bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP369: Triaging Acute Ischemic Stroke Patients Across a Network of Hospitals is Safe and Reduces Transfer Denials for Thrombectomy
Authors: Holder Derek , Leeseberg Kevin , Giles James , Lee Jin-Moo , Ford Andria , Namazie-Kummer Sheyda
Published: January 2019

Introduction:
The introduction of thrombectomy into evidence-based stroke care has dramatically increased the volume of stroke patients transferred to comprehensive stroke centers (CSC), often overwhelming their capacity. This has led to increased transfer denials of severe stroke patients who needed thrombectomy.

Hypothesis:
A “distributive stroke network” (DSN) to triage low severity acute stroke patients to a primary stroke center (PSC) upon initial neurology consultation will be safe, thereby providing additional volume to treat severe strokes at a CSC.

Methods:
A clinical severity algorithm for external consultations based on NIHSS and time since last known well was created to triage mild acute ischemic stroke patients (both tPA-treated and untreated) to the PSC, while triaging more severe strokes to the CSC. We evaluated clinical outcomes, safety endpoints, stroke consultation volumes, and transfer denials by comparing a stroke cohort after DSN implementation, to a cohort (matched for NIHSS and acuity) admitted to the CSC prior to DSN implementation.

Results:
The pre-DSN CSC cohort had similar demographics to the post-DSN PSC cohort. Safety outcomes (symptomatic hemorrhage or the need for PSC to CSC transfer) and favorable discharge outcome (home/inpatient rehabilitation vs. nursing home/death) did not differ between pre- and post-DSN cohorts. The post-DSN PSC cohort had a faster time from consult to admission (3 vs. 5 hours) and shorter hospital length of stay (LOS) (2 vs. 3.5 days) compared to the pre-DSN CSC cohort. After DSN implementation, there were fewer CSC stroke transfer denials. Total consultation rates increased over the same period.

Conclusion:
Triaging external patients to a PSC or CSC during initial consultation (distributive stroke network) based on stroke severity and acuity significantly reduced transfer denials to the CSC. In addition, this DSN algorithm was safe, led to faster admission, and a shorter LOS.
Abstract WP372: International Comparison of Patient Characteristics and Quality of Care for Ischemic Stroke
Authors: Wangqin Runqi , Laskowitz Daniel , Wang Yongjun , Li Zixiao , Wang Yilong , Liu Liping , Liang Li , Matsouaka Roland , Saver Jeffrey , Fonarow Gregg , Bhatt Deepak , Smith Eric , Schwamm Lee , Bettger Janet , Hernandez Adrian , Peterson Eric , Xian Ying
Published: January 2019

Background and Purpose:
Adherence to evidence-based guidelines is an important indicator of hospital stroke care quality; yet, there is lack of assessment of patient characteristics and performance measures in acute ischemic stroke for most world regions.

Methods:
We analyzed data of 19,604 acute ischemic stroke patients in China National Stroke Registry and 194,876 patients in GWTG-Stroke registry in US between 2012 to 2013 and compare their baseline characteristics and hospital performance measures.

Results:
Compared with US, Chinese patients were younger and had lower prevalence of comorbidities except for history of stroke/TIA or smoking. NIHSS was similar (China vs. US: median 4 [IQR 2-7] vs. 4 [1-10]). Chinese patients were more likely to have delays from last-known-well to hospital arrival (median 1,318 minutes [330-3,209] vs. 644 [142-2,055]), less likely to receive thrombolytic therapy (2.5% vs. 8.1%), and were more likely to experience treatment delays (door-to-needle time 95 minutes [72-112] vs. 62 [49-85]). Adherence to early and discharge antithrombotics, smoking cessation counseling, and dysphagia screening were relatively high (e.g.>80%) in both countries. However, large gaps existed in administration of intravenous thrombolytics within 3 hours (18.3% vs. 83.6%), door-to-needle time ≤60 minutes (14.6% vs. 48.0%), deep vein thrombosis prophylaxis (65.0% vs. 97.8%), anticoagulation for atrial fibrillation (21.0% vs. 94.4%), lipid treatment for low-density lipoprotein > 100 mg/dL (66.3% vs. 95.8%), and rehabilitation assessment (58.8% vs. 97.4%). Door-to-CT ≤25 minutes was relatively low in both countries (26.4% vs. 27.9%).

Conclusions:
We found significant differences in clinical characteristics and gaps in adherence for certain performance measures between China and US. Additional efforts are needed for continued improvements in acute stroke care and secondary prevention in both nations, especially China.
Abstract WP376: Home-Time as a Surrogate Marker of Global Disability After Ischemic and Hemorrhagic Strokes in Canada
Authors: Yu Amy Y. X. Y , Fang Jiming , Porter Joan , Austin Peter C , Smith Eric E , Kapral Moira K
Published: January 2019

Objective:
The 90-day home-time (90HT) indicator is a patient-centered outcome metric that is correlated with global disability after ischemic stroke (IS), but has not been well-characterized after intracerebral hemorrhage (ICH). 90HT is defined as the total number of days a patient is living outside of a healthcare institution in the first 90 days after stroke. We determined the association between 90HT and discharge modified Rankin Scale (mRS) after IS or ICH in the population of Ontario, Canada.

Methods:
All admissions for stroke in the Ontario Stroke Registry between 2003 and 2013 were included and 90HT was calculated using linked administrative data. We used Spearman’s rank correlation to quantify the correlation between 90HT and discharge mRS. We used multivariable logistic regression analysis with adjustment for age, sex, stroke severity, Charlson comorbidity index, pre-admission dependence, rural residency, and socioeconomic status to determine the association between 90HT and poor outcome (mRS>2).

