bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract NS14: Stroke Follow-up: Characteristics of Patients Re-hospitalized to Acute Care 30 Days after Discharge from Rehabilitation
Authors: Black Terrie , Illig Sandra , Illig Caitlin , Bennett Taryn
Published: July 2021

Background/Purpose:
According to the National Quality Forum, readmission measures can serve as indicators of whether care coordination has been optimized. The Center for Medicare and Medicaid Services has adopted an All-Cause Unplanned Readmission Measure for 30 days post discharge from inpatient rehabilitation facilities and will require reporting on the measure in 2016.

The purpose of this study was to explore characteristics of stroke patients who were discharged from rehabilitation and readmitted within 30 days to an acute care hospital versus those patients discharged from an inpatient rehabilitation facility who did not require readmission to an acute care facility.

Methods:
We conducted a descriptive, cross-sectional analysis on patients with stroke who completed and were discharged from intensive rehabilitation between October 1, 2011 and September 30, 2012. The overall sample size included 9,386 patients. We examined characteristics of those readmitted to acute care within 30 days (n = 645) post discharge rehabilitation versus those that did not have a re-hospitalization to acute care within 30 days. In addition, we examined those patients who died at follow-up (n = 609) separately.

Results:
Stroke patients requiring hospitalization within 30 days were primarily male (55%). Slightly more patients (male and female) had left body involvement (41%) versus right body involvement (37%). The majority of patients who required re-hospitalization had been discharged home (77.2%) and were living with family or relatives (88%). There was no difference in average age (67 years) between those patients requiring re-hospitalization versus those that did not; however, those who died had an average age of 75 years. The primary reasons for re-hospitalization included: need for other rehabilitation therapy (n = 87), another stroke (n=76) and falls (n=29).

Conclusion:
In conclusion, identifying patient characteristics and reasons for re-hospitalization in the post-stroke rehabilitation patients can provide valuable insight to the rehabilitation team. Additional research is needed to identify those patients most at risk to prevent re-hospitalization to acute care after discharge from inpatient rehabilitation.
Abstract T MP7: TICI 2B vs. TICI 3: Differences in Infarct Volumes and Clinical Outcomes in Proximal Intracranial Large Vessel Occlusions Treated With Endovascular Therapy
Authors: Rangaraju Srikant , Aghaebrahim Amin , Streib Christopher , Jadhav Ashutosh P , Jovin Tudor G
Published: July 2021

Introduction:
Successful recanalization independently predicts good outcome following endovascular therapy for acute large vessel occlusions. Thrombolysis In Cerebral Infarction (TICI) status 2B (near-complete revascularization) and 3 (complete revascularization) are routinely combined to reflect successful recanalization. Whether outcomes in these two groups are truly comparable, has not been demonstrated.

Methods:
In a retrospective analysis of a prospectively collected patient cohort at our center (2008-2013), we identified adults with intracranial internal carotid and middle cerebral artery M1 occlusions who underwent endovascular therapy within 8 hours from symptom onset, achieved operator-measured TICI2B or TICI3 status and had a documented 90 day modified Rankin Score (mRS). Baseline characteristics (age, NIHSS score, time to groin puncture, ASPECTS, risk factors), final infarct volume, rate of good outcome (mRS 0-2), intracranial hemorrhage and mortality were assessed.

Results:
99 patients (TICI2B:N=64, TICI 3:N=35, Median NIHSS 16, median ASPECTS 9) were included. No differences in baseline characteristics were identified (Figure A). Patients with TICI3 status had smaller final infarct volume (6.2cc vs. 22.5cc, p=0.007, Figure B), higher rate of good outcome (74.3% vs 45.3%, p=0.006), lower mortality (5.7% vs. 28.1%, p=0.008, Figure C) and similar hemorrhage rates (p=0.2) as compared to TICI2B. After controlling for age, NIHSS and ASPECTS, TICI3 status independently predicted good outcomes (OR 4.74 95%CI 1.53-14.67, p=0.007).

Conclusions:
Patients with TICI3 recanalization have smaller infarct volumes and better clinical outcomes as compared to TICI2B. With the improving efficiency of mechanical thrombectomy, future thrombectomy stroke trials should report TICI2B and TICI3 status separately.
Abstract T MP70: Dense Households and Weak Social Networks Increase Risk of Recurrent Vascular Events
Authors: Fei Kezhen , Albala Sarah , Quarles Leigh , Boden-Albala Bernadette
Published: July 2021

Background:
Social isolation is associated with increased vascular events post stroke, but the role of living arrangements versus social networks on stroke outcomes has not been well explored. We aim to characterize these associations overall and by race-ethnicity.

Methods:
The Stroke Warning Information and Faster Treatment (SWIFT) study tested a stroke preparedness intervention on arrival times for stroke/TIA recurrence to the ED. Stroke/TIA patients able to consent were prospectively recruited and randomized. Baseline data collection included demographics, medical history, socioeconomic status (SES), and social support networks. Living arrangements were categorized as living alone, living with one or 2 people, or living with three or more people (dense household). Weak social support networks defined as 4 or less family or friend visits in past week. Participants were followed for a mean of 2.9 years. An outcome of vascular event was defined as stroke, TIA, MI, or death post enrollment. Multivariate logistic regression models examined the relationship between vascular outcomes, living arrangements and social support networks adjusting for demographics, health and SES.

