bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP36: Post-ischemic Hyperperfusion After Reperfusion Therapy Predicts Hemorrhagic Transformation
Authors: Okazaki Shuhei , Yoshimoto Takeshi , Yamagami Hiroshi , Kajimoto Katsufumi , Hayakawa Mikito , Koga Masatoshi , Morita Yoshiaki , Toyoda Kazunori , Nagatsuka Kazuyuki , Yamamoto Haruko
Published: June 2021

Background and Purpose:
Post-ischemic hyperperfusion has been considered as a risk factor of hemorrhagic transformation and poor prognosis. To date, however, there is a lack of data about the pathological significance of hyperperfusion after reperfusion therapy. In this study, we evaluated the relationship between hemorrhagic transformation and post-ischemic hyperperfusion after reperfusion therapy by using arterial spin labeled perfusion MRI (ASL) and
123
I IMP-SPECT.

Methods:
We retrospectively collected data of acute stroke patients with middle cerebral artery (MCA) occlusion who received intravenous thrombolysis and/or endovascular therapy, and underwent pulsed ASL using Q2TIPS-FAIR with 3D-TGSE readout and
123
I IMP-SPECT using dual-table ARG method within 14 days of stroke onset from November 2015 to June 2016. Ipsilateral-contralateral regional cerebral blood flow ratio (IC ratio) was calculated by using three-dimensional stereotactic ROI template (3DSRT) software.

Results:
Among 47 consecutive acute stroke patients with the MCA occlusion who received reperfusion therapy, 21 underwent only ASL and 10 underwent both ASL and SPECT after reperfusion therapy. The IC ratio of ASL was well correlated with that of SPECT in the MCA territory (r=0.65, p <0.001). Hemorrhagic transformation was observed in 7 patients. IC ratio was higher in patients with hemorrhagic transformation after reperfusion therapy than those without hemorrhagic transformation (2.19±0.35 vs 0.99±0.19, p=0.005). Focal post-ischemic hyperperfusion (IC ratio >1.5) was detected in 7 of 31 patients (23%). The presence of post-ischemic hyperperfusion was significantly associated with hemorrhagic transformation after reperfusion therapy (odds ratio 9.3, 95% confidence interval 1.4 to 64.0, p=0.03).

Conclusions:
Post-ischemic hyperperfusion detected by ASL predicts hemorrhagic transformation after reperfusion therapy. ASL hyperperfusion may indicate the disruption of blood brain barrier after reperfusion therapy.
Abstract WP361: Sex Differences in Intracerebral Hemorrhage Severity and Mortality
Authors: Marini Sandro , Morotti Andrea , Ayres Alison M , Crawford Katherine , Friedman Nicolette H , Kourkoulis Christina E , Lena Umme K , Gurol Edip M , Viswanathan Anand , Greenberg Steven M , Biffi Alessandro , Anderson Christopher D , Rosand Jonathan
Published: June 2021

Background and objective:
Due to conflicting results in multiple studies, uncertainty remains regarding sex differences in incidence, pathophysiology, and outcome after intracerebral hemorrhage (ICH). We investigated the differential impact of sex on ICH severity and mortality.

Methods:
We analyzed prospectively collected ICH patients ascertained between 1994 and 2015 at a single tertiary care academic medical center. Clinical variables including past medical history, medications, hemorrhage characteristics, and case-fatality rate at 90 days and one year were assessed. Categorical and continuous characteristics were compared between sexes using chi-square test and t-test, respectively. Multivariable logistic regression was used to examine associations between sex and ICH severity as well as outcome.

Results:
A total of 2403 patients were investigated: 1292 (53.8 %) male and 1111 female (46.2%). Men with ICH were younger (72 vs. 77 years), had greater smoking and alcohol use, and were more likely to have hypertension, diabetes, hypercholesterolemia and coronary artery disease (all p< 0.05), consistent with previous studies. Lobar hemorrhages frequency was higher in women compared to men (46.5% lobar hemorrhages in women vs 37.1% lobar hemorrhages in men, p<0.001). Hematoma expansion was more frequent in men (19% vs. 12.5%, p=0.001) in univariate analysis, and after controlling for admission INR, time from onset to CT, baseline hematoma volume, spot sign and blood pressure values, men continued to demonstrate a higher risk of hematoma expansion (Odds Ratio [OR] 1.98, 95% confidence interval [CI] 1.11 - 3.52, p=0.020). The overall case fatality at 90 days was 37.4%. Controlling for univariate differences and known predictors of mortality, male sex was independently associated with both 90-day (OR 1.53, CI 1.05 - 2.23, p=0.025) and one year mortality (OR 1.80, CI 1.20 - 2.69, p=0.005).

Conclusions:
Sex independently affects early ICH expansion and outcome after ICH, with men experiencing a higher risk of both expansion as well as early and late mortality. Further research is needed to explore the biological mechanisms mediating these observed differences.
Abstract WP367: Volume of Intracerebral Hemorrhage Varies According to the Kind of Anticoagulant: Direct Oral Anticoagulants vs Warfarin
Authors: Shiga Yuji , Takeshima Shinichi , Nomura Eiichi , Sato Michiyoshi , Nishigaki Masakazu , Kuriyama Masaru
Published: June 2021

Background and Hypothesis:
The effectiveness and safety of anticoagulants, which are widely used for preventing stroke recurrence, in stroke prevention is well established, they rarely cause severe adverse events, such as intracerebral hemorrhage (ICH). Direct oral anticoagulants (DOACs) have recently become an option for anticoagulation therapy. The incidence of hemorrhagic events in patients under DOAC therapy has been investigated in several studies, but it is unclear whether the severity of a hemorrhagic event is influenced by the use of DOACs. We hypothesized that the severity of ICH is different in patients under warfarin versus those under DOAC therapy.

