bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP67: Sex Disparities in Atrial Fibrillation as a Predictor of Poor Discharge Disposition After Ischemic Stroke Hospitalization: The Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study
Authors: Martin Ryan C , Rose David Z , Wang Kefeng , Ciliberti-Vargas Maria A , Romano Jose G , Dong Chuanhui , Asdaghi Negar , Koch Sebastian , Waddy Salina P , Robichaux Mary , Waters Michael F , Sacco Ralph L , Rundek Tatjana , Burgin W. S
Published: July 2021

Background:
It is unknown whether atrial fibrillation (AF) is responsible for increased morbidity and disability seen in women with ischemic stroke. We sought to determine whether patients with ischemic stroke and AF had poorer outcomes than ischemic stroke patients without AF and whether this effect is more pronounced among women.

Methods:
We analyzed data from the FL-PR CReSD Study, a large quality improvement registry of Florida (N=66) and Puerto Rico (N=9) hospitals based on the Get With The Guidelines-Stroke (GWTG-S) program. Discharge disposition was utilized as a surrogate marker for morbidity and disability, with discharge to home or rehabilitation in comparison to other discharge dispositions (skilled nursing facility, hospice or died). Multilevel generalized linear models were used to evaluate AF and sex disparities in discharge disposition adjusted for demographics, risk factors (hypertension, diabetes, heart failure, previous stroke/TIA), and NIHSS and CHADS2 scores.

Results:
We examined a total of 55,945 ischemic stroke patients, of whom 11,797 (21%) had AF at discharge. AF patients were older than non-AF patients (79.0±10.9 years vs. 68.7±14.4 years), had higher proportion of women (54% vs. 49%) and more severe strokes (mean NIHSS 10±9 vs. 7±7). Among AF patients, women were older (81±10 vs. 76±11 years) and had greater NIHSS (11±9 vs. 9±8) and CHADS2 scores (3.9±0.9 vs. 3.7±1.0) than men. Overall, AF patients were less likely discharged to home or rehabilitation than those without AF (54% vs. 71%, OR 0.93, 95% CI 0.89-0.98). There was a significant effect modification between AF and discharge disposition by sex. In stratified analyses by sex, AF was associated with less discharged to home or rehabilitation among women (OR 0.85, 95% CI 0.79-0.91), but not among men (OR 1.04, 95% CI 0.96-1.11).

Conclusion:
Women with AF were less likely discharged to home or rehabilitation facility after ischemic stroke. Baseline differences in age, stroke severity, risk factors, and comorbidities between men and women had little impact on the poorer outcome and discharge disposition after ischemic stroke in women. Further studies are warranted to identify the causes of sex-specific differences in stroke outcomes for patients with AF.
Abstract TMP72: Geographic, Demographic and Socioeconomic Analysis of StrokeNet Research Network Population Coverage
Authors: Sozener Cemal B , Longstreth Karl E , Frasure Jamey , Kleindorfer Dawn , Adeoye Opeolu , Scott Phillip A
Published: July 2021

Introduction:
StrokeNet is an NIH research network to advance research for acute treatment, prevention, and recovery/rehabilitation following stroke.

Hypothesis/Objective:
We characterized the adult population with geographic access to a StrokeNet acute care research site and its representativeness of the overall US population.

Methods:
Data on research sites was obtained from the StrokeNet National Coordinating Center and geocoded. Ground and air-ambulance data identify transport times of 60, 90 and 120 minutes, corresponding to transport distances of 20, 40 and 65 miles, respectively. Geographic Information System (GIS) software overlaid these radii on thematic maps of StrokeNet adult acute care hospitals, their referral clinics, and participating VAMC hospitals. The analysis used complete 2010 US census data and 2013 data for economic variables, coded to the block group level. Descriptive data presented with comparison to national averages.

Results:
281 sites were identified as of August 1, 2015. 38%, 50%, and 60% of the total US population were within 20, 40 and 65 miles of an identified site. Geographic coverage and analysis for gender, race, age, and income are presented below. High rates of access were identified for Hispanic/Latino, Black, and Asian populations and households with high median incomes. Limited rural access was identified. Data on rehabilitation and pediatric access to be presented.

Conclusions:
Current StrokeNet sites provide geographic access to acute care research opportunities for a substantial portion of the US population. The encompassed population reflects the demographic and socioeconomic makeup of the nation as a whole.
Abstract TMP75: The Georgia Stroke Professional Alliance (GA-SPA) - a Six Year Review, of a Collaborate, State-wide Stroke Professional Network, Reaching Across State-lines and the Nation to Improve Stroke Care, Professional Education, and Community Outreach
Authors: Bryant Katja ,   Georgia Stroke Professional Alliance (GA-SPA), Thomas Alexis , Brennan Kelli , Zimmermann Susan , Goings Denise , Camp Deborah , Doppelheuer Shannon , Connely Kerrin , Brasher Cynthia , Biles Diadra , Lugtu James , Whitworth Catherine , Pruitt Jean
Published: July 2021

Background:
In 2009, the Georgia Stroke Professional Alliance (GA-SPA) was established. GA-SPA success has been marked by unsurpassed transparency and collaboration among the members and their partners. GA-SPA continues to make professional stroke education and community outreach as one of their greatest priorities. A focus and commitment to improvements of stroke care is an underpinning for sustained success.

Purpose:
To expand the state-wide collaboration of health care professionals committed to improving the quality of stroke care and stroke education throughout the region.

