bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P11: Clinical Utility of Aspects in Late Window Stroke Thrombectomy Patients: Insights From Star
Authors: Porto Guilherme B , Hubbard Zachary , Al Kasab Sami , Almallouhi Eyad , Starke Robert , De Leacy Reade A , Raper Daniel , Rai Ansaar , Dumont Travis , Wolfe Stacey , Jabbour Pascal , Ogilvy Christopher S , Park Min S , Levitt Michael , Polifka Adam , Crowley Richard , Arthur Adam S , Osbun Joshua , Crosa Roberto , Maier Ilko , Kim Joon Tae , Casagrande Walter , Grossberg Jonathan A , Chowdhry Shakeel , Mokim Maxim , Matouk Charles , Fragata Isabel , Williamson Richard , Yoo Albert J , Mascitelli Justin , Kan Peter , Psychogios Marios-Nikos , Spiotta Alejandro M
Published: March 2021

Introduction:
Recent trials have proven safety and efficacy of mechanical thrombectomy for patients presenting with emergent large vessel occlusion beyond 6 hours of symptom onset. While evidence supports using baseline CT scan to evaluate the candidacy for mechanical thrombectomy for patients presenting in the early window, late window trials have used advanced imaging such as CT and MR perfusion. We aim to assess outcomes of MT stratified by admission Alberta Stroke Program Early CT Score (ASPECTS).

Methods:
We used data from the prospectively maintained registries of 28 stroke centers in the Stroke Thrombectomy and Aneurysm (STAR) collaboration. Demographics, comorbidities, LVO site, ASPECTS, MT technique, radiographic and clinical outcome data were collected. Patients with M1 or ICA occlusion were included in these analyses. Multivariable analysis was performed using a generalized linear model with logit link to assess for variables associated with favorable outcomes.

Results:
3356 patients in the STAR database were reviewed and 347 (10.3%) of those underwent MT in the late window (table). Median age was 69, 189 (54.5%) were female, and 181 (52.2%) were white. 295 patients ASPECTS ≥6. In this group, 200 (68.8%) had M1 occlusion, and the remaining had ICA occlusion. Aspiration thrombectomy was used in 139 (47.1%) of patients. Successful reperfusion was achieved (mTICI≥2b) in 264 (76.1%). sICH was observed in 15 (5.1%). Excellent functional outcome (mRS 0-2) was observed in 124 (42%) patients. ASPECTS score was independently associated with favorable outcomes (aOR 1.2, 95% CI 1.1-1.4, P=0.006).

Conclusion:
Excellent outcomes are observed in patients with good ASPECT score presenting in the late window irrespective of perfusion criteria. Admission CT scan could be used to triage patients presenting with emergent large vessel occlusion beyond 6 hours of symptom onset.
Abstract P127: Non-English Speakers and English Speakers Score Differently on Individual Components of the National Institutes of Health Stroke Scale
Authors: Pollard Rebecca , Sillau Stefan , Malenky Igor , Eklund Kelsey , Leppert Michelle H , Michael Sean , Orjuela Karen D
Published: March 2021

Introduction:
The National Institutes of Health Stroke Scale (NIHSS) is widely used for rapid assessment of neurologic deficits in acute stroke. Multiple components of the scale require intact language function, which may be difficult for English-speaking providers to assess in non-English speaking patients (NESP). We sought to characterize patterns of NIHSS scoring in English-speaking patients (ESP) and NESP.

Methods:
This was a retrospective study of consecutive stroke alert cases who presented to the emergency department at our primarily English-speaking comprehensive stroke center. Baseline characteristics and clinical data including NIHSS components were compared between ESP and NESP. Chi-squared/Fisher’s exact statistics were used to compare frequencies and T-tests were used to compare means. Relative risks were calculated for language effects on NIHSS components, controlling for gender, age, race, and stroke diagnosis.

Results:
A total of 1166 patients were included, of which 87.5% were ESP and 12.5% were NESP. There were no significant differences between groups in total NIHSS scores or in frequencies of stroke diagnosis, tissue plasminogen activator treatment, or endovascular treatment. For individual NIHSS components, NESP were more likely than ESP to score for level of consciousness questions (34.9% vs 22.3%, adjusted RR 1.91, CL 1.39-2.62, p=0.0005), level of consciousness commands (21.9% vs 10.1%, adjusted RR 3.62, CL 2.42-5.43, p<0.0001), and best language (30.1% vs 22.6%, adjusted RR 1.84, CL 1.32-2.56, p=0.0016). Other NIHSS components did not differ significantly between groups after covariate adjustments.

Conclusions:
Despite similarities in total NIHSS scoring between NESP and ESP, scoring of individual components heavily dependent on language function and comprehension differed between groups. NESP were more likely to be assessed as aphasic, unable to answer questions, and unable to follow commands. Disparities in NIHSS scoring trends raise questions for further investigation into possible underlying pathophysiologic mechanisms, potential provider biases from language barriers that may influence clinical assessment, and the role of more inclusive screening tools and interventions to help mitigate these gaps.
Abstract P132: Successful Conduct of an Acute Stroke Clinical Trial During COVID
Authors: Grotta James C , Parker Stephanie , Jacob Asha , bowry ritvij , Bratina Patti , Rajan Suja S , Wang Mengxi , Nour May , Mackey Jason , Collins Sarah , Jones William , Schimpf Brandi , Ornelas David , Spokoyny Ilana , Im Jenny F , Gilbert Greg , Yamal Jose-Miguel
Published: March 2021

Introduction:
Most clinical research stopped during COVID due to possible impact on data quality and personnel safety. We aimed to assess the impact of COVID on study conduct at sites that continued to enroll patients during the pandemic.

