bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP3: Network-wide Incidence Of Intracranial Hemorrhage In Patients With Acute Ischemic Stroke Receiving Tenecteplase
Authors: Fourcand Farah , Sahito Sindhu , Ali ChHassan , Marandi Elahe , Haimi Joshua , Dubinsky Ilya , Song Yong-Bum , Mehta Siddhart , Tabibzadeh Navid , Gadallah Nancy E , Panezai Spozhmy , Kirmani Jawad F
Published: February 2023

Background:
Intravenous tenecteplase (TNK) is currently being used as a thrombolytic agent in acute ischemic stroke (AIS) and has has been shown to be non-inferior to intravenous alteplase according to recent studies. Intracranial hemorrhage (ICH) as a complication of alteplase is approximately at 6%. The aim of our study was to determine the rate of significant ICH in patients receiving TNK indicated for AIS in a real world setting.

Methods:
A network-wide (3 CSCs, 6 PSCs), multicenter retrospective chart review of patients receiving TNK from February 2020 to January 2022 was performed using the Get With The Guidelines database. TNK bolus dose of 0.25mg/kg was used according to a network-wide policy. ICH was categorized using ECASS-3 criteria. Fisher exact test statistic was used to determine if a significant association existed between the presence of ICH and baseline ASPECTS score, endovascular treatment (EVT), and IV eptifibatide use. A benchmark less than 2% PH-2 incidence was set based on historical alteplase related PH-2 rates within our network. Social science statistics software was used for data analysis.

Results:
Out of 180 patients who received TNK, 25 subjects (13.89%) developed hemorrhagic transformation. Mean age was 71.88 (95% CI 65.54, 78.22). Forty-eight percent of subjects were female. Median ASPECTS score was 8 (95% CI 7.54, 8.78). Median 90 day mRS was 3 (95% CI 2.1, 3.9). Hemorrhagic transformation was classified as HI-1 in 5% (n=9), HI-2 in 1.7% (n=3), PH-1 in 3.8% (n=7), and PH-2 in 3.3% (n=6) subjects. No significant difference between subjects with other subtypes versus PH-2 was identified when adjusting for ASPECTS score >=7 versus <7 (Fisher value=1), EVT versus no EVT (Fisher value=0.65), or use of IV eptifibatide (Fisher value=0.06).

Conclusion:
Tenecteplase is associated with higher rates of PH-2 intracranial hemorrhage when compared with our benchmark rates of alteplase-related PH-2. This study is significantly limited by small sample size, retrospective nature, and uncontrolled variables. Larger, prospective studies are needed to validate our results.
Abstract TP30: Enrolling Patients During Covid-19: Lessons From The Timeless Clinical Trial
Authors: Staugaitis Abbey , Jabs Juline , Parlette Stacy L , Pakulski Melanie , Lui Catherine L , Garcia-Canga Blas , Davis Tammy R , Palikhey Sarensa , Purdon Barbara , Massaro Lori M
Published: February 2023

The COVID-19 pandemic negatively impacted clinical trial enrollment worldwide, and patient enrollment continues to lag prepandemic levels. The TIMELESS trial (NCT03785678) is a Phase III study to determine whether tenecteplase treatment increases the proportion of good clinical outcomes in patients with acute ischemic stroke who present 4.5-24 hours after symptom onset. The trial has successfully enrolled patients at >90 sites in the US and Canada despite the ongoing pandemic, associated hospital restrictions, and inherent challenges of enrolling patients in an acute stroke trial. The highest-enrolling study sites identified several barriers to patient enrollment and ways to turn obstacles into opportunities to improve the enrollment process. Common themes in patient enrollment failure included insufficient time to complete the consent process, inadequate coordination between departments, and logistic challenges due to hospital restrictions. Solutions included using telemedicine and electronic consent software to rapidly identify patients and provide sufficient time to complete the informed consent process. Software alerts for new stroke cases and HIPAA-compliant messaging applications ensured rapid activation of all staff needed for patient enrollment. Accessible drug storage for rapid dispensing and a comprehensive “step-forward randomization” workflow reduced or eliminated patient enrollment delays caused by study drug retrieval, preparation, and administration. Well-defined roles for the research teams, combined with training and mock enrollment drills, kept research teams engaged and working efficiently within a limited enrollment window. Clear enrollment workflows ensured coordinated responses from multiple departments and could be adapted to changing hospital COVID-19 restrictions. These challenges, while exacerbated by COVID-19, are relevant beyond the pandemic and acute stroke trials. The lessons and experiences of successful sites show that successful clinical trial enrollment requires clear channels of communication, collaboration with nonresearch stakeholders, and an engaged research team with well-defined roles who are committed to integrating research plans into each site’s clinical workflows.
Abstract TP33: Raising The Bar On Oral Care In The Stroke Population
Authors: Toler Rachel , Day Stacey
Published: February 2023

Objectives:
The purpose of this initiative is to increase compliance with basic oral care, especially in those patients who are dependent on others due to stroke. Although oral care seems like an intuitive hygienic practice to support positive patient outcomes, Speech Language Pathologists (SLPs) report low levels of compliance for stroke patients across hospital systems and settings. Poor oral hygiene in dependent, hospitalized patients can lead to serious complications, such as healthcare associated pneumonia (HAP), poor nutritional intake and increased length of hospital stay. Several epidemiological studies have linked poor oral health with cardiovascular disease, poor glycemic control in diabetics and a number of other conditions.

Methods:
Methodology includes providing education for staff throughout the year, increasing inventory of needed supplies and performing audits. Audits are completed to evaluate compliance for: a) Proper oral care tools (e.g., toothbrush, toothpaste, wall suction unit, suction canister, suction tubing, suction toothbrush kit) present in room b) Patient dependency for oral care c) Patient knowledge that oral care materials are in room d) Daily performance of oral care or teeth/dentures brushing by patient/family or nursing e) Quality of oral care - SLP needed to provide it or lemon glycerin swabs only were used f) Status of oral cavity. Real time feedback was given to nurses immediately after audit, as appropriate. Audit results shared quarterly at the hospital wide stroke committee to provide engagement with leadership.

