bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P18: Report on the Treatment Process and Impact of Mechanical Thrombectomy Before and After Coronavirus Disease in a Newly Opened Hospital of South Korea
Authors: EUN Jin , Park Hae-Kwan
Published: March 2021

Introduction:
The difficulty neurointernvetionists face in keeping “Time is brain” in the middle of the COVID-19 pandemic are inevitable. Our health system began shutting down entire hospital for two weeks after a transport agent was diagnosed with COVID-19. It took an additional two weeks to establish the process of emergency treatment. We intend to introduce our protocols and report on their progress so far.
Post-COVID-19 Protocol
(Figure 1)

Methods:
A total of 52 patients underwent mechanical thrombectomy at Eunpyeong St. Mary’s Hospital before the Covid-19 outbreak. For 18 patients who underwent mechanical thrombectomy through a new process after COVID-19, door-to-image time, door-to-puncture time, and TICI grade were compared.

Results:
For the treatment of all patients, portable chest x-ray imaging was performed, but the door-to-initial-brain-image time (min) was 15.5 vs. 15 (before COVID-19 vs. after COVID-19) (p=0.265). Door-to-needle-time (min) showed a delay of 9 minutes, from 144.5 to 153.5, but it was not statistically significant (p=0.299). Up to 95.2% of patients before COVID-19 achieved TICI grade 2b or higher, and 100% of patients after COVID-19 have achieved TICI grade 2b or 3. (Table 1)

Conclusions:
Overall, there was a slight increase in the door-to-needle time, but clear protocols and guidelines for management and collaboration with the clinical workforce have been able to reduce delays and ensure timely and adequate management. When referring to the protocol implemented while preparing for infectious diseases, it will be a reference not only for COVID-19, but also for other diseases that may occur in the future.
Abstract P180: Protocolized Selection for Telestroke Activation in The Extended Window for Thrombectomy
Authors: Berezoski Abigail , Forrest Heather , Meek Lorie Ann , Kolls Brad J , Marriott Elizabeth , Ehrlich Matthew , Feng Wayne , Jordan Dedrick , Graffagnino Carmelo , Shah Shreyansh , Mac Grory Brian C , Kam Wayneho , Hernandez Christian , Le Scott , Gehring Jodi A , El Husseini Nada K
Published: March 2021

Background:
The advent of biomarker-driven identification of candidates for acute therapies in the 4.5-24-hour time window has resulted in an increase in the number of telestroke consults with low yield for acute intervention. While the use of the Vision Aphasia Neglect (VAN) score and a National Institutes of Health Stroke Scale (NIHSS) cutoff score of ≥6 may help identify patients with Large Vessel Occlusions (LVO), there are no guideline-based protocols for using these scales as a decision point for telestroke activation.

Method:
We selected 5 spoke sites from an academic hub-and-spoke model telestroke network for inclusion in our study. In the extended window (4.5-24 hours), telestroke consultants assisted with appropriate selection for hospital transfers for mechanical thrombectomy (MT) with the goals of maximizing retention at the spoke sites. All sites were able to obtain computed tomography angiography (CTA) head and neck onsite. In the extended window, the following protocols were followed at the sites for telestroke activation: Sites A - B: NIHSS ≥6; Site C: NIHSS ≥6 and/or VAN positive; Sites D - E any acute-onset, focal neurological symptoms within 24 hours of symptom onset. Descriptive statistics were used.

Results:
Between July 2019 and February 2020, there were 1,114 telestroke consults with 351 (32%) extended window activations. In the extended window, the number of activations for NIHSS≥6 was less than a third of the total activations and the rate of transfer for MT was low across the sites regardless of whether the sites had adopted a protocolized activation (Table). However, 80% of all transfers had an NIHSS ≥6.

Conclusion:
In an academic telestroke network, protocols for selecting “high-yield” consults in the extended thrombectomy window did not lead to less telestroke activation or a higher yield for MT. More studies are needed to determine if this is due to the applied scales or whether targeted educational interventions at the sites would improve selection.
Abstract P181: Differential Clinical Outcomes Among Stroke Patients From Rural and Urban Areas in a Pilot Stroke Network
Authors: Llanos Natalia , Pardo Carlos , Pinilla Gabriel , Arango Akemi , Valderrama Jaime , Pugliese Isabella , Amaya Pablo
Published: March 2021

Objective:
To describe the clinical features of stroke patients from rural and urban areas and to identify possible associations with clinical outcomes.

Introduction:
There is little information in Latin America about risk factors, treatments, and outcomes in stroke patients from rural areas and urban people. The rural population faces multiple healthcare access barriers that might influence stroke outcomes. This paper describes and analyzes clinical features in stroke patients according to their location.

Methods:
Prospective cohort study of Colombian stroke patients using demographic and clinical data collected between 2018 and 2020 in a high complexity hospital from southwestern Colombia, as part of a pilot stroke network consisting of rural primary centers and a mothership center. Mode of transport to the stroke center, timing, clinical characteristics, interventions, and modified Rankin scale (mRS) at discharge and 3 months were assessed.

Results:
We included 579 stroke patients (66.14% ischemic), with a median age of 70 years (60-81). Urban subjects showed higher prevalence of dyslipidemia (p=0.009), previous hemorrhagic stroke (p=0.036), and TIA (p=0.002). Approximately 35% of cases were initially evaluated at a rural primary care center. These subjects exhibited a higher NIHSS scores (10 IQR 5-19 vs. 5 IQR 2-13; p=0.000) with a longer window (p<0.001) and were mainly transferred by ambulance (89.80%, p=0.000). Due to the severity, door-to-imaging time was shorter (p=0.001). Rural patients receive thrombolysis in 27.36% and underwent thrombectomy in 14.43%. Higher mRs at discharge (3 IQR 2-5 vs. 2 IQR 1-4; p=0.000) and three-months follow-up (3 IQR 1-6 vs. 1 IQR 0-4; p<0.001) were observed.

