bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP322: Predictors of 90-day Hospital Readmission After Ischemic Stroke
Authors: Chang Andrew D , Dakay Katarina , Hemendinger Morgan , Cutting Shawna M , Saad Ali , Jayaraman Mahesh V , McTaggart Ryan A , Furie Karen L , Yaghi Shadi
Published: October 2018

Background:
Hospital readmissions carry significant burden on both patients and providers, and may be preventable by appropriate identification of high-risk patients. In this study, we aimed to identify factors predictive of hospital readmission following ischemic stroke.

Methods:
We abstracted data from our ischemic stroke database and included all patients with ischemic stroke from April 1
st
, 2016 to March 31
st
2017. Follow-up information was obtained at 90 days and included whether patients had been readmitted to Rhode Island Hospital. Patients were divided into two groups - those who had been readmitted at 90 days vs. not readmitted at 90 days. We compared baseline demographics including age, vascular risk factors, NIHSS score, acute stroke treatment (mechanical thrombectomy and IV thrombolysis), stroke subtype determined based on ESUS criteria, and hospital acquired-infections, hospital readmission rate.

Results:
We identified 600 patients with ischemic stroke; 185 patients (30.8%) were readmitted at 90 days. On univariate analyses, readmitted patients were more likely to have a higher 24-hour NIHSS (3 vs 2; p=0.007), and more likely to have hypertension (82.0% vs 72.9%; p=0.021), atrial fibrillation (36.6% vs 23.8%; p=0.002), congestive heart failure (14.7% vs 5.8%; p=0.001), large vessel occlusion (54.5% vs 43.8%; p=0.033), and cardioembolic stroke subtype (36.4% vs 25.3%). Moreover, readmitted patients were less likely to have cryptogenic stroke subtype (31.8% vs 44.1%; p=0.006). On regression models, hypertension (adjusted OR 1.78; 95% CI 1.02-3.10, p=0.043), atrial fibrillation (adjusted OR 3.12; 95% CI 1.08-9.00, p=0.035), congestive heart failure (adjusted OR 2.80; 95% CI 1.29-6.06, p=0.009), and cardioembolic stroke subtype (adjusted OR 0.32; 95% CI 0.10-0.98, p=0.046) were predictive of hospital readmission at 90 days.

Conclusion:
Nearly 30% of patients admitted with ischemic stroke are re-admitted in the next 90 days. Efforts to identify causes of re-admission particularly among high risk patients are needed to reduce the re-admission rates among stroke patients.
Abstract TP329: Role of the Haptoglobin-CD163 Scavenging System in Intracerebral Hemorrhage
Authors: Leclerc Jenna L , Li Chris , Jean Stacy , Doré Sylvain
Published: October 2018

Background:
Hemoglobin (Hb) released by red blood cell lysis following intracerebral hemorrhage (ICH) causes neuroinflammation and cell death, inflicting irreversible brain damage. Haptoglobin (Hp) and CD163 form a scavenging system for Hb to protect tissues from its cytotoxic effects: Hp binds to Hb, and this complex is endocytosed by macrophages/microglia expressing the membrane receptor CD163. Currently, there is no effective treatment against ICH, and limited research exists on the respective functions of Hp and CD163 after ICH. This study aims to investigate the effects that Hp and CD163 have on outcomes after ICH in knockout animals.

Methods:
Automated striatal collagenase injection was used to induce ICH in wildtype (WT) control, CD163-/-, Hp-/-, and Hp-/-xCD163-/- mice. Functional motor outcomes were assessed at 24, 48 and 72h following ICH using neurological deficit scoring, open field locomotion, and accelerating rotarod. Animals were euthanized at 72h to measure anatomical outcomes through cresyl violet, Perl’s iron, and immunohistochemical staining.

Results:
Lesion volume, hematoma volume, and tissue injury in CD163-/- mice was 27.5+/-5.8% (p<0.0001), 30.6+/-4.6% (p=0.0021), and 23.0+/-4.1% (p=0.0041) smaller compared to WT, respectively. Lesion volume and tissue injury in Hp-/- mice was 28.2+/-7.2% (p=0.0006) and 29.5+/-2.5% (p=0.0011) smaller compared to WT, respectively. No significant differences in these measurements were detected between Hp-/-xCD163-/- and WT mice. Preliminary data for additional measures are as follow: Hp-/- mice had smaller hemispheric enlargement (an indicator of brain edema) and blood-brain barrier breakdown compared to WT mice, less iron and astrogliosis compared to WT and CD163-/- mice, and less induction of heme oxygenase compared to all other groups. The CD163-/- mice had less total Hb in brain tissue and less blood-brain barrier breakdown compared to WT mice. The Hp-/-xCD163-/- mice had less blood-brain barrier breakdown compared to WT mice.

Conclusion:
These initial findings demonstrate the differences in recovery following ICH. The outcomes of this preclinical study help in the design of future clinical trials to limit devastating brain damage following ICH.
Abstract TP33: Code Stroke vs Code STEMI: Greater Clinical Impact From Accelerating Door to Endovascular Reperfusion for Acute Ischemic Stroke Than Acute Myocardial Infarction
Authors: Aggarwal Sudhir , Saver Jeffrey L
Published: October 2018

Introduction:
Acute ischemia of brain or heart, from large vessel occlusions (LVOs), are two emergent conditions in which timely endovascular reperfusion can improve outcomes. Studies of onset to reperfusion time (OTR) have indicated greater gains from faster reperfusion in acute ischemic stroke (AIS) than ST-elevation myocardial infarction (STEMI), but are limited by uncertainty about time of onset, especially in AIS. Door to reperfusion time (DTR) is a more reliable index of time-benefit relationships, and has not been comparatively investigated in AIS vs STEMI.

