bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P242: Impact of Covid-19 on Acute Ischemic Stroke Care at Henry Ford Hospital’s Detroit and West Bloomfield Campuses
Authors: Aboul Nour Hassan , Affan Muhammad , Mohamud Ali , Haddad Yazeed W , Mohamed Ghada , Schultz Lonni , Latack Katie , Brady Megan , Scozzari Dawn , Katramados Angelos , Bou Chebl Alex , Ramadan Ahmad-Riad
Published: March 2021

Background:
Coronavirus 2019 (COVID19) has impacted acute stroke (AS) care with several reports globally showing drops in AS volumes during the pandemic. We studied the impact of COVID19 on AS and transient ischemic attack (TIA) care in a health system serving Southeast Michigan as we rolled out a policy aimed at limiting admissions and transfers.

Methods:
In this retrospective study conducted at 2 hospitals, we included consecutive patients presenting to the emergency department (ED) for whom a Stroke Alert (SA) was activated during the period 3/20 to 5/20/20 (COVID) and a similar period in 2019 (pre-COVID). We compared demographics, time metrics, and discharge outcomes.

Results:
264 patients were seen pre-COVID compared to 121 during COVID (p<0.001). Patients seen during COVID had an equal proportion of males (55% vs 51%, p=0.444), were majority African American (57 vs 58%, p=0.74), but had a higher presenting NIHSS (median: 5 vs 2, p=0.01) and longer times since last-known-well to ED arrival (median: 9.4 vs 4.8 hours, p=0.03) compared to pre-COVID. Fewer patients were transferred from other centers (42 vs 27% p=0.008). SA activation on arrival (median: 9.6 vs 15 min, p=0.004) and imaging initiation from arrival (median: 26.4 vs 34.8 min, p=0.042) were faster as well as a trend toward statistical significance for time to tPA administration (median: 37.8 vs 51 min, p=0.051) compared to pre-COVID. There were higher rates of AS and TIA (69% vs 55%) and lower rates of stroke mimics (17 vs 37%, p<0.001). Patients discharged from the stroke unit had significantly higher discharge NIHSS (median: 3 vs 2, p=0.002) and were more likely to have an unfavorable discharge mRS (3-6) (56 vs 33%, p=0.004). There were no significant differences in medical, social histories, time to first pass for patient undergoing thrombectomy and stroke etiologies between the groups. In 2020, 9 patients (8%) were COVID19 positive, 2 had unfavorable mRS 3-5 while 3 died.

Conclusion:
There was greater than 50% reduction in stroke admissions during the COVID19 pandemic which is consistent with other reports. Although patients were managed more quickly, they tended to have more severe strokes, fewer stroke mimic diagnoses, and worse outcomes compared to patients treated in the pre-COVID period.
Abstract P244: Association Between Diagnostic Work-Up and Outcomes of TIA in the Greater Cincinnati Northern Kentucky Stroke Study
Authors: Madsen Tracy E , Khoury Jane C , Alwell Kathleen S , Ferioli Simona , Woo Daniel , Mackey Jason , De Los Rios La Rosa Felipe , Demel Stacie L , Star Michael , Haverbusch Mary , Coleman Elisheva R , Walsh Kyle B , Slavin Sabreena , Jasne Adam , Mistry Eva , Kissela Brett M , Kleindorfer Dawn
Published: March 2021

Background:
Substantial practice variability exists with respect to the diagnostic workup and disposition of patients with TIA. Identifying the workup needed to prevent adverse outcomes is critical. We aimed to determine whether there is an association between specific elements of TIA management and outcomes.

Methods:
The GCNKSS is a population-based study of 1.3 million people living in a 5-county area of southern Ohio/ Northern Kentucky. For this study, all physician adjudicated, first-ever TIAs (clinically defined as sudden onset, focal neurologic symptoms lasting < 24 hours, with or without MRI correlate) presenting to the ED during 2015 were included; those with prior stoke or TIA were excluded. Multivariable logistic regression was performed to investigate associations between specific aspects of TIA management and an adverse outcome, defined as stroke, recurrent TIA, or all-cause mortality within 30 days, adjusted for demographics, co-morbidities, and symptom type and length as classified in the ABCD2 score.

Results:
In 2015, there were 477 adjudicated first ever TIA events presenting to the ED. Overall, 13% (n=62) occurred in Black individuals and 51% (n=243) in women. Regarding outcomes, 3% (n=16) had a stroke within 30 days, 6% (n=30) had a recurrent TIA within 30 days, and 1% (n=4) died within 30 days (all-cause mortality). 16.4% had acute infarct on MRI. In multivariable analysis, having an MRI was associated with reduced risk of adverse outcome, while performance of vessel imaging, echocardiogram, or admission to hospital were not significantly associated with outcomes (Table).

Conclusions:
Among common diagnostic and management strategies for TIA, only performance of MRI was associated with a lower likelihood of having an adverse outcome within 30 days. Possible contributors include variability in care between hospitals with differing MRI performance rates and changes in management of risk factors based on MRI results, though further work is needed.
Abstract P250: A Strategy for Reliable Identification of Ischemic Stroke, Thrombolytics, and Thrombectomy in Large Administrative Databases
Authors: Zachrison Kori S , Li Sijia , Reeves Mathew J , Adeoye Opeolu M , Camargo Carlos A , Schwamm Lee H , Hsia Renee Y
Published: March 2021

Background:
Administrative data are frequently used in stroke research. Ensuring accurate identification of ischemic stroke patients, and those receiving thrombolysis and endovascular thrombectomy (EVT) is critical to ensure representativeness and generalizability. We examined differences in patient samples based on different modes of identification, and propose a strategy for future patient and procedure identification in large administrative databases.

