bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP185: Impact of Age on Revascularization and Early Outcomes Post Mechanical Thrombectomy in Acute Ischemic Strokes with Large Vessel Occlusion; A Single Center Real World Data Analysis
Authors: Niazi Muhammad H , El-Ghanem Mohammad , Cockroft Kevin , Morrison Kathy , Richardson Alicia , Raymond Reichwein , Ermak David
Published: June 2021

Background:
Recently, five randomized control trials have demonstrated superiority of endovascular therapy (ET) to medical management in acute ischemic stroke (AIS) patients with anterior circulation large vessel occlusion (LVO). Some concerns have arisen in subset and meta analyses of the pivotal trials regarding the negative effect of advanced age (>80 years) on outcomes after ET.

Methods:
A retrospective analysis of patients with proven LVO who underwent ET was conducted from January 2015 to June 2016. Patients were divided in two groups based on age (≤80 and >80 years) and were analyzed for degree of revascularization (TICI score) and functional status at discharge using the modified Rankin Scale (mRS).

Results:
Fifty-four patients received ET during the study period. Those who had posterior circulation LVO and/or treated after 6 hours from last known normal were excluded, leaving 34 patients for final analysis. Twenty-two (64%) patients were ≤80 and 12 (36%) were >80. Seventy-seven percent of patients ≤ 80 had favorable recanalization (TICI ≥ 2b) while 66 % of patients > 80 had TICI ≥ 2b (
p value
0.69). Of patients >80 years, 0 % had a mRS ≤2 at discharge versus 36.3% ≤80 years (
p value
0.03). Similarly, 25% of patients > 80 and 54.5% of ≤80 had mRS 3 or 4 (
p value
0.15). Only 9% of ≤ 80 had mRS >4, as compared to >80 at 75% (
p value
<0.01). No statistically significant differences were found in the average time to revascularization, admitting NIHSS or administration of tPA.

Conclusion:
Age above 80 is a predictor of poor outcome after ET irrespective of successful recanalization. Our results confirm the questions raised in previous subset analyses. The reason octogenarians do poorly remains unclear, but our data suggests factors other than TICI score and time to revascularization. Although ET has shown superiority in AIS with LVO, further consideration and careful selection is recommended in patients above age of 80. More focused randomized control trials are needed to get a definitive answer.
Abstract TP188: Migraine History is the Only Predictor of Negative Diffusion Weighted Imaging in Patients Treated with IV-Thrombolytic
Authors: Lima Jussie , Mehta Tapan , Datta Neil , Bakradze Ekaterina , Beland Dawn , Staff Ilene , Fortunato Gilbert , Nouh Amre
Published: June 2021

Background:
Migraine, seizures, and psychiatric disorders are frequently reported as “stroke mimics” in patients with negative diffusion weighted imaging (DWI) after IV-tPA. We sought to determine predictors of negative DWI in suspected stroke patients treated with IV-tPA.

Methods:
A retrospective case-control study encompassing all acute stroke patients treated with IV-tPA (at our hospital or "dripped and shipped") from January 2013-December 2014 was conducted. A total of 275 patients were identified with 47 negative DWI cases and 228 positive DWI controls. Variables including demographic factors, stroke characteristics, and clinical comorbidities were analyzed for statistical significance. A multivariate logistic regression was performed (SPSS-24) to identify predictors of negative DWI.

Results:
Approximately 17% of patients had negative DWI after IV-tPA. Compared to controls, migraine history independently predicted negative DWI (OR 5.0 95% CI 1.03-24.6, p=0.046). Increasing age (OR 0.97 95% CI 0.94-0.99, p=0.02) and atrial fibrillation (OR 0.25 95% CI 0.08-0.77 p=0.01) predicted lower probability of negative DWI. Gender, admission NIHSS, treatment location, pre-admission modified Rankin scale, diabetes mellitus, hypertension, hyperlipidemia, symptom side, seizure history, and psychiatric history did not predict negative DWI status.

Conclusion:
In our study, only pre-existing migraine history independently predicted negative DWI after IV-tPA treatment in suspected stroke patients. Although helpful in acute evaluation, this should not preclude treatment with IV-tPA considering the outcomes of missed strokes and low complication risk of IV-tpa in these patients.
Abstract TP189: Age of Menarche and Risk of Future Strokes in Women
Authors: Rahman Haseeb A , Malik Ahmed , Rahman Aesha , Chaudhry Saqib , Thomas Abraham , Adil Malik , Qureshi Adnan
Published: June 2021

Background:
An increased risk of stroke has been found in women with early or late menarche in a cohort in the United Kingdom. It is uncertain if there is a similar increase in risk of stroke in women who experience early or late menarche in the United States.

Methods:
Using data from the observational component of the Women’s Health Initiative (WHI) [WHI Observational Study (OS)], we analyzed the 93,676 women aged 50-79 years, who participated in the OS over a period of 12±1 years. We compared the outcome of ischemic stroke in participants of 5 strata of age of menarche (10 years or younger, 11-12 years, 13-14 years, 15-16 years, and 17 years or older), as recorded at the baseline visit. An ordinal regression analysis was run to determine if there was a change in the risk of stroke over these strata.

Results:
Of the 93, 676 participants, 6067 reached menarche at 10 years of age or younger, and 965 reached menarche at 17 years of age or older. A smaller proportion of participants who developed an outcome of stroke were 10 years old or younger at menarche as compared to those who never developed stroke (6.4% vs. 6.5% p=0.85). A greater proportion of participants who developed an outcome of stroke were 11-12 years of age at menarche as compared to those who did not develop an outcome of stroke (42.8% vs. 41.3% p <.122). In the ordinal regression, there was a stronger correlation between developing a stroke and being a participant in the categories of 11- 12 years and 13-14 years of age at menarche than in the younger or older age group, respectively (0.14 and 0.103 vs 0.94 and 0.02 p=0.45).