Results:
We identified 40,242 unique admissions (84% IS, 16% ICH, median age was 74 years (IQR 63-82), and 53% were male). The median 90HT (IQR) was 55 days (0-82) for IS and 0 days (0-58) for ICH. Longer 90HT was correlated with lower mRS for both stroke types (IS r= -0.78; ICH r= -0.80). Figure 1 shows the distribution of 90HT by mRS by stroke type. In multivariable analysis, longer 90HT was associated with lower likelihood of poor outcome (Odds Ratio 0.76 95%CI [0.75-0.76] per 5 additional days at home) and stroke type did not modify this association.

Conclusions:
The correlation between 90HT and mRS categories was maintained regardless of stroke type, suggesting that longer 90HT derived from administrative data is a robust surrogate for lower global disability after IS or ICH. Further, 90HT is a sensitive metric, as we showed that patients with ICH experience shorter time at home than those with IS, consistent with the observation that the former have higher disability.
Abstract WP394: Impact of MRI/A versus CTA/P versus Direct Angiosuite Triage Protocols in Stroke Care Performance and Outcome of Transferred Patients for Endovascular Thrombectomy
Authors: Ortega-Gutierrez Santiago , Holcombe Andrea , Lopez-Cardenas Gloria , Hernandez Helin , Zheng-Lin Binbin , Ansari Sameer , Derdeyn Colin , Shaban Amir , Al Kasab Sami , Asi Khaled , Dandapat Sudeepta , Samaniego Edgar
Published: January 2019

Introduction:
Transferred thrombectomy patients face additional time delays that might worsen outcome when compared to direct admission. In 2015, we moved from an MRI/A to a CTA/P protocol to decrease treatment times in transferred patients. In 2017, we initiated a direct admission to angiosuite (DAN) strategy. Herein, we aim to describe procedural and clinical outcomes in transfer patients with acute LVO stroke triaged by these protocols.

Method:
We reviewed demographics, clot location, and treatment times for all thrombectomies from 2013 to June 2018. Primary outcome was MRS at 90 days. Secondary outcomes were door to groin time, difference between NIHSS at admission and discharge (ΔNIHSS). Distributions are analyzed with Wilcoxon Rank, chi-squared and Fisher’s Exact Tests. Logistic regression is used to evaluate MRS and mortality outcomes and adjusted for clot location, admission NIHSS and tPA use.

Results:
The analysis includes 178 patients: 25 MRI/A, 130 CT/A/P, and 23 DAN. The groups significantly differ by tPA (16% vs 4% vs 13%, p=0.03), NIHSS at arrival (median 16 vs 17 vs 21, continuous p=0.03) and clot location (ICA 8% vs 20% vs 35%, BA 24% vs 10% vs 26%, p=0.01) for MRI, CT, and DAN respectively. There is significant reduction in median door to groin time between all groups (MRI 170 min., CT 84 min., DAN 16 min., p<0.001). The median ΔNIHSS is significantly different between CT and MRI (10 vs 4, p=0.01) and borderline significant between DAN and MRI (11 vs 4, p=0.07). There is a trend towards decrease disability (MRS 4-5) for DAN patients when compared to MRI at both discharge (OR=0.847, 95% CI 0.18, 4.10) and 90 days (OR=0.38, 95% CI 0.07, 2.10). There is significant increased risk of mortality when comparing DAN and MRI at 90 days (p=0.02).

Conclusion:
DAN is feasible with faster procedural times and may have clinical benefit in select patients. RCTs are needed to assess the advantages and harm of decreasing imaging in benefit of time.
Abstract WP409: Heterogeneous Patterns of Depressive Symptoms Among Stroke Survivors: Implications for Screening
Authors: Dong Liming , Skolarus Lesli , Morgenstern Lewis , Lisabeth Lynda
Published: January 2019

Introduction:
Although routine screening for post-stroke depression is recommended by the AHA/ASA, the optimal screening method remains unclear. A high rate of false-positives is a potential issue of existing screening tools, as indicated in a recent meta-analysis. This study aims to examine patterns of depressive symptoms that may provide information to improve screening accuracy.

Methods:
The study sample consists of 613 first-ever stroke patients from the Brain Attack Surveillance in Corpus Christi project (2011-2015), a population-based stroke surveillance study. Depressive symptoms at 90 days after stroke were assessed by the 8-item Patient Health Questionnaire (PHQ-8). Symptom patterns were identified using latent class analysis. Depression status (PHQ-8≥10) by class was examined.

Results:
The sample was mainly composed of non-Hispanic Whites (38.3%) and Mexican Americans (57.3%), and equally distributed by sex. Mean age was 65.7 (SD=11.0). Prevalence of depression was 26.6% at 90 days after stroke. The best-fitting model yielded 4 classes (Figure). Notably, one class was characterized by symptoms that often overlap between depression and stroke, as opposed to psychological symptoms (termed overlapping symptom class). Percentages of participants classified as having depression were 84.1% in the psychological symptom class, 100.0% in the high-risk class, and 51.7% in the overlapping symptom class. The overlapping symptom class accounted for 28.8% of participants classified as having depression.