Results:
Prior to the institution of an oral care protocol, compliance was measured at less than 50%. Education, training and audits resulted in an average increase of 30% for performing Basic Oral Care when measured in patients from July 2021-March 2022.

Conclusions:
In conclusion, the audit process serves the function of focusing attention on oral care and measuring compliance; interventions must also include raising awareness, providing training, and obtaining support from both the nursing and hospital leadership. Formalizing oral care workflows and documentation to standardize oral care should further increase the percentage of patients who receive this basic, but salient intervention.
Abstract TP40: Magnetic Resonance Versus Computed Tomography As Preferred Screening Of Suspected Acute Stroke: A Retrospective Comparative Cohort Analysis
Authors: Miller Samantha , Weitzner Aidan , Warach Steven J , Dula Adrienne N
Published: February 2023

Background:
In published cohorts, MRI screened patients tend to have better outcomes than CT-screened, even though MRI takes longer to acquire and may delay initiation of thrombolysis. However, overall differences in stroke workflow and clinical outcomes in stroke centers that prefer MRI over CT have not been reported.

Methods:
Between 2019 and 2021 three stroke centers in our network, switched their code-stroke imaging protocol from CT-first preferred to MR-first preferred. Under the MR-first protocol, CT was performed for MRI contraindications, patient instability, or MR not immediately available during a code stroke. Data from one year prior to the switch (CT-first) was compared to the year following the switch (MR-first). Patient demographics, quality stroke metrics and outcomes were obtained from a prospectively maintained patient database.

Results:
A total of 1027 (CT-first) and 1056 (MR-first) cases were evaluated (Table). Ischemic stroke was more frequent and TIA less frequent under the MR-first protocol. Cross-over scanning occurred more frequently under the MR-first protocol (p<0.0001). Rate of thrombolysis was 11.8% of all cases under CT-first and 13.3% under MR-first. Door-to-treatment for thrombolytic and thrombectomy was longer under MR-first but fewer stroke mimics were treated under MR-first (0.7% vs 9.2%, p=0.0014). Clinical outcomes did not differ for thrombolysis, but discharge disposition to home vs hospice or death after thrombectomy was favored under the MR-first protocol (p =0.0176).

Conclusion:
Under an MR-first stroke protocol there was a greater rate of cross-over imaging and delayed workflow and treatment times, but less frequent thrombolytic treatment of stroke mimics and better outcomes in thrombectomy patients. Workflow metrics and outcomes for patients as imaged will be presented at the conference.
Abstract TP41: Assessing The Relationship Between The Los Angeles Motor Scale And Computed Tomography Perfusion Parameters In Acute Ischemic Stroke Secondary To Large Vessel Occlusion
Authors: Arthur Karissa C , Huang Shenwen , Gudenkauf Julie , Hamam Omar , Khalili Neda , Patel Navangi , Urrutia Victor C , Yedavalli Vivek
Published: February 2023

The Los Angeles Motor Scale (LAMS) is a rapid pre-hospital scale used to predict stroke severity. LAMS has also been shown to accurately predict large vessel occlusions (LVOs), however, to date there is no study exploring whether LAMS correlates with CT perfusion (CTP) parameters used to decide mechanical thrombectomy (MT) candidacy. The aim of this study is to elucidate the potential relationship between LAMS and these CTP parameters. We retrospectively reviewed patients with LVO between September 2019 and October 2021. Patients were included if they had available CTP data and neurologic exam on admission. LAMS was documented based on EMS exam or scored retrospectively based on admission neurologic exam. CTP data was processed by RAPID (IschemaView, Menlo Park, CA) with ischemic core volume (rCBF < 30%), Tmax volume (Tmax > 6 second delay), hypoperfusion index (HI), and CBV index. Spearman’s correlations were performed between LAMS and the aforementioned CTP parameters. Eighty-five patients were included, of which 11 had intracranial internal carotid artery (ICA) occlusions, 52 had M1 occlusions, and 22 had proximal M2 occlusions. Of all patients, 26 had LAMS of 0-3, and 59 had LAMS of 4-5. In all cases, LAMS was positively correlated with CBF <30% (Correlation Coefficient (CC): 0.32, p < 0.01), Tmax > 6 s (CC:0.23, p< 0.04), HI (CC:0.27, p < 0.01), and negatively correlated with CBV index (CC:-0.24, p < 0.05). These relationships between LAMS and CBF < 30% and HI were more pronounced in M1 occlusions (CC:0.42, p< 0.01; 0.34, p< 0.01 respectively) and proximal M2 occlusions (CC:0.53, p<0.01; 0.48, p< 0.03 respectively). LAMS also correlated with Tmax > 6 s in M1 occlusions (CC:0.42, p< 0.01), and negatively correlated with CBV index in M2 occlusions (CC:-0.69, p< 0.01). There was no significant correlation between LAMS and CTP parameters in intracranial ICA occlusions. Our results indicate that LAMS is positively correlated with estimated ischemic core, perfusion deficit, and HI, and negatively correlated with CBV index in patients with LVO. Vessel based analyses reveal stronger correlations with M1 and M2 occlusions. This is the first study showing that the LAMS may be correlated with estimated ischemic core and collateral status parameters in patients with LVO.
Abstract TP43: Circadian Variation In Stroke Onset On Weekdays Compared With Weekends/Holidays
Authors: Pariona-Vargas Fatima , Mun Katherine T , Lo Eng H , Starkman Sidney , Sanossian Nerses , Bahr Hosseini Mersedeh , Stratton Samuel , Eckstein Marc , Conwit Robin A , Liebeskind David S , Sharma Latisha K , Rao Neal M , Shkirkova Kristina , Avila Gilda , Kim-Tenser May A , Saver Jeffrey L
Published: February 2023

Background:
Ischemic and hemorrhagic stroke onset exhibit is known to exhibit diurnal variation throughout the 24-hour cycle. But whether this variation differs on weekdays compared with weekends/holidays has not been well delineated.

