantly associated with a higher frequency of platelet transfusion. RBCT was significantly associated with poor short-term functional outcomes regardless of CAD history. In patients with low ICH scores, platelet transfusion was significantly associated with poor functional outcomes.
Abstract T P329: Coo-Coo For Compliance: Improving Compliance of Acute Stroke Patient Documentation
Authors: Wolber Nicole E , Paletz Laurie , Steiner Nili , Robertson Betty , Guerra Sonia
Published: March 2022

Introduction/Background:
As a Joint Commission Comprehensive Stroke Center we are charged with the task of meticulous monitoring of vital signs and neurologic status after thrombolytic therapy to prevent complications. This can be difficult to document in real time. In accordance with best practices and the AHA guidelines and the American Association of Neuroscience Nurses, we sought to improve the documentation of vital signs and neurologic evaluations during and after t-PA. During our Joint Commission Comprehensive Stroke Survey we were cited for improving the documentation of vital signs and neurological checks after t-PA.

Background:
We identified nurses were starting documentation at awkward times, i.e. 1538 and attempting to add 15min to this time over a 24 hour period. The nurses were educated about rounding up to the 15min mark, making it easier to add 15min each time. We auditied documentation of every patient who received Acute Stroke Treatment, and sent feed back to nurses in “real time”. We discovered transportation from one department to another caused missed documentation. A transport monitor was purchased that can easily take a full set of vital signs during transport, and nurses were instructed to “back time” the documentation. We found that intensive documentation required the nurse to sift through multiple screens to document findings. The entire neuro team collaborated to create a Stroke Navigator for EPIC. This navigator contains all pieces of expected documentation of the stroke patient in one area of EPIC.

Conclusion:
From January to December 2013, our Stroke Team saw 970 patients. 82 were treated with IV tPA, 18 were sent for Interventional clot retrieval, 6 received both IV tPA and Interventional clot retrieval, and 4 received tPA at another facility and transported to Cedars Sinai for higher level of care. We found issues within the system, that increased the chances of having vital documentation missed, or delayed by the nursing staff. Prior to the implementation of these new strategies our compliance rate with documentation was
32%.
The results after the implementation of our new strategies were staggering. Our nurses were
94%
compliant with documentation.
Abstract T P330: Depression Cognition Screens
Authors: Robertson Betty , Paletz Laurie , Steiner Nili , Wolber Nicole , Guerra Sonia , Stern Martin
Published: March 2022

Introduction/Background:
Evidence suggests that approximately 1/3 of stroke survivors suffer from post stroke depression (PSD) and changes to their cognition. Delay in identifying these patients can effect rehabilitation resulting in poorer functional outcomes, reduced cognitive performance and possibly increase mortality. PSD can occur in all phases of stroke recovery with a peak incidence at 3 - 6 months. Early diagnosis is essential so to apply effective treatment or interventions that can result in enhanced recovery. As a Comprehensive Stroke Center, we at Cedar Sinai hospital are charged with the task of efficiently indentifying patients that are at risk by administrating the Patient Health Questionnaire (PHQ 2) to those who can participate.

Research Question:
Does administering the PHQ 2 during the acute phase of stroke/TIA adequately identify those at risk for Depression and cognitive decline?

Methods:
Plan: As per Joint Commission standard, depression cognition screens are to be conducted prior to discharge.

Do:
Chose a tool that efficiently and skillfully identifies patients at risk.

Study:
Analyze the results.

Act:
Administer the PHQ 2 to those patients who have the capacity. For those patients that have a positive screen, notify their primary care provider for further evaluation or possible intervention.