Methods:
GA-SPA members meet regularly at varying locations throughout the state and participate in exchanges of professional knowledge, provide clinical expertise regarding process improvement and best practices. GA-SPA collaborates closely with key stakeholders like the AHA/ASA, the Georgia Coverdell Acute Stroke Registry, the Department of Public Heath, the State Office of EMS, and key industry supporters to provide up to date stroke education and community outreach efforts.

Results:
GA-SPA serves as a subject matter resource on the delivery of stroke care and prevention for healthcare professionals across the continuum of care. Web based communication, a Facebook page and a membership list serve enhances the experience of professional collaboration and information exchange. Accomplishments: Proclamation by the Governor for a Stroke Awareness Day, FAST regional stroke awareness campaign, and annual community events with the Atlanta Braves, partnering with schools for stroke education, SCRN and CNRN review courses, promoting ASLS, ISC presentations. Mentoring amongst GA-SPA members has contributed to the successful certification and re-certification for many of the 35 certified Primary Stroke Centers and 4 Comprehensive Stroke Centers in Georgia, and 4 Remote Stroke Treatment Centers. GA-SPA consults with other states interested in these common goals, and assist with the creation of similar alliances.

Conclusion:
An alliance of state wide health professionals has been an effective method to promote professional stroke education and community stroke outreach. Other states should consider creating similar professional alliances to advance stroke care.
Abstract TMP77: Development of a Collaborative Transition Coaching Program for Reduction of Post-stroke Hospitalizations
Authors: Leonhardt Ann M , Burgen Denise M , Wolfe Jennifer , Luther Kelly
Published: July 2021

Issue:
All-cause 30 day hospital readmission rate following discharge for ischemic stroke has been instituted by CMS as a quality measure. Successful readmission reduction planning is a hospital imperative.

Purpose:
We set out to establish a stroke-specific transitions coaching program with the intention of decreasing readmissions in our ischemic stroke population.

Methods:
Fiscal year 2013 stroke readmissions to our hospital were individually reviewed for factors leading to readmission. After determining 62.5% of avoidable readmissions were attributed to outpatient factors, a regional home care agency was contacted for collaboration. The agency has proven readmission reductions utilizing the Coleman Care Transitions Model. This model incorporates visits prior to discharge, by telephone, and at home by a trained transitions coach to ensure understanding of medications, follow up visits, and recognition of concerning symptoms. Cost estimates for expanding the program to stroke patients were made using the prior year’s volume based on primary payer, county, and discharge destination. A business plan was established and training and informational sessions planned.

Results:
Of the outpatient factors contributing to readmission the most common were medication issues, seeking emergency care prematurely, and need for education or support. Based on the data and prior successes of the home care agency a pilot program was developed. The estimated cost for patients not covered by their primary insurance is $52,000 annually. The estimated cost for one hospital readmission is $11,200. Preventing 5 readmissions per year would save $56,000. A successful collaborative was formed resulting in the ability to enroll a larger number of ischemic stroke patients in the transitions coaching program.

Conclusions:
Solving the problem of readmissions after ischemic stroke is complex and requires extensive planning and collaboration. Identifying our issues and establishing a pilot program took nearly a year. Key stakeholders and a committed team are essential components of establishing a collaborative process of this magnitude. The pilot program will be evaluated by comparting readmission rates in the ischemic stroke population pre and post initiation.
Abstract TMP8: The New Alteplase Package Insert: What is the Potential Impact?
Authors: Shiue Harn , Albright Karen , Sands Kara , Sisson April , Lyerly Michael , Gropen Toby
Published: July 2021

Background:
Alteplase (tPA) contraindications for acute ischemic stroke (AIS) were originally derived from the 1995 NINDS trial. Recently, a history of intracranial hemorrhage (ICH) and recent stroke (within 3 months) were removed as contraindications from the drug package insert, which could increase the number of patients eligible for IV thrombolysis. We sought to define the potential impact on outcomes and health care costs in this newly eligible population.

Methods:
Consecutive patients (March 2014 - April 2015) who presented with AIS to our Comprehensive Stroke Center (CSC) were retrospectively analyzed. Demographics and tPA exclusions were recorded. The annual number of discharges with primary diagnosis of ischemic stroke in the U.S. was estimated from the National Inpatient Sample (2006 - 2011). A previously reported value of $25,000/patient was utilized to calculate lifetime cost savings in patients receiving tPA.

Results:
During the study period, 776 AIS were admitted to our CSC (median age 64; 55,74, 51% men, 62% white). Seventy-six percent of our patients (n=590) had ≥1 tPA exclusions according to the NINDS trial. Among these patients, 11 excluded had history of ICH, 15 with recent strokes, and 1 both. Following the new package insert, the proportion of patients with ≥1 tPA exclusion fell to 73% (n=563). Given the 432,000 ischemic stroke discharges annually, a 3% increase in patients eligible for tPA could translate to treatment of 12,960 more patients annually and a lifetime cost savings of $324,000,000. Furthermore, we estimate that 1,685 of these newly eligible patients will experience a favorable functional outcome based on the results of the NINDS trial (13% shift analysis for mRS 0-1).

Conclusions:
Our results suggest that the new tPA package insert has the potential to increase national tPA treatment rates, decrease U.S. health care costs, and improve functional outcomes in eligible AIS patients. National guidelines need to be updated to reflect these changes.
Abstract TP120: IL-17a Correlates With Coated-Platelet Levels Among Patients With Carotid Atherosclerosis
Authors: Kirkpatrick Angelia C , Vincent Andrea S , Guthery Leslie , Nguyen Nhan , Prodan Calin I , Dale George L
Published: July 2021

Introduction:
Coated-platelets are a subset of platelets with high procoagulant potential observed on dual agonist stimulation with collagen and thrombin. Elevated coated-platelets identify asymptomatic carotid stenosis patients at high risk for stroke or TIA and are associated with stenosis progression.