Methods:
We used nonpublic administrative data from the state of California to identify all ischemic stroke patients discharged from an emergency department or inpatient hospitalization from 2010-2017 based on ICD-9 (2010-2015), ICD-10 (2015-2017), and MS-DRG discharge codes. We identified patients with interhospital transfers, patients receiving thrombolytics, and patients treated with EVT based on ICD, CPT and MS-DRG codes. We determined what proportion of these transfers and procedures would have been identified with ICD versus MS-DRG discharge codes.

Results:
Of 365,099 ischemic stroke encounters, most (87.7%) had both a stroke-related ICD-9 or ICD-10 code
and
stroke-related MS-DRG code; 12.3% had only an ICD-9 or ICD-10 code, and 0.02% had only a MS-DRG code. Nearly all transfers (99.9%) were identified using ICD codes. We identified32,433 thrombolytic-treated patients (8.9% of total) using ICD, CPT, and MS-DRG codes; the combination of ICD and CPT codes identified nearly all (98%). We identified 7,691 patients treated with EVT (2.1% of total) using ICD and MS-DRG codes; both MS-DRG and ICD-9/-10 codes were necessary because ICD codes alone missed 13.2% of EVTs. CPT codes only pertain to outpatient/ED patients and are not useful for EVT identification.

Conclusions:
ICD-9/-10 diagnosis codes capture nearly all ischemic stroke encounters and transfers, while the combination of ICD-9/-10 and CPT codes are adequate for identifying thrombolytic treatment in administrative datasets. However, MS-DRG codes are necessary in addition to ICD codes for identifying EVT, likely due to favorable reimbursement for EVT-related MS-DRG codes incentivizing accurate coding.
Abstract P259: The Association Between Sex, Gender and Health Status of Stroke Survivors in the Canadian Population
Authors: Azizi Zahra , Raparelli Valeria , Norris Colleen M , El Emam Khaled , Pilote Louise ,   On behalf of the GOING-FWD Investigators
Published: March 2021

Background:
Stroke is one of the most common cerebrovascular diseases causing permanent disability, and decreased quality of life (QoL). Both sex and gender have been reported to be associated with health outcomes. Gender, unlike biological sex, encompasses the psycho-socio-cultural roles, behaviors and identities of men, women, and gender-diverse people.

Hypothesis:
To examine the association between sociocultural gender, biological sex and health status among stroke survivors in the Canadian population.

Methods:
Data from cycles 2013-2014 and 2015-16 (n=237,121) of the Canadian Community Health Survey (CCHS) were analyzed. The primary endpoint of the study was Health Utility Index (HUI), a measure of health status and QoL. This index measures a range of health domains (i.e. vision, hearing, speech, ambulation, dexterity, emotion, cognition, and pain) and ranges between -0.36 (severe health state) to 1 (perfect health state). A gender score was computed based on the Genesis-Praxy method, using a principal component analysis-derived propensity score method. The final gender scores ranging from 0 to 1 (higher score identifying characteristics traditionally ascribed to women) included household size, perceived life stress, education, sense of belonging to community, marital status, and income. All statistical analyses were performed using R (V.4.0.2) with survey design.

Results:
Amongst 3,773 (1.1%) stroke survivors in two cycles, 47.8% were female and a majority were older than 50 years (85.3%). Overall, 76.4% of the stroke survivors had moderate to severe HUI (<=0.88), however, this rate was higher in females (82.5% vs 70.2%, P<0.001). Median gender score was 0.49 [0.46-0.55]. Higher gender scores (OR=12.5, 95%CI=1.4-116.2, P=0.02) and female sex (OR=1.8, 95%CI=1.2-2.8, P=0.002) were independently associated with moderately to severely diminished health status (HUI) in a model adjusted for age, and comorbidities (i.e. hypertension, diabetes, heart disease, and history of cancer).

Conclusion:
Characteristics traditionally ascribed to women’s gender and female sex were associated with poorer health status in stroke survivors. Gender-related factors must be targeted for improving the health status of patients suffering from stroke.
Abstract P26: Association of Tranexamic Acid Use With Outcomes in Alteplase-Associated Intracranial Hemorrhage
Authors: Mahmoud Leana , Zullo Andrew , Shu Liqi , Yaghi Shadi , Liberman Ava L , Lee Vivien , Mistry Eva , Silver Brian , Snyder Thomas , Vaishnav Dhrumil , Nimjee Shahid M , Heaton Sharon , Forrest Cassandra , Demers-Peel Meaghan , Andrews Nicholas , Moody Scott , Spinney Megan , Chen Jimmy , Cutting Shawna M
Published: March 2021

Background:
Alteplase (tPA) is the standard of care in acute ischemic stroke (AIS) treatment, but it is associated with increased risk of symptomatic intracranial hemorrhage (sICH). Cryoprecipitate (Cryo) is recommended for tPA-associated sICH reversal. Tranexamic acid (TXA), an antifibrinolytic, is of interest as an adjunct therapy, but data in AIS is limited. We aim to assess the relationship of TXA and sICH reversal.

Methods:
We conducted a multicenter retrospective cohort study of AIS patients admitted between April 2015 and July 2020 who were treated for tPA-associated sICH. Patients with extracranial bleeds, who were not reversed, or who died within 24 hours were excluded. Demographics, clinical characteristics, imaging, and outcome data were collected from electronic health records. Outcomes included hematoma expansion, a poor functional outcome at 90 days (modified Rankin Score 3-6), and thrombotic events. We used Pearson chi-square, Fisher’s exact, and Wilcoxon rank-sum tests to compare outcomes between adjunct TXA treatment (TXA+Cryo) vs. Cryo only groups.