Methods:
We performed a systematic literature search to identify studies (RCTs and registries) between 2000 and 2015 reporting relation between DTR or OTR and clinical outcomes for AIS-LVO and STEMI. Study sample size weighting was used to estimate outcome change with every 15 min reduction in ischemia time from arrival at hospital, or onset.

Results:
Systematic search identified 5 AIS-LVO studies with 1287 patients, and 16 STEMI studies with 136495 patients. AIS-LVO studies were RCTs pooled and analyzed in the HERMES collaboration. For AIS, median (patient-level) DTR was 148 min (IQR 112-197) and median OTR 286 min (IQR 215-363); for STEMI, median (study-level) DTR was 90 min (range 30-270) and median OTR 219 min (range 75-330). Among clinical outcomes (Table), the most responsive to faster DTR was functional independence (mRS 0-2) at 90 days for AIS-LVO; for every 15 minutes faster DTR, 25 more patients per 1000 attained mRS 0-2. Mortality reduction with faster DTR was similar for both AIS-LVO and STEMI; for every 15 min acceleration, 3 to 6 more of 1000 treated patients survived. Each minute in the DTR mattered 2-3x more than OTR, while there was no major difference for STEMI.

Conclusion:
Considering important clinical outcomes, accelerating DTR has 5-fold greater benefit in AIS than in STEMI. The brain is an extremely vulnerable end-organ due to its eloquence, functional diversity, and sensitivity to ischemia.
Abstract TP331: Plasma IL-6 Levels are Independently Associated With Functional Outcome and Markers of Secondary Injury in Spontaneous Intracerebral Hemorrhage
Authors: Leasure Audrey C , Steinschneider Arthur F , Falcone Guido J , Gilmore Emily J , Sansing Lauren H , Sheth Kevin N
Published: October 2018

Introduction:
The impact of the inflammatory response after intracerebral hemorrhage (ICH) has not been well characterized in patients and little is known about the relationship between early markers of inflammation and functional outcome. It is hypothesized that cytokine levels may be associated with three-month functional outcome and radiologic markers of secondary injury.

Methods:
Fifty-four patients with spontaneous ICH were prospectively enrolled at Yale-New Haven Hospital. Blood samples were collected at 24 (n=44) and 72 (n = 33) hours post-ICH. Plasma cytokine levels were measured using commercially available multiplex ELISA kits (Millipore). Modified Rankin Scale (mRS) was collected at three months by telephone interview. Associations between cytokines and outcome were assessed using ordinal logistics regression. Linear regression was used to evaluate the association between cytokine levels and markers of secondary injury.

Results:
IL-6 was correlated with ICH volume (p = 0.003) and PHE volume (p = 0.009) in univariable analysis. In multivariable analysis, IL-6 was associated with midline shift after adjustment for ICH volume (p=0.027). 24h IL-6 (p < 0.001), IL-10 (p < 0.001), IL-15 (p = 0.001), admission Glasgow Coma Score (GCS), ICH volume, ICH Score, and external ventricular drain (EVD) placement were associated with higher (worse) mRS in univariable ordinal regression. After adjustment for the ICH score, 24h IL-6 (OR 2.00, 95% CI 1.2-3.3, p = 0.003) and IL-15 (OR 2.7, 95% CI 1.4-5.0, p = 0.007) were significantly associated with worse mRS.

Conclusions:
Plasma IL-6 is independently associated with 24h midline shift, a measure of global hemispheric swelling, and with functional outcome after spontaneous ICH. These data are consistent with the early robust increase in brain IL-6 in experimental models of ICH. These data warrant further investigation of IL-6 levels as a biomarker for secondary injury and poor outcome in ICH.
Abstract TP336: Acute Stroke in CADASIL: Emphasising on Intracerebral Haemorrhage
Authors: Chen Chih-Hao , Cheng Yu-Wen , Tang Sung-Chun , Chiou Hung-Yi , Jeng Jiann-Shing
Published: October 2018

Introduction:
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a common genetic cause of cerebral small vessel disease. In addition to ischemic stroke (IS), patients with CADASIL may also suffer from intracerebral hemorrhage (ICH). This study aimed to clarify the acute stroke presentation among CADASIL patients in Taiwan.

Methods:
We enrolled 106 genetically confirmed CADASIL patients (49 from a single university hospital; 57 from positive screening results of
NOTCH3
R544C hotspot mutation in a national stroke registry). Acute stroke events with well-documented clinical and neuroimaging features of were included for further analysis.

Results:
There were 25 (38%) ICH among 66 patients with well-documented acute stroke events. The mean ICH volume was 12.4 ml, and 39% had intraventricular hemorrhage. The most common ICH location was thalamus (56%) and putamen (20%). Among ICH patients, those with past history of hypertension (88%) had larger ICH volume (13.7 ml vs 3.6 ml) and worse functional outcome at discharge (modified Rankin scale, mRS, 3.5 vs 1.0). While in 41 IS events, subcortical white matter was the most common location (49%), and small vessel occlusion type was the predominant pattern (68%). Patients with ICH had significantly higher stroke severity (mean NIHSS score, 14.0 vs 4.4,
P
<0.01), worse function outcome at discharge (mRS 3.3 vs 2.1,
P
=0.02), and higher mortality rate (28% vs 2.4%
P
<0.01) then IS. Higher age (OR 1.11, 95% CI 1.02 - 1.21) and NIHSS score at admission (OR 1.44, 1.12 - 1.83) were predictors of poor function outcome (mRS >2) at discharge. Of 47 patients with available follow-up information, 22 (47%) of them had at least one recurrent stroke, and the recurrent events can be either ICH or IS in spite of the first stroke type.

