bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP268: Distribution of Acute Ischemic Strokes After Implementation of Endovascular Guidelines in Louisiana
Authors: Navalkele Digvijaya , Hargrove Paige , Chernyshev Oleg , Acosta Joseph , DeAlvare Leopoldo , Hidalgo Gonzalo , El Khoury Ramy , Martin-Schild Sheryl
Published: October 2018

Objective:
To highlight the distribution of acute ischemic strokes (AIS) after implementation of endovascular guidelines.

Background:
Louisiana Emergency Response Network (LERN) is an organization with a mission to build comprehensive statewide systems of care for time-sensitive conditions including stroke. Four levels of stroke centers were recognized in 2013. Level 1: Comprehensive stroke center; Level 2: Primary stroke center; Level 3: Acute stroke ready hospital and Level 4: Non-stroke hospitals. As of 2017, there are 2 comprehensive stroke centers in Louisiana and 15 primary stroke centers. Statewide education was provided regarding mechanical endovascular recanalization (MER) for large vessel occlusion (LVO) in AIS as AHA/ASA guidelines were updated in 2015.

Design/Methods:
Louisiana hospital inpatient discharge database for year 2014 and 2015 was retrospectively analyzed. Distribution of AIS and MER based on hospital level were explored.

Results:
A total of 9396 patients with AIS were identified in dataset for year 2014 and 10409 for the year 2015. Proportion of AIS treated in Level 1, 2 and 3 hospitals increased in 2015 {Level 1: 2014 VS 2015: 1034 (11%) VS 1342 (13%); Level 2: 3946 (42%) VS 5035 (48%); level 3: 3195 (34%) VS 3610 (35%)}. Proportion of AIS patients in level 4 hospitals declined in 2015 {Level 4: 2014 VS 2015: 1221 (13%) VS 422 (4%)}. In 2014, 8.2% (770/9396) received any form of recanalization therapy compared to 9.5% in 2015 (989/10409), with higher proportions in Level 1 (22.2% VS 26.2%) and 2 centers (9.4% VS 10.2%) than Level 3 (4.1% VS 3.2%) and 4 (2.6% VS 1.4%). In 2015, 1.8% of patients with AIS had MER; this compares to 0.8% in 2014.

Conclusion:
The reduction of patients treated in Level 4 hospitals in 2015 suggests our pre-hospital destination protocol facilitated transport to appropriate facilities. The proportion of patients with AIS receiving any form of recanalization increased in 2015, specifically in Level 1 and 2 centers. Improved destination of acute stroke patients likely contributed to increased recanalization rate and utility of MER. Statewide implementation of a revised initial destination protocol respecting the endovascular guidelines should lead to more LVO AIS patients receiving MER.
Abstract TP269: Simulation Training Improves Thrombolytic Treatment Logistics
Authors: Svobodova Veronika , Hlouskova Tereza , Oudova Michaela , Mikulik Robert
Published: October 2018

Background:
Shorter door-to-needle time (DNT) essentially contributes to the effectiveness of thrombolytic treatment. Simulation-based training could shorten DNTs. Here we present the first results of simulation training, designed to shorten DNT ≤ 20 minutes, conducted in the Czech Republic.

Methods:
The simulation-training scenario was developed and run by the Comprehensive Stroke Center of St. Anne’s University Hospital in Brno. It has a standard format (intro-simulation-debriefing-conclusion) and includes two rounds of simulation, as well as a video presentation of real thrombolytic cases. Between June 2016 and March 2017, St. Anne’s Hospital staff received this training, followed by 4 of the 5 closest primary stroke centers. The DNTs of hospitals which received training were compared to the DNT of all the other stroke centers in the Czech Republic in the 4-month period pre-training (March - June 2016), as well as post-training (April - July 2017), using data from the SITS registry.

Results:
In 5 centers participating in simulation training, DNT was 47 minutes (95%CI 45-52; 102 patients) pre-, and 29 minutes (95%CI 24-38; 88 patients) post-training. In 45 stroke centers without training, DNT was 40 minutes (95%CI 40-41; 860 patients) before and 30 minutes (95%CI 28-31; 421 patients) after the simulation period. In trained stroke centers, the percentage of patients that achieved DNT ≤ 20 minutes was 3% pre-training, and increased to 32% post-training (OR=15, 95%CI 4.5-53). In all other stroke centers, 11% and 27% of patients were thrombolyzed with DNT ≤ 20 minutes before and after the simulation period, respectively (OR=3, 95%CI 2.1-4.0).

Conclusion:
DNT was shortened in all stroke centers. Additionally, training further improved logistics and increased the percentage of patients thrombolyzed within 20 minutes. Simulation training is a powerful tool for improving hospital logistics.
Abstract TP271: Predictors of Non-adherence to Post-stroke Hospitalization Clinic Follow-up
Authors: Temple Carolina E , Gazi Melissa , Gropen Toby I , Lyerly Michael J
Published: October 2018

Introduction:
Stroke prevention clinics allow for longitudinal follow up of stroke patients to implement and reinforce secondary prevention strategies and monitor for stroke recurrence. Adherence rates to clinic follow up remains poorly studied, however.

Methods:
Consecutive patients with discharge diagnoses of acute ischemic stroke, intracerebral hemorrhage, or transient ischemic attack were identified in a prospective registry at a comprehensive stroke center. We excluded patients who were not scheduled for a follow up appointment or who died before their appointment. Patients were classified as a) arrived, b) cancelled by patient, or c) no-show for their clinic appointment. We compared demographics, socioeconomic (SE) factors, length of stay (LOS), geographic factors and stroke characteristics among these groups. Multivariable logistic regression was used with patients who arrived for their appointment as reference.