Conclusions:
Rural patients from southwestern Colombia were more likely to present with severe strokes even though they had lower rates of cardiovascular risk factors. They arrived later to the stroke center, but the final diagnosis was reached faster. Nonetheless, disability was higher at discharge and 3-months follow-up.
Abstract P182: Stroke Therapy in the Time of Covid-19
Authors: Hargrove Paige , Spann Deborah , Legendre Yvette , Colligan Ted , Martin-Schild Sheryl
Published: March 2021

Background:
The first surge of COVID-19 cases in Louisiana began in late March 2020 and was centered on the Greater New Orleans Area. Louisiana is divided into 9 regions; New Orleans is in Region 1. A statewide survey indicated 100% of hospitals experienced a decline in stroke presentations. We sought to determine if treatment of stroke with intravenous (IV) thrombolytic declined or was delayed relative to pre-COVID-19. We also sought to evaluate a change in door in-door out (DIDO) for secondary transfers among patients who screened positive for large vessel occlusions (LVO).

Methods:
Our statewide stroke registry, mandatory for hospitals attesting to Acute Stroke Ready Hospital status, was queried. We compared stroke volume, treatment rate with IV thrombolytic, treatment efficiency, and DIDO in 2019 with March 2020 and Q2 2020.

Results:
Monthly stroke presentations declined by 20% starting March 2020 compared to the average monthly volume in 2019. The IV thrombolytic rate was down from 10.3% to 8.8% in Q2 2020. In Q2 2020, the median door-to-needle time was 12 minutes longer than it was during 2019 and the proportion with a documented reason for delay increased from 29.1 in 2019 to 33.3% in March 2020 and 37.5% in Q2 2020. The median DIDO increased by 13 minutes compared to 2019 (129 vs 116 minutes).

Discussion:
Louisiana experienced a reduction in stroke presentation following the initial surge of COVID-19 cases. The treatment rate and efficiency with IV thrombolytic declined and DIDO was prolonged among patients with suspected LVO. Careful evaluation of how the stroke code processes changed in response to COVID-19 may help to recover efficiency in delivering acute stroke therapy.
Abstract P183: Preserved Acute Stroke Volumes and Treatment Metrics During the Covid 19 Pandemic
Authors: Diaz Rojas Maria V , Zhu Liang , Wu Tzu-ching , Ankrom Christy T , Zha Alicia , Jagolino-Cole Amanda L , Cossey TC
Published: March 2021

Stroke is a devastating disease with high morbidity/mortality. Many studies have shown lower stroke volumes during the Covid 19 pandemic, with possible causes including fear of contracting the virus, limited hospital capacity, etc. Telemedicine (TM) helps provide safe management of stroke patients, and may be advantageous to in-person coverage during crises. The UT Teleneurology (UTT) hub provides acute neurological coverage by stroke specialists to 18 spoke centers. The impact of the pandemic on acute stroke volumes and care is ongoing and its effects should be studied further. The purpose of this study is to compare TM acute stroke volumes and time metrics between the Covid 19 era (March-June 2020) and the previous year (March-June 2019). In a retrospective query of the UTT registry from 3/19 - 6/19 and 3/20 - 6/20, we identified 294 stroke patients who received tPA - 273 were included in our analysis - 4 were excluded after quality check, 17 were excluded as inpatient strokes. We compared baseline and clinical characteristics, volumes, and time metrics between the periods (table 1). Of the 273 patients, 172 received tPA via TM during the 2019 period and 109 received tPA via TM during the 2020 period. Baseline and clinical characteristics were similar between the groups except for race. Of note, there were no differences in acute TM volumes or the number of patients receiving tPA. There was no difference in most metrics, including door to needle time. During the pandemic, camera to needle time was longer (3 minutes), and there was a trend towards longer last well to door time. There were no differences in the volume of acute TM consults, the number of patients receiving tPA, or door to needle time between the pandemic period and the previous year. Camera to needle time was slightly longer during the pandemic, perhaps representing more demands on hospital staff. The trend towards longer last well to door time could be due to public fear of presenting to the hospital during a deadly pandemic.
Abstract P184: Effect of Acute Stroke Care Hospital Networks in Korea
Authors: Kang Jihoon , Kim Seong Eun , Song Hyunjoo , Bae Hee-joon
Published: March 2021

Purpose:
Stroke patients generally transport stroke patients either to nearest stroke hospital with secondary transfers or to hub hospitals in selective cases. This study aimed to determine the stroke community of close networks and to evaluate their role for the access the endovascular treatment (EVT).

Methods:
Using the nationwide acute stroke hospital (ASH) surveillance data assessed the major quality indicators of all stroke patients of South Korea, triage information both initial visit and secondary interhospital transfers were extracted according to the hospitals. Based on them, stroke community with dense linkages were partitioned using the network-based Louvain algorithm. The hierarchical model estimated the function of stroke community for the EVT.

Results:
For 6-month surveying period, 19113 subjects admitted to the 246 ASHs. Of them, 1831 (9.6%) were transferred from 763 adjacent facilities not ASH, while 1283 (6.7%) from the other ASHs. The algorithm determined the 113 stroke communities where composed median 7 hospitals (2 ASHs and 5 adjacent facilities) and treated about 30 subjects per month. Most of communities formed the spindle shape with higher centralization index and located within 150 Km (Figure). Stroke communities significantly affected 11% of EVT after adjustments.