Results:
The study cohort included 30 patients with tPA-related sICH (mean age 80 ±12.4 years; 60% female). Overall median (IQR) hematoma size was 4.4 ml (1.1-20). Multifocal bleeds were present in 39% of patients. TXA+Cryo was administered in 16 (53%) patients. Initial hematoma size was smaller in the TXA+Cryo group than the Cryo only group, median (IQR) of 2.4 ml (0.5-14.3) vs 24.1 ml (2.5-56.5), p=0.043. However, there were no marked differences between TXA+Cryo and the Cryo only groups for hematoma expansion (5 [33%] vs. 6 [50%] patients, p=0.38), poor functional outcome (15 [94%] vs. 11 [79%] patients, p=0.32), or thrombotic events (1 [6%] vs. 0, p=1.00).

Conclusion:
Among patients treated for tPA-related sICH, there was no difference in hematoma expansion, poor functional outcome, or thrombotic events in patients treated with adjunct TXA compared to Cryo alone.
Abstract P261: Machine Learning-Enabled Prediction of Long-Term Stroke Recurrence Using Data From Electronic Health Records
Authors: Abedi Vida , Avula Venkatesh , Chaudhary Durgesh , Shahjouei Shima , Khan Ayesha , Griessenauer Christoph J , Li Jiang , Zand Ramin
Published: March 2021

Objective:
The long-term risk of recurrent ischemic stroke, estimated to be between 17%-30%, cannot be reliably assessed. Our goal was to study whether machine-learning can be trained to predict stroke recurrence and identify key clinical variables and assess whether performance metrics can be optimized.

Methods:
We used patient-level data from electronic health records, 6 algorithms (Logistic Regression, Extreme Gradient Boosting, Gradient Boosting Machine, Random Forest, Support Vector Machine, Decision Tree), 4 feature selection strategies, 5 prediction windows, and 2 sampling strategies to develop 288 models for up to 5-year stroke recurrence prediction. We further identified important clinical features and different optimization strategies.

Results:
We included 2,091 ischemic stroke patients for this study. Model AUROC was stable for prediction windows of 1,2,3,4 and 5 years, with the highest score for the 1-year (0.79) and the lowest score for the 5-year prediction window (0.69). A total of 21(7%) models reached an AUROC above 0.73 while 110(38%) models reached an AUROC greater than 0.7. Among the 53 features analyzed, age, body mass index, and laboratory-based features (such as high-density lipoprotein, hemoglobin A1C, and creatinine) had the highest overall importance scores. The balance between specificity and sensitivity improved through sampling strategies.

Conclusion:
All the selected six modeling algorithms could be trained to predict the long-term stroke recurrence and laboratory-based variables were highly associated with stroke recurrence. The latter could be targeted for personalized interventions. Model performance metrics could be optimized, and models can be implemented in the same healthcare system as intelligent decision support to improve outcomes.
Abstract P267: Healthcare Resource Utilization and Costs of US Patients With Possible Large Hemispheric Infarction: A Real-World Assessment of Burden Associated With Cerebral Edema
Authors: Tsao Nicole , Hou Qiang , Chen Shih-Yin , MESSE Steven
Published: March 2021

Introduction:
Severe cerebral edema further compromises survival and functional outcomes in patients suffering from large hemispheric infarction (LHI). This study aims to compare the healthcare resource use and costs during the acute hospitalization and post-discharge, in a cohort of US patients with possible LHI with and without cerebral edema (CED).

Methods:
Using IBM MarketScan Commercial, Medicaid, and Medicare databases (2016Q1-2018Q4), a cohort of patients aged 18-85 were identified using ICD10 codes for hospitalization due to occlusion of the carotid or middle cerebral arteries, which are most closely associated with LHI. We classified patients with ICD10 codes G93.5 (compression of brain), G93.6 (cerebral edema), or a craniectomy procedure as having had CED. In addition to the inpatient resource use and outcomes, annualized frequency of resource utilization and costs during the follow-up period were reported in those who survived and continued to be enrolled in their health plan post-index hospitalization. Logistic regression was used to estimate the odds ratio of mortality, generalized linear models for mean in healthcare utilization and costs between those with and without CED, adjusting for age, sex, and comorbidity.

Results:
Of the 7,336 commercial, 1,946 Medicaid, and 5,015 Medicare patients with possible LHI, we found 7.8%, 6.9%, and 4.3% had CED, respectively. Those with CED had higher length of stay, mortality, and costs during the index hospitalization across the populations examined (Table). CED was also consistently associated with higher post-discharge resource utilization and costs in the commercially-insured population (Table).

Conclusions:
This real-world evidence from private and public health plans highlights the substantial clinical and economic burden during the index hospitalization and post-discharge in patients who develop cerebral edema after LHI.
Abstract P27: Safety and Efficacy of Alteplase in Ischemic Stroke Patients > 80 Years of Age in the Extended Time Window
Authors: Stretz Christoph , Mac Grory Brian C , Fakhri Nasir , Boyanpally Anusha , Asad Syed Daniyal , Modak Janhavi M , Effendi Muhammad , Kucher Oksana , Owusu Kent , Yaghi Shadi , Nouh Amre , Reznik Michael , Burton Tina , Cutting Shawna M , Sacchetti Daniel C , El JAMAL SLEIMAN , Madsen Tracy , Falcone Guido J , Petersen Nils H , Furie Karen L , gilmore emily j
Published: March 2021

Background:
While patients > 80 years of age were originally excluded from the ECASS 3 trial showing benefit in the 3 – 4.5-hour window, recent studies have shown that intravenous alteplase is safe and benefits this population. We aimed to assess safety and efficacy of intravenous thrombolysis in stroke patients above 80 presenting both in the 3 and 3 – 4.5-hour windows.