Methods:
BEST-MSU is an ongoing study of Mobile Stroke Units (MSU) vs standard management of tPA eligible acute stroke patients in the pre-hospital setting. MSU personnel include a vascular neurologist via telemedicine, and a nurse, CT tech, and medics on board using appropriate PPE. During COVID, consent, 90 d mRS and EQ5D could be obtained by phone instead of in person, otherwise management was the same. We compared patient demographics, study metrics, and infection of study personnel during intra- vs pre-COVID eras.

Results:
Four of 6 BEST-MSU sites continued to enroll during COVID. There was no difference in intra- (n= 41) vs pre- (n= 763) COVID enrolled tPA eligible patients’ age, sex, race (45% vs 41% Black), ethnicity (23% vs 19% Hispanic), or NIHSS (12 vs 12). MSU alert frequency did not change, but percent of screened patients enrolled and treated with tPA declined to 12% from 23% (p<.001); enrollment correlated with local stay at home and reopening (fig). There was no difference in alert to MSU arrival or arrival to tPA times, but on-scene time was 2 min longer (p=.04). There was no difference in ED door to CT, tPA, or EVT times, hospital LOS, discharge disposition, or 90d mRS or EQ5D accuracy. One MSU nurse tested positive but did not require medical care.

Conclusion:
Clinical research in the pre-hospital setting can be carried out accurately and safely during a pandemic. Study enrollment and tPA treatment rates declined, but otherwise there was no difference in patient demographics, deterioration of study processes, or serious infection of study staff.
Abstract P134: Economic and Clinical Model for Direct Transfer to Angiosuite Protocol Development
Authors: Requena Manuel , Vilaseca-Jolonch Andreu , Seguel Valeska , Guijarro Pablo , Molina Carlos , Tomasello Alejandro , Ribo Marc
Published: March 2021

Background and purpose:
Direct transfer to angiosuite (DTAS) has consistently shown to be effective and safe shortening in-hospital workflows and encouraging long-term outcome benefits. In order to generalize DTAS an organizational and manpower effort is necessary. We aim to perform a cost-effective analysis of the implementation of a new angiosuite primarily dedicated to DTAS of stroke patients that will allow generalization of this pathway

Material and methods:
Sixty-one patients who underwent endovascular treatment (EVT) following DTAS were matched for baseline variables to 117 patients who underwent conventional imaging protocol before EVT. An economic model based on actual data was developed to assess the short and long term clinical and economic implications. The DTAS development scenario estimates a gradual 20% increase of DTAS rate for 4 years followed by a stable 80% rate of DTAS. Initial investment and additional organizational costs were included: 4M є. A cost-effective study compared the DTAS development scenario (SC1) to a scenario with no organizational changes (SC2) over 10 years.

Results:
The 10 year model included 1775 EVT patients in each scenario: SC1 60% DTAS Vs SC2 0% DTAS. SC1 would be associated with better functional independence rates (mRS 0-2: 45.8% versus 40.2%; p=0.04) and a quality-adjusted life-years gain of 0.12 per patient. Despite the additional investment, SC1 development was associated with an estimated 15.1% reduction (26.25M є) of total costs (173.749M є). Cost savings was mainly due to long-term associated costs related with patient disability (є 26.4 million).

Conclusions:
Our economic model predicts that the development of a DTAS program is cost effective.
Abstract P135: Telestroke Mimic Score: Validation in the Mayo Clinic Population
Authors: Carlin Rachel , Demaerschalk Bart M , Zhang Nan
Published: March 2021

Introduction:
Telestroke consultations enable hospital providers to administer IV alteplase to patients who would otherwise not receive it due to lack of an in-house neurologist. However, up to 30% of acute stroke evaluations are deemed stroke mimics. These present a challenge with the limitations of a virtual neurological exam. The use of IV alteplase in these patients is not risk-free. With the rise in cost of IV alteplase, there are ethical and practical incentives to avoid administering alteplase to a stroke-mimic. Recently a retrospective analysis validated a TeleStroke Mimic Score (TM-Score) to help detect stroke mimics. We retrospectively applied this tool to our Stroke Telemedicine for Arizona Rural Residents (STARR) telestroke database to provide external validation in an independent study population.

Methods:
We analyzed 339 patients in our STARR database for validation of the TM-Score, which was applied in retrospect to determine if it predicts stroke-mimic given data available during each patient’s telestroke consult. We assessed its performance with a receiver-operating characteristic (ROC) curve. Patient characteristics are displayed in table form. A scatter plot of the data shows the relationship between the TM-Score and the likelihood of having a stroke mimic, compared to the nomogram in the original study.

Results:
When the TM-Score was applied to our validation cohort, the area under the ROC curve was 0.78, larger than that of the derivation cohort in the original study (0.75). Further analysis suggests that a TM-Score greater than 25 or less than 10 would provide a greater degree of confidence that the patient is presenting with stroke or stroke mimic, respectively. In our cohort, additional variables were significantly different between stroke and stroke mimic populations, including history of sleep apnea or diabetes.