Conclusion:
There is no significant increase in stroke risk in senior women in the United States who have menarche at an early (≤10 years) or late (≥17 years) age.
Abstract TP205: Framingham Stroke Risk Score Predicts Severity of Leukoaraiosis in Patients with Acute Ischemic Stroke
Authors: Kharal Ghulam A , Cloonan Lisa , Kanakis Allison S , Furie Karen L , Rost Natalia S
Published: June 2021

Introduction:
Severity of leukoaraiosis, or white matter hyperintensity (WMH) detected on T2 MRI, is associated with cognitive and functional decline and is a known risk factor for stroke and poor post-stroke outcomes. Fazekas score is a validated ordinal scale that accounts for WMH severity in the individual categories of periventricular (PVWM), deep WMH extent (DWMH) and deep WMH number of lesions (DWMNUM). Vascular risk factors (VRFs) are hypothesized to have differential effect on WMH lesion pathophysiology. We tested whether the Framingham Stroke Risk Score (FSRS), a collective score of several VRFs, is associated with WMH severity across individual Fazekas categories in a hospital-based cohort of patients with acute ischemic stroke (AIS).

Methods:
In 294 AIS patients, WMH was categorized into PVWM, DWMH, DWMNUM, and an average of all three categories per subject (“the condensed score”). Fazekas scores ranging 0-3 in each category were dichotomized (mild WMH≤1 vs. severe WMH ≥2). FSRS was calculated for each patient using a standardized formula awarding points for each FSRS variable (age, gender, systolic blood pressure, diabetes mellitus, cigarette smoking, coronary heart disease, left ventricular hypertrophy, atrial fibrillation) and added to obtain a total FSRS, which was then categorized into multiples of ten (FSRS ≥10, FSRS ≥20). Logistic regression models included binary FSRS category and Fazekas score for each WMH category using Stata 12.

Results:
As compared to AIS subjects with FSRS<20, those with FSRS≥20 had greater odds of severe leukoaraiosis across all four WMH categories
(Figure).

Conclusions:
In our cohort, FSRS predicts severity of leukoaraiosis across different Fazekas categories, suggesting compounded effect on WMH development from various VRFs comprising the FSRS. Future studies powered to discern the effect of individual elements of FSRS on WMH categories are warranted to further understand the pathophysiology of leukoaraiosis.
Abstract TP208: Sleep Disordered Breathing (SDB) - An Overlooked Modifiable Risk Factor in Acute Stroke Care
Authors: Shah Vishal , Gudlavalleti Ashrai , Latorre Julius G
Published: June 2021

Introduction:
In patients with acute stroke, part of the acute management entails identifying the risk factors; modifiable or non modifiable. Early recognition of these factors is essential for optimizing therapeutic procedures, especially those with a known effective treatment. In this sense, Sleep Disordered Breathing (SDB) has also been suggested as a modifiable and independent risk factor for stroke as defined by international guidelines and some studies have demonstrated that patients with stroke and particularly Obstructive Sleep Apnea (OSA) have an increased risk of death or new vascular events. Pathogenesis of ischemic stroke in SDB is probably related to worsening of existing cardiovascular risk factors such as hypertension and hypoxia driven cardiac arrhythmia leading to higher prevalence of ischemic stroke in patients with sleep disordered breathing disease. Despite strong evidence linking SDB to ischemic stroke, evaluation for SDB is rarely performed in patients presenting with an acute ischemic stroke.

Hypothesis:
Evaluation of SDB is rarely performed in patients presenting with acute ischemic stroke.

Methods:
We performed a retrospective review of all patients above the age of 18 who were admitted to the acute stroke service at University Hospital July 2014 to December 2014. Demographic data, etiology of stroke as identified per TOAST criteria, modifiable risk factors, presenting NIHSS and frequency of testing for SDB and their results were collected. The data was consolidated and tabulated by using STATA version 14.

Results:
Total of 240 patients satisfied our inclusion criteria. Only 24 patients ie 10% of those who satisfied our inclusion criteria received evaluation for SDB. Out of those evaluated, 62.5% ie 15 patients out of 24 patients had findings concerning for significant desaturation. Only 2 providers out of 8 stroke physicians ie 25% tested for SDB in more than 5 patients.

Conclusions:
Our observations highlight the paucity in evaluation for SDB in acute ischemic stroke in a tertiary care setting. Being a modifiable risk factor, greater emphasis must be placed on evaluation for SDB in patients in patients with acute stroke. Education must be provided to all patients and providers regarding identification of these factors.
Abstract TP227: Outcomes of a Regionalized Stroke Care System
Authors: Sequeira Denisse , Martin-Gill Christian , Lowry Gregory , Robinson Marcus , Siddiqui Hinnah , Guyette Francis X
Published: June 2021

Introduction:
Strokes are one of the leading causes of death and disability. Time-sensitive therapies are available including IV-TPA and endovascular therapies which require rapid and effective triage. Endovascular therapies are available at comprehensive stroke centers (CSC). We evaluated if there was any improvement in outcomes for patients who are transported directly to a CSC.

Hypothesis:
Patients that receive acute interventions for stroke have improved outcomes when transferred directly to CSC as compared to transport to a PSC and then transferred to a interventional facility.

Methods:
A retrospective cohort study of 5,188 patients transported from January 2012 to December 2013 with an EMS provider impression of suspected stroke via both air and ground transport. Of these, data was complete for 1,196 patients with a confirmed discharge diagnosis of ischemic stroke. Pre-hospital data was abstracted from EMS charts. Ischemic strokes were identified by final hospital discharge diagnosis and good functional status was defined as a modified Rankin scale <3 at discharge. Categorical outcomes were tested using Fishers Exact Test and Ordinal outcomes using the Mann Whitney Test.