Method:
We retrospectively reviewed medical records and computed tomography images of patients with ICH who were treated at our hospital during April 2011-May 2016. Patients’ clinical characteristics and ICH volume and location were compared between warfarin- and DOAC-treated patients.

Result:
Of the 1147 patients with ICH, 114 patients were taking anticoagulants on admission. Eighty-nine patients (78.1%) received warfarin, whereas 25 (21.9%) received DOACs. The following DOACs were used: dabigatran (two patients), rivaroxaban (10 patients), apixaban (12 patients), and edoxaban (one patients). Median ICH volume was significantly lesser in DOAC-treated patients than in warfarin-treated patients [8.1 (range, 0.05-160) ml vs 15.9 (range, 0.1-119) ml, respectively; p = 0.048). A significant correlation between ICH volume and HAS-BLED score was found only in the DOACs group (ρ= 0.560 p = 0.004) but not in the warfarin group (ρ= 0.025 p = 0.822). We found two patients with an ICH volume of >150 mL in the DOACs group. Their HAS-BLED score was 3, and they had experienced multiple stroke events (three or six times).

Conclusion:
ICH volume was lesser in DOAC-treated patients than in warfarin-treated patients. We also found that HAS-BLED can be a predictor of ICH volume in DOAC-treated patients.
Abstract WP371: Cortical Superficial Siderosis and Mortality in Cerebral Amyloid Angiopathy
Authors: Roongpiboonsopit Duangnapa , Charidimou Andreas , Boulouis Gregoire , Xiong Li , Lauer Arne , Ayres Alison , Vashkevich Anastasia , Gurol M. E , Rosand Jonathan , Greenberg Steven M , Viswanathan Anand
Published: June 2021

Objective:
To investigate whether magnetic resonance imaging (MRI) markers of cerebral small vessel disease predict overall mortality in cerebral amyloid angiopathy (CAA) patients.

Methods:
Subjects were consecutive survivors (age≥55) of spontaneous symptomatic CAA-related-lobar ICH and CAA presenting without lobar ICH, diagnosed according to the Boston criteria drawn from an ongoing longitudinal cohort study and Memory Disorder Unit. All subjects had brain MRI at presentation. Baseline clinical, imaging, laboratory data and mortality information were collected. Neuroimaging markers including focal (≤3 sulci) or disseminated (>3 sulci) cortical superficial siderosis (cSS), cortical subarachnoid hemorrhage (cSAH), cerebral microbleeds (CMBs), enlarged perivascular spaces (EPVS) and white matter hyperintensities (WMH) were evaluated. Overall mortality risk was assessed using Cox proportional hazards models adjusting for potential confounders.

Results:
A total of 335 patients with probable CAA were enrolled, 196 presenting with lobar ICH and 139 without lobar ICH. During a median follow-up time of 3.44 years (interquartile range 1.61- 5.52 years), 181 of 335 patients (54.0%) died, 37.3% were patients with lobar ICH and 16.7% were those without. In univariable analysis, disseminated cSS, moderate to severe WMH, higher age and CAA related-lobar ICH group were predictors of overall mortality (p<0.05 for all comparisons). After adjusting for moderate to severe WMH and multiple CMBs (CMBs ≥5 foci), disseminated cSS remained as an independent neuroimaging predictor of overall mortality (HR 1.66; 95% CI 1.05-2.64, p = 0.030). Other predictors of mortality were older age (HR 1.08; 95% CI 1.06-1.11, p < 0.001) and presence of lobar ICH (HR 1.87; 95% CI 1.34-2.61, p < 0.001). The mortality risk was even greater in patients with both disseminated cSS and lobar ICH (HR 2.28; 95% CI 1.41-3.69, p = 0.001) and as well as in older patients (age>75 years) with disseminated cSS (HR 1.86; 95% CI 1.08-3.23, p = 0.026).

Conclusion:
Disseminated cSS is an independent neuroimaging biomarker of increased risk of overall mortality in probable CAA, particular in those patients with lobar ICH and older age. These findings may serve identify important markers of CAA severity.
Abstract WP375: Fall Risk in Acute Ischemic Stroke
Authors: Cox Robynn S , Bradas Cheryl , Bowden Victoria , Buckholz Beth , Kerber Kathleen , McNett Molly
Published: June 2021

Fall Risk Factors among Hospitalized Acute Post-Ischemic Stroke Patients in an Urban Public Healthcare System

Background:
Falls remain an important benchmarking indicator for hospitals. The incidence of falls is a nursing-sensitive indicator, amenable to preventable measures. Research indicates factors associated with falls, but few studies specifically identify factors among hospitalized patients with acute ischemic stroke (AIS).

Purpose:
Identify prevalence and risk factors for falls among acute, hospitalized AIS patients within an urban safety net hospital.

Methods:
Retrospective cohort study. Data abstracted from stroke and fall registries, and medical records from 2013-2015 among all adult patients admitted for AIS. Variables included traditional risk factors for falls, as well as stroke-specific factors (NIHSS score, functional status, stroke location and vessel, administration of tPA).