Conclusion:
We found that the TM-Score is validated when applied to Mayo Clinic’s STARR telestroke population. Validation of this tool helps establish the utility and broader generalizability of this equation. Effective use of this tool can help reduce risk to the patient and has additional cost-saving implications. This should help ensure that the patient receives the appropriate targeted workup and treatment.
Abstract P145: Who Are We Missing? False Call Rates Decline for Stroke Code Activations During Early Phase of Covid-19 Pandemic
Authors: Olson-Mack Lindsay , Burley Jessica , Calara Robin , Claycomb Robert , Couts Linda , Kalafut Mary A , Libby K. Jill , Richetts Renee , Sahagian Gregory , Rockwell Jean M
Published: March 2021

Introduction:
To slow the spread of the novel coronavirus (COVID-19), the Department of Homeland Security restricted access across the US-Mexico border in March 2020. During the same time period hospitals throughout the US began reporting declines in emergency department (ED) visits, especially related to stroke. As a stroke receiving center and largest hospital within a Southern California border county serving a binational population, we sought to understand the impact COVID-19 and closure of an international border might have on stroke code activations (SCA) and discharges at our facility.

Methods:
A retrospective analysis involving 417 cases presenting to a tertiary hospital consisting of two campuses near the US-Mexico border in Southern California was performed. Inclusion criteria: all cases with SCA in the ED arriving from March 1, 2020 to June 30, 2020 and March 1, 2019 to June 30, 2019. Exclusion criteria: cases arriving to the ED that did not have SCA and cases for which stroke codes were initiated after hospitalization.

Results:
Pedestrian and private auto passenger border crossings decreased by over 5 million people between April and May 2020 compared to the same period in 2019. From March to June 2020, there were 162 ED SCA compared to 255 during the same period in 2019; a 36.5% decrease in SCA in 2020. Additionally, there was a significant increase in the percentage of ED SCA resulting in actual stroke discharge diagnoses during this period. In early 2020, 68.5% of ED SCA were discharged with a stroke diagnosis compared to 60.4% in 2019,

X
2

(1,
N
= 162) = 4.467,
p
< .05. However, despite the increased true positive rate, there was an overall decrease in the total number of patients with SCA who were diagnosed with stroke (111 in 2020 vs 154 in 2019).

Conclusion:
As the overall number of SCA decreased during the early months of the COVID-19 pandemic, so did the total number of patients discharged with a stroke diagnosis. This suggests that fewer patients with acute stroke presented as a SCA during the early COVID-19 pandemic in comparison to the same time period in 2019. It is critically important as a stroke center serving a large, binational population to ensure the population we serve is seeking appropriate and timely care for serious and complex diseases.
Abstract P148: Role of Endothelin B Receptors in Neuronal Progenitor Cell Differentiation and Mitochondrial Function in Ischemic Stroke
Authors: Ranjan Amaresh , Briyal Seema , Gulati Anil
Published: March 2021

Neuronal progenitor cells (NPCs) and mitochondria are well known to play roles in regeneration and functions of the brain, respectively. However, stimulation of endothelin-B receptors (ETBR) using an agonist, sovateltide (IRL-1620) on their fate in the brain after stroke remains elusive. We evaluated the effect of sovateltide mediated ETBR stimulation on differentiation of NPCs and fate of mitochondria after stroke. Ischemic stroke was induced by performing permanent right middle cerebral artery occlusion (MCAO) in rats. Sovateltide (5 μg/kg) or saline (equal volume) was injected intravenously; neurological and motor function evaluation was done at 24 hrs and day 7 post MCAO. Brain tissues were analyzed for NPCs differentiation and mitochondrial fate using techniques such as western blots, immunofluorescence, transmission electron microscopy and in situ PCR. In vitro hypoxia experiment was carried out to confirm sovateltide mediated neuronal differentiation. Neurological and motor functions were significantly improved in sovateltide treated rats at 24 hrs and day 7 post MCAO. Differentiation of NPCs was evident with upregulation of neuronal differentiation markers Neuro D1 (p=0.00002) as well as HuC/HuD (p=0.0037) along with neuronal marker Doublecortin (DCX) (p=0.00011) at 24 hrs post MCAO. However, significant upregulation only in HuC/HuD (p=0.043) was observed at day 7. Better preserved mitochondrial fate was observed in sovateltide rat brains with downregulation of mitochondrial fission marker, DRP1 (p<0.001), increase in fusion marker, MFN2 (p<0.0001) and increase in cross-sectional area x number (p<0.05) as well as mitochondrial/tissue area (p<0.05) at 24 hrs and day 7 post MCAO. In situ PCR analysis showed increased mitochondrial DNA (p=0.0418), indicating better mitochondrial biogenesis at day 7 post MCAO. In vitro exposure of sovateltide and hypoxia to cultured NPCs showed higher NeuroD1 and NeuN (a mature neuronal marker) expression confirming NPCs differentiation. Sovateltide mediated ETBR stimulation promotes differentiation of NPCs and mitochondrial fusion as well as biogenesis and helps in neuronal regeneration and function restoration in acute ischemic brains.
Abstract P158: Outcomes of Patients With a Transient Ischemic Attack Based on Inpatient Versus Urgent Outpatient Evaluations a Systematic Review and Meta-Analysis
Authors: Shahjouei Shima , Koza Eric , Chaudhary Durgesh , Holland Neil R , Avula Venkatesh , Li Jiang , abedi vida , Zand Ramin
Published: March 2021

Importance:
Management of transient ischemic attack (TIA)and the concept of urgent TIA clinic have gained significant attention over the past years.