Conclusions:
We found a high proportion of ICH among CADASIL patients with acute stroke events, and those with ICH had significant worse outcome than IS counterpart.
Abstract TP338: The Obesity Paradox in Spontaneous Intracerebral Hemorrhage in the Nationwide Inpatient Sample
Authors: Persaud Steven , Donath Elie , Dangayach Neha , Mocco J , Kellner Christopher P
Published: October 2018

Introduction:
Obesity is a well-established risk factor for cardiovascular disease and stroke. While a risk factor for the occurrence of these diseases, obesity has been shown to be unexpectedly protective in cardiac disease and ischemic stroke. Here we report the obesity paradox in patients with intracerebral hemorrhage (ICH) in the Nationwide Inpatient Sample (NIS).

Methods:
Clinical data for adult patients admitted for ICH were extracted from the Nationwide Inpatient Sample (NIS). Body habitus was classified as nonobese (body mass index [BMI] < 30 kg/m2), obese (BMI ≥ 30 kg/m2 and ≤ 40kg/m2), or morbidly obese (BMI>40kg/m2). Multivariable logistic regression analyzed the association of body habitus with in-hospital mortality rate, discharge disposition, extended length of stay, tracheostomy or placement of an endoscopic percutaneous gastrostomy, and ventriculoperitoneal shunt placement. Covariates included patient demographics, comorbidities, insurance status, occurrence of a craniotomy/craniectomy, and hospital characteristics. Cox proportional hazard regression also analyzed the effect of body habitus on in-hospital mortality.

Results:
In total, data from 61,324,882 patient discharges was screened from the NIS between 2007 to 2014. Of these, 99,212 patient discharges were 18 or older and admitted with atraumatic ICH as the primary diagnosis. In a multivariable logistic regression, both obese (0.67 [0.62, 0.76] p<.001) and morbidly-obese (0.85 [0.74, 0.97] p =0.02) patients were associated with decreased odds of in-hospital mortality as compared to those patients who were nonobese. This effect was not seen in other surrogate measures of outcome including non-routine discharge, extended hospitalization, tracheostomy/gastrostomy placement, and VP shunt placement. A Cox proportional hazards model also demonstrated that both obese (0.71 [-0.41, -0.26] p<.001) and morbidly obese (0.89 [-.021, -0.02] p<.001) patients had a significantly decreased risk of death during their hospital stay.

Conclusion:
Obesity appears to be associated with decreased inpatient mortality in spontaneous ICH in a large national dataset even when controlling for demographic and clinical course factors.
Abstract TP34: Real World Efficacy of Endovascular Thrombectomy in Patients With Acute Cerebral Large Vessel Occlusion in Japan - First Report From RESCUE-Japan Registry 2
Authors: Yoshimura Shinichi , Sakai Nobuyuki , Uchida Kazutaka , Ezura Masayuki , Okada Yasushi , Kitagawa Kazuo , Kimura Kazumi , Sasaki Makoto , Tanahashi Norio , Toyda Kazunori , Furui Eisuke , Matsumaru Yuji , Minematsu Kazuo , Yamagami Hiroshi , Morimoto Takeshi
Published: October 2018

Introduction:
Several randomized trials showed the endovascular thrombectomy (EVT) was effective in patients with acute cerebral large vessel occlusion, but the efficacy to general patients were unknown.

Methods:
Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism (RESCUE)-Japan Registry 2 was prospective registry of acute cerebral large vessel occlusion at centers in Japan. The patients were 20 years or elder and admitted within 24 hours after the onset of cerebral large vessel occlusion in both anterior and posterior circulation. Primary endpoint was good outcome defined by modified Rankin Scale (mRS) of 0-2 at 90 days after onset. Secondary endpoint was mortality. Adjusted odds ratio (OR) was estimated by logistic regression model accounted for potential confounders. Safety endpoints were all bleeding included intracerebral hemorrhage, gastrointestinal bleedings, recurrence of stroke, and other adverse events within 90 days.

Results:
Consecutive 2420 patients were recruited from October 2014 to September 2016, and follow-up ended at January 2017. Excluding 12 patients who did not meet inclusion criteria, 1281 patients were treated with EVT and 1127 were without. Mean age was 75 and 77 years in EVT and no-EVT groups, respectively. Posterior circulation accounted for 13% in both groups. Intravenous alteplase was administered in 47% and 32% of EVT and no-EVT groups, respectively. Good outcome was observed in 41.7% and 30.7% the EVT group and no-EVT group, respectively (p<0.0001). Adjusted OR of good outcome of EVT relative to no-EVT was 1.79 (95%CI: 1.39-2.29). Prespecified subgroup analyses showed the EVT was effective in anterior circulation [adjusted OR 1.7 (95%CI 1.3-2.2)] while not effective in posterior circulation [adjusted OR 1.3. (95%CI 0.6-3.0)] (interaction p=0.34). The mortality was 8.8% and 13.6% in EVT group and no-EVT group (p=0.0002). Intracerebral bleeding occurred within 72 hours from onset in 26% in EVT group while 19% in no-EVT group (p<0.0001).

