bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP175: Migraines and the Risk of Hemorrhagic Stroke
Authors: Farooq Muhammad Umar , Thomas Kathie
Published: June 2021

Background and Objectives:
Migraine is a common neurological disorder affecting 38 million people in the United States. Hemorrhagic stroke accounts for 13% of all stroke cases and the risk of having a hemorrhagic stroke is 94 in 100,000 or 0.94%. There are two types of hemorrhagic stroke; intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Previous research has investigated the association between migraine and vascular disease, with several studies demonstrating a possible link between migraines and ischemic stroke. The relationship between migraine and hemorrhagic stroke remains unclear.

Methods:
A retrospective review from January 2012-December 2014 of hemorrhagic stroke patients (n=3682) from 30 Michigan hospitals using a Get With the Guidelines (GWTG) database was conducted. Stroke subtypes and patient medical histories were examined. This sample set was comprised of 46.95% males and 53.05% females.

Results:
It was found that the risk for hemorrhagic stroke increased from 0.94% to 2.12% with a medical history of migraines. The risk of ICH with a history of migraine in this study was 1.41%, while the risk of SAH with a history of migraine was 3.11%. The median age for a hemorrhagic stroke in this sample set was 67 years. A patient with a medical history that included migraines, had a median hemorrhagic stroke age of 55 years. Of these patients with a history of migraine who developed a hemorrhagic stroke, 74.7% were female and 25.3% were male.

Conclusions:
This study demonstrated that a higher risk of hemorrhagic stroke is associated with a history of migraines. The median age for an individual with a hemorrhagic stroke and history of migraine was significantly lower (12 years) than the median age of the sample, which indicates that migraines as a risk factor for stroke might be more significant in middle age. Additionally, this risk seemed to impact females much more than males. A limitation of this study is that GWTG Stroke does not include whether the patient has a migraine with or without aura. Migraine with aura has been associated at a higher rate with ischemic stroke than migraine without aura. It would be beneficial for future studies regarding migraine and hemorrhagic stroke to include whether the migraine was associated with or without aura.
Abstract TP180: DERrAME: Disparities Among Ethnicities Regarding rt-PA in Acute Stroke Management and Evaluations
Authors: Nguyen David T , Ho James P , Pirastehfar Mohsen , Narula Rajiv , Hailey Lovella , Mortin Melissa , Rapp Karen , Agrawal Kunal , Huisa Branko , Modir Royya , Meyer Dawn , Hemmen Thomas , Kidwell Chelsea , Meyer Brett C
Published: June 2021

Background:
Since the introduction of recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke, rt-PA rate and number of stroke centers have increased. Despite this, studies have shown racial and ethnic disparities in stroke care especially in Black and Hispanic populations. How Hispanic ethnicity affects rt-PA evaluations has to date been unclear. In our patient population, we investigated whether ethnicity is associated with rt-PA use for acute ischemic strokes in the Hispanic population.

Methods:
We performed a retrospective review of IRB approved, prospectively collected data from the UC San Diego Stroke Registry. Patients were selected based on the presentation and primary diagnosis of Transient Ischemic Attack or Ischemic Stroke. Characteristics including risk factors were compared in Hispanic vs non-Hispanic samples to assess rt-PA treatment rates, process of care intervals for Hispanics vs non-Hispanics and rt-PA vs non-rt-PA patients.

Results:
We assessed 1489 patients (300 Hispanic vs. 1189 non-Hispanic whites) from July 2004 to July 2016. Comparing Hispanics to non-Hispanics, there was no difference in rt-PA rate (35.3% vs. 33.1%; p=0.49). In a subset evaluation of Hispanics only, comparing rt-PA(-) to rt-PA(+), there was no difference for male sex (56%), Hypertension (71%), Hyperlipidemia (29%), Diabetes (43%), Atrial Fibrillation (23%), and Smoking (20%). There was a noted difference in the Hispanic-only untreated vs treated subset for initial NIHSS (7.24 vs. 13.27; p<.001). In rt-PA treated patients only, the “onset to treatment” interval was significantly higher in Hispanics (2.42 vs. 2.13 hours p=0.003), while the “door to treatment” interval was not different (1.13 vs. 1.02 hours; p=0.07).

Conclusions:
This study shows the rate of rt-PA treatment and “door to treatment” intervals were not significantly different in Hispanic vs non-Hispanic patients. This data is supportive of current overall treatment decision models. However, the “onset to treatment” interval was significantly longer for Hispanic patients showing that it may take longer for this population to reach the treating hospital. This supports the need to develop culturally relevant education programs to address barriers in this population.
Abstract TP181: Albuminuria Should Be A Strong Predictor Of Acute Kidney Injury in Acute Ischemic Stroke Patients
Authors: Shimoyama Takashi , Suda Satoshi , Takayama Yohei , Ouchi Takahiro , Arakawa Masafumi , Suzuki Shizuka , Okubo Seiji , MIshina Masahiro , Kimura Kazumi
Published: June 2021

Background:
Acute kidney injury (AKI) in the setting of cardiovascular events is recognized as a high risk of poor clinical outcome. Although estimated glomerular filtration rate (eGFR) and albuminuria are known to be associated with ischemic stroke outcomes, solid evidence has not yet to be presented regarding the relationship among the two markers and AKI. The present study aimed to clarify this issue in patients with acute ischemic stroke.

Methods:
From a prospectively gathered registry, we examined acute ischemic stroke patients who were hospitalized within 48 hours after symptom from September 2014 to June 2016. Admission serum creatinine level was considered to be the baseline. AKI is defined by an increase in the serum creatinine level of ≥0.3 mg/dl within 48 hours; or percentage increase of 50% or more from the baseline value within 7 days after admission. We divided all patients into the AKI group and the non-AKI group, and compared clinical characteristics between the two groups. The factors associated with AKI were investigated by multivariate logistic regression analysis.