Conclusions:
Network analysis method effectively contoured the high centralizing stroke communities and helped the functions on the EVT accessibility.
Abstract P185: Feasibility and Outcome of Pharmacist-Enhanced Stroke Rounds
Authors: Walley Megan J , Lewis Samantha , Nobleza Christa Ohana S
Published: March 2021

Background:
Treatment of stroke patients is complex. Multidisicplinary rounds have been shown to decrease 30-day readmission rates, improve efficiency in work flow, communication between disciplines and promote patient-centered care. Pharmacy-enhanced intensive care unit rounds reduce adverse drug events (ADE) and provide real-time resource for drug selection, interaction and dosages. Reports on the feasibility of pharmacist-enhanced stroke rounds (PEnSR) and its effect on outcomes are few.

Objective:
Determine the effect of a pharmacy-enhanced stroke-rounds on patient and healthcare outcomes.

Methods:
A performance improvement analysis was done in the University of Mississippi Medical Center from September 1, 2019 to November 30, 2019. A pharmacist assigned to the stroke service performed medical reconciliation, monitored drug interaction, provided recommendations on drug choice and dosages for the stroke patients and alerts on medication errors. The primary outcome includes the proportion and severity of medication errors detected utilizing the EPIC iVent tool. The secondary outcomes include characteristics of interventions to prevent an ADE, cost-avoidance based on the errors and cost-analysis for the continued presence of a pharmacist for stroke rounds based on time spent to perform the role. A feedback-survey regarding the pharmacist was done at the end of analysis period.

Results:
A total of 77 interventions were performed during 2 month with a total cost avoidance of $40,250. Most common errors were minor. The most common intervention by the pharmacist was to initiate orders followed by discontinuing orders. Overall time spent daily for the stroke service was 5-hours. All residents and attendings of the stroke service were aware of the pharmacist’s presence, utilized the service and perceived that the PEnSR was beneficial.

Conclusion:
PEnSR was feasible and cost-effective and allows for the pharmacist to still contribute to other roles in the hospital. PEnSR also improves patient-centered care for stroke patients by preventing ADE resulting in hospital savings of ~$20,000/month. The UMMC-Stroke team has adapted PEnSR as part of the daily multidisciplinary stroke care.
Abstract P186: New Prehospital Triage for Stroke Patients Significantly Reduces Transport Time of EVT Patients Without Delaying IVT
Authors: Bar Michal , Cabal Martin , Volny Ondrej , Jaššo Petr , Holeš David , Vaclavik Daniel
Published: March 2021

Background and Purpose:
Ischemic stroke is a leading cause of mortality and morbidity worldwide. The time from stroke onset to treatment impacts clinical outcome. Here we examined whether changing a triage model from “drip and ship” to “mothership” yielded significant reductions of onset-to-groin time (OGT) in patients receiving EVT, and onset-to-needle time (ONT) in IVT-treated patients, compared to before FAST-PLUS test implementation. We also investigated whether the new triage improved clinical outcomes.

Methods:
In a prospective interventional multicenter study, we evaluated the effects of changing the prehospital triage system for suspected stroke patients in the Moravian-Silesian region, Czech Republic. In the new system, the validated FAST PLUS test is used to differentiate patients with suspected large vessel occlusion, and triage-positive patients are transported directly to the CSC. Time metrics and patient data were obtained from the regional EMS database and SITS database.

Results:
For EVT patients, the median OGT was 213 min in 2015, and 142 min in 2018; and median TT was 118 min in 2015, and 47 min in 2018. For tPA patients, the median ONT was 110 min in 2015, and 109 min in 2018; and median TT was 41 min in 2015, and 48 min in 2018. Clinical outcome did not significantly change. The median mRS at 3 months after stroke onset in both 2015 and 2018 was 2 among tPA patients, and 3 among EVT patients. The percentages of patients with favorable clinical outcome (mRS 0-2) were comparable between 2015 and 2018: 60% vs 59% in tPA patients, and 40% vs 44% in EVT patients.

Conclusions:
The new prehospital triage has yielded shorter onset-to-groin times for EVT patients. No changes were found in the onset-to-needle time for IVT-treated patients, or in the clinical outcome at 3 months after stroke onset.
Abstract P188: Transfer Time From Spoke ER Arrival to CSC Arrival in a Hub-Spoke Transfer Model of Thrombolysis for Acute Ischemic Stroke
Authors: Lee Vivien H , Segerstrom Paul A , Powers Ciarán J , Heaton Sharon , Nimjee Shahid M , Hannawi Yousef
Published: March 2021

Introduction:
Acute ischemic stroke (AIS) patients who present to a spoke Emergency Room (ER) and require transfer to a comprehensive stroke center (CSC) hub face potential delays

Methods:
We performed a retrospective review of 269 suspected AIS patients who received intravenous tissue plasminogen activator (tPA) from July 2016 to October 2017 in our academic telestroke network. During this period, nearly all tPA patients were transferred to the CSC hub. Data was collected on patient demographics, National Institutes of Health Stroke Scale (NIHSS), door to needle time (DTN), and distance to CSC. ER-to-CSC was defined as the time from patient arrival at Spoke ER to arrival at CSC. Top volume ER status was assigned to the 4 Spoke ERs with the highest volume of tPA.