Results:
For those with complete data mortality was 10% (CI 8.3-11.7) in this cohort with good functional outcomes in 37% (CI 34.3-39.7) of patients. IV- TPA was administered to 293 (24%) and endovascular interventions were performed in 167 (14%). There were 739 (63%) inter-facility transfers and 442 (37%) received directly from the scene. Transport to the CSC occurred by air in 798 (67%) cases as compared to 398 (33%) by ground. Mortality and good functional outcome did not differ between patients transferred and those taken directly to the CSC. Among patients receiving either TPA or endovascular therapy, direct transport to the CSC is associated with good functional outcome (Fisher’s exact= 0.041) but not with mortality.

Conclusions:
Among patients with a diagnosis of ischemic stroke presenting to a CSC, there is no difference in mortality and good functional outcome as a function of transfer from the scene or transfer from another facility. However, among those who received tPA or endovascular intervention good functional outcome was associated with direct presentation to the CSC.
Abstract TP229: Change Takes Time: EMS as the Spark Plug for Faster Acute Ischemic Stroke Care
Authors: Greenberg Karen , Lesenskyj Alexandra , Eichorn Daniel , Maxwell Christina , DeWitt Grace , Veznedarolgu Erol , D’Ambrosio Michael , Binning Mandy
Published: June 2021

Introduction:
It is well documented that a Prehospital Stroke Alert (PHSA) protocol leads to decreased treatment times for stroke patients. Outcomes measured typically include Door to Physician (DTP), Door to CT (DTCT), and Door to Needle (DNT) times. Our comprehensive stroke center’s PHSA system has been in place since 2012. This study evaluates 3 specific endpoints. First, Emergency Medical Services (EMS) improve their recognition of stroke symptoms as they gain experience with PHSA. Second, a PHSA protocol decreases intervention times of DTP, DTCT, and DNT over a study period of 3 years. Third, when patients present to our Neurologic Emergency Department (Neuro ED) as a PHSA, rather than a non-PHSA, the intervention times are markedly decreased, and acute ischemic stroke care is significantly expedited.

Methods:
A retrospective chart review was conducted for patients who presented to our hospital with an admitting diagnosis of stroke from 2012-2014. Patients were screened for presentation to the Neuro ED and further stratified based on whether a PHSA was called. PHSA was called if EMS deemed the patient’s Cincinnati Stroke Scale score as positive, and symptom onset was within 6 hours. We recorded DTCT, DTP, and DTN times over the years for all patients meeting these inclusion criteria.

Results:
Three hundred and five patients with an admission diagnosis of stroke were seen in the Neuro ED (Hours are 0700-1800, 7 days a week) from 2012 to 2014, 128 of which presented as PHSAs. EMS responders accurately diagnosed stroke in 82% of cases. Previously, EMS assessment of stroke was accurate only 66% of the time. PHSA patients had decreased DTP, DTCT, and DTN times over the 3 year period. When comparing the PHSA group to non-PHSA group, statistically significant differences were found in DTP and DTCT times within each year (p≤0.0001).

Discussion:
In conclusion, gaining experience with a PHSA protocol did in fact lead to EMS better recognizing stroke symptoms, reduction in the times of delivery of care for acute ischemic stroke patients over the years 2012-2014, and a markedly statistically significant difference in intervention times if patients were seen as a PHSA as opposed to a non-PHSA.
Abstract TP23: Prestroke Glucose Control Can be a Predictor for Outcome in Endovascular Therapy of Acute Ischemic Stroke
Authors: Chang Jun-Young , Han Moon Ku , Yum Kyu Sun , Lee Sangkil , Park Tai Hwan , Lee Soo Joo , Lee Kyung Bok , Lee Jun , Park Jong-Moo , Kim Dong-Eog , Kim Joon-Tae , Cha Jae-Kwan , Lee Byung-Chul , Lee Juneyoung , Cho Yong-Jin , Kim Wook-Joo , Shin Dong-Ick , Sohn Sung-Il ,   CRCS-5 investigators
Published: June 2021

Background:
The purpose of the study is to evaluate whether prestroke glycemic control is associated with functional outcome in patients with acute ischemic stroke after endovascular treatment.

Methods:
We reviewed the acute ischemic stroke patients who underwent endovascular recanalization in the participating centers between April 2008 and March 2015 from the Clinical Research Center for Stroke-5th division (CRCS-5) registry. The relationship between the level of HbA1c on admission and functional outcome at 3 month, stroke recurrence and composite outcome (stroke, myocardial infarction, or vascular death) occurrence were assessed.

Results:
All 829 study subjects were classified as 4 groups according to quartiles of HbA1c on admission: 1
st
quartile (HbA1c ≤5.6%), 2
nd
quartile (5.6% < HbA1c ≤5.9%), 3
rd
quartile (5.9% < HbA1c ≤6.5%), 4
th
quartile (HbA1c >6.5%). END occurred more frequently in the highest quartile of HbA1c (P=0.02). Among the components of END, the frequency of symptomatic hemorrhagic transformation occurred more often in the group with higher quartiles (P=0.03), while stroke recurrence or recurrence was not significantly different according to the quartiles of HbA1c (P=0.27). After adjusting for significant variables (age, sex, initial NIHSS, diabetes, complete recanalization, procedure time, occurrence of END, P<0.05), HbA1c on admission >6.5% was still inversely associated with favorable functional outcome at 3 month (adjusted OR 0.48, 95% CI 0.25-0.93 as quartiles, adjusted OR 0.40, 95% CI 0.22-0.73 as a dichotomized variable). No significant heterogeneities were observed according to the age, diagnosis of diabetes on admission, stroke subtype, recanalization degree, and reperfusion time. The cumulative risk of both stroke recurrence and composite even rates were not significantly different according to the quartiles of HbA1c on admission (P=0.64, P=0.19, respectively).