Conclusion:
Existing depression screening tools developed in non-stroke populations may have poor test characteristics in individuals with stroke. Additional research is needed to develop highly sensitive and specific screening tools to identify individuals with post-stroke depression in need of further evaluation and treatment. Understanding symptom patterns may increase our ability to personalize treatment for individual stroke survivors.
Abstract WP411: Rapid Transfer Program: Systemic Coordination of Transfers Dramatically Reduces Capacity Denials and Improves Customer Experience for Referring Facilities in a Large Metropolitan Area
Authors: Wells Meredith , Kim Dong , Spielman Amanda , Savitz Sean , Day Art , Wu Tzu-Ching , Fleming Cheryl , Clements Ross , Lacayo Myrzy
Published: January 2019

Introduction:
Memorial Hermann (MH) Healthcare System in Houston historically did not have a coordinated approach to triage of incoming neuroscience transfers. From July 2015 to June 2016, there were a total of 867 cancellations/denials for neurology or neurosurgery transfers that could not be accommodated through the existing acceptance process where the majority were sent to the MH-Texas Medical Center (TMC).

Hypothesis:
We hypothesized that creation of a streamlined approach to triaging transfer requests would allow for the following outcomes: Reduction in time of initial transfer request to acceptance Elimination of denials/cancellations due to capacity Leveraging of integrated physician network across TMC, Southwest, and Memorial City campuses

Methods:
In collaboration with the MH System Transfer Center, we created a model where one physician or “quarterback” is able to triage system transfers and accept on behalf of the admitting/specialist physicians at a MH receiving facility. We met with all stakeholders to understand individual campus challenges related to universal acceptance process, established a script/resource tool, and built up tertiary capabilities (comprehensive stroke) in the community so we could ensure a high-quality alternative to our TMC quaternary hospital.

Results:
Both stroke and neurosurgery populations are managed through the Rapid Transfer Program as of January 2017. Since the start of this program, there has been an approximate 18% increase in neuroscience transfers in the system and a drastic reduction of denials dues to capacity. Time of initial transfer request to time of acceptance decreased from almost 60 min to an average of 20 minutes. In June 2018, we had zero denials for neuroscience and 297 patients accepted by MH.

Conclusion:
The creation of an integrated and efficient model improved the customer experience for our referring partners. We met all goals and increased overall neuroscience transfer volume to our system.
Abstract WP421: Intravenous Tissue Plasminogen Activator in Patients With Severe Hyperglycemia
Authors: Yadav Randheer S , Cash Ravyn , Wiles Karen , Lakhani Sushil S , Torbey Michel , Lee Vivien H
Published: January 2019

Introduction:
Severe hyperglycemia (blood glucose > 500 mg/dL on presentation) is recognized to cause focal neurological deficits that can mimic acute stroke. We sought to describe patients with severe hyperglycemia who received intravenous tissue plasminogen activator (IVtPA) for possible acute ischemic stroke.

Methods:
With IRB approval, we retrospectively reviewed 579 patients who received IVtPA via telestroke from April 1, 2015 to October 1, 2017. Data was abstracted on demographics, neuroimaging, National Institutes of Health Stroke Scale (NIHSS), and clinical presentation. Hyperglycemia induced neurological deficits was defined as symptoms attributed to hyperglycemia without evidence of infarct on MRI brain diffusion weighted images (DWI)

Results:
Among 579 patients who received IVtPA, 8 (1.4%) presented with severe hyperglycemia. Among the patient with severe hyperglycemia, mean blood sugar level was 521 mg/dL. The mean IVtPA time administered was 3.1 hours (range, 2 to 4.3). In all 8 patients neurological symptoms lasted > 24 hours, and all had DWI performed. Four (50%) were diagnosed with ischemic stroke (DWI infarct) and 4 (50%) were diagnosed with hyperglycemia induced neurological deficits (DWI negative). Seven patients (87.5%) had CT brain perfusion imaging (CTP). All patients with ischemic stroke (3/3) had CTP defects, and 50% (2/4) of patients with hyperglycemia induced neurological deficits had CTP defects.

Conclusions:
Severe hyperglycemia on presentation among patients who receive IVtPA is not common (1.4%) and half of these were ultimately diagnosed with hyperglycemia induced neurological deficits. CTP showed focal perfusion defects in half of patients with hyperglycemia induced neurological deficits, suggesting this may be related to regional perfusion defects, possibly due to hyperglycemia induced microcirculatory changes. Further studies are warranted.
Abstract WP424: Identifying Gaps and Missed Opportunities for IV-Thrombolytic Treatment of Inpatient Stroke
Authors: Topiwala Karan , Tarasaria Karan , Staff Ilene , Beland Dawn , Schuyler Erica , Nouh Amre
Published: January 2019

Background:
Inpatient stroke-codes have traditionally seen low treatment rates with IV-thrombolytic due do an abundance of stroke mimics and contraindications for treatment. However, data regarding missed treatment opportunities are lacking.

Objective:
To identify the treatment gap and factors associated with missed treatment opportunities for inpatient strokes.

Methods:
A retrospective chart review was performed identifying all inpatient stroke codes from March 2017 to March 2018. Clinical, radiographic and demographic patient data were collected. Primary analysis was performed between stroke vs. non-stroke final diagnosis. Dichotomous variables were analyzed using Chi-Square test of proportions and continuous variables with Wilcoxon Ranked Sum test. Significant factors were then tested in a multivariate logistic regression model for independence.