Conclusions:
We retrospectively reviewed from September 2012 to September 2013 Stroke/TIA patients that had the capacity to participate in the PHQ 2 Depression Cognition screen. We identified that of 442 patients that completed the screen, 43 or 9.7% had depression screen of 3 or greater or demonstrated cognitive decline with score of 1 or less. If not for these evaluations these patient may have not been identified so to assure follow-up and/or treatment which could improve functional outcomes for this patient population. Furthermore it demonstrates the need for continued reevaluation since the incidence of this issue has not reached its peak.
Abstract T P331: Collaborative Multidisciplanary Approach in the Development and Implementation of an Aspiration Risk Tool Within a Certified Comprehensive Stroke Program
Authors: Styron Suzan , Mazabob Janine , Brown Gerard , Walton Michael W
Published: March 2022

Background and Issues:
Dysphagia is the leading neurological cause of aspiration pneumonia in stroke patients. Swallowing abnormalities are associated with a 3-fold higher mortality rate. Accreditation agencies and the American Stroke Association recommend institutions establish a dysphagia screening tool for stroke patients. Early identification decreases adverse health consequences and increases patient family satisfaction.

Purpose:
A multidisciplinary team of nurses and speech and language pathologists developed criteria to improve the identification of patients at risk for aspiration and created standardized tool.

Methods:
A review of the literature provided the frame work to formalize a screening tool. The tool assists the nurse in identifying patients at risk. The screening tool is divided into four sections; cognition, cough assessment, control of oral secretions and oral motor strength. It is required for the patient to pass all four levels. Failure to pass any one of the sections results in a formal dysphagia assessment. Patients that pass the four sections graduate to a water challenge. A cup containing 90cc of water is placed in front of the patient, and the patient is instructed to pick up the cup and take a drink. Nurses observe the patient’s ability to successfully coordinate the task. Observation of choking, coughing, nasal aspiration or requiring frequent verbal cues to swallow results in failure of the water challenge. The failing patient is kept NPO and a formal dysphagia assessment is ordered. Patients’ not exhibiting any signs of aspiration passes the screen.

Results:
The nursing staff recognized the importance of specific anatomical and mechanical components of dysphagia, which led to appropriate referrals to speech and language. Expedited referrals and reduced NPO time resulted in improved patient family satisfaction.

Conclusion:
Through a collaborative multidisciplinary team approach it is possible to develop and implement an evidenced based, reliable aspiration screening tool. This tool should not only be used for stroke patients but any person at risk for aspiration.
Abstract T P334: Statewide Collaborative for North Dakota Stroke Care
Authors: Ward Jody , Alexander Jerilyn , Dosch Ahren , Moe Pamela
Published: March 2022

Introduction:
The leading causes of death in North Dakota (ND) are heart disease, stroke and cancer. According to the Center for Disease Control and Prevention, stroke accounted for 507 (8%) of the deaths.

The ND healthcare system includes 53 counties, 36 critical access hospitals, 6 tertiary hospitals and 108 licensed ground ambulance services serving 723,393 individuals across 70,762 miles.

Hypothesis:
Improved efficiencies and patient outcomes related to acute stroke care through increased pre-notification by EMS, improved CT timing, and improved Last Known Well (LKW) to arrival times based on scientific guidelines across the continuum of the ND Stroke System of Care.
Method:
Measurement through data analysis from the Get With the Guidelines
®
Patient Management Tool following toolkit dissemination and education completion.

Results:
A benchmarking group of North Dakota facilities was created through the Get With The Guidelines-Stroke Patient Management Tool. Baseline data showed a LKW to arrival greater than 2 hours at 71% (429/606), CT in less than 25 minutes at 26% (102/392), and 61% (155/254) with EMS pre-notification. The Participating Hospital Advisory Council, comprised of stroke coordinators throughout ND developed a Stroke Toolkit based on current guidelines for healthcare providers and the general public.

The toolkit includes: 1) Treatment and Transfer Guidelines, 2) Stroke Education Modules, and 3) Feedback Reports. The education modules address: 1) Basics of Stroke, 2) Stroke Awareness and the EMS Provider, 3) Neuro Assessment/Checks, 4) Inclusion/Exclusion Criteria for Thrombolytic (tPA) Therapy, 5) Care of the Hospitalized Patient with Ischemic Stroke. The toolkit was approved by the ND State System of Care Taskforce and published through the ND Department of Health. Modules are recorded for widespread availability. The Stroke Toolkit will be disseminated throughout the state. Each tertiary stroke coordinator will provide on-site education to their specific regional referral hospitals.