Conclusion:
Prestroke glycemic control is associated with occurrence of symptomatic hemorrhagic ransformaion and functional outcome in patients with acute ischemic stroke after endovascular treatment. More stringent glycemic control of HbA1c below or equal to 6.5 % may have beneficial effect on neurological recovery after stroke.
Abstract TP240: The PLUMBER (Prevalence of Large Vessel Occlusion Stroke in Mecklenburg County Emergency Response) Study
Authors: Dozois Adeline R , Hampton Lorrie , Kingston Carlene W , Lambert Gwen , Porcelli Thomas J , Sorenson Denise , Templin Megan , VonCannon Shellie , Asimos Andrew W
Published: June 2021

Introduction:
Regional Emergency Medical System (EMS) protocols for acute stroke endorse routing patients with possible large vessel occlusion (LVO) acute ischemic strokes (AIS) directly to endovascular centers. These routing algorithms include prehospital stroke severity screens (PSSS) to determine the likelihood of an LVO AIS. An essential, but unreported, determinant of the predictive value of PSSS tools is the prevalence of LVO AIS stroke in the EMS population screened for stroke.

Hypothesis:
Among EMS patients transported to Mecklenburg county hospitals screened for stroke, acute LVO AIS prevalence ranges from 5-10%.

Methods:
We are conducting a prospective, observational study of all patients transported by the Mecklenburg county EMS agency who are either (1) dispatched as a possible stroke and/or (2) with a primary impression of stroke recorded by prehospital providers. We are reviewing medical records and neurovascular imaging studies to determine an acute LVO AIS diagnosis and the site(s) of occlusion.

Results:
Thus far, over a six-month period we have enrolled 1441 patients, of whom 33% (n=480) had a diagnosis consistent with acute stroke (ischemic stroke, hemorrhagic stroke, or transient ischemic attack), with 20% (n=287) being an AIS. Eighty-eight percent (n=253) of AIS patients underwent an intracranial CTA or MRA. The prevalence of LVO stroke in the EMS population enrolled was 5.7% (n= 82, 95% CI 4.6-7.0%), with the most common vessel occluded being M1 (n=46, 56% of LVO AIS). The prevalence of LVO AIS in patients dispatched as a possible stroke was 4.8% (n =56; 95% CI 3.6-6.1%), while the prevalence in patients with a primary impression of stroke was 10% (n=74; 95% CI 8.2-13%).

Conclusions:
Among patients screened for stroke by our county’s EMS agency, the prevalence of LVO AIS is low. This low LVO AIS prevalence, combined with a PSSS tool with modest accuracy, will yield poor predictive value for LVO AIS in an EMS population, resulting in a substantial rate of over-triage of non-LVO patients to endovascular centers. Data collection is ongoing to determine the accuracy of a prehospital stroke screen in identifying LVO AIS patients.
Abstract TP248: The Kaiser Permanente Stroke EXPRESS Program: Improving DTN Time in a 21-hospital Integrated Healthcare System
Authors: Nguyen-Huynh Mai N , Klingman Jeffrey G , Avins Andy , Eaton Abigail , Bhopale Sunil , Kim Anne C , Flint Alexander C ,   on behalf of KPNC Stroke FORCE team
Published: June 2021

Background:
Faster treatment with tPA in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke workflow across all 21 KPNC stroke centers to have all stroke alerts actively managed by a core group of vascular neurologists via telemedicine. We examined the effect of KPNC’s Stroke EXPRESS (EXpediting the PRrocess of Evaluating and Stopping Stroke) program on door-to-needle (DTN) time and symptomatic intracranial hemorrhage (sICH) rates.

Methods:
The Stroke EXPRESS program was rolled out across KPNC in a staggered fashion from 9/2015 to 1/2016 with the goals of expediting the evaluation and determination for tPA and speeding up the assessment for large vessel occlusion to allow for timely transfer for thrombectomy. We compared DTN times for 6 months before implementation to the same 6-month calendar period after implementation.

Results:
After implementation, tPA administrations increased from 38/month at baseline to 80/month (P<.001). Mean DTN times decreased significantly after implementation (40.8 ± 31.5 min vs. 61.3 ± 30.9 min at baseline, P<.001; median 33 min vs. 52 min, P<.001.) [Figure], and all centers achieved DTN time of <60 minutes routinely (88% vs 64%, Risk Ratio =1.4, p<.001). DTN times of < 30 min were much more common in the Stroke EXPRESS period (46% vs. 5% at baseline, P<0.001). There was no difference in sICH rates by ECASS criteria in the two periods: 4.3% vs. 4.3%, P=1.00.

Conclusions:
Implementation of the Stroke EXPRESS regional telemedicine program in KPNC was associated with an increase in tPA administrations, markedly shorter DTN times, and no change in the rate of sICH.
Abstract TP251: Pomona Large Vessel Occlusion Scale for Pre-hospital and Emergency Room Settings
Authors: Panichpisal Kessarin , Janjua Nazli , Tse-Chang Karen , Jones Kimberly.A.Jones A , Woolfolk Katrina , Keasler Debbie , Bhupat Desai , Moradiya Yogesh , Nugent Kenneth
Published: June 2021

Background:
Early detection of acute stroke with large vessel occlusion (LVO) in both pre-hospital and emergency room settings results in favorable clinical outcomes. There is still no universal guideline for LVO screening.