Results:
Between 2005 and 2009 1193 participants were enrolled: mean age 63 years; 51% Hispanics, 26% whites, and 17% Blacks; 50% female; and 42% < high school education. Over 24% lived alone, 23% lived with spouse/partner only, and 21% lived in dense households. In adjusted logistic models, post stroke vascular events were associated with dense households [RR 1.5 (95% CI: 1.1 - 1.9)], and weak family networks [RR 1.9 (95% CI: 1.4 - 2.8)]. Stratifying by race-ethnicity, the results remained significant for Hispanics where dense households [RR 1.9 (95% CI: 1.3 - 2.6)], weak family networks [RR 2.8 (95% CI: 1.5 - 5.1)], and weak friend networks [RR 1.5 (95% CI: 1.0 - 2.5)] increased vascular events post stroke.

Conclusion:
Living in dense households can increase risk of vascular events post stroke, while stronger social support networks can decrease this risk especially among Hispanic stroke survivors. Future research is needed to explore the mechanism of these associations and to identify possible racial/ethnic tailored interventions based on living arrangements and social networks.
Abstract T MP89: Development of Patient Reported Spasticity Symptom and Impact Assessment Measures
Authors: Evans Christopher , Burgess Somali Misra , Zorowitz Richard , Dunning Kari , Yaworsky Andrew , Ganapathy Vaidy , Gillard Patrick , Kissela Brett
Published: July 2021

Objectives:
To develop new patient-reported outcome (PRO) measures to assess symptoms and impacts of spasticity in accordance with the FDA Guidance on PRO development.

Methods:
Six focus group interview sessions involving 51 patients and 21 individual face-to-face interviews were conducted among patients with upper and lower limb (UL and LL) post-stroke spasticity (PSS) to elicit the symptoms and health-related quality of life impacts that these patients experience. A coding scheme consisting of the root concepts was developed using an iterative process. Patient transcripts were coded in ATLAS.ti using a framework that allowed responses to be organized by limb attribution (i.e., UL, LL, or unspecific limbs). The coded concepts were evaluated for saturation. Items for the symptom and impact instruments were developed based on: 1) frequency with which a concept was expressed spontaneously, 2) whether the item evaluated a symptom or impact of spasticity, 3) represented a single concept and 4) is likely to change with treatment of the condition. The draft measures were cognitively debriefed among 24 PSS patients to ensure patients’ comprehension of the items and response options.

Results:
The mean age of patients in this study was 65 years and more than 40% were female. The average time since stroke was approximately 4 years. Saturation of the symptom and impact concepts by limb category was achieved for all frequently reported items. Limited movement of the affected limb was the most frequently reported UL and LL PSS symptom (>70%) followed by limb curling (UL: 62%; LL: 38%), limb clenching (UL: 52%), spasms (UL: 52%, LL: 67%), pain (UL: 48%; LL: 52%) and stiffness (UL: 43%; LL: 62%). Specific UL impacts mentioned frequently were: difficulty getting dressed (86%), holding/gripping objects (71%), showering/bathing (62%), and other self-care activities (81%). Specific LL impacts mentioned frequently were: difficulty with mobility (100%), keeping balance (62%) and getting dressed (48%). A total of 32 impact and 21 symptom items across UL and LL categories were generated.

Conclusions:
The spasticity symptom and impact PRO measures represent a systematic approach to assessing outcomes that are meaningful to patients with spasticity.
Abstract T P104: Early Mobilization After Thrombolysis (rt-PA) in Acute Stroke: Are rt-PA Treated Patients Enrolled in a Trial of Early Mobilization (AVERT) Different From Those That Are Not?
Authors: Muhl Linnéa , Kulin Jenny , Dagonnier Marie , Churilov Leonid , Dewey Helen , Linden Thomas , Bernhardt Julie
Published: July 2021

Background:
A key treatment for acute ischaemic stroke is thrombolysis with recombinant tissue plasminogen activator (rtPA). However, treatment is not devoid of side effects and patients are carefully selected. AVERT (A Very Early Rehabilitation Trial) tests whether starting out of bed activity within 24 hours of stroke onset improves outcome. This international multi-center trial is powered (n=2104) to provide reliable evidence about the efficacy of early mobility training after stroke. Patients treated with rtPA can be recruited if the physician allows. The aim of this study was to identify factors that might influence the inclusion of rtPA treated patients in AVERT.

Methods:
Data from all patients thrombolysed at Austin Health between September 2007 and December 2011 were retrospectively extracted from medical records. Factors of interest included: demographic and stroke characteristics, 24 hour clinical response to rtPA treatment, cerebral imaging and process factors (day and time of admission).

Results:
Over the study period, 211 patients received rtPA at Austin Health. Fifty (24%) were recruited to AVERT (rtPA-AVERT). Of the 161 patients not recruited, 105 (65%) were eligible according to the inclusion/exclusion criteria, and could potentially have been included (pot-AVERT). There were no significant differences in demographics, Oxfordshire classification or stroke severity (NIHSS) on admission between groups. Size and localization of stroke on imaging and symptomatic intracerebral heamorrhage rate did not differ. Patients included in AVERT showed less change in NIHSS 24 hours post rtPA (median change=1, IQR (-1,4)) than those in the pot-AVERT group (median change=3, IQR (0,6)) by the median difference of 2 points (95%CI:0.3;p=0.03). A higher proportion of rtPA-AVERT patients were admitted on weekdays (p=0.04).