Hypothesis:
Specific inflammatory markers correlate with coated-platelet levels among patients with carotid atherosclerosis.

Methods:
Patients referred for carotid Doppler evaluation with at least one additional follow-up scan were analyzed. Coated-platelet levels were determined at baseline and reported as percent of cells converted to coated-platelets. Serum was obtained simultaneously for measurement of inflammatory markers using the Bio-Plex Pro Human Cytokine 27-plex Assay kit (Bio-Rad Laboratories). Rank order correlation between inflammatory marker concentrations and coated-platelet levels was determined using the Spearman correlation coefficient.

Results:
Among 28 subjects followed for a mean of 28.6 ± 5.7 months, 9 developed progression of carotid stenosis severity. IL-17a concentration significantly correlated with coated-platelet levels (r = 0.68, p = 0.005). There was a trend toward a significant correlation between IL-17a and progression of carotid stenosis severity (r = 0.46, p = 0.08), which was no longer apparent after controlling for baseline coated-platelet level (r = 0.26, p = 0.37).

Conclusions:
Coated-platelet levels correlate with IL-17a concentration among patients with carotid atherosclerosis. Produced by a subclass of T helper cells, IL-17a has been associated with plaque instability in previous human studies demonstrating increased expression of IL-17a mRNA in patients with symptomatic carotid plaques. These results, in combination with previous findings showing an association between coated-platelets and carotid stenosis progression, support a role for inflammation and coated-platelets in modulation of atherosclerotic plaque.
Abstract TP129: Aging is Associated with Vulnerability of Carotid Plaques in Patients With Type 2 Diabetes Mellitus
Authors: Yamagami Keitaro , Takasaki Morio , Kinoshita Takamasa , Hongo Taku , Hashiba Tetsuo , Miyahara Eiji , Yamada Keiichi , Fujimoto Yasuhiro
Published: July 2021

Introduction:
Type 2 diabetes mellitus (T2DM) is a well-known risk factor for atherosclerosis. A previous carotid ultrasound study found diabetic patients had more echolucent plaques compared with nondiabetic patients. Another MRI-based carotid plaque imaging study revealed diabetes was associated with development of vulnerable plaques. Therefore diabetes is considered as a predictor for the presence of unstable plaques. The aim of this study is to investigate the association between vulnerability of carotid plaques and clinical characteristics in patients with T2DM.

Methods:
This study included type 2 diabetic patients with moderate to severe carotid artery stenosis (n=38, mean age 67.8, range 40-83). Using black-blood MRI of carotid arteries, the signal intensity of carotid plaques were measured in all patients. Univariable and multivariable analysis was conducted to examine the association between signal intensity of carotid plaques and clinical characteristics.

Results:
Vulnerable plaques (VP) , defined as plaques presenting more than one and a half times higher signal intensity than that of ipsilateral sternocleidomastoid muscle, were found in 8 patients. The rates of symptomatic lesions were significantly higher in patients with VP compared to patients without VP [odds ratio (OR) 17.4, 95% confidence interval (CI) 1.495-202.470, p=0.024]. In univariable analysis, VP was associated with age (p=0.0016) and ischemic heart disease (OD 10.5, 95% CI 1.142-96.576, p=0.0422). The association between other factors (sex, hypertension, hyperlipidemia, smoking habit, HbA1c, diabetic retinopathy, diabetic nephropathy) and VP was not significant. Multivariate logistic regression analysis proved that age was an independent factor associated with VP (OD 1.319, 95% CI 1.072-1.939, p=0.0455).

Conclusion:
This study suggests that there is a significant correlation between presence of VP detected by carotid MRI and ischemic symptoms, and that aging contributes to vulnerability of carotid plaques in patients with T2DM.
Abstract TP132: The Clinical Role of Microembolic Signals in Adult Moyamoya Disease
Authors: Jeon Chiman , Jo Kyung-Il , Hong Seung-Chyul , Kim Jong-Soo
Published: July 2021

Background:
Both hemodynamic compromise and artery-to-artery embolism have been thought to be implicated in moyamoya disease (MMD) with ischemic symptoms. The relationship between microembolic signals (MESs) and ischemic stroke remains to be clarified. We aimed to identify associated risk factors of MESs and to explore clinical significance of MESs in adult MMD with ischemic stroke.

Methods:
A total of 48 patients (89 hemispheres) newly diagnosed with adult MMD were enrolled and angiographically classified according to the Suzuki staging system. For detection of MESs, transcranial doppler (TCD) monitoring was performed within 2 days after first admission. Recent ischemic events, including transient ischemic attack (TIA), which occurred within 3 months of diagnosis, were also recorded. Mean flow velocities in middle cerebral artery using TCD were also evaluated.

Results:
Eleven hemispheres were found to have MESs, and 78 had no MESs. Among clinical types of MMD in 89 hemispheres, ischemic-type MMD (n = 42, 47%) was most common. Antiplatelet agents were prescribed for 22 patients (43 hemispheres) before evaluation for MES. The incidence of recent ischemic event was associated with the MES status (P = 0.024). Recent ischemic event was found to be predictive of MESs in adult MMD (hazard ratio: 6.294; 95% CI 1.345-29.46). Detection of MESs was significantly higher in the high mean flow velocity of the middle cerebral artery (P = 0.019). After controlling for age, sex, recent ischemic event, and antiplatelets, ‘early stage’ MMD (Suzuki stage I and II) was the independent predictor of MESs at baseline (hazard ratio: 6.172; 95% CI 1.235-31.25).

