bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP355: The Threshold of Baseline National Institutes of Health Stroke Scale Score to Predict Favorable Outcome After Medical Therapy in Patients With Acute M2 Occlusion
Authors: Kinoshita Naoto , Yamagami Hiroshi , Hayakawa Mikito , Miyazaki Yuichi , Koga Masatoshi , Toyoda Kazunori , Nagatsuka Kazuyuki
Published: March 2022

Objective:
Although endovascular therapy is effective in acute ischemic stroke (AIS) patients with occlusion of the internal carotid artery or proximal middle cerebral artery (M1), the benefit are uncertain in those with the occlusion of distal middle cerebral artery (M2). To select the patient with potentially beneficial effects of endovascular therapy, we aimed to establish the threshold of NIHSS score as a predictive factor for favorable outcome in the patient with M2 occlusion treated with medical therapy alone.

Methods:
Among 2180 AIS patients admitted to our stroke center between October 2011 and February 2015 (ClinicalTrials.gov Identifier: NCT02251665), 72 patients met the following criteria; 1) arrived within 6 hours from the onset, 2) isolated M2 occlusion on MRA, and 3) ASPECTS of ≥ 6 on DWI. Three patients who received endovascular therapy were excluded. We evaluated predictive factors for favorable outcome, defined as a modified Rankin Scale (mRS) <3 or equal to the premorbid mRS at 90 days after the onset.

Results:
A total of 69 patients (26 women, 79.9±8.6 years old) was analyzed, and favorable outcome was achieved in 38 patients (55%). The favorable outcome group had a younger age (median 78 vs 82, p=0.03) and a lower baseline NIHSS score (9.5 vs 15, p=0.07) than the poor outcome group. Using receiver operating characteristic curves analysis, the optimal cutoff value of NIHSS score to predict favorable outcome was 9 (AUC 0.626). After adjusting for age, sex, onset to door time, and intravenous thrombolysis, NIHSS<9 was an independent predictor of favorable outcome (OR 3.95; 95% CI 1.04-18.22).

Conclusion:
In AIS patient with M2 occlusion who treated with medical therapy, the baseline NIHSS score <9 was related to favorable outcome.
Abstract TP361: Effect of Therapeutic Hypothermia on Innate Immune Responses and Functional Outcome After ICH
Authors: Rincon Fred , Harshyne Larry , Hooper Douglas C
Published: March 2022

Introduction:
The objective of this study was to evaluate the effect of therapeutic moderate hypothermia (MH, Tcore33-34°C) compared to normothermia (NT, Tcore36.5-37°C) on innate immune responses and functional outcome.

Methods:
In a clinical trial of temperature modulation after ICH, we measured daily levels of cytokine/chemokine TNFα, IL1, IL6 (M1 response), IL10 (M2 response), and CCL2 in peripheral blood of enrolled patients from day (D) 1-7. Levels were log-transformed to meet assumptions of normality. We used mixed models to evaluate the effect of temperature on the expression of cytokine levels, the t-test to determine the association between cumulative CCL2 log-levels and functional outcome, and Cox-regression to determine the impact of MH on long-term functional outcome adjusted for ICH score (median>2), and initial Sequential Organ Failure Assessment Score (iSOFA, median>3). Poor outcome was defined as mRS=5-6.

Results:
10 ICH patients participated in the study (MH=5, NT=5). Median age was 57 years (IQR 22), 55% women, 66% were Black, median GCS was 7 (IQR 4), and median ICH score was 2 (IQR 1). TNFα, IL1, IL6 vs. IL10 log-ratios decreased significantly over time in MH (Fig.1). Mixed models revealed a significant interaction (arm*day) for MH compared to NT for TNFα (β=-0.1, p=.008), IL1 (β=-.01, p=.02), and IL6 (β=-.04, p=.04) (Fig.1). Cumulative CCL2 log-levels at D7 were lower in ICH patients with mRS 0-4 at 6 months as compared to mRS 5-6 (3.7 ± 0.1 Log-pg/mL vs. 4.2 ± 0.1 Log-pg/mL, p=0.02). Adjusting for ICH score (HR 4.0, 95%CI 0.34-97) and iSOFA (HR 8.8, 95%CI 0.9-295), MH was not associated with poor outcome (HR 0.8, 95%CI 0.5-8.9).

Conclusions:
This novel data suggest that MH significantly up-regulates the anti-inflammatory M2 response compared to NT after ICH. Higher cumulative log-levels of CCL2 are associated with long-term poor functional outcome. MH was not associated with worst functional outcome.
Abstract TP363: Acute Intracerebral Hemorrhage treated in the Intensive Care Unit: Predictors of Admission, Prolonged Stay, and Functional Outcome
Authors: Wang Xia , Wartenberg Katja , Anderson Craig
Published: March 2022

Introduction:
Triggers for admission to the intensive care unit for patients with intracerebral hemorrhage (ICH) are unclear.

Objectives:
To determine the predictors of admission to the intensive care unit (ICU), factors associated with prolonged ICU stay and with long-term outcome in patients with ICH.

