bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract MP56: Nitric Oxide-Therapy but Not Remote Ischemic Conditioning is Cerebroprotective in Stroke: A Study in Mouse Model of Endothelial Dysfunction and Hypertension
Authors: Zaidi Syed M , Hoda Md Nasrul , Ahmed Farid , Alkhatabi Heba , Al Qahtani Muhammed H
Published: March 2021

Background:
Remote Ischemic Conditioning (RIC) was found effective in stroke models, likely
via
increased endothelial nitric oxide (NO); yet RIC failed to improve clinical outcomes (

NCT02342522

;

NCT02189928

). We anticipated that comorbidities neutralize the benefits of RIC in stroke.

Hypothesis:
NO-therapy but not RIC is vasculoprotective in hypertensive stroke.

Methods:
Aged (18±1-mo old) S100A1-hets mutant (S100A
+/-
) and wild-type (WT) mice were used. As needed, mice were treated with RIC, s-nitrosoglutathione (GSNO) reductase inhibitor (GRI; 5 mg/kg nebulized once daily for 2-wks), GSNO (100-ug/kg; nebulized once daily at 2h post-TES), and/or intravenous thrombolysis (IVT; 10mg/kg at 4h post-TES). Stroke and outcome measures were performed as mentioned below. Statistical significance was determined at P < 0.05.

Results:
S100A
+/-
compared to WT-type mice showed significantly higher mean arterial pressure (MAP) and lower plasma-NO, supporting a hypertensive phenotype with endothelial dysfunction in S100A
+/-
mice. In photothrombotic stroke (PTS), RIC significantly improved cerebral blood flow (CBF), behavior and reduced infarction in WT but not in S100A
+/-
mice at 48h. GRI in S100A
+/-
mice enhanced plasma NO, improved behavior and CBF, and reduced infarction significantly as compared to vehicle-treated S100A
+/-
at 48h post-PTS. RIC with GRI did not produce additive protection in S100A
+/-
mice at 48h post-PTS, demonstrating that the preservation of NO-pool with GRI protects against stroke, but RIC is not effective to enhance this endogenous protection in hypertensive mice. Moreover, GSNO nebulization but not RIC enhanced PbtO
2
, reduced BBB-leakage and brain hemoglobin (Hb)-content at 24h after thromboembolic stroke with and without IVT.

Conclusions:
NO-therapies but not RIC is effective in hypertensive stroke. RIC- and NO- therapies need further validation in comorbid stroke before embarking on the clinical trial.
Abstract MP57: Sex Differences in Stroke Outcome Are Associated With Constitutive Gut Dysbiosis and Stroke-Induced Gut Permeability
Authors: El-Hakim Yumna , Mani Kathiresh Kumar , Eldouh Amir , Dabney Alan , Pilla Rachel , Sohrabji Farida
Published: March 2021

Sex differences in experimental stroke are well documented, such that adult males show worse outcomes compared to adult females, including greater infarct volume, increased stroke-induced mortality and more severe sensory-motor impairment. Based on recent evidence that gut dysbiosis may be an early response to stroke, the present study tested the hypothesis that in the acute phase, stroke will result in greater gut dysbiosis and greater permeability of the gut blood barrier in males as compared to females. Male and female Sprague Dawley rats (5-7 months of age) were subject to endothelin-1-induced middle cerebral artery occlusion (MCAo). Fecal samples, blood draws and sensory motor tests were collected/conducted pre and 2d after MCAo. Fecal samples were subject to 16s sequencing. Serum samples were subject to gas chromatography for short chain fatty acid (SCFA) analysis. Gut permeability was assessed by histology, biochemical markers in serum and functional assays using oral dextran gavage. We confirmed stroke-induced sex differences, including increased mortality and more severe sensory motor deficit in males as compared to age-matched female rats. Fecal 16s sequencing showed greater bacterial diversity in females at baseline (pre stroke) while 2 days after stroke, these measures were similar between the sexes. Fecal levels of SCFAs, which are usually beneficial, were higher in males. In contrast, MCAo-induced gut permeability was much worse in males as compared to females. Male rats had a decreased villus length to crypt length ratio, higher levels of biochemical gut permeability markers in serum and higher levels of fluorescent-labeled dextrans following oral gavage in serum. Additionally, males had higher serum levels of proinflammatory cytokines IL-17A, MCP-1, IL-5 and EGF compared to females after stroke. Collectively, these results indicate that the worse stroke outcomes seen in males is associated with increased gut permeability in this group. These data suggest that therapeutics that target the gut epithelium in order to reinforce the gut-blood barrier post stroke may be an effective intervention especially in populations such as the elderly or those with co-morbid conditions who have already been shown to have more permeable barriers.
Abstract MP9: Incidence and Outcomes of Posterior Circulation Involvement in Moyamoya Disease
Authors: Tigchelaar Seth S , Wang Allan , Li Yiping , Steinberg Gary
Published: March 2021

Moyamoya disease (MMD) is a progressive, occlusive disease of the internal carotid arteries and their proximal branches, with the subsequent development of an abnormal vascular network of small, weak blood vessels that are prone to rupture. Steno-occlusive changes in the posterior cerebral arteries (PCA) may contribute to worse outcomes in MMD patients, however, there is a paucity of information on the incidence and natural history of MMD patients with PCA disease.