Conclusions:
EVT was shown effective in general patients with acute cerebral large vessel occlusion in terms of mRS and mortality at 90 days. The indication of EVT for posterior circulation should be reconsidered. 
Abstract TP346: Older Age is Not Associated With Worse Outcomes Following Decompressive Hemicraniectomy for Spontaneous Intracerebral Hemorrhage
Authors: Poblete Roy , Nguyen Peggy , Benjamin Emanuel , Bulic Sebina , Kim-Tenser May , Sanossian Nerses , Mack William
Published: October 2018

Introduction:
Despite low-quality evidence, decompressive hemicraniectomy (DHC) is commonly offered following large spontaneous IPH as a life-sparing measure. When done for large MCA stroke, older age strongly predicts worse outcomes. The relationship between age and outcomes following DHC for IPH is unknown.

Hypothesis:
In patients with spontaneous IPH who undergo DHC with or without hematoma evacuation, age is significantly associated with worse short-term outcomes.

Methods:
In this retrospective study, Nationwide Inpatient Sample (NIS) data was queried between years 2000-2011. The NIS is a large inpatient care database containing a 20% sample of discharge-level records in the US. For this study, subjects were categorized by age: 18-50, 51-60, 61-70, and >70. Cases of spontaneous IPH were isolated by the code 431.x and DHC by codes 01.25 or 01.52. Those with other neurologic injuries or surgeries were excluded. Demographic and sample characteristics were compared using χ
2
testing across groups. Multivariate Poisson regression using generalized estimating equations derived adjusted rate ratios with gender, length-of-stay and comorbidity index as covariates.

Results:
Within the 12-year period, 11,297 DHC cases for spontaneous IPH were estimated, with rates in decline. The frequency of DHC was similar between age groups. Crude outcome rates are shown in figure 1. In-hospital mortality was 28.9%, and was not associated with age (p=0.57). Poor outcome, including death and institutionalized care, occurred in 86.36% of cases, and was not associated with age in multivariate regression. Total complication rate was similar between groups, while herniation was associated with younger age (p<0.01).

Conclusions:
In conclusion, the majority of patients undergoing DHC for spontaneous IPH have poor outcome, with no association found between age, mortality and poor outcome. In younger individuals, the benefit of DHC may be offset by higher herniation rates.
Abstract TP348: Predicting 365 Day Outcomes for Spontaneous Intracerebral Hemorrhage And Intraventricular Hemorrhage Survivors With Poor Outcome on Day 30
Authors: Shah Vishank A , Yenokyan Gayane , Dlugash Rachel , McBee Nichol , Awad Issam , Hanley Daniel F , Ziai Wendy C
Published: October 2018

Objective:
Prediction of long-term functional outcome in spontaneous intracerebral and intraventricular hemorrhage (ICH/IVH) is typically based on a limited number of severity factors known on admission. We investigated whether factors known at day 30 including medical comorbidities and in-hospital events in poor outcome survivors could accurately predict good vs. poor functional outcome at day 365.

Methods:
We explored the relationship between ICH severity factors, medical comorbidities, prospectively collected and adjudicated events during first 30 days post ictus, and outcomes using data from the Clot Lysis: Evaluating Accelerated Resolution of Hemorrhage with Alteplase (CLEAR III) trial. We defined outcome using blinded assessment of mortality and modified Rankin scale (mRS) at 30 and 365 days (>3 signifying poor outcome). Multivariable logistic regression was used to predict mRS at day 365 from poor outcome survivors at day 30.

Results:
Of 500 patients included in CLEAR III with ICH and severe IVH requiring external ventricular drainage, 345 (69%) had mRS 4 or 5 on day 30. The best performing model for distinguishing between patients with and without good outcome at 365 days included: age (Odds Ratio [OR], 0.93; 95% Confidence Interval [CI], 0.90- 0.96), COPD (OR, 0.17; CI, 0.04-0.80), diabetes (OR, 0.50; CI, 0.25-0.98), hyperlipidemia (OR, 2.07; CI, 1.01-4.27), bacterial ventriculitis (OR, 0.34; CI, 0.13-0.91), cerebral perfusion pressure <50 mmHg during first week (OR, 0.08; CI, 0.01-0.50), absent IVH on day 30 CT scan (OR, 3.08; CI, 1.69-5.62), enrollment (e) eICH volume (OR, 0.91; CI, 0.87-0.95), eIVH volume (OR, 0.97; CI, 0.95-0.99), thalamic ICH location (OR, 0.29; CI, 0.14-0.60), and eGlasgow Coma Scale (OR, 1.15; CI, 0.1.06-1.26). Cross-validated area under ROC curve (95%CI) was 0.81 (0.77-0.86) vs. 0.78 (0.73-0.82) for standard ICH prediction model with only enrollment predictors.

Conclusions:
Among patients with spontaneous ICH and IVH requiring external ventricular drainage, 30-day prediction models for long-term functional outcomes have substantial predictive capability. Addition of medical comorbidities and in-hospital events to models using well-known ICH severity factors is of some value.
Abstract TP349: Clinical Outcomes of Direct Oral Anticoagulants versus Warfarin in Patients With Atrial Fibrillation Who Have Had an Intracerebral Hemorrhage
Authors: Janumpally Ravi , Ambartsumyan Arevik S , Duan Lewei , Gharibian Derenik , Sangha Navdeep
Published: October 2018

Introduction:
It has recently been demonstrated in a meta-analysis that patients with a history of intracerebral hemorrhage (ICH) and atrial fibrillation have a reduced risk of ischemic stroke (IS) with the initiation or resumption of oral anticoagulation (OAC). It remains uncertain if there is a difference in clinical outcomes between direct oral anticoagulants (DOAC) compared to warfarin (WF) in this patient population. We aimed to compare these two populations using data from the Southern California Kaiser Permanente (SCKP) health care system.