Conclusion:
Excluding a possible clinical instability, no significant clinical differences were identified between thrombolysed patients included in AVERT and those who were not. The study is ongoing and over 370 patients treated with rtPA have been included to date. These results suggest that data from rtPA treated patients in AVERT may be generalizable to the broader stroke population.
Abstract T P121: A Comparative Study of Duloxetine and Paroxetine in Japanese Patients With Post-Stroke Depression
Authors: Matsumoto Shuji , Shimodozono Megumi
Published: July 2021

Background and methods:
Patients with stroke may suffer from post-stroke depression and concomitant pain symptoms. A double-blind, parallel-group, controlled study was performed to investigate if duloxetine was superior to paroxetine in terms of improvement in symptoms of depression and pain in Japanese patients with post-stroke depression in a fixed-dose design. The efficacy and safety of duloxetine 60 mg/day were also assessed in comparison with those at the standard dose of 40 mg/day.

Results:
Changes in 17-item Hamilton depression rating scale (HAM-D) total score (mean ± standard deviation) for group D1 (duloxetine 40 mg/day), group M2 (duloxetine 60 mg/day), and group PX (paroxetine 20 mg/day) were –14.9 ± 5.6, –15.6 ± 6.4, and –11.4 ± 6.2, respectively, and the estimated differences in total score for group PX (Dunnett’s 95% simultaneous confidence interval) were 3.8 (3.2 to 4.4) for group D1 and 4.2 (3.6 to 4.8) for group D2. The superiority of groups M1 and M2 to group PX was thus confirmed, because the upper confidence limit of differences between groups D1 and PX and between groups D2 and PX was more than 3.2. The groups M1 and M2 presented a reduction in the pain, which was not observed in the group PX. The incidence of treatment-related adverse events was 21% for group D1, 28% for group D2, and 30% for group PX, indicating no significant difference between the three groups.

Conclusion:
These results demonstrate that duloxetine 40 mg/day and 60 mg/day is superior to paroxetine in terms of efficacy on post-stroke depression and central pain.
Abstract T P127: AHA Guidelines NUrse Practitioner Cardiovascular Risk Education Program Delivered in Outpatient Stroke Rehabilitation Program Leads to Increased Independence with Medications, Self Blood Pressure Monitoring, Improved BLood Pressures, and Rehabilitaion Outcomes
Authors: Breen Joan , Andrusin Jeanne , Ferlito Tom , Miller Lauren , Tucker Anne , Nazarova Maria , Wentland Ellen
Published: July 2021

Background:
Patients beginning an outpatient rehabilitation program often do not understand medications, good blood pressure (BP) control, and monitoring and recording of BPs

Methods:
An educational curriculum based on AHA guidelines and AHA Life’s Simple 7’s program was designed to improve patient understanding of medications, cardiovascular risk factors, and BP monitoring.

Results:
51 consecutive patients, (27 men, 24 women, ages 41-90) with admit NIHSS 0-16 treated from 12/2011 to 7/2013 had an average of 9.6(0-21) NP visits with calls to MD about BP meds in 16%. On rehab admit, 6 patient/caregivers reported AHA recommendations for normal BP, and 7 patients/caregivers checked and recorded BPs. After NP sessions, 71%(36/51) patients checked and recorded BPs independently, 29% with assist. 46 patients received an average of 16.5 PT sessions, with BPs taken pre, during, and after exercise. Among 647 pre-exercise BPs, 37% were in AHA normal range(<120/80). 32% in mild (121-139/81-90), 28 % moderate (140-159/91-99), and 6% severe (>160/100). BPs measured during the first 75% of PT sessions were compared to BPs during the last 25%. 63% of patients had fewer moderate-severe range BPs and more normal-mild range. 14% had no change in mild-normal range BPs. 20% had some worsening of BP control. On admission, 6/51 (12%) patients could describe the name, purpose, dosage, schedule of all their medications, 16(31%) could describe partially, and 29(57%) gave no information about meds; 76%(16 aphasic) relied on caregivers for medication administration. After NP education, 31% of dependent patients became independent with med administration; 47% (6 aphasic) administered meds independently. 27(53%) (11 aphasic) remained dependant on caregivers. SIS Stroke Recovery Scale Domain scores increased an average of 41%(-50 to 167%) with 23/24 reporting improvement. 6” walk scores improved an average of 55%.

Conclusions:
Community dwelling stroke patients often cannot translate previously provided medication, CV risk factor, BP instructions into practical use. Patients receiving NP education as part of an outpatient rehab program showed improved independence with medication administration, blood pressure self monitoring, blood pressure control and rehab outcomes.
Abstract T P139: Rising Rates of the Metabolic Syndrome Among Stroke Survivors in the United States
Authors: McManus Michael , Markovic Daniela , Valle Natalie , Ovbiagele Bruce , Towfighi Amytis
Published: July 2021

BACKGROUND:
Metabolic syndrome (MetS), a constellation of cardiometabolic risk factors clustering together, affects >47 million US adults and has been independently linked to primary and recurrent stroke risk. Prevalence and trends in MetS among stroke survivors in the United States are unknown.

OBJECTIVES:
To evaluate recent temporal trends in age and sex-specific MetS prevalence among adults with/without stroke in the US.

METHODS:
Prevalence of MetS was assessed among fasting adults ≥35 years who participated in National Health and Nutrition Examination Surveys 1999-2010 (n=9,343).