We retrospectively reviewed the charts of patients with MMD treated between 1987 and 2019. Demographics, peri-operative outcomes, and radiological phenotypes were recorded for 450 patients. PCA disease was scored as either 0 (no disease), 1 (mild), 2 (moderate), or 3 (severe, or occluded).

Out of 450 patients, 164 (34.4%) had concurrent PCA disease. In patients with PCA disease, the extent of occlussion was mild in 56 (34%), moderate in 41 (25%), and severe in 67 (40.9%) patients. In total, there were 319 females (70.9%), with a higher proportion of female MMD patients having severe or moderate PCA disease (p=0.038). Patients with severe and moderate PCA disease had higher Suzuki grades (p<0.0001), more extensive collateral angiopathy (p<0.0001), more frequent cerebrovascular accidents on presentation (p=0.012), higher hemodynamic scores (p=0.022), and a greater frequency of post-operative ischemic complications (p=0.019). Peak modified Rankin Scale (mRS) scores were higher in patients with any severity of PCA disease (p=0.0006).

Over a mean follow-up of 6.94±4.16 years, 28 patients (8.86%) developed new or progressive PCA disease. Bilateral disease was present in 66 patients (14.7%) and was associated with higher Suzuki grades (p<0.0001), more extensive collateral angiopathy (p<0.0001), and greater post-operative ischemic complications (p=0.011). Peak mRS scores were higher in patients with bilateral disease compared to patients with no PCA disease (p<0.0001).

PCA disease involvement is associated with higher rates of ischemic peri-operative complications and poor functional outcomes likely due to reduced collateral flow. Progression of PCA disease is not uncommon. Future studies are needed to assess the impact of PCA disease progression on long-term outcomes.
Abstract P100: Hemorrhagic Stroke in the Setting of COVID-19 is Associated With Anticoagulation Use
Authors: Kvernland Alexandra , Kumar Arooshi , Yaghi Shadi , Raz Eytan , Frontera Jennifer , Lewis Ariane , Czeisler Barry , Kahn D. Ethan , Zhou Ting , Ishida Koto , Torres Jose L , Riina Howard , Shapiro Maksim , Nossek Erez , Nelson Peter K , Tanweer Omar , Gordon David , Jain Rajan , Dehkharghani Seena , Henninger Nils , De Havenon Adam H , Mac Grory Brian , Lord Aaron , Melmed Kara R
Published: March 2021

Introduction:
While the thrombotic complications of COVID-19 have been described, there are limited data on its implications in hemorrhagic stroke. The clinical characteristics, underlying stroke mechanism, and outcomes in this group of patients are especially salient as empiric therapeutic anticoagulation becomes increasingly common in the treatment and prevention of thrombotic complications of COVID-19.

Methods:
We conducted a retrospective cohort study of patients with hemorrhagic stroke (both non-traumatic intracerebral hemorrhage and spontaneous non-aneurysmal subarachnoid hemorrhage) who were hospitalized between 3/1/20-5/15/20 at a NYC hospital system, during the coronavirus pandemic. We compared the demographic and clinical characteristics of patients with hemorrhagic stroke and COVID-19 to those without COVID-19 admitted to our hospital between 3/1/20-5/15/20 (contemporary controls) and 3/1/19-5/15/19 (historical controls), using Fischer’s exact test and non-parametric testing. We adjusted for multiple comparisons using the Bonferroni method.

Results:
During the study period, 19 out of 4071 (0.5%) patients who were hospitalized with COVID-19 had hemorrhagic stroke on imaging. Of all COVID-19 with hemorrhagic stroke, only 3 had non-aneurysmal SAH without intraparenchymal hemorrhage. Among hemorrhagic stroke and COVID-19 patients, coagulopathy was the most common etiology (73.7%); empiric anticoagulation was started in 89.5% vs 4.2% of contemporary and 10.0% of historical controls (both with p =<0.001). Compared to contemporary and historical controls, COVID-19 patients had higher initial NIHSS scores, INR, PTT and fibrinogen levels. These patients also had higher rates of in-hospital mortality [84.6% vs. 4.6%, p =<0.001]. Sensitivity analyses excluding patients with strictly subarachnoid hemorrhage yielded similar results.

Conclusion:
We observed an overall low rate of imaging-confirmed hemorrhagic stroke among patients hospitalized with COVID-19. Most hemorrhages in COVID-19 patients occurred in the setting of therapeutic anticoagulation and were associated with increased mortality. Further studies are needed to evaluate the safety and efficacy of therapeutic anticoagulation in COVID-19 patients.
Abstract P101: Mechanical Thrombectomy in COVID-19 Positive Patients With Large Vessel Occlusion: Pooled Review of Individual Case Series
Authors: Memon Muhammad Z , Nisar Taha , Singla Amit , Nanda Anil , Gupta Gaurav , Khandelwal Priyank
Published: March 2021

Background:
COVID-19 has been shown to induce a hypercoagulable state thereby increasing the risk of arterial thrombosis resulting in Large Vessel Occlusion Stroke (LVOs)

Objective:
We performed a systematic review of published reports to study the clinical characteristics, and outcomes of COVID-19 acute ischemic stroke (AIS) patients with LVO treated with mechanical thrombectomy (MT) and compared them with historical controls.

Methods:
We conducted a systematic literature search from December 2019 to July 2020 using multiple combinations of keywords from PubMed and Ovid databases according to the PRISMA meta-analyses and systemic reviews guidelines and then pooled data from individual case series. We included studies where COVID -19 associated LVO cases were treated with MT and their clinical outcomes were reported. We then compared these findings with the historic patient data from the five landmark randomized MT trials, the Hermes collaborators (HC).