Results:
Three hundred and eighty-nine patients (245 males, 74 [65-82] years old) were enrolled in the study. AKI occurred in 14 patients (3.6%) with acute ischemic stroke patients. Compared with patients without AKI, patients with AKI had increased serum creatinine level (1.20 mg/dl vs. 0.80 mg/dl, p=0.033) and urine albumin level (259.6 mg/g vs. 38.7mg/g, P<0.001). On the other hand, eGFR level was decreased in the AKI group than in the non-AKI group (45.5 ml/min/1.73 m
2
vs. 65.0 ml/min/1.73 m
2
, P=0.048). Poor clinical outcome at discharge (mRS ≥5) was frequently observed in the AKI group than the non-AKI group (42.9% vs. 16.5%, P=0.022). The optimal cut-off urine albumin value to distinguish the AKI from the non-AKI using receiver operating characteristics (ROC) curves was 170 mg/g, with 78.6% sensitivity and 79.2% specificity. Multivariate regression analysis showed that urine albumin level > 170mg/g was an independent factor of AKI (odds ratio [OR] 12.73; 95% confidence interval [CI], 3.10-52.30, P<0.001), but not eGFR <60 ml/min/1.73 m
2
(OR 0.96; 95% CI 0.26-3.54, P=0.944).

Conclusion:
Albuminuria should be a strong predictor for AKI in acute ischemic stroke patients.
Abstract TP186: High Hospital Mortality Among Non-black Stroke Patients with Metabolic Syndrome
Authors: Navalkele Digvijaya D , Boehme Amelia K , Harmon Kelly , Schluter Laurie , Freeman Melissa , El Khoury Ramy , Martin-Schild Sheryl
Published: June 2021

Introduction:
Limited information is available on race based stroke outcomes among patients with metabolic syndrome.

Methods:
We conducted a retrospective review of acute ischemic stroke patients between 2008 and 2015 who were admitted to stroke service at a comprehensive stroke center. Patients were categorized to have metabolic syndrome if they have three of the four criteria (history of hypertension or diabetes or triglycerides ≥ 150 mg/dl or high density lipoprotein (HDL) < 50 mg/dl for women or < 40 mg/dl for men). Patients with metabolic syndrome were grouped based on their race. Primary outcome was modified Rankin Scale score at discharge. Secondary outcomes measures were neurological worsening, hospital mortality, in-hospital complications, discharge stroke scale, and length of stay.

Results:
Total 659 patients were found to have metabolic syndrome. Among these patients, 206 (31%) were non-black and 453 (69%) were of black race. Compared to non-black patients with metabolic syndrome, black patients were more likely to be women (56% vs. 35%, p<0.0001) and have a prior history of stroke (55% vs. 35%, p<0.0001). Median admission diastolic blood pressure was higher among blacks compared to non-blacks (92 vs. 87mmHg, p = 0.0093). Higher proportion of black patients were on anti-platelets (67% vs. 56%, p = 0.01), statins (83% vs. 71%; p =0.001), and anti-hypertensive medications at home (90% vs. 81%, p = 0.001). Non-blacks had higher triglycerides (188 vs. 132 mg/dl, p<0.0001) and lower HDL levels (36 vs. 44 mg/dl, p< 0.0001). There was no difference in discharge modified Rankin Scale score among the groups. In-hospital myocardial infarction was significantly more frequent among non-blacks (9% vs. 4%, p = 0.03). In-hospital mortality was significantly higher in the non-black group (11% vs. 6%, p = 0.02).

Conclusion:
Non-black race was associated with higher in-hospital mortality among patients with metabolic syndrome admitted for stroke. Further exploration of higher mortality among this group of patients is warranted to improve stroke outcomes.
Abstract TP199: Stroke Awareness in Argentina, the Sifhon Population Survey
Authors: Dossi Daiana E , Hawkes Maximiliano A , Farez Mauricio F , Gomez Schneider Maia M , Torres Nicolas A , Pujol Lereis Virginia A , Povedano Guillermo , Rodriguez Lucci Federico , Ameriso Sebastián F
Published: June 2021

Introduction:
Stroke awareness in Latin America is scant. We conducted a large population survey in 13 provinces in Argentina to assess knowledge of cerebrovascular disease.

Methods:
We distributed 110,000 multiple-choice anonymous questionnaires using the house distribution system of a bottled water dispensing company, assessing information regards age, gender, educational level, general stroke information, attitude towards symptoms and treatment. Percentages of each choice were recorded for every question and a multivariate analysis was performed.

Results:
A total of 12,710 surveys were returned, age 51±17 years, 69% women. Almost 95% reported prior knowledge of the disease, 50% through public media, 37% through a relative/friend that had a stroke and 8% through their family doctor. The Spanish acronym for
accidente cerebrovascular
, ACV, was the most frequently identified name for stroke (79%), the Spanish equivalent to cerebral attack was used by 7% and 0,4% used the term “ictus”. Only 29% knew about TIA but 69% identified stroke risk factors. Although 73% recognized their signs and symptoms, 11% misinterpreted them as a heart attack and 34% ignored that stroke can present with severe headache. Although 73% considered the disease potentially disabling/fatal, 40% ignored its frequency. If symptoms, 25% would call 911 and 50% would go to an emergency room by own means. Only 63% knew the existence of a specific treatment. Lowest degree of knowledge was seen in young, single, non-university men.