Prevalence estimates were weighted to obtain nationally representative estimates (n=430,371,669). MetS was defined by the 2009 harmonized definition. Stroke was determined by self-report.

RESULTS:
In all groups except men 35-64 years, MetS prevalence was similar among adults with and without stroke in 1999-2002 (Table). MetS prevalence rates were flat from 1999 to 2010 among those without stroke, but increased among stroke survivors, such that up to 80% of men and 86% of women with stroke had MetS, with the greatest rise among the middle-aged. Stroke survivors aged 35-64 years were ~3 times more likely to have MetS than their counterparts without stroke (OR 3.24, 95% CI 1.60-6.55 for men and OR 2.55, 95% CI 1.45-4.50 for women).

DISCUSSION:
Due to a differential rise in MetS in stroke survivors over the last 10 years, as many as 9 out of 10 stroke survivors now have MetS, suggesting that Mets may increasingly be placing people at risk for stroke. Intensified efforts aimed at identifying and treating MetS, especially among middle-aged individuals, may be warranted to avert stroke risk.
Abstract T P163: Influenza-Like Illness is Associated With Risk of Ischemic Stroke: A Case-Crossover Analysis
Authors: Luna Jorge M , Kamel Hooman , Willey Joshua , Cheung Ken , Elkind Mitchell S
Published: July 2021

Background:
Acute triggers of ischemic stroke (IS) remain poorly characterized. Emerging evidence suggests infections may promote short-term pro-inflammatory, pro-coagulant states that precipitate stroke.

Objective:
We hypothesized that exposure to influenza-like illness (ILI) is associated with increased risk of IS, as time intervals between events decrease.

Methods:
HCUP/AHRQ administrative claims from all nonfederal hospitals in California (2009) were queried for IS, using a published ICD-9-CM surveillance algorithm, identifying 41,148 unique individuals. A patient identifier was used to link IS patients across hospitalizations with a validated algorithm for ILI using inpatient and emergency department records. For each IS case, ILI events within 15, 30, and 90-day risk periods preceding IS in 2009, were compared to the same time periods one and two calendar years prior (i.e., 2007 and 2008). A 4-day buffer period was used to ensure ILI preceded IS. Conditional logistic regression models, matched on individuals, were used to calculate odds ratios and 95% confidence intervals (OR, 95%CI) for given risk period, after adjusting for monthly prevalence and mean age of ILI hospitalizations. Effects stratified by age are also explored.

Results:
Median (IQR) age of cases was 74 (62-83) years; 52.4% were female. There were more ILI during the 90-days preceding strokes in 2009 (n=439) than in the same stroke-free calendar period one year prior (n=303) and two years prior (n=81). ILI was associated with IS with decreasing magnitude of effect using windows of 15-days (adjusted OR 6.5, 95%CI, 2.2-19.7), 30-days (adjusted OR=3.7, 95%CI 1.7-8.3), and 90-days (adjusted OR=3.3, 95%CI, 1.9-5.8). The risk associated with ILI was higher among younger patients. Using the 30-day window, the association between ILI and IS was strongest among those 45-to-65-years (n=27,545, adjusted OR=2.53, 95%CI, 0.95-6.8).

Conclusion:
Influenza-like illness may contribute to a heightened risk of ischemic stroke during short term periods post-infection, especially among younger patients. Presentation with influenza represents an opportunity for targeted prevention of stroke.
Abstract T P184: Outpatient Evaluation of Transient Ischemic Attack (TIA) Patients
Authors: Nachimuthu Nagakrishnal , Chan Michael E , Amor Martin I , Puma Alex , Armour Florence , Hwang Shirley S , Holland Neil R
Published: July 2021

Objectives:
We have started an open-access outpatient TIA Rapid Evaluation Center (TREC) at our community medical center. Patients referred to the TREC are seen on the next weekday and undergo a diagnostic evaluation then consultation with a stroke neurologist. The decision to refer a TIA patient to the TREC is left to the discretion of the attending physician.

METHODS:
We have collected prospective data from all TREC patients, including follow-up contact at 3 and 12 months to check for future cerebrovascular events. We performed a retrospective chart review on all patients admitted to the hospital with a primary diagnosis of TIA during the same period. This study had IRB approval.

RESULTS:
We saw 74 TREC patients within an average of 1.25 days of referral during its first year of operation, 56 from the emergency room and 18 from physician offices. Only 2 TREC patients needed admission to the hospital, the remainder completed their evaluation as out-patients. Only 1 TREC patient had a follow-up cerebrovascular event. During this same time period, 88 patients were admitted to the hospital with a primary diagnosis of TIA. Patients referred to the TREC had lower ABCD2 scores (average of 1.8 vs. 3.8, p <0.001) and were less likely to have a final diagnosis of TIA (19% vs. 77% p<0.001) than the hospitalized patients. More hospitalized TIA patients were seen on weekdays than weekends (74% vs. 27%). Nearly all patients underwent CT scan, lipid panel and EKG. However, TREC patients were more likely to undergo carotid ultrasound (99% vs. 84%, p=0.001) and MRI of the brain (89% vs. 68%, p=0.001). Hospital reimbursement from Medicare is $904 for a TREC patient and $5500 for a TIA hospitalization.