Results:
An initial search generated 12 studies but after excluding case reports and multiple reports comprising of the same series of patients, a total of five reports consisting of 51 patients were analyzed. The mean age of patients was 59 years (IQR 36-75), and 40 (78 %) were men. Median NIHSS on presentation was 20 (IQR 10-29). AIS with LVO was the presenting manifestation of COVID-19 in 16 (20%) of patients. Intracranial ICA was the most common site of occlusion found in 27 (53%) of patients with multi-territory occlusion in 10 (20 %). Final recanalization TICI ≥ 2b was achieved in 33 (64%) of patients but reocclusion was noted in 7 (14 %). Modified Rankin score (mRS) 0-2 was reported in 12 (23 %) of patients with 40 % in-hospital mortality. When compared to historic data from HC, COVID -19 patients were younger (59 vs 69 years), presented with a higher median NIHSS score (20 vs 17), and had a higher prevalence of ICA terminus occlusion (53% vs 21% ). Similarly, patient outcomes were poor in the COVID -19 group with mRs 0-2 in (23 % versus 46 %) and mortality (40 % vs 15 %) compared to Hermes group.

Conclusion:
COVID -19 AIS patients with LVO who underwent MT were younger, had multiple territory occlusions with a propensity for ICA terminus location, and had poor angiographic and clinical outcomes as compared to historic data.
Abstract P107: Intraluminal Carotid Thrombosis and Acute Ischemic Stroke Associated With COVID-19
Authors: Hamouda Diaa , Jillella Dinesh V , Bhatt Nirav , Koneru Sitara , Frankel Michael R , Nogueira Raul G
Published: March 2021

Background:
Intraluminal carotid thrombi (ILT) are uncommon and present in only 0.4 to 1.5 % of patients with stroke. The endothelial inflammation and hypercoagulable state associated with COVID-19 (caused by SARS-CoV-2) poses a risk of arterial and venous thromboembolism. Herein, we present a series of stroke patients with ILT in the setting of a recent SARS-CoV-2 infection.

Methods and Results:
From July 9
th
, 2020 to August 17
th
, 2020, four patients were identified with acute ischemic stroke with varying thrombus burden but similar morphological patterns of ILT. All patients had evidence of recent SARS-CoV-2 infection as confirmed by PCR (n=3) or IgG antibody (n=1) in addition to clinical and radiological manifestations consistent with COVID-19. General characteristics and imaging of the patients are shown in table 1. Mean age was 55.3 ±7.7 years. Most patients (3) had at least two vascular risk factors and none had a central embolic source other than ILT. D-Dimer was profoundly elevated in 3 patients. ILT involved the cervical (3) and intracranial (1) internal carotid artery. COVID-19 symptoms ranged from mild transient respiratory symptoms to severe pneumonia requiring critical care support. None of the patients received acute reperfusion therapy either due to presentation beyond the therapeutic window or due to the absence of large vessel occlusion and/or unfavorable imaging profile.

Conclusion:
In this small case series of relatively young patients with acute ischemic stroke we found an association between COVID-19 infection and ILT. This suggests a distinctive pathophysiological pattern of stroke in COVID-19 patients. Further studies are necessary to elucidate the underlying pathophysiology and target specific treatment modalities.
Abstract P122: The Impact of Center Certification Status on Acute Stroke Care Within a Multi-Hospital System in Western United States
Authors: Raychev Radoslav I , Moreno CrystalAnn , Corless Leslie , Tarpley Jason W , Zurasky John F , Loh Yince , Baraban Elizabeth
Published: March 2021

Introduction:
We aimed to investigate the impact of certification status on process of care metrics and clinical outcome in a large multi-center hospital system.

Methods:
We analyzed data obtained from the Providence Stroke Registry between January 2016 and December 2019. Key process of care metrics and clinical outcome were compared among patients with a discharge diagnosis of stroke and stratified based on site certification: comprehensive stroke center (CSC), thrombectomy-capable stroke center (TSC), primary stroke center (PSC) and no certification (NC). Donner’s adjusted chi-square tests were used to compare proportions for each metric grouped by certification. Generalized linear mixed effects logistic regression models were used to adjust for mode of patient arrival, age, sex, admit NIHSS, and medical history.

Results:
Data included 45,278 patients. Results from the analyses are summarized in the table. Donner’s adjusted chi-square analyses showed significant differences for metrics across certification groups. Results from the logistic regression models indicated significant differences in IV TPA and EVT treatment, as well as IV TPA treatment times across certification groups. There were no significant differences between TSC and CSC.

Conclusions:
Patients presenting with acute ischemic stroke at NC and PSC were significantly less likely to receive IV TPA or EVT with significantly less efficient IV tPA treatment times as compared to CSC. However, CSC and TSC sites performed similarly.
Abstract P129: Initial Real-World Experience With Viz LVO in Transferred Large Vessel Occlusion Stroke Patients
Authors: Morey Jacob , Zhang Xiangnan , Yaeger Kurt , Fiano Emily , Marayati Naoum Fares , Kellner Christopher P , De Leacy Reade A , Doshi Amish , Tuhrim Stanley , Fifi Johanna
Published: March 2021

Background and Purpose:
Randomized controlled trials have demonstrated the importance of time to endovascular therapy (EVT) on clinical outcomes in large vessel occlusion (LVO) acute ischemic stroke. Delays to treatment are particularly prevalent when patients require a transfer from hospitals without EVT capability onsite. A novel computer aided triage system, Viz LVO, has the potential to streamline workflows. This platform includes an image viewer, communication system, and an artificial intelligence (AI) algorithm that automatically identifies suspected LVO strokes on CTA imaging and rapidly triggers alerts. We hypothesize that the Viz application will decrease time-to-treatment.