Conclusions:
MESs, known to be indicative of artery-to-artery embolism in steno-occlusive cerebrovascular diseases, were observed in ‘early stage’ MMD, particularly with high MFVs and clinically associated with recent ischemic stroke. This necessitates the need for the efficacy of antiplatelets in the treatment of adult MMD with ischemic stroke in a prospective controlled study in the future.
Abstract TP162: Case Manager Guided Organized Post-stroke Care Aids in Achieving Risk Factor Goals
Authors: Kepplinger Jessica , Barlinn Kristian , Helbig Uwe , Pallesen Lars-Peder , Siepmann Timo , Reichmann Heinz , Puetz Volker , Bodechtel Ulf
Published: July 2021

Introduction:
Our ongoing post-stroke care program aims at risk factors control, life-style changes and adherence to secondary prevention medication to reduce stroke recurrence and persistent disability.

Methods:
Consecutive acute ischemic and hemorrhagic stroke patients were prospectively included in a 1-year post stroke care program that is accomplished through a certified stroke case manager. Scheduled and non-scheduled personal contacts were regularly provided to check on risk factor control and whenever felt necessary. Target values for vascular risk factors followed current recommendations of the European stroke guidelines.

Results:
Between 12/2011 and 07/2014 we enrolled 101 of 155 screened patients: 58/101 (57%) were male, mean age was 71+/-13 years, median baseline NIHSS score was 2 (range 0-16), 80/101 (79%) had an ischemic stroke, 3/101 (3%) hemorrhagic stroke and 18/101 (18%) patients had a TIA. Twelve out of 101 patients withdrew from the program and three patients died due to non-vascular causes. In total 628 personal (6.2/patient) and 2683 phone contacts (26.6/patient) were conducted by the case manager. Three hundred-seventy nine specific interventions were necessary mostly due to missing medication, non-compliance and social needs. No recurrent stroke occurred during the program. Achieved vascular risk factor values are presented in the Table.

Conclusion:
Our findings underline that organized post-stroke care may aid in achieving pre-defined goals for secondary prevention of stroke. Further data is needed to explore its impact on stroke recurrence, prevention of persistent disability and health-care costs.
Abstract TP184: Did Race Impact Risk Factor Control in the SAMMPRIS Trial?
Authors: Yamada Lidia B , Turan Tanya N , Cotsonis George A , Lynn Michael , Benavente Oscar , Derdeyn Colin P , Fiorella David , Lane Bethany F , Montgomery Jean , Janis Scott L , Chimowitz Marc I ,   the SAMMPRIS Investigators
Published: July 2021

Background:
WASID showed that Blacks with symptomatic intracranial atherosclerosis are at higher risk of recurrent stroke and have a greater vascular risk factor burden than whites. We sought to determine if aggressive medical management (AMM) in SAMMPRIS resulted in equal control of risk factors in Blacks vs. other races and eliminated the racial disparity in outcome.

Methods:
Data on all 451 SAMMPRIS patients receiving AMM were used to determine risk factor control in Blacks vs. Others. SBP, LDL, and exercise were recorded throughout the trial, averaged (from baseline until primary endpoint), and dichotomized as in/out of target. Chi-square and t-tests were used to compare risk factor control in Blacks vs. Others. For outcome analyses, data from 227 patients randomized to AMM only were used. Time to event curves for the primary endpoint were compared between Blacks vs. Others using the log-rank test and hazard ratios were calculated with Cox proportional hazards regression.

Results:
There were no differences between the percentage of Blacks (n=104) vs. Others (n=347) that were in-target for SBP (57.1% vs 62.3%, p=0.36), LDL (40.4% vs 48.5%, p=0.14), or exercise (40.4% vs 43.2%, p=0.61) and no difference in mean SBP (135.2 vs 133.3 mm Hg, p=0.19), LDL (80.7 vs 76.3 mg/dL, p=0.19), or PACE exercise score (3.6 vs 3.8, p=0.27). There was a numerically higher primary endpoint rate among Blacks, but no statistically significant difference in outcome (Figure). However, power to detect a HR of 1.5 for Black race (the HR for the primary endpoint in WASID) was only 20%.

Conclusions:
Control of SBP and LDL, and exercise, which were highly associated with a good outcome in SAMMPRIS, were not different between Blacks and other races. However, the study lacked sufficient power to detect a difference in outcome between blacks and other races and therefore we cannot conclude that reducing racial disparities in risk factor control will lead to reducing disparities in outcome.
Abstract TP226: Vertebral Artery Dissection is More Common Than Carotid Artery Dissection and More Difficult to Detect on Non-invasive Imaging
Authors: Nakawah Mohammad O , Volpi John
Published: July 2021

Background:
Cervical artery dissections (CAD) are among the most common causes of stroke in young and middle-aged adults. In contrast to carotid dissections (CD) and anterior circulation ischemia, the clinical manifestations of vertebral dissections (VD) and posterior circulation ischemia are often nonspecific (e.g. dizziness and ataxia), and thus a high index of suspicion is necessary for diagnosis. Therefore, the reported incidence of VD in the medical literature is likely to be an underestimation.

