bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P121: Update on Regional Stroke Activation Trends During Covid-19 Mitigation
Authors: Sayles Emily , Hsiao Jessica , Sucharew Heidi , Antzoulatos Eleni , Stanton Robert J , Broderick Joseph P , Kircher Charles , Peariso Katrina , Demel Stacie L , Flaherty Matthew L , Grossman Aaron W , Prestigiacomo Charles J , Kreitzer Natalie , Shirani Peyman , Walsh Kyle B , Lampton Holly , Khatri Pooja , Adeoye Opeolu
Published: March 2021

Background:
The University of Cincinnati Stroke Team provides acute stroke care to the southwest Ohio, northern Kentucky, and southeast Indiana catchment area of ~2 million people and 30 healthcare facilities. We previously published a significant decline in stroke activations and reperfusion treatment (IV thrombolysis and EVT) rates following state announcements of COVID-19 mitigation measures. Here, we update these trends after state reopening guidelines.

Methods:
We compared Stroke Team activations and reperfusion treatments logged in a prospectively collected database, comparing the same period in 2020 versus 2019. Kentucky and Ohio announced school and restaurant closures on March 12 and 13, respectively, followed by Indiana. A stepwise reopening of our tristate area started on May 1, 2020. We also compared trends in activations and treatment rates before (Weeks 1-10), during (Weeks 11-17), and after (Weeks 18-26) the lifting of COVID-19 mitigation efforts using the Poisson test, and graphically with segmented regression analysis.

Results:
Compared to 2019, stroke team activations declined by 12% in 2020 (95% CI 7 - 16%; p<0.01). During 2020, an initial decline in stroke activations following COVID-19 mitigation announcements was followed by a 28% increase in activations after reopening (Weeks 18-26: 95% CI 15 - 42%; p<0.01). In contrast, compared to 2019, treatment rates were unchanged (0%, 95% CI -15 - 18%; p=1.00), including specifically IV thrombolysis and thrombectomy rates. Similarly, an initial decline in reperfusion treatments was followed by a 24% nonsignificant increase after reopening (95% CI -10 - 71%; p=0.19) in 2020.

Conclusion:
The initial decline in stroke team activations during COVID-19 mitigation efforts was followed by an increase in activations after reopening. Hospital capacity and 911 services remained fully intact, suggesting that the reduction in activations were related to reduced presentation by patients for emergent stroke care.
Abstract P13: Faster Treatment Speed is Not Associated With Bleeds: Intravenous Alteplase Treatment in the Ultra-Early Time Window is Safe
Authors: Provencher Michelle , Scherman Ashley , Baraban Elizabeth , Jackson Robert , Stuchiner Tamela L , Cox Kailey L , McDonald Kristen , Tarpley Jason W , Kansara Amit , Rogers Bronwyn S , Van Horn Christine , Teeter Lisa , Fitzgerald Darcie D , Cowell Leigh
Published: March 2021

Previous studies have shown that faster Door to Needle (DTN) treatment times are associated with better outcomes for acute ischemic stroke patients. With the continued push for faster times, we aimed to determine if DTN treatment times in the 30- vs 45-minute time window yielded statistically significant differences in outcomes or complications.

Data obtained from a multi-state stroke registry included acute ischemic stroke patients ≥18 years of age discharged between January 2017 and April 2020, and treated with IV alteplase with DTN times between 25-30 or 40-45 minutes. Outcomes were 90-day Modified Rankin Score (mRS) (0-2 vs 3-6), discharge disposition [home or inpatient rehabilitation facility (IRF) vs other location], complications (any treatment-related complication vs none), and hospital length of stay (LOS). Patients with a documented reason for delay or who received thrombectomy were excluded. Outcomes of patients with 25- to 30-minute DTN times were compared to those with 40- to 45-minute DTN times using generalized linear models and multiple linear regression, adjusting for admission NIHSS, age, gender, race/ethnicity, and medical history.

Compared to the 20-25 minute group, patients treated in the 40-45 minute window had higher odds of a documented 90-day mRS of 3 or more (Adjusted Odds Ratio (AOR)=1.19, p=0.253, n=201 ) and treatment-related complication (AOR=1.35, p=0.569) and lower odds of discharge to home or IRF (AOR=0.846, p=0.359). There was little difference in LOS (β=-0.008, p=0.847). None of the outcomes reached statistical significance.

Administering alteplase in the 25- to 30-minute window is safe and did not result in an increase in bleeding complications. Although faster treatment times trended toward better outcomes, there was no statistically significant difference between the 25-30 and 40-45 minute DTN treatment times.
Abstract P137: Large Vessel Occlusion Prediction Scale Thresholds That Are Sensitive for DAWN Trial Participants
Authors: Keenan Kevin J , Smith Wade S , Jadhav Ashutosh P , Haussen Diogo C , Budzik Ronald F , Bonafe Alain , Bhuva Parita , Yavagal Dileep R , Ribo Marc , Cognard Christophe , Hanel Ricardo A , Hassan Ameer E , Sila Cathy A , Saver Jeffrey L , Liebeskind David S , Jovin Tudor G , Nogueira Raul G
Published: March 2021

Introduction:
Large Vessel Occlusion (LVO) prediction scales are used to triage prehospital suspected stroke patients with a high probability of LVO stroke to endovascular therapy centers. The sensitivities of these scales in the 6 to 24 hour window are unknown. Higher scale score thresholds are typically less sensitive and more specific. Knowing the highest scale score thresholds that remain sensitive could inform threshold selection for clinical use. Sensitivities may also vary between left and right sided LVOs.