Methods:
A prospective database was assessed for patients who presented to a stroke center utilizing Viz LVO in the Mount Sinai Health System in New York and underwent EVT following transfer for LVO stroke between July 2018 and March 2020. This time period was chosen due to the COVID-19 pandemic affecting stroke workflow after March 2020. Time intervals were compared for 55 patients divided into Pre- and Post-Viz cohorts.

Results:
The median initial door-to-neuroendovascular team (NT) notification time interval was significantly faster (25.0 minutes [IQR=12.0] vs 40.0 minutes [IQR=61.0]; p=0.01) with significantly less variation (p<0.05). The median initial door-to-skin puncture time interval was 25 minutes shorter in the Post-Viz cohort, although not statistically significant (p=0.15). Post Viz LVO implementation, the Viz notification was the first NT notification 38% (10/26) of the time.

Conclusions:
Our preliminary results have shown that Viz LVO implementation is associated with earlier, more consistent NT notification times and potentially treatment times. This platform presents a novel application of AI that can serve as an early warning system and a failsafe to ensure that no LVO is left behind. Further studies are warranted.
Abstract P139: Efficacy and Utility of Resident-Run Telestroke Evaluations
Authors: Hajighasemi Mohammad , Quinn Jeffrey , Paletz Laurie B , Song Shlee S , Schlick Konrad , Lyden Patrick D
Published: March 2021

Introduction:
Exposure to telestroke in neurology residency is sparse despite its implementation in daily practice. Due to COVID-19, we increased our utilization of telestroke. Given this change in workflow, we investigated how residents utilize telestroke for “Code Brain” (CB) acute stroke evaluations and if expanding the use of telestroke in neurology residency programs is justified.

Methods:
We retrospectively compared the number of CB evaluations, door to needle (DTN) times, door to decision (DTD) times, and NIHSS from March - June 2019 (in-person evaluations) against those in March - June 2020 (telestroke evaluations). We limited our study to resident-involved cases. Nighttime and weekend CBs are run by a neurology resident and are remotely supervised. Daytime CBs can be run by a resident, fellow, or attending. We assumed that nighttime CBs are resident-run and daytime evaluations are the stroke team’s evaluation. Statistical analysis was performed using R.

Results:
There were a total of 217 CBs in March - June 2019 and 115 in March - June 2020. In 2019, there were 120 daytime and 97 nighttime CBs; in 2020 there were 62 and 53. The mean DTN for the day for 2019 and 2020 was 45.9 ± 23.2 and 48.4 ± 20.2 (P=0.08). The mean DTN during the night for 2019 and 2020 was 67.3 ± 53.7 and 53.8 ± 25.8 (P=0.64). The mean DTD during the day for 2019 and 2020 was 48.1 ± 41.0 and 44.9 ± 37.6 (P=0.25). The mean DTD during the night for 2019 and 2020 was 60.9 ± 51.1 and 65.8 ± 94.6 (P=0.68). Using a generalized linear model approach to correct for shift (day/night), age, NIHSS, we found no significant differences in DTN or DTD before and after implementing resident-run telestroke. Using Cohen’s approach (1988) we estimated a Type 2 error probability at 7%.

Discussion:
Our findings show that resident-run telestroke CBs are comparable to CBs run by fellows and attendings as DTN and DTD were not significantly different between the CBs run by residents in-person or via telestroke. These metrics are also comparable for CBs in which a fellow or attending are supervising or running the CB. Implementing resident-run telestroke consultation showed no effect on DTN or DTD after accounting for patient age, NIHSS, or the time of day. These data should reassure programs seeking to grant telestroke privileges to trainees.
Abstract P146: Assessment of Telestroke Sub-Events and Their Contribution to Door-To-Needle Time in a Telestroke Network
Authors: Hackett Christopher T , Malhotra Konark , Cerejo Russell , Fuller Nicholas , Wright David G , Rana Sandeep , Fishman Robert , Tayal Ashis H
Published: March 2021

Introduction:
Data remains scarce on which telestroke related sub-events (component parts/time intervals) are associated with delays in door-to-needle (DTN) time and goals for each telestroke sub-event. We aimed to assess the telestroke sub-events that contribute to DTN. After establishing set goals for each sub-event, we further evaluated the odds of DTN within 45 minutes if sub-event goals were achieved.

Methods:
We retrospectively analyzed prospectively collected data from a hub-and-spoke model telestroke network from January 2017 to September 2019. To determine which sub-events significantly contributed to DTN time, a sequential multiple regression analysis was performed. We entered covariates (age, sex, time of telestroke [day or night], NIHSS, average number of telestroke consults at a given site) in the first block followed by sub-events (door-to-telestroke request, door-to-CT, request-to-page, stroke physician response time, telestroke phone-to-video, video duration prior to needle and video completion-to-needle) in the second block. Logistic regression models were performed to estimate the odds of achieving a DTN within 45 minutes if sub-event goals were achieved.