Method:
We proposed that the presence of any of the following signs (Pomona scale): gaze deviation, expressive aphasia or neglect has a high sensitivity and accuracy to predict LVO. We reviewed a historical cohort of all acute stroke activation patients at Pomona Valley Hospital during February 2014 to January 2016. We tested Pomona scale in both groups. The predictive performance of Pomona scale was compared with different NIHSS cutoffs ( ≥4, ≥6, ≥8, ≥10), Los Angeles Motor Scale (LAMS), Cincinnati Prehospital Stroke Severity (CPSS) scale, Vision Aphasia and Neglect scale (VAN) and Prehospital Acute Stroke Severity (PASS) scale.

Results:
LVO was detected in 129 of the 777 acute stroke activation (17%). Two hundred and forty-two patients had nonLVO stroke (31%). NIHSS ≥4 and Pomona scale had highest sensitivity (0.99 and 0.98 respectively) to predict LVO. LAM scale had lowest sensitivity (0.68). Pomona scale had moderate accuracy (0.61) which was comparable with VAN (0.66) and PASS (0.67). NIHSS ≥4 had the least accuracy (0.28). When Pomona scale was combined with arm weakness, it had highest accuracy (0.77) and high sensitivity (0.92) to predict LVO in acute ischemic stroke subgroup. Using various NIHSS cut off to screen for LVO had lower accuracy than using other LVO screening tools.

Conclusion:
Pomona scale is very sensitive to predict LVO. It may be used as a screening tool for LVO in emergency room setting. Combination of arm weakness and Pomona scale may be used as a Pre-hospital LVO screening with moderately high accuracy.
Abstract TP261: Improving Neurologist Responsiveness for Telestroke Consultations: We Do Better!
Authors: Wagner Jeffrey , Salottolo Kristin , Fanale Christopher V , Jensen Judd , Bar-Or David
Published: June 2021

Introduction:
Telemedicine is widely used for remote evaluation and treatment of acute stroke patients (telestroke). Because time equals brain, the NINDS and ACLS recommend a benchmark of 15 minutes from arrival to neurologic expertise. Our goal was to examine key time metrics and outcomes in an active telestroke network after implementing system-wide improvements.

Methods:
Our comprehensive stroke center (CSC) serves as the Rocky Mountain Region’s referral center for comprehensive stroke care. The telestroke program launched in 2006; stroke program leaders recently initiated several changes to improve time metrics, including a) a streamlined process for the centralized call center including centralized paging; b) a dedicated, on-call telestroke neurologist; c) outreach and education to the spoke hospitals for accessing the call center; d) back-up systems in place for technical issues and for times of high consult volumes. We examined the following metrics for all telestroke consults compared to patients admitted through the ED of the CSC over the past 18 months: median (interquartile range [IQR]) neurologist response time, transfer rate to the CSC, and IV t-PA rate. Median telestroke consult times (time to initiation of video consultation) were also reported, beginning April 2016.

Results:
Ten neurologists at the hub CSC responded to 4,283 pages from 45 spoke hospitals, averaging 8 pages/day. Overall, 14.4% of patients were transferred to the CSC for definitive care. The time to telestroke page response was 2 [1-3] minutes, which was comparable to neurologist response at the CSC of 0 [0-5] minutes for 686 patients. The median telestroke consult time was 2 [1-4] minutes for 70 patients. The IV tPA rate for treating acute ischemic stroke was comparable for telestroke vs. bedside consults (17.3% vs. 18.9%).

Conclusions:
Based on our mature telestroke network, it is possible to be as responsive with telestroke consults as with in-hospital consults. Several new, scalable processes resulted in improved time metrics. These time metrics should help define what should be expected from a Telestroke provider.
Abstract TP262: Chronic Stroke Disrupts Frequency-specific Oscillations in the Hippocampus and Cortex
Authors: Yazdan-Shahmorad Azadeh , He Jiwei , Kay Kenny , Rabiller Gratianne , Nishijima Yasuo , Rrank Loren , Liu Jialing
Published: June 2021

Introduction:
The mechanism underlying post-stroke cognitive impairment is not well understood. The hippocampus is involved in memory function yet remains structurally intact after cortical stroke. During the slow-wave state, the hippocampus exhibits Sharp-wave associated ripples (SPW-Rs), a high-frequency activity in the pyramidal layer of the hippocampal CA1 that plays a critical role in memory consolidation. However, it is unclear whether cortical stroke chronically affects SPW-Rs or any other hippocampal oscillations.

Hypothesis:
Stroke affects network oscillations that bind neurons into transient assemblies with coherent activity.

Methods:
Adult male rats (n=28) were subjected to distal middle cerebral artery occlusion (dMCAO), compared to controls (n=19) by sham-operation. After time periods of either two weeks or one month, we recorded the neural activity from different depths starting at deep cortical layers down to hippocampus using 16-site linear electrode arrays under urethane anesthesia. We defined two states of high theta (HT) and low theta (LT) by calculating the ratio of Hilbert amplitudes of theta (4-7 Hz) to delta (0.1-3 Hz) filtered local field potential (LFP) recorded from the CA1 stratum lacunosum moleculare. A threshold was manually set to capture sustained periods in which the theta:delta ratio was elevated. Periods of SWRs were also detected from the filtered LFP (150-250Hz) recordings of CA1 pyramidal layer.

Results:
Chronic stroke increased the frequency of alternation between HT and LT states by shortening the duration of HT states. Stroke also increased the rate of occurrence of SWRs during LT state. Furthermore, chronic stroke at one month reduced theta and delta power at the hippocampal pyramidal layer and the cortex ipsilaterally, while it reduced gamma power bilaterally in the pyramidal layer during the HT states.