Results:
Out of 211 codes, 36% (n=76) of patients had an acute stroke. An intracranial hemorrhage was present in 5.7% (n=12). Of the remaining 199 codes, 44% (n=87) were IV tPA eligible but only 3.4% (n=3) were treated. All treated patients had a confirmed stroke. Of the remaining 84 tPA-eligible patients, 44% (n=37) had >1 reason to hold treatment. The most frequent reason cited was NIHSS ≤4 in 40% (n=62), suspected metabolic encephalopathy in 23% (n=47) and abnormal blood pressure or blood sugar in 6.3% (n=13). From the eligible-but-untreated cohort, 82% (n=69) were stroke mimics while 18% (n=15) had strokes, constituting a missed treatment opportunity of 1 in 6 patients. Independent predictors of stroke were ejection fraction <30% (p=0.030, OR 3.06), post-operative status (p=0.003, OR 3.00), visual field cut (p=0.048, OR 2.61) and facial droop (p=0.048, OR 2.07). Sedative use (p=0.013, OR 0.33) and seizure at onset (p=0.015, OR 0.07) were inversely predictive of stroke.

Conclusion:
In the inpatient setting, 1 in 3 codes are true strokes and treatment rates with IV thrombolytic are low with a missed treatment opportunity of 1 in every 6 eligible patients. The most frequent reasons for not treating include NIHSS ≤4 and suspicion of metabolic encephalopathy. Identifying patients with NIHSS ≤4 and knowing predictors of true stroke can help narrow this treatment gap.
Abstract WP427: Thrombolysis in With Patients With Down Syndrome and Ischemic Stroke
Authors: Yi Xiyan , Kumar Varun , Savani Chirag , Singh Tejinder , Pathak Ambarish , Renati Swetha
Published: January 2019

Background:
Down Syndrome (DS) is a genetic disorder cause by trisomy 21. With improvements in medical care, the life expectancy of individuals with DS has increased. As this population ages, they are at risk of strokes. They may have a higher predisposition for cardio embolic strokes given that DS is associated with congenital heart disease. There is scarce data regarding strokes in the DS population.

Methods:
Nationwide Inpatient Sample (NIS) from 2005 to 2014 was utilized to identify down syndrome patients using ICD CM code 758.0 in secondary diagnostic field and acute ischemic stroke (AIS) with appropriate diagnostic codes in primary field. Intravascular thrombolysis utilization was identified by ICD9 procedure code 99.10 in any procedural field. Differences between categorical variables were tested using the chi-square test and continuous variables using the Student t-test.

Results:
We identified 4332783 patients with acute ischemic stroke (AIS), 1333 (0.03%) also had a diagnosis of DS. Average age was 71.2years; 47.2% were male and 52.8% female. Patients with DS and AIS were younger (45.6yo vs 71.2years; p<0.0001). They were also more likely to be female (60.7 % vs. 52.8%; p<0.0001). Despite being younger and having less comorbid conditions, patients with ischemic stroke who have DS are less likely to receive thrombolysis than those with ischemic stroke without DS (3.67% vs 5.77%; p =0.001). Although, there was no statistically significant difference in the use of mechanical thrombectomy. DS patients that received thrombolysis were more likely to be male (61.8% vs 38.2%; p=0.0011), and at a teaching hospital (p=0.0016). However, there was increased in-hospital mortality among those DS patients who received thrombolysis compared to the group without thrombolysis (20.5% vs. 5.7%; p=0.004).

Conclusion:
Patients with DS and AIS have a decreased rate of thrombolysis, yet similar rates of mechanical thrombectomy. However, those DS patients that received thrombolysis had increased in-hospital mortality. We postulate that this may be secondary to increased beta-amyloid peptide accumulation and risk of cerebral amyloid angiopathy in DS. Thrombolysis in this population needs to be further studied.
Abstract WP430: Very Mild Stroke Patients Not Treated with Thrombolytic Have Good Functional Outcomes
Authors: Cossey Tc , Zhu Liang , Jagolino Amanda , Bambhroliya Arvind , Ankrom Christy , Savitz Sean , Wu Tzu-Ching
Published: January 2019

Background:
Studies have shown that mild AIS patients who are eligible for IV-tPA and not treated due to mild symptoms have worse functional outcomes compared to similar patients who are treated. Other studies have shown that IV-tPA eligible, mild AIS patients who do not receive IV-tPA have good functional outcomes. The UT Teleneurology (UTT) telemedicine (TM) hub network provides acute neurological coverage to 18 spoke centers. Further studies are needed to investigate outcomes in mild AIS patients managed via TM.

Objective:
Compare characteristics and outcomes of IV-tPA eligible, mild AIS patients who are treated via TM with IV-tPA with those who are not treated due to mild symptoms.

Methods:
In a retrospective query of the UTT registry from 9/15 - 12/17, we identified 1,922 mild AIS stroke patients (NIHSS <6, final diagnosis AIS) who were urgently assessed via TM - 287 were treated with IV-tPA and 882 were not treated due to rapidly resolving or mild symptoms. Remaining patients were not treated for other reasons/exclusions. In-hospital strokes were excluded. Baseline characteristics and clinical variables were abstracted, and outcomes were compared (Table 1). Regression was used to study the effect of IV-tPA on discharge disposition, 90 day mRS, and LOS - adjusting for age, mRS, and NIHSS. All analyses were performed in SAS 9.4 (Cary, NC).

Results:
Patients who received IV-tPA were slightly younger, had less favorable premorbid mRS, and higher arrival NIHSS than patients who were not treated (Table 1). IV-tPA patients had longer LOS and less favorable discharge dispositions. Symptomatic ICH rate in the IV-tPA group was 1.4%. There was no significant difference in 90 day mRS between the groups. After adjusting for age, mRS, and NIHSS, there was no difference in discharge disposition or 90 day mRS (p <0.001).