Methods:
LVO prediction scale scores were retrospectively calculated using the NIHSS sub-item scores of patients enrolled in the DAWN Trial. All patients had last known well times between 6 to 24 hours, NIHSS scores ≥ 10, intracranial ICA or proximal MCA occlusions, and mismatches between their exam severities and infarct core volumes. Scale thresholds with sensitivities ≥ 85% were identified. Scores ≥ 5% more sensitive for left or right sided LVOs were identified. Specificities could not be calculated because all DAWN Trial patients had LVOs.

Results:
201 out of 206 patients had the required NIHSS sub-item scores. The highest score thresholds that maintained sensitivities ≥ 85% are bolded in the table.

Conclusions:
CPSS = 3, C-STAT ≥ 2, FAST-ED ≥ 4, G-FAST ≥ 3, RACE ≥ 5, and SAVE ≥ 3 are likely the highest thresholds that can be selected for extended window LVO triage without missing more than 15% of DAWN Trial eligible LVO strokes. For CPSS and SAVE, these are higher than the thresholds suggested by prior studies. CPSS = 3 and RACE ≥ 5 were more sensitive for right sided LVOs. These findings represent the maximum anticipated sensitivities of LVO prediction scales since the NIHSS scores were documented in hospitals during a clinical trial rather than in the prehospital setting. Inclusion of lower NIHSS or more distal LVO patients would lower sensitivities further. Selecting even higher scale thresholds for LVO triage would lead to many missed LVO strokes.
Abstract P140: Do Perfusion Computed Tomography Abnormalities in Patients With Transient Ischemic Attack Predict Subsequent Ischemic Stroke and Cardiovascular Event
Authors: Abdulrazaq Aisha , Ishfaq Muhammad F , Bhagavan Sachin , Ishfaq Ammad , French Brandi R , Pond Donna S , Clarke Dennis , Siddiq Farhan , Gomez Camilo r , Qureshi Adnan I
Published: March 2021

Background and purpose:
To determine if computed tomography (CT) perfusion (CTP) abnormalities in patients with transient ischemic attacks (TIA) are associated with development of ischemic strokes or adverse cardiovascular events within 24 months.

Methods:
Patients with a diagnosis of TIA who underwent CTP within 24 hours of symptom onset as part of the stroke/TIA imaging protocol were analysed. Abnormality was defined as an area of well demarcated mean transit time delay and/or cerebral blood flow reduction corresponding to an arterial territory as identified by an independent neuroradiologist. The patients were followed for at least 3 months and up to 24 months to identify occurrence of ischemic stroke and cardiovascular events (myocardial infarction or ischemia).

Results:
A total of 78 patients (mean age 67.60 +/- 15.1 ; 48 were men) with a diagnosis of TIA. A total of 17 patients (22%) had documented CTP abnormalities. Patients with CTP abnormalities were older and more likely to be men. There was no difference in the rates of ischemic stroke (5.9 % vs 3.3 %), or cardiovascular events (0% versus 1.6 %) when patients with CTP abnormalities were compared to those with normal CTP.

Conclusions:
In patients with TIA, an abnormal CTP does not predict the occurence of new ischemic stroke or cardiovascular events during follow up.
Abstract P144: Successful Regional Implementation of a Large Vessel Occlusion Screening Tool: An Interdisciplinary Process Improvement Project
Authors: Werner Amanda , Kaiser Brian L
Published: March 2021

Introduction:
Recommendations have recently been updated to support use of an LVO screening tool to assist in the identification and routing of eligible patients to endovascular stroke centers. Despite the recommendations for the use of an LVO screening tool, the general adoption and implementation is incomplete amongst many stroke systems nationwide.

Methods:
An interdisciplinary team selected the Vision, Aphasia, Neglect (VAN) tool for use amongst a series of Primary Stroke Centers and freestanding emergency departments. Educational plans surrounding the tool were developed and disseminated to prehospital EMS crews, Emergency Department nurses, and specialty transport crews. Staff education was bolstered utilizing existing EMR-based tools and the development of quick access materials for all personnel. Over a 12-month period, a combination of real time feedback and retrospective chart review were performed to ensure staff compliance and accuracy of LVO evaluations.

Results:
A total of 687 stroke alert patient were reviewed over a 12-month period—339 were triage arrivals and 348 were EMS arrivals. Initial compliance was low across both EMS and nursing, with only 23% of patients being screened for LVO status during the initial 6 months of implementation but increased to 66% compliance over the last 6 months. Sensitivity of VAN assessments increased from 88% to 93% and specificity increased from 80% to 86% over the same one-year period.

Conclusions:
Successful implementation of an LVO screening tool requires an interdisciplinary team to adopt a tool that is both user-friendly and validated for detection of LVO. Initial staff education and continuous feedback are essential elements to ensure the overall compliance and accuracy of assessments. Ongoing efforts are underway with a one-year goal of 80% compliance of screening while maintaining a high-level of accuracy. Additional staff education directed at the most common reason for a false positive screening, mistaking dysarthria for aphasia.
Abstract P156: Impact of Covid-19 on Thrombolysis and Thrombectomy Time Metrics at Henry Ford Hospital’s Detroit and West Bloomfield Campuses
Authors: Aboul Nour Hassan , Affan Muhammad , Mohamud Ali , Haddan Yazeed W , Mohamed Ghada , Schultz Lonni , Latack Katie , Brady Megan , Scozzari Dawn , Katramados Angelos , Kole max , Lewandowski Christopher , Marin Horia , Bou Chebl Alex , Ramadan Ahmad Riad
Published: March 2021

Background:
We propose that social distancing policies during COVID-19 may have negatively impacted the timely administration of intravenous tPA and mechanical thrombectomy (MT) in acute ischemic strokes (AIS).