Conclusion:
This study represents the largest general public stroke awareness survey in Spanish speaking populations. Respondents showed excellent recognition of risk factors, warning signs and need of a rapid response. The population had little knowledge of prevalence, severity, TIA, and acute treatment. Public media appear to have an essential role in education.
Abstract TP20: Uncertainties of Endovascular Therapy Outside the AHA Guidelines
Authors: Sarraj Amrou , Budzik Ronald F , Veznedaroglu Erol , English Joey D , Baxter Blaise W , Bartolini Bruno M , Liebeskind David S , Krajina Antonin , Shields Ryan D , Jin Nancy , Nogueira Raul G , Gupta Rishi , Chen Peng R , Farrell Christine M , Savitz Sean I , McCullough Louise D
Published: June 2021

Background:
The efficacy of endovascular therapy (EVT) in randomized clinical trials (RCTs) for acute strokes due to large vessel occlusion (LVO) led to AHA guidelines recommending EVT as standard of care for selected patients. However, many conditions were under-represented in the RCTs: ASPECTS <6, age ≥80 yo, NIHSS <6, onset to treatment >6 hrs and M2/ distal/ posterior circulation occlusions.

Objective:
We evaluated EVT outcomes in these populations compared to counterparts represented in the RCTs.

Methods:
A large multicenter international prospective cohort study of LVO patients treated with stent retriever thrombectomy (TREVO Registry) between 11/2013 and 4/2016 was analyzed. 90 day mRS was the primary outcome (0-2 good outcome). Multivariate logistic regression modeling was employed to evaluate EVT impact in the different groups.

Results:
Of 1000 patients, 81 had NIHSS <6 and 81.5% of those achieved a good outcome (aOR 3.6, 95% CI 1.9-6.8;
p<
0.001 compared with NIHSS ≥6) (Table 1). Over 80 yo, however, had low odds of independence (aOR 0.3, 95% CI 0.2-0.5;
p
<0.001 compared with <80 yo). Among 212 patients treated >6 hrs, 51% had a good outcome (aOR 0.78, 95% CI 0.55-1.1;
p
=0.17) compared to ≤6 hrs. Nearly half of patients with ASPECTS <6 (3-5) had a good outcome. Fig 1 illustrates mRS distributions stratified by the different subgroups. There were low rates of sICH for treated patients with NIHSS<6, age≥80, ASPECTS <6 or treatment >6 hrs. Fig 2 demonstrates the likelihood of good outcome by clot location. M2 and distal occlusions had the highest good outcome probabilities while proximal ICAs had the lowest (48.1%). More than half of vertebrobasilar patients achieved independence (54.8%).

Conclusion:
While effectiveness cannot be determined in the absence of medically treated controls, our analyses of real world data show several groups outside AHA guidelines may benefit from EVT. In particular, further study is needed to examine EVT benefits for mild stroke and M2 occlusions.
Abstract TP201: The Relationship Between Chronic Kidney Diseases and the Presence of Cerebral Small Vessel Disease in Patients With Acute Ischemic Stroke
Authors: Ueki Kana , Nakamura Asako , Yasaka Masahiro , Kuwashiro Takahiro , Gotoh Seiji , Takaguchi Go , Nakanishi Yasuyuki , Okada Yasushi
Published: June 2021

Introduction:
Cerebral small vessel diseases (SVDs) i.e. white matter lesion and cerebral microbleeds (CMBs) are related to the patients with stroke more deeply than those without. In general population, in addition to age, hypertension, diabetes chronic kidney diseases (CKD) is well known to be related to SVDs, but it remains unclear in patients with stroke. We investigated the relationship between CKD and the presence of SVDs in patients with acute ischemic stroke.

Methods:
We enrolled 493 patients with acute ischemic stroke patients or transient ischemic attack patients (mean age 71; 60% male) who had undergone 1.5T MR imaging within a week of the index events from April 2013 to march 2015. We evaluated kidney function by estimated glomerular filtration rate (eGFR) with the modification of diet in Renal Disease. CKD was defined as an eGFR less than 60mil/min/1.73m
2
. CMBs were defined as focal areas of very low signal intensity smaller than 10mm. White matter lesion as Periventricular hyper intensity (PVH)>grade 2 and Deep and Subcortical White Matter Hyper intensity (DSWMH)> grade 2 were defied as advanced PVH and advanced DSWMH, respectively. We investigated relationship between CKD and CMBs, advanced PVH and advanced DSWMH using a logistic regression analysis.

Results:
We noted CMBs in 173 patients (35%), PVH in 81 (16%), and DSWMH in 151 (31%). An univariate analysis revealed that the age, CKD, history of stroke, and antiplatelet agents were associated with presence of CMBs, advanced PVH and severe DSWMH . The multivariate analysis revealed that CMBs, advanced PVH and advanced DSWMH were associated with age (CMBs: odds ratio(OR) ; 1.32 ; 95% confidence interval(CI), 1.10-1.60, p=0.004, advanced PVH : OR ; 3.00 ; 95% CI, 2.17-4.26, p<0.01, advanced DSWMH: OR ; 1.94; 95% CI, 1.56-2.45, p<0.01 ), history of stroke(CMBs : OR ; 2.01 ; 95% CI, 1.21-3.34, p=0.007, advanced PVH : OR ; 2.25 ; 95% CI, 1.18-4.27, p=0.01, advanced DSWMH: OR ; 1.78 ; 95% CI, 1.03-3.06, p=0.038). CKD was associated with CMBs (OR ; 1.62 ; 95% CI, 1.04-2.52, p=0.03), but PVH and DSWMH were not.