Conclusion:
Data collected using Get With the Guidelines
®
Patient Management Tool in ND demonstrated a need for stroke education and intervention at all levels. The stroke toolkit will address this need.
Abstract T P337: Outcomes for a Cohort of Patients Not Treated with Thrombolytic Therapy Due to Mild or Rapidly Improving Stroke Symptoms: A Retrospective Review
Authors: Motz Deb , Sharp Johanna , Moore Tracy , Huey Dicky , Birnbaum Lee , Austin Tommye
Published: March 2022

Background:
Symptoms too mild and rapidly improving stroke symptoms (RISS) are relative contraindications for thrombolytic therapy (tPA) in acute ischemic stroke patients (AIS), yet several studies indicate that some of these patients may have a poor outcome. Baptist Health System (BHS) includes five Certified Primary Stroke Center hospitals which admit nearly 2,000 ischemic and hemorrhagic stroke patients a year.

Purpose:
The purpose of this study is to review the discharge ambulatory status and disposition of the AIS patients that were not treated with tPA because their symptoms were to mild, defined as NIHSS ≤ 5, or with RISS.

Methods:
A retrospective review was conducted using GWTG data to determine the total number of AIS admitted between 2011 - 2013, the total number of patients who were eligible for tPA with an NIHSS ≤ 5, and the total number of patients who did not receive tPA because of a documented reason of symptoms too mild or RISS.

Results:
From 2011 to 2013, BHS admitted 3,035 AIS patients, of which 396 patients arrived within 3.5 hours of last known well and had an NIHSS ≤ 5. Of those, 317 (80.05%) patients had an exclusion documented of symptoms too mild or RISS. The discharge disposition of these patients include: Home 59.94% (n=190), Acute Rehab Facility 22.40% (n= 71), Skilled Nursing Facility 14.82% (n- 47), Hospice 1.89% (n=6), Left AMA 0.63% (n=2), and Expired 0.31% (n=1). At discharge, the data reveals 51.74% (n=164) were able to ambulate independently with or without a device, 37.22% (n=118) were unable to ambulate without assistance from another person, 10.73% (n=34) were unable to ambulate and 1 patient died.

Conclusions:
In conclusion, despite being identified as having a mild and rapidly improving stroke, the patients not treated with IV tPA and an NIHSS ≤ 5 do not necessarily have mild outcomes. The exact reason for these short-term outcomes cannot directly be concluded from this review. This retrospective review of our community cohort shows that there are disabilities and extended care requirements in the context of a mild stroke and more data review, research, evaluation and consideration of the mild stroke patient is indicated.
Abstract T P339: Plan-Do-Study-Act Model Has Positive Impact on Dysphagia Screening in the Emergency Room
Authors: Motz Deb , Sharp Johanna , Moore Tracy , Huey Dicky , Austin Tommye
Published: March 2022

Background:
Dysphagia is a serious complication of stroke, which can cause aspiration pneumonia leading to increased length of stay or death. Baptist Medical Center (BMC) is one of five Primary Stroke Center Certified hospitals in the Baptist Health System (BHS). In October 2013 it was noted that BMC dysphagia screen measure results had trended downward to be the lowest in the system.

Purpose:
The purpose of this abstract is to outline actions taken to address the documentation of the dysphagia screen in the emergency room (ER) at BMC.