Methods:
We analyzed data from 3 comprehensive stroke centers in the US of consecutive patients > 80 years of age presenting with acute ischemic stroke who received intravenous alteplase in both the 3 and 4.5-hour time windows over a 3-year period. We collected baseline demographic data, stroke severity as assessed by NIHSS scores, and use of mechanical thrombectomy (MT). Primary outcome was symptomatic intracerebral hemorrhage, as defined by ECASS 2 criteria (hemorrhagic transformation post thrombolysis with worsening of NIHSS score by ≥ 4 points). Secondary outcomes included assessment of efficacy, evaluated by good functional outcome (mRS 0 – 2) at time of discharge.

Results:
We identified 418 patients with ischemic stroke above 80 years (64.8% women) who received alteplase: 344 (82.3%) within 3 hour and 74 (17.7%) in the 3 to 4.5-hour window, with similar stroke severity by NIHSS scores (median [IQR] 13 [12-32] vs. 12 [6-20], p = 0.87). In addition, 147 patients received MT, 128 (37.2%) versus 19 (25.7%), (p= 0.059) in the 3 and 3-4.5-hour groups. The overall rate of sICH was 6.1% and 4.0% (p = 0.49), in the 3 and 3-4.5-hour groups, respectively. Good functional outcome was achieved in 16.7% at time of discharge, for 17.7% in the 3-hour group and for 12.2% in the 3 – 4.5-hour group (p= 0.24).

Conclusions:
In our multi-center cohort, the use of alteplase in patients above 80 was safe, with low sICH rates similar to the literature, irrespective of age. Given the rare occurrence of our primary outcome in a selected cohort of acute stroke patients, our study was not powered to detect a possible significant difference in sICH.
Abstract P274: Evaluation of Glycemic Variability and Discharge Outcomes in Patients Presenting With Ischemic Stroke Following Intravenous Thrombolysis
Authors: Steck Mackenzie , Saeed Omar , Krishnaiah Balaji , Shah Samarth , Stoffel Jaclyn , Hudson Joanna
Published: March 2021

Presentation Objective:
Does glycemic variability worsen Modified Rankin Score (mRS) following ischemic stroke in patients treated with thrombolytics (tPA)?

Background/Purpose:
Acute hyperglycemia and strict glucose control have been identified as predictors of hemorrhage, increased length of stay and hypoglycemia following ischemic stroke. However, the role of glucose variability in patients with ischemic stroke treated with tPA is largely unknown. The aim of this study was to evaluate the role of glycemic variability on discharge outcomes in patients treated with tPA for ischemic stroke.

Methodology:
A retrospective review of adults with ischemic stroke who received tPA was completed. Patients hospitalized for at least 48 hours with image-confirmed ischemic stroke and symptom onset within 4.5 hours of presentation were included. Glycemic variability was measured using the J-index calculation and groups were defined as patients with normal or abnormal J-indices. Logistic regression models were developed to determine odds ratios for defined outcomes including NIHSS score, mRS and disposition at discharge. Statistical significance was a p-value of <0.05.

Results:
Of the 229 patients included, 132 (58%) had a normal J-index (4.7 – 23.6). In the univariate analysis, abnormal J-index was associated with higher rates of hypertension (94% vs 73%), type 2 diabetes mellitus (74% vs 12%), chronic kidney disease (34% vs 11%), higher initial blood glucose values (220 ±172 vs 111 ±20) and HbA1c, and worse outcomes in terms of NIHSS score, mRS and disposition at discharge. In the multivariate analysis, patients with an abnormal J-index had higher odds of unfavorable outcomes in terms of discharge mRS (OR 2.1; 95% CI 1.0 – 4.3, p=0.045) and hemorrhagic transformation (OR 4.1; 95% CI 1.7 – 10.2, p=0.002). There was no difference in discharge disposition (OR 1.4; 95% CI 0.7 – 3.0 p=0.4).

Conclusion:
Glycemic variability, following ischemic stroke, may result in unfavorable patient outcomes in patients treated with tPA. Additional studies are needed to determine the appropriate glucose management strategy.
Abstract P282: Which Telestroke Transfers to the Hub Expire or Receive Hospice Within 48 Hours of Arrival?
Authors: Chu Kristie , Zhu Liang , Ankrom Christy T , Trevino Alyssa , Joseph Michele , Zha Alicia , Cossey Tc , Savitz Sean I , Wu Tzu-ching , Jagolino-cole Amanda L
Published: March 2021

Introduction:
Telestroke (TS) expands access to acute stroke care and facilitates swift transfer of patients to tertiary stroke centers. However, patients transferred from spoke hospitals who expire shortly after arrival raises the question of whether there is opportunity to predict futility of transfer to a higher level of care. We examined acute ischemic stroke (AIS) patients transferred to our hub from TS spoke hospitals and identified who expired or went on to hospice within 48 hours of arrival.

Methods:
In our TS network, we identified AIS patients who were transferred from spoke hospitals following TS consultation (9/2015 - 12/2018). We compared demographic and clinical characteristics of patients who expired or went on to hospice within the first 48 hours versus those who did not. Hospice decision time was determined by chart review for documentation of goals of care discussions.

Results:
Of 530 transfers to the hub, there were 32 (6%) patients who expired or went on to hospice within 48 hours. Compared to those who did not, these patients had increased age (OR 1.08; 95% CI 1.05-1.12), higher incidence of atrial fibrillation (OR 2.24; 95% CI 1.02-4.90) or cancer (OR 3.04; 95% CI 1.17-7.87), higher pre-morbid mRS (OR 5.14; 95% CI 1.57-16.88), and higher NIHSS (OR 1.23; 95% CI 1.16-1.31). Interestingly, the same characteristics were also significantly different in those who expired or went on to hospice beyond 48 hours. There was no significant difference in demographic characteristics of sex and race/ethnicity. There was also no significant difference in the frequency of treatment with tPA or IAT; of the 32 patients who expired or went on to hospice within 48 hours, 21 (66%) had received tPA and 3 (9%) had undergone IAT. Palliative care was consulted for 31 (97%) of those patients.