Conclusions:
It seems that age and history of stroke are related to CMBs, advanced PVH and advanced DSWMH, and that CKD is associates with CMBs but not with either advanced PVH or advanced DSWMH.
Abstract TP206: The Influence of Contextual Factors on Gaps in Hypertension Management for Veterans with TIA/Minor Stroke
Authors: Sico Jason J , Miech Edward J , Damush Teresa M , Keating Ava B , Arling Gregory W , Phipps Michael S , Bravata Dawn M
Published: June 2021

Introduction:
Many patients with TIA/minor stroke do not achieve goal blood pressure their cerebrovascular event, thereby remaining at high risk for future events. Understanding the influence of contextual factors associated with post-event hypertension management may inform future intervention studies.

Methods:
As part of a national, observational study of TIA/minor stroke care across the Veterans Health Administration (VHA), in-person site visits were conducted at participating VHA medical centers in 2014-15. Semi-structured interviews were used to elicit provider perspectives about local practices related to the care of TIA/minor stroke patients. Study team members systematically applied codes transcribed files using qualitative, categorical, and quantitative descriptive codebooks. Investigators used Thematic Content Analysis and mixed-methods matrix displays to analyze coded data, generate, and then validate findings.

Results:
Seventy interviews were obtained from staff at 14 sites. Several contextual factors appeared to influence post-event hypertension care delivery for patients after a TIA/minor stroke. Neurologists reported that they perceived no direct responsibility for managing post-event blood pressure and were uncertain whether recommendations regarding blood pressure management were being implemented in primary care. Primary care providers expressed hesitancy about titrating antihypertensive medications post-event, citing concerns about permissive hypertension. Providers also reported that poor blood pressure control was not as salient to patients as symptoms, leading some patients to not adhere to their antihypertensives or not feel a sense of urgency in seeking prompt medical attention. VHA facilities did not have protocols to guide providers in the treatment of post-TIA/minor stroke hypertension, with centers expressing little compulsion to develop them.

Conclusions:
Multiple contextual factors at the provider- and system-levels were identified as barriers to achieving post-cerebrovascular event hypertension control; these data have informed the design of a recently funded vascular risk factor intervention.
Abstract TP209: Treatment and Prognosis for Patients with Trousseau Syndrome: Our Therapeutic Experience and Histological Evaluation of the Retrieved Clots
Authors: Shimbo Daisuke
Published: June 2021

Background and Purpose:
Several studies reported the association between nonbacterial thrombotic endocarditis (NBTE) and Trousseau syndrome (TS). NBTE is regarded as the formation of platelet and fibrin vegetation on cardiac valves with no evidence of inflammation. We report our therapeutic experience including the mechanical thrombectomy for patients with TS and evaluate the histological findings of the retrieved clots.

Methods:
Between 2011 and 2016, we treated 13 patients with TS in the department neurosurgery. Patient characteristics and clinical history were retrospectively reviewed.

Results:
There were 7 females and 6 males aged 56-83 years. Cancer types were as follows: 5 were lung, 3 were bile duct, 3 were pancreas, 1 was ovary and 1 was colon. There were 12 patients with stage IV cancer. Almost patients experienced multiple infarctions in all vascular territories and there were 9 patients with occlusion of main trunk. Eleven patients had received anticoagulation treatment with unfractionated heparin by continuous intravenous drip. Seven patients were treated with oral anticoagulants. Recurrent ischemia were detected in 7 patients and 5 patients experienced the recurrence in hospital. Only 4 patients were discharged from our hospital with favorable outcome (modified Rankin Scale 2). Nine patients were confirmed dead and the average time from the onset of ischemia to death was 44 days. We performed mechanical thrombectomy for 3 patients and evaluated the histological findings of the retrieved clots from one patient. Histological evaluation showed that the clots consisted fibrin and platelets without blood cells (Figure). Transthoracic echocardiography revealed NBTE on the aortic valve of this patient. These findings suggested that NBTE was embolic source of ischemic stroke in this patient.

Conclusions:
Patients with TS have an extremely poor prognosis. We demonstrated that NBTE is a main cause of cerebral artery occlusion in patients with TS.
Abstract TP213: Initial Vascular Lesion Patterns on Early Images Would Predict Vascular Outcomes in Acute Cerebral Artery Dissection
Authors: Lee Jun , Gwon Jungim , Kim Mingyeong
Published: June 2021

Introduction:
Imaging characteristics and prognosis on the follow-up imaging in patients with acute cervicocerebral artery dissection are not well established.

Hypothesis:
Initial lesion patterns on early vascular imaging would predict vascular imaging outcomes in acute cervicocerebral artery dissection.

Methods:
Individual clinical data and imaging features were obtained from 167 consecutive patients who presented with acute ischemic symptoms or headache due to cervicocerebral artery dissection. Patients were categorized according to their baseline vascular imaging features as either Stenosis Only, Aneurysm Only, or Both Stenosis and Aneurysm. The angiographic characteristics and improvements of early vascular lesions between baseline (within 7 days after symptoms onset) and follow-up vascular images (6-month or 1-year after symptom onset) were compared.

Results:
A total of 76 patients who underwent baseline and 6-month or 1-year vascular imaging were included. Patients in the Stenosis Only group (n=36) were younger (mean age, 45±11) than those in the Aneurysm Only (n=9, 55±7) and Both Stenosis and Aneurysm (n=31, 48±12) groups (p=0.044). The most common sites of lesions were the distal vertebral artery and posterior inferior cerebellar artery (n=43, 57%). All patients in Aneurysm Only group had their lesions in the posterior circulation (61% in Stenosis Only, 77% in Both Stenosis and Aneurysm; p=0.047). A total of 43 patients (57%) showed improvement of initial lesions on follow-up vascular images (58% in Stenosis Only vs. 22% in Aneurysm Only vs. 65% in Both Stenosis and Aneurysm; p=0.076). The proportion of patients who obtained improvements on follow-up vascular images on baseline images was lower in Aneurysm Only compared with groups with stenosis (Stenosis Only and Both Stenosis and Aneurysm) (Odds ratio 0.18, 95% CI 0.03 to 0.94; p=0.035).