Objective:
To calculate the odds of subsequent ischemic stroke within 2, 7, 30, and 90 days and death within 90 days among the TIA patients who received acute care in a TIA clinic versus those admitted to a hospital.

Data Sources:
We performed a systematic review and meta-analysis of all the published TIA outcome studies. Included studies were obtained by searching Medline, Web of Science, Scopus, All EBM reviews series, International Clinical Trial Registry Platform (ICTRP), Trip database, and CINAHL, last updated in March 2020, irrespective of the study design, document type, or language.

Study Selection:
We accepted both the classic time-based definition of TIA and the new tissue-based definition and studies with a combined record of TIA and minor ischemic stroke patients. We excluded studies with a diagnosis of index TIA event after ischemic stroke occurrence, low suspicious for TIA, TIA acute care in settings other than an outpatient clinic or hospital, multicentric studies, or duplicate reports of the same database.

Data Extraction and Synthesis:
The study was conducted and reported according to PRISMA, MOOSE, and EQUATOR guidelines. Critical appraisal and methodological quality were conducted by ROBINS-E tool. Data were pooled under random-effects models.

Results:
Systematic review yielded to 19,547 reports, of which titles and abstracts of 9,113 reports were screened. The overall subsequent ischemic stroke odds ratios were estimated by meta-analyses as follows: 4 studies within 2 days with 1,829 patients (OR: 0.93, 95% CI: -0.52-2.38), 5 studies within 7 days with 1,801 patients (OR: 0.68, 95% CI: -0.73-2.08), 4 studies within 30 days with 1,768 patients (OR:1.01, 95% CI: -0.72 - 2.73), and 6 studies within 90 days with 2,319 population (OR: 0.94, 95% CI: 0.22-1.66). The 90-day risk of death by analyzing 3 studies, 1162 patients, was calculated as OR:1.29, 95% CI: 0.76-3.34.

Conclusion and Relevance:
Hospital management of TIA patients in the acute phase may not be associated with a lower risk of stroke and death compared with urgent outpatient management.
Abstract P163: LVO Screening and Transfer During Covid-19 Surge in Louisiana
Authors: Hargrove Paige , Spann Deborah , Legendre Yvette , Colligan Ted , Martin-Schild Sheryl
Published: March 2021

Background:
The first surge of COVID-19 cases in Louisiana began in late March 2020 in the Greater New Orleans Area and quickly spread throughout the state. We sought to determine if LVO screening and door in-door out (DIDO) among patients who screened positive for large vessel occlusions (LVO) deteriorated.

Methods:
Our statewide stroke registry, mandatory for hospitals attesting to Acute Stroke Ready Hospital status, was queried. We compared LVO screening and transfer efficiency during Q1 and Q2 2020 with Q3 and Q4 2019.

Results:
Patients presenting within 24hr of last seen normal declined by 11%. The proportion arriving by ambulance increased (50.6% vs 40.7%, p<0.0001). Screening for LVO increased (84.4% vs 77.0%%, p<0.0001). Use of Vision-Aphasia-Neglect assessment increased (74.6% vs 66.2%%, p<0.0001). The proportion screening positive for LVO insignificantly decreased (23.1% vs 26.0%, p=0.1233). The median time from door in to transfer request was stable (63min during both time periods). The median time from transfer request to departure increased (58min vs 48min). The DIDO increased by 24 minutes (135min vs 111min). Delay due to achieving acceptance in hub center and secondary transfer ambulance were the most common reasons documented for prolonged DIDO.

Discussion:
Louisiana experienced a reduction in acute stroke presentation during COVID-19. Screening for LVO actually improved during this time, but DIDO was compromised due to problems securing transfer acceptance and secondary ambulance service. Earlier identification and initiation of secondary transfer for patients screening positive for LVO should help improve efficiency in delivering acute stroke therapy.
Abstract P167: Inconsistency in the Application of National Institutes of Health Stroke Scale Scores (NIHSS) Between Neurologist and Emergency Room Nurses During Acute Ischemic Stroke
Authors: Glidden Michele , Templeton Evan , Bartlett Stephanie , DCruz Lynn , McNew Abbie , Nemati Donya , Smith Danika , Zabel Samantha , Comer Amber R
Published: March 2021

Background:
The National Institutes of Health Stroke Scale (NIHSS) score is the gold standard for assessing stroke severity. One 2006 study demonstrated research nurses had better interrater reliability in clinical trials than neurologists, but little is known about NIHSS score consistency between neurologists and registered nurses in clinical practice. Consistent baseline NIHSS scoring by neurologists and nurses is crucial to determine stroke acuity, deliver evidence-based treatment, and optimize patient outcomes. The purpose of this study was to determine whether a difference existed between healthcare providers’ NIHSS scores and determine factors affecting inconsistencies in scores.

Methods:
A retrospective chart review of patients treated at a single Comprehensive Stroke Center safety net hospital compared the initial NIHSS scores given to the same patient by neurologists and emergency department nurses from January 2018 to December 2019. Of the 588 charts reviewed, 438 met inclusion criteria. Patients were divided into two cohorts based on score differences between neurologists and nurses: clinically meaningful score difference ≥2 (n= 152, 34.70%) and non-meaningful score difference <2 (n= 286, 65.30%,).

Results:
Only two variables were significantly associated with greater score inconsistencies: higher NIHSS score (p = <.01) and patients presenting with aphasia (p =<.01). Clinically meaningful score inconsistencies were 44% more likely to occur in aphasic stroke patients.