Methods:
Patient records with ICH and AF diagnosis were obtained from the SCKP Database, and divided into two cohorts: WF or DOAC. Subjects were included if the OAC was started after the index ICH. CT scans within 24 hours of symptom onset were examined for: ICH location, ICH size (Using the ABC/2 method), and leukoariosis. If available, an axial gradient echo sequence MRI scan taken within 180 days, either before or after the index ICH was examined for microbleeds. Differences in demographics, concurrent medications with an antithrombotic effect and statins, and traditional vascular risk factors were assessed using Kruskal-Wallis and Chi-Square tests.

Results:
Eighty-one subjects were identified (53 WF and 28 DOAC). In the DOAC group, 18 patients were on dabigatran, 9 on apixaban and 1 on rivaroxaban. There was no difference between WF and DOAC in baseline demographics, concurrent medications and location of ICH. The mean ICH volume was 15.4cc in DOAC and 5.6cc in WF (P=0.09). Time to start drug from ICH was 15.0 and 24.5 months for DOAC and WF respectively (P=0.26). More patients died in WF (28.3%) vs DOAC (10.7%) (P=0.0478). There was no difference in time to IS, ICH and major hemorrhage between the two groups. The composite outcome of IS, ICH, Major Hemorrhage and death was 35.8 % in WF vs 25% in DOAC group (P=0.32).

Conclusion:
Our results, while limited in size, suggest that patients with a previous ICH with AF, who are started on a DOAC have lower mortality compared to WF. There was a higher percentage of patients in the WF group who met the composite outcome of IS, ICH, major hemorrhage and death, but this did not reach statistical significance.
Abstract TP353: Stroke Alert: A Process That Works
Authors: Dambrosio Robin , Grant Lois , Avis Elizabeth
Published: October 2018

Background and Issues:
Stroke, an interruption of blood supply to the brain, can leave patients with devastating neurologic deficits. To diagnose and treat hospitalized patients with stroke, this university hospital had a Stroke Alert (SA) system in place, with the goal of minimizing devastating sequella of each event.

In early 2015, a need to strengthen the in-house SA was recognized. At this time, the response to SA was a neurology physician, who coordinated care. Recognition of stroke and activation of this alert had been underutilized.

Purpose:
To raise stroke awareness, to increase SA activations, and to bring timely and appropriate treatment to in-patients experiencing stroke, a process change was enacted.

Methods:
In February, 2015, the Stroke Program Manager introduced the concept of involving the Rapid Response Team (RRT) and RRT nurses in the SA. The RRT nurses received targeted stroke education, as well as house-wide education in recognition of signs and symptoms of stroke, as well as activation of the system. RRT was then activated with each SA.

To measure the effectiveness of this process change, the number of SAs were counted and calculated to a rate per 1000 patient days. The results were graphed and compared.

Results:
The rate of SA per 1000 patient days was 0.793 in 1Q15, and rose to 1.626 by 1Q17.

Conclusions:
This data suggests the involvement of RRT, RRT nurses, and house-wide education contributed to an increase in SA activations. This increase in activations increased the opportunity to bring timely and appropriate treatment to in-patients experiencing stroke.
Abstract TP354: Comprehensive Stroke Center Recertification Visit Preparation
Authors: Fuhrman Sue , Lazzaro Marc
Published: October 2018

Background and Issues:
The Comprehensive Stroke Center (CSC) Program Coordinator (PC) started her role at the same time as the CSC recertification application was due. The required documentation and components of a program that need to be presented to reflect compliance with standards is extensive. By having less than 6 months to become familiar with the program, address gaps, educate staff, and partner with providers and other disciplines, and assure optimal patient care is provided; a team approach using a multitude of preparation/communication methods was needed.

Purpose:
The purpose of this program effort was to identify and implement strategies that prepare the organization for a successful CSC Recertification.

Methods:
Many approaches were used in the preparation process which included: Observe and shadow in key areas (ED, IP, NICU, IR, IP Rehab, Clinic, Neurocritical Care, Neuro IP Team and other areas); Review evidence to assure most current guidelines provide basis for program; Consolidate Primary and Comprehensive Stroke Center standards; Complete gap analysis; Engage Interprofessional team; Identify our documents which reflect standards compliance; Identify educational needs/provide education; Develop online resources and tools for constant accessibility; Collaborate on presentation materials; Communicate, communicate, communicate; Practice presentation and interaction; Complete a team walking tour of survey; Engage staff in a mock survey; Keep everyone updated via newsletters and staff meeting updates.

Results and Conclusions:
Team members and staff verbalized a high degree of readiness for the survey with the preparation methods utilized. Lessons learned include: Prioritize actions based on our patient-centered mission/vision/values; Realize that everything may not be in its final state before the survey but have a plan to ensure completion; Engaging the full team in the preparation process helps identify potential issues and solutions that may not have otherwise been known; Utilize technology to expedite communication and education; have a physical presence throughout the care process areas.
Abstract TP356: Advanced Stroke Life Support® Course Significantly Improves Knowledge of Stroke Diagnosis and Management for Prehospital and Hospital-Based Providers
Authors: Anzardo Evelyn V , Motola Ivette , Brotons Angel A , Carter Steven P , Rodriguez Richard D , Issenberg S. Barry
Published: October 2018

Introduction:
Comprehensive stroke education is necessary for rapid and effective diagnosis and treatment of stroke victims, especially in the prehospital and emergency department settings. Early acute stroke recognition and appropriate treatment lead to improved patient outcomes. Prehospital and hospital-based health care providers can make the difference between the opportunity for recovery, or a life of long-term disability, and even death. Advanced Stroke Life Support (ASLS®) is a one-day, evidence-based stroke course consisting of didactic lectures and interactive instruction. The sessions include video-based cases where the learners diagnose and develop a management plan for patients with strokes or stroke mimics; skills sessions where learners examine standardized patients who simulate major stroke syndromes; and an interactive game as a course summary. The purpose of this study is to evaluate the ASLS® course’s impact on knowledge of stroke diagnosis and management among prehospital and hospital-based providers.