Methods:
We evaluated consecutive patients with acute cerebral ischemia [(ACI), including ischemic stroke (IS) and transient ischemic attack (TIA)] and intraparenchymal hemorrhage (IPH) enrolled during ambulance transport to 60 receiving stroke centers in the NIH FAST-MAG trial. Enrollment required onset within the prior 2 hours, excluding confounding by wake-up and unwitnessed onset strokes. The patterns of time of onset were analyzed: 1) hourly, 2) in 4-hour increments, and 3) daytime (08:00-19:59) vs. night-time (20:00-07:59). Diurnal variation in presenting demographic/clinical features were assessed using ANOVA, Kruskal-Wallis, t-tests, and Wilcoxon Rank-Sum.

Results:
Among 1615 patients (1202 enrolled on weekdays and 442 on weekends/holidays), 64% had IS, 12.5% TIA, and 23.5% IPH. ACI patients had different patterns of onset time (Figure). During weekdays, a broad plateau of highest rates of onset occurred 09:00-22:00. Conversely, during weekends/holidays, a unimodal peak was observed between 14:00-16:00. In contrast, patterns of onset time in IPH patients were broadly similar, with bimodal peaks on both weekdays and weekends/holidays. However, the first peak occurred earlier on weekdays (09:00-12:00 vs. 11:00-13:00), with the second peak occurring within 17:00-20:00 in both groups.

Conclusion:
Acute cerebral ischemia shows marked, and intraparenchymal hemorrhage minor, pattern differences in onset times on weekdays vs. weekends/holidays, likely related to variations in times of greater physical activity and stress. These findings can inform EMS resource allocation to stroke, aligned with weekday vs. weekend/holiday onset patterns.
Abstract TP49: The Pupillary Light Reflex Detects Large Vessel Occlusion
Authors: Maxin Anthony J , Gulek-Bakirci Bernice G , Lim Do H , McGrath Lynn B , Levitt Michael R
Published: February 2023

Introduction:
The pupillary light reflex (PLR) is a well-validated biomarker for neurologic monitoring and a decision-making tool for traumatic brain injury patients. We studied a machine learning-based mobile pupillometry platform in patients with acute ischemic stroke (AIS) with a large-vessel occlusion (LVO) prior to thrombectomy, compared to healthy volunteers.

Methods:
Pupillometry measurements were conducted with a mobile pupillometry platform (PupilScreen) and a digital infrared pupillometer (NeurOptics) for both pre-thrombectomy AIS subjects and healthy volunteers at an academic medical center. To correct for subject age differences, comparisons used the absolute inter-eye difference in each parameter for each subject by measuring the right:left (R:L) eye ratio absolute distance away from 1. Inter-eye difference means across subjects between AIS and healthy cohorts were analyzed for PLR changes in the presence of acute LVO using a t-test for independent means.

Results:
Seven AIS patients (4 female, 3 male; 1 Hispanic, 6 Caucasian; mean age 60.9 years) and 32 healthy patients (19 female, 13 male; 1 Hispanic, 2 African American, 3 Native American, 5 Asian, 21 Caucasian; mean age 34.4) were enrolled. All LVOs were of the middle cerebral artery, with 3 on the left and 4 on the right. NPi value was above 3 (briskly reactive) for all subjects. However, the smartphone pupillometer demonstrated a statistically significant (p<0.05) increase in mean inter-eye differences for maximum diameter (mean inter-eye difference of 0.14 vs 0.03), minimum diameter (0.21 vs 0.03), and percent change (0.23 vs 0.05). The mean inter-eye differences were lateralized to the side of the LVO for maximum and minimum diameters (right LVO, max pre vs post R:L 0.95 vs 1.0, min 0.91 vs 0.98) (left LVO, max 0.98 vs 0.96, min 1.15 vs 0.93), and were increased in latency and mean constriction velocity whereas they were decreased in maximum constriction velocity and mean dilation velocity, but this was not statistically significant in this cohort.

Conclusions:
Patients with AIS from LVO demonstrate inter-eye differences in PLR parameters, and mobile pupillometry could be used as a pre-intervention biomarker of AIS in future study. Further investigation in a larger cohort is necessary.
Abstract TP5: Helicopter Emergency Medical Services (HEMS) Transportation Utilization For Acute Ischemic Strokes At A Community Based Hospital In South Florida
Authors: Persaud Lisa , Oliva Jadthiel , Belnap Starlie , De Los Rios La Rosa Felipe
Published: February 2023

Background:
Efficiency in the transfer of patients with ischemic stroke is a vital factor for patient prognosis. A comprehensive stroke center servicing remote areas in south Florida became HEMS direct-from-field capable on October 15, 2020. In some remote areas, the transfer of patients is via ground or air; the severity of the clinical presentation determines the mode. Concern about HEMS overutilization for lower stroke acuities prompted this study.
Purpose:
The purpose of this project was to evaluate the current HEMS stroke triage process, assess the accuracy of stroke diagnosis, and use this information to improve EMS education to prevent over-triage for stroke.

Methods:
A retrospective cohort study from October 15, 2020, to July 31, 2021, collected HEMS adult stroke alert data and compared it to the prior year's summary ground EMS (GEMS) stroke alert data. Using HEMS transportation logs, presenting stroke symptoms and pre-hospital assessment were abstracted. In addition, we evaluated initial NIHSS, downgrade rate, stroke diagnosis percentage, treatment rate, and times.