Methods:
In this retrospective study conducted at 2 large stroke centers serving Southeast Michigan, we included consecutive patients admitted to our stroke unit from 3/20/20 to 5/20/20 (COVID) and a similar epoch in 2019 (pre-COVID). We compared demographics and time metrics.

Results:
247 patients with AIS were included in the tPA analysis, 167 (68%) in 2019 vs 80 (32%) in 2020. Overall mean age was 67.2, 60% male and 49% African Americans (AA). tPA was given in 13/80 in 2019 vs 17/167 patients in 2019 (16% vs 10%, p=0.143). There was no difference in tPA rates between AA and non-AA in 2020. There was a trend toward faster tPA administration in 2020 vs 2019 (median: 37.8 vs 51 min, p=0.051), significant among AA (37.8 vs 58.8 min, p=0.029). Mild/rapidly improving strokes was less frequently a tPA exclusion in 2020 vs 2019 (0% vs 10%). Delayed presentation was significantly less frequent among non-AA in 2020 vs 2019 (54% vs 66%, p=0.045) but there was a trend toward more frequent delayed presentations in AA vs non-AA in 2020 (76 vs 54%, P=0.073). 69 patients were eligible to receive MT, 42 (61%) in 2019 and 27 (39%) in 2020. Mean age was 67.9 and 36% were AA. No differences were detected between 2019 and 2020 in MT rates or time metrics. In 2020, there was a slight trend toward lower MT rates for AA vs non-AA patients (69% vs 30%, p=0.10).

Conclusion:
During the COVID-19 pandemic in Detroit there was a trend toward faster tPA administration compared to the same period pre-COVID, especially among AA. There was no significant difference in MT rates or time metrics. In our AA-majority city, there was a trend towards more delayed presentations and lower MT rates among AA during COVID. The reasons for these differences are yet to be determined and warrant further research.
Abstract P159: Patients Transferred Within a Telestroke Network for Large Vessel Occlusion
Authors: Reddy Sujan T , Savitz Sean I , Friedman Elliott , Arevalo Octavio , Zhang Jing , Ankrom Christy T , Trevino Alyssa , Wu Tzu-ching
Published: March 2021

Introduction:
In a telestroke network, patients at a referring hospital (RH) with large vessel occlusion (LVO) are transferred to a comprehensive stroke center (CSC) for endovascular thrombectomy (EVT). However, a significant number of patients do not ultimately undergo thrombectomy after CSC arrival.

Methods:
Within a 17 hospital telestroke network, we retrospectively analyzed patients with suspected or confirmed LVO transferred to a CSC and characterized the reasons why these patients did not undergo EVT based on the 2019 AHA guidelines.

Results:
Of 400 patients transferred to our hub, 68 (17%) were based on vascular imaging at RH. Time from RH arrival to neuroimaging was significantly longer in patients that underwent both CT & CTA brain and neck compared to only CT brain (53 vs. 13 minutes, p <0.05). Accuracy of anterior circulation LVO (ACLVO) detection based on clinical suspicion was 62% (205 of 332 patients). Among 234 ACLVO patients (Table 1), overall 175 (74%) [early window group: 123 (73%) patients and late window group: 52 (80%) patients] met at least one EVT ineligibility criterion. The reasons for EVT ineligibility varied from large core infarct (aspects <6 or core volume >70cc on perfusion imaging in late window), low NIHSS (<6), distal occlusion, and poor baseline mRS (>1) (Table 2).

Conclusion:
Instituting rapid acquisition and interpretation of vascular imaging at referring hospitals for LVO detection and establishing benchmarks for door to vascular imaging is urgently needed for referring hospitals.

Table 1: Study flowchart
Abstract P16: Alteplase Within 4.5 Hours via Telemedicine and In-Person for Central or Branch Retinal Artery Occlusion vs Medical Management
Authors: Khrlobyan Manya , Burchette Raoul , Modjtahedi Bobeck , Ali Shayan , Le Duy , Ajani Zahra , Cheng Pamela , Sangha Navdeep S
Published: March 2021

Introduction:
Central or branch retinal artery occlusion (CRAO/BRAO) results in acute monocular vision loss. Only one prospective study of IV tPA use within 4.5 hours with a recent updated patient-level meta-analysis showed favorable visual outcomes but long-term visual outcomes were not reported. We evaluated the use of IV tPA within 4.5 hours for CRAO/BRAO vs medical management and assessed 90-day visual outcomes. Given the increasing use of telemedicine (TM), we also assessed the diagnostic accuracy of CRAO/BRAO evaluated via TM vs in-person.

Methods:
Data were retrospectively abstracted for CRAO/BRAO treated with IV tPA vs medical management within a large managed healthcare system. 90-day visual outcomes were reported as Low Vision (no light perception, light perception, hand motion, finger counting) and mean LogMAR, which was converted from Snellen, and classified as normal-mild impairment (LogMAR 0.4-0.5), moderate-severe impairment (LogMAR 0.6-1.3) and blind-low vision (LogMAR >1.3). Visual outcomes were analyzed using the Wilcoxon rank-sum and signed-rank tests.

Results:
Between 2012-2019, 21 patients received IV tPA within 4.5 hours for presumed CRAO/BRAO vs 34 medically managed. One patient evaluated via TM and one patient evaluated in-person were misdiagnosed and excluded from analysis. Of those accurately diagnosed and treated with IV tPA, 15 were evaluated via TM and 4 in-person. At 90 days, intragroup analysis revealed at least a one-point improvement on the Low Vision scale (68% tPA, p= 0.007 vs 30% non-tPA, p=0.63) and the LogMAR scale (32% tPA, p=0.03 vs 12% non-tPA, p=0.38) with 26% of tPA patients having normal-mild impairment in vision vs 9% in non-tPA patients. Initial to 90-day vison on the Low Vision scale showed visual improvement in the tPA group (p=0.001) and a trend towards improvement on the LogMAR scale (p=0.07).