Conclusions:
Complete or partial improvements on follow-up images are obtained in over half of the patients with acute cervicocerebral artery dissection. Patients with only aneurysm on early images showed poor imaging prognosis compared to patients with stenosis.
Abstract TP225: Predicting Large Vessel Occlusion in the Real World: Use of the Cincinnati Pre-hosptial Stroke Severity Score in Patients with Suspected Acute Ischemic Stroke
Authors: Whaley Michelle , Frei Donald , Snyder Meredith , Casper Christy , Chase Melissa
Published: June 2021

Background:
The Colorado Stroke Advisory Board (COSAB) asked three Joint Commission (JC) comprehensive stroke centers (CSC) and one primary stroke center (PSC) to assist with determining the usefulness of the Cincinnati Pre-Hospital Stroke Severity Score (CPSSS) in predicting large vessel occlusion (LVO) in patients with acute stroke symptoms.

Purpose:
The purpose of the study was to determine the real world applicability of the CPSSS in predicting LVO.

Methods:
CPSSS and LVO data was collected by stroke coordinators at three CSCs and one PSC for all patients brought to their respective emergency departments via local emergency medical services (EMS) from June 2016 to July 2016 as stroke alerts. The CPSSS was calculated retrospectively using the initial documented neurological exam and LVO was determined by initial computed tomography (CT) imaging results or physician notes in the electronic medical record.

Results:
Our study included 235 patients that were brought to 4 certified stroke centers in the Denver metropolitan area during a two month period in 2016. Eighty percent of patients (N=187/235) correctly screened negative on the CPSSS. Ten percent (N=23/235) of patients screened positive and were later determined to have LVO based on initial imaging. Four patients went on for endovascular treatment at a CSC that initially screened negative using the CPSSS. Nine percent (N=21/235) of patients screened false-positive for LVO. Top reasons for false positive CPSSS include intracerebral hemorrhage, altered mental status, seizure, and brain stem stroke.

Conclusion:
CPSSS is a reasonable screening tool to assess for LVO. More study is recommended to determine how to avoid missing LVO in stroke patients with mild symptoms on initial presentation.
Abstract TP231: Every IV Thrombolysis Case Should be Less Than 45 Minutes: Not So Easy All the Time
Authors: Cavanaugh Sean , Williams Jennifer , Ford Andria , Panagos Peter , Heitsch Laura
Published: June 2021

Background:
Target Stroke establishes the goal to administer IV Alteplase within 60 minutes of ED arrival. High-performing centers frequently treat within 45 minutes. Median door-to-needle (DTN) times at our tertiary care academic hospital are consistently < 30 minutes. Monthly case reviews investigate factors associated with DTN times greater than 45 minutes.

Methods:
Utilizing our stroke registry, patients treated with Alteplase from 2013-2015 were identified. Baseline demographics, medical comorbidities, weekend or after hours (7PM-7AM) presentation, initial NIHSS, initial BP greater than 185/110 and management, posterior circulation symptoms and ED crowding using the National Emergency Department Overcrowding Scale (NEDOCS) were extracted. Arrival date and time of arrival were cross-referenced with NEDOCS. Patients were divided into cohorts of treatment less than 45 minutes vs. greater than 45 minutes. Continuous variables were tested for normal distribution using Shapiro-Wilk, then either an unpaired t test or Wilcoxon’s test was applied to test for significance. Dichotomous variables were tested for significance with Chi-square analysis.

Results:
A total of 239 patients were included in the analysis. Data is presented in Table 1. After adjusting for multiple comparisons, there was a statistically significant difference in the distribution of baseline NIHSS scores (p=0.0006), diabetes (p=0.0023), and minor strokes (NIHSS less than 3, p=0.0003).

Conclusion:
Diabetics and patients with minor symptoms are more likely to have longer DTN times. Elevated BP, ED crowding, weekend and after hour arrivals do not significantly delay evaluation and treatment. While not significant after adjusting for multiple tests, both posterior stoke recognition and method of treating BP should be scrutinized as they are modifiable risk factors. Future awareness of discrete patient characteristics may help identify patients at risk for prolonged DTN.DTN.
Abstract TP236: Geographical Disparity of Acute Stroke Care Capabilities in Japan From a Nationwide Database: J-ASPECT Study
Authors: Arimura Koichi , Nishimura Kunihiro , Kada Akiko , Kamitani Satoru , Ogasawara Kuniaki , Ono Junichi , Shiokawa Yoshiaki , Aruga Toru , Toyoda Kazunori , Nakagawara Jyoji , Miyachi Shigeru , Yoshimura Shinichi , Okuchi Kazuo , Nagata Izumi , Matsuda Shinya , Nakamura Fumiaki , Onozuka Daisuke , Hagihara Akihito , Suzuki Akifumi , Sayama Tetsuo , Nishimura Ataru , Kurogi Ryota , Kurogi Ai , Ido Keisuke , Iihara Koji
Published: June 2021

Objective:
We previously demonstrated comprehensive stroke care (CSC) capabilities of the hospitals affect in-hospital mortality of patients with acute stroke. With the advent of unprecedented aging society, proper implementation of stroke centers requires understanding of geographical disparity of patient characteristics as well as stroke care capabilities. The aim of this study was to elucidate such geographical disparity regarding acute stroke care in Japan using a nationwide database.