Conclusions:
A relatively small but significant proportion of TS transfers to our hub expired or went on to hospice within 48 hours. These patients were characterized by increased age, poorer pre-stroke functional status and high stroke severity. In light of the current strain on resources with the pandemic, telepalliative services may help to better serve certain patients, in particular those who are elderly or debilitated, at spoke hospitals without the need for transfer to hub.
Abstract P287: Delays in the Identification and Assessment of In-Hospital Stroke Patients
Authors: Cummings Stephanie , Olsen Andrew , Messe Steven
Published: March 2021

Introduction:
In-hospital stroke is associated with worse outcomes and fewer stroke interventions compared to patients with community-acquired stroke. We assessed factors associated with delays in symptom identification and stroke team alerting, and use of acute interventions for in-hospital strokes.

Methods:
The local Get With The Guidelines-Stroke and an in-hospital quality improvement database at our tertiary care hospital were screened over a 26-month period ending 10/2019, yielding 98 in-hospital strokes.

Results:
Strokes were more common on surgery services (70%), were predominantly ischemic (83%), and were moderate-to-severe (median NIHSS 16; interquartile range [IQR] 6-24). There were long delays from the time of last known normal (LKN) until stroke symptom identification (SxID) (median 5.1 hours, IQR 1.0-19.7 hours) and from SxID to stroke alert (median 2.1 hours, IQR 0.5-9.9 hours). In univariable analysis, being in an ICU, being intubated, being on a surgical service, having no lateralized weakness or neglect, and higher NIHSS were associated with delays; in multivariable analysis only intubation was associated with being above median from LKN to SxID (OR 4.3, 95% CI 1.2-16.2, p=0.03) and above median for SxID to stroke alert (OR 8.5, 95% CI 2.0-36.4). Acute stroke interventions were given to 15 patients (15%), including 3 (3%) who received IV tPA and 12 (12%) who underwent IA thrombectomy. Patients who received stroke interventions had shorter times from last normal to SxID (median 0.7 vs 8.2 hours, p=0.002) and times from SxID to stroke alert (median 0.2 vs 3.4 hours, p=0.006). Urgent vascular imaging occurred in 68/98 (69%) of patients and 23/68 (34%) had a large vessel occlusion (LVO). Of those patients with an LVO, 78% had lateralizing arm weakness or neglect on exam.

Conclusions:
There are long delays from LKN to SxID and from SxID to stroke alert in hospitalized patients leading to low rates of acute stroke treatment. Intubation was a robust risk factor for delays and protocols should be established to monitor these patients more carefully. Despite these delays, 1/3 of patients who had vascular imaging had an LVO identified that might have been eligible for intervention.
Abstract P288: Association Between Vision Impairment and Cognitive Decline in Older Adults With Stroke: Health and Retirement Study
Authors: Hreha Kimberly , Downer Brian , Ehrlich Joshua R , Taglialatela Giulio
Published: March 2021

Introduction:
Nearly 800,000 people in the United States sustain a stroke each year. Up to 60% of stroke survivors have visual impairments and/or ocular deficits, which may negatively impact functional performance, quality of life, and increase the risk for depression. Poor vision has been associated with cognitive decline in older adults, but little is known if vision impairment is a risk factor for cognitive decline among older adults who have survived a stroke. The purpose of this study was to evaluate the association between vision impairment and cognitive decline among stroke survivors and compare the cognitive trajectories of stroke survivors with and without visual impairment.

Methods:
We used data from four waves (2010-2016) of the Health and Retirement Study to investigate the cognitive health of stroke survivors with and without visual impairment. Vision (excellent-very good [ref], good, fair-poor) and stroke diagnosis were self-reported. Cognition was measured using the Telephone Interview for Cognitive Status. Linear mixed effects regression was used to model the association between overall, near, and far vision and change in cognitive function, adjusting for confounders.

Results:
The final sample included 1,475 stroke survivors. A majority were female (55.6%) and white (66.3%) and the mean age was 71.0 (11.7).
Fair-poor
overall (
B
=-1.30,
p
<0.01), near (
B
=-1.53,
p
<0.001), and far (
B
=-1.27,
p
<0.001) vision, as well as
good
near (
B
=-0.82,
p
<0.001) and far (
B
=-0.48,
p
<0.05) vision were associated with significantly lower baseline cognitive function compared to excellent-very good vision. The association between self-rated vision and cognition decline was not statistically significant.

Conclusions:
We found that people with worst vision had lower cognitive functioning but not greater cognitive decline than stroke survivors with excellent-to-very good vision. Further research should investigate if specific types of vision impairment potentiate the risk of cognitive impairment and dementia in stroke survivors.
Abstract P289: Gender Differences in Rates of Stroke in Patients With Hypertrophic Obstructive Cardiomyopathy With and Without Atrial Fibrillation
Authors: Rojulpote Chaitanya , Gonuguntla Karthik , Patil Shivaraj , Buch Tapan , Karambelkar Pranav , Miller Jacob , Bhattaru Abhijit , Rojulpote Krishna Vamsi , Perosevic Nikola
Published: March 2021

Introduction:
Stroke is a known complication of hypertrophic obstructive cardiomyopathy (HOCM) and this complication is more common in patients with accompanying atrial fibrillation (AF). However, data regarding gender related differences with respect to this complication is sparse.

Objective:
We sought to understand the gender differences in rates of stroke in patients with HOCM with and without AF.