Methods:
With IRB approval, we conducted a retrospective chart review study using the Neurology Database of Houston Methodist Neurological Institute to identify all patients diagnosed with CAD between August 2011 and March 2015. All patients presented with cerebral ischemia (TIA or stroke). The diagnosis of CAD was made by a stroke neurologist and was based on clinical presentation and appropriate vascular imaging studies. Patients with incidental CAD and those with questionable diagnosis of CAD clinically and radiographically were excluded. Over the studied period (32 months), a total of 677 TIA patients and 3230 stroke patients were admitted to our tertiary-care hospital.

Results:
Of 52 patients with CAD-related TIA or ischemic stroke, there were 34 patients (65.4%) with VD and 18 patients (34.6%) with CD. The average age of presentation is 47 years (range: 18 to 75 years) for VD patients and 51 years (range: 34 to 78 years) for CD patients. CAD was slightly more common in males, with 18 VD patients (52.9%) and 10 CD patients (55.5%) in our studied population were males. Out of 30 patients with VD who underwent both noninvasive vascular imaging (MRA or CTA) and cerebral angiogram, dissection was detected on noninvasive imaging in 10 patients (33.3%). On the other hand, out of 13 patients with CD who had both types of imaging modalities, dissection was detected on noninvasive testing in 8 patients (61.5%).

Conclusions:
VD was detected approximately twice as frequently as CD in our study. Both conditions are slightly more common in men with an average age of presentation is about 50 years. In addition, our data suggest that noninvasive testing is more likely to diagnose carotid dissection (in two-third of cases) than vertebral dissection (in one-third of cases).
Abstract TP239: Improving Door-To-Needle Time With Direct Pharmacy Ordering Process
Authors: Perry Trevor , Gama John , Jost Peter , Tovar Juan , Olson-Mack Lindsay , Rockwell Jean M
Published: July 2021

Background:
Efficient emergency department (ED) code stroke processes lead to improved door-to-needle (DTN) times for the administration of IV tissue plasminogen activator (tPA) for qualifying acute ischemic stroke (AIS) patients. A code stroke initiation in the ED activates a cascade of actions involving multiple steps and can result in variations of processes, consequently leading to delayed treatment.

Hypothesis:
We sought to implement an efficient, standardized tPA ordering method, called Direct Pharmacy Ordering Process (DPOP), as part of our code stroke process to improve DTN times.

Methods:
A retrospective review of 401 records from our internal code stroke database was completed prior to and post implementation (June, 2013 to December, 2013 and April, 2014 to April, 2015, respectively) of DPOP. DPOP allows the ED physician to call for tPA directly to the pharmacist, who then calculates dosage, mixes and dispenses the medication. Charts were reviewed for patients’ time of ED arrival, time of CT scan results, time of tPA orders, and time of tPA administration. Inclusion criteria: AIS patients for whom an ED code stroke was initiated and who received tPA. Exclusion criteria: code strokes initiated after hospital administration, ED code stroke patients not receiving tPA, and patients receiving tPA but for whom process times could not be determined.

Results:
After applying criteria, a total of 46 patients’ records were included (16 pre-DPOP and 30 post-DPOP). There was a substantial reduction in all turn-around-times when pre-DPOP and post-DPOP data were compared. Mean time from CT results to time pharmacy received tPA requests decreased from 38 minutes to 17; mean time from CT results to administration of tPA, decreased from 52 minutes to 36, with a decreased median time from 54 minutes to 34. Additionally, DPOP eliminated illegible orders and orders with omissions, further improving timeliness.

Conclusion:
We implemented an improvement process for ordering IV tPA that led to substantial reductions in time for our code stroke process. Additionally, DPOP eliminated problems inherent to written prescriptions, thus leading to reductions in median time of tPA administration from the time of reported CT results by >20 minutes for most AIS cases receiving tPA.
Abstract TP245: Feasibility of Mobile, Wearable Telestroke Devices
Authors: Warach Steven , King Ben T , Chandler Kristen V , Topel Christopher , Tabas Irene A , Morton Johanna L , Milling Truman J
Published: July 2021

Background:
Wearable technologies offer potential telestroke applications that are more mobile and potentially less expensive than traditional telemedicine carts. In an earlier, pilot phase of this research program the best performing software and hardware combination for transmission of encrypted video and audio streaming was selected for further testing.

Method:
We tested Vuzix M100 smart glasses device and Pristine EyeSight HIPAA-compliant video streaming services. The device wearers, emergency physicians, performed the NIHSS, and a remote vascular neurologist or neurology resident viewed the exam. Providers recorded their score and evaluated the functionality of the device with a standardized list of questions.

Results:
The device was assessed in 52 subjects. The providers wearing the device reported the device useful (Agree or Strongly Agree) in making an assessment in 79% of cases and that they could assess the patient well 90% of the time. However, the wearers also reported both distraction from and interference with patient interaction due to the device in 98% of cases evaluated. The viewers also reported finding the device useful in making an assessment of stroke symptoms in 79% of cases (a different set of 79% than the wearers), but in only 65% of cases did they Agree or Strongly Agree that they could assess the patient well. Viewers reported an inadequate field of view for visual field testing in 63% of cases. The inter-rater agreement between the wearer and viewer on the total NIHSS showed moderate agreement (κ = 0.45). Although the technology was easy to use in 92% of the assessments, technical problems (mainly connectivity lags) were reported by the wearer 46% of the time and by the viewer 31% of the time. The technology was rated inadequate for assessing patients in 1 case by the wearers and 3 cases by the viewers.