Results:
The analysis included a total of 52 HEMS stroke alerts. Assessment tools utilized by HEMS included the Cincinnati stroke scale (4%) and the FAST-ED (37%); the majority of cases (59%) did not document a stroke assessment tool. The median NIHSS was 10, with 37% presenting with a score <6. Respectively, 6% and 15 % of cases were downgraded upon arrival and after CT imaging. Significantly (p<.001), more HEMS cases were diagnosed as a stroke (69%) compared to GEMS (57%). Stroke treatment rates remained similar (HEMS=23%; GEMS=23%). Median door-to-needle times were significantly faster for HEMS (15min) than GEMS (25min) (p<.05). Median door-to puncture times were significantly faster for HEMS (61mins) than GEMS (72mins) (p<.05).

Conclusion:
With low downgrade rates and high diagnosis accuracy, the current HEMS triage process, although not consistently documented, accurately detects stroke, even for low acuity cases. Patients arriving via HEMS receive equal access to stroke treatment with significantly faster treatment times, ensuring the best possible prognosis. EMS educational efforts should focus on improving documentation compliance.
Abstract TP51: Establishing Stroke Pre-alert Criteria Reduces Delays In Endovascular Management
Authors: Dabhi Nisha , Chu Lucy , Aldridge Chad M , Chapman Sherita N
Published: February 2023

Background:
Mechanical thrombectomy (MT) is standard of care for patients with cerebral large vessel occlusions (LVO). Efficacy of MT depends on the timeliness of reperfusion. Establishing a pre-alert criteria to activate the stroke team prior to patient arrival in the emergency department (ED) may help rapidly identify candidates for MT.

Objective:
To determine whether establishment of pre-alert criteria can improve door-to-groin (DTG) and door-to-reperfusion (DTR) times.

Methods:
We retrospectively reviewed electronic prehospital and hospital records of stroke-alerted patients prior to (pre-protocol) and after (post-protocol) implementation of our stroke pre-alert protocol. We initiated our protocol in November 2022 to pre-alert patients that EMS found with (1) positive on Cincinnati Pre-Hospital Stroke Scale with last known well (LKW) <4.5 hours or positive CPSS and Vision-Aphasia-Neglect with LKW <24 hours, (2) Glasgow Coma Score >8, (3) glucose 60-400mg/dL, (4) systolic blood pressure >90, (5) oxygen saturation >90%, and (6) no seizures at presentation. Patients stroke-alerted in the ED prior to protocol (April 1, 2020-November 10, 2021) were historical controls.

Results:
EMS presented 667 (49% female) patients to our hospital, of which 195 patients arrived after pre-alert protocol initiation. Among post-protocol patients, 13.8% (27/195) underwent MT, while 11% (52/472) of pre-protocol patients underwent MT. Among patients who underwent MT, 26 post-protocol patients (96%) and 22 pre-protocol patients (42%) were pre-alerted [X
2
=21, p<0.001]. Mean DTR decreased by 63.83 minutes in post-change group [19.83-115.85]. Mean DTG decreased by 65.26 minutes in post-change group [36.54-102.90].

Conclusion:
Establishment of a reasonable pre-alert criteria facilitates stroke alert activation and reduces time to MT intervention in patients presenting to the ED with an LVO. More studies are needed to determine an optimal pre-alert criteria to further reduce MT delays.
Abstract TP54: Organized Post-stroke Care: Results From A Prospective Cohort Study
Authors: Barlinn Kristian , Winzer Simon M , Helbig Uwe , Pallesen Lars-peder M , Trost Heike , Siepmann Timo , Puetz Volker , Rosengarten Bernhard , Schmitt Jochen , Barlinn Jessica
Published: February 2023

Introduction:
Pilot data suggests that organized post-stroke care enhances achievement of secondary prevention goals in stroke patients. We aimed to further investigate whether organized post-stroke care favourably affects stroke recurrence and survival.

Methods:
Prospective, quasi-experimental study of consecutive stroke patients admitted at two tertiary stroke centers in Saxony, Germany. According to health insurance provider status, patients were non-randomly assigned to either 12-months post-stroke pathway plus conventional care or conventional care alone. The organized post-stroke care pathway was facilitated by certified case managers and included pre-scheduled home- and phone visits aiming at educational intervention and achievement of guideline-based secondary prevention treatment goals. Primary outcomes were stroke recurrence and vascular death at 12-months. Further outcomes included favourable functional outcome (i.e. mRS 0-1), health-related quality of life and vascular risk factor control at 12-months.

Results:
In total, 1109 patients were recruited between 11/2011 and 12/2020. Of these, 1009 patients (91%) were assigned to organized post-stroke care and 100 (9%) to conventional care (mean age 70.6±12.8 years, 54% male, median NIHSS 3 [IQR, 1-5] points, 77.5% AIS, 17.9% TIA and 4.6% ICH). Baseline demographics and clinical characteristics were well balanced between both groups (p≥0.05). At 12-months, recurrent stroke rate was lower in the post-stroke care than in the conventional care group (5.5% vs. 14%; aOR 0.35, 95%CI 0.18-0.66; p=0.001). This association was not modified by stroke severity (TIA/minor stroke versus major stroke). Vascular death occurred in 0.2% in the post-stroke care and 3% in the conventional care group (aOR 0.07, 95%CI 0.01-0.41; p=0.003). Organized post-stroke care more frequently yielded individual treatment goals for hypertension, lipids, HbA1c, body-mass-index and secondary prevention adherence than conventional care (p<0.05).