Conclusions:
Ischemic stroke affects brain states and several major oscillations not only in the cortex but also in the hippocampus. The aberrant brain oscillation may disrupt neural network activity that gives rise to complex cognitive behaviors, underlying post stroke cognitive impairment.
Abstract TP281: Reducing Door-to-Needle Times in Acute Ischemic Stroke : Multidisciplinary Team-based Approach at a Single Center
Authors: Ohara Nobuyuki , Kobayashi Junya , Goda Toshiaki , Ikegami Takeshi , Watanabe Kotaro , Asada Kiyokazu , Marutani Akiko , Nishi Noriyuki , Takahashi Daisuke , Yamada Tomonori
Published: June 2021

Background:
The benefits of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke are time dependent, and national guidelines recommend door-to-needle (DTN) time within 60 minutes. Several strategies have been reported to be associated with reducing DTN times. However, effectiveness of such strategies has not been fully evaluated.

Methods:
In 2014, we assembled a multidisciplinary team called ‘Acute Stroke Team (AST)’ aiming for improving outcomes of patients with acute ischemic stroke, especially by reducing onset-to-treatment time. A new protocol was implemented to minimize delays: AST staff prenotification, parallel process workflow, and rapid acquisition of laboratory testing and brain imaging. AST reviewed all intravenous tPA cases and discussed the points of improvement. AST also organized both public and in-hospital lectures, and simulation training course. We compared patients received intravenous tPA within 4.5 hours from the symptom onset at our institute in the pre AST (April 2011 - August 2014) and post AST (September 2014 - July 2016) period. Using univariate methods and multivariable logistic regression, we assessed the associated factors with favorable outcomes.

Results:
In the pre and post AST period, 46 and 36 patients were treated with intravenous tPA, respectively. Compared with pre AST period, the median (interquartile range) DTN times was reduced from 71 (63-95) minutes to 55 (49-71) minutes (p<0.01), and the percentage of patients with DTN times within 60 minutes were improved from 22% to 64% (P<0.001) in the post AST period. By multivariable analysis, shorter DTN times (OR 0.98, 95% CI 0.95-0.99, p=0.025), lower age (OR 0.90, 95% CI 0.85-0.96, p=0.001) and lower NIHSS on admission (OR 0.88, 95% CI 0.82-0.95, p=0.001) were independently associated with independent ambulation at hospital discharge.

Conclusions:
Multidisciplinary team-based approach reduced DTN times. Reducing DTN times was associated with improving patient outcomes. Future efforts should focus on sustainability and safety of this approach.
Abstract TP283: Association Between Spanish Language and Emergency Medical Service Use in Ischemic Stroke Patients Treated with IV-tPA
Authors: Rostanski Sara K , Kummer Benjamin R , Stillman Joshua I , Marshall Randolph S , Williams Olajide , Willey Joshua Z
Published: June 2021

Introduction:
Use of emergency medical services (EMS) is associated with decreased door-to-needle time in acute ischemic stroke. While racial and ethnic disparities in EMS use are well documented, the role of patient language in EMS use has been understudied. We sought to characterize EMS use by patient language among IV-tPA treated patients at a single center with a large Spanish-speaking patient population.

Methods:
We identified all patients who received IV-tPA over five years (7/2011-6/2016) at an academic medical center in New York City. Primary language, EMS use, pre-notification, and patient demographics were recorded from the EMR. We compared baseline characteristics, EMS use, and stroke pre-notification between English and Spanish-speaking patients. Logistic regression was used to measure the association between primary patient language and EMS use, adjusting for potential confounders.

Results:
Over the study period, 391 patients received IV-tPA; 208 (53%) primarily spoke English and 174 (45%) primarily spoke Spanish. Nine patients (2%) spoke other languages and were excluded. Mean age (66 vs. 69, p=0.09), male sex (43% vs. 33%, p=0.05) and median NIHSS (7 vs. 6, p=0.12) did not differ between English and Spanish-speaking patients. Of the 380 (97%) patients with EMS data, EMS use was higher among Spanish-speaking patients (69% vs. 80%, p<0.01). Pre-notification did not differ by language (63% vs. 61%, p=0.8). In a multivariable model adjusting for age, sex, and initial NIHSS, Spanish speakers remained more likely to use EMS (OR 1.9, 95% CI 1.1-3.2, p=0.02).

Conclusion:
Among patients treated with IV-tPA at an urban academic medical center, EMS usage was higher in Spanish-speakers compared to English-speakers. Although language is not an exact surrogate for ethnicity, these findings are in contrast to previously published work demonstrating low rates of EMS usage among Hispanics. Future studies should evaluate differences in EMS utilization according to primary language as well as ethnicity.
Abstract TP285: Acute Infarct Volume Accounts for a Small Fraction of Explained Variance in Quality of Life Measures at 3 Months
Authors: Lin Chen , Corado Carlos , Chatterjee Neil , Carroll Timothy , Naidech Andrew , Prabhakaran Shyam
Published: June 2021

Introduction:
Limited data exist regarding the relationship between acute infarct volume and health-related quality of life (HRQOL) measures after ischemic stroke. We sought to evaluate whether acute infarct volume predicts domain-specific Neuro-Quality of Life (Neuro-QoL) scores at 3 months.

Methods:
Between August 2012 and July 2014, we prospectively enrolled consecutive patients presenting with image-verified ischemic strokes and calculated acute infarct volume on diffusion-weighted imaging calculated using an automated algorithm. Clinical outcome scores at 3 months included modified Rankin score (mRS) and Neuro-QoL scores in 4 domains (general concerns, upper extremity, lower extremity, and executive function). We evaluated whether acute infarct volume predicted outcomes at 3 months using ordinal and linear regression as appropriate, adjusting for baseline mRS, payor status, NIHSS score, and post-stroke rehabilitation services.

Results:
Among 608 patients who met inclusion criteria (mean age 64.8 years, 50.5% females), the mean acute infarct volume was 6.59 mL and median initial NIHSS score was 2. At 3 months, 22.2% of subjects had mRS >1. In ordinal regression, acute infarct volume was independently associated with mRS at 3 months (p=0.027), adjusting for covariates. Table 1 describes the predictive models for each HRQoL measure along with the R
2
value of the model and the fraction contributed by acute infarct volume.