Methods:
An analysis of BMC’s dysphagia screen fall outs revealed four contributing factors for this quality measure including: no screen completed (34%), oral intake prior to the screen (38%), a delay in stroke diagnosis 22%) or incomplete documentation (6%). Initially the dysphagia screen was completed on paper while the rest of the ER documentation was completed in the electronic medical record (EMR). In October a performance improvement effort was implemented using a Plan-Do-Study-Act Model (PDSA). Initial changes included placing dysphagia screening forms in each room for easier access, 1:1 teaching with staff for fall outs, and designating a nurse Stroke Champion. Inconsistent improvement was seen so dysphasia documentation was add to the EMR, a patient complaint list was developed and attached to each computer, and any patient with a Head CT order was automatically screened. In April, the directors started assigning a dysphagia screen education module to any staff member with 2 or more fallouts. The PDSA graph and action plan was posted in the ER and discussed during monthly staff meetings.

Results:
Dysphagia screen documentation in stroke patients in the ER at BMC improved from a low of 73.7% in October 2013 to 100% in May 2014. The drop in April 2014 to 88.5% was attributed to leadership changes and staff turnover.

Conclusion:
A focus on dysphagia improved the screening of stroke patients in the ER. The commitment to 1:1 teaching and further education emphasized the importance of screening. Dysphagia screening results will continue to be monitored, posted, and discussed monthly.
Abstract T P343: Stroke Education To Enhance EMS Field Triage
Authors: Connelly Kerrin M
Published: March 2022

Background:
Intravenous tPA is widely accepted as an effective treatment for acute ischemic stroke (AIS), but a limited number of patients are eligible due to time constraints or contraindications. tPA also has limited effectiveness on large vessel occlusions. For patients eligible for mechanical endovascular reperfusion (MER) therapy, critical time is spent and often wasted transporting patients between facilities. By outlining clinical criteria to help determine whether a patient would be more appropriately treated at a comprehensive stroke center (CSC) as opposed to a primary stroke center (PSC), EMS can make better informed transport decisions in the field.

Purpose:
To provide basic clinical criteria in an easy use format to guide pre-hospital providers in making clinical decisions in the field regarding whether to transport directly to a CSC.

Methods:
A badge card was developed with suggested criteria for transport to a CSC. It includes clinical symptoms and additional criteria including time from symptom onset and anticoagulant use. Stroke outreach and education is done with ground and air EMS providers to describe the clinical presentation of patients who may be candidates for MER therapy.

Results:
EMS providers report increased knowledge of symptoms of large vessel occlusion, as well as other criteria that might make transport directly to CSC preferable. Challenges include educating diverse groups of EMS providers across the region, lack of positive randomized studies to lend evidence to support MER therapy being superior to IV tPA in AIS, and providing a message consistent with other CSCs due to variation in practice.

Conclusion:
Equipping pre-hospital providers with tools and education to make educated decisions regarding appropriate destination for AIS patients who might be eligible for MER therapy can reduce transport time and therefore time to treatment. It also encourages EMS to play a more active role in the treatment of stroke patients.
Abstract T P345: Knowledge Translation in Stroke Care in Toronto: Impact of member informed improvements to a Virtual Community of Practice
Authors: Donald Michelle , Skrabka Krystyna , Avinoam Gail , Willems Jacqueline , Sharp Shelley , Linkewich Elizabeth
Published: March 2022

Background:
The Toronto Stroke Networks Virtual Community of Practice (VCoP) is a secure social media platform, part of an evidence-informed knowledge translation (KT) approach to bridge identified gaps in knowledge for successful implementation of stroke best practices. In 2014, a formative developmental evaluation examined members’ perspectives about the value of the VCoP. Key themes emerged: networking, response time, validation of practice, and prioritization of best practices. Themes informed subsequent improvements: enhanced search functions, ability to share documents within a discussion forum, and formal facilitation.

Objective:
To examine the impact of VCoP enhancements on KT using value cycles 1-5 of the

Wenger (2011) model:

1.immediate value: activity / interactions

2.potential value: knowledge capital

3.applied value: changes in practice

4.realized value: performance improvement

5.reframing value: redefining success

Methods:
Each theme was explored to identify potential improvement opportunities. Discussion with developers informed feasibility. Three priorities were identified: enhanced search functions, ability to share documents within discussion forums, and formal facilitation to prompt discussion. VCoP members were informed of improvements. Qualitative (members’ narratives) and quantitative indicators (e.g. response times, number of discussion threads) were examined.