Results:
Among 269 AIS patients who received tPA at spoke ERs, the mean age was 65.4 years (range, 21 to 95), 49% were female, and 91.8% were white. The initial median NIHSS was 6 (range, 0 to 30) and the mean DTN was 73.1 minutes (range, 14 to 234). The mean distance from Spoke ER to CSC was 55.2 miles (range 5.8 to 125) and the mean ER-to-CSC was 2.6 hours (range 0.62 to 6.3) (Figure 1). In univariate analysis, the following factors were significantly associated with ER-to-CSC: distance (p < 0.0001), DTN (p < 0.0001), NIHSS (p 0.0007), and top volume ER status (p 0.0034). Patient sex, age, race, SBP, weight, initial NIHSS, daytime shift, and weekend status were not significantly associated with ER-to-CSC. Significant variables from the univariate analysis were included in multivariate linear regression model in which DTN (P < 0.0001), distance (P < 0.0001), and NIHSS (P 0.024) association with ER-to-CSC remained significant.

Conclusions:
In our series of AIS tPA patients transferred to CSC, the mean time from spoke ER arrival to CSC arrival was 2.6 hours. Factors associated with CSC arrival time include markers of ER performance (DTN), severity (NIHSS), and distance. Further study is warranted to improve transfer time in AIS.
Abstract P193: Effects of Biaxial Ankle Passive Movement Therapy on Cortical Activations in Patients With Chronic Stroke a Functional Near-Infrared Spectroscopy Pilot Study
Authors: Kim Hogene , Cho Ji-Eun
Published: March 2021

Introduction:
The objective of this study was to investigate the effect of passive biaxial ankle movement therapy on cortical activities. We hypothesized that biaxial ankle passive movement therapy changes patterns of sensorimotor cortical activations during ankle passive movement in chronic stroke.

Methods:
Seventeen patients with stroke were randomized to either experimental or control group. The experimental group (n=11) received the biaxial ankle training and the control group (n=6) had conventional therapies on affected ankle for a 30-minute daily session, five times a week for a month. Outcome measure was cortical activations by measuring the relative changes of oxygenated hemoglobin concentration between ipsilesional-/contralesional hemisphere during passive ankle movement using functional near-infrared spectroscopy(fNIRS)(Figure 1). All assessments was conducted before and after the training. Significance level was 0.05.

Results:
fNIRS images showed that ipsilesional oxyhemoglobin concentration increased around primary sensorimotor cortex (SMC) area in both control and experimental groups at the baseline (
P
<0.05). After the ankle training, the ipsilesional oxyhemoglobin concentration significantly increased around somatosensory area for both control and experimental groups (
P
<0.05, Figure 2).

Conclusions:
The results of this study showed significant ipsilesional cortical activation in SMC during biaxial ankle movement before and after the ankle training. Further study on the analysis according to the direction of ankle movement for both ipsilesional and contralesional brain area is needed.
Abstract P201: Octogenarian and Nonagenarian Outcomes Among Acute Ischemic Stroke Patients
Authors: GADHIA RAJAN R , Vahidy Farhaan S , Nisar Tariq , Hooper Destiny , Chiu David , Lee Jason , McCane Charles D , GADHIA RAJAN R , Ling Ken
Published: March 2021

Objective:
Most acute stroke treatment trials exclude patients above the age of 80. Given the clear benefit of revascularization with intravenous tissue plasminogen activator (IV tPA) and mechanical thrombectomy (MT), we sought to assess functional outcomes in patients treated above the age of 80.

Methods:
We conducted a review of all patients admitted to Houston Methodist Hospital between January 2019 and August 2020 with an acute ischemic stroke (AIS) presentation[MOU1] for whom premorbid, discharge, and 90 day modified Rankin Scale scores were available. Patients were categorized by acute stroke treatment (IV tPA, MT, both or none[MOU2] ). mRS values were assessed during admission prior to discharge and at 90 days post stroke event. A delta mRS (Discharge vs. 90-day [MOU3] ) was defined and grouped as no change, improved, or worsened to assess overall functional disability in regards to the index stroke presentation.

Results:
A total of 865 patients with AIS presentation were included, of whom 651 (75.3%) were <80 years and 214 (24.7%) were > 80 years of age at presentation. A total of 208 patients received IV tPA, 176 underwent revascularization with MT only, 71 had both treatments, and 552 had no acute intervention. In patients >80 yrs who had no acute stroke intervention. mRS improvement was noted in 71.4% compared to 54.1% observed in those patients <80 years. Among patients who received IV tPA, 81.5% of > 80 years improved vs. 61.6% in the younger cohort. A similar trend was noted in the MT and combined treatment groups (76.2% vs. 71.2% and 78.6% vs. 79.3%, respectively).

Conclusion:
Based on our cohort of acute stroke patients, there was no significant difference in outcomes (as measured by delta mRS) for octogenarians and nonagenarians when compared to younger patients. There was a trend towards improvement in the elderly patients. Chronological age by itself may be an insufficient predictor of functional outcome among stroke patients and age cutoffs for enrollment of patients in acute stroke trials may need additional considerations.
Abstract P202: Estimation of Arm Kinematics in Stroke Survivors With Wearable Sensors
Authors: Nie Jeffrey Z , Nie James W , Hung Na-Teng , Slutzky Marc
Published: March 2021

Introduction:
Stroke is the leading cause of long-term disability in the US, often resulting in upper extremity (UE) motor impairment. Numerous clinical metrics have been developed and used to evaluate UE motor function to assess rehabilitation outcomes, but most of these are innately subjective and/or have relatively low sensitivity to change due to the use of ordinal scales. As a result, there is a growing interest in the use of kinematics to evaluate UE motor function, as they provide completely objective, high resolution quantitative measurements. However, obtaining kinematic measurements in stroke survivors can be a challenging task, as non-ideal environments (e.g., hospital rooms), expense, and a limited ability to perform calibration poses can make traditional optical tracking systems impractical. To overcome these challenges, we developed and compared two methods using different wearable sensors to estimate elbow angle and wrist position during reaching movements in people with stroke.