Results:
N=683 AIS stroke patients, with 1.6% fall rate. Falls among AIS patients accounted for 6% of all hospital falls. AIS patients who experienced an inpatient fall had a mean age of 67 (range 46-86), were mostly male (82%), and ambulating independently prior to arrival (91%). Mean NIHSS scores upon admission were higher among those who experienced a fall, when compared to AIS patients who did not fall (mean=8.73, 7.01, respectively). Most patients who experienced a fall demonstrated weakness and/or paresis upon initial exam (90%), with 64% experiencing small vessel ischemic changes, and 36% MCA strokes. Administration of tPA was not associated with increased falls. LOS was significantly increased among AIS patients who experienced a fall (7.7 vs. 4.8, respectively,
p
<0.01).

Conclusions:
Fall rates among hospitalized AIS patients may be lower than earlier reports, reflecting increased vigilance among providers and widespread integration of fall prevention strategies. Elevated NIHSS scores and weakness/paresis upon initial exam may be important predictors of falls among newly diagnosed AIS patients who had previously been able to ambulate independently. Consistent with fall literature among other populations, the occurrence of a fall in the inpatient setting can substantially increase length of stay.
Abstract WP380: Simulation Based Acute Stroke Responders Training Improves Door-to-Thrombolytic Time
Authors: Tse-Chang Karen , Mendoza Ann , MacKenzie Jeff , Woolfolk Katrina , Jones Kimberly , Keasler Deborah
Published: June 2021

Background:
The evaluation of acute ischemic stroke (AIS) patients should be performed expeditiously. Our stroke program maintained our Target: Stroke Honor Roll status in 2014, however, door-to-needle (DTN) time in Quarter 1 and 2 of 2015 showed no significant improvement and did not achieve DTN under 60 minutes in 75% of patients nor under 45 minutes in 50% of patients, despite in-servicing Emergency Department (ED)’s staff on program goals and order sets.

The purpose of this project was to more effectively educate emergency stroke responders on clinical recognition and implementation of the organization’s stroke protocol order sets. Simulation as an experiential learning technique, promoting, applied thinking, delegation, and leadership skills. Evidence suggests simulation based training for adult learners promote their engagement and immediate application of learned material.

Methods:
Simulation: Stroke code responders, including 5 nurses per session, participated in the 90 minute scenario. Stroke protocol order sets were reviewed prior to the simulation of a right hemispheric syndrome. Participants elicited a focused history, National Institutes of Health Stroke Scale, relayed the findings to the neurologist, evaluate exclusion and inclusion criteria, and administered weight-based doses of tissue plasminogen activator (tPA). After a debrief, the participants repeated the simulation to reinforce new knowledge and skills. Descriptive statistics were used to compare mean DTN time before and after simulation training.

Results:
153 ED nurses, 8 ED physicians, 6 neurologists, 4 pharmacists, 6 radiology technicians, and 10 phlebotomists participated. Pre -training Q1-Q2 2015 median DTN was 55 minutes, 65% </= 60 minutes, and 31% </= 45 minutes. Post-training data from Q1 2016 median DTN was 46 minutes, 75% </= 60 minutes, and 50% </= 45 minutes.

Conclusion:
Simulation based stroke responders training helped to decrease DTN time.
Abstract WP385: Gender Differences in Nutritional Status After a Stroke
Authors: Sanjuan Menendez Estela , Lopez Espuela Fidel , Portilla Juan Carlos , Santana Katherine E , Holguin Mohedas Marta , Casado Naranjo Ignacio , Hidalgo Jimenez Noelia
Published: June 2021

Introduction:
Malnutrition has been associated with a worse outcome in stroke. Its frequency is not well established and sometimes the impact is not considered.

Objective:
To explore gender differences on nutritional status (NS) after acute stroke and its impact on stroke outcome at 90 days.

Methods:
We evaluated consecutive acute stroke patients admitted to the Stroke Unit. We analyzed baseline demographics, vascular risk factors, analytic and anthropometric parameters, and stroke characteristics. We determined NS at baseline and 90 days by Mini Nutritional Assessment (MNA) scale to detect patients at malnutrition risk (MR). We divided groups by gender. Chi square test was applied for qualitative variables and T student for quantitative. A probability value of <0.05 was considered significant for all tests.

Results:
We included 95 patients, 45 women (47,4%). Differences were found comparing women vs men and age (77,9 ± 1,02 vs 75,1 ± 0,9), alcohol consumption (6,7% vs 60%), smoking (4,4% vs 26%) and body mass index (30,1 ± 5,1 vs 27,3 ± 4,5); p<0.05. There were no significant differences related to gender and stroke type (ischemic 88,9% vs 84%, p=0.49) nor stroke severity at baseline (NIHSS 5±4 vs 4±4 p=0.18), neither in risk factors (hypertension, diabetes, atrial fibrillation, dislipidemia), comorbidities nor socioeconomic differences. There were no gender differences in the occurrence of in-hospital complications (27,3% vs 16,3%; p=0,2), dysphagia (6,7% vs 6,0%; p=0.89) nor in NIHSS scoring at discharge (3±3 vs 2±3; p=0.08). On admission, MR was present in 28,5% of the patients. There were no differences between gender and DR (31,1% vs 26%; p=0.58).

At 90 days, MR increased to 46,4%. We found significant gender differences (57,8% vs 32%; p=0.024).