Results:
Preliminary results indicate that formal facilitation supports increased value in activity and interaction (Cycle 1) on the VCoP. Within the first month of formal facilitation, posts in discussion forums increased from 3.75/month (FY13/14) to 11; average response times decreased from 18 to 8 days. Early examination of narratives indicates themes aligning with Cycle 2: members express value in VCoP information. Further evaluation, in progress, examines the impact of improved search functions and document upload capabilities including analysis of themes aligning with the Wenger Cycles, number of uploaded documents, and search effectiveness.

Conclusions:
Member informed enhancements to the VCoP contribute to KT through enhanced activity, member interactions, and knowledge capital.
Abstract T P35: Extensive Cerebral Microbleeds Predict Parenchymal Hemorrhage and Poor Outcome After Intravenous Thrombolysis
Authors: Yan Shenqiang , Lou Min
Published: March 2022

Background and Purpose:
Thrombolysis-related hemorrhagic transformation (HT) subtypes may have different prognostic implications. We aimed to analyze the impact of cerebral microbleeds (CMBs) burden on HT subtypes and outcome after intravenous thrombolysis.

Methods:
We retrospectively examined clinical and radiological data from 300 consecutive acute ischemic stroke patients who underwent gradient-recalled echo (GRE) T2*-weighted MRI before intravenous thrombolysis. Logistic regression analysis was used to determine the impact of CMBs on HT subtypes and neurological outcome.

Results:
Of the included patients, 101 (33.7%) were women, with a median age of 67 years (mean 66.12 ± 13.26 years, range 23-94 years). We observed 596 CMBs in 119 (39.7%) patients on initial GRE scans. HT occurred in 88 (29.3%) patients, among which 62 were hemorrhagic infarction and 26 were parenchymal hemorrhage (PH). Logistic regression analysis indicated that the presence of extensive (≥3) CMBs was independently associated with PH (odds ratio 6.704; 95% CI: 2.054 to 21.883; p = 0.002) and poor clinical outcome (odds ratio 2.281; 95% CI: 1.022 to 5.093; p = 0.044).

Conclusions:
The presence of extensive (≥3) CMBs increased the risk of PH 24 hours after intravenous thrombolysis, and predicted poor clinical outcome independently.
Abstract T P353: The Essence of Stroke Educators: Standardizing Stroke Education to Optimize Patient/Family Perceptions and Understanding of Stroke Information
Authors: Gorman Bridget , Rowell Marguerite
Published: March 2022

Background/Purpose:
Providing stroke education to patient and family members is essential to optimize stroke recovery, maximize functional status, and prevent secondary cerebrovascular events. Due to complexity of cerebrovascular disease and potential cognitive deficits, the delivery of succinct, consistent, individualized, high-quality stroke education continues to be a challenge. Furthermore, incorporating patients’ perceptions of education needed vs. education received often is overlooked. The purpose of this study was to determine if the perceived quality and understanding of stroke education improved through the use of an interactive stroke education booklet compared to a printed packet of stroke information.

Methods:
A patient-report instrument was used to evaluate direct and indirect perceptions and understanding of the quality of stroke education needed and received. In total, 124 stroke patients were randomized to stroke booklet (n=73) or stroke packet (n=51). Independent samples t-tests were used to determine differences between the booklet and the packet on the total score of the patient-report instrument, and on separate subscales (education needed vs. received vs. delivered). A hierarchical multiple regression was used to determine if age, education level, number of hospital admissions, living arrangement, or length of stay would predict scores on the patient report instrument. Significant results were noted if p<0.05.

Results:
Statistically significant differences between booklet and packet were not found for the total score of the patient report tool (p=0.44), or on subscales education needed (p=0.95), received (p=0.14), and delivered (p=0.51). When type of education received was controlled, patient demographic characteristics were not statistically significant predictors of score.