Materials and methods:
We analyzed the data obtained from the Japanese Diagnosis Procedure Combination-based Payment System in 445 institutions between 2010 and 2012. Patients hospitalized emergently for ischemic stroke(IS), non-traumatic intracerebral hemorrhage(ICH) and non-traumatic subarachnoid hemorrhage(SAH) were identified using International Classification of Diseases-10 diagnosis codes. We classified the location of the hospitals into 4 areas, “Metropolitan Employment Area-Central (MEA-C)”, “ Metropolitan Employment Area-Outlying (MEA-O)”, “Micropolitan Employment Area-Central (McEA-C)”, and “ Micropolitan Employment Area-Outlying (McEA-O)”. We investigated patient characteristics, medical backgrounds, interventions and outcomes for each area.

Results:
Data obtained from a total of 214,910 patients with acute strokes (136,753 IS, 60,379 ICH and 17,778 SAH) were analyzed. As for patient characteristics, elderly patients and those with hypertension were more common in McEA-C and McEA-O, and stroke severity was more severe in McEA-C in all stroke types. As for hospital characteristics, proportion of admission by ambulance and CSC capabilities of the hospitals were smaller in all stroke types. Moreover, emergent interventions such as intravenous rt-PA infusion were performed at a lesser extent and in-hospital mortality was higher in McEA-C and McEA-O, and severe disability with mRS 3-6 was more often noted in McEA-C in all stroke types.

Conclusion:
We demonstrated geographical disparity of acute stroke care in Japan from a nationwide database. For proper implementation of stroke centers, centralization of acute stroke care capabilities should be considered in the rural areas to improve outcomes of acute stroke.
Abstract TP242: A Brief Educational Intervention Improves Paramedic Stroke Knowledge
Authors: Oostema John A , Chassee Todd , Oakley Mel , Reeves Mathew J
Published: June 2021

Introduction:
Emergency Medical Services (EMS) are an important component of stroke systems of care. EMS transport has been associated with faster emergency department (ED) stroke evaluations and higher t-PA delivery rates, especially among EMS recognized cases with hospital prenotification. However, delivery of high quality care including hospital prenotification requires that paramedics received regular education and training to improve their ability to identify and treat stroke cases.

Methods:
We identified opportunities for improvement in EMS care of suspect stroke patients through a review of local EMS stroke-related performance data and focus group discussions with paramedics. We then developed a 20-minute online educational module that reviewed basic stroke pathophysiology, discussed acute stroke therapies, and stressed the importance of performing stroke screening examinations and hospital prenotification for suspect stroke cases. The training was provided to all paramedics in a single agency. Scores on 10 item multiple-choice assessment were compared before and after receipt of the online training module using Fisher Exact tests and Wilcoxon Rank Sum Tests.

Results:
A total of 40 paramedics underwent the training. Overall quiz scores improved from a median of 9 (interquartile range [IQR] 7 to 9) to 10 (IQR 9 to 10, p=0.0002). Prior to training, only 43% of paramedics correctly identified 4.5 hours as the window for t-PA treatment, with 43% choosing 6 hours. Correct t-PA window identification improved significantly following education (43% to 87.5%, p<0.0001). Improvements were also seen for questions regarding the most common presenting complaints among EMS missed strokes (72.5% to 90%) and the recommended time frame for verbal hospital prenotification (80% to 95%), although these differences were not statistically significant.

Conclusions:
Overall, paramedics demonstrated good baseline knowledge regarding stroke, however important misconceptions regarding the time frame for t-PA eligibility were common. A brief, on-line educational intervention improved stroke knowledge. Further work is needed to determine the impact of stroke education on real world paramedic performance.
Abstract TP243: Evaluation of Transfer Time for Trauma, Stroke and Cardiac Patients
Authors: Espaillat Kiersten
Published: June 2021

Introduction:
Since the 1960’s, the “Golden Hour” has been a phrase well known in trauma circles- the sooner patients reached definitive care, the better their outcomes. In light of the positive endovascular stroke treatment trials we looked to evaluate the time EMS spends at the bedside before transferring a patient. We sought to understand the delays that occur after a diagnosis is made, after a hospital is selected, and after EMS arrives- what happens?

Methods:
We evaluated trauma, stroke, and cardiac patients who were transferred via helicopter from either the scene or a referring hospital. An air ambulance was requested for all of these patients either by EMS crews at the scene or by physicians in the referring hospital. We measured time to departure as the length of time between the Air crew arriving at the patient and the crew departing with the patient for the definitive care hospital.

Results:
We evaluated patients in 2015 and 2016 who were transferred via air ambulance for trauma, cardiac, and stroke. There were 749 trauma flights from the scene and 337 interfacility transfers (IFC). For cardiac, there were 38 from the scene and 178 IFC transfers. Finally, for stroke there were 338 from the scene and 301 IFC transfers. Cardiac had the most interesting results with the
shortest IFC time at 8 minutes
, but the longest IFC time at 22 minutes. Stroke and Trauma were similar at 17 and 16 minutes with no difference between scene and IFC.