Methods:
We developed frameworks specific for two different types of sensors, inertial measurement units (IMU) and virtual reality (Vive) trackers, to estimate elbow angle and wrist position. We assessed each sensor’s estimation accuracy during pure flexion-extension motion, performed by a manual goniometer, and pure pronation-supination motion, performed by a healthy participant. We also compared each sensor’s ability to longitudinally track a stroke survivor’s UE function by using the wrist position estimates to compute sweep areas during a sweeping task.

Results:
For the IMUs, our results demonstrated accuracy to within 4.8° and 1.2 cm for elbow angle and wrist position, respectively. For the Vive, our results demonstrated accuracy to within 2.2° and 0.9 cm. The change in sweep area estimated by each method agreed with each other, as the difference between estimates was approximately 4% of the change in sweep area.

Conclusion:
These methods can be used to develop and accurately assess kinematic metrics for use in evaluating stroke rehabilitation outcomes.
Abstract P213: Identification of Rural Needs and Gaps of Stroke Care Rehabilitation: Results From a Statewide Healthcare Provider and Stroke Patient Survey
Authors: Barnes Olivia , Santana Adela , Malina Beth L , Myers Gary , Goldman Amy , Storer Tammy , McDowell Gene , Schwarz Sarah , Frans Rebecca
Published: March 2021

Introduction:
Urban and rural stroke care disparities are pervasive for post-acute stroke rehabilitation. Mission:Lifeline Stroke conducted a needs assessment to identify needs and gaps in care for stroke rehabilitation throughout rural Nebraska (NE).

Purpose:
The assessment included surveys of healthcare providers (HCPs) and stroke survivors to inform a robust understanding of stroke rehabilitation needs across NE, addressing barriers and facilitators to care, including outpatient therapy, social support, equipment, and patient-facing resources.

Methods:
HCPs were recruited through the Nebraska Stroke Advisory Council to complete a 17-question online survey. Survivors in NE were recruited through social media and existing stroke support groups to complete a 26-question online survey.

Results:
Respondents of the HCP survey (N=260) identified the top barrier to providing care to survivors as lack of insurance (62%), lack of caregiver support (42%), and lack of specialized services (42%). Respondents of the survivor survey (N=30) identified top barriers as lack of insurance (74%), financial burden (64%), and lack of caregiver/social support (50%). Both HCPs’ and survivors identified lack of caregiver and social support as resources missing from their community, and survivors identified communication about support groups or sources of emotional support (n=4) as the top missing resource. In addition, 39% of survivors indicated an interest in attending a support group. HCPs indicated missing resources primarily include specialized rehab equipment, technology, and services (52%), and professional opportunities for staff (37%). Regarding resources provided to survivors, most HCPs indicated community resources (94%) are provided, proceeded by follow-up/continued outpatient therapy (88%). In slight contrast, survivors indicated the top resources they learned of when discharged were outpatient physical therapy (82%), outpatient occupational therapy (70%), and outpatient speech therapy (56%).

Conclusion:
Although both healthcare providers and survivors identified outpatient therapies are made available, there is a need for more communication about support groups and physical resources such as rehab equipment, technology, and services.
Abstract P217: Direct Myosin-2 Inhibition Restores Cerebral Perfusion in Cortical and Subcortical Regions Resulting in Functional Improvement After Ischemic Stroke
Authors: Penzes Mate , Turos Demeter , Mathe Domokos , Rauscher Anna , Toth Peter , Ivic Ivan , Gyimesi Máté , Doboi Arpad , Malnasi-Csizmadia Andras
Published: March 2021

Inefficient cerebral reperfusion is a major unresolved problem in ischemic stroke treatment because hypoxia-induced constriction of capillaries remains persistent even after recanalization by thrombolysis or thrombectomy. Capillary constriction is mediated by actomyosin contraction in precapillary smooth muscle cells (SMCs). We have developed and tested a formulation and administration technique to target the ischemic brain region and developed a promising small-molecule myosin-2 inhibitor (para-aminoblebbistatin (AmBleb) that mainly exerts its effect through direct inhibition of smooth muscle myosin-2 (SMM) in SMCs. The efficacy of SMM inhibition was tested in a rodent transient Middle Cerebral Artery Occlusion (tMCAO) stroke model. SMM was targeted by the direct administration of AmBleb into the ischemic region. AmBleb significantly accelerated the improvement of neurological deficits. Regional cerebral blood flow (rCBF) in the most important cortical and subcortical regions (e.g. motor- and somatosensory cortices, optic pathways, striatum, corpus callosum) showed drastic improvement in the AmBleb treated animals in line with the significant reduction of neurological deficits. We further optimized AmBleb and developed our lead compound MPH-222, which possesses significantly improved pharmacological properties than those of AmBleb. As observed with AmBleb, MPH-222 also fully relaxed isolated human and rat cerebral arterioles, and improved neurological functions of tMCAO operated rats characterized by significantly improved neurological deficits as well as enhanced locomotor symmetry. Moreover, as opposed to AmBleb, markedly lower MPH-222 dose was enough to achieve efficient concentrations in the ischemic region when catheter-based direct intra-arterial administration was applied. This result suggests that direct myosin inhibitor administration may be an optimal add-on therapy to thrombectomy. Funded by the Hungarian National Research, Development and Innovation Office (NVKP 16-1-2016-0051 and PIACI-KFI-2019-00488).
Abstract P223: Effect of Collateral Status and Level of Reperfusion Achieved From Mechanical Thrombectomy on Rehabilitation Outcomes
Authors: Hsieh Billie , Ibrahim Lamya , Tariq Muhammad Bilal , Taleb Shayandokht , Parker Dorothea , Rahbar Mohammad H , Green Charles , Gupta Resmi , wozny joseph , Tahanan Amirali , Paladugu Sreelekha , Aggarwal Seema , Russell Mary , Wewior Natalia , Norris Dominique , Silos Christin , Sheth Sunil , Savitz Sean I
Published: March 2021

Background:
Good collateral flow has been shown to have better outcomes after acute ischemic stroke (AIS), including for patients receiving IV thrombolysis (IVT) and mechanical thrombectomy (MT).