Discussion:
Acute infarct volume, though significant, accounts for 1-5% of explained variance in HRQoL measures at 3 months after ischemic stroke. These data imply that other undiscovered biologic, clinical, and imaging factors may better predict post-stroke HRQoL than what is currently available.
Abstract TP29: Benefit of Intravenous Alteplase Prior to Mechanical Thrombectomy of Large Vessel Occlusion Ischemic Stroke
Authors: Patel Pratit , Kim Jae , Ezzeddine Mustapha
Published: June 2021

Purpose:
Intravenous alteplase (IV-tPA) in combination with mechanical thrombectomy is the current standard treatment for ischemic stroke due to large vessel occlusion (LVO). IV-tPA has poor revascularization rate in LVO, and the benefit to the patient with LVO is unclear. The purpose of this study was to compare outcomes between patients with LVO who underwent thrombectomy alone and patients who received IV-tPA prior to thrombectomy.

Materials and Methods:
We searched our institutional database for patients who presented with acute strokes between 1/2008 and 12/2014. We reviewed all clinical data and images of consecutive patients that underwent thrombectomy. Patients with ASPECT score less than 5 were excluded from the analysis. Group 1 received IV-tPA prior to thombectomy. Group 2 underwent thrombectomy alone.

Results:
In Group 1, 67 patients (32 males) were identified with mean age of 65 years, mean ASPECT score of 7.1, mean initial NIHSS of 16, 58 (87%) with M1 occlusion and 9 (13%) with ICA occlusion. In Group 2, 46 patients (29 males) were identified with mean age of 66, mean ASPECT score of 7.4, mean initial NIHSS of 15, 40 (87%) with M1 occlusion and 6 (13%) with ICA occlusion. There were no significant differences in the baseline characteristics except that more males were represented in the Group 2. TICI 2b or greater revascularization was achieved at similar rates in both groups - 61% and 63% of patients in Group 1 and Group 2, respectively. Stentriever thrombectomy was performed in 43% vs 50% in Group 1 and Group 2, respectively. Mean 3-month follow up modified Rankin scale score was 3.4 in both groups.

Conclusions:
Our analyses suggest that iv-tPA for LVO does not improve outcomes if the patient ultimately undergoes mechanical thrombectomy. IV-tPA may carry unnecessary cost in these patients with unclear benefit. Also, the majority of the patients in Group 2 presented with “wake-up strokes” or unknown time of onset and longer time to revascularization. Mechanical thrombectomy alone was the major factor in determining outcome regardless of iv-tPA administration.
Abstract TP296: Does Rapid
®
Reduce Groin Puncture Times in Acute Ischemic Stroke ?
Authors: Kamal Haris , Zhu Liang , Abdelhamid Nour , Sarraj Amrou
Published: June 2021

Background:
RCTs proved the benefit of Intra-arterial therapy(IAT) in acute ischemic stroke(AIS) with large vessel occlusion (LVO) in patients with favorable imaging (CT, CTA or CTP)profile. Time to reperfusion is an important factor correlating with clinical outcomes. One major delay results from the decision making by physicians whether to proceed with IAT. We sought to evaluate if implementing an automated software analysis (RAPID) with instant email distribution to the treating physicians reduces decision and IAT groin puncture times.

Methods:
Retrospective cohort study of patients undergoing IAT between 1/2014 to 7/2016. The “intervention” being RAPID installation took place in February 2016. We stratified patients based on the software installation to (pre) and (post) intervention groups. Primary outcome was time from ED arrival to groin puncture. Logistic regression compared the 2 groups. Adjustment was made for age, NIHSS at presentation, time of day (working vs after hours or holidays), IV tPA.

Results:
186 patients with LVO treated with IAT were identified. 136 were in the (pre)RAPID® cohort while 50 were in the (post) group. Table 1 shows the baseline characteristics in the 2 groups. Median times from arrival to groin puncture were (116±61 minutes in the pre vs. 118±39 minutes in the post, P= 0.82). This insignificance was maintained after adjustment to the clinical and logistic variables mentioned. Table 2 shows the times and clinical/radiographic outcomes in the two groups. While adjusting for the factors aforementioned above, we found no significant difference (p>0.05) among the age, time of day of presentation and number of patients receiving tPA.

Conclusion:
Despite our non-significant results, we recognize that there are many factors and logistics involved in reducing the door to groin puncture. RAPID®may still help in reducing the times but further working on streamlining all the factors involved only will lead to shorter groin puncture times.
Abstract TP30: Is IV tPA Use Associated With Acute Carotid Stent Closure in Patients Presenting With Acute Ischemic Stroke With Tandem Lesions Treated With Endovascular Therapy?
Authors: Dharmadhikari Sushrut , Jadhav Vikram , Fnu Abhishek , Xavier Andrew
Published: June 2021

Introduction:
Carotid occlusions are responsible for 10-25% of large vessel acute ischemic strokes (AIS). While endovascular therapy (ET) is now standard of care for large vessel AIS, tandem lesions remain a therapeutic challenge. Outcomes of patients with tandem lesions undergoing ET with carotid revascularization remain unknown. We aimed to determine the prevalence, risk factors and outcomes of acute carotid stent closure (ACSC) in AIS patients with tandem lesions undergoing ET.

Methods:
Retrospective review of endovascular database of AIS patients treated in a single tertiary care center from 2010-2016. Patients with tandem lesions identified. Baseline demographics, home medications, IV tPA use, procedural characteristics and outcomes collected. Patients grouped according to carotid stent patency. Data analyzed using SPSS. Factors with p < 0.20 included in multivariate model.