Conclusions:
S
tandardization of stroke education through dedicated stroke educators may be most beneficial in increasing the perception and understanding of stroke information. Further research is warranted to determine if there is a correlation between perception of understanding stroke education and stroke educators spending adequate time with patients/families displaying caring and compassion during education.
Abstract T P366: Moyamoya Following Treatment of Intracranial Tumors
Authors: Storey Armide , Orbach Darren , Scott R. Michael , Smith Edward
Published: March 2022

Introduction:
We present our experience with the management of patients initially diagnosed with intracranial tumor who subsequently developed moyamoya following tumor treatment.

Hypothesis:
We hypothesized that moyamoya associated with brain tumors would demonstrate similar radiographic findings and response to surgery as idiopathic moyamoya and that radiotherapy would increase stroke risk.

Methods:
Single institution series reviewing all moyamoya cases from 1985-2014 to identify those initially diagnosed with intracranial tumor who subsequently developed moyamoya.

Results:
26 patients (12M/14F) diagnosed with 27 intracranial tumors later developed moyamoya. Average age at tumor diagnosis was 4.6yr (range 0.5 - 14.7) and 9.8yr at moyamoya diagnosis (range 5.0 - 19.7). 21 tumors had radiotherapy, 16 chemotherapy, and 14 surgical resection, 2 of whom underwent surgery alone without adjuvant therapy. Radiotherapy patients had moyamoya diagnosed 3.9yr after radiation (range 0.2 - 13.8). All patients (100%) presenting with stroke had radiation. Initial moyamoya symptoms included TIA (58%), stroke (42%), and seizure (19%); moyamoya was incidental discovery in 23%. 13 patients (50%) had stroke on imaging; their average Suzuki grade was 3. 45 pial synangiosis were performed, 19 with bilateral surgery. Postoperative complications included stroke in 2 patients (4.4% per operation). 2 patients had a stroke during follow up unrelated to moyamoya but rather from small vessel disease in the brain stem resulting from radiotherapy. Postoperative arteriograms demonstrated Matsushima grade A/B collaterals in 75% of patients studied (n=24 hemispheres). Eight patients required further treatment for tumor recurrence or progression.

Conclusions:
In conclusion, pediatric brain tumor patients develop moyamoya arteriopathy clinically and radiographically similar to idiopathic moyamoya. Radiotherapy is associated with increased incidence of radiographic stroke in this cohort. Secondary injury from radiation may occur in the posterior fossa, but ischemia from moyamoya in the cerebral hemispheres can be corrected with revascularization conferring durable protection from stroke.
Abstract T P368: High Risk of Mortality in Congenital Heart Disease Patients Who Suffer Strokes
Authors: Cheng Henry H , Rajagopal Satish , McDavitt Erica , Esch Jesse , Williams Kathryn , Thiagarajan Ravi , Grant Ellen , Rivkin Michael J
Published: March 2022

Introduction:
Congenital heart disease (CHD) patients have many risk factors for stroke. Our goal was to describe CHD patients who suffered strokes and determine factors associated with in-hospital mortality.

Methods:
Patients with acquired or CHD who suffered a stroke (radiologic evidence of arterial/venous infarct; subdural, subarachnoid, parenchymal or epidural hemorrhage) from 1/2010-5/2014 at our hospital were identified. Patient charts were retrospectively reviewed.

Results:
Seventy-five stroke patients were identified. Median age at diagnosis was 5.7 months (IQR 0.6, 33.2), and 26 (35%) were neonates. Twenty-six patients (35%) had single ventricle CHD, and 9 (12%) had Fontan circulations.

Seven patients (9%) presented with neurologic symptoms at home. The remainder developed neurologic findings after being hospitalized for a median duration of 9.5 days (IQR 4.0, 21.8). Thirty-four patients (45%) presented with clinically evident neurologic deficits (e.g. weakness, seizures). Forty-seven patients (63%) had arterial infarcts, and 14 (19%) had parenchymal hemorrhages.