Results:
Of 226 patients included, 81 (35%) arrived, 85 (38%) cancelled and 60 (27%) were no-shows for their clinic visit. Age, race, sex, mode of arrival, and SE factors did not differ between the groups, nor did their Charlson comorbidity index. Patients were more likely to arrive for their appointment if they lived closer to the clinic (although rural/urban residence did not differ, had shorter LOS, lower admission NIHSS, and lower discharge mRS. Stroke classification did not differ although endovascular thrombectomy patients were very likely to keep their appointment (Table). When controlling for distance to clinic, smokers were at a higher odds of being a no show (OR 3.3 95% CI 1.3-8.5) or cancelling their appointment (OR 3.0, 95% CI 1.2-7.3).

Conclusions:
In this sample of stroke patients, only 35% kept their post hospitalization stroke clinic appointment. We identified several characteristics associated with lack of follow-up adherence which can guide future work to improve post hospitalization care in this high risk patient group.
Abstract TP277: The Neurointensivists’ Role in Management of Cerebral Venous Sinus Thrombosis
Authors: Stretz Christoph , Ghoshal Shivani , Marcolini Evadne , Hwang David Y , Petersen Nils H , Schindler Joseph L , Sheth Kevin N , Falcone Guido J , Gilmore Emily J
Published: October 2018

Introduction:
Cerebral venous sinus thrombosis (CVST) represents an important cause of both ischemic and hemorrhagic strokes in young people. While recent guidelines recommend management in a stroke unit, the impact of Neurocritical care in this condition has not been studied. We aimed to assess whether the introduction of a Neurocritical Care program influenced clinical outcomes in CVST patients.

Methods:
We retrospectively reviewed electronic medical records of adult patients admitted to Yale New Haven Hospital’s Neuroscience ICU (NICU) between 2010 and 2017 with a diagnosis of CVST. Demographics, vascular risk factors, comorbidities, length of stay and discharge modified Rankin scale (mRS) were collected. Patients were excluded for transfer after 24 hours of initial presentation. We compared two time periods, before (epoch 1, 2010-2012) and after (epoch 2, 2013-2017) the introduction of continuous staffing of CVST cases by neurointensivists in the NICU. Univariable and multivariable logistic regression were utilized to model the odds of poor outcome (dichotomized mRS 0-2 vs 3-6).

Results:
Fifty-three patients with CVST met the inclusion criteria during the study period (mean age 39 (+/- 17) years, 51 % female). 20 patients were identified for Epoch 1 and 33 patients for Epoch 2. Overall, 40 patients (76%) had a good (mRS 0-2) outcome. For epochs 1 and 2, good outcomes were observed in 12 (60%) and 28 (85%) patients, respectively (p=0.04). In both univariable and multivariable regression analysis (adjusted for age and sex), admission during epoch 2 was associated with a significantly reduced odds of a poor outcome (OR 0.27, CI 0.07 - 0.98; p =0.048) and (OR 0.27, CI 0.07- 1; p=0.05), respectively.

Conclusions:
In this small, single-center cohort of patients with CVST, most patients experienced a good outcome. The institution of continuous neurointensivist coverage was independently associated with better outcomes. Further validation in prospective, multicenter cohort studies is needed.
Abstract TP279: A System of Stroke Care Delivered Through Telemedicine Improves Patient Outcomes
Authors: Morrow Benjamin , Jovin Tudor G , Fair Lynette , Landis Jonathon , Wechsler Lawrence
Published: October 2018

Introduction:
Implementing traditional hub and spoke models of tele-stroke care consisting of an urgent evaluation for acute therapy decision making has been shown to improve care delivery to the acute ischemic stroke population. However, outcomes of patients retained in spoke facilities after acute evaluation are inequitable with longer inpatient length of stay and higher mortality despite lower prevalence of severe stroke and large vessel occlusion as compared to patients treated at the hub. We analyzed the effect of continued involvement of a vascular neurologist in the care of all stroke patients via tele-stroke rounds during the inpatient stay at a spoke facility.

Methods:
The stroke alert protocol in the spoke facility was revised to include calls to the tele-stroke service for all patients presenting to the ED with stroke symptoms regardless of severity or time. A tele-stroke evaluation by a vascular neurologist from the hub hospital occurred for all patients including both acute evaluation and stroke etiology work-up initiated immediately by the tele-stroke provider. Inpatient tele-stroke rounds then occurred on all patients with at least one further telemedicine evaluation to review findings and make final recommendations. Outcomes were compared for three months prior to starting telestroke follow-up and three months after instituting this program.

Results:
A total of 143 patients (91 pre implementation and 52 post implementation) were included. The results are summarized in the table. In the three months after starting tele-stroke follow-up by vascular neurologists length of stay, 30 day mortality and readmissions were reduced. Utilization of IV tPA increased from 3.3% of all stroke patients to 10%.

Conclusion:
These results indicate that implementation of a remote telemedicine stroke service to manage patients beyond the initial acute evaluation in a spoke facility is feasible and can positively influence patient outcomes.
Abstract TP281: Dual Notification and Early Transfer of Acute Stroke Patients: A Pilot Study
Authors: Spokoyny Ilana , Hirsch Karen , Mlynash Michael , Bernier Eric , Baulch Michael , Merritt Byron , Hage John , Centurion Alejandro , Albers Gregory
Published: October 2018

Introduction:
Significant disparities in clinical care exist for acute stroke patients in geographic areas without direct access to a Comprehensive Stroke Center (CSC). Stroke patients treated with IV tPA are often transferred to CSCs for endovascular therapy. These transfer patients have longer delays to intervention and are less likely to be treated compared to patients who present to CSCs. This pilot study assessed the feasibility and effectiveness of a novel notification and transfer process in a regional system of stroke care.