Conclusions:
Although overall NIHSS scores are similar between physicians and nurses, patients with aphasia and more severe strokes were more likely to be scored inconsistently. Neurologists and nurses have different training and certification requirements with nurses required to certify annually while neurologists are not. Implementing a policy that requires all providers to undergo the same training in specific areas of the NIHSS may eliminate disparity and ensure patients are given the interventions needed for best outcomes.
Abstract P17: Outcomes After Thrombolysis for Ischemic Stroke in Costa Rica Compare Favorably With International Cohorts
Authors: Mandava Pitchaiah , Torrealba-Acosta Gabriel , Barboza Miguel A , Fernández-Morales Huberth , Qasim Muhammad , Litvak Paul , Rothlisberger Travis , Tsivgoulis Georgios K , Alexandrov Andrei V , Kent Thomas A
Published: March 2021

Background:
More than 70% of strokes occur in resource-poor countries. Outcomes are often not well documented. rt-PA for acute ischemic stroke was approved in 2012 for use in Costa Rica (CR). A hub and spoke model was initiated and a dataset established, the CR Stroke Registry Program (CRSRP) for conditional- and post-approval monitoring. Here, we compared CRSRP rt-PA outcomes to similarly treated subjects from the 1995 NINDS rt-PA trial and the 2019 CLOTBUST-ER control arm.

Methods:
Subjects were matched using a published pairing methodology and day 7-10/discharge modified Rankin Score (mRS), symptomatic intracerebral hemorrhages (SICH) and early mortality compared. A mortality model was generated from 15 randomized controlled trials (RCTs) and outcomes compared at similar baselines. SICH rates were compared with other cohorts: Get With The Guidelines (GWTG), a combined international IV thrombolysis trial pool, and 2 Ibero-American populations.

Results:
Of 424 CRSRP patients, 284 receiving rt-PA under 3 hrs were matched with 308 NINDS subjects. 131 non-diabetic CRSRP subjects, treated within 4.5 hrs, NIHSS 10 - 24 and Alberta Stroke Program Early CT Score (ASPECTS)>7, were matched with 300 CLOTBUST-ER subjects. Percent achieving either mRS 0-1 or 0-2 did not differ between CRSRP and either NINDS or CLOTBUST-ER (mRS 0-1: CRSRP:33.9% vs NINDS:33.6%; CRSRP:23.8% vs CLOTBUST-ER:27.0%, all p>=.05 / mRS 0-2: CRSRP:40.0% vs NINDS:41.4%; CRSRP:31.1% vs CLOTBUST-ER:36.1%, all p=>.05). Mortality was higher for CRSRP vs CLOTBUST-ER (6.6% vs 0.8%; p=0.05) but not vs NINDS (6.8% vs 4.3%; p=0.3). A predictive model (R
2
=0.39) showed neither cohort exceeded expected pooled mortality, with CLOTBUST-ER the lowest mortality. SICH rate was higher in CRSRP vs CLOTBUST-ER (7.3% vs 0.0% p=0.008) but not vs NINDS (5.7% vs 6.8% p=0.7)). SICH rates were not higher when compared with 4 international cohorts.

Conclusion:
Functional outcomes of Costa Rican patients receiving rt-PA compared favorably with 2 RCTs (NINDS and CLOTBUST-ER). SICH and mortality were higher than CLOTBUST-ER, although both were within expected range compared to other international cohorts. Systems of care development in order to further lower SICH and participate in the endovascular era are underway.
Abstract P173: Stroke Mimics in Patients With Discordance Between VAN Determination by EMS and Experienced Stroke Teams
Authors: Navalkele Digvijaya , Vahidy Farhaan S , Emily Nichols , Nisar Tariq , Salmeron William , Hargrove Paige , Salerian Justin A , Vidal Gabriel , Jennings Bethany , Samai Alyana , Franco Lia , Martin-Schild Sheryl
Published: March 2021

Background:
Discordance between pre-hospital (EMS) and experienced stroke team (ED) determination of Vision-Aphasia-Neglect (VAN) assessment threatens VAN’s utility in routing patients with large vessel occlusion (LVO) to thrombectomy centers. Discordance may be due to a fluctuating exam in the setting of stroke or stroke mimics. We sought to evaluate the rate and etiology of stroke mimics in patients with discordant versus concordant VAN assessments.

Methods:
The EMS run reports were linked with stroke registries from three CSCs in New Orleans, Louisiana from 2/2019-7/2019. EMS-VAN was compared to that of CSCs in all patients who presented within 6 hours of last seen normal. Stroke mimics were compared in patients with concordance vs discordance between VAN determination by EMS and experienced stroke teams.

Results:
EMS documented VAN in 63.2% of stroke codes brought to CSCs. Concordance was 66.9%; the k, CI was 0.35, 0.20 - 0.50. The proportion of stroke mimics was largest in concordant VAN negative patients (64.4%) with seizures and altered mental status (23.7% each) the most frequent causes. The proportion of stroke mimics was smallest in concordant VAN positive patients (17.3%) with seizures as the most frequent cause (44.4%). Similar high frequency of seizure mimic was determined in VAN discordant patients; seizure accounted for 47.8% of discordant mimics and 20% of all discordant patients.