Conclusions:
Similar to a recent prospective study with patient level meta-analysis, we found that IV tPA within 4.5 hours for CRAO/BRAO may lead to improved visual outcomes at 90 days compared to medical management. Diagnostic accuracy of CRAO/BRAO was similar irrespective of method of being evaluated via TM or in-person. Our study was limited by small sample size and retrospective design.
Abstract P160: Characteristics of Telestroke Using Emergency Departments in a National Sample
Authors: Zachrison Kori S , Boggs Krislyn M , Hayden Emily M , Gao Jingya , Camargo Carlos A , Schwamm Lee H
Published: March 2021

Background:
Most data on spoke emergency departments (EDs) using telestroke come from single academic hub-and-spoke networks. Our objective was to describe characteristics of EDs using telestroke in a national sample.

Methods:
We surveyed a convenience sample of 366 EDs among those who self-identified as using telestroke on the 2016 National ED Inventory (NEDI)-USA, which goes to all US EDs. Surveys were mailed to ED directors, with follow-up phone calls to non-responders. The survey characterized ED staffing, transfer patterns, in-person consultant availability, alteplase use, and frequency of telestroke consultations. Descriptive statistics are reported.

Results:
Of the 4,410 EDs responding to the NEDI-USA telemedicine question, 1,824 (41%) reported using telestroke. Compared to non-surveyed telestroke EDs (n=1458), the 366 surveyed EDs had lower annual ED visit volume, and were more often rural and critical access hospitals. Of these, 320 (91%) affirmed use of telestroke on our secondary survey. Many were rural (n=157, 49%); few were academic (n=4, 1%). Only 132 EDs (41%) reported that
>
80% of attending physicians were board certified or board eligible in emergency medicine. Joint Commission Stroke Center certification was reported by 101 EDs (32%) and alternative certification by another 53 (17%). Fifty-two EDs (16%) reported availability of an in-person neurologist, with 32 (10%) available within 30 minutes, and 29 (9%) available 24/7. Frequency of telestroke consultation varied (Figure). Most EDs administered alteplase in the past year (n=261, 82%); some reported alteplase administration without telestroke consultation (n=94, 30%). EDs frequently admitted TIA and stroke patients without thrombolysis (78% and 55% respectively), but fewer (24%) admitted alteplase-treated patients.

Conclusions:
Telestroke is frequently used in US EDs. Of those surveyed, many had non-emergency medicine attending staffing and use the technology regularly.
Abstract P171: JSTTEP: An Interprofessional Intervention to Reduce Early Risk After Hospitalization for Stroke
Authors: Bahouth Mona N , Raghavan Preeti , Tenberg Amelia , Segall Harrison , Zink Elizabeth K , Supnekar Jyo , Reed Emily , Prieto Maria F , Issa John , Robinson Eileen , Surkhang Dechen , Timmons Veronica , Lien Peiting , Johnson Brenda , zeiler steven r , Urrutia Victor C
Published: March 2021

Background:
The transition period from hospital to home is a highly vulnerable time for patients after stroke. COVID-19 restrictions have exacerbated safety concerns, stressed the health care system, and put patients at high risk after discharge. Here we describe pilot results from the Joint Stroke Transitional Technology-Enhanced Program (JSTTEP) designed to reduce post-stroke complications, avoid hospital readmission, and enhance recovery.

Methods:
JSTTEP is a novel, interprofessional program for patients discharged from the Johns Hopkins Comprehensive Stroke Center. In the first weeks after hospital discharge, stroke patients complete a series of multidisciplinary telemedicine visits to (1) reduce the risks of adverse events in the transition from hospital to home, and (2) develop a plan to facilitate a full recovery. The first joint visit is with stroke neurology and physical therapy for risk mitigation, and the second is with physiatry and occupational therapy for a recovery plan. Patients and caregivers participate in an interactive, online group education session covering topics about vascular risk factor modification, nutrition, exercise, fall prevention, and self-management skills.

Results:
In the first 4 months of the program, 50 patients were enrolled. Average age was 61 years; 26/50 (52%) were women, 23/50 (46%) were African American, and mean baseline NIHSS was 5.4. Of those 45/50 (90%) completed their visit, with 4/50 (8%) requiring conversion from video to phone visit. Unexpected 30-day hospital readmission rate was 3/50 (6%), one of whom was readmitted due to neurological issues identified during the JSTTEP appointment. Interpreter services were utilized for 5 completed video visits (Arabic, Mandarin, Spanish, Twi, Urdu). Patients reported the ability to include family members remotely in the visit as an advantage.

Conclusions:
The data demonstrate the feasibility and potential benefit of an interprofessional stroke telemedicine program designed to enhance post-stroke recovery. JSTTEP increased access to post-hospital care and reduced risks for adverse outcomes. The ongoing benefits and scaling of such a clinic will rely on permanent legislative and insurance changes to support such a care model.
Abstract P174: Reducing Door to Telestroke Request Time in a Telestroke Network Reduces Door to Needle Time
Authors: Hackett Christopher T , Cerejo Russell , Malhotra Konark , Rana Sandeep , Wright David G , Williamson Richard , Fishman Robert , Tayal Ashis H
Published: March 2021

Introduction:
Prior studies have demonstrated the importance of measuring and monitoring telestroke sub-events of door-to-needle time (DTN) such as door-to-telestroke request, but there is limited data on educational efforts to reduce sub-events contributing to DTN. We educated spoke coordinators, nurses and physicians at our telestroke sites on tips to reduce sub-events of DTN, developed a reference pocket card and reviewed sub-event metrics during monthly telestroke quality meetings with spoke sites. We aimed to evaluate if our educational activities and monthly data review affected door-to-telestroke request within 10 minutes of arrival, completion-of-video to needle within 1 minute and DTN within 60 minutes.