Conclusions:
Acute Stroke patients are delayed in arriving at definitive care. The lack of a national goal for stroke patients is a current impediment leading change. Based on this data though, it is possible to move more efficiently in the transport of critically ill patients.
Abstract TP245: Prediction of Hemorrhagic Transformation in Patients With Acute Ischaemic Stroke and Atrial Fibrillation With Ct Perfusion Aspects Scores
Authors: Wang Qiaoshu , Cao Yanyan , Zhao Yongbo , Caplan Louis
Published: June 2021

Background and Purpose:
Hemorrhage transformation (HT) is common in patients with acute cerebral infarction caused by atrial fibrillation. The prediction of HT is crucial after acute stroke, especially for the patients received vessel recanalization therapy. The Alberta Stroke program early CT score (ASPECTS) is used to estimate early ischemic changes within the MCA territory in the acute stroke setting. Several studies indicated that CT perfusion (CTP) and MR diffusion weighted imaging (DWI) ASPECTS scores was useful to quantify the degree of ischemic brain tissue. Hereby we did the study to explore the association of CT perfusion ASPECTS scores with HT in patients with acute ischemic stroke and atrial fibrillation.

Methods:
This was a single center retrospective study. All patients with middle cerebral artery infarction and atrial fibrillation from September 2008 to September 2013 were included. MR imaging including DWI and gradient echo sequence (GRE), and CTP were required to identify the HT and determine the scores of CTP- ASPECTS. Demographic and clinical characteristics of the HT positive and negative groups were explored.

Results:
Fifty-four patients were analyzed, among them twenty-four patients (44%) developed HT. According to logistic regression analysis, mean transit time (MTT), cerebral blood volume (CBV) and DWI-ASPECTS scores were associated with HT (
p
= 0.035, 0.044, and 0.020 respectively). The following receiver operating characteristics (ROC) analysis revealed area under the curve of MTT, CBV, CBF and DWI were 0.588, 0.737, 0.687, and 0.841 respectively. CBV-ASPECTS score was found to have medium prediction value of HT among all CTP-ASPECTS parameters. ROC analysis also indicated that CBV-ASPECTS score < 7 was the optimal threshold.

Conclusions:
CTP-ASPECTS was useful to predict the HT of acute ischemic stroke caused by atrial fibrillation and CBV-ASPECTS score < 7 was the preferable parameter.
Abstract TP250: A Substantial Rate of Neurological and Non-Neurological Stroke Mimics Are Transported by Emergency Medical Services for Acute Stroke Evaluation
Authors: Briard Joel N , Zewude Rahel T , Kate Mahesh , Butcher Ken , Gioia Laura C
Published: June 2021

Introduction:
The impact of prehospital triage of stroke mimics to designated stroke centers may be considerable, yet little information exists regarding stroke mimics in the prehospital setting. We aimed to describe the rate and clinical characteristics of neurological and non-neurological stroke mimics transported by Emergency Medical Services (EMS) to the Emergency Department (ED) for acute stroke evaluation.

Methods:
A retrospective, cross-sectional, observational analysis of a centralized EMS database of patients transported by EMS to the ED for suspected stroke during an 18-month period. Hospital charts and neuroimaging were utilized to determine the final diagnosis (acute stroke, stroke mimic, as well as specific underlying diagnoses).

Results:
A total of 960 patients were transported by EMS to the ED with suspected stroke, among whom 405 (42.2%) were stroke mimics (mean age ± SD: 66.9 ± 17.1 years; 54% male). Stroke mimics were neurological in origin in 223 (55.1%) patients and non-neurological in 182 (44.9%). Most common neurological diagnoses were seizures (n=44,19.7%), migraines (n=42,18.8%) and peripheral neuropathies (n=25, 11.2%). Most common non-neurological mimics included cardiovascular (15.9%), psychiatric (11.9%), and infectious (8.9%) diagnoses. Neurological mimics were younger (64.1 ± 17.3 years) than non-neurological mimics (70.5 ± 16.1 years, p<0.001). Median prehospital Glasgow Coma Scale scores were similar between groups (15 vs. 15, p=0.26). Mean prehospital systolic blood pressure was slightly higher in neurological (147.8±24.2 mmHg) than non-neurological mimics (141.2±26.2 mmHg, p=0.01).

Conclusions:
Stroke mimics represent a substantial number of patients transported by EMS for suspected stroke, with a considerable amount being non-neurological in origin. Prospective prehospital studies are warranted to help refine prehospital identification of acute stroke and thus minimize the number of stroke mimics transported by EMS for acute stroke evaluation.
Abstract TP256: mStroke: "Mobile Stroke" - Improving Acute Stroke Care With Smartphone Technology
Authors: Andrew Benjamin Y , Stack Colleen M , Yang Julian P , Dodds Jodi A
Published: June 2021

Introduction:
The use of mobile electronic care coordination via smartphone technology is a novel approach aimed at increasing efficiency in acute stroke care. One such platform, StopStroke© (Pulsara Inc., Bozeman, MT), serves to coordinate personnel (EMS, nurses, physicians) during stroke codes with real-time digital alerts. This study was designed to examine post-implementation data from multiple medical centers utilizing the StopStroke© application, and to evaluate the effect of method of arrival to ED and time of presentation on these results.

Methods:
A retrospective analysis of all acute stroke codes using StopStroke© from 3/2013 – 5/2016 at 12 medical centers was performed. Preliminary unadjusted comparison of clinical metrics (door-to-needle time [DTN], door-to-CT time [DTC], and rate of goal DTN) was performed between subgroups based on both method of arrival (EMS vs. other arrival to ED) and time of day. Effects were then adjusted for confounding variables (age, sex, NIHSS score) in multiple linear and logistic regression models.