Methods:
INTERACT2 was an international, open, blinded endpoint, randomized controlled trial of 2839 patients with spontaneous ICH (<6 hours) and elevated systolic blood pressure (SBP) who were allocated to receive intensive (target SBP <140mmHg) or guideline-recommended (target SBP <180mmHg) blood pressure lowering treatment. Demographic, clinical and radiological indicators associated with an ICU admission, prolonged ICU stay, and poor functional outcome at 90 days were identified by multivariable logistic regression models.

Results:
Younger age, prior stroke, severe clinical deficit, large ICH volume, intraventricular hemorrhage (IVH), early neurological deterioration as well as need for intubation and surgical intervention were identified as predictors for an admission to the ICU. For patients who were admitted to the ICU, those with prior antihypertensive medication, severe clinical deficit, early deterioration, ICH volume ≥15 ml, lobar ICH location, IVH, who underwent intubation or surgical procedures required ICU stays longer. Older age, severe clinical deficit, early deterioration, shorter time to randomization, ICH volume ≥15 ml, and requirement for intubation and surgical intervention were associated with major disability or mortality at 90 days.

Conclusions:
Future plans for risk stratification of ICU admissions for ICH patients may include assessment of ICH volume, presence of IVH, NIHSS, need for intubation along with the age factor.
Abstract TP384: Educating Staff: A Travelers Guide
Authors: Power Martha , Daignault Gabrielle L , Frye John , Gallo Michelle L , McKee Bruce L , Schaffer Angela J , Stoppe Maggie M
Published: March 2022

Background and Issues:
The West Virginia University (WVU) Medicine Stroke EducationTeam (SET) provides innovative stroke education to Nursing and Ancillary staff. The 2015 WVU Stroke Care Fair emphasized broadening all caregivers’ knowledge of the patient experience from the community to rehabilitation. The title “A Travelers Guide through Stroke Care” was chosen to highlight the patient’s journey and transition through the phases of stroke treatment and recovery.

Purpose:
The goal of the Stroke Fair is to educate the interdisciplinary team on the various aspects of stroke recognition, care and recovery. This enhanced understanding improves transitions of care, compliance with performance measures and better patient outcomes by facilitating best practice in stroke care.

Methods:
The SET meets monthly for planning and developing stroke education. The highlight of our educational year is the annual Stroke Fair. The 2015 Stroke Fair used a transportation model to present information in a fun and engaging format. Various modes of transportation represented the stages of the journey. Each site was stationed by a SET member who escorted the participants along their leg of the journey and took on the role of the method of transportation assigned to that section. Four one-hour lectures were provided. The community and ED were represented by the helicopter team. The ICU took on the role of mountain climbers. The in-hospital care was symbolized by a train ride. Participants then sailed to the rehabilitation journey.

Results:
One hundred twelve staff members from Nursing, Pharmacy, Care Management, Rehabilitation Services, and Health Information Management participated. Evaluation comments included: “Provided a view of the big picture”

“Learned more about appropriate hand-off of care”

“I learned how to utilize CPG”

“Stroke Fair is awesome as usual”

“Great props and costumes”

“This is always so fun; appreciate the creativity and enthusiasm from the whole group”

Conclusions:
The WVU SET believes providing quality stroke education contributes to our continued best practice as evidenced by receipt of the Gold Plus GWTG award, Target Stroke Honor Roll Elite award and our Magnet Hospital status.
Abstract TP390: Patterns of Care, Variations and Temporal Trends in Stroke Care: a Brazilian Primary Stroke Center Report
Authors: Alves Monique B , Silva Gisele S , Miranda Renata A , Massaud Rodrigo M , Vacari Andreia M , Cendoroglo Miguel , Diccini Solange
Published: March 2022

Our aims were to describe temporal trends of the performances measures for ischemic stroke and to evaluate factors influencing stroke quality performances indicators.

Methods:
We evaluated consecutive patients discharged with ischemic stroke at Hospital Israelita Albert Einstein from January 2009 to December 2013. Clinical characteristics and ten predefined performance measures selected by the Get with the Guidelines (GWTG) stroke program as targets for stroke quality improvement were evaluated.

Results:
We evaluated 551 patients, the median age was 77.0 years old [64.0-84.0], 58.4% were man and the median time from symptom onset to hospital admission was 345.0 minutes [104.5-1417.5]. The median length of stay was 8.0 days [4.0-14.0], 17.1% received thrombolytic treatment. A good outcome at discharge (modified Rankin scale <3) was observed in 67.6% of the patients, 7.9% of the patients had died. The quality indicators that were different between years were: use of antithrombotic therapy at discharge, cholesterol-lowering therapy, smoking cessation counseling and stroke education. In the univariate analysis being discharged in a Joint Commission visit year (OR 1.84 [1.29-2.61], p<0.01), female sex (OR 0.68 CI [0.48-0.96], p=0.03), dyslipidemia (OR 1.95 [1.33-2.88], p<0.01) and receiving thrombolytic treatment (OR 1.81 [1.08-3.02], CI p=0.02) were found to be associated with a perfect care index of 85% or higher. After multivariate adjustment, only thrombolytic treatment OR 2.06 CI 95%[1.21-3.51] p<0.01, dyslipidemia OR 2.03 [1.36-3.02] p<0.01 and discharge in a Joint Commission’s visit year OR 1.8 CI 95%[1.29-2.65] p<0.01 remained in the model as predictors of higher perfect care index.