Methods:
Prospectively collected data was analyzed retrospectively from a hub-and-spoke model telestroke network. Education of the spokes was completed between January 2019 and April 2019. We compared data for one year prior to education (January 2018 - December 2018) and one year after education (May 2019 - April 2020). Logistic regression analyses were performed to determine the odds of achieving a door-to-telestroke request within 10 minutes, DTN within 60 minutes and completion-of-video to needle within 1 minute in treated patients. We entered possible confounding variables (EMS arrival; NIHSS; posterior symptoms) in the first block followed by the pre/post education groups in the second block.

Results:
Overall, telestroke was requested 2574 times during the study (1338 pre-education; 1236 post-education). A Chi square test suggested a trend towards more thrombolytic and thrombectomy treatments occurred after education compared to before education (14.6% vs. 12%), OR = 1.25 (95%CI 0.99 - 1.56), p=0.06. Door-to-telestroke request <10 minutes was more likely after education of the spokes, OR=2.15 (95%CI 1.27 - 3.66), p=0.005. DTN with 60 minutes was also more likely after education on telestroke sub-events OR = 1.83 (95%CI 1.04 - 3.20), p=0.035. Completion-of-video to needle with 1 minute was not significantly different after education, OR=0.76 (95%CI 0.37 - 1.59), p=0.47.

Conclusions:
Education and regular review of sub-events data reduced door-to-telestroke request and door-to-needle time in our telestroke network.
Abstract P178: Rapid Improvement in Timely tPA Administration With Initiation of Telestroke in a Predominantly Rural Catchment Area
Authors: Kambhampati Sarita K , Vu Peter , Benge Jared F , Fournier Lauren E , Rasmussen Winkler Jennifer
Published: March 2021

Introduction:
In acute ischemic stroke (AIS) treatment, reduction in tPA Door-To-Needle time (DTN) by 15 minutes improves functional outcomes. Telestroke has demonstrated timely tPA administration over several years of implementation. However, telestroke care in the rural setting is less well characterized, and many telestroke studies have only shown improvement in DTN over longer periods. We evaluated reduction in DTN over a 6 month period after implementing an internal telestroke process in a rural spoke-hub model in central Texas.

Methods:
Data was abstracted from local databases from 6 months before and 6 months after initiation of telestroke at each center over years 2017-2019. Patients who presented to the emergency room at 1 of 5 spokes in central Texas with AIS symptoms were included, 393 pre-telestroke and 362 post. Patients who did not receive tPA were excluded. Patients with documented delay such as initial tPA refusal, further imaging or management of acute comorbidities were also excluded, leaving 80 cases, 33 pre-telestroke and 47 post. Chi-square analyses for changes in DTN were used. T-test analysis was used for continuous variables. Primary outcome assessed reduction in DTN with secondary outcome of number of tPA administrations.

Results:
Total stroke volume did not increase over the study period [average per site pre-telestroke 78.6 (SD 58.1) and post-telestroke 72.4 (SD 45.7)] (
t
(4)=0.91,
p
=0.42). Attainment of <45 minute DTN improved from 18.2% pre- to 48.9% post-telestroke (
p
= 0.01), and <60 minute DTN improved from 36.3% to 80.1% (
p
<0.0001). Total tPA volume at each site increased over the period, with a moderate effect size though not statistically significant (average per site of 6.6 administrations pre-telestroke to 9.4 post-telestroke,
t
(4)=-1.72,
p
=0.16,
d=-0
.77)

Conclusions:
Telestroke within a rural catchment area in central Texas resulted in significant reduction in DTN within 6 months of implementation. This study showed that successful telestroke processes can be implemented in a relatively short time period even in the rural setting. Further investigation of telestroke at rural stroke centers is needed to improve access and quality of care.
Abstract P187: When A Global Crisis Closes Your Clinic: A Telemedicine Approach for Transient Ischemic Attack and Minor Stroke Care During the Covid-19 Pandemic
Authors: Dugue Rachelle , Willey Joshua Z , Miller Eliza C , Kronish Ian M , Chang Bernard P
Published: March 2021

Introduction:
Recent work has demonstrated the safety and feasibility of rapid outpatient evaluation for presentations of TIA and non-disabling stroke. Our outpatient TIA and stroke clinic, Rapid Access Vascular Evaluation-Neurology (RAVEN) clinic, instituted in 2016, encountered unprecedented challenges in operations during the COVID-19 surge in New York City, leading to the creation of a telemedicine approach to minimize patient and staff exposure risk. To date, few virtual TIA/stroke clinics have reported on safety and feasibility outcomes.

Hypothesis:
We hypothesized that rapid follow-up of patients with suspected TIA and minor stroke via telemedicine would be feasible and safe during the pandemic.