Conclusions:
Our results substantiate the effectiveness of case management-based post-stroke care in unselected stroke patients.
Abstract TP61: The Prevalence Of Psychiatric Symptoms Of Post-intensive Care Syndrome In Hemorrhagic Stroke Survivors Compared To Other Neurocritical Patients: Preliminary Findings
Authors: Blaginykh Elena , Bruening Lindsay , Street Sarah , Uchino Ken , Gomes Joao A
Published: February 2023

Background:
Post-intensive care syndrome (PICS) consists of cognitive, psychiatric, and physical symptoms associated with intensive care unit (ICU) hospitalization. The occurrence of PICS in neurocritical patients is poorly characterized. We aimed to measure the prevalence of psychiatric symptoms of PICS including depression, anxiety, and post-traumatic stress disorder (PTSD) in hemorrhagic stroke (HS) and other neurocritical patients discharged to a long-term acute care facility.

Methods:
We reviewed patient data from January 2020 to December 2021 collected as a part of the virtual follow-up visits within 3 months after ICU discharge. Patients were excluded if the evaluation was not possible or denied. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9), anxiety with the General Anxiety Disorder-7 (GAD-7) tool, and PTSD with Post-traumatic Checklist for DSM-5 (PCL-5). PHQ-9 and GAD-7 scores of 5 and more were defined as depression and anxiety. PCL-5 scores of 33 and more were defined as PTSD. Univariate analysis was performed to examine the prevalence of PICS. Pearson’s chi-square test was used to determine the difference in PICS symptoms' prevalence among hemorrhagic stroke survivors and other neurocritical patients.

Results:
Of the 52 neurocritical patients that had a virtual clinic follow-up, 26 (50%) patients had complete and 11 (21%) incomplete evaluations for depression, anxiety, and PTSD. The prevalence of psychiatric symptoms in this population reached 77% with depression as the most prevalent symptom (61%). The most common neurologic diagnoses were hemorrhagic stroke (33%), acute ischemic stroke (15%), seizures (15%), and status epilepticus (10%). Among hemorrhagic stroke survivors, the prevalence of depression was 56%, anxiety 19%, and PTSD 1%. Other neurocritical patients in 63% of cases had depression, 21% had anxiety, and 9% had PTSD. The prevalence of psychiatric symptoms of PICS in the two groups was not significantly different.

Conclusions:
Psychiatric symptoms of PICS are as prevalent in hemorrhagic stroke survivors as in other neurocritical patients. Further research is warranted to better understand PICS in this population.
Abstract TP62: Community Readiness Assessment Of Pre-hospital Telestroke Services In The Ambulance
Authors: Talana Angel L , Guirguis Kyrillos , Matthews Joseph A , Chojecka Pola , Chapman Sherita , Koenig Matthew A
Published: February 2023

Background:
We are implementing telemedicine in the ambulance to help retain more stroke patients in rural community hospitals and improve thrombolytic treatment times. Our objective was to assess community acceptability of prehospital telestroke services in rural communities on Oahu and identify patient-centered goals.

Methods:
Data were collected through a mixed method survey on Oahu using a short Likert-scale questionnaire followed by a semi-structured interview. Data were summarized by descriptive and inferential statistics. Comparisons between rural and urban groups were made by chi-square analysis and Wilcoxon rank-sum two-tailed test. Rural communities were defined as those with >45 min drive time to a Comprehensive Stroke Center. Interviews were transcribed, coded, and analyzed using inductive and deductive methods.

Results:
Responses were collected from 263 Oahu residents (66.0% female; 47.3% age 35-64; 51.0% rural residents) who were representative of the island population (39.3% Asian; 32.4% Native Hawaiian/Pacific Islander; 44.3% White) and 29 interviews were conducted. Most respondents were comfortable using telemedicine in the ambulance (65.1%) and believed that it would improve the emergency care they receive (65.6%). Most respondents would feel more comfortable staying at their local hospital if they have access to a specialist by telemedicine (74.7%). There were no significant differences between rural and urban respondents’ impressions of telemedicine. Compared to urban respondents, rural respondents were less confident in their local hospital being capable of providing high quality medical care (67.4% rural vs 83.0% urban, p < 0.01) or stroke care (65.9% vs 83.9%, p < 0.001) and more likely to believe they would receive better stroke care outside of their local area (53.1% vs 36.0%, p < 0.05).

Conclusions:
Most respondents support use of prehospital telemedicine. Rural residents were less likely to perceive their local hospital could provide high quality stroke care and had a less favorable impression of using telemedicine to avert EMS bypass of the local hospital. These findings suggest a potential misalignment of the project goal with some patients’ goal to use EMS to bypass rural hospitals for stroke care.
Abstract TP63: Challenges Of Delivering Equal Care In Mobile Stroke Units: The Experience In Urban Colorado
Authors: Eklund Kelsey , Sillau Stefan , Ornelas David , O'Banion Darcy , Bina Heather , Jones William , Orjuela Karen D
Published: February 2023

Introduction:
A Mobile Stroke Unit (MSU) has served Aurora, CO since 2016. This service is activated by 911 for stroke-like symptoms. We sought to characterize the population served by this MSU to determine whether it differed from the area’s population and to design targeted community-based interventions for the future.

Methods:
A retrospective study of the MSU transport cases in Aurora, CO was performed; self-identified variables such as age, race/ethnicity, preferred language, and activation zipcode were recorded and compared to frequencies from the Aurora census using Chi-squared tests. NIHSS and time from last known well (LKW) to dispatch were collected and analyzed with ANOVA type models. Tukey-Kramer and omnibus F-tests were utilized for testing adjustments.