Methods:
The Nationwide Inpatient Sample was queried from 2010 to 2014 using ICD-9 codes 425.1 and 425.11 for HOCM in all diagnosis fields. AF was identified by ICD-9 code 427.31. We excluded patients with an indicator for transfer to another acute-care facility to reduce the possibility of data duplication. Chi-square was used for statistical analysis.

Results:
From 2010 to 2014, we identified 73,347 patients with HOCM (Mean age 63.76 ± 16.5 years; females 59% and Caucasians 67.5%). The overall rate of ischemic stroke in this cohort was 2153 (2.9%). Rate of ischemic stroke between males and females was similar (2.9% vs 3%; p <0.001). AF was present in 26,393 (36%), male vs female (39.4% vs 33.7%; p <0.001). Overall, prevalence of stroke in HOCM patients with and without AF was significant 3.5% vs 2.6%; p<0.001. Between males and females, the rates of stroke in HOCM patients with and without AF were not different (3.5% vs 3.5%, p =0.4 and 2.4% vs 2.7%; p =0.9).

Conclusion:
Although stroke rates were higher in HOCM patients with AF, stroke rates were similar in both genders of HOCM patients with and without AF. It is important to consider anticoagulation in these patients to reduce the risk of stroke.
Abstract P293: Disparate Outcomes for Stroke Patients With Documented Substance Use Compared to Those Without Substance Use
Authors: Corless Leslie , Stuchiner Tamela L , Garvin Cameron , Lesko Alexandra C , Baraban Elizabeth
Published: March 2021

Background:
Few studies have shown the impact of substance use (SU) on treatment and outcomes of stroke patients. Research suggests stigma related to SU impacts patient experience in healthcare settings. In this study we assessed whether there were differences in patient characteristics and outcomes for stroke patients with SU compared to those with no substance use (NSU).

Methods:
Retrospective data from two Oregon hospitals included patients admitted with stroke diagnosis, 18 years or older, who discharged between October 2017 and May 2019. Patients with documented SU and specific SU type were compared to patients with NSU with regard to demographics, medical history, stroke subtypes, treatment, discharge disposition and length of stay (LOS). SU was defined as any documented abuse of alcohol (ETOH), methamphetamine (MA), cannabis, opiates, cocaine, benzodiazepines, and Methyl-enedioxy-methamphetamine (MDMA). Non parametric median tests and Pearson’s chi square tests were used.

Results:
Among 2,030 patients included in the analysis, 13.8% (n=280) were SU and 86.2% (n=1,750) were NSU. Patients with SU were significantly younger, median age (61 vs. 73, p <.001) and less were female (35.4% vs. 53.6%, p <0.001). Those with SU had lower prevalence of dyslipidemia (43.6% vs. 59.5%, p <0.001), AFIB (12.5% vs. 22.2%, p <0.001), and previous TIA (6.1% vs 10.8%, p=0.02), and more smoked (54.3% vs 13.3% p <0.001). More patients with SU arrived via transfer (38.4% vs 27.4%, p=.001). Fewer patients with SU expired or were discharged to hospice (8.9% vs 13.7%) and a greater percent left against medical advice (AMA) (3.2% vs 0.6%) (p<.001). When comparing specific SU types to NSU, all SU groups were younger, had similar medical histories and a greater proportion left AMA. Only MA users had differentiating stroke diagnoses with a higher percent of SAH (14.5% vs 5.6%) (p=.003) in addition to longer LOS (6 vs 4 days, p=.006). No differences were found in acute stroke treatment rates.

Conclusion:
Patients with SU were demographically different from the NSU population and did differentiate on some stroke care outcomes and processes, potentially indicating opportunities to address stigma around substance use to meet the needs of patients with both stroke and substance use.
Abstract P297: The Accuracy of the Comprehensive Stroke Performance CSTK-5b Measure Rates
Authors: Panuganti Pradeep , Forrest Cassandra , Nimjee Shahid M , Powers Ciaran , Heaton Sharon , Lee Vivien H
Published: March 2021

Introduction:
Symptomatic intracerebral hemorrhage (ICH) is a feared complication of reperfusion therapy in acute ischemic stroke. The Joint Commission (JC) national quality measure Comprehensive Stroke (CSTK-5b) reflects the rate of symptomatic ICH after mechanical thrombectomy (MT) and is used as a marker of comprehensive stroke center (CSC) performance. We sought to determine the accuracy of the CSKT-5b as determined by vascular neurologists.

Methods:
We reviewed the CSTK-5b failures in our JC certified CSC program for the years 2018 and 2019. Our CSC abstractors follow the instructions from the Joint Commission National Quality Measures manual without deviation and do not allow for clinician over-ride or adjudication (consistent with manual instructions). All CSKT-5b failures were reviewed by study neurologists to determine the true CSTK-5b rate. Data was collected on National Institute of Health Stroke Scale (NIHSS), symptomatic ICH, and neuroimaging results. European Cooperative Acute Stroke Study (ECASS) definitions were used and included hemorrhagic infarction (HI) (grade 1 or 2) and parenchymal hematoma (PH) (grade 1 or 2).

Results:
Among 361 MT patients for the 2 year period, the CSTK-5b failure rate reported to JC was 34/250 (13.6%), whereas the true rate was 21/250 (8.4%). Among the 13 cases that were miscoded, the ECASS grading included 1 HI-1, 7 HI-2, 1 PH-1, and 4 subarachnoid hemorrhage, and all had a 4 point change in NIHSS that was determined to be clinically unrelated to ICH. Comparing annual data, the 2018 CSTK-5b failure rate was 14/111 (12.6%) whereas the true CSTK-5b failure rate was 7/111 (6.3%). In 2019, the CSTK 5b failure rate was 20/139 (14.4%), whereas the true CSTK-5b failure rate was 14/139 (10.1%).