Conclusion:
Clinical characteristics like dyslipidemia and being treated with thrombolysis and being admitted in a Joint Commission visit year seems to influence adhesion to quality performance indicators in our Stroke Center. A more continuous evaluation of Stroke Centers by Joint Commission instead of pre specified evaluation visits seems to be justified.
Abstract TP392: Cracking the Code, a Multidisciplinary Approach to Safe, Effective, and Evidence Based Bedside Dysphagia Screening of Stroke Patients With Three Textures
Authors: Bryant Katja , Virani Aneesha , Keable Kristi , Painter Allison , Anker Kim , Croley Jennifer , Douglas Jan , Moore Kathi , Pruitt Jean , Mersfelder Jenna
Published: March 2022

Background:
Within the first three days of a stroke, 42-57% patients present with dysphagia characterized by difficulty swallowing, aspiration, and silent aspiration. Early dysphagia screening is commonly completed using a variety of screening tools, to prevent dysphagia related adverse health consequences and decrease NPO time.

Hypothesis:
The current study proposes that implementing a specific and effective dysphagia screening tool will result in early identification of dysphagia, reduced duration of NPO status, and prevent dysphagia related health consequences.

Methods:
A multidisciplinary team compared literature against our current screening process with water and applesauce in non-specific amounts. A new standard of care for dysphagia screening with a distinct algorithm for decision-making was developed. The algorithm established screening with three general oral intake consistencies including three ounces of water, three teaspoons applesauce and half piece of a graham-cracker. Instructions guiding the practicing nurse were created in the EMR and initiated in Q1 of 2015. Simultaneously, 100% practitioner training was completed by speech pathologists and clinicians. A quality report to monitor compliance with new standard of care and outcomes was recently developed.

Results:
Literature investigation on dysphagia screening in stroke patients yielded the importance of the establishment of a swallow screening tool in patients who exhibit stroke and stroke-like symptoms and in patients reporting or suspected to have dysphagia in general. One of the most common practices is the water swallow screen, which screens patients for safe tolerance of thin liquids. However, in implementation, eludes to patients ability to safely tolerate regular diet consistencies. Based on the significant differences in swallow biomechanics for liquid vs. solid consistencies, we determined the importance of screening the patients swallowing ability beyond passing a screen with thin liquids.

Conclusions:
The new revised, three texture dysphagia screen improves the ability to identify dysphagia earlier and reduce the duration of NPO status. A validation data collection to support these hypotheses is underway.
Abstract TP396: Small Changes Yield Big Dividends
Authors: Hamm Theresa , Helland Brian
Published: March 2022

Background and Purpose:
As a Primary Stroke Center (PSC) serving central Iowa, our facility cares for nearly 800 stroke patients per year. We are also a chest pain and trauma center and our Emergency Department (ED) processes over 86,000 visits per year. High volumes often result in multiple bed and staff assignment changes, flexing with acuity and flow of patients entering the ED, creating some confusion on the part of our EMS partners arriving with stroke alert patients. This led to a perceived indifference on the part of the ED staff. This concern was related to the stroke coordinator by EMS leadership generating a frank discussion with ED leadership.

Methods and Results:
Leadership in the ED, EMS, and the stroke coordinator met to discuss EMS perceptions and concerns. While the PSC was clearly meeting national goals in terms of door to CT and needle times, the negative perception on the part of EMS had the potential to impact destination decisions in the field which could ultimately negatively affect patients. These discussions resulted in a process change. It was determined that an overhead page (which was already in place for trauma alerts) should be implemented for all time critical diagnoses, thereby creating a consistent communication method. Additionally, a page was generated to the stroke team and a physician to physician call was placed when the patient arrived in the ED after rapid assessment.

Outcomes:
As a direct result of this process change, door to CT times were decreased to an average of 6 minutes (an improvement of approximately 3 minutes) and a door to needle time to an average of 40 minutes (a decrease of 12 minutes). The Rapid Response Team is now attending stroke alerts in order to facilitate rapid treatment. There is an increased awareness by hospital administration and staff regarding the high volume of patients served, and a heightened awareness on the part of our patients and their families related to the emergent treatment of stroke. EMS leadership reports a significant improvement in satisfaction among providers leading to an increase in patients arriving via EMS.

Conclusion:
A simple change in stroke alert process has yielded multiple positive outcomes.
Abstract TP398: Telestroke: Expanding the Utilization of Endovascular Treatment
Authors: Guzik Amy , Johnson Rayetta
Published: March 2022

Background:
The Comprehensive Stroke Center at Wake Forest Baptist Medical Center in Winston-Salem, N.C. implemented a telestroke network system in January of 2010 to provide 24/7 access to one of their board certified vascular neurologists. There are presently fourteen hospitals in the network with over 1900 consults and a tPA administration rate of 42%.

In early 2015, positive results from four stroke interventional trials showed that recanalization rates were much higher after stent retrieval compared with tPA alone. It was shown that these devices can safely and effectively remove a blood clot that is causing a stroke, with improved clinical outcomes over IV tPA alone. Wake Forest Baptist has made the commitment to expand the use of intraarterial therapy to give every telestroke patient with a large vessel occlusion an opportunity to experience the outstanding clinical outcomes that have been seen in stroke patients treated at their medical center.