In the adjusted analysis, female gender was associated with a worst NS at 90days [OR 3,56 (1,1-11,5)]. Modified Rankin scale (mRs) score at 90 days was <=2 in 77,8% of women and 82% of men, p=0.607. MNA score at 90 days was independently associated with a better outcome (mRs<=2) at 90 days adjusted by gender OR 0,13 (0,14-0,46).

Conclusion:
In our series, female gender was independently related to worse nutritional status at 90 days after the stroke.
Abstract WP389: Improving Systems of Care With Stroke Severity Adjusted EMS Triaging and Bypass Criteria Protocols to a Comprehensive Stroke Center
Authors: Deleener Mary E , Greenfield Brett
Published: June 2021

A validated pre-hospital assessment tool to detect severe strokes including intracranial hemorrhages and large vessel occlusions along with protocols for bypassing to comprehensive stroke centers remains an ongoing debate.

The long term goals align with the emphasis of developing formalized stroke severity adjusted EMS triaging and bypass protocols to recognize both large vessel ischemic and intracerebral hemorrhagic stroke patients early in the pre-hospital setting with the utilization of a recognized, validated assessment tool, formal bypass criteria protocols, and formalized training for emergency medical service personnel. These goals align with the topic of

careful selection of patients who meet strict criteria for bypassing

acute stroke ready and primary stroke centers throughout the Southeastern New Jersey region which includes one acute ready hospital and two primary stroke centers to the closest Comprehensive Stroke Center in Atlantic City, New Jersey. The first specific aim is to analyze the EMS field diagnostic accuracy completed by both AtlantiCare EMS ACLS providers and Mid Atlantic Medevac EMS personnel. A therapeutic bypass yield will be analyzed in order to determine the effectiveness of the formalized training to conduct effective stroke severity EMS triaging assessments and a formal bypass protocol to the Comprehensive Stroke Center in Atlantic City, New Jersey. Sensitivity results of the near-infrared (NIR) technology device as a pre-scanning tool for hemorrhages prior to CT scan and operator error will be analyzed. Final diagnosis, CT results, and the need for comprehensive services will serve as the sole factor for the therapeutic bypass yield analysis.

The second aim is to analyze the percentage of bypassed patients to the Comprehensive Stroke Center that undergo comprehensive interventions or medical services.

Policy/Protocol Design (refer to images)

IRB Information
: FWA#00011915 and RP# 15-039ex IRB
Abstract WP392: The Experiences of Young Adult Stroke Survivors Who Go Directly Home From Acute Care
Authors: Seagraves Karen B
Published: June 2021

Introduction:
Young adults are the fastest growing population of stroke patients. Current treatments enable physicians to reverse ischemic stroke, and young adult stroke survivors (YASS) are increasingly discharged directly home with few to no neurological deficits. Without acute rehabilitation needs, there are limited opportunities to identify and address the psychosocial issues that may result from this significant health event. The purpose of this study was to explore the experiences of YASS who went home from acute care with few to no neurological deficits.

Method:
Qualitative research methods were used. YASS <55 years who received intravenous/intra-arterial treatment for a large vessel acute stroke and discharged directly home from a metropolitan hospital were recruited. Participants were interviewed in person using in-depth, semi-structured one hour interviews. They were asked about post-stroke discharge experiences and what it is like to be a YASS. Interviews were audio-recorded, transcribed verbatim by the interviewer and analyzed with a level one summary to discern themes.

Results:
Three YASS, one female and two males, age 34-55 years and 3-7 years post-stroke participated. Analysis of the data identified six overarching themes: stress as a precursor to stroke, experiencing invisible symptoms, fear and anxiety of future stroke, emotional responses, no personal frame of reference for the event, and sources of strength to recover.

Discussion:
YASS that did exceptionally well following a treated stroke still experienced emotional and cognitive changes. All participants spoke of experiencing high levels of life stress preceding their strokes which they perceived as a “hidden” risk factor. They felt their outward appearances and functional levels were incongruent with inner symptoms of feeling “not themselves”. They expressed fear and anxiety of having another stroke. Perceptions of their experiences were based on their healthcare providers that used positive expressions for their outcomes (i.e. “lucky” and “miraculous”). The YASS talked about family support and faith that helped recovery.

Conclusion:
Further research is needed to explore this emerging population of YASS to take steps toward optimizing their experiences and recovery.
Abstract WP393: Lean Process Improvement Enables Attainment of Target: Stroke Phase II Goals
Authors: McCann Cory L , Tkach Aleksander , Bennett Alicia , Loosli Joel , Troyer Jamie , Jex Alicia , Wold Jana J , Majersik Jennifer J
Published: June 2021

Background and Issues:
In 2014, the University of Utah Hospital successfully treated >50% of acute ischemic stroke (AIS) tPA-eligible patients within 60 minutes. Target: Stroke phase II added the goal to treat 50% within 45 minutes, providing an opportunity for improvement.

Purpose:
The purpose of this project was to improve door-to-needle (DTN) times by streamlining IV tPA protocols.

Methods:
In late 2015, we assembled a multi-disciplinary team to analyze current Emergency Department (ED) processes and identify improvement opportunities in the current “brain attack” (BA) protocol. Using lean process engineering tools, including time study analysis, gemba walks, and cause and effect diagrams, we mapped our baseline state and identified delaying activities that did not add value to the BA process. We defined a new BA process (see Fig) to decrease waste and improve team communication. Key changes included: 1) definition of key team member roles; 2) a straight-to-CT plan; and 3) three planned time-outs with checklists to ensure maintenance of patient safety.