Hypothesis:
In patients with AIS who undergo MT, good collateral flow is associated with better functional independence measure (FIM) change.

Design/Methods:
Data was collected retrospectively for patients who presented with AIS and were treated with MT. A total of 54 patients from 4 inpatient rehabilitation facility (IRF) locations between April 2017 and August 2019 were included. Collateral score was collected from angiograms and CT angiogram (CTA) in cases where an angiogram was not available. FIM change was defined as the difference in FIM at admission to IRF and discharge from IRF. Regression analyses were conducted to estimate the relationship between collateral score and FIM change. The predictors in the model included collateral score, FIM at admission to IRF, age at onset, and gender. Logistic regression was used for categorical variables and linear regression was applied for continuous variables. Statistical significance level was set at 0.05. Collaterals were scored from 0 to 4, with 0 to 2 being poor and good collateral flow defined as scores 3 and 4. The primary outcome of this study was FIM change.

Results:
The mean age was 70.4 years, and 54.5% was female. Regression analyses did not show any significant differences in FIM change in patients with collaterals ranging from poor to good p = 0.807 (Table 1), when adjusted for age, gender, and severity as represented by FIM at admission to IRF.

Conclusion:
In this patient cohort, good collateral flow was not associated with improvement in FIM change.
Abstract P226: Population-Wide Trends in Age-Specific Utilization of Endovascular Thrombectomy for Acute Ischemic Stroke
Authors: Kim Youngran , Krause Trudy , Lee Songmi , Abdelkhaleq Rania , Salazar Marioni Sergio , Tariq Muhammad Bilal , Khose Swapnil , Zhang Guo-Qiang , Savitz Sean I , McCullough Louise D , Sheth Sunil
Published: March 2021

Introduction:
There is limited information on age-specific utilization of endovascular thrombectomy (EVT) among acute ischemic stroke (AIS) patients. We assess the real-world trends in utilization of EVT by age group including patients aged ≥85 years.

Methods:
Using the Texas Public Use Data File (10/1/2015- 9/30/2019), we identified AIS hospitalizations with a primary diagnosis of AIS in Texas. The data was non-sampled and included hospital discharges from all state-licensed hospitals. We excluded patients <18 years or with missing age information and categorized patients into 18-44, 45-64, 65-74, 75-84, and 85+ years. EVT was identified using ICD-10 procedure codes and the percentages of those that received EVT were reported by one-year periods: 10/2015-09/2016, 10/2016-9/2017, 10/2017-9/2018, and 10/2018-9/2019. Annual percent changes (APCs) in EVT utilization were estimated using log-linear models and trends were tested. EVT capable hospitals were defined as hospitals that performed at least one EVT per year.

Results:
Of a total of 162,314 AIS patients, 35,481 (21.9%) patients were age 75-84 years and 23,333 (14.4%) were ≥85. The use of EVT increased from 2.0% (95% CI, 1.8-2.1) to 5.0% (95% CI, 4.8-5.3) during the 4 years of the study period. Significant increases in EVT were observed across all age categories. The largest percent increase was observed among those 85 years and older, with a 56.1% increase annually. The number of EVT capable hospitals increased from 46 to 68 hospitals and those performing high EVT volumes substantially increased.

Conclusions:
The use of EVT increased by 36.5% annually in Texas over recent years and the largest increase occurred in the very elderly patients despite inconsistent results in this population. These findings likely represent the rapid adoption of EVT procedures, even outside of clinical trial-based findings.
Abstract P227: Incentives for Uptake and Adherence With Outpatient Stroke Rehabilitation: A Three Arm Randomized Controlled Trial
Authors: Young Sherry Hsueh Yi , Sim Rita , YU Christine , YAN Xiaoxi , De Silva Deidre A , CHAKRABORTY Bibhas , Matchar David B
Published: March 2021

Introduction:
While rehabilitation has been demonstrated to be effective in improving outcomes of stroke, uptake of outpatient rehabilitation services (ORS) in Singapore remains relatively low. This study aims to determine if rehabilitation uptake and adherence can be increased by providing coordinated transportation (increased convenience) and eliminating out-of-pocket costs (reduced expense).

Hypothesis:
It was hypothesized that the uptake rate of ORS over 3 months, number of sessions attended, and time to discontinuation would be greater for participants in the intervention arms of which barriers of transportation and out-of-pocket costs are addressed, as compared to participants in the control arm.

Methods:
A total of 266 participants were recruited from the stroke and acute rehabilitation units of two tertiary hospitals in Singapore, and randomized to one of three study arms: the control arm, denoted
Education
(
E
), inclusive of a stroke rehabilitation educational program; the first intervention arm, denoted
Transportation Incentives
(
T
), inclusive of free transportation services for the first 3 months post-discharge; or the second intervention arm, denoted,
Transportation & Sessions Incentives
(
T&S
), inclusive of up to 3 months of both free transportation and no out-of-pocket costs for participants’ stroke ORS.