Results:
During the study, 3361 telestrokes were completed and 306 (9.1%) patients received IV thrombolytics. After exclusions, 253 patients treated with IV thrombolytics were included. Five sub-events contributed to DTN time above and beyond the nuisance variables: door-to-telestroke request, stroke physician response time, telestroke phone-to-video, video duration prior to needle, and video completion-to-needle; each
p
<0.001. DTN time within 45 minutes was more likely when door-to-telestroke request <10 minutes (OR=12.30, 95%CI 3.47-43.65), video completion to needle <1 minute (OR=4.21, 95%CI 1.45-12.20) and telestroke phone-to-video <7 minutes (OR=5.24, 95%CI 1.41-19.49).

Conclusions:
Telestroke sub-events involving door-to-telestroke request, stroke physician response, telestroke phone-to-video, video duration prior to needle, and video completion-to-needle significantly contribute to DTN time. Successful achievement of sub-event goals was related to greater likelihood of administration of thrombolytic therapy within 45 minutes.
Abstract P147: Unanticipated Benefits of a Large Vessel Occlusion Screening Tool in a Primary Stroke Center
Authors: Werner Amanda , Kaiser Brian L
Published: March 2021

Introduction:
Use of an LVO screening tool to triage patients suspected of having an LVO and expedite transfer to an endovascular capable stroke center (ESC) has some benefit for patients within 15 minutes of an ESC. The benefits of using an LVO screening tool amongst Primary Stroke Centers (PSC) that are geographically isolated from an ESC is of less clear benefit.

Methods:
The implementation of the Vision, Aphasia, Neglect (VAN) LVO screening tool at a regional series of PSCs and freestanding emergency departments was accomplished in anticipation of pursuing thrombectomy-capable certification at one of the facilities. The use of VAN was incorporated into a tiered stroke alert system to identify patients eligible for endovascular treatment up to 24 hours. Retrospective data was collected and assessed for pre and post implementation time metrics: workflow timestamps, volume of treated and transferred patients, mimic and complication rates, median door-to-needle times, and median door-in-door-out times.

Results:
The 12-month calendar year prior to and immediately following VAN implementation was reviewed and included final diagnosed ischemic (n=469) and hemorrhagic (n=96) patient volumes. Implementation of VAN was associated with reductions in median door-to-transfer times from 143 to 122 minutes and median door-to-needle times from 48 to 38 minutes. Thrombolytic treatment rates increased by 5%, mimic rate decreased by 5%, without significant changes in thrombolytic complications.

Conclusions:
In conclusion, use of VAN as an LVO screening tool in a Primary Stroke Center which is geographically isolated from an ESC was associated with an unanticipated improvement of multiple program metrics including reduced door to transfer times, reduced door to needle times, increased percentage of patients treated with thrombolytics, and increased staff satisfaction and engagement. These unanticipated benefits are likely the result of a combination of factors including increased staff awareness of stroke symptoms and optimization of regional stroke alert workflows that occurred in conjunction with LVO implementation.
Abstract P151: Remote Enrollment Practices for Acute Stroke Clinical Research Trials During a Pandemic
Authors: Streib Christopher D , Tessmer Megan , Staugaitis Abbey , Gaffney Denise , Sangha Navdeep S
Published: March 2021

Introduction:
Many clinical trials have suffered poor enrollment or have been placed on hold due to the COVID-19 pandemic. Limitations on in-person interaction with patients, legally authorized representatives, coordinators, and physician investigators disrupt research processes including screening, consent, randomization, and study interventions. Remote enrollment practices incorporating telemedicine and electronic consent may address these enrollment limitations.

Methods:
We retrospectively reviewed clinical trial enrollments in two pivotal phase-III acute stroke trials (NCT03735979, NCT03785678) at two high-volume stroke centers that routinely use remote enrollments in clinical research. Individual elements of acute clinical stroke trial enrollment, including: screening, consent, randomization, and intervention were reviewed. For each research phase, we compared the rate of successful completion and research protocol violations for in-person vs remote research via Fisher’s exact test.

Results:
Forty patients were reviewed (median age 72 [IQR 63-84], 50% female, median NIHSS 13 [IQR 7.5-19.5]; 35 patient were enrolled and 5 were screened and consented, but found ineligible on qualifying imaging. All research phases were completed successfully with the exception of one in-person study intervention. Fisher’s exact test revealed no differences in protocol violations between research elements conducted remotely (predominantly via telemedicine) versus in-person (see Table).

Conclusion:
Our study revealed no difference in successful completion of acute clinical trial research elements when conducted remotely or in-person. Incorporation of remote research, especially telemedicine, may enable stroke clinical trial enrollments both during the COVID 19 pandemic and beyond.
Abstract P166: The Primary Stroke Center Transfer Experience to Higher Levels of Care: A Qualitative Study
Authors: Patterson Jennifer L , Dusenbury Wendy , Devlin Thomas G , Stanfill Ansley , Tsivgoulis Georgios K , Alexandrov Andrei V , Alexandrov Anne W
Published: March 2021

Background:
Transfer times from primary stroke centers/acute stroke ready hospitals (PSCs/ASRHs) to higher levels of care have been shown to be excessive in many cases, promoting some to believe that bypass regulations should be instituted. Yet barriers to rapid transfer remain undescribed in the literature. The purpose of this work is to investigate these issues and the locus of control for transfer time delays.