The following guidelines were developed to assist the network physician in determining when to consider interventional treatment:

- The time from onset is less than 6 hrs. (up to 12 hrs. in a suspected basilar artery stroke)

- A NIHSS score equal to or greater than 10 (indicating large vessel occlusion)

Method:
Education was provided regarding the new interventional treatment guidelines and for quick reference, the protocol was placed on the screen of the telestroke robot/cart in each of the network hospitals and a cell phone number was provided that gave 24/7 access to communicate with the neurointerventionalist on call. A retrospective study was performed to determine if there had been an increase in patient transfers for an interventional procedure.

Results:
In FY'14, 14 of 139 patients (10%) transferred received an IR procedure and in FY'15, 26 of 146 (17%) patients received an IR procedure. An increase of 7% was identified in telestroke patients that were transferred and underwent an interventional treatment. A combination of providing guidelines regarding when to consider interventional treatment as well as 24/7 access to a neurointerventionalist has significantly increased number of telestroke patients receiving interventional treatment.
Abstract TP399: Ambulance Membership Impact on 911 Utilization for Prehospital Stroke Triage and Transport in a Rural Community
Authors: Rankin Pauline M , Marsh Dianne , McLaughlin James
Published: March 2022

According to the American Heart and Stroke Association, 50% of people presenting to the emergency room with stroke symptoms arrive by private vehicle. Thrombolytic and interventional therapies offer significant clinical benefit, but require rapid prehospital stroke triage and delivery. The mode of transportation to the emergency department influences our ability to provide these therapies. Previous studies have identified factors that influence the utilization of 911 services. Information regarding ambulance service membership as a determinant for activating 911 is not well documented. Our 180 bed primary stroke center in rural Pennsylvania has been active in promoting community stroke education with an emphasis on activation of 911 at the onset of stroke symptoms. As part of our ongoing process improvement program, we found in 2014, 71% of stroke patients presented to our center by private vehicle. The purpose of this project is to determine the reasons for nonuse of 911 services including the role of ambulance service membership. Patient demographics were collected from Get With The Guidelines Stroke data base. We reviewed a sample population of 114 patients representing all those with a discharge diagnosis of stroke or transient ischemic attack from January to June 2015. A standard questionaire of 16 variables was utilized and patients were contacted by telephone or postal service. Of the 57 responses received, 22 (39%) arrived by ambulance of which 19 (86%) were members of a community ambulance service verses 35 (61%) arrived by private vehicle of which 17 (49%) were members of a community ambulance service. In conclusion, the results suggest that in a rural environment, membership in a community ambulance service appears to increase utilization of 911 services for prehospital stroke triage and transport, which may translate into earlier treatment and better outcomes. Our goal is to continue to monitor this data and modify our community stroke education efforts to include the potential value of ambulance membership in the treatment of acute stroke.
Abstract TP404: Transforming From a Primary Stroke Center to a Comprehensive Stroke Center
Authors: Patterson Michele , Berumen Joseph , Loyola Susan , Motz Deb , Page Ashley , Moore Tracy , Cline Beth , Huey Dicky , Austin Tommye
Published: March 2022

Background:
St. Luke’s Baptist Hospital (SLBH) received certification as a Primary Stroke Center (PSC) in 2009. In 2015 a plan to achieve Comprehensive Stroke Center (CSC) certification was developed. This certification establishes SLBH as a Center of Excellence that provides a wide range of interventional treatments for the management of complex stroke patients. The purpose is to describe the transformation process from PSC to CSC.

Methods:
Medical Director and APN Stroke Coordinator were appointed to provide program oversight. Gap analysis assessed the requirements for CSC. This led to additional order sets, screening tools, performance measures, staff education and a protocol to manage multiple complex stroke patients. Post hospital follow up was initiated. A dashboard kept the team on task with increased CSC requirements and performance measures. CSC purpose, opportunity, short and long term program goals and CSC team roles were defined. Order sets and forms were revised to include ICH reversal, stroke severity scores and depression screening and were approved by the Stroke Committee, CSC Medical Director, Quality, and Medical Executive Board Committees. A CSC kickoff, highlighting the differences between PSC and CSC, was held to inform all hospital staff of this initiative. To further improve effectiveness and success in this CSC endeavor, rehabilitation, case management, pharmacy, dietary, community outreach and an EMS representation were added to the stroke committee.

Results:
Intense coordination of all components and requirements resulted in certification as a CSC. SLBH is the first stroke center to achieve CSC certification in San Antonio, Texas.

Conclusion:
With the support and commitment of hospital administration, resources were provided for successful attainment of a CSC Certification. Passionate work, a focused goal and a joint effort enabled SLBH to obtain certification readiness in 6 months. Front line staff involvement, stroke committees, multidisciplinary team collaboration, and administrative support are imperative for successful CSC certification.
Abstract TP413: How Good Is That "doc In The Box"?
Authors: BOYER MORGAN
Published: March 2022