Results:
The uptake rate of ORS was 73.0% for
E
(CI, 63.8%-82.3%), 81.8% for
T
(CI, 73.8%-89.8%), and 84.3% for
T&S
(CI, 76.7%-91.8%). The differences of
T
and
T&S
versus the control arm (
E
) were not statistically significant (p = 0.22 and p = 0.10, respectively). However, the average number of rehabilitation sessions attended were significantly higher in both the intervention arms: 5.50 (SD, 7.65) for
T
and 7.51 (SD, 9.52) for
T&S
versus 3.26 (SD, 4.22) for the control arm (
E
) (p-value for
T
vs
E
= 0.017; p-value for
T&S
vs
E
= 0.000.) Kaplan-Meier analysis indicated that persistence was higher for
T&S
compared to
E
(p=0.029).

Conclusions:
This study has demonstrated that incentives can improve utilization of ORS. Such incentives should be considered in finance policy, such as care bundling, for stroke or similar common conditions.
Abstract P229: Trends in Utilization of Magnetic Resonance Imaging for Stroke Patients With Cardiac Rhythm Devices
Authors: Culbertson Collin J , Perino Alexander C , Gardner Rebecca M , Balasubramanian Vidhya , Vora Nirali
Published: March 2021

Introduction:
Magnetic resonance imaging (MRI) has historically been contraindicated for patients with MRI non-conditional (i.e. legacy) cardiac implantable electronic devices (CIED). Recent trials have demonstrated safety of MRI in legacy CIED patients, with the Center for Medicare & Medicaid Services (CMS) revising MRI coverage to include these patients in 4/2018. We sought to determine the effect of this policy change on MRI utilization for legacy CIED patients with acute ischemic stroke or transient ischemic attack (AIS/TIA) and contemporary use of MRI for these patients.

Methods:
We performed an interrupted time series analysis of MRI utilization for AIS/TIA patients with the CMS MRI coverage revision for legacy CIED patients serving as the intervention. Using Optum claims data from 1/2012 to 7/2019, we identified AIS/TIA hospitalizations and CIED implantations and interrogations using ICD-9/10 and CPT codes, respectively. The intervention’s effect on MRI utilization for AIS/TIA was determined for patients with and without CIEDs separately. For patients treated after the CMS coverage revision, we used multivariable logistic regression to determine the association between lack of CIED and MRI utilization for AIS/TIA.

Results:
We identified 417,899 patients hospitalized for AIS/TIA, of which 30,425 patients (7%) had a CIED (CIED patients: age 78.0 ±10.2 years, 45% female; non-CIED patients: age 74.1 ±11.8 years, 55% female). From 2012 to 2019, MRI utilization for AIS/TIA increased from 3% to 20% for CIED patients and 58% to 66% for non-CIED patients. The CMS coverage revision was associated with a 4.2% absolute (25% relative) additional increase in MRI utilization for CIED patients with AIS/TIA. In multivariable regression, non-CIED patients treated after the CMS coverage revision, as compared to CIED patients, were substantially more likely to undergo MRI for AIS/TIA (adjusted OR 6.7, 95% CI: 6.3-7.1, p<0.001).

Conclusions:
Despite an increase in MRI utilization for AIS/TIA patients with CIEDs attributable to the CMS coverage revision and trials demonstrating safety, a large disparity in use of MRI for AIS/TIA patients with CIEDs persists. Identification and resolution of barriers to appropriate MRI use in AIS/TIA patients with CIEDs are needed.
Abstract P23: The Contribution of Stroke Preparedness to Regional Variation in Tissue Plasminogen Activator Treatment
Authors: Springer Mellanie V , Bi Ran , Skolarus Lesli E , Lin Chun Chieh , Burke James F
Published: March 2021

Introduction:
Unexplained regional variation exists in tissue plasminogen activator (tPA) treatment for stroke. Whether regional differences in stroke preparedness (stroke knowledge and intent to call 911) exist and contribute to tPA administration is unknown. We therefore sought to determine the contribution of stroke preparedness to regional variation in stroke treatment, as an association might support region-specific stroke preparedness interventions.

Methods:
We performed a retrospective ecological cross-sectional study measuring the association of regional stroke preparedness and regional tPA administration. We used Medicare data to determine the percentage of tPA-treated hospitalized stroke patients in 2007, 2009, & 2011, adjusting for the number of stroke hospitalizations in each hospital service area (HSA) (primary outcome). We determined stroke preparedness from Behavior Risk Factor Surveillance System survey questions assessing stroke symptom knowledge (score range 0-6) and intent to call 911 (score range 0-1) (exposure of interest). The association between regional preparedness and tPA treatment was assessed using multiple linear regression, adjusting for regional characteristics (demographic factors, the presence of EMS bypass, number of primary stroke centers, and hospital stroke volume).

Results:
There were 1738 HSAs. The adjusted percentage of stroke patients receiving tPA ranged from 1.37% (MIN) to 11.29% (MAX). Across HSAs, a median (IQR) of 86% (81%-90%) of responses to a witnessed stroke indicated intent to call 911 and a median (IQR) of 4.42 (4.24-4.59) out of 6 stroke symptoms were correctly recognized. Every 1% increase in accuracy in the question assessing intent to call 911 was associated with a 0.44% increase in adjusted tPA rate (p=0.049). Accurate stroke symptom recognition was not significantly associated with adjusted tPA rates across regions (p=0.05).