Methods:
Six national focus groups with PSC/ASRH staff experienced with stroke transfers were conducted by web conference. Interviews were conducted using pre-scripted open-ended questions; information was recorded, and data were transcribed, for theme identification.

Results:
Participants were from Northeast, Mid-Atlantic, Southeast, Midwest, and West Coast USA. Data were grouped into 3 main categories representing where transfer problems initiated. Themes emerging within the
Internal PSC/ASRH
Category
were exclusively emergency department (ED) physician focused including knowing how/when to use advanced imaging and telemedicine resources. Of note, all participants were compliant with door-to-CT and treatment time metrics. Within the
Transport Category
, themes included inadequate time-to-response by ground and air ambulances, and specialty transport costs. Within the
Internal Comprehensive Stroke Center (CSC) Category
, themes included complex communication, overwhelmed systems, and poor guidance on patient selection.

Conclusions:
While ED physician contributors to transfer delays are within the control of PSCs/ASRHs, more challenging factors to rapid transfer include factors within transport systems and CSCs themselves. Quantification of these factors is warranted to support transfer system redesign with rapid access to care.
Abstract P172: Dedicated Ground Transport Reduces Door in Door Out Times to Less Than 60 Minutes
Authors: Ronosky Kristen , Cameron Amos P , Campbell Joe , Leckey Ronald D , Hackett Christopher T
Published: March 2021

Introduction:
Prior studies have found conflicting results in regards to whether air or ground transportation to transfer stroke patients is associated with quicker door-in-door-out (DIO) times. We aimed to examine DIO times in acute stroke patients from two community primary stroke centers (one with air/ground; one with dedicated ground transport only) from a similar geographical location. Additionally, we aimed to examine whether there were differences in DIO comparing the hospitals.

Methods:
We prospectively collected and retrospectively analyzed stroke transfer data from two community hospitals in a health system between 10/1/2018 and 03/31/2020. A hierarchical logistic regression was performed in two steps to determine which factors were associated with DIO ≤ 90 minutes. First, possible confounding variables such as age, gender and arrival mode (EMS or private vehicle) were entered. Next, we entered variables of interest; transfer mode (ground vs air), if the patient was transferred for mechanical endovascular reperfusion (MER) and if the patient was transferred from the hospital with dedicated ground transport or not. A subgroup analysis determined if DIO differed between hospitals. Two-sided Fisher’s exact test examined proportion of DIO ≤ 60 minutes comparing hospitals.

Results:
During the study 334 patients were transferred [234 hospital with air/ground (100 air, 134 ground) and 100 hospital with dedicated ground transport]. We found that patients were more likely to be transferred within 90 minutes of arrival if: transferred by air, OR = 14.99 (95%CI 4.34 - 51.76) p < 0.001; transferred for MER, OR = 2.97 (95%CI 1.37 - 6.46) p = 0.006 and transferred by dedicated ground transport, OR = 14.93 (95%CI 4.35 - 51.30) p < 0.001. A subgroup analysis suggested that there was no difference in DIO between patients transferred by air or dedicated ground (p = 0.88). Although, we found significantly more patients were transferred within 60 minutes by the hospital utilizing a dedicated EMS (6.0% vs 1.3%), OR = 4.92 (95%CI 1.20 - 20.06) p = 0.02.

Conclusions:
In conclusion, a dedicated ground transport ambulance allowed for quicker DIO times overall, including a greater proportion of all transfers within 60 minutes but similar DIO times to MER patients transported by air.
Abstract P198: Daily Step Count at Two Months is the Strongest Predictor of Daily Steps at One Year Post-Stroke
Authors: Handlery Reed , Regan Elizabeth , Hainline Garrett , Fritz Stacy
Published: March 2021

For survivors of stroke, walking can improve endurance, community participation and decrease risk of subsequent stroke. Unfortunately, survivors take 4000 fewer steps per day compared to other adults. Early identification of survivors prone to long-term inactivity would be valuable, as interventions could be implemented to improve physical activity (PA) levels and reduce subsequent stroke risk.

Secondary data from the Locomotor Experience Applied Post Stroke (LEAPS) trial was used. Included participants had walking speeds of <0.80 m/s at 2 months post-stroke. Daily steps were assessed at 2 months and 1 year post-stroke using an activity monitor. Stepwise regression was used to predict daily step counts at 1 year based on modifiable (walking speed, endurance, balance, balance confidence, daily step counts) and nonmodifiable (age at time of stroke, gender, race, ethnicity, initial stroke severity, side of stroke and LEAPS intervention group) factors.

Data was available for 206 survivors, mean age=63 (13) years, 43% female (88/206), mean walking speed=.41 (.22) m/s, mean step count=2922 (2749) steps per day. The strongest predictor of daily steps at 1 year was daily steps at 2 months (p=<0.001, adjusted R
2
=.34). For every 1-step increase at 2 months, there was an increase of .54 (95% CI .38, .71) steps at 1 year. The next strongest predictor was walking endurance (Six Minute Walk), which significantly increased adjusted R
2
by .02 (p=.009). For every 1-meter increase in Six Minute Walk distance at 2 months, there was an increase of 8 (95% CI 2, 14) steps at 1 year. Together, baseline steps and Six Minute Walk distance explained 36% of the variance in daily steps at 1 year. No other factors significantly added to the prediction model.