Results:
From May-July 2015: mean Door-to-CT was 19 minutes and DTN was <45 minutes in 27% of eligible patients. In the two quarters following process change implementation, mean door-to-CT time was 15 minutes and DTN was <45 minutes in 60% of eligible patients. There was no observable increase in adverse events with the decreased treatment times.

Conclusions:
Lean process improvement methodology can expedite DTN times, supporting current Target: Stroke goals. Incorporating time-outs into standardized processes that aim to deliver care more quickly may improve patient safety without substantially slowing down DTN times. Further investigation is required to determine whether the new BA process improved safety and added value by improving patient outcomes and decreasing institution cost.
Abstract WP394: Needs of Stroke Survivors Post Hospital Discharge Stroke Follow-up Call
Authors: Mojares Joseph , Aldrich Sherydahn , Novales-Fiel Maria
Published: June 2021

Background:
This project attempts to discover the subjective response needs of 30-day post-acute stroke patients and their family members that were treated in two Northern California hospitals. The goal is to determine the functional level of the Stroke Survivor (SS) as measured by the Modified Rankin Scale (mRS) and to identify post-discharge needs.

Purpose:
The objective of this project is to identify the patient’s mRS score and post-discharge needs. The study includes stroke education reinforcement, primary care physician follow-up, ancillary services follow-up, discern hospital readmissions rates, and increase patient satisfaction.

Methods:
A list of discharged acute ischemic stroke patients over a three month period was provided to the Stroke Nurse Champion (SNC). A stroke phone call template was created to elicit the patient’s history, diagnosis, and mRS score. Patients with intracranial hemorrhage diagnosis, patients discharged to Skilled Nursing Facilities, and deceased patients were excluded from the study. The SNC performed chart review to determine patient course of hospitalization and stroke care management; places follow-up phone call to patient or family member; and identify the SS needs. When needs were discovered, they were addressed using electronic in-house messaging to patient’s primary care providers and ancillary staff.

Results:
Of the 63 participants, nine required stroke resource follow-up. The average mRS score of 1.84 revealed the patient’s knowledge of self-management to be 100%. There were 13 cases that needed outpatient therapy and Home Health therapy with mRS >2. The study outcome includes readmission rate of 0.03% (n=2) and stroke patient satisfaction >12.5%.

Conclusions:
Based on the mRS score, the SS appropriately met the level of care including rehabilitation needs at home. Post discharge needs of SS included psychosocial support, medication modification and appropriate durable medical equipment. Overall, the SS were satisfied with their care with low incidence of hospital readmission due to their stroke education provided during their hospitalization. Further plans for each hospital facility to consider continuing this project or to change the focus to outpatient support services as well.
Abstract WP395: Can Nursing-driven Stroke Alert Activations be Effective?
Authors: Anderson Nicole L , Castle Amy L , Asaithambi Ganesh
Published: June 2021

Background:
Earlier stroke alert activations in the emergency department can assemble needed resources quickly in order to shorten treatment delays among eligible patients. We compared the impact of nursing-driven stroke alert activations to EMS- or physician-directed stroke alert activations.

Methods:
From January 2015 to June 2016, we reviewed data from all emergency department stroke alert activations at an acute stroke ready hospital. We compared nursing (RN)-driven to paramedic (EMS)- and physician (MD)-driven stroke alert activations to determine rates of stroke mimic diagnoses at discharge and use of intravenous alteplase as well as median door-to-stroke alert, door-to-CT, and door-to-needle times.

Results:
There were 175 stroke alert activations during the study period (42 RN, 87 pre-hospital, 46 MD). Stroke mimics prompting stroke alert activations were not significantly different between RN- and EMS-activations (26.2% RN vs 34.5% EMS, p=0.42) but was significantly higher for MD activations (50% MD, p=0.04). Compared to RN-activations, EMS-activations had shorter door to stroke alert (-7 [-10, -5] minutes EMS vs 4 [1, 7] minutes RN, p<0.01) and door to CT (0 minutes EMS vs 14 [8, 16] minutes RN, p<0.01) times; MD-activations had longer door to stroke alert (11.5 [6, 22] minutes MD, p<0.01) and door to CT (20.5 [14, 30.75] minutes MD, p<0.01). Door-to-needle times were similar between RN- and MD-activations (51 [38, 54] minutes RN vs 58 [49, 63] MD, p=0.25); there was a trend towards quicker DNTs for EMS-activations (39 [31, 43] minutes EMS, p=0.057). Rates of alteplase usage were similar for RN-activations (19%) compared to EMS- (12.6%, p=0.43) and MD- (23.9%, p>0.99) activations.

Conclusion:
Because of a high level of accuracy, nursing-driven stroke alert activations should be encouraged if indicated in order to shorten stroke alert time metrics when pre-hospital alerts have not occurred. Further studies are needed to examine the impact of nursing-driven stroke alert activations.
Abstract WP400: Simulation Training is a Feasible Implementation Strategy for Evidence Based Stroke Swallowing Screening
Authors: Stonecypher Karen , Garrett Racquell , Kimmel Barbara , Daniels Stephanie , Anderson Jane
Published: June 2021

Backgroud and Purpose:
A well-established best practice in providing safe, high quality care for patients with stroke is screening swallowing prior to oral intake. Effective implementation strategies are needed to support evidence based swallowing screening. The use of simulation is now being widely used to train healthcare professionals in evidence based practices. The purpose of this project was to assess the feasibility of simulation training modules (STMs) to support delivery of evidence based swallowing screening with frontline emergency department (ED) nurses.