Methods:
The pilot was carried out at Stanford University Hospital, a CSC, and Community Hospital of Monterey Peninsula (CHOMP), a Primary Stroke Center (PSC) which regularly transfers complex stroke patients to Stanford. The process interventions included dual notification of PSC and CSC at the time of stroke patient arrival to the ER, earlier communication between the PSC ER physician and the CSC stroke team, rapid imaging interpretation by CSC stroke physicians, and streamlined transport between centers. Outcome measures including treatment rates and times were compared to the two prior years.

Results:
The pilot spanned 105 days and included 134 stroke calls and 43 ischemic stroke patients. A higher proportion of ischemic stroke patients were transferred during the pilot (10/43 (23%) vs. 14/122 (11%) in the prior year and vs. 11/96 (11%) 2 years prior, p<0.001). Transfer time did not differ (231 min vs. 253 min, pilot vs. 1 year prior, p=0.33), but when the process was assessed using statistical process control methodology the control chart showed a significant reduction in process variability. All transfers were determined to be appropriate for higher level of care (i.e. requiring hemicraniectomy or neuroICU monitoring), an improvement from the prior year when 2 patients were retrospectively determined to have been unnecessary transfers.

Conclusions:
An early communication-based intervention to better connect PSCs with CSCs is feasible and increased transfer rates for appropriate patients, with trends toward shorter transfer times. A similar system may be a viable option for hospitals without telemedicine or adequate neurology coverage. The next step is implementation of an iterated version across a larger health system.
Abstract TP283: Nationwide Trends of Thirty Day Readmissions : Carotid Versus Vertebral Artery Dissections
Authors: Mehta Tapan , Patel Smit , Male Shailesh , Lakshminarayan Kamakshi , Tummala Ramachandra , Ezzeddine Mustapha
Published: October 2018

Introduction:
Carotid and vertebral artery dissection significantly increases risk of ischemic stroke. Due to variability in treatment for stroke prevention and different mechanisms of dissection-related stroke, it is important to understand differences in 30 day unplanned readmission rates (30RR) and related causes of readmission in this population.

Methods:
We used the year 2014 NRD (Nationwide Readmission Database) which is designed to generate national estimates of readmission. The patients with carotid and vertebral dissections were identified by primary discharge diagnosis with ICD9-CM code 443.21 and 443.24. All causes of 30RR were calculated for patients admitted between January and November 2014 by excluding elective readmissions. Differences in readmission rates due to different causes were examined with univariate analysis.

Results:
The NRD contained 1164 (Weighted N = 2550) admissions due to carotid dissection (CD), and 1244 (Weighted N = 2644) admissions due to vertebral dissections (VD). There was no significant difference for comparing average age of readmitted patients [57.5 years (CD) Vs. 56.74 years (VD), p=0.49]. 30RR for CD (15.45%) was higher compared to VD (13.43%) (p=0.037). Major cause specific 30RR in CD and VD included acute cerebrovascular event (4.54% vs 6.43%, p=0.004), sepsis (0.07% vs 0.06%, p= 0.78) and TIA (0.07% vs 0.04%, p=0.09).

Conclusion:
The 30RR for acute cerebrovascular events was elevated in carotid and vertebral dissection patients in a nationally representative readmission database. Although the 30RR is higher for carotid compared to vertebral artery dissection, acute cerebrovascular event related readmissions remains significantly high in vertebral artery dissection patients. Further investigations are necessary to explore these differences, including analysis of the various treatments and the specific anatomic features of these dissections.
Abstract TP288: Development and Preliminary Results of a Community Partnered Stroke Preparedness Intervention in Chicago
Authors: Aggarwal Neelum T , Song Sarah , Kwon Soyang , Wymore Erin , Kandula Namratha , Brown Jen , Eisenstein Amy , Richards Christopher , Mason Maryann , Beckstrom Heather , Jones Peggy , Washington Knitasha , Prabhakaran Shyam
Published: October 2018

Objective:
Delayed recognition and hospital arrival after acute stroke leads to worse outcomes. Given multi-level barriers to calling 9-1-1 for stroke, we sought to develop a community-partnered stroke preparedness intervention in Chicago’s underserved communities (where EMS use is low, despite high stroke incidence and mortality) tailored to neighborhood and cultural needs and barriers.

Methods:
As part of the CEERIAS study, we recruited local laypersons to serve as community promoters for a training program that sought to instruct them on delivering targeted messages to their communities. Each half-day training session was facilitated by CEERIAS study investigators, and consisted of a mix of didactic material on stroke statistics relevant to South Side communities, hospital-based tours of the “stroke patient journey,” role playing and tailored strategies for community messaging based on aim 1 focus group findings, and distribution of stroke education materials, “Pact to Act FAST” pledge cards, and website (www.ceerias.com) instructions.

Results:
We conducted 21 training sessions for 242 community promoters (81 African-American [AA] males, 133 AA females, 4 Hispanic males, 5 Hispanic females, 3 Caucasian males, 16 Caucasian females) between October 2015 and May 2016. Since training, these community promoters have distributed >110,000 educational materials including FAST cards and magnets and participated in 167 community events. A total of 38,221 Pact to Act FAST pledges have been registered (Figure), 80.3% of which registered in South Side Chicago zip codes (Figure).