Methods/Results:
We performed a retrospective chart review of patients with TIA and minor stroke who were referred to the virtual clinic from the emergency department (ED) between March and June 2020 (the local peak of the COVID-19 pandemic) when RAVEN in-person visits were suspended. A total of 24 patients were discharged early from the ED and referred for RAVEN evaluation with 20 patients evaluated as scheduled; 4 were lost to RAVEN follow-up. Ultimately, 60% of these patients were diagnosed with TIA or minor stroke after completing their remote evaluation; the rest were diagnosed as stroke mimics (seizure, migraine with aura, neuropathy, peripheral vertigo, stroke recrudescence). The median NIHSS calculated at initial ED evaluation was 1 with a maximum NIHSS of 5. A new medical intervention for secondary prevention was prescribed for 70% of patients prior to ED discharge. Amongst patients contacted by phone 3-5 months post-RAVEN evaluation, 4 of 15 had an increased modified Rankin score. Of the 24 patients referred for RAVEN evaluation, 7 returned to the ED within 90 days, with 3 patients citing neurologic complaints. On follow-up via phone conducted 2-5 months after RAVEN evaluation, 3 of 17 patients self-reported either a positive COVID-19 test or suspected COVID-19 diagnosis over the study period.

Conclusion:
A telemedicine-based approach to evaluate TIA and stroke in the RAVEN model helped limit patient infection risk, optimize resource allocation, establish accurate, timely diagnoses, and effectively implement secondary prevention strategies.
Abstract P194: Artificial Intelligence-Powered Non-Invasive and Frequency-Tuned Electromagnetic Field Therapy Improves Upper Extremity Motor Function in Sub-Acute Stroke Patients: A Pilot Randomized Controlled Trial
Authors: Weisinger Batsheva S , Bornstein Natan M , Shohami Esther , Segal Yaron , Alter Ariela , Lifshitz Assaf , Prasad Atul , Pandey Dharam
Published: March 2021

Background:
Neural oscillations at specific frequencies have been associated with increased neuroplasticity. Additionally, exposure to extremely low frequency and low intensity electromagnetic fields (ELF-EMF) increases plasticity-related processes, with associated clinical improvements.

Aim:
The purpose of this double-blind sham-controlled trial was to explore the benefit of BrainQ’s novel and non-invasive, artificial intelligence-powered, frequency-tuned ELF-EMF treatment (BQ) in improving upper extremity motor function (UEMF) in a sub-acute ischemic stroke population.

Methods:
Study was planned for 50 subjects, but was discontinued due to COVID-19 at 25 subjects. Participants were randomized to receive 40 minutes of BQ treatment (active or sham) 5 days/week, for 8 weeks, in conjunction with 10 minutes of physical therapy. The BQ treatment uses artificial intelligence-based algorithms to extract motor-related spectral features in EEG for use as treatment frequencies. BQ treatment is delivered via a wearable device that transmits frequency-tuned ELF-EMF, facilitating neuroplasticity processes within the central nervous system. Primary endpoint: Fugl-Meyer Assessment - Upper Extremity (FMA-UE); Secondary endpoints: mRS, Action Research Arm Test (ARAT), Box and Block Test (BBT), NIHSS.

Results:
FMA-UE scores improved significantly (and sooner) in the treatment group versus sham at week 4 (23.2±3.91 vs. 9.9±3.2; 13.6 points greater than sham p=0.0070) and after 8 weeks of treatment (31.5±2.97 vs. 23.1±4.99; p=0.0611). For mRS, at week 9 the treatment group showed a mean improvement of 2.5±0.18 points versus 1.3±0.16 points in the sham group (p=0.0005), i.e. a mean of 1.2 points higher than that of the sham group. Significant improvements were also observed in the ARAT-Pinch subscale (week 9: p=0.0082), BBT (week 6: p=0.0169; week 9: p<0.0001), and NIHSS (week 9: p=0.0340). No related adverse events were reported, supporting the safety of the treatment.

Conclusion:
Our results show that BQ treatment significantly improves UEMF in a sub-acute ischemic stroke population across multiple clinical metrics. Further studies are planned and ongoing with larger study populations, and in related indications.
Abstract P195: Assessing the Validity of Predicting Resting Metabolic Rate in Chronic Stroke Patients
Authors: Novitskaya Maria , Ryan Alice
Published: March 2021

Chronic stroke patients may have lower resting metabolic rate (RMR) due to disability and ensuing loss of skeletal muscle. Established equations used to estimate RMR based on weight, height, age, or lean body mass in healthy non-stroke individuals may not be accurate for a hemiparetic patient population. The purpose of this study is to determine resting metabolic rate in chronic stroke survivors and compare to RMR calculated with established equations in healthy adults. Adults (n=71; 56 males, 15 females; 40 African American, 27 Caucasian, 4 other / not reported) aged 44-76 years (61 ± 7.5 yrs) who had a history of chronic stroke (> 3 months prior) underwent a 30 minute test after a 12-hour fast to measure RMR by indirect calorimetry, total body DXA scan, and treadmill test (VO2 peak). Estimated RMR was calculated using nine established equations. RMR measured in the total group (1552 ± 319 kcal/day) was significantly different from all nine estimated RMR values (Katch-McArdle 1664 ± 242 kcal/day, P=0.05; Livingston 1671 ± 239 kcal/day, P<0.001; Mifflin 1703 ± 254 kcal/day, P<0.001; Owen 1761 ± 269 kcal/day, P<0.001; Harris Benedict 1782 ± 308 kcal/day, P<0.001; revised Harris-Benedict 1795 ± 306 kcal/day, P<0.001; Cunningham 1818 ± 247 kcal/day, P<0.001; Schofield 2147 ± 301 kcal/day, P<0.001; IMNA 2428 ± 405 kcal/day, P<0.001). Calculated RMR was between 9% and 60% greater than measured RMR, regardless of race. Appendicular lean mass (r=0.65, P<0.001), total lean mass (r=0.65, P<0.001), and VO2 peak (r=0.50, P<0.001) were associated with measured RMR. RMR estimation equations established in healthy adults are not reliable for the chronic stroke population, indicating the need for a more accurate predictive equation to better assist nutritional status in patients with conditions of muscle atrophy.
Abstract P196: Patients Most Likely to Benefit From Home-Based Telerehabilitation After Stroke
Authors: Paik Sang Min , Cramer Steven C
Published: March 2021

Introduction:
Higher doses of rehabilitation therapy are associated with better outcomes after stroke. Many patients do not receive high-dose therapy, however, e.g., due to limited availability and access, especially in the COVID era. Telehealth approaches can overcome many barriers, and evidence suggests that some forms of telerehabilitation are efficacious after stroke. However, uncertainty exists as to which patients are most likely to benefit from telerehabilitation. This issue was examined in the current study.