Conclusion:
Our mild AIS patients who did not receive IV-tPA and were managed by stroke specialists via TM had similar 90 day functional outcomes to those who received IV-tPA.
Abstract WP434: Effect of Race on Rates of Hemicraniectomy During Acute Ischemic Stroke Hospitalization in the United States
Authors: Orjuela Karen D , Lekoubou Alain , Kinfe Bishu , Ovbiagele Bruce
Published: January 2019

Background:
surgical decompressive techniques have shown a significant reduction in mortality in acute ischemic stroke (AIS) compared to medical treatment. Limitations in acute stroke therapies have been described among Hispanic and African American populations compared to other races.

Objective:
To investigate trends in hemicraniectomy among hospitalized patients in the United States, with emphasis on treatment by race.

Methods:
The Nationwide Inpatient Sample was queried from 2006 to 2015 for all patients older than 18-years of age with a primary diagnosis of AIS who had procedure codes for craniotomy excluding posterior fossa territory infarctions. Frequency of hemicraniectomy in patients with AIS hospitalization was determined. We utilized multivariable logistic regression analyses to study the independent association between race and trends in hemicraniectomy.

Results:
A population of patients with AIS (n=715649) was analyzed. The queried was divided by hemicraniectomy (n=1514) and no hemicraniectomy (n=714135). Demographic variables included age, gender (male or female), race (White, African American, Hispanic, others) and payer status (Medicare, Medicaid, private, other). In multivariable analysis, adjusted for potential confounders the odds to have a hemicraniectomy was greatest in the 18-44 age group [age 45-64 (Odds Ratio [OR]: 0.49, 95% CI: 0.42-0.58); age 65-84 (OR: 0.16, 95% CI: 0.13-0.20); age ≥85 (OR: 0.007, 95% CI: 0.003-0.01)]. Medicare insurance [Medicaid (OR: 1.5, 95% CI: 1.2-1.9); Private insurance (OR: 1.7, 95% CI: 1.43-2.03)]; urban teaching hospital (OR: 1.57, 95% CI: 3.63-12.05); prior administration of intravenous tPA (OR: 2.64, 95% CI: 2.21-3.16); being admitted after 2009 (2009-2011 OR: 1.68, 95% CI: 1.13-2.13; 2012-2014 OR: 1.81, 95% CI: 1.44-2.27) and coma status (OR: 15.8, 95% CI: 13.1-19.2) were found to increase the likelihood of having a hemicraniectomy after an AIS. The Hispanic population was more likely to have a hemicraniectomy when compared to White (OR: 1.28, 95% CI: 1.02-1.60).

Conclusions:
Over the last decade in the United States, being Hispanic was independently associated with an increased likelihood to have a hemicraniectomy.
Abstract WP44: Impact of Thrombus Length on Recanalization and Collateral Grade
Authors: Herpich Franziska , Liang John W , Ajiboye Norman A , Shah Syed O
Published: January 2019

Introduction:
Endovascular therapy (EVT) has been shown to substantially improve clinical outcome. Thrombus length (TL) and its relationship with successful recanalization, collateral grade, number of required thrombectomy device passes and time from groin puncture to recanalization have not been routinely assessed. This study investigates the potential association between TL and these variables.

Methods:
A retrospective study of consecutive patients receiving EVT admitted from 2010 to 2016 in a single, tertiary care, academic center was performed. Demographic and clinical characteristics were collected. TL and collateral grade were measured via CT angiogram. The operative report was used to determine the TICI score, the required number of thrombectomy device passes, and time from groin puncture to recanalization. A successful recanalization was defined as having a TICI Score of 3 or 2b while scores of 1 or 2a were regarded as poor recanalization. We performed 2-sided Fisher’s exact and t-tests to assess statistical significance.

Results:
We analyzed 219 consecutive patients with acute occlusion of the M1 segment of the middle cerebral artery treated with stent retrievers. TL ranged from 3mm to 65mm, with a mean of 19.3mm +/- 14.1mm. Successful recanalization was obtained in 177 patients (84%). Thrombus length of >40mm was associated with poor recanalization, when compared to <=40mm (odds ratio: 6.012, 95% CI: 2.22-16.24, p< 0.001). Similarly, the collateral grade for patients was dependent on the thrombus length; with collateral grades of patients with a TL >40mm significantly skewed towards poorer grades (odds ratio: 5.95, 95% CI 1.67-21.12, p< 0.01). Time from groin puncture to recanalization was dependent on clot length (p<0.0001). Additionally, the number of thrombectomy passes, when controlled for the surgeon performing the procedure, was dependent on TL (p< 0.001).

Conclusion:
In our cohort, TL of >40mm was associated with poor recanalization and poor collateral grades. Clot lengths over 40 mm also required more thrombectomy passes and longer time to recanalization. Further prospective studies should determine if clot lengths >40mm affect patient outcomes.
Abstract WP442: Cause of Death After Intracerebral Hemorrhage in the Longitudinal Follow-up of ICH Survivors in ERICH (ERICH-L) Study
Authors: Gilkerson Lee A , Behymer Tyler P , Sekar Padmini , Moomaw Charles J , Kourkoulis Christina , Coleman Elisheva R , Sawyer Russell , Woo Daniel , Flaherty Matthew L , Biffi Alessandro , Rosand Jonathan
Published: January 2019

Introduction:
Anticoagulant therapy after intracerebral hemorrhage (ICH) in patients with atrial fibrillation or deep vein thrombosis has been associated with a marked reduction of death. Prevention of ischemic stroke could explain this reduction. We sought to describe the causes of death after discharge and beyond 30 days in a longitudinal follow-up of a multi-racial/ethnic cohort of ICH. We hypothesized that recurrent ICH and ischemic stroke are the most common cause of death after ICH.