A Comprehensive Stroke Center with a telestroke program is a hub for 14 partner hospitals. It has been providing expert stroke neurology consultation using telemedicine for 3 years. Accuracy of the physician assessment of a potential stroke patient using telemedicine is not widely reviewed. Utilizing real time audio/video encounters and the ability to visualize radiology images, it is expected that the physician would be able to make an accurate consult impression of acute ischemic stroke (AIS) and recommend safe treatment options. All patients that were consulted and subsequently transferred to the hub were analyzed for variances between consult impression for AIS and a final discharge diagnosis of AIS. In the first year of the telemedicine program, the stroke neurologists accurately diagnosed 79% of AIS patients transferred to the hub facility. In the second and third year, the accuracy decreased to 76% (p value > 0.05). The consult volume has greatly increased over the three years without impacting the level of care the stroke neurologists have be able to provide. In addition to an average of 77% accuracy in determining AIS, the use of tissue plasminogen activator (tPA) is dramatic when compared to the institutional treatment rate of 18%. The tPA treatment rate for patients consulted using telemedicine with an AIS impression transferred to the hub was compared to the true treatment rate based on discharge diagnosis (Table 1). Table 1 demonstrates a high rate of tPA administration using telemedicine. When the rates are adjusted to recognize the final diagnosis, the rate does not significantly change. Patients that were accepted from a partner hospital post-tPA infusion without a final stoke diagnosis did not experience any adverse sequela related to tPA administration. In conclusion, the Comprehensive Stroke Center Telestroke Program has demonstrated an average of 77% accuracy for evaluating the AIS patient and safe thrombolysis treatment recommendations.
Abstract TP415: Stroke Knowledge and Prehospital Delay in Elderly Acute Ischemic Stroke Patients
Authors: Shin Cha-Nam , An Kyungeh , Sim Jeongha
Published: March 2022

Background:
Stroke is one of the leading causes of deaths in Korea and worldwide. Due to delayed hospital arrival after stroke onset, acute ischemic stroke (AIS) patients are unable to receive a reperfusion therapy promptly. Early recognition of stoke symptoms is crucial to reduce prehospital delay time and further stroke morbidity and mortality. With rapidly increasing aging population in Korea, the prevalence of AIS is growing. Yet, little is reported about stroke knowledge and the association with prehospital delay in elderly AIS patients in Korea.

Purpose:
We hypothesized that the level of stroke knowledge would be different by socioeconomic status (SES) and associated with prehospital delay among elderly AIS patients.

Methods:
A cross-sectional, descriptive study was conducted in a convenience sample of 188 older adults who hospitalized with AIS in Korea. Data, including stroke knowledge were collected by interview using structured questionnaires. Descriptive statistics, chi-square test, Mann-Whitney U test, and univariate and multivariate Cox regression analyses were used.

Results:
More than one third (36.7%) did not know any of stroke symptoms, whereas one symptom was recognized by 48.9% and 2 or more symptoms by 14.4%. Individuals who had low income (χ
2
=10.47) showed poorer knowledge than their counterparts (
p
<.05). Those who arrived to the hospital within 3 hours were more likely to recognize hemiparesis (χ
2
=7.38) and headache (χ
2
=7.67) as primary symptoms at
p
<.01. Individuals who recognized more than 2 primary symptoms had shorter arrival time (
U
=1145.5,
p
<.05). Multivariate Cox regression analyses revealed that knowledge on hemiparesis was associated with hospital arrival time (hazard ratio=.329, 95% confidence interval=.187-.578) at
p
=.000.

Conclusion:
While stroke symptoms were poorly recognized by most patients, none of the SES except income was significantly associated with the level of stroke knowledge. The study findings suggest that clinicians who handle elderly AIS patients should pay attention who have low income as they showed lower level of stroke knowledge. Also, continuous public education on stroke symptoms is necessary to increase the level of stroke knowledge, which will shorten hospital arrival time.
Abstract TP417: Improving Stroke Rehabilitation Intensity Data Collection: Collaborative Implementation of a Quality Assurance Framework
Authors: Linkewich Elizabeth , Cheung Donna , Willems Jacqueline , Sharp Shelley , Quant Sylvia
Published: March 2022

Background and Issues:
A minimum of 3 hours of rehabilitation intensity (RI) is a stroke best practice standard of care that has been established in Ontario. As collection of RI time has been mandated in Ontario, the Ontario Stroke Network has been working with stakeholders to capture RI data using workload measurement systems (WMS). Given that this is a new indicator and variability exists in use of WMS across Toronto, there is a need for standardization in RI data collection.

Purpose:
To develop a quality assurance (QA) framework for RI data collection in Toronto that can be used locally and provincially to ensure consistent and accurate data collection and reporting.

Methods:
The Toronto Stroke Networks formed a working group comprised of clinical and decision support leads from 6 rehabilitation centres. This group developed standard approaches to capturing RI data. They also examined factors that influence the quality of the data, ranked these factors by level of influence on data quality, and established mitigation strategies for the top ranked factors. Additionally, a reporting and monitoring plan was determined.

Results:
Through collaborative sharing of information, a QA framework was developed and adopted by the group. The top ranked factors affecting data quality included: 1) When the RI data field is left blank; 2) Inaccurate data entry by staff; 3) Variations in service interruptions and alternate level of care; and 4) Timeliness in entering data. Mitigation strategies included use of lock out periods, clear definitions, processes for staff feedback and education, and establishment of a quarterly reporting structure for organizational comparison. This QA framework has been shared with provincial stakeholders to inform system planning in other regions.