CONCLUSIONS:
40% of all TIA patients at our hospital were referred to the TREC and seen within 1.25 days during its first year of operation. TIA patients referred to the TREC had lower ABCD2 scores and were less likely to have a final diagnosis of TIA. Day of the week seen did not influence the referral decision. TREC patients were more likely to have a complete diagnostic evaluation at a cost savings of $4600 for Medicare patients. Out-patient evaluation of TIA can be an efficient, safe, and less costly alternative to hospital admission.
Abstract T P195: Do Women Benefit More From tPA Than Men? Results From the BASIC Project
Authors: Lisabeth Lynda , Reeves Mathew , Baek Jonggyu , Brown Devin , Zahuranec Darin , Smith Melinda , Morgenstern Lewis
Published: July 2021

Background:
Pooled analysis of IV tPA treatment trials showed that women received benefit from treatment while men did not, though it is unclear if these results generalize to treatment in the community. We examined the benefit of tPA by sex in a population-based stroke study in a community without an academic medical center.

Methods:
Ischemic strokes were identified from the BASIC Project (2009-2012). tPA treated (n=70) and non-tPA treated cases (arriving ≤3 hours of symptom onset, n=145) with complete data were included. Data were from interviews (baseline and 90 days post-stroke) and medical records. Functional outcome was measured by modified Rankin scale (0-2 vs ≥3). The effect of tPA treatment on functional outcome (mRS 0-2) was determined using a matched propensity score (PS) analysis. Models were adjusted for age and sex-specific effects generated using a treatment by sex interaction. Because the matched analysis resulted in reduced sample size due to inability to match some tPA (n=22) and non-tPA cases (n=97), we explored 2 alternative PS methods (adjustment, weighting) which retained the full sample.

Results:
tPA treatment rates were similar in women and men (33% vs 32%, respectively; p=0.94). 25% of women and 32% of men had favorable outcome (p=0.04). Women were older than men (median age 76 vs 72; p=0.02), but initial NIHSS (median 8 vs 7; p=0.36) and 90-day mortality (24% vs 20%; p=0.51) did not differ by sex. Covariates were well balanced between tPA and non-tPA cases after PS matching. In the matched analysis, tPA was associated with favorable outcome in women (OR=4.2; 95% CI: 0.6-30.2) but not men (OR=0.79; 95% CI: 0.1-4.3). Results were consistent when alternative PS models were considered (Figure).

Conclusion:
Results from this community-based study were consistent with the previous pooled analysis of tPA trial data, suggesting that women benefit from treatment while men do not. Larger population-based studies are needed to replicate these findings.
Abstract T P2: Critical Delays In Intra-Arterial Therapy and Opportunities for Improvement
Authors: Honarmand Amir R , Prabhakaran Shyam , Soltanolkotabi Maryam , Feiz Farnoosh , Beck Ryan , Beck Carolyn , Lee Vivien H , Conners James , Hurley Michael C , Curran Yvonne M , Shaibani Ali , Ansari Sameer A
Published: July 2021

Background and purpose:
It has been demonstrated that every 30-minute delay in time to revascularization is associated with 10% absolute decrease in the probability of a good outcome from intra-arterial therapy (IAT) in acute ischemic stroke (AIS) patients. We investigated the potential critical time intervals among patients with direct presentation compared to inter-hospital transfers to comprehensive stroke centers (CSCs) for IAT.

Methods:
We performed a retrospective review of consecutive AIS patients who underwent IAT at 4 institutions since 2012 and abstracted symptom onset time (SOT), first emergency department arrival time (EDAT), and time of groin puncture (GP). Patients were categorized into those who were transferred from outside institutions and those who presented directly to the CSCs (non-transferred). We compared times using Mann-Whitney tests and proportions using Fisher’s exact tests.

Results:
Fifty-six patients were studied (58% male, mean age 65.3 years) were studied, of which 34 (60.7%) patients were inter-hospital transfers. Of the studied time intervals, SOT to CSC arrival time in non-transferred group was significantly less than that of transferred group (78.1 vs. 271.1 min, respectively; p<0.001). Additionally, there was a trend towards reduced SOT to GP time in non-transferred group (251.4 vs. 308.5 min; p=0.059). No significant difference was observed in first EDAT to GP time between non-transferred and transferred group (199.2 vs. 215.7; p=0.11). In non-transferred group, 5 (23%), 14 (64%), and 3 (13%) patients and in transferred group 2 (6%), 26 (76%), and 6 (17%) patients achieved SOT to GP time of <3, 3-6, >6 hours, respectively (p=0.17). Additionally, first EDAT to GP time of <120 minutes was achieved in only 3 cases (5.3%).

Conclusions:
Both among direct referrals and inter-hospital transfer patients, onset and initial arrival to treatment times are far from optimal. Nearly 90% of the time from onset to treatment is accounted for prior to CSC arrival among transfers while nearly 70% of the time elapses at CSCs among non-transfers. There are considerable opportunities for reducing delays in several key steps in the process including early team activation, inter-hospital transport, and rapid multimodal imaging protocols.
Abstract T P212: The Impact of the Method of Ischemia/reperfusion Injury on Stroke Outcomes in Type 2 Diabetes
Authors: Li Weiguo , Qu Zhi , Ma Handong , Prakash Roshini , Hoda Md Nasrul , Fagan Susan C , Ergul Adviye
Published: July 2021