Results:
Out of 280 AIS patients undergoing ET, a total of 32 patients with tandem lesions identified. ACSC seen in 25% of patients. Baseline demographics similar in two groups. IV tPA use associated with 3 times greater risk of ACSC (12.5% vs 37.5%; p = 0.10). Number of stents (No ACSC 1.13 ± 0.33 vs ACSC 1.75 ± 1.04; p = 0.013) significant in univariate analysis. Baseline mRS, IV tPA use, Number of Stents, Post Stent Angioplasty, Residual ICA stenosis and Poor TICI recanalization grade included in the multivariate model. Number of stents (p = 0.028) and Poor TICI recanalization grade (p = 0.031) reached significance on multivariate linear regression analysis. Patients with ACSC had significantly greater hospitalization days (7.08 ± 3.73 vs 13.5 ± 6.86; p = 0.002), worse discharge mRS (2.17 ± 2.09 vs 4.5 ± 0.75; p = 0.005), worse discharge NIHSS (4.33 ± 4.53 vs 14.71 ± 4.85; p = 0.001), unfavorable disposition (16.67% vs 62.5%; p = 0.023) and worse 90 days mRS (2.0 ± 2.25 vs 4.67 ± 0.82; p = 0.01).

Conclusions:
ACSC seen in 25% of AIS with tandem lesions treated with ET. IV tPA use associated with 3 times greater risk of ACSC (37.5% vs 12.5%) presumably due to an inability for antiplatelet loading. Number of stents and poor TICI recanalization grade reached significance on multivariate analysis. ACSC associated with significantly worse outcomes. Larger studies are required to confirm these findings
Abstract TP305: Patient Expectations and Physician Preferences of Informed Consent for tPA
Authors: Mendelson Scott J , Gordon Elisa , Richards Christopher , Holl Jane , Prabhakaran Shyam
Published: June 2021

Objective:
To assess the optimal content and contextual parameters, based on patient and physician input, of the informed consent process for tPA in acute ischemic stroke patients.

Background:
Consent-related delays may contribute to worse outcomes, as any delay in tPA eligible patients is associated with worse outcomes. Informed consent, an under-studied barrier to timely tPA delivery, potentially delays or results in a refusal of therapy in up to 20% of eligible patients.

Methods:
A mixed-methods qualitative study identified patient and caregiver information expectations and physician preferences in describing risks and benefits of tPA during acute stroke patient evaluations. Through interviews of stroke patients and caregivers who provided informed consent for tPA, and of neurologists and emergency medicine physicians, several themes were identified. These themes as well as strategies to standardize the informed consent process were further explored with mixed focus groups of stroke patients who received tPA, stroke patients who did not receive tPA, and caregivers.

Results:
Interviewed stroke patients or their surrogates (n=15) who provided informed consent preferred a shared decision-making model of informed consent while recognizing the time urgency of tPA therapy. Interviewed physicians (n=9) expressed a desire to include patients or their surrogates in decision-making and stressed the importance of describing tPA risks, such as intracerebral hemorrhage. Stroke patients and caregivers (n=22) participating in focus groups (n=4) expressed varying information expectations. The majority of focus group participants expressed minimal information needs and preferred a verbal description of risks and benefits as compared with detailed pictographs. A minority desired a greater amount of information regarding the risk, benefits, and indication for tPA when deciding upon treatment.

Conclusions:
Qualitative analyses of informed consent for tPA suggest that a standardized shared decision-making model which includes descriptions of risks could be developed to meet patient expectations and physician preferences. Optimizing the shared decision-making process for tPA could reduce consent-related delays and refusals of tPA.
Abstract TP307: Anxiety, Depression and Posttraumatic Stress Disorder (PTSD) are Associated With Worse Outcomes After Stroke: Preliminary Results
Authors: Stein Laura A , Goldmann Emily , Luciano Jean M , Messe Steven R , Cucchiara Brett L , Kasner Scott E , Mullen Michael T
Published: June 2021

Introduction:
The impact of anxiety, depression, and PTSD on outcome after stroke is incompletely understood. We aim to evaluate the prevalence of these disorders after stroke and evaluate associations with outcomes including healthcare utilization, medication adherence, return to work, and quality of life.

Methods:
We performed telephone surveys on stroke patients discharged to home or acute rehabilitation 6-12 months after discharge from a comprehensive stroke center. Patients with preexisting psychiatric disease, prior stroke, and those unable to communicate were excluded. Demographics, including education, relationship status, and household size were recorded. Stroke etiology, location, and severity (NIHSS) were abstracted from medical records. Surveys included: employment status, the Hospital Anxiety and Depression Scale, PTSD Checklist-Stressor Specific Version (PCL-S), Stanford Healthcare Utilization Survey, Morisky Medication Adherence Scale, modified Rankin Scale (mRS) and quality of life (Euro QOL-5D).

Results:
Data collection is ongoing. Currently, 36 of 118 eligible subjects completed the survey. Responders and non-responders did not differ by demographic or clinical features. Of the 36 subjects, 31% screened positive for anxiety, depression, or PTSD. Subjects screening positive were similar to those who did not with respect to demographics, stroke etiology and location, and NIHSS (median 2 vs 2, p=0.44). Good functional outcome (mRS 0-2) was less likely in those who screened positive, 55% vs 96%, p=0.01. These subjects were less likely to return to work (14% vs 100%, p<0.001) and reported lower scores on the Euro QOL-5D (any problem with mobility 81% vs 36%, p=0.03; self-care 55% vs 8%, p=0.005; usual activities 82% vs 40%, p=0.031; anxiety/depression 73% vs 16%, p=0.002, and quality of life median 55 vs 80, p=0.002).

Conclusions:
Preliminary results show anxiety, depression, and PTSD are common after stroke and are associated with not returning to work, worse functional outcome and quality of life. More research is needed to characterize whether these associations are causal and determine if treating mood disorders can improve outcomes.