Results:
A total of 320 MSU patients were included from 2016 to 2021. English speakers comprised 89.3% (vs. 68.2% of the population) and Spanish speakers 7.2% (vs. 21.1%); analysis of preferred language between MSU patients and the Aurora population demonstrated a significant difference (p = 1.75 x 10
-13
). English-speaking MSTU patients were older than Spanish-speaking patients (67.7 ± 15.9 years vs. 59.3± 17.3 years). Analysis of race/ethnicity demonstrated significant differences (p = <0.001), with 58.9% of the MSTU patients being White (vs. 58.1% in Aurora), 21.8% African American (vs. 16.7%), 15.5% Hispanic (vs. 13.9%), 3.5% Asian (vs. 6.8%), and 0.3% other (vs. 4.5%). Mean NIHSS score was 7.8. Mean time from LKW to dispatch was 86.9 minutes. This time was significantly longer among English-speaking patients (91.4 minutes) than Spanish-speaking patients (46.9 minutes, p = 0.01). No statistical differences were found amongst other sub-groups.

Conclusion:
There was an increased representation of English-speaking patients with stroke-like symptoms who activated the MSU in Aurora, compared to the general population. Time from LKW to dispatch was significantly longer for English speakers than Spanish-speaking patients, a difference perhaps attributable to age differences. The differences observed through this analysis emphasize the need to develop and deliver educational stroke programing to non-English speakers and older individuals, to maximize the impact of the MSU in Aurora.
Abstract TP68: Experiences Of Community-dwelling Stroke Survivors With A Virtual Multidisciplinary Stroke Clinic During The Covid Pandemic
Authors: Chau Janita P , Lo Suzanne H , Lau Alexander Y , Lee Vivian , Choi Kai Chow , Shum Edward Wai Ching , Hung Sheung Sheung , Mok Vincent C , Siow Kee Chen Elaine , Ching Jessica Yuet Ling , Lam Simon Kwun Yu
Published: February 2023

Background:
Past research has supported the benefits of dance in improving balancing and walking ability in people with neurological conditions. More evidence on stroke survivors’ satisfaction and perceived benefits of dance interventions on their recovery is needed.

Purpose:
This study explored the experiences of participating in a virtual ballet-adapted dance intervention among people with lower limb paresis after a stroke.

Methods:
A qualitative study was conducted with a convenience sample of stroke survivors with unilateral paresis recruited from a support group. The participants attended a virtual dance intervention and learned to perform simple ballet-adapted moves in a sitting or standing position. They then danced together in a group with a Cantopop song of the 80’s. The ballet-adapted moves were designed to improve survivors’ range of motion and control of the joints at ankles, knees, hips, shoulders, and elbows. The participants were interviewed individually after the group dance about their satisfaction with the dance experience. Interview data were transcribed verbatim and analyzed thematically.

Results:
Fourteen stroke survivors (mean age=62.79 years, SD=9.35) were recruited. Nine of them (64%) walked with a stick. The mean duration after stroke was 10.64 year (SD=8.71). The survivors agreed that the ballet-adapted moves could be performed safely at home, and it was particularly helpful during the coronavirus pandemic to engage them in physical activities. They appreciated the integration of familiar songs in the dance and the group dance experience, which was interesting, easier to memorise the steps, and offered them opportunities to meet people. The experience of mastering new dance moves and working towards a group goal conveyed a sense of accomplishment after stroke. No adverse events were reported during and after the dance.

Conclusion:
The stroke survivors were satisfied with the virtual ballet-adapted dance intervention. Further studies to investigate the effects of the intervention on improving survivors’ physical and psychosocial outcomes are needed.
Abstract TP7: The Utilization Of Tenecteplase In Reducing Door-to Needle Time In Ischemic Stroke Patients
Authors: Jeong Jordan M , Huang Anna , Radeos Michael S , Sokup Brenda , Ostrovsky Alexander , Archibald Arielle , Lamani Hajrie , Inzerillo Michael , Kindschuh Mark W
Published: February 2023

Introduction:
In September 2021 our emergency department (ED) switched from alteplase to tenecteplase for thrombolysis in acute ischemic stroke (AIS)
1
. Recent evidence suggests that tenecteplase may be as safe and effective as alteplase, while easier to dose and administer. We sought to reduce our door-to-needle (DTN) time, as faster treatment of AIS patients with fibrinolytics has been associated with improved outcomes
2
, reductions of in-hospital mortality and symptomatic intracerebral hemorrhage (ICH)
3
.

Methods:
Direct arriving patients entered into the Get With The Guidelines® Stroke (GWTG-Stroke) Patient Management Tool
TM
who received thrombolytics and were discharged from January 2019 through July 2022 were included. We compared outcomes before and after the switch from alteplase to tenecteplase in September 2021. The main outcome of this study was DTN time adjusted for demographic and clinical characteristics, including age, race/ethnicity, time of last known well, and presenting NIHSS. Data are presented as odds ratios (ORs) with 95% confidence intervals (CI) and statistical significance set at an alpha of 0.05.

Results:
Between January 2019 and July 2022, 127 patients met the inclusion criteria for this study, of which 82 received alteplase and 45 received tenecteplase. Patients who received tenecteplase had a median DTN time of 42 minutes (95% CI: 37.5-50.4) versus 60 minutes (95% CI: 60.2-74.9) for those who received alteplase (p<0.0001). A greater percentage of patients received tenecteplase, compared to patients who received alteplase, within 60 minutes (77.8% vs 51.2%, adjusted OR 3.74 (95% CI, 1.56-8.93) (p<0.01) and within 45 minutes (53.3% vs 30.5%, adjusted OR 3.26 (95% CI, 1.39-6.06) (p < 0.01). Rates of ICH within 36 hours did not differ significantly for patients receiving tenecteplase versus alteplase (4.4% versus 3.7%; p = 0.83), however it should be noted that overall ICH rate amongst the included patient population was 3.9% (n = 5).