Conclusions:
A community-partnered stroke preparedness campaign was effective in increasing stroke awareness in underserved minority communities, as noted by the high volume of Pact to Act FAST pledges. Data on 9-1-1 calls for stroke and early arrival after stroke at neighborhood hospitals will be analyzed to assess effect of the intervention.
Abstract TP289: Language Barrier Does Not Significantly Affect Door-to-Needle Time for Intravenous Tissue Plasminogen Activator
Authors: Anderson Noriko , Janarious Afra , Stradling Dana , Yu Wengui
Published: October 2018

Introduction:
The earlier acute stroke patients receive intravenous (IV) tissue plasminogen activator (tPA), the better the chance of recovery. Nearly half the patients at our medical center speak Spanish, Vietnamese, or other languages. Language may be a barrier to timely acute stroke therapy.

Objective:
To determine if primary language influences evaluation and door-to-needle time for IV tPA.

Methods:
This is a single center retrospective study of all acute stroke patients who received IV tPA at our center from January 2013 to December 2016. Primary language, last known well-to-door time, door-to-imaging time, and door-to-needle time were abstracted from chart review. The patients were divided into English and non-English speaking groups. Non-English speaking patients were further divided into Spanish, Vietnamese, and an Other language group (including Korean, Punjabi, Romanian, Cantonese, Mandarin, Tagalog and Arabic). Student’s t-test and an ANOVA with Tukey post-hoc test were used to analyze differences between groups.

Results:
During the 4-year study period, 190 patients received IV tPA for acute ischemic stroke. Among them, 120 were English speaking and 70 non-English speaking. The non-English speaking patients included 35 Spanish, 22 Vietnamese, and 13 other language-speaking minorities. Between the non-English and English speaking groups there was no significant difference in average last known well-to-door-time (70.2 minutes vs 65.8 minutes, p=0.42), door-to-imaging time (14.3 minutes vs 16.5 minutes, p=0.07), and door-to-needle time for IV tPA (47.5 minutes vs 50.3 minutes, p=0.42). Subgroup analyses comparing English, Spanish, Vietnamese and Other language groups also showed no significant differences between the groups.

Conclusions:
Primary language had no effect on timely acute stroke management for IV tPA recipients in our center. This was likely due to physician/staff diversity, the availability of interpreters, and English-speaking family members or friends. While our study focused on patients that
received
tPA, we suspect that primary language may influence the last known well-to-door time for
all
ischemic stroke patients, thereby limiting the number of non-English speaking patients eligible to receive tPA.
Abstract TP293: IV Thrombolytic Stroke Treatment in the 3-4.5 Hour Time Window: Practice Diverges From Guidelines
Authors: Lowenkopf Ted , Corless Leslie , Lucas Lindsay , Baraban Elizabeth
Published: October 2018

Introduction:
IV alteplase (tPA) is recommended but not FDA approved in the US in the 3-4.5 hour time window. Current guidelines recommend treatment for those under age 80 with no preceding history of stroke and diabetes. This study analyzes treatment rates and reasons for exclusion from a large multistate stroke registry.

Methods:
Data obtained from a multi-hospital system’s GWTG Registry included acute ischemic stroke (AIS) patients discharged January 2012-May 2017 who arrived within 4.5 hours of last-known-well. Exploratory analyses reviewed tPA treatment rates and exclusion practice patterns for all AIS patients who arrived in the 0-3 and 3-4.5 hour windows and AIS patients over the age of 80 or with a history of diabetes and previous stroke who arrived in the 3-4.5 hour window.

Results:
A total of 6,392 patients met inclusion criteria with 83.5% (n=5,337) arriving in the 0-3 hour window and 16.5% (n=1,055) in 3-4.5 hours. Treatment rates in the 0-3 hour and 3-4.5 hour windows were 41.1% and 9.8%, respectively. Of patients arriving in the 0-3 hour window, 55.5% had a documented exclusion compared to 57.4% in the 3-4.5 hour window. In the 0-3 hour window, the top exclusions were rapid improvement (42.5%), mild stroke (37.1%) and bleeding risk (9.1%). In the 3-4.5 hour window, top exclusions were rapid improvement (28.0%) and mild stroke (27.0%). Among patients over 80 arriving in the 3-4.5 hour window (n=429), the tPA treatment rate was 3.3% and 62.9% had a documented reason for exclusion. The top reasons for exclusion were age over 80 years (25.6%) and rapid improvement (19.6%). Among patients with a history of both previous stroke and diabetes arriving in the 3-4.5 hour window (n=643), the tPA treatment rate was 8.7% and 61.4% had a documented exclusion. The top reasons for exclusion were rapid improvement (23.5%) and stroke too mild (23.5%). Only 6.8% were excluded based on a preceding history of diabetes and stroke.

Conclusions:
Treatment rates were dramatically lower in the 3-4.5 hour time window. The majority of patients over 80 presenting in the 3-4.5 hour time window were excluded from treatment based on age. Contrary to professional guideline recommendations, a preceding history of stroke and diabetes is rarely documented as the cause for not treatment.
Abstract TP296: Time Trends in Race-Ethnic Differences in Do-Not-Resuscitate Orders After Stroke
Authors: Bailoor Kunal , Sanchez Brisa N , Lank Rebecca J , Li Chengwei , Case Erin , Garcia Nelda M , Lisabeth Lynda D , Morgenstern Lewis B , Zahuranec Darin B
Published: October 2018

Introduction:
Do-not-resuscitate (DNR) orders are common after stroke and have recently received increased attention. However, there has been little study of trends in DNR status. We investigated time trends in DNR use after stroke in a community with a large minority population.

Methods:
Cases of ischemic stroke (IS) or intracerebral hemorrhage (ICH) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) study from June 2007 through October 2016. Demographics, clinical characteristics, and DNR status were collected from medical charts by trained abstractors. Race-ethnic differences in DNR orders were assessed with logistic regression models and adjusted for potential confounders. Time trends were assessed with a linear term for time (years) and further explored with interaction terms between time and race-ethnicity or time and stroke type.