Methods:
The ASLS® course was delivered to prehospital and hospital-based providers throughout the United States. All instructors were trained in a train-the-trainer program administered by the ASLS® home site faculty. A total of 9,678 prehospital and hospital-based personnel participated in the course between November 19, 2014 and May 31, 2017. Outcomes were measured using previously validated 25-item written pre-course and post-course assessments.

Results:
A total of 9,678 participants were included in statistical analyses. Using IBM SPSS Statistics, v.24, paired sample t-tests were performed on the data. Learners demonstrated a statistically significant increase in knowledge from pre- to post-course assessment, from a pre-course mean of 64.4% to a mean of 89.1% at post-course assessment (p < .001). Statistically significant increases in knowledge also occurred within both learner groups, with performance for prehospital learners rising from 63.8% to 90% (p < .001). Hospital-based learners improved from 64.8% to 88.6% (p < .001).

Conclusions:
Prehospital and hospital-based providers who participated in the ASLS® one-day course significantly improved their knowledge of stroke diagnosis and management.
Abstract TP357: BP Management on the Mobile Stroke Unit for Ultra-Early Treatment of ICH and Acute Ischemic Stroke
Authors: Alexandrov Anne W , Bryndziar Tomas , Rike Joseph , Swatzell Victoria , Dusenbury Wendy , Rhudy James , Hossein Zadeh Maleki Ana , Koury Dave , Chulpayev Boris , Krishnaiah Balaji , Nearing Katherine , Malkoff Marc , Metter E. Jeffrey , Alexandrov Andrei V ,   REACH-MOST Investigators
Published: October 2018

Background:
Lowering of blood pressure (BP) is discouraged in current ASA guidelines for emergency medical service (EMS) personnel. However, ultra-early treatment with IVtPA and BP lowering in ICH are possible on mobile stroke units (MSU). We examined the effectiveness and safety of two antihypertensive agents for MSU treatment.

Methods:
Consecutive MSU patients were treated with target ICH BP parameters less than 140/90, and IVtPA BP parameters by current guidelines. BP was measured by noninvasive oscillometric cuff, and cycled every 5 minutes per EMS MSU protocol. Available agents were labetalol IV 10-20mg and/or nicardipine double-strength premix infusion started at 5mg/hour and titrated. Preference in usage, and effect were recorded and analyzed for the first year of MSU operation.

Results:
During 168 service days, 127 acute stroke patients were transported (68±16, range 23-96 years; 58% women; 65% African American, 34% White; 1% Hispanic). Fifteen (12%) had hemorrhage on CT (1 aneurysmal SAH, 1 SDH, 1 subacute AIS with HT-2; 12 HTN ICH [median ICH score 2, IQR 1-3] of which 1 had a positive spot sign on CTA). AIS cases (n=100) had median NIHSS 9 (IQR 7-17); 38% were treated with IVtPA at a median 13 (IQR 11-16) minutes from scene arrival, one of these by IO route, with 1 angioedema and 0 sICH. Labetalol was used for 9 patients, with all but one (89%) requiring the addition of nicardipine infusion. In 24 patients nicardipine was the first agent selected, with 100% achieving target BP control prior to hospital arrival.

Conclusions:
MSU use of nicardipine double-strength premix infusions provides rapid, reliable, and safe BP control. When time is of the essence, elimination of labetalol, in favor of a dihydropyridine calcium channel blocker infusion may provide the most rapid achievement of prescribed BP parameters.
Abstract TP358: Stroke Nurse Activation Improves Time Metrics For Reperfusion In Acute Stroke Treatment
Authors: Sanjuan Estela , Rubiera Marta , Ribo Marc , Boned Sandra , Santana Katherine E , Rodriguez-Samaniego Maite , Giron Pilar , Rodriguez-Luna David , Muchada Marian , Rodriguez Noelia , Pagola Jorge , Juega Jesus M , Sanchis Mireia , Løpez Espuela Fidel , Molina Carlos A
Published: October 2018

Background and aim:
Shortening door-to-needle(DTN) and door-to-groin (DTG) times without compromising safety, is one of the major goals of reperfusion therapy. A pre-hospital Stroke Code(SC) activation leading to a direct transfer of patients to CT(CT-SC) or to Angio-suit(Angio-SC), bypassing emergency room(ER) in selected patients, has been implemented in our center. To ensure quality and continuous care in this hyperacute process, an expert stroke nurse from the stroke unit is recruited and involved in direct SC transfers. We aimed to assess the impact of the presence of an expert stroke nurse on reperfusion treatment metrics and the safety and feasibility of leaving the Stroke Unit to take care of the SC.

Methods:
Direct transfers after SC activation are performed when the arriving patient has RACE score>4 within <6h from symptoms onset. When information is incomplete or unclear the patient is evaluated in ER before CT(ER-SC). An expert stroke nurse is notified in direct SC transfers.

Results:
During 2016, 812 patients were transferred to our center after SC activation. 289 patients (35,6%) underwent reperfusion treatment [ER-SC 98(33%), CT-SC 146(50%), Angio-SC 48(17%)].