Methods:
The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study was a prospective, multi-center, case-control study of ICH among whites, blacks, and Hispanics. Subjects previously in the ERICH study were approached for enrollment in the Longitudinal Follow-up of ICH Survivors (ERICH-L) study. A standardized research interview was completed over the phone and 959 contacts were made with participants and surrogates to capture outcomes of interest at 6-month intervals, including information on ICH recurrence, ischemic stroke, cognitive performance, and cause of death. The median follow-up was 4.3 years with an IQR of 3.2-5.4. The cause of death categories were ICH, cardiac, ischemic CVA, other, cancer, pulmonary, renal, endocrine, accidents, infection, dementia and unknown.

Results:
There were 180 deaths (18.8%) reported by surrogates contacted in the ERICH-L study. Of those, 63 causes of death were unknown or considered unverifiable. The most common cause of death reported was decline from the index ICH (32.7%). The next most common cause of death was cardiac (14%), other (12.1%), infection (11.2%), cancer (10.3%) and ischemic stroke (1.9%). Some examples reported as other are liver failure, old age, myelodysplastic syndrome, suicide and Parkinson’s Disease. Recurrent ICH occurred in 4 out of 107 known causes of death. By year 5, cardiac causes surpassed ICH as the cause of death.

Conclusion:
Cardiac causes of death were more common than either recurrent ICH or ischemic stroke, surpassed only by decline from the index ICH. Future efforts to prevent causes of death after ICH should address cardiac disease and risk factors. This finding may explain the effect of restarting anticoagulant or antiplatelet therapy and improved mortality.
Abstract WP453: Intracerebral Hemorrhage Outcomes in the Very Elderly
Authors: Forman Rachel , Slota Katarzyna , Ahmad Fawaz , Koffman Lauren
Published: January 2019

Background:
Intracerebral hemorrhage (ICH) outcomes have been well described, but there is a paucity of data regarding complications and outcomes in the “very elderly.” As the population ages the incidence of ICH in the very elderly will likely increase. Our objective is to describe ICH outcomes in this patient population that may assist in prognostication for this specific group.

Methods:
Retrospective study of patients admitted to the Neurosciences ICU at our tertiary care center with the diagnosis of primary spontaneous intracerebral hemorrhage from January 2012 to 2018. Only patients with age equal to or greater than 80 years old were included.

Results:
1590 patients were initially screened, 187 patients met inclusion criteria. 66% were female and median age of all patients was 85 (80-92). Median ICH score on admission was 2 (IQR 1-3). Location of ICH included: lobar (39%), deep (51%), and cerebellum (10%). ICH etiologies included hypertensive (55%), amyloid angiopathy (25%), coagulopathy (5%), and the remaining 11% were other or unknown. Neurosurgical procedures included external ventricular drains (9%), ventriculoperitoneal shunts (2%) and decompression (4%). Five percent had seizures and an additional 1.5% were treated for status epilepticus. Tracheostomy and percutaneous gastrostomy placement performed in 8.5%. Thirty four percent of patients were designated as comfort measures and ICU mortality was 17%. Disposition at hospital discharge included: home (13%), acute rehabilitation (23%), subacute nursing facility (24%), long term acute care facility (4%), hospice (17%) and death (19%). The median ICU length of stay was 2 (range 0-30) days and median hospital stay was 5 (0-30) days. Patients with an ICH score >1 on admission had a 6 times higher chance of experiencing an unfavorable outcome (LTAC, SNF or death), when compared to patients with lower ICH score. This persisted after correcting for age and sex (OR 3.02-11.2, p<0.001) in a logistic regression prediction model.

Conclusions:
This study shows that a significant proportion (36%) of ICH patients > 80 years old have a good outcome, with discharge to home or to rehab. ICH score >1 on admission may be used to predict a poor outcome in this patient population, which varies from younger age groups.
Abstract WP461: Etiology and Trends of 30-day Readmissions Following Intracerebral Hemorrhage (ICH)-review of 5 Years Nationwide Readmission Database
Authors: Yi Xiyan , Kumar Varun , Savani Chirag , Singh Tejinder , Pathak Ambarish , Renati Swetha
Published: January 2019

Background:
Intracerebral hemorrhage (ICH) is the second most cause of stroke following ischemic stroke in United states and associated with poor short-term outcomes. It is important to understand the etiology of readmission and outcomes associated with ICH population; however, data is scarce.

Methods:
Nationwide Readmissions Database (NRD) from 2010-14 was utilized to identify ICH using appropriate ICD-9CM codes in primary diagnostic field. Admissions within 30 days of discharge from index admission were considered as early readmission and P values for trends were generated by Cochrane-Armitage test for categorical variables and simple linear regression for continuous variables.