Conclusions:
As data accuracy in capturing RI data is important for current state analysis and benchmarking, a comprehensive QA framework was developed to support data accuracy and has been used for local monitoring and reporting of RI data. Identified factors that influence data quality related to processes for data capture. As mitigation strategies will further support these processes, this QA framework ensures accurate data collection and confidence in using RI data to support system planning.
Abstract TP418: The Evolution of Four Stroke Support Groups into the City-wide Stroke Connection
Authors: Barrilleaux Wendy , Kiihnl David N , Ellerbusch Teresa , Geiger Susan
Published: March 2022

Background:
In our city, there are three Primary Stroke Centers within a one and a half mile radius. Previously, each of these hospitals, plus the local rehabilitation facility, hosted a monthly stroke support group at their own facility. The stroke coordinators at these facilities reported that the preparation for these meetings is very time consuming and the participation is generally poor.

Purpose:
The purpose of this project was to establish a city-wide stroke support group. Our goals were to integrate our efforts while shifting the focus to community reentry and coping with long term issues after stroke.

Methods:
The three stroke coordinators, along with a physical therapist from the local rehabilitation center, met to discuss our current state of providing stroke support groups. We realized that, although fiercely competitive, this is one area where collaboration between facilities would be warranted. A committee was formed to create the new group with the plan to go into effect in January 2015. First, we identified a venue that is accessible, with ease of parking, convenient, and without a specific alliance to one facility over another. Secondly, marketing duties were divided up between the four facilities. All marketing pieces include the branding of all four facilities. Every month, there is a newspaper advertisement and marketing through social media. An invitation is created every month which announces the speaker and the topic. Each facility is responsible for mail outs to their own database. Lastly, each committee member chose three months in which they agreed to lead the meetings. The leader for the month is responsible for choosing the topic for the month, inviting a speaker, setting up, and cleaning up.

Results:
The four monthly support groups were combined and a new name was given: the City-Wide Stroke Connection. The meeting is free and open to all stroke survivors and caregivers.

Conclusion:
In conclusion, the City-Wide Stroke Connection has been effective in increasing participation from an average of five to 25 attendees per month. In addition, the stroke coordinators have reported a decrease in annual work load.
Abstract TP420: At-risk Stroke Patients in Need of In-hospital Lifestyle Interventions: Data From a Multi-state Health System
Authors: Baraban Elizabeth , Stuchiner Tamela , Lowenkopf Theodore
Published: March 2022

Introduction:
Lifestyle factors such as weight, diet and smoking are associated with stroke incidence and recurrence. Targeted interventions on these risk factors can be successful in reducing stroke and TIA (Transient Ischemic Attack) rates. The objective of this study was to assess the number of patients presenting to a hospital with an ischemic stroke (ISC) or TIA who received lifestyle interventions in a large, multi-hospital health system.

Methods:
Data from 25 hospitals in a multi-state healthcare system stroke registry from 2002 to May 2015 were used. Patients with a diagnosis of ISC or TIA were included. Patients on comfort care, transferred to an outside facility from the emergency department, discharged to hospice or expired were excluded. Lifestyle intervention outcome measures included the percentage of patients who received information on weight and activity management, anti-hypertensive diet, cholesterol reducing diet and anti-smoking treatment. Outcomes were evaluated by risk groups including patients with Body Mass Index (BMI) ≥25, those prescribed anti-hypertensive or cholesterol lowering medications in-hospital and smokers.

Results:
A total of 39,200 patients met inclusion criteria. Analytic sample sizes ranged from 6, 576 to 39,200. Over sixty-four percent had BMI≥25 (n=16,527), 75.5% (n=23,364) were prescribed anti-hypertensive medication, 78.4% (n=29,609) were prescribed cholesterol lowering medication and 16.8% (n=6,576) were smokers. Among those with BMI ≥ 25, only 42.6% (n=6,560) received weight management intervention. Among those that were prescribed anti-hypertensive medication, 50.6% (n=8,463) received information on antihypertensive diet. Among those that were prescribed cholesterol lowering medication, 57.1% (n=10,648) received cholesterol lowering diet information. For those that smoked, 90.1% (n=5,923) received anti-smoking treatment.

Conclusions:
This large patient cohort demonstrates there are improvement opportunities for in-hospital stroke prevention efforts. While hospitals do a good job appropriately providing smoking treatment to stroke patients, lifestyle interventions such as weight management and diet should also be addressed for those at-risk.
Abstract TP430: Interventions to Enhance Adherence to Secondary Preventative Medication After Stroke a Systematic Review and Meta-Analysis
Authors: Al AlShaikh Sukainah , Quinn Terry , Dunn William , Dawson Jesse
Published: March 2022

Background and Purpose:
Non-adherence to secondary preventative medications after stroke is common. Numerous strategies exist to promote adherence and we performed a systematic review and meta-analysis of these strategies after stroke.

Methods:
We systematically reviewed MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Databases, and the Web of Knowledge for studies of interventions to enhance adherence to secondary preventative medication after stroke. We followed PRISMA guidance. We performed meta-analysis where data allowed.