Methods:
Data are from patients randomized to telerehabilitation (TR) in an 11-site, assessor-blind trial (JAMA Neurol 76:1079) that provided 6 weeks of intensive arm motor therapy to hemiparetic patients with stroke 4-36 weeks prior. The primary endpoint was change in arm motor Fugl-Meyer (FM) from pre-treatment to 1-month post-treatment. Predictors of TR-related FM gain were identified using forward stepwise multivariable linear regression analysis, advancing the most significant predictor from each of 8 categories (demographics, stroke characteristics, medical history, amount of outside therapy, motivation, sensorimotor impairment, cognitive/affective status, and functional status) if it survived bivariate screening with p<0.1.

Results:
In patients >90 days post-stroke onset (n=44), sex (r=.33, p=.028), # hours of outside therapy post-randomization (r=.36, p=.019), spasticity (r=-.37, p=.014), and NIHSS visual field score (r=-.28, p=.068) were bivariate predictors of TR-related FM gain. In multivariable analysis, all except therapy hours survived as significant (P<0.05) predictors: TR-related FM gains were higher in females and lower in patients with spasticity or visual field defects. When the 15 patients randomized to TR ≤90 days post-stroke were added in secondary analysis, multivariable analysis found that sex, # hours of therapy post-randomization, and NIHSS neglect score were significant predictors.

Conclusions:
In patients with stable motor status >90 days post-stroke, behavioral gains from home-based TR were greatest in patients who were female and who had less spasticity and visual field defects. These results might be useful for patient selection and for design of future TR-based therapeutic approaches.
Abstract P197: Impact of Cranioplasty on Neurological Recovery in Syndrome of the Trephined: A Prospective Longitudinal Study
Authors: Sveikata Lukas , Vasung Lana , El Rahal Amir , Bartoli Andrea , Schnider Armin , Leemann Beatrice
Published: March 2021

Introduction:
Syndrome of the Trephined (SoT) is a common and underdiagnosed complication after decompressive craniectomy (DC). This study aimed to address the knowledge gap in SoT incidence, risk factors, and the impact of cranioplasty timing on neurological recovery.

Methods:
In a prospective single-center study we examined 40 consecutive patients that underwent a large DC and cranioplasty for diverse etiologies. The participants underwent a cognitive, motor, and radiological evaluation 1-4 days before and after cranioplasty. SoT was diagnosed when neurological symptoms worsened before cranioplasty (’a priori’) or a neurological improvement was observed after cranioplasty without previous overt symptoms (’a posteriori’). The primary outcome was the occurrence of SoT, and secondary outcome was improvement of disability after cranioplasty (mRS 0-3 as good outcome). We used logistic regression models to assess risk factors for SoT and the impact of cranioplasty timing on neurological recovery. Hemorrhagic lesions were defined as initial brain injury or DC-related intraparenchymal or subarachnoid hemorrhage. Radiologic signs were sinking skin flap, paradoxical midline shift, or slit-like ventricle.

Results:
Of 40 patients enrolled, 14 (35%) developed ’a priori’ and 12 (30%) ’a posteriori’ SoT. Cranioplasty resulted in mRS improvement in 7 (18%) patients 1-4 days after surgery. A shift towards good outcome was observed 1-4 days post-cranioplasty (62% vs. 42%, p=0.025) and at 90 days (73% vs. 42%, p=0.005) compared to 1-4 days pre-cranioplasty in the SoT group, but not in the non-SoT group. A composite score (0-3) of traumatic brain injury, hemorrhagic lesions, and radiologic markers had 92% sensitivity and 86% specificity to predict SoT. Increasing delay to cranioplasty was associated with decreased odds of disability improvement after cranioplasty, when adjusting for age and baseline disability (OR 0.96, p=0.03).

Conclusions:
In this prospective study, SoT occurred more frequently than previously reported after DC. Earlier cranioplasty was associated with neurological improvement. A proposed 3-variable score could help predict SoT and better allocate scarce rehabilitation resources by warranting an earlier cranioplasty.
Abstract P199: Predictors of Early Change in PHQ-9 Depression Scores Following Acute Stroke: A Secondary Analysis of the Michigan Stroke Transitions Trial
Authors: Strong Brent , Dong Liming , Fritz Michele , Lisabeth Lynda D , Reeves Mathew J
Published: March 2021

Introduction:
Predictors of changes in depression in the early transitional period following an acute stroke are not well understood. We conducted a secondary analysis of patients enrolled in the Michigan Stroke Transitions Trial (MISTT) to characterize factors associated with changes in depressive symptoms from 7 to 90 days after returning home.