At diagnosis, 49 patients (65%) were on inotropes, 48 (64%) were intubated, and 18 (24%) were on ECMO. Twenty-seven patients (36%) had CPR within 30 days of diagnosis. Twenty-four patients (32%) had ≥3 cardiac procedures (surgical or catheter based) during their hospitalization before stroke diagnosis with a median duration of 3 days (IQR 1, 9) between their last procedure and diagnosis.

Forty-eight patients (64%) survived to hospital discharge. Survivors had a median total hospital length of stay of 1.1 months (IQR 0.5, 2.7). Factors associated with in-hospital mortality were: inotropes (p<0.01), intubation (p<0.01), and ECMO (p=0.03) at time of stroke diagnosis; and ≥3 cardiac procedures before stroke diagnosis (p=0.02). Recent CPR (p=0.06) and stroke type (p=0.09) were not associated with in-hospital mortality.

Of 37 surviving patients with neurologic follow-up, 21 (57%) had chronic neurologic deficits due to their strokes (median follow-up: 6.0 months, IQR 2.5-22.8).

Conclusions:
A majority of CHD stroke patients present while hospitalized and without focal neurologic findings. In-hospital mortality is high and associated with severity of illness.
Abstract T P369: Increased Prevalence of Potential Right-to-Left Shunting in Children with Sickle Cell Anemia and Stroke
Authors: Dowling Michael M , Ramaciotti Claudio , Kanter Julie , Osunkwo Ifeyinwa , Inusa Baba , Iyer Rathy , Kwiatkowski Janet , Johnson Clarissa , Rhodes Melissa M , Owen William , Strouse John J , Quinn Charles , Panepinto Julie A , Neumayr Lynne , Sarnaik Sharada , Hynan Linda S , Plumb Patricia , Kirkham Fenella
Published: March 2022

Children with sickle cell anemia (SCA; HbSS and HgbSβ
0
thalassemia) suffer stroke at a rate 220x higher than other children, but are typically less extensively investigated for modifiable risk factors. In patients without SCA, “paradoxical embolization” via intracardiac or intrapulmonary "right-to-left" shunting is a recognized stroke risk factor. Hypercoagulable states and increased right heart pressures predispose to paradoxical embolization and both occur in SCA. We hypothesized that children with SCA and overt stroke have an increased prevalence of potential right-to-left shunting compared to controls.

We performed contrasted transthoracic echocardiograms (conventional 2D, color Doppler, and 4 contrast injections with agitated saline, including 2 during Valsalva) on children (ages 2-19y) with SCA and history of overt stroke, and a control group of children with neither SCA nor stroke, at 14 institutions in the US and UK. Potential right-to-left shunting was defined as any potential shunt detected by any method, including “late bubbles” (contrast appearing in the left heart >5 cardiac cycles following injection). Echocardiograms were reviewed locally and centrally, with adjudication of conflicts.

We enrolled 153 children with SCA and stroke and 129 controls. There were no significant differences in age or gender between the groups. The prevalence of potential right-to-left shunting was significantly higher in the SCA and stroke group (43.1% vs. 20.0% in controls (p<0.001). There was no significant difference in intracardiac shunting (22.9% vs. 16.2%, p=0.157) but there was a higher proportion with intrapulmonary shunting (“late bubbles” only) in the SCA and stroke group (27.5% vs. 5.5% in controls, p<0.001).

Our findings suggest that intracardiac and intrapulmonary shunting could be an independent, potentially modifiable risk factor for stroke or stroke recurrence in children with SCA. Additional therapeutic interventions in patients at risk of stroke or stroke recurrence via paradoxical embolization, including antiplatelet agents or shunt closure, should be evaluated in children with SCA.
Abstract T P373: Experience with a Multidisciplinary Pediatric Neurovascular Conference for Complex Disease Management
Authors: Ladner Travis R , Mahdi Jasia , Attia Albert , Froehler Michael T , Le Truc , Lorinc Amanda , Mocco J , Naftel Robert , Newton Allen , Pruthi Sumit , Tenenholz Todd , Vance E H , Wushensky Curtis , Wellons John C , Jordan Lori C
Published: March 2022

Introduction:
In 2013 our institution established a multidisciplinary pediatric neurovascular conference (PNVC) for coordination of care. Here we review our initial experience.