Results:
We carried out the search in March - April 2014 and identified a total of 12,237 titles. Title review identified 143 papers for abstract review, 57 were retrieved for full-text review and 17 met our eligibility criteria. The total number of participants enrolled was 3942 patients with stroke/TIA (2090 participants were finally analysed in the intervention group and 824 participants as controls). We separated findings of included studies depending on secondary preventative medication classes reported. In the meta-analyses, we included three studies reported the effect of intervention to the
overall
secondary preventative medications regimen, six studies effect of intervention reported adherence to
blood-pressure lowering drugs
, and three studies reported effect of intervention on adherence to
lipid-lowering drugs
. There was no sufficient number of studies reported adherence to antithrombotic drugs after stroke. Forest-plots were constructed for each analysis (figure).

Conclusion:
Interventions in identified studies lead to improvement in adherence to secondary preventative medication after stroke. However, existing data is limited thus need to be interpreted with caution.

Figure:
Forest plots of meta-analyses of intervention studies (Favours A = Control, Favours B = Intervention)
Abstract TP433: Early Decompressive Hemicraniectomy Optimizes Highest Rehabilitation Potential in Patients With Acute Malignant Middle Cerebral Artery Syndromes
Authors: Sheikhi Lila E , Dani Dhimant
Published: March 2022

Objectives:
Early decompressive hemicraniectomy in malignant middle cerebral artery (MCA ) syndrome is shown to improve long term clinical outcomes in patients. Longer hospitalization and ventilator days expose patients to increased risk of complications. We explore pertinent short term clinical predictors for the highest potential of functional recovery with acute rehabilitation in patients who present with malignant MCA syndromes requiring decompressive hemicraniectomy.

Methods:
This is a retrospective review of 53 patients from 2008-2013 on patients with acute ischemic malignant MCA strokes who underwent decompressive hemicraniectomy. We quantified midline shifts on brain imaging obtained prior to surgery. The primary objective was identifying patient factors leading to acute rehabilitation compared to other discharge outcomes including long term acute care facilities (LTAC), subacute nursing facilities (SNF), or expiration.

Results:
See Table.

Conclusions:
Younger patients presenting with malignant MCA syndromes receiving decompressive hemicraniectomies at smaller midline shifts are observed to achieve less ventilator days, reduced hospital length of stay and discharge with optimal rehabilitation potential.
Abstract TP435: Hospital of Origin Does Not Influence Outcome in Patients Treated With Decompressive Hemicraniectomy After Malignant Middle Cerebral Artery Infarction
Authors: Smyth Duncan , Weatherall Mark , Rosemergy Ian , Lanford Jeremy
Published: March 2022

Introduction:
Decompressive hemicraniectomy has been shown to reduce mortality in malignant middle cerebral artery (MCA) infarction. This procedure has been done for malignant MCA infarction at our institution, a tertiary referral centre, since 2011. We aimed to review the outcomes of patients receiving this procedure based on hospital of origin.

Hypothesis:
Patients originating outside of a tertiary centre would have worse outcomes and delays in obtaining decompressive hemicraniectomy for malignant MCA infarction.

Methods:
We retrospectively reviewed the medical records of all patients who underwent decompressive hemicraniectomy for malignant MCA infarction from March 2011 until March 2014. We compared 30-day mortality as well as time to surgery between patients presenting to the tertiary referral centre and patients presenting to peripheral hospitals. We compared 30-day mortality between those patients receiving surgery within 48 hours and those receiving surgery over 48 hours. We also compared the clinical characteristics of the patients in our cohort to data from published trials.

Results:
Eighteen patients underwent decompressive hemicraniectomy during this period of time. The 30-day mortality rate was 10/18 (55.6%). There was no difference in mortality between those presenting to the tertiary referral centre and those presenting to peripheral centres (3/6 [50%] vs 7/12 [58.3%], p=0.99). There was no difference in time to surgery between those presenting to the tertiary referral centre and those presenting to peripheral hospitals (median 44.2 vs 30.5 h, p=0.3933). There was weak evidence of reduced mortality for those undergoing the procedure within 48 hours of onset (6/14 [42.9%] vs 4/4 [100%], p=0.092). The patients in our cohort had no statistically significant difference in mortality compared to those in the hemicraniectomy trials but did have a longer time to surgery and a greater percentage of males.

Conclusions:
Mortality rates and time to surgery were comparable regardless of hospital of origin for decompressive hemicraniectomy after malignant MCA infarction.
Abstract TP438: De Novo Ivy Sign Indicates Postoperative Hyperperfusion in Moyamoya Disease
Authors: Horie Nobutaka , Morikawa Minoru , Morofuji Yoichi , Izumo Tsuyoshi , Nagata Izumi , Matsuo Takayuki
Published: March 2022

Background and Purpose:
The ivy sign on fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) is a specific finding in moyamoya disease (MMD). This sign indicates decreased cerebral perfusion, dilated pial vasculature, and slow leptomeningeal collateral flow. This study aimed to clarify the characteristics of perioperative changes in the ivy sign in relation to cerebral hyperperfusion (HP), which frequently occurs in MMD of unknown etiology.

Methods:
This prospective study included patients with MMD who underwent superior temporal artery-middle cerebral artery single bypass. FLAIR MRI was performed to evaluate the appearance of the ivy sign in the ipsilateral hemisphere preoperatively and on postoperative days 2 and 30. The ivy sign was assessed in combination with perioperative symptoms and cerebral hemodynamics using single-photon emission computed tomography (SPECT).