Results:
After excluding cases with missing DNR status and recurrent events, 2,860 cases were available. Mean age was 69 (range 45-102), 50% were female, and race-ethnicity was Mexican American (MA, 58%), non-Hispanic White (NHW, 37%), and African American (AA, 5%). Overall, 17% had a DNR order during the hospitalization. Time trends in DNR orders differed for IS and ICH (interaction p=0.04, see Table). However, change in DNR status over time within each stroke type was modest (non-significant increase over time for IS and non-significant decrease for ICH). MAs were less likely than NHWs to have DNR orders (p=0.007) There was no evidence of interaction between time and race-ethnicity (p=0.57), suggesting that the race-ethnic disparity is stable over time.

Conclusions:
Use of DNR orders after stroke has been largely stable over the past 10 years, with only slight differences in time trends comparing IS to ICH. Mexican Americans remain less likely than NHWs to use DNR orders after stroke with no evidence of change over time.
Abstract TP297: Ischemic Stroke in Young Adults: An Analysis From 2009-2016 Using Get With the Guidelines
Authors: Farooq Muhammad Umar , Thomas Kathie
Published: October 2018

Background and Objectives:
Emerging literature indicates that stroke incidence among U.S. citizens ages 18 to 45 have increased in recent years. An increase in young strokes leads to a the disproportionately large economic impact due to decreased productivity earlier compared to older stroke victims. Some literature has revealed significant differences in young stroke occurrence, with the Midwest seeing one of the most significant increases in young strokes. Risk factors for a stroke at a younger age include high blood pressure, obesity, smoking, and diabetes. The objective of this study was to review trends on ischemic strokes, especially between the ages of 18 and 45, as well as risk factors for young strokes.

Methods:
A retrospective review of acute ischemic stroke patients was conducted from 2009-2016 in 11 Midwest states (IN, IL, IA, KS, MI, MN, MO, ND, SD, and WI) using the American Stroke Association’s Get With The Guidelines (GWTG) Stroke database. Annual trends using rate per 10,000 were reviewed for age (18-45, 46-65, 66-85, and >85), obesity, smoking status, drug use/abuse, hypertension, and diabetes mellitus.

Results:
Over the course of 8 years, there was no significant difference in stroke rate per 10,000 in any of the age groups (18-45, 46-65, 66-85, and >85). Focusing on the 18-45-year age group, the rate of stroke per 10,000 in 2009 was 604.7, 609.9 in 2010, 618.8 in 2011, 592.3 in 2012, 581.3 in 2013, 572.7 in 2014, 588.9 in 2015, and 608.2 in 2016. There was no significant difference in the rate per 10,000 for smoking, hypertension, and diabetes. There was a significant difference (p<0.05) in the rate per 10,000 for obesity and drug use/abuse. Obesity increased from a rate of 0.16 per 10,000 ischemic strokes in 2009 to 2111.4 per 10,000 in 2016. Drug use/abuse increased from a rate of nearly 0 per 10,000 ischemic strokes in 2009 to 655 per 10,000 in 2016.

Conclusions:
A majority of ischemic strokes are still happening in older individuals, with no significant differences in young strokes being reported from the Midwest region GWTG data from 2009-2016. Given the conflicting research in young stroke incidence, additional research needs to be completed. Future studies should look to determine if there are any differences in stroke rate based on urbanization category.
Abstract TP301: Primary Language Predicts Outcomes in Acute Ischemic Stroke
Authors: Janarious Afra U , Anderson Noriko , Stradling Dana , Yu Wengui
Published: October 2018

Introduction:
Intravenous (IV) thrombolysis with tissue plasminogen activator (tPA) is the only FDA approved medical therapy for acute ischemic stroke. There is a paucity of data regarding the effect of primary language on outcomes in stroke patients. The aim of this study was to determine if primary language impacts outcomes of acute stroke patients receiving IV thrombolysis.

Methods:
This is a retrospective study of patients with acute ischemic stroke who received IV tPA at our institution from January 1, 2013 to December 31, 2016. Subjects were divided by primary language based on structured chart review. Subgroups for Non-English speakers were Spanish, Vietnamese, and Other language. Outcomes were modified Rankin scale (mRS) at discharge, favorable outcome (mRS score 0-2) at discharge, mortality at hospital discharge, and length of stay (LOS). Statistical analysis of data was done with unpaired t test and ANOVA multi-variant analysis as appropriate.

Results:
During the study period, 190 patients received IV tPA for acute stroke. Among them, 120 primarily spoke English, 35 Spanish, 22 Vietnamese, and 13 Other languages. Favorable outcome at discharge was highest in Vietnamese group at 50%, followed by English (48%), Spanish (40%), and Other language group (7.7%). English and Vietnamese groups scored nearly two points better on average mRS at discharge than the Other language group. The mortality rate was highest in the Other language group at 15.4%, followed by English (9.2%), Vietnamese (4.5%), and then Spanish group (2.9%). English speaking patients had shorter mean LOS (4.2 days versus 5.2 days; 95% CI 0.068-2.02) compared to Non-English speaking patients. Average LOS for the Other language group was one week longer than other groups. The Other language group was also least likely to be discharged home (7.7%) compared to English (34.5%), Spanish (42.9%) and Vietnamese (50.0%) groups.