Methods:
MISTT was an open, parallel, randomized clinical trial testing the efficacy of social worker case management alone or in conjunction with a website to improve outcomes following acute stroke. Patient-reported outcomes including PHQ-9 were collected via telephone interviews conducted 7 and 90 days after patients returned home. PHQ-9 score ranges from 0-27 with higher scores indicating more severe symptoms. Key demographic variables were extracted from medical records. Multivariable linear regression was used to identify independent predictors of change in PHQ-9 score from 7 to 90 days using the GLM procedure in SAS. All analyses were adjusted for baseline (7-day) PHQ-9 score and pre-specified confounders (Table). We accounted for missing data using inverse probability weighting.

Results:
Of 265 patients enrolled in MISTT, 164 had PHQ-9 scores available at both 7 and 90 days and were included in the analysis. The mean PHQ-9 score was 5.4 at 7 days and 4.9 at 90 days. The mean within person change from 7 to 90 days was -0.5. In the final model, being unmarried (versus married), and moderate or severe stroke severity (versus mild) were associated with an increase in depressive symptoms (Table). As expected, 7-day PHQ-9 score was a strong predictor of 90-day score. Accounting for missing data did not meaningfully change model results.

Conclusions:
Increases in PHQ-9 scores following stroke hospitalization were seen in unmarried patients and those with greater stroke severity. Identifying factors associated with worsening symptoms over time may help guide clinical management during the early transition period.
Abstract P209: Community-Based Outpatient Stroke Rehabilitation Program Achieves Excellent Return to Work Outcomes: Characteristics and Rehabilitation Outcomes of Stroke Survivors Who Return to Work
Authors: Breen Joan C
Published: March 2021

Background:
Return to employment and driving are goals for many stroke survivors. There are few reports of patient centered outcomes like return to work or the characteristics of those who achieve these goals.

Methods:
Prospective observational study of stroke patients treated between 12/2011-7/2019 in an interdisciplinary outpatient rehabilitation program addressing physical, cognitive/communicative, risk factors, psychosocial, driving and vocational issues.

Results:
Of 190 consecutive patients,104(55%) were working prior to their stroke. 50% (73% men, 27% women) of those working pre-stroke returned to work upon program completion with 90% returning to their prior job, and 65% at prior hours. 24% of returning workers owned their own business, and 76% had other occupations. Returning workers had average age of 54 years, average NIHSS score of 4(range 0-11), average{mRS} of 2.7 (6% with 1; 25% with 2; 58% with 3; 10% with 4), and 31% were aphasic. 39 suffered ischemic strokes and 13 had hemorrhages. Locations were: 18 Left, 15 Right,11 Bilateral hemisphere, 8 Brainstem). 93% of patients working pre-stroke were driving. 80% who returned to work also resumed driving. Returning workers had average percent improvement in 6” walk and Berg Balance scores of 97% and 50% respectively; this group also improved in all 9 Stroke Impact scale domains with SIS total score improving an average of 22%. In comparison, of those not returning to work 34 had ischemic strokes, 18 had hemorrhages. This group had average age 55.6, average NIHSS score 7.3(range2-16), average {mRS} of 3.3(11% with 2, 54% with 3, 33% with 4, 2% with 5), 42% were aphasic, and 20% resumed driving. Returning workers had average admit Montreal Cognitive Assessment score of 25/30 and Stroke Self Efficacy Score of 85%; with average scores of 21/30 and 71% for those not returning to work. Average length of stay was 4.6(range .5-24) and 7.4(range1.7-18) months for those returning and not returning to work. Other demographic and outcome measures are collected.

Conclusions:
Despite significant disability, stroke survivors can achieve successful recovery, including return to work and driving. Further study of patients returning to work can help direct rehabilitation efforts for patients with return to work goals.
Abstract P21: Tenecteplase: As First Choice “Give and Go” Stroke Thrombolysis Treatment
Authors: CLARK Wayne M , McConnell Tegan , Jacobson Noah D , Bozorgchami Hormozd
Published: March 2021

Tenecteplase (TNK) is more fibrin specific and has longer activity duration than Alteplase (ALT). Compared to ALT, recent acute stroke treatment studies have found TNK at doses up to 0.4mg/kg to have equivalent safety and efficacy. A major advantage of TNK is that it is given as a five second bolus without the need for a 60 minutes infusion. The 2018 AHA/ASA guidelines suggest that TNK may be considered as an alternative to ALT. In January 2019 we switched to TNK for our first line acute stroke treatment at our institution.

Methods:
Following AHA/ASA plus ECAS3 < 4.5 hour stroke thrombolytic treatment guidelines, we treated consecutive patients with TNK 0.25mg/kg max 25mg at our main “hub” hospital in 2019. We compared these results to patients we treated with ALT in 2019 using telestroke at our 10 “satellite” hospitals. Safety was assessed by SICH on CT at 24 hours. For LVO patients early vessel opening was accessed by angiogram, and clinical success was determined by three month Modified Rankin Score (MR 0-1).

Results:
We have successfully treated 22 patients with TNK: Baseline median NIH was 9 (2-20); with a mean treatment time of 148±58 minutes. There were no systemic bleeding or mortality events and 0% SICH occurred. 19/22 patients had initial LVO on presentation with 9/19 (47%) having early vessel opening post TNK prior to thrombectomy. 14/22 (64%) of patients had excellent recovery (MR 0-1) at three months. During the same time we also treated 76 patients with Alteplase: Median BL NIHSS of 14 (2-27) (P = 0.001) with 0% SICH, 5% mortality and 30% MR 0-1 (P = 0.02 worse compared to TNK).

Conclusion:
We successfully changed to TNK as our preferred stroke thrombolytic and our initial experience with it has been very favorable. We are currently in the process of switching to TNK at several of our spoke hospital sites. TNK should be considered as an alternative to Altepase especially at sites that need to transfer patients for thrombectomy.