Conclusions:
Non-physician abstractors relying on instructions from the JC manual over-estimate the rate of CSKT-5b measure failure. The determination of symptomatic ICH after MT is complex and requires clinical knowledge for accuracy.
Abstract P299: Heart Brain Clinic: Integrated Management of Ischemic Stroke
Authors: Tariq Muhammad Bilal , Tulod Kathleen , Sharrief Anjail Z , Dhoble Abhijeet , Gurung Sidhanta , Jamilla Lacap Maria , Smalling Richard W , Gonzales Nicole R
Published: March 2021

Background:
About 25% of acute ischemic strokes (IS) are categorized into stroke of undetermined etiology and many ultimately have a cardiac source for stroke. Neurologists and cardiologists can improve decision making, as has been shown with other multidisciplinary clinics. We report our experience in creating our Heart Brain Clinic (HBC) with a focus on patients with patent foramen ovale (PFO).

Methods:
Demographic and clinical data were collected retrospectively for patients with PFO evaluated for IS in the inpatient or outpatient setting. Patients were divided into routine care and HBC groups. We compared time from stroke to PFO closure and number of clinic visits prior to decision about closure. Nonparametric analysis was used to calculate difference between medians, while chi square test was used for categorical values.

Results:
HBC began in 12/2018 with coordination of administrative and staffing efforts between neurology and cardiology departments. From 2/17 to 7/20, 73 patients were evaluated for PFO (42 routine care, 31 HBC; Table 1). At the time of data analysis, 67 patients had received recommendations about PFO closure and 52 patients underwent PFO closure. More than 50% of all patients traveled from outside Houston. HBC patients required fewer clinic visits (p=0.023) prior to decision about closure; however, in patients who underwent PFO closure, there was no difference in weeks from stroke to closure. Patients seen in HBC were recommended to not undergo closure more often than routine care (p= 0.007)

Conclusions:
Our data demonstrates that a multidisciplinary, patient-centered approach to management of IS patients with PFO is feasible and may improve the quality of care in this younger patient population. The difference in recommendation to not pursue PFO closure between groups may reflect selection and referral bias. Additional work is needed to determine whether this approach improves other aspects of healthcare.
Abstract P3: Andexanet Alfa for Acute Bleeding During Treatment With Edoxaban
Authors: Benz Alexander P , Xu Lizhen , Eikelboom John W , Middeldorp Saskia , Milling Truman J , Crowther Mark , Yue Patrick , Conley Pamela , Lu Genmin , Connolly Stuart J ,   ANNEXA-4 Investigators
Published: March 2021

Introduction:
We previously reported results of a prospective cohort study evaluating andexanet alfa (andexanet) for anticoagulation reversal in patients with acute bleeding on a factor Xa inhibitor. Study enrollment continued to accumulate additional data on patients on edoxaban, which are presented here.

Methods:
Patients with acute major bleeding within 18 hours of edoxaban intake were prospectively enrolled. Patients received a 400 or 800 mg bolus and a 480 or 960 mg 2-hour follow-on infusion of andexanet, depending on edoxaban dosage and time of last dose. The co-primary efficacy outcomes were change in anti-factor Xa activity and the rate of excellent or good hemostasis, 12 hours after andexanet treatment, as determined by an independent adjudication committee. Efficacy was analyzed in patients with confirmed major bleeding and baseline anti-factor Xa activity ≥75 ng/mL. Safety was analyzed in all patients.

Results:
A total of 36 patients (mean age 82 years, 61.1% male and 91.7% with atrial fibrillation) with acute major bleeding on edoxaban received andexanet. The primary site of bleeding was intracranial in 29 (80.6%) patients. In the efficacy population (n=20), median anti-factor Xa activity decreased from 160.5 (interquartile range [IQR] 106.2-222.2) ng/mL at baseline to 50.9 (IQR 19.9-119.4) ng/mL at the end of bolus (median decrease 69.2%, 95% confidence interval [CI] 25.5-80.2%). Excellent or good hemostasis at 12 hours was achieved in 75.0% (95% CI 50.9-91.3%) of patients overall and in 81.3% (95% CI 54.4-96.0%) of those with intracranial hemorrhage (ICH). Within 30 days, a total of 4 (11.1%) patients experienced at least one thrombotic event and 4 (11.1%) others died.

Conclusions:
In patients with acute bleeding on edoxaban, andexanet significantly decreased anti-factor Xa activity. Excellent or good hemostasis at 12 hours was observed in 75.0% of patients overall and 81.3% of those with ICH. Thrombotic events occurred at a rate expected in such patients.
Abstract P301: Evaluating the Impact of a Pharmacist-Managed Hypertension Collaborative Care Model in Vascular Neurology Patients in an Inpatient Acute Care Setting
Authors: Smith Ann , Bledsoe Kathleen , Madden Thomas , Artale Jamie , Sindlinger Ted
Published: March 2021

Introduction:
The utility of pharmacist-managed collaborative practice agreements (CPA) in the management of hypertension is well established in the outpatient setting. There has been little evaluation of the use of CPAs in the inpatient acute care setting, and none described specifically in the vascular neurology population. Treatment of hypertension is a critical intervention for the secondary prevention of acute ischemic stroke. This quality improvement project evaluated the implementation of a CPA for the inpatient acute care management of hypertension in vascular neurology patients at University of Virginia Health.

Methods:
A CPA was developed between the neurosciences clinical pharmacist group and the inpatient vascular neurology service, legally vetted, and implemented in June 2019. All vascular neurology patient charts in which an electronic CPA referral was placed from June 2019 through June 2020 were reviewed. Patients were excluded if they were discharged within 24 hours of the referral being placed. The primary objective was to describe and evaluate the implementation of a pharmacist-driven hypertension management practice in the inpatient acute care setting. All patient demographic and clinical data were analyzed using descriptive statistics. Secondary safety outcomes included documented hypotensive events (SBP <90) and acute kidney injury (AKI, increase in SCr by 0.3 mg/dl within 48 hours).