Discussion:
VAN assessment as performed by trained EMS providers had only fair correlation with experienced stroke team members. The rapidly evolving exam of patients with seizures may explain a significant portion of stroke mimics among patients whose exams change between EMS and ED stroke team assessments.
Abstract P20: Bridging Therapy Increases Hemorrhagic Complications Without Improving Functional Outcomes in Atrial Fibrillation Associated Stroke
Authors: Akbik Feras , Alawieh Ali , Cawley C. Michael , Howard Brian , Tong Frank , Nahab Fadi B , Saad Hassan , Dimisko Laurie , Mustroph Christian M , Pradilla Gustavo , Maier Ilko , Goyal Nitin , Starke Robert , rai ansaar , Fargen Kyle , Psychogios Marios , Jabbour Pascal M , De Leacy Reade A , Keyrouz Salah G , Dumont Travis , Kan Peter , Arthur Adam S , Crosa Roberto , Gory Benjamin , Spiotta Alejandro M , Grossberg Jonathan A
Published: March 2021

*
on behalf of the Stroke Thrombectomy and Aneurysm Registry (STAR) Collaborators

Introduction:
Intravenous thrombolysis complications are enriched in AF associated stroke, as these patients have worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications. These data suggest that AF patients may be at particularly high risk for complications of bridging therapy for large vessel occlusions treated with mechanical thrombectomy (MT). Here we determine whether clinical outcomes differ in AF associated stroke treated with MT and bridging therapy.

Methods:
We performed a retrospective cohort study of the Stroke and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4,169 patients who underwent MT for an anterior circulation stroke, 1,517 (36.4 %) of which had comorbid AF. Prospectively defined baseline characteristics and clinical outcomes were compared.

Results:
Hemorrhagic complications after MT were similar in patients with or without AF. In patients without AF, bridging therapy improved 90-day outcomes (aOR 1.32, 1.02-1.74, p<0.05) without increasing hemorrhagic complications. In patients with AF, bridging therapy independently predicted hemorrhagic complications in AF patients (aOR 2.08, 1.06-4.06, p<0.033) without improving functional outcomes.

Conclusions:
Bridging therapy in AF patients undergoing thrombectomy independently increased the odds of intracranial hemorrhage and did not improve functional outcomes. AF patients may represent a high-risk subgroup for thrombolytic complications. Randomized trials are warranted to determine whether patients with AF associated stroke may benefit by deferring bridging therapy at thrombectomy-capable centers.
Abstract P208: Telehealth for Stroke Survivors With Aphasia - Preliminary Effectiveness Results From the High-Intensity Tele-Speech Therapy for Stroke Pilot
Authors: Mehta Sonia , SICO Jason J
Published: March 2021

Introduction:
Speech rehabilitation therapy (SRT) for stroke survivors with residual speech and cognitive impairment is standard of care. SRT is associated with high attrition rates when delivered in person in the clinic. SRT delivered via telehealth has the promise to address these concerns while improving both access to SRT and outcomes and promoting social distancing and reducing COVID exposure for high-risk stroke patients.

Hypothesis:
The High-Intensity Tele-speech Therapy for Stroke (HITTS) pilot program will result in measurable improvements in standardized performance and subjective reports in communication for participants compared to their baseline.

Methods:
We adapted evidence-based aphasia therapies implemented into a telehealth delivery model for four stroke survivor:care partner dyads over a six-week period. Following an initial face-to-face evaluation, skilled SRT was delivered via telehealth for five hours per week. Standardized pre- and post-therapy assessments were completed as well as analyses of meeting therapy goals identified by the dyad as meaningful.

Results:
Participants completing HITTS showed significant clinical improvements in standardized assessment scores with all participants who completed the program. Three of the four dyads completed the HITTS program and without missing any sessions and completing more than 90% of assigned work. On average 85% of self-identified therapy goals were met by the end of HITTS.

Conclusions:
The HITTS pilot of delivering SRT via telehealth shows promise as a viable and potentially effective means of improving attrition and outcomes while increasing engagement of care partners. Telehealth delivery models have become increasingly more important during the COVID era. A larger scale study with a usual care comparator group and longer follow-up period is needed to see if these results can be replicated and whether gains are sustained beyond the intervention period.
Abstract P215: Declining Gastrostomy Tube Utilization in Acute Ischemic Stroke
Authors: Pfaff Lee , Albright Karen C , Latorre Julius Gene , Otite Fadar O
Published: March 2021

Objective:
To test the hypothesis that placement of percutaneous feeding tubes (PEG) in acute ischemic stroke (AIS) patients has declined following increased usage of intravenous thrombolysis (IV-tPA) and mechanical thrombectomy (MT) over the last decade.

Methods:
We identified all primary adult AIS admissions contained in the 2005-2017 National Inpatient Sample using International Classification of Diseases (ICD) codes. Age and sex-specific proportions of hospitalizations with coexisting ICD procedural codes for PEG were computed. Joinpoint regression was used to evaluate trends over time. Multivariable adjusted logistic regression was used to compare odds of PEG use between periods and demographic subgroups.

Results:
From 2005-2017, 4.3% of all AIS hospitalizations had coexisting codes for PEG but usage differed by age, with highest proportion of usage in patients >=80 year old (y.o) (5.2%) and lowest frequency of usage in adults 18-39 y.o (2.7%). On joinpoint regression, there was no significant change in PEG use from 2005-2009, usage declined annually by -3.0% from 2009-2015 (95%CI -4.2% to -1.8%) and then declined sharply by -9.2% (95%CI -13.4 to -4.8%) from 2015 to 2017 (figure 1). The pace of decline was faster in patients >=80y.o compared to other age groups. After multivariable adjustment for clinical and hospital level factors, patients hospitalized in the period 2014-2017 had 25% reduced odds of PEG when compared to admissions in the period 2005-2009 (OR 0.76, 95%CI 0.72-0.79). Female sex and white race were associated with lower odds of PEG compared to males and black patients, respectively. IV-tPA and MT usage increased over time with marked increase in usage after 2015.