Daily steps at 2 months post-stroke was the strongest predictor (explaining 34% of the variance) of steps at 1 year. Survivors with low daily steps early after stroke may benefit from targeted walking interventions to increase PA and long term health outcomes.
Abstract P203: Assessing Sexual Dysfunction Among Stroke Survivors and Barriers to Address This Issue by Healthcare Providers at a Latin American Reference Hospital
Authors: Montalvan Victor , Ulrich Angela , Zunt Joseph , TIRSCHWELL David L
Published: March 2021

Background:
Sexual dysfunction affects at least one half of patients after a stroke. Problems related to sexual function are rarely assessed or addressed by physicians.

Objective:
To determine the frequency and factors associated with sexual dysfunction among stroke survivors and self-reported barriers of physicians to discuss sexual dysfunction during regular consultation.

Methods:
We administered a questionnaire to a cross-sectional sample of stroke survivors to assess the frequency and factors associated with sexual dysfunction and the aspects of sexuality most commonly affected by stroke. A qualitative approach was used to determine the willingness to address sexual issues and related barriers among physicians participating in the study.

Results:
Among 150 patients, sexual dysfunction was identified in 89 (59%). Only 10% self-reported their sexual function as optimal. Markedly decreased frequency of sexual encounters (49%) and markedly decreased sexual desire (33%) were the aspects of sexual function most commonly reported by patients after a stroke. Fear of having a new stroke [OR:3.2, 95% CI (1.5 – 6.3)], depression [OR:2.1, 95% CI (1.0– 4.3)], and self-perception of having impaired motor function [OR:2.5, 95% CI (1.2 – 5.0)] were significantly associated with sexual dysfunction. In the qualitative assessment of physicians (N= 15), when asked how often they addressed sexual aspects during regular consultation with a stroke survivor, none answered “very often”, and only 8 (51%) answered “sometimes”. At the end of the study, 10 (66%) physicians verbalized the perception that addressing this issue encouraged their patents to be more open to personal concerns and prompted a stronger doctor-patient relationship.

Conclusion:
Sexual dysfunction affected more than a half of stroke survivors, and was significantly associated with depression, fear of having a new stroke, and with the self-perception of impaired motor function. Addressing sexual issues during the regular consult by physicians was infrequent. Barriers reported by physicians included

limited time during regular consultation and the belief that this issue should be addressed under the scope of other specialties.
Abstract P206: Wearable Myoelectric Interface Training for Improving Arm Movement in Chronic Stroke
Authors: Hung Na-Teng , Paul Vivek , Kovach Torin , Slutzky Marc W
Published: March 2021

Impaired arm movement after stroke is due not only to weakness and spasticity, but also to abnormal co-activation (a.k.a. abnormal synergies). Yet, few stroke therapies are aimed to reduce this co-activation. We designed a myoelectric computer interface (MyoCI) that provides feedback to stroke survivors to reduce this abnormal co-activation and associated arm impairment. Here, we describe a novel, wearable version of the MyoCI to control custom-designed computer games as a home-based therapy for chronic stroke survivors. This therapy, called the myoelectric interface for neurorehabilitation training (MINT), enables high-intensity, high-dose training using an inexpensive device at home. The MINT device records surface EMGs from 2-3 arm muscles and wirelessly controls games on a laptop or tablet. By mapping the muscle activities to orthogonal directions of cursor movements, the games operantly condition the participants to learn to reduce abnormal co-activation between the muscles. We are currently investigating this device in severely impaired stroke survivors (Fugl-Meyer score <30). Participants were asked to train 90 min per day, 6 days a week, for a total of 6 weeks, with different variants of the paradigm (2 or 3 muscles at a time) vs. a sham control group that trained on one muscle. We surveyed participants about their engagement with the game using a modified Intrinsic Motivation Inventory (IMI). Eighteen participants have completed the 6-week training to date. They averaged 75±19 min of daily training out of the 90 that were asked. Overall, 60% of participants surveyed enjoyed, and 90% were positively motivated by, the training. A few participants had significant difficulty with the laptops due to inexperience with computers. Participants’ performance on the game, measured by weighted time-to-target, improved steadily overall in the experimental group, while the sham control group stayed at high performance throughout. The MINT provides a motivating, enjoyable way to provide high-intensity therapy in the home to stroke survivors. This therapy is a new mechanism of action for stroke rehabilitation and we are evaluating its efficacy in an ongoing randomized controlled trial.
Abstract P207: Association Between Rehabilitation and Functional Outcomes of Stroke Survivors: A Population-Based Study
Authors: Azizi Zahra , Alipour Pouria , Rotondi Michael , Ardern Chris I
Published: March 2021

Background:
The increasing rate of stroke and its consequent disabilities has contributed to a growing proportion of stroke survivors requiring rehabilitation. Further research is needed to understand the provision of rehabilitation in the community settings and relationship between variance in stroke care and patient outcomes.

Hypothesis:
To investigate the association between rehabilitation and functional outcomes of stroke survivors.

Method:
Data for this analysis was derived from the Canadian Community Health Survey (CCHS) (merged cycles 2013-2016: 237,121 participants). Participants reporting complications from stroke were selected to assess the effect of physiotherapy (PT) and other allied health (AH) utilization. Primary endpoints included need for assistance in activity of daily living (ADL) and injury due to fall in the past 12 months (Inj-Fall). All statistical analyses were performed using R (V.4.0.2) and survey design.