Conclusion:
Wearable smart glass technology is feasible in assessing stroke patients and shows promise as a telestroke solution, however interference with physician-patient interaction, limited field of view for visual field testing and connectivity glitches are perceived limitations.
Abstract TP251: Onset-to-Door Times and Means of Transportation for Acute Ischemic Stroke Patients Attending a Public Hospital in Bogota DC, Colombia. Is an Ambulance the Fastest Way to Reach the Hospital?
Authors: Vicini-Parra Javier , Ospina Jenny , Correa Cristian , Gomez Natalia , Bohorquez Stephania , Arroyo Lorena , Echavarria Luisa , Ruiz Jorge , Casallas Adriana , Espinosa-Jovel Camilo A , Ramos-Romero Martha L , Betancourt Andres , Barrios Gustavo , Hedmont Daniel , Sobrino-Mejia Fidel E
Published: July 2021

Introduction:
A prospective stroke database was implemented as part of a still-growing comprehensive stroke centre (CSC). This CSC is located within a referral public hospital (Hospital Occidente de Kennedy) in Bogota DC, Colombia , that serves 2.3 million people of mainly low economic income. In this abstract, we present the data pertaining patients who were thrombolysed in our institution during the first year of data collection, and specify onset-to-door (OTD) times as they relate to the means of transportation used.

Hypothesis:
Acute stroke patients who arrive in ambulance have the shortest onset-to-door times.

Methods:
Printed forms were filled for every patient who arrived with diagnosis of acute ischemic stroke (AIS) or transient ischemic attack (TIA). Data was transcribed to an electronic database (Numbers, Apple Inc.) and analyzed with SPSS Statistics version 23 (IBM Corporation). A retrospective descriptive analysis was performed for central tendency and dispersion measures.

Results:
Since August 1st 2014 until July 31st 2015, 39 patients (17.7% of AIS patients) were thrombolysed. Mean onset-to-door times are shown in table 1. Prenotification was received for only 1 patient. All patients came from their homes.

Conclusions:
Almost half of our thrombolysed patients arrived in taxi to our institution. Taxi was the fastest means of transportation, ambulance was the slowest and private cars were in the middle of those. This confirmed our suspicion that the state-owned emergency medical services (SEMD) are suboptimal and that stroke patients prefer to use public transportation rather than SEMD. This should warn public health authorities on he urgent need to improve our SEMD. In the meantime, this finding prompts us to include taxi drivers in our periodic stroke campaigns.
Abstract TP271: Improvement of Cerebral Blood Flow With DS-1040 in a Rat Thromboembolic Stroke Model
Authors: Noguchi Kengo , Edo Naoko , Ito Yusuke , Morishima Yoshiyuki , Yamaguchi Kyoji
Published: July 2021

Introduction:
DS-1040 is a novel inhibitor of the activated thrombin-activatable fibrinolysis inhibitor (TAFIa) and is in clinical development for the treatment of acute ischemic stroke (AIS). The objective of this study was to investigate the effect of DS-1040 on cerebral blood flow (CBF) in a rat thromboembolic stroke model.

Methods:
The CBF was transcranially and continuously monitored during the experiment by laser Doppler flowmetry system using a probe fixed to the skull above the territory of the right middle cerebral artery (MCA) of an anesthetized male SHR/Izm rat. After recording basal CBF, non-autologous whole blood clot was injected into the internal carotid artery. We conducted a 3-arm study. Saline (control) and DS-1040 (3.0 mg/kg) were intravenously injected as a bolus 5 min after the clot injection. The dosage of DS-1040 was set to achieve full inhibition of TAFIa during the experiment. Recombinant tissue plasminogen activator (rt-PA, 7.0 mg/kg; positive control) was intravenously injected 5 min after the clot injection by 10% bolus and 90% infusion for 60 min. The CBF(%) was defined as percent of the CBF at each time point to the mean basal CBF and the area under the curve of the CBF(%) after the drug injection, AUC
5-110min
, was calculated.

Results:
The CBF(%) decreased after the clot injection, indicating the clot embolized the MCA. A significant increase of the AUC
5-110min
was observed in the rt-PA group (8416.2 %·min ± 642.4 %·min, mean ± SE) compared to the control group (3728.7 %·min ± 684.2 %·min), indicating the model is sensitive to tPA. DS-1040 also significantly increased the AUC
5-110min
(6645.3 %·min ± 861.9 %·min) compared to the control group.

Conclusions:
DS-1040 restored CBF in a rat thromboembolic stroke model suggesting DS-1040 is expected to be beneficial for the treatment of patients with acute ischemic stroke. To the authors’ knowledge, this is the first report of an inhibitor of TAFIa improving the CBF in a thromboembolic stroke model.
Abstract TP281: Increased Susceptibility to Excitotoxic Injury in Rat Hippocampal Slices Exposed to Intermittent Hypoxia
Authors: Jagadapillai Rekha , Mellen Nicholas , Sachleben Leroy R , Gozal Evelyne
Published: July 2021

Introduction:
The effect of sustained hypoxia (SH) on brain metabolism has been well studied. However less is known about intermittent hypoxia (IH), a hallmark of obstructive sleep apnea (OSA), associated with increased risk for stroke, outcome severity and functional consequences.

Hypothesis:
Impaired glutamate homeostasis after IH may underlie increased brain vulnerability to stroke-induced excitotoxicity.