Conclusion:
Overall the rate at which PEG tube have been utilized has decreased significantly over the last decade. This decrease is likely from multifactorial advances in acute stroke (IV-tPA and MT) and post stroke neuro critical care.
Abstract P220: Hemorrhagic Stroke Patients Admitted to Inpatient Rehabilitation Facilities Improve Differently Based on Their Involvement of Corticospinal Tract
Authors: Taleb Shayandokht , Parker Dorothea , Ibrahim Lamya , Hsieh Billie , Haque Muhammad E , George Sarah , Boren Seth , Rahbar Mohammad H , Gupta Resmi , Tahanan Amirali , Green Charles , Savitz Sean I
Published: March 2021

Introduction:
We asked whether intracerebral hemorrhage (ICH) patients admitted to inpatient rehabilitation facilities(IRF) improve differently based on their involvement of the corticospinal tract(CST).

Aim:
To predict associating radiological factors affecting discharge FIM score.

Methods:
We reviewed the patients’ characteristics and their respective imaging findings presenting with ICH between 4/17 to 8/19. The ICH volume and edema around the ICH were measured using analyze software. The main outcome measure was FIM score at time of discharge. Statistical significance was set at 0.05.

Results:
Among the 53 patients included, 49% were female. The median age of the patients was 62 years (IQR 25,89). The median length of stay at IRF was 22days (IQR 14,26). In univariate analysis, FIM score at the time of discharge FIM score at the time of discharge admission were significantly associated with NIHSS (estimate -1.26, p<0.001), and ICH volume (estimate -3.45, p=0.01). However, the univariate analysis did not reveal an association of age (estimate -0.15, p=0.4) and gender (estimate 0.207, p=0.97) with FIM score at the time of discharge.Multiple regression analysis reflected that the CST involvement had a decrement in functional improvement on FIM in comparison with patients with intact CST when adjusting for age (
p
= 0.008), gender (
p
<0.01), NIHSS at the time of admission (
p
<0.01), and the ICH volume (
p
=0.02).

Conclusion:
This preliminary study suggests that functional improvement declines in ICH patients with CST involvement.
Abstract P222: Psychological Recovery After Aneurysmal Subarachnoid Haemorrhage: The Role of Post-Traumatic Growth and Self-Compassion
Authors: Thorburn Joanne M
Published: March 2021

Aneurysmal subarachnoid haemorrhage (aSAH), a subset of haemorrhagic stroke, is a potentially fatal condition with a mortality rate of approximately 50%. Of those that survive, some 60% will experience ongoing disability and impairment. Forty per cent of remaining survivors will experience what is deemed as a good neurological recovery. Despite good recovery, people have been found to experience negative psychosocial outcomes such as high levels of post-traumatic stress symptoms (PTSS), depression and reduced levels of overall well-being. As a result, aSAH has been viewed as a traumatic life experience with the potential for ongoing psychological sequelae. More recently the literature has identified that traumatic experiences can also elicit an opportunity for growth. Post-traumatic growth (PTG) states that for some people, the experience of trauma may also result in positive psychological gains. PTG has previously been investigated as an outcome after natural disasters and in a range of medical conditions; however, no studies have investigated PTG after an aSAH. A recent study identified that PTG may play a psychologically buffering role after a diagnosis of breast cancer. It is possible that PTG may also play a protective role in recovery after an aSAH; however, this has not been investigated. This study comprised N = 251 adults who had experienced an aSAH, and were recruited from Australia, U.K., U.S.A., New Zealand, and Canada. This study examined whether people who have survived an aSAH experience PTG; if predictors including self-compassion (SC) and social support (SS) influence the development of PTG after an aSAH; and if PTG moderates the relationship between PTSS, and depression and subjective well-being. Regression analyses were utilised to analyse the data. Results showed that people experience PTG after an aSAH; SC predicted PTG; PTG was not found to moderate the relationship between PTSS and either Depression or SWB domains. Supplementary analyses were conducted with SC not a significant moderator between PTSS and either depression or SWB domains. However, SC was found to mediate the relationship between PTSS and Depression and PTSS and SWB domains.
Abstract P228: Developing a Community Paramedicine Program to Reduce Stroke All-Cause Readmissions
Authors: Velasco Cesar , Wattai Brandon , Richardson Alicia , Reichwein Raymond K
Published: March 2021

Introduction:
According to the Centers for Medicare & Medicaid Services (CMS) readmission is a key indicator of hospital quality. Readmitted stroke patients experience greater mortality, longer lengths of stay, and higher costs. Lessening these occurrences have been challenging; but a growing Emergency Medical Services (EMS) concept- Community Paramedicine (CP) - provides a solution. The CP program is designed to provide follow-up home visits to patients after discharge. This program does not bill for services; its executive approval and subsequent expansion was instead predicated on cost avoidance.