Methods:
A train-the-trainer approach was used with (n=8) nurse champions who received didactic instruction and training with video clips and medical mannequins programmed to simulate auditory elements of stroke swallowing screening. After demonstration of mastery, each nurse champion then trained their peers using the same format. Feasibility for implementation of the STMs was evaluated through process mapping. Acquisition of skills was evaluated with a competency checklist and medical mannequins simulated with various stroke patient profiles. Knowledge was assessed using a pre/posttest.

Results:
A portable simulation lab was set up in the ED and nurse champions trained 100% of nursing staff over a two-month period. A total of 16 simulation sessions were needed to train all nursing staff (N=42). Didactic and video clip review was completed in 45-minute group sessions followed by 30-minute simulation practice sessions. Competency and knowledge was assessed 2-weeks after completing STMs. Competency checkoff sessions were completed in approximately 15-minutes. There was a significant increase in nurses’ knowledge and skills from baseline to posttest.

Conclusions:
It is feasible to implement STMs with frontline ED nurses. The STMs were beneficial for training and acquisition of skills in a controlled environment with a variety of patient examples. Repeated practice is critical to develop the auditory perceptual skills necessary for swallowing screening interpretation. STMs can be used in the ED for nurses to independently practice and improve swallowing screening skills.
Abstract WP401: What Goes Around Comes Around: The Impact of Adding the Stroke Coordinator to Daily Rounds
Authors: Stone Suzanne , Dirickson Amanda
Published: June 2021

Background:
Multidisciplinary rounds have classically consisted of the attending, advanced practice providers, residents and fellows. For most large comprehensive stroke centers (CSC), the stroke coordinator role is not intimately engaged in these teaching rounds thus disconnected from the team during focused discussions on care management. In order to advance the quality and comprehensiveness of patient care the stroke coordinator was added to clinical rounds.

Purpose:
We propose allocating dedicated time to the stroke coordinator role for daily morning rounds with the stroke neurologist and team to increase compliance with quality care measures.

Method:
Following the core and care team measures required for certification of a comprehensive Stroke Center, the stroke program manager selected three targets for improvement from the provider team and collected retrospective and prospective data for comparison once implementing the role change. Baseline patient data (collected the year prior to initiation of the stroke coordinator at rounds, was compared to patient safety and quality variables after initiation of rounds.

Results:
The action of provider intervention triggered by scoring threshold in depression screening improved a yearly mean of 52% to 82%. The documentation of rTPA compliance went from a mean of 0% to 94%, The timely documentation of NIHSS as a severity score in acute ischemic stroke rose from a mean of 90% to 93%

Conclusions:
Each of the metrics reflect Improvement over time. During rounds the coordinator would actively discuss gaps in care including documentation of eligibility for TPA, team action on patients with high scores on depression screening and timely documentation of NIHSS. In addition, the stroke coordinator reflected feeling more like a team member and not an "outsider looking in". It can further be hypothesized that the team remained very receptive to suggestions in the care of stroke patients, as the stroke coordinator was well known to them and available for questions and discussion each day. The closer role of stroke coordinator is still ongoing due to its success.
Abstract WP408: Tacls: Taking Action for Optimal Community and Long Term Stroke Care
Authors: Green Theresa L , Lindsay Patrice
Published: June 2021

Introduction:
In Canada, approximately 12% of acute stroke patients are admitted to long-term care (LTC; or residential aged care) facilities following an acute stroke event. An additional 20-30% of patients are discharged home from hospital with referral for community-based homecare. Training programs for health care providers in these settings is variable and at times inconsistent with best practices. Internationally, focus is now shifting from a predominant inpatient acute care focus, to one encompassing ongoing care and support in the community for people living with stroke. In 2015, an educational resource called Taking Action for Optimal Community & Long Term Stroke Care (TACLS) was launched across Canada to ensure the appropriate knowledge and skills of front line care providers for stroke survivors in community and LTC facilities; the focus of this resource is on rehabilitation and recovery.

Methods:
The purpose of this interactive session is to introduce the TACLS resource and to engage health professionals in an examination of current international community based rehabilitation and recovery programs. The discussion/workshop will allow participants to examine, compare and contrast components of the TACLS program with programs being developed or offered elsewhere.

Results:
As health care providers helping stroke survivors live well and longer means investing in the use of best practice tools and resources that fit the local context and organizational practices. Bringing together international opinions and observations around post-stroke community care will allow cross-collaboration and inter-professional networking opportunities that ultimately will benefit patients living with stroke in community based settings.

Discussion:
As care shifts from hospital to community based settings, the importance of tools available to support stroke survivors in this area of the care continuum is essential. In Canada, utilizing the HSF education resource (TACLS) provides information to support community based health care providers working with people who have had a stroke in helping them achieve optimal outcomes, regain their best level of functioning, and live meaningful lives.
Abstract WP41: A Multi-Parametric Perfusion Model Improves Assessment of Penumbral Flow in Stroke Imaging
Authors: Livne Michelle , Kossen Tabea , Madai Vince , Zaro-Weber Olivier , Moeller-Hartman Walter , Heiss Wolf-Dieter , Sobesky Jan
Published: June 2021

Introduction:
Perfusion imaging by DSC-MRI (dynamic susceptibility contrast MRI) is the clinical method of choice for identification of penumbral flow (PF) in acute stroke. To date, the tissue at risk is estimated by a single predefined perfusion map. However, integration of various perfusion parameters may amplify the pathophysiological information and yield better estimation of PF. We therefore combined the common perfusion maps in a generalized linear model (GLM) to predict PF as defined by positron emission tomography (PET).