Conclusions:
In conclusion, switching from alteplase to tenecteplase for the treatment of acute ischemic stroke significantly reduced DTN time in our ED without increasing ICH.
Abstract TP71: Predicting Benefit Of Thrombectomy In Patients With NIHSS <6 And Potential Role Of Thrive Score In Patient Selection For Reperfusion Therapy
Authors: Senetar Alexander J , Mehta Amol R , Perez Dezaray , Patel Devin , Shah Rishubh , Murtaza Yasmeen , Snider Isabelle , Marcille Melanie , Li Grace , Miller Joshua , Kung Justin , Kim Dongwoo , Hoh Brian L , Simpkins Alexis N
Published: February 2023

Introduction:
Evidence is unclear for invention in patients with a mild stroke (low NIHSS) and LVO (large vessel occlusion) as only 15-17 patients with NIHSS < 6 were included in the randomized trials. Cohort studies report good and poor outcomes in low NIHSS LVO cases, with some reporting poor complications secondary to complications and associated with burden of chronic illness. The THRIVE (Total Health Risk in Vascular Events) score was previously associated with poor outcomes in stroke patients. We hypothesized that the THRIVE score may be associated with poor outcomes in low NIHSS LVO patients.

Methods:
An IRB approved retrospective stroke study from January 2015 to December 2019 was used. Out of 2401 eligible acute ischemic stroke patients, 107 patients with an NIHSS < 6 with an LVO were included in the analysis. Non-parametric t-test, Chi-squared, and logistic regression were used for statistical analysis.

Results:
Of the 107 patients, the median age was 65 (55-74, interquartile range (IQR), 36% were female, 79% Caucasian, 44% had a discharge modified Rankin Score (mRS) of 0-1, 65% had a THRIVE score < 3, and time from LSN to presentation was 210 minutes (89 – 723 IQR). There was no difference in age, gender, race, time from LSN, or percent of patients with a THRIVE score < 3 (55% with IR vs 65% No IR). However, patients treated with a thrombectomy were significantly less likely to have a good neurologic outcome with discharge mRS of 0-1 if taken for thrombectomy (0% IR group versus 49% No IR, p=<0.0001). Of those taken for IR, 4 were basilar artery occlusions with poor outcomes, 4 MCA occlusions re-occluded post-IR were complicated by re-occlusion or high-grade stenosis. Notably, 54% had TTP lesions with cortex, but only 2 patients had significant cortical infarcts, and there was no symptomatic hemorrhagic conversion.

Conclusion:
Decision-making on IR for patients with low NHISS should be tailored to the patient, as it is likely that the inherent clinical factors prompting thrombectomy to be considered despite the low NIHSS are the important driving factors increasing the likelihood of worse outcomes. Further research is needed to evaluate the type of neurologic deficits and the eloquence of the tissue involved.
Abstract TP73: User-centered Mobile Applications For Stroke Survivors (MAPPS): A National Survey Of Patient Preferences
Authors: Ramaswamy Srinath , Gilles Nadege , Gruessner Angelika , Burton Dee , Fraser Marilyn , Weingast Sarah , Kunnakkat Saroj , Afable Aimee , Kaufman David , Singer Jonathan , Balucani Clotilde , Levine Steven R
Published: February 2023

Introduction:
Existing mobile health (mHealth) smartphone applications (apps) for stroke survivors (SS) are poorly adopted. Little is known about SS’ perceptions and preferences for such apps. We conducted a national survey of SS' preferences for a hypothetical mHealth app for post-stroke care, and studied the influence of demographic variables on these preferences.

Methods:
Focus groups were conducted to identify SS perceptions and knowledge of mHealth apps. Using a grounded theory approach, recurring themes were identified. A multiple-choice questionnaire of five desired app features was generated using the themes. The national survey was mailed to SS (n= 11, 720) across the United States. Survey responses, demographic variables (age, sex, race), education, and time-since-stroke were recorded.

Results:
Ninety-six SS participated in focus groups. High cost, complexity of use, and lack of technical support were identified as possible impediments to adoption of mHealth apps. In the national survey (n=1,194, 10% response), ability to track fitness and diet (84%) and communicating with others (70%) emerged as the most and least useful app features, respectively. African-American and Hispanic SS found the app's features (all five) more useful compared to White SS (ORs 1.73 to 4.41). Stroke survivors with stroke greater than ten years ago deemed the features less useful compared to SS with stroke within one year (ORs 0.01 to 0.78). Perceived usefulness was higher in women (
P
= 0.04 to <0.001) and younger SS (
P=
0.006 to <0.001) only in univariate analysis.

Conclusion:
Successful adoption of mHealth apps among SS will likely depend on app development that is driven by patient preferences and demographics. A patient-centered app may help address health disparities in post-stroke care.
Abstract TP8: Apparent Diffusion Coefficientvalue Could Be The New Perspective To Ascertain Effectiveness Of Mechanical Thrombectomy In Large Ischemic Regions
Authors: Umemura Takeru , Hatano Taketo , Ogura Takenori , Miyata Takeshi , Agawa Yuji , Nagata Izumi
Published: February 2023

Introduction:
Recently, we reported that apparent diffusion coefficient (ADC) values are independently associated with diffusion-weighted imaging (DWI) reversal, and DWI lesions with mean ADC ≥ 520 х 10
-6
mm
2
/s are salvageable by mechanical thrombectomy. These areas regain neurological function. This study aimed to determine the effectiveness of mechanical thrombectomy in especially large ischemic regions with mean ADC ≥ 520 х 10
-6
mm
2
/s.

Materials and Methods:
We conducted a retrospective cohort study including patients with acute ischemic stroke who underwent endovascular mechanical thrombectomy with successful recanalization between April 2017 and March 2021. DWI reversal was assessed through follow-up magnetic resonance imaging 24 h after treatment. Cases with Alberta stroke program early CT score (ASPECTS)-DWI values 3-5 were enrolled in this study. They were classified as DWI lesions with mean ADC ≥ 520 х 10
-6
mm
2
/s and mean ADC < 520 х 10
-6
mm
2
/s. The primary outcome was modified Rankin scale (mRS) score 0-3 (on a scale of 0-6) at 3 months.