Results:
We identified 276,401 patients who survived to discharge after ICH during 2010-14, 27,689 (10%) were readmitted within 30 days (Mean age 68.3 years; 52.8% male). We observed an increase in ICH hospitalization (From 55,405 in 2010 to 56,685 in 2014) with significant decline in 30-day readmissions (10.4 % in 2010 to 9.7% in 2014, ptrend<0.0001). A large proportion of patients (58%) had significant baseline burden of comorbidities with a CCI score ≥ 3. Compared to non-readmitted patients they were associated with longer length of stay (14 vs 10 days) and higher mean cost (33,561 vs 24,360 dollars). Common etiologies of readmissions were neurological (29.3%), infectious (13.6%), kidney or urinary (10.1%), cardiac (9.3%) and pulmonary (8.9%). Among neurological causes ICH (11.8%), Ischemic stroke (5.2%), Epilepsy (2.4%) and late effects of ICH (2.4%) were common etiologies. (Figure)

Conclusion:
One in 10 patients were readmitted within 30 days after discharge from index hospitalization for ICH. Neurological conditions remain the most common causes for readmission followed by infectious causes. Identification of these high-risk patients and better transition of care will further reduce the readmission rate and morbidity.
Abstract WP465: Roles of Nurses in Providing Intravenous rt-PA Therapy for Patients With Acute Cerebral Infarction
Authors: Takahashi Mika , Nakada Migiwa , Matsuura Arisa , Shiromaru Mizue
Published: January 2019

Purpose:
Intravenous rt-PA therapy is effective, however the frequency of this therapy for cerebral infarctions in Japan is only 6 to 7 percent, and the roles of nurses after patients are admitted to hospitals vary depending on the institutions. This study aimed to identify the roles of nurses conducting this treatment.

Methods:
We conducted a questionnaire survey with 67 participating hospitals. Questions for supervisors were about institutional arrangements, and those for the nurse were about the role of nurses. The research was conducted with the approval of the Ethics Committee of Nakamura Memorial Hospital.

Results:
The facility size of 18 facilities was with less than 300 beds, 24 with 300 - 500 beds, and 26 with 500 beds or more. The facilities reported that they have ‘nursing service regulations’ (n = 55), ‘roles are clearly defined’ (n = 55), ‘arrangements for routine examinations’ (n = 65), ‘target time frames for each task’ (n = 53), and ‘meetings with other staff members involved’ (n = 35). In more than 80% of the facilities, nurses conduct ‘procedures for accepting patients’, ‘vital sign measurements’, and ‘‘physical preparation of the patient’. Few conducted the ‘NIHSS evaluation’, ‘information collection’, ‘ordering of pre-examinations’, and ‘confirmation of the results of blood samples’. About half of the facilities reported that the ‘NIHSS evaluation’ and ‘information collection’ are the roles of physicians and nurses in cooperation. Further, ‘blood sample collection and insertion of intravenous catheters,’ (
p
=.004), ‘observing patients during pre-examination and transfer’, (
p
=.008), and ‘insertion of urethral indwelling catheters’ (
p
=.004) were significantly correlated with the number of beds, the roles of nurses in facilities with
<
300 beds. Items in ‘patient’s observations during pre-examination and transfer,’ (
p
=.006) were significantly different from the use of role allocation rules, and this role was conducted by nurses in facilities with clear role allocations.

Conclusions:
In this treatment, preparations for treatment and observing patients are commonly considered the roles of nurses, but nurses in smaller hospitals were assigned more roles, suggesting that the main factor behind this is the number of physicians available.
Abstract WP471: Increasing Stroke Education Retention and Quality of Life in the Outpatient Setting
Authors: Dahl Stephanie
Published: January 2019

Introduction:
Retaining stroke education after discharge is pertinent for recovery and gives patients insight about controlling risk factors and how to activate emergency medical systems should stroke symptoms occur, and therefore prevent strokes in the future. There was no standardized approach to the provision and documentation of patient education in a local urban outpatient stroke clinic, where patients are cared for during the weeks following discharge from the hospital.

Purpose:
The purpose of this project was to implement a standardized approach to stroke patient education in the outpatient Advance Practice Nurse (APN) stroke clinic. The goal was ensure all stroke patients receive and retain stroke education tailored to their specific risk factors and how to activate emergency services should signs and symptoms of stroke arise; thereby enhancing quality of life.

Method:
This project targeted the ischemic stroke and transient ischemic attack population. The Stroke Patient Education Retention (SPER) survey, EQ-5D and EQ-VAS questionnaire were used to measure increased retention of stroke education and quality of life, respectively. Each patient completed the survey prior to the appointment. Next, the participants were given specific stroke education about risk factors and signs and symptoms of stroke. Patients completed the surveys via telephone about one week later.

Results and Conclusion:
The project included 19 participants; the study was unable to contact two patients for post-implementation survey resulting in a total of 14 participants. Thirteen out of 14 patients who completed pre- and post-implementation survey showed improvement of SPER score. Furthermore, 86% of participants showed an increase of three or more points in the SPER survey, which displays an increase of education retention. For quality of life, there was no significant improvements with stroke education reiteration. In conclusion, this project did not prove individualized stroke education reiterated increases quality of life, however, it does successfully showcase education given within a couple weeks of patient discharge is retained.
Abstract WP476: Transfer to Nearest Primary Stroke Center Portends Significant Delays and Poorer Outcomes in Stroke Patients With Large Vessel Occlusions
Authors: Arango Audrey , Suhan Laura , Yakoby Jordan , DeCarvalho Briana , Inman Maya , Bhatnagar Avani , Kulhari Ashish , Mehta Siddhart , Panezai Spozhmy , Kirmani Jawad F
Published: January 2019

Background:
Comprehensive stroke centers (CSC) provide around the clock complex services when compared primary stroke centers (PSC) for acute ischemic stroke patients. As most stroke treatments are time-sensitive, a delay in admitting these patients due to transfer from PSC can cause an increased degree of dependence and disability and poorer outcomes. This is due to CSC’s having more robust availability of intravenous, intra-arterial, and endovascular revascularization therapies. We propose that patients that are transferred to a CSC from PSC have increased onset to puncture times and are more likely to have a larger degree of disability compared to those who are directly admitted to comprehensive stroke centers.