Expert nurse was recruited to attend 138 SC patients who received reperfusion and to 89 who did not(25 hemorrhagic strokes, 17 stroke mimics, 47 ischemic strokes). Our mean DTN time was 28+/-17min and DTG time 41+/-50min in this period. DTN and DTG times were significantly lower in direct transfers compared with ER-SC (DTN 26,2min vs 37,5min p=0.003 and DTG 41,4min vs 79,2min p<0.001). When the expert nurse was present, those times where even lower (DTN 24,3 and DTG 38,9). Regarding feasibility and safety, no major incidents were found in the stroke unit while expert nurse was attending a SC. Nurse mean time out of the stroke unit was 27+/-11,4min in treated patients, while in not treated was 25min+/-10,3min.

Conclusions:
Expert stroke nurse recruitment from the Stroke Unit is feasible and safely helps to improve time indicators in acute stroke reperfusion treatment.
Abstract TP360: The Use of Decision Aids for End-of-Life Surrogate Decision Making for Critically-ill Stroke Patients: A Systematic Review
Authors: Carhuapoma Lourdes R , Hollen Patricia J
Published: October 2018

Background:
In severe stroke, prognostic uncertainty creates challenges for surrogates when asked to maintain or forego life-sustaining treatments for seriously-ill patients. Surrogates experience adverse psychological symptoms associated with decisional conflict surrounding end-of-life (EoL) decision making. A 2013 IOM report maintains that quality of care can be improved by integrating patients and caregivers into decision making at every possible level.

Purpose:
This review was performed to identify levels of evidence in studies of decision aids (DAs) on surrogate decision making in critical illness; determine the feasibility and acceptability of DAs to facilitate EoL surrogate decision making for acutely-ill stroke patients; and evaluate the outcomes of DAs for EoL surrogate decision making for severe stroke patients.

Methods:
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used to generate literature pertaining to DAs used to facilitate surrogate decision making in critical illness. Final keywords used included: “decision aid or decision tool”, “surrogate decision making or family decision making”, and “prognosis or outcome or recovery”. The total number of articles produced was 607 via CINAHL and PubMed. Inclusion/exclusion criteria were used to identify articles of relevance. Following screening, nine studies were selected. Monthly searches will continue to identify current literature.

Results:
Research designs ranged from pilot studies to randomized controlled trials. Four trials provided direction: one was performed in an ICU with patients with prolonged mechanical ventilation; two examined a DA to facilitate goals of care for advanced dementia patients; and one evaluated a video aid to determine the accuracy of surrogate decision making. No studies explored the use of a DA for critically-ill stroke patients.

Conclusion:
There is a need to investigate the feasibility and acceptability of a DA aimed to reduce psychological symptoms in surrogates for critically-ill stroke patients by promoting shared EoL decision making and reducing decisional conflict as well as regret.
Abstract TP361: The Association Between Socioeconomic Factors And Arrival Time To Emergency Departments After Stroke - The T
3
Trial
Authors: Maduka Chinonyelum , Gunaratne Anoja W , Dale Simeon , Mnatzaganian George , D’Este Catherine , McInnes Elizabeth , Middleton Sandy
Published: October 2018

Background:
Socio-economic factors (SES) are associated with mortality, morbidity and access to health services. For optimal outcomes following stroke, it is critical that patients present to Emergency Departments (ED) with minimal delay after the onset of stroke symptoms.

Purpose:
To identify the relationship between residential postcode-based Socio-Economic Indexes For Areas (SEIFA), which ranks geographical areas in terms of relative socioeconomic advantage and disadvantage, and time to ED presentation after the onset of stroke symptoms.

Methods:
We used data from the pre-implementation cohort of the Triage, Treatment and Transfer of patients with stroke in ED’s (T
3
trial) - a cluster randomized controlled trial conducted in 26 Hospitals in three states and one territory in Australia. SEIFA index scores were categorised into tertiles. A multivariable Cox regression modeled the relationship between SEIFA groups and time to ED presentation from symptom onset, adjusting for highest education level, age, sex, modified Rankin Scale (mRS), stroke severity and correlation of arrival time within hospitals using the cluster Huber-White sandwich estimator.

Results:
Of 689 patients, time to arrival was known for 669 (97%). Median arrival time was 2 hours (hrs) (Interquartile range (IQR) 5.5, range 0.05-46). Median arrival time for patients in the lowest SEIFA group was 3 hrs (IQR 6.5, range 0.05-46) compared to 2 hrs (IQR 3.5, range 0.5-38) and 2.5 hrs (IQR 6, range 0.5-26) in those in the middle and higher SEIFA strata, respectively, p=0.2. Multivariable analysis showed that older age (Hazard ratio (HR); 1.56, 95% Confidence interval (CI): 1.14-2.13), female sex (HR; 1.15, 95% CI: 1.03-1.28), moderate or severe stroke severity (HR; 1.44, 95% CI: 1.08-1.92) and middle SEIFA level (HR; 1.29, 95% CI: 1.04-1.59) were all significantly associated with longer time to ED presentation. A disability mRS score of 2 or more (HR; 0.74, 95% CI: 0.58-0.93) was inversely associated with the time to ED presentation, with shorter time to ED presentation observed with increasing disability.