Conclusions:
This study demonstrated an outcome advantage for tPA patients whose primary language is more frequent (English, Spanish, and Vietnamese) at a multi-ethnic regional hospital. Patients whose primary language was uncommon (Other language) had higher mortality rate, longer LOS, and were less likely to be discharged home than frequent language groups.
Abstract TP302: Life After Thrombectomy
Authors: Dandapani Bhuvaneswari K , Bartolone Kai , Dandapani Hari G , Drewberry-Reeves Logan , Roy Vikram , Dandapani Nikila B , Shaheen Fawad
Published: October 2018

Background:
Multiple randomized clinical trials have shown the benefits of thrombectomy in the treatment of acute stroke after 90 days; a recent study showed extended benefit in the functional outcomes of the original cohort of randomized patients. However, data on real-world experience on long-term outcomes, including recurrent vascular events and risk factor controls, is lacking.

Aim:
To study long-term clinical outcomes, risk factor modification, medication compliance, and recurrent events in patients undergoing thrombectomy in a community-based setting.

Methods:
Retrospective data was collected on 143 cases performed between 2013 and 2017 in a non-academic medical center. Long-term follow-up was performed by reviewing hospital and clinic records of available patients.

Results:
At the time of discharge, 79% of the 143 thrombectomy patients survived, 11% had died, and 10% went to hospice. Post-hospitalization data, ranging from 30-days to 3 years, was available in 83 patients. A majority of the survivors (81%) were living with family at home. Within that time frame, cardiovascular events occurred in 39% of patients, with 5 deaths (6%). Only 7% (6/83) of patients had a recurrent stroke; most of them were lacunar. Two patients had repeat thrombectomies, and one was treated with IV tpa. Seventy-nine percent (66/83) continued to be on anti-platelet agents. A surprising number (34/83) of long-term survivors continued to smoke and drink heavily (20/83). Only 78% of patients had regular medical care. Twenty-percent of survivors were depressed and 20% were demented.

Conclusions:
Although thrombectomy helps reduce disability and benefits stroke survival, there is a high incidence of cardiovascular and cerebrovascular events afterwards, due to poor control of risk factors, inadequate medical follow-up, and lack of lifestyle changes. Thrombectomy is a costly procedure; to be cost-effective in the long-term, it is imperative that the survivors are not left without proper medical surveillance and secondary prevention strategies.
Abstract TP304: Stroke-Specific Quality of Life as an Independent Outcome in Intracerebral Hemorrhage
Authors: Leasure Audrey C , Sreekrishnan Anirudh , Ormseth Cora H , Miyares Laura C , Mampre David M , McLaughlin Chris , Amin Hardik , Sansing Lauren H , Falcone Guido J , Sheth Kevin N
Published: October 2018

Introduction:
Quality of life (QoL) is important to patients and decision makers. However, little is known about QoL in intracerebral hemorrhage (ICH) survivors. The purpose of this study is to investigate the relationship between clinical characteristics, measures of disability, and the stroke-specific quality of life (SS-QoL) among ICH survivors.

Methods:
Sixty-eight ICH subjects were prospectively enrolled at Yale-New Haven Hospital from July 2015 to February 2017. The SS-QoL, modified Rankin Scale (mRS), and Barthel Index (BI) were obtained by phone interview at 3 (n=15), 6 (n=43), and 12 (n=10) months post ICH. The SS-QoL is a self-reported, 12-domain assessment utilizing 5-point Likert scales. SS-QoL domain scores are the mean of individual scores in each domain. A summary score was calculated as the mean of all 12 domain scores with a range of 1-5. Higher scores indicate better QoL. SS-QoL scores ≥4, BI scores ≥ 90, and mRS ≤ 2 were considered good. Logistic regression was used to investigate associations between covariates and QoL.

Results:
The mean SS-QoL summary score was 3.8 (SD 0.80) at a mean follow up time of 6 months. Fifty-three percent of subjects reported a good QoL, compared to 66% and 78% of subjects with a good outcome on the mRS and BI, respectively. Subjects scored highest in the self-care (mean score 4.2) and vision (4.3) domains of the SS-QoL and lowest in the energy (3.2), social (3.3), and thinking (3.4) domains. Known predictors of outcome after ICH including age, sex, race/ethnicity, admission GCS, ICH location, ICH volume, and IVH extension were not associated with SS-QoL scores.

Conclusion:
The SS-QoL provides information on domains that are not captured by the mRS and the BI and is not associated with traditional predictors of outcome after ICH. These data support further studies on the use of QoL as an outcome independent of disability measures.
Abstract TP307: Industry Sponsored Clinical Trials Have Reshaped Stroke Guidelines & Therapies
Authors: Wang David Z , Raghav Sista , Liu Huihui , Nair Deepak , Ding Hong
Published: October 2018

Background:
Evidence based medicine usually derives from well conducted clinical trials. The findings from these trials often become part of a guideline and subsequently are written into practice protocols. Recent debate has been focusing on the influence of clinical care paradigm by the findings from the industry supported clinical trials. This study examined stroke clinical trials that have been supported by the industry.

Method:
Large medical database such as Google Scholar, Pubmed, Embase and Medline were searched in order to identify published stroke trials. These trials were categorized into either non-industry supported or industry supported groups by examining the disclosure statements printed in the publication. Trials were further categorized by their indications/agents tested. Descriptive statistics were used for the analysis.

Results:
Since 1970, 148 stroke related clinical trials were identified. Among them, 42 (28%) had no identifiable information of industrial support and 20 (14%) had no available information. However, 86 (58%) trials had full or partial industrial support. Among them, 23 (16%) were for carotid stenting, 22 (15%) for antiplatelet agents, 11(7%) for thrombolytics and 6 (4%) for anticoagulants. All published intravenous tPA plus intra-arterial thrombectomy trials using new generations of stent assisted clot retrievers were fully or partially sponsored by industry and all 4 new oral anticoagulants trials were fully sponsored by the industry.