Conclusions:
Overall, there was little regional variation in intent to call 911 and stroke symptom recognition. Intent to activate EMS in response to a witnessed stroke is likely a modest contributor to regional variation in tPA treatment.
Abstract P231: Geographic Location Impacts Access to Stroke Rehabilitation Services
Authors: Thompson Stephanie , Davis Alan , Gommans John , McNaughton Harry , Barber Alan , Fink John N , Cadilhac Dominique A , Matire Harwood , Abernethy Ginny , Feigin Valery L , Denison Hayley , Corbin Marine , Levack William , Douwes Jeroen , Ranta Anna
Published: March 2021

Background:
Non-urban hospitals often operate under greater resource constraints and less specialisation due to reduced economy of scale. We assessed whether access to stroke rehabilitation services is affected by hospital geographic location. In addition, we assessed the impact of specific rehabilitation interventions on patient outcomes.

Methods:
REGIONS Care is a New Zealand (NZ) nationwide prospective observational study with up to one-year follow-up exploring ethnic and geographic inequities in stroke care access and outcome. For this analysis, we compared rehabilitation outcomes and service access in urban versus non-urban hospital settings. The main outcome was favorable modified Rankin Scale of 0-2 at 3, 6, and 12 months. Outcomes were adjusted for age, stroke severity, pre-morbid function, and other potential confounders using multivariate logistic regression.

Results:
This cohort included 2379 patients with a confirmed diagnosis of stroke who were admitted to a NZ hospital between 1 May 2018 and 31 October 2018. There was no significant difference between geographic locations in access to inpatient services (OR=1.00; p=0.99) or reaching inpatient rehabilitation within seven days of admission (OR=1.16; p=0.32). Patients in non-urban areas had poorer access to intensive inpatient therapy (OR=0.54; p<0.001) and community rehabilitation services (OR=0.68; p<0.001). Compared to patients in urban areas, access to community rehabilitation within seven days of hospital discharge (OR=0.59; p=0.003) was also poorer. Documented goal setting with input from the patient/carer and the interdisciplinary team (IDT) was higher in non-urban centres (OR=1.42; p<0.001). Intensive therapy during inpatient rehabilitation was associated with improved mRS at 3 months (aOR=1.34; p=0.05), 6 months (aOR=1.47; p=0.04) and 12 months (aOR=1.62; p=0.008).

Conclusions:
Patients admitted to non-urban hospital experience better IDT goal setting, but poorer access to community rehabilitation services and less intensive physical therapy during inpatient rehabilitation. Reduced therapy intensity resulted in a lower rate of functional independence at 3 months. These results will drive service improvements in the stroke rehabilitation space.
Abstract P232: Patient and Caregiver Agreement on Stroke Survivor Quality of Life in the Year After Stroke Onset
Authors: de Havenon Adam H , Braun Robynne , Delic Alen , Wong Ka-ho , Cramer Steven C , Worrall Bradford B
Published: March 2021

Background:
The burden of post-stroke disability falls on both stroke survivors and their caregivers. To better understand patient and caregiver perspectives on post-stroke quality of life (QoL), we explored their agreement on a QoL testing instrument in the year after an ischemic stroke.

Methods:
This is a secondary analysis of the IMS-III trial. The primary outcome are scores of the 5 domains of the EQ-5D-3L during the year after stroke onset. We included pairs of EQ-5D-3L scores obtained from both the patient and their proxy to determine the level of agreement and Cohen’s Kappa for the individual domains.

Results:
There were 1,042 instances of a paired EQ-5D-3L during the first year of follow-up, derived from six study visits described in Table 1. The agreement between patient and proxy was highest for the Mobility and Self-Care domains of the EQ-5D-3L (Table 2), achieving a Kappa of 0.7407 and 0.7567, respectively. The agreement for the Anxiety/Depression domain of the EQ-5D-3L was lowest, with a Kappa of 0.6009 (Table 2).

Conclusion:
In the year after ischemic stroke, the agreement between patients and their caregivers was highest for the motor domains of QoL and lowest for the mental health domain. Depression and anxiety are known to be under-diagnosed and under-treated after stroke. Further research is warranted to explore the reasons for less agreement between patient and caregiver perception of the stroke survivor’s mental health QoL after ischemic stroke.
Abstract P234: Stroke in Texas: Leveraging Population Level Data to Inform Public Health
Authors: Krause Trudy M , Ganduglia-Cazaban Cecilia M , Savitz Sean I , Rajan Suja S
Published: March 2021

Introduction:
We studied variation in stroke rates, post-discharge health services, and outcomes across payors in Texas.

Methods:
Claims for 48,331 stroke patients in 2016 and hospital data covering 58,114 discharges were analyzed. Prevalence and incidence rates per region were reported as a variation from the state mean by payor type (Medicaid, Medicare and Commercial). Stroke overall, ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage are reported. Stroke outcomes are reported for the following measures: Discharges to rehabilitation, 30-Day Follow-Up with neurologist, death within 45 days

Results:
Among all payors, east Texas had the highest incidence and prevalence of ischemic stroke (Fig) but Northern Texas had the highest incidence of ICH among Medicaid and Commercial payors. Medicaid patients showed the greatest increases across ages and displayed a higher prevalence rate among those aged 40-64 than the 65+ group. Medicaid had a higher rate for each age group when compared to commercial. Within Medicaid and commercial, the 0-17 age had a very high rate of death from ischemic stroke (121/1000 and 83/1000, respectively), greater than any of the other age bands except over age 65; these high rates were not observed in ICH. Commercial and Medicaid patients had low rates of discharge to rehabilitation compared with Medicare (354/1000, 130/1000, 424/1000, respectively). Outpatient follow-up rates with a neurologist were low: Medicaid rates were very low compared to Commercial and Medicare (22/1000, 387/1000, 267/1000, respectively).

Conclusion:
Statewide review revealed dramatic variation in regional rates across all payors and ages. Graphic display and public reporting of statewide data on stroke through population level transparency can be leveraged to identify areas of risk, intervention strategies, and inform public health policy.