Conclusions:
Targeted education for people with stroke symptoms and the importance of getting to hospital rapidly may help to reduce arrival time to ED and access to critical treatments.
Abstract TP362: Implementation of a Stroke Response Nurse to Decrease Door to Groin Puncture Times in Patients Undergoing Endovascular Intervention for Acute Ischemic Stroke
Authors: Burnett Nicole , Huang David , Soares-Sardinha Sharmila , Waller Ann
Published: October 2018

Background:
A focus on timely reperfusion is a key component to improving outcomes for patients with acute ischemic stroke undergoing endovascular procedures. Since there are many patient factors such as vascular anatomy and procedure tolerance that cannot be controlled, the ability of endovascular centers to expedite the pre-groin puncture process including pre-procedure imaging and assessments is key to achieving reduction of door to reperfusion times.

Methods:
A Plan-Do-Study-Act (PDSA) improvement cycle revealed a baseline process that was cumbersome with delayed door-to-groin (DTG) puncture times. A key experiment in the PDSA cycle included implementation of a Stroke Response Nurse (SRN) to improve DTG puncture times for patients transferring from outside hospitals. The responsibility of the SRN included meeting the patient and the neurology team at a new point of entry (CT scan) in order to provide ICU-level care, bringing a stroke treatment bag with needed monitoring equipment, supplies and medications, facilitate assessments and stabilization of the patient. After initial assessments and imaging are completed, the SRN transports the patient directly to the endovascular suite and hands off care at the bedside to the interventional team.

Results:
Pre-implementation analysis revealed a mean DTG puncture time of 134.3 minutes. In 2015, this time was reduced to 64.4 minutes with a further reduction noted in 2016 to 47.3 minutes. Overall, the implementation of the SRN resulted in a reduction in DTG puncture times of 64.8% from pre-implementation. Door to first pass of thrombectomy device also decreased from 106.2 minutes in 2015 to 73.5 minutes in 2016.

Conclusions:
Patients in need of endovascular therapy for acute ischemic stroke require ICU-level expertise to help with stabilization and treatment upon arrival. In addition, expediting pre-procedure imaging and decision making is key to reducing DTG puncture times. Implementation of an SRN can help to facilitate direct-to-CT scan patient arrivals and evaluations which have led to significant reductions in DTG puncture times.
Abstract TP364: Optimization of Data Abstraction and Quality Measure Reporting using EHR
Authors: Robison Trudy , Snyder Meredith , Adler Tovah , Anderson Anita , Holzmann Matthew , Boxberger Cherie’ , Shepherdson Rick
Published: October 2018

Background and Purpose:
Despite significant investment in EHR’s, most stroke centers continue to populate stroke registries, such as Get with the Guidelines - Stroke using manual abstraction. This is necessary because of a lack of EHR integration and persistence of non-discrete required data elements.

Methods:
American Heart Association (AHA) identified the need to offer a more interoperable version of Get with the Guidelines - Stroke (GWTG-S) as a strategic priority for 2016. AHA engaged a consultant to work with two pilot hospital locations to optimize stroke data collection in the EHR and allowing for automated data population into GWTG-S. The pilot work included: 1) Analysis of current documentation and abstraction methods to support reporting of performance data; 2) Design and implementation of improvement opportunities for a) Discrete capture of data elements for electronic reporting b) Improving clinical documentation and ordering c) Clinical decision support and d) Data structures and transmission. 3) Proof-of-concept data extract report; 4) ROI analysis for improvement opportunities and 5) Proposed implementation strategies and timelines for improvement opportunities.

Results:
The pilot sites implemented Epic tools including Orders, Notes, Narrators and Flowsheets to increase the percentage of discrete elements available for uploading into GWTG-S and to populate hospital quality reporting systems

Conclusion:
The optimization process improved stroke team ability to:1) Decrease manual abstraction, and allow the stroke team to conduct more concurrent review and handle additional patients without additional staff; 2) Quantify data collection; abstraction; and analysis processes for the emergency department team; neurology; interventional team; and stroke unit; 3) Leverage EHR tools for the clinical team to improve utilization; and 4) Demonstrated the critical collaboration between clinical operations and the information technology team.
Abstract TP365: Gender Differences in Symptom Perception and Care-Seeking Behavior in Acute Stroke
Authors: ZRELAK Patricia A
Published: October 2018

Background:
Evidence suggests gender differences in: care seeking behaviors during stroke; stroke knowledge; perceptions of stroke symptoms; physical location at the time of event and decision making, and the impact of having a witness.

Aims:
To determine the impact of gender on the time to presentation (greater or equal to 4.5 hours or greater than 4.5 hours), symptom perception and clinical signs, stroke knowledge and decision making, physical location at the time of stroke, and the presence and impact of having a witnessed stroke.

Study Design:
A descriptive study based on a convenience sample of 60 subjects admitted to an academic medical center for stroke.

Methods:
Patients were asked a series of questions regarding the care seeking decision process, the role of others in the decision process, physical location at the time of event and the decision to seek care, and general stroke knowledge. They also answered a 28 symptom questionnaire which was compared to medical findings.

Results:
There were approximately equal number of men and women in the late and early presenting groups. Early presenting men were more likely to: have a higher admission NIHSS score (7.7 vs 4.8), to receive alteplase (71% vs 20%), to arrive by EMS, and have a witnessed stroke compared to early arriving women. Men were more likely to take an active role in the decision making process to seek care, while care seeking decision making in females was more likely to be transferred to nonspousal family members. Both early and late presenting women reported more non-focal symptoms than men. While most patients had at least one sign or symptom associated with national used stroke symptom acronyms, both genders delayed care because they didn’t perceive their symptoms as being urgent.

Limitations:
Small convenience sample from a single hospital with no control for stroke etiology.

Conclusion:
More research is needed to better understand the influence of gender on patient perception of stroke and care seeking behaviors.