Diabetes worsens functional outcome after ischemic stroke and is associated with greater hemorrhagic transformation (HT) occurrence. We have shown that male diabetic Goto-Kakizaki (GK) rats develop greater HT and neurological deficit despite smaller infarcts after temporary (3/21 hr) middle cerebral artery occlusion (MCAO) induced by the suture model. The impact of the duration of ischemia/reperfusion (I/R) and the method of ischemia on neurovascular injury and functional outcome in diabetic stroke remain unknown. To address this gap, control Wistar and diabetic GK rats were subjected to 90 min/23 hr, 3 hr/21 hr, or 3 hr/7 day MCAO by suture occlusion or embolus placement. In all groups, infarct size, edema, HT occurrence and severity (hemoglobin level), and functional outcome (grip strength and composite deficit score) were measured (Table). Infarct size was smaller in GK rats with suture or embolic MCAO, but expanded with longer reperfusion period. Edema, HT occurrence and severity were all increased in GK rats after 90 min and 3 hr occlusion with the suture model, but not in the embolic MCAO. Motor deficit was greater in diabetic rats. These findings suggest that diabetes accelerates the development of HT and amplifies vascular damage especially in the suture model where blood flow is rapidly reestablished. These results highlight the importance of earlier vascular protection to improve neurological outcome of acute ischemic stroke in diabetes.
Abstract T P25: Poor Collaterals Necessitate Early Reperfusion: Relationship Between Time to Reperfusion, Collateral Flow, and Clinical Outcome
Authors: Hwang Yang-Ha , Kang Dong-Hun , Kim Yong-Won , Kim Yong-Sun
Published: July 2021

Background:
Clinical outcome following reperfusion can be affected by the adequacy of baseline collaterals during endovascular therapy. We examined the relationship between onset-to-reperfusion time (ORT), collateral grade, and clinical outcome with the hypothesis that there is a narrow therapeutic time window for good clinical outcomes in patients having poor collaterals.

Methods:
Among 300 patients who underwent endovascular therapy for acute large vessel occlusion in the anterior circulation, we identified 220 patients having a final TICI score of 2 or more. Patients’ collateral grades, using the ASITN/SIR scale on baseline angiography, were dichotomized into poor (0-1) versus partial/complete (2-4). Favorable functional outcome was defined as a 3-month mRS of 0-2.

Results:
Angiographic data on collaterals were available for 207/220 patients, with 76 in the poor collateral group and 131 in the partial/complete group. The TICI 2b-3 reperfusion rates were similar between the two groups [51/76 (67%) vs. 89/131 (68%), p=0.902], though functional outcomes were significantly different [35/76 (46%) vs. 81/131 (63%), p=0.027]. In the poor collateral group, the odds of favorable outcome significantly dropped for patients reperfused beyond 6-hour from onset [28/53 (54%) vs. 7/24 (29%); odds ratio 0.35 (95% CI 0.13-0.99); p=0.045], whereas the probability of favorable outcome in partial/complete group was not as influenced by reperfusion beyond the 6-hour time window [56/85 (66%) vs. 25/46 (54%); odds ratio 0.62 (95% CI 0.30-1.29); p=0.195]. In subgroup analysis of the poor collateral group, each 30-minute increase in ORT was associated with a decreased chance of favorable outcome despite reperfusion after adjustment for age, baseline NIHSS score, and baseline ASPECTS score [odds ratio 0.77 (95% CI 0.64-0.93); p=0.006].

Conclusions:
Onset-to-reperfusion time in patients with poor collaterals is an another important factor affecting favorable outcome, and future trials would benefit from a non-invasive imaging technique to detect poor collaterals along with a strategy for early reperfusion.
Abstract T P253: A Quality Improvement Project to Improve Stroke Assessment Adherence for Patients After Surgical or Interventional Radiology Intervention
Authors: Adler Tovah R , Graves Alexandra , Casper Christy , Cox Stephanie , Jones William , Neumann Robert , Newsome Franklin , Rapp Kimberly , Smith Doreen , Waite Kathi
Published: July 2021

Objective:
The Joint Commission (TJC) Comprehensive Stroke Center (CSC) certification includes the standard that hospitals must use processes based upon clinical practice guidelines (CPGs) or evidence-based practice to facilitate the delivery of clinical care, including patients admitted directly from the Operating Room or Interventional Radiology. Included in this standard is the requirement that assessment and documentation post-procedure be consistent with selected CPGs. This project was designed to improve assessment and documentation adherence at a single academic hospital.

Methods:
Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team was created to identify ways to improve compliance for required assessments when recovering a patient. The team reviewed current policies, guidelines, and order sets related to post procedure assessments. Comparison of pre-intervention and post-intervention adherence to charting standards was performed. Pre-intervention patients included a review of 4 records by TJC CSC reviewers during their on-site visit. Each patient had insufficient documentation; therefore, the institution was cited in this area. Post-intervention patients were prospectively identified. A Neuro ICU Self-Audit Tool was created to identify patients, remind staff of required assessments, and serve as a self-audit tool affirming their adherence to the guideline. Additional interventions included education (via email, poster in-services, staff meeting updates, and one-on-one teaching) for Neuro ICU nurses. A Post Cerebral Arteriography order set was created and the electronic health record modified to make it easier to document assessments.

Results:
Compliance improved to 98% in 4 consecutive months. 100% of cases were reviewed by the primary and charge nurses. 10% of cases were reviewed by the stroke program data analyst to ensure accuracy and inter rater reliability. Outliers were reviewed by the stroke leadership team and feedback given to unit nursing leadership and the nurse.