Conclusion:
This was the first study examined the sponsorship of clinical trials to treat stroke. Industry supported trials are important in our search for new and better stroke therapies. The findings from many of these trials have been incorporated into stroke care guidelines. The influence is significant. They are much more productive comparing to NIH sponsored trials. To great extent, the findings from the industry sponsored trials have reshaped the stroke treatment paradigm.
Abstract TP31: High Systolic Blood Pressure After Successful Endovascular Treatment Affects Functional Outcome in Acute Ischemic Stroke
Authors: Maier Ilko , Tsogkas Ioannis , Behme Daniel , Bähr Mathias , Knauth Michael , Psychogios Marios-Nikos , Liman Jan
Published: October 2018

Background:
Endovascular treatment (EVT) has been shown to significantly improve functional outcome in patients with acute large cerebral vessel occlusions. To date, no evidence based recommendations on blood pressure management after successful EVT exist. Previous studies showed an association between high pre-EVT systolic blood pressure (SBP) and functional outcome, but do not answer the question on how to manage blood pressure after successful recanalization.

Methods:
Prospectively derived data from patients with acute large vessel occlusion within the anterior circulation and EVT was analyzed in this monocentric study. Mean systolic- and maximum SBP as well as SBP-peaks have been obtained for the first 24 hours after successful EVT. Predictive value of SBP for discharge National Institute of Health Stroke Scale (NIHSS)-reduction of ≥50% and discharge modified Rankin scale (mRS) ≤2 has been investigated using logistic regression models and Receiver Operating Characteristic Curve analysis.

Results:
From 168 patients with successful EVT, 95 (56.5%) had favorable NIHSS-based- and 74 (44%) a favorable mRS-based outcome. Mean- (NIHSS-group: 127 vs 132 mmHg, p=0.024; mRS-group: 127 vs 131 mmHg, p=0.035) and maximum SBP (NIHSS-group: 159 vs 170 mmHg, p<0.001; mRS-group: 157 vs 169 mmHg, p<0.001) as well as number of SBP peaks (NIHSS-group: 0 vs 2, p=0.003; mRS-group: 0 vs 1.5, p=0.004) were lower in patients with favorable outcome. Multivariable logistic regression showed high SBP to predict unfavorable outcome. Cut-off mean SBP was 140.5 mmHg and maximum SBP 159 mmHg.

Maier et al., Systolic blood pressure and outcome after EVT, abstract page 2

Conclusions:
High SBP in the first 24 hours after recanalization of acute anterior cerebral vessel occlusions is associated with unfavorable functional outcome. Interventional studies are needed to determine the role of SBP management as a modifiable parameter in the early phase after successful EVT.
Abstract TP312: Assessment of the Data Collection Strategies for Stroke Patient-centered Outcomes: Implementation of the International Consortium for Health Outcomes in Brazil
Authors: Martins Sheila C , Martins Magda C , Carbonera Leonardo A , Souza Ana C , Portal Marcelle , Martin Kelin , Rodrigues Gabriel , Cuervo Liliana M , Brondani Rosane , Almeida Andrea G , Weiss Gustavo , Parrini Mohamed , Nasi Luiz A
Published: October 2018

Introduction:
In 2015, international experts defined a standard set of patient-centered outcome measures after stroke as part of the International Consortium for Health Outcomes (ICHOM). It aims to make outcomes comparable around the world, allowing the value-based healthcare delivery. In developing countries, it is still a challenge to implement outcome measurement for stroke patients after hospital discharge, due to different structures and healthcare network characteristics. The study objective is to assess the implementation strategies of the outcome measures of ICHOM stroke in 6 Brazilian hospitals.

Methods:
For 1 year, we progressively implemented ICHOM outcome measurements in 6 stroke centers: 1 private, 1 public university and 4 primary stroke centers with telemedicine guidance. The data collection strategies included: in person interview, interview by phone or a link to an online form sent by e-mail.

Results:
429 patients were included in the 90-day follow-up interview. In person interview was made for 80 patients (mean interview time of 5 minutes), by phone in 285 (mean interview time 8 minutes) and by e-mail in 64. There was loss of follow-up in 15% of in-person interviews, 28% on phone and 62% on e-mail. In the private hospital, where there is better data registry, only 18% of the patients were lost to follow-up, while 54% of telemedicine patients weren’t found for the interview, mainly because of lack of phone number register or even wrong number. Higher succeeded attempts occurred on evening calls compared to business hours’ calls.

Conclusion:
The data collection for outcome measurements of stroke patients in Brazil is still a challenge. The barrier for phone interviews was data registry error, and the correct phone number being registered allows the follow-up. Though requiring further validation, e-mail contact seems to be a good initial strategy, decreasing the need for phone calls and saving time. The phone calls are the option for patients who do not answer e-mails.
Abstract TP315: Secondary Stroke Risk Factors Can Be Appropriately Managed With Telemedicine
Authors: Patel Ranish K , Larsen Darren T , Sharma Josephine , Lutsep Helmi L
Published: October 2018

Introduction:
Access to specialized outpatient follow-up care after ischemic stroke can be limited by distance. We investigated the use of home telemedicine to monitor secondary stroke risk factors, as compared to traditional in-person stroke clinic follow-up.