Methods:
In 18 patients with (sub)acute stroke, consecutive DSC-MRI and O15-water PET was performed (median age/NIHSS: 58 y , 12). PF was defined as cerebral-blood-flow (CBF) < 20 mL/100g/min on PET. MRI perfusion maps included: CBF, CBV, MTT, Tmax, TTP (cerebral-blood-volume, mean-transit-time, time-to-maximum and time-to-peak respectively). Probability maps for PF prediction were generated by a) single maps and b) multi-parametric maps (GLM) and underwent cross validation. ROC analysis assessed performance for PF prediction as area-under the curve (AUC).

Results:
Single maps showed AUC values between 0.57 and 0.72 (Tmax and CFB showing best performance). The GLM approach yielded an AUC of 0.75. Comparison by the Wilcoxon signed rank test showed that while the absolute difference was moderate, it was significant (p<0.04).

Conclusions:
Our results suggest that a multi-parameter perfusion model yields the highest accuracy for PF prediction. This finding, while preliminary, suggest a straight-forward model that can be easily integrated in clinical routine for improved stroke stratification based on the mismatch paradigm.
Figure 1: Performance in penumbral flow prediction
The graph shows performance in PF prediction for perfusion parameters and GLM. The error-bars represent standard-error. (*) marks significance for p value<0.05.
Abstract WP421: Pravastatin Can Reduce the Progression of Carotid Intima-media Complex Thickness: The Japan Statin Treatment Against Recurrent Stroke (J-STARS) Echo Study
Authors: Koga Masatoshi , Toyoda Kazunori , Minematsu Kazuo , Yasaka Masahiro , Nagai Yoji , Hosomi Naohisa , Origasa Hideki , Kitagawa Kazuo , Uchiyama Shinichiro , Matsumoto Masayasu
Published: June 2021

Background and purpose:
The preventive effect of 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins) on progression of carotid intima-media complex thickness (IMT) has been shown exclusively in non-stroke Western patients. The Japan Statin Treatment Against Recurrent Stroke (J-STARS) Echo Study aims to determine the effect of pravastatin on carotid IMT in Japanese patients with hyperlipidemia with noncardioembolic ischemic stroke.

Methods:
This is a substudy of the J-STARS, a multicenter, randomized, open-label, blinded-endpoint, parallel-group trial to examine whether pravastatin reduces stroke recurrence in patients with noncardioembolic stroke. The patients were randomized to receive pravastatin (10 mg daily, usual dose in Japan) (pravastatin group) or not to receive any statins (control group). Carotid ultrasonography was performed by well-trained certified examiners and the recorded data was measured centrally. The primary outcome was IMT change of the distal wall in a continuous 2-cm section on the central side of the common carotid artery bifurcation over 5 years of observation. The IMT change was compared using mixed models for repeated measures.

Results:
Of 1578 patients who were enrolled in the J-STARS, 864 were registered in this echo substudy. After excluding 71 without baseline ultrasonography, 793 (530 men, 66.4±8.3 years old) were analyzed. Of the 793 patients, 388 were randomly assigned to the pravastatin group and 405 to the control group. Baseline characteristics were not significantly different except baseline NIH Stroke Scale [median 0 (IQR 0-2) vs. 1 (0-2), p=0.019] between the two groups. The baseline IMT (mean±SD) was 0.887±0.155 mm in the pravastatin group and 0.887±0.152 mm in the control group (p=0.990). Each annual change of the IMT (mean±SD) over 5 years of observation was 0.011±0.085 mm, 0.023±0.114 mm, 0.017±0.114 mm, 0.018±0.118 mm and 0.021±0.116 mm in the pravastatin group and 0.008±0.074 mm (p=0.650), 0.020±0.087 mm (p=0.985), 0.017±0.097 mm (p=0.586), 0.030±0.113 mm (p=0.202) and 0.040±0.118 mm (p=0.018) in the control group.

Conclusion:
Japanese usual dose of pravastatin significantly reduced the progression of carotid mean IMT at 5 years in patients with noncardioembolic stroke.
Abstract WP436: Reduced Blood Flow in the Pial Collaterals and Penetrating Arterioles During Chronic Hypoperfusion in Type 2 Diabetic Mice
Authors: Nishijima Yasuo , Akamatsu Yosuke , Kanoke Atsushi , Yang Shih Y , Tominaga Teiji , Liu Jialing
Published: June 2021

Introduction:
The degree of cortical hypoperfusion following carotid steno-occlusion depends on the dynamic compensation from the collateral circulation. The presence of collaterals is associated with a reduced risk of stroke and transient ischemic attack (TIA) in patients with steno-occlusive carotid artery disease. Although metabolic syndrome negatively impacts collateral status among patients with ischemic stroke, it is unclear whether type 2 diabetes (T2DM) specifically affects leptomeningeal collateral flow regulation and the adaptation of collateral vessels at the circle of Willis during hypoperfusion.

Methods:
Spatial and temporal changes of the leptomeningeal collateral flow and the flow dynamics of the penetrating arterioles in the distal MCA and ACA branches over two weeks following unilateral common carotid artery occlusion (CCAO) were determined by optical coherent tomography in
db/+
and
db/db
mice, a mouse model for obesity and type 2 diabetes. The temporal adaptation of the circle of Willis (CW) following CCAO was assessed by measuring CW vessel diameters.