Conclusions:
Improvement of adherence to post-procedure assessments is possible using the PDSA methodology. The success of this project allowed this hospital to achieve its TJC CSC certification.
Abstract T P259: What Should Really be Happening to Our Stroke Patients Post-Acute Care?: A System Best Practice Model for Inpatient Rehab
Authors: Sharp Shelley , Linkewich Elizabeth , Willems Jacqueline , Tahair Nicola , Levy Charissa , Bayley Mark
Published: July 2021

Background:
A regional Stroke Report Card identified poor performance on system efficiency, effectiveness, and integration of stroke best practice. This engaged regional funders and 17 organizations (11 acute, 6 rehab) to collaborate in stroke system planning. The focus included stroke unit care and access to timely and appropriate rehabilitation, including increased access for severe stroke. Changes in acute care, including pre-hospital, have facilitated access to stroke unit care in the city. A model of patient flow from acute care was needed to understand other system capacity needs.

Purpose:
To use best practice and benchmarks to delineate post-acute patient flow and facilitate alignment of resources for inpatient rehabilitation.

Methods:
Administrative data from national reporting and local rehab referral system databases were used to review current system usage from acute care. A model of proportional distribution of cases from acute, specifically to inpatient rehab, was established using provincial benchmarks, evidence informed targets, and organization market share of total inpatient rehab system capacity. Iterative discussions were required to confirm the organizations’ commitment to stroke best practice. New volume and case mix changes were applied to determine capacity and resource planning needs across organizations.

Results:
The best practice model, approved by all stakeholders, proposes 40% of stroke patients discharged alive from acute care should access inpatient, 13% outpatient rehabilitation and 6% to Complex Continuing Care and Long Term Care. Current practice is 26%, <5% and 13% respectively. A projected volume increase of 278 patients is distributed across 5/6 rehab providers. This results in a total proportional system shift from 20% (n=160) to 41.5% (n =446) of severe patients receiving access to high intensity rehab. A reduction in the overall proportion of moderate and mild stroke patients from 65% (519) to 49.5% (n=534) and 15% (n=119) to 9% (n=96) respectively.

Conclusion:
Significant investment/redistribution of resources within the system is required to support patient flow and provide care in the right place at the right time. System funder support is critical to create a quality of care (best practice) system.
Abstract T P270: Effectiveness of National Institute of Health Stroke Scale Training
Authors: Jones Amy , Campbell Gladys
Published: July 2021

Background and Purpose:
Staff voiced a need for hands on training regarding scoring of complex stroke patients. Random reviews of medical record documentation of the National Institute of Health Stroke Scale (NIHSS) scoring and discussions with staff reflected variations in scoring for the same deficits. The primary training method utilized by all staff has been computer based with preceptor skill verification. Continued issues with confusion in scoring led to development of a unique solution for our facility and community partners using this scale.

Method:
Members of our nursing and medical team developed a unique learning opportunity that provided participants with both didactic and hands on participation for scoring of patients with the NIHSS. Lectures consisted of overview of stroke syndromes including complex syndromes, basic NIHSS knowledge and scoring requirements, followed by review of complex scoring strategies and a live classroom scoring presentation by a provider on a test patient. The learning opportunity was further enhanced by interactive sessions for hands on by each participant through scoring every component of the scale in a non-threatening environment. This was accomplished through the use of smart phones and computers which blinded individual responses. Standardized test patients trained by the instructors executed scenario responses ranging from normal to extremely abnormal and/or complex. Participants scored scenarios executed using the NIHSS and received immediate feedback on scoring rationales. Questions and inaccuracies were addressed and clarified in each session.

Results:
The initial class evaluations and changes in pre and post class scoring results indicate less variation in scoring for all items, especially related to scoring of the complex patient.

Conclusion:
Computer based learning is the most common and widely used approach to staff education for training staff on use of the NIHSS. However, face to face interaction with the learner and instructor appears to be the most effective method for skill attainment with scoring of complex stroke patients.
Abstract T P291: Impact of Diastolic Dysfunction for Predicting Mortality in Ischemic Stroke and Transient Ischemic Attack Patients
Authors: Tateishi Yohei , Tsujino Akira , Hamabe Jumpei , Tasaki Osamu , Horie Nobutaka , Izumo Tsuyoshi , Hayashi Kentaro , Nagata Izumi , Maemura Koji
Published: July 2021

Background:
The aim of this study is to identify whether diastolic dysfunction predicts 90-day mortality and develop and validate a risk score model using information available at hospital presentation in ischemic stroke or transient ischemic attack (TIA) patients

Methods:
Consecutive ischemic stroke or TIA patients within 48 hours of onset were enrolled. Diastolic filling pressure was estimated as the ratio of early transmitral flow velocity (E) to mitral annular velocity (e’) on transthoracic echocardiography performed within 24 hours of presentation. Plasma brain natriuretic peptide (BNP) and D-dimer were measured on admission. We calculated initial diffusion weighted imaging (DWI) lesion volume. Stroke severity was assessed by the National Institute of Health Stroke Scale (NIHSS) score. Mortality was evaluated at 90-day follow-up. Univariate and multivariate analyses were conducted to identify predictors of 90-day mortality.