Methods:
In 2018, following success in reducing readmissions in the heart failure population (which resulted in $1.38 saved over 2 years), CP was implemented in the stroke population. The intervention was modified to meet the needs of stroke patients and address key factors in stroke readmissions. The financial impact model consists of comparing readmission rates in the same primary disease category. A projection of readmissions that would have occurred for patients without the intervention is made using the rates observed in patients not seen by CP, allowing for projection of readmissions prevented through this intervention. The number of saved bed days is calculated using average length-of-stay and cost avoidance is calculated by multiplying the saved days with the average cost/day.

Results:
From July 2018-December 2019, CP visited 164 stroke patients, of which only 2 became a 30 day readmission (1.22%). Of the 658 stroke patients that did not receive a visit, 67 were readmitted (10.18%) in the same time period. Applying the same financial impact model, it is estimated that 9 readmissions were prevented, resulting in a cost avoidance of more than $191,029.

Conclusion:
Community Paramedicine is a versatile tool that decreases readmissions. During the visits, key barriers were addressed, such as medication discrepancies, absence of help in the home, lack of transportation, progressing symptoms, and overwhelmed caregivers. This successful model is replicable and well-supported by hospital leadership due to demonstrable cost avoidance. It’s a “win” for all; patients avoid readmission; the organization saves money; and patients receive optimal care.
Abstract P235: Epidemiologist
Authors: Kelley Kim , Mccausland Meghan , Armstrong Beth
Published: March 2021

Reducing Door to CT Times in Rural Hospitals Using a Collaborative Quality Improvement Approach

Introduction:
Rural hospitals are a critical component of stroke systems of care, and play a key role in the race to treatment within the time windows for stroke. Faster treatment leads to better outcomes for stroke patients and rural hospitals often face unique challenges. Despite limited resources to conduct quality improvement (QI), a group of 13 rural hospitals in a large western state undertook a project to identify opportunities and implement strategies to reduce delays along their leg of the race to treatment. The project focused on reducing the time from the door to the CT scan for stroke patients arriving at rural hospitals. The project’s aim was to achieve a 25-minute door-to-CT median time for 60% of stroke patients, and performance in the 75
th
percentile for this national performance benchmark.

Methods:
The rural hospitals created a collaborative group from their existing QI committee. The group used evidence-based QI strategies, including leadership support, a SMART (specific, measurable, achievable, relevant, and time-based) goal, the plan-do-study-act model, Ishikawa diagrams, and data-driven interventions tailored to each organization. QI Analysts established a baseline for median door-to-CT times then collected monthly aggregate data using a national data collection tool for rural hospitals. Project leads regularly presented data at committee meetings and data were trended from baseline to project end. The project culminated in a conference to share the outcomes, challenges, and strategies used to achieve the project goals.

Results:
After implementing key QI interventions, the door-to-CT median time went from a baseline of 47 minutes to a median time of 25 minutes in the last two quarters. As a group, the hospitals achieved their goal of performing in the 75th percentile of a large national stroke registry.

Conclusion:
This project demonstrated that despite resource challenges, rural hospitals can successfully do data-driven QI for stroke and meet national benchmarks. The project implemented crucial elements for successful QI initiatives in rural regions: rurally relevant, self-designed, collaborative, leadership-supported and peer-led.
Abstract P240: The Impact of Patient Demographics on the Utilization of Video vs Telephonic Care in a Telemedicine Clinic During the COVID-19 Pandemic
Authors: Okpala Nnedinma , Cohen A. Sarah , Okpala Munachi , Hinojosa Evelyn , Miller Shawanda , Ankrom Christy T , Wu Tzu-ching , Monday Kimberly , Savitz Sean I , Sharrief Anjail Z
Published: March 2021

Background:
In response to the COVID-19 pandemic, stroke outpatient care was transformed to telemedicine (TM) through video (VTM) and telephonic (TPH) visits. While TM offers potential benefits over in-person visits for stroke patients, accessibility of VTM may be limited for patients at highest risk for poor outcomes. We recommended VTM for all patients, but offered TPH visits if patients did not have adequate equipment or declined VTM. We examined whether demographic variables influenced the TM visit type completed (VTM vs TPH) for patients seen during the pandemic.

Methods:
We conducted a retrospective review of charts for patients seen in our stroke clinic between 3/16/20 (fully operational TM) and 5/31/20. We determined visit type: VTM vs in-person vs TPH and abstracted demographic and clinical data. We focused on TM visits and used t-tests, Fisher’s exact tests, and chi-squared as appropriate for univariate analyses and logistic regression for multivariate analyses.

Results:
Among 463 visits, 47 in-person visits were excluded, leaving 416 (328 VTM and 88 TPH). Mean age was 61.5 and by race/ethnicity: 42.9% non-Hispanic white (NHW), 36.9% non-Hispanic Black (NHB), 11.6% Hispanic, 4.3% Asian, and 4.3% other (Table 1). In univariate analyses, visit type was significantly associated with race (p = 0.024), insurance type (p=0.001), and visit type (new vs established). In adjusted analysis, NHB race was associated with 1.90 times higher odds (95% CI 1.09-3.32) of TPH vs VTM compared to NHW. Medicaid insurance was associated with 3.90 times higher odds (95% CI 1.54-9.88) of TPH vs VTM visit compared to private insurance.

Conclusions:
We found that NHB patients and patients with Medicaid were less likely to complete VTM visits compared to TPH. This suggests barriers to VTM based on race and insurance type and deserves further study. If video visits are superior to TPH visits for clinical care, these barriers may widen disparities in secondary stroke prevention during the pandemic.