Methods:
Patients seen for management of ischemic stroke or TIA at a single institution were enrolled prior to discharge or at the time of a 7-day follow-up call. Participants who lived within a 75 mile radius were assigned to standard clinic follow up, and those who lived outside a 75 mile radius were assigned to telemedicine follow up. Patients were seen by a nurse and physician at 30 days, 90 days, and 1 year post discharge and blood pressures were taken at each visit. Outcomes assessed were those achieving a goal systolic blood pressure <140 mmHg (<130 mmHg if diabetic); low density lipoprotein <100 mg/dl; BMI <25 (if baseline BMI 25-27) or >10% weight loss if BMI >27; Physician based Assessment and Counseling for Exercise (PACE) score >3; knowledge of >2 stroke signs; patient adherence; and patient satisfaction with quality of care, coordination with primary care physician, and overall experience, as assessed via anonymous survey. A Fisher’s exact test, and a Wilcoxon rank sum test were used for statistical analysis at these three time points.

Results:
16 patients (63% male, mean age 63.1) were enrolled to clinic follow up, and 8 patients (50% male, mean age 62.5) were enrolled to telemedicine follow up. Adherence to follow up at 1 year post-stroke in the telemedicine cohort (87.5%) did not differ significantly from the clinic cohort (56.2%, p=0.189). The proportion of the telemedicine cohort (80%) and clinic cohort (50%) who met blood pressure goals at 1 year post-stroke did not differ significantly (p=0.180). Serum LDL, weight loss, exercise, knowledge of 3 or more stroke signs, and satisfaction scores similarly demonstrated no significant difference between the two cohorts.

Conclusion:
Telemedicine may serve as an alternative to standard clinic follow-up in the management of secondary stroke risk factors in the outpatient setting.
Abstract TP317: Optimal Blood Pressure Level of Ischemic Stroke Changed by Time and Targeted Outcomes
Authors: Kang Jihoon , Kim Beom Joon , Han Moon-Ku , Bae Hee-Joon
Published: October 2018

Purpose:
This study explored the differences of associating patterns of blood pressure (BP) according to the different stroke outcomes and investigated their changes by the elapsed time after stroke onset.

Methods:
Patients who arrived within 48 h of stroke onset were consecutively identified between 2008 and 2014 in retrospective manner. Of them, all measured systolic BP (SBP) during hospitalization were summarized into mean values at acute (first 3 days) and subacute stage (afterward to 10 days) per person. Stroke outcomes were poor outcome (modified Rankin Scale > 2) at discharge and time to composite event of stroke, myocardial infarction and death for 1 y follow-up period.

The adjusted odds ratios (AOR) for poor outcome were interpolated through whole range of mean of SBP (SBP
mean
) in separate to acute and subacute stage using restricted cubic spline technique (RCS) added to logistic regression models with predetermined covariates. The interpolation of hazards for composite event by SBP
mean
in acute and subacute stage were analyzed using RCS added to Cox proportional hazard models.

Results:
This study enrolled 3723 subjects (mean age, 66.7 ± 13.2 years-old and median baseline NIHSS score, 3). SBP
mean
in acute and subacute stage were 134.3 ± 15.9 and 135.6 ± 14.8 mmHg.

AORs for poor outcome showed linear trends through SBP
mean
in both stages, however, there was significant increases of risk at higher values of SBP
mean
in acute stage not in subacute stage (Figure 1). For 1 y of observation, SBP
mean
in both acute and subacute stage demonstrated U-shaped associations with hazards for composite event (Figure 2). There were significant higher hazard levels below 120 mmHg of SBP
mean
in subacute stage.

Conclusion:
In ischemic stroke, association patterns of BP are measured differently depending on stroke outcome. And prompt ranges of BP would be changed by the elapsed time after onset.
Abstract TP321: Effect of Very Early Mobilization After IV Alteplase on 90 Day Functional Outcome
Authors: Clark Diane K , Stuchiner Tamela , Robison John , Lucas Lindsay , Yanase Lisa R
Published: October 2018

Purpose:
To determine if very early mobilization impacts outcomes at 90 days for ischemic stroke patients receiving intravenous alteplase (tPA).

Background:
Early mobilization of critical care patients improves outcome, length of stay, and patient satisfaction. Outcomes data of very early mobilization for stroke patients have been mixed, and data for patients mobilized within 24 hours of receiving tPA is limited. We have presented safety data for a nursing-driven early mobility protocol for stroke patients.

Methods:
Medical records of ischemic stroke patients who received tPA between 2012 and 2016 at two urban hospitals were reviewed for timing of earliest mobilization following tPA treatment. Patients who received endovascular treatment, were placed on comfort care day zero or one, were mobilized after the first 24 hours, transferred out or left against medical advice, or for whom there was no 90 day modified Rankin Scale (mRS) reported were excluded from the analysis. Multinomial regression was used to determine if the time first mobilized to highest safe level within 24 hours after tPA treatment impacted mRS at 90 days, adjusting for patients’ disability status prior to stroke, stroke severity using National Institutes of Health Stroke Scale (NIHSS), and age.

Results:
Of 193 patients included in the final analysis, 43.0% (n=83) were female, mean age was 70.6 (±13.0), and the median admit NIHSS was 6.0 [Interquartile range (IQR): 3.0, 11.0]. The median time first mobilized after tPA was 9.0 hours [IQR: 5.0, 16.0]. At 90 days, 31.6% (n=61) of patients reported no symptoms (mRS 0), 35.2% (n=68) some symptoms or slight disability (mRS 1-2), 19.2% (37) moderate to severe disability (mRS 3-5), and 14.0% (n=27) had expired (mRS 6). There was no relationship between mobilizing earlier and likelihood of moderate or severe disability (Adjusted Odds Ratio (AOR) = 1.05 per hour increase in mobilization; p=0.183) or death (AOR=1.06 per hour increase in mobilization; p=0.143) compared to no symptoms at 90 days.

Conclusions:
This study showed that earlier mobilization within 24 hours after tPA did not worsen functional outcome based on 90 day mRS. Our data support very early mobilization to their highest safe level of stroke patients receiving tPA.