Results:
Overall, 3,773 (1.1%) patients with stroke (47% females, 71.1% older than 60 years) were studied. Total of 0.2% and 1.6% of stroke survivors in 2013-14 had consulted PT and AH compared to 9.1% and 21% in 2015-16, respectively. Consequently, the rate of need for ADL and Inj-Fall were significantly greater in 2013-14. In general, age was a significant predictor of low accessibility to PT (OR=0.66(0.51-0.85)) or AH (OR=0.79(0.66-0.93)) whereas no significant association between sex and access to PT or AH (P=0.1). As expected, higher income was associated with greater PT utilization (OR=2.11(1.1-4.2)). Finally, PT or AH consultations were significantly associated with less need for assistance in ADL and lower Inj-Fall (Table1).

Conclusion:
Results of this study reinforce the beneficial effect of rehabilitation on ADL and injury in stroke survivors. Future longitudinal work is necessary to understand directionality of the relationship, and the impact of healthcare access, within varied healthcare systems and models of health .
Abstract P216: Speed-Accuracy Tradeoffs During Cognitive and Upper-Limb Horizontal Movement Tasks in Chronic Strokes
Authors: Kim Hogene , Lee Hyunjong , Ilho Kwon
Published: March 2021

Objectives:
This study investigated cognitive-motor interference on the relationship of speed and accuracy during a cognitive and upper-limb motor dual task.

Method:
Nine stroke patients (56.5±7.3 years; M:9) participated in a series of cognitive-motor dual tasks. A subject with chronic stroke was seated with paretic hand fastened on the handle and then one of five motor tasks was provided (Figure 1A). Visual feedback in a front screen was synchronized as the handle cursor moves within the movement trajectory with two difficulty levels (5cm or 10cm). In a dual task, a cognitive task, Serial Seven(S7), was concurrently provided with a randomly chosen number at the onset of the motor task by a test administrator.Figure 1 Cognitive-Motor dual task setup (left up) and trajectory shapes (Diagonoal; Mediolateral; Anteroposterior; Cross; Circle) and level of difficulties (Easy 10cm or Hard 5cm) in motor tasks. The motor speed and accuracy and the cognitive speed and accuracy were evaluated during one-minute trial time. Pearson-correlation coefficients evaluated outcome relationship of the speed and accuracy in single or cognitive-motor dual tasks with the significance level 0.05 using a commercial statistics package (SPSS ver 22, Chicago IL,US).

Results:
There were significant positive correlation between single and dual motor speeds (
Easy
:R
2
=0.678,p<0.001;
Hard
: R
2
=0.714,p<0.001) and significant negative correlationbetween single motor speed and dual cognitive speed (
Easy
: R
2
=0.661,p<0.001;
Hard
:R
2
=0.6523,p<0.001) (Figure 1B)

Conclusions:
There were significant correlations between the upper-limb horizontal movements with visual feedback and S7 cognitive task. This study may provide useful information on upper-limb motor robotic therapies using 2D horizontal upper-limb movements.
Abstract P218: Effects of Bilateral Transcutaneous Electrical Nerve Stimulation Combined With Task-Oriented Training on the Recovery of Upper Limb Motor Impairment in People With Chronic Stroke
Authors: CHEN Peiming , Liu Tai-Wa , Lai Claudia K.Y , Chung Raymond C.K , Ng Shamay S.M
Published: March 2021

Background:
Transcutaneous electrical nerve stimulation(TENS) is an effective physiological intervention for people with stroke which aims at reducing muscle spasticity, enhancing muscle strength, and improving motor control and function. In view of the potentials to enhance greater cortical activation of the lesion side by eliciting spare neural pathways through bilateral intervention, this study examined whether the combined use of bilateral TENS (Bi-TENS) and task-oriented training (TOT) was superior to unilateral TENS(Uni-TENS)+TOT, placebo-TENS+TOT and no active treatment to improve the motor impairment of upper limb function in people with stroke.

Method:
There were 120 subjects with stroke(44 females, mean age=61.52±6.73 years, post-stroke duration=6.04±3.12years) being randomly allocated into 4 groups, including the Bi-group (n=30), Uni-group (n=30), placebo group (n=30) and control group (n=30). Subjects in the Bi-group, Uni-group and placebo group got 60 minutes TENS and TOT simultaneously per time for 20 times(3 times per week for 7 weeks). In the Bi-group, TENS stimulated the radial and median nerves of the bilateral upper limbs. In the Uni-group, TENS and placebo-TENS stimulated the affected and unaffected side, respectively. In the placebo group, placebo-TENS were placed on bilateral sides. In the control group, subjects did not receive any active treatment. Level of motor impairment was assessed by the Fugl-Meyer Assessment of Upper Extremity (FMA-UE).

Result:
The Bi-group had a significant greater improvement in FMA-UE than the Uni-group(mean change=2.02, p=0.005), placebo group (mean change=2.49, p=0.001) and control group(mean change=3.08, p<0.001) at post-intervention. The Bi-group(mean change=3.25, p<0.001) and Uni-group(mean change=1.23, p=0.015) showed a significant within-group improvement in FMA-UE since 10 sessions of treatment. No significant change was found in the placebo and control groups.

Conclusion:
Bi-TENS is superior to Uni-TENS, placebo-TENS and no active treatment in augmenting the recovery of upper limb motor impairment in people with chronic stroke.

Author Disclosures:
The authors received research support from the Health and Medical Research Fund12131821 from the Food and Health Bureau, HKSAR.