Results:
A total of 265 patients with ischemic stroke or TIA were enrolled. Of these, nineteen (7%) patients deceased at 90-day follow-up. At univariate analysis, higher age (p=0.002), atrial fibrillation (p<0.001), use of antiplatelet agent (p=0.005) and anticoagulant agent (p=0.017), cardioembolic infarction (p<0.001), higher NIHSS score (p<0.001), larger DWI lesion volume (p=0.002), internal carotid artery occlusion (p<0.001), higher E/e’ (p<0.001), PT-INR level (p=0.004), BNP level (p<0.001) and D-dimer level (p<0.001) and lower albumin level (p=0.002) were associated with death. Multivariable predictors of 90-day mortality included higher E/e’ (Odds ratio [OR]=1.176; 95% confidence interval [CI], 1.051 to 1.317), NIHSS score (OR=1.180; 95% CI, 1.067- 1.306) and D-dimer level (OR=1.137; 95% CI, 1.009 to 1.281). The END score (1 point each for E/e’ of >= 18.5, NIHSS score of >= 17 and D-dimer level of >= 2.0) stratified patients with a predicted probability of death rate from 0% to 77.8%. The c statistic was 0.947.

Conclusions:
Diastolic dysfunction could be one of the most important predictors of 90-day mortality of acute ischemic stroke and TIA. The END score may assist clinicians in estimating stroke mortality at hospital presentation.
Abstract T P51: Tolerability and Safety of External Counterpulsation (ECP) in Acute Ischemic Stroke: Final Results of the Counterpulsation to Upgrade Forward Flow in Stroke (CUFFS) Trial
Authors: Alexandrov Anne W , Liebeskind David S , Raman Rema , Alexandrov Andrei V , Hemmen Thomas M , Shahripour Reza B , Barlinn Kristian , Sisson April , Rapp Karen , Starkman Sidney , Grunberg Ileana D , Meyer Brett C , Ernstrom Karin , Guluma Kama Z
Published: July 2021

Background/Purpose:
External counterpulsation (ECP) has been cited as a method that may improve brain perfusion and functional outcome in ischemic stroke. We sought to understand the tolerability and safety of ECP within 48 hours of ischemic stroke.

Methods:
A randomized, patient-blinded design was used in MCA strokes ineligible for reperfusion arriving within 46 hours of stroke onset at 3 CSCs. A 1-hour ECP session (ViaCare, Scottcare Inc.) was provided with 200-300 mm Hg pressures in treatment group patients, and the lowest device pressure with air-leak cuffs in shams. TCD and NIHSS measures were collected before, during and after ECP; patients were followed for 30-days post-treatment.

Results:
23 patients were randomized (13 treatment; 10 sham); age (mean 58+12), race (78% White; 74% non-Hispanic) and gender (65% male) were similar between groups, baseline NIHSS was 6 in treatment cases and 6.5 in sham patients (p=ns), and all other baseline measures were similar between groups. There was no difference in time to ECP between groups. During ECP, an unexpected increase in sham group PSV, EDV, MFV, and proportional velocity change (PVC) was observed, with very little augmentation of MFV or PVC observed in the treatment group (Table). Tolerability was 100% in shams vs. 92% in the treatment group, with 54% sustained tolerance during high pressure. A >2 point NIHSS decrease during ECP occurred in 70% of shams vs. 38% of treatment group patients, and persisted at 30 days; mRS and Barthel indices at 30-days were similar between groups (Figure). One adverse event (AE) occurred in each group, and 1 treatment group patient had 3 serious AEs. No sICH, new ischemic strokes, or deaths occurred.

Conclusions:
ECP is safe in acute ischemic stroke, although 60-minute sustained tolerance of higher pressures remains questionable. The ViaCare device did not augment MFV compared to our experience with other ECPs. Sham arms should be cautiously undertaken in the future designs of ECP studies.
Abstract W MP113: Transient Ischemic Attacks Requiring Hospitalization of Children in the United States: Kids’ Inpatient Database 2003-2009
Authors: Adil Malik M , Qureshi Adnan I , Beslow Lauren A , Jordan Lori C
Published: July 2021

Objective:
To assess the prevalence of and risk factors for transient ischemic attacks requiring hospitalization in children in a large national sample.

Methods:
Using the Healthcare Cost and Utilization Project Kids’ Inpatient Database, ICD-9 code (435.XX) identified children 1-18 year(s) admitted for TIA from 2003-2009. Descriptive analysis was performed to identify patient characteristics; and trend analysis was performed to determine any change in annual average hospitalization days from 2003-2009 utilizing the Cochran-Armitage trend test.

Results:
TIA was the primary diagnosis for hospitalization in 531 children over the 3-year sample (Table). Important secondary diagnoses during the same hospital admission included sickle cell disease (20%), congenital heart disease (11%), migraine (12%), moyamoya disease (10%) and stroke (4%). Anemia, coagulopathy, diabetes, hypertension, and obesity were rare co-morbid conditions, each noted in ≤6% of children. TIAs were more common in adolescents with 67% occurring in those aged 11-18 years. The mean length of stay decreased from 3.0 days (95% confidence interval (CI) 2.4 -3.6) in 2003 to 2.3 days (95% CI 2.0-2.7) in 2009 (p<0.04). No children died; 97% were discharged to home. During the same time period 2590 children were admitted with ischemic stroke; therefore 4.8 children with ischemic stroke were admitted for every child with TIA.

Conclusion:
Recognized risk factors for TIA including sickle cell disease, congenital heart disease, moyamoya, recent stroke and migraine were present in <60% of children. Admissions for ischemic stroke were about 5-fold more common than TIA in children. Further study is required to understand the risk of stroke after TIA in children to guide appropriate evaluation and treatment.