Results:
Of 42 consecutive patients (55 sides) who underwent bypass surgery, 32 (58.2%) showed an increase in the ivy sign (de novo ivy sign) on postoperative day 2; this had disappeared by day 30. Interestingly, these 32 patients had a significantly higher incidence of HP on SPECT and HP syndrome, and there was no correlation between the de novo ivy sign and a preoperative ivy sign or the preoperative cerebral hemodynamics. In multivariate analysis, a de novo ivy sign was significantly correlated with postoperative HP.

Conclusions:
In MMD, a de novo ivy sign could indicate postoperative HP after bypass, which is not always correlated with preoperative hemodynamic impairment. Additional factors other than preoperative cerebral hemodynamics might be involved in postoperative HP in MMD.
Abstract TP443: Homocysteine Level in PFO Related Stroke Patients With Respect to Medical Therapy vs PFO Closure
Authors: Deng Wenjun , Wickham Thomas , McMullin David , Feeney Kathleen , Silverman Scott , Inglessis Ignacio , Palacios Igor , Lo Eng H , Buonanno Ferdinando , Ning MingMing
Published: March 2022

Background:
Homocysteine is an independent risk factor of ischemic stroke by promoting vascular endothelial dysfunction and thrombotic process through oxidative stress. We previously found that PFO closure may reduce total homocysteine level (tHcy) in plasma. Here, we compare the effect of PFO closure and medical treatment in reducing mild homocysteinemia in PFO-related stroke patients.

Method:
28 PFO-related stroke patients with mildly elevated tHcy (>12 μmol/l) were prospectively recruited in accordance with IRB. 14 received PFO closure and 14 were treated by medical therapy (antiplatelet/anticoagulant) alone. None of the patients were on folate or vitamin B supplementation. Plasma was collected at baseline and 1 year follow-up after treatment. tHcy level was determined by selected reaction monitoring using mass spectrometry.

Result:
Compared to medical therapy, PFO closure resulted in a lower tHcy level during follow-up (PFO closure: 11.13 ± 3.94 μmol/L, medical therapy: 15.48 ± 3.55 μmol/L, p = 0.006), with no difference at baseline (PFO closure: 17.77 ± 4.39 μmol/L, medical therapy: 16.47 ± 7.50 μmol/L, p = 0.575). Mild hyperhomocysteinemia patients post PFO closure had a significant reduction of tHcy by 37.34% (p = 0.0005), with 71.43% of the patients (10 of 14) having tHcy levels back to normal (<12 μmol/l), while most of medically treated patients (13 of 14) stayed abnormal (p = 0.4820) (χ2-test, adjusted p = 0.002).

Conclusion:
We found that compared with routine medical therapy, PFO closure reduced tHcy level in patients with mild hyperhomocysteinemia. Since PFO stroke patients tend to be younger, the life-time risk of even mildly elevated tHcy may be relevant for future thrombotic risk. Understanding the mechanism of PFO-related tHcy changes is important in optimizing medical treatment (e.g. folate replacement); studies are ongoing.
Abstract TP45: One Threshold Does not Fit All: Hounsfield Unit Thresholds to Segment Clot on NCCT are Patient Specific
Authors: Qazi Emmad , Wilson Alexis T , McDougall Connor , Boesen Mari , Al-Ajlan Fahad S , Pordeli Pooneh , Batchelor Connor , Khan Khayam , Sajobi Tolulope T , Lee Ting-Yim , Hill Michael D , Demchuk Andrew M , Goyal Mayank , d'Esterre Christopher D , Menon Bijoy K , Forkert Nils D
Published: March 2022

Introduction:
The hyperdense sign is a marker of thrombus on non-contrast computed tomography (NCCT). Currently, pre-specified Hounsfield unit (HU) threshold are used arbitrarily for clot segmentation. We aimed to test if HU thresholds best discriminating clot on thin slice NCCT are patient specific and dependent on factors such as age, hematocrit, and NCCT slice thickness.

Methods:
Data are from the ESCAPE randomized controlled trial. Only patients with thin slice baseline NCCT (<2.5mm) and M1-MCA occlusion on baseline CT-Angiography (CTA) were included. CTA was co-registered to NCCT using in-house software. Proximal and distal clot interface was identified on CTA and super-imposed onto the NCCT. Three Regions of Interest (ROIs) (36- 100 voxels) were placed on the NCCT in the 1) clot as defined on co-registered CTA, 2) contralateral brain tissue, and 3) contralateral patent M1 MCA artery. Optimal patient specific HU thresholds differentiating “clot” from “normal vessel” and “brain tissue” voxels were calculated using receiver operating characteristic (ROC) analysis.

Results:
70 patients were included. ROC analysis showed that the optimal HU threshold discriminating clot on NCCT varies considerably between patients (Figure 1A). Hematocrit was associated with contralateral artery HU (p<0.001); no significant correlation was found with age (p=0.156) and slice thickness (p=0.473). Predictive ability of contralateral artery and brain tissue HU in determining optimal HU threshold discriminating clot was similar (p<0.001, Figure 1B). Model comparison using Bayesian Information Criterion suggests that we can reasonably use contralateral brain tissue HU or contralateral artery HU to derive patient-specific optimal HU thresholds that best discriminates clot.

Conclusion:
HU thresholds on NCCT that best discriminates clot are patient specific. Signal from brain tissue or patent artery silhouette can be used to derive these patient specific thresholds.