Hypothesis:
Collaboration yields coordinated care for children with complex cerebrovascular disease and treatment protocols for commonly discussed conditions.

Methods:
Clinical and demographic data were obtained from medical records for patients presented to PNVC from April 2013 to July 2014. Survey data were collected from PNVC participants.

Results:
The PNVC met 26 times in the study period. Overall, 78 children were presented a total of 112 times, 41% with history of stroke. Of 64 (82%) with a diagnosed vascular lesion, AVM (30%), cavernous malformation (14%), and moyamoya (11%) were most common. Most discussions were for review of imaging (35%), need for additional imaging (27%), or treatment plan (25%) [Table]. Follow-up angiography was performed in 27%. A surgical operation was employed in 22%; 18% received neurointervention; 9% received radiosurgery. Twenty-three patients (29%) were discussed more than once. Standardized care protocols for AVM and moyamoya were developed from discussions among physicians from 7 different specialties [Figure]. Participants cited PNVC’s greatest utility as facilitation of a collaborative approach to patient care.

Conclusion:
A multidisciplinary conference among a diverse group of providers guides complex care decisions, helps standardize care protocols, promotes faculty collaboration, and supports continuity of care in pediatric neurovascular disease.
Abstract T P376: Trends in Hospitalization for Non Traumatic Pediatric Stroke from 1997 to 2009: The Kids’ Inpatient Database
Authors: Khoury Philip R , Khoury Jane C
Published: March 2022

Introduction:
Pediatric stroke is known to be a small proportion of all strokes seen in the US. There has been little recent publication of temporal trends in hospitalization rates due to stroke in children. The Kids’ Inpatient Database (KID) is a sample of pediatric discharges available from community non-rehabilitation hospitals collected every 3 years (2,521 hospitals in 1997 to 4,121 hospitals in 2009, the most recent year in this study).

Methods:
Using data on children less than 19 years of age from KID for the years 1997, 2000, 2003, 2006, and 2009, we wanted to examine whether rates and costs of stroke related hospitalizations have changed over time. Only the primary discharge diagnosis was considered for hospitalizations due to stroke. Hospitalizations having a secondary diagnosis of traumatic brain injury and those with a secondary diagnosis of in-hospital birth were excluded. Stroke was defined for this study as ICD-9 codes of 430.xx, and 431.xx (hemorrhage); and 433.xx, 434.xx, and 436 (ischemic, IS). SAS® survey software was used to determine the appropriate weighted variances and estimates, due to the KID sampling scheme. Trends in rates over time were assessed using the Cochran-Armitage test.

Results:
For the five years sampled between 1997 and 2009, there were 8841 estimated hospitalizations with a primary diagnosis of stroke, out of 13,643,666 total estimated hospitalizations. Estimates for pediatric hospitalizations due to hemorrhage increased from 28/100,000 to 31/100,000 (p<.01) between 1997 and 2009. For IS, the hospitalization rate increased from 30/100,000 to 37/100,000 (P<.001). Combined rates increased from 59/100,000 to 68/100,000 (p<.0001). The average total charge for a hospitalization due to hemorrhage increased from $66,800 in 1997 to $149,000 in 2009. Charge for an IS hospitalization increased from $28,000 in 1997, to $75,600 in 2009. All charges are expressed in 2009 dollars.

Conclusion:
Cost per pediatric hospitalization with a primary diagnosis of stroke more than doubled between 1997 and 2009. There was an increase of 15% in the rate of pediatric hospitalizations with diagnosis of stroke in the same time period. Whether this change is due to changes in coding, or an increase in stroke incidence needs to be investigated further.