Results:
During the study period, 26 referrals were placed, and 19 patients were included for review. On average, patients were on 2 anti-hypertensive medications prior to admission. From the time of referral to discharge (mean 6 days), systolic blood pressure (SBP) was reduced on average by 36 mmHg (mean percentage reduction 20%) and diastolic blood pressure (DBP) by 12 mmHg (mean percentage reduction 7%). Ten patients (53%) met the goal of SBP < 140 at discharge. There were 5 hypotensive events and 4 instances of AKI, all of which were mild and recovered prior to discharge.

Conclusion:
A pharmacist-managed hypertension CPA was successfully implemented in vascular neurology patients in the inpatient acute care setting. The practice demonstrated improved blood pressure control and minimal adverse outcomes.
Abstract P302: Neuroimaging Embolic Infarct Pattern in Work-Up For Embolic Source of Undetermined Etiology in Acute Ischemic Stroke
Authors: Sosh Daniel L , Campbell Courtney M , Foreman Beth , Carter Rebecca , Hinduja Archana , Lakhani Sushil , Orsinelli David A , Lee Vivien H
Published: March 2021

Introduction:
Embolic infarct pattern on Neuroimaging as a marker for positive cardioembolism results in the work-up for Embolic Source of Undetermined Etiology (ESUS) in acute ischemic stroke (AIS) is unclear.

Methods:
Among 1625 acute ischemic stroke (AIS) hospitalized at our academic stroke program from July 2017 to April 2019, 350 (21.5%) had complete ESUS work-up performed (defined as including TEE and cardiac monitoring). Data was abstracted on demographics, medical history, initial National Institutes of Health Stroke Scale (NIHSS), systolic blood pressure (SBP), troponin level, neuroimaging findings, and cardiac test results. Positive ESUS work-up for cardioembolism was defined as results that prompted management change. Embolic infarct pattern was defined as infarct confirmed on neuroimaging to affect 2 or more vessel territories.

Results:
Among 350 with complete ESUS work-up performed, the mean age was 59.0 (range, 23 to 88) and 170 (48.6%) were female. The mean initial NIHSS was 5.4 (range, 0 to 32). Neuroimaging infarct pattern suggested embolic pattern in 75 (21.4%), single vessel pattern in 274 (78.3%), and not visible in 1 (0.3%). Among 274 with single vessel infarct pattern on neuroimaging, affected territory was MCA in 184, Vertebrobasilar in 46, PCA in 34, and ACA in 10. Cardioembolism source was identified in 96 (27.4%) of patients with completed ESUS work-up (7.1% had positive findings on TEE and 20.3% had new-atrial fibrillation diagnosed on cardiac monitoring). Compared to patients with single territory infarct pattern, patients with embolic pattern were more likely to have a history of diabetes mellitus (44.0% vs 31.3%, p 0.0392), higher SBP (159.0 vs 147.9mm Hg, p 0.002) and higher troponin (0.87 vs 0.07 ng/mL, p 0.0124), but there was no significant difference based upon age, sex, history of hypertension, initial NIHSS, HgbA1c, LDL, or rate of positive ESUS work up for cardioembolism (22.7% vs 28.5%, p 0.0088).

Conclusion:
Among AIS patients with complete ESUS work-up, the most common neuroimaging pattern was single territory MCA infarct (52.6%) followed by embolic infarct pattern (21.4%). Embolic pattern did not increase the positive yield of ESUS work-up for cardioembolism.
Abstract P303: Research Process Development Mitigates Effect of COVID-19 on Stroke Trial Enrollment
Authors: Rock Theodore , Aitken Kinga , Wong Ka-Ho , Dela Cruz Michael , De Havenon Adam H , Majersik Jennifer J
Published: March 2021

Introduction:
With hundreds of thousands of clinical trial patients enrolled yearly, the COVID-19 pandemic caused a significant, unexpected disruption in clinical trials across the world. US data showed a 70% enrollment reduction in April and a 38% reduction in July 2020, compared to pre-pandemic rates. We implemented processes during the initial phase of the pandemic to minimize participant and staff viral exposure, develop remote procedures, and ease communication barriers, while still maintaining enrollment goals.

Methods:
Our stroke research team developed multiple processes to help mitigate pandemic effects on our enrollment. We developed watchlists for eligible and interested patients who could not be enrolled due to national and local restrictions. As research staff was unable to approach patients in person, phone and email scripts were developed to ensure information was disseminated in a consistent fashion. Remote and alternate consent methods were implemented. We tracked the evolving national and local guideline changes, and began re-opening trials on May 23, 2020. We implemented a rotating pool of coordinators, including a site-specific sanitation plan, once it was safe to be on campus in-person. In person meetings were moved to a virtual platform. Enrollment data across for 10 active subacute stroke studies, each active over the 3 years of, 2018-2020, was analyzed for the months from March to June, with 2020 individually compared to 2018 and 2019 via the Student T-Test.

Results:
Total enrollment during these 4 months were 15 participants in 2018, 11 in 2019, and 15 in 2020, with no statistical difference between the years. No study patients nor staff contracted symptoms of COVID-19.

Conclusion:
Enrollment shows no significant changes despite COVID-19. New processes allowed the timely reopening of clinical trials, an overall maintenance of enrollment rates, including a non-significant increase in 2020 compared to previous years. Our telehealth and virtual communication focused processes prioritize the safety of patients and staff while ensuring quality control and appropriate enrollment numbers.