Results:
In total, ASPECTS-DWI values 3-5 were confirmed in 20 patients. Six patients had DWI lesions with mean ADC ≥ 520 х 10
-6
mm
2
/s, and the remaining 14 patients had DWI lesions with mean ADC < 520 х 10
-6
mm
2
/s. DWI reversals were significantly larger in cases with mean ADC ≥ 520 х 10
-6
mm
2
/s than in those with mean ADC < 520 х 10
-6
mm
2
/s (p=.049). The mRS scores at 3 months in cases with mean ADC ≥ 520 х 10
-6
mm
2
/s and ADC < 520 х 10
-6
mm
2
/s were 3 (0.75-3.75) and 5 (4-6), respectively. mRS score was significantly improved in cases with mean ADC ≥ 520 х 10
-6
mm
2
/s than in cases with mean ADC < 520 х 10
-6
mm
2
/s (p=.011).

Conclusions:
In large ischemic regions (ASPECTS-DWI: 3-5), DWI lesions with mean ADC ≥ 520 х 10
-6
mm
2
/s are associated with preferable outcomes. The ADC value is easily assessed and a useful tool to predict viable lesions. Therefore, the ADC value could be a new perspective to ascertain the effectiveness of mechanical thrombectomy in large ischemic regions.
ABBREVIATIONS:
ASPECTS = Alberta stroke program early CT score; ADC = apparent diffusion coefficient; DWI = diffusion-weighted imaging; mRS = modified Rankin scale
Abstract TP80: Regional Trends And Variation In Mortality By Subgroups Following Mechanical Thrombectomy In Geriatric Acute Ischemic Stroke-related Hospitalizations In Urban Facilities, 2016-2019
Authors: Desai Rupak , Singh Monika , Anil Peethambar Gowri , Rana Nishtha , Jitta Sahas Reddy , Madine Makarand , Sanikommu Sailaja , Perera Ayodya , Juveria Fnu , Gudiwada Mohan Chandra Vinay Bharadwaj , Rupareliya Chintan
Published: February 2023

Background:
Mechanical thrombectomy (MT) has been proven to be a successful treatment option for patients with acute ischemic stroke (AIS) in numerous randomized controlled trials. The majority of trials underrepresent patients aged 70 and above, and there is little contemporary data on regional trends and variation in mortality.

Methods:
This retrospective study using the National Inpatient Sample (2016-2019) seeks to identify any regional relationships between geriatric patients' in-hospital mortality after MT for AIS at urban facilities and trends in inpatient mortality. Regional Inpatient mortality based on sex and race and trends between 2016 and 2019 were assessed.

Results:
Our study group consisted of 52455 AIS-MT admissions (median 78 yrs, 57.1% male, 77.2% white, 89.6% Medicare enrollees) with a 14.1% inpatient mortality rate. Despite having a lower comparative burden of traditional CVD risk factors, the hospitals from the Northeast had a higher inpatient mortality rate (17.2%, n=1650) and risk (adjusted OR:1.25, 95% CI:1.03-1.51) than the other regions. Similar trends were observed in male (18.1%), females (16.6%), white (17.3%) and black (13.8%) participants (P<0.001) undergoing AIS-MT. Highest inpatient mortality among Hispanics was linked to Midwest-based participants (16.2%) without regional variation in rates for Asians. There were declining trends in mortality between 2016 to 2019 in West region without any change in other regions (from 14.0% to 11.5%, ptrend=0.002)
(Fig. 1)
.

Conclusion:
Among demographically comparable geriatric patients with AIS undergoing MT in the US, the Northeast region admissions showed the highest inpatient mortality even after controlling for confounding factors with a relatively lower burden of CVD risk factors. This disparity warrants further research to validate these findings.
Abstract TP82: Factors Associated With Trainee Burden In Post-stroke Goals Of Care Meetings
Authors: Oh Daniel M , Lee Edward , Oh Samuel , Kamal Naveed , Sahoo Anurag , Sung Gene Y
Published: February 2023

Introduction:
Goals of care discussions with patients or surrogates are a crucial part of inpatient care. Explaining neurological diagnoses, functional outcomes, and prognoses can be challenging. We surveyed trainees regarding factors associated with burden in goals of care meetings.

Methods:
An anonymous online survey was sent to neurology and neurosurgery trainees at the Los Angeles County + University of Southern California and Vanderbilt University Medical Centers. The survey inquired awareness of hospice criteria, reliance on verbal communication, moral injury (sense of futility, helplessness, or densensitization), need for preparing surrogate decision makers, and factors associated with burden using a 5-point Likert scale. Proportions of responses with agree or strongly agree were calculated.

Results:
22 out of 69 residents (31.9%) filled out the survey. 36.4% were aware of any stroke-specific hospice criteria. 86.4% felt physician’s communication skill the most important factor for a constructive goals of care meeting. 36.4% felt neurologists and neurosurgeons relied too much on verbal communication to explain neurological deficits and prognosis. 40.9% felt moral injury during goals of care discussions. 77.3% felt that the patients or surrogate decision makers need to be more prepared. 27.2% felt underprepared for goals of care meetings. Top three factors of burden were time (86.4%), redundancy in explaining (81.8%), and lack of health literacy in patients or surrogates (77.3%). Most helpful factors were a team member who speaks the same language (72.7%), delivering poor prognosis upfront when applicable (68.2%), and frequent bedside updates (54.5%). 90.9% wished there was a customized goals of care planning resource for the surrogates prior to the formal meeting.

Conclusions:
Majority of trainees found communication and language the most helpful factors for goals of care meetings. Meanwhile, time, redundancy, and lack of health literacy among patients and surrogates were top factors of burden. Majority also felt that patients or surrogates needed to be better prepared and wished for customized resources prior to the meetings. Customized resource might help improve the quality of goals of care discussions and decrease trainee burden.