Methods:
Patients were evaluated over a 30-month period from January 2016- July 2018 using retrospective data from a university affiliated community based comprehensive stroke center. The time of onset of symptoms were recorded as well as the puncture times for stroke thrombectomy patients. Patients were separated by arrival mode and times were analyzed using average calculations. Modified Rankin Scores for all of the patients were collected using existing registry data and follow up visits. GraphPad Quick Calcs Web site was used to obtain descriptive statistics and intergroup differences.

Results:
A total of 1,412 ischemic stroke patients from January 2016 to July 2018 were studied. The patients that were transferred from other facilities (n=70) took longer to initiate acute interventional treatment than those that arrived via EMS from the field (n=156); 474 minutes vs 389 minutes respectively; from the onset of symptoms to recanalization (a delay of more than an hour). The patients that were transferred from other facilities had a median mRS score of 3, while the patients that arrived by EMS from the field had a median MRS score of 1 at 90 days. The multivariate analysis performed took into account the risk factors and initial clinical severity. The 90 days’ outcome were statistically significantly different (p<0.01).

Conclusion:
Patients that arrive to the CSC via EMS are promptly triaged and treated sooner than those that arrive to PSC’s prior to being transferred to CSC’s. This loss of time results in a statistically significant poorer outcome.
Abstract WP479: Bedside Modified Volume-Viscosity Swallow Test Might be Reliably to Predict Risk of Aspiration Pneumonia After Stroke
Authors: Ye Ting , Huang Sheng-Yan , Dong Yi , Dong Qiang
Published: January 2019

Background:
Dysphagia is a common complication after stroke, which could lead to aspiration. Early and reliable bedside detection and intervention of dysphagia is necessary to prevent dysphagia-related aspiration pneumonia. Compared to water swallow test (WST) , modified volume-viscosity swallow test(V-VST) provides more detail information of management. To predict the risk of aspiration pneumonia from dysphagia tool in acute stroke patients, we developed modified V-VST and validated its predictability of risk of aspiration pneumonia.

Methods:
This was a prospective observational study enrolled acute stroke within 14 days. Only patients with Glasgow Coma Scale score higher than 10 were included into analyze. All patients had bedside WST and if failed would have a V-VST after admission was documented. Modified V-VST assessment, includes tongue movement to V-VST, including tongue rolling, extending to front, left and right. The primary outcome was the rate of pneumonia, which was diagnosed by either chest CT or chest X-ray. Multiple logistic regression models were performed in patients who failed the tests. The area under curves (AUCs) were compared among all tests.

Results:
From 7/2017-6/2018, 562 hospital-based acute stroke patients were enrolled. The overall incidence of pneumonia after acute stroke was 15.9 % (95%CI 13.0-19.2%). Of 157 patients who failed WST, 101 had a positive V-VST, and 173 had a positive modified VVST. The modified VVST was the most powerful to predict the risk of pneumonia (OR 6.156 in WST, 3.058 in VVST, 18.076 in modified VVST, P<.001), after adjusted age, sex, NIHSS score, length of stay, interval of onset to admission and smoke status. The AUC of modified V-VST was 0.851(95% 0.806-0.897)

Conclusions:
Bedside modified V-VST is an easy and sensitive tool to predict post-stroke aspiration pneumonia. A large prospective interventional study is needed to confirm our findings.
Abstract WP489: Evaluation of Post-discharge Callback Data from Stroke Patients and Caregivers
Authors: Carrillo-Gutierrez Cristina , Jaime Frances , Smith Kimberly , Elsehety Marwah , Strug Polina , Headley Janelle , Sostand Shanequa , Harrison Nicole , Savitz Sean I , Sharrief Anjail Z
Published: January 2019

Background and Purpose:
The early period after hospital discharge is a critical time for stroke patients during which transitions of care can be optimized. In our Comprehensive Stroke Center, patients are called within 3 days of discharge to conduct point of service feedback utilizing yes/no and open-ended questions related to the hospital stay, discharge instructions, follow-up care, and prescriptions. We sought to examine post-discharge feedback to identify areas of need.

Methods:
A multidisciplinary team collaborated to classify callback responses for patients discharged from 1/1/2018 to 6/30/2018 within the following domains from the Hospital Consumer Assessment of Healthcare Providers and Systems survey: care from doctors, care from nurses, hospital environment, experience in the hospital, and transitions of care. We provide a descriptive analysis (Table 1).

Results:
Among 700 patients discharged in the study period, 378 (54%) were discharged home and 207 (55%) of these were contacted for feedback. Eighty four (40.5%) of patients/caregivers expressed at least one concern (129 total), with the largest proportion in the transitions of care domain (67.4 %). Patients reported difficulties with prescriptions (15.5%), obtaining outpatient therapy services (13.2%) and follow-up appointments (10.9%), new or persistent clinical symptoms (8.5%), and insufficient hospital discharge education (5.4%). Approximately 5% (11/207) of all patients reported hospital readmission during the call.

Conclusions:
This study reveals that stroke patients and caregivers identify transitional care as an area for improvement following discharge from a CSC. Interventions aimed at facilitating care from hospital to home after stroke are warranted, and we are implementing patient-centered initiatives to enhance the discharge process and provide additional support early after stroke discharge.