Methods:
P4 organotypic rat hippocampal slices cultured for 7 days, were exposed for 7 additional days to IH (alternating 2 min 5% O2 - 15 min 21% O2), SH (5% O2) or normoxia (RA; 21% O2), followed by 3 glutamate challenges (first and last 200 μM, 15 min, emulating a physiological stimulus; second, 10 mM, 10 min, emulating stroke-induced excitotoxicity). Viability was assessed by propidium iodide (PI) uptake at baseline then after each glutamate challenge to assess whether hypoxia impairs the response to physiological or excitotoxic glutamate release. Glial GFAP, neuronal MAP2, EAAT1 and EAAT2 glutamate transporters expression was assessed by immunohistochemistry. Spontaneous and evoked Ca2+ transient activity was assessed in Fluo-8LTM AM loaded slices, by optical recording of Ca2+ spikes proximal to a bipolar stimulating electrode, before and after each of 3 single 2 ms stimuli (0.6 mA). Ca2+ transients after high K+ were used to determine the total number of viable cells.

Results:
Viability, GFAP, MAP2, EAAT1 and EAAT2 expression and basal Ca2+ spikes activity significantly decreased in IH. The number of neurons with spikes evoked within 500 ms of stimuli was not significantly different, but RA evoked responses were more tightly clustered. Residual network activity, assessed by number of neurons with spikes 500 ms post stimulus, was significantly different RA>SH>IH. Overall number of spiking cells after high K+, representing total viable cells, confirmed the viability data obtained with PI staining.

Conclusions:
IH is more detrimental to cell survival and glutamate homeostasis than SH, suggesting that in addition to vascular changes, impaired glutamate homeostasis may increase OSA patients’ susceptibility to ischemic events.
Abstract TP293: Radial Access for Neurovascular Procedures-Patient Preference and Outcomes
Authors: Satti Sudhakar R , Vance Ansar Z , Golwala Sohil
Published: July 2021

Introduction:
Radial access for neurovascular procedures is rarely performed or even considered. There is increasing evidence from the interventional cardiology literature that radial access is associated with lower costs, lower incidence of myocardial infarction, stroke, decreased major access site complications, and even decreased mortality. Roadblocks for adopting or considering radial access for neurovascular procedures includes physician bias, physician training, and limitations in technology/devices. As we move towards a patient centered health care delivery, patient preference and complication rates should be considered. The 2 goals of this poster presentation are to provide a simplified approach to performing radial access for neurovascular and to present data on patient preference and outcomes for radial access.

Hypothesis:
Radial access for neuro interventional procedures is preferred by patients over traditional femoral access and can be performed with a high degree of technical success and low rates of complications.

Methods:
Over a two-year period, 25 patients that had undergone conventional femoral angiography and presented for repeat angiography or subsequent neurovascular intervention were offered radial access. By including only patients that had undergone both femoral and radial access, we felt that this would provide the best comparison between the 2 techniques. Patient assessment survey included: Preference for femoral versus radial, degree of stress between the 2 procedures, degree of pain during and post-procedurally, any immediate/delayed complications, recovery time and ambulation time.

Results:
There was 100% patient preference for radial access and no minor (hematoma or pseudoaneurysm) or major access site complications (bleeding requiring transfusion, pseudoaneurysm requiring intervention, arteriovenous fistula, delayed occlusion).

Conclusion:
Radial access was preferred by patients over femoral access for neurovascular procedures and associated with low complications and high technical success.
Abstract TP302: COAST: Coordinating Options for Acute Stroke Therapy
Authors: Spokoyny Ilana , Agrawal Kunal , Kemp Stephanie M , Albers Gregory W , Janis L. S , Elkind Mitchell S , Girgus Meighan , Meyer Brett C
Published: July 2021

Introduction:
The consent process for stroke therapies is limited by the hectic nature of the emergency environment, limited understanding by the patient and family, and time-sensitivity of the event. Patients are often unable to consent, placing the burden on surrogates to infer treatment wishes. Given time-based thrombolytic options, understanding true patient preferences is of paramount importance. We have piloted in a single center (UCSD) study the “Coordinating Options for Acute Stroke Therapy” (COAST) Advanced Directive form to assess and document patient treatment preferences prior to the time of acute stroke presentation.

Methods:
The COAST initiative was piloted at a large comprehensive stroke center (UCSD), with deployment including electronic medical record (EMR) integration and provider training. COAST has since been initiated at a second comprehensive stroke center (Stanford), with ongoing expansion into the NIH StrokeNet under a central IRB. In collaboration with the AHA, educational materials are being created to supplement the COAST form and improve the process for a potential larger national deployment.

Results:
Patients with a history of stroke, or those at high risk, complete COAST prior to hospital discharge or at clinic visits. The EMR has proven crucial to the deployment and tracking of COAST patients. In a plan to disseminate it “COAST to COAST”, participating StrokeNet centers are deploying the initiative, and collecting data for analysis. A preliminary report on the patients who have completed a COAST form, the optimal location for recruitment, and data on recurrent events, will be provided at the International Stroke Conference.

Conclusions:
The COAST advanced directive is a much needed innovation which will make stroke care more efficient, optimize patient autonomy, improve healthcare quality, and streamline the ethical management of complex care decisions in acute stroke. The inherent benefit of COAST is in providing patients and their families with more information regarding stroke and its treatment options, allowing them to take a more active role in their care.
Abstract TP324: Mild Cognitive Impairment and Treatment for Ischemic Stroke and Acute Myocardial Infarction
Authors: Levine Deborah A , Galecki Andrzej T , Zahuranec Darin A , Nallamothu Brahmajee K , Morgenstern Lewis B , Lisabeth Lynda D , Kabeto Mohammed U , McCammon Ryan , Langa Kenneth M
Published: July 2021

Background and Objectives:
Cardiovascular disease (CVD) is the leading cause of death and serious morbidity in older adults with mild cognitive impairment (MCI), many of whom will not progress to dementia. It is unclear whether patients with pre-existing MCI (without dementia) get evidence-based treatments for CVD less often than patients without MCI. We compared treatment for acute ischemic stroke and acute myocardial infarction (AMI) between MCI patients and cognitively normal patients in a nationally representative sample.