Results:
The final dataset included 2589 unique cases. Patients arriving by EMS were older (median age 67 vs. 64,
P
< 0.0001), had more severe strokes (median NIHSS score 8 vs. 4,
P
< 0.0001), and were more likely to receive tPA (20% vs. 12%,
P
< 0.0001) than those arriving to ED via alternative method. After adjustment for age, sex, NIHSS score and case time, patients arriving via EMS had shorter DTC (6.1 min shorter, 95% CI [2, 10.3]) and DTN (12.8 min shorter, 95% CI [4.6, 21]) and were more likely to meet goal DTN (OR 1.83, 95% CI [1.1, 3]). Adjusted analysis also showed longer DTC (7.7 min longer, 95% CI [2.4, 13]) and DTN (21.1 min longer, 95% CI [9.3, 33]), and reduced rate of goal DTN (OR 0.3, 95% CI [0.15, 0.61]) in cases occurring from 1200-1800 when compared to those occurring from 0000-0600.

Conclusions:
By incorporating real-time pre-hospital data obtained via smartphone technology, this analysis provides unique insight into acute stroke codes. Additionally, mobile electronic stroke care coordination is a promising method for more efficient and efficacious acute stroke care. Furthermore, early activation of a mobile coordination platform in the field appears to promote a more expedited and successful care process.
Abstract TP258: Large Vessel Occlusion Screening Tool for Acute Ischemic Stroke Patients
Authors: Ruff Ilana M , Caprio Fan Z , Jiang Linda , Mendelson Scott J , Richards Christopher T , Bernstein Richard A , Jahromi Babak S , Ansari Sameer A , Shaibani Ali , Hurley Michael C , Malik Sanjeev , Potts Matthew B , Curran Yvonne , Bergman Deborah , Prabhakaran Shyam
Published: June 2021

Introduction:
With randomized data proving the benefit of endovascular therapy for large vessel occlusion (LVO), there is increasing interest in developing a rapid screening tool to predict LVO in acute ischemic stroke (AIS) patients in the emergency department (ED) setting.

Methods:
We implemented a new LVO screening tool in our ED in March 2016. The LVO score ranged from 0-6 and included one point for each of the following individual components: level of consciousness, gaze deviation, aphasia, dysarthria, facial droop, and arm weakness. LVO was defined as an intracranial occlusion of the internal carotid artery, M1 and M2 segments of the middle cerebral artery, A1 and A2 segments of the anterior cerebral artery, P1 and P2 segments of the posterior cerebral artery, basilar artery, or vertebral arteries. We calculated c-statistics to determine the discrimination of the LVO score for presence of LVO on emergent vascular imaging and identified the optimal cut-off score with maximum sensitivity and specificity.

Results:
Among 65 consecutive confirmed AIS patients between March and July 2016, 63.1% had a positive LVO screen (score > 0); 97% of the patients underwent emergent CT angiography. Eleven (16.9%) patients had an LVO in the territory of ischemic infarct, 10 of which were in the anterior circulation. The LVO score had a c-statistic of 0.77 (95%CI 0.59-0.96, p< 0.005) for predicting LVO. An optimal cut-off score > 2 was present in 19 patients (29.2%) and was associated with 72.7% sensitivity and 79.6% specificity; positive and negative predictive values were 42.1% and 93.5%, respectively.

Conclusions:
In a preliminary analysis, a simple LVO screening tool had acceptable discrimination for predicting LVO in AIS patients in the ED. Further validation and refinement of the tool is necessary.
Abstract TP26: Endovascular Therapy and Outcomes in a Large Biracial Cohort of Patients with Acute Ischemic Stroke
Authors: Rebello Leticia C , Anderson Aaron , Haussen Diogo C , Belagaje Samir R , Grossberg Jonathan A , Bouslama Mehdi , Doppelheuer Shannon , Bianchi Nicolas , Frankel Michael R , Nogueira Raul G
Published: June 2021

Background:
The ethnic disparities in stroke outcomes have been well described. Stroke is twice more common and leads to higher mortality rates among blacks as compared to whites. We compared the outcomes of patients undergoing endovascular stroke therapy (ET) in a high-volume center according to their racial profile after age adjustment.

Methods:
Retrospective analysis of a prospectively collected ET database between September/2010-September/2015. The baseline characteristics of African-American vs. Caucasian patients were compared. Given the impact of age on stroke outcomes additional analyses were performed dichotomizing patients using the median age of the overall cohort. Primary and secondary efficacy outcomes included the rates of good outcome (90-day mRS 0-2) and successful reperfusion (mTICI 2b-3), respectively. Safety outcome was accessed by rates of any parenchymal hematoma (PH-1 and PH-2) and 90-day mortality.

Results:
781 patients fit the inclusion criteria and were included in the analysis; 440 were included in the Caucasian group (56% overall cohort) and 341 in the African-American group (44%). Caucasian patients were significantly older (69±13 vs. 60±14 years-old, p<0.01) but the remaining baseline characteristics were otherwise well-balanced. This included similar baseline CT perfusion core volumes (rCBF<30%, 17.6 ± 20.8 vs. 17.9 ± 32.8; p=0.93). There were no differences in the rates successful reperfusion (mTICI 2b-3: 83% vs. 85%, p=0.37), any PH (8% vs. 5%, p=0.26), or final infarct volume (32 IQR 12-89 vs. 25 IQR 9-67; p=0.12) across the two groups. In the overall cohort, there was a lower proportion of 90-day good outcome (39% vs. 49%; p<0.01) and higher 90-day mortality (32% vs. 16%; p<0.01) among Caucasians presumably due to their older age. Subgroup analysis of patients 65 years-old or younger showed similar rates of 90-day good outcomes (59% vs. 53%; p=0.33) and mortality (17% vs. 12%; p=0.22) across Caucasian and African-American patients.

Conclusion:
Aggressive treatment of acute ischemic stroke with endovascular therapy leads to similar outcomes across African-American and Caucasian patients. Greater availability of ET may diminish the ethnic/racial disparities in stroke outcomes.