Results:
Following unilateral CCAO,
db/db
mice exhibited diminished leptomeningeal collateral flow compensation compared to
db
/+ mice, which coincided with a reduced dilation of distal ACA branches, leading to reduced flow not only in pial vessels, but also in penetrating arterioles bordering the distal MCA and ACA. However, no apparent cell death was detected in either strain of mice during the first week after CCAO.
db/db
mice also experienced a more severe early reduction in the vessel diameters of several ipsilateral main feeding arteries in the CW, in addition to a delayed post-CCAO adaptive response by one to two weeks compared to
db/+
mice.

Conclusions:
T2DM is an additional risk factor for hemodynamic compromise during cerebral hypoperfusion, which may increase the severity and the risk of stroke or TIA.
Abstract WP439: Mean Platelet Volume and Platelet Count are not Associated With Coated-Platelet Levels Among Patients With Asymptomatic Carotid Stenosis
Authors: Kirkpatrick Angelia C , Elias Adrienne M , Vincent Andrea S , Donna-Ferreira Fabiola M , Malatinszky George C , Dale George L , Prodan Calin I
Published: June 2021

Background:
Coated-platelets, a subset of activated platelets observed with dual-agonist stimulation with collagen and thrombin, represent 30% of the platelet population in normal controls. In recently published work, we have shown that elevated coated-platelet levels (>45%) are predictive of stroke in asymptomatic carotid stenosis. We now investigate if platelet count and mean platelet volume (MPV) are related to coated-platelet levels.

Methods:
Coated-platelet levels were measured in a cohort of asymptomatic outpatients referred for carotid ultrasound studies. Platelet count and mean platelet volume for each subject were recorded from the VA electronic medical record at the closest possible time period (within ≤6 months) to the date of coated-platelet sample. Correlations between each parameter and coated-platelet levels were determined and those reaching significance at p≤0.1 were included in a multiple regression model with LDL and systolic blood pressure (SBP), variables previously known to correlate with coated-platelet levels.

Results:
Platelet count and mean platelet volume data were available within the specified period for 289 patients (96% male, mean age 66 years). On univariate analysis, coated-platelet levels correlated with platelet count (r = 0.15, p=0.01), but not with MPV (r=-0.04, p=0.53). When platelet count was included in a multiple regression analysis with LDL and SBP, platelet count was no longer significantly associated with coated-platelet levels. In the final model, higher coated-platelet levels were associated with LDL (p=0.008) and SBP (p=0.007) after controlling for all potentially confounding variables, including medications and comorbidities.

Conclusions:
Among asymptomatic patients with carotid atherosclerosis, neither MPV, which has been previously shown to correlate with platelet aggregation, nor platelet count are significantly associated with coated-platelet levels after accounting for all potential confounding variables. These findings support the notion of coated-platelets as a unique measure of platelet procoagulant potential.
Abstract WP448: Reference Ranges of L5 LDL—a Risk Factor for Ischemic Stroke—in Healthy Adults
Authors: Chu Chih-Sheng , Chan Hua-Chen , Tsai Ming-Hsien , Stancel Nicole , Lee Hsiang-Chun , Cheng Kai-Hung , Tung Yi-Ching , Chan Hsiu-Chuan , Wang Chung-Ya , Shin Shyi-Jang , Lai Wen-Ter , Yang Chao-Yuh , Dixon Richard A. , Chen Chu-Huang , Ke Liang-Yin
Published: June 2021

Background:
The most electronegative subfraction of low-density lipoprotein (LDL), L5, is atherogenic in vitro and in vivo, and its plasma levels are elevated in patients with high cardiovascular disease risk and ischemic stroke (Blood 2016;127:1336-45). Because L5 LDL may be a useful biomarker for predicting cardiovascular disease, we defined a reference range for L5 plasma levels in healthy adults and examined the power of L5 levels to differentiate patients with hyperlipidemia (HLP) or coronary artery disease (CAD) from healthy individuals.

Methods:
We enrolled 35 healthy individuals, 40 patients with stable CAD, and 35 patients with HLP without evidence of CAD. Plasma LDL was isolated from each individual, and the percentage of L5 in total LDL (L5%) was quantified by using fast-protein liquid chromatography with an anion-exchange column.

Results:
Plasma L5% and L5 concentration (ie, [L5]) were significantly higher in patients with HLP or CAD than in healthy controls (P<0.001). The reference ranges of L5% and [L5] in healthy adults were determined to be less than 1.6% and less than 1.7 mg/dL, respectively. In individuals with an L5% greater than 1.6%, the odds ratio was 9.636 for HLP or CAD (Figure). In individuals with an [L5] greater than 1.7 mg/dL, the odds ratio was 17.684 for HLP or CAD (Figure). The power of L5% and [L5] to differentiate patients with HLP or CAD from healthy individuals was superior to that of the LDL/HDL ratio.

Conclusions:
The power of L5% and [L5] in predicting cardiovascular risk is superior to that of other markers currently in use. Therefore, the reference ranges of L5% and [L5] identified in this study may be clinically useful in the prevention and treatment of cardiovascular disease. As previously reported, elevated plasma L5 levels may promote or aggravate ischemic stroke by enhancing platelet aggregation and platelet-endothelium interactions.