Methods:
Prospective study of patients aged ≥65 years hospitalized with ischemic stroke (n=517) or AMI (n=509) from the Health and Retirement Study and Medicare data from 2000-2011. We compared receipt of CVD process measures (Table) within 12 months of the stroke or AMI hospitalization from Medicare claims between subjects with pre-existing MCI (modified Telephone Interview for Cognitive Status [TICS-m] score, 7-11, a valid measure of MCI) and those with normal cognition (TICS-m score, 12-27), and used logistic regression to adjust associations for age, sex, race, education, number of preexisting functional limitations, and comorbidity.

Results:
Compared with cognitively normal patients, patients with pre-existing MCI were significantly less likely to receive all 3 AMI process measures, and they got stroke process measures less frequently but results were not statistically significant (Table). MCI patients were less likely than cognitively normal patients to receive any post-MI revascularization (adjusted odds ratio, 0.54; 95% CI, 0.33-0.88), but not the other CVD process measures, after adjustment (Table).

Conclusion:
Older MCI patients less frequently got process measures for AMI and ischemic stroke compared with cognitively normal patients. Patient factors explain some but not all of this reduced use. We need to better understand decision making for CVD treatment in older MCI patients and reasons for treatment differences.
Abstract TP329: True Failures Versus Ambiguous Documentation in Core Measures Noncompliance
Authors: Wheeler Natalie C , Meurer William J , Pandey Aditya S , Burke James F , Foley Jenevra , Maddox Kate , Adelman Eric E
Published: July 2021

Introduction:
Stroke Core Measures are intended to ensure that patients receive high quality, guideline-concordant acute stroke care. Compliance data is collected and reported to the public and to regulatory agencies for benchmarking and for reimbursement.

Hypothesis:
Core Measures noncompliance within one academic institution will often reflect ambiguous or incomplete documentation instead of true failure to provide medically appropriate care.

Methods:
We retrospectively reviewed Core Measures data for all ischemic and hemorrhagic stroke patients discharged from the University of Michigan between January 2013 and May 2014. Core Measures data was collected and reported per routine practice and contemporaneously reviewed by the institutional team. For this study, Core Measures failures were cross-referenced with the full medical chart and classified as “true failures” when care was not compliant with the Core Measure standard or “documentation failures” when chart review revealed poor documentation of otherwise appropriate care--for example, where a normal neurological examination was not explicitly linked with a decision to defer assessment for rehabilitation. Determinations of the basis for noncompliance on chart review were made by two different reviewers, with 100% agreement.

Results:
A total of 40 failures in 872 patients were identified and reviewed. Core Measures failures were documentation failures in 20 patients. Additional details are provided in Table 1.

Conclusion:
The high number of documentation-based failures in our experience illustrates potential problems in the use of administratively-defined measures as a marker of the quality of clinical care.
Abstract TP362: Early Hematoma Enlargement in Intracerebral Hemorrhage Patients on the Mobile Stroke Unit
Authors: Jia Judy , Bowry Ritvij , Cai Chunyan , Parker Stephanie , Grotta James
Published: July 2021

Introduction:
Hematoma enlargement (HE) in intracerebral hemorrhage (ICH) possibly occurs soon after onset but is not captured due to delays in imaging. The Mobile Stroke Unit (MSU) can identify ICH patients in the prehospital setting and can increase our understanding of ICH patients in the first hour of onset.

Methods:
This was a prospective, observational study to examine patients within 4 hours of symptom onset and early HE in ICH due to hypertension and/or coagulopathies. A baseline head CT (HCT) was performed on the MSU, followed by a 1-hour HCT at the destination hospital. Patients during MSU control weeks were included but not required to have a 1-hour HCT. Blood pressure was treated to a systolic goal of <150mmHg. Hematoma volume (HV) was measured by the ABC/2 method. HE was defined as an increase in HV by >6cc or >30% between scans. Patients were categorized by time to first HCT (≤61min, 62-120min, and 120-270min). Overall HE for each group was calculated using the scan nearest to 24 hours. HE on the 1-hour HCT was calculated for the ≤61min group and for the all patients collectively. The additional HE between the 1-hour HCT and scan nearest to 24 hours was also captured.

Results:
Twenty-three patients (19 MSU) were included. Four of 8 (50%) patients in the ≤61min group, 3/7 (42.9%) in the 62-120min group, and 3/8 (37.5%) in the 120-270min group had HE in the first 24hrs, p=1.0 (Figure 1). Among the patients who had a 1-hour HCT, the incidence of HE over the first hour in the ≤61min group was 0.4 (2/5) and 0.36 (4/11) for all 3 groups. Additional HE beyond the 1-hour HCT occurred in only 1/9 patients (no follow up scan in 2 patients).

Conclusion:
There was a high incidence of HE 1 to 2 hours after onset in ICH patients. This period may be an optimal window for treatment. Limitations include a small sample size and confounding due to early intervention in the MSU group. A larger study is currently ongoing.